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Study flow diagram.
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Figure 1

Study flow diagram.

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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 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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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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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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Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 1 Overall morbidity.
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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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Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 2 Wound infection.
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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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Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 3 Faecal fistula.
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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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Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 4 Total length of hospital stay (days).
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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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Comparison 1 Early appendicectomy versus delayed appendicectomy for appendiceal phlegmon, Outcome 5 Time away from normal activities (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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Comparison 2 Early appendicectomy versus delayed appendicectomy for appendiceal abscess, Outcome 1 Total length of hospital stay (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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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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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 lowa,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 lowa,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 lowa,b

—

Mortality

Median follow‐up: 33,5 months

See comment

See comment

Not estimable

40
(1 study)

⊕⊕⊝⊝
Lowb

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 lowa,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 lowa,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).

Figuras y tablas -
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 lowa

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 lowa,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 lowa,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.

Figuras y tablas -
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
Figuras y tablas -
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
Figuras y tablas -
Comparison 2. Early appendicectomy versus delayed appendicectomy for appendiceal abscess
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