Nonoperative Management of Uncomplicated Acute Appendicitis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials Comparing Antibiotic Treatment and Appendectomy in Children and Adolescents.

BACKGROUND

This systematic review with meta-analysis aims to evaluate the current evidence comparing antibiotic therapy with the surgical gold standard (appendectomy) for the treatment of uncomplicated acute appendicitis (UAA) in children and adolescents.

METHODS

This systematic review and meta-analysis followed PRISMA guidelines and was registered in PROSPERO, CRD420251011305. MEDLINE and CENTRAL were systematically searched up to March 2025. Randomized controlled trials (RCTs) comparing antibiotic therapy and appendectomy in patients aged 0-18 years with UAA were included. Summary data were extracted from published reports of eligible RCTs. Full text eligibility and data extraction were performed independently by two reviewers. Primary outcome was the complication-free treatment success rate at 30 days. Secondary outcomes included recurrence and complicated appendicitis at surgery. Risk ratios (RR) with 95% CIs were calculated using a random effects model.

RESULTS

Of 815 records screened, six studies met inclusion criteria and were included in the review. A clinically relevant difference emerged in terms of complication-free treatment success between the two groups (1333 participants; RR 0.90, 95% CI 0.84-0.96; I2 63%; and moderate certainty of evidence) favoring surgical management over antibiotic therapy among the five studies included in the meta-analysis. Recurrence after successful NOM occurred in 6%-24% of patients at 1 year

CONCLUSION

Antibiotic therapy could represent a feasible treatment option for UAA in children and adolescents, although in terms of complication-free treatment success, appendectomy remains the gold standard.

TRIAL REGISTRATION: CRD420251011305.