title: Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis.
abstract: BACKGROUND
  For more than a century, appendicectomy has been the treatment of choice for appendicitis. Recent trials have challenged this view. This study assessed the benefits and harms of antibiotic therapy compared with appendicectomy in patients with non-perforated appendicitis.
  
  
  METHODS
  A comprehensive search was conducted for randomized trials comparing antibiotic therapy with appendicectomy in patients with non-perforated appendicitis. Key outcomes were analysed using random-effects meta-analysis, and the quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
  
  
  RESULTS
  Five studies including 1116 patients reported major complications in 25 (4·9 per cent) of 510 patients in the antibiotic and 41 (8·4 per cent) of 489 in the appendicectomy group: risk difference -2·6 (95 per cent c.i. -6·3 to 1·1) per cent (low-quality evidence). Minor complications occurred in 11 (2·2 per cent) of 510 and 61 (12·5 per cent) of 489 patients respectively: risk difference -7·2 (-18·1 to 3·8) per cent (very low-quality evidence). Of 550 patients in the antibiotic group, 47 underwent appendicectomy within 1 month: pooled estimate 8·2 (95 per cent c.i. 5·2 to 11·8) per cent (high-quality evidence). Within 1 year, appendicitis recurred in 114 of 510 patients in the antibiotic group: pooled estimate 22·6 (15·6 to 30·4) per cent (high-quality evidence). For every 100 patients with non-perforated appendicitis, initial antibiotic therapy compared with prompt appendicectomy may result in 92 fewer patients receiving surgery within the first month, and 23 more experiencing recurrent appendicitis within the first year.
  
  
  CONCLUSIONS
  The choice of medical versus surgical management in patients with clearly uncomplicated appendicitis is value- and preference-dependent, suggesting a change in practice towards shared decision-making is necessary.
authors.affiliation: Departments of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.|Departments of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
authors.forename: V
authors.initials: V
authors.lastname: Sallinen
authors.affiliation: Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.|Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: E A
authors.initials: EA
authors.lastname: Akl
authors.affiliation: Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Departments of Medicine, McMaster University, Hamilton, Canada.
authors.forename: J J
authors.initials: JJ
authors.lastname: You
authors.affiliation: Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Departments of Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Agarwal
authors.affiliation: University of Balamand, Tripoli, Lebanon.
authors.forename: S
authors.initials: S
authors.lastname: Shoucair
authors.affiliation: Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway.
authors.forename: P O
authors.initials: PO
authors.lastname: Vandvik
authors.affiliation: Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Division of General Internal Medicine, Department of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland.
authors.forename: T
authors.initials: T
authors.lastname: Agoritsas
authors.affiliation: Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
authors.forename: D
authors.initials: D
authors.lastname: Heels-Ansdell
authors.affiliation: Departments of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.|Departments of Medicine, McMaster University, Hamilton, Canada.
authors.forename: G H
authors.initials: GH
authors.lastname: Guyatt
authors.affiliation: Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
authors.forename: K A O
authors.initials: KA
authors.lastname: Tikkinen
mesh_terms: D000900:Anti-Bacterial Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001062:Appendectomy / Q000009:adverse effects / Q000379:methods*; D001064:Appendicitis / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D006801:Humans; D007902:Length of Stay; D012008:Recurrence; D018582:Sick Leave; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents