Impact of an Outpatient Appendectomy Protocol on

Clinical Outcomes and Cost: A Case-Control Study

Luc Dubois, MD, Kelly N Vogt, MD, Ward Davies, MD, Christopher M Schlachta, MD, FACS

BACKGROUND: Although elective outpatient surgery is commonplace, surgeons remain hesitant to discharge
patients the same day after emergent surgery. We created a formal protocol to select patients for
early discharge after laparoscopic appendectomy for acute appendicitis, and we assessed its
safety and potential cost savings.
STUDY DESIGN: We matched patients who were discharged early from the recovery room with similar patients
from a control group on the basis of age ⫾ 3 years, presence or absence of a comorbidity,
laparoscopic procedure, and nonperforated appendicitis; we compared them to assess the im-
pact of early discharge on morbidity, return visits to the emergency room, and total cost
incurred by our institution.
RESULTS: During the first year of our protocol, 72 of 161 (45%) patients who presented with acute
appendicitis and underwent appendectomy were discharged early, with a median post-operative
length of stay of 4.7 hours. When compared with matched controls, patients discharged early
had similar complication rates (4.3% early group vs 7.1%, p ⫽ 0.72) and number of postop-
erative visits to the emergency room (11.4% vs 11.4%, p ⫽ 0.8), but had a reduced median
length of stay (4.7 vs 16.2 hours, p ⬍ 0.001) and an average reduction in cost of $323.46 per
patient.
CONCLUSIONS: Adoption of a protocol to select patients for early discharge after laparoscopic appendectomy
resulted in a 45% reduction in the need for in-hospital beds, with no negative impact on return
visits to the emergency room or number of complications. This translates to an approximate
savings of $323 per patient when compared with standard care. (J Am Coll Surg 2010;211:
731–737. © 2010 by the American College of Surgeons)

With the advent of minimally invasive techniques, many
abdominal procedures (laparoscopic cholecystectomy,1
gastric bypass,2 incisional hernia repair3) are performed as
outpatient surgery. Although this has become routine for
elective procedures, surgeons remain hesitant to discharge
patients on the same day after emergent surgery. Appen-
dectomy is the most common emergent procedure per-
formed by general surgeons, and there are a number of
studies describing early discharge after both open and lapa-
roscopic appendectomy.4-10 These studies are limited by
their variable definition of outpatient (often as patients
discharged within 24 hours), lack of a formal patient selec-
Disclosure Information: Nothing to disclose.
Presented at the Canadian Surgical Forum, Victoria, BC, September 2009.
Received April 29; Revised July 19; Accepted July 20.
From the Departments of Surgery (Dubois, Vogt, Davies, Schlachta) and
Biostatistics and Epidemiology (Dubois), Schulich School of Medicine and
Dentistry, The University of Western Ontario, London, Ontario, Canada.
Correspondence address: Dr Luc Dubois, Department of Surgery, Division of
General Surgery, Schulich School of Medicine and Dentistry, The University
of Western Ontario, London Health Sciences Centre, 339 Windermere Rd,
London, Ontario, Canada N6A 5A5 email: ldubois@uwo.ca
tion protocol, and lack of controls necessary to determine
whether early discharge is safe in regard to morbidity or
return visits to the emergency room (ER). In addition, no
study has formally assessed the potential cost savings asso-
ciated with early discharge from the recovery room after
appendectomy.
The objectives of this study were to describe our outpa-
tient laparoscopic appendectomy protocol, assess its safety
by comparing morbidity and emergency room revisit rates
with matched controls, and formally assess any cost savings
associated with adoption of this protocol. We hypothesize
that by using a predetermined protocol, patients can be
safely discharged from the recovery room after laparoscopic
appendectomy with no impact on morbidity or return vis-
its to the emergency room, and this would translate into
fewer hospital beds and lower costs.
METHODS
Patients
All patients who presented to University Hospital, London
Health Sciences Center, from mid-September 2006 to

© 2010 by the American College of Surgeons ISSN 1072-7515/10/$36.00

Published by Elsevier Inc. 731 doi:10.1016/j.jamcollsurg.2010.07.017
732 Dubois et al Impact of Outpatient Appendectomy J Am Coll Surg

Table 1. Inclusion and Exclusion Criteria for Outpatient Ap-
pendectomy Protocol
Preoperative Postoperative
Inclusion criteria Exclusion criteria
Laparoscopic appendectomy Complicated appendicitis
(perforation or
gangrenous)
Age ⱖ16 y or ⱕ65 y Conversion to open
procedure
Have adult available to monitor Unstable vital signs or
for first 24 h fever
Live within 30 minutes of a Inability to tolerate oral
hospital intake
Deemed reliable for follow-up Inability to void urine
Exclusion criteria Pain uncontrolled by oral
analgesia
Pregnancy
Insulin-dependent diabetes
Immunosuppressive diseases or
medications
mid-September 2007 were assessed for potential enroll-
ment into our outpatient appendectomy protocol (study
cohort). These patients were compared with a historical
cohort of patients who presented to University Hospital
the previous year with acute appendicitis. Patient records
from both cohorts were reviewed and data extracted on
baseline characteristics, operative details, complications,
and return visits to the emergency room within 30 days of
discharge from hospital. We defined a postoperative com-
plication as any complication within 30 days of operation,
as documented in the patient’s health record. Preoperative
length of stay (hours) was determined from the time the
patient presented to the emergency room until the time the
patient entered the operating room; postoperative length of
stay (hours) was defined as the time the patient left the
operating room until the time the patient was discharged
from hospital. Patients were seen in follow-up as part of
routine clinical care by the operating surgeon. Our institu-
tion’s ethics review board approved this study.
Protocol
All patients presenting to our institution with acute appen-
dicitis during the study were considered for entry into the
outpatient appendectomy protocol. Patients were assessed
both pre- and postoperatively by the surgical team. Patients
were enrolled if they met preoperative inclusion criteria;
they were excluded if they were pregnant, had insulin-
dependent diabetes, or any history of active immunosup-
pressive diseases or medications (Table 1). Patients who
were enrolled preoperatively were reassessed in the recovery
room after surgery, and early discharge was withheld if the
patient met any of the postoperative exclusion criteria (Ta-
ble 1). Our institution has both a recovery room and a “day
surgery” area as part of our recovery area. Patients would
typically spend 1 hour in the recovery room and then be
transferred to the “day surgery” area with a lower nurse-to-
patient ratio before discharge. We considered discharges
that occurred from either area to be from the recovery
room. Patients discharged from the recovery room received
a telephone call the next day from the nursing staff as a
safety measure. No additional institutional costs were re-
quired to execute this protocol beyond the minor staff costs
associated with the postoperative telephone call.
No effort was made to standardize the operative proce-
dure. The choice of equipment, appendiceal stump ligation
method, and use of perioperative antibiotics were at the
discretion of the operating surgeon. All patients who un-
derwent a laparoscopic appendectomy had a Foley catheter
inserted at the time of the procedure, which was removed
immediately after the procedure. There were no changes in
routine surgical practice between the historical and study
cohort time periods. In the historical cohort, patients who
underwent an appendectomy were admitted to a ward bed
from the recovery room and considered inpatients.
Matching
We compared both cohorts overall, including patients who
had and hadn’t been enrolled into the protocol as part of
the study cohort, to see if adoption of the protocol in the
study cohort had any impact on the overall complication
rate or number of return visits to the emergency room. We
then matched selected patients who were discharged early
to similar patients from the historical cohort on the follow-
ing potential confounders: age ⫾ 3 years, presence or ab-
sence of comorbidity, nonperforated appendix, and laparo-
scopic procedure. These matched patients were compared
using appropriate statistical methods for pair-matched,
case-control comparisons.
Cost analysis
Cost data were obtained from the London Health Sciences
Center (LHSC) Case Costing Initiative. This institution-
maintained database contains all costs incurred by LHSC
on a per-patient basis. By using this database we were able
to compare per-patient costs between the 2 cohorts in order
to assess a potential cost savings. Costs are expressed in
Canadian dollars and include all costs incurred by the in-
stitution relating to nursing care, diagnostic tests, surgical
procedures, and return visits to the emergency room. To
account for inflation between the historical and study co-
hort time periods we used an inflationary correction factor
derived from LHSC laparoscopic cholecystectomy data.
We used the ratio of mean laparoscopic cholecystectomy
Vol. 211, No. 6, December 2010 Dubois et al Impact of Outpatient Appendectomy 733

costs (1.034%) from the 2 time periods as a proxy for

inflation and adjusted the per-patient costs from the his-
torical cohort to make them comparable to costs from the
study cohort.

Statistical analysis
Nonmatched analysis of categorical variables was carried
out using either a Pearson chi-squared test or Fisher’s exact
test, where appropriate, and continuous variables were
compared using the Mann-Whitney U test. Matched anal-
ysis was carried out using McNemar’s test with Yates con-
tinuity correction for categorical variables and the Wil-
coxon signed-rank test for continuous variables. Cost data
were compared using a paired t-test. All statistical tests were
2-sided, with significance set at p ⫽ 0.05, and were carried
out using SPSS (version 16).

RESULTS
Protocol
During the first year of the protocol, 161 patients pre-
sented to our institution with acute appendicitis and un-
derwent an appendectomy. Of the 161 patients, 72 (45%)
were ultimately discharged from the recovery room, with a
median length of stay of 4.7 hours (range 3 to 16.4 hours).
Figure 1 illustrates the flow of patients through the proto-
col. The most common preoperative reason for exclusion
was open appendectomy (n ⫽ 23); the most common rea-
son for admission from the recovery room was complicated
appendicitis (n ⫽ 23, perforation or gangrenous). The
characteristics of patients discharged from the recovery
room are summarized in Table 2. These patients were
younger, had fewer comorbidities, lower body mass indi-
ces, and fewer complications than those who were admitted Figure 1. Flow of patients during first year of outpatient appendec-
tomy protocol.
after surgery.
⫽ 0.95). In terms of outcomes, no difference existed with
Nonmatched comparison regard to number of complications, postoperative visits to
Patients in the study cohort, consisting of all patients who the emergency room, length of follow-up, and percentage
presented to our institution with appendicitis during the of patients not seen in follow-up. The only significant dif-
first year of the protocol, were comparable with respect to ference was in postoperative length of stay, with patients in
baseline characteristics to the historical cohort, which con- the outpatient cohort having a much shorter length of stay
sisted of all patients from the previous year with appendi- in the hospital (median, 13.1 vs 29.7 hours, p ⬍ 0.001).
citis (Table 3). The only difference between cohorts was the When comparing specific complications, the only differ-
higher proportion of laparoscopic appendectomies in the ence was in the rate of wound infections, which was higher
study cohort (85.7% vs 69.2%, p ⫽ 0.018). There was no among the historical cohort (8.3% vs 3.1%, p ⫽ 0.07),
significant difference in method of diagnosis of appendici- likely related to the higher proportion of open procedures
tis between the cohorts (p ⫽ 0.16), although CT scan was in this group (Table 4). There were no mortalities in either
the most common method in the historical cohort (44%) group.
and ultrasound was the most common method in the study
cohort (39%). Despite this small difference in radiographic Matched comparison
diagnosis the rates of negative appendectomy were similar Pair-matching the patients discharged from the recovery
between the historical and study cohorts (2.6% vs 1.9%, p room to similar patients in the historical cohort on age ⫾ 3
734 Dubois et al Impact of Outpatient Appendectomy J Am Coll Surg

Table 2. Characteristics and Outcomes of Patients Dis- DISCUSSION

charge from the Recovery Room Compared to Those Who
Adoption of an outpatient appendectomy protocol re-
Were Admitted During the Study Cohort.
Discharged from
sulted in 72 of 161 (45%) patients being discharged from
Characteristic recovery room Not discharged p value the recovery room after laparoscopic appendectomy with a
n 72 89 median postoperative length of stay of 4.7 hours. When
Age, y, median 25 (16–60) 35 (15–78) 0.002 compared with matched controls, there was no increase in
(range) complications or in the number of return visits to the emer-
Males, % 38 (52.8) 54 (60.7) 0.310 gency room. After adjusting for inflation, adoption of this
Body mass index, 23.3 (17.2–32.4) 25.4 (17.2–43.4) 0.011 protocol resulted in an average cost savings of roughly $323
kg/m2, median per patient. In addition to the cost savings associated with
(range)
our protocol, patients who underwent an appendectomy
Presence of 15 (20.8) 37 (41.6) 0.005
comorbidity, % and were discharged early did not require any in-hospital
Complication, % 3 (4.2) 14 (15.7) 0.018 beds, unlike patients in the historical cohort who would
Postoperative visit to 8 (11.1) 14 (15.7) 0.390 usually be admitted to a hospital bed after a short stay in the
ER, % recovery room. This approach improves patient access to
Postoperative length 4.7 (3.0–16.4) 40 (8.3–337.8) ⬍0.001 in-hospital beds by limiting the need for this resource when
of stay, h, median, caring for patients with appendicitis. Our study is the first
(range) to report on a specific protocol to select patients for dis-
Patients not seen in 8 (11.1) 9 (10.1) 0.840 charge from the recovery room after laparoscopic appen-
follow-up, %
dectomy for acute appendicitis. We are also the first to
assess the potential negative effects of early discharge on
years, laparoscopic procedure, nonperforated appendix, morbidity and return visits to the emergency room by com-
and presence or absence of comorbidity was successful for paring these patients with matched controls from a histor-
70 of the 72 patients discharged from the recovery room. ical cohort.
The 2 patients excluded from the matching did not have Previous studies of early discharge after laparoscopic
any of the outcomes of interest. The matched groups were appendectomy often defined early or “outpatient” as
similar in terms of baseline characteristics, with no signifi- discharge within 24 hours; Brosseuk and Bathe4 re-
cant differences in body mass index or gender, in addition
ported on the outcomes of 39 patients who underwent
to the matched variables. There was no significant differ-
“day-care” appendectomy, which they defined as dis-
ence in complications or postoperative visits to the emer-
charge within 24 hours after operation. Although they
gency room (Table 5). The 3 complications among the
did not report on the specific length of stay, they did
early discharge group included 1 wound infection, 1 case of
report that many patients were discharged within 8
acute renal failure from the IV contrast used in a preoper-
hours. They did not report on the use of a formal pro-
ative CT scan (the patient recovered fully with supportive
tocol but do state that patients were discharged home if
care), and 1 postoperative intra-abdominal hematoma re-
they had satisfactory home arrangements, were consid-
quiring laparoscopy and evacuation. The 5 complications
in the matched control group included 2 wound infections, ered reliable for follow-up, and had no prohibitive co-
1 case of group A streptococcus cellulitis and toxic shock morbidities (which they did not define specifically).
syndrome, 1 case of deep vein thrombosis, and 1 postop- They did not compare this group with a control group,
erative ileus. Postoperative length of stay was significantly but did report that only 2 patients developed complica-
shorter among patients discharged from the recovery room tions and that 2 patients returned to the emergency
compared with matched controls (median 4.7 vs 16.2 room after early discharge. Interestingly, 28% of those
hours, p ⬍ 0.001). discharged early by these authors had either a gangre-
nous or perforated appendix. We decided to exclude
Cost analysis such patients from our protocol because perforation or
After adjusting for inflation to 2007 costs in Canadian gangrene of the appendix carries a much higher morbid-
dollars, the average cost per patient for patients discharged ity rate, although this did not seem to be a problem for
from the recovery room was $4,844.89 ⫾ $685.91; the the patients in this study. Jain and colleagues5 reported
average cost per patient in the matched control group was on the outcomes of 35 of 75 patients discharged within
$5,168.35 ⫾ $1,216.25. This translates into a mean dif- 12 hours after undergoing laparoscopic appendectomy
ference of –$323.46 (95% CI –$670.04, $23.11, p ⫽ for acute appendicitis. They did not report on their
0.067) per patient. specific selection protocol, but did state that only pa-
Vol. 211, No. 6, December 2010 Dubois et al Impact of Outpatient Appendectomy 735

Table 3. Comparison of Baseline Characteristics and Outcomes Between Study (Outpatient) and Historical Cohorts
Characteristic Study cohort Historical cohort p value
n 161 156
Age, y,median (IQR) 29 (22–45) 34 (22–54) 0.110
Males, % 92 (57.1) 74 (47.4) 0.080
Body mass index, median (IQR) 24.7 (22.1–27.7) 24.5 (22.2–28.5) 0.530
Presence of comorbidity, n (%) 52 (32.3) 55 (35.3) 0.580
‡
Clinical diagnosis, n (%) 27 (16.8) 32 (20.5)
CT scan, n (%) 58 (39.1) 69 (44.2)
Ultrasound, n (%) 63 (39.1) 43 (27.6)
Perforated appendix:, n (%) 35 (21.7) 36 (23.1) 0.780
Laparoscopic, n (%) 138 (85.7) 108 (69.2) ⬍0.001
WBC (⫻ 103/mm3), median (IQR) 13.4 (10.8–17.0) 13.9 (11.2–16.4) 0.720
Complication, n (%)* 17 (10.6) 21 (13.5) 0.490
Postoperative visit to ER†, n (%) 22 (13.7) 24 (15.4) 0.660
Postoperative length of stay, h, median (IQR) 13.1 (4.8–42.3) 29.7 (13.9–47.5) ⬍0.001
Length of follow-up, d, median (IQR) 25 (15–30) 23 (11–33) 0.940
Patients not seen in follow-up, n (%) 20 (12.8) 17 (10.6) 0.530
*Complications ⫽ within 30 days of surgery.
†
Visit to ER ⫽ within 30 days of discharge.
‡
p ⫽ 0.16 (method of diagnosis).
ER, emergency room; IQR, interquartile range.

tients with an inflamed or normal appendix were dis- discharged within 24 hours. Of these, only 12 visited
charged early, and those with perforated appendicitis their general practitioners within the first 2 postopera-
were treated as inpatients. Although they did not com- tive weeks, and only 2 patients required readmission.
pare these patients with a control group, they did report Most of these visits were related to wound issues or
that none of the patients who were discharged early abdominal pain. Given these results and our successful
developed a complication or returned to the emergency experience with laparoscopic cases, we are considering
room after discharge. In the most recent study on the
topic, Gilliam and associates6 reported on the outcomes Table 4. Comparison of Complications Between Study (Out-
of 104 consecutive patients who underwent a laparo- patient) and Historical Cohorts
scopic appendectomy, 66 of whom were discharged Study Historical
within 24 hours with an overall median length of stay of Complication cohort cohort
22 hours. They did not report on a specific protocol but n 161 156
did state that patients with minimal comorbidities, a Wound infection,n (%) 5 (3.1) 13 (8.3)*
responsible adult at home, and patients who lived within Intra-abdominal abscess, n (%) 3 (1.9) 1 (0.6)
a 1-hour drive from the hospital were offered early dis- Ileus, n (%) 2 (1.2) 2 (1.3)
charge. They also reported that no patient required re- Wound hematoma, n (%) 1 (0.6) 1 (0.6)
admission, and 3 patients developed complications: 1 Deep vein thrombosis or pulmonary 2 (1.2) 1 (0.6)
wound infection and 2 pelvic abscesses. Similar to these embolism, n (%)
studies, we limited our protocol to laparoscopic appen- Atrial fibrillation, n (%) 1 (0.6) 0
dectomies. Our goal was not to compare open with lapa- Iatrogenic small bowel injury†, n (%) 1 (0.6) 0
roscopic appendectomy; rather we chose to limit our Urinary tract infection, n (%) 0 1 (0.6)
protocol to patients who had undergone a laparoscopic Cellulitis and GAS toxic shock 0 1 (0.6)
syndrome, n (%)
procedure because this approach has been shown to be
Acute renal failure (IV contrast 1 (0.6) 0
associated with less postoperative pain, quicker return to nephropathy), n (%)
activities, and a shorter postoperative hospital stay when Bleeding duodenal ulcer, n (%) 0 1 (0.6)
compared with open appendectomy.11 There are, how- Intra-abdominal hematoma, n (%) 1 (0.6) 0
ever, reports of patients being discharged early after
*p ⫽ 0.07.
open appendectomy. Ramesh and Galland9 reported on †
requiring a laparotomy and small bowel resection on postoperative day 5.
a series of 147 patients with an open appendectomy GAS, group A streptococcus.
736 Dubois et al Impact of Outpatient Appendectomy
Table 5. Comparison of Patients Discharged from Recovery Room with Similar Patients from the Historical Cohort Pair-
Matched on Age ⫾ 3 Years, Laparoscopic Procedure, Nonperforated Appendix, and Presence or Absence of Comorbidity
Cases (patients
Characteristic discharged early)
n 70
Age, y, median (range)* 24.5 (16–60)
Males, n (%) 37 (52.9)
Body mass index, kg/m2, median (range) 23.4 (17.2–34.1)
Presence of comorbidity, n (%)* 13 (18.6)
Laparoscopic, n (%)* 70 (100)
Perforated appendix, n (%)* 0 (0)
Postoperative visit to ER, n (%) 8 (11.1)
Complications, n (%) 3 (4.3)
Postoperative length of stay, h, median (range) 4.7 (4.2–5.9)
*matched variable.
extending our protocol to include patients with open
appendectomy for early discharge. Our results, in com-
bination with those from the studies discussed here,
show that patients can be discharged early after appen-
dectomy with no effect on morbidity or return visits to
the emergency room. We were initially concerned that
many patients who were discharged early would return
to the emergency room. Although our revisit rate may be
considered high compared with those from other pub-
lished reports, it did not differ from that in our control
group. Only 30% of patients who came back to the
emergency room after early discharge were admitted,
and this did not differ between the study and the histor-
ical cohorts. Although we did not assess patient satisfac-
tion directly, only 1 of 73 patients refused to be dis-
charged from the recovery room and was admitted.
Our study is limited by the use of a historical cohort as
opposed to a concurrent control group; although using the
immediate previous year limits any confounding time ef-
fects, and the management of appendicitis did not change
significantly between the 2 years, except for the larger pro-
portion of laparoscopic cases during the study cohort,
which we controlled for by matching. This larger propor-
tion of laparoscopic cases may have been due to the sur-
geons’ knowledge of the protocol and desire to discharge
patients from the recovery room. We are also limited by our
retrospective data collection, which may have underesti-
mated the number of return visits to the emergency room
because we did not telephone patients to determine if they
had been seen in other institutions, or by their primary care
physician after their surgery. Although this is a limitation,
there is no reason to believe that this underestimation
would have affected either cohort differently, so it would be
unlikely to have altered our conclusions. Although we did
not conduct a randomized controlled trial, we did adjust
for confounding by using a matched analysis. A random-
J Am Coll Surg
Controls (matched patients from
historical cohort) p value
70
24.5 (17–63)
34 (48.6) 0.610
24.6 (17.2–39.1) 0.110
13 (18.6)
70 (100)
0 (0)
8 (11.4) 0.800
5 (7.1) 0.720
16.2(10.6–30.8) ⬍0.001
ized design would have provided us with more protection
from bias but it would have been an unblinded trial because
neither patients nor surgeons could have been blinded to
the treatment arm of the trial, which could have limited the
trial’s validity.
By using a standardized a priori protocol we were able to
select and safely discharge 45% of all patients who pre-
sented with appendicitis during the first year of our proto-
col from the recovery room, with a median postoperative
length of stay of 4.7 hours. When compared with matched
controls, there was no increase in complications or return
visits to the emergency room. Although no randomized
study exists to confirm the safety of this approach, we be-
lieve that properly selected patients who undergo laparo-
scopic appendectomy for uncomplicated acute appendici-
tis can be safely discharged from the recovery room.
Furthermore, this study suggests that an uncomplicated
laparoscopic appendectomy for acute appendicitis should
become a routine outpatient procedure, much like a lapa-
roscopic cholecystectomy.
Author Contributions
Study conception and design: Dubois, Schlachta, Vogt,
Davies
Acquisition of data: Dubois, Schlachta
Analysis and interpretation of data: Dubois, Schlachta, Vogt,
Drafting of manuscript: Dubois, Schlachta
Critical revision: Dubois, Schlachta, Vogt, Davies
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