A COMPARISON BETWEEN PRESENATATION TIME AND
DELAY IN SURGERY IN SIMPLE AND ADVANCED APPENDICITIS
Fraz Fahim, Sharoon Shirjeel
South Surgical Ward, Department of Surgery,
Background: Acute appendicitis is the most common cause of acute
abdomen. Serial examinations and investigations increase diagnostic
accuracy. But this causes delay, which
may result in gangrene and perforation.
Our aim is to determine the affect of delay by the patient as well as by
the physician on the stage of the disease as determined intraoperatively and to
determine the percentage of negative appendectomies. Methods: 102
consecutive patients presenting to the
Key Words: Appendicitis,
negative appendectomies, appendix.
INTRODUCTION
Acute appendicitis develops
in 10% of the general population. Rare in infancy, the maximal reported
incidence is in teens and twenties.1,2 Overall it is the most common
cause of acute abdomen.3
Surgical teaching has advocated early appendectomy.
This is done at the cost of diagnostic accuracy to avoid the morbidity
associated with perforation of the acutely inflamed appendix.3
However the operation may be delayed because the patient is sometimes kept
under observation with serial WBC counts and repeated examinations. In some cases the patient may just present
late to the hospital due to various reasons.
This leads to a delay in definitive treatment for which both patient and
hospital factors may be responsible. The question before us was that does this
delay by the patient or by the physician have any effect on the stage of
disease as it is determined per-operatively. The current literature is divided
over this issue. Some studies suggest that these delays may increase the
morbidity 4,5,6. Our study
will be a pointer to the effects of these delays on the outcome of the patient
and hence will help in the ultimate decision to wait or not to wait.
The objective of this study is to determine the
affect of delay by the patient and by the physician on the stage of the disease
as determined intra-operatively. We also
want to determine the percentage of negative appendectomies in our unit.
MATERIAL AND METHODS
102 consecutive patients
presenting to the emergency department, aged 10 to 85 years underwent emergency
appendectomy for the clinical diagnosis of acute appendicitis between
Duration of complaints before presentation to the
hospital was regarded as patient delay and reported in days. The time from
arrival in the ER to surgery was regarded as physician delay and was reported
in hours. A policy of routine prophylactic antibiotic regimen of intravenous
Ampicillin 500mg, Gentamycin 80mg and Metronidazole 500mg at induction was
instituted except in cases where any of these drugs were contraindicated i.e.
first trimester pregnancy, hypersensitivity etc. All appendectomies were done
under general anesthesia. The operative findings were classified into five
categories as not inflamed, minimally inflamed, acutely inflamed, gangrenous
and perforated according to operative and histopathology reports. For the purpose
of the study, the last two categories were grouped together as “advanced
appendicitis” while the first three as “simple appendicitis”. Cases that seemed
non-inflamed intraoperatively but turned out to be inflamed on histopathology
were classified as appendicitis. Criteria
for inflammation on visual examination were edema, hyperemia, dilated blood
vessels and/or obvious gangrene with or without perforation. Histological findings of “periappendicitis”
or “sub-acute appendicitis” were not considered appendicitis. Duration of
postoperative nil per oral was also noted.
Postoperative wound infection occurring within one
month was noted and treated with antibiotics and drainage of pus if present.
RESULTS
Of the 102 patients preoperatively diagnosed as having
acute appendicitis 96 (94.1%) were found to be correctly diagnosed on
histopathology and 6 (5.9%) were misdiagnosed. 2 males and 4 female patients
were misdiagnosed hence the male to female ratio among the misdiagnosed cases was
2:1. 10 (9.8%) of patients had perforated appendices.
Of
the 96 correctly diagnosed cases, 81 (84.3%) were simple appendicitis and 15
(15.7%) were advanced appendicitis. The means age for simple appendicitis (22.8
years) was lesser than for advanced appendicitis (27.3 years). (Table 1 – Patient Characteristic)
15.2% (n=46 males) from among males had advanced
disease as did 16% (n=50 females) from among the females. Hence the advanced disease was almost equally
common in both the sexes.
Postoperative
oral consumption started earlier (14.2 hrs vs 32.8 hrs) and hospital stay was
shorter (1.6 days vs 3.2 days) in simple appendicitis. Post operative wound
infection occurred in 11.1% (9 patients) of simple and 26% (4 patients) of
advanced appendicitis.
Patients’
delay ranged from 0.04 days (1 hour) to 30 days (Table 2). 60 patients (62.5%) of the patients presented within one
day of the onset of symptoms. A prolonged average delay period of 6.1 days was
seen in misdiagnosed cases. The mean delay period was not significantly different
among either of the groups.
Patients
> 30 year old had marginally longer delay in presentation (2.99 days), than
those less than or equal to 30 years (2.48 days). Gender did not affect
preadmission delay, but patients presenting with fever at presentation had a
mean patient delay of 1.96 days while those without fever averaged 3.17
days.
Physician
delay ranged from
Table-1:
Patient Characteristics, Operative and Post Operative Course of Patients at the
Two Stages of Diseases
|
Acute Appendicitis N=81 |
Advanced Appendicitis N=15 |
Characteristics Gender Male Femal Mean
Age (Yrs) |
39 42 22.80 |
7 8 27.3 |
Operative & Post-op Course Mean Duration of NPO (Hrs) Wound Infection (%) |
1413 1.63 11.1 |
32.76 3.2 26.00 |
*Male : Female = 0.93 : 1
Table-2: Patient’s Delay In The Study Group
Patient Delay (Days) |
Simple App N-81 |
Advance App N=15 |
Mis-diagnosed N=6 |
Total Group N=102 |
0.5 |
32 |
2 |
2 |
36 |
0.51-1.0 |
24 |
7 |
1 |
32 |
1.1-2.0 |
9 |
3 |
1 |
13 |
2.1-3.0 |
5 |
1 |
1 |
7 |
>3.0 |
11 |
2 |
1 |
14 |
Mean Delay |
1.59 |
2.43 |
6.1 |
2.56 |
Table-3: Physician’s Delay in the Study
Group
Physician Delay (Hrs) |
Simple App N-81 |
Advance App N=15 |
Mis-diagnosed N=6 |
Total Group N=102 |
3 |
5 |
1 |
1 |
7 |
3-6 |
24 |
4 |
1 |
29 |
6-9 |
16 |
6 |
2 |
24 |
9-12 |
23 |
4 |
1 |
28 |
>12 |
14 |
0 |
1 |
14 |
Mean Delay |
9.24 |
7.3 |
7.9 |
8.96 |
DISCUSSION
The percentage of negative
appendectomies in our center i.e. 5.9 % (6) is lower than the comparable
studies. Rao et al give a figure of 7%7, but higher figures of 9%8
and even up to 19%5 have also been quoted9. The
well-known fact that the misdiagnosis rate is higher in female10 is
corroborated by our data. This is perhaps because of the gynecological pelvic
disease and female functional abnormalities. Apart from the traditional wait
and see approach, we also use USG, CT Scan and diagnostic laparoscopy to reach
a diagnosis11. This has reduced the rate of negative appendectomy7.
However the rate of negative appendectomy was similar in open and laparoscopic
appendectomies12.
The approach to acute appendicitis is influenced by
the desire to reduce the misdiagnosis rate to avoid unnecessary surgery on the
one hand. And by the attempt to operate at an early stage of the disease in
order to reduce the associated morbidity on the other hand5. In
doubtful diagnosis, surgery is delayed and close observation of the patient is
usually done to allow the clinical picture to become clearer and hence to reach
a more precise diagnosis. This approach may or may not affect the stage of the
disease. The problem of delay is compounded by the fact that the patients and the
surgeons both share the responsibility for it. In-hospital logistics like heavy
workload and non-availability of the theatres may cause a further unavoidable
delay.
The lag period between onset of symptoms and surgery
was divided into a pre-hospital delay (the responsibility of the patient or the
referring physician) and hospital delay (due to the observation period or
hospital logistics). Conflicting evidence exists as to the role of delay as a
whole and its two components on the course and outcome of acute appendicitis.
There is evidence that patient delay affects perforation rates while in
hospital delay does not 5,8. But some authors suggest that both the
components are associated with advanced disease and increased morbidity6.
The wait and see approach may be associated with significant morbidity.
62.5% of the patient presented within a day of onset
of symptoms. However patient delay did not correlate with advanced disease in
our study, even though patients with fever presented earlier on average.
86.3% were operated within 12 hours of presentation.
We seem to have operated patient with advanced disease with a significantly
lesser physician delay. This is due to the recognition of a more toxic state in
these patients on the basis of clinical examination and hence the conscious
decision to give them priority for operation.
The male to female ratio is 1 : 1 in most cases
except in the age group of teens and twenties when the ratio is recognized as
There was a high rate of postoperative wound infection,
more so in the perforated cases13,14. One of the factors responsible
could be the bacterial contamination, but inadequate asepsis and sterilization
because of the extremely heavy workload may be the major determinant15.
CONCLUSION
While in our series,
contrary to our initial expectation, patient delay did not turn out to be
associated with advanced appendicitis, we did find that this condition is
recognizable clinically and gets to the operating table two hours earlier on
average. There is however a significant lag period of observation leading to a
physician delay in simple appendicitis, which can possibly contribute to,
increased morbidity.
In this context, we would like to stress that the
mainstay of diagnosis of acute appendicitis are its clinical symptoms and
signs. However there is also an increased need to use USG and CT Scan in the
emergency setting to diagnose appendicitis when the clinical picture is
ambiguous.
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________________________________________________________________________________________________________
Address for Correspondence:
Dr. Fraz Fahim, 143, Street 2, Cavalry Grounds,
Email: surgeononline@hotmail.com