Peritoneal lavage versus drainage for perforated appendicitis in children

Abdominal drainage to prevent intraperitoneal abscess after appendectomy for complicated appendicitis

RATIONALE

This is the third update of a Cochrane review first published in 2015 and last updated in 2021. Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. People who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer postoperative complications in comparison to uncomplicated appendicitis. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.

OBJECTIVES

To evaluate the benefits and harms of abdominal drainage in reducing 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 CENTRAL, MEDLINE, Embase, two other databases, and five trials registers, together with reference checking, citation searching, and contact with study authors, to identify studies for inclusion in the review. The latest search date was 12 October 2023.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in people with complicated appendicitis comparing (1) use of drain versus no drain, (2) open drain versus closed drain, or (3) different schedules for drain removal. We excluded studies in which not all participants received antibiotics after appendectomy.

OUTCOMES

Our critical outcome was intraperitoneal abscess. Important outcomes were wound infection, morbidity, mortality, and hospital stay.

RISK OF BIAS

We used the Cochrane RoB 1 tool to assess the risk of bias in RCTs and quasi-RCTs.

SYNTHESIS METHODS

We synthesised the results for each outcome in a meta-analysis using the random-effects model, except for the Peto odds ratio, which only has a fixed-effect model. We planned to use the Synthesis Without Meta-analysis (SWiM) approach to report studies when it was not possible to undertake a meta-analysis of effect estimates. We used GRADE to assess the certainty of evidence for each outcome.

INCLUDED STUDIES

We included eight studies (five RCTs and three quasi-RCTs) with a total of 739 paediatric and adult participants, of which 370 participants were randomised to the drainage group and 369 participants to the no-drainage group. The studies were conducted in North America, Asia, and Africa and published between 1973 and 2023. The majority of participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open or laparoscopic appendectomy. All studies were at overall high risk of bias.

SYNTHESIS OF RESULTS

Use of drain versus no drain We assessed the certainty of the evidence for 30-day mortality as moderate due to imprecision. We assessed the certainty of the evidence for all other outcomes as very low, downgraded mainly due to high risk of bias, inconsistency, and imprecision. The evidence is very uncertain regarding the effects of abdominal drainage versus no drainage on intraperitoneal abscess at 30 days (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.55 to 2.12; 7 studies, 671 participants; very low-certainty evidence), wound infection at 30 days (RR 1.76, 95% CI 0.89 to 3.45; 7 studies, 696 participants), and morbidity at 30 days (RR 1.84, 95% CI 0.14 to 24.50; 2 studies, 124 participants) in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis. Approximately 113 (57 to 221 participants) out of 1000 participants in the drainage group developed intraperitoneal abscess, compared with 104 out of 1000 participants in the no-drainage group. There were seven deaths in the drainage group (N = 291) compared with one in the no-drainage group (N = 290); abdominal drainage probably increases the risk of 30-day mortality (Peto odds ratio 4.88, 95% CI 1.18 to 20.09; 6 studies, 581 participants; moderate-certainty evidence) in paediatric and adult participants undergoing open appendectomy for complicated appendicitis. Abdominal drainage may increase hospital stay by 1.58 days (95% CI 0.86 to 2.31; 5 studies, 516 participants; very low-certainty evidence) in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis, but the evidence is very uncertain. Open drain versus closed drain No studies compared open drain versus closed drain for complicated appendicitis. Early versus late drain removal No studies compared early versus late drain removal for complicated appendicitis.

AUTHORS' CONCLUSIONS

The evidence is very uncertain whether abdominal drainage prevents intraperitoneal abscess, wound infection, or morbidity in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis. Abdominal drainage may increase hospital stay in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis, but the evidence is very uncertain. Consequently, there is no evidence for any clinical improvement with the use of abdominal drainage in people undergoing open or laparoscopic appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in paediatric and adult participants undergoing open appendectomy for complicated appendicitis. Larger studies are needed to more reliably determine the effects of drainage on mortality outcomes.

FUNDING

This Cochrane review was funded by the National Natural Science Foundation of China (Grant No. 81701950, 82172135), Natural Science Foundation of Chongqing (Grant No. CSTB2022NSCQ-MSX0058, cstc2021jcyj-msxmX0294), Medical Research Projects of Chongqing (Grant No. 2018MSXM132, 2023ZDXM003, 2024jstg028), and the Kuanren Talents Program of the Second Affiliated Hospital of Chongqing Medical University.

REGISTRATION

Registration: not available. Protocol and previous versions available via doi.org/10.1002/14651858.CD010168, doi.org/10.1002/14651858.CD010168.pub2, doi.org/10.1002/14651858.CD010168.pub3, and doi.org/10.1002/14651858.CD010168.pub4.

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

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

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

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

Irrigation of peritoneal cavity with cold atmospheric plasma treated solution effectively reduces microbial load in rat acute peritonitis model

Accurate and timely diagnosis of appendicitis in children can be challenging, which leads to delayed admittance or misdiagnosis that may cause perforation. Surgical management involves the elimination of the focus (appendectomy) and the reduction of the contamination with peritoneal irrigation to prevent sepsis. However, the validity of conventional irrigation methods is being debated, and novel methods are needed. In the present study, the use of cold plasma treated saline solution as an intraperitoneal irrigation solution for the management of acute peritonitis was investigated. Chemical and in vitro microbiological assessments of the plasma-treated solution were performed to determine the appropriate plasma treatment time to be used in in-vivo experiments. To induce acute peritonitis in rats, the cecal ligation and perforation (CLP) model was used. Sixty rats were divided into six groups, namely, sham operation, plasma irrigation, CLP, dry cleaning after CLP, saline irrigation after CLP, and plasma-treated saline irrigation after CLP group. The total antioxidant and oxidant status, oxidative stress index, microbiological, and pathological evaluations were performed. Findings indicated that plasma-treated saline contains reactive species, and irrigation with plasma-treated saline can effectively inactivate intraperitoneal contamination and prevent sepsis with no short-term local and/or systemic toxicity.

Aspiration versus peritoneal lavage in appendicitis: a meta-analysis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Meta-analysis of peritoneal lavage in appendicectomy

Background

The use of peritoneal lavage to prevent postoperative intra‐abdominal abscess (IAA) after appendicectomy has been debated widely.

Methods

A systematic review and meta‐analysis of suction alone versus lavage for appendicitis was performed to determine the relative benefit of lavage. Primary outcomes were postoperative IAA and wound infection (WI). Inclusion criteria were human studies reporting a comparison of appendicectomy with or without peritoneal lavage.

Results

Eight studies met the inclusion criteria, the majority of which were retrospective. Only three were RCTs. Four studies included analysis only of the paediatric population. The rate of IAA was 1·0–19·5 per cent in patients receiving suction alone and 1·5–18·6 per cent in those having lavage. WI rates were 1·0–29·2 per cent for suction alone and 0·8–20·5 per cent for lavage. The pooled risk difference for IAA was 0·01 (95 per cent c.i. −0·03 to 0·06; P = 0·50) and that for WI was 0·00 (−0·05 to 0·05; P = 0·98). Analyses of both outcomes indicated a medium degree of heterogeneity between effect estimates with I² values of 71 per cent (P = 0·001) and 70 per cent (P = 0·010) for IAA and WI respectively.

Conclusion

There is no evidence of benefit of lavage over suction for postoperative infective complications, and no individual study demonstrated a significant benefit in patients receiving lavage.

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.

Intracavity lavage and wound irrigation for prevention of surgical site infection

BACKGROUND

Surgical site infections (SSIs) are wound infections that occur after an operative procedure. A preventable complication, they are costly and associated with poorer patient outcomes, increased mortality, morbidity and reoperation rates. Surgical wound irrigation is an intraoperative technique, which may reduce the rate of SSIs through removal of dead or damaged tissue, metabolic waste, and wound exudate. Irrigation can be undertaken prior to wound closure or postoperatively. Intracavity lavage is a similar technique used in operations that expose a bodily cavity; such as procedures on the abdominal cavity and during joint replacement surgery.

OBJECTIVES

To assess the effects of wound irrigation and intracavity lavage on the prevention of surgical site infection (SSI).

SEARCH METHODS

In February 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries and references of included studies and relevant systematic reviews. There were no restrictions on language, date of publication or study setting.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) of participants undergoing surgical procedures in which the use of a particular type of intraoperative washout (irrigation or lavage) was the only systematic difference between groups, and in which wounds underwent primary closure. The primary outcomes were SSI and wound dehiscence. Secondary outcomes were mortality, use of systemic antibiotics, antibiotic resistance, adverse events, re-intervention, length of hospital stay, and readmissions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion at each stage. Two review authors also undertook data extraction, assessment of risk of bias and GRADE assessment. We calculated risk ratios or differences in means with 95% confidence intervals where possible.

MAIN RESULTS

We included 59 RCTs with 14,738 participants. Studies assessed comparisons between irrigation and no irrigation, between antibacterial and non-antibacterial irrigation, between different antibiotics, different antiseptics or different non-antibacterial agents, or between different methods of irrigation delivery. No studies compared antiseptic with antibiotic irrigation. Surgical site infectionIrrigation compared with no irrigation (20 studies; 7192 participants): there is no clear difference in risk of SSI between irrigation and no irrigation (RR 0.87, 95% CI 0.68 to 1.11; I2 = 28%; 14 studies, 6106 participants). This would represent an absolute difference of 13 fewer SSIs per 1000 people treated with irrigation compared with no irrigation; the 95% CI spanned from 31 fewer to 10 more SSIs. This was low-certainty evidence downgraded for risk of bias and imprecision.Antibacterial irrigation compared with non-antibacterial irrigation (36 studies, 6163 participants): there may be a lower incidence of SSI in participants treated with antibacterial irrigation compared with non-antibacterial irrigation (RR 0.57, 95% CI 0.44 to 0.75; I2 = 53%; 30 studies, 5141 participants). This would represent an absolute difference of 60 fewer SSIs per 1000 people treated with antibacterial irrigation than with non-antibacterial (95% CI 35 fewer to 78 fewer). This was low-certainty evidence downgraded for risk of bias and suspected publication bias.Comparison of irrigation of two agents of the same class (10 studies; 2118 participants): there may be a higher incidence of SSI in participants treated with povidone iodine compared with superoxidised water (Dermacyn) (RR 2.80, 95% CI 1.05 to 7.47; low-certainty evidence from one study, 190 participants). This would represent an absolute difference of 95 more SSIs per 1000 people treated with povidone iodine than with superoxidised water (95% CI 3 more to 341 more). All other comparisons found low- or very low-certainty evidence of no clear difference between groups.Comparison of two irrigation techniques: two studies compared standard (non-pulsed) methods with pulsatile methods. There may, on average, be fewer SSIs in participants treated with pulsatile methods compared with standard methods (RR 0.34, 95% CI 0.19 to 0.62; I2 = 0%; two studies, 484 participants). This would represent an absolute difference of 109 fewer SSIs occurring per 1000 with pulsatile irrigation compared with standard (95% CI 62 fewer to 134 fewer). This was low-certainty evidence downgraded twice for risks of bias across multiple domains. Wound dehiscenceFew studies reported wound dehiscence. No comparison had evidence for a difference between intervention groups. This included comparisons between irrigation and no irrigation (one study, low-certainty evidence); antibacterial and non-antibacterial irrigation (three studies, very low-certainty evidence) and pulsatile and standard irrigation (one study, low-certainty evidence). Secondary outcomesFew studies reported outcomes such as use of systemic antibiotics and antibiotic resistance and they were poorly and incompletely reported. There was limited reporting of mortality; this may have been partially due to failure to specify zero events in participants at low risk of death. Adverse event reporting was variable and often limited to individual event types. The evidence for the impact of interventions on length of hospital stay was low or moderate certainty; where differences were seen they were too small to be clinically important.

AUTHORS' CONCLUSIONS

The evidence base for intracavity lavage and wound irrigation is generally of low certainty. Therefore where we identified a possible difference in the incidence of SSI (in comparisons of antibacterial and non-antibacterial interventions, and pulsatile versus standard methods) these should be considered in the context of uncertainty, particularly given the possibility of publication bias for the comparison of antibacterial and non-antibacterial interventions. Clinicians should also consider whether the evidence is relevant to the surgical populations under consideration, the varying reporting of other prophylactic antibiotics, and concerns about antibiotic resistance.We did not identify any trials that compared an antibiotic with an antiseptic. This gap in the direct evidence base may merit further investigation, potentially using network meta-analysis; to inform the direction of new primary research. Any new trial should be adequately powered to detect a difference in SSIs in eligible participants, should use robust research methodology to reduce the risks of bias and internationally recognised criteria for diagnosis of SSI, and should have adequate duration and follow-up.

Outcome reporting in randomised controlled trials and meta-analyses of appendicitis treatments in children: a systematic review

Background

Acute appendicitis is the most common surgical emergency in children. Despite this, there is no core outcome set (COS) described for randomised controlled trials (RCTs) in children with appendicitis and hence no consensus regarding outcome selection, definition and reporting. We aimed to identify outcomes currently reported in studies of paediatric appendicitis.

Methods

Using a defined, sensitive search strategy, we identified RCTs and systematic reviews (SRs) of treatment interventions in children with appendicitis. Included studies were all in English and investigated the effect of one or more treatment interventions in children with acute appendicitis or undergoing appendicectomy for presumed acute appendicitis. Studies were reviewed and data extracted by two reviewers. Primary (if defined) and all other outcomes were recorded and assigned to the core areas ‘Death’, ‘Pathophysiological Manifestations’, ‘Life Impact’, ‘Resource Use’ and ‘Adverse Events’, using OMERACT Filter 2.0.

Results

A total of 63 studies met the inclusion criteria reporting outcomes from 51 RCTs and nine SRs. Only 25 RCTs and four SRs defined a primary outcome. A total of 115 unique and different outcomes were identified. RCTs reported a median of nine outcomes each (range 1 to 14). The most frequently reported outcomes were wound infection (43 RCTs, nine SRs), intra-peritoneal abscess (41 RCTs, seven SRs) and length of stay (35 RCTs, six SRs) yet all three were reported in just 25 RCTs and five SRs. Common outcomes had multiple different definitions or were frequently not defined. Although outcomes were reported within all core areas, just one RCT and no SR reported outcomes for all core areas. Outcomes assigned to the ‘Death’ and ‘Life Impact’ core areas were reported least frequently (in six and 15 RCTs respectively).

Conclusions

There is a wide heterogeneity in the selection and definition of outcomes in paediatric appendicitis, and little overlap in outcomes used across studies. A paucity of studies report patient relevant outcomes within the ‘Life Impact’ core area. These factors preclude meaningful evidence synthesis, and pose challenges to designing prospective clinical trials and cohort studies. The development of a COS for paediatric appendicitis is warranted.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0783-1) contains supplementary material, which is available to authorized users.

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.

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 Library (Issue 1, 2014), MEDLINE (1950 to February 2014), EMBASE (1974 to February 2014), Science Citation Index Expanded (1900 to February 2014), and Chinese Biomedical Literature Database (CBM) (1978 to February 2014).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared abdominal drainage and no drainage in patients 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).

MAIN RESULTS

We included five trials involving 453 patients with complicated appendicitis who were randomised to the drainage group (n = 228) and the no drainage group (n = 225) after emergency open appendectomies. All of the trials were at a high risk of bias. There were no significant differences between the two groups in the rates of intra-peritoneal abscess or wound infection. The hospital stay was longer in the drainage group than in the no drainage group (MD 2.04 days; 95% CI 1.46 to 2.62) (34.4% increase of an 'average' hospital stay).

AUTHORS' CONCLUSIONS

The quality of the current evidence is very low. It is not clear whether routine abdominal drainage has any effect on the prevention of intra-peritoneal abscess after open appendectomy for complicated appendicitis. Abdominal drainage after an emergency open appendectomy may be associated with delayed hospital discharge for patients with complicated appendicitis.

Intraperitoneal drains during open appendicectomy for gangrenous and perforated appendicitis

Intra-abdominal drains are still routinely used in the surgical management of gangrenous and perforated appendicitis. A systematic review was performed with the aim of establishing their influence on postoperative complications in such cases. A literature search was conducted using the search engines PubMed and Cochrance Central Register of Controlled Trials. Included were retrospective case-controlled and prospective randomized controlled trials on the use of drain for open appendicectomy in gangrenous and perforated appendicitis. Twelve articles were found that met the inclusion criteria. Intrabdominal abscesses, postoperative ileus, surgical site infections, fecal fistulas and burst abdomen had significant higher incidences in the drain vs non drain group (10.3%, 20.3%, 32.5%, 3.4% and 5.7% vs 4.7%, 8.5%, 16.2%, 0% and 0%, respectively). In most cases the risk was more than doubled in the drain group compared to the non-drain one. There were no significant differences among groups in terms of mortality while the results were underpowered to effectively evaluate wound dehiscence and adhesions. The use of intra-abdominal drains in the management of gangrenous and perforated appendicitis by open appendicectomy is associated with an increased rate of common postoperative complications.

Placement of prophylactic drains after laparotomy may increase infectious complications in neonates

PURPOSE

The aim of this study was to determine if the placement of prophylactic drains influences the incidence of postoperative adverse events in neonates.

METHODS

Neonatal patients undergoing laparotomy between April 2000 and December 2007 were prospectively assigned to aggressive peritoneal cavity lavage, without the placement of prophylactic drains, before abdominal closure (non-drainage group, n = 111). The historical control group consisted of neonates who underwent laparotomy with routine prophylactic drain placement between January 1993 and March 2000 (drainage group, n = 87). The incidence of postoperative adverse events was compared between the two groups.

RESULTS

There were no significant differences in the incidence of overall complications (drainage, 48%; non-drainage, 36%: p = 0.08), infectious complications (drainage, 34%; non-drainage, 26%: p = 0.20) or surgical site infections (drainage, 20%; non-drainage, 14%: p = 0.25) between the two groups. In the subgroup analysis, the incidences of total postoperative complications and infectious complications were significantly higher in the drainage group compared with the non-drainage group for upper gastrointestinal tract operations (52 vs. 20%; 39 vs. 6.7%) (p = 0.04 and 0.02, respectively).

CONCLUSION

Prophylactic drainage did not reduce the incidence of postoperative complications, and the placement of drains may possibly increase the incidence of infectious complications.

Prevention of infectious complications after laparoscopic appendectomy for complicated acute appendicitis--the role of routine abdominal drainage

PURPOSE

Complicated acute appendicitis is still associated with an increased morbidity. If laparoscopy has been accepted as a valid approach, some questions remain concerning intra-abdominal abscess formation. Routine prophylactic drainage of the abdomen has been proposed. However, this practice remains a matter of debate, poorly validated in the literature. With the present study, we investigated the impact of drainage in laparoscopic appendectomy for complicated appendicitis.

METHOD

This is a case match study of consecutive patients operated on by laparoscopy in a single institution. One hundred and thirty patients operated for complicated appendicitis (local peritonitis without perforation, with perforation, or with periappendicular abscess) with prophylactic intraperitoneal drainage were matched one by one to 130 patients operated without drainage. Uncomplicated appendicitis and generalized peritonitis were excluded. Primary endpoint was surgical complications and secondary endpoints were transit recovery time and length of hospital stay.

RESULTS

Patients without drain had significantly less overall complications (7.7% vs. 18.5%, p = 0.01). Moreover, the absence of drainage was of significant benefit for transit recovery time (2.5 vs. 3.5 days, p = 0.0068) and length of hospital stay (4.2 vs. 7.3 days, p < 0.0001).

CONCLUSION

No benefits were observed for prophylactic drainage of the abdominal cavity during emergency laparoscopic treatment of complicated appendicitis. For this reason, this practice may be abandoned.

Diagnosis and treatment of acute appendicitis in children: a survey among Dutch surgeons and comparison with evidence-based practice

BACKGROUND

Considerable variability exists in the surgical approach to acute appendicitis in children, affecting both quality and costs of care. A national survey provides insight into daily surgical practice and enables comparison of practice with the available evidence.

METHODS

A national survey was conducted in all 121 Dutch hospitals asking detailed information concerning diagnosis and treatment of children suspected of acute appendicitis. An evidence-based practice (EBP) score was developed on the basis of a critical appraisal of the literature, allowing for classification of reported practices with regard to the level of evidence and identification of hospitals working in accordance with the best available evidence.

RESULTS

The overall response rate was 93%. For the diagnosis of acute appendicitis, respondents relied predominantly on patient history (29%) and clinical examination (31%), followed by laboratory results (22%). Only 20% of the departments routinely measured total white blood cell count (WBC), C-reactive protein (CRP) and leukocyte differential count (proportion of polymorphonuclear cells), being part of the triad that provides diagnostic evidence. Although strong evidence exists in favour of routine prophylaxis for suspected appendicitis, only two thirds of surgical departments reported this as part of their routine practice. For a number of issues, reasonably consistent evidence is available (e.g. primarily versus delayed closure, drainage versus lavage, routine peritoneal culturing). Thirty-eight percent of the departments routinely cultured abdominal fluid despite various reports that it provides no therapeutic advantage. Not more than 22% of the departments closed the skin in perforated appendicitis in spite of clear supportive evidence. Considerable variation exists in cleaning the abdomen in perforated appendicitis, despite evidence favouring lavage. Comparing departments in terms of compliance with available evidence revealed that most paediatric surgery departments worked according to evidence-based medicine.

CONCLUSIONS

Available evidence on diagnosis and treatment of acute appendicitis in children is only partly applied in a small proportion of hospitals in the Netherlands. It is recommended that national guidelines be published, which could decrease health care costs and increase more uniform policy, improve quality of care for this group of patients and improve training of residents in general surgery in the Netherlands.

Receiver-operating characteristic analysis of leukocyte counts and serum C-reactive protein levels in children with advanced appendicitis

PURPOSE

To assess the diagnostic value of the white blood cell count (WBC) and serum C-reactive protein (CRP) level in children with advanced appendicitis.

METHODS

We reviewed 289 children ranging in age from 3 to 15 years old, who underwent appendectomy in our hospital between 1993 and 2003. The advanced appendicitis group consisted of patients with associated perforation, abscess formation, or purulent ascites, and the simple appendicitis group consisted of patients who underwent uncomplicated appendectomy. We compared the age, sex, duration of abdominal pain before surgery, preoperative WBC and CRP level, and hospital stay in the two groups. We analyzed the diagnostic value of WBC and CRP level using a receiver-operating characteristic (ROC) curve.

RESULTS

The children in the advanced appendicitis group had a significantly longer duration of pain, a higher serum CRP level, and longer hospitalization than those in the simple group. The serum CRP levels had good diagnostic value in differentiating between the advanced and simple groups. Both the CRP level and the WBC in the patients who suffered abdominal pain for longer than 48 h before surgery had diagnostic value in differentiating between the advanced and simple groups.

CONCLUSION

These findings suggest that increased values of CRP and WBC more than 48 h after the onset of acute abdominal symptoms are indicators of advanced appendicitis.

Treatment strategy when using intraoperative peritoneal lavage for perforated appendicitis in children: a preliminary report

We attempt to quantify the amount of peritoneal irrigation required to significantly decrease the intraperitoneal bacteria in children with perforated appendicitis, as no ideal volume of peritoneal lavage has yet been determined. A series of 11 children who were operated on for peritonitis caused by perforated appendicitis were reviewed retrospectively. All children were treated with our treatment protocol that included intraoperative peritoneal lavage using a large volume of saline. Peritoneal fluid samples were taken before and after peritoneal lavage and then were cultured to determine the colony counts. Twenty of 24 bacteria were available for evaluation of the changes in the flora counts. We found 85% of species to be resistant to peritoneal lavage when 3-5 l of saline per square meter of body surface area (l/m2) were used. In contrast, 5.8+/-1.54 l/m2 of peritoneal lavage fluid was necessary to completely eradicate the intraperitoneal bacterial flora. The residual bacteria showed a greater decrease when lavage fluid in excess of 6 l/m2 was used. Although this is only a preliminary report, these findings could be used to justify a true prospective randomized trial in the future.

The occurrence of an abdominal wall abscess 11 years after appendectomy: report of a case

Most complications after appendectomy occur within 10 days; however, we report herein the unusual case of a patient in whom a wound abscess was detected more than 10 years after an appendectomy. A 26-year-old woman presented to our hospital with nausea and vomiting, pain, and a mass in the right lower abdominal wall. She had undergone an appendectomy 11 years previously. Physical examination revealed a tender mass, 5 cm in diameter, under the appendectomy scar. An abdominal ultrasonography demonstrated a low-echoic mass lesion measuring 9.0 x 5.0 x 2.0 cm. Incision of the connective tissue revealed about 3 ml of cream-colored and odorless fluid in the abscess cavity. Fistulography revealed an abscess cavity not communicating with the bowel lumen. Floss was discovered in the connective tissue and removed. Debridement of the abscess wall was performed and a piece of the wall was sent for histologic examination. Pathological examination revealed panniculitis of the subcutaneous tissue, and panniculitis with granulation and granuloma of the abscess wall. This case report demonstrates that a preoperative diagnosis should be based not on one finding, but on all findings collected, inclusively.

[How can pain of surgery be limited?]

Postoperative pain is due to direct stimulation of nociceptors by surgical trauma, and by algogenic substances produced by damaged tissues. Control of surgical pain can be obtained by limiting the extent of damage to tissues as well as the choice of incision. Endoscopic or video-assisted surgery is an effective mean to reduce pain caused by surgical approach. It is widely used in abdominal, thoracic, orthopaedic surgery, and urology. Many studies have shown a reduction of postoperative pain by laparoscopy for gynaecological surgery and cholecystectomy, but for other procedures the potential advantage of laparoscopic surgery has not yet been established. Conventional open surgery is still widely used. It has been suggested that transverse laparotomies are less painful than midline incisions, and that incision by electrocautery was less painful than with scalpel; but this has not been strictly established. Infiltration of wounds or nerves with local anaesthetic agents is a way of clinical research, which merits further investigation. Whether delicacy in surgery is capable of minimising pain by limiting tissue attrition remains to be demonstrated. Finally, drains and catheters, particularly the naso-gastric tube, which are responsible for pain, could be abandoned when not essential.

The approach to common abdominal diagnosis in infants and children

This article focuses on salient points in the evaluation of abdominal pain in infants and children. Specifically, the authors address appendicitis and abdominal pain associated with either vomiting, constipation, or gastrointestinal bleeding. A discussion of common abdominal masses, urologic, and gynecologic problems, and considerations in the evaluation of immunologically suppressed or neurologically impaired children, and children with recurrent abdominal pain is also presented. The authors establish logical, focused approaches to the initial evaluation and management of abdominal pain and suggest criteria for timely surgical referral.