M. M. Symer1, J. Abelson1, T. Sun2, A. Sedrakyan2, H. Yeo1,2 1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy And Research,New York, NY, USA
Introduction: Acute appendicitis is one of the most common surgical diseases in the U.S., with up to 30% of patients presenting with perforation. Recent data suggests that it is safe to treat some patients with antibiotics alone. Despite this, there is no consensus on the optimal timing of surgical management. We evaluated 1-year outcomes in early versus delayed surgery for perforated appendicitis in a large administrative database.
Methods: We analyzed the New York Statewide Planning and Research Cooperative database, an all-payer, in- and out-patient longitudinal database which captures all admissions and surgical procedures in New York State. ICD-9 codes were used to identify all patients undergoing appendectomy for perforated appendicitis from 2000 to 2013. Primary outcome was any complication within one year of follow up. Secondary outcomes included length of stay, hospital charges, utilization of laparoscopy, and conservative management failure rate. Outcomes were compared in patients undergoing appendectomy before or after 48h from admission.
Results:31,167 patients ≥18 y.o. age were identified for analysis, 28,015(89.9%) of whom underwent early appendectomy. Patients undergoing immediate appendectomy were more likely to be male (54.8% vs. 45.2% p<0.01), white (69.8% vs. 64.2% p<0.01), and have commercial insurance (53.1% vs 45.4%, p<0.01). Of the 3152 patients initially managed nonoperatively, 1610(51.1%) required surgery on their index admission and an additional 715(22.7%) were readmitted urgently and underwent appendectomy at another admission (failure of conservative management). Only 827(26.2%) made it to interval appendectomy within one year of index admission. Patients undergoing late appendectomy were more likely to have at least one complication (47.9% vs. 33.2%, p<0.01) and less likely to have a laparoscopic procedure (40.0% vs 42.1%, p=0.03). After multivariate adjustment, patients undergoing delayed surgery were more likely to have a complication (OR 1.56 95%CI 1.43-1.69), be readmitted (OR 1.55 95%CI 1.42-1.70), have high hospital costs (OR 4.79 95%CI 4.35-5.27), and have a prolonged length of stay (OR 6.12 95%CI 5.61-6.68).
Conclusion:While recent data have suggested that non-operative management or delayed operative management of appendicitis is safe, there is a paucity of real world data on this topic. In this population-level study of early versus late appendectomy in adults with perforated appendicitis we demonstrate more complications, longer length of stay, and higher costs in patients who do not undergo immediate surgery.
