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Alabbad J, Alhamly H, Alrubaiaan A, Kabli A, Abdulraheem F. The utility of intraperitoneal drain placement after laparoscopic appendectomy for perforated appendicitis in postoperative intraperitoneal abscess prevention. Surg Endosc 2024; 38:3571-3577. [PMID: 38750172 DOI: 10.1007/s00464-024-10869-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/17/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Perforated appendicitis is associated with postoperative development of intraperitoneal abscess. Intraperitoneal drain placement during appendectomy is thought to reduce the risk of developing postoperative intraperitoneal abscess. The aim of this study was to determine whether intraperitoneal drainage could reduce the incidence of intraperitoneal abscess formation after laparoscopic appendectomy for perforated appendicitis. METHODS This is a retrospective study of all patients (aged 7 and above) who were diagnosed with perforated appendicitis and subsequently underwent laparoscopic appendectomy between January 2018 and December 2022 at two government hospitals in the state of Kuwait. Demographic, clinical, and perioperative characteristics were compared between patients who underwent intraoperative intraperitoneal drain placement and those who did not. The primary outcome was the development of postoperative intraperitoneal abscess. Secondary outcomes included overall postoperative complications, superficial surgical site infection (SSI), length of stay (LOS), readmission and postoperative percutaneous drainage. RESULTS A total of 511 patients met the inclusion criteria between 2018 and 2022. Of these, 307 (60.1%) underwent intraoperative intraperitoneal drain placement. Patients with and without drains were similar regarding age, sex, and Charlson Comorbidity Index (CCI) (Table 1). The overall rate of postoperative intraperitoneal abscess was 6.1%. Postoperatively, there was no difference in postoperative intraperitoneal abscess formation between patients who underwent intraperitoneal drain placement and those who did not (6.5% vs. 5.4%, p = 0.707). Patients with intraperitoneal drains had a longer LOS (4 [4, 6] vs. 3 [2, 5] days, p < 0.001). There was no difference in the overall complication (18.6% vs. 12.3%, p = 0.065), superficial SSI (2.9% vs. 2.5%, p = 0.791) or readmission rate (4.9% vs. 4.4%, p = 0.835). CONCLUSIONS Following laparoscopic appendectomy for perforated appendicitis, intraperitoneal drain placement appears to confer no additional benefit and may prolong hospital stay.
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Affiliation(s)
- Jasim Alabbad
- Mubarak Al-Kabeer Hospital, Jabriya, Kuwait.
- Department of Surgery, College of Medicine, Kuwait University, P.O. Box 24923, 3110, Safat, Kuwait.
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Takeda K, Yamada T, Uehara K, Matsuda A, Shinji S, Yokoyama Y, Takahashi G, Iwai T, Kuriyama S, Miyasaka T, Kanaka S, Yoshida H. The benefits of interval appendectomy and risk factors for nonoperative management failure in the therapeutic strategy for complicated appendicitis. Surg Today 2024:10.1007/s00595-024-02842-w. [PMID: 38598170 DOI: 10.1007/s00595-024-02842-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE Emergency surgery (ES) for complicated appendicitis (CA) is associated with high morbidity. Interval appendectomy (IA) decreases this rate; however, nonoperative management (NOM) is not always successful. Some patients require unplanned ES due to NOM failure (IA failure: IA-F). This study aimed to verify the benefits of IA and to evaluate the risk factors for NOM failure. METHODS Patients diagnosed with CA who underwent surgery between January 2012 and December 2021 were included in this study. We compared the surgical outcomes of the ES group with those of the IA success (IA-S) and IA-F groups. We also analyzed 14 factors that predicted NOM failure. RESULTS Among 302 patients, the rate of severe complications (Clavien-Dindo grade ≥ III) was significantly higher in the ES group (N = 165) than in the IA-S group (N = 102). The rates were equal between the ES (N = 165) and IA-F (N = 35) groups. NOM was successful in 110 patients and failed in 27. Lack of abscesses, comorbidities, high WBC count, and free air were independent risk factors for NOM failure. CONCLUSIONS Considering the benefits of IA and the non-inferior surgical outcomes of IA-F compared to ES, IA is a good therapeutic strategy for CA. However, in patients exhibiting four independent risk factors for NOM failure, careful monitoring of unplanned ES is necessary.
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Affiliation(s)
- Kohki Takeda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan.
| | - Takeshi Yamada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Kay Uehara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Akihisa Matsuda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Seiichi Shinji
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Yasuyuki Yokoyama
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Goro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Takuma Iwai
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Sho Kuriyama
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Toshimitsu Miyasaka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Shintaro Kanaka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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Lamm R, Kumar SS, Collings AT, Haskins IN, Abou-Setta A, Narula N, Nepal P, Hanna NM, Athanasiadis DI, Scholz S, Bradley JF, Train AT, Pucher PH, Quinteros F, Slater B. Diagnosis and treatment of appendicitis: systematic review and meta-analysis. Surg Endosc 2023; 37:8933-8990. [PMID: 37914953 DOI: 10.1007/s00464-023-10456-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/07/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The optimal diagnosis and treatment of appendicitis remains controversial. This systematic review details the evidence and current best practices for the evaluation and management of uncomplicated and complicated appendicitis in adults and children. METHODS Eight questions regarding the diagnosis and management of appendicitis were formulated. PubMed, Embase, CINAHL, Cochrane and clinicaltrials.gov/NLM were queried for articles published from 2010 to 2022 with key words related to at least one question. Randomized and non-randomized studies were included. Two reviewers screened each publication for eligibility and then extracted data from eligible studies. Random effects meta-analyses were performed on all quantitative data. The quality of randomized and non-randomized studies was assessed using the Cochrane Risk of Bias 2.0 or Newcastle Ottawa Scale, respectively. RESULTS 2792 studies were screened and 261 were included. Most had a high risk of bias. Computerized tomography scan yielded the highest sensitivity (> 80%) and specificity (> 93%) in the adult population, although high variability existed. In adults with uncomplicated appendicitis, non-operative management resulted in higher odds of readmission (OR 6.10) and need for operation (OR 20.09), but less time to return to work/school (SMD - 1.78). In pediatric patients with uncomplicated appendicitis, non-operative management also resulted in higher odds of need for operation (OR 38.31). In adult patients with complicated appendicitis, there were higher odds of need for operation following antibiotic treatment only (OR 29.00), while pediatric patients had higher odds of abscess formation (OR 2.23). In pediatric patients undergoing appendectomy for complicated appendicitis, higher risk of reoperation at any time point was observed in patients who had drains placed at the time of operation (RR 2.04). CONCLUSIONS This review demonstrates the diagnosis and treatment of appendicitis remains nuanced. A personalized approach and appropriate patient selection remain key to treatment success. Further research on controversies in treatment would be useful for optimal management.
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Affiliation(s)
- Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1015 Walnut Street, 613 Curtis, Philadelphia, PA, 19107, USA.
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Nisha Narula
- Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Pramod Nepal
- Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joel F Bradley
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Philip H Pucher
- Department of Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Bethany Slater
- Division of Pediatric Surgery, University of Chicago Medicine, Chicago, IL, USA
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Neville JJ, Aldeiri B. Drain placement in paediatric complicated appendicitis: a systematic review and meta-analysis. Pediatr Surg Int 2023; 39:171. [PMID: 37031267 DOI: 10.1007/s00383-023-05457-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/10/2023]
Abstract
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.
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Affiliation(s)
- J J Neville
- Department of Paediatric Surgery, University Surgery Unit, University Hospitals Southampton, Southampton, UK.
| | - B Aldeiri
- Department of Paediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital Trust, London, UK
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Postoperative Antibiotics for Complicated Appendicitis in Children: Piperacillin/Tazobactam versus Ceftriaxone with Metronidazole. J Pediatr Surg 2023; 58:1128-1132. [PMID: 36931937 DOI: 10.1016/j.jpedsurg.2023.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/10/2023] [Indexed: 02/19/2023]
Abstract
INTRODUCTION Recent studies are discordant regarding postoperative use of piperacillin/tazobactam (PT) versus ceftriaxone/metronidazole (CM) for pediatric complicated appendicitis. Some argue that the broader spectrum PT decreases intraabdominal abscess formation; however, antibiotic stewardship, and once-a-day dosing favor CM. We aim to compare outcomes of postoperative antibiotic utilization using a large administrative database. METHODS We queried the Pediatric Health Information System for patients 2-18 years old who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Patients were grouped into PT, CM, or other using the first postoperative day antibiotics. Adverse events and antibiotic use trends were evaluated. RESULTS We included 29,015 children from 45 hospitals. CM was used in 51.9% and 31.3% received PT. Wide variation was seen among hospitals with PT use decreasing over the years. Overall rate of abscess was 9.2%. On multivariable regression, PT was associated with higher risk for abscess formation (RR 1.35, 99% CI 1.04-1.75) and readmission (RR 1.38, 99% CI 1.13-1.68) compared to the CM group. However, following adjustment for hospitals with high CM prevalence, these associations were no longer significant. CONCLUSION Postoperative use of PT for complicated appendicitis is associated with higher rates of readmissions and intraabdominal abscess when compared to CM. However, this effect is mitigated when adjusting for common practice patterns. LEVEL OF EVIDENCE Level III. STUDY TYPE Retrospective Comparative Study.
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Morita K, Fujiogi M, Michihata N, Matsui H, Fushimi K, Yasunaga H, Fujishiro J. Oral Antibiotics and Organ Space Infection after Appendectomy and Intravenous Antibiotics Therapy for Complicated Appendicitis in Children. Eur J Pediatr Surg 2023; 33:74-80. [PMID: 36220134 DOI: 10.1055/a-1958-7915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND There is little consensus regarding management after appendectomy for complicated appendicitis in children. Recent literature suggests that patients may be safely discharged without oral antibiotics after adequate intravenous antibiotics therapy. We conducted a nationwide retrospective cohort study comparing the proportion of postoperative organ space infection between patients discharged with and without oral antibiotics after appendectomy followed by intravenous antibiotics therapy for complicated appendicitis. METHODS Using the Diagnosis Procedure Combination database, we identified patients between 3 and 18 years of age who had undergone appendectomy for complicated appendicitis between July 2010 and March 2018. Propensity score-matched analyses were performed to compare outcomes between the groups with and without oral antibiotics. The primary outcome was readmission due to organ space infection within 60 days of discharge and the secondary outcome was 60-day readmission due to any reason. Additionally, we conducted a stabilized inversed probability of treatment weighting analysis as a sensitivity analysis. RESULTS We identified 13,100 eligible patients who had received oral antibiotics (n = 3,501) and who had not received oral antibiotics (n = 9,599). Propensity score matching created 2,769 pairs. Readmissions due to organ space infection were 3.4% and 5.2% in the nonusers and users of oral antibiotics, respectively (p = 0.007). The oral antibiotics users also had a significantly higher proportion of readmission due to any reason than the nonusers (5.5 vs. 7.4%, p = 0.004). The sensitivity analyses demonstrated consistent results. CONCLUSION Among children who had undergone appendectomy for complicated appendicitis, oral antibiotics following discharge after adequate intravenous antibiotics therapy may increase organ space infection.
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Affiliation(s)
- Kaori Morita
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Japan
| | - Michimasa Fujiogi
- Department of Pediatric Surgery, National Center for Child Health and Development, Setagayaku, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Bunkyo-ku, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Liao J, Zhou J, Wang J, Xie G, Wei H. Prophylactic abdominal drainage following appendectomy for complicated appendicitis: A meta-analysis. Front Surg 2023; 9:1086877. [PMID: 36743896 PMCID: PMC9889918 DOI: 10.3389/fsurg.2022.1086877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/28/2022] [Indexed: 01/19/2023] Open
Abstract
Background To date, the value of prophylactic abdominal drainage (AD) following appendectomy in patients with complicated appendicitis (CA), including adults and children, has yet to be determined. This paper presents a meta-analysis of the effects of prophylactic AD on postoperative complications in patients with CA, with the goal of exploring the safety and effectiveness of prophylactic AD. Methods PubMed, Science Direct, Web of Science, Cochrane Library, and Embase databases were searched for relevant articles published before August 1, 2022. The primary outcomes were the complication rates [overall incidence of postoperative complications, incidence of intra-abdominal abscess (IAA), wound infection (WI), and postoperative ileus (PI), and the secondary outcome was the perioperative outcome]. The meta-analysis was performed with STATA V. 16.0A. Results A total of 2,627 articles were retrieved and 15 high-quality articles were eventually included after screening, resulting in a total of 5,123 patients, of whom 1,796 received AD and 3,327 did not. The results of this meta-analysis showed that compared with patients in the non-drainage group, patients in the drainage group had longer postoperative length of hospitalization (LOH) (SMD = 0.68, 95% CI: 0.01-1.35, P = 0.046), higher overall incidence of postoperative complications (OR = 0.50, 95% CI: 0.19-0.81, P = 0.01), higher incidence of WI (OR = 0.30, 95% CI: 0.08-0.51, P = 0.01) and PI (OR = 1.05, 95% CI: 0.57-1.54, P = 0.01), the differences were statistically significant. However, there was no significant difference in the incidence of IAA (OR = 0.10, 95% CI: -0.10 to 0.31, P = 0.31) between the two groups. The results of subgroup meta-analysis showed that in the adult subgroup, the overall incidence of postoperative complications in the drainage group was higher than that in the non-drainage group (OR = 0.67, 95% CI: 0.37-0.96, P = 0.01). However, there were no significant differences in IAA (OR = 0.18, 95% CI: -0.28 to 0.64, P = 0.45) and WI (OR = 0.13, 95% CI: (-0.40 to 0.66, P = 0.63) and PI (OR = 2.71, 95% CI: -0.29 to 5.71, P = 0.08). In the children subgroup, there were no significant differences in the incidence of IAA (OR = 0.51, 95% CI: -0.06 to 1.09, P = 0.08) between the two groups. The overall incidence of postoperative complications (OR = 0.46, 95% CI: 0.02-0.90, P = 0.04), incidences of WI (OR = 0.43, 95% CI: 0.14-0.71, P = 0.01) and PI (OR = 0.75, 95% CI: 0.10-1.39, P = 0.02) were significantly higher than those in the non-drainage group. Conclusion This meta-analysis concluded that prophylactic AD did not benefit from appendectomy, but increased the incidence of related complications, especially in children with CA. Thus, there is insufficient evidence to support the routine use of prophylactic AD following appendectomy.
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Muacevic A, Adler JR, Alamin A, Mohamed M, Osman M, Mohammed MJ, Abdalla H, Eltyeb HA, Ali O, Mohamad R, Hamid S, Faycal Mirghani S, Hamad Y, Mohamed HK. Evaluation of Drain Insertion After Appendicectomy for Complicated Appendicitis: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e32018. [PMID: 36600842 PMCID: PMC9799077 DOI: 10.7759/cureus.32018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 12/02/2022] Open
Abstract
This meta-analysis aims to evaluate the comparative outcomes of drain insertion versus no drain after appendicectomy for complicated appendicitis. A systematic search of PubMed, Cochrane Library and Scopus was conducted, and all studies comparing drain versus no drain after appendicectomy for complicated appendicitis were included. Abdominal collection, surgical site infection (SSI), bowel obstruction, faecal fistula, paralytic ileus, length of hospital stay (LOS) and mortality were the evaluated outcome parameters for the meta-analysis. Seventeen studies reporting a total number of 4,255 patients who underwent appendicectomy for complicated appendicitis with (n=1,580) or without (n=2,657) drain were included. There was no significant difference between the two groups regarding abdominal collection (odds ratio (OR)=1.41, P=0.13). No-drain group was superior to the drain group regarding SSI (OR=1.93, P=0.0001), faecal fistula (OR=4.76, P=0.03), intestinal obstruction (OR=2.40, P=0.04) and paralytic ileus (OR=2.07, P=0.01). There was a difference regarding mortality rate between the two groups (3.4% in the drain group vs 0.5% in the no-drain group, risk difference (RD)=0.01, 95% CI (-0.01, 0.04), P=0.36). In conclusion, this meta-analysis has shown that drains have no effect on the development of intra-abdominal collections in complicated appendicitis, but it can significantly increase the risk of postoperative complications such as fistula, surgical site infection (SSI), bowel obstruction, ileus and length of hospital stay.
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Liao YT, Huang J, Wu CT, Chen PC, Hsieh TT, Lai F, Chen TC, Liang JT. The necessity of abdominal drainage for patients with complicated appendicitis undergoing laparoscopic appendectomy: a retrospective cohort study. World J Emerg Surg 2022; 17:16. [PMID: 35300711 PMCID: PMC8928608 DOI: 10.1186/s13017-022-00421-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/08/2022] [Indexed: 12/17/2022] Open
Abstract
Background This study aimed to evaluate the necessity of abdominal drainage after laparoscopic appendectomy in patients with complicated appendicitis. Methods Patients with acute appendicitis undergoing laparoscopic appendectomy at two hospitals between January 2014 and December 2018 were retrospectively included. Complicated appendicitis was defined as the American Association for the Surgery of Trauma (AAST) grade ≥ II. The patients were classified according to the AAST grade and the indwelling of abdominal drainage. The postoperative surgical outcomes and recovery were compared among patient groups to evaluate the impact of abdominal drainage for patients with complicated appendicitis undergoing laparoscopic appendectomy. Results A total of 1241 patients was retrospectively included. Among them, there were 820 patients with simple appendicitis (AAST grade I) and 421 patients with complicated appendicitis (AAST grade ≥ II). For complicated appendicitis, the drainage group (N = 192) tended to harbor more overall complications, intra-abdominal abscess formation, time to resume a soft diet, and the postoperative length of hospitalization (P = 0.0000 for all). Multivariate logistic regression confirmed that abdominal drainage increased the risk of overall complications [Odds ratio (OR) 2.439; 95% confidence interval (CI) 1.597–3.726; P ≤ 0.0001] and failed to decrease the risk of intra-abdominal abscess formation (OR 1.655; 95% CI 0.487–5.616; P = 0.4193). Multivariate linear regression analysis also showed that the drainage group harbored longer postoperative length of hospitalization (Coefficients: 20.697; 95% CI 15.251–26.143; P < 0.0001) and time to resume a soft diet (Coefficients: 45.899; 95% CI 34.502–57.297; P < 0.0001). Conclusions Abdominal drainage did not prevent overall complications in patients with complicated appendicitis; paradoxically, it delayed the convalescence. Our results discourage the routine use of abdominal drainage and suggest that abdominal drainage should be performed sparingly.
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Affiliation(s)
- Yu-Tso Liao
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC.,Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan, ROC
| | - John Huang
- Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan, ROC
| | - Chia-Tung Wu
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan, ROC
| | - Pei-Chen Chen
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan, ROC
| | - Tsung-Ting Hsieh
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan, ROC
| | - Feipei Lai
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan, ROC.,Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan, ROC
| | - Tzu-Chun Chen
- Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan, ROC
| | - Jin-Tung Liang
- Division of Colorectal Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan, ROC.
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Tsai YW, Lee SY, Jiang JH, Chuang JH. Inappropriate manipulation and drainage exacerbate post-operative pain and prolong the hospital stay after laparoscopic appendectomy for pediatric complicated appendicitis. BMC Surg 2021; 21:437. [PMID: 34953485 PMCID: PMC8709970 DOI: 10.1186/s12893-021-01413-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 11/26/2021] [Indexed: 11/30/2022] Open
Abstract
Background This study examined whether drain placement or not is associated with the postoperative outcomes of pediatric patients following trans-umbilical single-port laparoscopic appendectomy (TUSPLA) for complicated appendicitis. Methods
The medical records of pediatric patients undergoing TUSPLA for acute complicated appendicitis from January 2012 to September 2018 in Kaohsiung Chang Gung Memorial Hospital were reviewed retrospectively. They were classified according to whether they received passive drainage with a Penrose drain (Penrose group) (19), active drainage with a Jackson-Pratt drain with a vacuum bulb (JP group) (16), or no drain (non-drain group) (86). The postoperative outcomes of the three groups were compared. Results Postoperative visual analog scale pain score was significantly higher in the non-drain group than in either the JP group or Penrose group. Patients in the Penrose group had a significantly longer postoperative hospital stay than those in the non-drain group and a higher rate of intra-abdominal abscess, while patients in the JP group had a significantly shorter postoperative hospital stay; moreover, no patient in JP group developed a postoperative intra-abdominal abscess. Conclusions Compared to passive drainage with a Penrose drain or no drain, active drainage with a JP drain shorter the postoperative hospital stay and decreased the risk of postoperative intra-abdominal abscess.
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Affiliation(s)
- Yi-Wen Tsai
- Department of Pediatric Surgery, Kaohsiung Chang Gung Memorial hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung, 83301, Taiwan, R.O.C
| | - Shin-Yi Lee
- Department of Pediatric Surgery, Kaohsiung Chang Gung Memorial hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung, 83301, Taiwan, R.O.C
| | - Jyun-Hong Jiang
- Department of Pediatric Surgery, Kaohsiung Chang Gung Memorial hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung, 83301, Taiwan, R.O.C
| | - Jiin-Haur Chuang
- Department of Pediatric Surgery, Kaohsiung Chang Gung Memorial hospital, No. 123, Dapi Road, Niaosong District, Kaohsiung, 83301, Taiwan, R.O.C..
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Oba T, Yamada T, Matsuda A, Otani M, Matsuda S, Ohta R, Yoshida H, Sato N, Hirata K. Patient backgrounds and short‐term outcomes of complicated appendicitis differ from those of uncomplicated appendicitis. Ann Gastroenterol Surg 2021; 6:273-281. [PMID: 35261953 PMCID: PMC8889856 DOI: 10.1002/ags3.12523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/08/2021] [Accepted: 10/15/2021] [Indexed: 11/24/2022] Open
Abstract
Background Appendicitis is classified as either complicated (CA) or uncomplicated (UA). Some authors have shown that the epidemiologic trends of CA and UA may differ. The aim of this study was to clarify differences in backgrounds and surgical outcomes between CA and UA patients. Methods This study was a cohort study. We extracted case data from the Japanese Diagnosis Procedure Combination (DPC) database from January 2014 to December 2017. Patients were classified into three groups, depending on whether they underwent emergency appendectomy for CA (CA group), emergency appendectomy for UA (UA group), or elective appendectomy (EA group). We evaluated patient characteristics and surgical outcomes for each group. Results We included 89,355 adult patients in the study, comprising 29,331 CA, 48,691 UA, and 11,333 EA patients. Old age, larger body mass index, smoking, and medication with antidiabetic drugs, oral corticosteroids, oral antiplatelet drugs, and oral anticoagulant drugs were independent risk factors for CA. The percentage of CA increased with age. In‐hospital mortality (0.15%, 0.02%, and 0.00%) and 30‐d mortality (0.09%, 0.01%, and 0.00%), respectively, of CA patients were significantly higher than those of the UA and EA groups. The duration of postoperative antibiotic administration, duration of fasting, and time before removal of a prophylactic drain were significantly longer in the CA group than in the UA and EA groups. Conclusion Backgrounds and treatment outcomes of CA and UA patients after emergency surgery are entirely different. Thus, the treatment strategy of CA and UA patients should differ accordingly.
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Affiliation(s)
- Takuya Oba
- Department of Surgery 1 School of Medicine University of Occupational and Environmental Health Fukuoka Japan
| | - Takeshi Yamada
- Department of Gastrointestinal and Hepato‐Biliary‐Pancreatic Surgery Nippon Medical School Tokyo Japan
| | - Akihisa Matsuda
- Department of Gastrointestinal and Hepato‐Biliary‐Pancreatic Surgery Nippon Medical School Tokyo Japan
| | - Makoto Otani
- Occupational Health Data Science Centre University of Occupational and Environmental Health Fukuoka Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health School of Medicine University of Occupational and Environmental Health Fukuoka Japan
| | - Ryo Ohta
- Department of Gastrointestinal and Hepato‐Biliary‐Pancreatic Surgery Nippon Medical School Tokyo Japan
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato‐Biliary‐Pancreatic Surgery Nippon Medical School Tokyo Japan
| | - Norihiro Sato
- Department of Surgery 1 School of Medicine University of Occupational and Environmental Health Fukuoka Japan
| | - Keiji Hirata
- Department of Surgery 1 School of Medicine University of Occupational and Environmental Health Fukuoka Japan
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Li Z, Li Z, Zhao L, Cheng Y, Cheng N, Deng Y. Abdominal drainage to prevent intra-peritoneal abscess after appendectomy for complicated appendicitis. Cochrane Database Syst Rev 2021; 8:CD010168. [PMID: 34402522 PMCID: PMC8407456 DOI: 10.1002/14651858.cd010168.pub4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND This is the second update of a Cochrane Review first published in 2015 and last updated in 2018. Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial. OBJECTIVES To assess the safety and efficacy of abdominal drainage to prevent intraperitoneal abscess after appendectomy (irrespective of open or laparoscopic) for complicated appendicitis; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, Web of Science, the World Health Organization International Trials Registry Platform, ClinicalTrials.gov, Chinese Biomedical Literature Database, and three trials registers on 24 February 2020, together with reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing emergency open or laparoscopic appendectomy for complicated appendicitis. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing appendectomy for complicated appendicitis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We used the GRADE approach to assess evidence certainty. We included intraperitoneal abscess as the primary outcome. Secondary outcomes were wound infection, morbidity, mortality, hospital stay, hospital costs, pain, and quality of life. MAIN RESULTS Use of drain versus no drain We included six RCTs (521 participants) comparing abdominal drainage and no drainage in participants undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia, and Africa. The majority of participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was assessed as at low risk of bias. The evidence is very uncertain regarding the effects of abdominal drainage versus no drainage on intraperitoneal abscess at 30 days (risk ratio (RR) 1.23, 95% confidence interval (CI) 0.47 to 3.21; 5 RCTs; 453 participants; very low-certainty evidence) or wound infection at 30 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-certainty evidence). There were seven deaths in the drainage group (N = 183) compared to one in the no-drainage group (N = 180), equating to an increase in the risk of 30-day mortality from 0.6% to 2.7% (Peto odds ratio 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; low-certainty evidence). Abdominal drainage may increase 30-day overall complication rate (morbidity; RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants; low-certainty evidence) and hospital stay by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants; low-certainty evidence) compared to no drainage. The outcomes hospital costs, pain, and quality of life were not reported in any of the included studies. There were no RCTs comparing the use of drain versus no drain in participants undergoing emergency laparoscopic appendectomy for complicated appendicitis. Open drain versus closed drain There were no RCTs comparing open drain versus closed drain for complicated appendicitis. Early versus late drain removal There were no RCTs comparing early versus late drain removal for complicated appendicitis. AUTHORS' CONCLUSIONS The certainty of the currently available evidence is low to very low. The effect of abdominal drainage on the prevention of intraperitoneal abscess or wound infection after open appendectomy is uncertain for patients with complicated appendicitis. The increased rates for overall complication rate and hospital stay for the drainage group compared to the no-drainage group are based on low-certainty evidence. Consequently, there is no evidence for any clinical improvement with the use of abdominal drainage in patients undergoing open appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in just under 400 recruited participants. Larger studies are needed to more reliably determine the effects of drainage on morbidity and mortality outcomes.
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Affiliation(s)
- Zhuyin Li
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhe Li
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Longshuan Zhao
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Nansheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yilei Deng
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Affiliation(s)
- Katherine He
- Department of General Surgery, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street CA-034, Boston, MA 02115, USA
| | - Shawn J Rangel
- Department of Pediatric & Thoracic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue - Fegan 3, Boston, MA 02115, USA.
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Guaitoli E, Gallo G, Cardone E, Conti L, Famularo S, Formisano G, Galli F, Giuliani G, Martino A, Pasculli A, Patini R, Soriero D, Pappalardo V, Casoni Pattacini G, Sparavigna M, Meniconi R, Mazzari A, Barra F, Orsenigo E, Pertile D. Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis. J INVEST SURG 2020; 34:1089-1103. [PMID: 32167385 DOI: 10.1080/08941939.2020.1740360] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.Methods: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Results: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.
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Affiliation(s)
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Eleonora Cardone
- Department of Surgery, Santa Maria del Popolo degli Incurabili Hospital, Napoli, Italy
| | - Luigi Conti
- Department of Surgery, G. Da Saliceto Hospital, Piacenza, Italy
| | - Simone Famularo
- Department of Medicine and Surgery University of Milan Bicocca HPB Unit, San Gerardo Hospital, Monza, Italy
| | - Giampaolo Formisano
- Department of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | | | - Giuseppe Giuliani
- Department of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Antonio Martino
- Department of General Surgery, University of Genoa, Genova, Italy
| | | | - Romeo Patini
- Odontostomatology and Oral Surgery, Sacro Cuore Hospital, Rome, Italy
| | - Domenico Soriero
- Department of General Surgery, University of Genoa, Genova, Italy
| | | | | | - Marco Sparavigna
- Department of General Surgery, University of Genoa, Genova, Italy
| | - Roberto Meniconi
- Department of General Surgeon and Transplantations, San Camillo-Forlanini Hospital, Rome, Italy
| | - Andrea Mazzari
- Mini Invasive and General Surgery, Cristo Re Hospital, Rome, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy
| | - Elena Orsenigo
- Department of General and Emergency Surgery, San Raffaele Scientific Institute, Milano, Italy
| | - Davide Pertile
- Department of General Surgery, University of Genoa, Genova, Italy
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