Back to basics:A meta-analysis of stump management during open appendicectomy for uncomplicated acute appendicitis

AIM: To compare simple ligation vs stump invagination during open appendicectomy for uncomplicated acute appendicitis on the risk of postoperative complications. METHODS: A meta-analysis was conducted on randomised controlled trials comparing the two stump closure methods in open appendicectomy. Databases searched were Pub Med, EMBASE and Cochrane Library databases. Included were those studies focusing on inflamed and suppurative appendicitis while perforated and gangrenous appendix was excluded. We also excluded retrospective case-control studies, commentaries, historical technical articles, or trials involving laparoscopic appendicectomies. The outcome of the meta-analysis was to find eventual differences in theincidence of postoperative ileus and wound infections between the two techniques of stump invagination. RESULTS: Seven studies were included corresponding to 1468 patients. Postoperative complications consisted in wound infections(7%), ileus(4%), pyrexia(2%), vomiting(1%), obstructions from adhesions(0.1%). No cases of peritonitis, fecal fistulas(stump leaks), abdominal abscesses or wound dehiscences were reported. Postoperative ileus within the first 72 h was four times more frequent with stump invagination compared to simple ligation(OR: 4.06; 95%CI: 2.14-7.70; P < 0.0001). No significant differences were noted for wound infections(OR: 1.24; 95%CI: 0.83-1.87; P = 0.30) while for the remaining complications the incidence was extremely low in both groups. There was a high homogeneity on results(Q value for heterogeneity of postoperative ileus P = 0.17; Q value for heterogeneity of wound infections P = 0.98). CONCLUSION: Stump invagination does not seem to prevent infective complications but is associated with an increased risk of postoperative ileus in uncomplicated cases. Appropriate studies on complicated appendicitis should now evaluate the influence of the two techniques in this higher-risk subgroup.

Intraperitoneal drains during open appendicectomy for gangrenous and perforated appendicitis

Intra-abdominal drains are still routinely used in the surgical management of gangrenous and perforated appendicitis. A systematic review was performed with the aim of establishing their influence on postoperative complications in such cases. A literature search was conducted using the search engines Pub Med and Cochrance Central Register of Controlled Trials. Included were retrospective case-controlled and prospective randomized controlled trials on the use of drain for open appendicectomy in gangrenous and perforated appendicitis. Twelve articles were found that met the inclusion criteria. Intrabdominal abscesses, postoperative ileus, surgical site infections, fecal fistulas and burst abdomen had significant higher incidences in the drain vs non drain group(10.3%, 20.3%, 32.5%, 3.4% and 5.7% vs 4.7%, 8.5%, 16.2%, 0% and 0%, respectively). In most cases the risk was more than doubled in the drain group compared to the non-drain one. There were no significant differences among groups in termsof mortality while the results were underpowered to effectively evaluate wound dehiscence and adhesions. The use of intra-abdominal drains in the management of gangrenous and perforated appendicitis by open appendicectomy is associated with an increased rate of common postoperative complications.