William Bonadio
Maimonides Medical Center, New York
Title: Impact of in hospital delay to appendectomy on perforation rates in children with appendicitis
Biography
Biography: William Bonadio
Abstract
Background: There is controversy regarding whether in-hospital time delay to appendectomy in children with appendicitis affects risk for perforation. Objective: To evaluate the impact of time delay from ED presentation to OR appendectomy on rates of developing appendiceal perforation in children who present with CT-confirmed, uncomplicated [no radiographic evidence of perforation] appendicitis. Methods: Retrospective case review of 248 consecutive children aged <18 years with CT-confirmed uncomplicated appendicitis during a 4-year period. Results: There were 149 males and 99 females; all received subsequent appendectomy. Despite all receiving ED parenteral antibiotic therapy, 54 [22%] developed in-hospital appendiceal perforation [surgeon operative observation and/or pathologist histologic analysis]. No patient developed perforation when appendectomy was performed within 9 hours after ED presentation; the rate of perforation was approximately 6-fold greater in those with in-hospital delay >9 hours [25%] vs <9 hours [4.6%]. The rate of developing perforation increased to 21% during hours 9 - 16, and 41% after 24 hours. Regression analysis showed 3 factors were significantly associated with developing perforation: longer mean time delay from ED presentation to OR appendectomy, presence of fever, and presence of an appendicolith. The risk for developing perforation increased by 1.10 for each hour of time delay from ED presentation to OR appendectomy; the estimated odds ratio for developing perforation per interval of in-hospital delay is 2.05 at 8 hours, 4.22 at 16 hours, and 8.67 at 24 hours. Conclusions: Increasing in-hospital time delay from ED presentation to OR appendectomy is associated with increased risk for developing appendiceal perforation in children who present with CT-documented uncomplicated appendicitis. Risk is approximately 6-fold greater in those who experience delay >9 hours vs those whose delay is <9 hours. Antibiotic therapy does not reliably prevent progression of the disease. Appendectomy should be considered an urgent procedure to maximize outcome and prevent complications associated with appendix perforation.