title: Risk of perforation increases with delay in recognition and surgery for acute appendicitis.
abstract: BACKGROUND
  Appendicitis remains a common indication for urgent surgical intervention in the United States, and early appendectomy has long been advocated to mitigate the risk of appendiceal perforation. To better quantify the risk of perforation associated with delayed operative timing, this study examines the impact of length of inpatient stay preceding surgery on rates of perforated appendicitis in both adults and children.
  
  
  METHODS
  This study was a cross-sectional analysis using the National Inpatient Sample and Kids' Inpatient Database from 1988-2008. We selected patients with a discharge diagnosis of acute appendicitis (perforated or nonperforated) and receiving appendectomy within 7 d after admission. Patients electively admitted or receiving drainage procedures before appendectomy were excluded. We analyzed perforation rates as a function of both age and length of inpatient hospitalization before appendectomy.
  
  
  RESULTS
  Of 683,590 patients with a discharge diagnosis of appendicitis, 30.3% were recorded as perforated. Over 80% of patients underwent appendectomy on the day of admission, approximately 18% of operations were performed on hospital days 2-4, and later operations accounted for <1% of cases. During appendectomy on the day of admission, the perforation rate was 28.8%; this increased to 33.3% for surgeries on hospital day 2 and 78.8% by hospital day 8 (P<0.001). Adjusted for patient, procedure, and hospital characteristics, odds of perforation increased from 1.20 for adults and 1.08 for children on hospital day 2 to 4.76 for adults and 15.42 for children by hospital day 8 (P<0.001).
  
  
  CONCLUSIONS
  Greater inpatient delay before appendectomy is associated with increased perforation rates for children and adults within this population-based study. These findings align with previous studies and with the conventional progressive pathophysiologic appendicitis model. Randomized prospective studies are needed to determine which patients benefit from nonoperative versus surgically aggressive management strategies for acute appendicitis.
authors.affiliation: Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Dominic
authors.initials: D
authors.lastname: Papandria
authors.forename: Seth D
authors.initials: SD
authors.lastname: Goldstein
authors.forename: Daniel
authors.initials: D
authors.lastname: Rhee
authors.forename: Jose H
authors.initials: JH
authors.lastname: Salazar
authors.forename: Jamir
authors.initials: J
authors.lastname: Arlikar
authors.forename: Amany
authors.initials: A
authors.lastname: Gorgy
authors.forename: Gezzer
authors.initials: G
authors.lastname: Ortega
authors.forename: Yiyi
authors.initials: Y
authors.lastname: Zhang
authors.forename: Fizan
authors.initials: F
authors.lastname: Abdullah
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001062:Appendectomy; D001064:Appendicitis / Q000175:diagnosis* / Q000453:epidemiology* / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D057210:Delayed Diagnosis / Q000009:adverse effects*; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D055815:Young Adult
keywords: Acute appendicitis; Appendectomy; Delayed operation; Kids’ Inpatient Database; National Inpatient Sample; Perforated appendicitis; Surgical outcomes