Prophylactic Drainage After Appendectomy for Perforated Appendicitis in Adults

Author(s):
Sinong Qian; Georgia Vasileiou; Gerd Daniel Pust; Tanya Zakrison; Rishi Rattan; Martin Zielinski; Mohamed Ray-Zack; Muhammad Zeeshan; Nicholas Namias; Daniel Yeh

Background:

We sought to assess the efficacy of prophylactic abdominal drainage to prevent postoperative complications after appendectomy for perforated appendicitis.

Hypothesis:

Prophylactic abdominal drainage doesn’t prevent postoperative complications after appendectomy for perforated appendicitis.

Methods:

In this post hoc analysis of a prospective multicenter study of appendicitis in adults (≥18 y), we included patients with perforated appendicitis diagnosed intra-operatively. Subjects were divided into groups based on receipt of prophylactic drains. Demographics and postoperative outcomes including surgical site infection (SSI), intra-abdominal abscess (IAI), Clavien-Dindo complications, secondary interventions, and hospital length of stay (LOS) were analyzed. Multivariate logistic regression for cumulative 30-day incidence of IAI was performed controlling for age, Charlson Comorbidity Index (CCI), antibiotic duration, presence of drains, and Operative AAST Grade.

Results:

A total of 634 subjects were included in the analysis. In comparing Drain (n= 159) vs. No-Drain (n=475) groups, there was no difference in male gender (61% vs. 55%, p= 0.168), weight (87.9±27.9 vs. 83.8±23.4 kg, p= 0.071), Alvarado score (7[6-8] vs. 7[6-8], p= 0.591), WBC count (14.8±4.8 vs. 14.9±4.5, p= 0.867), or CCI (1[0-3] vs. 1[0-2], p= 0.113). The Drain group was significantly older (51±16, 48±17 yrs, p= 0.017). Drain use increased as AAST EGS Appendicitis Operative Severity Grade increased: Grade 3 (62/311, 20%), Grade 4 (46/168, 27%), and Grade 5 (51/155 33%), p= 0.007. For index hospitalization, the Drain group had a higher complication rate (43% vs 28%, p= 0.001) and longer LOS (4[3-7] vs 3[1-5] d, p< 0.001).  We failed to detect a difference between groups in incidence of SSI, IAI, or secondary interventions (Table 1). There was no difference in 30-d ED visits, readmissions, or secondary interventions. Multivariable logistic regression showed that only AAST Grade (OR: 2.7, 95% CI (1.5-4.7), p= 0.001) was predictive for cumulative 30-d incidence of IAI.

Conclusions:

Prophylactic drainage after appendectomy for perforated appendicitis in adults does not appear to prevent complications and is associated with increased hospital LOS. The Operative AAST Grade is a strong predictor of intra-abdominal infections up to 30-days.