Surgery or no surgery for pediatric uncomplicated appendicitis? A systematic review and meta-analysis to inform management.

Abstract

Several studies have advocated for nonoperative management of uncomplicated acute appendicitis, given its favorable safety profile. However, the paucity of data regarding the long-term failure rates of nonoperative management imposes limitations on shared clinical decision-making with patients and families. We conducted a systematic review and meta-analysis comparing operative and nonoperative management of acute uncomplicated appendicitis in children (PROSPERO CRD42021270347). Single- or double-arm studies published in MEDLINE and EMBASE between 2000 and 2024 were included. Our primary outcome was nonoperative management failure rate at 1 year, defined as patients who returned with recurrent appendicitis, need for exploratory surgery for abdominal pain, or elective interval appendectomy. Secondary outcomes were rates of 30-day emergency department visits and 1-year readmissions. Initial search yielded 2,249 articles, of which 48 articles were included. One-year mean failure rate was 22.3% (95% confidence interval, 21.7-23.0%), and beyond 1 year was 54.2% (95% confidence interval, 41.4-67.0%). Patients who underwent nonoperative management were more likely to visit the emergency department within 30 days and be readmitted within 1 year compared with those who underwent surgery. Our findings demonstrate a 1-year nonoperative management failure rate of more than 20% and more than 50% beyond 1 year. Patients undergoing nonoperative management returned to the emergency department and required readmission more frequently than patients whose acute uncomplicated appendicitis was treated operatively.