The American Journal of Surgery (2008) 195, 590 –593

North Pacific Surgical Association

Timing of intervention does not affect outcome in acute

appendicitis in a large community practice
Courtney Clyde, M.D., Timothy Bax, M.D., Anders Merg, M.D.,
Mark MacFarlane, M.D., Paul Lin, M.D., Steven Beyersdorf, M.D.,
M. Shane McNevin, M.D.*

Surgical Specialists of Spokane, 105 W 8th Ave., Suite 7060, Spokane, WA 99208, USA

KEYWORDS: Abstract
Appendicitis; BACKGROUND: Surgical management of acute appendicitis remains one of the most frequent
Laparoscopy; problems faced by gastrointestinal surgeons. Traditional management has emphasized urgent surgical
Surgical outcomes care. Recent literature suggests delayed surgery for acute appendicitis does not affect outcome. The
outcomes of patients undergoing urgent and delayed appendectomy in a large community surgical
practice are compared.
METHODS: All patients undergoing appendectomy between August 2002 and May 2007 were
reviewed retrospectively. The data were gathered from a large community surgical practice. Patient
demographics, treatment times, and surgical, pathologic, and postsurgical outcomes were documented.
RESULTS: A total of 1,198 patients underwent appendectomy (575 female/623 male). The mean
time to surgical intervention was 7.1 hours (range, 1–24 h). The percentage of patients undergoing
laparoscopy versus open versus surgical conversion was 63%, 33%, and 4%, respectively. The
percentage of patients with acute appendicitis versus perforated acute appendicitis versus negative
exploration was 77%, 14%, and 8.5%, respectively. Postoperative wound or intra-abdominal septic
complications were observed in 5.3% and 2.6% of patients, respectively. There was no correlation
between the duration of symptoms or time to surgical intervention and surgical approach, pathologic
outcome, length of stay, or postoperative septic complications.
CONCLUSIONS: Outcome variables documented in this study were independent of duration of
symptoms or time to surgical intervention. This would suggest that short delays in surgical intervention
for acute appendicitis are well tolerated. Outcome is related more clearly to the severity of the acute
appendicitis at presentation.
© 2008 Elsevier Inc. All rights reserved.

Acute appendicitis is one of the most frequent acute
surgical conditions encountered by the gastrointestinal sur-
geon.1,2 Traditional management has emphasized urgent
surgical intervention using either an open or laparoscopic
* Corresponding author. Tel.: ⫹1-509-747-6194; fax: ⫹1-509-747-
4313.
E-mail address: skmcnevin@comcast.net
Manuscript received November 7, 2007; revised manuscript January
30, 2008
approach. This has led to the recommendation that all ap-
pendicitis patients should have surgery performed as close
to the time of diagnosis as possible, although there are
controversial data supporting this approach.1–5
Numerous studies have documented outcome variables
related to time of day of the procedure and fatigue of the
surgical team.6 In addition, in the era of cost containment,
emergent surgical procedures performed after hours are
more costly (personal communication). Also, many other

0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjsurg.2008.01.005
C. Clyde et al Outcomes of acute appendicitis
Figure 1 Patient demographics of 1,198 patients undergoing
appendectomy.
acute abdominal conditions such as acute cholecystitis and
acute diverticulitis have been managed successfully with an
urgent but not emergent approach.7–9 Recent data have
challenged the need for emergent surgical treatment of acute
appendicitis.
We reviewed our surgical experience with appendicitis
to determine which surgical variables affected postoperative
outcome. Specifically, we were interested in determining
whether timing of intervention or the severity of the under-
lying appendicitis played a larger role in postoperative pa-
tient outcome.
Methods
A retrospective chart review of all patients undergoing
appendectomy in a single community surgical specialty
practice between August 2002 and May 2007 was con-
ducted. Institutional review board authorization was ob-
tained.
Patient demographics and comorbidities, symptom dura-
tion, laboratory and radiographic evaluation and findings,
treatment times, surgical type and findings, pathologic find-
ings, and postsurgical outcomes were documented.
Results
A total of 1,198 patients underwent appendectomy dur-
ing the study period. Patient demographics are listed in
Fig. 1. The ratio of males to females was 1.1. Patients
70
60
50
Lap
40
Open
30
Conv.
20
10
0
<6 <12 <18 <24
Time to operative intervention (hours)
Figure 2 Type of surgery versus time to surgical intervention.
Blue, laparoscopic; maroon, open; white, conversion.
591
90
80
70
60
% Acute
50
Perf.
40
Neg.
30
20
10
0
<6 <12 <18 <24
Time to operative intervention (hours)
Figure 3 Pathologic findings versus time to surgical interven-
tion. Blue, acute; maroon, perforation; white, negative.
experienced symptoms before medical attention for a mean
of 2.2 days (range, 0 –21 d). Patients underwent surgical
intervention a mean of 7.1 hours (range, 1–24 h) after first
seeking medical attention. The mean length of stay was 1.3
days (range, 1–9 d).
Surgical approach was according to surgeon preference.
The percentage of patients undergoing laparoscopy versus
open versus surgical conversion was 63%, 33%, and 4%,
respectively. There was no correlation between surgical
approach and time to surgical intervention. Surgical and
pathologic findings revealed acute appendicitis versus per-
forated acute appendicitis versus negative exploration in
77%, 14%, and 8.5% of patients, respectively. Likewise,
there was no correlation between pathologic outcome and
time to surgical intervention. These relationships are shown
in Figs. 2 and 3. Fig. 4 shows the relationship between
length of stay and time to surgical intervention. Again there
appeared to be no correlation between these variables. Sim-
ilar relationships were seen related to reported duration of
symptoms (data not shown).
Postoperative wound or intra-abdominal septic compli-
cations were observed in 5.3% and 2.6% of patients, respec-
tively. Fig. 5 shows the incidence of wound and intra-
abdominal septic complications related to time to surgical
intervention, respectively. There was no correlation be-
tween these variables. Similar relationships were seen re-
lated to reported duration of symptoms (data not shown).
The incidence of wound and intra-abdominal septic com-
plications appeared most related to surgical approach and
pathologic findings; this is shown in Figs. 6 and 7. The rate
of wound infection was increased in patients undergoing an
open appendectomy or a converted laparoscopic procedure
as well as patients with appendiceal perforation. The rate of
intra-abdominal sepsis was increased in patients with per-
1.6
1.4
1.2
L
1
O
S 0.8 LOS
0.6
0.4
0.2
0
<6 <12 <18 <24
Time to operative intervention (hours)
Figure 4 Length of stay versus time to surgical intervention.
592
7 9
6 8
5 7
% 4 Wound Inf.
3 Abscess
2 3
1 2
0 1
<6 <12 <18 <24
Time to operative intervention (hours)
Figure 5 Inflammatory complications versus time to surgical
intervention. Blue, wound infection; maroon, abscess.
forated appendicitis and those patients undergoing a con-
verted laparoscopic procedure.
Comments
Traditional management of acute appendicitis has em-
phasized emergent surgical management, but there are a
paucity of data to support this recommendation. Many acute
abdominal conditions now are managed with an urgent but
not emergent surgical plan. In addition, a number of studies
also have documented negative patient and economic out-
comes related to time of day of the procedure, presumably
related to surgical team fatigue.
In the current study the outcome variables documented
were independent of the duration of symptoms or the time to
surgical intervention. The obvious disadvantage of the ex-
perimental design in this study was its retrospective nature
and the lack of control groups, making clear proof of the
conclusions impossible. In addition, the majority of the
patients (83%) in this study underwent surgery within 12
hours of presentation, making clear conclusions about the
longer surgical delays difficult. That being said, clear infer-
ences can be drawn suggesting that short delays in surgical
intervention are well tolerated and reported duration of
symptoms is an unreliable predictor of severity of disease
and outcome of surgical therapy.
Postoperative outcome in this study was related more
closely to the severity of the appendicitis at presentation.
Our data suggest that te severity of appendicitis likely is
determined at the time of presentation and is unaffected by
time to surgical intervention. Further, the results also show
a lower wound complication rate with the laparoscopic
25
20
% 9. Broderisk-Villa G, et al. Hospitalization for acute diverticulitis does not
15
Wound Inf.
Abscess
10
0
Lap Open Conv.
Type of Operation
Figure 6 Inflammatory complications versus type of surgery.
Blue, wound infection; maroon, abscess.
The American Journal of Surgery, Vol 195, No 5, May 2008
% 6
5 Wound Inf.
4 Abscess
0
Acute Perf. Neg.
Pathologic findings
Figure 7 Inflammatory complications versus pathologic find-
ings. Blue, wound infection; maroon, abscess.
approach, although the need for open conversion is associ-
ated with increased wound and intra-abdominal septic com-
plications. The reasons for open conversion cannot be de-
termined by this study but presumably were related to the
severity of the underlying appendicitis or technical issues
related to performance of the surgery. Severity of the un-
derlying appendicitis also clearly affects outcome in this
study with increases in wound and intra-abdominal sepsis
with appendiceal perforation.
Our data suggest that outcome in acute appendicitis is
related most closely to the severity of the acute appendicitis
at presentation and is unaffected by timing of surgical in-
tervention and that improved wound complication rates are
seen with the laparoscopic approach. Based on these data an
urgent but not emergent protocol for surgical management
of acute appendicitis with the laparoscopic approach when
possible has been adopted in our community.
References
1. Fisher AC. Acute appendicitis. Curr Probl Surg 2001;7:267–72.
2. Liu CD, McFadden DW. Acute abdomen and appendix. Surgery 1997;
2:1246 – 61.
3. Prystowsky JB, Birkhahn RH, Gaeta TJ, et al. Appendicitis. Curr Probl
Surg 2005;42:688 –742.
4. Garfield JL, Fahim F, Shirjeel S, et al. Diagnostic pathways and delays
on route to operative intervention in acute appendicitis. Am Surg 2004;
70:1010 –3.
5. Fahim F, Broderisk-Villa G, Burchette RJ, et al. A comparison between
presentation time and delay in surgery in simple and advanced appen-
dicitis. J Ayub Med Coll Abbottabad 2005;17:37–9.
6. Boult M. Patient safety: the fatigue factor. Health Serv J 2005;115:
34 –5.
7. Welschbillig-Meunier K, et al. Percutaneous cholecystostomy for high
risk patients with acute cholecystitis. Surg Endosc 2005;19:1256 –9.
8. Kolla SB, et al. Early versus delayed laparoscopic cholecystectomy for
acute cholecystitis, a prospective randomized trial. Surg Endosc 2004;
18:1323–7.
mandate routine elective colectomy. Arch Surg 2005;140:576 – 81.
Discussion
Ravi Moonka, M.D. (Seattle, WA): I have met a number of
surgeons in my professional travels who enjoy taking emer-
C. Clyde et al Outcomes of acute appendicitis
gency room call. I wish I could say I was one of them. I
know I risk the disdain of trauma surgeons everywhere
when I say I find call psychologically and sometimes phys-
ically uncomfortable. Across the United States at least, call
cases tend to be uncompensated, litigious, and disruptive of
one’s elective practice.
And yet, even though it is the most common general
surgery call case, I like appendicitis. The patients tend to be
young, refreshingly normal, and surprisingly appreciative,
and the treatment tends to be quick, definitive, and chal-
lenging but not overly so. I would like appendicitis even
more if I could treat it on my own terms.
For this and other reasons, I enjoyed the presentation
under discussion. The project itself suggests finding ways to
make our jobs logistically easier is a reasonable field of
inquiry. I also respect the work necessary to complete the
study. This was not a review of a large government-main-
tained database examined from the comfort and safety of
one’s office, but rather the careful abstraction of 1,200
charts. That kind of heavy lifting in my view is what yields
the type of detailed clinical information on which we can
actually base treatment decisions. It certainly seems un-
likely a study of this magnitude would miss a significant
difference in outcomes. Finally, I like any manuscript which
confirms my own clinical impressions, and, in my experi-
ence, a modest delay in performing an appendectomy for
appendicitis does not impact patient outcome.
593
The paper is retrospective and subject to selection bias.
Patients who had delayed surgery may have had less im-
pressive presentations, and may represent a less severely ill
cohort that might be expected to have better results com-
pared to the immediate surgery group. I think we are going
to have to live with that, since a randomized trial addressing
this issue is not realistic. However, it would be helpful to
compare various parameters of severity of disease between
the 2 populations at presentation, such as temperature and
the white blood cell count, to show they were in fact similar
groups.
What do the conclusions of this study tell us about
appendicitis? Patients with a delay in surgery for appendi-
citis do fine. Is that because hydration, bowel rest, and
intravenous antibiotics are effective treatment, or are certain
patients destined to perforate and others are not?
Finally, I must tell you my wife was not completely happy
with this study. She had appendicitis at age 12, and her oper-
ation was delayed until the following morning. She is not much
of a complainer, but she has made it clear it would have been
her preference to have had surgery that night. Patients with
delayed surgery do no worse, but nor do they do better than
patients having an immediate operation, and it is the expecta-
tion of the lay public that an appendectomy will be done as
soon as possible. How do we meet that expectation but still put
the operation off until the next morning?
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