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Early versus delayed (interval) appendicectomy for the management of appendicular abscess and phlegmon: a systematic review and meta-analysis

Authors:
Akinfemi Akingboye at The Dudley Group NHS Foundation Trust
Akinfemi Akingboye
Fahad Mahmood at Queen Elizabeth Hospital Birmingham
Fahad Mahmood
Shafquat Zaman at Sandwell and West Birmingham Hospitals NHS Trust
Shafquat Zaman
Jenny Wright
Jenny Wright
Jenny Wright
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Abstract

Objective The safety and role of emergency (EA) versus interval appendicectomy (IA) for appendicular abscess and phlegmon remains debatable with no optimal strategy identified. The aim of this systematic review and meta-analysis is to evaluate outcomes of managing appendicular abscesses and phlegmon with emergency or interval appendicectomy.Methods We conducted a systematic search of electronic databases using key terms including ‘appendicular abscess’, ‘appendicular phlegmon’ and ‘interval appendicectomy’. Randomised controlled trials and observational studies comparing the two management approaches were included. Operative time, post-operation complication, unplanned bowel resection, rate of surgical site infection, post-operative length of stay and overall mortality rate were evaluated.ResultsWe identified six studies (2 RCTs and 4 observational studies) with a total of 9264 patients of whom (n = 1352) underwent IA, and (n 7912) underwent EA. The EA group was associated with statistically significant unplanned bowel resection (OR 0.55, 95% CI [0.33–0.90], P = 0.02) and longer total operating time (MD − 14.11, 95% CI [− 18.26–− 9.96] P = 0.00001). However, the following parameters were compared for both EA and IA groups; there were no significant statistical differences: surgical site infection (OR 0.49, 95% CI [0.17–1.38], P = 0.18), post-operative intra-abdominal collection (RD − 0.01, 95% CI [− 0.04–0.01], P = 0.29), total length of hospital stay (MD 1.83, 95% CI [− 0.19–3.85], P = 0.08), post-operative length of hospital stay (MD − 0.27, 95% CI [− 3.66–3.13], P = 0.88) and mortality rate (MD − 0.27, 95% CI [− 3.66–3.13], P = 0.66).Conclusion Emergency operation for appendicular abscess and phlegmon may lead to a higher rate of reported morbidity when compared with interval appendicectomy. Although emergency appendicectomy performed for appendicular abscess and phlegmon is a feasible and safe operative approach, it is associated with significantly increased operative time and unplanned bowel resection (ileocolic and right hemicolectomies) compared to interval appendicectomy.
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SYSTEMATIC REVIEWS AND META-ANALYSES
Early versus delayed (interval) appendicectomy for the management
of appendicular abscess and phlegmon: a systematic
review and meta-analysis
Akinfemi A. Akingboye
1
&Fahad Mahmood
1
&Shafquat Zaman
2
&Jenny Wright
2
&Fatima Mannan
1
&
Ali Yasen Y. Mohamedahmed
2
Received: 21 October 2020 / Accepted: 18 November 2020
#Springer-Verlag GmbH Germany, part of Springer Nature 2021
Abstract
Objective The safety and role of emergency (EA) versus interval appendicectomy (IA) for appendicular abscess and phlegmon
remains debatable with no optimal strategy identified. The aim of this systematic review and meta-analysis is to evaluate
outcomes of managing appendicular abscesses and phlegmon with emergency or interval appendicectomy.
Methods We conducted a systematic search of electronic databases using key terms including ‘appendicular abscess’,‘appen-
dicular phlegmon’and ‘interval appendicectomy’. Randomised controlled trials and observational studies comparing the two
management approaches were included.Operative time, post-operation complication, unplanned bowel resection, rate of surgical
site infection, post-operative length of stay and overall mortality rate were evaluated.
Results We identified six studies (2 RCTs and 4 observational studies) with a total of 9264 patients of whom (n= 1352)
underwent IA, and (n7912) underwent EA. The EA group was associated with statistically significant unplanned bowel
resection (OR 0.55, 95% CI [0.33–0.90], P= 0.02) and longer total operating time (MD −14.11, 95% CI [−18.26–−
9.96] P= 0.00001). However, the following parameters were compared for both EA and IA groups; there were no
significant statistical differences: surgical site infection (OR 0.49, 95% CI [0.17–1.38], P= 0.18), post-operative intra-
abdominal collection (RD −0.01, 95% CI [−0.04–0.01], P= 0.29), total length of hospital stay (MD 1.83, 95% CI [−
0.19–3.85], P= 0.08), post-operative length of hospital stay (MD −0.27, 95% CI [−3.66–3.13], P= 0.88) and mortality
rate (MD −0.27, 95% CI [−3.66–3.13], P=0.66).
Conclusion Emergency operation for appendicular abscess and phlegmon may lead to a higher rate of reported
morbidity when compared with interval appendicectomy. Although emergency appendicectomy performed for appen-
dicular abscess and phlegmon is a feasible and safe operative approach, it is associated with significantly increased
operative time and unplanned bowel resection (ileocolic and right hemicolectomies) compared to interval
appendicectomy.
Keywords Abscess .Phlegmon .Appendicectomy .Interval and emergency
*Akinfemi A. Akingboye
a.akingboye@nhs.net
Fahad Mahmood
fahad.mahmood@nhs.net
Shafquat Zaman
shafquatzaman@nhs.net
Jenny Wright
jenny.wright7@nhs.net
Fatima Mannan
fmannan90@gmail.com
Ali Yasen Y. Mohamedahmed
dr.aliyasen1@gmail.com
1
Department of General Surgery, Russells Hall Hospital, The Dudley
Group NHS Foundation Trust, Russells Hall Hospital, Pensnett Road,
Dudley DY1 2HQ, UK
2
Department of General Surgery, Sandwell & West Birmingham
Hospitals, West Bromwich B71 4HJ, UK
https://doi.org/10.1007/s00423-020-02042-3
/ Published online: 8 January 2021
Langenbeck's Archives of Surgery (2021) 406:1341–1351
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Early appendectomy in perityphlitic abscess was shown to significantly increase the risk of a more extensive operation (ileocecal resection or right-sided hemicolectomy) compared to primary NOM with interval appendectomy, based on a study by Akingboye et al. published in 2021. However, NOM fails in approximately 6 %, ultimately requiring appendectomy [5]. When stool was seen in the drainage of our patient, failure of NOM was suspected, which is why surgical exploration was indicated. ...
... When stool was seen in the drainage of our patient, failure of NOM was suspected, which is why surgical exploration was indicated. Surprisingly, intraoperative findings revealed a sigmoido-ileal fistula as a result of a complicated diverticulitis (CDD type 3c) [5]. Generally, for differential diagnosis intestinal fistula formation occurs rarely (3 %) in complicated diverticulitis, more commonly it is found in Crohn's disease or malignancy [6,7]. ...
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Introduction: Diverticulitis is a common gastrointestinal disease usually presenting with a typical clinical picture depending on the stage of the disease. In complicated cases, the clinical presentation may be untypical, thus delaying diagnosis and treatment. Presentation of case: We present a case of a young patient who was initially treated for obscure intraabdominal abscesses presumably due to gangrenous appendicitis; however, intraoperative exploration revealed a normal appendix and a coloenteric fistula resulting from an unknown and untreated perforated diverticulitis. Discussion: A patient with a perityphlitic abscess was initially managed with primary non-operative management (NOM) in accordance with the current Jerusalem guidelines, but surgery was eventually necessary due to failure of NOM. Intraoperative findings revealed a sigmoido-ileal fistula, a rare but potentially detectable complication of diverticulitis through colonoscopy. This case highlights the challenges in diagnosing and treating common surgical diseases with uncommon clinical presentations, emphasizing the importance of a detailed patient history and not relying solely on imaging studies. Conclusion: Intraabdominal abscesses require prompt treatment with non-operative management, while intestinal fistulae associated with diverticulitis are a rare consequence of chronic inflammation, often asymptomatic and often detected incidentally during surgery. In most cases simple fistulous tract resection is usually sufficient as first line therapy.
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... USG is undoubtedly an initial imaging modality due to its inherited advantages, especially since it is pivotal in resource-poor settings. Sonography has a sensitivity of 56 to 94% and a specificity of 47 to 95% [24]. Most appendicular abscesses show an illdefined hypoechoic unilocular or multilocular fluid collection with internal echogenic debris covered by an irregularly thick wall. ...
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... However, the treatment of a periappendiceal abscess has always been a challenge. Early surgery may cause serious complications such as total peritonitis and postoperative anastomotic leakage [2]. We report a case of acute appendicitis with a giant periappendiceal abscess and intestinal obstruction. ...
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... 1 An appendicular abscess occurs between 2% and 10% of patients with appendicitis. 2 The presentation includes constant abdominal pain, fever, and histologic findings of chronic inflammation. 1 Only 1 case of chronic appendicular abscess presenting as bowel obstruction and 3 cases mimicking neoplasm have been reported in the literature. ...
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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. 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Introduction: Complicated appendicitis (CA) is often indicated for emergency surgery; however, preoperative predictors of pathological complicated appendicitis (pCA) remain unclear. Furthermore, characteristics of CA that can be treated conservatively have not yet been established. Methods: Three hundred and five consecutive patients diagnosed with acute appendicitis were reviewed. The patients were divided into two groups: an emergency surgery and a conservative treatment group. The emergency surgery group was pathologically classified as having uncomplicated appendicitis (pUA) and pCA, and the preoperative predictors of pCA were retrospectively assessed. Based on the preoperative pCA predictors, a predictive nomogram whether conservative treatment would be successful or not was created. The predictors were applied to the conservative treatment group, and the outcomes were investigated. Results: In the multiple logistic regression analysis of the factors contributing to pCA, C-reactive protein ≥3.5 mg/dL, ascites, appendiceal wall defect, and periappendiceal fluid collection were independent risk factors. Over 90% of cases without any of the above four preoperative pCA predictors were pUA. The accuracy of the nomogram was 0.938. Conclusion: Our preoperative predictors and nomogram are useful to aid in distinguishing pCA and pUA and to predict whether or not conservative treatment will be successful. Some CA can be treated with conservative treatment.
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Management of appendiceal mass and abscess in children; early appendectomy or initial non-operative treatment? A systematic review and meta-analysis
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  • Dec 2020
  • SURG ENDOSC
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Comparison of Treatment Methods of Appendiceal Mass and Abscess: A Prospective Cohort Study
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  • Oct 2019
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Early versus late surgical management for complicated appendicitis in adults: a multicenter propensity score matching study
Article
Full-text available
  • Aug 2019
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Optimal literature search for systematic reviews in surgery
Article
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  • Feb 2018
  • LANGENBECK ARCH SURG
Background The aim of the present study was to determine empirically which electronic databases contribute best to a literature search in surgical systematic reviews. Methods For ten published systematic reviews, the systematic literature searches were repeated in the databases MEDLINE, Web of Science, CENTRAL, and EMBASE. On the basis of these reviews, a gold standard set of eligible articles was created. Recall (%), precision (%), unique contribution (%), and numbers needed to read (NNR) were calculated for each database, as well as for searches of citing references and of the reference lists of related systematic reviews (hand search). ResultsCENTRAL yielded the highest recall (88.4%) and precision (8.3%) for randomized controlled trials (RCT), MEDLINE for non-randomized studies (NRS; recall 92.6%, precision 5.2%). The most effective combination of two databases plus hand searching for RCT was MEDLINE/CENTRAL (98.6% recall, NNR 97). Adding EMBASE marginally increased the recall to 99.3%, but with an NNR of 152. For NRS, the most effective combination was MEDLINE/Web of Science (99.5% recall, NNR 60). Conclusions For surgical systematic reviews, the optimal literature search for RCT employs MEDLINE and CENTRAL. For surgical systematic reviews of NRS, Web of Science instead of CENTRAL should be searched. EMBASE does not contribute substantially to reviews with a surgical intervention.
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Cochrane Handbook for Systematic Reviews of Interventions
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  • Sep 2019
The revised edition of the Handbook offers the only guide on how to conduct, report and maintain a Cochrane Review ? The second edition of The Cochrane Handbook for Systematic Reviews of Interventions contains essential guidance for preparing and maintaining Cochrane Reviews of the effects of health interventions. Designed to be an accessible resource, the Handbook will also be of interest to anyone undertaking systematic reviews of interventions outside Cochrane, and many of the principles and methods presented are appropriate for systematic reviews addressing research questions other than effects of interventions. This fully updated edition contains extensive new material on systematic review methods addressing a wide-range of topics including network meta-analysis, equity, complex interventions, narrative synthesis, and automation. Also new to this edition, integrated throughout the Handbook, is the set of standards Cochrane expects its reviews to meet. Written for review authors, editors, trainers and others with an interest in Cochrane Reviews, the second edition of The Cochrane Handbook for Systematic Reviews of Interventions continues to offer an invaluable resource for understanding the role of systematic reviews, critically appraising health research studies and conducting reviews.
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Neutrophil-to-lymphocyte ratio predicts acute appendicitis and distinguishes between complicated and uncomplicated appendicitis: A systematic review and meta-analysis
Article
  • Apr 2019
  • AM J SURG
Objectives: to investigate whether Neutrophil-to-lymphocyte ratio (NLR) can predict acute appendicitis and whether it can distinguish between uncomplicated and complicated appendicitis. Methods: A search of electronic information sources was conducted to identify all studies reporting NLR in patients with clinical suspicion or confirmed diagnosis of acute appendicitis. We considered two comparisons:1) appendicitis versus no appendicitis; 2) uncomplicated appendicitis versus complicated appendicitis. ROC curve analysis was performed to determine cut-off values of NLR for appendicitis and complicated appendicitis. Results: Seventeen studies, enrolling 8,914 patients were included. NLR of 4.7 was cut-off value for appendicitis with sensitivity of 88.89% and specificity of 90.91% with AUC of 0.96. NLR of 8.8 was cut-off value for complicated appendicitis with sensitivity of 76.92% and specificity 100% with AUC of 0.91. NLR >4.7 was predictor of acute appendicitis (OR:128,P < 0.0001) and, NLR >8.8 was predictor of complicated appendicitis (OR:43,P < 0.0001). Conclusions: NLR predicts both diagnosis and severity of appendicitis. This may have implications for prioritising cases for surgery, for monitoring conservatively treated patients and for patients who do not routinely undergo CT scan (pregnant or paediatric patients).
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Meta-analysis of laparoscopic surgery versus conservative treatment for appendiceal abscess
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  • Dec 2018
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Objective: To systematically evaluate the safety and efficacy of laparoscopic surgery versus conservative treatment for appendiceal abscess. Methods: The databases of CNKI, Wangfang, VIP, PubMed, EMBASE and Cochrane Library were searched to retrieve randomized controlled trials (RCT) or clinical controlled trials (CCT) comparing laparoscopic surgery with conservative treatment for appendiceal abscess published before June 2018. The search terms were Chinese or English. Chinese search terms included appendix, abscess, and laparoscopy; English search terms included appendix, abscess, and laparoscope. References of the resulted papers, related reviews or meta-analysis references were also induded. Literature inclusion criteria: (1)RCT or CCT, whether or not to assign concealment or blinding; (2) appendiceal abscess was diagnosed at admission; (3) laparoscopic group: laparoscopic appendectomy or laparoscopy surgical methods, such as irrigation and drainage, for appendiceal abscess; conservative treatment group: conservative methods, such as antibiotics or percutaneous abscess drainage were used to treat appendiceal abscess. Exclusion criteria: (1) review, case report, single cohort study and other non-controlled studies literature; (2) single study sample size ≤ 20; (3) subjects with simple appendicitis or perforation of appendix to form diffuse peritonitis; (4) no valid data available for extraction; (5) repeated publication of the literature. Data were extracted from the included studies, and the Cochrane Collaboration RevMan 5.1.0 version software was used for this meta-analysis. Results: Three RCTs and four CCTs with a total of 591 patients were included in this study. There were 312 patients in the laparoscopic group and 279 patients in the conservative group. Compared with the conservative group, the laparoscopic group had higher uneventful recovery rate (OR=11.91, 95%CI: 4.59 to 30.88, P<0.05), shorter hospital stay (WMD=-2.98, 95%CI: -5.96 to -0.01, P=0.05), lower incidence of recurrent or residual abscess (OR=0.07, 95%CI:0.03 to 0.20, P<0.05), and shorter time to recover to normal condition for body temperature and white blood cell respectively (SMD=-2.12, 95%CI:-2.49 to -1.75, P<0.05; SMD=-2.07, 95%CI: -3.84 to -0.29, P<0.05). However, no significant difference was found in hospital charge(P>0.05). Conclusions: Laparoscopic surgery for appendiceal abscess is safe and feasible. It can improve the recovery with shorter postoperative hospital stay and less recurrent or residual abscess.
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Early versus late surgical management of complicated appendicitis in children: A statewide database analysis with one-year follow-up
Article
  • Oct 2017
Background: Complicated appendicitis is common in children, yet the timing of surgical management remains controversial. Some support initial antibiotics with delayed operation whereas others support immediate operation. While a few randomized trials have evaluated this question, they have been small, single-center trials with limited follow-up. We present a database analysis of outcomes in early versus late surgical management of complicated appendicitis with one-year follow-up. Methods: We conducted a retrospective review of children with complicated appendicitis presenting between 2000 and 2013, utilizing a New York State database. We compare children undergoing later versus early appendectomy with a primary outcome measure of any complication within one year as determined from ICD-9 codes. Results: 8840 children were included in the analysis, 7708 of whom underwent early appendectomy. Patients with late appendectomy were significantly more likely to have at least one complication when compared to those undergoing early appendectomy (34.6% vs 26.7%, p<0.01). Conclusions: We present the first population-level study evaluating early versus late appendectomy in children with complicated appendicitis with a one-year follow-up period. Children undergoing late appendectomy were more likely to have a complication than those undergoing early appendectomy. These data corroborated previous studies supporting early operative management. Level of evidence: This study provides level III evidence of a treatment study.
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Early versus delayed appendicectomy for appendiceal phlegmon or abscess
Article
  • Jun 2017
Background: 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 and avoid complications. The timing of appendicectomy for appendiceal phlegmon or abscess is controversial. Objectives: To assess the effects of early versus delayed appendicectomy for appendiceal phlegmon or abscess, in terms of overall morbidity and mortality. Search methods: We searched the Cochrane Library (CENTRAL; 2016, Issue 7), MEDLINE Ovid (1950 to 23 August 2016), Embase Ovid (1974 to 23 August 2016), Science Citation Index Expanded (1900 to 23 August 2016), and the Chinese Biomedical Literature Database (CBM) (1978 to 23 August 2016). We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform search portal (23 August 2016) and ClinicalTrials.gov (23 August 2016) for ongoing trials. Selection criteria: We included all individual and cluster-randomised controlled trials, 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: Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). Main results: We included two randomised controlled trials with a total of 80 participants in this review. 1. Early versus delayed open appendicectomy for appendiceal phlegmonForty participants (paediatric and adults) with appendiceal phlegmon were randomised either to early appendicectomy (appendicectomy as soon as appendiceal mass resolved within the same admission) (n = 20), or to delayed appendicectomy (initial conservative treatment followed by interval appendicectomy six weeks later) (n = 20). The trial was at high risk of bias. There was no mortality in either group. There is insufficient evidence to determine the effect of using either early or delayed open appendicectomy onoverall morbidity (RR 13.00; 95% CI 0.78 to 216.39; very low-quality evidence), the proportion of participants who developed wound infection (RR 9.00; 95% CI 0.52 to 156.91; very low quality evidence) or faecal fistula (RR 3.00; 95% CI 0.13 to 69.52; very low quality evidence). The quality of evidence for increased length of hospital stay and time away from normal activities in the early appendicectomy group (MD 6.70 days; 95% CI 2.76 to 10.64, and MD 5.00 days; 95% CI 1.52 to 8.48, respectively) is very low quality evidence. The trial reported neither quality of life nor pain outcomes. 2. Early versus delayed laparoscopic appendicectomy for appendiceal abscessForty paediatric participants with appendiceal abscess were randomised either to early appendicectomy (emergent laparoscopic appendicectomy) (n = 20) or to delayed appendicectomy (initial conservative treatment followed by interval laparoscopic appendicectomy 10 weeks later) (n = 20). The trial was at high risk of bias. The trial did not report on overall morbidity or complications. There was no mortality in either group. We do not have sufficient evidence to determine the effects of using either early or delayed laparoscopic appendicectomy for outcomes relating to hospital stay between the groups (MD -0.20 days; 95% CI -3.54 to 3.14; very low quality of evidence). Health-related quality of life was measured with the Pediatric Quality of Life Scale-Version 4.0 questionnaire (a scale of 0 to 100 with higher values indicating a better quality of life). Health-related quality of life score measured at 12 weeks after appendicectomy was higher in the early appendicectomy group than in the delayed appendicectomy group (MD 12.40 points; 95% CI 9.78 to 15.02) but the quality of evidence was very low. This trial reported neither the pain nor the time away from normal activities. Authors' conclusions: It is unclear whether early appendicectomy prevents complications compared to delayed appendicectomy for people with appendiceal phlegmon or abscess. The evidence indicating increased length of hospital stay and time away from normal activities in people with early open appendicectomy is of very low quality. The evidence for better health-related quality of life following early laparoscopic appendicectomy compared with delayed appendicectomy is based on very low quality evidence. For both comparisons addressed in this review, 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, quality of life and the length of hospital stay.
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