O2153: A Prospective Randomized Control Trial For Antibiotic Irrigation Versus Suction Alone For Intraoperative Management Of Intraabdominal Contamination In Pediatric Perforated Appendicitis

Background: The standard of care for management of perforated appendicitis in children has historically been appendectomy and remains so despite more recent studies showing potential benefits to non-operative management. Optimal intraoperative control of intraabdominal contamination is varied with the goal being to reduce postoperative complications commonly associated with perforated appendicitis. Studies have compared peritoneal irrigation with saline to suction alone showing that suction alone is likely superior. Several studies in adults with perforated appendicitis have shown decreased surgical site infection rate with antibiotic irrigation. We hypothesized that irrigation with antibiotic irrigation should decrease rate of intraabdominal abscess formation and surgical site infection in pediatric patients undergoing surgery for perforated appendicitis.

Methods: We performed a prospective randomized controlled trial of children under 18 years of age at a single institution with a diagnosis of perforated appendicitis. One hundred and fifty-four patients were enrolled in the study, 77 were randomized to intraoperative antibiotic irrigation with a clindamycin and gentamycin solution and 77 were randomized to suction of intraabdominal contamination only. Primary outcomes investigated were development of postoperative wound infection and intraabdominal abscess. Secondary outcomes included length of stay, percutaneous drain for abscess, development of postoperative ileus and readmission.

Results: There were no statistically significant differences in baseline demographic variables between groups. There was a statistical difference in presence of fecalith in the peritoneal cavity at time of surgery between groups (17 in the antibiotic irrigation group (22%) and 30 in the suction only group (41%), p=0.012) which created an imbalance in clinical characteristics between groups, necessitating a multivariable logistic regression analysis to adjust for this difference. The odds ratio for intraabdominal abscess formation with the presence of fecalith vs no fecalith was statistically significant at 4.19 (1.97, 8.91 95% confidence interval, p< 0.001). The odds of abscess formation were reduced when antibiotic irrigation was used compared to suction only with an odds ratio of 0.63, but not to a statistically significant extent (0.3, 1.32 95% confidence interval, p=0.222). There was no statistically significant difference in the rate of surgical site infection (1 in the antibiotic irrigation group versus 1 in the suction only group, p=0.97). Additionally, there were no statistically significant differences in length of stay, percutaneous drain for abscess, development of postoperative ileus and readmission between groups.

Conclusion: Our study shows that antibiotic irrigation is not superior to suction alone for reducing the risk of surgical site infection or intraabdominal abscess formation in pediatric patients with perforated appendicitis. However, we believe that continued evaluation possibly from larger, multicenter randomized control trials may be necessary to make definitive conclusions.