Reevaluating Nonoperative Management for Pediatric Uncomplicated Acute Appendicitis
Myron Yaster MD. Lynne G. Maxwell MD, Francis Veyckemans MD
As many of you know, I am very skeptical of the many studies that are published which rely on systematic reviews and meta-analysis (“garbage in…garbage out”). In today’s PAAD[1] and its accompanying editorial[2] Faria et al. report their systematic review and meta-analysis comparing operative management (OM) and nonoperative management (NOM) for children and adolescents with uncomplicated appendicitis. Faria et al. found that NOM was associated with a significantly higher risk of treatment failure at 1 year, lower treatment success at 1 year, and an increased rate of major complications compared with appendectomy. As the editorial by Rangel points out “previous meta-analyses have reached divergent conclusions[3-5] and highlights the inherent challenges of attempting to define superiority, equivalence, or noninferiority between 2 fundamentally different treatment pathways, each with distinct risks, tradeoffs, and implications for family decision-making.”[2]
As anesthesiologists, we don’t make the “cold steel” vs antibiotic surgical decision. However, because acute appendicitis is such a common pediatric (and adult) abdominal emergency, I thought a PAAD review would be beneficial to all of you. Myron Yaster MD
Original article
Faria I, Cintra ACG, de Oliveira LGAM, Squizzato F, Maia AS, Cunha AG, Radhakrishnan RS. Reevaluating Nonoperative Management for Pediatric Uncomplicated Acute Appendicitis: A Systematic Review and Meta-Analysis. JAMA Pediatr. 2025 Oct 5. doi: 10.1001/jamapediatrics.2025.4091. Epub ahead of print. PMID: 41046476.
Editorial
Rangel SJ. Management of Uncomplicated Appendicitis-Moving Past the Superiority Debate. JAMA Pediatr. 2025 Oct 5. doi: 10.1001/jamapediatrics.2025.4150. Epub ahead of print. PMID: 41046477.
“Previous meta-analyses, including those of randomized clinical trials (RCTs) and observational studies, have shown that NOM for acute UA (uncomplicated appendicitis) in the pediatric population is considered an effective alternative to surgery, with variability in success rates and high heterogeneity of studies.[3, 6] However, gaps remain in the literature regarding 1-year recurrence of appendicitis, associated complications, and patient quality of life, addressed by 2 new RCTs.[7,8] Therefore, we aimed to conduct a broader systematic review and updated meta-analysis restricted to RCTs to enhance statistical robustness and provide insights on complications and return-to-school metrics for patients undergoing antibiotic therapy (NOM) or surgical treatment in the pediatric population.”[1]
What did they find? “In this systematic review and meta-analysis of 7 studies and 1480 patients, NOM was shown to provide inferior outcomes compared with surgical treatment for children and adolescents with UA. NOM was associated with higher treatment failure, readmission rates, complications, and increased length of stay; lower success of treatment; a recurrence rate of appendicitis of 18.47 events/100 observations in 1 year; and a shorter time to return to normal activities and school. Our primary outcomes showed low heterogeneity, and our main outcomes were supported by trial sequential analysis (TSA). Our findings differ from those of the main previous meta-analysis,[5] suggesting that operative management offers fewer complications for pediatric patients with UA.”[1]
Different systematic reviews and meta-analysis and different results. What to make of this? Both today’s original article and the editorial offer some insight. What exactly is treatment success and failure? “While success or failure may be useful for powering clinical trials, they are inherently subjective, heterogeneous, and often difficult to interpret. They combine outcomes of markedly different clinical significance for patients and families. For example, a child managed with NOM who later develops recurrent appendicitis requiring rehospitalization and appendectomy is not equivalent to a child managed operatively who experiences a superficial surgical site infection treated successfully in the ambulatory setting with oral antibiotics; however, both scenarios have been classified as “failure” events in clinical trials.”[2] Further, “Limited follow-up in most published studies, including the meta-analysis by Faria et al, represents an additional concern. Similar to earlier trials and meta-analyses, the current report emphasizes short-term outcomes and 1-year follow-up, with a prior meta-analysis concluding that NOM is effective because most children leave the hospital without undergoing appendectomy and remain symptom-free during this interval. However, emerging data[9] demonstrate that recurrence rates increase steadily with longer follow-up, with failure rates approaching 30% to 40% or more at 5 years.”[2]
Faria et al underline this in their discussion. “While our analysis demonstrates that NOM is associated with higher recurrence and reintervention rates compared with operative appendectomy, these outcomes alone do not determine the optimal approach for every patient. For some families, the opportunity to avoid surgery, even temporarily, along with the potential for faster return to daily activities and reduced short-term disruption, may outweigh the possibility of future recurrence. Recent trials have emphasized the importance of patient-centered outcomes, such as time to return to school, caregiver work absence, and short-term quality of life, which are often underreported in surgical literature but play a major role in family decision-making.[10] We intentionally analyzed outcomes in this meta-analysis to allow clinicians and caregivers to weigh specific trade-offs: durability vs early recovery, surgical risk vs avoidance, and predictability vs flexibility. Both operative and nonoperative approaches are valid in the treatment of pediatric UA, and the choice should take into account family values, local expertise, and the evolving evidence base. This nuanced understanding reinforces the importance of shared decision-making at the bedside, where individualized priorities must guide treatment selection.”[1]
The critical issue is to determine whether appendicitis is complicated or not. We all remember of cases where the child complained of moderate abdominal pain with no major radiologic signs and in whom severe peritonitis was found at surgery. In Europe, the presumptive diagnosis of appendicitis almost always results in emergency surgery: surgeons prefer removing a normal appendix (in case, for example, of mesenteric adenitis) than taking the risk of peritonitis or sepsis because appendicitis was more complicated than initially suspected based on the child’s examination and radiologic findings. The only exception is the presence of an appendicular plastron (appendicolith): in this case antibiotic therapy is started and surgery is delayed for some days or weeks. A late complication that is not addressed in those maximum one-year follow up studies is the risk of intraperitoneal adherences which is present in both approaches (abscess, peritonitis, surgical manipulations). Adherences can indeed result later in intestinal obstruction, infertility or favor extrauterine pregnancy. Registries to follow up patients with operative and non-operative treatment of acute uncomplicated (nonperforated) appendicitis or retrospective studies looking for their presence in the patient’s history could be helpful to clarify these risks.
What would you do or recommend if it was your child or grandchild? I (MY) recently faced this question with one of my wife’s Hawaiian elementary school friends who was visiting Colorado to see her grandchild (and let’s just say she is older than 21!). She presented with textbook classic symptoms of acute appendicitis. I urged her to go directly to the University hospital and when the choice of operative v non-operative management was offered, she and her husband, who are both non physicians, looked to me for advice. I suggested/recommended/urged operative surgery and I am so glad they did. At surgery, the appendix had ruptured with peritonitis.
OK, that’s an anecdote, but again what would you do? Send your thoughts and comments to Myron (myasterster@gmail.com) who will post in a Friday Reader Response.
References
1. Faria I, Cintra ACG, de Oliveira L, Squizzato F, Maia AS, Cunha AG, Radhakrishnan RS: Reevaluating Nonoperative Management for Pediatric Uncomplicated Acute Appendicitis: A Systematic Review and Meta-Analysis. JAMA pediatrics 2025.
2. Rangel SJ: Management of Uncomplicated Appendicitis-Moving Past the Superiority Debate. JAMA pediatrics 2025.
3. Podda M, Gerardi C, Cillara N, Fearnhead N, Gomes CA, Birindelli A, Mulliri A, Davies RJ, Di Saverio S: Antibiotic Treatment and Appendectomy for Uncomplicated Acute Appendicitis in Adults and Children: A Systematic Review and Meta-analysis. Annals of surgery 2019, 270(6):1028–1040.
4. Brucchi F, Filisetti C, Luconi E, Fugazzola P, Cattaneo D, Ansaloni L, Zuccotti G, Ferraro S, Danelli P, Pelizzo G: Non-operative management of uncomplicated appendicitis in children, why not? A meta-analysis of randomized controlled trials. World J Emerg Surg 2025, 20(1):25.
5. Huang L, Yin Y, Yang L, Wang C, Li Y, Zhou Z: Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children: a meta-analysis. JAMA pediatrics 2017, 171(5):426–434.
6. Decker E, Ndzi A, Kenny S, Harwood R: Systematic review and meta-analysis to compare the short-and long-term outcomes of non-operative management with early operative management of simple appendicitis in children after the COVID-19 pandemic. Journal of Pediatric Surgery 2024, 59(6):1050–1057.
7. St Peter SD, Noel-MacDonnell JR, Hall NJ, Eaton S, Suominen JS, Wester T, Svensson JF, Almström M, Muenks EP, Beaudin M: Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomised, non-inferiority trial. The Lancet 2025, 405(10474):233–240.
8. Adams SE, Perera MRS, Fung S, Maxton J, Karpelowsky J. Non-operative management of uncomplicated appendicitis in children: a randomized, controlled, non-inferiority study evaluating safety and efficacy. ANZ J Surg. 2024 Sep;94(9):1569-1577.
9. Patkova B, Svenningsson A, Almström M, Eaton S, Wester T, Svensson JF: Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial. Annals of surgery 2020, 271(6):1030–1035.
10. Hall NJ, Sherratt FC, Eaton S, Walker E, Chorozoglou M, Beasant L, Stanton M, Corbett H, Rex D, Hutchings N: Patient-centred outcomes following non-operative treatment or appendicectomy for uncomplicated acute appendicitis in children. BMJ Paediatrics Open 2023, 7(1):e001673.