Appendicitis 2006

It has been 120 years since Reginald Fitz first described the relationship between appendicitis with perforation presenting as a right lower quadrant abscess. During this time, thousands of articles have been written in an attempt to refine the diagnosis, workup, and treatment of this common disease.¹ Enhancement of our clinical acumen, the liberal use of CT imaging, improved antibiotic utilization and, in the last decade, the utility of laparoscopy for simple and complex appendicitis have all led to an improved patient outcome.

More recently, however, studies have begun to analyze hospital and physician utilization in the treatment of appendicitis. In 2004, a retrospective study of 126 children from the University of Michigan suggested that surgery for nonperforated, acute appendicitis could be delayed until daytime hours without increased complications, specifically perforation.² This highly quoted study, along with other similar studies has led to a change in practice patterns for many pediatric surgeons throughout the country.^3,4

These data have provoked several studies conducted this year in the adult surgical population with varying conclusions. These recent studies have focused on defining a safe time frame which surgery for appendicitis can be delayed without adverse outcome and to optimize hospital and physician utilization, specifically daytime surgery. Abou-Nukta et al, in a retrospective review of 380 patients with acute appendicitis, concluded that delays of 12 to 24 hours after presentation did not increase perforation rates or hospital stay.⁵ However, this study focuses only on patient symptoms after admission to the hospital, without addressing prehospital onset of symptoms, making their conclusions suspect. In another retrospective review of 219 patients, Bickell et al studied the timing of acute appendicitis from prehospital onset of symptoms to the time of surgery. This study concluded that rupture rates would rise significantly after 36 hours; this sends the unimplied message that it is safe to wait inside that time frame.⁶ A third large retrospective review also published this year, of 436 appendectomies, found that there was no difference in outcome of patients who waited 12 to 24 hours in the hospital without surgery versus those who were operated on in less than 12 hours. Once again, there were no data on the onset of symptoms.⁷

Beyond defining the appropriate time frame for delay of surgery, Styrud et al took this concept one step further in a prospective trial of using antibiotics versus surgery in acute appendicitis.⁸ They concluded that acute nonperforated appendicitis can be treated successfully with antibiotics. The caveats include the following: 18 patients in the antibiotic treated group required surgery within 24 hours of treatment; 14% of the same antibiotic-treated group developed recurrent symptoms of appendicitis in the first year.

Although the above 4 studies challenge the question of timing in the treatment of acute appendicitis, Temple et al published a study in the Annals of Surgery over a decade ago entitled, “The natural history of appendicitis in adults.”⁹ This highly referenced prospective study was designed at a time when hospital and physician resources were not as heavily scrutinized. Their conclusions stood then and they still stand today: “Delay in diagnosis and treatment increases the complication rates in appendicitis.”

In this issue of the Annals, Ditillo and colleagues revisit the question of the optimal timing for operative intervention in adults with acute appendicitis.¹⁰ The power of this study lies in several areas. First, it is one of the largest studies to date of over 1000 patients with very solid data accrual in both the prehospital onset of symptoms and the in-hospital setting to the time of surgery. This large database allows for a greater power in analysis with stratification of time lines and correlation with appendiceal pathology. Second, grading of the appendiceal pathology creates a spectrum that goes well beyond the simplistic, digital approach of the intact versus ruptured appendix. Moreover, this study shows that physical findings and CT results can predict progressive appendiceal pathology.

The heart of this study lies in the correlation between duration of symptoms and grade of appendiceal pathology. For example, when the total time interval of symptoms was less than 12 hours, 94% of patients had simple appendicitis, but 6% had perforation, phlegmon, or abscess. Are the 6% of patients with complicated appendicitis merely poor historians and, in fact, was their symptom duration much longer? Or does this suggest that there is, in fact, a wide variation in the natural history of this disease? And if your study population is large enough, will you identify this small subset of patients whose surgery can't be delayed?

As the authors conclude, any delay in surgery for acute appendicitis could be deleterious for the patient and recommend a prospective trial to give us the definitive answer. Again, the weakness of the study lies in the potential for author bias in a retrospective review and potential for difficulty in accurate data collection.

These data should have surgeons take pause, however, and reassess their practice patterns. As a practicing general surgeon still taking call, I am not comfortable putting such heavy reliability on the patient's capacity to tell me the exact timing of the onset of their symptoms. Second, I have been practicing long enough to see such wide variations in the timing of symptoms and surprising appendiceal pathology that I feel any delay of time is unwarranted. My comments are based on anecdote, but Ditillo and his colleagues at Yale have helped confirm my clinical suspicion.

As a profession, we have prided ourselves on always focusing on the patient's quality of life, not the surgeon's. As we are constantly scrutinized by society on our practice patterns, the message we must continue to send is: the patient is first, the convenience of the hospital staff and physicians is second. If I develop right lower quadrant pain with a low-grade fever and some mild nausea during my travels in New England, I'm going to head straight to Yale New Haven Hospital for my care. Maybe Fitz was ahead of his time when he included in the title of his classic article published in October 1886: “Perforating inflammation of the vermiform appendix: with special reference to its early diagnosis and treatment.”