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Early Versus Delayed Appendect PDF
Early Versus Delayed Appendect PDF
a r t i c l e i n f o a b s t r a c t
Article history: Background: The optimal timing for performing appendectomy in adults remains controversial.
Received 6 July 2017 Method: A one-year retrospective review of adult patients with acute appendicitis who underwent
Received in revised form appendectomy. The cohort was divided by time-to-intervention into two groups: patients who under-
17 October 2017
went appendectomy within 8 h (group 1), and those who had surgery after 8 h (group 2). Outcome
Accepted 26 October 2017
measures including perioperative morbidity and mortality, post-operative length of stay, and the 30-day
readmission rate were compared between the two groups.
Keywords:
Results: A total of 116 patients who underwent appendectomy met the inclusion criteria: 75 patients
Appendicitis
Early appendectomy
(65%) in group 1, and 41 (35%) in group 2. There were no differences between group 1 & 2 in periop-
Delayed appendectomy erative complications (6.7% vs. 9.8%, P ¼ 0.483), postoperative length of stay (median [IQR]; 19.5 [11.5
Complication e40.5] vs. 20.0 [11.25e58.5] hours, P ¼ 0.632), or 30-day readmission rate (2.7% vs. 4.9%, P ¼ 0.543).
Morbidity There were no deaths in either group.
Outcome Conclusion: Delayed appendectomy performed more than 8 h was not associated with increased peri-
operative complications, postoperative length of stay, 30-day readmission rate, or mortality.
© 2017 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.amjsurg.2017.10.057
0002-9610/© 2017 Elsevier Inc. All rights reserved.
484 K. Seudeal et al. / The American Journal of Surgery 215 (2018) 483e486
appendicitis were identified based on ICD-9 codes (540, 540.0, interquartile ranges (IQR). Categorical data were tested using the
540.1, 540.9) and ICD-10 codes (K35, K35.3, K35.3, K35.8). Pearson c2 test. Differences in means between groups were
All patients undergoing appendectomy during the study period compared using the unpaired Student t-test or Mann-Whitney rank
who met the inclusion criteria were included in the analysis. In- sum test.
clusion criteria for the subjects were (1) patients between the age
of 18e90 years at time of appendectomy, (2) patients diagnosed 3. Results
with appendicitis by ultrasound, computed tomography (CT) scan,
magnetic resonance image (MRI), or by clinical suspicion, and (3) During the one-year study period, a total of 116 patients met the
patients who underwent appendectomy during the same hospi- inclusion criteria for the study population. Seventy-five patients
talization in which they were diagnosed. Exclusion criteria were (1) (65%) underwent appendectomy within 8 h of arrival to the ED, and
patients discharged from the hospital before undergoing appen- 41 patients (35%) after 8 h. The overall mean (SD) age was 42.2
dectomy (i.e. interval appendectomy, patients leaving against (17.5) years. Male patients accounted for 54% (n ¼ 63) of the pop-
medical advice), and (2) pregnant patients who were diagnosed ulation. The median (IQR) time from onset of abdominal pain to
with acute appendicitis. arrival to the ED was 24 (12e48) hours. The median (IQR) time from
The study population was divided into two groups by time-to- arrival to ED to skin incision was 6 (3.3e10) hours.
intervention: the early appendectomy (group 1) included patients Table 1 presents detailed overall patient characteristics and
who underwent surgery within 8 h, and the delayed appendectomy comparison between the two study groups. There was no signifi-
(group 2) included patients who had surgery after 8 h. The two cant difference between the two groups. All patients presented
study groups were then then compared for differences in the un- with abdominal pain. Overall, 93% (108/116) of patients underwent
derlying characteristics including demographic, clinical, radio- a preoperative computed tomography (CT) scan of the abdomen
graphic and perioperative data. Outcome measures included and pelvis. The most common finding in the CT scan was the
mortality and morbidity, postoperative length of stay, and 30-day presence of peri-appendiceal inflammation in 94% (102/108) of
readmission rate. patients, followed by the presence of fecalith in 35% (38/102). No
Data was collected manually via patient chart review within the statistically significant difference was identified between the two
electronic medical record. Statistical analysis was performed using groups regarding the CT scan findings. Abdominal ultrasound was
SAS Enterprise Guide 7.1. Statistical significance was considered for used in 15 patients, and magnetic resonance imaging (MRI) was
P < 0.05. Categorical variables are presented as frequencies and used in one patient.
percentages, and continuous variables were reported as means and Table 2 presents detailed overall perioperative data and com-
standard deviation (SD) or, if the data were skewed, as medians and parison between the two study groups. We found no significant
Table 1
Overall patient demographic, clinical and radiologic data and comparison between early appendectomy (group 1) and delayed appendectomy (group 2).
Background Demographics
Age in years, mean (SD) 42.2 (17.5) 42.6 (18) 41.4 (16.7) 0.585
Gender (Male/Female) 63/53 39/36 24/17 0.561
Body Mass Index (Kg/m2), mean (SD) 28.9 (6.7) 29 (6.7) 28.5 (7) 0.796
Prior abdominal surgeries, n (%) 41 (35) 23 (30.7) 18 (44) 0.1622
Medical Comorbidities
CAD, n (%) 3 (2.6) 1 (1.3) 2 (4.9) 0.285
CVA, n (%) 2 (1.7) 1 (1.3) 1 (2.4) 0.667
CHF, n (%) 3 (2.6) 1 (1.3) 2 (4.9) 0.285
COPD, n (%) 4 (3.4) 1 (1.3) 3 (7.3) 0.126
Diabetes, n (%) 11 (9.5) 6 (8) 5 (12.2) 0.516
Chronic Kidney Disease, n (%) 3 (2.6) 2 (2.7) 1 (2.4) 0.941
Clinical and Imaging Data
Timing from onset of abdominal pain to arrival to 24 (12e48) 24 (12e48) 24 (15e48) 0.314
ED in hours, median (IQR)
Symptoms associated with abdominal pain
Fever, n (%) 14 (12.1) 10 (13.3) 4 (9.8) 0.768
Nausea, n (%) 65 (56) 41 (54.7) 24 (58.5) 0.701
Anorexia, n (%) 24 (21) 18 (24) 6 (14.6) 0.338
Diarrhea, n (%) 11 (9.5) 9 (12) 2 (4.9) 0.323
Physical Examination/labs
Temperature in Celsius, mean (SD) 36.9 (0.6) 36.9 (0.6) 36.9 (0.6) 0.911
Localized peritonitis, n (%) 112 (96.6) 73 (97.3) 39 (95.1) 0.688
Diffuse peritonitis, n (%) 4 (3.4) 2 (2.7) 2 (4.9) 0.534
White blood count (x109/L), mean (SD) 13.9 (4.5) 13.8 (4.2) 13.5 (5.1) 0.513
Radiologic Data
Abdomen and Pelvis CT Scan, n (%) 108 (93) 68 (91) 40 (97.5) 0.163
CT scan Findings
Peri-appendiceal inflammation, n (%) 102 ((94) 67 (98.5) 35 (87.5) 0.560
Fecolith, n (%) 38 (35) 27 (40) 11 (27.5) 0.408
Phlegmon/Abscess, n (%) 4 (3.7) 1 (1.5) 3 (7.5) 0.126
Pneumoperitoneum, n (%) 4 (3.7) 1 (1.5) 3 (7.5) 0.661
Ultrasound, n (%) 15 (13) 9 (12) 6 (5.2) 0.687
MRI, n (%) 1 (0.9) 1 (1.3) 0 (0) 1.000
CAD ¼ coronary artery disease, CVA ¼ cerebrovascular accident, CHF ¼ congestive heart failure, COPD ¼ chronic obstructive pulmonary disease, ED ¼ Emergency Department,
CT ¼ computerized tomography, MRI ¼ magnetic resonance Image.
K. Seudeal et al. / The American Journal of Surgery 215 (2018) 483e486 485
Table 2
Overall perioperative data between early appendectomy (group 1) and delayed appendectomy (group 2).
Perioperative Data Overall (N ¼ 116) Early Appendectomy (Group 1) Delayed Appendectomy (Group 2) p-value
(8 h, n ¼ 75) (>8 h, n ¼ 41)
Time in hours from arrival at ED to Incision, median (IQR) 6 (3.3e10) 4 (2e5.5) 12 (9.9e14.4) 0.001
Time in hours between onset of symptoms 32.75 (18e57) 26 (16e52) 41 (31e82) 0.001
to skin incision, median (IQR)
Operative Time in minutes, mean (SD) 56 (25) 55 (21) 63 (31) 0.699
Pre-operative antibiotics, n (%) 113 (97) 73 (97.3) 40 (97.5) 0.941
Post-operative Antibiotics usage, n (%) 42 (36) 25 (33.3) 17 (41.5) 0.386
Pathologic diagnosis
Acute nonperforated appendicitis, n (%) 104 (90) 69 (92) 35 (85.4) 0.69
Perforated appendicitis, n (%) 8 (6.7) 3 (4) 5 (12.2) 0.54
Other pathology, n (%)
Normal appendix, n (%) 1 (0.9) 1 (1.3) 0 (0)
Carcinoid, n (%) 1 (0.9) 1 (1.3) 0 (0)
Adenocarcinoma, ruptured, n (%) 1 (0.9) 0 (0) 1 (2.4)
Sessile serrated adenoma, n (%) 1 (0.9) 1 (1.3) 0 (0)
differences between the two groups regarding the operative time perioperative morbidity, postoperative length of stay, or the 30-day
(P ¼ 0.699), pathologic diagnosis of non-perforated and perforated readmission rate. Our findings are concordant with recent studies
appendicitis (P ¼ 0.691, P ¼ 0.540), and administration of pre- and suggesting that short delays of less than 12e24 h in performing
postoperative antibiotics (P ¼ 0.941, P ¼ 0.386). The two groups appendectomy have not been associated with an increase in
differ significantly regarding the time from arrival to ED to skin morbidity or mortality.1,5,6 A large, population-based study using
incision (P < 0.001), and the time from onset of symptoms to skin the American College of Surgeons National Surgical Quality
incision (P < 0.001). Diagnosis of acute appendicitis was confirmed Improvement Program (NSQIP) database supports this semi-
in 96.7% (112/116) of patients, eight of them had perforated elective approach, suggesting that appendectomy may be delayed
appendicitis. Histopathologic examination in four patients showed up to 24e48 h without a significant increase in adverse outcome.7
one normal appendix, one carcinoid tumor, one ruptured appen- In that study, no difference was seen in the complication rate for
diceal neoplasm, and one sessile serrated adenoma. One hundred- those undergoing appendectomy within one day of admission;
thirteen patients (97%) received preoperative antibiotics and only however, there was a two-fold increase in complication rates for
42 patients (36%) received postoperative antibiotics. Laparoscopic any patient in which time-to-operation was delayed more than
appendectomy was performed in 115 patients (99.14%). The 48 h. Prior smaller studies have found similar results.8,9
remaining patient underwent a conversion to open procedure. In contrast to the studies supporting safe delay of appendec-
Table 3 presents overall outcomes and comparison between the tomy, there have been studies that demonstrate a negative impact
two study groups. There were no deaths in the study population. on outcomes with short delays of even 6e12 h in intervention.2 A
Overall, nine patients (6.7%) had postoperative complications recent study from the UK found no increased rate of complicated
including one post-operative bleeding (0.9%), two surgical site in- appendicitis when appendectomy was performed within 48 h.10
fections (2.6%), one pneumonia (1.7%), one urinary tract infection However, an in-hospital delay of greater than 48 h was associated
(0.9%), and multiple organ system failure in two patients (1.7%). with a significantly increased risk of developing complicated
Four patients (3.4%) were readmitted within 30 days of surgery. appendicitis.
There were no significant differences in the measured outcomes Unplanned readmission within 30 days of performing appen-
between the two groups regarding perioperative morbidity (6.7% vs dectomy in our study was 3.4% (n ¼ 4), which is comparable to the
9.8%, P ¼ 0.483) and 30-day readmission rate (2.7% vs. 4.9%, 3.7% reported in a large study.11 Reasons for readmission were
P ¼ 0.543). There was no significant difference in the postoperative either infection, bleeding, inadequate pain control, nausea, vomit-
length of stay (median [IQR] 19.5 [11.5e40.5] hours vs 20.0 ing, or ileus. Intra-abdominal infections and nonspecific abdominal
[11.25e58.5] hours, P ¼ 0.632) between the two groups. pain are the most common reasons for readmission.
In certain circumstances, when a delay to operative intervention
is justified, patients with acute appendicitis should be maintained
4. Discussion
on intravenous fluids and intravenous antibiotics during the wait-
ing period.4 Patients who are admitted with acute appendicitis
In this study, we found that a delay of more than 8 h in per-
overnight can be safely managed nonoperatively until surgery can
forming appendectomy was not associated with increased
Table 3
Outcomes and comparison between early appendectomy (group 1) and delayed appendectomy (group 2).
Perioperative Data Overall (N ¼ 116) Early Appendectomy (Group 1) Delay Appendectomy (Group 2) p-value
(8 h, n ¼ 75) (>8 h, n ¼ 41)
Perioperative Mortality 0 0 0 e
Perioperative Morbidity, n (%) 9 (7.8) 5 (6.7) 4 (9.8) 0.483
Bleeding, n (%) 1 (0.9) 1 (1.3) 0 (0) 0.460
Infection-SSI, n (%) 3 (2.6) 2 (2.7) 1 (2.4) 0.941
Pneumonia, n (%) 2 (1.7) 1 (1.3) 1 (2.4) 0.663
Urinary Tract Infection, n (%) 1 (0.9) 0 (0) 1 (2.4) 0.176
MODS, n (%) 2 (1.7) 1 (1.3) 1 (2.4) 0.663
PLOS in hours, median (IQR) 19.75 (11.50e41.80) 19.5 (11.50e40.5) 20.0 (11.25e58.50) 0.632
Readmission Within 30 days, n (%) 4 (3.4) 2 (2.7) 2 (4.9) 0.534
SSI ¼ surgical site infection, PLOS ¼ postoperative length of stay, MODS ¼ multiple organ dysfunction syndrome, IQR ¼ interquartile range.
486 K. Seudeal et al. / The American Journal of Surgery 215 (2018) 483e486