Management of appendiceal mass and abscess in children; early appendectomy or initial non-operative treatment? A systematic review and meta-analysis

Paul van Amstel,Johanna H. van der Lee,Ralph de Vries,Tania C. Sluckin,L. W. Ernest van Heurn,Ramon R. Gorter,Tim van Amstel,Joep P. M. Derikx,Roel Bakx

doi:10.1007/s00464-020-07822-y

Abstract

BackgroundAppendiceal mass and abscess and its treatment are associated with significant morbidity and high costs. Still, the optimal treatment strategy is the point of debate. Therefore, this systematic review and meta-analysis aimed to compare overall complications between initial non-operative treatment (NOT) and early appendectomy (EA) in children with appendiceal mass and/or abscess.MethodsPubmed and Embase were searched. Only randomized controlled trials and prospective or historical cohort studies that compared NOT with EA in children with appendiceal mass or abscess in terms of complications were eligible for inclusion. Risk of bias was assessed. Primary outcome was the overall complication rate. Secondary, length of stay and readmission rate were investigated. A meta-analysis of overall complications associated with both treatment strategies was performed.Results14 of 7083 screened studies were selected, including 1022 children in the NOT group and 333 in the EA group. Duration of follow-up ranged between four weeks and 12 years. Risk of bias was moderate in four and serious in 10 studies. NOT was associated with a lower overall complication rate (risk ratio (RR) 0.37 [95% confidence interval (CI) 0.21–0.65]). However, NOT led to increased length of stay (mean difference varied between 0.2 and 8.4 days) and higher readmission rate (RR 1.75 [95%CI 0.79–3.89]), although not significantly. Interval appendectomy after NOT was performed as a routine procedure in all but one study. This study found a recurrence rate of 34% in a group of 38 patients during a follow-up period of 3.4 ± 1.7 years.ConclusionNOT may reduce the overall complication rate compared to EA, but the evidence is very uncertain. As evidence is scarce, and of low level, and heterogeneity between studies is substantial, the results should be interpreted with caution. Large prospective studies are needed to determine the optimal treatment strategy for children with appendiceal mass and/or abscess.

Highlights

Appendiceal mass and abscess and its treatment are associated with significant morbidity and high costs
7083 articles were screened for title and abstract and 220 studies were assessed for full text. 206 articles were excluded because of various reasons
Follow-up ended for most studies after interval appendectomy with a range of four [22]—23 weeks [21] after initial non-operative treatment (NOT) [6,12–19.] Two studies reported long-term follow-up of 3–12 years [5, 23]

Summary

Introduction

Appendiceal mass and abscess and its treatment are associated with significant morbidity and high costs. This systematic review and meta-analysis aimed to compare overall complications between initial non-operative treatment (NOT) and early appendectomy (EA) in children with appendiceal mass and/or abscess. A meta-analysis of overall complications associated with both treatment strategies was performed. NOT was associated with a lower overall complication rate (risk ratio (RR) 0.37 [95% confidence interval (CI) 0.21–0.65]). Large prospective studies are needed to determine the optimal treatment strategy for children with appendiceal mass and/ or abscess. Complex appendicitis and its treatment are associated with significant morbidity (complications occurring in up to 30% of patients), prolonged length of hospital stay, and high costs [2]. Heterogeneity in the treatment of children with an appendiceal mass and/or abscess (e.g., initially non-operative treatment versus early appendectomy)

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Results

Conclusion