The time a patient spends in the hospital prior to having an appendectomy has no impact on the incidence of perforated appendicitis, according to a large retrospective study from the state of Washington.

 

Dr. F. Thurston Drake, a chief surgical resident at the University of Washington, was the lead author of the paper. He said, "Our data certainly suggest that we should think about perforation as a more complex outcome than just time with disease, and that we may have to face the fact that perforation is not that modifiable of an outcome using the sort of tools we have once patients reach the hospital.”

 

Dr. Beat Schnuriger, a staff surgeon at Bern University Hospital in Switzerland, was the lead author of a 2014 paper about intentionally postponing appendectomy. He told Reuters Health that the association of outcomes and in-hospital delays to appendectomy has been studied by several investigators, none of whom found an impact on appendiceal perforation rates."This finding has been confirmed by the current study," Dr. Schnuriger said.

 

As reported online July 2 in JAMA Surgery, researchers from several different institutions analyzed patient records from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP) for the years 2010 and 2011. The information in SCOAP is collected by trained chart abstractors, not billing records as in the case with other administrative databases.

 

For the two years studied, 9,048 patients had appendectomies for the presumptive diagnosis of appendicitis. The 4% who had negative appendectomies and those with incomplete data were excluded.Pathology reports showed perforated appendicitis in 15.8% of patients.

 

Of the 7,505 patients included in the study, the mean interval from admission to the emergency room until the first incision in the operating room was 8.6 hours for both perforated and non-perforated patients.

"I thought there would be more of a difference in how long patients take to get to the operating room," said Dr. Drake. "But we sliced the data every which way-by means, medians, as a continuous variable, in deciles, in hours, before imaging, after imaging, adjusted, and unadjusted-and we could not find a difference.”

 

In the perforated group, 55.3% were male, while 52.1% were male in the non-perforated cohort, and patients with perforated appendicitis were older-48.8 vs. 38.2 years (p<0.001 for both).

 

The perforated group had significantly fewer patients with private insurance, 54.2% compared to 63.6% and more Medicare patients, 17.0% vs. 6.4% (p<0.001 for both).Although African-American patients had the longest average wait times, they had the second lowest perforation rate.

 

Important outcomes such as infection rates and costs for each group were not included in the study due to the absence of such information in the SCOAP database.

 

"In contrast to appendiceal perforation rates, there is evidence from other studies that surgical site infections might be more frequent with increasing in-hospital delay to appendectomy," said Dr. Schnuriger, who was not part of the Washington group.

 

The fully adjusted regression model showed that factors significantly associated with perforation were male sex with an odds ratio (OR) of 1.24; 95% CI (1.08-1.43), increasing age-OR 1.04; (95% CI 1.03-1.04), lack of insurance or unknown insurance status-OR 1.43; (95% CI 1.24-1.66), and three or more comorbidities OR 2.18; (95% CI 1.36-3.49).

 

Dr. Drake said he takes two things from these data. One is that perforation is probably a more complicated event than simply time with disease, and the likely multifactorial causes or risk factors for perforation are worth further study. The other is that "waiting a few hours, especially with antibiotics initiated, does not seem likely to change outcomes related to perforation, particularly now that we know from some of the European studies that antibiotic therapy alone is safe, albeit with a legitimate risk of recurrence.”

 

Dr. Schnuriger added, "Lack of health care insurance has been identified as an independent risk factor for appendiceal perforation, which is a severe abdominal disorder associated with longer OR time, a significant postoperative infectious complication rate, and increased hospital length of stay. From the ethical point of view this is a very concerning finding."

Attempts to assess the risk of perforation according to the time symptoms began have been hampered by the difficulty in obtaining accurate data from patient histories. Dr. Drake's group is working on a survey study regarding time of symptom onset, socioeconomic status and other aspects of decision-making by patients with appendicitis including not only those who had surgery, but also patients who had non-operative management and those treated with percutaneous drains.

"These data are really exciting and just what all of the research to-date has only been hinting at with important, but necessarily flawed, projects using retrospective cohorts or administrative data sets," said Dr. Drake.

 

Dr. Schnuriger agreed that the entire history of abdominal pain needs to be evaluated further to increase the understanding of the disease, but is not sure whether this would help someday to get the right patient at the right time to the OR.