Interval appendectomy practices for complicated appendicitis in children: a systematic review from the APSA Outcomes and Evidence-Based Practice Committee

Background: This review summarizes considerations within the existing recent literature that guide the practice of interval appendectomy (IA) after initial non-operative management (NOM) of complicated appendicitis (CA) in children. Methods: A systematic review of English language articles published from 2000 to 2025 was conducted in Medline, Embase, and Cochrane Central Register of Controlled Trials to address four elements which could impact the decision for IA after NOM of CA: (1) the incidence of recurrent appendicitis; (2) the time period in which recurrence occurs; (3) the patient or disease-related risk factors which increase recurrence; and (4) the incidence of appendiceal neoplasms identified by IA. Results: Of the 3,022 articles initially reviewed, 46 met inclusion criteria. Recurrence was reported in 2–50% of patients. When IA is pursued, the optimal timing remains undefined, although evidence suggests most recurrences occur within three to six months, so there may be potential benefit to performing IA within three months after the initial presentation. Risk factors for recurrent appendicitis are not well characterized, though the presence of an appendicolith may increase recurrence risk. Across studies, the incidence of appendiceal neoplasms was rare, with most studies not documenting any cases; all reported neoplasms were neuroendocrine tumors. Conclusion: Current evidence does not favor any single approach to IA, including routine IA, selective IA, or indefinite NOM; rather a shared-decision ought to be made between the surgeon and patient’s caregivers. Utilization and timing of IA must balance surgical risks with the risk of recurrent disease; however, the risk of neoplasm should not primarily drive management. Level of Evidence: I−IIV.