Category Archives: Abdominal

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis

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“Appendectomy has long been the standard treatment for appendicitis, even though successful use of antibiotic therapy as an alternative was reported more than 60 years ago. Although there have been several randomized trials of antibiotics for appendicitis
in adults, exclusion of important subgroups (in particular, patients with an appendicolith, who
may be at an increased risk for complications), small sample sizes, and questions about applicability to the general population have limited the use of this treatment. As recently as 2014, more than 95% of U.S. patients with appendicitis underwent appendectomy. However, with the pandemic of coronavirus disease 2019 (Covid-19), health systems and professional societies such as the American College of Surgeons have suggested reconsideration of many aspects of care delivery, including the role of antibiotics in the treatment of appendicitis.”

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Antibiotic Duration After Laparoscopic Appendectomy for Acute Complicated Appendicitis

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“Uncomplicated and complicated appendicitis are currently distinguished as 2 different disease entities that require different treatments. The role of antibiotic treatment as an alternative for surgery in simple or uncomplicated appendicitis has been studied in adults and, more recently, in children. Acute complicated appendicitis with necrosis or perforation of the appendix is treated by appendectomy and usually followed by additional antibiotic
treatment aimed at reducing postoperative infectious complications. Restriction and proper use of antibiotics are important for reducing and preventing harmful adverse effects to the patients and preventing antibiotic resistance. In American guidelines, an antibiotic length of 4 to 7 days is advised after complicated appendicitis. To our knowledge, few studies have
investigated the reduction of antibiotic administration after appendectomy and these were mostly performed in children. Restricting antibiotic duration to fewer than 5 days after surgery in complicated appendicitis is seldom done, fearing infectious complications. However, 3 days of antibiotic treatment has been observed to be feasible and safe in a retrospective cohort of adults with complicated appendicitis.”

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Advantages comparison of peritoneal drainage versus no drainage after laparoscopic appendectomy for complicated appendicitis

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“Acute appendicitis is a prevalent acute abdominal condition necessitating emergency surgical intervention. Laparoscopic appendectomy (LA) has rapidly evolved as the standard of care treatment for acute appendicitis. For decades, placing an intra-abdominal drainage tube following LA has been perceived as beneficial in averting the development of postoperative abdominal abscesses, monitoring postoperative abdominal bleeding, and preventing postoperative appendix stump leakage. The rationale behind peritoneal drainage stemmed from the widespread belief among surgeons that the accumulation of inflammatory exudate within the abdominal cavity escalated the risk of postoperative complications, including intra-abdominal abscesses, appendix stump leakage, wound infections, and intestinal obstructions. However, the past few years have witnessed unprecedented scientific progress, which has translated into improved surgical, and the necessity of peritoneal drainage following LA has come under increasing scrutiny.”

Primary outcomes following peritoneal drainage versus no peritoneal drainage for laparoscopic appendectomy in term of A bowel obstruction, B intra-abdominal abscess, C appendix stump leakage, D wound infection and E postoperative VAS score Green squares represent the point estimates of the treatment effect OR, with 95% CI indicated by horizontal bars. Blue diamonds represent the summary estimate from the pooled studies with 95% CI
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Aspiration versus peritoneal lavage in appendicitis

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“The management of IAA remains controversial with different strategies suggested to decrease its incidence: antibiotic prophylaxis, post-operative antibiotic therapy, peritoneal irrigation with saline solution or suction only of the abscess/purulent liquid without irrigation of the cavity during appendectomy. In the literature, many studies address this topic; however, currently there is no evidence to clearly demonstrate the effectiveness of peritoneal irrigation over suction only. Italian guidelines recommend thorough peritoneal lavage (6–8 L of warm saline) and aspiration to minimize the IAA rate in complicated appendicitis. The recent WSES (World Society of Emergency Surgery) guidelines report that “Peritoneal irrigation does not have any advantage over suction alone in complicated appendicitis in both adults and children. The performance of irrigation during laparoscopic appendectomy does not seem to prevent the development of IAA and wound infections
in neither adults nor paediatric patients”. WSES recommendation is “to perform suction only in complicated appendicitis patients with intra-abdominal collections undergoing laparoscopic appendectomy” [QoE: Moderate; Strength of recommendation: Strong; 1B]). The concern regarding irrigation and lavage is that these procedures might help spread the infectious material.”

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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
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Safety Zones for Anterior Abdominal Wall Entry During Laparoscopy

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“Trauma to abdominal wall blood vessels occurs in 0.2% to 2% of laparoscopic procedures. Both superficial and deep abdominal wall vessels are at risk. The superficial vessels may be located by transillumination; however, the deep epigastric vessels cannot be effectively located by transillumination and, thus, other techniques should be used to minimize the risk of injury to these vessels.”

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Watchful Waiting for men with minimally symptomatic inguinal hernia. (Original 2006 study and 2013 follow up.)

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2013

“Annually, more than 20 million inguinal herniorrhaphies are performed worldwide, and it is one of the most common operations performed by general surgeons. Up to one third of patients with inguinal hernias are asymptomatic or minimally symptomatic at the time of presentation. Historically, surgeons have recommended repair of an inguinal hernia at diagnosis even if minimally symptomatic to avoid a hernia accident, which is defined as a bowel obstruction caused by the hernia or strangulation of the contents of the hernia, or both. However, on the basis of the results of 2 recent randomized clinical trials (RCTs), one conducted in the United Kingdom and the other in North America, watchful waiting (WW) has now become an accepted alternative to routine repair. In 2011, the longer-term
results of the United Kingdom trial were published. Using Kaplan-Meier analysis, 72% of patients were predicted to crossover (CO) from WW to surgery by 7.5 years causing the authors to conclude that routine repair should be recommended for minimally symptomatic
patients without medical contraindications to surgery.”

“The results of this study show that WW remains a safe strategy even on long-term follow-up. However, patients who present to their physicians to have the hernia evaluated, especially if they are elderly, should be informed that they will almost certainly come to
surgery eventually. These results should not be extrapolated to the broader population of all patients with asymptomatic or minimally symptomatic hernias.”

Fitzgibbons, Robert J Jr et al. “Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias.” Annals of surgery vol. 258,3 (2013): 508-15. Full Text for Emory Users

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