Antibiotics versus Surgery for Uncomplicated Acute Appendicitis in Adults: A Meta-Analysis of Randomized Controlled Trials

Abstract

Introduction: Appendectomy has been used to treat appendicitis for a century, but randomized controlled trials (RCTs) have challenged its efficacy in uncomplicated disease. We performed a meta-analysis to quantify 1-year antibiotic-first efficacy and compare complications with appendectomy in adults. Methods: Following PRISMA 2020, MEDLINE, Embase, CENTRAL, and trial registries were searched to June 2026 for RCTs comparing antibiotics with appendectomy in adults (≥16 years) with imaging- or clinically diagnosed uncomplicated appendicitis. The co-primary outcomes were overall treatment-related complications (risk ratio [RR], random-effects DerSimonian–Laird model) and pooled 1-year efficacy of antibiotics (proportion avoiding appendectomy, logit-transformed model). Heterogeneity (I²), leave-one-out sensitivity analyses, subgroup analysis by diagnostic modality, and Egger’s test were performed; bias was assessed with RoB 2. Results: Eight RCTs (3,202 participants) were included. Pooled 1-year efficacy of antibiotics was 70.9% (95% CI 65.3–76.0%; I²=43%), consistent across imaging-confirmed (71.4%) and clinically diagnosed (70.0%) appendicitis. For complications, the pooled RR was 0.91 (95% CI 0.19–4.48; I²=90%), with very high heterogeneity explained by trial design: omitting the single trial using open appendectomy reversed the estimate and removed heterogeneity (RR 2.25, 95% CI 1.39–3.64; I²=4%), indicating that antibiotics do not reduce, and may increase, complications versus contemporary laparoscopic surgery, particularly with an appendicolith. Conclusion: An antibiotics-first strategy allowed seven of ten adults to avoid appendectomy at one year and is reasonable for uncomplicated appendicitis. However, it does not reduce complications compared to laparoscopic appendectomy and carries recurrence. Shared decision-making, appendicolith exclusion, and follow-up are essential.