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Abdominal Lavage Effectiveness In Appendicitis

by Similoluwa Oluwalana - 071

Abdominal Lavage Effectiveness In Appendicitis

Laparoscopic surgery is the preferred method for appendix removal, offering benefits like lower infection rates and faster recovery. However, in complicated appendicitis cases, especially with laparoscopy, there’s a heightened risk of postoperative intra-abdominal abscess (I.A.A.), leading to increased hospitalizations and re-operations. The controversial use of peritoneal lavage in laparoscopy has been extensively debated, with conflicting views on its efficacy. Some studies suggest benefits in reducing bacterial growth, while others highlight potential complications, such as interloop abscesses and intra-abdominal adhesions. Recent meta-analyses indicate that although lavage may improve operative time, its impact on I.A.A. is inconclusive and may even elevate the risk in children. Surgeons considering lavage must carefully weigh the associated risks and consider all factors related to postoperative I.A.A.

 

THE STUDY BACKGROUND

Acute appendicitis stands as a prevalent cause of hospital admission, with laparoscopic surgery being the favored approach for appendix removal in Western medical practices [1] [2]. The benefits of laparoscopy over open-field appendectomies include reduced wound infection (W.I.) rates, improved visualization, diminished postoperative pain, shorter hospitalization, and a decreased incidence of incisional hernias [3]. However, in cases of complicated appendicitis, the application of laparoscopy becomes challenging, often resulting in a significantly higher rate of postoperative intra-abdominal abscess (I.A.A.) [4] [5].

Post-appendectomy, I.A.A. poses a substantial challenge, leading to increased hospitalizations, re-operations, and diminished overall surgical success [5]. Efforts to optimize surgical outcomes and manage postoperative complications have led to a contentious exploration of peritoneal lavage in laparoscopy. Peritoneal lavage, with or without antibiotics, as a preventive measure against I.A.A., has sparked widespread controversy within the medical community [6–9]. Despite the debate, several studies have failed to demonstrate a significant advantage in using peritoneal lavage, particularly in patients with diverse origins [10] [11]. Proponents of lavage argue for its efficacy in reducing bacterial growth through complete peritoneal washing. At the same time, critics highlight potential complications, including the diffusion of bacterial contamination and the formation of interloop abscesses [12].

Complications associated with lavage, mainly when an antibiotic solution is administered, encompass the development of intra-abdominal adhesions and plasma plasmacytitis, leading to the formation of ascidios [13–15]. Despite potential drawbacks, a substantial body of literature indicates that most surgeons employ lavage for complex appendices [16]. Recent findings from a meta-analysis complicate the discourse, revealing that while lavage significantly improves operative time, its impact on the I.A.A. remains inconclusive and may even elevate the risk in children [17][18]. Therefore, considering all risk factors related to postoperative I.A.A. is imperative before opting for irrigation techniques. In conclusion, the delicate balance between the advantages and challenges of laparoscopic surgery and the ongoing debate surrounding peritoneal lavage underscores the need for evidence-based decision-making in appendicitis management.

 

THE STUDY METHOD

The research methodology involved a comprehensive search initiated in October 2023, spanning the last 30 years without language limitations. Utilizing four databases, including Cochrane Library and Embase, the search focused on keywords such as ‘aspiration,’ ‘suction,’ ‘lavage,’ ‘wash,’ and ‘irrigation.’ Inclusion criteria considered only randomized and controlled studies for complex appendicitis, excluding cases of non-acute or complex appendicitis by C-section. Two authors conducted data extraction and study selection independently, with disputes resolved through discussion with a third-panel member.

To assess study quality and risk of bias, the selected trials underwent evaluation using ROBINS-I, a Cochrane-recommended risk-of-bias instrument. This evaluation tool scrutinizes seven distinct areas of bias, with the aggregated results providing a comprehensive global risk assessment. Visualization of the risk of bias was presented using a funnel graph. The study’s rigorous methodology aimed to analyze the chosen trials thoroughly. It ensures a robust foundation for the research outcomes.

 

ANALYSIS

Both authors independently extracted data from each trial in the data analysis phase, addressing discrepancies in a subsequent follow-up. The results of binary variables were amalgamated with continuum variable values, and the collective estimates were presented as odds ratios (OR) and mean differences (M.D.). The efficacy estimates were calculated using either a randomized or a fixed effect model due to the considerable variation in trial results stemming from diverse designs and demographics. Statistical analysis was conducted using RevMan 5.3, and the variability in efficacy estimation was assessed using I2, with heterogeneity considered low if below 50%. The intra-abdominal abscess (I.A.A.) and wound infection (W.I.) scores were visually plotted and evaluated, with statistical significance set at p<0.05. This meticulous data analysis aimed to provide a comprehensive understanding of the effectiveness of the interventions under investigation.

 

RESULTS

Study Characteristics:

  – Surveyed 563 publications and selected seven for analysis.

  A total of 1087 cases were operated on, 533 underwent abdominal irrigation, and 554 were suctioned.

Wound Infection (W.I.):

  – Seven studies investigated the impact of peritoneal lavage and aspiration on postoperative W.I.

  – No statistically significant difference was found between the two methods for treating W.I. (OR, 1.82; 95% CI, 0.40, 2.61; p=0.96)

Abdominal Abscesses:

  – Seven research findings indicated that peritoneal lavage and aspiration during the operation did not influence the incidence of postoperative abdominal abscesses.

  – No statistically significant difference was found in the rate of occurrence of postoperative abdominal abscesses (OR, 1.16; 95% CI, 0.71, 1.89; p=0.56)

The results suggest no significant difference in treating postoperative wound infections or the incidence of abdominal abscesses between peritoneal lavage and aspiration in appendicitis. 

 

DISCUSSION

The discussion delves into the rationale behind peritoneal lavage following appendectomy, asserting its reasonability in minimizing intra-abdominal abscess (I.A.A.) occurrence. However, it critically notes the diminishing utility of lavage in scenarios with minimal or no bacterial contamination beyond the appendix. In complex appendicitis cases, where patients commonly exhibit right iliac fossa peritonitis, the objection to lavage lies in the potential transmission of infective microorganisms to the entire peritoneal cavity, especially in local sepsis [19].

The discussion emphasizes that the population benefiting from lavage is specifically identified as those with complex appendicitis. Meta-analyses conducted in the article are conclusive, indicating that peritoneal lavage does not provide an advantage over aspiration in treating postoperative infections. Previous research also failed to demonstrate any evident benefit to the patient. The inclusion of superiority studies could not establish the equivalence of lavage with aspiration. Despite the limited number of studies in the present analysis, it is asserted that these meta-analyses offer the most convincing evidence to date, revealing no reduction in postoperative infectious complications in the treatment group [19].

The research scope covered 563 publications in the database, ultimately selecting seven studies for analysis. Among the 1087 cases that underwent appendectomy, 533 received abdominal lavage, and 554 underwent abdominal suction. The results indicated no statistically significant differences in the incidence of postoperative wound infection (W.I.) and the occurrence of abdominal abscesses between abdominal lavage and suction alone [19].

While the discussion acknowledges the limitations, it emphasizes the need for a more extensive range of studies to strengthen the findings and ensure the conclusions’ robustness. Despite the compelling evidence the meta-analyses provide, the few studies involved underscore the importance of additional research in this domain [19].

 

LIMITATIONS

  1. Limited Study Availability: The research needs to be revised due to a scant number of available randomized and controlled studies explicitly examining the efficacy of lavage in laparoscopic appendectomy, potentially affecting the generalizability of findings.
  2. Incomplete Post-operation Data: The absence or omission of post-operation information represents a limitation, compromising a comprehensive understanding of outcomes related to suction and abdominal lavage in laparoscopic appendectomy.
  3. Standardization Challenges: Despite efforts to standardize information from the literature, challenges in achieving complete standardization may persist, introducing potential inconsistencies in reporting methods and data collection across studies.
  4. Interpretation Caution: The need for cautious interpretation is emphasized due to potential population heterogeneity. Variations in the severity of abdominal infection, irrigation liquid quantities, and antibiotic use among studies may hinder making uniform conclusions.
  5. Population Diversity: The inherent heterogeneity within the studied population, considering factors like the extent of abdominal infection, irrigation liquid amounts, and antibiotic application, presents a challenge, limiting broad, conclusive statements applicable across diverse patient groups.

Acknowledging these limitations is crucial, necessitating future research efforts to address these constraints and enhance the overall reliability of conclusions in the comparison between suction and abdominal lavage in laparoscopic appendectomy.

 

CONCLUSION

In conclusion, the findings of this study revealed no statistically significant differences in the incidence of post-operation wound infection (W.I.) and the occurrence of abdominal abscesses between suction and abdominal lavage in the context of laparoscopic appendectomy. This underscores the need for future endeavours, encompassing subsequent multi-center, high-quality research, to elucidate and ascertain the most beneficial approach during appendectomy. The quest for a definitive understanding in this domain remains ongoing, calling for comprehensive investigations to guide optimal surgical practices and enhance patient outcomes in appendectomy.

 

References

  1. Nguyen NT, Zainabadi K, Mavandadi S, et al. Trends in utilization and outcomes of laparoscopic versus open appendectomy. Am J Surg. 2004; 188(6):813-820. (https://pubmed.ncbi.nlm.nih.gov/15619488/)
  2. Zwintscher NP, Johnson EK, Martin MJ, Newton CR. Laparoscopy utilization and outcomes for appendicitis in small children. J Pediatr Surg. 2013; 48(9):1941-1945. (https://pubmed.ncbi.nlm.nih.gov/24074619/)
  3. Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg. 2004; 239(1):43-52. (https://pubmed.ncbi.nlm.nih.gov/14685097/ )
  4. Teoule P, Laffolie J, Rolle U, Reissfelder C. Acute appendicitis in childhood and adulthood. Dtsch Arztebl Int. 2020;117(45):764-774. (https://pubmed.ncbi.nlm.nih.gov/33303077/)
  5. Fike FB, Mortellaro VE, Juang D, Sharp SW, Ostlie DJ, St Peter SD. The impact of postoperative abscess formation in perforated appendicitis. J Surg Res.2011;170(1):24-26. (https://pubmed.ncbi.nlm.nih.gov/21722936/)
  6. Parcells JP, Mileski JP, Gnagy FT, Haragan AF, Mileski WJ. Using antimicrobial solution for irrigation in appendicitis to lower surgical site infection rates. Am J Surg. 2009; 198(6):875-880. (https://pubmed.ncbi.nlm.nih.gov/19969188/)
  7. Roth RM, Gleckman RA, Gantz NM, Kelly N. Antibiotic irrigations. A plea for controlled clinical trials. Pharmacotherapy. 1985; 5(4):222-227. (https://pubmed.ncbi.nlm.nih.gov/3860922/)
  8. Gupta R, Sample C, Bamehriz F, Birch DW. Infectious complications following laparoscopic appendectomy. Can J Surg. 2006; 49(6):397-400. (https://pubmed.ncbi.nlm.nih.gov/17234078/)
  9. Moore CB, Smith RS, Herbertson R, Toevs C. Does the use of intraoperative irrigation with open or laparoscopic appendectomy reduce postoperative intra-abdominal abscess? Am Surg. 2011; 77(1):78-80. (https://pubmed.ncbi.nlm.nih.gov/21396349/)
  10. Schein M, Gecelter G, Freinkel W, Gerding H, Becker PJ. Peritoneal lavage in abdominal sepsis. A Controlled Clinical Study. Arch Surg. 1990; 125(9):1132-1135. (https://jamanetwork.com/journals/jamasurgery/article-abstract/595296)
  11. Hunt JL. Generalized peritonitis. To irrigate or not to irrigate the abdominal cavity. Arch Surg. 1982; 117(2):209-212. (https://pubmed.ncbi.nlm.nih.gov/7053762/)
  12. Platell C, Papadimitriou JM, Hall JC. The influence of lavage on peritonitis. J Am Coll Surg. 2000; 191(6):672-680. (https://pubmed.ncbi.nlm.nih.gov/11129810/)
  13. Rappaport WD, Holcomb M, Valente J, Chvapil M. Antibiotic irrigation and the formation of intraabdominal adhesions. Am J Surg. 1989; 158(5):435-437. (https://pubmed.ncbi.nlm.nih.gov/2801925/)
  14. Hupuczi P, Papp Z. Postoperative ascites associated with intraperitoneal antiseptic lavage. Obstet Gynecol 2005; 105(5 Pt 2):1267-1268. (https://pubmed.ncbi.nlm.nih.gov/15863582/)
  15. Hartwich JE, Carter RF, Wolfe L, et al. The effects of irrigation on outcomes in cases of perforated appendicitis in children. J Surg Res. 2013; 180(2):222-225. (https://pubmed.ncbi.nlm.nih.gov/23380245/)
  16. Mogilner JG, Slijper N, Kandelis E, Sukhotnik I. The management of pediatric appendicitis: an opinion survey of Israeli pediatric surgeons. Harefuah. 2007; 146(6):414–9, 504, 3. (https://pubmed.ncbi.nlm.nih.gov/17674807/)
  17. Siotos C, Stergios K, Prasath V, et al. Irrigation versus suction in laparoscopic appendectomy for complicated appendicitis: A meta-analysis. J Surg Res. 2019; 235:237-243. (https://pubmed.ncbi.nlm.nih.gov/30772726/)
  18. Snow HA, Choi JM, Cheng MW, Chan ST. Irrigation versus suction alone during laparoscopic appendectomy; a randomized controlled equivalence trial. Int J Surg. 2016; 28:91-96. (https://pubmed.ncbi.nlm.nih.gov/26952962/)
  19. Wu H, Chen X, Ren Y, Yang F. Effect of intraoperative abdominal lavageversus suction alone on postoperative wound infection in patients with appendicitis: A meta-analysis.Int Wound J. 2023; 1‐7. (https://onlinelibrary.wiley.com/doi/epdf/10.1111/iwj.14613)

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