“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.
| Study | Country | Type of the study | Number of patients | Type of operation | Inclusion/exclusion criteria and definition of complicated appendicitis |
| Stone et al., 1978 [25] | Georgia | Retrospective cohort | Total: 94; DG: 49; NDG: 45 | Open | Inclusion and exclusion criteria: NA. Definition of complicated appendicitis: gangrenous or perforated appendicitis |
| Greenall et al., 1978 [26] | United Kingdom | RCT | Total: 103; DG: 48; NDG: 55 | Open | Exclusion criteria: appendicular mass/abscess. Definition of complicated appendicitis: gangrenous appendicitis, associated with turbid infected fluid |
| Dandapat and Panda, 1992 [27] | India | RCT | Total: 86; DG: 40; NDG: 46 | NA | NA |
| Tander et al., 2003 [28] | Turkey | RCT | Total: 140; DG: 70; NDG: 70 | Open | Inclusion 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] | Turkey | Retrospective cohort | Total: 226; DG: 109; NDG: 117 | Open | Inclusion 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] | Switzerland | Case match study | Total: 260; DG: 130; NDG: 130 | Laparoscopic | Exclusion 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] | Kenya | RCT | Total: 90; DG: 45; NDG: 45 | Open | Inclusion 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] | USA | Retrospective cohort | Total: 148; DG: 43; NDG: 105 | Laparoscopic | Inclusion 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] | Korea | Retrospective cohort | Total: 342; DG: 108; NDG: 234 | Open: 181; Laparoscopic: 161 | Inclusion criteria: children under 18 years old who were diagnosed with acute appendicitis. Definition of complicated appendicitis: perforated appendicitis |
| Schlottmann et al., 2016 [35] | Argentina | Retrospective cohort | Total: 225; DG: 169; NDG: 56 | Laparoscopic | Inclusion and exclusion criteria: NA. Definition of complicated appendicitis: intraoperatively as the presence of gangrenous/perforated appendicitis with peritonitis |
| Abdulhamid and Sarker, 2018 [36] | Iraq | Retrospective cohort | Total: 227; DG: 114; NDG: 113 | Open | Inclusion criteria: open appendectomy for complicated appendicitis irrespective of age. Definition of complicated appendicitis: perforated with localized abscess formation |
| Aneiros Castro et al., 2018 [37] | Spain | Retrospective cohort | Total: 192; DG: 79; NDG: 63 | Laparoscopic | Inclusion 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] | Peru | Retrospective cohort | Total: 150; DG: 50; NDG: 100 | Open | Inclusion 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] | Japan | Propensity-matched study | Total: 1,762; DG: 485; NDG: 1304 | Open: 346; Laparoscopic: 958 | Inclusion 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] | UK | Retrospective cohort | Total: 76; DG: 26; NDG: 50 | Laparoscopic | Inclusion 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] | Germany | Retrospective cohort | Total: 65; DG: 32; NDG: 33 | Open: 11; Laparoscopic: 55 | Inclusion 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] | Pakistan | RCT | Total: 68; DG: 34; NDG: 34 | Open | Exclusion 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 |
Surgical Focus 