The utility of peritoneal drains in patients with perforated appendicitis

The utility of intraperitoneal drain placement after laparoscopic appendectomy for perforated appendicitis in postoperative intraperitoneal abscess prevention

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.

Comparison Between Early Appendectomy vs. Conservative Management in Cases of Appendicular Mass

INTRODUCTION

At present, the treatment of choice for appendicular masses is unclear. Recent studies claimed that conservative management of appendicular masses was safe in terms of frequency of perforation. However, there is controversy in the existing literature.

OBJECTIVE

This research is designed to compare the results of early appendectomy versus conservative management of appendicular masses.

MATERIAL AND METHODS

It was a randomized controlled trial performed in the Combined Military Hospital, Lahore. The study lasted six months, from 01/03/2019 to 30/09/2019. It involved 60 patients of both genders aged between 16 and 70 years diagnosed with appendicular masses with an Alvarado score of 4-7. These patients were randomly divided into two treatment groups. In Group A patients, an early appendectomy was performed, while patients in Group B were managed conservatively. Outcome variables were the mean length of hospital stay and frequency of appendicular perforation.

RESULTS

The mean age of the patients was 26.8±11.9 years. There were 33 (55.0%) male and 27 (45.0%) female patients, with a male-to-female ratio of 1.2:1. The mean length of hospital stay was significantly longer in patients managed conservatively as compared to those undergoing early appendectomy (2.80±1.54 vs. 1.83±0.83; p=0.004). However, the frequency of perforation was not significantly higher in the conservative group as compared to the early appendectomy group (16.7% vs. 10.0%; p=0.448).

CONCLUSION

Conservative management of patients with appendicular mass was associated with prolonged hospital stays, yet it was found equally safe in terms of frequency of appendicular perforation, which advocates conservative management of patients with appendicular mass, particularly in high-risk patients.

Prophylactic abdominal drainage following appendectomy for complicated appendicitis: A meta-analysis

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.

Retrospective evaluation of the use of small-bore wire-guided catheters for the management of peritoneal effusion in cats and dogs

OBJECTIVE

To describe the use of small-bore wire-guided catheters in the management of peritoneal effusion in cats and dogs and to detail any associated adverse events.

DESIGN

Retrospective study.

SETTING

University teaching hospital ANIMALS: Forty-five client-owned animals that had peritoneal catheters placed for management of peritoneal effusion between July 2010 and June 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty-five cases were included (25 dogs and 20 cats). Twenty-eight animals had the catheter placed to aid management of a uroabdomen, 8 of which recovered without surgical management, 11 had the catheter placed to allow autotransfusion of hemoabdomen, 3 had peritonitis, and 3 had ascites secondary to cardiac disease. Twenty-seven cases (15 dogs and 12 cats) received sedation (n = 24) or local anesthesia alone (n = 3) to facilitate catheter placement, and 6 cases had the catheter placed while under general anesthesia. Median length of catheter persistence was 24 hours (range: 2-144 h). The most common adverse events reported were impaired drainage (n = 7) and leakage at the insertion site (n = 4).

CONCLUSIONS

Peritoneal catheters can be inserted percutaneously for management of peritoneal effusion. Indications include stabilization and conservative management of uroabdomen, and autotransfusion. They can often be placed with minimal or no sedation and adverse events appear infrequent in occurrence.

Inappropriate manipulation and drainage exacerbate post-operative pain and prolong the hospital stay after laparoscopic appendectomy for pediatric complicated appendicitis

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.

Abdominal drainage to prevent intra-peritoneal abscess after appendectomy for complicated appendicitis

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.

Total Leukocyte Count Depicting the Degree of Inflammation in Acute Appendicitis

Introduction Acute appendicitis (AA) is the most common cause of acute abdomen in young adults. The diagnosis is usually made on various clinical findings. However, a missed case of acute appendicitis is a catastrophe as it later presents with life-threatening complications and results in medicolegal issues. Raised total leukocyte count (TLC) is a frequent finding in patients with acute appendicitis. As a convention, a normal leukocyte count usually rules out the differential diagnosis of acute appendicitis. Recent studies claimed that a substantial proportion of patients with normal TLC also had acute appendicitis and warranted a careful evaluation of such cases before sending them home. However, the reported frequency of acute appendicitis among TLC normal patients varied greatly among studies which necessitated the present study. Aim Our aim was to determine the frequency of acute appendicitis in patients of normal TLC. Materials and methods This descriptive cross-sectional study was conducted at the Department of Surgery, KRL Hospital Islamabad. This study was carried out from 1 July 2019 to 31 December 2019. This study involved 238 patients of both genders aged between 12 and 70 years suspected of acute appendicitis on physical and ultrasound findings but with a normal TLC (4,500-11,000 WBCs/µL). The outcome variable was the frequency of acute appendicitis among such patients which was diagnosed upon surgery (inflamed appendix with free fluid) and histopathology of excised tissue (mucosal inflammation, neutrophil infiltrates, wall necrosis). Frequency of acute appendicitis was compared across various age and gender groups. Written informed consent was obtained from every patient. Results The mean age of the patients was 27.4±15.5 years. Majority (n = 167, 70.2%) of the patients were aged ≤25 years, followed by 40 (16.8%) patients aged ≥46 years and 31 (13.0%) patients aged between 26 and 45 years. There were 135 (56.7%) male and 103 (43.3%) female patients with a male to female ratio of 1.3:1. All of the patients (100.0%) had pain in the right iliac fossa (RIF) while rebound tenderness, anorexia, nausea/vomiting, fever and dysuria were noted in 83.6%, 79.0%, 73.9%, 63.9% and 15.1% patients, respectively. The diagnosis of acute appendicitis was made in 198 (83.2%) patients with normal TLC and suspicion of acute appendicitis on physical findings and ultrasound. When stratified, there was no statistically significant difference in the frequency of acute appendicitis across various age (p-value = 0.988) and gender (p-value = 0.913) groups. Conclusion In the present study, contrary to the routine impression that normal TLC rules out the differential diagnosis of acute appendicitis, a substantial proportion of patients with clinical and ultrasound suspicion of acute appendicitis but normal TLC had acute appendicitis which is worrisome as a missed case may later present with complications. The present study thus warrants cautious evaluation of clinically suspected cases with normal TLC count to avoid a missed appendicitis and improve the outcome in future surgical practice.

Prophylactic Drainage after Appendectomy for Perforated Appendicitis in Adults: A Post Hoc Analysis of an EAST Multi-Center Study

Background: We sought to assess the efficacy of prophylactic abdominal drainage to prevent complications after appendectomy for perforated appendicitis. Methods: In this post hoc analysis of a prospective multi-center study of appendicitis in adults (≥ 18 years), we included patients with perforated appendicitis diagnosed intra-operatively. The 634 subjects were divided into groups on the basis of receipt of prophylactic drains. The demographics and outcomes analyzed were surgical site infection (SSI), intra-abdominal abscess (IAA), Clavien-Dindo complications, secondary interventions, and hospital length of stay (LOS). Multivariable logistic regression for the cumulative 30-day incidence of IAA was performed controlling for age, Charlson Comorbidity Index (CCI), antibiotic duration, presence of drains, and Operative American Association for the Surgery of Trauma (AAST) Grade. Results: In comparing the Drain (n = 159) versus No-Drain (n = 475) groups, there was no difference in the frequency of male gender (61% versus 55%; p = 0.168), weight (87.9 ± 27.9 versus 83.8 ± 23.4 kg; p = 0.071), Alvarado score (7 [6-8] versus 7 [6-8]; p = 0.591), white blood cell (WBC) count (14.8 ± 4.8 versus 14.9 ± 4.5; p = 0.867), or CCI (1 [0-3] versus 1 [0-2]; p = 0.113). The Drain group was significantly older (51 ± 16 versus 48 ± 17 years; p = 0.017). Drain use increased as AAST EGS Appendicitis Operative Severity Grade increased: Grade 3 (62/311; 20%), Grade 4 (46/168; 27%), and Grade 5 (51/155; 33%); p = 0.007. For index hospitalization, the Drain group had a higher complication rate (43% versus 28%; p = 0.001) and longer LOS (4 [3-7] versus 3 [1-5] days; p < 0.001). We could not detect a difference between the groups in the incidence of SSI, IAA, or secondary interventions. There was no difference in 30-day emergency department visits, re-admissions, or secondary interventions. Multi-variable logistic regression showed that only AAST Grade (odds ratio 2.7; 95% confidence interval7 1.5-4.7; p = 0.001) was predictive of the cumulative 30-day incidence of IAA. Conclusions: Prophylactic drainage after appendectomy for perforated appendicitis in adults is not associated with fewer intra-abdominal abscesses but is associated with longer hospital LOS. Increasing AAST EGS Appendicitis Operative Grade is a strong predictor of intra-abdominal abscess.

Prophylactic Drain Placement in Childhood Perforated Appendicitis: Does Spillage Matter?

Background: Prophylactic abdominal drains for perforated appendicitis in children have generally been regarded as obsolete because several studies showed inferior results for drain placement in the past. Despite these results, prophylactic abdominal drains for perforated appendicitis remain omnipresent in pediatric surgery especially when gross spillage is observed at the time of appendectomy. Here, we hypothesize that even if accounting for gross intra-abdominal spillage, prophylactic drain placement for perforated appendicitis in children is not beneficial. Patients and Methods: The charts of all children (<18 years) who underwent an appendectomy at our institution from July 2013 to March 2020 were analyzed. The data from 65 patients who presented with perforated appendicitis were included. Patients were grouped according to the amount of intraoperative spillage. Demographics, laboratory data, operative findings, and postoperative outcomes were analyzed. Results: Of all patients, 34 were male, and 31 were female, with a mean age of 10.5 ± 3.7 years. There were no statistically significant differences between the groups for age and sex (p = 0.6985 and p = 0.6222, respectively). Prophylactic drains were placed according to the surgeon's preference in 32 children. There were no statistically significant differences between the groups in the rate of intra-abdominal abscess formation, wound infection, and bowel obstruction, regardless of the amount of spillage encountered during an appendectomy. However, independently of the amount of spillage, the length of hospital stay was longer in the children in which a drain had been placed (p = 0.0041). Conclusion: In our cohort, we could not find a benefit from drain placement even in case of gross spillage at the time of appendectomy. Rather, drain placement was associated with an increase in length of hospital stay.

Abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis

BACKGROUND

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 from postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.This is an update of the review first published in 2015.

OBJECTIVES

To assess the safety and efficacy of abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 6), Ovid MEDLINE (1946 to 30 June 2017), Ovid Embase (1974 to 30 June 2017), Science Citation Index Expanded (1900 to 30 June 2017), World Health Organization International Clinical Trials Registry Platform (30 June 2017), ClinicalTrials.gov (30 June 2017) and Chinese Biomedical Literature Database (CBM) (1978 to 30 June 2017).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared abdominal drainage and no drainage in people undergoing emergency open appendectomy for complicated appendicitis.

DATA COLLECTION AND ANALYSIS

Two review authors identified the trials for inclusion, collected the data, and assessed the risk of bias independently. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio for very rare outcomes), and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). We used GRADE to rate the quality of evidence.

MAIN RESULTS

We included six RCTs (521 participants), comparing abdominal drainage and no drainage in patients undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia and Africa. The majority of the participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was at low risk of bias.There was insufficient evidence to determine the effects of abdominal drainage and no drainage on intra-peritoneal abscess at 14 days (RR 1.23, 95% CI 0.47 to 3.21; 5 RCTs; 453 participants; very low-quality evidence) or for wound infection at 14 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-quality evidence). The increased risk of 30-day overall complication rate (morbidity) in the drainage group was rated as very low-quality evidence (RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants). 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 (OR) 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; moderate-quality evidence). There is 'very low-quality' evidence that drainage increases hospital stay compared to the no drainage group by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants).Other outlined outcomes, hospital costs, pain, and quality of life, were not reported in any of the included studies.

AUTHORS' CONCLUSIONS

The quality of the current evidence is very low. The effect of abdominal drainage on the prevention of intra-peritoneal 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 no drainage group is also subject to great uncertainty. Thus, there is no evidence for any clinical improvement by using 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 people recruited to the studies. Larger studies are needed to determine the effects of drainage on morbidity and mortality outcomes more reliably.

Clinical-epidemiological profile of acute appendicitis: retrospective analysis of 638 cases

OBJECTIVE

to describe the clinical and epidemiological profile of acute appendicitis (AA) of the patients treated at a referral center in the Juiz de Fora macro-region, Minas Gerais State, Brazil.

METHODS

we conducted a retrospective, observational study in the Dr. Mozart Geraldo TeixeiraEmergency Hospital. We selected 638 patients diagnosed with AA, and analyzed the variables gender, age, evolutionary phase, length of hospital stay, pathological diagnosis, use of antibiotics, use of drains, complications and mortality.

RESULTS

AA was more prevalent in young adults (19-44 years) and males (65.20%). The mean hospital stay was seven days and phase II was the most prevalent. We found the histopathological diagnosis of primary tumor of the appendix in six patients (0.94%), adenocarcinoma being the most common histologic type (66.7%). Regarding the use of antibiotics, 196 patients underwent antibiotic prophylaxis and 306 received antibiotic therapy. Eighty-one patients used some kind of drain, for an average of 4.8 days. Seventeen patients died (2.67%), predominantly males (70.59%), with mean age of 38.47 years.

CONCLUSION

AA has a higher prevalence in males and young adults. The length of stay is directly associated with the evolutionary phase. The most common complication is infection of the surgical site. Mortality in our service is still high when compared with developed centers.

OBJETIVO

avaliar a epidemiologia e os resultados do tratamento cirúrgico de doentes portadores de graus III e IV, mais avançados, da Síndrome de Mirizzi (SM) de acordo com a classificação de Csendes.

MÉTODOS

estudo retrospectivo, de corte transversal através da revisão de prontuários de 13 pacientes portadores de graus III e IV da SM operados de dezembro de 2001 a setembro de 2013, entre 3691 colecistectomias realizadas neste período.

RESULTADOS

a incidência da SM foi 0,6% (23 casos) e os graus III e IV perfizeram 0,35% deste número. Houve um predomínio de tipo IV (12 casos). O diagnóstico pré-operatório foi possível em 53,8% dos casos. A conduta preferencial foi derivação biliodigestiva (10 casos) e foi optado por drenagem com tubo "T" e sutura da via biliar em três ocasiões especiais. Três pacientes apresentaram fístula biliar resolvida com conduta expectante e um caso de coleperitônio necessitou reoperação. No seguimento ambulatorial dos pacientes que realizaram a anastomose biliodigestiva (oito), 50% estão assintomáticos, 25% apresentaram estenose da anastomose e 25% perderam seguimento. O tempo médio de acompanhamento foi 41,8 meses.

CONCLUSÃO

de incidência baixa e de diagnóstico pré-operatório em apenas metade dos casos, a SM em graus avançados tem na anastomose biliodigestiva sua melhor conduta, porém não isenta de morbimortalidade.

Analysis of antibiotics selection in patients undergoing appendectomy in a Chinese tertiary care hospital

Background

To investigate the status of antibiotics use in acute appendicitis patients who undergo appendectomy in a Chinese tertiary care hospital.

Methods

A retrospective analysis of 93 patients who underwent appendectomy from June 1, 2011 to May 30, 2012 and had recorded use of intravenous antibiotics. We defined simple appendicitis and suppurative appendicitis as mild appendicitis. Gangrenous appendicitis and perforated appendicitis were classified as advanced appendicitis. The occurrence of advanced appendicitis, postoperative complications and length of hospital stay were the three major end points for outcomes analysis.

Results

100 % of the patients received antibiotics therapy before and after operation. 45 patients received Fluoroquinolones (48.4 %), 41 patients received Cephalosporins (44.1 %) and 7 patients received Carbapenems (7.5 %). We found no statistical difference between antibiotics selection and the occurrence of advanced appendicitis (P = 0.3337). Both the monovariate analysis and multivariate analysis showed no statistical difference between antibiotics selection and the postoperative complications (P > 0.05). The average stay of patients receiving Fluoroquinolones was 2.6 days shorter than patients who received Cephalosporins (P = 0.0085).

Conclusion

It is a lack of a standardized guideline for antibiotics selection in our hospital. All the antibiotics prescription were empirical. We tended to choose high levels of antibiotics, pay insufficient attention to the anaerobic bacteria and have a long duration of antibiotics therapy. We also found that antibiotics selection bore no relationship with the occurrence of advanced appendicitis and postoperative complications. Fluoroquinolones may lead to a shorter hospital stay, but this result may also be affected by the fewer underlying diseases and lower severity of the patients.

Experimental comparison of abdominal drainage systems

BACKGROUND

In an experimental study the performance of different closed abdominal drainage systems was tested.

METHODS

A vacuum bottle designed for Redon Drainage, a flexible plastic bulb designed for Jackson-Pratt drains and a V.A.C.^® Negative Pressure Wound Therapy System were used. In a porcine cadaveric study mimicking the abdominal cavity the intrinsic pressure (IP) at one and three minutes (T0, T3) and the amount of evacuated fluid were measured.

RESULTS

The Redon and Jackson drainage displayed a rapid decline to IP values of almost zero comparing T0 and T3. Only the V.A.C.^® system was able to preserve constant values of negative IP values measured at both time points. Only the V.A.C.^® system was able to remove almost the whole amount of inserted fluid.

CONCLUSIONS

In an experimental setting the V.A.C.^® system was superior to the other two tested systems in delivering constant negative IP and the amount of evacuated fluid.

Could an abdominal drainage be avoided in complicated acute appendicitis? Lessons learned after 1300 laparoscopic appendectomies

INTRODUCTION

Complicated appendicitis (CA) may be a risk factor for postoperative intra-abdominal abscess formation (IAA). In addition, several publications have shown an increased risk of postoperative collection after laparoscopic appendectomy. Most surgeons prefer to place a drain to collect contaminated abdominal fluid to prevent consequent abscess formation. We aimed to evaluate the utility of placing an intra-abdominal drain in laparoscopic appendectomy for complicated acute appendicitis.

MATERIAL AND METHODS

From January 2005 to June 2015 all charts of consecutive patients who underwent laparoscopic appendectomy for CA were revised. CA was defined as a perforated appendix with associated peritonitis. The sample was divided into two groups, G1: intra-abdominal drain and G2: no drain. Demographics, operative factors and 30-day postoperative complications were analyzed.

RESULTS

In the study period 1300 laparoscopic appendectomies were performed. Laparoscopic findings showed that 17.3% of the surgeries were for complicated acute appendicitis (225 patients). Fifty-six patients (25%) were in G1 and 169 patients (75%) in G2. No significant differences in clinical presentation and demographics were found (p: NS). G1 had an increased conversion rate (G1: 19.6% vs. G2: 7.1%; p: 0.007). No differences were found in the overall morbidity (G1: 32.1% vs. G2: 21.3%, p: NS). The rate of postoperative IAA was 14.2% in G1 and 8.9% in G2 (p: NS). Length of stay was higher in G1 (G1: 5.2 days vs. G2 2.9 days, p: 0.001). There was no mortality in either group.

CONCLUSION

The placement of intra-abdominal drain in complicated acute appendicitis may not present benefits and may even lengthen hospital stay. These observations suggest that there is no need of using a drain in laparoscopic appendectomy for complicated acute appendicitis.