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 an increasingly high complication rate the longer surgery is delayed. But is that the case?
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, an indicator of perforation. 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.”
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 supports the idea that within the first 24 hours appendectomy can be safely performed as an urgent rather than emergency procedure.
That said, Dr. Bonadio contested the authors’ findings in a subsequent letter, referencing 2 prior studies that contradict the findings of Serres et al. The Serres study’s corresponding author, Dr. Rangel, replied with a rational argument for the validity of their study and also pointing to 2 prior articles supporting their findings.
While this appears to be an interesting case of “He said, she said,” this information should provide a wealth of resources for both plaintiff and defense attorneys to assess the issues surrounding delays in treatment of appendicitis – once diagnosed. The study itself, Dr. Bonadio’s letter, Dr. Rangel’s response and the 2 references in each of the latter should help attorneys assess the viability of a lawsuit for “delayed treatment of appendicitis.” How long was the delay? Were complications due to delayed presentation (expected) or delayed surgery (potentially not a factor)? Was the patient treated with antibiotics? For some patients, that’s all they need. And finally, there is “delayed” 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.