0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Time to Appendectomy and Risk of Perforation in Acute Appendicitis

Frederick Thurston Drake, MD, MPH1,2,3; Neli E. Mottey, BS1,2; Ellen T. Farrokhi, MD, MPH2,4; Michael G. Florence, MD5; Morris G. Johnson, MD6; Charles Mock, MD, PhD1,3; Scott R. Steele, MD7; Richard C. Thirlby, MD8; David R. Flum, MD, MPH1,2
[+] Author Affiliations
1Department of Surgery, University of Washington Medical Center, Seattle
2University of Washington Surgical Outcomes Research Center, Seattle
3Department of Global Health, University of Washington, Seattle
4Providence Regional Medical Center, Everett, Washington
5Department of Surgery, Swedish Medical Center, Seattle, Washington
6Skagit Valley Hospital, Mt Vernon, Washington
7Department of Surgery, Madigan Army Medical Center, Ft Lewis, Tacoma, Washington
8Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
JAMA Surg. 2014;149(8):837-844. doi:10.1001/jamasurg.2014.77.
Text Size: A A A
Published online

Importance  In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy.

Objective  To evaluate whether there is an association between time and perforation after patients present to the hospital.

Design, Setting, and Participants  Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations.

Main Outcomes and Measures  The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital and operating room (OR) start time. The relationship between in-hospital time and perforation was adjusted for potential confounding using multivariate logistic regression. Additional predictors of interest included sex, age, number of comorbid conditions, race and/or ethnicity, insurance status, and hospital characteristics such as community type and appendectomy volume.

Results  A total of 9048 adults underwent appendectomy (15.8% perforated). Mean time from presentation to OR was the same (8.6 hours) for patients with perforated and nonperforated appendicitis. In multivariate analysis, increasing time to OR was not a predictor of perforation, either as a continuous variable (odds ratio =  1.0 [95% CI, 0.99-1.01]) or when considered as a categorical variable (patients ordered by elapsed time and divided into deciles). Factors associated with perforation were male sex, increasing age, 3 or more comorbid conditions, and lack of insurance.

Conclusions and Relevance  There was no association between perforation and in-hospital time prior to surgery among adults treated with appendectomy. These findings may reflect selection of those at higher risk of perforation for earlier intervention or the effect of antibiotics begun at diagnosis but they are also consistent with the hypothesis that perforation is most often a prehospital occurrence and/or not strictly a time-dependent phenomenon. These findings may also guide decisions regarding personnel and resource allocation when considering timing of nonelective appendectomy.

Figures in this Article

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Figures

Place holder to copy figure label and caption
Figure.
Percentage of Perforation by Deciles of Time From Presentation to Operating Room Start

Patients were ordered by time to treatment and divided into deciles. Percentage of perforation and 95% CIs were calculated for each decile. The range of elapsed time from hospital presentation to operating room start time is shown for each decile (ie, the shortest time and the longest time for each decile).

Graphic Jump Location

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
Jobs
JAMAevidence.com

Users' Guides to the Medical Literature
Acute Appendicitis

The Rational Clinical Examination
Make the Diagnosis: Appendicitis, Adult

brightcove.createExperiences();