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      Ideal Timing of Surgery for Acute Uncomplicated Appendicitis

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          Abstract

          Background:

          Early surgery for appendicitis is thought to avoid complications associated with appendiceal rupture.

          Aims:

          This study was to evaluate the effect of timing of surgery on complications, length of stay (LOS) and cost in patients undergoing appendectomy.

          Materials and Methods:

          Retrospective review of 396 patients with appendectomies from January 1, 2005 to December 31, 2007 was performed. Demographic data, time of presentation, physical findings, diagnostic data, operating room times, LOS, cost and complications were collected. Patients were divided into 4 groups based on time from presentation to appendectomy.

          Results:

          Pathology confirmed appendicitis in 354 (89%) patients. Most patients (90%) had surgery within 18 h of presentation. Timing of surgery did not affect the incidence of purulent peritonitis ( P = 0.883), abscess ( P = 0.841) or perforation ( P = 0.464). LOS was significantly shorter for patients with emergency department registration to operating room times less than 18 h ( P < 0.0001). Costs were significantly higher for patients with times to operating room greater than 18 h ( P < 0.001).

          Conclusion:

          Timing of surgery did not affect the incidence of complications or perforated appendicitis. However, delay in surgical consultation and surgery are associated with increased LOS and increased hospital costs. The optimal timing of appendectomy for uncomplicated acute appendicitis appears to be within 18 h of emergency department presentation.

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          Most cited references22

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          The natural history of appendicitis in adults. A prospective study.

          The authors relate prehospital delay and in-hospital delay to the incidence of perforation of appendicitis. Quality assurance studies use perforation rate as an index of quality of care. This is based on the assumption commonly presented in retrospective reports that in-hospital delay to surgery influences the incidence of perforation. Only one limited study prospectively found that prehospital delay increased the perforation rate. During a 6-month period, 95 consecutive adults undergoing appendectomies at Foothills Hospital in Calgary, Alberta, were questioned as to onset and type of first symptom (i.e., epigastric discomfort, anorexia nervosa, vomiting, and abdominal pain). Time of emergency room (ER) arrival, surgery consultation, and operating room start were taken from the chart. Surgical and pathology reports were used to identify status of appendix (normal, inflamed, suppurative, gangrenous, perforated) and presence of abscess cavity. The status of appendix was related to prehospital and in-hospital delay to establish significance. There were 13 (14%) normal, 67 (70%) inflamed, and 15 (16%) perforated appendices. Patients with perforated appendices waited 2.5 times longer before reporting to the ER, compared with patients with inflamed appendices (57 hours vs. 22 hours, p < 0.007). Once in the hospital, patients with perforated appendices were identified and treated faster than those with inflamed appendices (7 vs. 9 hours, p < 0.039). Analysis by ER physician was 3 hours whether the appendix was normal, inflamed, or perforated. Analysis by the surgeon was significantly shorter in patients with perforated appendices than patients with inflamed appendices (4 vs. 6 hours, p < 0.039). This prospective study identifies that delay in presentation accounts for the majority of perforated appendices. Clinical evaluation is effective for identifying patients with more advanced disease. Indiscriminate appendectomy as an attempt to decrease perforation is not supported by these data. Hospital perforation rates likely reflect patient factors, illness attitude, and access to medical care.
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            Is it safe to delay appendectomy in adults with acute appendicitis?

            To examine whether delayed surgical intervention in adult patients with acute appendicitis is safe by correlating the interval from onset of symptoms to operation (total interval) with the degree of pathology and incidence of postoperative complications. Prompt appendectomy has long been the standard of care for acute appendicitis because of the risk of progression to advanced pathology. This time-honored practice has been recently challenged by studies in pediatric patients, which suggested that acute appendicitis can be managed in an elective manner once antibiotic therapy is initiated. No such data are available in adult patients with acute appendicitis. A retrospective review of 1081 patients who underwent an appendectomy for acute appendicitis between 1998 and 2004 was conducted. The following parameters were monitored and correlated: demographics, time from onset of symptoms to arrival at the emergency room (patient interval) and from arrival to the emergency room to the operating room (hospital interval), physical, computed tomography (CT scan) and pathologic findings, complications, length of stay, and length of antibiotic treatment. Pathologic state was graded 1 (G1) for acute appendicitis, 2 (G2) for gangrenous acute appendicitis, 3 (G3) for perforation or phlegmon, and 4 (G4) for a periappendicular abscess. The risk of advanced pathology, defined as a higher pathology grade, increased with the total interval. When this interval was 71 hours group compared with total interval<12 hours (95% confidence interval = 4.7-37.1). Although both prolonged patient and hospital intervals were associated with advanced pathology, prehospital delays were more profoundly related to worsening pathology compared with in-hospital delays (P < 0.001). Advanced pathology was associated with tenderness to palpation beyond the right lower quadrant (P < 0.001), guarding (P < 0.001), rebound (P < 0.001), and CT scan findings of peritoneal fluid (P = 0.01), fecalith (P = 0.01), dilation of the appendix (P < 0.001), and perforation (P < 0.001). Increased length of hospital stay (P < 0.001) and antibiotic treatment (P < 0.001) as well as postoperative complications (P < 0.001) also correlated with progressive pathology. In adult patients with acute appendicitis, the risk of developing advanced pathology and postoperative complications increases with time; therefore, delayed appendectomy is unsafe. As delays in seeking medical help are difficult to control, prompt appendectomy is mandatory. Because these conclusions are derived from retrospective data, a prospective study is required to confirm their validity.
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              Delayed versus immediate surgery in acute appendicitis: do we need to operate during the night?

              Over the last 4 years, the authors changed their management of acute nonperforated appendicitis from emergent surgery within the first 2 to 6 hours of admission to initiation of antibiotic therapy with operation within 24 hours of admission in those seen in the late evening or early morning. They examined, therefore, whether a delay in operation for acute appendicitis would affect outcome measures of patient morbidity and resource use. The medical records of 126 patients with acute appendicitis occurring between 1998 and 2001 were retrospectively reviewed. Incidence of perforation at surgery, length of stay (LOS), hospital charges, operating time, and complications as a function of duration between emergency room (ER) triage and operation (ER-OR) or admission and operation (Admit-OR) were analyzed by Student's t test, and regression analysis with P less than.05 considered significant. Thirty-eight children (26%) were operated on within 6 hours of ER triage, whereas the remaining 88 children (74%) were operated on between 6 and 24 hours from ER triage. No significant difference was noted in perforation rate, LOS, costs, or operative time, nor were substantial changes in complications noted between those with an ER-OR < or =6 hours and greater than 6 hours. Likewise, no significant differences in these outcome measures were noted for Admit-OR greater than 6 when compared with < or =6 hours. Only costs with ER-OR greater than 12 hours and LOS with Admit-OR greater than 6 hours were significantly (without Bonferroni correction) different than < or = 6 hours. Multivariable linear regression analysis identified only LOS as a significant predictor of time to OR. In children with acute appendicitis, delaying surgery until the daytime hours did not significantly affect operating time, perforation rate, or complications. Delayed management allows greater efficiency and effective use of physician and hospital resources, including decreased resident involvement in operations during the night.
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                Author and article information

                Journal
                N Am J Med Sci
                N Am J Med Sci
                NAJMS
                North American Journal of Medical Sciences
                Medknow Publications & Media Pvt Ltd (India )
                2250-1541
                1947-2714
                January 2013
                : 5
                : 1
                : 22-27
                Affiliations
                [1] Department of Plastic and Reconstructive Surgery, Tulane University Hospital and Clinics, 1430 Tulane Avenue, New Orleans, Louisiana, USA
                [1 ] Department of Surgery, University of Maryland School of Medicine, Program in Trauma, 22 South Greene Street, Baltimore, Maryland, USA
                [2 ] Department of Applied and Clinical Research, Berkshire Medical Center, 725 North Street, Pittsfield, USA
                [3 ] Biostatistical Consulting Center at University of Massachusetts, Amherst, 418 Arnold House, 715 North Pleasant Street, University of Massachusetts, Amherst, USA
                [4 ] Department of Surgery, Berkshire Medical Center, 725 North Street, Pittsfield, Massachusetts, USA
                Author notes
                Address for correspondence: Dr. Jacqueline J Wu, Department of Surgery, Berkshire Medical Center, 725 North Street, Pittsfield, MA, USA. E-mail: jwu@ 123456bhs1.org
                Article
                NAJMS-5-22
                10.4103/1947-2714.106186
                3560134
                23378951
                8eb61020-01bf-44c7-8bb8-42270aa2147c
                Copyright: © North American Journal of Medical Sciences

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Original Article

                Medicine
                appendectomy,delayed surgery,hospital costs,length of stay
                Medicine
                appendectomy, delayed surgery, hospital costs, length of stay

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