Nonoperative Treatment of Appendicitis To the Editor We appreciate the meta-analysis1 and Editorial2 evaluating nonoperative treatment of uncomplicated appendicitis in children in this issue of JAMA Pediatrics. However, we propose an alternative interpretation of the evidence and future direction of this work.1,2 The meta-analysis demonstrates consistent safety and efficacy of antibiotics alone to treat an initial episode of acute uncomplicated appendicitis across 5 pediatric studies.1 These results are similar to a recent meta-analysis performed across 10 pediatric studies and across the multiple randomized clinical trials, observational studies, and systematic reviews performed in adults.3,4 Therefore, we agree with the authors’ conclusions that antibiotics are feasible and effective for the initial treatment of acute uncomplicated appendicitis. In contrast, the related Editorial concludes that “nonoperative treatment remains an experimental proposition.”2 The editorialists call for higher-quality clinical trials with more robust study designs, such as randomized clinical trials, to ensure the internal validity of the results. However, the efficacy of nonoperative treatment of appendicitis has already been described in numerous randomized clinical trials and meta-analyses.1,3,4 While we agree with the need for additional studies of nonoperative treatment to assess long-term success and patient-reported outcomes, we believe these future studies should determine the effectiveness of nonoperative treatment in clinical practice. As acknowledged by the editorialists, antibiotics alone and surgery are 2 very different treatment strategies with discordant risks and benefits. These different risk/benefit profiles lead to preferences and biases in patients, families, and physicians for 1 treatment vs another. Therefore, the next logical step is to study the effectiveness of nonoperative treatment outside of the tightly controlled randomized clinical trial, where strict criteria and limited enrollment can affect external validity. Patient-choice trials are associated with higher enrollment rates of a broader patient population; therefore, they are an efficient way to assess the effectiveness of nonoperative treatment in a more diverse population. Because they facilitate informed treatment choice, similar to what occurs in clinical practice, they intrinsically support aligning patient preferences with their treatment and subsequently their outcomes. Available data already clearly support the efficacy and safety of antibiotics alone as an initial treatment for uncomplicated appendicitis in both children and adults. Therefore, additional rigorously controlled trials with high internal validity but potentially limited external validity are not warranted.5 Patients and families need trials that generate results reflective of outcomes in clinical practice. This is best accomplished by enrolling broad patient populations and incorporating the inherent biases that exist in clinical care.

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阑尾炎的非手术治疗

阑尾炎的非手术治疗 致编辑 我们感谢本期 JAMA Pediatrics 中评估儿童无并发症阑尾炎非手术治疗的荟萃分析 1 和社论 2。然而，我们对这项工作的证据和未来方向提出了另一种解释。 1,2 荟萃分析表明，在 5 项儿科研究中，单独使用抗生素治疗急性无并发症阑尾炎的初始发作具有一致的安全性和有效性。1 这些结果是类似于最近在 10 项儿科研究和多项随机临床试验、观察性研究和成人系统评价中进行的荟萃分析。 3,4 因此，我们同意作者的结论，即抗生素对儿童是可行和有效的。急性无并发症阑尾炎的初始治疗。相比之下，相关社论得出结论，“非手术治疗仍然是一个实验命题。”2 社论者呼吁进行具有更稳健研究设计的更高质量的临床试验，例如随机临床试验，以确保结果的内部有效性。然而，许多随机临床试验和荟萃分析已经描述了非手术治疗阑尾炎的疗效。 1,3,4 虽然我们同意需要对非手术治疗进行额外研究以评估长期成功和患者报告结果，我们相信这些未来的研究应该确定非手术治疗在临床实践中的有效性。正如社论所承认的，单独使用抗生素和手术是两种截然不同的治疗策略，风险和收益不一致。这些不同的风险/收益概况导致患者、家庭和医生对一种治疗与另一种治疗的偏好和偏见。因此，下一个合乎逻辑的步骤是在严格控制的随机临床试验之外研究非手术治疗的有效性，严格的标准和有限的招募会影响外部有效性。患者选择试验与更广泛的患者群体的更高入组率相关；因此，它们是在更多样化的人群中评估非手术治疗有效性的有效方法。因为它们促进了知情的治疗选择，类似于临床实践中发生的情况，它们本质上支持使患者的偏好与其治疗以及随后的结果保持一致。现有数据已经​​明确支持单独使用抗生素作为儿童和成人无并发症阑尾炎的初始治疗的有效性和安全性。因此，没有必要进行额外的、内部效度高但外部效度可能有限的严格对照试验。5 患者和家属需要产生能反映临床实践结果的试验。这最好通过招募广泛的患者群体并结合临床护理中存在的固有偏见来实现。5 患者和家属需要能够产生反映临床实践结果的试验。这最好通过招募广泛的患者群体并结合临床护理中存在的固有偏见来实现。5 患者和家属需要能够产生反映临床实践结果的试验。这最好通过招募广泛的患者群体并结合临床护理中存在的固有偏见来实现。