A clear-eyed look at the evolving conversation around uncomplicated appendicitis — and what it means for surgeons.
What’s happening?
We used to think there were only two kinds of people: those who had their appendix out, and those who hadn’t yet.
The scalpel was a rite of passage. You doubled over in pain, someone pressed your abdomen, and off you went to the OR—no questions asked, just the quiet hush of a pre-op hallway and the promise of a scar that would someday be mistaken for a story worth telling.
But that story is changing. Fast.
Surgeons are increasingly encountering a new kind of clinical moment:
A stable, otherwise healthy patient presents with acute right lower quadrant pain. Imaging confirms appendicitis — no perforation, no abscess, no appendicolith, no peritonitis. The labs are reassuring. Vitals are normal.
Historically, this patient would go to the OR without much discussion.
Now, that conversation is changing.
Several large randomized trials and systematic reviews — including publications in NEJM, JAMA, and the Cochrane Database — support nonoperative management with antibiotics as a viable first-line approach for selected patients with acute uncomplicated appendicitis. Major surgical societies, including the American College of Surgeons and the World Society of Emergency Surgery, have acknowledged antibiotics as an appropriate option in specific contexts.
What does the data actually say?
Surgery (Appendectomy):
- Success rate: ~95–99%
- Recurrence rate: <1%
- Complications: 12–24% (mostly minor, including surgical site infections and post-op ileus)
- Pros: One and done, definitive treatment. Still the gold standard.
- Cons: OR time, anesthesia, wound healing, longer sick leave
Antibiotic Therapy:
- Success rate at 1 year: 62–75%
- Recurrence/need for appendectomy: ~25–39% within 1–5 years
- Complications: 6–13% (typically minor, lower wound infection rate)
- Pros: Avoids surgery for most, quicker return to daily activities
- Cons: Recurrence risk, need for close follow-up, potential delayed surgery
Outcomes like quality of life and 30-day health status appear similar between groups. Notably, patients who fail antibiotics and require surgery later often report lower satisfaction and longer total time to recovery.
Importantly, no increased risk of perforation has been observed with initial nonoperative management — if patients are carefully selected.
So, who’s a candidate for antibiotics alone?
Most guidelines agree on a few criteria:
- Hemodynamically stable
- Nonpregnant, immunocompetent adults
- Imaging-confirmed uncomplicated appendicitis
- No appendicolith
- No perforation, phlegmon, abscess, or diffuse peritonitis
- Symptoms <48 hours
- Appendiceal diameter <13 mm
- No history of IBD
- Reliable for close follow-up and reassessment
Presence of an appendicolith is a key red flag — significantly increasing the risk of treatment failure and abscess formation. For these patients, surgery remains the preferred approach.
What are patients choosing?
Despite the evidence, many patients still opt for surgery. It’s definitive. It feels cleaner. For some, it’s about avoiding the anxiety of recurrence. For others, it’s about trust in the surgical solution.
That said, a significant number — especially younger adults and those concerned about surgical downtime — prefer to try antibiotics. Surveys suggest that when properly counseled, roughly 40% of eligible patients would choose antibiotics.
Surgeons, therefore, are increasingly tasked with not just recommending a course of action, but helping patients weigh risks, timelines, and priorities — and making space for preference.
Where do we go from here?
The evidence is strong, but not absolute. While surgery remains the gold standard — especially for complicated appendicitis — antibiotics are no longer fringe. They’re endorsed, studied, and increasingly appropriate in the right contexts.
That doesn’t mean the scalpel is obsolete. It means something more interesting: our toolbox just got bigger.
Antibiotics aren’t a replacement — they’re another arrow in the quiver. A new kind of precision. A way to meet patients not just where their appendix is, but where their lives are.
There are moments when cutting is still the clearest answer. But there are also moments — a wedding in two days, a crucial work trip, a single parent with no backup — where delaying the knife might serve the patient better.
This isn’t about choosing between tradition and innovation. It’s about recognizing that medicine is moving, and our role is shifting with it — from decision-makers to decision-shapers.
The question isn’t just should we cut?
The real question is: what does the patient need right now — and what tools can we use to get them there?