Source: Faria I, Godinho Cintra AC, Mello de Oliveira LGA, et al. Reevaluating nonoperative management for pediatric uncomplicated acute appendicitis: a systematic review and meta-analysis. JAMA Pediatr. 2026;180;(1):26-34; doi: 10.1001/jamapediatrics.2025.4091.Investigators from the University of Texas Medical Branch, Galveston, TX, and the Federal University of Bahia, Salvador, Brazil, conducted a systematic review and meta-analysis to compare the effectiveness and safety of nonoperative management (NOM) vs appendectomy for children with uncomplicated appendicitis. They used a standardized process to identify randomized controlled trials comparing NOM and surgical management of patients <18 years old with appendicitis. Data on short- and long-term outcomes (up to 1 year) were abstracted from the selected studies. Primary outcomes were treatment success and treatment failure. Treatment success was defined as the absence of unplanned operations and complications in both treatment groups, lack of recurrent appendicitis with appendectomy for those in the NOM group, and absence of negative pathology for children in the appendectomy group. Treatment failure included negative pathology for surgery patients, need for intervention within 48 hours or subsequent appendectomy for those in the NOM group, and complications and additional procedures for those in both groups. Data from the selected studies were pooled and the overall risk ratio (RR) among those in the NOM or appendectomy group calculated; outcomes at 1 year also were determined for the subgroup of patients from studies that had follow-up for that duration. Secondary outcomes included time to return to normal activities and time to return to school. Mean differences between children in the 2 groups were calculated.A total of 7 studies that included 1,480 patients were identified. Treatment success was assessed in 5 trials. The initial success rate for children randomized to NOM was 84.7 events/100 observations. However, overall treatment success was significantly less frequent for those in the NOM group than children in the appendectomy group (RR, 0.68; 95% confidence interval CI, 0.59, 0.78). A similar result was seen in patients followed to 1 year (RR, 0.67; 95% CI, 0.60, 0.75). A treatment failure was noted in 36.6% for children in the NOM group vs 7.0% for those randomized to appendectomy. Treatment failure was significantly more frequent in those in the NOM group, both overall (RR, 5.09; 95% CI, 3.67, 7.07) and at 1 year (RR, 4.97; 95% CI, 3.57, 6.91). By 1 year after the index admission, the appendicitis recurrence rate in children initially treated with NOM was 18.5 events/100 observations. Children in the NOM group returned to normal activities, and returned to school, significantly faster than those in the appendectomy group (mean difference, -4.93 days; 95% CI, -8.68, -1.19 and -1.36 days; 95% CI, -2.64, -0.08).The authors conclude that children treated with appendectomy had a higher treatment success rate and lower treatment failure rate than those in the NOM group.Dr Chang has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.For children with appendicitis, an urgent appendectomy has been the standard of care.1 Though appendectomies are generally safe, there still are associated risks and complications.1 In the past decade, NOM of uncomplicated appendicitis to treat nonperforated appendicitis increasingly has been investigated and used as an alternative to surgery. (See AAP Grand Rounds. 2022;483:30.)1,2The results of an older meta-analysis of 4 nonrandomized prospective and 1 randomized controlled trial (RCT) found that up to 90% of patients treated with NOM successfully avoided an appendectomy in the first month, but about one-quarter underwent appendectomies within a year and were considered treatment failures.3 Since then, 6 additional RCTs have been conducted, including 1 large RCT demonstrating that one-third of NOM patients experienced treatment failure within a year. (See AAP Grand Rounds. 2025;535:52).4 The current meta-analysis synthesizes data from the 7 RCTs comparing NOM to appendectomies, and similarly found that NOM had more treatment failures.With the large number of patients in the current meta-analysis and rigorous inclusion of only RCTs, it is clear that a substantial number of children who receive NOM may undergo appendectomies within a year. However, treatment failure in research studies may not be considered failure clinically or to families who wish to see if surgery can be avoided. Notably, there was no difference in the incidence of abscess formation or perforated appendicitis between groups, and the incidence of surgical site infections was actually lower in the NOM group, though only 3 RCTs reported these outcomes. In addition, the high success rate of NOM in the short term means that for young or medically complex children who live far from a hospital with the surgical or anesthetic expertise to perform their appendectomies, urgent transfers for surgical intervention can likely be avoided for uncomplicated appendicitis.Treatment failures are more likely in NOM than in surgical management of uncomplicated appendicitis.Despite the higher treatment failure rate, surgery for up to 1 year following the index admission was avoided in 64% of the patients in the NOM group, emphasizing a role for shared decision making in children with uncomplicated appendicitis.
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