Brief Article
Copyright ©2013 Baishideng Publishing Group Co., Limited. All rights reserved.
World Journal of Gastrointestinal Surgery. Nov 27, 2013; 5(11): 300-305
Published online Nov 27, 2013. doi: 10.4240/wjgs.v5.i11.300
Drainage vs no drainage in secondary peritonitis with sepsis following complicated appendicitis in adults in the modern era of antibiotics
Sheraz Ahmed Rather, Shams UL Bari, Ajaz A Malik, Asima Khan
Sheraz Ahmed Rather, Ajaz A Malik, Department of Surgery, Sheri Kashmir Institute of Medical Sciences Soura, Srinagar, Kashmir 190006, India
Shams UL Bari, Department of General Surgery, Sheri Kashmir Institute of Medical Sciences Medical College Bemina, Srinagar, Kashmir 190006, India
Asima Khan, Resident Accident and Emergency Sheri Kashmir Institute of Medical Sciences Medical College Bemina, Srinagar, Kashmir 190006, India
Author contributions: Rather SA and Bari SUL performed most of the procedures; Bari SUL and Malik AA designed the study and compiled the data; Rather SA and Khan K wrote the manuscript.
Correspondence to: Shams UL Bari, Assistant Professor, MBBS, MS, Consultant Surgeon, Department of General Surgery, Sheri Kashmir Institute of Medical Sciences Medical Col- lege Bemina, R/o: Professor Colony, Naseem Bagh, Hazratbal, Srinagar, Kashmir 190006, India. shamsulbari@rediffmail.com
Telephone: +91-194-2429203 Fax: +91-194-2493316
Received: May 25, 2013
Revised: October 13, 2013
Accepted: October 19, 2013
Published online: November 27, 2013
Abstract

AIM: 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.

METHODS: 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.

RESULTS: 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%).

CONCLUSION: 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.

Keywords: Appendicitis, Antibiotics, Drainage, Gangerenous, Peritonitis

Core tip: The routine placement of the drain after appendicectomy irrespective of the severity of the appendicitis increases both the morbidity and the cost of treatment. The surgeons need to do away with the habits of riding on drains perhaps as a soup to their consciences. Post-operative management of the patient with the drain as compared to those without drain is troublesome, requiring increased work and manpower for the hospital.