Is endoscopic retrograde appendicitis therapy a better modality for acute uncomplicated appendicitis? A systematic review and meta-analysis

Ying Wang; Chen-Yu Sun; Jie Liu; Yue Chen; Chandur Bhan; John Pocholo Whitaker Tuason; Sudha Misra; Yu-Ting Huang; Shao-Di Ma; Xing-Yu Cheng; Qin Zhou; Wen-Chao Gu; Dan-Dan Wu; Xia Chen

doi:10.12998/wjcc.v9.i33.10208

Is endoscopic retrograde appendicitis therapy a better modality for acute uncomplicated appendicitis? A systematic review and meta-analysis

World J Clin Cases. 2021 Nov 26;9(33):10208-10221. doi: 10.12998/wjcc.v9.i33.10208.

Authors

Ying Wang¹, Chen-Yu Sun², Jie Liu³, Yue Chen⁴, Chandur Bhan², John Pocholo Whitaker Tuason², Sudha Misra², Yu-Ting Huang⁵, Shao-Di Ma⁶, Xing-Yu Cheng⁴, Qin Zhou⁷, Wen-Chao Gu⁸, Dan-Dan Wu⁹, Xia Chen¹⁰

Affiliations

¹ Department of Endoscopy Center, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China.
² Internal Medicine, AMITA Health Saint Joseph Hospital Chicago, Chicago, IL 60657, United States.
³ Department of Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China.
⁴ Department of Clinical Medicine, School of the First Clinical Medicine, Anhui Medical University, Hefei 230032, Anhui Province, China.
⁵ University of Maryland Medical Center Midtown Campus, Baltimore, MD 21201, United States.
⁶ Department of Epidemiology and Health Statistics, School of Public Health Anhui Medical University, Hefei 230032, Anhui Province, China.
⁷ Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States.
⁸ Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan.
⁹ Department of Endoscopy Center, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China. 16013255@qq.com.
¹⁰ Department of Nursing,The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China.

Abstract

Background: Previous studies had shown endoscopic retrograde appendicitis therapy (ERAT) is an effective treatment for acute appendicitis. However, different studies reported conflicting outcomes regarding the effectiveness of ERAT in comparison with laparoscopic appendectomy (LA).

Aim: To compare the effectiveness of ERAT with LA.

Methods: Randomized controlled trials (RCTs) and retrospective studies of ERAT for acute uncomplicated appendicitis were searched in PubMed, Cochrane Library, Web of Science, Embase database, China National Knowledge Infrastructure (CNKI), the WanFang Database, and Chinese Scientific Journals Database (VIP) from the establishment date to March 1 2021. Heterogeneity was assessed using the I-squared statistic. Pooled odds ratios (OR), weighted mean difference (WMD), and standard mean difference (SMD), with 95% confidence intervals (CI) were calculated through either fixed-effects or random-effects model. Sensitivity analysis was also performed. Publication bias was tested by Egger's test, and Begg's test. The quality of included RCT were evaluated by the Jadad scale, while Newcastle-Ottawa scale is adopted for assessing the methodological quality of case-control studies. All statistical analysis was performed using Stata 15.1 statistical software. All statistical analysis was performed using Stata 15.1 statistical software. This study is registered with PROSPERO, CRD42021243955.

Results: After screening, 10 RCTs and 2 case-control studies were included in the current systematic review. Firstly, the length of hospitalizations [WMD = -1.15, 95%CI: -1.99, -0.31; P = 0.007] was shorter than LA group. Secondly, the level of post-operative CRP [WMD = -10.06, 95%CI: (-17.39, -2.73); P = 0.007], TNF-α [WMD = -7.70, 95%CI: (-8.47, -6.93); P < 0.001], and IL-6 Levels [WMD = -9.78, 95%CI: (-10.69, -8.88); P < 0.001; P < 0.001] in ERAT group was significantly lower than LA group. Thirdly, ERAT group had a lower incidence of intestinal obstruction than LA group. [OR = 0.19, 95%CI: (0.05, 0.79); P = 0.020]. Moreover, the quality of 10 RCTs were low with 0-3 Jadad scores, while the methodological quality of two case-control studies were fair with a score of 2 (each).

Conclusion: Compared with LA, ERAT reduces operation time, the level of postoperative inflammation, and results in fewer complications and shorter recovery time, with preserving the appendix and its immune and biological functions.

Keywords: Acute appendicitis; Endoscopic retrograde appendicitis therapy; Laparoscopic appendectomy; Meta analysis; Randomized controlled study.