Delaying Surgery for Complicated Appendicitis Reduces Risk of Extended Resection
Key findings
- To understand outcomes related to delayed surgery in complicated appendicitis, Massachusetts General Hospital researchers analyzed four years of data from the American College of Surgeons National Surgical Quality Improvement Program
- 2,858 hemodynamically stable patients with complicated acute appendicitis underwent delayed appendectomy (≥24 hours after diagnosis; mean, 35 hours), and 8,160 underwent early surgery (within <24 hours; mean, 2 hours)
- The early surgery group experienced increased rates of extended resection, conversion to open appendectomy during minimally invasive approaches, and any-cause 30-day mortality, although the latter increase was only borderline statistically significant
- Delayed surgery did not increase morbidity and was associated with significantly shorter operative time
- An initial trial of non-operative management, such as antibiotic therapy, may be appropriate for hemodynamically stable patients with complicated appendicitis who do not indicate emergency surgery
An unsettled issue in colorectal surgery is managing complicated acute appendicitis in patients with no absolute indication for emergency surgery (e.g., hemodynamic instability or generalized peritonitis). Some experts advocate early intervention while others recommend a "cooling down" period preoperatively. Published clinical trials and systematic reviews are available to support either approach.
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Rocco Ricciardi, MD, MPH, chief of Colon and Rectal Surgery in theDivision of Gastrointestinal & Oncologic Surgery at Massachusetts General Hospital and associate professor of Surgery at Harvard Medical School, Rodrigo Moisés de Almeida Leite, MD, member of the Colon and Rectal Surgery Program, and colleagues analyzed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to address this question. In the Journal of Gastrointestinal Surgery, they say delayed surgery was associated with shorter operative time and improved or comparable clinical outcomes.
Methods
The researchers examined ACS NSQIP files from January 2016 through December 2019. They identified patients who underwent appendectomy for complicated appendicitis (defined as the presence of perforation and/or abscess) and excluded those with septic shock and those who were hemodynamically unstable.
The final cohort included 11,018 patients:
- 2,858 underwent delayed appendectomy (≥24 hours after diagnosis; mean, 35 hours)
- 8,160 (74%) underwent early appendectomy (<24 hours after diagnosis; mean, 2 hours)
Primary Outcome: Extended Resection
279 patients required extended resection: exploratory laparotomy celiotomy (n=138), laparoscopic or open partial colectomy with anastomosis (n=101), laparoscopic or open partial colectomy with the removal of terminal ileum (n=32), or excision of at least one intestinal lesion (n=8).
The incidence of extended resection was 2% in the early surgery group and 1% in the delayed surgery group (adjusted RR [aRR], 2.15; P<0.001).
Secondary Outcomes
Among patients who had minimally invasive surgery, early intervention was associated with an increased risk of conversion to open appendectomy (aRR, 1.14; P=0.037).
The researchers also analyzed some 30-day clinical outcomes:
- Any-cause mortality—0.22% with early surgery vs. 0.09% with delayed surgery (aRR, 2.17; P=0.054)
- Any-cause morbidity—No significant difference between groups
- Superficial surgical site infection—No significant difference between groups
Length of Stay and Operative Time
Early surgery was associated with a significantly shorter hospital stay (adjusted coefficient, −1.10; P<0.001).
However, total operative time was significantly longer during early surgery (adjusted coefficient, 13.41; P<0.001).
Applying the Findings to the Clinic
The reductions in extended resection and reduced operative time, without increases in morbidity, suggest delayed intervention is an appropriate choice for hemodynamically stable patients with complicated acute appendicitis. A trial of non-operative management, such as antibiotic therapy, may be preferable.
In fact, the most recent guidelines of the World Society of Emergency Surgery report better outcomes with delayed surgery, especially for patients with an abscess >3 cm.
The team still advises considering early intervention for patients with uncomplicated appendicitis because prompt appendectomy typically aids in faster resolution of pain.
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