What are the risks and benefits of early versus delayed removal of appendix in people with symptomatic complicated appendicitis?
The human appendix is a tube at the connection of the small and the large intestines. Possible functions of the appendix may be to protect the body against infection and to maintain healthy levels bacteria in the gut when recovering from diarrhoea. Appendicitis covers a variety of clinical conditions resulting from inflammation of the appendix.
Complicated appendicitis is defined as appendiceal phlegmon (simple inflammatory mass without pus located in bottom right of the appendix) or appendiceal abscess (pocket of pus surrounding an acutely inflamed and/or ruptured appendix). People with this condition usually need surgical removal of the appendix to relieve their symptoms and avoid complications. The timing of surgical removal of the appendix is controversial. Immediate surgery is technically demanding. Some experts question the appropriateness of delayed appendectomy, as people are unlikely to experience a recurrence after a successful non-surgical treatment. However, the true diagnosis could be uncertain in some cases, and postponing the appendectomy may delay diagnosis of underlying disease.
We searched for all relevant randomised controlled trials up to 23 August 2016. We identified two trials involving 80 participants. One compared early versus delayed open appendicectomy in 40 children and adults with appendiceal phlegmon. The other trial compared early versus delayed keyhole (laparoscopic) appendicectomy (where surgery is performed through a very small incision) in 40 children with appendiceal abscess. Studies took place in the USA and India. The age of the individuals in the trials varied between 1 year and 84 years, and 27.5% were females.
Both two studies were small and had a number of limitations so we cannot be certain about how the effects of the two surgical approaches compare. From one trial in children and adults comparing open with delayed appendicectomy, there was insufficient evidence to show the effect of using either approach on the overall complication rate or the proportion of participants who developed wound infection. Our certainty in a longer stay in hospital stay and time away from normal activities with open appendicectomy is very low. There were no deaths in the study. Quality of life, and pain were not reported in this trial.
The other trial in children with appendiceal abscess receiving either early or delayed keyhole appendicectomy did not report on overall complication rates. The trial did not provide enough evidence to show the effect of using either approach on the length of hospital stay among participants. We have very low certainty that children who had early keyhole appendicectomy had better quality of life compared with children who had delayed keyhole appendicectomy. The study did not report if there were any deaths, and did not provide information on pain, or time away from normal activities.
At present the benefits and harms of early versus delayed appendicectomy are not well understood because the current information is based upon very low quality evidence.
Quality of the evidence
Both trials were at a high risk of bias. Overall, we judged the quality of the evidence to be very low. Thus, further well-designed trials are urgently needed.