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Appendectomy Timing: Waiting Until the Next Morning May Result in Higher Risk of Surgical Site Infections
Pedro G Teixeira*, Emre Sivrikoz*, Kenji Inaba*, Peep Talving*, Lydia Lam*, Demetrios Demetriades
Los Angeles County + University of Southern California Medical Center, Los Angeles, CA

Background: Immediate appendectomy to prevent perforation has been challenged by recent studies supporting a semi-elective approach to acute appendicitis.
Objective: To investigate the association between time from admission to appendectomy (TTA) and the incidence of perforation and infectious complications.
Methods: Patients admitted with appendicitis from July/2003-June/2011 were reviewed. Age, gender, admission white blood cell count (WBC), surgical approach (open versus laparoscopic), TTA, and pathology report were abstracted. Primary outcomes included perforation and surgical site infection (SSI). Logistic regression was performed to identify independent predictors of perforation and to investigate the association between TTA and SSI.
Results: Over 8yrs, 4,529 patients were admitted with appendicitis and 4,108 (91%) underwent appendectomy. Perforation occurred in 23% (942). Logistic regression identified three independent predictors of perforation: age>=55 [OR(95%CI):1.66(1.21-2.29); p=0.002], WBC>16,000 [OR(95%CI): 1.38(1.15-1.64); p<0.001], and female gender [OR(95%CI): 1.20(1.02-1.41); p=0.02]. Delay to appendectomy was not associated with higher perforation rate. However, after controlling for age, leukocytosis, gender, laparoscopic approach, and perforation, TTA>6h was independently associated with an increase in SSI [OR(95%CI): 1.54(1.01-2.34); p=0.04]. Delay >6h resulted in a significant increase in SSI among patients with nonperforated appendicitis from 1.9% to 3.3% [OR(95%CI): 2.16(1.03-4.52), p=0.03], raising the incidence of SSI in nonperforated appendicitis to levels similar to those with perforation (3.3% versus 3.9%, p=0.47).
Conclusion: In this series, appendectomy delay did not increase the risk of perforation but was associated with a significantly increased risk of SSI in patients with nonperforated appendicitis. Prompt surgical intervention is warranted to avoid additional morbidity in this population.

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