Appendectomy – Is it Urgent or an Emergency?
A recent study addressed the correlation between the time to appendectomy (TTA) and the risk of complication in a pediatric population.
About 70 000 children are diagnosed annually with appendicitis and require an appendectomy, surgical removal of the appendix, as treatment.
The main concern associated with appendectomy is in cases of complicated appendicitis, which accounts for 30% of all cases treated with surgical intervention. Complicated appendicitis is associated with longer hospital stays and additional medical follow up compared to uncomplicated cases. Age, sex and insurance status have been identified as risk factors for complicated appendicitis. Some studies raised a possible correlation between the delay of treatment and the risk of complicated appendicitis, however, the findings were inconclusive.
A recent study in JAMA Pediatrics reported on the risk of postoperative complications and complicated appendicitis in 2429 children treated either as an emergency or within 24 hours of presentation. The study assessed the correlation between the delay in appendectomy and the risk of complicated appendicitis. During 2013-2014, patients under 18 with suspected appendicitis who were undergoing appendectomy surgery in one of 23 member hospitals were included in the study. Member hospitals exchanged clinical and laboratory data as a part of the American College of Surgeons Pediatric National Surgical Quality Improvement Program (NSQIP-Pediatric)with the goal of collecting disease-related outcome data in standardized and consistent medical records. The data included pathology findings, time points of care (administration to the hospital and appendectomy) and hospital identifiers. The study was limited to the window of treatment from hospital admission to appendectomy, up to 24h. Patients were divided into early and late appendectomy groups based on whether their TTA was shorter or longer than corresponding hospital’s median TTA for all patients treated during the study period. Complicated appendicitis, the primary endpoint of the study, was identified based on standardized criteria developed by the NSQIP-Pediatrics’ Data Definitions Committee. Out of 2429 participants with a median age of 10 years, 60% were males. The median TTA among all patients was 7.4 hours, ranging from 4.9-12.9. Out of 2429 patients who underwent an appendectomy, 574 patients (23.6%) were diagnosed with complicated appendicitis. Researchers found that an increased risk of complicated appendicitis was associated with age younger than 8 years, female sex, Hispanic ethnicity, and public insurance. There was no association between TTA and the risk of complicated appendicitis.
Study results suggest that it is unlikely that the timing of appendectomy within 24hours from the time to hospital admission effects the risk of complicated appendicitis. As such, it should be considered as an urgent but not an emergency operation.
A limitation of the study is that no data on the timing of antibiotics administration was included in the analysis. Previous studies suggest an important contribution of antibiotics in the initial treatment of pediatric appendicitis. Different hospitals might follow slightly different protocols regarding the initial antibiotics treatment, possibly affecting the results of the study.
Despite these limitations, the researchers conclude that the appendectomy procedure can be performed urgently but not necessarily as an emergency treatment, and hospital resources such as availability of staff during the night and etc should be taken into the account, without concern of risk of complications, while surgery performed within reasonable time frames.
Written by Bella Groisman, PhD
Reference:
Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children, JAMA pediatrics, june 2017, Stephanie K. Serres, MD, PhD et al
