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The aim was to investigate available evidence regarding effectiveness and safety of surgical versus conservative treatment of acute appendicitis.There is ongoing debate on the merits of surgical and conservative treatment for acute appendicitis.A systematic literature search (Cochrane Library, Medline, Embase) and hand search of retrieved reference lists up to January 2016 was conducted to identify randomized and nonrandomized studies. After critical appraisal, data were analyzed using a random-effects model in a Mantel-Haenszel test or inverse variance to calculate risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs).Four trials and four cohort studies (2551 patients) were included. We found that 26.5% of patients in the conservative group needed appendectomy within 1 year, resulting in treatment effectiveness of 72.6%, significantly lower than the 99.4% in the surgical group, (RR 0.75; 95% CI 0.7–0.79; P = 0.00001; I2 = 62%). Overall postoperative complications were comparable (RR 0.95; 95% CI 0.35–2.58; P = 0.91; I2 = 0%), whereas the rate of adverse events (RR 3.18; 95% CI 1.63–6.21; P = 0.0007; I2 = 1%) and the incidence of complicated appendicitis (RR 2.52; 95% CI 1.17–5.43; P = 0.02; I2 = 0%) were significantly higher in the antibiotic treatment group. Randomized trials showed significantly longer hospital stay in the antibiotic treatment group (RR 0.3 days; 95% CI 0.07–0.53; P = 0.009; I2 = 49%).Although antibiotics may prevent some patients from appendectomies, surgery represents the definitive, one-time only treatment with a well-known risk profile, whereas the long-term impact of antibiotic treatment on patient quality of life and health care costs is unknown. This systematic review and meta-analysis helps physicians and patients in choosing between treatment options depending on whether they are risk averse or risk takers.