Li Zhe, Zhao Longshuan, Cheng Yao, Cheng Nansheng, Deng Yilei
Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Zhengzhou, Henan Province, China, 450000.
Cochrane Database Syst Rev. 2018 May 9;5(5):CD010168. doi: 10.1002/14651858.CD010168.pub3.
Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer from postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.This is an update of the review first published in 2015.
To assess the safety and efficacy of abdominal drainage to prevent intra-peritoneal abscess after open appendectomy for complicated appendicitis.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 6), Ovid MEDLINE (1946 to 30 June 2017), Ovid Embase (1974 to 30 June 2017), Science Citation Index Expanded (1900 to 30 June 2017), World Health Organization International Clinical Trials Registry Platform (30 June 2017), ClinicalTrials.gov (30 June 2017) and Chinese Biomedical Literature Database (CBM) (1978 to 30 June 2017).
We included all randomised controlled trials (RCTs) that compared abdominal drainage and no drainage in people undergoing emergency open appendectomy for complicated appendicitis.
Two review authors identified the trials for inclusion, collected the data, and assessed the risk of bias independently. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio for very rare outcomes), and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). We used GRADE to rate the quality of evidence.
We included six RCTs (521 participants), comparing abdominal drainage and no drainage in patients undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia and Africa. The majority of the participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was at low risk of bias.There was insufficient evidence to determine the effects of abdominal drainage and no drainage on intra-peritoneal abscess at 14 days (RR 1.23, 95% CI 0.47 to 3.21; 5 RCTs; 453 participants; very low-quality evidence) or for wound infection at 14 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-quality evidence). The increased risk of 30-day overall complication rate (morbidity) in the drainage group was rated as very low-quality evidence (RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants). There were seven deaths in the drainage group (N = 183) compared to one in the no drainage group (N = 180), equating to an increase in the risk of 30-day mortality from 0.6% to 2.7% (Peto odds ratio (OR) 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; moderate-quality evidence). There is 'very low-quality' evidence that drainage increases hospital stay compared to the no drainage group by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants).Other outlined outcomes, hospital costs, pain, and quality of life, were not reported in any of the included studies.
AUTHORS' CONCLUSIONS: The quality of the current evidence is very low. The effect of abdominal drainage on the prevention of intra-peritoneal abscess or wound infection after open appendectomy is uncertain for patients with complicated appendicitis. The increased rates for overall complication rate and hospital stay for the drainage group compared to no drainage group is also subject to great uncertainty. Thus, there is no evidence for any clinical improvement by using abdominal drainage in patients undergoing open appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in just under 400 people recruited to the studies. Larger studies are needed to determine the effects of drainage on morbidity and mortality outcomes more reliably.
阑尾切除术，即通过手术切除阑尾，主要用于治疗急性阑尾炎。因复杂性阑尾炎（定义为坏疽性或穿孔性阑尾炎）而接受阑尾切除术的患者更易出现术后并发症。对于复杂性阑尾炎患者，阑尾切除术后常规使用腹腔引流以减少术后并发症存在争议。这是对2015年首次发表的综述的更新。
评估复杂性阑尾炎患者行开放性阑尾切除术后，腹腔引流预防腹腔脓肿的安全性和有效性。
我们检索了Cochrane对照试验中心注册库（CENTRAL）（Cochrane图书馆，2017年第6期）、Ovid MEDLINE（1946年至2017年6月30日）、Ovid Embase（1974年至2017年6月30日）、科学引文索引扩展版（1900年至2017年6月30日）、世界卫生组织国际临床试验注册平台（2017年6月30日）、ClinicalTrials.gov（2017年6月30日）以及中国生物医学文献数据库（CBM）（1978年至2017年6月30日）。
我们纳入了所有比较复杂性阑尾炎患者行急诊开放性阑尾切除术后腹腔引流与不引流的随机对照试验（RCT）。
两位综述作者确定纳入的试验，收集数据，并独立评估偏倚风险。我们使用Review Manager 5进行荟萃分析。我们计算二分结局的风险比（RR）（或极罕见结局的Peto比值比），以及连续性结局的均差（MD）并给出95%置信区间（CI）。我们使用GRADE对证据质量进行评级。
我们纳入了6项RCT（521名参与者），比较了复杂性阑尾炎患者行急诊开放性阑尾切除术后腹腔引流与不引流的情况。这些研究在北美、亚洲和非洲开展。大多数参与者患有穿孔性阑尾炎并伴有局部或全身性腹膜炎。所有参与者在开放性阑尾切除术后均接受抗生素治疗。没有一项试验的偏倚风险较低。没有足够的证据来确定腹腔引流与不引流在术后14天时对腹腔脓肿的影响（RR 1.23，95%CI 0.47至3.21；5项RCT；453名参与者；极低质量证据），或对术后14天伤口感染的影响（RR 2.01，95%CI 0.88至4.56；5项RCT；478名参与者；极低质量证据）。引流组30天总体并发症发生率（发病率）增加的风险被评为极低质量证据（RR 6.67，95%CI 2.13至20.87；1项RCT；90名参与者）。引流组有7例死亡（N = 183），而不引流组有1例死亡（N = 180），这相当于30天死亡率的风险从0.6%增加到2.7%（Peto比值比（OR）4.88，95%CI 1.18至20.09；4项RCT；363名参与者；中等质量证据）。有“极低质量”证据表明，与不引流组相比，引流使住院时间延长2.17天（95%CI 1.76至2.58；3项RCT；298名参与者）。其他列出的结局，如住院费用、疼痛和生活质量，在所纳入的任何研究中均未报告。
当前证据质量极低。对于复杂性阑尾炎患者，开放性阑尾切除术后腹腔引流对预防腹腔脓肿或伤口感染的效果尚不确定。与不引流组相比，引流组总体并发症发生率和住院时间增加的情况也存在很大不确定性。因此，对于复杂性阑尾炎患者行开放性阑尾切除术，没有证据表明使用腹腔引流能带来任何临床改善。引流导致死亡率增加源于在招募的不到400人中观察到8例死亡。需要开展更大规模的研究来更可靠地确定引流对发病率和死亡率结局的影响。
