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Effect of Delaying Surgery on Outcomes in Adults with Acute Appendicitis

Authors

Tori Socha

The most common emergent surgery performed worldwide is appendectomy; appendicitis accounts for approximately 1 million hospital stays each year. Recent advances in imaging and antibiosis have enabled improved preoperative assessment and treatment, allowing for nonsurgical management of abscesses and phlegmons, potentially limiting the need for immediate surgery to halt disease progression. Studies have shown that delaying surgery in pediatric patients while providing fluids and antibiotics is not associated with untoward patient outcomes; however, data on the effect of surgical delays on subsequent outcomes in adults are, according to researchers, limited by small sample size and single-institution studies. The researchers recently conducted a study to determine the effect of delays from surgical admission to induction of anesthesia on 30-day outcomes in adults with acute appendicitis. Study results were reported in Archives of Surgery [2010;145(9):886-891]. The current data were from a retrospective cohort study with principal exposure being time to operation. The researchers used regression models to determine probabilities of outcomes adjusted for patients and operative risk factors. Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from January 1, 2005, through December 31, 2008, were used to identify patients eligible for the study. Eligible patients were ≥16 years of age who had undergone an appendectomy based on primary Current Procedural Terminology codes and had a postoperative diagnosis of acute appendicitis based on International Classification of Diseases, Ninth Revision diagnosis codes. The patients were classified as having simple versus complicated appendicitis based on the presence or absence of generalized peritonitis or abscess. Duration from surgical admission to induction of anesthesia was studied as a continuous variable as well as when restructured into a categorical variable. The data were divided into 3 categories based in time from surgical admission to induction of anesthesia: ≤6 hours, >6 hours through 12 hours, and >12 hours. The primary outcome measures were 30-day overall morbidity and 30-day serious morbidity/mortality. Overall morbidity was defined as having documentation of a serious morbidity or at least 1 of the following ACS NSQIP postoperative complications: superficial surgical site infection, deep surgical site infection, pneumonia, unplanned intubation (without preoperative ventilator dependence), peripheral neurologic deficit, urinary tract infection, and deep vein thrombosis. Serious morbidity/mortality was defined as having documentation of mortality or at least 1 of the following: organ space surgical infection, wound dehiscence, neurologic event, cardiac arrest, myocardial infarction, bleeding requiring transfusion, pulmonary embolism, ventilator dependence of >48 hours, progressive or acute renal insufficiency, and sepsis or septic shock. There were 32,782 patients included in the analysis. Of those, 75.2% (n=24,647) underwent surgery within 6 hours of surgical admission, 15.1% (n=4934) underwent surgery >6 through 12 hours after admission, and 9.8% (n=3201) underwent surgery >12 hours after admission. The length of stay following the surgery was 2.2 days for the >12-hour group compared with 1.8 days for the other 2 groups; the difference was statistically significant (P<.001), but not clinically meaningful. There were no statistically significant differences among the 3 groups in adjusted overall morbidity (5.5%, 5.4%, and 6.1%, respectively; P=.33) or serious morbidity/mortality (3.0%, 3.6%, and 3.0%, respectively; P=.17). In regression models, the duration of time between surgical admission and induction of anesthesia was not predictive for overall morbidity or serious morbidity/mortality. The researchers cited limitations to the study, including the lack of data on symptoms, insurance status, date or time of presentation to the emergency department, and reasons for potential delay prior to surgery. Also, the data do not indicate timing or appropriateness of antibiotics or administration of intravenous fluids prior to the surgery. In conclusion, the researchers said that “delay of appendectomy for acute appendicitis in adults does not appear to adversely affect 30-day outcomes.”

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