Appendicolith in non-operative management of acute appendicitis: Implications for recurrence and future directions

Table 1 Limitations of the Kupietzky et al’s study[1]

Limitation type	Specific issue	Potential impact
Design limitations	Retrospective design prone to selection/information bias; Excluded patients with complicated appendicitis	Recurrence rates in NOM group may be skewed; Findings may not generalize to mixed populations
Sample size/Power	Only 68 patients with appendicoliths (8.5% of cohort); Follow-up duration varied (median 44.2 months)	Underpowered to detect subgroup differences; Long-term recurrence risks underestimated
Clinical Heterogeneity	Multiple surgeons involved in NOM decisions; Non-standardized imaging follow-up protocols	Variability in intervention consistency; Reduced reliability of results
External validity	Single-center study (Hadassah Medical Center, Israel)	Findings may not apply to other healthcare settings or cultural contexts

NOM: Nonoperative management.

Table 2 Comparative analysis of the impact of appendicoliths on nonoperative management of uncomplicated acute appendicitis

Dimension	Conclusion of Kupietzky et al’s study[1] conclusion (797 patients)	Conclusion of other studies (systematic reviews/meta-analyses)	Difference in perspective
Overall recurrence rate	No significant difference (26.5% vs 19.1%, P = 0.14)	Significantly increased (OR = 2.75; 95%CI: 1.05-7.20)	Study populations differ (current study restricted to uncomplicated cases; other studies include complicated cases)
Treatment failure rate	No statistical difference (26.5% vs 19.1%, P = 0.14; short-term follow-up within 30 days)	Significant failure (OR = 0.42; 95%CI: 0.21-0.84; long-term follow-up including 30 days to 2 years)	Definition of failure varies (short-term vs extended follow-up)
Impact of appendicolith characteristics	No correlation with recurrence (sample size n = 68; insufficient power for subgroup analysis)	Stone size, location (e.g., proximal), and number may increase risk (mechanistic studies suggest mechanical obstruction)	Limited by sample size and study design
Pediatric patients	Not specifically analyzed (mean age 254 years)	Stronger negative impact in children	Age stratification missing
Clinical recommendations	Prioritize surgery (e.g., laparoscopic appendectomy); if NOM is chosen, close surveillance is warranted	Recommend surgery for appendicoliths; inform patients of recurrence risks (approximately 23%-30%) and consider interval appendectomy	Variability in evidence strength

NOM: Nonoperative management.