N. Lunardi1,2, M. Thornton1,2, B. L. Zarzaur3, S. Agarwal4, M. Berger5, S. Sharath6,7,8, P. Kougias6,8, S. Bhat1, T. H. Pham1,2, C. J. Balentine3,9,10 1University Of Texas Southwestern Medical Center, Department Of Surgery, Dallas, TX, USA 2VA North Texas Health Care System, Department Of Surgery, Dallas, TX, USA 3University Of Wisconsin, Department Of Surgery, Madison, WI, USA 4Duke University Medical Center, Department Of Surgery, Durham, NC, USA 5Duke University Medical Center, Department Of Anesthesiology, Durham, NC, USA 6SUNY Downstate Health Sciences Center, Department Of Surgery, Brooklyn, NY, USA 7SUNY Downstate Health Sciences Center, Department Of Epidemiology & Biostatistics, Brooklyn, NY, USA 8New York Harbor Health Care System, Department Of Surgery, Brooklyn, NY, USA 9Wisconsin Surgical Outcomes Research Program, Madison, WI, USA 10William S. Middleton VA, Department Of Surgery, Madison, WI, USA
Introduction: Nonoperative management of acute appendicitis is frequently offered to patients at high-risk for morbidity or mortality with surgery because it is seen as a safer alternative to appendectomy, but the consequences of nonoperative failure in these patients have not been assessed. We hypothesized that the consequences of failing nonoperative management would be substantial for patients at high risk of complications with surgery, potentially reducing the benefits of nonoperative management.
Methods: We identified patients with acute appendicitis who were managed nonoperatively (n=39,127) or with surgery (n=396,715) in the 2004 to 2017 National Inpatient Sample. We used a logistic regression model to predict the risk of morbidity or mortality after appendectomy. We then applied this model to the patients treated nonoperatively to predict the risk of morbidity or mortality if they had been treated surgically. We divided the nonoperative patients into two groups for analysis based on their predicted morbidity/mortality risk with surgery: (1) high risk: 1-2 standard deviations above the mean predicted risk, and (2) highest risk: ≥2 standard deviations above the mean. We evaluated morbidity, mortality, length of stay, hospital costs, and rates of non-home discharge for patients who failed nonoperative management, with nonoperative failure defined as having surgery or interventional radiology procedures after initial nonoperative management.
Results: Our sample included 1,512 high risk patients who failed non-operative management with a median age of 63 (IQR 51-74). We also included 2,469 of the highest risk patients who failed nonoperative management, with a median age of 70 (IQR 59-80). For the high-risk patients in our cohort, 19% experienced a complication, 2% died, and 17% were discharged to skilled nursing facilities after nonoperative failure. Their median length of stay was 9 days (IQR 6-14) and the median cost of hospitalization was $18,823 (IQR $12,691-$29,543). For the highest-risk patients who failed nonoperative management, morbidity was 25%, mortality was 8%, and 37% were discharged to skilled nursing facilities after nonoperative failure. Their median length of stay was 13 days (IQR 8-20), with median hospital costs of $27,467 (IQR $17,214-$48,066) per admission.
Conclusion: Nonoperative management is not a panacea for patients who are high-risk for surgery, since nonoperative failure is associated with a significant risk of morbidity, mortality, and disability as well as higher costs and prolonged hospitalization. Surgeons should exercise considerable caution and vigilance when offering nonoperative management to these highly vulnerable patients.