Antibiotics Versus Surgery for Uncomplicated Acute Appendicitis in Adults

BACKGROUND: Acute uncomplicated appendicitis has traditionally been managed surgically, but recent trials suggest nonoperative treatment with antibiotics may be effective in selected adults. This meta-analysis compares long-term outcomes of antibiotics versus surgery and evaluates predictors of treatment failure, including the presence of an appendicolith. METHODS: We systematically searched MEDLINE, Embase, CENTRAL, and clinical trial registries up to July 2024. We included randomized controlled trials (RCTs) comparing antibiotics versus appendectomy in adults with imaging-confirmed uncomplicated appendicitis. The primary outcome was 1-year treatment success. Secondary outcomes included complication rates, recurrence, and subgroup analysis by appendicolith. A meta-regression explored the relationship between appendicolith prevalence and treatment failure. RESULTS: Seven RCTs (n=3164) were included. The 1-year treatment success rate was significantly lower in the antibiotics group (73.8%) versus surgery (98.1%) (RR 0.78, 95% CI: 0.73-0.84). Complication rates were comparable (RR 0.57, 95% CI: 0.29-1.12). Patients with appendicolith had a significantly higher failure rate (up to 46%). Meta-regression confirmed a positive correlation between appendicolith prevalence and antibiotic failure. CONCLUSIONS: Antibiotics can be effective in selected patients, but recurrence and treatment failure remain concerns, particularly in the presence of appendicolith. Appendectomy remains the definitive treatment. This meta-analysis, including the most recent trials and a novel meta-regression, provides timely insights for shared decision-making.