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

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