Early versus delayed appendicectomy for appendiceal phlegmon or abscess

Shiyi Zhou; Yao Cheng; Nansheng Cheng; Jianping Gong; Bing Tu

doi:10.1002/14651858.CD011670.pub3

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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 versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 1: Overall morbidity

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Analysis 1.2

Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 2: Wound infection

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Analysis 1.3

Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 3: Abdominal abscess

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Analysis 1.4

Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 4: Bowel obstruction

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Analysis 1.5

Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 5: Faecal fistula

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Analysis 1.6

Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 6: Unplanned bowel resection

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Analysis 1.7

Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 7: Total length of hospital stay (days)

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Study	Number in study	Comparison	Results	Comment
Total length of hospital stay (days)
Khan 2021b	62 (31 versus 31)	Early appendicectomy versus delayed appendicectomy	Early appendicectomy versus delayed appendicectomy: mean (days): 4.8 versus 7.1, P = 0.045	Trial authors reported that early appendicectomy was associated with a shorter hospital stay than delayed appendicectomy.
Kumar 2018	46 (23 versus 23)	Early appendicectomy versus delayed appendicectomy	Early appendicectomy versus delayed appendicectomy: less than 7 days (1 versus 0); 8 to 14 days (16 versus 5); 15 to 21 days (5 versus 11); 21 to 28 days (1 versus 4); more than 28 days (0 versus 3)	Trial authors reported that the early appendicectomy was associated with a shorter hospital stay than delayed appendicectomy.

Analysis 1.8

Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 8: Total length of hospital stay (days)

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Analysis 1.9

Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 9: Time away from normal activities (days)

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Analysis 2.1

Comparison 2: Early versus delayed laparoscopic appendicectomy for appendiceal abscess, Outcome 1: Unplanned bowel resection

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Analysis 2.2

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

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Analysis 2.3

Comparison 2: Early versus delayed laparoscopic appendicectomy for appendiceal abscess, Outcome 3: Quality of life (score on a scale from 0 to 100)

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Summary of findings 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon

Outcomes	Anticipated absolute effects^* (95% CI)		Relative effect (95% CI)	Number of participants (trials)	Certainty of the evidence (GRADE)	Comments
Early versus delayed open or laparoscopicappendicectomy for appendiceal phlegmon
Patient or population: paediatric and adult participants with appendiceal phlegmon Setting: secondary and tertiary care Intervention: early open or laparoscopic appendicectomy Comparison: delayed open or laparoscopic appendicectomy
Outcomes	Risk with delayed appendicectomy	Risk with early appendicectomy	Relative effect (95% CI)	Number of participants (trials)	Certainty of the evidence (GRADE)	Comments
Overall morbidity Median follow‐up: 33.5 months^k	342 per 1000	253 per 1000 (65 to 979)	RR 0.74 (0.19 to 2.86)	146 (3)	⊕⊝⊝⊝ Verylow^a,b,c	—
Wound infection Median follow‐up: 33.5 months^k	94 per 1000	93 per 1000 (45 to 190)	RR 0.99 (0.48 to 2.02)	788 (7)	⊕⊝⊝⊝ Verylow^a,d,e	—
Abdominal abscess Median follow‐up: 33.5 months^k	58 per 1000	15 per 1000 (5 to 46)	RR 0.26 (0.08 to 0.80)	626 (4)	⊕⊝⊝⊝ Verylow^a,f	—
Faecal fistula Median follow‐up: 33.5 months^k	5 per 1000	9 per 1000 (2 to 44)	RR 1.75 (0.36 to 8.49)	388 (5)	⊕⊝⊝⊝ Verylow^a,g	—
Mortality Median follow‐up: 33.5 months^k	See comment	See comment	Not estimable	788 (7)	⊕⊝⊝⊝ VeryLow^a,h	There was no mortality in either group.
Total length of hospital stay (days) Follow‐up: 33.5 weeks^k	The mean total length of hospital stay in the delayed appendicectomy group was 5.41 to 14.7 days	The mean total length of hospital stay in the early appendicectomy group was 2.02 fewer (3.13 to 0.91 fewer)	MD −2.02 (−3.13 to −0.91)	680 (5)	⊕⊝⊝⊝ Very Low^a,i	Two additional trials did not report mean or SD values that were suitable for pooling (Khan 2021b; Kumar 2018). Both trials (108 participants) reported that early appendicectomy was associated with a shorter hospital stay than delayed appendicectomy.
Time away from normal activities (days) Median follow‐up: 33.5 months^k	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 more (1.52 to 8.48 more)	MD 5.00 (1.52 to 8.48)	40 (1 study)	⊕⊝⊝⊝ Very low^a,j	—
The basis for the assumed risk* is the mean baseline risk from the studies in the meta‐analysis. 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; SD: standard deviation
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded 2 levels for very serious risk of bias: all trials with unclear risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, and selective reporting; all trials at high risk of bias for blinding of participants and personnel ^bDowngraded 2 levels for very serious imprecision: small sample size and a confidence interval that included both potential benefit and potential harm from the intervention ^cDowngraded 1 level for serious inconsistency: unexplained statistical heterogeneity (I² = 72%) ^dDowngraded 1 level for serious imprecision: a confidence interval that included both potential benefit and potential harm from the intervention ^eDowngraded 1 level for serious inconsistency: unexplained statistical heterogeneity (I² = 47%) ^fDowngraded 1 level for serious imprecision: few events and a wide confidence interval ^gDowngraded 2 levels for very serious imprecision: small sample size, few events, and a confidence interval that included both potential benefit and potential harm from the intervention ^hDowngraded 1 level for serious imprecision: no events ⁱDowngraded 2 levels for very serious inconsistency: unexplained statistical heterogeneity (I² = 89%) ^jDowngraded 2 levels due to very serious imprecision (very small sample size) ^kThe length of follow‐up is based on one trial because the other trials did not report it.

Summary of findings 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon

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

Outcomes	Anticipated absolute effects^* (95% CI)		Relative effect (95% CI)	Number of participants (trials)	Certainity of the evidence (GRADE)	Comments
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	Risk with delayed appendicectomy	Risk with early appendicectomy	Relative effect (95% CI)	Number of participants (trials)	Certainity of the evidence (GRADE)	Comments
Overall morbidity	Not reported
Wound infection	Not reported
Abdominal abscess	Not reported
Faecal fistula	Not reported
Mortality Follow‐up: 12 weeks	See comment	See comment	Not estimable	40 (1)	⊕⊝⊝⊝ Very low^a,b	There were no deaths 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 fewer (3.54 fewer to 3.14 more)	MD −0.20 (−3.54 to 3.14)	40 (1)	⊕⊝⊝⊝ Very low^a,b	—
Time away from normal activities (days)	Not reported
The basis for the assumed risk* is the mean baseline risk from the studies in the meta‐analysis. 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 certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aDowngraded 2 levels for very serious risk of bias: unclear risk of bias for random sequence generation, allocation concealment, and blinding of outcome assessment; high risk of bias for blinding of participants and personnel ^bDowngraded 2 levels due to very serious imprecision: very small sample size

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

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Table 1. Sensitivity analyses for comparison 1: early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon

Outcome	Main analysis (95% CI); I²	Sensitivity analysis excludingKumar 2004	Sensitivity analysis excludingKhan 2016	Sensitivity analysis excludingKumar 2018	Sensitivity analysis excludingPathan 2018	Sensitivity analysis excludingRavi 2018	Sensitivity analysis excludingKhan 2021a	Sensitivity analysis excludingKhan 2021b
Overall morbidity	RR 0.74 (0.19 to 2.86); I² = 72%	RR 0.45 (0.21 to 1.00); I² = 40%	‐	RR 1.58 (0.03 to 90.11); I² = 87%	‐	RR 2.25 (0.08 to 62.71); I² = 81%	‐	‐
Wound infection	RR 0.99 (0.48 to 2.02); I² = 47%	RR 0.85 (0.44 to 1.66); I² = 40%	RR 0.90 (0.38 to 2.13); I² = 46%	RR 1.09 (0.46 to 2.56); I² = 55%	RR 1.23 (0.56 to 2.72); I² = 36%	RR 0.96 (0.43 to 2.16); I² = 54%	RR 1.20 (0.54 to 2.65); I² = 47%	RR 0.86 (0.44 to 1.67); I² = 41%
Abdominal abscess	RR 0.26 (0.08 to 0.80); I² = 0%	‐	RR 0.13 (0.03 to 0.58); I² = 0%	RR 0.28 (0.07 to 1.07); I² = 12%	RR 0.42 (0.11 to 1.64); I² = 0%	‐	RR 0.24 (0.06 to 0.92); I² = 17%	‐
Bowel obstruction	RR 0.16 (0.02 to 1.34); I² = 0%	‐	‐	RR 0.33 (0.01 to 7.87)	‐	RR 0.09 (0.01 to 1.55)	‐	‐
Faecal fistula	RR 1.75 (0.36 to 8.49); I² = 0%	RR 1.45 (0.23 to 9.07); I² = 0%	‐	RR 1.75 (0.36 to 8.49); I² = 0%	‐	RR 1.46 (0.23 to 9.06); I² = 0%	RR 3.00 (0.49 to 18.55); I² = 0%	RR 1.46 (0.23 to 9.06); I² = 0%
Total length of hospital stay	MD −2.02 (−3.13 to −0.91); I² = 89%	MD −2.67 (−3.39 to −1.95); I² = 77%	MD −1.11 (−3.14 to 0.93); I² = 91%	‐	MD −2.45 (−3.57 to −1.34); I² = 87%	MD −1.58 (−2.95 to −0.20); I² = 92%	MD −1.18 (−3.03 to 0.67); I² = 91%	‐
CI: confidence interval; RR: risk ratio; MD: mean difference

Table 1. Sensitivity analyses for comparison 1: early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon

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Comparison 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Overall morbidity Show forest plot	3	146	Risk Ratio (M‐H, Random, 95% CI)	0.74 [0.19, 2.86]

1.2 Wound infection Show forest plot	7	788	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.48, 2.02]

1.3 Abdominal abscess Show forest plot	4	626	Risk Ratio (M‐H, Random, 95% CI)	0.26 [0.08, 0.80]

1.4 Bowel obstruction Show forest plot	2	106	Risk Ratio (M‐H, Random, 95% CI)	0.16 [0.02, 1.34]

1.5 Faecal fistula Show forest plot	5	388	Risk Ratio (M‐H, Random, 95% CI)	1.75 [0.36, 8.49]

1.6 Unplanned bowel resection Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.7 Total length of hospital stay (days) Show forest plot	5	680	Mean Difference (IV, Random, 95% CI)	‐2.02 [‐3.13, ‐0.91]

1.8 Total length of hospital stay (days) Show forest plot	0		Other data	No numeric data

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

Comparison 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon

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Comparison 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess

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

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

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

Comparison 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess

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