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Reevaluating Nonoperative Management for Pediatric Uncomplicated Acute Appendicitis: A Systematic Review and
Isabella Faria1, Ana Carolina Godinho Cintra2, Luiz Gustavo Albuquerque Mello de Oliveira2
1Department of Surgery, University of Texas Medical Branch, Galveston.
JAMA Pediatrics
|October 5, 2025
Summary
Nonoperative management (NOM) for pediatric appendicitis shows higher failure and complication rates within a year compared to appendectomy. This meta-analysis offers crucial data for informed clinical decisions regarding treatment durability and safety.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Clinical Trials
Background:
- Nonoperative management (NOM) is an alternative to surgery for acute uncomplicated appendicitis in children.
- Concerns exist regarding NOM's durability, complication rates, and long-term failure.
- An updated meta-analysis of randomized clinical trials (RCTs) is needed to clarify NOM vs. appendectomy outcomes.
Purpose of the Study:
- To evaluate the safety and effectiveness of NOM compared to appendectomy for uncomplicated appendicitis in children.
- To utilize the highest level of available evidence (RCTs) for this comparison.
Main Methods:
- Systematic review and meta-analysis of RCTs comparing NOM with surgical management in pediatric patients (<18 years).
- Searched PubMed, Embase, Scopus, Cochrane, and Web of Science through March 2025.
- Extracted data following PRISMA guidelines; conducted random-effects meta-analyses; assessed risk of bias; performed trial sequential analysis.
Main Results:
- Seven RCTs (1480 patients) were included.
- NOM had significantly higher treatment failure (RR 4.97) and lower success (RR 0.67) at 1 year.
- Major complications (Clavien-Dindo ≥IIIb) were more frequent with NOM (RR 33.37); appendicitis recurrence was 18.47% with NOM.
- NOM showed faster return to school/activities, but this may be offset by reinterventions.
Conclusions:
- This meta-analysis found significantly higher treatment failure and major complication rates within one year for NOM in children compared to appendectomy.
- Results contrast with earlier studies, highlighting the need for updated evidence.
- Provides crucial data for pediatricians and surgeons to inform shared decision-making with families for individualized, patient-centered treatment.
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