Meta-Analysis
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Nov 26, 2021; 9(33): 10208-10221
Published online Nov 26, 2021. 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
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
Ying Wang, Dan-Dan Wu, 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
Chen-Yu Sun, Chandur Bhan, John Pocholo Whitaker Tuason, Sudha Misra, Internal Medicine, AMITA Health Saint Joseph Hospital Chicago, Chicago, IL 60657, United States
Jie Liu, 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
Yue Chen, Xing-Yu Cheng, Department of Clinical Medicine, School of the First Clinical Medicine, Anhui Medical University, Hefei 230032, Anhui Province, China
Yu-Ting Huang, University of Maryland Medical Center Midtown Campus, Baltimore, MD 21201, United States
Shao-Di Ma, Department of Epidemiology and Health Statistics, School of Public Health Anhui Medical University, Hefei 230032, Anhui Province, China
Qin Zhou, Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States
Wen-Chao Gu, Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
Xia Chen, 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
Author contributions: Wu DD, Chen X, Wang Y, Liu J and Sun CY designed the research study; Wang Y, Sun CY and Chen Y selected and collected the data; Wang Y, Sun CY and Liu J analyzed the data; Bhan C, Tuason JPW, Misra S, Huang YT, Ma SD, Cheng XY, Zhou Q and Gu WC provided critical opinions and revised the manuscript; Wang Y and Sun CY wrote the manuscript; Wang Y, Sun CY and Liu J contributed equally to this work and should be considered as co-first authors; all authors approved the final manuscript.
Conflict-of-interest statement: Allauthors have no conflict(s) of interest to declare in relation to this manuscript.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised in accordance with this checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Wu Dan-Dan, MSN, RN, Associate Chief Nurse, Department of Endoscopy Center, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, No. 17 Lujiang Road, Hefei 230001, Anhui Province, China. 16013255@qq.com
Received: June 5, 2021
Peer-review started: June 5, 2021
First decision: June 27, 2021
Revised: August 1, 2021
Accepted: October 14, 2021
Article in press: October 14, 2021
Published online: November 26, 2021
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: Endoscopic retrograde appendicitis therapy, Acute appendicitis, Meta analysis, Laparoscopic appendectomy, Randomized controlled study

Core Tip: Acute appendicitis is one of the common surgical emergencies all over the world, with a mean cost of about $9000 per procedure. It is recognized that the conventional treatment of acute appendicitis was laparoscopic appendectomy (LA), while an increasing number of surgical complications, include bleeding, adhesive intestinal obstruction, infection of the incision, and intestinal fistula, have been reported. Therefore, we conducted a meta-analysis to compare the effectiveness of endoscopic retrograde appendicitis therapy (ERAT) with standard treatment. After screening, 12 studies were included in the current systematic review and we found that, 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.