In Reply We thank Minneci and Deans for their comment on our Editorial. We agree that the two 2017 meta-analyses of nonoperative treatment of pediatric appendicitis indeed have demonstrated the feasibility and initial success of this approach. While Huang et al¹ did not report a pooled estimate for risk of treatment failure at 1 year, Georgiou et al² found an overall nonoperative treatment efficacy of 82% at final reported follow-up, with both studies yielding similar histopathological appendicitis recurrence rates of 14% to 16%.^1,2 In comparison, two 2017 meta-analyses of adult data, demonstrated an overall treatment effectiveness at 1 year of 64%³ and 73%,⁴ with Harnoss et al⁴ reporting a complication-free treatment success for nonoperative treatment at 1 year of 68% vs 90% for the operative treatment.⁴ The conclusions drawn from the pediatric meta-analyses published to date generate consensus that nonoperative treatment is “feasible and effective,” albeit a higher risk for treatment failure compared with appendectomy, especially in the setting of acute appendicitis with appendicolith,¹ and that further evaluation by means of large randomized trials is needed with regard to longer-term clinical outcomes and cost-effectiveness.² In fact, Georgiou et al² recommend that nonoperative treatment of children with acute uncomplicated appendicitis “be reserved for those participating in carefully designed research studies.” We regret that Minneci and Deans have focused their contention on only 1 aspect of our conclusion in which we state that “nonoperative treatment remains an experimental proposition meriting ongoing consideration as a treatment strategy” for this condition and that “this therapeutic option should only be offered to pediatric patients under protocol in the setting of a clinical trial.”⁵ We stand by our recommendation that future studies should have attention “to longer follow-up and patient-centered outcomes, cost utility, and shared decision making.”⁵ This last area is essential as we attempt to understand how to align patients’ wishes, values, and their particular circumstances with their treatment plan. We commend Minneci and Deans on their ongoing work with preference-based trials and look forward to their long-term results. Their findings will provide critical information as we build a repository of evidence addressing all the previously mentioned categories so that we can provide patients’ families complete information to aid in their decision making. In spite of ongoing debates as to what the best study design is to establish superiority and to balance internal vs external validity, the current available evidence does not support routine nonoperative treatment of uncomplicated acute appendicitis in general practice.

在回复中，我们感谢Minneci和Deans对我们社论的评论。我们同意，2017年对小儿阑尾炎进行非手术治疗的两项荟萃分析确实证明了这种方法的可行性和初步成功。虽然Huang等[ ^1]并未报告对1年治疗失败风险的汇总估计，但Georgiou等[ ^2]发现在最终报告的随访中总体非手术治疗疗效为82％，两项研究均得出类似的组织病理学阑尾炎复发率。 14％至16％。^{1 ，2}相比较而言，成人两个数据2017荟萃分析，证实在1年64％的总体治疗效果³和73％，⁴与Harnoss等人⁴报道非手术治疗1年无并发症的成功率为68％，而手术治疗为90％。⁴迄今为止发表的儿科荟萃分析得出的结论一致认为，非手术治疗“可行且有效”，尽管与阑尾切除术相比，治疗失败的风险更高，尤其是在急性阑尾炎伴阑尾结石的情况下¹，并且进一步就长期临床结果和成本效益而言，需要通过大型随机试验进行评估。²实际上，Georgiou等人²建议将“急性非并发症性阑尾炎患儿的非手术治疗”保留给精心设计的研究参与者。” 我们感到遗憾的是，Minneci和Deans仅将他们的论点集中在我们结论的一个方面，在该结论中，我们指出“非手术治疗仍然是一项实验性主张，值得继续考虑将其作为治疗策略”，并且指出“仅应提供这种治疗选择根据临床试验中的协议向儿科患者开放。” ⁵我们支持我们的建议，即未来的研究应注意“长期随访和以患者为中心的结果，成本效用和共同的决策制定”。⁵当我们试图了解如何使患者的意愿，价值观和他们的特殊情况与他们的治疗计划保持一致时，这最后一个领域至关重要。我们赞扬Minneci和Deans开展的基于偏好的试验，并期待他们的长期结果。当我们建立一个证据库来解决前面提到的所有类别时，他们的发现将提供关键信息，以便我们可以为患者家属提供完整的信息，以帮助他们做出决策。尽管关于最佳研究设计是建立优势并平衡内部有效性与外部有效性之间的争论一直在进行，但目前可获得的证据并不支持一般实践中对非并发症性急性阑尾炎进行常规的非手术治疗。