Endoscopic Direct-vision Therapy vs. Antibiotics for Acute Uncomplicated Appendicitis: A Retrospective Cohort Study

BACKGROUND Endoscopic direct-vision appendicitis therapy (EDAT) is an emerging ultra-minimally invasive technique for acute uncomplicated appendicitis (AUA). Although laparoscopic appendectomy (LA) is definitive and antibiotic therapy is non-invasive, the comparative efficacy of EDAT versus antibiotics alone remains unclear. PURPOSE To compare the short-term outcomes and recurrence rates of EDAT versus antibiotic therapy in patients with AUA. METHODS This retrospective cohort study included 92 patients with AUA treated at a tertiary center: 41 who underwent EDAT between December 2023 and December 2024 and 51 who received antibiotic therapy between December 2023 and December 2024. Clinical outcomes, including symptom relief, hospital stay, inflammatory markers, treatment success, and recurrence, were compared. Subgroup analyses were performed based on the presence of fecaliths and baseline inflammation severity. RESULTS Baseline characteristics were comparable between groups (all P > 0.05), except for a significantly higher prevalence of fecaliths in the EDAT group (43.9% vs. 21.6%, P = 0.022). EDAT was associated with significantly faster abdominal pain relief [median 12.0 (IQR 12.0–24.0) h vs. 24.0 (12.0–36.0) h, P = 0.008], shorter hospital stay [3.0 (2.0–3.5) days vs. 4.0 (3.0–5.0) days, P < 0.001], and lower postoperative inflammatory markers (WBC: 6.83 ± 1.39 vs. 8.53 ± 1.87 ×10⁹/L, P < 0.001; CRP: 7.89 ± 2.98 vs. 21.16 ± 12.21 mg/L, P < 0.001). Initial treatment success was 100% in both groups (EDAT: 41/41, antibiotics: 51/51; P = 1.000). At a mean follow-up of 7.88 ± 3.52 months (EDAT) and 14.92 ± 2.61 months (antibiotics), recurrence rates were 7.3% (3/41) vs. 27.5% (14/51), respectively (P = 0.014). Subgroup analyses confirmed that EDAT's advantages were consistent across patients with and without fecaliths, as well as across different levels of baseline inflammation severity. CONCLUSION In selected patients with AUA, EDAT offers faster recovery, better inflammatory control, and significantly lower recurrence rates than antibiotic therapy. The presence of fecaliths and elevated baseline CRP predicts antibiotic failure, suggesting that EDAT may be particularly advantageous in these subgroups.