Is surgical treatment necessary for uncomplicated acute appendicitis?

Since McBurney advocated early surgical intervention, appendectomy has been the mainstay for the treatment of appendicitis. For simple and nonperforated appendicitis, however, conservative treatment with antibiotics has been proposed. Several randomized controlled trials and systematic reviews show conflicting results with regard to the safety and efficacy of nonsurgical treatment with antibiotics. Generally, complicated appendicitis was defined as the presence of peritonitis, perforation, abscess, or suspicion of a tumor on a computed tomography (CT) scan. In France, 243 patients with uncomplicated acute appendicitis assessed by CT imaging were randomized to antibiotics and appendectomy groups, and the 30‐day peritonitis rate was more frequent in the antibiotics group (AG) (8%) than in the appendectomy group (OG) (2%). Furthermore, in AG, 14 of 120 (12%) patients underwent appendectomy during the first 30 days and 9 of these 14 patients (64%) were shown to have complicated appendicitis. In Finland, 530 patients with uncomplicated acute appendicitis assessed by CT were randomized to two treatment arms. In AG, 186 of 256 (73%) patients did not require surgery within 1 year, whereas in OG, all but one (99%) underwent successful appendectomy. Intension‐to‐treat analysis yielded a nonsignificant difference in treatment efficacy (P = .89). Secondary outcomes, including overall complication rate (3% vs 21%), pain score at discharge (2.0 vs 3.0), and length of sick leave (7 vs 19 days), were better for AG. Rollins reviewed five randomized controlled trials with 1430 patients and showed a 39% reduction in complication rate in AG compared to OG (RR; 0.61, 95% CI 0.44‐0.83, P = .002). Incidence of complicated appendicitis was not increased in patients undergoing appendectomy after failed antibiotics treatment when compared to those undergoing primary appendectomy (11% vs 18%). Harnoss reviewed four randomized controlled trials and four cohort studies with 2551 patients and showed that 26.5% of patients in AG needed appendectomy within 1 year, resulting in treatment effectiveness of 72.6%, significantly lower than the 99.4% in OG (RR; 0.75, 95% CI 0.7‐0.79, P = .00001). Overall postoperative complications were comparable, whereas the rate of adverse events and the incidence of complicated appendicitis were significantly higher in AG. In the NOTA study, 159 patients aged 15 years or more were enrolled in a prospective study of antibiotics treatment for acute appendicitis without perforation and peritonitis. Clinical diagnosis was made by the attending general surgeon and confirmed by Alvarado and acute inflammatory response scoring systems. Failure rate at 7 days was 11.9%, and recurrence rate at 2 years was 13.8%. Although neither score correlated with recurrence, both were independent predictors of treatment failure. Thus, appendectomy may be more effective than antibiotics at reducing treatment failure including recurrence, but may be less effective at reducing some complications including wound infection, with uncomplicated acute appendicitis. However, the evidence is weak and results varied by outcome measured. Until better‐quality evidence is available from further trials, the current evidence does not support a change of practice to medical management of uncomplicated appendicitis.