Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children
Serres et al. “Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children.”
Once a child has been diagnosed with appendicitis, do they need to be rushed to the OR? Can appendectomy be performed as an urgent (within 24 hours, rather than emergent) procedure without compromising patient outcomes and increasing complication rates, particularly if there are scheduling and staffing limitations?
Complicated appendicitis has been reported to occur in up to 30% of children who undergo appendectomy. Children with complicated appendicitis are known to have longer length of stay (LOS), increased hospital costs, and greater risk of repeat hospital visits in comparison to those with uncomplicated disease. What are the factors that cause some patients to have complicated vs. uncomplicated cases? Younger children, female sex, Latino and African-American ethnicity, and public health insurance have all been associated with increased risk for complicated appendicitis. The association between delayed surgical treatment and complicated appendicitis is still unclear.
Retrospective cohort study using the NSQIP-Pediatric database (23 US pediatric hospitals included)
<18 years old
2,429 patients (1,467 male and 962 female)
Excluded: those without appendicitis on the pathology report, >24 hours for time to appendectomy (TTA), OSH transfers, patients who underwent CT scan, hospitals with <40 patients during study period
Primary endpoint: complicated appendicitis found at surgery
Secondary endpoints: LOS, incisional SSI, percutaneous drainage procedures, reoperation, hospital revisits
TTA = time between ED registration and first operative incision
Complicated appendicitis = on pathology, 1. visible hole in appendix, 2. diffuse fibrinopurulent exudate throughout peritoneal cavity, 3. intra-abdominal abscess, or 4. fecalith outside appendix
The median TTA was 7.4 hours. The rate of complicated appendicitis was 23.6%, with a wide range of 5.2% and 51.1% across hospitals. In both a univariable mixed-effects model and multivariable analysis, TTA was not associated with increased risk of complicated appendicitis (univariable model: OR per 1-hour increase in TTA, 1.00; 95% CI, 0.97-1. multivariable analysis: OR, 0.99; 95% CI, 0.97-1.02). In 2/23 hospitals, the odds of complicated disease in the late appendectomy group relative to early group were significantly different. Longer TTA was associated with longer LOS (0.06 days for each additional hour of TTA). Longer TTA was not associated with increased risk of incisional SSIs (OR, 0.96; 95% CI, 0.88-1.04), percutaneous drainage procedures (OR, 1.02; 95% CI, 0.97-1.07), unplanned reoperation (OR, 1.00; 95% CI, 0.93-1.07), or hospital revisits (OR, 1.01; 95% CI, 0.99-1.04).
Take Home Points:
This study has some limitations in terms of generalizability, most notably, in its exclusion of patients who underwent CT scans. The authors argue that CT scans would have lengthened the evaluation period and biased surgeons in how they managed patients. While that makes sense, it leaves us wondering what types of patients were left out, as the decision to CT scan often differs between institutions. The study does not address time of onset of symptoms to hospital presentation or time of initiation of antibiotics, which are both likely factors in the development of complicated appendicitis. At the end of the day, the decision of when to take a patient to surgery will be made on a case-by-case basis (and likely not one made in the ED). This study suggests that a surgeon may not be unreasonable in waiting to take a patient to surgery (but within 24 hours), particularly if it means there will be increased availability of staff and other resources if they do so.