Early versus delayed appendicectomy for appendiceal phlegmon or abscess

Yao Cheng; Xianze Xiong; Jiong Lu; Sijia Wu; Rongxing Zhou; Nansheng Cheng

doi:10.1002/14651858.CD011670.pub2

Ранняя аппендэктомия в сравнении с отсроченной при аппендикулярной флегмоне или абсцессе

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Referencias

References to studies included in this review

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estudios excluidos
otras referencias

Kumar S, Jain S. Treatment of appendiceal mass: prospective, randomized clinical trial. Indian Journal of Gastroenterology 2004;23(5):165‐7.

Schurman JV, Cushing CC, Garey CL, Laituri CA, St Peter SD. Quality of life assessment between laparoscopic appendectomy at presentation and interval appendectomy for perforated appendicitis with abscess: analysis of a prospective randomized trial. Journal of Pediatric Surgery 2011;46(6):1121‐5.

St Peter SD, Aguayo P, Fraser JD, Keckler SJ, Sharp SW, Leys CM, et al. Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial. Journal of Pediatric Surgery 2010;45(1):236‐40.

References to studies excluded from this review

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estudios incluidos
otras referencias

Aranda‐Narváez JM, González‐Sánchez AJ, Marín‐Camero N, Montiel‐Casado C, López‐Ruiz P, Sánchez‐Pérez B. Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon. Revista Española de Enfermedades Digestivas 2010;102(11):648‐52.

Bahram MA. Evaluation of early surgical management of complicated appendicitis by appendicular mass. International Journal of Surgery 2011;9(1):101‐3.

Blakely ML, Williams R, Dassinger MS, Eubanks JW, Fischer P, Huang EY, et al. Early vs interval appendectomy for children with perforated appendicitis. Archives of Surgery 2011;146(6):660‐5.

Myers AL, Williams RF, Giles K, Waters TM, Eubanks JW, Hixson SD, et al. Hospital cost analysis of a prospective, randomized trial of early vs interval appendectomy for perforated appendicitis in children. Journal of the American College of Surgeons 2012;214(4):427‐34.

Erdoğan D, Karaman I, Narci A, Karaman A, Cavuşoğlu YH, Aslan MK, et al. Comparison of two methods for the management of appendicular mass in children. Pediatric Surgery International 2005;21(2):81‐3.

Goh BK, Chui CH, Yap TL, Low Y, Lama TK, Alkouder G, et al. Is early laparoscopic appendectomy feasible in children with acute appendicitis presenting with an appendiceal mass? A prospective study. Journal of Pediatric Surgery 2005;40(7):1134‐7.

Handa N, Muramori K, Taguchi S. Early appendectomy versus an interval appendectomy for appendiceal abscess in children. Fukuoka Igaku Zasshi 1997;88(12):389‐94.

Senapathi PS, Bhattacharya D, Ammori BJ. Early laparoscopic appendectomy for appendicular mass. Surgical Endoscopy 2002;16(12):1783‐5.

Weber TR, Keller MA, Bower RJ, Spinner G, Vierling K. Is delayed operative treatment worth the trouble with perforated appendicitis is children?. The American Journal of Surgery 2003;186(6):685‐8.

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Ahmed I, Deakin D, Parsons SL. Appendix mass: do we know how to treat it?. Annals of the Royal College of Surgeons of England 2005;87(3):191‐5.

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Boomer L, Freeman J, Landrito E, Feliz A. Perforation in adults with acute appendicitis linked to insurance status, not ethnicity. Journal of Surgical Research 2010;163(2):221‐4.

Buckius MT, McGrath B, Monk J, Grim R, Bell T, Ahuja V. Changing epidemiology of acute appendicitis in the United States: study period 1993–2008. Journal of Surgical Research 2012;175(2):185‐90.

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Cueto J, D'Allemagne B, Vázquez‐Frias JA, Gomez S, Delgado F, Trullenque L, et al. Morbidity of laparoscopic surgery for complicated appendicitis: an international study. Surgical Endoscopy 2006;20(5):717‐20.

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Frazee RC, Bohannon WT. Laparoscopic appendectomy for complicated appendicitis. Archives of Surgery 1996;31(5):509‐11.

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Vons C, Barry C, Maitre S, Pautrat K, Leconte M, Costaglioli B, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open‐label, non‐inferiority, randomised controlled trial. Lancet 2011;377(9777):1573‐9.

Willemsen PJ, Hoorntje LE, Eddes EH, Ploeg RJ. The need for interval appendectomy after resolution of an appendiceal mass questioned. Digestive Surgery 2002;19(3):216‐20.

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Yau KK, Siu WT, Tang CN, Yang GP, Li MK. Laparoscopic versus open appendectomy for complicated appendicitis. Journal of the American College of Surgeons 2007;205(1):60‐5.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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estudios excluidos

Kumar 2004

Methods	Randomised controlled trial
Participants	Country: India Study dates: from 1998 to 2001 Number randomised: 60 Postrandomisation dropout: 0 (0%) Children: not mentioned Adults: not mentioned Females: 3 (5%) Appendiceal phlegmon: 60 (100%) Appendiceal abscess: 0 (0%) Inclusion criteria: Participants with appendiceal mass determined on medical history, physical examination, and imaging results (e.g. ultrasonography, plain abdominal X‐ray) Exclusion criteria: Free air in the peritoneal cavity (on plain films) Pus collection in the right iliac fossa or pelvis Colonic malignancy or ileocaecal tuberculosis
Interventions	Participants with appendiceal mass (N = 60) were randomly assigned to 3 groups Group 1: early open appendicectomy (n = 20) Further details: open appendicectomy as soon as appendiceal mass resolved within the same admission Group 2: delayed open appendicectomy (n = 20) Further details: initial conservative treatment followed by interval open appendicectomy 6 weeks later Group 3: conservative treatment without appendicectomy (n = 20).Group excluded from review
Outcomes	Short‐term outcome measures (< 3 weeks): Operative time, operative difficulty, postoperative complications, length of hospital stay, and duration of time away from work. Long‐term outcome measures (median 33,5 weeks): number of hospital visits made, presence of severe incisional pain, scar appearance, and patients with recurrent appendicitis.
Notes	Funding source: no information provided Declarations of interest: no information provided
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Comment: no information provided
Allocation concealment (selection bias)	Unclear risk	Comment: no information provided
Blinding of participants and personnel (performance bias) All outcomes	High risk	Comment: it is not possible to blind the participants and healthcare providers unless sham surgery was provided, which may be unethical
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Comment: no information provided
Incomplete outcome data (attrition bias) All outcomes	Low risk	Comment: there were no postrandomisation dropouts
Selective reporting (reporting bias)	High risk	Comment: the trial protocol was not available. Some outcomes of interest in the review were not reported so that the trial was considered to be high risk of bias for selective reporting.
Differences in baseline characteristics	Low risk	Comment: there was no baseline imbalance in important characteristics.

St Peter 2010

Methods	Randomised controlled trial
Participants	Country: USA Study dates: from 2006 to 2009 Number randomised: 40 Postrandomisation dropout: 0 (0%) Children: 40 (100%) Adults: 0 (0%) Girls: 19 (47.5%) Appendiceal phlegmon: 0 (0%) Appendiceal abscess: 40 (100%) Inclusion criteria: 7‐18 years old Well‐defined abdominal abscess determined on computer tomography imaging Exclusion criteria: People with a postoperative abscess People with a comorbid condition
Interventions	Participants with appendiceal abscess (N = 40) were randomly assigned to 2 groups Group 1: early laparoscopic appendicectomy (n = 20) Further details: emergent (immediate) laparoscopic appendicectomy Group 2: delayed laparoscopic appendicectomy (n = 20) Further details: initial conservative treatment and percutaneous drainage of the abscess (when possible), followed by interval laparoscopic appendicectomy approximately 10 weeks later
Outcomes	Mortality, total hospital stay, total hospital costs, and quality of life (Pediatric Quality of Life Scale‐Version 4.0)
Notes	Funding source: no information provided Declarations of interest: no information provided
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Comment: no information provided
Allocation concealment (selection bias)	Unclear risk	Quote: "[t]he randomisation sequence was accessed to identify the next allotment" Comment: no information provided about the method of allocation concealment
Blinding of participants and personnel (performance bias) All outcomes	High risk	Comment: it is not possible to blind the participants and healthcare providers unless sham surgery was provided, which may be unethical
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Comment: no information provided
Incomplete outcome data (attrition bias) All outcomes	Low risk	Comment: there were no postrandomisation dropouts
Selective reporting (reporting bias)	Low risk	Comment: the study protocol is available. All of the study's pre‐specified outcomes were reported
Differences in baseline characteristics	Low risk	Comment: no baseline imbalance in important characteristics

Characteristics of excluded studies [ordered by study ID]

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estudios incluidos

Study	Reason for exclusion
Aranda‐Narváez 2010	A non‐randomised study
Bahram 2011	A non‐randomised study
Blakely 2011	Randomised controlled trial about perforated appendicitis without appendiceal abscess
Erdoğan 2005	A non‐randomised study
Goh 2005	A non‐randomised study
Handa 1997	A non‐randomised study
Senapathi 2002	A non‐randomised study
Weber 2003	A non‐randomised study

Data and analyses

Open in table viewer

Comparison 1. Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Overall morbidity Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.1 Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 1 Overall morbidity.
2 Wound infection Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.2 Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 2 Wound infection.
3 Faecal fistula Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.3 Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 3 Faecal fistula.
4 Total length of hospital stay (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.4 Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 4 Total length of hospital stay (days).
5 Time away from normal activities (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.5 Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 5 Time away from normal activities (days).

Open in table viewer

Comparison 2. Early appendicectomy versus delayed appendicectomy for appendiceal abscess

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Total length of hospital stay (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 2.1 Comparison 2 Early appendicectomy versus delayed appendicectomy for appendiceal abscess, Outcome 1 Total length of hospital stay (days).
2 Quality of life (score on a scale from 0‐100) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 2.2 Comparison 2 Early appendicectomy versus delayed appendicectomy for appendiceal abscess, Outcome 2 Quality of life (score on a scale from 0‐100).

Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 1 Overall morbidity.

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Analysis 1.2

Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 2 Wound infection.

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Analysis 1.3

Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 3 Faecal fistula.

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Analysis 1.4

Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 4 Total length of hospital stay (days).

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Analysis 1.5

Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 5 Time away from normal activities (days).

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Analysis 2.1

Comparison 2 Early appendicectomy versus delayed appendicectomy for appendiceal abscess, Outcome 1 Total length of hospital stay (days).

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Analysis 2.2

Comparison 2 Early appendicectomy versus delayed appendicectomy for appendiceal abscess, Outcome 2 Quality of life (score on a scale from 0‐100).

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Summary of findings for the main comparison. Early versus delayed open appendicectomy for appendiceal phlegmon

Early versus delayed open appendicectomy for appendiceal phlegmon
Patient or population: paediatric and adult patients with appendiceal phlegmon Setting: secondary and tertiary care Intervention: early open appendicectomy Comparison: delayed open appendicectomy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Delayed appendicectomy	Early appendicectomy
Overall morbidity Median follow‐up: 33,5 months	0 per 1000	300 per 1000	RR 13.00 (0.78 to 216.39)	40 (1 study)	⊕⊝⊝⊝ Very low^a,b	—
Wound infection Median follow‐up: 33,5 months	0 per 1000	200 per 1000	RR 9.00 (0.52 to 156.91)	40 (1 study)	⊕⊝⊝⊝ Very low^a,b	—
Faecal fistula Median follow‐up: 33,5 months	0 per 1000	50 per 1000	RR 3.00 (0.13 to 69.52)	40 (1 study)	⊕⊝⊝⊝ Very low^a,b	—
Mortality Median follow‐up: 33,5 months	See comment	See comment	Not estimable	40 (1 study)	⊕⊕⊝⊝ Low^b	There was no mortality in either group.
Total length of hospital stay (days) Follow‐up: 3 weeks	The mean total length of hospital stay in the delayed appendicectomy group was 14.7 days	The mean total length of hospital stay in the early appendicectomy group was 6.7 days higher (2.76 to 10.64 higher)	MD 6.70 (2.76 to 10.64)	40 (1 study)	⊕⊝⊝⊝ Very low^a,b	—
Time away from normal activities (days) Median follow‐up: 33,5 months	The mean time away from normal activities in the delayed appendicectomy group was 20 days	The mean time away from normal activities in the early appendicectomy group was 5 days higher (1.52 to 8.48 higher)	MD 5.00 (1.52 to 8.48)	40 (1 study)	⊕⊝⊝⊝ Very low^a,b	—
Quality of life Median follow‐up: 33,5 months	Not reported
Pain (days) Follow‐up: 3 weeks	Not reported
The basis for the assumed risk* was the control group proportion in the study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; MD: mean difference.
GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^aDowngraded one level for serious risk of bias. ^bDowngraded two levels for very serious imprecision (small sample size).

Summary of findings for the main comparison. Early versus delayed open appendicectomy for appendiceal phlegmon

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Summary of findings 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess

Early versus delayed laparoscopic appendicectomy for appendiceal abscess
Patient or population: paediatric participants with appendiceal abscess Setting: secondary and tertiary care Intervention: early laparoscopic appendicectomy Comparison: delayed laparoscopic appendicectomy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Delayed appendicectomy	Early appendicectomy
Overall morbidity	Not reported
Wound infection	Not reported
Faecal fistula	Not reported
Mortality Follow‐up: 12 weeks	See comment	See comment	Not estimable	40 (1 study)	⊕⊝⊝⊝ Very low^a	There was no mortality in either group.
Total length of hospital stay (days) Follow‐up: 12 weeks	The mean total length of hospital stay in the delayed appendicectomy group was 6.7 days	The mean total length of hospital stay in the early appendicectomy group was 0.2 days lower (3.54 lower to 3.14 higher)	MD −0.20 (−3.54 to 3.14)	40 (1 study)	⊕⊝⊝⊝ Very low^a,b	—
Time away from normal activities (days)	Not reported
Quality of life (Pediatric Quality of Life Scale‐Version 4.0, a scale of 0 to 100 with higher values indicating better quality of life) Follow‐up: 12 weeks	The mean quality of life score in the delayed appendicectomy group was 84.37 points	The mean quality of life score in the early appendicectomy group was 12.40 points higher (9.78 to 15.02 higher)	MD 12.40 (9.78 to 15.02)	40 (1 study)	⊕⊝⊝⊝ Very low^a,b	We considered the observed mean difference in quality of life score to be clinically significant.
Pain (days)	Not reported
The basis for the assumed risk* was the control group proportion in the study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference.
GRADE Working Group grades of evidence High quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: we are very uncertain about the estimate.
^aDowngraded two levels due to very serious imprecision (small sample size). ^bDowngraded one level for serious risk of bias.

Summary of findings 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess

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Comparison 1. Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Overall morbidity Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2 Wound infection Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3 Faecal fistula Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4 Total length of hospital stay (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

5 Time away from normal activities (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

Comparison 1. Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon

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Comparison 2. Early appendicectomy versus delayed appendicectomy for appendiceal abscess

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Total length of hospital stay (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2 Quality of life (score on a scale from 0‐100) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

Comparison 2. Early appendicectomy versus delayed appendicectomy for appendiceal abscess

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Referencias

References to studies included in this review

Kumar 2004 {published data only}

St Peter 2010 {published data only}

References to studies excluded from this review

Aranda‐Narváez 2010 {published data only}

Bahram 2011 {published data only}

Blakely 2011 {published data only}

Erdoğan 2005 {published data only}

Goh 2005 {published data only}

Handa 1997 {published data only}

Senapathi 2002 {published data only}

Weber 2003 {published data only}

Additional references

Addiss 1990

Ahmed 2005

Andersen 2005

Anderson 2012

Andersson 1994

Andersson 2007

Andreu‐Ballester 2009

Boomer 2010

Buckius 2012

Cheng 2012

Cheng 2013

Cheng 2015a

Cheng 2015b

Cirocchi 2008

Clavien 2009

Cueto 2006

Deeks 2011

Deelder 2014

Egger 1997

Endnote X7 [Computer program]

Frazee 1996

Gillick 2001

Hall 2010

Higgins 2011

Kang 2000

Körner 1997

Lee 2010

Livingston 2007

Markides 2010

Nitecki 1993

Oliak 2000

Pieper 1982

Rehman 2011

RevMan 2014 [Computer program]

Salminen 2015

Santacroce 2012

Sauerland 2010

Schünemann 2009

Shipsey 1985

Simillis 2010

Sterne 2011

Vons 2011

Willemsen 2002

Williams 1998

Wilms 2011

Yau 2007

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Data and analyses

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