Acute Appendicectomy or Conservative Treatment for Complicated Appendicitis (Phlegmon or Abscess)? A Systematic Review by Updated Traditional and Cumulative Meta-Analysis

BACKGROUND: The existing evidence on the treatment of complicated appendicitis favors conservative treatment rather than acute appendicectomy. Update traditional meta-analysis and consequently cumulative meta-analysis was performed to track the accumulation of evidence over time. METHODS: Studies were identified by a systematic literature search of the EMBASE, PubMed, Cochrane Library and Google Scholar databases. The main outcome measures were duration of the first hospitalization, overall duration of hospitalization, duration of intravenous (IV) antibiotic treatment, overall complications, abdominal/pelvic abscesses, wound infections, re-admissions and unplanned re-operations. RESULTS: Overall complications, abdominal/pelvic abscesses, wound infections and unplanned procedures were significantly lower in the conservative treatment cohort. In contrast, subgroup analysis of three randomized controlled trials (RCTs) revealed no significant difference in abdominal/pelvic abscesses (odds ratio (OR): 0.46, 95% confidence interval (CI): 0.17 - 1.29, P = 0.14). No significant differences were found in the duration of the first and overall hospitalizations. Of the note, high-quality RCTs demonstrated a shorter hospital stay by 1 day for the laparoscopic appendicectomy cohort compared to conservative treatment (mean difference (MD): -0.99, 95% CI: -1.31 to -0.67, P < 0.0001). CONCLUSION: The present meta-analysis demonstrates that a shift in paradigm has begun, with a more widespread use of the laparoscopic approach for the management of complicated appendicitis.