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Review
. 2024 May 2;5(5):CD011670.
doi: 10.1002/14651858.CD011670.pub3.

Early versus delayed appendicectomy for appendiceal phlegmon or abscess

Shiyi Zhou  1 , Yao Cheng  2 , Nansheng Cheng  3 , Jianping Gong  2 , Bing Tu  2
Affiliations
Review

Early versus delayed appendicectomy for appendiceal phlegmon or abscess

Shiyi Zhou et al. Cochrane Database Syst Rev. .

Abstract

Background: This is an update of a Cochrane review first published in 2017. Acute appendicitis (inflammation of the appendix) can be simple or complicated. Appendiceal phlegmon and appendiceal abscess are examples of complicated appendicitis. Appendiceal phlegmon is a diffuse inflammation in the bottom right of the appendix, while appendiceal abscess is a discrete inflamed mass in the abdomen that contains pus. Appendiceal phlegmon and abscess account for 2% to 10% of acute appendicitis. People with appendiceal phlegmon or abscess usually need an appendicectomy to relieve their symptoms (e.g. abdominal pain, loss of appetite, nausea, and vomiting) and avoid complications (e.g. peritonitis (infection of abdominal lining)). Surgery for people with appendiceal phlegmon or abscess may be early (immediately after hospital admission or within a few days of admission), or delayed (several weeks later in a subsequent hospital admission). The optimal timing of appendicectomy for appendiceal phlegmon or abscess is debated.

Objectives: To assess the effects of early appendicectomy compared to delayed appendicectomy on overall morbidity and mortality in people with appendiceal phlegmon or abscess.

Search methods: We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers on 11 June 2023, together with reference checking to identify additional studies.

Selection criteria: We included all individual and cluster-randomised controlled trials (RCTs), irrespective of language, publication status, or age of participants, comparing early versus delayed appendicectomy in people with appendiceal phlegmon or abscess.

Data collection and analysis: We used standard methodological procedures expected by Cochrane.

Main results: We included eight RCTs that randomised 828 participants to early or delayed appendicectomy for appendiceal phlegmon (7 trials) or appendiceal abscess (1 trial). The studies were conducted in the USA, India, Nepal, and Pakistan. All RCTs were at high risk of bias because of lack of blinding and lack of published protocols. They were also unclear about methods of randomisation and length of follow-up. 1. Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon We included seven trials involving 788 paediatric and adult participants with appendiceal phlegmon: 394 of the participants were randomised to the early appendicectomy group (open or laparoscopic appendicectomy as soon as the appendiceal mass resolved within the same admission), and 394 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed open or laparoscopic appendicectomy several weeks later). There was no mortality in either group. The evidence is very uncertain about the effect of early appendicectomy on overall morbidity (risk ratio (RR) 0.74, 95% confidence interval (CI) 0.19 to 2.86; 3 trials, 146 participants; very low-certainty evidence), the proportion of participants who developed wound infections (RR 0.99, 95% CI 0.48 to 2.02; 7 trials, 788 participants), and the proportion of participants who developed faecal fistulas (RR 1.75, 95% CI 0.36 to 8.49; 5 trials, 388 participants). Early appendicectomy may reduce the abdominal abscess rate (RR 0.26, 95% CI 0.08 to 0.80; 4 trials, 626 participants; very low-certainty evidence), reduce the total length of hospital stay by about two days (mean difference (MD) -2.02 days, 95% CI -3.13 to -0.91; 5 trials, 680 participants), and increase the time away from normal activities by about five days (MD 5.00 days; 95% CI 1.52 to 8.48; 1 trial, 40 participants), but the evidence is very uncertain. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscess We included one trial involving 40 paediatric participants with appendiceal abscess: 20 were randomised to the early appendicectomy group (emergent laparoscopic appendicectomy), and 20 were randomised to the delayed appendicectomy group (initial conservative treatment followed by delayed laparoscopic appendicectomy 10 weeks later). There was no mortality in either group. The trial did not report on overall morbidity, various complications, or time away from normal activities. The evidence is very uncertain about the effect of early appendicectomy on the total length of hospital stay (MD -0.20 days, 95% CI -3.54 to 3.14; very low-certainty evidence).

Authors' conclusions: For the comparison of early versus delayed open or laparoscopic appendicectomy for paediatric and adult participants with appendiceal phlegmon, very low-certainty evidence suggests that early appendicectomy may reduce the abdominal abscess rate. The evidence is very uncertain whether early appendicectomy prevents overall morbidity or other complications. Early appendicectomy may reduce the total length of hospital stay and increase the time away from normal activities, but the evidence is very uncertain. For the comparison of early versus delayed laparoscopic appendicectomy for paediatric participants with appendiceal abscess, data are sparse, and we cannot rule out significant benefits or harms of early versus delayed appendicectomy. Further trials on this topic are urgently needed and should specify a set of criteria for use of antibiotics, percutaneous drainage of the appendiceal abscess prior to surgery, and resolution of the appendiceal phlegmon or abscess. Future trials should include outcomes such as time away from normal activities and length of hospital stay.

PubMed Disclaimer

Conflict of interest statement

Shiyi Zhou: none known Yao Cheng: none known Nansheng Cheng: none known Jianping Gong: none known Bing Tu: none known

Figures

1
1
Study flow diagram
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 1: Overall morbidity
1.2
1.2. Analysis
Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 2: Wound infection
1.3
1.3. Analysis
Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 3: Abdominal abscess
1.4
1.4. Analysis
Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 4: Bowel obstruction
1.5
1.5. Analysis
Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 5: Faecal fistula
1.6
1.6. Analysis
Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 6: Unplanned bowel resection
1.7
1.7. Analysis
Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 7: Total length of hospital stay (days)
1.9
1.9. Analysis
Comparison 1: Early versus delayed open or laparoscopic appendicectomy for appendiceal phlegmon, Outcome 9: Time away from normal activities (days)
2.1
2.1. Analysis
Comparison 2: Early versus delayed laparoscopic appendicectomy for appendiceal abscess, Outcome 1: Unplanned bowel resection
2.2
2.2. Analysis
Comparison 2: Early versus delayed laparoscopic appendicectomy for appendiceal abscess, Outcome 2: Total length of hospital stay (days)
2.3
2.3. Analysis
Comparison 2: Early versus delayed laparoscopic appendicectomy for appendiceal abscess, Outcome 3: Quality of life (score on a scale from 0 to 100)
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Khan 2016 {published data only}
    1. Khan MA, Ali S, Parhar AB, Ahmad W. Management of appendicular mass as an early exploration versus interval appendicetomy. Pakistan Journal of Medical & Health Sciences 2016;10(3):697-9.
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Khan 2021a {published data only}
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Khan 2021b {published data only}
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Pathan 2018 {published data only}
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Ravi 2018 {published data only}
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St Peter 2010 {published data only}
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References to studies excluded from this review

Abdulraheem 2021 {published data only}
    1. Abdulraheem OA, Amer IA. Laparoscopic versus conservative treatment of appendicular mass: outcome and benefit comparisons. Egyptian Journal of Surgery 2021;40(3):806-14.
Blakely 2011 {published data only}
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    1. Myers AL, Williams RF, Giles K, Waters TM, Eubanks JW 3rd, 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. - PubMed
Demetrashvili 2019 {published data only}
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Dhaded 2016 {published data only}
    1. Dhaded RB, Chandrahasa D, Maitra J, Karbhari SS. A comparative study of early versus interval appendicectomy in cases of appendiceal mass. SAS Journal of Surgery 2016;2(1):1-8.
Elsaady 2019 {published data only}
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Goh 2005 {published data only}
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Hall 2017 {published data only}
    1. Hall NJ, Eaton S, Stanton MP, Pierro A, Burge DM. Active observation versus interval appendicectomy after successful non-operative treatment of an appendix mass in children (CHINA study): an open-label, randomised controlled trial. Lancet Gastroenterology & Hepatology 2017;2(4):253-60. - PubMed
Israr 2021 {published data only}
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Patel 2015 {published data only}
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Ravichandran 2021 {published data only}
    1. Ravichandran K, Jayaraman R, Nithya K. A prospective study on appendicular mass. International Surgery Journal 2021;8(4):1114-7.
Shinde 2020 {published data only}
    1. Shinde N, Devani R, Baseer MA, Desai K. Study of management of appendicular abscess in children. African Journal of Paediatric Surgery 2020;17(3 & 4):64-7. - PMC - PubMed

References to ongoing studies

ChiCTR1900021559 {published data only}
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References to other published versions of this review

Cheng 2015
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