] ever since he first reported the use of an abdominal drain in empyema gallbladder, its usage has been extended to almost all surgical procedures. The very purpose of the drains, to reduce the potential source of infection, detect post-operative bleed and anastomotic leakage or to establish the tract for the drainage of the collected material even after its removal may not be always served. Likewise drainage following appendicectomy (one of the commonest gastrointestinal operation) is usually determined by whether the underlying appendicitis is simple/complicated and largely determined by the surgeons’ belief.
In the absence of any universally accepted antibiotic regime for appendicitis, traditionally broad spectrum antibiotic coverage is routinely adopted[8
]. However the choice of antibiotics in complicated appendicitis is largely influenced by the institutional protocols[12
]. A commonly followed guideline[9
] recommends triple antibiotics. However there has been a recent trend towards single or dual drug regimes in children[12
], in order to reduce the cost and simplify dosing schedules. While these paediatric trials are not adequately powered[13
], the randomised trials in adults have failed to show any difference in antibiotic regimes[17
]. We have adopted a cost effective policy of two/three drug regimens (3th
generation cephalosporin with or without salbactum plus metronidazole 7.5 mg/kg q8H), which was instituted at the time of diagnosis of complicated appendicitis. It has been seen that post-operative abscesses occurred in patients who had organisms on culture that were sensitive to the treatment antibiotics[18
]. Unlike Kokoska et al[19
], Ong et al[18
] found that culture of the postoperative abscess did correlate with the initial peritoneal culture, although this does not alter management. Contrary to the commonly held belief, recently, the natural history of immunological mechanisms of the peritoneum has been better understood and its natural defence mechanisms to clear the infection have been elucidated[20
]. These studies highlight the importance of the peritoneal fluid, and its drainage can even prove counterproductive.
Two randomized controlled trials (RCT) investigated the value of prophylactic drainage after open appendicectomy for acute/simple appendicitis[4
]. Although both arms (drainage, no-drainage) of the trials had a relatively large sample size (> 90 patients each group), the studies were performed without a power and sample size calculation and were therefore ranked as level 2b. One study reported a significantly higher wound infection rate in drained patients with acute/simple appendicitis[23
], whereas the other study found similar wound and intra-abdominal infection rates in drained and non-drained patients[4
In complicated appendicitis (gangrenous/perforated), the role of prophylactic drainage has been studied in five RCTs. Because of the same reasons mentioned above, the level of evidence was classified as 2b in each RCT. The results showed higher wound infection rates in drained patients (range 43%-85%) than in non-drained patients (29%-54%). The pattern of intra-abdominal infection was not uniform among the studies, as two studies reported slightly higher intra-abdominal infection rates in non drained patients[24
], one study a higher rate in drained patients[4
], and another a similar rate in both groups[6
]. Interestingly, the development of fecal fistulas was only observed in drained patients with a rate ranging from 4.2% to 7.5%.
Petrowsky et al[7
] performed meta-analysis including series of gangrenous or perforated appendicitis only. Four RTCs (all level 2b) were included in the meta-analysis with the end point wound infection, whereas data from 3 RTCs were available for the end points intra-abdominal infection and fecal fistula. The analysis calculated an odds ratio for wound infection of 1.75 (CI: 0.96-3.19). The odds ratio for fecal fistula of 12.4 (CI: 1.14-1.35) favours the no drainage group; whereas the odds ratio for the end point intra-abdominal infection of 1.43 (CI: 0.39-5.29) favours neither group.
We observed almost similar incidence of major wound infection in patients in the drainage (15.9%) and non-drainage (18.18%) cohorts which is not statistically significant (P
> 0.05). Dandapat et al[5
] also showed that peritoneal drainage does not prevent wound infection. The author believes that protection of the wound during the primary surgery is of utmost priority, and the effective antibiotics compliment to the aseptic precautions in reducing the incidence of wound infection. Ciftci et al[15
] observed that the most crucial point to avoid the wound infection is the application of antibiotics with aerobic and anaerobic coverage. In our study all the wounds were closed primarily in both the cohorts. There is an apprehension that primary closure of surgical incision after appendicectomy for complicated appendicitis may result in increased incidence of surgical site infection[26
]. These incisions are often managed with delayed closure. However Rucinski et al[28
] did a meta-analytic study of 2532 patients with gangrenous and perforated appendicitis. They concluded that primary closure of the skin and subcutaneous tissue after appendicectomy for gangrenous or perforated appendicitis, combined with the use of antibiotics in the perioperative period, is not associated with an increased risk of incision infection when compared with delayed closure.
On the one hand there seems to be a tendency on the part of the treating physician to continue the parental antibiotics and analgesics longer in the drainage cohort than in the non-drainage cohort and thus delay the discharge of the former[29
]. On the other hand there seems to be tendency on the part of the patient to continue to assume the sick role until the drains are removed. Furthermore the post-operative care of the patients with the drain as compared to those without drain is troublesome, requiring increased work and manpower for the hospital. We had one patient (1.1%) in the drainage cohort whose postoperative course was complicated by the fecal fistulae. The exact cause of the fistulae remained unsolved in our series. However, these drains themselves are also a potential source of infection; may induce anastomotic leakage and may cause damage by mechanical pressure and suction[31
The incidence of paralytic ileus and intra-abdominal collection in the two cohorts is not statistically different in our series. Also the incidence and indications of the second operation is not significantly different in the two cohorts in our series.
In a conclusion, the routine placement of the drain after appendicectomy is not indicated regardless of the severity of the appendicitis. It not only increases the morbidity, but is also not a cost effective method. The surgeons need to shun away the deeply inculcated habits of riding on drains perhaps as a soup to their consciences. The criticism of the study is that it is not a randomised controlled prospective trial and thus cannot generate the level 1 evidence. The results cannot be translated completely into the laparoscopic era, where the profile of postoperative outcome would be certainly different. However the author maintains that these patients were diagnosed and operated as secondary peritonitis with sepsis where the role of laparoscopy is still not fully defined. But the power of the study is adequate enough to validate the end points of the study.