Non-operative Treatment of Uncomplicated Appendicitis in Older Adults\: Current Evidence and Limitations

Background In acute appendicitis, while operative management (OM) remains standard, non-operative management (NOM) with antibiotics is an alternative, especially in the elderly population. However, elderly NOM evidence is limited. Aim This scoping review explored the efficacy and safety of NOM compared with OM for acute, uncomplicated appendicitis in elderly patients (≥65 years), identified gaps in the literature, and proposed evidence-based recommendations to guide future research. Methods Following PRISMA Scoping review guidelines, we applied the Population, Concept, and Context (PCC) framework for criteria definition. PubMed and Embase were searched, and Covidence facilitated study selection. The primary outcome was 30-day post-treatment complication, and the secondary outcomes were treatment success (90 days and 1 year), readmission (at 30- and 90-day), and hospital stay (median duration). Risk of bias was assessed using the Newcastle–Ottawa Scale. Results Of 770 records identified, four retrospective cohort studies conducted in the United States met inclusion criteria, with sample sizes ranging from 2,640 to 474,845 elderly patients (≥65 years) with uncomplicated appendicitis. Methodological quality was moderate to high (Newcastle–Ottawa Scale scores 6–8.5). Frailty was variably assessed across studies, and only two stratified outcomes by frailty status. In the largest included study (Ashbrook et al., 2024), overall complication rates were similar between non-operative management (NOM) and operative management (OM) (37.7% vs 36.4%); however, complication rates increased markedly with frailty (28.8% in non-frail vs 57.1% in frail patients). In frailty-stratified analyses, operatively managed patients experienced higher complication rates than those managed non-operatively within both frail (66.3% vs 33.7%) and non-frail (69.8% vs 30.2%) groups. NOM success rates ranged from 62% to 82% but were generally associated with longer hospital length of stay, particularly when NOM failed or surgery was delayed. Estimated readmission following NOM was approximately 20%, primarily due to symptom recurrence or treatment failure. Reporting of antibiotic regimens and follow-up periods was inconsistent across studies. Conclusions Current evidence comparing non-operative and operative management of uncomplicated appendicitis in elderly patients is limited to observational data and demonstrates heterogeneous outcomes. While overall complication rates may appear similar at the population level, frailty substantially modifies treatment-related risk, with higher complication rates observed among operatively managed patients within frailty strata. Non-operative management can achieve acceptable short-term success in selected patients but is associated with longer hospital stays and increased readmission rates. These findings underscore the importance of incorporating standardized frailty assessments into clinical decision-making and highlight the need for prospective studies and randomized trials specifically designed for frail older adults.