Evaluation of Drain Insertion After Appendicectomy for Complicated Appendicitis

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“This meta-analysis aims to evaluate the comparative outcomes of drain insertion versus no drain after appendicectomy for complicated appendicitis. Abdominal collection, surgical site infection (SSI), bowel obstruction, faecal fistula, paralytic ileus, length of hospital stay (LOS) and mortality were the evaluated outcome parameters for the meta-analysis. Seventeen studies reporting a total number of 4,255 patients who underwent appendicectomy for complicated appendicitis with (n=1,580) or without (n=2,657) drain were included.
There was no significant difference between the two groups regarding abdominal collection (odds ratio (OR)=1.41, P=0.13). No-drain group was superior to the drain group regarding SSI (OR=1.93, P=0.0001), faecal fistula (OR=4.76, P=0.03), intestinal obstruction (OR=2.40, P=0.04) and paralytic ileus (OR=2.07, P=0.01). There was a difference regarding mortality rate between the two groups (3.4% in the drain group vs 0.5% in the no-drain group, risk difference (RD)=0.01, 95% CI (-0.01, 0.04), P=0.36).”

Table 2. Characteristics of included studies.

DG: drain group, NDG: no-drain group, RCT: randomized controlled trial, NA: not available.

StudyCountryType of the studyNumber of patientsType of operationInclusion/exclusion criteria and definition of complicated appendicitis
Stone et al., 1978 [25]GeorgiaRetrospective cohortTotal: 94; DG: 49; NDG: 45OpenInclusion and exclusion criteria: NA. Definition of complicated appendicitis: gangrenous or perforated appendicitis
Greenall et al., 1978 [26]United KingdomRCTTotal: 103; DG: 48; NDG: 55OpenExclusion criteria: appendicular mass/abscess. Definition of complicated appendicitis: gangrenous appendicitis, associated with turbid infected fluid
Dandapat and Panda, 1992 [27]IndiaRCTTotal: 86; DG: 40; NDG: 46NANA
Tander et al., 2003 [28]TurkeyRCTTotal: 140; DG: 70; NDG: 70OpenInclusion criteria: paediatric cases with uncomplicated perforated appendicitis. Exclusion criteria: appendicular mass/abscess. Definition of complicated appendicitis: gross or microscopic evidence of appendicular perforation with no more discolouration of peritoneal fluid after washing out
Narci et al., 2007 [29]TurkeyRetrospective cohortTotal: 226; DG: 109; NDG: 117OpenInclusion criteria: children with macroscopic perforation. Exclusion criteria: appendix could not be visualized and drained without appendectomy. Definition of complicated appendicitis: macroscopic perforation
Allemann et al., 2011 [30]SwitzerlandCase match studyTotal: 260; DG: 130; NDG: 130LaparoscopicExclusion criteria: simple acute appendicitis (i.e., no peritoneal reaction), generalized peritonitis, preoperatively known immunodeficiencies, aged <16 years and incomplete dataset. Definition of complicated appendicitis: localized peritonitis, perforation of the appendix, presence of pus or fibrin membranes around the appendix or frank peri-appendicular abscess
Jani and Nyaga, 2011 [31]KenyaRCTTotal: 90; DG: 45; NDG: 45OpenInclusion criteria: advanced appendicular pathology and aged over 13 years. Exclusion criteria: simple acute appendicitis or laparoscopic appendicectomy. Definition of complicated appendicitis: perforated, mass or phlegmon
Pakula et al., 2014 [32]USARetrospective cohortTotal: 148; DG: 43; NDG: 105LaparoscopicInclusion criteria: patients with the diagnosis of gangrenous or perforated appendicitis based on the review of pathology and operative reports. Exclusion criteria: simple or suppurative appendicitis and those treated with interval appendectomy. Definition of complicated appendicitis: gangrenous and perforated appendicitis
Song and Jung, 2015 [33]KoreaRetrospective cohortTotal: 342; DG: 108; NDG: 234Open: 181; Laparoscopic: 161Inclusion criteria: children under 18 years old who were diagnosed with acute appendicitis. Definition of complicated appendicitis: perforated appendicitis
Schlottmann et al., 2016 [35]ArgentinaRetrospective cohortTotal: 225; DG: 169; NDG: 56LaparoscopicInclusion and exclusion criteria: NA. Definition of complicated appendicitis: intraoperatively as the presence of gangrenous/perforated appendicitis with peritonitis
Abdulhamid and Sarker, 2018 [36]IraqRetrospective cohortTotal: 227; DG: 114; NDG: 113OpenInclusion criteria: open appendectomy for complicated appendicitis irrespective of age. Definition of complicated appendicitis: perforated with localized abscess formation
Aneiros Castro et al., 2018 [37]SpainRetrospective cohortTotal: 192; DG: 79; NDG: 63LaparoscopicInclusion criteria: patients with perforated appendicitis. Exclusion criteria: incidental appendectomy during another laparoscopic surgical procedure and those treated with interval appendectomy. Definition of complicated appendicitis: identifiable macroscopic hole in the appendix during the surgery
Miranda-Rosales et al., 2019 [38]PeruRetrospective cohortTotal: 150; DG: 50; NDG: 100OpenInclusion criteria: aged >18 years with complicated appendicitis. Exclusion criteria: laparoscopic appendicectomy, patients on anticoagulation, immunocompromised and pregnancy. Definition of complicated appendicitis: localized or generalized peritonitis and appendicular abscess
Fujishiro et al., 2021 [39]JapanPropensity-matched studyTotal: 1,762; DG: 485; NDG: 1304Open: 346; Laparoscopic: 958Inclusion criteria: complicated appendicitis in children (aged 15 years and below). Exclusion criteria: interval appendectomies. Definition of complicated appendicitis: perforation, gangrene or intra-abdominal abscess
Nazarian et al., 2021 [40]UKRetrospective cohortTotal: 76; DG: 26; NDG: 50LaparoscopicInclusion criteria: over the age of 16 with complicated appendicitis. Exclusion criteria: caecal/appendicular malignancy. Definition of complicated appendicitis: histologically proven gangrenous or perforated appendicitis
Schmidt et al., 2020 [41]GermanyRetrospective cohortTotal: 65; DG: 32; NDG: 33Open: 11; Laparoscopic: 55Inclusion criteria: age range from two to 17 years who presented with perforated appendicitis. Exclusion criteria: severe neurological dysfunction and inflammatory bowel disease. Definition of complicated appendicitis: perforated appendicitis on histology
Mustafa et al., 2020 [34]PakistanRCTTotal: 68; DG: 34; NDG: 34OpenExclusion criteria: immunocompromised patients and those with generalized peritonitis (perforated appendix with pus in three or more quadrants of the abdominal cavity visible per-operatively). Definition of complicated appendicitis: perforated appendicitis intra-operatively

“The commonly reported risk factors for collection are perforated appendicitis, high total leucocyte count and duration of symptoms. Irrigation of the peritoneal cavity was found to be an increasing risk of development of the intra-abdominal collection, and the pus can spread during washout from the localized area of infection in the right iliac fossa to the other compartments in the abdomen resulting in generalized peritonitis. Moreover, a recent systematic review concluded that suction only is not inferior to suction and irrigation in terms of the development of the postoperative collection and the adoption of a suction-only approach may reduce the operative time. Assessment of the effect of these known risk factors for the collection was not possible in this review due to the lack of data in the included studies. Interestingly, the incidence of the post-appendicectomy collection was found to be higher in laparoscopic appendicectomy when compared to the open approach in the Cochrane meta-analysis that was performed in 2002; however, in the subsequent update of the same review in 2004 and 2010, the likelihood of intra-abdominal collection decreased from OR=2.77 in 2002 to OR=1.87 in 2010.”

Abu, Abduelraheim et al. “Evaluation of Drain Insertion After Appendicectomy for Complicated Appendicitis: A Systematic Review and Meta-Analysis.” Cureus vol. 14,11 e32018. 29 Nov. 2022, Free Full Text

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