SUNDAY, SEPTEMBER 26, 2010

Delayed Appendectomy: A Different Kind of Peer Review

Let’s look at a seemingly straightforward paper entitled “Effect of delay to operation on
outcomes in adults with acute appendicitis” recently published in a respected journal by a
large and geographically diverse group of surgeons. The authors looked at almost 33,000
patients with appendicitis who underwent appendectomy at different time intervals after
being admitted to a hospital. The data were collected from the American College of
Surgeons National Surgical Quality Improvement Program [NSQIP] database over the four
years from 2005 through 2008. They found no significant differences in risk-adjusted 30-
day complication or mortality rates whether the patients underwent appendectomy within 6
hours of surgical service admission, 6 to 12 hours after admission or more than 12 hours
after admission. 

The authors acknowledged several limitations of the study. It was retrospective and
therefore reasons for the delays to surgery for most patients could not be determined. The
data were taken from a database with limited clinical information. Absent were data on
antibiotic usage, fluids administered and reasons for choosing the laparoscopic or open
approach to appendectomy. The authors and the accompanying editorialist suggested that
since the outcomes were comparable it would be acceptable to delay appendectomy until
daylight hours and have a well-rested surgeon perform the appendectomy. Allusions were
made to possible money savings by not having operating room staffs and anesthesiologists
awakened and called in at night. No data were presented to support this theory.

Not mentioned by the authors but occurring to me are some other issues. The NSQIP
database is contributed to on a voluntary basis by mostly academic tertiary care medical
centers. I doubt the findings of this study are universally applicable. The three groups of
patients based on the timing of the surgery were not really similar. In fact they were
statistically significantly different and arguably clinically different in almost all respects. I
don’t know about the authors’ practice patterns, but at every hospital I have ever worked in,
including my present one, waiting to do an appendectomy until the morning means that
someone’s elective surgery will have to be “bumped” [delayed] while I do my appendectomy.
This causes the elective schedule to run late and staff has to work overtime [$$$$$] anyway.
Also, most private practice surgeons need to get these cases done so they don’t interfere
with office hours or their own elective surgery cases. 

Then there is the little problem of the patients and their desires. Here is where the
“Different Kind of Peer Review” comes in. USA Today did a story on the above study. It was
well-written [see HealthNewsReview critique] and summarized the findings accurately. Of
the more than 40 comments posted online at the time I write this, the overwhelming
majority expressed extreme negativity regarding waiting to have an appendectomy.
Commenters railed against pain and suffering while waiting for surgery, government
rationing of healthcare and lazy, avaricious doctors. Anecdotes about perforation of the
appendix, peritonitis, near-death and veganism [yes, veganism] were offered. Finally, good
luck defending yourself if you are sued by someone who waited 18 hours for an
appendectomy only to have a bad outcome due to perforation, sepsis, abscess and
reoperation. That would emphatically negate any money saved by waiting, assuming such
saving even exists.
I do not see delayed appendectomy catching on soon. What do you think?
Posted by Skeptical Scalpel at 8:27 PM 
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Labels: appendectomy, Outcomes

3 comments:
Vickie said...
I have an idea: how about no more surgery at night, at all? That would be very efficient.
You could send all the doctors home at night to get some rest. Are you in pain? Here,
have some morphine while we wait for the doctor to be well-rested. Forget about how
well-rested the patient is after spending the night in excruciating pain.

While we're at it, let's take care of those pesky pregnant women and their unpredictable
labors. How about rushing into c-sections so doctors can get home for dinner? Oh wait,
they already do that.

Sounds like this is not really the direction that would be best for the patients. Here's a
good thought experiment: If the appendicitis patient were also a surgeon, would he agree
to wait overnight??? Yeah, I thought so.
September 27, 2010 8:17 AM

Clark Venable said...
What we're seeing more and more is surgeons wanting to start an add-on case at 0600--
they don't have to operate at 2 am yet they don't disrupt the elective or office schedule.
September 27, 2010 9:27 AM

Skeptical Scalpel said...
Two problems with the 0600 start. 
1. If you have no house staff and are already awake and seeing the patient, it makes no
sense to wait.
2. I have never worked in a hospital where a case scheduled for 0600 started at 0600. It
would usually be that they called for the patient at 0600. He arrives at 0620. Ritualistic
Q&A by nurses and anesthesia, time out etc. Case starts at 0645 or 7 and runs over into
the elective schedule.
September 27, 2010 7:38 PM
LATEST RESEARCH SHOWS APPENDECTOMY MAY BE BEST FOR PATIENTS WITH POSITIVE CT
EXAM
Author: admin
June 29, 2010
When CT results suggest appendicitis, but a patient’s symptoms are inconsistent with the acute
condition, physicians should consider a diagnosis of chronic or recurrent appendicitis and surgical
treatment, according to a new study published in the online edition of the journal Radiology.
"The decision to forego surgery in these patients often results in missed appendicitis, with a possible increased
risk of perforation," said study co-author Emily M. Webb, M.D., assistant professor of clinical radiology at the
University of California, San Francisco.
Acute appendicitis, which occurs when the appendix - a small, tube-like structure attached to the large intestine
- becomes blocked and inflamed, requires prompt surgical removal. Left untreated, an inflamed appendix will
eventually perforate, or burst, spilling infectious materials into the abdominal cavity, which can be life-
threatening.
In the less common chronic and recurrent appendicitis, patients experience milder symptoms that may come
and go. According to the National Institutes of Health, appendicitis can affect anyone, but is more common
among people 10 to 30 years old. Appendicitis leads to more emergency abdominal surgeries than any other
cause.

For the study, the researchers reviewed CT reports and medical records of 2,283 patients who underwent CT
for suspected appendicitis at the University of California, San Francisco Medical Center between 2002 and
2007. Patients in the study included 856 men and 1,427 women between the ages of 18 and 99 years old with
a mean age of 46.
"We wanted to look at patients with a positive CT scan but atypical clinical symptoms who did not have their
appendix immediately removed," Dr. Webb said.
Of the study’s 2,283 patients, 516, or 23 percent, had CT findings that indicated a probable or definite
appendicitis. Of those 516 patients, 450 (87 percent) had their appendix surgically removed within four days.
Ninety-five percent of those cases were confirmed as acute appendicitis.
Forty-nine (10%) of 516 patients had nonsurgical treatment, including antibiotics or percutaneous abscess
drainage. An additional four of 516 patients were lost to follow up.
Thirteen (three percent) of the 516 patients with positive CT findings did not receive immediate surgical
treatment because their symptoms - including a normal appetite, absence of nausea and vomiting, normal
white blood cell count and mild or resolving pain - were atypical for acute appendicitis. Of those, five (38
percent) ultimately had their appendix removed after seeking treatment for the same symptoms an average of
four months later. Appendicitis was confirmed in all cases.
"The results of our study confirm that CT is a good diagnostic tool for appendicitis and that surgeons should be
wary of dismissing positive CT findings," Dr. Webb said. "Prompt treatment of chronic or recurrent appendicitis
can prevent patients from developing complications or other future ill effects."
The study’s findings may also help explain the disparity between CT results that indicate appendicitis and
patient symptoms that do not.
"When the appendix is not completely obstructed, it can result in a milder form of appendicitis that is chronic or
recurring," Dr. Webb said. "But the three forms of appendicitis, acute, chronic and recurrent, are
indistinguishable on CT scans."
"Acute Appendicitis: Clinical Outcome in Patients with an Initial False-Positive CT Diagnosis." Collaborating
with Dr. Webb were Joseph W. Stengel, D.O., Liina Poder, M.D., Benjamin M. Yeh, M.D., Rebecca Smith-
Bindman, M.D., and Fergus V. Coakley, M.D.
Radiology is edited by Herbert Y. Kressel, M.D., Harvard Medical School, Boston, Mass., and owned and
published by the Radiological Society of North America, Inc. (http://radiology.rsnajnls.org/)
Delaying surgical admission for acute appendicitis in adults for
several hours considered not be harmful
Tagged with: adult with acute appendicits and appendectomy, delaying appendectomy considered not harmful for acute

appendicitis, duration from surgical admission to inducton anesthesia for appendicitis patients not clinically

meaningful, impact of delaying of surgical admission for acute appendicitis, risk of morbidity and mortality from delaying

appendectomy in adults with acute appendicitis, win-win situation from delaying appendectomy for patients and the surgeon

Thursday, September 30, 2010, 12:10

This news item was posted in Colon, General Health, Healthy News, Journal category and has 0 Comments so
far.

For patient with acute appendicitis where characterized by inflammation of the appendix, appendectomy or
appendicsectomy (the surgical removal of vermiform appendix both with laparotomy or laparoscopy) should be
performed as emergency procedure, because the risk of morality in this patient is high.

However, according to recent study results, the investigators said that delaying that surgical admission for acute
appendicitis in adults for 12 hours or more considered not be harmful.
The purpose of the study itself to determine the impact of such delaying admission to induction of anesthesia on
outcomes after appendectomy in adults.

Reported as September issue of the Archives of Surgery, the study authors, Angela M. Ingraham, MD, MS, from the
American College of Surgeons in Chicago, Illinois, and colleagues, write, “Increased time from onset of symptoms to
operative intervention is associated with more advanced disease. Recent developments in imaging and antibiosis
have afforded improved preoperative assessment and treatment, allowing for non-operative management of
abscesses and phlegmons and potentially limiting the need for immediate operative intervention to halt disease
progression.”
The data for observation come from the American College of Surgeons National Surgical Quality Improvement
Program database which were consisted of 32,782 patient from January 1, 2005 to December 31, 2008.

In this observation, the time to operation was the principal exposure, and primary study endpoints were 30 day overall
morbidity and serious morbidity or mortality.
The regression models used for adjusting for patient and surgical risk factors due to probabilities of outcomes.
In this study, the investigators found;
- 24,647 (75.2%) patients, appendectomy was performed within 6 hours of surgical admission,
- 4934 (15.1%) patients had delaying of appendectomy between 6 hours to 12 hours,
- 3201 ((9.8%) patients had delaying of appendectomy more than 12 hours after surgical admission.
The investigators note that there were not clinically meaningful regarding to significant differences of operative
duration (51, 50, and 55 minutes respectively; P 12-hour group vs 1.8 days for remaining groups; P < .001).

Also in regression models, according to investigators, duration from surgical admission to induction of anesthesia did
not predict overall morbidity or serious morbidity or mortality. There were no significant differences in adjusted overall
morbidity, serious morbidity, or mortality.

Based on this findings, the authors write, “This information can guide the use of potentially limited operative and
professional resources allocated for emergency care”, because “delay of appendectomy for acute appendicitis in
adults does not appear to adversely affect 30-day outcomes.”
The authors acknowledged that their study had possible several limitations such as retrospective design, possible
differences in patient or organizational factors, lack of randomization, and use of operative and diagnostic codes to
identify appendicitis, however, they conclude, “Because of the growing issues surrounding access to emergency care
and specialist coverage, care for emergency general surgery patients is increasingly the responsibility of acute care
surgeons and specialized services, which cover the speacialties of trauma, emergency general surgery and critical
care.”
John G. Hunter, MD, from Oregon Health & Science University in Portland, as accompanying critique note that these
findings validate the practice of treating acute appendicitis urgently rather than emergently.
 Dr. Hunter said, “Financial saving without any evidence of adversity to the patient and the promise of a well-rested
surgeon in the morning provide benefit sufficiently ample for me to embrace these recommendations.” Finally, “at the
end of the day, it is clearly a win-win situation when the interests of the patient, the surgeon, and the hospital are in
complete alignment around such a shift in surgical practice.”
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