E. A. Alore1, J. L. Ward1, S. R. Todd1, C. T. Wilson1, S. D. Gordy1, M. K. Hoffman1, J. W. Suliburk1 1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA
Introduction: The optimal timing of appendectomy for acute appendicitis has frequently been questioned with mixed results. We utilized population level data from the American College of Surgery National Surgical Quality Improvement Project (ACS-NSQIP) to evaluate outcomes of open and laparoscopic appendectomy performed on hospital day (HD) 1, HD 2 and HD 3 of admission. We hypothesized that delayed appendectomy would be associated with increased morbidity and 30-day mortality.
Methods: The ACS-NSQIP database was queried for all patients undergoing an open or laparoscopic appendectomy from 2007-2015 within 3 days of admission. All had a post-operative diagnosis of appendicitis. Chi square test for trend, Pearson’s Chi square, Fisher’s exact and Kruskal-Wallis tests were employed using an alpha level of 0.05. A reverse stepwise logistic regression using the criterion of p>0.2 for removal from the model was performed to determine predictors of morbidity and mortality.
Results: In ACS-NSQIP, 212,577 patients underwent an appendectomy from 2007-2015 for acute appendicitis. There was a significant decrease in appendectomies performed on HD 1 over time (83% in 2007 vs. 78% in 2015; p<0.001). Of non-elective appendectomies performed from 2012-2015 (n=112,122), there were significantly worse outcomes for those performed on HD 3 as demonstrated by increased 30-day mortality, reoperation, surgical site infection as well as cardiovascular, pulmonary, and thromboembolic complications (Table 1). However, significantly more patients undergoing appendectomy on HD 3 had comorbid conditions (36%; p<0.001) in comparison to those on HD 1 (19%) or HD 2 (21%). On subgroup analysis of laparoscopic versus open appendectomy, open had significantly higher morbidity and mortality for all major postoperative complications, regardless of day of operation, including organ/space surgical site infections (4.6% open vs 2.1% laparoscopic; p<0.001). A significantly greater proportion of appendectomies performed on HD 3 were open (19%; p<0.001) in comparison to HD 1 (8%) or HD 2 (8%). On logistic regression, presence of comorbid conditions and open operation were predictive of major complications; however, HD was not (p=0.54).
Conclusion: Population level data from ACS-NSQIP demonstrates similar outcomes of appendectomy for acute appendicitis when the operation is performed on HD 1 or HD 2; however, outcomes are significantly worse for appendectomies performed on HD 3. The increased morbidity and mortality of appendectomy performed on HD 3 is likely not attributable to the HD of operation, but rather a result of the increased number of comorbid conditions and open surgeries in this group.
