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DOI 10.1007/s11605-011-1486-x
ORIGINAL ARTICLE
Received: 12 December 2010 / Accepted: 8 March 2011 / Published online: 10 May 2011
# 2011 The Society for Surgery of the Alimentary Tract
Abstract
Introduction The effect of age and gender on time to perforation in acute appendicitis has not been well characterized. This study
examined the relationship between duration of disease and appendiceal perforation in different subgroups of age and gender.
Methods This study is a retrospective analysis of 380 patients who underwent an appendectomy from January 2000 to June
2005 at a rural teaching hospital.
Results Factors associated with perforated appendicitis included age, symptom duration, CT scan, and distance from the hospital.
Factors associated with increased patient time included age, temperature >101.5 F, and referral from an outside institution.
Factors associated with shorter system time included right lower quadrant tenderness, classic or severe presentation, and leading
diagnosis of acute appendicitis. Preoperative CT scan increased system time by approximately 3 h. Analyzing symptom duration
and time to perforation, males have a higher prevalence of perforated appendicitis compared to females with similar duration of
symptoms. In patients older than 55 years of age, 29% had perforated appendicitis at 36 h of symptoms and 67% at 36 to 48 h of
symptoms. In a multivariate regression analysis, age greater than 55 years (odds ratio (OR) 3.0, P value 0.007), fever (OR 4.3,
P 0.007), and symptom duration more than 24 h (OR 4.1, P 0.001) were significant predictors of perforated appendicitis.
Conclusions There is an early risk of perforated appendicitis even within the first 36 h of symptoms. This risk appears to be
higher in males and patients older than 55 years, a quarter of whom are perforated within the first 36 h of symptom duration.
Additionally, perforation in acute appendicitis may be more of a continuous phenomena worsening exponentially with
duration of symptoms rather than a threshold phenomenon.
Keywords Timing . Operation . Appendectomy . Acute
appendicitis . Perforated appendicitis . Delays . Waiting time
Introduction
The delay associated with the treatment of acute appendicitis can be broadly divided into patient-related delay and
The abstract was presented as an oral presentation at the 5th Annual
Academic Surgical Congress of the Association for Academic Surgery
held at the Marriott Rivercenter Hotel in San Antonio, TX, USA from
February 35, 2010.
T. Augustin (*) : B. Cagir : T. J. VanderMeer
Department of Surgery, Guthrie-Robert Packer Hospital,
One Guthrie Square,
Sayre, PA 18840, USA
e-mail: [email protected]
1224
Patient Variables
Delay
Data were then collected on the remaining 380 patients.
Chart review was done to collect information on patient
demographics including age, gender, race, insurance,
distance from the hospital based on the zip code of
residence, relevant clinical history including comorbidities
(diabetes mellitus, coronary artery disease, congestive
cardiac failure, hypertension, or renal insufficiency or
failure), radiological studies including CT scans, and
1225
Results
Clinical Characteristics and Perforation
There were 380 patients who underwent an appendectomy
for acute appendicitis. Eighty-one (21%) patients were
found to have perforated appendicitis. Median age for the
overall population was 30 years. Patients with perforated
appendicitis were significantly older that the group with no
perforation. There was no difference in gender distribution
between the two groups. On physical exam, patients with
perforated appendicitis were noted to have a significantly
increased prevalence of right lower quadrant tenderness and
dysuria compared to the nonperforated group. There was no
difference in abdominal pain, nausea or vomiting, diarrhea,
anorexia, or mean heart rate, temperature, or WBC count
between the two groups. Patients found to have perforated
appendicitis underwent CT scans significantly more often
than patients who were found not to have a perforation.
Seventeen patients (28%) with perforated appendicitis were
noted to have evidence for the same on CT scan. Patients
with perforated appendicitis had a significantly longer
patient time (60 vs. 33 h, P<0.005). The mean duration
of symptoms prior to ER presentation for the entire
population was 38.5 h. There was no significant difference
in system time between the two groups. Patients with
perforated appendicitis were noted to live farther from the
hospital compared to the nonperforated group. Although
statistically significant, this result is unlikely to be a
clinically significant difference. There was no significant
difference in place of first examination or insurance status
between the two groups. As expected, the length of stay
was significantly longer for patients with perforated
appendicitis (Table 1).
Factors Associated with Patient Time
Patients older than 45 years of age were noted to have a
significantly longer patient time. There was no significant
difference based on gender, insurance status, anorexia,
nausea or vomiting, or peri-umbilical pain. Patients with
temperature more than 101.5 F on presentation had a
significantly longer patient time probably reflecting advanced disease on presentation. Distance from the hospital
did not influence patient time. Patients who were first
examined outside of the RPH ER were noted to have a
significantly longer patient time. Additionally, patients who
underwent CT scans on admission were also noted to have
a significantly longer patient time, suggesting that patients
1226
Overall N
Nonperforated
appendicitis
N (%a)
Mean age (median; rangeb)c,d
Women, N (%)e
Clinical exam, N (%)e
Abdominal pain
RLQ tenderness
Nausea/vomiting
Diarrhea
Anorexia
Dysuria
Median heart rate (range)e
Mean temperature (range)e
Mean WBC count (range)e
380
34 (30; 679)
149 (39)
299 (79)
31 (26; 779)
121 (40)
377 (99)
194 (51)
262 (69)
38 (10)
241 (63)
14 (4)
88 (48144)
98.8 (95.1104.4)
14.5 (336)
297 (99.3)
146 (49)
202 (68)
26 (9)
190 (63)
8 (3)
87 (47144)
98.8 (95.7104.4)
14.6 (4.928.1)
221 (58)
26 (11)
161 (54)
9 (5.5)
60 (74)
17 (28)
<0.005
<0.005
60 (48; 1.5336)
8.9 (6.5; 0.876)
24 (21.5; 189)
<0.005
0.82
0.04
257 (68)
117 (31)
84 (22)
2.9 (2; 015)
208
88
68
2
49
29
16
6
0.21
0.92
<0.005
CT scan, N (%)e
Performed
Perforated appendicitis
Mean delay in hours (median; range)c,d
Patient time
System time
Mean distance from hospital in miles (median; range)c,d
First examined, N (%)e
RPH ER
Outside RPH ER
Medicaid or self pay, N (%)e
Mean length of stay (median; range)c,d
(70)
(29)
(23)
(1; 010)
Perforated
appendicitis
81 (21)
44 (50; 381)
28 (35)
80
48
56
12
51
6
90
99.2
14.5
(98.7)
(59)
(69)
(15)
(63)
(7)
(60145)
(95.1104)
(325.3)
(60)
(36)
(20)
(5; 027)
P value
<0.005
0.34
0.61
0.03
0.97
0.10
0.39
0.04
0.15
0.06
0.45
Median and mean values are reported for variables that are not normally distributed
Based on chi-square
Characteristics
Age (years)
15
1545
4555
>55
Gender
Male
Female
Insurance
Medicaid or self pay
Other insurance
Temperature (F)
101.5
>101.5
Anorexia
No
Yes
Nausea or vomiting
No
Yes
Peri-umbilical and RLQ pain
No
Yes
Distance from the hospital
Less than 20 miles
More than or equal to 20 miles
Location of first examination
RPH ER
Outside RPH ER
CT performed
No
Yes
1227
Number
(24;
(24;
(36;
(24;
2336)
2336)
3168)
1.5336)
P value
70
177
51
51
35
34.5
48.6
47
215
134
38 (24; 2168)
39.4 (24; 3336)
0.57
84
265
40 (24; 1336)
33.2 (24; 2336)
0.34
307
21
0.009
53
227
0.38
106
243
0.87
235
105
0.31
184
165
37 (24; 1.5336)
39.8 (24; 3336)
0.25
239
108
<0.005
147
202
0.05
0.006
1228
Table 3 Time from registration
in the ER to surgery: system
time
RPH ER
Outside RPH ER
CT performed
No
Yes
Discussion
In an analysis of patients undergoing appendectomy for
acute appendicitis in a rural population, we found that (1)
CT scans significantly contribute to system delays in the
Number
71
180
52
52
8.5
9.9
9
8.9
(6.6;
(6.2;
(6.7;
(6.8;
0.6529.9)
0.35126.9)
0.975.7)
0.8113)
P value*
0.68
218
137
0.16
84
271
0.22
231
96
9 (6.5; 0.740)
12 (6.7; 0.9127)
0.22
21
308
0.65
167
182
0.01
228
127
0.01
247
102
0.59
107
19
0.01
43
306
<0.005
239
112
10 (7.2; 1.564)
9.5 (3.9; 0.4113)
<0.005
149
206
<0.005
(2/28)
7%
(10/94)
1 1/2 to 2 days
(8/32)
2 to 4 days
(28/66)
4 to 8 days
(12/34)
1229
8%
11%
25%
42%
35%
(2/6)
33%
(2/21)
(8/56)
1 1/2 to 2 days
(5/16)
2 to 4 days
(16/44)
4 to 8 days
(9/22)
(1/2)
9%
P <0.005
0%
P = 0.001
(3/35)
7%
(2/38)
14%
(3/16)
31%
8%
5%
19%
(12/22)
36%
41%
50%
55%
(3/12)
25%
(1/4)
25%
1230
(1/19)
5%
(6/49)
1 1/2 to 2 days
(1/12)
2 to 4 days
(9/35)
4 to 8 days
(9/19)
(0/1)
(0/7) 0%
P= 0.001
(2/31)
6%
(1/33)
12%
(2/13)
8%
P= 0.001
6%
3%
15%
(10/17)
25%
47%
0%
(2/9)
(1/4)
59%
22%
25%
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