Time to Appendectomy and Risk of Perforation in Acute Appendicitis

Abstract

IMPORTANCE In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy. OBJECTIVE To evaluate whether there is an association between time and perforation after patients present to the hospital. DESIGN, SETTING, AND PARTICIPANTS Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations. MAIN OUTCOMES AND MEASURES The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital and operating room (OR) start time. The relationship between in-hospital time and perforation was adjusted for potential confounding using multivariate logistic regression. Additional predictors of interest included sex, age, number of comorbid conditions, race and/or ethnicity, insurance status, and hospital characteristics such as community type and appendectomy volume. RESULTS A total of 9048 adults underwent appendectomy (15.8% perforated). Mean time from presentation to OR was the same (8.6 hours) for patients with perforated and nonperforated appendicitis. In multivariate analysis, increasing time to OR was not a predictor of perforation, either as a continuous variable (odds ratio = 1.0 [95% CI, 0.99-1.01]) or when considered as a categorical variable (patients ordered by elapsed time and divided into deciles). Factors associated with perforation were male sex, increasing age, 3 or more comorbid conditions, and lack of insurance. CONCLUSIONS AND RELEVANCE There was no association between perforation and in-hospital time prior to surgery among adults treated with appendectomy. These findings may reflect selection of those at higher risk of perforation for earlier intervention or the effect of antibiotics begun at diagnosis but they are also consistent with the hypothesis that perforation is most often a prehospital occurrence and/or not strictly a time-dependent phenomenon. These findings may also guide decisions regarding personnel and resource allocation when considering timing of nonelective appendectomy.

A prospective clinical study of the effects of the physical features of the appendix on perforation

“…Bickell et al [21] have reported that the risk for developing a perforated appendix is high when the period from the onset of symptoms to surgery exceeds 36 h. In a study of an elderly population, Omari et al [14] have reported that pre-hospital delay is higher in the perforated group (p<0.0001). In contrast, Drake et al [9] have found no relationship between the time to treatment and perforation. In our study,pre-hospital delay was higher in the perforated group (p=0.015).…”

“…There is a need for objective tests for a definite diagnosis. Despite the use of a variety of objective diagnostic methods, such as radiological imaging, laboratory tests, and scoring systems, in the diagnosis of complicated appendicitis and studies [8][9][10][11] of factors affecting the risk of perforation in AA, such as body mass index (BMI), gender, age, season, and time to appendectomy, no comprehensive study has examined the risk factors directly related to perforation. Therefore, we investigated the factors associated with perforation in AA, such as BMI, the physical parameters and location of the appendix and time to operation.…”

Clinical study and management of hollow viscus perforation of abdomen

“…For appendicular perforation emergency appendicectomy with peritoneal lavage is sufficient. 9 Nowadays iatrogenic perforations are common due to minimally invasive or endoscopic procedures. The incidence of perforation due to upper GI scopy was 1.2%.…”

Clinical Value of the Platelet-to-Lymphocyte Ratio for Diagnosing Complicated Acute Appendicitis

“…However, Drake el al. 29 showed that perforation was not associated with elapsed time from hospital presentation to operating room start among adult patients. This result is compatible with the view that disease progression in appendicitis has a more complex pathophysiology and complicated appendicitis may be a separate biological or host-response entity.…”

“…This result is compatible with the view that disease progression in appendicitis has a more complex pathophysiology and complicated appendicitis may be a separate biological or host-response entity. 29 Laboratory markers may contribute to the diagnostic process of AA however they can not to change the diagnosis of suspected cases on their own. When they used in a combination with physical examination, medical history and radiological findings they show greater promise.…”