- Scheijmans, J. C. G. et al. Antibiotic treatment versus appendicectomy for acute appendicitis in adults: an individual patient data meta-analysis. The Lancet Gastroenterology & Hepatology 10, 222–233 (2025).
A meta-analysis recently published in the Lancet Gastroenterology reexamined patient data from previous studies and conducted an overall evaluation using strictly uniform criteria.1
Meta-analyses have already been conducted on this topic. The difference here is that simple meta-analysis methods usually use aggregated summary statistics; the new study relies on individual participant data, which allows for detailed subgroup analyses and a consistent application of definitions. Furthermore, none of the meta-analyses had previously considered the data from the most recent study (CODA study).
Individual patient data were available for six randomized controlled trials. A total of 2,101 adults with imaging-confirmed acute appendicitis were included in the analysis, 60.5% of whom were male; 1,050 were randomly assigned to antibiotic treatment and 1,051 to surgery.
After one year, the complication rate in the antibiotic cohort was 5.4%, compared to 8.3% in the appendectomy group (odds ratio 0.49; risk difference -4.5 percentage points). One in three (33.9%) of the patients who were not initially operated on subsequently underwent the procedure within one year.
As previous studies have reported, the presence of appendicoliths (fecal stones) increases the risk of antibiotic failure and the likelihood of subsequent appendectomy. This signal was confirmed here: Patients with corresponding findings in preinterventional imaging had an increased risk of complications within one year without surgery (15% without surgery versus 6.3% with surgery; OR 2.82; risk difference 13.2 percentage points). Almost half (48.7%) of the patients with appendicoliths who were initially treated only with antibiotics underwent surgery within a year (versus 30.6% without appendicoliths).
"In addition to the standardization of imaging criteria for the severity of appendicitis, the actual role of antibiotics remains a major knowledge gap, requiring large double-blind studies in the future," the authors concluded. They lament that – despite a gradual paradigm shift in practice – there is still a lack of uniform, international criteria to optimize patient selection and treatment strategies.
A growing number of studies suggest that antibiotic treatment may be a safe alternative to surgery in patients with imaging-confirmed uncomplicated acute appendicitis. The selection of appropriate patients should be guided by imaging, as patients with appendicoliths, for example, may not be optimal candidates for non-surgical management.
The authors also emphasize the importance of patient-centered endpoints, such as quality of life:
“In particular, it has been shown that some patients may not have the same expectations of treatment success as surgeons and are willing to accept a significant risk of initial antibiotic treatment failure to avoid surgery.”1