Clinical efficacy and safety of endoscopic retrograde appendicitis treatment for acute appendicitis in children: a systematic review and meta-analysis

Abstract

Objectives

To evaluate the clinical efficacy of endoscopic retrograde appendicitis therapy (ERAT) in the management of acute appendicitis in pediatric patients.

Methods

A comprehensive search was conducted across seven electronic databases. Methodological quality of included studies was assessed using the Cochrane risk of bias tool. Statistical analyses were performed using RevMan 5.3 and Stata 13 software.

Results

Ten studies involving 1,372 pediatric patients were included (ERAT group: 660; control group: 712). Compared to the control group, the ERAT group demonstrated significant advantages in multiple outcomes: shorter operative time [WMD = − 9.98, 95%CI: (-17.47, − 2.49); P = 0.009], higher fecalith detection rate [RR = 1.81, 95%CI: (1.43, 2.30); P < 0.00001], shorter postoperative feeding time [SMD = − 3.21, 95%CI: (− 4.04, − 2.38); P < 0.00001], lower postoperative white blood cell count [WMD = − 1.45, 95%CI: (− 1.93, − 0.96); P < 0.00001], faster normalization of white blood cell levels [WMD = − 1.62, 95%CI: (− 2.03, − 1.20); P < 0.00001], quicker resolution of fever [WMD = − 1.15, 95%CI: (− 1.48, − 0.81); P < 0.00001], shorter duration of abdominal pain relief [SMD = − 1.18, 95%CI: (− 1.59, − 0.77); P < 0.00001], reduced bed rest time [WMD = − 1.39, 95%CI: (− 1.61, − 1.18); P < 0.00001], fewer complications [RR = 0.27, 95%CI: (0.18, 0.39); P < 0.00001], higher initial treatment success rate [RR = 1.11, 95%CI: (1.06, 1.16); P < 0.0001], shorter hospital stay [WMD = − 2.21, 95%CI: (− 2.69, − 1.73); P < 0.00001], and lower hospitalization costs [SMD = − 2.84, 95%CI: (− 3.47, − 2.20); P < 0.00001]. However, no statistically significant difference was observed in recurrence rates between groups [RR = 0.78, 95%CI: (0.51, 1.19); P = 0.24].

Conclusions

ERAT demonstrates unique advantages in pediatric acute appendicitis, including alleviating symptoms, accelerating recovery, reducing hospitalization duration and costs, minimizing complications, preserving appendiceal function, and optimizing healthcare resource utilization. Nevertheless, postoperative recurrence remains a concern, necessitating further validation through multicenter, large-scale randomized controlled trials.

Study registration

PROSPERO CRD420251020742, date of registration: March 27th, 2025.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-025-00659-7.

Introduction

Acute appendicitis (AA) represents the most prevalent acute abdominal condition in the pediatric population. The pediatric appendix, anatomically positioned at the terminus of the cecum, undergoes a developmental transition from a funnel-shaped structure to a tubular form with distal obliteration. Its incidence demonstrates an age-dependent increase, exhibiting a male-to-female ratio of approximately 1.4:1 [1–3]. The European Association for Endoscopic Surgery categorizes AA into acute uncomplicated appendicitis (AUA) and acute complicated appendicitis (ACA), with ACA encompassing gangrenous changes with or without perforation, intra-abdominal abscess, or periappendiceal abscess. AUA is defined by the exclusion of these complications, comprising both simple and suppurative appendicitis [4–6].

The pathogenesis of AA remains incompletely elucidated, with proposed mechanisms including appendiceal luminal obstruction [7], gut microbiota dysbiosis [8, 9], neurogenic mechanisms [10, 11], genetic predisposition [12, 13], and constipation [14]. While histopathological examination remains the diagnostic gold standard, experienced clinicians can achieve diagnostic accuracy rates exceeding 90% through comprehensive clinical evaluation [15].

Current therapeutic strategies present clinical dilemmas. Broad-spectrum antibiotics targeting predominant Gram-negative pathogens (Bacteroides fragilis and Escherichia coli) and secondary enterococcal/streptococcal infections [16, 17] are associated with high recurrence rates [18]. Surgical interventions (laparoscopic or open appendectomy) impose operative trauma [19] and eliminate the appendix’s documented immunomodulatory functions in intestinal immunity and microbiota regulation [20, 21], while carrying risks of postoperative complications [22]. Endoscopic retrograde appendicitis therapy (ERAT) has emerged as an organ-preserving alternative combining colonoscopy with endoscopic retrograde appendiceal intubation. This innovative approach employs contrast injection, appendicolith extraction, luminal irrigation, and stent placement to decompress the obstructed appendix, thereby alleviating inflammation while preserving anatomical integrity and physiological function [23].

Despite growing clinical interest, existing systematic reviews [24, 25] have yet to comprehensively evaluate ERAT’s therapeutic efficacy in pediatric AA populations. This meta-analysis therefore aims to critically assess the clinical outcomes and safety profile of ERAT in the management of childhood acute appendicitis.

Materials and methods

The Preferred Reporting Items declared by the Systematic Review and Meta-Analysis (PRISMA) [26] was utilized in the performance of this study.

Search strategy

A systematic review of electronic databases (PubMed, Embase, Web of Science, Cochrane library, China National Knowledge Infrastructure (CNKI), Chinese VIP Information Database and Wan Fang Med Databas) was done independently by two authors from inception to 15 March 2025. We also searched Clinical Trials. Gov (www.clinicaltrials.gov) and the Chinese Clinical Trials Center (https://www.chictr.org.cn) for unpublished reports. Meanwhile, we conducted an expanded reference search of the selected studies. Search terms included “endoscopic retrograde appendicitis treatment” “endoscopic appendicitis treatment” “retrograde appendicitis treatment” “non-invasive appendicitis treatment” “erat” “children” “child”. The detailed search strategy is provided in Appendix A.

Selection of studies

Inclusion criteria: (1) Study type: randomized controlled trials, retrospective studies and prospective studies; (2) Type of participants: participants of younger than 18 years old diagnosed with AA; (3) Type of intervention: intervention was endoscopic retrograde appendicitis therapy, while control group receiving laparoscopic appendectomy (LA), open appendectomy (OA) or antibiotics; (4) Outcomes: literatures should provide accurate comprehensive statistical indicators: operative time, appendiceal fecalith, postoperative feeding time, postoperative white blood cell count, time interval of white blood cells count returning to normal range, time interval of body temperature returning to normal range, duration of abdominal pain relief, bed rest time, complications, initial treatment success rate, length of hospital stay, the cost of hospitalization and recurrence; (5) Articles published in English or Chinese.

Exclusion criteria: (1) Duplicate publications, nursing reports, meta-analyses, conference papers, review papers or supplemental literature, etc.; (2) Studies without sufficient data, control groups or interventions; (3) Modified Jadad score ≤ 3.

Data extraction and management

The inclusion criteria were pre-developed by all investigators. Two independent reviewers gradually eliminated the preliminary screening data, and made an independent decision on whether to include each paper according to the eligibility criteria. The data of the eligible studies were extracted separately using a pre-designed data extraction form, and if there was a disagreement on the final opinion of the literature, it was resolved by consensus with the senior authors. The following data were extracted: author’s name, the time of publication, study type, age of patients, interventions of experimental and control group, number of cases, the type of appendicitis, outcomes and risk of bias. If there were differences in units of measurement between studies, they were uniformly converted to international unified units.

Literature quality evaluation

Two review authors independently assessed the risk of bias of the included studies and cross-checked the results. Disagreement was assessed by a third senior researcher for inclusion. The quality and methods of the included RCTs were assessed using the Cochrance Manual 5.1.0 [27] and the modified Jadad scale [28]. For case–control studies, the MINORS item [29] was used for methodological evaluation.

Statistical analysis

All synthesis, calculation and analysis of extracted data were performed using Review Manager 5.3 and Stata 13.0 statistical software. The risk ratio (RR) and corresponding 95% confidence interval (95%CI) were calculated for dichotomous outcomes. Mean difference (MD) and 95%CI were calculated for continuous outcomes. For continuous outcomes which measure the same underlying construct using different scales, the standard mean difference (SMD) and 95%CI were calculated [30]. Statistical heterogeneity was assessed using Cochran’s Q statistic, and Higgins and Thompson’s I² (Tau², Chi² and I² statistics). The fixed-effect model was used for meta-analysis when p ≥ 0.10 and I² ≤ 50%, indicating adequate homogeneity. Otherwise, the random-effect model was used. Data of the outcomes were recorded for this meta-analysis when two or more trials reported the same outcome. Sensitivity analyses were performed to investigate the robustness of this meta-analysis. Meanwhile, the risk of publication bias was evaluated by funnel plot and Egger’s test. We aimed to assess potential publication bias based on the symmetry of the funnel plot. If it was difficult to judge whether the funnel plot was symmetric, Egger’s test was used to further clarify whether publication bias was present [31]. A P value < 0.05 was considered statistically significant.

Results

Results of the literature search

The preliminary search yielded PubMed (n = 14), Embase (n = 23), Web of Science (n = 45), Cochrane library (n = 12), CNKI (n = 23), VIP (n = 29), Wan Fang (n = 24) and Chinese Clinical Trial Registry (n = 1). In addition, the references of the included literature were traced back to supplement the acquisition of relevant information. After excluding all ineligible articles, four RCT studies and six non-RCT studies with a total of 1372 patients were included in this review. The details of screening and number of records identified, included, and excluded were shown in the study flow diagram [26] (Fig. 1).

Fig. 1.

Flow chart of screening articles for inclusion in the study

Characteristics and quality assessment of the included studies

All included studies were conducted in China. A total of 1372 subjects was recruited, including 660 cases and 712 controls. One trial [41] compared ERAT with open appendectomy (OA), four trials [33, 34, 38, 39] compared ERAT with antibiotics, and the others compared ERAT with LA. Four RCT trials were graded using the modified Jadad scale and the Cochrance Manual 5.1.0. The results of the modified Jadad scale showed that four trials scored at least 4 (shown in Appendix B), the Cochrance Manual 5.1.0 showed that randomization was used in all four RCTs with complete outcome data, and there were no selective reporting of trials results (shown in Fig. 2 and Fig. 3). All included RCT studies used appropriate sequence generation methods. No trials were reported as double-blind trials because informed consent is required for surgical treatment, and it is difficult to achieve double blinding. However, we considered all the trials to be at low risk of bias because the lack of blinding was unlikely to affect the results. For the remaining six non-RCTs, the MINORS scale showed a total score of 17 ≥ for each trial (shown in Table 1). The above results indicated that the overall quality of the included articles was acceptable. The main characteristics of the included studies were presented in Table 2.

Fig. 2.

Risk of bias graph

Fig. 3.

Risk of bias summary

Table 1.

MINORS scale of six non-RCTs

Study	Jia 2022	Tu 2024	Xia 2023	Xi 2023	Zhang 2023	Zhang 2024
A clearly stated aim	2	2	2	2	2	2
Inclusion of consecutive patients	2	2	1	2	2	2
Prospective collection of data	2	2	2	2	2	2
Endpoints appropriate to the aim of the study	1	1	1	1	2	2
Unbiased assessment of the study endpoint	1	1	1	1	1	1
Follow-up period appropriate to the aim of the study	1	1	1	1	1	1
Loss to follow up less than 5%	2	2	2	2	2	2
Prospective calculation of the study size	2	2	2	2	2	2
An adequate control group	2	2	2	2	2	2
Contemporary groups	2	2	1	1	2	2
Baseline equivalence of groups	2	2	2	2	2	2
Adequate statistical analyses	2	2	2	2	2	2

Table 2.

Characteristics of included studies

Reference	Studies types	Patients age	Treatment		Sample size		Disease	Outcomes	Modified Jadad score
			Experiment	Control	Experiment	Control
Jia et al. [32]	Case–control	2 to 16 years old	ERAT	LA	30	30	AUA	①③④⑨⑪⑫⑬	—
Kang et al. [33]	RCT	1 to 13 years old	Modified ERAT	Antibiotics	36	47	AUA	⑦⑨⑩⑪⑬	5
Tu et al. [34]	Case–control	0 to 18 years old	ERAT	LA / Antibiotics	59	69/91	AUA	①②③⑨⑩⑪⑫⑬ / ②⑨⑩⑪⑬	—
Wang et al. [35]	RCT	2 to 13 years old	ERAT	LA	42	42	AUA	①⑥⑧⑨⑪	4
Xi et al. [36]	Case–control	2 to 10 years old	ERAT	LA	65	65	AUA	①⑥⑧⑨⑪⑬	—
Xia et al. [37]	Case–control	5 to 15 years old	ERAT	LA	29	36	AA	①③⑤⑪⑫⑬	—
Zeng et al. [38]	RCT	5 to 15 years old	ERAT	Antibiotics	30	30	AA	④⑤⑥⑦⑨⑪⑬	5
Zhang et al. [39]	Case–control	1 to 16 years old	Modified ERAT	LA / Antibiotics	228	66/95	AUA	①⑨⑩⑪⑫⑬ / ②⑨⑩⑪⑫⑬	—
Zhang et al. [40]	Case–control	0 to 18 years old	ERAT	LA	60	60	AUA	①③④⑦⑨⑪⑬	—
Zheng et al. [41]	RCT	2 to 16 years old	ERAT	OA	81	81	AA	①③⑤⑥⑧⑨⑪⑬	4

LA: laparoscopic appendectomy; OA: open appendectomy. AA: acute appendicitis; AUA: acute uncomplicated appendicitis. ①operative time; ②appendiceal fecalith; ③postoperative feeding time; ④postoperative white blood cell count; ⑤time interval of white blood cells count returning to normal range; ⑥time interval of body temperature returning to normal range; ⑦duration of abdominal pain relief; ⑧bed rest time; ⑨complications; ⑩initial treatment success rate; ⑪length of hospital stay; ⑫the cost of hospitalization; ⑬recurrence

Meta-analysis of outcomes

Eight studies compared the operative time of the ERAT groups and control groups. As there was significant heterogeneity (I² = 98%, P < 0.00001), we used a random-effect model. The result indicated that the operative time of the ERAT groups was significantly shorter than that of the control group [WMD = − 9.98, 95%CI: (− 17.47, − 2.49); z = 2.61, P = 0.009]. Shown in Fig. 4.

Fig. 4.

Forest plot of operative time

The fecalith detection rate was reported in two studies. There was no heterogeneity (I² = 0%, P = 0.44), so we used a fixed-effect model. The statistical analysis suggested that the fecalith detection rate in the ERAT groups was higher than that in the control groups. The result was statistically significant [RR = 1.81, 95%CI: (1.43, 2.30); z = 4.95, P < 0.00001]. Shown in Fig. 5.

Fig. 5.

Forest plot of appendiceal fecalith

Five studies reported the postoperative feeding time in the ERAT and control groups. With significant heterogeneity (I² = 90%, P < 0.00001), we used a random-effect model. The result showed that the postoperative feeding time of the ERAT group was significantly shorter than that of the control group [SMD = − 3.21, 95%CI: (− 4.04, − 2.38); z = 7.57, P < 0.00001]. Shown in Fig. 6.

Fig. 6.

Forest plot of postoperative feeding time

The postoperative white blood cell count was reported in three studies. There was low heterogeneity (I² = 40%, P = 0.19), so we used a fixed-effect model. The statistical analysis suggested that the postoperative white blood cell count in the control groups was higher than that in the ERAT groups [WMD = − 1.45, 95%CI: (− 1.93, − 0.96); z = 5.84, P < 0.00001]. Shown in Fig. 7.

Fig. 7.

Forest plot of postoperative white blood cell count

Three studies compared the time interval of white blood cells count returning to normal range between the ERAT and control groups. Due to high heterogeneity (I² = 67%, P = 0.05), we used a random-effect model. The statistical analysis demonstrated that the ERAT groups had a shorter time interval of white blood cells count returning to normal rang than the control groups [WMD = − 1.62, 95%CI: (− 2.03, − 1.20); z = 7.69, P < 0.00001]. Shown in Fig. 8.

Fig. 8.

Forest plot of time interval of white blood cells count returning to normal range

Four studies compared the time to return to normal temperature in the ERAT and control groups. Due to significant heterogeneity (I² = 96%, P < 0.00001), we used a random-effect model. The statistical analysis indicated that patients who received ERAT could return to normal temperature faster than the control group. The result was statistically significant [WMD = − 1.15, 95%CI: (− 1.48, − 0.81); z = 6.69, P < 0.00001]. Shown in Fig. 9.

Fig. 9.

Forest plot of time interval of body temperature returning to normal range

The duration of abdominal pain relief was reported in three studies. Due to significant heterogeneity (I² = 57%, P = 0.10), we used a random-effect model. The statistical analysis indicated that patients who received ERAT could have shorter time to relief the abdominal pain than the control group [SMD = − 1.18, 95%CI: (− 1.59, − 0.77); z = 5.59, P < 0.00001]. Shown in Fig. 10.

Fig. 10.

Forest plot of duration of abdominal pain relief

Three records reported the bed rest time in ERAT group and control group. With significant heterogeneity (I² = 83%, P = 0.003), so we used a random-effect model. The bed rest time in ERAT group was shorter than control group [WMD = − 1.39, 95%CI: (− 1.61, − 1.18); z = 12.68, P < 0.00001]. Shown in Fig. 11.

Fig. 11.

Forest plot of bed rest time

Nine studies reported the incidence of complications in the ERAT and control groups. There was no heterogeneity (I² = 0%, P = 0.45), so we used a fixed-effect model. The statistical analysis showed that the incidence rate of complications in the control groups was higher than that in the ERAT groups. The result was statistically significant [RR = 0.27, 95%CI: (0.18, 0.39); z = 7.03, P < 0.00001]. Shown in Fig. 12.

Fig. 12.

Forest plot of complications

Three studies compared the initial treatment success rate in the ERAT and control groups. There was low heterogeneity (I² = 13%, P = 0.32), so we used a fixed-effect model. The statistical analysis demonstrated that the ERAT groups had a higher rate of initial treatment success than the control group [RR = 1.11, 95%CI: (1.06, 1.16); z = 4.13, P < 0.0001]. Shown in Fig. 13.

Fig. 13.

Forest plot of initial treatment success rate

Ten studies compared the length of hospital stay between the ERAT and control groups. With significant heterogeneity (I² = 97%, P < 0.00001), we used a random-effect model. The result showed that the length of hospital stay of the ERAT group was significantly shorter than that of the control group [WMD = − 2.21, 95%CI: (− 2.69, − 1.73); z = 9.03, P < 0.00001]. Shown in Fig. 14.

Fig. 14.

Forest plot of length of hospital stay

Four studies compared the cost of hospitalization between the ERAT and LA groups. Due to significant heterogeneity (I² = 82%, P = 0.0009), we used a random-effect model. The statistical analysis showed that patients in the ERAT groups had the lower cost of hospitalization than patients in the LA groups [SMD = − 2.84, 95%CI: (− 3.47, − 2.20); z = 8.75, P < 0.00001]. Shown in Fig. 15.

Fig. 15.

Forest plot of the cost of hospitalization

Nine studies reported the recurrence rate of AA. There was low heterogeneity (I² = 44%, P = 0.07), so we used a fixed-effect model. The statistical analysis showed that the recurrence rate in the ERAT groups was no difference in the control groups [RR = 0.78, 95%CI: (0.51, 1.19); z = 1.17, P = 0.24 < 0.05]. Shown in Fig. 16.

Fig. 16.

Forest plot of recurrence rate

Sensitivity analysis

Furtherly, sensitivity analysis was performed to investigate the robustness of this meta-analysis. The results of sensitivity analysis shown that one study had a significant influence on the result of duration of operation [40]. For the remaining twelve outcomes, the pooled results did not change significantly after the individual studies were excluded one by one, indicating that the results were more stable. All the results of sensitivity analysis were shown in Appendix D.

Potential biases in the review process

For all outcomes, no obvious publication bias was depicted by the funnel plot (shown in Appendix C) and result from Egger’s test (P > 0.05). All outcomes of bias analysis were shown in Table 3. However, there was a high degree of statistical heterogeneity in some of the pooled analyses (i.e. operative time, postoperative feeding time, time interval of white blood cells count returning to normal range, time interval of body temperature returning to normal range, time of bed rest, length of hospital stay, the cost of hospitalization) and some researchers or professors thought that data for these outcomes should not be pooled. We attempted to use subgroup analysis to exclude the possibility of heterogeneity due to different treatments in the control group, but no satisfactory results were obtained, and some unexplained heterogeneity remained. In addition, the number of patients included in the special age group of children was a bit small, and it was difficult to perform subgroup analyses by age, region and gender. So, we believed that these results may be reasonable in the light of clinical practice. Based on our analysis and discussion, it might be attributed to different technical proficiency of the doctors and the inconsistent medical resources of different hospitals.

Table 3.

Publication bias of outcomes by Egger’s test

Study	Egger’s test
	T	P
Operative time	0.96	0.376 *
Fecalith detection rate	-	-
Postoperative feeding time	− 1.65	0.197 *
Postoperative white blood cell count	− 0.88	0.539 *
Time interval of white blood cells count returning to normal range	2.29	0.262 *
Time interval of body temperature returning to normal range	0.01	0.990 *
Duration of abdominal pain relief	− 1.23	0.434 *
Bed rest time	2.55	0.238 *
Complications	1.06	0.323 *
Initial treatment success rate	1.36	0.403 *
Length of hospital stay	− 0.37	0.721 *
The cost of hospitalization	− 0.82	0.498 *
Recurrence	0.94	0.378 *

^*p ≥ 0.05

Discussion

According to the literature [42], acute appendicitis in children accounted for about 25% of acute abdominal pain in children’s surgery, with a peak incidence from 10 to 19 years old. Obstruction of the lumen of the appendix, especially appendiceal fecalith, might cause acute appendicitis [43]. The treatment of acute appendicitis mainly included drug treatment and surgical treatment. Antibiotics were the mainstay of drug therapy [44], but the recurrence rate was as high as 40%, and 8% of patients did not respond to antibiotic therapy. Laparoscopic appendectomy remained as the conventional surgical treatment for acute appendicitis in children [45].

Emerging evidence indicateed that the appendix functioned as a multifunctional organ capable of synthesizing and secreting a diverse array of bioactive compounds, including digestive enzymes, prokinetic peptides, and growth-associated signaling molecules [46]. This lymphoid-rich structure had been implicated in immunoregulatory processes through its participation in pathogen recognition and immune surveillance mechanisms. Furthermore, the appendix served as a microbial reservoir housing commensal microbiota that contributed to intestinal homeostasis maintenance and microbiome restoration following enteric dysbiosis [47].

The conceptual framework of Endoscopic Retrograde Appendicitis Therapy (ERAT) was initially pioneered by Professor Liu Bingrong in 2012, marking the first international description of this innovative technique [48]. Subsequent clinical validation through a pediatric cohort study demonstrated a 96.9% technical success rate with 6.9% recurrence rate (median follow-up duration: 12 months) [49]. This minimally invasive approach has gained increasing acceptance among guardians of pediatric patients due to its unique capacity for appendiceal preservation with maintained physiological functions, coupled with scarless postprocedural outcomes. These distinctive advantages position ERAT as a preferred therapeutic option for families advocating conservative management strategies or expressing reservations regarding conventional surgical interventions [50].

Despite extensive research efforts over past decades, antibiotic therapy for acute appendicitis continued to demonstrate unsatisfactory long-term efficacy, particularly in cases complicated by appendiceal fecaliths. The landmark APPAC (Appendicitis Acuta) trial revealed a 39.1% cumulative recurrence rate at 5-year follow-up in antibiotic-treated cohorts [51–53]. This persistent therapeutic challenge underscored the critical need for alternative management strategies.

Endoscopic retrograde appendicitis therapy (ERAT) addressed the pathophysiological cornerstone of appendiceal obstruction through dual mechanisms included targeted removal of fecaliths and purulent material and restoration of luminal patency. This approach demonstrated particular therapeutic superiority in chronic appendicitis secondary to appendicolith formation, where mechanical obstruction constituted the primary disease driver [54, 55].

Emerging comparative evidence [56–58] positioned ERAT as a paradigm-shifting intervention for uncomplicated acute appendicitis in adults, offering distinct advantages over conventional antibiotic therapy and laparoscopic appendectomy. Clinical benefits included significant reduction in procedural discomfort, enhanced postoperative recovery kinetics, improved quality-of-life metrics during convalescence, preservation of appendiceal immunological function. Furthermore, ERAT demonstrated unique clinical utility in complex comorbid scenarios where surgical intervention proves contraindicated. Notable applications included concurrent acute pancreatitis with systemic inflammatory response syndrome (“cytokine storm”) [59], inflammatory bowel disease (particularly Crohn’s disease) [60] requiring conservative management.

These clinical advantages, coupled with expanding technical standardization and operator expertise, are propelling ERAT into mainstream gastroenterological practice as a viable therapeutic alternative. Ongoing research continues to refine its role in the evolving management algorithm of appendiceal pathology [61, 62].

Summary of results

This review systematically assessed the efficacy and safety of ERAT for the treatment of AA in children. In the result of operation time, there seemed to be a literature [40] that affected the robustness of the results during the sensitivity analysis, and we eliminated this article and found the same results as before, with the operation time of ERAT being significantly smaller than that of LA. It was worth noting that there was no statistical difference in the recurrence rate between the ERAT groups and the control groups, but the recurrence rate of the ERAT groups was indeed lower than control groups, and the initial treatment success rate of the ERAT groups was statistically different from control groups. In addition, the sample size of children was limited and the follow-up time was far from enough, so the recurrence rate of the ERAT deserves further tracking.

This review pooled the results of ten studies that assessed the effectiveness of ERAT in children. The pooled results showed that ERAT for AA in children had a shorter operative time than OA and LA, and had a unique advantage in terms of appendiceal fecalith detection rate. Meanwhile, it was proved in this review that postoperative feeding time, time of white blood cells count returning to normal range, time of body temperature returning to normal range, time of abdominal pain relief, bed rest time and length of hospital stay were shorter in the ERAT group than in the control group. In addition, this study suggested that the ERAT technique reduced children’s complications and the cost of hospitalization compared with other conventional treatments, which could not only reduce the physical burden on children and financial burden on children’s parents, but also improve the utilization of medical resources.

However, accumulating evidence from recent studies [63, 64] had suggested no significant correlation between the presence of appendicolith and the occurrence of acute appendicitis in adult populations. Whether this association holds true in pediatric acute appendicitis remains unvalidated in the current meta-analysis, primarily due to the limited sample size and inadequate extraction of sufficient quantitative data for relevant outcome measures.

This study constitutes the first comprehensive and up-to-date systematic review evaluating ERAT interventions for pediatric acute appendicitis. While current evidence may not yet establish definitive clinical protocols, our findings could offer practical references for optimizing therapeutic decision-making in clinical practice. Particularly amidst global concerns over declining birth rates, preserving children’s health through minimally invasive approaches warrants heightened clinical attention. It should be emphasized that the conclusions drawn herein require cautious interpretation given the inherent limitations of available studies. Future multicenter studies with extended follow-up periods are imperative to validate these preliminary observations.

Limitations of the study

This review has several limitations. Firstly, the pooled analyses exhibited significant heterogeneity, likely attributable to clinical diversity across studies including variability in disease severity, operator experience and inconsistent outcome definitions. Secondly, the generalizability of findings was constrained by the predominance of single-center, small-sample studies conducted exclusively within China, raising concerns about geographical bias and limiting cross-population validation. Thirdiy, the evidence hierarchy remains suboptimal due to scarce randomized comparisons between ERAT and first-line alternatives (laparoscopic appendectomy, antibiotic-only regimens) and insufficient age-stratified analyses (pediatric, adolescent subgroups). These limitations underscore the need for internationally harmonized ERAT protocols and multicenter registries to capture longitudinal outcomes across diverse healthcare settings.

Conclusion

Our meta-analysis consolidated ERAT as a viable minimally invasive strategy for pediatric acute appendicitis, demonstrating superior perioperative outcomes including reduced operative duration, expedited postoperative recovery, shortened hospital stays and reduced financial burden, while preserving the appendix’s anatomical and immunological integrity: a critical advantage in developing pediatric population. Notably, the procedure’s safety profile was reinforced by low complication rates, addressing pediatrician’s concerns over traditional surgical risks. However, the non-negligible recurrence rate (pooled 5.5%) underscores the imperative for risk stratification, and more data and time are needed to assess the recurrence rate in children who have undergone ERAT. And due to current limitations, including heterogeneity across studies and insufficient longitudinal data, necessitate rigorously designed multicenter RCTs to standardize ERAT protocols and validate predictive biomarkers for recurrence. These findings position ERAT not merely as an alternative to surgery, but as a paradigm shift toward organ-preserving management in pediatric acute appendicitis.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

SL and ZYL participated in the study conception, SL and TG collected the data and performed the statistical analysis, SL and ZYL drafted the manuscript, SL, ZYL and TG contributed to revise the manuscript.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.