N. Kincaid1, M. Yanagisawa1, L. Burkhalter2, R. Foglia1 1University Of Texas Southwestern Medical Center,Division Of Pediatric Surgery,Dallas, TX, USA 2Children’s Medical Center,General Surgery,Dallas, Tx, USA
Introduction: Management of acute appendicitis traditionally required urgent operation. The aim of this study is to determine what effect a moderate delay in performing an appendectomy has on rate of perforation and length of stay (LOS).
Methods: After IRB approval, medical records between Jan. and Dec. 2011 were reviewed for all pediatric patients who had an appendectomy with a diagnosis of appendicitis in one children’s hospital system. Interval and negative appendectomies were excluded. Data includes gender, age, and these time points: ED arrival, decision for surgery, start of surgery, and discharge. Delay in operation was assessed using time elapsed between surgical decision and start of surgery. There were two groups: Group P patients who underwent prompt operation in <6 hrs. and Group D patients whose surgery was delayed ≥ 6 hrs. Operative delay was either due to postponing a night (9:00pm to 4:00am) surgery or other scheduling conflicts. LOS is calculated from ED arrival to discharge. Data is expressed as X ± sd, significance is noted at p<0.05.
Results: There were 871 patients, 534 boys, 337 girls, and their age was 10.5±3.6 years. 244(28%) patients had perforated (PA) and 627(72%) had non-perforated appendicitis (NPA). There were 599(69%) Group P patients with an average delay of 2.0±1.6 hours and 272(31%) Group D patients with an average delay of 8.8±2.6 hrs. The perforation rate was 31% in Group P and 22% in Group D (p<0.02).
In PA, there were183 Group P patients delayed 1.9±1.6 hours with a LOS of 102.3±63.7 hrs. and 61 Group D patients delayed 8.8±2.8 hrs., with a LOS of 112.5±58.9 hrs. (p=NS). In NPA, 416 Group P patients had a delay of 2.1±1.7 hours and a LOS of 30.1±19.6 hrs. The 211 Group D patients, with a delay of 8.9 ± 2.6 hrs., had a 31% longer LOS of 39.3 ± 27.4 hrs. (p<0.01) (see table 1). There were 173(82%) patients in Group D whose surgeries were postponed overnight. They had a maximal LOS of 40.6±27.5 hrs. with p<0.01 compared to Group P.
Conclusion:A moderate (6 hr) operative delay for appendicitis doesn’t increase risk of perforation. The fact that perforation rate was lower (22% vs 31%) in those whose surgery was delayed does not mean that surgery should be delayed to decrease the perforation rate! These findings may reflect the surgeon’s judgment to operate early in selected cases. In NPA, a moderate delay prolonged LOS by 31%; and in PA, a 10 hour delay didn’t prolong the LOS. Hospitals are increasingly focused on LOS. Efforts should be directed towards optimizing hospital resource utilization, having a refreshed operative team, and doing what is best for patients.
