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Factors influencing surgical management of acute appendicitis in a large university hospital without a dedicated emergency theatre

  • Megan Power FoleyEmail author
  • Michael MacLean
  • Ciaran Doyle
  • Timothy Nugent
  • Michael E. Kelly
  • Fady Narouz
  • Brian Mehigan
  • Paul McCormick
  • John Larkin
Original Article
  • 13 Downloads

Abstract

Background

Acute appendicitis is the most common surgical emergency. Its management reflects the efficacy of acute care surgery. Limited theatre space is an escalating issue, especially without dedicated emergency theatre access. Pre-operative delays are associated with longer length of stay, higher costs and post-operative complications.

Aims

Calculate time to theatre (TTT) from admission to appendicectomy and investigate factors impacting TTT.

Methods

A retrospective review of all emergency appendicectomies from June 2017 to October 2018. Demographic, clinico-pathological and radiological data were extracted from electronic patient record.

Results

One hundred forty-eight patients underwent emergency appendicectomy during the study period. Fifty-six percent (n = 84) were male, and the median (range) age was 30.5 (17–76) years. Sixty-one percent had pre-operative imaging. The median (range) TTT was 18.37 (2–114) h; 7.5% (n = 11) waited > 48 h, 29.7% (n = 44) were operated on after 8 p.m. and 26% (n = 38) were done on elective lists. Male gender, admission CRP > 100 and admission before 12 p.m. significantly shortened TTT (p = 0.030, p = 0.004 and p = 0.001, respectively). However, pre-operative ultrasound, previous acute appendicitis and surgery on an elective list significantly prolonged TTT (p = 0.015 and p = 0.024, respectively). The median (range) LOS was 3 (1–24) nights. Ten percent (n = 15) had post-operative complications; however, longer TTT was not associated with higher complication rates (p = 0.196).

Conclusions

This review highlights the impact of limited theatre access for on-call emergency admissions, with a significant portion of appendicectomies being done on elective lists or out-of-hours.

Keywords

Acute appendicitis Emergency surgical care Surgical management Surgical outcomes 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

This study was a retrospective clinical audit, comparing our institution’s practice to published international standards. No new interventions were performed.

References

  1. 1.
    Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Vega Rivera F, Mock C (2014) Global disease burden of conditions requiring emergency surgery. Br J Surg 101:e9–e22CrossRefGoogle Scholar
  2. 2.
    Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT (2015) Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 386(10000):1278–1287.  https://doi.org/10.1016/S0140-6736(15)00275-5 CrossRefPubMedGoogle Scholar
  3. 3.
    Debnath J, George RA, Ravikumar R (2017) Imaging in acute appendicitis: what, when, and why? Med J Armed Forces India 73(1):74–79.  https://doi.org/10.1016/j.mjafi.2016.02.005 CrossRefPubMedGoogle Scholar
  4. 4.
    Dahlberg MJA, Pieniowski EHA, Boström LÅS (2018) Trends in the management of acute appendicitis in a single-center quality register cohort of 5,614 patients. Dig Surg 35(2):144–154.  https://doi.org/10.1159/000477269 CrossRefPubMedGoogle Scholar
  5. 5.
    Kabir SA, Kabir SI, Sun R, Jafferbhoy S, Karim A (2017) How to diagnose an acutely inflamed appendix; a systematic review of the latest evidence. Int J Surg 40:155–162.  https://doi.org/10.1016/j.ijsu.2017.03.013 CrossRefPubMedGoogle Scholar
  6. 6.
    Gwynn LK (2001) The diagnosis of acute appendicitis: clinical assessment versus computed tomography evaluation. J Emerg Med 21(2):119–123CrossRefGoogle Scholar
  7. 7.
    Petroianu A (2012) Diagnosis of acute appendicitis. Int J Surg 10(3):115–119.  https://doi.org/10.1016/j.ijsu.2012.02.006 CrossRefPubMedGoogle Scholar
  8. 8.
    Lin HF, Lai HS, Lai IR (2014) Laparoscopic treatment of perforated appendicitis. World J Gastroenterol 20(39):14338–14347CrossRefGoogle Scholar
  9. 9.
    Dalton MK, McDonald E, Bhatia P, Davis KA, Schuster KM (2016) Outcomes of acute care surgical cases performed at night. Am J Surg 212(5):831–836.  https://doi.org/10.1016/j.amjsurg.2016.02.024 CrossRefPubMedGoogle Scholar
  10. 10.
    Nasr A, Reichardt K, Fitzgerald K, Arumugusamy M, Keeling P, Walsh TN (2004) Impact of emergency admissions on elective surgical workload. Ir J Med Sci 173(3):133–135CrossRefGoogle Scholar
  11. 11.
    Heng M, Wright JG (2013) Dedicated operating room for emergency surgery improves access and efficiency. Can J Surg 56(3):167–174.  https://doi.org/10.1503/cjs.019711 CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Executive Committee and Council of the Association of Surgeons of Great Britain and Ireland. Emergency general surgery: the future. A consensus statement. 2007Google Scholar
  13. 13.
    National Surgical Research Collaborative (2013) Multicentre observational study of performance variation in provision and outcome of emergency appendicectomy. Br J Surg 100(9):1240–1252.  https://doi.org/10.1002/bjs.9201 CrossRefGoogle Scholar
  14. 14.
    Schnüriger B, Laue J, Kröll D, Inderbitzin D, Seiler CA, Candinas D (2014) Introduction of a new policy of no nighttime appendectomies: impact on appendiceal perforation rates and postoperative morbidity. World J Surg 38(1):18–24.  https://doi.org/10.1007/s00268-013-2225-0 CrossRefPubMedGoogle Scholar
  15. 15.
    Teixeira PG, Sivrikoz E, Inaba K, Talving P, Lam L, Demetriades D (2012) Appendectomy timing: waiting until the next morning increases the risk of surgical site infections. Ann Surg 256(3):538–543.  https://doi.org/10.1097/SLA.0b013e318265ea13 CrossRefPubMedGoogle Scholar
  16. 16.
    Lee JM, Kwak BS, Park YJ (2018) Is a one night delay of surgery safe in patients with acute appendicitis? Ann Coloproctol 34(1):11–15.  https://doi.org/10.3393/ac.2018.34.1.11 CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Jeon BG, Kim HJ, Jung KH, Lim HI, Kim SW, Park JS, Kim KH, Kim ID (2016) Appendectomy: should it be performed so quickly? Am Surg 82(1):65–74PubMedGoogle Scholar
  18. 18.
    van Dijk ST, Dijkgraaf MG, Boermeester MA (2018) Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis. Br J Surg 105(8):933–945.  https://doi.org/10.1002/bjs.10873 CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Martin Wall (2018) Extra 2,500 hospital beds could cost €1m each, HSE warns. The Irish Times. 11thGoogle Scholar
  20. 20.
    van Veen-Berkx E, Elkhuizen SG, Kuijper B (2016) Kazemier G; Dutch Operating Room Benchmarking Collaborative. Dedicated operating room for emergency surgery generates more utilization, less overtime, and less cancellations. Am J Surg 211(1):122–128.  https://doi.org/10.1016/j.amjsurg.2015.06.021 CrossRefPubMedGoogle Scholar

Copyright information

© Royal Academy of Medicine in Ireland 2019

Authors and Affiliations

  1. 1.Department of Colorectal & General SurgerySt. James’ HospitalDublin 8Ireland
  2. 2.School of Medicine, Trinity CollegeUniversity of DublinDublin 2Ireland

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