Risk factors for postoperative morbidity following appendectomy in the elderly: a nationwide prospective cohort study
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A limited number of studies investigating perioperative risk factors associated with emergency appendectomy in elderly patients have been published to date. Whether older age may be associated with poorer outcomes following appendectomy is still a matter of debate. The primary aim of this study was to determine the predictors of postoperative morbidity following appendectomy in patients aged ≥ 65 years.
Data regarding all elderly patients who underwent emergency appendectomy from January 2017 to June 2018 admitted 36 Italian surgical departments were prospectively collected and analyzed. Baseline demographics and perioperative variables were evaluated. Uni- and multivariate analyses adjusted for differences between groups were carried out to determine possible predictors of adverse outcomes after appendectomy.
Between January 2017 and June 2018, 135 patients aged ≥ 65 years with a diagnosis of AA met the study inclusion criteria. Twenty-six patients (19.3%) were diagnosed with some type of postoperative complication. Decreasing the preoperative hemoglobin level showed a statistically significant association with postoperative complications (OR 0.77, CI 0.61–0.97, P = 0.03). Preoperative creatinine level (P = 0.02, OR 2.04, CI 1.12–3.72), and open appendectomy (P = 0.03, OR 2.67, CI 1.11–6.38) were significantly associated with postoperative morbidity. After adjustment, the only independent predictor of postoperative morbidity was preoperative creatinine level (P = 0.04, OR 2.01, CI 1.05–3.89).
In elderly patients with AA, perioperative risk assessment in the emergency setting must be as accurate as possible to identify modifiable risk factors that can be addressed before surgery, such as preoperative hemoglobin and creatinine levels.
KeywordsAcute appendicitis Appendectomy Elderly Postoperative complications Frail patients
The authors thank Dr. David C. Nilson, Ph.D., for revising the English. List of ERASO Collaborative Study Group members on behalf of SICUT (Italian Society of Emergency and Trauma Surgery), ACOI (Italian Society of Hospital Surgeons), SICG (Italian Society of Geriatric Surgery), SICE (Italian Society of Endoscopic Surgery and New Technologies), and the WSES (World Society of Emergency Surgery) Italian Chapter: Agresta F, Alemanno G, Anania G, Antropoli M, Argenio G, Atzeni J, Avenia N, Azzinnaro A, Baldazzi G, Balducci G, Barbera G, Bellanova G, Bergamini C, Bersigotti L, Bianchi PP, Bombardini C, Borzellino G, Bozzo S, Brachini G, Buonanno GM, Canini T, Cardella S, Carrara G, Cassini D, Castriconi M, Ceccarelli G, Celi D, Ceresoli M, Chiarugi M, Cillara N, Cimino F, Cobuccio L, Cocorullo G, Colangelo E, Costa G, Crucitti A, Dalla Caneva P, De Luca M, De Manzoni Garberini A, De Nisco C, De Prizio M, De Sol A, Dibella A, Falcioni T, Falco N, Farina C, Finotti E, Fontana T, Francioni G, Fransvea P, Frezza B, Garulli G, Genna M, Giannessi S, Gioffrè A, Giordano A, Gozzo D, Grimaldi S, Gulotta G, Iacopini V, Iarussi T, Laterza E, Leonardi A, Lepre L, Lorenzon L, Luridiana G, Malagnino A, Mar G, Marini P, Marzaioli R, Massa G, Mecarelli V, Mingoli A, Nigri G, Occhionorelli S, Paderno N, Palini GM, Paradies D, Paroli M, Perrone F, Petruzzelli L, Pezzolla A, Piazza D, Piazza V, Piccoli M, Pisanu A, Podda M, Poillucci G, Porfidia R, Rossi G, Ruscelli P, Spagnoli A, Sulis R, Tartaglia D, Tranà C, Travaglino A, Tomaiuolo P, Valeri A, Vasquez G, Zago M, Zanoni E.
GP study conception and design, literature search, data acquisition, interpretation and analysis; drafting and critically revising the article for important intellectual content; final approval of the version to be published. MP study conception and design, literature search, data acquisition, interpretation and analysis; drafting and critically revising the article for important intellectual content; editing and revising the English for the final version to be published; final approval of the version to be published. AP data interpretation and analysis; drafting and critically revising the article for important intellectual content; and final approval of the version to be published. LM data interpretation and analysis; drafting and critically revising the article for important intellectual content; and final approval of the version to be published. PDC data acquisition, interpretation and analysis; drafting and critically revising the article for important intellectual content; final approval of the version to be published. GM data interpretation and analysis; critically revising the article for important intellectual content; and final approval of the version to be published. GC study conception and design, literature search, data acquisition, interpretation and analysis; drafting and critically revising the article for important intellectual content; final approval of the version to be published. RS data interpretation and analysis; drafting and critically revising the article for important intellectual content; final approval of the version to be published. NC study conception and design, literature search, data acquisition, interpretation and analysis; drafting and critically revising the article for important intellectual content; final approval of the version to be published.
This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Compliance with ethical standards
Conflict of interest
Gaetano Poillucci, Mauro Podda, Adolfo Pisanu, Lorenzo Mortola, Patrizia Dalla Caneva, Lorenzo Mortola, Giulia Massa, Gianluca Costa, Riccardo Savastano and Nicola Cillara have no conflict of interest to declare.
This study was approved by the Ethics Committee of the University “La Sapienza” (Rome, Italy. Protocol ID: Rif_CE_452_2016) and secondary approval was obtained from all ethics committees of the other participating centers. The study protocol was registered at ClinicalTrials.gov (ClinicalTrials.gov identifier: NCT02825082).
- 1.U.S. Census Bureau. The elderly population 2010. https://www.census.gov/library/publications/2011/dec/c2010br-09.html. Accessed 3 Feb 2019.
- 2.Office for National Statistics (ONS). National population projections 2014-based statistical bulletin 2015. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/bulletins/nationalpopulationprojections/2015-10-292015. Accessed 3 Feb 2019.
- 4.Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the surgery workforce. Ann Surg. 2003;238:170–7.Google Scholar
- 5.Podda M, Cillara N, Di Saverio S. Appendicitis. In: Encyclopedia of gastroenterology. 2nd ed. New York: Elsevier; 2018. https://doi.org/10.1016/b978-0-12-801238-3.66055-5.
- 6.Gomes CA, Sartelli M, Di Saverio S, Ansaloni L, Catena F, Coccolini F, Inaba K, Demetriades D, Gomes FC, Gomes CC. Acute appendicitis: proposal of a new comprehensive grading system based on clinical, imaging and laparoscopic findings. World J Emerg Surg. 2015. https://doi.org/10.1186/s13017-015-0053-2.Google Scholar
- 12.Costa G, Massa G, ERASO (Elderly Risk Assessment for Surgical Outcome) Collaborative Study Group. Frailty and emergency surgery in the elderly: protocol of a prospective, multicenter study in Italy for evaluating perioperative outcome (The FRAILESEL Study). Updates Surg. 2018;70:97–104.CrossRefGoogle Scholar
- 14.NCEPOD Classification of Intervention. https://www.ncepod.org.uk/classification.html. Accessed 3 Feb 2019.
- 16.Wen SW, Naylor CD. Diagnostic accuracy and short-term surgical outcomes in cases of suspected acute appendicitis. CMAJ. 1995;152:1617–26.Google Scholar
- 20.Di Saverio S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, Sugrue M, De Moya M, Gomes CA, Bhangu A, Agresta F, Moore EE, Soreide K, Griffiths E, De Castro S, Kashuk J, Kluger Y, Leppaniemi A, Ansaloni L, Andersson M, Coccolini F, Coimbra R, Gurusamy KS, Campanile FC, Biffl W, Chiara O, Moore F, Peitzman AB, Fraga GP, Costa D, Maier RV, Rizoli S, Balogh ZJ, Bendinelli C, Cirocchi R, Tonini V, Piccinini A, Tugnoli G, Jovine E, Persiani R, Biondi A, Scalea T, Stahel P, Ivatury R, Velmahos G, Andersson R. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg. 2016. https://doi.org/10.1186/s13017-016-0090-5.Google Scholar
- 21.Agresta F, Campanile FC, Podda M, Cillara N, Pernazza G, Giaccaglia V, Ciccoritti L, Ioia G, Mandalà S, La Barbera C, Birindelli A, Sartelli M, Di Saverio S, Joined Italian Surgical Societies Working Group. Current status of laparoscopy for acute abdomen in Italy: a critical appraisal of 2012 clinical guidelines from two consecutive nationwide surveys with analysis of 271,323 cases over 5 years. Surg Endosc. 2017;31:1785–95.CrossRefGoogle Scholar
- 25.Healthcare cost and utilization project nationwide inpatient sample 2007. https://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp. Accessed 5 Feb 2019.
- 27.Guller U, Jain N, Peterson ED, Muhlbaier LH, Eubanks S, Pietrobon R. Laparoscopic appendectomy in the elderly. Surgery. 2004;135:479–88.Google Scholar
- 29.Ukai T, Shikata S, Takeda H, Dawes L, Noguchi Y, Nakayama T, Takemura YC. Evidence of surgical outcomes fluctuates over time: results from a cumulative meta-analysis of laparoscopic versus open appendectomy for acute appendicitis. BMC Gastroenterol. 2016. https://doi.org/10.1186/s12876-016-0453-0.Google Scholar
- 36.Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Hurme S, Mecklin JP, Sand J, Virtanen J, Jartti A, Grönroos JM. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018;320:1259–65.CrossRefGoogle Scholar
- 37.Poillucci G, Mortola L, Podda M, Di Saverio S, Casula L, Gerardi C, Cillara N, Presenti L, ACTUAA-R Collaborative Working Group on Acute Appendicitis. Laparoscopic appendectomy vs antibiotic therapy for acute appendicitis: a propensity score-matched analysis from a multicenter cohort study. Updates Surg. 2017;69:531–40.CrossRefGoogle Scholar
- 38.Podda M, Cillara N, Di Saverio S, Lai A, Feroci F, Luridiana G, Agresta F, Vettoretto N, ACOI (Italian Society of Hospital Surgeons) Study Group on Acute Appendicitis. Antibiotics-first strategy for uncomplicated acute appendicitis in adults is associated with increased rates of peritonitis at surgery. A systematic review with meta-analysis of randomized controlled trials comparing appendectomy and non-operative management with antibiotics. Surgeon. 2017;15:303–14.CrossRefGoogle Scholar
- 40.Podda M, Gerardi C, Cillara N, Fearnhead N, Gomes CA, Birindelli A, Mulliri A, Davies RJ, Di Saverio S. Antibiotic treatment and appendectomy for uncomplicated acute appendicitis in adults and children: a systematic review and meta-analysis. Ann Surg. 2019. https://doi.org/10.1097/sla.0000000000003225.Google Scholar