â??Compellingâ?? support for urgent, not emergent, appendectomy

Last Updated: 2017-06-19

By Megan Brooks

NEW YORK (Reuters Health) - A new study supports the growing view that appendectomy can be safely performed on an urgent rather than emergency basis, researchers say.

In a large retrospective review, performing appendectomy within 24 hours of presentation was not associated with increased risk of complicated appendicitis or adverse outcomes, report Dr. Shawn Rangel and colleagues from Boston Children's Hospital online today in JAMA Pediatrics.

“This has long been a controversial topic with practice gradually transitioning to treatment delay despite very limited data to date,” Dr. Rangel told Reuters Health by email. “This is the first multicenter study that addresses the biases that have limited previous studies. From a clinical practice standpoint, this provides the best available evidence to validate this practice (treatment delay until the following morning for children that present with appendicitis "off hours") and address persistent concerns that delay is harmful for practitioners who still operate in the middle of the night.”

This “rigorous and thoughtful analysis . . . offers compelling support for the safety of appendectomy performed at a prompt time (within 24 hours of presentation) in a way that optimally uses existing hospital and operating room resources,” write the authors of an editorial published with the study.

The study team examined the association between time to appendectomy (TTA) and risk of complicated appendicitis and postoperative complications in more than 2,400 children younger than 18 who underwent appendectomy within 24 hours of presentation at 23 children's hospitals.

Over the two-year study period, they found a 23.6% incidence of complicated appendicitis in patients undergoing appendectomy at a median TTA of 7.4 hours.

On univariate and multivariable analyses, TTA was not associated with increased probability of complicated appendicitis. With the exception of a small increased length of stay (0.06 days), secondary outcomes, including incisional and organ space infections, percutaneous drainage procedures, reoperation, and hospital revisits, showed no association with TTA.

“These findings may have important implications for many hospitals at which performing an appendectomy at night poses significant logistical and fiscal challenges,” write Dr. Rangel and colleagues.

“The ultimate decision surrounding timing of appendectomy should balance the benefits of a timely intervention (eg, potentially lower hospital cost, LOS, and lost days from school and work on behalf of the patient and their family) against a hospital’s available resources but should not be influenced by concern for clinically relevant disease progression if it can be performed in a reasonable time frame,” they conclude.

In their editorial, Dr. Rachel Landisch of Children's Hospital of Wisconsin in Milwaukee and colleagues say, “This multi-institutional report reinforces contemporary practice and the perspectives of many, but not all, pediatric surgeons, that is, performing appendectomy at a time with optimal resources available within 24 hours of presentation does not increase the risk for complex disease.”

“Over the past decade,” they add, “mounting evidence among pediatric and adult studies demonstrates that delaying surgery is not only safe, but also fosters more efficient and considerate use of physician and hospital resources. Broad acceptance of this practice became evident in a 2012 survey of nearly 500 pediatric surgeons in which 96% did not consider nonperforated appendicitis to be a surgical emergency.” (http://bit.ly/2rKgLRB)

Dr. Landisch and colleagues also note that a “robust argument for the efficacy of antibiotics can be made by considering trials of nonoperative management of appendicitis. A 2017 meta-analysis of 5 randomized clinical trials and prospective studies comparing primary antibiotic therapy with surgical removal of the appendix for uncomplicated appendicitis among 404 pediatric patients concluded that nonoperative management was successful in 90.5% of the study cohort.” (http://bit.ly/2pqK36U)

The study had no commercial funding and the authors have disclosed on conflicts of interest.

SOURCE: http://bit.ly/2rwYO9Z and http://bit.ly/2sIlrvu

JAMA Pediatr 2017.