Appendicectomy had been the standard treatment for acute appendicitis since McBurney's description in 1894. The idea that uncomplicated appendicitis could be treated with antibiotics alone was considered heretical in surgical teaching. However, accumulating evidence from European trials began to challenge this 120-year-old surgical dogma.

Proof

Landmark RCTs and pivotal trials that established the evidence base

APPAC (2015) was the first major RCT comparing antibiotics to appendicectomy for CT-confirmed uncomplicated appendicitis. At 1 year, 73% of antibiotic-treated patients did not require surgery. The 5-year follow-up (2020) showed 39.1% eventually underwent appendicectomy, meaning 61% successfully avoided surgery over 5 years. CODA (2020) — the largest trial at 1,552 patients — demonstrated antibiotics were non-inferior to appendicectomy for 30-day health status, though 29% in the antibiotics group underwent appendicectomy within 90 days.

APPAC2015Landmark

73% of antibiotic group did not require surgery at 1 year; 27% appendicectomy rate

JAMARCTN=530

APPAC 5-year2019Landmark

39.1% recurrence requiring appendicectomy at 5 years; 60.9% avoided surgery

PloS oneRCT follow-upN=530

CODA2020Landmark

30-day EQ-5D health status: non-inferior; 29% appendicectomy rate at 90 days in antibiotics group

NEJMRCTN=1,552

Guidelines

Integration into clinical practice guidelines and recommendations

WSES 2020 guidelines endorsed antibiotics as a viable first-line treatment option for uncomplicated appendicitis in patients willing to accept a recurrence risk. The emphasis shifted to shared decision-making — presenting antibiotics as a reasonable alternative to surgery rather than a deviation from standard of care.

WSES 2020 Appendicitis Guidelines

Antibiotics acceptable for uncomplicated appendicitis; shared decision-making recommended

Now

Current standard of care and ongoing research directions

Non-operative management of uncomplicated appendicitis is now an established evidence-based option. Appendicectomy remains the definitive treatment, but antibiotics-first is increasingly offered, particularly when patients prefer to avoid surgery or when surgical access is limited. CT confirmation of uncomplicated disease and patient selection remain key to good outcomes.

Landmark Trials in This Story

APPAC2015Landmark

Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial

73% of antibiotic group did not require surgery at 1 year; 27% appendicectomy rate

JAMARCTN=530

APPAC 5-year2019Landmark

Cost analysis of antibiotic therapy versus appendectomy for treatment of uncomplicated acute appendicitis: 5-year results of the APPAC randomized clinical trial

39.1% recurrence requiring appendicectomy at 5 years; 60.9% avoided surgery

PloS oneRCT follow-upN=530

CODA2020Landmark

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

30-day EQ-5D health status: non-inferior; 29% appendicectomy rate at 90 days in antibiotics group

NEJMRCTN=1,552

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Frequently Asked Questions

Can appendicitis be treated without surgery?+

Yes, for uncomplicated appendicitis. The APPAC trial showed 73% of patients treated with antibiotics avoided surgery at 1 year, and 61% at 5 years. The CODA trial (1,552 patients) confirmed antibiotics were non-inferior to surgery for health outcomes. However, about 30-40% eventually need appendicectomy.

What were the key trials that challenged the need for appendicectomy?+

Two landmark trials: APPAC (2015, Finland, N=530) showed 73% of antibiotic-treated patients avoided surgery at 1 year. CODA (2020, USA, N=1,552) — the largest trial — confirmed antibiotics were non-inferior to appendicectomy for 30-day health status, though 29% of the antibiotic group underwent surgery within 90 days.