Irrigation Versus Suction in Laparoscopic Appendectomy for Complicated Appendicitis: A Meta-analysis

SAGES guideline for the diagnosis and treatment of appendicitis

BACKGROUND

Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis.

METHODS

A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts.

RESULTS

Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty.

CONCLUSIONS

These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.

Effect of intraoperative abdominal lavage versus suction alone on postoperative wound infection in patients with appendicitis: A meta-analysis

There is much controversy about the application of abdominal irrigation in the prevention of wound infection (WI) and intra-abdominal abscess (IAA) in the postoperative period. Therefore, we performed a meta-analysis of the effect of suctioning and lavage on appendectomy to assess the efficacy of either suctioning or lavage. Data were collected and estimated with RevMan 5.3 software. Based on our research, we found 563 publications in our database, and we eventually chose seven of them to analyse. The main results were IAA after the operation and WI. Inclusion criteria were clinical trials of an appendectomy with suctioning or lavage. In the end, seven trials were chosen to meet the eligibility criteria, and the majority were retrospective. The results of seven studies showed that there was no statistically significant difference between abdominal lavage and suctioning treatment for post-operative WI (OR, 1.82; 95% CI, 0.40, 2.61; p = 0.96); There was no statistically significant difference between the two groups in the risk of postoperative abdominal abscess after operation (OR, 1.16; 95% CI, 0.71, 1.89; p = 0.56). No evidence has been found that the use of abdominal lavage in the treatment of postoperative infectious complications after appendectomy is superior to aspiration.

Therapeutic strategy for acute appendicitis based on laparoscopic surgery

PURPOSE

The treatment strategies for acute appendicitis differ depending on the facility, and various studies have investigated the usefulness of conservative treatment with antibiotics, laparoscopic surgery, and interval appendectomy (IA). However, although laparoscopic surgery is widely used, the clinical strategy for acute appendicitis, especially complicated cases, remains controversial. We assessed a laparoscopic surgery-based treatment strategy for all patients diagnosed with appendicitis, including those with complicated appendicitis (CA).

METHODS

We retrospectively analysed patients with acute appendicitis treated in our institution between January 2013 and December 2021. Patients were classified into uncomplicated appendicitis (UA) and CA groups based on computed tomography (CT) findings on the first visit, and the treatment course was subsequently compared.

RESULTS

Of 305 participants, 218 were diagnosed with UA and 87 with CA, with surgery performed in 159 cases. Laparoscopic surgery was attempted in 153 cases and had a completion rate of 94.8% (145/153). All open laparotomy transition cases (n = 8) were emergency CA surgery cases. No significant differences were found in the incidence of postoperative complications in successful emergency laparoscopic surgeries. In univariate and multivariate analyses for the conversion to open laparotomy in CA, only the number of days from onset to surgery ≥ 6 days was an independent risk factor (odds ratio: 11.80; P < 0.01).

CONCLUSION

Laparoscopic surgery is preferred in all appendicitis cases, including CA. Since laparoscopic surgery is difficult for CA when several days from the onset have passed, it is necessary that surgeons make an early decision on whether to operate.

Drain placement in paediatric complicated appendicitis: a systematic review and meta-analysis

Children undergoing appendicectomy for complicated appendicitis are at an increased risk of post-operative morbidity. Placement of an intra-peritoneal drain to prevent post-operative complications is controversial. We aimed to assess the efficacy of prophylactic drain placement to prevent complications in children with complicated appendicitis. A systematic review was performed in accordance with PRISMA guidelines. Cochrane, MEDLINE and Web of Science databases were searched from inception to November 2022 for studies directly comparing drain placement to no drain placement in children ≤ 18 years of age undergoing operative treatment of complicated appendicitis. A total of 5108 children with complicated appendicitis were included from 16 studies; 2231 (44%) received a drain. Placement of a drain associated with a significantly increased risk of intra-peritoneal abscess formation (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.16-2.24, p = 0.004) but there was no significant difference in wound infection rate (OR 1.46, 95% CI 0.74-2.88, p = 0.28). Length of stay was significantly longer in the drain group (mean difference 2.02 days, 95% CI 1.14-2.90, p < 0.001). Although the quality and certainty of the available evidence is low, prophylactic drain placement does not prevent intra-peritoneal abscess following appendicectomy in children with complicated appendicitis.

The Straw Pressure Gradient and Gravity (SPGG) Technique: A Safe and Cost-Effective Technique for Laparoscopic Suction

Suction devices are frequently used during laparoscopic surgery. However, their cost and limitations can be significant, depending on the clinical case, theatre setting and national health system. Furthermore, the continuous need to reduce the costs of the consumables in minimally invasive surgical procedures and their environmental burden creates extra pressure on the healthcare systems globally. Therefore, we present a new technique for laparoscopic suctioning, the Straw Pressure Gradient and Gravity (SPGG) technique. It is a safe, cost-effective and environmentally friendly technique compared to traditional suction devices. The technique involves using a sterile, single-use Suction Catheter 12-16 French after positioning the patient according to the targeted collection. The catheter is inserted via the laparoscopic port nearest the collection and directed using laparoscopic graspers. The outer end needs to be clamped to avoid fluid spillage, and the catheter tip is placed in the collection. Then after the clamp is released, the fluid will be successfully drained due to the pressure gradient into a pot placed at a lower level than the intra-abdominal collection. Minimal wash can be performed via the gas vent by using a syringe. SPGG is a safe and easy-to-learn technique that requires similar skills as placing an intra-abdominal drain during laparoscopy. It is softer than rigid, traditional suction devices and atraumatic. It can be used for suction, irrigation, collection of fluid for sampling and as a drain in case of an intraoperative indication. SPGG is a cost-effective device as it is cheaper than the average disposable suction device system and has multiple uses, which can significantly decrease the annual cost of laparoscopies. It can also reduce the number of consumables and lighten the environmental burden of laparoscopic procedures.

Effectiveness of intraoperative peritoneal lavage with saline in patient with intra-abdominal infections: a systematic review and meta-analysis

Background

Intraoperative peritoneal lavage (IOPL) with saline has been widely used in surgical practice. However, the effectiveness of IOPL with saline in patients with intra-abdominal infections (IAIs) remains controversial. This study aims to systematically review randomized controlled trials (RCTs) evaluating the effectiveness of IOPL in patients with IAIs.

Methods

The databases of PubMed, Embase, Web of Science, Cochrane library, CNKI, WanFang, and CBM databases were searched from inception to December 31, 2022. Random-effects models were used to calculate the risk ratio (RR), mean difference, and standardized mean difference. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to rate the quality of the evidence.

Results

Ten RCTs with 1318 participants were included, of which eight studies on appendicitis and two studies on peritonitis. Moderate-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (0% vs. 1.1%; RR, 0.31 [95% CI, 0.02–6.39]), intra-abdominal abscess (12.3% vs. 11.8%; RR, 1.02 [95% CI, 0.70–1.48]; I2 = 24%), incisional surgical site infections (3.3% vs. 3.8%; RR, 0.72 [95% CI, 0.18–2.86]; I2 = 50%), postoperative complication (11.0% vs. 13.2%; RR, 0.74 [95% CI, 0.39–1.41]; I2 = 64%), reoperation (2.9% vs. 1.7%; RR,1.71 [95% CI, 0.74–3.93]; I2 = 0%) and readmission (5.2% vs. 6.6%; RR, 0.95 [95% CI, 0.48–1.87]; I2 = 7%) in patients with appendicitis when compared to non-IOPL. Low-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (22.7% vs. 23.3%; RR, 0.97 [95% CI, 0.45–2.09], I2 = 0%) and intra-abdominal abscess (5.1% vs. 5.0%; RR, 1.05 [95% CI, 0.16–6.98], I2 = 0%) in patients with peritonitis when compared to non-IOPL.

Conclusion

IOPL with saline use in patients with appendicitis was not associated with significantly decreased risk of mortality, intra-abdominal abscess, incisional surgical site infection, postoperative complication, reoperation, and readmission compared with non-IOPL. These findings do not support the routine use of IOPL with saline in patients with appendicitis. The benefits of IOPL for IAI caused by other types of abdominal infections need to be investigated.

Perforated appendicitis: The solution to pollution is not dilution

BACKGROUND

Surgical dogma states that the "solution to pollution is dilution." We hypothesized that withholding irrigation during pediatric Single Incision Laparoscopic Surgery (SILS) appendectomies for perforated appendicitis would decrease postoperative abscess rate.

METHODS

From May 2011 to 5/2015, during SILS appendectomies, saline irrigation and suctioning was performed. From June 2015 to 8/2021, only suctioning was performed. The operations and peri-operative management were otherwise identical. We retrospectively reviewed 46 patients in the Irrigation (I) Group and 91 patients in the Non-Irrigation (NI) Group.

RESULTS

Abscess rate decreased from 19.6% in Group I to 9.9% in Group NI, but this did not reach statistical significance (p = 0.12). Operative duration was significantly longer in patients who developed postoperative abscesses in Group NI (odds ratio 1.67, p = 0.002) and overall (odds ratio 1.45, p = 0.0002).

CONCLUSIONS

Withholding irrigation during SILS appendectomies trended toward a decreased postoperative abscess rate. Increased operative times were associated with postoperative abscess formation.

Implementing a surgical site infection prevention bundle for emergency appendectomy: Worth the effort or waste of time?

BACKGROUND

The aim of this study was to evaluate feasibility and impact of an intraoperative surgical site infection prevention bundle for emergency appendectomy.

METHODS

Consecutive adult patients undergoing emergency appendectomy were prospectively included during a 10-year study period (2011-2020). The care bundle was implemented as of November 1, 2018, and focused on 4 intraoperative items (disinfection, antibiotic prophylaxis, induction temperature control >36.5°C, and intracavity lavage). The primary outcome was the compliance to bundle items. Thirty-day surgical site infections were assessed by the independent Swiss National SSI Surveillance Program (2011 to October 2018) and by an institutional audit (November 2018-2020). Independent risk factors for surgical site infection were identified through multinominal logistic regression analysis.

RESULTS

Of 1,901 patients, 449 (23.6%) were included after bundle implementation. Overall surgical site infection rate was 111 (5.8%). In 42 patients with surgical site infection (37.8%), antibiotic treatment alone was done, and additional surgical management was necessary in 31 patients (27.9%), computed tomography-guided drainage in 30 patients (27%), and bedside wound opening in 9 cases (8.1%). Overall compliance to the bundle was 79.9%. Overall surgical site infection rates were decreased after bundle implementation (17/449 [3.8%] vs 94/1,452 [6.5%], P = .038), mainly due to a decrease in superficial incisional infections (P = .014). Independent risk factors for surgical site infection were surgical duration ≥60 minutes (odds ratio: 1.66, P = .018), contamination class IV (odds ratio: 2.64, P < .001), and open or converted approach (odds ratio: 4.0, P < .001), and the bundle was an independent protective factor (odds ratio: 0.58, P = .048).

CONCLUSION

Implementation of an intraoperative surgical site infection prevention bundle was feasible and might have a beneficial impact on surgical site infection rates after emergency appendectomy.

Non-Operative Management of Appendicitis: Evolution, not Revolution

Background: The medical fascination with the appendix vermiformis dates from the clandestine prosectors of the fifteenth century. The surgical management of appendiceal inflammation dates from 1735, but acceptance that acute appendicitis (AA) should be treated primarily by resection with or without drainage would not follow for 150 years. Recent publication of several randomized clinical trials (RCTs) of non-operative management (NOM) of AA affords the opportunity to review the historical record, describe the evolution of AA management toward NOM, and assess what is in the best interest of the patient. Methods: Review and synthesis of historical and contemporary English, French, German, and Italian literature with expert opinion. Results: Modern understanding of AA dates to the landmark 1886 clinico-pathologic correlative study by Reginald Fitz, which coined the term appendicitis and coincided with recognition by surgeons that AA could be diagnosed pre-operatively and managed surgically, with mortality rates of approximately 10%. Not until 1901 did Albert Ochsner advocate NOM, paradoxically for severe cases unlikely to survive operation. Markedly decreased mortality coincided with the introduction of sulfanilamide in 1935 and penicillin and curare in 1942. The first large series of patients with AA treated primarily with NOM was published in 1956 by Eric Coldrey. Modern management evolved rapidly in the late twentieth century, including effective anti-anaerobic antibiotic agents (1970s), laparoscopic appendectomy (LA; 1980), and pelvis computed tomography with rectal contrast (1998) all representing important contributions. Randomized controlled trials of NOM of AA date to 1995, with one large trial (2015) showing that open appendectomy was not non-inferior to NOM, and another (2020) demonstrating non-inferiority between (mostly) LA and NOM. However, one-year failure rates are high (∼30%) and appear to increase further with longer follow-up. Conclusions: Laparoscopic appendectomy is curative and cost-effective management for AA, with low morbidity. Results of recent RCTs of NOM of AA indicate that LA remains the treatment of choice, particularly if a fecalith is present. However, patient preferences must be taken into account; some may prefer NOM for the 60%-70% chance that surgery may be avoided, which should be considered when providing informed consent. Non-operative management should be undertaken in the outpatient setting if possible. Antibiotic management-whether or not for NOM-should adhere to the principles of stewardship.

Aspiration versus peritoneal lavage in appendicitis: a meta-analysis

BACKGROUND

Acute appendicitis is one of the most frequent abdominal surgical emergencies. Intra-abdominal abscess is a frequent post-operative complication. The aim of this meta-analysis was to compare peritoneal irrigation and suction versus suction only when performing appendectomy for complicated appendicitis.

METHODS

According to PRISMA guidelines, a systematic review was conducted and registered into the Prospero register (CRD42020186848). The risk of bias was defined to be from low to moderate.

RESULTS

Seventeen studies (9 RCTs and 8 CCTs) were selected, including 5315 patients. There was no statistical significance in post-operative intra-abdominal abscess in open (RR 1.27, 95% CI 0.75-2.15; I2 = 74%) and laparoscopic group (RR 1.51, 95% CI 0.73-3.13; I2 = 83%). No statistical significance in reoperation rate in open (RR 1.27, 95% CI 0.04-2.49; I2 = 18%) and laparoscopic group (RR 1.42, 95% CI 0.64-2.49; I2 = 18%). In both open and laparoscopic groups, operative time was lower in the suction group (RR 7.13, 95% CI 3.14-11.12); no statistical significance was found for hospital stay (MD - 0.39, 95% CI - 1.07 to 0.30; I2 = 91%) and the rate of wound infection (MD 1.16, 95% CI 0.56-2.38; I2 = 71%).

CONCLUSIONS

This systematic review has failed to demonstrate the statistical superiority of employing intra-operative peritoneal irrigation and suction over suction-only to reduce the rate of post-operative complications after appendectomy, but all the articles report clinical superiority in terms of post-operative abscess, wound infection and operative times in suction-only group.

Adult appendicitis: Clinical practice guidelines from the French Society of Digestive Surgery and the Society of Abdominal and Digestive Imaging

INTRODUCTION

The French Society of Digestive Surgery (SFCD) and the Society of Abdominal and Digestive Imaging (SIAD) have collaborated to propose recommendations for clinical practice in the management of adult appendicitis.

METHODS

An analysis of the literature was carried out according to the methodology of the French National Authority for Health (HAS). A selection was performed from collected references and then a manual review of the references listed in the selected articles was made in search of additional relevant articles. The research was limited to articles whose language of publication was English or French. Articles focusing on the pediatric population were excluded. Based on the literature review, the working group proposed recommendations whenever possible. These recommendations were reviewed and approved by a committee of experts.

RESULTS

Recommendations about appendicitis in adult patients were proposed with regard to clinical, laboratory and radiological diagnostic modalities, treatment strategy for uncomplicated and complicated appendicitis, surgical technique, and specificities in the case of macroscopically healthy appendix, terminal ileitis and appendicitis in the elderly and in pregnant women.

CONCLUSION

These recommendations for clinical practice may be useful to the surgeon in optimizing the management of acute appendicitis in adults.

Irrigation during laparoscopic appendectomy for complicated appendicitis increases the operative time and reoperation rate: a meta-analysis of randomized clinical trials

This meta-analysis of randomized clinical trials (RCT) aimed to compare peritoneal irrigation followed by suction with aspiration only during laparoscopic surgery for complicated appendicitis (LA). PRISMA guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates. We retained six eligible RCT published between 2012 and 2019. They involved a total of 1019 patients (541 patients in the aspiration group and 478 patients in the irrigation group). Aspiration only during LA is associated with shorter operative time (MD = 8.50 min, 95% CI [- 12.97 to - 4.02], p = 0.0002) and lower reoperation rate (OR = 0.37 95% CI [0.14-0.96], p = 0.04). There was no difference between aspiration group and irrigation group in terms of Intraperitoneal abscess (IPA) (OR = 0.99 95% CI [0.54-1.81], p = 0.95), morbidity rate (OR = 1.14 95% CI [0.44-2.98], p = 0.79), wound infection (OR = 0.94 95% CI [0.20-4.40], p = 0.94), and hospital stay (MD = 0.65 day, 95% CI [- 0.52 to 1.82], p = 0.27). Irrigation during LA prevents post-appendectomy IPA in neither adults nor pediatric patients. However, it lengthens the operative time and involves a higher reoperation rate.

A Novel Suction-and-Irrigation Laparoscopic Surgical Instrument: Internal Design and Preclinical Performance Evaluation

Objective: Laparoscopic instruments with suction and irrigation functions often lead to tissue damage during removal of the aspirated tissues, owing to the presence of aspiration into the side holes of their catheters. To address this problem, we designed a novel irrigation-and-suction catheter and assessed its preclinical efficacy.

Methods: We made structural improvements to the irrigation-suction catheter to prevent tissue aspiration through its side holes. We ran a simulation program to perform experimental assessments before printing out the catheter tip models using a three-dimensional (3D) printer. Model 1 was the control, and Models 2, 3, and 4 were the improved models. Using these, we performed 10 repetitions of 15-s suction followed by 15-s irrigation, for a total of 5 times per model. We recorded the number of aspirations that occurred through the side holes and analyzed each model using nonparametric methods.

Results: Models 2 and 3 showed fewer aspirations because the velocity and pressure around their side holes were lower than those of Model 1; this was statistically significant. On the other hand, Model 4 had a lesser preventive effect against aspiration due to higher velocity and pressure around its side holes.

Interpretation of Results: We confirmed that side-hole aspiration can be prevented with an internal structure that completely separates the irrigation and suction paths. Even if the irrigation and suction paths are not completely separated, adding a septal structure at the distal end of the catheter may prevent aspiration.

Effect and safety of peritoneal lavage for appendectomy: A meta-analysis

BACKGROUND

Whether peritoneal lavage is beneficial for the postoperative outcomes of appendectomy is debatable. This study is a meta-analysis of randomized controlled trials (RCTs) that aimed to determine whether peritoneal lavage leads to improved appendectomy outcomes.

METHODS

PubMed, Embase, and Cochrane Library databases were searched for articles published before September 2020. The meta-analysis calculated the pooled effect size by using a random effects model. The primary outcome was the incidence of intra-abdominal abscess. Secondary outcomes were the incidence of surgical-site infection, hospital stay duration, operation time, and readmission incidence.

RESULTS

Eight RCTs involving 1487 patients were reviewed. The lavage group had a nonsignificantly lower incidence of intra-abdominal abscess (risk ratio [RR]: 0.81; 95% confidence interval [CI]: 0.55-1.18) and surgical-site infection (RR: 0.73; 95% CI: 0.31-1.72) than did the nonirrigation group. Furthermore, the lavage group showed a nonsignificantly shorter hospital stay duration and lower readmission incidence than did the nonirrigation group. However, the lavage group required significantly more operation time than did the nonirrigation group (mean difference: 7.59 min; 95% CI: 4.67-10.50).

CONCLUSION

Our study revealed that performing peritoneal lavage has no advantage over suction or drainage only in appendectomy. Moreover, peritoneal lavage significantly increased operation time. Consequently, for improving efficiency and reducing operation time, we suggest skipping peritoneal irrigation during appendectomy. However, the available evidence is of variable quality; therefore, high-quality prospective RCTs are required in the future.

Effectiveness of intraoperative peritoneal lavage (IOPL) with saline in patient with intra-abdominal infections: a systematic review and meta-analysis protocol

INTRODUCTION

Intra-abdominal infections (IAIs) are common surgical emergencies and cause a significant worldwide burden per year. Since the concept of intraoperative peritoneal lavage (IOPL) was proposed in 1905, it has been widely used in the surgery practice. However, the effectiveness of IOPL in patients with IAIs has always been controversial. Our objective is to identify whether it is beneficial to flush the abdominal cavity with saline in IAIs surgery through a comprehensive systematic review and meta-analysis.

METHODS AND ANALYSIS

This protocol is reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Electronic databases (including the Cochrane library, MEDLINE, EMBASE, Web of Science, etc) and clinical trial registry platforms will be searched from inception to 8 September 2019. Randomised controlled trials, quasi-randomised clinical trials and cohort studies comparing IOPL and suction alone in IAIs will be included. The primary outcomes are mortality and abscess rate. Two independent reviewers will screen literature, collect data and assess risk of bias of included studies. Discussion or a third reviewer will be referred for any disagreements. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to assess the quality of the evidence. We will perform meta-analysis using random-effects model. Subgroup analysis, sensitivity analysis and publication bias will be conducted if data are enough.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review and meta-analysis protocol. Results of this study will be published in a peer-reviewed journal, presented at relevant conferences and disseminated to local and international policy makers.

PROSPERO REGISTRATION NUMBER

CRD42019145109.

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

BACKGROUND AND AIMS

Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.

METHODS

This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.

CONCLUSIONS

The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.

Irrigation Versus Suction Alone During Laparoscopic Appendectomy for Uncomplicated Acute Appendicitis

Purpose

To compare the surgical outcomes of peritoneal irrigation versus suction alone during laparoscopic appendectomy and to identify the risk factors of surgical site infection in patients with uncomplicated acute appendicitis.

Methods

Data from patients with uncomplicated acute appendicitis between January 2014 and March 2016 were reviewed. We compared the irrigation and suction alone groups with regard to the following parameters: postoperative complication incidence rate, length of hospital stay, operation time, time to flatus, time to diet commencement, and duration of postoperative antibiotic.

Results

A total of 578 patients underwent laparoscopic appendectomy for uncomplicated acute appendicitis. Twenty-five patients were excluded from the analysis because of need for drain insertion, loss to follow-up, simultaneous surgery for another indication, presence of an appendix tumor, or pregnancy. A total of 207 patients (37.4%) had undergone irrigation, and 346 patients (62.6%) received suction alone during laparoscopic appendectomy. The preoperative fever rate was significantly higher in the irrigation group than in the suction alone group. Operative time was also significantly longer in the irrigation group than in the suction alone group (53.8 ± 18.5 minutes vs. 57.8 ± 21.4 minutes, P = 0.027). The postoperative complication rate was higher in the irrigation group than in the suction alone group (4.5% vs. 12.6%, P = 0.001). Multiple logistic regression analysis showed that irrigation and preoperative fever were risk factors for surgical site infection after laparoscopic appendectomy for uncomplicated acute appendicitis.

Conclusion

There is no advantage to irrigating the peritoneal cavity over suction alone during laparoscopic appendectomy for uncomplicated acute appendicitis. Irrigation may actually prolong the operative time and therefore be detrimental.

Laparoscopic versus open approach for diffuse peritonitis from appendicitis ethiology: a subgroup analysis from the Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) study

Diffuse peritonitis represents a life-threatening complication of acute appendicitis (AA). Whether laparoscopy is a safe procedure and presents similar results compared with laparotomy in case of complicated AA is still a matter of debate. The objective of this study is to compare laparoscopic (LA) and open appendectomy (OA) for the management of diffuse peritonitis caused by AA. This is a prospective multicenter cohort study, including 223 patients with diffuse peritonitis from perforated AA, enrolled in the Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) study from February to May 2018. Two groups were created: LA = 78 patients, mean age 42.51 ± 22.14 years and OA = 145 patients, mean age 38.44 ± 20.95 years. LA was employed in 34.98% of cases. There was no statically significant difference between LA and OA groups in terms of intra-abdominal abscess, postoperative peritonitis, rate of reoperation, and mortality. The wound infection rate was higher in the OA group (OR 21.63; 95% CI 3.46-895.47; P = 0.00). The mean postoperative hospital stay in the LA group was shorter than in the OA group (6.40 ± 4.29 days versus 7.8 ± 5.30 days; P = 0.032). Although LA was only used in one-third of cases, it is a safe procedure and should be considered in the management of patients with diffuse peritonitis caused by AA, respecting its indications.

Peritoneal irrigation vs suction alone during pediatric appendectomy for perforated appendicitis: A meta-analysis

BACKGROUND

There currently exists no substantial evidence reporting the efficacy of peritoneal irrigation in reducing the incidence of postoperative intra-abdominal abscess in pediatric patients. The purpose of our study was to perform a meta-analysis to compare rates of intra-abdominal abscess after appendectomy between irrigation and suction alone groups.

METHODS

We identified studies by a systematic search in EMBASE, PubMed, Web of Science, and the Cochrane Library to recognize randomized controlled trials and case control studies from the 1950 to May 2019. We limited the English language studies. We checked the reference list of studies to recognize other potentially qualified trials. We analyzed the merged data with use of the Review Manager 5.3.

RESULTS

We identified 6 eligible papers enrolling a total of 1633 participants. We found no significant difference in the incidence of postoperative intraabdominal abscess, wound infection, and the length of hospitalization between 2 group, but duration of surgery is longer in irrigation group (MD = 6.76, 95% CI = 4.64 to 8.87, P < .001; heterogeneity, I = 25%, P = .26).

CONCLUSION

Our meta-analysis did not provide strong evidence allowing definite conclusions to be drawn, but suggested that peritoneal irrigation during appendectomy did not decrease the incidence of postoperative IAA. This meta-analysis also indicated the need for more high-quality trials to identify methods to decrease the incidence of postoperative IAA in pediatric perforated appendicitis patients.Trial registration number Standardization of endoscopic treatment of acute abdomen in children: 14RCGFSY00150.

REsiDENT 1 (Re-assessment of Appendicitis Evaluation during laparoscopic appendectomy: Do we End a Non-standardized Treatment approach and habit?): peritoneal irrigation during laparoscopic appendectomy-does the grade of contamination matter? A prospective multicenter resident-based evaluation of a new classification system

Background

Laparoscopic appendectomy has progressively gained acceptance as the standard of care for acute appendicitis. Focusing on the incidence of postoperative intra-abdominal abscess after a laparoscopic appendectomy, discordant data have been reported ranging from 1.5 to 20%. Besides, evidence advocating advantages from peritoneal irrigation over suction only are lacking. Most studies are burdened by a high level of heterogeneity regarding the severity of the appendicitis and modalities of peritoneal irrigation. One of the main drawbacks is the lack of an accepted classification for different degrees of appendicitis and peritoneal contamination. The aim of the study is to introduce a classification to clarify the relationship between grade of appendicitis, contamination, and postoperative incidence of IAA considering the surgeon’s attitude toward irrigation or suction alone. Preoperative, intra-operative, and postoperative predictive factors for infectious complication will also be assessed. This study is meant to be the first Italian multicenter resident-based observational study.

Methods

Patients suffering from acute appendicitis will be enrolled during a 1-year period, according to inclusion and exclusion criteria. Participants will fill an online form reporting all clinical and intra-operative data of each patient undergoing a laparoscopic appendectomy. General surgery residents will be responsible for data collection. Our proposal of classification is based on the histological grade of appendicitis and intra-operative degree of peritoneal contamination. For each grade, a progressively increasing score is assigned.

Discussion

The observational nature of this study is mandatory to examine surgeons’ attitude toward peritoneal contamination during laparoscopic appendectomy for appendicitis. Identification of different severity grades of acute appendicitis and their relationship with the development of postoperative abscesses is necessary. The resulting classification and score, even considering peritoneal lavage or suction alone, will define risk classes of peri-appendiceal contamination each one related to a specific incidence rate of postoperative IAA. Nowadays, maximum effort should be made to reach the best procedural standardization and surgical decision-making should be supported by solid evidence, especially in an emergency surgery setting.