Objective: to compare non-operative treatment (NOT) with antibiotics of acute uncomplicated appendicitis (AUA) in children as an alternative to appendectomy (AP).
Design: systematic review with meta-analysis.
Data sources: the authors searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase databases in December 2015. They used the search terms “nonoperative” “non-operative”, “conservative”, “appendicitis”, “child” and “children”. Language was restricted to English. They excluded studies that were unpublished or published only in abstract form. The authors also reviewed the references of included articles.
Study selection: the review included all types of studies. The exclusion criteria were: complicated appendicitis, studies of adults and children, and studies of children with malignancies. The authors used the Jadad scale to assess the quality of one randomised controlled trial and the methodological index for nonrandomized studies (MINORS) for nonrandomised studies. A total of 10 studies were included; 7 were prospective and 3 retrospective, 6 were comparative and only 1 was randomised (pilot study).
Data extraction: two reviewers extracted the data independently and differences were resolved by consensus. The primary outcome was discharge from hospital without appendectomy during the initial episode. The authors performed one-sided and two-sided meta-analyses using the random effects model. The study did not include a sensitivity analysis.
Main results: 413 children received NOT, which was efficacious in 97% (95% confidence interval [IC 95], 95.5 to 98.7) with a low index of heterogeneity (I2, 0%) during the initial admission. The duration of followup ranged between 2 and 54 months, and 14% of patients (95 CI, 7 to 21; I2, 80%) required AP for recurrent appendicitis. The long-term efficacy of NOT was 82% (95 CI, 77 to 87; I2, 34%). The length of stay (4 studies) was half a day longer in PA patients (95 CI, 0.2 to 0.8; I2, 54%). The length of stay including recurrent episodes was 1.1 shorter in patients that underwent AP (95 CI, –1.2 to 3.5; two studies; I2, 93%), and the risk of complications (five studies; I2, 0%) was similar in both groups.
Conclusion: this study shows that the evidence currently available does not support NOT in place of AP in patients with AUA. For the time being, it is recommended that NOT only be offered to children included in carefully designed research studies, which are currently justified.
Conflicts of interest: the authors disclosed no conflicts of interest.
Funding source: no external funding.