Appendicolith in non-operative management of acute appendicitis: Implications for recurrence and future directions

Appendicoliths are frequently encountered in acute appendicitis (AA) and historically considered a risk factor for treatment failure in nonoperative management (NOM). However, the impact of appendicoliths on recurrence rates in uncomplicated AA remains controversial. This editorial critically appraises the study by Kupietzky et al, which explored the relationship between appendicolith characteristics and NOM outcomes. Kupietzky et al conducted a retrospective analysis of 797 patients with uncomplicated AA, comparing recurrence rates between those with and without appendicoliths. The study focused on long-term follow-up (median 44.2 months) and subgroup analyses of stone characteristics. The study revealed no significant difference in overall recurrence rates between groups (26.5% vs 19.1%, P = 0.14). However, patients with appendicoliths experienced earlier recurrence (3.9 months vs 5.9 months, P = 0.04) and had larger appendix diameters (10.2 mm vs 8.5 mm, P = 0.001). Subgroup analyses showed no correlation between stone size, location, or number and recurrence risk. Appendicoliths do not independently increase the overall recurrence risk after NOM for uncomplicated AA but may accelerate recurrence timelines. Clinical decisions should prioritize individualized risk assessment, considering patient age, symptom severity, and radiological features. These findings challenge traditional paradigms and advocate for shared decision-making between clinicians and patients.