Appendicitis in the modern era: universal problem and variable treatment

Abstract

Background: Acute appendicitis is the second most common gastrointestinal diagnosis mandating urgent operation in the U.S. The current state of adult appendectomy, including patient and hospital characteristics, complications, and predictors for complications, are unknown.

Methods: Retrospective review of U.S. Nationwide Inpatient Sample 2003-2011 for appendectomy in ≥18-year-olds was performed. Primary outcomes measures included postoperative complications, length of stay, and patient mortality. Categorical variables were analyzed by χ2, trend analyses by Cochran-Armitage. Multivariable logistic regression was performed to adjust for predictors of developing complications.

Results: 1,663,238 weighted appendectomy discharges occurred. Over the study period, complications increased from 3.2 to 3.8% (p < 0.0001), but the overall mortality decreased from 0.14 to 0.09% (p < 0.0001) and mean LOS decreased from 3.1 to 2.6 days (p < 0.0001). The proportion of laparoscopic appendectomy increased over time, 41.7-80.1% (p < 0.0001). Patients were increasingly older (≥65 years: 9.4-11.6%, p < 0.0001), more obese (3.8-8.9%, p < 0.0001), and with more comorbidities (Elixhauser score ≥3: 4.7-9.8%, p < 0.0001). After adjustment, independent predictors for postoperative complications included: open surgery (OR 1.5, 95% C.I. 1.4-1.5), male sex (OR 1.6, 95% CI 1.5-1.6), black race (vs. white: OR 1.5, 95% CI 1.4-1.6), perforated appendix (OR 2.8, 95% CI 2.7-3.0), greater comorbidity (Elixhauser ≥3 vs. 0, OR 11.3, 95% CI 10.5-12.1), non-private insurance status (vs. private: Medicaid OR 1.3, 95% CI 1.2-1.4; Medicare OR 1.7, 95% CI 1.6-1.8), increasing age (>52 years vs. ≤27: OR 1.3; 95% CI 1.2-1.4), and hospital volume (vs. high: low OR 1.2; 95% CI 1.1-1.3). Predictors of laparoscopic appendectomy were age, ethnicity, insurance status, comorbidities, and hospital location.

Conclusions: Laparoscopic appendectomy is increasing but is unevenly deployed across patient groups. Appendectomy patients were increasingly older, with more comorbidities and with increasing rates of obesity. Black patients and patients with public insurance had less utilization of laparoscopy and inferior outcomes.