The optimal management for acute appendicitis has been discussed for years. Several points are matter of debate, namely laparoscopic versus open surgery and clinical examination versus CT scan. Recently, several studies have analysed the antibiotic therapy alone versus immediate intervention. A failure rate of 27-32% have been reported, and two thirds of these progressed to complicated appendicitis. Which means that if medical treatment fails, appendicectomy will be performed in a severely infected environment.
"Although certainly a number of patients may benefit solely from antibiotic therapy for uncomplicated appendicitis, the complications from failure are severe, and our ability to predict specific outcomes is limited."
Laura Harmon et al.
Several papers have hypothesised that the decreased time delay to the
operation room (OR) may reduce perforation and surgical site infections (SSI). However all the studies failed to pre-operatively differentiate non perforated from perforated appendicitis. Additionally, there is still a debate about the acceptable duration of time delay to the OR to minimise perforation.
In this setting, Laura Harmon et al. from the Department of Surgery from the University of Texas Medical Branch, performed a retrospective cohort study with 411 patients with non perforated appendicitis verified by CT scan, to determine if there is a temporal component to perforation.
Many studies agree a time delay to the OR more than 24h is too long, but is there a specific time point to achieve a minimum perforation and complication rate? This was the answer the authors were looking for. And they got it!
They collected 411 patients with non perforated appendicitis diagnosed pre-operatively by CT scan according to Radiologic Society of North America (no free air, no phlegmon, no abscess, no excessive inflammation). From the 411 patients with non perforated appendicitis 19,5% were perforated at surgery.
All patients received preoperative antibiotics one hour within surgery. There was a reduction of perforation rate according to time delay to OR from 27% at the 6- 9h interval, to 17% at the 3- 6h interval, to 10% at the 0- 3h interval (p<0.04).
These results favours a fast track surgery for acute appendicitis in order to reduce perforation rate. Additionally SSI and in-hospital length of stay were also increased with perforation rates and time delay greater than 3 hours. Important to enhance that all organ space infections occurred in patients who were delayed to operation more than 3 hours (p<0.001). A mean length of stay of 0.93 days for non perforated appendicitis versus 2.81 days for perforated appendicitis was noted (p<0.001). Another important data is the more frequent perforation found in patients with symptoms more than 72h.
The authors' data suggest that delay to the OR not only increases perforation rates but also increases deep space infection.
It was interesting to read from Laura Harmon et al. from the USA that they "felt the 3-hour mark point serves as the earliest time that surgeons are generally contacted for treatment of appendicitis in today's acute care model". What the h..l? When I was reading this I thought about the portuguese model and started to laugh. Our acute care model (if there is any...) makes the surgeon a "first line" of care for every small acute or chronic wound, all abdominal pains, all isolated cranial traumas, hemathuria, urinary track infections, lower limbs pain and oedema, teeth problems, broken noses (and many other pathologies that other doctors from several specialities do not want to treat...), and at the end... or within all those cases... he must perform surgery. Will a 3-hour interval be possible in the portuguese model?
Lastly, the authors suggest we can reduce health care costs with this time goal of 3 hours to OR for acute appendicitis. In the USA a patient with non perforated appendicitis cost from $24000 to $40000, and a patient with a perforated appendicitis from $34000 to $61000. Several billion dollars a year are spent treating acute appendicitis. In conclusion, surgeons should fast track patients to the OR for non perforated appendicitis in less than 3h. This will decrease complications and costs.
As we know, operations performed during night period are associated to a higher complications rate. So, a question emerges in my mind after reading this paper. Will these data make surgeons perform appendectomy for simple acute appendicitis during night period? Or will it be ok to delay operation for the fresh morning surgical team?
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon