Appendicitis is a Severe Disease in Elderly Patients: A Twenty-Year Audit

Abstract

Background and Objectives:

Life expectancy has increased substantially. Elderly patients currently represent a large part of patients requiring emergency abdominal surgery. The aim of this study was to evaluate the postoperative outcomes of elderly patients who underwent appendectomy in a single French tertiary center.

Methods:

We retrospectively reviewed the medical records of all patients who underwent appendectomy for acute appendicitis between January 1, 1994 and December 31, 2014. We used the French threshold of ≥ 75 y-old to define elderly patients. Hence, elderly patients who underwent appendectomy were compared to the younger group.

Results:

During the study period, 2,060 consecutive patients underwent appendectomy for acute appendicitis. Laparoscopic appendectomy was performed in 52% of cases. Similar rates of laparoscopic approach were recorded in both groups, but conversion to open surgery was six times more frequent in elderly patients (17% vs. 3%; P < .0001). A higher incidence of complicated appendicitis was observed in the elderly group (63% vs. 13.6%; P < .0001). Complications occurred more frequently in the elderly group (46% vs. 8%; P < .0001). 30-d mortality was 0.15% for patients < 75 y and 6.15% for elderly patients (P < .0001). Unsuspected presence of an appendiceal neoplasm was higher (7.7%) in the elderly population.

Conclusion:

This study highlights the fact that appendicitis in the elderly is associated with a higher rate of complicated appendicitis, morbidity, and mortality.

INTRODUCTION

Life expectancy in Europe has increased greatly.¹ The proportion of the elderly population requiring surgery has increased even faster than the rate of population aging, and elderly patients currently account for a non-negligible part of surgical practices.² The incidence of appendicitis remains constant in most Western countries³ and forms a substantial economic burden due to the large number of patients.⁴ Surgeons ordinarily think of appendectomy as a simple procedure from which patients recover quickly. Although this is frequently the case for most adult patients, caution should be used when extrapolating this belief to the care of geriatric patients, especially during the management of the more complex situation of perforated appendicitis and peritonitis. Indeed, elderly patients were found to have higher incidence of complicated appendicitis with reported rates of perforation as high as 70%⁵ and of morbidity as high as 48%.⁶

The aim of the present study was to evaluate the outcome of appendectomy for acute appendicitis in patients 75 y of age and older. We performed a 20-y audit from a single tertiary center in Paris, France. The analysis of more than 2,000 patients operated on consecutively allowed a reliable evaluation of both short-term morbidity and mortality as well as the identification of risk factors for poor outcomes in the elderly population.

MATERIALS AND METHODS

We reviewed the medical records of all patients who underwent appendectomy for acute appendicitis between January 1, 1994 and December 31, 2014. All patients with a diagnosis of appendicitis underwent surgery because the nonoperative management, which may be an alternative for uncomplicated appendicitis,⁷ has never been adopted at our institution. The following data were obtained for each patient: age, sex, body temperature on admission, white blood cell count, level of C-reactive protein, lower right abdominal tenderness, mental confusion and/or disorientation prior to surgery, associated illnesses, American Society of Anesthesiologists (ASA) classification, imaging prior to surgery, surgery type, operative findings, intraoperative complications, postoperative complications, the need for postoperative intensive care unit admission, pathology results, and length of postoperative hospital stay. This retrospective study was approved by the institutional review board.

All procedures were performed in the emergency department by the chief resident or under the supervision of the attending surgeon. We considered appendicitis as complicated when the surgeon described the presence of a gangrenous or perforated appendix as well as an intra-abdominal abscess. In cases of pelvic abscess or localized peritonitis antibiotics were continued for 3 to 5 d. Postoperative complications were defined as any deviation from the normal postoperative course during the first 30 postoperative days. Postoperative complications were graded as related or unrelated to surgical site. Mortality refers to 30-d or in-hospital mortality. Postoperative infections were classified as wound infection, intra-abdominal infection, pulmonary infection, or septicemia. The age-adjusted Charlson comorbidity index was retrospectively calculated for patients ≥ 75 y-old.^8,9

Data Analysis

For this study, we used the French threshold of ≥ 75 y-old to define elderly patients.^10,11 Then we analyzed the study variables twice. First, elderly patients (≥ 75 y) who underwent appendectomy were compared to the younger group (< 75 y). For the second analysis, elderly patients were divided by age: younger than 85 y or 85 y or more, based on a previous report for major colorectal surgery.¹²

Statistical Analysis

Quantitative variables are expressed as means and standard deviation or median and range; qualitative variables are presented as total number of events and percentage. Continuous variables were compared between groups with Student's t test or Wilcoxon-Mann-Whitney test, as appropriate. Categorical variables were compared with χ2 or Fisher exact test. A P value of < 0.05 was considered significant. Statistical analyses were performed using SPSS version 21 (SPSS Inc., Chicago, IL).

RESULTS

During the study period 2,060 consecutive patients underwent appendectomy for acute appendicitis in our department. Median age was 30 y (range 10–93); 55.4% were males. Stratification by age yielded 65 elderly patients (3.2%) and 27 patients aged ≥ 85 y (1.3%). Both groups had a significant female predominance. Preoperative patient data are presented in Table 1.

Table 1.

Patients' Demographics, Operation Method, Presence of Neoplasia, Short-term Complications, and Mortality

	Patients < 75 y (n = 1995)	Patients ≥ 75 y (n = 65)	P
Sex, woman, n (%)	902 (45.1%)	37 (56.9%)	0.040
Age, median (range)	29.5 (10–74.6)	83 (75–93)
ASA score, n (%)
1 or 2	1836 (92%)	40 (62%)	< 0.0001
≥3	159	22	< 0.0001
Laparoscopy	1040 (52%)	30 (46%)	0.210
Conversion rate (%)	60 (3%)	11 (17%)	< 0.0001
Complicated appendicitis, n (%)	259 (13%)	41 (63%)	< 0.0001
Presence of neoplasm on histology, n (%)	19 (1%)	5 (8%)	0.001
Adenocarcinoma	3 (0.15%)	2 (3.1%)	0.01
Neuroendocrine tumor	13 (0.65%)	0
Morbidity, n (%)
Overall	161 (8%)	30 (46%)	< 0.0001
Related to surgical site	128 (6.4%)	21 (32.4%)	< 0.0001
Unrelated to surgical site	49 (2.5%)	15 (23.1%)	< 0.0001
Postoperative infection, n (%)
Overall	107 (5.4%)	15 (23.1%)	< 0.0001
Wound infection	52 (2.6%)	10 (15.4%)	< 0.0001
Intra abdominal abscess	35 (1.8%)	3 (4.6%)	0.112
Pulmonary	9 (0.5%)	1 (1.5%)	0.271
Septicemia	11 (0.6%)	1 (1.5%)	0.316
Need for ICU after surgery, n (%)	18 (0.9%)	14 (21.5%)	< 0.0001
30-d mortality, n (%)	3 (0.2%)	4 (6.2%)	< 0.0001

ASA, American Society of Anesthesiologists; ICU, intensive care unit.

Over the 20-y period, the mean number of appendectomies performed by year was the same but the proportion of patients beyond 65 y-old gradually increased. Laparoscopic appendectomy was performed in 52% of cases. Surgical practices have gradually evolved during the study period and laparoscopy became the standard approach in 2006. Similar rates for the use of a laparoscopic approach were recorded in all groups (52% vs. 46%; P = .21). However, between-group conversion rates differed significantly: laparoscopy was converted to open appendectomy in 17% of the elderly group compared to 3% of the nonelderly group (P < .0001).

A significantly higher incidence of complicated appendicitis was observed in the elderly group (63% vs. 13.6%; P < .0001) (Figure 1). Overall morbidity was 9.3%, but complications occurred more frequently in the elderly group compared with the younger group (46% vs. 8%; P < .0001). The rate of infectious complications was higher in the elderly group (23% vs. 5.4%; P < .0001) and it was mainly related to a higher rate of wound infection. Seven patients died after appendectomy. Overall 30-d mortality was 0.1% for patients younger than 75 y and 6.1% for elderly patients (P < .0001). Acute peritonitis resulting in multiple organ failure was the cause of the two deaths observed in the younger group. Five elderly patients died after appendectomy during the study period, two of them presented generalized acute peritonitis whereas the other three developed cardiac arrhythmia after surgery and died from cardiovascular collapse. Finally, the unsuspected presence of an appendiceal neoplasm was considerably higher in the elderly population (7.7% vs. 0.9%; P = .001), among whom 3.1% were adenocarcinomas. Table 1 summarizes intraoperative characteristics and postoperative outcomes.

Figure 1.

Percentage of perforated appendicitis, overall complication rate and mortality by age.

Subgroup Analysis of Patients Older than 75 y

Results of logistic regression show that the incidence of complications was not dependent on coexistent illness but significantly related with the open surgical approach (odds ratio (OR) 9.3 [95% CI, 1.77 – 48.9]; P = .008) and surgery for complicated appendicitis (OR 6.9 [95% CI, 1.45 – 34.3]; P = .015).

Surgical delay and coexistent illness did not influence the rate of complicated appendicitis, while the only factor independently related to complicated appendicitis in the elderly group was the presence of abdominal tenderness at admission (OR 8.3 [95% CI, 1.64 – 42.3]; P = .011) (Table 2).

Table 2.

Factors Related to Complicated Appendicitis in the Elderly Group (≥75). Univariate and Multivariate analysis

	Univariate Analysisb			Multivariate Analysis
	Complicated Appendicitis (n = 41)	Uncomplicated Appendicitis (n = 20)	P	OR [95% CI]	P
Sex, woman (n, %)	25 (61%)	12 (60%)	0.579
ASA score ≥ 3 (n, %)	16 (39%)	5 (25%)	0.212
Charlson score ≥ 3 (n, %)	13 (32%)	12 (60%)	0.034	0.18 [0.04–0.78]	0.022
Symptoms on admission (n, %)
Confusion	5 (12%)	1 (5%)	0.351
Abdominal tenderness	30 (73%)	11 (55%)	0.039	8.33 [1.6–42.3]	0.011
Fever	22 (54%)	11 (55%)	0.481
Surgical delaya (n, %)
> 2 d	26 (63%)	11 (55%)	0.194	2.72 [0.6–11.3]	0.168
> 5 d	10 (24%)	4 (20%)	0.402
> 10 d	5 (12%)	4 (20%)	0.388

OR, odds ration; ASA, American Society of Anesthesiologists.

^aDuration of symptoms before appendectomy.

^bIncluded all factors with P < 0.2 in univariate analysis.

Comparative analysis of patients between 75 and 84 y old and those older than 85 y is summarized in Table 3. There were significantly more women in the group ≥ 85 y old (77.7% vs. 42%; P = .004), but no differences in clinical presentation at admission. There was no significant difference between the two groups with respect to the overall morbidity rate, surgical complications, and mortality rate.

Table 3.

Comparative Analysis Between Patients Older than 85 Years and Aged Between ≥ 75 Years and < 85 Years

	≥ 75 to < 85 years (n = 38)	Patients ≥ 85 years (n = 27)	P
Sex, woman, n (%)	16 (42%)	21 (77.7%)	0.004
ASA score, n (%)
1 or 2	19 (50%)	21 (77.7%)
≥ 3	19 (50%)	6 (22.2%)	0.003
Charlson score, n (%)
3 or 4	18 (47.4%)	7 (25.9%)	0.065
≥ 5	18 (47.4%)	17 (63%)	0.256
Symptoms on admission, n (%)
Confusion	3 (7.9%)	3 (11.1%)	0.489
Abdominal tenderness	26 (68.4%)	15 (55.5%)	0.070
Fever	22 (57.9%)	11 (40.7%)	0.054
Surgical delaya n (%)
> 2 d	18 (47.4%)	19 (70.4%)	0.065
> 5 d	6 (15.8%)	8 (29.6%)	0.175
> 10 d	4 (10.5%)	5 (18.5%)	0.316
Complicated appendicitis, n (%)	25 (65.8%)	16 (59.3%)	0.431
Length of hospital stay, d (mean)	9.6	7.5	0.886
Morbidity, n (%)
Overall	20 (52.6%)	10 (37%)	0.161
Related to surgical site	12 (31.6%)	3 (11%)	0.043
Unrelated to surgical site	13 (34.2%)	8 (29.6%)	0.454
Need for ICU after surgery,
n (%)	12 (31.6%)	2 (7.4%)	0.014
ICU length of stay, day	3	0.2	0.014
30-day Mortality, n (%)	3 (7.9%)	1 (3.7%)	0.445

ASA, American Society of Anesthesiologists; ICU, intensive care unit.

^aDuration of symptoms before appendectomy.

DISCUSSION

This study evaluated the outcomes of 2,060 consecutive appendectomies performed in a single tertiary center over a 20 y period. Postoperative complications were more frequently observed in the elderly group (≥ 75 y). This morbidity can be partially explained by a higher rate (5-times more frequently) of complicated appendicitis in this group. Multivariate analysis showed that the age over 75 y and an ASA score of ≥ 3 are independent risk factors for complicated appendicitis. Furthermore, mortality after appendectomy in the elderly was not a rare event (6.15%).

Delay for surgery after the onset of symptoms is considered to be an important prognostic factor in the management of acute appendicitis. In our study, 14% of elderly patients had a surgical delay ≥ 10 d. Although it is possible that the time taken for key decisions is longer in these patients, we could not raise conclusions with retrospective data. We found surgical delay and coexistent illness did not influence the rate of complicated appendicitis, whereas the presence of abdominal tenderness at admission did.

Some authors reported the use of score systems to be useful in distinguishing uncomplicated from complicated acute appendicitis based on clinical and imaging features,¹³ while others have shown that score systems are not able to differentiate complicated from uncomplicated appendicitis in the elderly population.¹⁴ Omari et al. recently found that the patient's prehospital time delay was the most important risk factor for perforation and postoperative complications although it was not dependent on the presence of comorbid diseases or in-hospital time delay.¹⁵ Nonetheless, acute abdominal pain in elderly patients is still considered to be challenging to diagnose and treat. Delay prior to correct treatment, due to an incorrect preliminary diagnosis from an emergency department consequent to low symptom specificity, has been shown to lead to increased morbidity.^16,17 The preoperative distinction between uncomplicated and complicated disease is challenging¹³ and it is particularly true in elderly patients.¹⁴ Thus, physicians who evaluate elderly patients with suspicion of acute abdominal pain must be well aware that their clinical impression of surgical illness is of greater importance than laboratory tests in the decision to request radiological assessment or surgical consultation.¹⁸

In this study, wound infection represented the main cause of morbidity in both groups. We have never used delayed primary closure as an option for contaminated surgical wounds. Although, it was considered to be a strategy to reduce the rate of surgical site infection, recent high-quality studies have not shown any significant benefit to using this strategy.^19,20 Moreover, delayed primary wound closure has its own disadvantages including pain from routine dressing, necessity for later wound suturing, and increase cost of treatments.

Our results and others have demonstrated that perforation worsens the condition dramatically resulting in higher rates of morbidity and mortality.^15,21 Some authors propose the early use of computed tomography (CT) scan to facilitate prompt diagnosis where presentation is more equivocal, which may eventually lead to improved surgical outcomes.^{13,15,21–23}

We observed that laparoscopy has become the surgical approach of choice since 2006. The utility and benefits of laparoscopic appendectomy were not well established in the surgical literature of the 1990s and early 2000s because some studies have demonstrated an increased risk of intra-abdominal infectious complications.^24,25 However, recent studies have shown that laparoscopic appendectomy is as safe as open appendectomy and provides the benefits of minimally invasive surgery.^26,27 Also, it was shown that hospital stay increases with age and is significantly longer for open versus minimally invasive appendectomy.⁴

Interestingly, age at time of procedure of greater than 85 y does not seem to correlate to worse postoperative outcomes. Patients over 85 y had significantly fewer comorbidities and lower complications rate. The only death observed in this group was related to a previous cardiovascular condition instead of septic complications or multivisceral failure. This can be partially explained by the fact that people living this long are generally healthier, with no self-reported diseases or functional impairment.²⁸

Several trials have shown that acute appendicitis can be treated with antibiotics.^7,29–32 Thus, in the face of the important rate of morbidity and mortality observed in elderly patients, one may be tempted to propose nonoperative management of acute appendicitis. However, initial trials were weakened by several design limitations,^29,31,32 and two recent randomized control trials failed to show noninferiority of antibiotic treatment for uncomplicated appendicitis.^7,30 These trials were designed for uncomplicated appendicitis, but the incidence of appendiceal perforation in acute appendicitis increases in patients above 60 y of age to reach 32%–72%^{5,15,21,33–36} (63% in the present study). Moreover, Vons et al. show that despite CT-scan assessment, 18% of patients were unexpectedly identified at surgery to have complicated appendicitis with peritonitis.⁷ Thus, we believe there is not enough evidence in the current literature to support nonoperative management in the elderly.

Our study has the usual limitations of a retrospective review. First, the number of patients above 75 y is relatively small. Also, treatment choices were made at the surgeon's discretion, with no consistent criteria for assignment of patients to laparoscopy or specific therapeutic courses. Finally, in order to highlight the risk factors leading to appendiceal perforation one would ideally collect clinical data before and not after perforation occurred. However, this study highlights the fact that appendicitis is not a pathology exclusively observed in young people and, in the elderly, is associated with a higher rate of complicated appendicitis, morbidity, and mortality.

CONCLUSIONS

Management of emergency surgical disease in the elderly requires that the surgeon combine everyday surgical practice with geriatrics. The elderly have specific characteristics that must be considered from the outset, both before and after surgery and until the end of hospital care. This study highlights the fact that appendicitis in the elderly is associated with a higher rate of complicated forms, morbidity, and mortality, as well as a higher presence of unsuspected appendiceal neoplasms. Geriatric comanagement programs have been associated with improved postoperative results after surgery, such as shorter length of stay, less mortality, and lower readmission rate.^37,38 Therefore, researchers should seek to develop management strategies tailored specifically to the elderly population.