Drainage vs no drainage in secondary peritonitis with sepsis following complicated appendicitis in adults in the modern era of antibiotics.
ABSTRACT To compare the profile of postoperative outcome in secondary peritonitis with sepsis due to complicated appendicitis in two cohorts (drainage vs no-drainage) after appendicectomy in adults in the modern era of effective antibiotics.
A retrospective review of all adult patients who were operated for secondary peritonitis with sepsis due to complicated appendicitis was carried out. Total of 209 patients were identified from May 2005 to April 2009 with operative findings of gangrenous or perforated appendix. The patients were divided into two cohorts, those where prophylactic drainage was established (n = 88) and those where no drain was used (n = 121). Abdominal drain was removed once the drainage ceased or decreased (< 10-20 mL/d in closed system of drainage or when once daily dressing was minimally soaked in open system). Broad spectrum antibiotics to cover the gut flora were started in both cohorts at diagnosis and were stopped once septic features resolved. Peritoneal fluid for aerobic culture and sensitivity were routinely obtained intra operatively; however antibiotic regimens were not changed unless patient failed to respond to the antibiotics based on the institutional protocol. The co-morbidities and their influence on primary end points were noted. Immunocompromised patients, appendicitis complicated by inflammatory bowel disorder and tumors were excluded from the study.
Disease stratification and other demographic features were comparable in both cohorts. There was zero mortality in drainage group while as one patient (0.82%) died in the non-drainage group. The median duration (in days) of hospital stay (6.5 vs 4); antibiotic use (5 vs 3.5); regular parental analgesic use (5 vs 3.5) and paralytic ileus (2.5 vs 2) was more common in the drainage group. Incidence of major wound infection in patients 14 (15.9%) vs 22 (18.18%) and residual intra-abdominal sepsis (inter loop collection/abscess) -7 (8%) vs 13 (10.74%) requiring secondary intervention was not significantly different in drainage and non-drainage cohorts respectively. One patient in the drainage cohort had faecal fistula (1.1%).
The complicated appendicitis in the modern era of antibiotics does not necessitate the use of prophylactic drain placement which at times may even prove counterproductive.
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ABSTRACT: To compare the therapeutic efficacy of four antibiotic regimens: penicillin, tobramycin, and clindamycin; penicillin, tobramycin, and ornidazole; piperacillin alone; and ceftriaxone and ornidazole in the treatment of children operated on for perforated appendicitis. Prospective randomised study. Teaching hospital, Turkey. 200 patients aged between 1 and 16 years treated from December 1991 to December 1995 who were randomly assigned to one of four groups each consisting of 50 patients. Preoperative antibiotics given intravenously, peritoneal drainage by Penrose drains without irrigation, appendicectomy with the inversion of the stump by a purse string, taking peritoneal swabs, and primary skin closure. Comparability of the groups, duration of fever, leucocytosis, antibiotic treatment, stay in hospital, nasogastric intubation, and drainage, as well as results of cultures and complications. There were no significant differences between the groups for any variable studied. The predominant bacterial species were Escherichia coli, Klebsiella spp, Pseudomonas spp, Fusobacteria, and Peptostreptococci which were appropriately covered by all the antibiotic regimens. Fourteen patients had complications including wound infections (n = 10), prolonged ileus (n = 2) and intra-abdominal abscess (n = 2) all of which were treated conservatively. There was no mortality and no major complications. All regimens had the same clinical and bacteriological efficacy. There is no gold standard for antimicrobial chemotherapy in perforated appendicitis. Different antibiotic combinations or a single broad spectrum antibiotic, which include both aerobic and anaerobic coverage, can safely be used in children with perforated appendicitis.The European Journal of Surgery 09/1997; 163(8):591-6.
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ABSTRACT: Many surgeons continue to place a prophylactic drain in the pelvis after completion of a colorectal anastomosis, despite considerable evidence that this practice may not be useful. The authors conducted a systematic review and meta-analysis of randomized controlled trials to determine if placement of a drain after a colonic or rectal anastomosis can reduce the rate of complications. A search of the Medline database of English-language articles published from 1987 to 1997 was conducted using the terms "colon," "rectum," "postoperative complications," "surgical anastomosis," and "drainage." A manual search was also conducted. Four randomized controlled trials, including a total of 414 patients, were identified that compared the routine use of drainage of colonic and/or rectal anastomoses to no drainage. Two reviewers assessed the trials independently. Trial quality was critically appraised using a previously published scale, and data on mortality, clinical and radiologic anastomotic leakage rate, wound infection rate, and major complication rate were extracted. The overall quality of the studies was poor. Use of a drain did not significantly affect the rate of any of the outcomes examined, although the power of this analysis to exclude any difference was low. Comparison of pooled results revealed an odds ratio for clinical leak of 1.5 favoring the control (no drain) group. Of the 20 observed leaks among all four studies that occurred in a patient with a drain in place, in only one case (5%) did pus or enteric content actually appear in the effluent of the existing drain. Any significant benefit of routine drainage of colon and rectal anastomoses in reducing the rate of anastomotic leakage or other surgical complications can be excluded with more confidence based on pooled data than by the individual trials alone. Additional well-designed randomized controlled trials would further reinforce this conclusion.Annals of Surgery 03/1999; 229(2):174-80. · 7.19 Impact Factor
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ABSTRACT: Most protocols for the operative treatment of perforated appendicitis use a routine culture. Although isolated studies suggest that routine culture may not be necessary, these recommendations generally are not based on objective outcome data. The authors reviewed the records of 308 children who underwent operative treatment for perforated appendicitis between 1988 and 1998 to determine if information gained from routine culture changes the management or improves outcome. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation. Mean patient age was 7.5 years, 51% were boys, and there was no mortality. The majority of children (96%) underwent culture that was positive for either aerobes (21%), anaerobes (19%), or both (57%). Antibiotics were changed in only 16% of the patients in response to culture results. The use of empiric antibiotics, as compared with modified antibiotics, was associated with a lower incidence of infectious complication, shorter fever duration, and decreased length of hospitalization. We also investigated the relationship between culture isolates and antibiotic regimens with regard to outcome. The utilization of antibiotics suitable for the respective culture isolate or organism sensitivity was associated with an increased incidence of infectious complication and longer duration of both fever and length of hospitalization. Finally, the initial culture correlated poorly with subsequent intraabdominal culture (positive predictive value, 11%). These outcome data strongly suggest that the practice of obtaining routine cultures can be abandoned, and empiric broad spectrum antibiotic coverage directed at likely organisms is completely adequate for treatment of perforated appendicitis in children.Journal of Pediatric Surgery 06/1999; 34(5):749-53. DOI:10.1016/S0022-3468(99)90368-8 · 1.31 Impact Factor