Is Appendicitis a Ticking Time Bomb? Time to Treatment and Risk of Perforation after Patients Reach the Hospital

Abstract

BACKGROUND In the traditional model of appendicitis, time is the major driver of disease progression: luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has guided clinical behavior related to timing of operation. Our objective was to evaluate whether there is an association between time and perforation after patients present to the hospital. METHODS Using data from Washington's Surgical Care and Outcomes Assessment Program, we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy (2010-2011). Elapsed time was measured between presentation to the Emergency Department (ED) and Operating Room (OR) start time. The relationship between in-hospital time and perforation was adjusted for potential confounding using multivariate logistic regression. RESULTS 9,408 adults underwent appendectomy (15.8% perforated). Mean time from ED to OR was the same (8.6 hours) for perforated and non-perforated appendicitis. In multivariate analysis, increasing time from ED to OR was not a predictor of perforation either as a continuous variable (OR 1.0 95%CI 0.99-1.01) or when considered as a categorical variable (patients ordered by elapsed time and divided into deciles). Factors associated with perforation were male sex, increasing age, 3+ co-morbid conditions, and lack of insurance. CONCLUSIONS There was no association between perforation and time in-hospital prior to surgery. These findings may reflect selection of patients for earlier intervention who are at higher risk for perforation or the effect of antibiotics begun at diagnosis, but they are also consistent with the theory that perforation is most often a pre-hospital occurrence and/or that perforation is not strictly a time-dependent phenomenon.