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Kumar SS, Collings AT, Lamm R, Haskins IN, Scholz S, Nepal P, Train AT, Athanasiadis DI, Pucher PH, Bradley JF, Hanna NM, Quinteros F, Narula N, Slater BJ. SAGES guideline for the diagnosis and treatment of appendicitis. Surg Endosc 2024; 38:2974-2994. [PMID: 38740595 DOI: 10.1007/s00464-024-10813-y] [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: 12/20/2023] [Accepted: 03/21/2024] [Indexed: 05/16/2024]
Abstract
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.
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Affiliation(s)
- Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ivy N Haskins
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Stefan Scholz
- Division of General and Thoracic Pediatric Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pramod Nepal
- Division of Colon & Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Arianne T Train
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | | | - Philip H Pucher
- School of Pharmacy and Biosciences, University of Portsmouth & Department of General Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Joel F Bradley
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nader M Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Francisco Quinteros
- Division of Colorectal Surgery, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Nisha Narula
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bethany J Slater
- University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, USA.
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Alzate-Ricaurte S, Garcia Moreno IC, Serna Lorza JD, Hincapie-Ayala D, Diaz MC, Alzate Gallego ED, Sanchez Sanchez JP. Case Report: A rare instance of acute appendicitis induced by Balantidium Coli parasitic infection. Front Pediatr 2024; 12:1410850. [PMID: 38803639 PMCID: PMC11128594 DOI: 10.3389/fped.2024.1410850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/29/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction Acute appendicitis secondary to parasitic infections is uncommon, being detected in less than 1% of cases. Balantidium coli is a parasite found in pigs and primates with zoonotic potential. To date, only three cases of acute appendicitis induced by this parasite have been documented globally. Case A 7-year-old female patient, who consumed pork daily, presented to the emergency department with a one-day history of abdominal pain in the lower quadrants, described as colic-like, alongside abdominal distension. Initial abdominal radiography led to a diagnosis of intestinal obstruction. Conservative management without therapeutic response necessitated referral to a higher complexity center. Upon admission, an abdominal computed tomography scan diagnosed acute appendicitis and secondary ileus. During surgical intervention, an appendiceal phlegmon formed by loops of the small intestine was mechanically released, revealing a perforated appendix with extensive fecal peritoneal contamination. Pathological analysis identified an inflammatory infiltrate and the presence of Balantidium coli trophozoites. Medical treatment included Piperacillin-Tazobactam and Metronidazole. The patient was discharged after 10 days of medical treatment. Discussion Acute appendicitis caused by Balantidium coli is a rare occurrence. It is crucial to identify parasites in pathological samples due to their impact on postoperative management. The close contact between humans and pigs, especially in developing countries, suggests that the prevalence of parasitic infection and colonization by Balantidium coli may be higher than currently recognized. Regarding the identification of this patient's specific exposure, the regular consumption of pork suggests the hypothesis that improper processing is linked to the acquisition of the parasitic infection.
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Affiliation(s)
- Sergio Alzate-Ricaurte
- Departamento de Cirugía Pediátrica, Fundación Valle del Lili, Cali, Colombia
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Isabel Cristina Garcia Moreno
- Departamento de Cirugía Pediátrica, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | | | | | | | - Edgar Darío Alzate Gallego
- Departamento de Cirugía Pediátrica, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
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Cioffi SPB, Altomare M, Podda M, Spota A, Granieri S, Reitano E, Zamburlini B, Virdis F, Bini R, Gupta S, Torzilli G, Mingoli A, Chiara O, Cimbanassi S. The burden of the knowledge-to-action gap in acute appendicitis. Surg Endosc 2023; 37:9617-9632. [PMID: 37884735 PMCID: PMC10709474 DOI: 10.1007/s00464-023-10449-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/05/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND The burden of emergency general surgery (EGS) is higher compared to elective surgery. Acute appendicitis (AA) is one of the most frequent diseases and its management is dictated by published international clinical practice guidelines (CPG). Adherence to CPG has been reported as heterogeneous. Barriers to clinical implementation were not studied. This study explored barriers to adherence to CPG and the clinico-economic impact of poor compliance. METHODS Data were extracted from the three-year data lock of the REsiDENT-1 registry, a prospective resident-led multicenter trial. We identified 7 items from CPG published from the European Association of Endoscopic Surgery (EAES) and the World Society of Emergency Surgery (WSES). We applied our classification proposal and used a five-point Likert scale (Ls) to assess laparoscopic appendectomy (LA) difficulty. Descriptive analyses were performed to explore compliance and group comparisons to assess the impact on outcomes and related costs. We ran logistic regressions to identify barriers and facilitators to implementation of CPG. RESULTS From 2019 to 2022, 653 LA were included from 24 centers. 69 residents performed and coordinated data collection. We identified low compliance with recommendations on peritoneal irrigation (PI) (25.73%), abdominal drains (AD) (34.68%), and antibiotic stewardship (34.17%). Poor compliance on PI and AD was associated to higher infectious complications in uncomplicated AA. Hospitalizations were significantly longer in non-compliance except for PI in uncomplicated AA, and costs significantly higher, exception made for antibiotic stewardship in complicated AA. The strongest barriers to CPG implementation were complicated AA and technically challenging LA for PI and AD. Longer operative times and the use of PI negatively affected antibiotic stewardship in uncomplicated AA. Compliance was higher in teaching hospitals and in emergency surgery units. CONCLUSIONS We confirmed low compliance with standardized items influenced by environmental factors and non-evidence-based practices in complex LA. Antibiotic stewardship is sub-optimal. Not following CPG may not influence clinical complications but has an impact in terms of logistics, costs and on the non-measurable magnitude of antibiotic resistance. Structured educational interventions and institutional bundles are required.
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Affiliation(s)
- Stefano Piero Bernardo Cioffi
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy.
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy.
| | - Michele Altomare
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Mauro Podda
- Department of Surgical Sciences, Cagliari State University, Cagliari, Italy
| | - Andrea Spota
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Stefano Granieri
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Vimercate, Italy
| | - Elisa Reitano
- Division of General Surgery, Department of Translational Medicine, Maggiore Della Carità Hospital, University of Eastern Piedmont, Novara, Italy
- Research Institute Against Digestive Cancer, IRCAD, Strasbourg, France
| | - Beatrice Zamburlini
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Francesco Virdis
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | - Roberto Bini
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
| | | | | | - Andrea Mingoli
- Advanced Technologies in Surgery, Department of Surgical Sciences, University of Rome Sapienza, Rome, Italy
| | - Osvaldo Chiara
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery Trauma Team, ASST GOM Niguarda, Viale Ettore Majorana, 20162, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Sobocki J, Pędziwiatr M, Bigda J, Hołówko W, Major P, Mitura K, Myśliwiec P, Nowosad M, Obcowska-Hamerska A, Orłowski M, Proczko-Stepaniak M, Szeliga J, Wallner G, Zawadzki M. The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part II. Wideochir Inne Tech Maloinwazyjne 2023; 18:379-400. [PMID: 37868279 PMCID: PMC10585467 DOI: 10.5114/wiitm.2023.127884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/27/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method. Aim The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions. Material and methods The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. The recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method. Results and conclusions There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The second part of the guidelines covers sections 6 to12 and the following challenges for surgical practice: acute appendicitis, acute mesenteric ischemia, abdominal injuries, bowel obstruction, diverticulitis, laparoscopy in pregnancy and postoperative complications requiring a reoperation.
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Affiliation(s)
- Jacek Sobocki
- Chair and Department of General Surgery and Clinical Nutrition, Medical Center of Postgraduate Education Warsaw, Warsaw, Poland
| | - Michał Pędziwiatr
- 2 Department of General Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - Justyna Bigda
- Department of General, Endocrine and Transplant Surgery, University Medical Center, Medical University of Gdansk, Gdansk, Poland
| | - Wacław Hołówko
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Major
- 2 Department of General Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland
| | - Kryspin Mitura
- Faculty of Medical and Health Sciences, Siedlce University of Natural Sciences and Humanities, Siedlce, Poland
| | - Piotr Myśliwiec
- 1 Department of General and Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Małgorzata Nowosad
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Aneta Obcowska-Hamerska
- Department of General, Vascular and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Orłowski
- Department of General and Oncological Surgery, Florian Ceynowa Specialist Hospital, Wejherowo, Poland
| | - Monika Proczko-Stepaniak
- Department of General, Endocrine and Transplant Surgery, University Medical Center, Medical University of Gdansk, Gdansk, Poland
| | - Jacek Szeliga
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum of the Nicolaus Copernicus University, Torun, Poland
| | - Grzegorz Wallner
- 2 Department and Clinic of General, Gastroenterological and Cancer of the Digestive System Surgery, Medical University of Lublin, Lublin, Poland
| | - Marek Zawadzki
- Department of Oncological Surgery, Provincial Specialist Hospital, Wroclaw, Poland
| | - the Expert Group: Prof. Tomasz Banasiewicz, Prof. Andrzej Budzyński, Prof. Adam Dziki, Prof. Michał Grąt, Prof. Marek Jackowski, Prof. Wojciech Kielan, Prof. Andrzej Matyja, Prof. Krzysztof Paśnik, Prof. Piotr Richter, Prof. Antoni Szczepanik, Prof. Mirosław Szura, Prof. Wiesław Tarnowski, Prof. Krzysztof Zieniewicz
- Chair and Department of General Surgery and Clinical Nutrition, Medical Center of Postgraduate Education Warsaw, Warsaw, Poland
- 2 Department of General Surgery, Jagiellonian University, Collegium Medicum, Krakow, Poland
- Department of General, Endocrine and Transplant Surgery, University Medical Center, Medical University of Gdansk, Gdansk, Poland
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
- Faculty of Medical and Health Sciences, Siedlce University of Natural Sciences and Humanities, Siedlce, Poland
- 1 Department of General and Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland
- Department of General, Vascular and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
- Department of General and Oncological Surgery, Florian Ceynowa Specialist Hospital, Wejherowo, Poland
- Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum of the Nicolaus Copernicus University, Torun, Poland
- 2 Department and Clinic of General, Gastroenterological and Cancer of the Digestive System Surgery, Medical University of Lublin, Lublin, Poland
- Department of Oncological Surgery, Provincial Specialist Hospital, Wroclaw, Poland
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Wu C, Fields AC, Zhao B, Castillo-Angeles M, Havens JM, Salim A, Askari R, Nitzschke SL. Early surgery for perforated appendicitis: Are we moving the needle on postoperative abscess? Am J Surg 2023; 226:256-260. [PMID: 37210329 DOI: 10.1016/j.amjsurg.2023.05.002] [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: 03/09/2023] [Revised: 04/16/2023] [Accepted: 05/02/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Perforated appendicitis is often managed nonoperatively though upfront surgery is becoming more common. We describe postoperative outcomes for patients undergoing surgery at their index hospitalization for perforated appendicitis. METHODS We used the 2016-2020 National Surgical Quality Improvement Program database to identify patients with appendicitis who underwent appendectomy or partial colectomy. The primary outcome was surgical site infection (SSI). RESULTS 132,443 patients with appendicitis underwent immediate surgery. Of 14.1% patients with perforated appendicitis, 84.3% underwent laparoscopic appendectomy. Intra-abdominal abscess rates were lowest after laparoscopic appendectomy (9.4%). Open appendectomy (OR 5.14, 95% CI 4.06-6.51) and laparoscopic partial colectomy (OR 4.60, 95% CI 2.38-8.89) were associated with higher likelihoods of SSIs. CONCLUSIONS Upfront surgical management of perforated appendicitis is now predominantly approached by laparoscopy, often without bowel resection. Postoperative complications occurred less frequently with laparoscopic appendectomy compared to other approaches. Laparoscopic appendectomy during the index hospitalization is an effective approach to perforated appendicitis.
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Affiliation(s)
- Christine Wu
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Adam C Fields
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Bixiao Zhao
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Manuel Castillo-Angeles
- Division of Trauma, Burn, Surgical Critical Care, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Joaquim M Havens
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA; Division of Trauma, Burn, Surgical Critical Care, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Ali Salim
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA; Division of Trauma, Burn, Surgical Critical Care, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Reza Askari
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA; Division of Trauma, Burn, Surgical Critical Care, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Stephanie L Nitzschke
- Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA; Division of Trauma, Burn, Surgical Critical Care, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
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6
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Shiihara M, Sudo Y, Matsushita N, Kubota T, Hibi Y, Osugi H, Inoue T. Therapeutic strategy for acute appendicitis based on laparoscopic surgery. BMC Surg 2023; 23:161. [PMID: 37312100 PMCID: PMC10265908 DOI: 10.1186/s12893-023-02070-y] [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: 12/27/2022] [Accepted: 06/04/2023] [Indexed: 06/15/2023] Open
Abstract
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.
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Affiliation(s)
- Masahiro Shiihara
- Department of Surgery, Kamifukuoka General Hospital, 931 Fukuoka Fujimino-Shi, Saitama, 356-0011, Japan.
| | - Yasuhiro Sudo
- Department of Surgery, Kamifukuoka General Hospital, 931 Fukuoka Fujimino-Shi, Saitama, 356-0011, Japan
| | - Norimasa Matsushita
- Department of Surgery, Kamifukuoka General Hospital, 931 Fukuoka Fujimino-Shi, Saitama, 356-0011, Japan
| | - Takeshi Kubota
- Department of Surgery, Kamifukuoka General Hospital, 931 Fukuoka Fujimino-Shi, Saitama, 356-0011, Japan
| | - Yasuhiro Hibi
- Department of Surgery, Kamifukuoka General Hospital, 931 Fukuoka Fujimino-Shi, Saitama, 356-0011, Japan
| | - Harushi Osugi
- Department of Surgery, Kamifukuoka General Hospital, 931 Fukuoka Fujimino-Shi, Saitama, 356-0011, Japan
| | - Tatsuo Inoue
- Department of Surgery, Kamifukuoka General Hospital, 931 Fukuoka Fujimino-Shi, Saitama, 356-0011, Japan
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Zhou Q, Meng W, Ren Y, Li Q, Boermeester MA, Nthumba PM, Rickard J, Zheng B, Liu H, Shi Q, Zhao S, Wang Z, Liu X, Luo Z, Yang K, Chen Y, Sawyer RG. Effectiveness of intraoperative peritoneal lavage with saline in patient with intra-abdominal infections: a systematic review and meta-analysis. World J Emerg Surg 2023; 18:24. [PMID: 36991507 DOI: 10.1186/s13017-023-00496-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Abstract
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.
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8
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Kurihara H, Tilsed J. Focus on identifying and closing knowledge gaps in acute appendicitis. Eur J Trauma Emerg Surg 2023; 49:1-3. [PMID: 36780050 PMCID: PMC9924202 DOI: 10.1007/s00068-022-02209-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Affiliation(s)
- Hayato Kurihara
- IRCCS Fondazione Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jonathan Tilsed
- Hull University Teaching Hospitals NHS Trust, Anlaby Road, Hull, HU3 2JZ, UK.
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9
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Cioffi SPB, Granieri S, Scaravilli L, Molteni M, Altomare M, Spota A, Virdis F, Bini R, Renzi F, Reitano E, Ragozzino R, Gupta S, Chiara O, Cimbanassi S, Albanesi F, Altomare M, Andreatta E, Baldari L, Benuzzi L, Bevilaqua E, Bonomi AM, Brachetti G, Cannavale G, Chierici AP, Cioffi SPB, Cirelli R, Colletti G, D’abrosca V, Danelli P, Del Prete L, Di Capua F, Di Vittorio F, Ferrari D, Ferrario L, Fiore L, Frattaruol C, Froiio C, Gibelli L, Giusti I, Giustizieri U, Grandi S, Granieri S, Iacob G, Kersik A, Lombardi P, Longhi M, Lorusso L, Manara M, Manzo E, Marin JN, Maspero M, Messina V, Milito P, Molteni M, Monti E, Nicastro V, Novelli G, Paleino S, Pavesi S, Perali C, Pezzoli I, Ragozzino R, Santolamazza G, Scaravilli L, Spota A, Tornatore G, Toti F, Tripodi V, Vaterlini E, Vignati B. Surgeons' attitudes during laparoscopic appendectomy: do subjective intraoperative assessments affect the choice of peritoneal irrigation? A spin-off analysis from the REsiDENT-1 multicentre prospective observational trial. Surg Endosc 2023; 37:729-740. [PMID: 36307601 DOI: 10.1007/s00464-022-09674-0] [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: 05/12/2022] [Accepted: 09/24/2022] [Indexed: 01/18/2023]
Abstract
AIMS Laparoscopic appendectomy (LA) for acute appendicitis (AA) is one of the most performed procedures. The effects of peritoneal lavage (PL) and the reasons to perform it have not been cleared and all meta-analyses didn't show a statistical advantage to prevent infectious complications. This study aims to investigate surgeons' perceptions during LA, comparing intraoperative findings with histological results, and exploring how surgeons' subjectivity influences the decision-making process on PL. METHODS Data were extracted from the two-year data lock from REsiDENT-1 registry, a prospective resident-led multicentre observational trial. This study investigates the relationships between PL and postoperative intraabdominal abscesses (pIAA) introducing a classification for AA to standardize the intraoperative grading. We included pre, intra, and postoperative variables. We applied our classification proposal, used a five-point Likert scale (Ls) to assess subjective LA difficulty and ran a concordance analysis between the assessment of AA and histology. Subsequently, a multivariate logistic regression model was built to find factors influencing PL. RESULTS 561 patients were enrolled from twenty-one hospitals and 51 residents. 542 procedures were included in the logistic regression analysis and 441 in the concordance analysis, due to missing data. PL was used in 222 LA (39, 6%). We discovered a moderate positive monotonic relationship between surgical evaluation and histology, p < 0.001. Despite this, the reliability of the surgeon's assessment of appendicitis is progressively lower for gangrenous and perforated forms. The increasing grade of contamination, the increasing grade of subjective difficulty and the intraoperative finding of a gangrenous or perforated appendicitis were independent predictors of PL. CONCLUSION This study shows how surgeons' evaluation of AA severity overestimated more than half of gangrenous or perforated appendices with the perception of a challenging procedure. These perceptions influenced the choice of PL. We proved that the evaluation during LA could be affected by subjectivity with a non-negligible impact on the decision-making process.
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Affiliation(s)
- Stefano Piero Bernardo Cioffi
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy. .,Department of Surgical Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy.
| | - Stefano Granieri
- General Surgery Unit, ASST Vimercate, Via Santi Cosma e Damiano 16, 20871, Vimercate, Italy
| | - Luca Scaravilli
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.,General Surgery Residency Program, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Mattia Molteni
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.,General Surgery Residency Program, San Raffaele Hospital University, Via Olgettina 60, 20132, Milan, Italy
| | - Michele Altomare
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.,Department of Surgical Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Andrea Spota
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Francesco Virdis
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Roberto Bini
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Federica Renzi
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Elisa Reitano
- IRCAD Research Institute Against Digestive Cancer, Strasbourg, France
| | - Roberta Ragozzino
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Shailvi Gupta
- University of Maryland, Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.,Department of Pathophysiology and Transplants, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST GOM Niguarda, Milano, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.,Department of Pathophysiology and Transplants, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
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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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