The quest for alternative treatment strategies for acute appendicitis: How much less is “less invasive”?

10.1055/a-2858-6984 Recent insights into the pathogenesis of acute appendicitis prompted a re-evaluation of the optimal treatment strategy. Historically, acute appendicitis was considered a progressive disease, starting with mild inflammation and eventually leading, when not treated appropriately, to necrosis and perforation of the appendix. This justified an emergency appendectomy, often at inconvenient times. Emerging evidence questions the progressive nature and supports the idea of two distinct types, each with their own unique characteristics: simple or uncomplicated acute appendicitis (UAA; mild inflammation, no risk of perforation) and complex or complicated appendicitis (severe inflammation with tendency to perforate). While in most cases of complex appendicitis an appendectomy remains the gold standard treatment, its necessity for patients with UAA is debated. The search for less invasive alternative treatment strategies aligns with the ethical principle of “first do not harm.” Arguments in favor of nonoperative treatment (NOT) include, among others, the potential risk of post-appendectomy complications, the potential adverse effects of anesthesia, the potential functional role of the appendix in gut immunity and microbiome regulation [ 1 ], and the potential psychological impact of surgery on patients, specifically children and their parents. “....although endoscopic retrograde appendicitis therapy seems to be better when compared with conventional nonoperative treatment, an important question arises: How much less invasive is less invasive?” NOT strategies for UAA typically consist of antibiotic treatment and have shown promising outcomes in current literature. In the latest individual patient data meta-analysis, Scheijmans et al. reported the outcomes of NOT compared with appendectomy in 2101 adult patients with UAA selected from six randomized controlled trials (RCTs) [ 2 ]. Findings demonstrated that NOT avoided surgery (at 1-year follow-up) in 70% of patients, with a comparable complication rate (risk difference –4.5% [95%CI –11.6 to 2.6]). Importantly, the presence of a fecalith was associated with higher failure rates of NOT, causing reluctance to apply NOT in this subgroup [ 2 ]. To improve the outcomes of NOT in patients with fecalith-associated UAA, alternative strategies have emerged. In this issue of Endoscopy , Ma et al. address the outcomes of an alternative NOT strategy [ 3 ]. In their multicenter retrospective study, they compared the outcomes of conventional NOT (antibiotic) with a new NOT strategy consisting of antibiotic administration combined with endoscopic retrograde appendicitis therapy (ERAT) [ 3 ]. The potential value of ERAT as an alternative treatment strategy for UAA has already been reported in systematic reviews in both adult and pediatric populations [ 4 ] [ 5 ]. In contrast to these systematic reviews, the study by Ma et al. focused specifically on patients with fecalith-associated UAA [ 3 ]. The ERAT strategy involved bowel preparation (2 L of polyethylene glycol electrolyte solution 4–6 hours pre-procedure or five administrations of cleansing enema [300–500 mL/enema] completed by 30 minutes before the procedure), an endoscopy with cannulation of the appendix, and subsequent wash-out and fecalith retrieval. Evaluation of the appendiceal lumen was done by either direct visualization or angiography (T-ERAT). In cases of stenosis or residual stones a plastic stent was placed to ensure adequate drainage. Post-intervention, antibiotic administration was continued until symptom resolution and discharge [ 3 ]. The authors found that for these patients, the ERAT strategy significantly outperformed the conventional NOT (antibiotic) strategy. ERAT (combined with post-intervention antibiotic administration) had a significantly higher technical treatment success rate of 96% compared with 78% for conventional NOT treatment [ 3 ]. Moreover, they reported a longer median recurrence time (279 days vs. 32 days, P < 0.001) and reduced hospital stay (3 days vs. 4 days, P <0.001) in the ERAT group [ 3 ]. At the 1-year follow-up, appendicitis recurrence was significantly less frequent after ERAT than after conventional NOT (14% vs. 43%) [ 3 ]. The authors concluded that their ERAT strategy appeared to be the preferred NOT strategy for patients with UAA with a fecalith, although a well-powered multicenter RCT is needed to confirm these findings [ 3 ]. First, the authors should be congratulated for their impressive study and contributions in tailoring the optimal NOT strategy for this subgroup. However, although their ERAT strategy seems to be better when compared with conventional NOT treatment, an important question arises: How much less invasive is less invasive? Despite its higher efficacy compared with antibiotics alone, ERAT involves bowel preparation, endoscopic procedures with potential anesthesia or sedation, and fluoroscopic exposure in T-ERAT procedures. More importantly, median hospitalization was 3 days. This raises questions about the true invasiveness and patient burden compared with appendectomy, which is a well-established procedure with low complication rates and short hospital stays. Recently, same-day discharge after appendectomy was reported to be safe without an increased risk of readmission, complications, or unplanned hospital visits reducing its impact on patients even more [ 6 ]. Moreover, outpatient oral antibiotic regimens and even non-antibiotic NOT strategies are being increasingly explored, promising further reductions in patient burden and healthcare costs [ 7 ] [ 8 ]. It is therefore necessary to start a broader discussion: To what extent is it justified to avoid appendectomies in patients with uncomplicated appendicitis? Which criteria define acceptably “less invasive” alternative treatment strategies for patients with UAA? What outcomes are important for patients, families, (medical) societies, and policymakers? To what extent should we preserve the appendix and are we already convinced enough about the immunomodulatory and microbiome-preserving function of the appendix? Is there enough robust high-quality evidence available supporting us to make well-considered decisions? Until these questions are addressed, the quest for alternative less invasive treatment strategies should be continued, but for now, in clinical practice, appropriate treatment selection should be guided by careful risk–benefit analysis and shared decision making, considering individual circumstances and preferences. With the study by Ma et al., our therapeutic arsenal for fecalith-associated UAA has expanded, but further research is necessary to define its suitability, and modifications might be needed to reduce its “invasiveness.” Publication History Article published online: 17 July 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany Refers to: Endoscopic retrograde appendicitis therapy plus antibiotics versus antibiotics alone for uncomplicated acute appendicitis with appendicolith: a propensity score-matched cohort Endoscopy eFirst DOI: 10.1055/a-2858-6984