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The American Journal of Surgery (2008) 195, 590 –593

North Pacific Surgical Association

Timing of intervention does not affect outcome in acute


appendicitis in a large community practice
Courtney Clyde, M.D., Timothy Bax, M.D., Anders Merg, M.D.,
Mark MacFarlane, M.D., Paul Lin, M.D., Steven Beyersdorf, M.D.,
M. Shane McNevin, M.D.*

Surgical Specialists of Spokane, 105 W 8th Ave., Suite 7060, Spokane, WA 99208, USA

KEYWORDS: Abstract
Appendicitis; BACKGROUND: Surgical management of acute appendicitis remains one of the most frequent
Laparoscopy; problems faced by gastrointestinal surgeons. Traditional management has emphasized urgent surgical
Surgical outcomes care. Recent literature suggests delayed surgery for acute appendicitis does not affect outcome. The
outcomes of patients undergoing urgent and delayed appendectomy in a large community surgical
practice are compared.
METHODS: All patients undergoing appendectomy between August 2002 and May 2007 were
reviewed retrospectively. The data were gathered from a large community surgical practice. Patient
demographics, treatment times, and surgical, pathologic, and postsurgical outcomes were documented.
RESULTS: A total of 1,198 patients underwent appendectomy (575 female/623 male). The mean
time to surgical intervention was 7.1 hours (range, 1–24 h). The percentage of patients undergoing
laparoscopy versus open versus surgical conversion was 63%, 33%, and 4%, respectively. The
percentage of patients with acute appendicitis versus perforated acute appendicitis versus negative
exploration was 77%, 14%, and 8.5%, respectively. Postoperative wound or intra-abdominal septic
complications were observed in 5.3% and 2.6% of patients, respectively. There was no correlation
between the duration of symptoms or time to surgical intervention and surgical approach, pathologic
outcome, length of stay, or postoperative septic complications.
CONCLUSIONS: Outcome variables documented in this study were independent of duration of
symptoms or time to surgical intervention. This would suggest that short delays in surgical intervention
for acute appendicitis are well tolerated. Outcome is related more clearly to the severity of the acute
appendicitis at presentation.
© 2008 Elsevier Inc. All rights reserved.

Acute appendicitis is one of the most frequent acute approach. This has led to the recommendation that all ap-
surgical conditions encountered by the gastrointestinal sur- pendicitis patients should have surgery performed as close
geon.1,2 Traditional management has emphasized urgent to the time of diagnosis as possible, although there are
surgical intervention using either an open or laparoscopic controversial data supporting this approach.1–5
Numerous studies have documented outcome variables
* Corresponding author. Tel.: ⫹1-509-747-6194; fax: ⫹1-509-747- related to time of day of the procedure and fatigue of the
4313.
surgical team.6 In addition, in the era of cost containment,
E-mail address: skmcnevin@comcast.net
Manuscript received November 7, 2007; revised manuscript January emergent surgical procedures performed after hours are
30, 2008 more costly (personal communication). Also, many other

0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2008.01.005
C. Clyde et al Outcomes of acute appendicitis 591

90
80
70
60
% Acute
50
Perf.
40
Neg.
30
20
10
0
<6 <12 <18 <24
Time to operative intervention (hours)

Figure 3 Pathologic findings versus time to surgical interven-


Figure 1 Patient demographics of 1,198 patients undergoing tion. Blue, acute; maroon, perforation; white, negative.
appendectomy.

experienced symptoms before medical attention for a mean


acute abdominal conditions such as acute cholecystitis and of 2.2 days (range, 0 –21 d). Patients underwent surgical
acute diverticulitis have been managed successfully with an intervention a mean of 7.1 hours (range, 1–24 h) after first
urgent but not emergent approach.7–9 Recent data have seeking medical attention. The mean length of stay was 1.3
challenged the need for emergent surgical treatment of acute days (range, 1–9 d).
appendicitis. Surgical approach was according to surgeon preference.
We reviewed our surgical experience with appendicitis The percentage of patients undergoing laparoscopy versus
to determine which surgical variables affected postoperative open versus surgical conversion was 63%, 33%, and 4%,
outcome. Specifically, we were interested in determining respectively. There was no correlation between surgical
whether timing of intervention or the severity of the under- approach and time to surgical intervention. Surgical and
lying appendicitis played a larger role in postoperative pa- pathologic findings revealed acute appendicitis versus per-
tient outcome. forated acute appendicitis versus negative exploration in
77%, 14%, and 8.5% of patients, respectively. Likewise,
there was no correlation between pathologic outcome and
Methods time to surgical intervention. These relationships are shown
in Figs. 2 and 3. Fig. 4 shows the relationship between
A retrospective chart review of all patients undergoing length of stay and time to surgical intervention. Again there
appendectomy in a single community surgical specialty appeared to be no correlation between these variables. Sim-
practice between August 2002 and May 2007 was con- ilar relationships were seen related to reported duration of
ducted. Institutional review board authorization was ob- symptoms (data not shown).
tained. Postoperative wound or intra-abdominal septic compli-
Patient demographics and comorbidities, symptom dura- cations were observed in 5.3% and 2.6% of patients, respec-
tion, laboratory and radiographic evaluation and findings, tively. Fig. 5 shows the incidence of wound and intra-
treatment times, surgical type and findings, pathologic find- abdominal septic complications related to time to surgical
ings, and postsurgical outcomes were documented. intervention, respectively. There was no correlation be-
tween these variables. Similar relationships were seen re-
lated to reported duration of symptoms (data not shown).
The incidence of wound and intra-abdominal septic com-
Results plications appeared most related to surgical approach and
A total of 1,198 patients underwent appendectomy dur- pathologic findings; this is shown in Figs. 6 and 7. The rate
ing the study period. Patient demographics are listed in of wound infection was increased in patients undergoing an
Fig. 1. The ratio of males to females was 1.1. Patients open appendectomy or a converted laparoscopic procedure
as well as patients with appendiceal perforation. The rate of
intra-abdominal sepsis was increased in patients with per-
70
60
50 1.6
Lap 1.4
40
Open 1.2
30 L
Conv. 1
O
20 S 0.8 LOS
10 0.6
0.4
0
0.2
<6 <12 <18 <24
0
Time to operative intervention (hours)
<6 <12 <18 <24
Time to operative intervention (hours)
Figure 2 Type of surgery versus time to surgical intervention.
Blue, laparoscopic; maroon, open; white, conversion. Figure 4 Length of stay versus time to surgical intervention.
592 The American Journal of Surgery, Vol 195, No 5, May 2008

7 9
6 8

5 7
% 4 Wound Inf.
% 6
5 Wound Inf.
3 Abscess 4 Abscess
2 3
1 2
0 1
<6 <12 <18 <24 0
Acute Perf. Neg.
Time to operative intervention (hours)
Pathologic findings

Figure 5 Inflammatory complications versus time to surgical


Figure 7 Inflammatory complications versus pathologic find-
intervention. Blue, wound infection; maroon, abscess.
ings. Blue, wound infection; maroon, abscess.

forated appendicitis and those patients undergoing a con- approach, although the need for open conversion is associ-
verted laparoscopic procedure. ated with increased wound and intra-abdominal septic com-
plications. The reasons for open conversion cannot be de-
termined by this study but presumably were related to the
severity of the underlying appendicitis or technical issues
Comments related to performance of the surgery. Severity of the un-
Traditional management of acute appendicitis has em- derlying appendicitis also clearly affects outcome in this
phasized emergent surgical management, but there are a study with increases in wound and intra-abdominal sepsis
paucity of data to support this recommendation. Many acute with appendiceal perforation.
abdominal conditions now are managed with an urgent but Our data suggest that outcome in acute appendicitis is
not emergent surgical plan. In addition, a number of studies related most closely to the severity of the acute appendicitis
also have documented negative patient and economic out- at presentation and is unaffected by timing of surgical in-
comes related to time of day of the procedure, presumably tervention and that improved wound complication rates are
related to surgical team fatigue. seen with the laparoscopic approach. Based on these data an
In the current study the outcome variables documented urgent but not emergent protocol for surgical management
were independent of the duration of symptoms or the time to of acute appendicitis with the laparoscopic approach when
surgical intervention. The obvious disadvantage of the ex- possible has been adopted in our community.
perimental design in this study was its retrospective nature
and the lack of control groups, making clear proof of the
conclusions impossible. In addition, the majority of the
References
patients (83%) in this study underwent surgery within 12
hours of presentation, making clear conclusions about the
1. Fisher AC. Acute appendicitis. Curr Probl Surg 2001;7:267–72.
longer surgical delays difficult. That being said, clear infer- 2. Liu CD, McFadden DW. Acute abdomen and appendix. Surgery 1997;
ences can be drawn suggesting that short delays in surgical 2:1246 – 61.
intervention are well tolerated and reported duration of 3. Prystowsky JB, Birkhahn RH, Gaeta TJ, et al. Appendicitis. Curr Probl
symptoms is an unreliable predictor of severity of disease Surg 2005;42:688 –742.
4. Garfield JL, Fahim F, Shirjeel S, et al. Diagnostic pathways and delays
and outcome of surgical therapy.
on route to operative intervention in acute appendicitis. Am Surg 2004;
Postoperative outcome in this study was related more 70:1010 –3.
closely to the severity of the appendicitis at presentation. 5. Fahim F, Broderisk-Villa G, Burchette RJ, et al. A comparison between
Our data suggest that te severity of appendicitis likely is presentation time and delay in surgery in simple and advanced appen-
determined at the time of presentation and is unaffected by dicitis. J Ayub Med Coll Abbottabad 2005;17:37–9.
6. Boult M. Patient safety: the fatigue factor. Health Serv J 2005;115:
time to surgical intervention. Further, the results also show
34 –5.
a lower wound complication rate with the laparoscopic 7. Welschbillig-Meunier K, et al. Percutaneous cholecystostomy for high
risk patients with acute cholecystitis. Surg Endosc 2005;19:1256 –9.
8. Kolla SB, et al. Early versus delayed laparoscopic cholecystectomy for
25 acute cholecystitis, a prospective randomized trial. Surg Endosc 2004;
20
18:1323–7.
% 9. Broderisk-Villa G, et al. Hospitalization for acute diverticulitis does not
15
Wound Inf. mandate routine elective colectomy. Arch Surg 2005;140:576 – 81.
Abscess
10

0
Lap Open Conv.
Discussion
Type of Operation

Figure 6 Inflammatory complications versus type of surgery. Ravi Moonka, M.D. (Seattle, WA): I have met a number of
Blue, wound infection; maroon, abscess. surgeons in my professional travels who enjoy taking emer-
C. Clyde et al Outcomes of acute appendicitis 593

gency room call. I wish I could say I was one of them. I The paper is retrospective and subject to selection bias.
know I risk the disdain of trauma surgeons everywhere Patients who had delayed surgery may have had less im-
when I say I find call psychologically and sometimes phys- pressive presentations, and may represent a less severely ill
ically uncomfortable. Across the United States at least, call cohort that might be expected to have better results com-
cases tend to be uncompensated, litigious, and disruptive of pared to the immediate surgery group. I think we are going
one’s elective practice. to have to live with that, since a randomized trial addressing
And yet, even though it is the most common general this issue is not realistic. However, it would be helpful to
surgery call case, I like appendicitis. The patients tend to be compare various parameters of severity of disease between
young, refreshingly normal, and surprisingly appreciative, the 2 populations at presentation, such as temperature and
and the treatment tends to be quick, definitive, and chal- the white blood cell count, to show they were in fact similar
lenging but not overly so. I would like appendicitis even groups.
more if I could treat it on my own terms.
What do the conclusions of this study tell us about
For this and other reasons, I enjoyed the presentation
appendicitis? Patients with a delay in surgery for appendi-
under discussion. The project itself suggests finding ways to
citis do fine. Is that because hydration, bowel rest, and
make our jobs logistically easier is a reasonable field of
intravenous antibiotics are effective treatment, or are certain
inquiry. I also respect the work necessary to complete the
study. This was not a review of a large government-main- patients destined to perforate and others are not?
tained database examined from the comfort and safety of Finally, I must tell you my wife was not completely happy
one’s office, but rather the careful abstraction of 1,200 with this study. She had appendicitis at age 12, and her oper-
charts. That kind of heavy lifting in my view is what yields ation was delayed until the following morning. She is not much
the type of detailed clinical information on which we can of a complainer, but she has made it clear it would have been
actually base treatment decisions. It certainly seems un- her preference to have had surgery that night. Patients with
likely a study of this magnitude would miss a significant delayed surgery do no worse, but nor do they do better than
difference in outcomes. Finally, I like any manuscript which patients having an immediate operation, and it is the expecta-
confirms my own clinical impressions, and, in my experi- tion of the lay public that an appendectomy will be done as
ence, a modest delay in performing an appendectomy for soon as possible. How do we meet that expectation but still put
appendicitis does not impact patient outcome. the operation off until the next morning?
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