Elsevier

Journal of Pediatric Surgery

Volume 54, Issue 11, November 2019, Pages 2234-2241
Journal of Pediatric Surgery

Review Article
Early appendectomy vs. conservative management in complicated acute appendicitis in children: A meta-analysis,☆☆

https://doi.org/10.1016/j.jpedsurg.2019.01.065Get rights and content

Abstract

Background

No consensus exists among surgeons regarding the optimal treatment of complicated acute appendicitis in children (CAA). Existing studies present heterogeneity of data and only few studies analyzed free perforated appendicitis (FPA) separately from appendicular abscess (AAb) and appendicular phlegmon (AP).

Method

Studies which have been judged eligible for this systematic review and consequent meta-analysis are those comparing non-operative management (NOM) with operative management (OM) in children with CAA. Studies were subgrouped between those analyzing mixed patients with CAA, those focusing on patients with AAb/AP and those focusing on patients with FPA.

Results

Fourteen studies fulfilled the inclusion criteria and were included in the meta-analysis with a total of 1288 patients. In the fixed-effects model the complication rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.07, 95%CI = 0.02–0.27) and to the OM arm for the FPA subgroup (RR = 1.86, 95%CI = 1.20–2.87); the re-admission rate was significantly favorable to the initial NOM arm for the AAb/AP subgroup (RR = 0.35, 95%CI = 0.13–0.93) and to the OM arm for the FPA subgroup (RR = 1.49, 95%CI = 1.49–7.44). There was no statistical heterogeneity for the two subgroups of patients. The costs weren't significantly different between NOM and OM. The length of stay was favorable to OM. The pooled proportion rate of NOM success was 90%, the pooled relapse rate of appendicitis was 15.4%.

Conclusions

Children with AAb/AP reported better results in terms of complication rate and re-admission rate if treated with NOM. Conversely children with FPA showed lower complication rate and re-admission rate if treated with OM.

Level of evidence

II

Section snippets

Background

No consensus exists among surgeons regarding the optimal treatment of acute appendicitis (AA) in children. Even if appendectomy is the most frequently performed general surgical emergency procedure in children, a large observational study performed in United Kingdom including 703 children showed a 30-day adverse event rate of 11% and a negative appendectomy rate of 19.2% [1]. These considerations led some surgeons to suggest the possibility to try to apply the non-operative management (NOM) in

Literature search strategy

Electronic searches were performed using Medline, Embase, PubMed, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews until 7 November 2018. The search terms were: ‘pediatric’, ‘complicated appendicitis’, ‘children’, ‘abscess’, ‘perforated appendicitis’, ‘ruptured appendicitis’, ‘phlegmon’, ‘appendicular mass’ combined with AND/OR. The reference lists of all retrieved articles were reviewed for further identification of potentially relevant studies. Review

Results

Fourteen studies fulfilled the inclusion criteria and were included in the meta-analysis: 2 RCT and 12 observational studies (publication dates 1998–2017) (Fig. 1). There were a total of 1288 patients (666 in the OM group and 622 in the initial NOM) (Table 1). Six studies [8], [11], [5], [18], [16], [17] analyzed patients with CAA mixing patients with AAb/PA and with FPA, one study focused on patients with FPA [10] and 6 studies focused on patients with AAb/AP [7], [21], [13], [15], [19], [22].

Discussion

In the management of CAA the surgeon could choose between different options: immediate appendectomy (OM) or NOM with or without PD of an AAb. Furthermore, after successful NOM, once the child is returned to normal activity, many surgeons suggest DA. Several observational studies [8], [11], [5], [24], [21], [7], [12], [18], [20], [9], [15], [14], [19], [22], [6], [16], [17], two RCTs [10], [13] and some meta-analysis [24], [23], [28], [29] compared NOM vs OM in children, but no definitive data

Conclusions

Children with AAb/AP reported better results in terms of complication rate and re-admission rate if treated with NOM. Pooled NOM success rate is 90% and pooled relapse rate of appendicitis after NOM is 15.4%. Conversely children with FPA showed lower complication rate and re-admission rate if treated with OM. No heterogeneity among studies were present in the subset analysis. The costs weren't significantly different between NOM and OM. The IA-LOS was favorable to OM.

The following are the

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      A meta-analysis by Similis et al. revealed that conservative treatment of acute appendicitis with abscess was associated with significantly fewer overall complications compared to immediate appendectomy [2]. However, another meta-analysis by Furgazzola et al. found that, among children with acute appendicitis with abscess, conservative treatment was associated with lower complication and readmission rates compared with immediate appendectomy [3]. However, the treatment options for appendicitis with abscess in adults remain controversial.

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      However, it is unclear whether this strategy is appropriate in all cases, especially if the diagnosis of appendicitis is considered preoperatively. A recent meta-analysis by Fugazzola and colleagues39 found that children with appendicitis who presented with localized appendicular abscess or phlegmon had lower rates of complications and readmission when treated initially with nonoperative management (with or without percutaneous drainage and/or delayed appendectomy) compared with initial operative management. In contrast, the patients who presented with freely perforated appendicitis had higher complication and readmission rates associated with initial nonoperative management.

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    Conflict of interest: The authors declare to have no conflict of interest.

    ☆☆

    Financial disclosure: The present paper has no external source of funding.

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