YJPSU-58761; No of Pages 7

Journal of Pediatric Surgery xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Review Article

Immediate surgery or conservative treatment for complicated acute

appendicitis in children? A meta-analysis
George Vaos a,⁎, Anastasia Dimopoulou a, Eleana Gkioka b, Nick Zavras a
a
Department of Paediatric Surgery, Attikon University General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
b
Second Department of Paediatrics, Athens Medical Center, Athens, Greece

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: This study carried out a meta-analysis to compare immediate surgery (IS) with conservative treatment
Received 13 April 2018 (CT) of complicated acute appendicitis (CAA) in children.
Received in revised form 19 July 2018 Methods: Systematic literature research was performed for relevant studies published from 1969 to date.
Accepted 20 July 2018 Trials of IS compared with CT were included. Outcomes of interest were postoperative morbidity and length of
Available online xxxx
hospital stay (LOS).
Results: Fifteen trials were studied (1.243 patients). CT achieved better rates of any complication type
Key words:
Complicated acute appendicitis
(odds ratio [OR] 0.22, [95% confidence interval (CI): 0.14, 0.38], p = 0.001) and wound infection (OR: 0.40
Immediate appendectomy [95% CI: 0.17, 0.96], p = 0.041). Neither intraabdominal abscess (OR: 1.03 [95% CI: 0.31, 3.37], p = 0.958) nor
Conservative treatment postoperative ileus (OR: 0.29 [95% CI: 0.06, 1.44], p = 0.130) was affected by the treatment option. The
Children polled difference in LOS showed a trend for shorter LOS in the IS group (standard mean difference [SMD]:
0.25 [95% CI: 0.07, − 0.43], p = 0.007).
Conclusions: IS was associated with shorter LOS, while overall complication rates and wound infection
declined significantly with CT. The development of intraabdominal abscess and postoperative ileus was
not affected by the treatment of choice. The heterogeneity of most studies depicts the need for randomized
controlled trials (RCTs) to discover safe management of CAA in children.
Level of evidence: III: Type of study: Meta-analysis.
© 2018 Elsevier Inc. All rights reserved.

Contents

1. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
1.1. Registration number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
1.2. Literature search strategy and study design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
1.3. Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
1.4. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
1.5. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
1.6. Outcomes of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
1.7. Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
2.1. Literature information and study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
2.2. Meta-analysis results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

Acute appendicitis (AA) is the most common surgical condition for

⁎ Corresponding author at: Department of Pediatric Surgery, Attikon University General
Hospital, National and Kapodistrian University of Athens, School of Medicine, 1 Rimini Str,
Haidari 12462, Athens, Greece. Tel.: +30 2105831299; fax: +30 2105326411.
E-mail address: gvaos@med.uoa.gr (G. Vaos).
urgent surgery in the pediatric population, accounting for 1%–8% of
admissions in the emergency department [1,2]. The clinical distinction
of the disease is between uncomplicated acute appendicitis (UAA) and

https://doi.org/10.1016/j.jpedsurg.2018.07.017
0022-3468/© 2018 Elsevier Inc. All rights reserved.

Please cite this article as: Vaos G, et al, Immediate surgery or conservative treatment for complicated acute appendicitis in children?
A meta-analysis, J Pediatr Surg (2018), https://doi.org/10.1016/j.jpedsurg.2018.07.017
2 G. Vaos et al. / Journal of Pediatric Surgery xxx (2018) xxx–xxx
complicated acute appendicitis (CAA). Although appendectomy is a
common surgical procedure, a delay in diagnosis leading to CAA may
cause a significant increase of morbidity, length of hospital stay (LOS),
and cost [3].
A substantial number of studies in children with UAA showed the
efficacy of conservative treatment (CT) with high success rates [4–6].
Furthermore, there has been an expansive tendency to treat CAA
initially with antibiotics, interval appendectomy, or both [7,8]. Similis
et al. [9], in a meta-analysis including 17 nonrandomized studies
(16 retrospective and 1 prospective), found that the CT of CAA was re-
lated to a decrease of complications and reoperations compared to im-
mediate surgery (IS), and similar LOS. However, there is no standard
approach for the management of CAA in children, because the term
varies across the personal experience of surgeons and different criteria
among centers [1].
The purpose, therefore, of this study was to compare the outcomes
of IS to CT in CAA in children based on currently available literature.
1. Methods
1.1. Registration number
This meta-analysis has been registered in the international prospec-
tive register of systematic review (PSOSPERO CRD 42018090343
https://www.crd.york.ac.uk/PROSPERO).
1.2. Literature search strategy and study design
A systematic literature search on PubMed was performed, using
the Medical Subject Heading (MeSH) terms “immediate surgery”,
“conservative treatment”, “antibiotics”, “complicated appendicitis”,
“perforated or ruptured appendicitis”, “phlegmon” “appendiceal
mass”, “appendectomy (open or laparoscopic)”, “comparative
studies”, and “children”. These terms and their combinations were
also used as keywords. The search included eligible, prospective,
randomized, and nonrandomized and observational (prospective
and retrospective) studies that reported postoperative outcomes of
pediatric patients with CAA treated with IS and those who were treated
conservatively between 1969 and December 31, 2017. The related-
articles function was also used for additional search. The retrieved arti-
cles were evaluated based on title and abstract. The full text of those
articles that were eligible was screened. Furthermore, the references
of the articles were also investigated by hand. Studies that were not
written in English were excluded. All the studies and analyses were in
accordance to the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) statement [10].
1.3. Inclusion and exclusion criteria
Studies were included in this study if they met the following criteria:
(a) report precisely the treatment as IS (open or laparoscopic) or CT,
(b) compare patients with CAA treated surgically or conservatively,
and (c) report the outcome measures as previously defined. Cases of
gangrenous appendicitis without evidence of perforation were not
considered as CAA Clinical studies, such as reviews, mixed studies
(including both adults and children), case series, editorials, conference
proceedings, and letters to the editors, were excluded.
1.4. Data extraction
Two reviewers (GV and NZ) separately extracted the following: first
author; year of publication; country; journal; study design; level of
evidence; treatment methods; population characteristics; number of
children treated with each method; duration of symptoms before
admission; and clinical characteristics on admission: temperature,
diarrhea, hematological results, and the presence of intraabdominal
Please cite this article as: Vaos G, et al, Immediate surgery or conservative treatment for complicated acute appendicitis in children?
A meta-analysis, J Pediatr Surg (2018), https://doi.org/10.1016/j.jpedsurg.2018.07.017
abscess confirmed by radiological investigation. Furthermore, outcomes
such as postoperative complications and LOS were included in the
analysis. Any disagreement was discussed separately and resolved
with the aid of a third independent researcher (AD).
1.5. Definitions
CAA was defined as the operating findings of a perforated appen-
dix according to the surgeon's diagnosis [11], or periappendicular
abscess or phlegmon [12,13], or appendiceal perforation confirmed
in pathology report. IS was defined as a prompt appendectomy
performed on admission or within the first 48 h of hospitalization
after patient stabilization with intravenous fluids and antibiotics
[14]. CT was considered CAA managed with intravenous fluids,
broad-spectrum antibiotics and/or abscess drainage under radiolog-
ical guidance [15]. Wound infection was defined as superficial when
infection was in the skin area of the wound only or deep when the
infection was in the area of the muscles, fascia and surrounding
tissues [16].
1.6. Outcomes of interest
The selected indices for analysis in the present meta-analysis
were postoperative complications [overall, wound infection (deep or
superficial), abdominal or pelvic abscess, ileus or intestinal obstruction]
and LOS.
1.7. Statistical analysis
Statistical meta-analysis was performed with STATA SE statistical
software (Copenhagen: The Nordic Cochrane Centre, The Cochrane
Collaboration, 2011). Pooled odds ratios (OR), standardized mean dif-
ferences (SMD), and 95% confidence interval (CI) for all outcomes
were calculated, using the DerSimonian–Laird random-effects model
to account for heterogeneity among the studies. Heterogeneity was
estimated using the I 2 statistic, with a value ≥50% representing a high
level of heterogeneity. Publication bias was evaluated with the Egger's
bias test and Funnel plot.
Moreover, sensitivity analysis was performed by omitting one study
at a time to evaluate whether selected studies significantly influenced
the outcomes of the meta-analysis and the heterogeneity. Pooled effects
were recalculated after exclusion of such studies. Meta-regression
models were also used to detect any parameters that could have af-
fected the outcome. Additionally, the meta-analysis was also performed
for those studies that limit the definition to abscesses and phlegmons in
order to search for any possible changes.
2. Results
2.1. Literature information and study characteristics
The literature search provided 75 possibly related reports. After
screening titles and abstracts, 25 were retrieved for full-text screening,
of which 15 [2,11–13,17–27] were included in the present systematic
review (Fig. 1).
The general characteristics of the included studies are shown in
Table 1. Among these studies, 8 were retrospective [2–23]; 5 were
prospective, nonrandomized studies [11,17,19,20,27]; and 2 were
randomized control trials (RCTs) [24,25], one of which was nonblinded
[25]. These studies included 1243 patients with CAA. Among the
included patients, 581 (46.7%) were treated initially with CT, whereas
the remaining were treated surgically.
 G. Vaos et al. / Journal of Pediatric Surgery xxx (2018) xxx–xxx 3

Articles retrieved in initial search: 75
Articles excluded on the basis of
titles and abstracts: (n: 50)
Full-text articles screened and assessed for eligibility: 25
10 articles excluded due to:
-duplicates (n: 3),
-inability to extract the
necessary data (n: 5),
-lack of control groups (n: 2)
Studies included in the meta-analysis: 15
Fig. 1. Study selection flowchart.
results were observed for wound infection. The odds of developing a
wound infection were 60% lower in the CT group than in the immediate
surgery group (pooled OR: 0.4 [95% CI: 0.17, 0.96], p = 0.041 and I2 =
24.6%, p = 0.225). On the other hand, the choice of treatment procedure
did not statistically affect the odds of developing intraabdominal
abscess significantly (pooled OR: 1.03 [95% CI: 0.31, 3.37], p = 0.958
and I 2 = 50.8%, p = 0.071) or postoperative ileus (pooled OR: 0.29
[95% CI: 0.06, 1.44], p = 0.130 and I 2 = 25.7%, p = 0.260). We
accumulated the outcomes of interest in Table 2.
Sensitivity analysis for studies that limit the definition to abscesses
and phlegmons showed that pooled SMD for the outcome of LOS
was 0.80 days (95% CI [0.00; 1.61], p = 0.051) which favors IS, but
there was a significant heterogeneity among these studies (test for
heterogeneity; P b 0.001 and I 2 = 96.1%, Fig. 4). Regarding the compli-
cation rate, the odds of developing a complication were lower in
the group that was treated with CT, but the heterogeneity among
studies was high again (OR: 0.27 [95% CI: 0.08, 0.85], p = 0.026 and
I2 = 81.0%, p b 0.001, Fig.5).
3. Discussion

2.2. Meta-analysis results
Pooled standardized mean difference (SMD) for the outcome of LOS,
when including all studies, was 0.74 days (95% CI [0.12; 1.35], p =
0.019), which favors IS. Because there was significant heterogeneity
among the studies (test for heterogeneity: P b 0.001 and I 2 = 95.2%),
the effect of parameters such as age of patients, gender, and study de-
sign was estimated with meta-regression models, but no statistically
significant effect was detected. Meta-analysis was also performed after
removal of 5 studies [11, 12.19, 20, 24] because the effect from these
studies seemed like outliers, and it was not clear how LOS was evaluated
in the CT group. The polled SMD showed again a small trend for shorter
LOS in the IS group, and the heterogeneity was eliminated (SMD: 0.25
[95% CI: 0.07, − 0.43], p = 0.007 and I 2 = 0%, p = 0.788) (Fig. 2).
Furthermore, publication bias is graphically represented with a funnel
plot and was evaluated with Egger's bias test. No publication bias was
detected (Egger's bias test p = 0.713).
The outcome of complication rate was evaluated using a pooled
odds ratio (OR). The odds of developing a complication were lower
in the group that was treated with CT, but the heterogeneity among
studies was again high (OR: 0.27 [95% CI: 0.11, 0.70], p = 0.007 and
I2 = 77.4%, p b 0.001). After exclusion of three studies that had extreme
odds ratios [12,15,25], the heterogeneity vanished (I2 = 0%, p = 0.851,
Fig. 3), and the OR remained statistically significant, favoring CT. The
odds of any complication rate were 78% lower in the CT group than in
the IS group (pooled OR: 0.22 [95% CI: 0.14, 0.38], p b 0.001). Similar
We consistently reviewed the prevailing literature that compared
IS with CT in children with CAA. We found 15 studies [2,11–13,17–27]
addressing 581 children treated conservatively initially. The major-
ity of these studies (60%) were published during the past decade
[2,11–13,24–27]. This finding may reflect a conservative approach
to CAA in children based on the current evidence of the conservative
approach to acute appendicitis in promising studies in adults with
CAA [9], or UAA in children [4–6].
The management of CAA in children is still a field of controversy.
Generally, the initial management includes fluid resuscitation and in-
duction of broad-spectrum antibiotics [28], but there is no agreement
on what scenario should take place [29]. The traditional approach of
urgent appendectomy is an option based on the assumption that the in-
flamed appendix should be removed to eliminate the risk of infection
[9]. However, the emergency surgical approach may be difficult owing
to an edematous and fragile appendix and the surrounding intestinal
loops and tissues [30]. A second reasonable option is initial treatment
with antibiotics to avoid a troublesome operation and to intervene
when the infection is under control and operative hazards are dimin-
ished [31]. A third option is to manage the CAA initially with antibiotics
and perform an interval appendectomy usually at six to eight weeks
postdischarge [22]. In the present study, an interval appendectomy
was the treatment of choice for all patients treated conservatively
[2,11–13,17–27]. Some authors suggest that interval appendectomy is
not indicated in pediatric patients after successful conservative manage-
ment of CAA, because the rate of recurrence is about 8%–14%, whereas

Table 1
Characteristics of the 15 studies included in this meta-analysis.

Study Year Country Journal Study Design Randomization Level of evidence

22
1 Karp MP et al. 1986 USA J Pediatric Surgery Prospective non-RCT II
2 Bufo A.J. et al. 23 1998 USA J of Laparoendoscopic Retrospective non-RCT III
3 Samuel M, et al.24 2002 UK J Pediatr Surg Prospective non-RCT II
4 Weber TR et al.25 2003 USA American J Surgery Prospective non-RCT II
5 Ho CM et al.26 2004 Taiwan J Formos Med Assoc Retrospective non-RCT III
6 Erdoğan D et al.27 2005 Turkey Pediatr Surg Int Retrospective non-RCT III
7 Vane DW et al.28 2006 USA World J surgery Retrospective non-RCT III
8 Roach JP et al.30 2007 USA American J Surgery Retrospective non-RCT III
9 Henry MCW et al.29 2007 USA J of Pediatric Surgery Prospective non-RCT II-a
10 St. Peter SD et al.31 2010 USA J of Pediatric Surgery Prospective RCT I
11 Blakely ML et al.32 2011 USA Archives of Surgery Prospective RCT II
12 Calvert CE et al.33 2014 USA American Surgeon Retrospective non-RCT III
13 Furuya T et al.34 2015 Japan Indian J Surgery Retrospective non-RCT III
14 Tanaka Y et al.35 2016 Japan J of Pediatric Surgery Prospective non-RCT II
15 Tsai HY et al.2 2017 Taiwan Pediatric Neonatology Retrospective non-RCT III

RCT: Randomized Control Trial.

Please cite this article as: Vaos G, et al, Immediate surgery or conservative treatment for complicated acute appendicitis in children?
A meta-analysis, J Pediatr Surg (2018), https://doi.org/10.1016/j.jpedsurg.2018.07.017
4 G. Vaos et al. / Journal of Pediatric Surgery xxx (2018) xxx–xxx

Study %

ID SMD (95% CI) Weight

Ho CM et al. (2004) 0.51 (-0.01, 1.03) 11.83

Erdogan D et al. (2005) 0.07 (-0.55, 0.69) 8.32

St. Peter SD et al. (2010) 0.04 (-0.58, 0.66) 8.35

Blakely ML et al. (2011) 0.29 (-0.05, 0.64) 27.04

Calvert CE et al. (2014) 0.34 (-0.05, 0.73) 20.88

Furuya T et al. (2015) 0.35 (-0.36, 1.06) 6.36

Tanaka Y et al. (2016) 0.02 (-0.41, 0.45) 17.22

Overall (I-squared = 0.0%, p = 0.788) 0.25 (0.07, 0.42) 100.00

NOTE: Weights are from random effects analysis

-1.06 0 1.06
Favours CT Favours IS

SMD: Standardized Mean Difference, IS: Immediate Surgery, CT: Conservative Treatment

Fig. 2. Forest plot of Standardized Mean Difference for LOS (selected studies).

they are exposed to an 11%–18% risk of postoperative complications
[32]. Very recently, an RCT by Hall et al. demonstrated that more than
three-quarters of patients could avoid appendectomy after successful
CT of an appendix mass. Active observation resulted in a shorter LOS
and shorter period away from activity and was cheaper than interval ap-
pendectomy [33]. Others claim that the primary outcome in future trials
should be the success rate of nonsurgical management, defined as not
performing an appendectomy at all [34].
The choice of management showed a shorter LOS in the IS group.
These results are comparable to two very recent pediatric retrospective
studies [35,36], not included in our meta-analysis because they were
published beyond the study period, and in a meta-analysis [37] based
on two pediatric RCT studies [24,25]. This is opposite to the results of
Similis et al., who found no statistically significant differences between
IS and CT [9], and those of Andersson et al. [15] in a mixed meta-
analysis, including both adults and children, who showed a shorter

Study %

ID OR (95% CI) Weight

Bufo A. J. et al. (1998) 0.22 (0.05, 1.10) 10.28

Weber TR et al. (2003) 0.35 (0.09, 1.29) 15.11

Ho CM et al. (2004) 0.29 (0.08, 1.07) 14.97

Erdogan D et al. (2005) 0.06 (0.00, 1.20) 2.95

Vane DW et al. (2006) 0.29 (0.01, 5.88) 2.89

Roah JP et al. (2007) 0.13 (0.01, 2.37) 3.07

Henry MCW et al. (2007) 0.32 (0.13, 0.81) 30.45

Calvert CE et al. (2014) 0.12 (0.03, 0.46) 14.63

Tanaka Y et al. (2016) 0.07 (0.01, 0.59) 5.65

Overall (I-squared = 0.0%, p = 0.851) 0.23 (0.14, 0.38) 100.00

NOTE: Weights are from random effects analysis

.00314 1 318
Favours CT Favours IS
IS: Immediate Surgery, CT: Conservative Treatment

Fig. 3. Forest plot of odds ratio for complication rate.

Please cite this article as: Vaos G, et al, Immediate surgery or conservative treatment for complicated acute appendicitis in children?
A meta-analysis, J Pediatr Surg (2018), https://doi.org/10.1016/j.jpedsurg.2018.07.017
 G. Vaos et al. / Journal of Pediatric Surgery xxx (2018) xxx–xxx 5

Table 2
Outcomes of interest.

Study Year Hospitalization (days) Mean (SD) Any Complication (%) Wound Infection (%) Abdominal Infection (%) Ileus (%)
IS vs CT IS vs CT IS vs CT IS vs CT IS vs CT

1 Karp MP et al.22 1986 11.3 (6.2) vs 12.5 () 6.8% vs 16.7% 3.4% vs NA 1.1% vs 8.3% 2.3% vs NA
2 Bufo A.J. et al.23 1998 6.2 (3.1) vs 4.3 (2.1) 21.0% vs 6.0% 6.5% vs 6.0% 10.8% vs 0.0%
3 Samuel M, et al.24 2002 4.8 (0.4) vs 13.2 (1.5) 11.8% vs 0.0%
4 Weber TR et al.25 2003 28.2% vs 12.0% 7.0% vs 8.0% 19.7% vs NA 0.0% vs NA
5 Ho CM et al.26 2004 11.9 (6.1) vs 16.3 (10.2) 33.3% vs 12.5%
6 Erdoğan D et al.27 2005 8.7 (3.2) vs 8.9 (2.6) 26.3% vs 0.0% 5.3% vs 0.0% 15.8% vs 0.0%
7 Vane DW et al.28 2006 4.9 (1.7) vs 4.1 (1) 5.1% vs 0.0% 1.7% vs 0.0% 3.4% vs 0.0%
8 Roach JP et al.30 2007 7.1 (0.5) vs 8.3 (0.7) 10.0% vs 0.0%
9 Henry MCW et al.29 2007 8.8 (6.7) vs 6.5 (5.7) 41.7% vs 18.8% 10.4% vs 0.0% 22.9% vs 4.2% 8.3% vs 6.3%
10 St. Peter SD et al.31 2010 6.5 (3.8) vs 6.7 (6.6) 20.0% vs 25.0%
11 Blakely ML et al.32 2011 9 (5.3) vs 11.2 (9.2) 29.7% vs 55.2% 9.4% vs 9.0% 18.8% vs 37.3%
12 Calvert CE et al.33 2014 6.5 (6.7) vs 9 (7.7) 31.0% vs 5.2% 9.5% vs 0.0% 11.9% vs 0.0%
13 Furuya T et al.34 2015 26.2 (7.6) vs 28.6 (6) 86.7% vs 0.0% 40.0% vs 0.0% 33.3% vs 0.0% 13.3% vs 0.0%
14 Tanaka Y et al.35 2016 12.9 (5.2) vs 13 (3.9) 21.2% vs 1.8% 1.1% vs 8.3%
15 Tsai HY et al.2 2017 6.4 (2.2) vs 15.8 (6.9) 6.8% vs 16.7%

IS: Immediate Surgery, CT: Conservative Treatment, NA: data were not reported.

LOS in the CT group. One could suggest that some authors took into
account the total LOS in the case of CT, for example, LOS from first
admission and LOS from second admission for interval appendectomy
or recurrent appendicitis. Tanaka et al. [27] reported a total LOS of
12.9 ± 5. 2 days in the IS group and 20.1 ± 4.7 days in the CT group
(p: 0.00023), respectively, taking into account the overall LOS for pa-
tients of a CT group. Moreover, no evidence of significant publication
bias was found in this analysis according to Funnel plots and Egger's
tests. This finding indicates that the results of this meta-analysis were
highly stable. Also, the difference in LOS between the two study groups
could be attributed to surgeons choosing to continue antimicrobial
therapy for longer than current guidelines recommend in patients
who were treated conservatively [38]. However, one should keep in
mind that most studies were retrospective, with only a small proportion
of RCTs.
This study revealed a lower complication rate in the CT group,
regarding overall complication rate and wound infection. Similarly,
Similis et al. [9] found that in the group of pediatric patients with CAA,
CT was associated with significantly fewer overall complications
and less wound infection. In contrast, our results demonstrated
that there was no statistical difference regarding the development of
intraabdominal abscess or postoperative ileus. This finding could be
associated with the differences in the severity of the disease between
patients studied by Similis et al. [9] and the present study. Furthermore,
according to the meta-analysis of Duggan et al. [37], the severity of the
disease had a negative impact on the development of postoperative
complications, because the absence of abscess on admission decreased
considerably the odds of having a postoperative adverse event in
children treated with IS. However, in the same study, wound infection
was not affected by the presence of abscess on admission in children
treated either with IS or CT.
However, the present study has a number of limitations. Firstly, it
comprised mainly of retrospective and prospective, nonrandomized tri-
als, whereas only one study was of Level I. Moreover, in some studies, a
selection of patients with milder symptoms was performed, and most
studies referred to older children. Furthermore, a remarkable number
of studies were conducted at single centers with different plans in the
management of CAA. It is worth noting that none of the analyzed studies

Study %

ID SMD (95% CI) Weight

Samuel M et al. (2002) 7.13 (5.94, 8.32) 9.39

Ho CM et al. (2004) 0.51 (-0.01, 1.03) 11.25

Vane DW et al. (2006) -0.53 (-0.99, -0.06) 11.36

Henry MCW et al. (2007) -0.37 (-0.77, 0.03) 11.46

Blakely ML et al. (2011) 0.29 (-0.05, 0.64) 11.55

Furuya T et al. (2015) 0.35 (-0.36, 1.06) 10.81

Tanaka Y et al. (2016) 0.02 (-0.41, 0.45) 11.41

Tsai HY et al. (2017) 1.60 (1.16, 2.05) 11.39

Bufo A. J. et al. (1998) -0.70 (-1.15, -0.24) 11.37

Overall (I-squared = 96.1%, p = 0.000) 0.80 (-0.00, 1.61) 100.00

NOTE: Weights are from random effects analysis

-8.32 0 8.32
Favours CT Favours IS

Fig. 4. Forest plot of Standardized Mean Difference for LOS (sensitivity analysis for studies that limit the definition to abscesses and phlegmons).

Please cite this article as: Vaos G, et al, Immediate surgery or conservative treatment for complicated acute appendicitis in children?
A meta-analysis, J Pediatr Surg (2018), https://doi.org/10.1016/j.jpedsurg.2018.07.017
6 G. Vaos et al. / Journal of Pediatric Surgery xxx (2018) xxx–xxx
Study
ID
Weber TR et al. (2003)
Ho CM et al. (2004)
Vane DW et al. (2006)
Henry MCW et al. (2007)
Blakely ML et al. (2011)
Furuya T et al. (2015)
Tanaka Y et al. (2016)
Bufo A. J. et al. (1998)
Overall (I-squared = 81.0%, p = 0.000)
NOTE: Weights are from random effects analysis
.00025
Favours CT
Fig. 5. Forest plot for odds ratio for complication rate (sensitivity analysis for studies that limit the definition to abscesses and phlegmons).
reported the quality of life of patients, who underwent interval
appendectomy, and that of their families or possible postoperative
complications.
The present study shows that the optimal treatment of CAA has not
yet been clarified. Each method of treatment has its advantages and
disadvantages. Overall postoperative complication rate and wound
infection rate were lower in the CT group than in the IS group. IS may
show a slight trend for shorter LOS than the CT group. Furthermore,
the method that was used did not statistically affect intraabdominal
abscess or postoperative ileus. It is apparent that more RCTs are
warranted to discover safe management of children with CAA.
Competing interests
The authors declare that they have no conflicts of interest.
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Please cite this article as: Vaos G, et al, Immediate surgery or conservative treatment for complicated acute appendicitis in children?
A meta-analysis, J Pediatr Surg (2018), https://doi.org/10.1016/j.jpedsurg.2018.07.017