Non-operative management of acute appendicitis is not readily generalisable to Honduras: a viewpoint from a low-resource setting

Non-operative management (NOM) of acute appendicitis has been validated by trials such as Appendicitis Acuta and Comparison of Outcomes of Antibiotic Drugs and Appendectomy, with treatment failure rates of approximately 25-30% within one year, raising hopes that a less invasive approach could become the standard of care. However, the conditions underpinning these trials, such as early presentation, reliable imaging, uninterrupted access to antibiotics, structured follow-up, and immediate surgical backup, are not consistently available in Honduras. Up to 54% of patients at a Honduran tertiary centre present with gangrenous or perforated disease, considerably reducing the proportion of patients eligible for NOM, while sociocultural practices such as abdominal manipulation (sobada), weak referral networks, and limited diagnostic capacity further delay access to care. We argue that NOM cannot currently be recommended as a standard approach across the Honduran health system, although it may have a role in well-resourced tertiary centres. Importantly, this is not a rejection of NOM evidence: the primary drivers of poor outcomes in Honduras, late presentation and limited system capacity, are not addressed by NOM and could worsen if applied without adequate infrastructure. We propose that strengthening point-of-care diagnostics, referral pathways, antibiotic supply chains, and follow-up capacity should be the immediate priority, both to improve outcomes directly and to build the foundations for selective NOM implementation as the health system evolves.