Elsevier

Surgery

Volume 147, Issue 6, June 2010, Pages 818-829
Surgery

Original Communication
A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon)

https://doi.org/10.1016/j.surg.2009.11.013Get rights and content

Background

No standardized approach is available for the management of complicated appendicitis defined as appendiceal abscess and phlegmon. This study used meta-analytic techniques to compare conservative treatment versus acute appendectomy.

Methods

Comparative studies were identified by a literature search. The end points evaluated were overall complications, need for reoperation, duration of hospital stay, and duration of intravenous antibiotics. Heterogeneity was assessed and a sensitivity analysis was performed to account for bias in patient selection.

Results

Seventeen studies (16 nonrandomized retrospective and 1 nonrandomized prospective) reported on 1,572 patients: 847 patients received conservative treatment and 725 had acute appendectomy. Conservative treatment was associated with significantly less overall complications, wound infections, abdominal/pelvic abscesses, ileus/bowel obstructions, and reoperations. No significant difference was found in the duration of first hospitalization, the overall duration of hospital stay, and the duration of intravenous antibiotics. Overall complications remained significantly less in the conservative treatment group during sensitivity analysis of studies including only pediatric patients, high-quality studies, more recent studies, and studies with a larger group of patients.

Conclusion

The conservative management of complicated appendicitis is associated with a decrease in complication and reoperation rate compared with acute appendectomy, and it has a similar duration of hospital stay. Because of significant heterogeneity between studies, additional studies should be undertaken to confirm these findings.

Section snippets

Study selection

A database search using Medline, EMBASE, Ovid, and Cochrane was performed on all studies to compare CT and AA for patients who presented with complicated appendicitis. The following MeSH search headings were used: “complicated appendicitis,” “perforated appendicitis,” “appendiceal abscess,” “appendiceal mass,” “conservative treatment,” “acute appendectomy,” “interval appendectomy,” “comparative study,” and “treatment outcome.” The above terms and their combinations were also searched as text

Eligible studies

Using the search key words listed above, 74 publications were identified. In all, 48 studies were excluded after reviewing the title and abstract. These results included 21 studies reporting on only 1 modality of treatment, 11 studies reporting on appendiceal mass/abscess formation, and 5 studies reporting on histologic or radiologic evaluation of appendiceal specimens. Furthermore, the excluded studies consisted of 5 case-based discussions on appendiceal masses/abscesses and 6 studies that did

Discussion

No standardized approach is available to the management of patients who present with appendicitis complicated by a local or contained perforation and with an appendiceal abscess or mass formation. Traditionally, appendectomy was considered the treatment of choice for complicated appendicitis, based on the surgical principle of removing the offending organ to resolve infection. However, the current meta-analysis showed that CT of complicated appendicitis results in a decreased overall

References (50)

  • T.R. Weber et al.

    Is delayed operative treatment worth the trouble with perforated appendicitis is children?

    Am J Surg

    (2003)
  • P.M. Rao et al.

    Appendiceal and peri-appendiceal air at CT: prevalence, appearance and clinical significance

    Clin Radiol

    (1997)
  • F.A. Moore et al.

    Evolving concepts in the pathogenesis of postinjury multiple organ failure

    Surg Clin North Am

    (1995)
  • K.A. Kogut et al.

    The association of elevated percent bands on admission with failure and complications of interval appendectomy

    J Pediatr Surg

    (2001)
  • M.V. Mazziotti et al.

    Histopathologic analysis of interval appendectomy specimens: support for the role of interval appendectomy

    J Pediatr Surg

    (1997)
  • M.R. Price et al.

    Recurrent appendicitis after initial conservative management of appendiceal abscess

    J Pediatr Surg

    (1996)
  • D. Oliak et al.

    Nonoperative management of perforated appendicitis without periappendiceal mass

    Am J Surg

    (2000)
  • D. Puapong et al.

    Routine interval appendectomy in children is not indicated

    J Pediatr Surg

    (2007)
  • D. Moher et al.

    Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement

    Onkologie

    (2000)
  • M. Egger et al.

    Bias in meta-analysis detected by a simple, graphical test

    BMJ

    (1997)
  • N. Mantel et al.

    Statistical aspects of the analysis of data from retrospective studies of disease

    J Natl Cancer Inst

    (1959)
  • M. Egger et al.

    Misleading meta-analysis

    BMJ

    (1995)
  • Wells GA SB, O'Connell D, Peterson J, Welch V, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of...
  • J. Bass et al.

    Interval appendectomy: an old new operation

    J Laparoendosc Adv Surg Tech A

    (2006)
  • C.V. Brown et al.

    Appendiceal abscess: immediate operation or percutaneous drainage?

    Am Surg

    (2003)
  • Cited by (267)

    • Appendicitis and non-specific abdominal pain in childhood

      2024, Paediatrics and Child Health (United Kingdom)
    • Nationwide management of perforated pediatric appendicitis: Interval versus same-admission appendectomy

      2023, Journal of Pediatric Surgery
      Citation Excerpt :

      Some argue for the use of initial early appendectomy with some studies citing benefits such as shorter duration of hospital stays, fewer radiographic studies performed per patient, and fewer post-admission complications and repeat hospitalizations compared to interval appendectomy [2,3]. However, other retrospective studies and meta-analyses have shown that interval appendectomy up to 6 to 9 weeks after the diagnosis of perforated appendicitis may be a superior strategy citing decreased rates of overall post-operative complications such as wound infections and intrabdominal abscesses compared to early appendectomy [4,5]. Some have also argued that interval management may be a more optimal utilization of hospital resources and result in less economic burden to the healthcare system [6,7].

    View all citing articles on Scopus
    View full text