No association found between time to appendectomy and appendix perforation

1. Increased in-hospital time to surgery was not associated with an increased risk of appendix rupture among adults treated with appendectomy.

2. Factors that increased the risk of perforation included male gender, lack of insurance, and >3 comorbid conditions.

Evidence Rating Level: 2 (Good)

Study Rundown: Previous reports have demonstrated conflicting results on the effect of in-hospital wait times prior to surgery and the risk of appendix rupture in patients that undergo appendectomy. The authors of this study retrospectively analyzed the pattern of appendix perforation in 9048 adult patients that underwent an appendectomy from 2010-2011 in the United States. The results demonstrated that time to surgical treatment were not associated with increased rate of appendix perforation. Factors that were associated with appendix rupture include male gender, uninsured status and >3 comorbid conditions. The results of this study suggest that delayed time to seek care may be a more important risk factor than in-hospital wait times for perforation. The strengths of this study are the large database derived from multiple centers. However, the database did not capture important cofounders such as the use of antibiotics for suspected appendicitis or outcome measures such as post-operative length-of-stay, which may still be influenced by time to treatment.

Click to read the study in JAMA Surgery

Relevant Reading: Non-patient factors related to rates of ruptured appendicitis

In-Depth [retrospective study]: This retrospective review analyzed 9048 adult patients that underwent appendectomy from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP). The primary outcome was the presence of appendix perforation and the association to in-hospital wait times. Time-interval analysis demonstrated similar mean time from patient presentation to OR (8.6 hours) between the perforated and non-perforated group. There was no association between in-hospital wait times and rate of appendix perforation (above). Male gender was associated with a decreased hospital wait time compared to females (8.2 vs. 9.0 hours) but had a higher risk of perforation (OR: 1.24; 95% CI: 1.08-1.43). Uninsured status was associated with a significantly increased hospital wait time and an increased risk of perforation compared to private insurance (OR: 1.43; 95 % CI: 1.24-1.66). Finally, >3 comorbid conditions (OR: 2.18; 95% CI: 1.36-3.49) were associated with increased rate of appendix rupture.

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