'Emergency' appendix surgery can wait: MDs

Acute appendicitis may not require emergency surgery, U.S. and Canadian doctors have found.

Acute appendicitis may not require emergency surgery, U.S. and Canadian doctors have found.

Removing an appendix is one of the most common surgical procedures performed worldwide and accounts for an estimated 25,000 hospital stays in Canada each year, researchers say. 

'It's probably safe to postpone operations to the light of day.'— Dr. Avery Nathens

Although it is assumed the disease would be more severe and complications worse the longer a patient waits to have an appendectomy because of the risk that an appendix might burst, a new study suggests otherwise.

Delays of 12 hours or more before the surgery did not appear to harm how patients fared 30 days after the surgery, the study of 32,782 patients who had undergone the procedure showed.

"It's probably safe to postpone operations to the light of day," said the study's senior author, Dr. Avery Nathens, division head of general surgery at St. Michael's Hospital in Toronto.

The study, in Tuesday's issue of the Archives of Surgery, divided participants into three groups, depending on how long they waited for the operation after being admitted to the hospital:

The patients had their appendectomies between 2005 and 2008.

Of the total:

  • 24,647 or 75 per cent had surgery within six hours of being admitted to the hospital.
  • 4,934 or 15 per cent had their appendectomies after waiting six to 12 hours.
  • 3,201 or nearly 10 per cent waited more than 12 hours.

Complications, deaths and length of hospital stay were not clinically significant between the groups, Dr. Angela Ingraham of the American College of Surgeons in Chicago and her colleagues found.

The findings could help surgeons to prioritize patients, and identify those who really need an operation in the middle of the night.

For Canadian hospitals, the challenge now is to ensure patients with appendicitis have the opportunity to receive their surgery during the day, when operating rooms tend to be busy with elective surgeries like cancer operations and hip replacements, said Nathens, who is also director of trauma at St. Mike's. 

Appendicitis symptoms

  • Typically, appendicitis pain starts in the upper part of abdomen and then migrates to right lower area.
  • Loss of appetite.
  • No significant fever. 

For patients, Nathens said, the key message is that research suggests it isn't the time waiting at the hospital that matters most, but how long they wait at home before going to emergency.

The researchers acknowledged some limitations of the study, such as not knowing how much time had elapsed between when symptoms arose and when the patients arrived at the hospital. They also didn't know whether surgeons triaged patients to operate first on the cases that seemed the worst.

Let weary surgeons sleep

Several generations of general surgeons have the indelible memory of a beeper going off just as they drift to sleep, alerting them to a patient in the emergency department with acute appendicitis, Dr. John Hunter of the department of surgery at Oregon Health & Science University in Portland said in a journal commentary accompanying the study.

The surgeons would then spend between four hours to the whole night examining, imaging and treating the patient, leading to yawns and struggles to pay attention the next day.

The main benefit of the latest findings is to validate the practice of treating acute appendicitis urgently rather than as an emergency, Hunter said.

"The ability of a surgeon to sleep through the night results in a day without the fatigue engendered by a sleepless night caring for a patient with acute appendicitis," Hunter said.

"A secondary benefit is the savings to the hospital generated by minimizing staff and anesthesiologist presence late in the evening and during the wee hours of the morning."

Pediatric researchers have also found similar results in smaller studies on children, Nathens said.