Introduction:
Acute appendicitis remains the most common general surgical emergency seen in most hospitals and the most common cause of acute abdomen requiring surgical intervention.
Aim:
The aim was to study the intraoperative features and postoperative outcomes of appendicular perforation in adults.
Objectives:
First, to study the incidence, clinical presentation, and complications of perforated appendicitis in a tertiary care hospital. Second, to study morbidity and mortality in an operated case of perforated appendicitis.
Materials and Methods:
This prospective observational study was conducted at a tertiary care centre in a government setup from August 2017 to July 2019. Data were collected from patients (N=126) who had an intraoperative finding of perforated appendicitis. The inclusion criteria are as follows: patients over the age of 12 with a perforated appendix, as well as any patients with intraoperative findings like perforated appendicitis, gangrenous perforated appendicitis, or a disintegrated appendix. The exclusion criteria are as follows: all patients with appendicitis below 12 years of age with perforated appendicitis; all patients with appendicitis with intraoperative findings of acute nonperforated appendicitis; and all patients with intraoperative findings of an appendicular lump or mass.
Results:
Perforation was found in 13.8% of the cases of acute appendicitis in this study. With a mean age of 32.5 years, the most common age of presentation in perforated appendicitis was 21–30 years. The most prevalent presenting symptom in all patients (100%) was abdominal pain, followed by vomiting (64.3%) and fever (38.9%). Patients with perforated appendicitis had a 72.2% complication rate. Peritoneal pollution of more than 150 ml was linked to a 100% increase in morbidity and mortality (54.5%). The mean duration of the hospital stay in patients with a perforated appendix was 7.28±5 days. Surgical site infection (42%) was the most common early complication, followed by wound dehiscence (16.6%), intestinal obstruction (1.6%), and faecal fistula (1.6%). The most common late complications were intestinal obstruction (2.4%), intra-abdominal abscess (1.6%), and incisional hernia (1.6%). The mortality rate in patients with perforated appendicitis was 4.8%.
Conclusion:
To conclude, prehospital delay was an important factor contributing to appendicular perforation and leading to adverse outcomes. A higher rate of morbidity and prolonged duration of hospital stay were seen in patients with delayed presentation, with features of generalised peritonitis and perforation of the base of the appendix. Delayed presentations in as elderly population with underlying co-morbid conditions associated with severe peritoneal contamination were associated with higher mortality (26%) in perforated appendicitis. Conventional surgery and open procedures remain the preferred approach in a government setup like ours where laparoscopy may not be available during odd hours. Since this study was done over a short duration, certain long-term outcomes could not be assessed. Hence, there is still a need for further studies.
Keywords: complications, gastroenterology, general surgery, perforated appendicitis, tertiary care hospital
Introduction
Highlights
The incidence of perforation in acute appendicitis was 13.8%.
Male preponderance was seen with a male : female ratio of 1.47 : 1.
Only a quarter of patients presented within 48 h of the onset of their first symptoms.
Length of hospital stay was increased significantly.
Surgical site infections and wound dehiscence were the main early complications.
The Mortality rate was less than 5%.
Acute appendicitis remains the most common general surgical emergency seen in most hospitals and the most common cause of acute abdomen requiring surgical intervention. Most commonly, patients present with complaints like fever, pain in the abdomen, and vomiting. Delay in presentation leads to complications like abscess formation, gangrene, perforation, and peritonitis. The proportion of perforations increases with the increasing duration of symptoms1. Although the mortality rate has reduced dramatically in recent years, the morbidity rate associated with appendicular rupture remains high2.
The present prospective observational study examines the intraoperative features and postoperative outcomes of adult appendicular perforation. The objectives of this study were to observe the incidence of perforated appendicitis at a tertiary care hospital, as well as the clinical presentation, morbidity and mortality, duration of hospital stay, and complications in perforated appendicitis patients.
Materials and Methods
After receiving approval from the Institutional Ethical Committee, this prospective observational study was conducted at a tertiary care centre in a government setting for 2 years, from August 2017 to July 2019. According to hospital protocol, all patients with acute appendicitis who were suspected of having perforated appendicitis or peritonitis related to perforated appendicitis were admitted to the emergency care unit. All of these individuals were then posted for emergency surgery after undergoing ultrasonography and haematological testing. After obtaining informed consent, data were collected from patients (N=126) who had an intraoperative finding of perforated appendicitis.
The inclusion criteria are as follows: patients over the age of 12 with a perforated appendix, as well as any patients with intraoperative findings like perforated appendicitis, gangrenous perforated appendicitis, or a disintegrated appendix.
The exclusion criteria are as follows: all patients with appendicitis below 12 years of age with perforated appendicitis; all patients with appendicitis with intraoperative findings of acute nonperforated appendicitis; and all patients with intraoperative findings of an appendicular lump or mass.
This work has been reported in line with the STROCSS criteria3.
Results
Perforation was found in 13.8% of the cases of acute appendicitis in our study. With a mean age of 32.5 years, the most common age of presentation in perforated appendicitis was 21–30 years.
Male predominance was seen, with a male : female ratio of 1.47 : 1, and perforated appendicitis was more common in rural areas.
The co-morbid conditions commonly observed in the present study were diabetes mellitus and stroke. We also had two pregnant females with perforated appendicitis in their second trimester of pregnancy.
24.6% of patients presented within 48 h of the commencement of the first symptom. The most prevalent presenting symptom in all patients (100%) was abdominal pain, followed by vomiting (64.3%) and fever (38.9%).
The most prominent clinical symptom was tenderness in the right iliac fossa with guarding.
In 60% of cases, ultrasound findings of perforated appendicitis were correlated with intraoperative findings of perforated appendicitis.
A grid-iron incision (43.6%) and McBurney’s incision (31.8%) were used to treat perforated appendicitis with localised peritonitis, whereas the midline incision was used to treat patients with generalised peritonitis (19.9%). When expertise was available, a laparoscopic procedure was performed in 4% of cases.
Patients with perforated appendicitis had a 72.2% complication rate.
Peritoneal collection of more than 150 ml was linked to a 100% increase in morbidity and mortality (54.5%).
The retrocaecal (54.7%) was the most prevalent location for a perforated appendix, with the body of the appendix being the most common site of perforation (51.6%).
Perforation of the base was linked to increased morbidity and adverse outcomes.
If the base and caecum were healthy, an appendectomy was performed in 96% of patients with perforated appendicitis. Resection procedures such as hemicolectomy (2.4%) or tube cecostomy were required for patients with concomitant caecal involvement and gross contamination (1.6%). 73.8% underwent abdominal drain placement during surgery.
The histopathology report was consistent with the intraoperative finding of perforated appendicitis in 98.4% of patients while in two patients, the histopathology report was unavailable as no specimen could be sent as the appendix was completely disintegrating.
The mean duration of the hospital stay in patients with a perforated appendix was 7.28±5 days.
Surgical site infection (42%) was the most common early complication, followed by wound dehiscence (16.6%), intestinal obstruction (1.6%), and faecal fistula (1.6%). The most common late complications were intestinal obstruction (2.4%), intra-abdominal abscess (1.6%), and incisional hernia (1.6%). The mortality rate in patients with perforated appendicitis was 4.8%.
Discussion
Acute appendicitis is the most common surgical emergency. When acute appendicitis progresses to perforation, the consequences often lead to prolonged and difficult convalescence or even death. A major cause of increased morbidity in perforated appendicitis is the delayed presentation with associated underlying co-morbidities4.
The data presented above suggest that the incidence of perforated appendix in adults was 13.8% (126 out of 914 emergency appendicectomies); similar findings were noted in studies conducted by Drake et al.5 (15.8% incidence) and Shirah et al.6 (14.11% incidence) in study populations of 9048 and 2573, respectively.
The findings suggest that the most common age group presenting with perforated appendicitis was 21–30 years of age (31.8%) with the youngest patient of 12 years and oldest 78 years, with the mean age of 32.5 years (Table 1). These findings were in accordance with studies done by Ghag et al. 7 and Balogun et al. 8 where the most common age group was also 21–30 years of age. Data suggests the male preponderance with male : female ratio of 1.47 : 1, thus, correlating with studies done by Drake et al.5, Shirah et al.6, Akhil 9, and Pramod and Prakashkumar10.
Table 1.
Age distribution of perforated appendicitis patients.
| Age distribution (years) | N (%) |
|---|---|
| 12–20 | 37 (29.3) |
| 21–30 | 40 (31.8) |
| 31–40 | 16 (12.7) |
| 41–50 | 10 (07.9) |
| 51–60 | 9 (07.1) |
| 61–70 | 10 (07.9) |
| 71–80 | 4 (03.2) |
| Grand total | 126 (100) |
The data presented in Table 2 suggests that 6.4% of patients had some underlying co-morbid conditions. which were diabetes mellitus (1.6%), cardiovascular accidents (1.6%), bronchial asthma (0.8%), chronic obstructive pulmonary disease (0.8%), mitral stenosis with mitral regurgitation and atrial fibrillation (0.8%), and hypertension (0.8%). Surgical site infections and wound dehiscence were seen in patients with diabetes mellitus. The mortality rate in these patients with underlying co-morbidities was found to be 67%. Similar findings were noted by Andersson et al.11 and Drake et al.5.
Table 2.
Co-morbidities of patients at the time of presentation.
| Co-morbidities | N |
|---|---|
| Diabetes mellitus | 2 |
| Hypertension | 1 |
| Stroke | 2 |
| COPD | 1 |
| Bronchial asthma | 1 |
| Heart disease – MS, MR, AF, CCF | 1 |
AF, atrial fibrillation; CCF, congestive cardiac failure; COPD, chronic obstructive pulmonary disease; MS, mitral stenosis; MR, mitral regurgitation.
The findings indicate that the mean duration from onset of the first symptom to presentation to the hospital was 3.7±2.3 days. 62.7% patients presented to the hospital 3–5 days after the onset of the first symptom, while only 24.6% presented within 48 h of the onset of the first symptom (Table 3). The morbidity seen in patients with delayed presentation was high (85%) as compared to patients presenting early (32.2%). Mortality was seen only in patients presenting late with underlying co-morbid conditions. These findings correlate with studies done by Omari et al.12, Sirikurnpiboon et al. 13, Ghag et al. 7, Shirah et al. 6, Anandaravi et al.14, and Balogun et al.8. Thus, delay in surgical intervention for perforated appendicitis in patients presenting late to the emergency department is a significant factor influencing outcomes in the postoperative period.
Table 3.
Associated conditions at the time of presentation.
| Associated conditions | N |
|---|---|
| Pregnancy | 2 |
| Deaf and mute | 1 |
| Albinism | 1 |
| Carcinoma prostrate | 1 |
The most common symptom in patients with perforated appendicitis was pain in the abdomen (Table 4), seen in all patients (100%) followed by vomiting (64.3%), and fever (38.9%), thus correlating with the findings observed by Paidipelly et al.15, Tantarattanapong et al.16, and Pramod and Prakashkumar10. Risk factors for acute and perforated appendicitis in a semirural population: a retrospective study. The most common sign seen in 125 patients (99%) was tenderness in the right iliac fossa (Table 5), followed by guarding in 78 patients (61.9%), and tachycardia in 71 patients (56.3%). Patients with signs of generalised peritonitis were found intraoperatively to have moderate-to-severe peritoneal contamination and higher rates of complications postoperatively. These observations coincide with studies by Sirikurnpiboon et al.13, Tantarattanapong et al.16, and Pramod and Prakashkumar10.
Table 4.
Symptoms of perforated appendicitis.
| Symptoms | N (%) |
|---|---|
| Pain in abdomen | 126 (100) |
| Vomiting | 81 (64.3) |
| Fever | 49 (38.9) |
| Loose stools | 6 (04.7) |
| Not passed stool | 3 (02.4) |
| Distension of abdomen | 2 (01.6) |
Table 5.
Signs of perforated appendicitis.
| Signs | N (%) |
|---|---|
| Tenderness in RIF | 125 (99) |
| Guarding | 78 (61.9) |
| Tachycardia | 71 (56.3) |
| Rebound tenderness | 50 (39.7) |
| Febrile | 33 (26.2) |
| Absent bowel sounds | 14 (11.1) |
| Abdominal distension | 12 (09.5) |
| Hypotension | 8 (06.3) |
| Rigidity | 4 (03.2) |
RIF, Right iliac fossa
The interpretation of the data (Table 6) suggests that 89 patients (78.1%) had less than 50 millilitre (mild) peritoneal collection, 14 patients (12.3%) had 50–150 ml (moderate) peritoneal collection, and 11 patients (9.6%) had more than 150 ml (severe) peritoneal collection, which was found similar to Ghag et al.7. The rate of complications in patients with mild, moderate, and severe peritoneal collection was 42, 80, and 100%, respectively. The mortality rate was 54.5% in patients with severe peritoneal contamination. Thus, severe peritoneal collection is associated with a higher rate of morbidity and mortality in the postoperative period. The most common position of perforated appendicitis was retrocaecal (54.7%) followed by pelvic (35.7%) (Table 7). This finding coincides with studies conducted by Naderan et al.17, Ghag et al.7, and Paidipelly et al. 15. The retrocaecal position of the appendix often poses a diagnostic difficulty, both clinically and radiologically, which leads to delayed diagnosis and is thus most commonly associated with appendicular perforation and peritonitis.
Table 6.
Amount of peritoneal collection.
| Peritoneal collection | N (%) |
|---|---|
| Less than 50 ml | 89 (78.1) |
| 50–150 ml | 14 (12.3) |
| More than 150 ml | 11 (09.6) |
| Grand total | 114 (100) |
Table 7.
Intraoperative position of the appendix.
| Position of appendix | N (%) |
|---|---|
| Retrocaecal | 69 (54.7) |
| Pelvic | 45 (35.7) |
| Ileal | 4 (03.2) |
| Postileal | 5 (04) |
| Subhepatic | 3 (02.4) |
| Grand total | 126 (100) |
Appendicectomy was the surgical procedure performed in 96% of cases (Table 8). In patients with perforation of the base of the appendix, three patients underwent right hemicolectomy (2.4%) and two were managed by a tube cecostomy (1.6%). One patient was managed initially by appendicectomy but developed a faecal fistula; hence, she underwent an ileo-caecal resection with ileo-ascending anastomosis and an ileostomy, which was complicated by surgical site infection managed by antibiotics and daily dressing. The patient was discharged after recovery. Out of the three patients that underwent right hemicolectomy, two patients died due to anastomotic leak and sepsis; the third patient had surgical site infection and was discharged after recovery. Tube cecostomy in two patients were complicated by surgical site infection, managed by removal of the cecostomy followed by spontaneous closure. Thus, the highest morbidity (67%) and mortality (50%) were seen in patients with perforation of the base of the appendix. These findings matched those of Ghag et al.7. Other studies do not mention the procedure done for the management of perforated appendicitis (Fig. 1).
Table 8.
Procedure performed.
| Surgery | N (%) |
|---|---|
| Appendicectomy | 121 (96) |
| Right hemicolectomy | 3 (02.4) |
| Tube cecostomy | 2 (01.6) |
| Grand total | 126 (100) |
Figure 1.
Gangreous appendix.
Data suggest intraoperative evidence of Fecolith (Fig. 2) in 10.3% patients with perforated appendicitis, which is almost identical to the study by Naderan et al.17. The incidence of faecoliths is high in other studies, probably due to a smaller sample size in these studies. The aetiology often appears to be due to an appendicolith obstructing the lumen, leading to infection or inflammation of the Peyer’s patches, finally leading to intraluminal obstruction, venous and arterial congestion, and perforation. At surgery, 73.8% patients with perforated appendicitis had intra-abdominal drain placement; results are similar with Pramod and Prakashkumar10. Drains were needed in patients with peritoneal contamination requiring peritoneal lavage and drainage (Table 9).
Figure 2.
Perforation at the body of appendix with fecolith.
Table 9.
Intra-abdominal drain insertion.
| Drain kept | N (%) |
|---|---|
| Yes | 93 (73.8) |
| No | 33 (26.2) |
| Grand total | 126 (100) |
Histopathology co-relation was seen in 98% cases (Table 10). A histopathology report was not available in two cases where specimens could not be sent due to a completely disintegrating appendix. One of these patients developed a faecal fistula postoperatively which was managed conservatively. There was no evidence of a mucocele of the appendix or a carcinoid tumour in any specimen. A higher value in our study as opposed to Akhil9. can be attributed to the macroscopic perforation of the appendix sent for histopathology (Figs 3–7).
Table 10.
Histopathology correlation.
| Histopathology | N (%) |
|---|---|
| Gangrenous | 11 (08.7) |
| Nongangrenous perforated | 113 (89.7) |
| Tip | 44 (35) |
| Body | 65 (51.6) |
| Base | 4 (03.1) |
| No report available | 2 (01.6) |
| Grand total | 126 (100) |
Figure 3.
Disintegrated appendix with perforation at the base.
Figure 7.
Faecal fistula.
Figure 4.
Surgical site infection.
Figure 5.
Wound dehiscence.
Figure 6.
Radiograph showing postoperative intestinal obstruction.
The mean length of hospital stay from the data was 7.28±5 days (Table 11) which matched with studies done by Omari et al 12, Sirikurnpiboon et al. 13, and Tantarattanapong et al. 16.
Table 11.
Duration of hospital stay.
| Duration of hospital stay (days) | N (%) |
|---|---|
| 0–2 | 5 (03.9) |
| 3–5 | 44 (34.9) |
| 6–8 | 48 (38.1) |
| 9–11 | 14 (11.1) |
| 12–14 | 6 (04.8) |
| 15–17 | 4 (03.2) |
| 21–23 | 2 (01.6) |
| 24–26 | 2 (01.6) |
| 36–38 | 1 (00.8) |
| Grand total | 126 (100) |
The overall complication rate was 72.3% (Table 12). The most common early complication was surgical site infection (42%) followed by wound dehiscence (16.7%), intestinal obstruction (1.6%) and faecal fistula (1.6%), and late complications were intestinal obstruction (2.4%), intra-abdominal abscess (1.6%) and incisional hernia (1.6%). A similar higher rate of complications was seen in a study done by Omari et al.12 and Ghag et al.7. The mortality rate of 4.8% in patients with perforated appendicitis (Table 12) shows similar results as studies done by Omari et al.12. Out of the six patients that died in our study, three died due to septicaemia, one died due to renal failure, one died due to congestive cardiac failure, and one died due to Acute respiratory distress syndrome. All patients that died were above 50 years of age. These patients had delayed presentation, that is, 72 h after onset of the first symptom, and intraoperatively had extensive purulent peritoneal contamination.
Table 12.
Complications in perforated appendicitis patients.
| Complications | N (%) |
|---|---|
| Early | |
| Surgical site infection | 53 (42) |
| Wound dehiscence | 21 (16.6) |
| Intestinal obstruction | 2 (01.6) |
| Faecal fistula | 2 (01.6) |
| Death | 6 (04.8) |
| Late | |
| Intestinal obstruction | 3 (02.4) |
| Intra-abdominal abscess | 2 (01.6) |
| Incisional hernia | 2 (01.6) |
| Grand total | 91 (72.2) |
Conclusion
The prehospital delay was an important factor contributing to appendicular perforation and leading to adverse outcomes. A higher rate of morbidity and prolonged duration of hospital stay were seen in patients with delayed presentation, with features of generalised peritonitis and perforation of the base of the appendix. Delayed presentations in an elderly population with underlying co-morbid conditions associated with severe peritoneal contamination were associated with higher mortality (26%) in perforated appendicitis.
Conventional surgery and open procedures remain the preferred approach in a government setup like ours where laparoscopy may not be available during odd hours. Since our study was done over a short duration, certain long-term outcomes could not be assessed. Hence, there is still a need for further studies.
Ethical approval
Institutional Ethical Committee approval is taken.
Consent
Written informed consent was obtained from the patient for the publication of this original research article and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
sources of funding
No funding received.
Author contribution
Dr K.P.: study concept, data collection, data analysis, writing the paper. Dr A.K.: study concept, data collection, data analysis, writing the paper. Dr S.J.: study concept, data collection, data analysis, writing the paper. Dr V.G.: data collection, data analysis, writing the paper.
Conflicts of interest disclosure
None declared.
Research registration unique identifying number (UIN)
As this is a Observational Prospective Cohort study and not a Human study, registration not done.
Guarantor
No.
Provenance and peer review
Not commissioned, externally peer-reviewed
Footnotes
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
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