Evidence-based Evaluation On Key Questions In Surgical Abdominal Infection

Background and objective:Intra-abdominal infections(IAIs)are a series of infectious diseases caused by the invasion of bacteria into the abdominal cavity and organs,which representing with a wide spectrum of pathological conditions.In terms of the etiology of IAIs,IAIs caused by biliary tract is the most common,accounting for about 32.6%;followed by gastrointestinal tract,accounting for about 24.1%,and IAIs caused by pancreas and liver are 19.1%and 17.7%,respectively.Among patients with IAIs,the proportion of male patients is more than twice that of female patients.Complicated intra-abdominal infections(cIAIs)is the second leading cause of sepsis in intensive care units following respiratory infections(67.4%).The mortality caused by cIAIs is about 10%globally.In order to solve controversial problems and improve the management of cIAIs,academic organizations around the world have developed guidelines for the diagnosis and treatment of IAIs.In 2018,the World Surgery Infection Society(WSIS)initiated the development of clinical practice guidelines(CPGs)for cIAIs.Based on the results from expert consultations and two rounds of surveys,29 key questions were finally included in WSIS cIAIs guidelines.We aim to focus on the six key questions and conduct evidence-based evaluations from CPGs,systematic reviews and clinical research,so as to provide support for the development of WSIS guidelines.Methods:1)We conducted a systematic search in PubMed,EMBASE,Web of Science,CBM,CNKI,Wanfang and other databases,and included CPGs,SR/MAs,and primary studies(PSs);2)We used AGREE II,AMSTAR-2,and Cochrane collaboration risk of bias tool to assess the methodological quality of include CPGs and SR/MAs and PSs,and used RIGHT and PRISMA to assess the reporting quality of included CPGs and SR/MAs.Also,we analyzed the factors influencing the quality of the included CPGs and SR/MAs;3)We conducted systematic reviews for 6 key questions which evaluated the effectiveness and safety of intraoperative peritoneal lavage,minimally invasive surgery(percutaneous drainage,video-assisted retroperitoneal debridement),drainage tube placement,and colectomy(subtotal colectomy vs.segmental colectomy).Results:1)As for the methodological quality of the included guidelines,the AGREE Ⅱ scores for all guidelines were ≤60%,and the average score was 33%.As for the reporting quality of the included guidelines,the reporting rates of 5 items were≤5%.The guidelines developed by the Surgical Infection and Critical Care Medicine Group of the Chinese Medical Association’s Surgery Branch and the Society of Surgical Infections had the highest reporting rate,which are 83%and 69%,respectively.2)As for the methodological quality of the included SR/MAs,only one SR/MA had high quality,and 75%of them had a very low quality.And 91.7%of them were not registered and had no protocol,83.3%of the SR/MAs did not provide a list of excluded studies and reasons for exclusion.As for the reporting quality of the included SR/MAs,among 42 items,a total of 8 items(19%)had reporting rates of less than 10%.3)A total of 5 SR/MAs were conducted.Intraoperative intraperitoneal irrigation(IOPL)did not reduce the mortality(RR=0.57,95%CI:0.32～1.04,I2=24.0%)and abscess formation in patients with IAIs(RR=0.89,95%CI:0.55～1.44,I2=37.4%).Compared with traditional open necrosectomy,intraoperative percutaneous drainage(PCD)reduced the mortality(RR=0.52,95%CI:0.37～0.72,I2=0.0%),pancreatic fistula rate(RR=0.36,95%CI:0.19～0.70,I2=0.0%)and postoperative bleeding rate(RR=0.30,95%CI:0.17～0.53,I2=0.0%)in infected pancreatic necrosis(IPN)patients.Compared with traditional open necrosectomy,video-assisted retroperitoneal debridement(VARD)did not reduce the mortality in patients with IPN(RR=0.71,95%CI:0.43～1.16,I2=13.2%),but reduced the occurrence of pancreatic fistula(RR=0.59,95%CI:0.39～0.89,I2=0.0%).There is no studies comparing the effectiveness of placing drainage tube and not placing drainage tube after drainage of retroperitoneal abscess.Compared with segmental colectomy,subtotal colectomy did not reduce the mortality in patients with C.difficile colitis(OR=1.07,95%CI:0.22～5.32,I2=49.8%).Conclusions:1)The methodological quality and reporting quality of cIAIs guidelines were generally low.Not declaring conflicts of interest,not reporting funding and not using evidence grading system caused the low quality of guidelines.2)The methodological quality and reporting quality of cIAIs SR/MAs were generally low.No registration and protocol,not providing a list of excluded studies and reasons for exclusion were the main reasons for low quality of SR/MAs.3)The six systematic reviews showed that IOPL did not reduce the mortality and abscess formation of IAI patients;minimally invasive techniques(PCD,VARD)may reduce the complications of IPN patients;the effectiveness and safety of drainage tube placement after drainage of retroperitoneal abscess were not clear and high-quality studies are urgently needed;compared with segmental colectomy,subtotal colectomy did not reduce the mortality of patients with C.difficile colitis.