Edited by: Mahesh C. Misra, All India Institute of Medical Sciences, India
Reviewed by: Giuseppe Sammarco, University of Catanzaro, Italy; Demetrios Demetriades, USC, United States
This article was submitted to Visceral Surgery, a section of the journal Frontiers in Surgery
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The objective of this study is to compare clinical and surgical outcomes of appendectomy among elderly and non-elderly subjects.
A systematic search was conducted on PubMed, Scopus, and Google academic databases. Studies, observational in design, that compared peri-and postoperative outcomes of appendectomy, in patients with acute appendicitis, between elderly and non-elderly/younger subjects were considered for inclusion. Statistical analysis was performed using STATA software.
A total of 15 studies were included. Compared to non-elderly patients, those that were elderly had an increased risk of complicated appendicitis [relative risk (RR), 2.38; 95% CI: 2.13, 2.66], peritonitis [RR, 1.88; 95% CI: 1.36, 2.59], and conversion from laparoscopic to open appendectomy [RR, 3.02; 95% CI: 2.31, 3.95]. The risk of overall postoperative complications [RR, 2.59; 95% CI: 2.19, 3.06], intra-abdominal abscess [RR, 1.84; 95% CI: 1.15, 2.96], wound infection [RR, 3.80; 95% CI: 2.57, 5.61], and use of postoperative drainage [RR, 1.14; 95% CI: 1.09, 1.19] was higher among the elderly. The risk of readmission (30 days) [RR, 1.61; 95% CI: 1.16, 2.24] and mortality (30 days) [RR, 12.48; 95% CI: 3.65, 42.7] was also higher among elderly.
Findings suggest an increased risk of peri-and postoperative complications among elderly subjects undergoing appendectomy, compared to non-elderly subjects.
Acute appendicitis (AA) is among the common clinical conditions encountered in a surgical emergency unit. The global incidence of acute appendicitis is around 10% with the peak during 20–40 years of life (
Despite the non-operative or conservative management being available for AA, appendectomy remains the gold standard for managing acute appendicitis (
The study processes complied with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines (
Upon identification of studies on literature search and removal of the duplicates, two subject experts from the team reviewed the studies and screened the titles and abstracts as the initial step. The full text of possible studies was subsequently reviewed. Any disagreements in the inclusion of the studies were resolved through discussions between the study authors. Only those studies were included in the meta-analysis that fulfilled the inclusion criteria. To identify additional literature, the reference list of the included studies was also reviewed.
Studies that compared clinical and/or surgical outcomes for appendectomy, done with the indication of acute appendicitis, between elderly and non-elderly/younger subjects, were considered for inclusion. Studies that were observational in design—either cohort or case-control or analyzed retrospective data—were considered for inclusion.
Case reports or review articles were excluded. Those studies that did not provide data on the outcomes of interest or those that did not compare outcomes between elderly and non-elderly/younger subjects were excluded.
Through the use of a pretested data extraction sheet, two study authors separately extracted data from the included studies. Data extracted mainly included the study identifier, i.e., the name of the first author with the year of publication, study setting and design, subject characteristics, sample size, and the key findings. The Newcastle-Ottawa Quality Assessment Scale was used to assess the quality of included studies (
This meta-analysis was conducted using STATA version 16.0. The effect sizes, along with 95% CI, were reported as pooled relative risk (RR) for categorical outcomes and weighted mean difference (WMD) for continuous outcomes. Subgroup analysis was done based on the type of appendectomy used in the study: open, laparoscopic, or mixed (i.e., some subjects received open and some received laparoscopic appendectomy). For the analysis,
Using the search strategy and after removal of the duplicates, overall, 749 citations were obtained (
The selection process of the studies included in the review.
Characteristics of the studies included in the meta-analysis.
Angeramo et al. ( |
Prospective follow up | Argentina | Patients undergoing laparoscopic appendectomy; around 51% male; BMI ≥ 30 kg/m2 (5.6%); ASA score of I or II (98%) | Elderly: ≥65 years |
2009 (elderly: 122; non-elderly: 1887) | |
Cohen-Arazi et al. ( |
Retrospective review | Israel | Patients who underwent appendectomy due to acute appendicitis (heterogenous population with some undergoing laparoscopic appendectomy and some open appendectomy); mean age in the elderly group was 74.6 years whereas those in the non-elderly group were in the age range of 20–45 years | Elderly: ≥65 years |
198 (elderly: 74; non-elderly: 124) | |
Dhillon et al. ( |
Retrospective review | USA | Patients undergoing an appendectomy (specific details on whether LA or open appendectomy not provided): those who underwent an interval appendectomy or an appendectomy for a reason other than appendicitis were excluded; mean age in the elderly group was 67.4 years and in non-elderly group was 37.3 years; males (53.5%); mean BMI of 25.8 kg/m2 | Elderly: ≥65 years |
1,242 (elderly: 52; non-elderly: 1,190) | |
Fan et al. ( |
Retrospective review | USA | Patients ≥18 years of age undergoing appendectomy with preoperative imaging consistent with acute appendicitis; ASA score of I or II (83%); male (52%); median age in the elderly group was 71 years and in non-elderly group was 34 years; around 97% had laparoscopic appendectomy and only around 3% had open appendectomy | Elderly: ≥65 years |
21,586 (elderly: 2060; non-elderly: 19,526) | |
Kirshtein et al. ( |
Retrospective review | Israel | Patients undergoing laparoscopic appendectomy due to acute appendicitis; females (~60%); mean age in elderly group was 70.1 years and mean age in young group was 32.7 years; increased use of anti-coagulants in elderly (32.7%) compared to young (1.4%); increased comorbidities in elderly (57.4%) compared to younger group (9.5%) | Elderly: ≥60 years |
477 (elderly: 54; non-elderly: 423) | |
Lasek et al. ( |
Observation study (both retrospective data and prospectively collected data used) | Multicentric (Poland and Germany) | Patients undergoing laparoscopic appendectomy due to acute appendicitis; males (~52%); median BMI of 26 kg/m2; obesity (18%); majority with ASA I and II (95%) | Elderly: ≥65 years |
4,618 (elderly: 334; non-elderly: 4,284) | |
Mima et al. ( |
Retrospective review | Japan | Patients undergoing interval laparoscopic appendectomy due to acute appendicitis; females (~54%); BMI ≥25 kg/m2 (28%); comorbidities (8%) | Elderly: ≥70 years |
47 (elderly: 18; non-elderly: 29) | |
Renteria et al. ( |
Retrospective review | USA | Patients undergoing appendectomy due to acute appendicitis; laparoscopic appendectomy in around 91% patients; male (90.7%); mean BMI of 30.3 kg/m2; ASA I/II (69.3%); comorbidities (44%) | Elderly: ≥60 years |
257 (elderly: 62; non-elderly: 195) | |
Segev et al. ( |
Retrospective review | Israel | Patients undergoing appendectomy due to acute appendicitis; laparoscopic appendectomy in 55% patients; male (55.4%); mean age of 78 yrs in elderly group and 23 yrs in non-elderly group | Elderly: ≥68 years |
1,898 (elderly: 68; non-elderly: 1,830) | |
Weinandt et al. ( |
Retrospective review | France | Patients undergoing appendectomy due to acute appendicitis; laparoscopic appendectomy in 52% patients; male (54.5%); median age of 83 yrs in elderly group and 29.5 yrs in non-elderly group; ASA I/II (91%) | Elderly: ≥75 years |
2,060 (elderly: 65; non-elderly: 1,995) | |
Pokharel et al. ( |
Retrospective review | Nepal | Patients undergoing open appendectomy (94.5%) due to acute appendicitis; male (40% in elderly and 33.3% in non-elderly group) | Elderly: ≥60 years |
200 (elderly: 50; non-elderly: 150) | |
Zbierska et al. ( |
Retrospective review | Poland | Patients undergoing appendectomy due to acute appendicitis; majority undergoing laparoscopic appendectomy (53.2%); female (56%); mean age of 71.6 yrs in elderly group and 32.4 yrs in non-elderly group | Elderly: ≥65 years |
274 (elderly: 23; non-elderly: 251) | |
Guller et al. ( |
Retrospective analysis of NIS data (NIS is publicly available database in USA) | USA | Patients undergoing laparoscopic appendectomy due to acute appendicitis; mean age of 72.5 yrs in elderly group and 29.8 yrs in non-elderly group; female (52.9% in elderly and 48.5% in non-elderly group) | Elderly: ≥65 years |
32,406 (elderly: 1,475; non-elderly: 30,931) | |
Guller et al. ( |
Retrospective analysis of NIS data (NIS is publicly available database in USA) | USA | Patients undergoing open appendectomy due to acute appendicitis; mean age of 73.9 yrs in elderly group and 27.8 yrs in non-elderly group; female (48.7% in elderly and 38.6% in non-elderly group) | Elderly: ≥65 years |
112,884 (elderly: 8,001; non-elderly: 104,883) | |
Ghnnam et al. ( |
Retrospective analysis of medical records | Egypt | Patients undergoing open appendectomy (?) due to acute appendicitis; mean age of 74.9 yrs in elderly group and 23.2 yrs in non-elderly group; female (52.2% in elderly and 27.5% in non-elderly group) | Elderly: ≥60 years |
63 (elderly: 23; non-elderly: 40) | |
Sammut et al. ( |
Retrospective review | Malta | Patients undergoing appendectomy due to acute appendicitis; majority with open appendectomy (54%); female (72.7% in elderly and 48.6% in non-elderly group) | Elderly: >75 years |
173 (elderly: 33; non-elderly: 140) |
There was heterogeneity with regard to the cut-offs used by the included studies to define “elderly.” A total of 7 studies used the cut-off of ≥ 65 years to label subjects as elderly, whereas 4 studies used the cut-off of ≥ 60 years. Two studies used ≥ 75 years as cut-off, and one study each used the cut-off of ≥ 68 and ≥ 70 years, respectively (
The total operative time (in minutes) [WMD, 5.96; 95% CI: 2.32, 9.61,
Operative time and length of hospital stay among elderly subjects, compared to non-elderly subjects.
Clinical outcomes of appendectomy among elderly subjects, compared to non-elderly subjects.
Postoperative complications of appendectomy among elderly subjects, compared to non-elderly subjects.
Risk of readmission and mortality among elderly subjects, compared to non-elderly subjects.
Subgroup analysis base showed that, irrespective of the type of appendectomy (i.e., laparoscopic, open, and mixed), elderly subjects, compared to younger subjects, had an increased risk of complicated appendicitis, overall postoperative complication, wound infection, and length of hospital stay (in days) (
Outcomes in elderly, compared to non-elderly, based on the type of appendectomy.
Complicated appendicitis | RR 2.11 (1.91, 2.33); ( |
RR 2.35 (1.41, 3.94); ( |
RR 3.06 (2.12, 4.41); ( |
Peritonitis | RR 1.97 (1.42, 2.75); ( |
---- | RR 1.05 (0.36, 3.07); ( |
Conversion to open surgery | RR 2.61 (2.19, 3.11); ( |
---- | RR 4.35 (2.15, 8.81); ( |
Overall complication | RR 2.22 (1.74, 2.82); ( |
RR 2.81 (1.94, 4.07); ( |
RR 2.98 (1.62, 5.46); ( |
Post-operative intra-abdominal abscess | RR 1.96 (1.03, 3.74); ( |
RR 1.50 (0.14, 16.2); ( |
RR 1.33 (0.26, 6.94); ( |
Post-operative wound infection | RR 2.25 (1.18, 4.31); ( |
RR 4.71 (3.23, 6.87); ( |
RR 3.91 (1.63, 9.37); ( |
Use of post-operative drain | RR 1.14 (1.09, 1.19); ( |
---- | RR 0.72 (0.19, 2.71); ( |
Readmission | RR 1.63 (1.13, 2.34); ( |
---- | RR 1.18 (0.38, 3.66); ( |
Mortality | RR 2.56 (0.79, 8.27); ( |
RR 33.8 (25.9, 44.1); ( |
RR 17.7 (4.2, 75.3); ( |
Operative time (min) | WMD 2.92 (−1.24, 7.09); ( |
WMD 30.0 (18.0, 24.0); ( |
WMD 9.21 (−4.15, 22.6); ( |
Length of hospital stay (days) | WMD 1.57 (1.13, 2.02); ( |
WMD 3.64 (3.05, 4.22); ( |
WMD 2.66 (1.42, 3.90); ( |
The current meta-analysis was conducted to compare the outcomes of appendectomy among elderly and non-elderly subjects. Additionally, it also aimed to understand if the outcomes differ by the type of appendectomy; i.e., laparoscopic or open. The study found an increased risk of adverse clinical outcomes among elderly subjects, and this was largely irrespective of the type of appendectomy. The total operative time and the length of hospital stay were higher for the elderly. Compared to non-elderly patients, those that were elderly had an increased risk of complicated appendicitis, peritonitis, postoperative complications, intra-abdominal abscess, wound infection, and conversion from laparoscopic to open appendectomy. The risk of readmission and mortality within 30 days of operation was also higher in elderly subjects.
A recent systematic review and meta-analysis by Wang et al. documented that, among the elderly subjects, postoperative mortality was lower following laparoscopic appendectomy (
In our review, we noted an increased risk of complicated appendicitis such as perforation or gangrene among elderly subjects. This is possibly attributed to the delayed presentation (
The meta-analysis documented an increased risk of peri- and postoperative adverse outcomes in elderly subjects, compared to non-elderly subjects. Due to this increased risk, non-surgical/conservative management may be more advisable for elderly subjects but considering that the risk of life-threatening complications, such as complicated appendicitis (perforation, gangrene, or necrosis) and generalized peritonitis, is more common in the elderly, surgical approach is still the advisable management strategy. The results of this meta-analysis can impact the clinical practice and underscore the need for an enhanced vigilance and awareness of the surgeon regarding the non-specific presentation of acute appendicitis in the elderly. This might lead to an early diagnosis and management in this high-risk group. Furthermore, this could alleviate the risk of peri-operative complications and possibly reduce the need for conversion from laparoscopic to open surgery. The findings also support the need for better peri- and postoperative care for elderly subjects undergoing appendectomy and emphasize that the surgeon should be careful while treating the elderly, irrespective of the mode of appendectomy, i.e., open or laparoscopic.
There could be differences in the outcomes across the included studies based on the services available at the treating hospital, the skills of the surgeon, and the quality of post-operative care provided. This could be one of the factors leading to a moderate degree of heterogeneity noted for some of the outcomes. Furthermore, the included studies did not mention clearly whether the estimates presented in their study were accounted or adjusted for the baseline differences in the elderly and non-elderly subjects. This is important to consider as, in some of the included studies, there were baseline differences, particularly concerning the presence of comorbidities, and these could affect the outcome of the surgery. All the included studies were observational, and, of them, mostly used retrospectively collected data. The possibility that important confounders are not adjusted in the analysis cannot be ruled out. The included studies were from a diverse geography and possibly involved surgical teams with varied skills, techniques, and experience. These also may have contributed to the heterogeneity.
Publicly available datasets were analyzed in this study. This data can be found at: PubMed, Scopus and Google academic databases from inception until October 2021 for relevant publications.
JY conceived and designed the study. JY, WH, LY, and QC were involved in literature search and data collection. QC, WH, and LY analyzed the data. JY and XL wrote the paper. XL reviewed and edited the manuscript. All authors read and approved the final manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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