Written by Shannon Markus
Large multicenter trials show that nonoperative antibiotic management of acute uncomplicated appendicitis is a safe, effective, and cost-effective alternative to urgent appendectomy for many adults and children. See Editor’s note at the end for counterpoint.
Save a life without the knife
The authors critically reviewed the four largest trials comparing nonoperative treatment of uncomplicated appendicitis with urgent appendectomy to summarize outcomes and consider implications for emergency practice. Evidence shows that ~90% of patients initially respond to antibiotics, with faster pain relief, shorter disability, and similar rare serious complication rates. About 20–30% experience recurrence within a year, which can be safely managed with surgery or repeat antibiotics. Presence of an appendicolith increases the likelihood of appendiceal rupture and reduces nonoperative treatment success. In 2020, the American College of Surgeons stated that many patients could be managed with antibiotics (although they seem to continue to preferentially endorse operative management), and in 2025 added that this may reduce complications, sick leave, and pain medication use. Authors state that outpatient management and ED discharge are feasible for up to 90% of patients. Slow uptake among surgeons may reflect a focus on immediate cure; however, emergency physicians are playing an increasing role in shared decision-making, initiating nonoperative treatment, and safely facilitating outpatient care following formal surgical consultation.
How will this change my practice?
The article presents pretty compelling evidence supporting the offering of medical management for acute uncomplicated appys in the right patients. While the benefits may be a little overstated, the most rigorous trials suggest that antibiotics successfully treat approximately 65–75% of patients at one year, thereby avoiding surgery. In contrast, appendectomy offers near-definitive immediate success (98–99%), but carries higher complication rates in certain populations. On the other hand, surveys indicate that most informed adults and families would choose antibiotics even if the likelihood of eventual appendectomy were as high as 50%, so I personally think we, as clinicians, have an obligation to present both options clearly to support informed decision-making. This review does a good job of equipping clinicians to do so by offering practical examples of patient-centered decision-making conversations in Box 2 below.
For me, the bottom line is there is no single “right” answer. The physician’s role is to educate, and the patient’s role is to decide which risks and trade-offs they are willing to accept between two reasonable treatment options.
Editor’s note: I guess this is the case AGAINST non-op appendicitis treatment—the evidence doesn’t support it. After a recent meta-analysis of seven RCTs found 5x greater risk of failure with non-op management, I’m not on board with non-operative management. ~Clay Smith
Source
Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. 2025 Dec 4:S0196-0644(25)01283-1. doi: 10.1016/j.annemergmed.2025.09.035. Epub ahead of print. PMID: 41348058.
