Delays in Appendectomy and Risk for Complicated Appendicitis
Although appendicitis is among the more common surgical conditions of childhood, complicated appendicitis requires considerably more resources and intervention. Delays in seeking care can contribute to the risk of developing complicated appendicitis, but it’s less clear whether delayed surgical treatment (once a patient has presented to medical attention) increases this risk.[1]
In a recent study, Serres and colleagues[1] evaluated the relationship between delay in surgery and the risk for complicated appendicitis. The data were obtained from the National Surgical Quality Improvement Program, and the analysis included 2013 and 2014 data submitted by 29 member hospitals. The data were from children seen only at the treatment hospital to eliminate delays in care experienced when patients presented first to outlying hospitals. Patients who had a CT were excluded because CT provides more detail about the status of the appendix and influences treatment beyond what exam and ultrasound might indicate. In addition, the investigators found that patients who had a CT generally had a longer evaluation period, potentially confounding the calculation of time to appendectomy.
“Time to appendectomy” was calculated as the time between emergency department registration and the first operative incision, looking only at children who had an appendectomy within the first 24 hours (95% of all study children). Those who had appendectomy after 24 hours were considered outliers. An appendectomy was defined as “early” if it occurred before the median time for that hospital, with the remaining cases being labeled as “late appendectomy.” Patients were classified as having complicated appendicitis if they had a perforation, fibrinopurulent exudate in the peritoneal cavity, an intra-abdominal abscess, or a fecalith in the peritoneal cavity.
The analysis included 2429 children. The median time to appendectomy was 7.4 hours among all children at all hospitals. Race was not associated with time to appendectomy, but boys were more likely to receive early appendectomy, as were commercially insured children.
Overall, 23.6% of the children developed complicated appendicitis. Younger children were overrepresented in the group with complicated appendicitis, as were girls, Hispanic patients, and children with public insurance. In multivariable analyses, however, the time to appendectomy was not associated with the odds of having complicated appendicitis; whereas age less than 8 years (adjusted odds ratio [aOR], 2.59), female sex (aOR, 1.56), and Hispanic ethnicity (aOR, 1.56) all remained positively associated with complicated appendicitis.
Among all children, the median length of hospital stay was 2 days. Although delayed time to appendectomy was associated with a longer length of stay, it was not associated with such secondary outcomes as increased risk for incisional infection, the need for drainage procedures, the risk of requiring an unplanned repeat procedure, or repeat presentation to a hospital.
The investigators concluded that the timing of appendectomy, within the first 24 hours, does not appear to be related to the risk for complicated appendicitis. They suggest that these data support managing acute appendicitis urgently rather than emergently.
Viewpoint
It’s important to remember the narrow definition of patients included in the study. Everyone who had a CT of the abdomen was excluded because the decision-making process is often so different with those patients who receive CT imaging. In addition, the concept of “delayed” appendectomy applied only to timing within the first 24 hours. The study doesn’t address delays beyond the first 24 hours.
That said, I can think of several reasons why treating the need for appendectomy “urgently” rather than as an emergency is beneficial, especially within children’s hospital environments. Of primary concern, it’s more likely that exclusively pediatric personnel would be available, including nurses, anesthesia providers, and even the surgeons. These data are no substitute for prospective studies to answer this question, but this may be the most comprehensive retrospective look we’ll get for some time.