Povidone-iodine Irrigation for Pediatric Perforated Appendicitis May Be Protective: A Bayesian Pilot Randomized
Kathryn Tinsley Anderson1,2, Luke Randall Putnam1,2, Marisa Angeline Bartz-Kurycki1,2
1McGovern Medical School, University of Texas Health Sciences Center at Houston, Department of Pediatric Surgery, Houston, TX.
Insights
Povidone-iodine irrigation may reduce intra-abdominal abscesses in children with perforated appendicitis. This pilot study suggests potential benefits, including shorter hospital stays and fewer readmissions, warranting further investigation.
Area of Science:
- Pediatric Surgery
- Infectious Disease Prevention
- Surgical Site Infections
Background:
- Appendicitis is a common surgical emergency in children.
- Perforated appendicitis carries a higher risk of postoperative complications, such as intra-abdominal abscess (IAA).
- Current management strategies aim to minimize these risks.
Purpose of the Study:
- To evaluate the efficacy of povidone-iodine (PVI) irrigation versus no irrigation (NI) in reducing postoperative IAA in children with perforated appendicitis.
- To assess the impact of PVI irrigation on secondary outcomes, including length of stay (LOS) and readmission rates.
Main Methods:
- A pilot randomized controlled trial involving 100 pediatric patients with perforated appendicitis.
- Patients were randomized to receive either PVI irrigation or no irrigation.
- Outcomes included 30-day IAA, LOS, emergency department visits, and readmissions, analyzed using Bayesian and frequentist statistics.
Main Results:
- The PVI group showed a 12% rate of postoperative IAA compared to 16% in the NI group.
- Bayesian analysis estimated an 89% probability that PVI reduces IAA.
- PVI irrigation demonstrated a high probability of benefit for all secondary outcomes, including reduced LOS and readmissions.
Conclusions:
- Povidone-iodine irrigation shows a strong probability of reducing postoperative IAA in children with perforated appendicitis.
- The study suggests a high probability of decreased LOS and other favorable outcomes with PVI irrigation.
- These findings support the continuation of a definitive trial to confirm the benefits of PVI irrigation.
Objectives:
A randomized controlled trial was conducted to test the hypothesis that povidone-iodine (PVI) irrigation versus no irrigation (NI) reduces postoperative intra-abdominal abscess (IAA) in children with perforated appendicitis.
Methods:
A 100 patient pilot randomized controlled trial was conducted. Consecutive patients with acute perforated appendicitis were randomized (1:1) to PVI or NI from April 2016 to March 2017 and followed for 1 year. Patients and postoperative providers were blinded to allocation. The primary endpoint was 30-day image-confirmed IAA. Secondary outcomes included initial and total 30-day length of stay (LOS), emergency department (ED) visits, and readmissions. Intention-to-treat analyses were performed to estimate the probability of clinical benefit using Bayesian regression models (an optimistic prior for the primary outcome and neutral priors for secondary outcomes). Frequentist statistics were also used.
Results:
Baseline characteristics were similar between treatment arms. The PVI arm had 12% postoperative IAA versus 16% in the NI arm (relative risk 0.72, 95% credible interval 0.38-1.23). Bayesian analysis estimates 89% probability that PVI reduces IAA. High probability of benefit was seen in all secondary outcomes for the PVI arm: fewer ED visits and readmissions, and shorter initial and total 30-day LOS. The probability of benefit in reduction of total 30-day LOS in PVI patients was 96% and was significant (P = 0.05) on frequentist analysis.
Conclusions:
PVI irrigation for perforated appendicitis in children demonstrated a strong probability of reduction in postoperative IAA with a high probability of decreased LOS. With the favorable probability of benefit in all outcomes, this pilot study serves as evidence to continue a definitive trial.
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