Efficacy of endoscopic retrograde appendicitis therapy in children with suppurative vs. simple appendicitis: a retrospective cohort study

Objective To evaluate the efficacy of endoscopic retrograde appendicitis therapy (ERAT) in the treatment of pediatric suppurative appendicitis. Methods In this retrospective cohort study, children undergoing ERAT for acute appendicitis between January 2019 to March 2025 were categorized according to disease severity into suppurative or simple appendicitis groups. Data encompassing baseline characteristics, preoperative profiles, procedural outcomes, and follow-up were collected and subjected to intergroup comparison. Results The study included 61 children (31 suppurative, 30 simple). Two patients in the suppurative group were excluded from the follow-up analysis due to missing data at the one-week time point. Preoperative fever, vomiting, appendicoliths, and inflammatory markers were significantly more common in the suppurative group (all P < 0.05). The mean operative time was significantly longer in the suppurative group (105.5 ± 34.1 vs. 86.3 ± 34.4 min, P < 0.001). While ERAT achieved a 100% success rate in simple appendicitis, the success rate was significantly lower in the suppurative group (74.2% vs. 100%, P < 0.001), with appendiceal perforation being the primary complication (12.9%, 4/31). Treatment failure led to appendectomy in 6 patients (20.7%) with suppurative appendicitis. Among initially successful cases, the suppurative group had a significantly prolonged recovery, including longer time to pain relief and hospital stay (both P < 0.001). At 6-month follow-up, the recurrence rate was numerically higher in the suppurative group (21.7% vs. 10.0%), although the difference was not statistically significant ( P = 0.117). Parental satisfaction scores trended lower and pain scores higher in the suppurative group during follow-up. Conclusion For suppurative appendicitis, particularly with a thin-walled appendix or large fecalith, ERAT is not recommended due to low success rates and perforation risk; laparoscopic appendectomy remains the standard. ERAT is a safe, effective organ-preserving option only for carefully selected patients with simple appendicitis or select non-necrotizing fecalith impaction.