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September 18, 2026The American Surgeon

Robustness of Randomized Trials Comparing Operative and Non-Operative Management of Acute Uncomplicated Appendicitis: A Fragility Analysis

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Why the study?

Is the evidence from RCTs comparing non-operative management to operative management for acute uncomplicated appendicitis robust based on fragility index?

Population

5 RCTs comparing non-operative management and operative management of acute uncomplicated appendicitis

Comparison

Non-operative management (NOM) vs Operative management (OM)

Design

Systematic_review

Key result

A fragility analysis of 5 RCTs comparing non-operative and operative management for acute uncomplicated appendicitis found all trials to be robust, favoring operative management as the standard of care.

Authors

VWVictoria L. WalkerSKSamantha W. KerrGSGregory T. Scarola

Discussion

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Overview

Supports operative management as standard for acute uncomplicated appendicitis; confirms statistical robustness of RCT evidence.

Key Points

  • To evaluate the statistical robustness and fragility of randomized controlled trials comparing operative and non-operative management for acute uncomplicated appendicitis.
  • Conducted a systematic search of PubMed and Google Scholar (January 2000 to September 2025) for two-arm randomized trials comparing non-operative and operative management with statistically significant dichotomous primary outcomes (P < 0.05).
  • Calculated the fragility index (FI), reverse fragility index (RFI), fragility quotient (FQ), and reverse fragility quotient (RFQ), classifying an FI of 3 or less as fragile.
  • Included 5 randomized controlled trials, comprising 1 positive superiority trial favoring operative management at 6 months (FI = 10, FQ = 0.056) and 4 negative non-inferiority trials where non-inferiority was not confirmed.
  • The negative non-inferiority trials demonstrated a median RFI of 30 (range: 4–55) and a median RFQ of 0.050 (range: 0.017–0.189).
  • The trial displaying the greatest robustness (RFI = 55, RFQ = 0.065) evaluated outcomes at 12 months with an absolute difference in failure rates of 26.7% (90% CI: 22.4–30.9), failing to show non-inferiority for antibiotic management.

Study Design

Type

Systematic Review (n=5)

Structured PICO

Is the evidence from RCTs comparing non-operative management to operative management for acute uncomplicated appendicitis robust based on fragility index?

P
Population
5 randomized controlled trials comparing non-operative management and operative management of acute uncomplicated appendicitis.
I
Intervention
Non-operative management (NOM)
C
Comparator
Operative management (OM)
O
Outcome
Fragility index (FI), reverse FI (RFI), fragility quotient (FQ), and reverse FQ (RFQ) of statistically significant dichotomous primary outcomes

RCTs comparing operative and non-operative management of acute uncomplicated appendicitis are robust, favoring operative management as the standard of care.

Cite This Study

Walker et al. (2026) conducted a systematic review in Acute uncomplicated appendicitis (n=5). Non-operative management vs. Operative management was evaluated on Fragility index (FI) and reverse fragility index (RFI). A fragility analysis of 5 RCTs comparing non-operative and operative management for acute uncomplicated appendicitis found all trials to be robust, favoring operative management as the standard of care.

synapsesocial.com/papers/6aacf5ed0c46fbdff987dd94https://doi.org/10.1177/00031348261489292
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