Early discharge after laparoscopic appendectomy for complicated appendicitis: Is it safe?

Olga La Manna, MD, Yves Bendavid, MD, FRCSC, FACS, MSc, Pierre Drolet, MD, Madeleine Poirier, MD, Margaret Henri, MD, Jean-Francois Latulipe, MD, Michel Morin, MD

Maisonneuve-Rosemont Hospital, affiliated with University of Montreal

BACKGROUD: Laparoscopic appendectomy is recognized as an efficient and safe technique for both uncomplicated and complicated appendicitis. Recent studies have shown an equivalent result between open appendectomy and laparoscopic appendectomy for intra-abdominal abscess. Superior outcomes have been demonstrated regarding surgical site infection, length of stay, hospital costs and return to normal activity. Up to 25% of appendicitis is gangrenous, perforated or abscessed at the time of surgery. Some of the patients with complicated appendicitis progress better than other after surgery and might not require long course of IV antibiotics and prolonged hospital stay. An early discharge of selected patients will minimize hospital costs while reducing the risk of medical error and nosocomial infection for the patient.

METHOD: We did a retrospective review of 143 consecutive patients with complicated appendicitis managed by laparoscopic appendectomy between June 2008 and December 2010 at Maisonneuve-Rosemont Hospital, Montreal, Qc, Canada. We included the paediatric population. Outcomes such as operative time, intraoperative findings, time to diet, postoperative fever, length of antibiotics and postoperative complication were analyzed. Patients were separated between the early discharge group (≤3 days) and the control group (>3 days).

RESULTS: Fifty-two patients (36.4%) left the hospital at the third post-operative day or before, mean length of stay of 2.38 (1-3 days) vs 6,62 (4-17 days) for control group. Seven patients (13.5%) in the early discharge group had complication. In this group, one patient (1.9%) with bowel obstruction required rehospitalization for medical treatment of his condition. In the control group, 19 of the 91 patients (20.9%) developed 22 complications. Five (5.5%) required rehospitalization. Eleven patients (12.1%) had intra-abdominal abscess managed by antibiotics only (5), percutaneous drainage (5) and surgical procedure (1). None of the patients in the early discharge group had intra-abdominal abscess, wound infection or prolonged ileus. Other complication include: residual pain (2), umbilical hematoma (1), perianal abscess (1), hematochezia (1) and diarrhea (1) in the early discharge group and residual pain (6) and urinary retention (1) in the control group. No mortality occurred. Groups were similar in term of comorbidities (ASA class), age, sex ratio, time to surgery and operative time. A trend toward longer hospitalization is observed with fever at admission and postoperatively, longer duration of symptoms, longer time to normal diet and severity of intraoperative findings.

CONCLUSION: Early discharge was not associated with a higher rate of complication or a higher rate of rehospitalization. Thus, for selected patients, early discharge after laparoscopic appendectomy for complicated appendicitis is safe. Criteria such as normalized leucocyte count, no fever and return to regular diet seem sufficient to safely discharge patient with oral antibiotics. Our study demonstrated that a subgroup of patients progress better, the surgeon experience is essential to identify those patients. We suggest that the hospital stay of a patient should not be prolonged solely on the diagnosis of complicated appendicitis if the postoperative clinical course is satisfying.

Session: Poster Presentation

Program Number: P031

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