The safety and efficacy of appendectomy, endoscopic retrograde appendicitis therapy, and antibiotic treatment for acute uncomplicated appendicitis: a systematic review and network meta-analysis of randomized controlled trials.

Abstract

Background: Appendicitis, as a prevalent acute abdominal condition in general surgery, has established a comprehensive diagnostic and therapeutic framework. However, significant academic debate persists regarding the optimal treatment strategy. With advancements in minimally invasive techniques, endoscopic retrograde appendicitis therapy (ERAT) has emerged as an innovative therapeutic approach, providing new options for clinical decision-making. This study employed network meta-analysis to systematically evaluate and compare the clinical efficacy and safety profiles of three treatment modalities: conventional appendectomy, the ERAT, and pharmacological conservative therapy.

Methods: We systematically reviewed randomized controlled trials (RCTs) published through 2024 that evaluated the three treatment strategies for acute uncomplicated appendicitis. Databases searched included PubMed, Web of Science, Embase, CNKI, Cochrane Central Register of Controlled Trials, and Wanfang. The surface under the cumulative ranking curve (SUCRA) was used to rank the comparative effectiveness of each intervention.

Results: A total of 23 RCTs were included. Regarding complications, the ERAT group (SUCRA, 99.7%) demonstrated significantly lower rates than antibiotics (SUCRA, 37.8%; OR, 0.20; 95% CI, 0.06-0.67), while appendectomy (SUCRA, 12.5%) showed significantly higher rates versus the ERAT (OR, 6.33; 95% CI, 2.35-17.03), with no significant difference between appendectomy and antibiotics. For recurrence, appendectomy (SUCRA, 99.9%) exhibited lower rates than both antibiotics (SUCRA, 2.2%; OR, 0.06; 95% CI, 0.03-0.11) and the ERAT (SUCRA, 53.2%; OR, 0.27; 95% CI, 0.12-0.64), while the ERAT showed significantly lower recurrence than antibiotics (OR, 0.22; 95% CI, 0.08-0.57). Treatment failure analysis revealed appendectomy (SUCRA, 94.6%) had significantly lower rates than antibiotics (SUCRA, 2.2%; OR, 0.05; 95% CI, 0.02-0.15), with no other significant intergroup differences. Hospital stay showed no statistical differences. Cochrane RoB 2.0 assessment indicated overall sound methodological quality. Network meta-analysis demonstrated good consistency (P > 0.05) with low heterogeneity (τ² low-to-moderate; I² < 50%), and adult subgroup analysis yielded similar trends.

Conclusion: Each treatment modality demonstrates unique value in specific clinical scenarios. Conventional appendectomy remains the most reliable definitive treatment approach at present. As a minimally invasive alternative, the ERAT shows promising potential in select patient populations, though broader clinical implementation requires further evidentiary support. While antibiotic therapy avoids surgical intervention, it carries significantly higher risks of recurrence and treatment failure. Additional rigorously designed multicenter randomized controlled trials are needed to optimize current therapeutic decision-making frameworks.

Trial registration: The network meta-analysis and systematic review were registered in PROSPERO on December 2, 2024. (CRD42024616515).