Selective non-operative management of post-appendectomy abscesses in children: a comprehensive systematic review and pairwise meta-analysis.

Post-appendectomy intra-abdominal abscess remains a common complication following pediatric appendicitis. Although drainage has traditionally been considered standard treatment, increasing evidence suggests selected patients may be successfully managed with antibiotics alone. A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines and registered in PROSPERO (CRD420251075191). PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched through June 20, 2025. Eligible studies included pediatric patients (0-18 years) with post-appendectomy abscess managed with antibiotic vs. invasive drainage. The primary outcome was failure of first-line treatment requiring escalation. Secondary outcomes included recurrence and length of hospital stay. Ten observational studies involving 363 pediatric patients were included (152 drainage, 211 conservative). Treatment success was 80.9% with drainage and 89.1% with antibiotics. Pooled analysis demonstrated no statistically significant difference in treatment success (RR 1.00; 95% CI 0.95-1.05) or recurrence (RR 0.99; 95% CI 0.57-1.74). Drainage was associated with longer hospital stays (MD 3.40 days; 95% CI 0.65-6.14; p = 0.02). Subgroup analyses demonstrated consistent findings. All included studies demonstrated a serious risk of bias due to confounding by indication. An antibiotics-first approach appears viable for clinically stable pediatric patients, achieving comparable outcomes with shorter hospitalization.