Antibiotic-Based Nonoperative Management Versus Appendectomy for Uncomplicated Acute Appendicitis in Children: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Objectives: Acute appendicitis is the leading cause of emergency abdominal surgery in children. Although appendectomy remains the standard treatment, antibiotic-based nonoperative management (NOM) is an alternative for selected patients. We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs) comparing these strategies in pediatric uncomplicated acute appendicitis. Methods: PubMed, MEDLINE via Ovid, Scopus, and CINAHL were searched through 15 July 2026; CENTRAL and ClinicalTrials.gov were searched on 13 October 2026 (PROSPERO: CRD420261447254). Pediatric RCTs were included. RoB 2 and GRADE were used. Random-effects pooling required compatible outcomes. Results: Eight RCTs involving 1920 children were included. Both one-year comparative trials favored appendectomy, but their different composite endpoints were not pooled. NOM avoided appendectomy at one year in 62.5–70.0% in three trials. Clinical complications were uncertain (RR 1.61, 95% CI 0.63–4.13; I2 = 54.9%). No significant pooled difference was found in hospital stay or return to normal activities. Recurrence and school outcomes were reported separately. Conclusions: Appendectomy provides more reliable definitive treatment. NOM can avoid surgery in selected children but carries a risk of subsequent failure or recurrence. Comparative safety and recovery remain uncertain. Families should be informed of these trade-offs and the limitations of the pooled evidence.