SGEM#512: When you go your way, and I Go Mine – Surgery or Antibiotics for Acute Appendicitis.

Date: June 12, 2026 Guest Skeptic: Mr. Ross Fisher. Ross is a paediatric surgeon, presentation guru (P-Cubed), and long-time friend of the SGEM.  Reference: Talan et al. Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. June 2026 Case: A 29-year-old healthy man presents to the emergency department (ED) with 18 hours of abdominal pain that began around the umbilicus and migrated to the right lower quadrant. He has anorexia, nausea, a temperature of 38.1°C, and focal right lower quadrant (RLQ) tenderness without diffuse peritonitis. The white blood cell (WBC) count is 13,500/µL. CT abdomen/pelvis shows an 8-mm inflamed appendix with periappendiceal fat stranding but no abscess, phlegmon, perforation, mass, or appendicolith. He is hemodynamically stable, not immunocompromised, has no history of inflammatory bowel disease (IBD), can return to the ED if worse, and asks whether he really needs surgery tonight. Background: Appendicitis is one of those diagnoses we don’t want to miss. It’s common, it can be sneaky, and the classic textbook presentation only shows up around half the time. That means labs and scores can help, but they often can’t rule out appendicitis. In 2026, imaging (especially CT scans) is still doing much of the heavy lifting. For more than a century, appendicitis was taught as a surgical emergency: diagnose it, call surgery, and remove the appendix before it ruptures. This new narrative review challenges that mental model. It argues that modern imaging can identify uncomplicated appendicitis, that perforated and nonperforated appendicitis may be biologically different entities, and that short delays to surgery in uncomplicated disease do not appear to increase perforation risk. This new narrative review notes that the American College of Surgeons (ACS) has endorsed antibiotics as a safe alternative for selected patients while continuing to endorse appendectomy. The SGEM has followed this topic for years, and our interpretation of the literature has evolved as the evidence has changed (see list of other SGEM episodes at the end of this blog post). In 2015, the SGEM emphasized diagnostic uncertainty and concern that failed antibiotics could increase morbidity; in 2017, the pediatric conclusion was that NOTA was “not ready for prime time.” By 2019, we were more open to antibiotics in selected patients, using shared decision-making and acknowledging that nonoperative care may be better than we thought, though it may (or may not) come with a small absolute increase in complications. So, the question is no longer whether to cut or not to cut. The ED question is: who is safe for an antibiotic-first pathway, who needs the surgeon now, and who can reliably come back if things go sideways? This is a classic preference-sensitive decision: surgery is highly definitive, while antibiotics may reduce pain, disability, and time away from school or work, but with a meaningful recurrence/appendectomy risk. This review by Talan et al explicitly places emergency physicians in the shared decision-making role for selected uncomplicated appendicitis patients. Clinical Question: In ED patients with imaging-confirmed acute uncomplicated appendicitis, can initial nonoperative management with antibiotics and observation, with appendectomy reserved for worsening, nonresponse, or recurrence, be considered a safe and effective alternative to urgent appendectomy? This matters because appendicitis sits right at the intersection of emergency medicine, surgery, radiology, antibiotics, patient values, and system capacity. Some patients want the most definitive treatment. Others want to avoid surgery if it's safe to do so. Our job is not to sell one option. Our job in the emergency department is to explain the trade-offs. Reference: Talan et al. Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. June 2026 Population: Adults and children with clinically suspected, localized, imaging-confirmed acute, uncomplicated appendicitis. The included trials enrolled children as young as 5 years and adults older than 80 years. Exclusions: The major exclusions were diffuse peritonitis, severe systemic illness/sepsis, pregnancy, immunocompromise, renal failure, inflammatory bowel disease (IBD), prior antibiotic-treated appendicitis, and imaging evidence of major abscess, phlegmon, perforation, mass, or tumour. Some trials also excluded appendicolith, abnormal WBC thresholds, prolonged pain duration, or older age. Intervention: Nonoperative treatment: initial antibiotics plus observation, with appendectomy if the patient worsened, failed to improve, or later recurred. Antibiotic regimens varied but generally used parenteral antibiotics followed by oral antibiotics to complete a total therapy of 7–10 days. Comparison: Urgent appendectomy with perioperative antibiotics, usually laparoscopic in the more recent trials. Outcome Primary Outcome: There was no single primary outcome in the review. Across the major trials, the most important outcomes were 1-year appendectomy/treatment failure rates for antibiotic-first care, and in CODA, 30-day EQ-5D health-status noninferiority. Secondary Outcomes: Complications/serious adverse events, pain resolution or pain medication use, disability days, recurrence, ED return visits, feasibility of ED discharge/outpatient treatment, cancer detection, cost-effectiveness, and appendicolith subgroup outcomes Type of Study: Narrative review of the major comparative trials, not a true systematic review or meta-analysis. Authors’ Conclusions: “Nonoperative treatment of uncomplicated appendicitis will be increasingly considered as experience and confidence grows among physicians and as awareness grows among patients in this new treatment option. Emergency physicians are being asked about nonoperative treatment of uncomplicated appendicitis and have an important role now to inform patients of their treatment options and expected associated outcomes, and an emerging role in expanding access to safe and cost-effective care for patients with appendicitis, including those who can be managed by nonoperative treatment of uncomplicated appendicitis as outpatients.” Quality Checklist for Systematic Reviews: (Yes/No/Unsure) Was the clinical question sensible and answerable? Yes Was the search for studies detailed and exhaustive? No Were the primary studies of high methodological quality? Unsure Were the assessments of studies reproducible? No Were the outcomes clinically relevant? Yes Was there low statistical heterogeneity for the primary outcomes? N/A Was the treatment effect large enough and precise enough to be clinically significant? Unsure Who funded the review? The authors stated that no funding was received for this work. Did the authors declare any conflicts of interest? The authors reported no conflicts of interest. Results: The review focused on four major comparative trials: APPAC, CODA, MPSC, and APPY. Together, they included more than 2,000 adults and more than 2,000 children. The review did not provide a pooled table of sex, race, baseline pain duration, comorbidities, or socioeconomic demographics. Key Result: In selected patients with uncomplicated appendicitis, antibiotics initially worked in about 90% and reduced pain/disability, but roughly one-third underwent appendectomy within 1 year, with higher appendectomy rates among patients with appendicolith. Primary Outcome: APPAC reported a 1-year appendectomy rate of about 27% in adults treated with antibiotics. CODA found antibiotics noninferior to appendectomy for 30-day EQ-5D health status, but the 1-year appendectomy rate was 36% without appendicolith and 52% with appendicolith. MPSC reported a 1-year appendectomy rate of about 33% in children APPY reported about 34% treatment failure/appendectomy in the antibiotic group. The table on page 3 of the review summarizes these trial-specific results. Secondary Outcomes: These generally favoured antibiotics for short-term recovery, but not always for adverse events. APPAC reported fewer 1-year complications with antibiotics than surgery, 2.8% vs 20.5%, with faster pain resolution and fewer disability days. CODA reported similar serious adverse event rates, 3% vs 3%, and fewer disability days with antibiotics. MPSC reported similar complicated appendicitis rates, 3.6% vs 3.3%, and fewer disability days with antibiotics. APPY reported no serious adverse events in either group, but more mild-to-moderate adverse events with antibiotics, largely GI distress; antibiotics reduced post-discharge pain medication use and disability days. The ED discharge data came mainly from CODA. In a CODA sub-analysis, 335 of 726 antibiotic-treated adults, 46%, were discharged from the ED after longer-acting parenteral antibiotics, observation, oral tolerance, stable status, and pain control. Serious adverse events over 7 days were uncommon: 0.9 per 100 outpatients vs 1.3 per 100 inpatients. ED discharge was associated with fewer appendectomies and about one day less disability, without a significant increase in first-week ED return visits. Summary of the Four RCTs: 1. Narrative Review: This was not a systematic review, and that matters. No PRISMA diagram, no duplicate screening, no formal risk-of-bias assessment, and no pooled estimate. That does not make it useless, and we should not judge it against a formal SRMA. It just means we should treat it for what it is, an expert narrative synthesis, not the final word. Open Label 2. Open-Label: The included RCTs were not masked and vulnerable to performance, detection, and preference bias. You really can’t blind antibiotics vs surgery....