Friday, May 19, 2006

Timely Treatment for Appendicitis?

Acute appendicitis remains for me just as interesting, sometimes challenging, and rewarding for me as it was when I was an intern. Generally, it presents in a straightforward manner, and the operation relieves the patient's symptoms so well that most are far more comfortable in the recovery room than they were preoperatively. The preoperative pain can be difficult to manage, as it is frequently a gnawing, colicky type of discomfort that never really goes away with narcotics --- sort of like having a red hot chili pepper stuck inside your abdomen. Traditionally, there has been concern that delaying surgery for acute appendicitis may lead to an increased risk for perforation. It has been my habit to take patients with presumed appendicitis to the operating room as soon as it can reasonably be accomplished, in order to decrease the risk of perforation, but also to relieve their discomfort in a timely manner. After all, that is how I would want myself or my family to be treated.

Since acute symptoms do not always present between the hours of 9 to 5, a large number of patients will hit the ED in the middle of the night with appendicitis.....meaning we need to get out of bed and take them to the OR in the middle of the night. Some surgeons apparently feel that is not absolutely necessary, and undertook a study of delaying appendectomy for 12 to 24 hours after presentation; the article Effects of Delaying Appendectomy for Acute Appendicitis for 12 to 24 Hours was published in this month's Archives of Surgery, and came from the Dept. of Surgery at the Hospital of Saint Raphael (New Haven, Conn.). They retrospectively reviewed 309 patients who presented with acute appendicitis; 233 were operated upon within about 12 hours (mean 6.7 +/- 2.7 hours) after presentation, and 76 had surgery 12 to 24 hours after presentation (mean 16.7 +/- 3.6 hours). The delay in surgery occurred for many reasons, including a delay in diagnosis, lack of OR availability, etc. They found that (emphasis is mine):

There were no statistically significant differences between the early and late groups in the length of stay, operative time, the percentage of advanced appendicitis, or the rate of complications.

In selected patients, delaying appendicitis for acute appendicitis for 12 to 24 hours after presentation does not significantly increase the rate of perforations, operative time, or length of stay. It decreases the use of the nursing staff, anesthesia team, and surgical house staff during the night shifts, and it decreases the interruption of the regular operating room schedule.
Now, far be it from me to suggest that such an "evidence-based medicine" approach is a bit whacky, but....well, it's whacky. OK, you can prove that it makes no "statistically significant" difference to significantly delay surgery in the average patient presenting with acute appendicitis. But, does it make any sense to delay a procedure that relieves a patient's discomfort? Especially since it appears that the delay is more about the surgeon's convenience than about patient care? I just don't "get" this approach to patient care --- it seems a bit smarmy. "Yeah, we'll wait to do the surgery until morning! That's the ticket!".

There is another, unspoken part of this argument that bothers me as well; I know that GruntDoc may disagree, but the ED physician does not always make the correct diagnosis (and neither do I). Some patients need to go to the OR with peritonitis, presumed to be from appendicitis, but who actually have perforated diverticulitis, Crohn's disease, perforated ulcer, etc. --- which needs more prompt attention. I worry that this type of "study" will reinforce a rather lazy approach to the evaluation of the patient with presumed appendicitis among surgeons who are a bit reluctant to get out of bed at 2 AM. I agree with one of the physicians who commented on this paper when it was presented at the New England Surgical Society meeting in Sept. of '05 --- he asked if the authors had considered another title: Surgeon Convenience and Elective OR Schedule First, Patients Second.