Risk and outcomes of 24-h delayed and weekend appendectomies

Outcomes of emergency appendectomies and cholecystectomies performed at weekends

PURPOSE

To determine the impact of hospital admissions and operations at weekends on two common emergency general surgeries (cholecystectomy and appendectomy) and their outcomes.

METHODS

A total of 539 patients were included in the study. Information on patient demographics, comorbidities, admission date, surgery date, complications, readmission, and follow-up details were collected from electronic medical records.

RESULTS

Most patients were admitted to hospital on weekdays (n = 391), and 444 surgeries were performed on weekdays, while 86 surgeries were performed at weekends. No significant difference was found between the type of surgery performed on weekday and weekend admissions (P = 0.384). Surgical procedures of patients admitted to hospital on a weekend tended to be delayed by a median of one day compared with weekday admissions, with a similar overall length of stay for both groups. Weekend admissions were associated with higher complication rates than weekday admissions (12.2 vs. 6.1%). Patients who were operated on at weekends were younger in age than those admitted on weekdays (32 vs. 30 years old, P = 0.019). More appendectomies were performed at weekends (77.9% vs. 45.9%), and fewer cholecystectomies were performed (22.1 vs. 54.1%, P = 0.000).

CONCLUSIONS

The surgical procedures of patients admitted to hospital on weekends tended to be delayed by 1 day and had a higher rate of complications. Appendectomy was the most common performed weekend surgery.

Possibility for avoidance of urgent nighttime operations for acute appendicitis in a regional core university hospital

INTRODUCTION

In recent years, a shortage of surgeons and anesthesiologists, particularly in regional hospitals, has become a social issue in Japan. In such hospitals, urgent surgery at night has been performed with difficulty. Therefore, we retrospectively assessed the outcomes of appendectomies for the patients visited at nighttime in our hospital categorized as a local university hospital.

METHODS

A retrospective review was conducted on 82 patients of acute appendicitis presented to our hospital between 5:30 p.m. to 8:30 a.m., between January 2014 and April 2019. We compared patients who underwent urgent nighttime appendectomy (group A) and patients who underwent appendectomy during the daytime, or so-called short interval appendectomy (group B). The evaluated factors were preoperative characteristics (age, sex, body mass index, cardiopulmonary complications, laboratory data, body temperature, presence of the Blumberg sign, and CT findings), operation characteristics, and postoperative characteristics (surgical-site infection [SSI], complications, and length of hospital stay).

RESULTS

Patients in group A were significantly younger than patients in group B. Patients in group A were significant more likely to experience an SSI.

DISCUSSION

Patients diagnosed with acute appendicitis during the nighttime can undergo short interval appendectomy, which leads to a decreased risk of SSI, has no effect on length of hospital stay after surgery, and lessens medical staff burden.

Inflammatory Markers and Duration of Symptoms Have a Close Connection With Diagnosis and Staging of Acute Appendicitis in Children

Background: For children with acute appendicitis (AA), a clear diagnosis is a challenge. The purpose of this study is to explore whether inflammatory markers in the blood combined with symptom duration are helpful in the diagnosis of acute appendicitis and in predicting the severity of acute appendicitis. Methods: All the selected patients underwent appendectomy between November 10, 2011 and November 15, 2019, in whom preoperative WBCC, CRP, and NE% had been measured in a short time. All patients were divided into two groups: uncomplicated AA and complicated AA, postoperatively. Results: For our standards, 813 patients were selected, 442 of them had complicated AA. The mean [standard deviation (SD)] age for the uncomplicated AA group was 9.78 ± 2.02 years and for the complicated AA group was 9.69 ± 2.16 years (P = 0.55). Elevated WBCC, CRP, and NE% had a higher relatively sensitivity in complicated AA than uncomplicated AA especially when WBCC, CRP, and NE% were at normal levels, which had a sensitivity of 100% in uncomplicated AA, but this only applied to nine patients. CRP values were significantly different in three time groups, whether uncomplicated or complicated AA. Conclusion: The combination of WBCC, CRP, and NE% values is very sensitive for the diagnosis of acute appendicitis, and when we predict complicated AA using the CRP value, we also need to consider the time of symptom onset.

Time to appendectomy for acute appendicitis: A systematic review

OBJECTIVE

The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations regarding time to appendectomy for acute appendicitis in children within the context of preventing adverse events, reducing cost, and optimizing patient/parent satisfaction.

METHODS

The committee selected three questions that were addressed by searching MEDLINE, Embase, and the Cochrane Library databases for English language articles published between January 1, 1970 and November 3, 2016. Consensus recommendations for each question were made based on the best available evidence for both children and adults.

RESULTS

Based on level 3-4 evidence, appendectomy performed within 24h of admission in patients with acute appendicitis does not appear to be associated with increased perforation rates or other adverse events. Based on level 4 evidence, time from admission to appendectomy within 24h does not increase hospital cost or length of stay (LOS). Data are currently limited to determine an association between the timing of appendectomy and parent/patient satisfaction.

CONCLUSIONS

There is a paucity of high-quality evidence in the literature regarding timing of appendectomy for patients with acute appendicitis and its association with adverse events or resource utilization. Based on available evidence, appendectomy performed within the first 24h from presentation is not associated with an increased risk of perforation or adverse outcomes.

TYPE OF STUDY

Systematic Review of Level 1-4 studies.

Outcomes of common general surgery procedures for patients discharged over weekends at a tertiary care hospital in Saudi Arabia

BACKGROUND

Hospitals usually reduce staffing levels and services over weekends. This raises the question of whether patients discharged over a weekend may be inadequately prepared and possibly at higher risk of adverse events post-discharge.

OBJECTIVES

To assess the outcomes of common general surgery procedures for patients discharged over weekends, and to identify the key predictors of early readmission.

DESIGN

Retrospective cohort study.

SETTING

A tertiary care center.

PATIENTS AND METHODS

Patients discharged from general surgery services during the one-year period between January and December 2016 after cholecystectomy, appendectomy, or hernia repairs were included. Patient demographic information, comorbidities, and complications as well as admission and follow-up details were collected from electronic medical records.

MAIN OUTCOME MEASURES

Outcomes following weekend discharge, and the predictors of early readmission.

SAMPLE SIZE

743 patients.

RESULTS

The operations performed: 361 patients (48.6%) underwent a cholecystectomy, 288 (38.8%) an appendectomy, and 94 (12.6%) hernia repairs. A significantly lower number of patients were discharged over the weekend (n=125) compared to those discharged on weekdays (n=618). Patients discharged during the weekend were younger, less likely to have chronic diseases, and had a significantly shorter average length of stay (LOS) (median 2 days, IQR: 1, 4 vs. median 3 days, IQR: 1, 5, P=.002). Overall, the 30-day readmission rate was 3.2% (n=24), and weekend discharge (OR=2.25, 95% CI 0.52-9.70) or any other variable did not predict readmission in 30 days. However, 14-day post-discharge follow-up visits were significantly lower in the weekend discharge subgroup (83.1% vs. 91.2%, P=.006).

CONCLUSION

Weekend discharge was not associated with higher readmission rates. Physicians may consider discharging post-operative patients over a weekend without an increased risk to the patient. Day of discharge, length of stay and increased patient age are not predictors of early readmission.

LIMITATIONS

Single-center study and retrospective.

CONFLICT OF INTEREST

None.

Is a One Night Delay of Surgery Safe in Patients With Acute Appendicitis?

Purpose

With varied reports on the impact of time to appendectomy on clinical outcomes, the purpose of this study was to determine the effect of preoperative in-hospital delay on the outcome for patients with acute appendicitis.

Methods

A retrospective review of 1,076 patients who had undergone an appendectomy between January 2010 and December 2013 was conducted.

Results

The outcomes of surgery and the pathologic findings were analyzed according to elapsed time. The overall elapsed time from onset of symptoms to surgery was positively associated with advanced pathology, increased number of complications, and prolonged hospital stay. In-hospital elapsed time was not associated with any advanced pathology (P = 0.52), increased number of postoperative complications (P = 0.14), or prolonged hospital stay (P = 0.24). However, the complication rate was increased when the in-hospital elapsed time exceeded 18 hours.

Conclusion

Advanced pathology and postoperative complication rate were associated with overall elapsed time from symptom onset to surgery rather than in-hospital elapse time. Therefore, a short-term delay of an appendectomy should be acceptable.

Effect of a Standardized Protocol of Antibiotic Therapy on Surgical Site Infection after Laparoscopic Surgery for Complicated Appendicitis

BACKGROUND

Although it is accepted that complicated appendicitis requires antibiotic therapy to prevent post-operative surgical infections, consensus protocols on the duration and regimens of treatment are not well established. This study aimed to compare the outcome of post-operative infectious complications in patients receiving old non-standardized and new standard antibiotic protocols, involving either 5 or 10 days of treatment, respectively.

METHODS

We enrolled 1,343 patients who underwent laparoscopic surgery for complicated appendicitis between January 2009 and December 2014. At the beginning of the new protocol, the patients were divided into two groups; 10 days of various antibiotic regimens (between January 2009 and June 2012, called the non-standardized protocol; n = 730) and five days of cefuroxime and metronidazole regimen (between July 2012 and December 2014; standardized protocol; n = 613). We compared the clinical outcomes, including surgical site infection (SSI) (superficial and deep organ/space infections) in the two groups.

RESULTS

The standardized protocol group had a slightly shorter operative time (67 vs. 69 min), a shorter hospital stay (5 vs. 5.4 d), and lower medical cost (US$1,564 vs. US$1,654). Otherwise, there was no difference between the groups. No differences were found in the non-standardized and standard protocol groups with regard to the rate of superficial infection (10.3% vs. 12.7%; p = 0.488) or deep organ/space infection (2.3% vs. 2.1%; p = 0.797).

CONCLUSIONS

In patients undergoing laparoscopic surgery for complicated appendicitis, five days of cefuroxime and metronidazole did not lead to more SSIs, and it decreased the medical costs compared with non-standardized antibiotic regimens.

Comparing mortality risk of patients with acute hip fractures admitted to a major trauma centre on a weekday or weekend

Proximal femoral fractures are a major public health concern with estimated annual direct and social costs amounting to £2 billion and average 30-day mortality risk of 7.5%. In response to the recent debate over out-of-hours hospital provision we investigated the ‘weekend effect’ at a major trauma centre, caring for acute injuries. A single centre, multi-surgeon review of 2060 patients performed. The distribution of patient and treatment variables compared in patients admitted on a weekday or the weekend. Fewer patients met performance indicators during weekend admission, time to surgery (63 vs. 71%) and time to geriatric review (86 vs. 91%). Weekend admission 30-day mortality was marginally lower than weekday (9.7% vs. 10.2%, OR 0.94, 95% CI 0.67 to 1.32, p = 0.7383). Increasing age, female gender, co-morbidities and confusion increased mortality risk. Binary regression analysis including these variables found no significant ‘weekend effect’. Despite the unit observing an increasing workload in the last five years, with meticulous workforce planning, senior doctor provisions and careful use of resources, it is possible to provide a seven-day fracture neck of femur service with no variation in thirty-day mortality by the day of admission.