Meta-Analysis of Randomized Trials Comparing Antibiotic Therapy with Appendectomy for Acute Uncomplicated (No Abscess or Phlegmon) Appendicitis

Abstract

BACKGROUND: The objective was to conduct a meta-analysis of randomized controlled trials evaluating the efficacy and morbidity of the management of acute uncomplicated (no abscess or phlegmon) appendicitis by antibiotics versus appendectomy. METHODS: Appropriate trials were identified. The seven outcome variables were overall complication rate, treatment failure rate for index hospital admission, overall treatment failure rate, length of stay (LOS), utilization of pain medication, duration of pain, and sick leave. Both fixed and random effects meta-analyses were performed using odds ratios (ORs) and weighted or standardized mean differences (WMDs or SMDs, respectively). RESULTS: Five trials totaling 980 patients (antibiotics=510, appendectomy=470) were analyzed. In three of the seven outcome analyses, the summary point estimates favored antibiotics over appendectomy, with a 46% reduction in the relative odds of complications (OR 0.54; 95% confidence interval [CI] 0.37, 0.78; p=0.001); a reduction in sick leave/disability (SMD -0.19; CI -0.33, -0.06; p=0.005), and decreased pain medication utilization (SMD -1.55; CI -1.96, -1.14; p<0.0001). For overall treatment failure, the summary point estimate favored appendectomy, with a 40.2% failure rate for antibiotics versus 8.5% for appendectomy (OR 6.72; CI 0.08, 12.99; p<0.001). Initial treatment failure, LOS, and pain duration were similar in the two groups. CONCLUSIONS: Non-operative management of uncomplicated appendicitis with antibiotics was associated with significantly fewer complications, better pain control, and shorter sick leave, but overall had inferior efficacy because of the high rate of recurrence in comparison with appendectomy.