Acute Appendicitis in the Twenty-First Century: Should We Modify the Management Protocol?

Background: Recent data challenge the traditional management of acute appendicitis with early surgical intervention. This study evaluated the impact of timing of appendectomy and other potential risk factors on progression of acute appendicitis. Study Design: A search of the relevant databases of a tertiary medical center identified 1,604 patients with verified acute appendicitis who underwent appendectomy in 2004-2007. Demographic and clinical data and time from symptom onset to emergency room admission ("patient interval") and from emergency room admission to surgery ("hospital interval") and their combination were analyzed by pathological grade. Results: On multivariate analyses, independent risk factors for appendiceal perforation were age <20 years (OR = 1.58, 95 % CI 1.07-2.35) or >50 years (OR = 2.84, 95 % CI 1.82-4.45) (relative to 20-50 years), white cell count >10 × 103/mm³ (OR = 4.45, 95 % CI 2.05-9.67), body temperature >37.8 °C (OR = 2.23, 95 % CI 1.45-3.41), hospital interval >24 h (OR = 2.84, 95 % CI 1.49-5.4), patient interval >48 h (OR = 3.84, 95 % CI 2.35-6.29), and combined interval >48 h (OR = 4.29, 95 % CI 2.2-8.36). No association with perforation was found for the hour of emergency room arrival, hour of operation, surgical approach, or the performance of preoperative imaging. Conclusions: In the general population, the risk of advanced pathological grade of appendicitis increases with time. Thus, prompt appendectomy is warranted. Prospective studies of subgroups of perforated and nonperforated appendicitis are needed.