Perspective: Delays in appendectomy and risk for complicated appendicitis

By Charles A. Pilcher MD FACEP
January, 2018

Cases of missed appendicitis leading to complications such as perforation and intra-peritoneal abscess continue to be the subject of many medical malpractice lawsuits. The standard of care for the treatment of appendicitis is clearly evolving. Since its advent, laparoscopy has become the most common approach. Currently, there is debate about the role of antibiotics, suggesting that they may be a non-surgical option for carefully selected cases. There is also an evolving trend to delaying surgery, primarily for the convenience of the medical personnel involved. The latter has received little attention, that is until a recent study by Serres et al. in JAMA Pediatrics addressed the question head-on: “How urgently is appendectomy required once the diagnosis is made?” We already know that patients who delay seeking care have higher complication rates, but once they get to the hospital, the impact of delays in surgery are unknown. One might expect a similarly high complication rate the longer surgery is delayed.

Serres et al. attempted to answer this question and concluded that there is no association between time to appendectomy (TTA: Time from arrival to first operative incision) and risk of complications within a 24 hour window.

That said, however, the devil is as usual in the details.

Their retrospective study looked at 2429 children under 18 years of age who had an appendectomy within 24 hours of arrival at one of 23 children’s hospitals during 2013 and 2014. “Early” TTA was considered any time less than the median for each hospital. “Late” TTA was any time longer than the median. “Complicated appendicitis” was defined as those with a perforation, fibrinopurulent exudate in the peritoneal cavity, an intra-abdominal abscess, or a fecolith (small stone from the appendix) found within the peritoneal cavity. In addition to the primary outcome of “complicated appendicitis,” the authors also looked at secondary outcomes such as length of stay (LOS), wound infection and other postoperative complications.

The authors’ results were counter-intuitive. They report that “No increased risk of complicated appendicitis was found in the “late” group versus the “early” group.” This supports the idea that within the first 24 hours appendectomy can be safely performed as an urgent rather than emergency procedure.

The median TTA was 7.4 hours (range, 5.0-19.2 hours). The average age of the patients was 10 years; 60.4% were male. All patients had an exam and ultrasound, but the study excluded those who had a CT scan. “Complicated appendicitis” was defined as incisional infection, need for drainage procedures, risk of requiring an unplanned repeat procedure, or repeat presentation to a hospital, and was diagnosed in 23.6% of all patients. That number did not differ statistically  between those patients who got an “early” versus a “late” appendectomy. Length of stay (LOS) increased in the “late” group; for each hour of “delay,” patients spent an extra 1.44 hours more in the hospital. Finally, subgroups of younger children, females and Hispanics  had a higher risk of complications than others.

This information will undoubtedly factor into the analysis of the viability of a lawsuit for “missed appendicitis.” How long was the delay? Were complications due to delayed presentation (expected) or delayed surgery (not a factor)? Was the patient treated with antibiotics; for some patients, that’s all they need. And finally, there is “late” surgery, as defined by the study’s authors, and there is “inordinately late” surgery, a matter that still may be argued in court, and a matter that will clearly vary from patient to patient.

 

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