Delay Of Appendectomy Research Articles

Impact of Delay in Appendectomy on the Outcome of Appendicitis: A Post Hoc Analysis of an EAST Multicenter Study.

Background: Association between time-to-appendectomy and clinical outcomes is controversial with conflicting data regarding risk of perforation. The purpose of this study was to explore the associations between in-hospital delay in treatment of simple appendicitis with the incidence of complicated appendicitis discovered at appendectomy. Methods: The Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database was queried and patients with acute appendicitis diagnosed on imaging were included. Upgrade was defined as gangrenous or perforated finding at appendectomy. Time intervals from emergency department (ED) triage to appendectomy were recorded in six-hour groups. Upgrade percentage for each group was presented and rates of a composite end point (30-day incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED visit, hospital re-admission, and mortality) were compared with Bonferroni correction to determine statistical significance (p = 0.05/9 = 0.005). Results: Of 3,004 included subjects, 484 (16%) experienced upgrade at appendectomy. Upgrade rates (%, 95% confidence interval [CI]) were: group 0-6 hours, 17% (95% CI, 14-19); group 6-11 hours, 15% (95% CI, 13-17%); group 12-17 hours, 16% (95% CI, 13-19); group 18-23 hours, 17% (95% CI, 12-23); group 24-29 hours, 30% (95% CI, 20-43); and group 30+ hours, 24% (95% CI, 14-37) (p = 0.014, NS by Bonferroni). Of 484 subjects with upgrade, 200 (41%; 95% CI, 37-46) had a worse composite outcome compared with 518 (21%; CI, 19-22) of 2,520 subjects with no upgrade (p < 0.001). The upgrade group was older (49 ± 17 years vs 39 ± 16 years), had a higher Charlson comorbidity index (CCI; 1.6 ± 1.9 vs 0.7 ± 1.4) and was more likely to have positive smoking history (20% vs 14%), and prior surgery (30% vs 22%; p < 0.001). Conclusions: We propose that ≥24-hour delay from ED triage to appendectomy is not associated with increased rate of severity upgrade from simple to complicated appendicitis. When upgrade occurs, it is correlated with older age, higher CCI, smoking history, and prior surgery and is associated with worse clinical outcomes.

Short-term outcome after appendectomy is related to preoperative delay but not to the time of day of the procedure: A nationwide retrospective cohort study of 9224 patients.

Acute appendicitis is among the most common indications for emergency abdominal surgery. The risk of perforation might increase with a delay in treatment. Therefore, appendicitis is considered a surgical emergency, leading to appendectomies being frequently performed off-hours. However, numerous studies from other medical specialties have shown less favourable outcomes in patients admitted or treated off-hours than in those treated during regular working hours. The purpose of this study was to determine whether the time of day of the procedure and preoperative delay in appendectomy have significant impacts on morbidity and mortality rates. All appendectomies recorded in a prospective national quality measurement database (Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie (AQC)) between 2010 and 2017 were retrospectively analysed. The inclusion criteria were appendicitis (International Classification of Diseases diagnostic codes K35-K37), surgical treatment (appendectomy), and available information on the time of day the appendectomy was performed. We stratified patients into four groups according to the start of the operation-'MORNING' for surgeries started between 7:00 a.m. and 12:59 p.m., 'AFTERNOON' for surgeries started between 1:00 p.m. and 6:59 p.m., 'EVENING' for surgeries started between 7:00 p.m. and 11:59 p.m., and 'NIGHT' for surgeries started between midnight and 6:59 a.m. In a further analysis, we examined differences between patients who underwent surgery on the admission day and those who underwent surgery later. A total of 9224 patients with a mean age of 36±19 years (54% men) were included and further analysed. The occurrence of any complication was the primary outcome, whereas in-hospital mortality was the secondary outcome. Variables were entered into bivariate and multivariate analyses. Of the appendectomies, 38% were performed during the afternoon, 31% in the evening, 18% in the morning, and 13% at night-time. Patients who underwent surgery at night had slightly lower American Society of Anesthesiologists scores, were more often managed as emergency cases (98% of the cases), had fewer comorbidities, and were more often covered by statutory instead of private health insurance than the other patients. Junior attending and resident surgeons performed 88% of all night-time operations. The average duration of surgery was not significantly longer in the night-time group than in the day-time groups. The overall complication rate was 4.7%, ranging from 3.5% in the 'NIGHT' group to 5.0% in the 'AFTERNOON' group. However, the differences between the groups were not significant. The in-hospital mortality rate was 0.12% (n=11), ranging from 0.082% (n=1) in the 'NIGHT' group to 0.17% (n=5) in the 'EVENING' group. The timing of appendectomy was not associated with mortality. However, the rates of complications, in-hospital mortality, and conversion were all significantly higher in patients with a preoperative delay of >24h. The time of day of performing an appendectomy does not seem have any significant effect on complication and mortality rates. However, a longer length of preoperative stay significantly increases the risk of complications and mortality. Night-time operations should be preferred over next-day surgery considering the equal perioperative risks observed in this study.

The risk factors for infected and perforated appendicitis

It is believed that the appendix will be perforated if the surgery of an acute appendicitis is delayed. However, some of the recent studies, contested this hypothesis and shown that only a delay in the treatment cannot fully explain perforated appendicitis. This study aimed to examine the prevalence and risk factors for perforated appendicitis in patients with acute appendicitis. A cross-sectional study was conducted in Shahid Beheshti Medical center. Data from 526 patients diagnosed with acute appendicitis were extracted from file related to the patients who undergone appendectomy since 2011 till the end of 2015. Performing an appendectomy after more than 48 hours from the onset of symptoms was defined as a delayed appendectomy. Data related to the patients’ age, gender, type of appendicitis, and the delay in appendectomy were gathered using a checklist. Descriptive statistics (frequency, percentage) were used to describe the data. Chi-square and Fisher's exact tests were used to analyze the data. Among the 526 patients with a diagnosis of acute appendicitis, 24.3% were perforated while 75.7% were non-perforated appendicitis. Of the total patients, 72.2% were referred to the hospital and were operated in less than 48 hours while 27.8% were referred and operated with a delay more than 48 hours. The rate of septic appendicitis was 55.5% and 72.6% in patients without and with delayed appendectomy, respectively but the rate of perforated appendicitis was 28.9% and 12.3% in patients without and with delayed appendectomy, respectively (P value < 0.05). The majority of cases of perforated appendicitis were occurred males (73.4%) and in the age range of 15 to 34 years (33.8%). Physiopathology of perforated appendicitis is very complex and a delay in appendectomy cannot fully justify the physiopathology of perforated appendicitis. The fact that perforation cannot fully explained be a delay in appendectomy may prevent many cases of unnecessary surgeries in patients with acute appendicitis. Further studies are recommended to confirm the findings of the present study. Keywords: Acute appendicitis, perforated appendicitis, infected appendix.

Association of Delay in Appendectomy With Perforation in Children With Appendicitis.

The aim of this study was to assess whether increased time from emergency department (ED) triage to appendectomy is associated with a greater risk of children developing appendiceal perforation. We performed a multicenter retrospective cohort study of children younger than 18 years hospitalized with appendicitis. To avoid enrolling patients who had perforated prior to ED arrival, we included only children who had a computed tomography (CT) scan demonstrating nonperforated appendicitis. Time to appendectomy was measured as time from ED triage to incision. The main outcome was appendiceal perforation as documented in the surgical report. Variables associated with perforation in bivariate analysis (P < 0.05) were adjusted for using logistic regression. Overall, 857 patients had a CT scan that demonstrated nonperforated appendicitis. The median age was 12 years (interquartile range, 9-15 years), and 500 (58%) were male. The median time to appendectomy was 11 hours (interquartile range, 8-15 hours). In total, 111 patients (13%) had perforated appendicitis at operation. Children who developed perforation were more likely to require additional CT scans and return to the ED and had a significantly longer length of stay. After adjusting for potential confounders, every hour increase in the time from ED triage to incision was independently associated with a 2% increase in the odds of perforation (P = 0.03; adjusted odds ratio, 1.02; 95% confidence interval, 1.00-1.04). Delays in appendectomy were associated with an increase in the odds of perforation. These results suggest that prolonged delays to appendectomy might be harmful for children with appendicitis and should be minimized to prevent associated morbidity.

Pediatric Appendicitis Can Be Safely Managed as an Urgent, Rather than Emergent, Procedure

Although studies are inconclusive, many physicians feel that a delay in appendectomy may result in complications (perforation) and prolonged hospital

Does delay in appendectomy affect surgical site infection in children with appendicitis?

PurposeThe purpose of this study was to investigate the association between time from diagnosis to operation and surgical site infection (SSI) in children undergoing appendectomy. MethodsPediatric patients undergoing appendectomy in 2010–2012 were included. We collected data on patient demographics; length of symptoms; times of presentation, admission and surgery; antibiotic administration; operative findings; and occurrence of SSI. Results1388 patients were analyzed. SSI occurred in 5.1% of all patients, 1.4% of simple appendicitis (SA) patients, and 12.4% of complex appendicitis (CA) patients. SSI did not increase significantly as the length of time between ED triage and operation increased (all patients, p=0.51; SA patients, p=0.91; CA patients, p=0.44) or with increased time from admission to operation (all patients, p=0.997; SA patients, p=0.69; CA patients, p=0.96). However, greater length of symptoms was associated with an increased risk of SSI (p<0.05 for all, SA and CA patients). In univariable analysis, obesity, and increased admission WBC count were each associated with significantly increased SSI. In multivariable analysis, only CA was a significant risk factor for SSI (p<0.0001). ConclusionWe found no significant increase in the risk of SSI related to delay in appendectomy. A future multi-institutional study is planned to confirm these results.

Appendectomy Timing

To investigate the association between time from admission to appendectomy (TTA) and the incidence of perforation and infectious complications. Immediate appendectomy to prevent perforation has been challenged by recent studies supporting a semielective approach to acute appendicitis. Patients admitted with appendicitis from July 2003 to June 2011 were reviewed. Age, sex, admission white blood cell count, surgical approach (open vs laparoscopic), TTA, and pathology report were abstracted. Primary outcomes included perforation and surgical site infection (SSI). Logistic regression was performed both to identify independent predictors of perforation and to investigate the association between TTA and SSI. Over 8 years, 4529 patients were admitted with appendicitis and 4108 (91%) patients underwent appendectomy. Perforation occurred in 23% (n = 942) of these patients. Logistic regression identified 3 independent predictors of perforation: age 55 years or older [odds ratio (95% confidence interval) OR (95% CI), 1.66 (1.21-2.29); P = 0.002], white blood cell count more than 16,000 [OR (95% CI), 1.38 (1.15-1.64); P < 0.001], and female sex [OR (95% CI), 1.20 (1.02-1.41); P = 0.02]. Delay to appendectomy was not associated with higher perforation rate. However, after controlling for age, leukocytosis, sex, laparoscopic approach, and perforation, TTA of more than 6 hours was independently associated with an increase in SSI [OR (95% CI), 1.54 (1.01-2.34); P = 0.04]. Delay of more than 6 hours resulted in a significant increase in SSI from 1.9% to 3.3% among patients with nonperforated appendicitis [OR (95% CI), 2.16 (1.03-4.52); P = 0.03], raising the incidence of SSI in nonperforated appendicitis to levels similar to those with perforation (3.3% vs 3.9%, P = 0.47). In this series, appendectomy delay did not increase the risk of perforation but was associated with a significantly increased risk of SSI in patients with nonperforated appendicitis. Prompt surgical intervention is warranted to avoid additional morbidity in this population.

Delay in Appendectomy Increased SSI Risk

Delay in Appendectomy Increased SSI Risk

Delayed diagnosis in pediatric appendicitis.

Delay in appendectomy occurs from failure to contact a physician, or from a physician's failure to make a proper diagnosis. In our study delay was due to physician error in 32 of 422 children who had appendectomy. Symptoms consistent with appendicitis were documented on the initial visit in each case, but 22 patients had a history of previous similar pain or recent viral illness to confuse the diagnosis. Misdiagnosis was responsible for the delay in 14 cases (gastroenteritis in ten and urinary tract infection in four). Antibiotics given before proper diagnosis in 22 instances increased diagnostic difficulty in 20. Late referral is increasing, perhaps because of a perceived innocuous nature of appendicitis. Complicated appendicitis was found in 26 children (81%), compared with 38% of the total experience. Their hospital stay averaged nine days, as opposed to 6.6 days in the nondelayed group. Failure of resolution of symptoms after therapy begins mandates reassessment to avoid progression of this common surgical disease.