Sunday, September 26, 2010

Delayed Appendectomy: A Different Kind of Peer Review


It seems that USA Today writer Rita Rubin is pushing an agenda which is that appendectomy for acute appendicitis should be delayed until it is convenient for the surgeon. The first article she wrote on this was in September of 2010. A similar article was published today. I blogged about this issue when the original article appeared. Here is my critique of the paper the articles were based on and why the concept of delaying appendectomy is not practical. I had entitled the post “A Different Kind of Peer Review” because the idea was reviewed by prospective patients in the form of comments on the USA Today website back in September.

The seemingly straightforward paper entitled “Effect of delay to operation on outcomes in adults with acute appendicitis” was published in a respected journal by a large and geographically diverse group of surgeons. The authors looked at almost 33,000 patients with appendicitis who underwent appendectomy at different time intervals after being admitted to a hospital. The data were collected from the American College of Surgeons National Surgical Quality Improvement Program [NSQIP] database over the four years from 2005 through 2008. They found no significant differences in risk-adjusted 30-day complication or mortality rates whether the patients underwent appendectomy within 6 hours of surgical service admission, 6 to 12 hours after admission or more than 12 hours after admission.

The authors acknowledged several limitations of the study. It was retrospective and therefore reasons for the delays to surgery for most patients could not be determined. The data were taken from a database with limited clinical information. Absent were data on antibiotic usage, fluids administered and reasons for choosing the laparoscopic or open approach to appendectomy. The authors and the accompanying editorialist suggested that since the outcomes were comparable it would be acceptable to delay appendectomy until daylight hours and have a well-rested surgeon perform the appendectomy. Allusions were made to possible money savings by not having operating room staffs and anesthesiologists awakened and called in at night, but no data were presented to support this theory.

Not mentioned by the authors but occurring to me are some other issues. The NSQIP database is contributed to on a voluntary basis by mostly academic tertiary care medical centers. I doubt the findings of this study are universally applicable. The three groups of patients based on the timing of the surgery were not really similar. In fact they were statistically significantly different and arguably clinically different in almost all respects. I don’t know about the authors’ practice patterns, but at every hospital I have ever worked in, including my present one, waiting to do an appendectomy until the morning means that someone’s elective surgery will have to be “bumped” [delayed] while I do my appendectomy. This causes the elective schedule to run late and staff has to work overtime [$$$$$] anyway. Also, most private practice surgeons need to get these cases done so they don’t interfere with office hours or their own elective surgery cases. Most patients with uncomplicated acute appendicitis can undergo laparoscopic appendectomy and be discharged home well within 24 hours of arriving at the hospital. Delaying the surgery for several hours will lead to increased lengths of stay and more costs and charges.

Then there is the little problem of the patients and their desires. Here is where the “Different Kind of Peer Review” comes in. Of the more than 40 comments about the September 2010 article posted online, the overwhelming majority expressed extreme negativity regarding waiting to have an appendectomy. Commenters railed against pain and suffering while waiting for surgery, government rationing of healthcare and lazy, avaricious doctors. Anecdotes about perforation of the appendix, peritonitis, near-death and veganism [yes, veganism] were offered. Similar sentiments are being expressed by the commenters on today's article. Finally, a surgeon would have a difficult time defending a lawsuit by someone who waited 12 hours for an appendectomy only to have a bad outcome due to perforation, sepsis, abscess and/or reoperation. That would emphatically negate any money saved by waiting, assuming such saving even exists.

I do not see delayed appendectomy catching on soon. What do you think?


Vickie said...

I have an idea: how about no more surgery at night, at all? That would be very efficient. You could send all the doctors home at night to get some rest. Are you in pain? Here, have some morphine while we wait for the doctor to be well-rested. Forget about how well-rested the patient is after spending the night in excruciating pain.

While we're at it, let's take care of those pesky pregnant women and their unpredictable labors. How about rushing into c-sections so doctors can get home for dinner? Oh wait, they already do that.

Sounds like this is not really the direction that would be best for the patients. Here's a good thought experiment: If the appendicitis patient were also a surgeon, would he agree to wait overnight??? Yeah, I thought so.

Clark Venable said...

What we're seeing more and more is surgeons wanting to start an add-on case at 0600--they don't have to operate at 2 am yet they don't disrupt the elective or office schedule.

Skeptical Scalpel said...

Two problems with the 0600 start.
1. If you have no house staff and are already awake and seeing the patient, it makes no sense to wait.
2. I have never worked in a hospital where a case scheduled for 0600 started at 0600. It would usually be that they called for the patient at 0600. He arrives at 0620. Ritualistic Q&A by nurses and anesthesia, time out etc. Case starts at 0645 or 7 and runs over into the elective schedule.

Anonymous said...

i have been doing it based on selected patients and it has worked fine

Skeptical Scalpel said...

How do you select the patients? I hope it continues to work. All it would take is one unexpected perforation that ends up with an abscess or infertility or some other bad outcome, and that might lead to a suit for delay in treatment.

vishwanath said...

It is difficult to differentiate which patient will go to resolution and which patient will go to perforation and abscess. There is no clear grading system in appendicitis.
Once you made a diagnosis of acute appendicitis it is better to operate

Skeptical Scalpel said...

Vishwanath-We agree. But to be honest, some research has shown that perforated appendicitis may be a different disease than simple acute appendicitis. They say that perfed appendicitis more or less starts that way, and simple appendicitis rarely progresses to perforation.

Here's a link to a paper suggesting the above.

Anonymous said...

To Vicki
I am a surgeon in an average sized midwestern city. I have worked 116 hours in the last 7 days (I just calculated it). Those are hours physically in the hospital and don't count the extra hour or two on the computer after my children are asleep to finish charting each night. I doubt you have ever come close to working those long hours. There are plenty of studies that show there are no difference in outcomes if your appendectomy is delayed until daylight hours. Do you really want me operating on you right now while I can barely keep my eyes open.

Skeptical Scalpel said...

Anon, there's another option. You need to get someone to cover your practice for a night and get some sleep. Surely, a colleague can take over for a night in an average-sized Midwestern city.

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