Surgery to remove an inflamed appendix can safely be postponed for 12 to 24 hours without patients suffering any more complications than those who have an appendectomy sooner, a Canadian-led study has found.
The study, which involved almost 33,000 adult patients at about 400 North American centres, is helping lay to rest the notion that a diseased appendix must be removed without delay.
“The long-standing belief was that the longer you wait in a patient with appendicitis, the more likely they’re going to rupture their appendix,” said Dr. Avery Nathens, head of general surgery and director of trauma at St. Michael’s Hospital in Toronto.
“This particular study suggests that’s probably not the case,” said Nathens, principal researcher of the study published in this week’s issue of the Archives of Surgery.
The appendix is a finger-like appendage attached to the large intestine, located on the lower right side of the abdomen.
Appendicitis occurs when the structure becomes infected and enlarged, likely after getting clogged by a small bit of undigested food or fecal matter.
Pain from appendicitis usually starts in the upper abdomen and migrates to the lower right side and a person may have a fever, he said. “With appendicitis, typically it hurts to move. You often have no desire to eat.”
Left untreated, the appendix can continue to swell until it bursts, allowing fecal matter to invade the abdominal cavity and setting the stage for a serious infection there or elsewhere in the body.
Doctors would likely want to operate right away on a patient whose appendix has already ruptured, Nathens said.
But the study showed there was no difference in complication rates among patients who had an appendectomy within six hours, between six and 12 hours or between 12 and 24 hours after arriving at the hospital.
The 2005-2008 study, which analyzed surgical and other hospital records, showed about 75 per cent of patients had their operations within six hours of admission, 15 per cent within six to 12 hours and 10 per cent after 12 hours.
Patients who had their operations beyond 12 hours had a slightly longer length of hospital stay — 2.2 days compared to 1.8 days for those operated on within 12 hours.
Nathens attributed the difference to discharge times, which tend to occur more often during the day than in the evening.
“What we’ve learned from studies like this . . . is it’s not the waiting in hospital that leads to the risk of rupture,” he said, noting that patients are closely monitored and generally given antibiotics and pain killers.
“It’s the wait that occurs between the onset of symptoms and the patient arriving at the emergency department. So the die is already cast before the patient arrives at the hospital in most cases . . . If they’re sick at home, they need to seek medical attention.”
For doctors and hospitals, the study’s findings mean there is some much-needed wiggle room when it comes to operating room time, which is limited during night hours when treatment for appendicitis is often sought on an emergency basis.
“We have shown that these operations are safely postponed to the light of day,” Nathens said. “The challenge now is to ensure that patients with conditions like appendicitis have the opportunity to receive the care they require at a time of day traditionally dominated by elective surgery, like cancer operations and hip replacements.”
Appendectomy is one of the most common surgical procedures performed worldwide and accounts for an estimated 25,000 hospital stays in Canada each year. In a related commentary, surgeon Dr. John Hunter of the Oregon Health and Science University, said the findings “provide the justification for performing appendectomy as soon as is convenient (usually in the morning) for acute appendicitis.”
“As a surgeon, I posit that the primary benefit of the current article is to validate the practice of treating acute appendicitis urgently rather than emergently . . . Delaying appendectomy until the next day decreases the need for a ’deep’ night staff. Even more expensive is the need to call in a crew to perform appendectomy in the middle of the night.”