Background: Acute appendicitis is one of the most frequent surgical emergencies and is a common cause of non-traumatic acute abdominal emergencies that require surgical intervention. Most complicated appendicitis started de novo as simple appendicitis raising the notion that it is a disease in evolution that has become of clinical importance due to delayed or missed diagnosis.
Complicated appendicitis has been associated with a significant risk of postoperative septic complications, including wound infections and intra-abdominal abscess formation. This study aimed to evaluate the types of complicated appendicitis and their relationship to patient’s demographic data, postoperative course and the length of hospital stay in Al-Basra Teaching Hospital.
Methods: This was a prospective clinical study involving patients with acute appendicitis admitted to Al-Basra Teaching Hospital from January 2017 to October 2019. The demographic data, types of complicated appendicitis, hospitalization duration, and postoperative complications were evaluated. The patients were divided into six groups according to age. All data were recorded and analyzed.
Results: A total of 1210 patients, age from 6 to 69 years, mean age of patients was 23.45, males out-numbered females. Perforated appendicitis represents the main type of complicated appendicitis, and it was reported mostly among elderly patients. Patients with complicated appendicitis had a longer hospitalization and more postoperative complications than patients with non-complicated appendicitis.
Conclusion: we concluded that nearly one third of the patients with acute appendicitis had complicated appendicitis, so they need a special pre and postoperative care and old age had non classical clinical picture with poor outcome.
Acute Appendicitis; Complicated Appendicitis; Types of Complicated Appendicitis
Acute appendicitis (AA) is one of the most frequent surgical emergencies with a lifetime risk of 7-8% . Appendicitis is the most common cause of non-traumatic acute abdominal pain , and is the most common acute abdominal condition requiring surgery [3-9]. Despite several studies on this issue, most complicated appendicitis started de novo as simple appendicitis raising the notion that it is a disease in evolution that has become of clinical importance due to delayed or missed diagnosis . Complicated appendicitis including abscess, phlegmon and generalized peritonitis still leads to considerable morbidity and mortality rates worldwide, due to the high life-time prevalence of acute appendicitis . Complicated appendicitis has been associated with a significant risk of postoperative septic complications, including wound infection and intra-abdominal abscess formation [12,13]. Wound dehiscence and fecal fistula are rare, but difficult complications of the disease following surgery . The aim of this study was to evaluate the types and percentage of complicated appendicitis and their relationship to patient’s age, sex, and their impact on the postoperative outcome and length of hospital stay in the Al-Basra Teaching Hospital.
Materials and Methods
This was a prospective clinical study involving patients with acute appendicitis admitted to the Department of surgery in the Al- Basra Teaching Hospital from January 2017 to October 2019. The Al-Basra Teaching Hospital is a 600-bedded public hospital with 700 to 1000 patients attending the outpatient clinics every day and about 1000-1250 patients attending the emergency unite every day. A total of 1210 patients with acute appendicitis were included in this study, they were divided into six groups according to age, first age group 0-9 years the second group between 10-19 years, the third group between 20-29 years, the fourth group between 30-39 years, and the fifth group between 40-49 years and the sixth group above. All the patients were followed up from the time of admission until they discharged. Informed consent was obtained from each patient who enrolled in this study, and the study was approved by the ethics committee. Patient’s demographic data, types of complicated appendicitis, the length of hospital stay, and postoperative complications were evaluated and all the data were transferred to the SPSS software, version 23 (SPSS Inc. Released 2007. SPSS for Windows, Version 23. Chicago, SPSS Inc.), for data interpretation and statistical analysis.
A total of 1210 patients, age from 6 to 69 years, with a mean age of 23.45 years. Of these, there were 697 (57.6%) men and 498 (42.3%) women. The first age group includes 105 (8.7 %) patients, the second group includes 491 (40.6%) patients, the third group includes 335 (27.6%) patients, the fourth group includes 199 (16%) patients, the fifth group includes 55 (4.5%) patients and 25 (2%) patients were in the sixth group. Males outnumbered females in all age groups. Most of the patients were young in the second group 491(40.6%) patients (Table 1).
Complicated appendicitis was reported in 377 (31.15%) patients. Perforated appendicitis representing the main type of complicated appendicitis that were observed in 215 (17.76%) patients, gangrenous appendicitis reported in 110 (9.09%) patients, appendicular mass was reported in 30 (2.47%) patients, and appendicular abscess reported in 22 (1.81%) patients (Figure 1).
Complicated appendicitis was observed in 227(18.76%) male patients, 150 (12.39%) female patients respectively. Perforated appendicitis was the main type of complicated appendicitis in both genders. Males outnumber females in all types of complicated appendicitis (x2 =92.32, p value 0.00) as shown in table 2.
In the sixth age group 18 out of 25 patients had complicated appendicitis. Perforated appendicitis were the main type of complicated appendicitis they had, and it was reported in 9 out of 25 patients of them (x2 = 54.06. p value 0.00) as shown in table 3.
The length of hospital stays (LOS) range from 1-10 days, with a mean of 1.59 day for patients with non-complicated appendicitis. Whereas, the (LOS) for patients with complicated appendicitis range from 1-6.7 days with a mean of 2.90 days (Table 4).
Patients with perforated appendicitis and those with gangrenous appendicitis were hospitalized for 2-5 days, whereas, patients with appendicular abscess and appendicular mass hospitalized for 5-10 days (Table 5).
Nearly two third of patients with complicated appendicitis 256 out of 377 patients developed postoperative complications, in the form of surgical site infection, ileus and seroma formation as shown in table 6. Most patients who developed surgical site infection were managed in outpatient clinic and they didn’t need readmission for any further surgical intervention. Whereas, 85 of 833 Patients with non-complicated appendicitis developed postoperative surgical site infection that was statistically significant (X2= 131.82, p value 0.00) and they did well with conservative therapy (Table 6).
The incidence of acute appendicitis seems to have risen greatly, particularly in Europe, United State of America and Australia, with up to 16% of the population undergoing appendectomy in the first half of this century . The incidence rates have fallen in the past 30 years in these countries, and the individual life time risk of appendectomy is 8.6% and 6.7% among males and females respectively .
Although the diagnosis of appendicitis is a clinical, the decision is challenging in some people. There is a high incidence of complicated appendicitis primarily due to delay in seeking medical treatment .
The surgery is the gold standard for more than a century because of its low incidence of postoperative complications, early recovery and short hospital stay. Nevertheless, surgical treatment exposes the patients to risk due to general anesthesia and other complications such as surgical site infection, adhesion and intestinal obstruction, incisional hernia, infertility in female and pneumonia .
This study, showed that male patients underwent an emergency appendectomy more than female patients, and this was also reported by other studies [16,17]. In our study, we found that most patients who underwent appendectomy were young age10 to 19 years and this was statistically significant and this finding is consistent with other studies [16-24].
This study, showed that 377 (31.15%) patients had complicated appendicitis and this was consistent with other studies . Perforated appendicitis was the main complicated appendicitis being observed in our study, a close result was reported by other studies .
The highest rate of complicated appendicitis was observed among patients above fifty years, and this was statistically significant (X2 = 54.06, p value 0.00), and we found that perforated and gangrenous appendicitis were the main complicated appendicitis that were observed among them, similar results was reported by others studies [26,27]. Gangrene and perforation occur much more frequently in elderly patients. Elderly patients with a lax abdominal wall and/or obesity may harbor a gangrenous appendix with little evidence of it, leading to a clinical picture may simulate subacute intestinal obstruction .
Appendicular mass was observed as a third type of complicated appendicitis in our study, and it was mainly observed among patients above fifty years, and all of them have been treated conservatively after colonic cancer have been excluded by imagine studies and they showed good response and never needed emergency appendectomy during their hospitalization. Furthermore, they were given an appointment for elective appendectomy if needed. This is also consistent with other studies .
In the present study, an appendicular abscess was a fourth type of complicated appendicitis observed in 1.81% of patients, and it was mainly observed in patients above fifty years. One of 25 patients were treated by open drainage, antibiotics cover and intra-abdominal drain which remained in situ for a few days until they discharged well. This is consistent with findings reported by other studies .
This study, showed that all patients with non-complicated appendicitis had a shorter length of hospital stay and most of them were discharged on the first and second postoperative days. Whereas, patients with complicated appendicitis had a longer length of hospital stay for 2-10 days.
Those patients with appendicular mass were hospitalized for a longer period of time as they managed conservatively and they discharged without doing appendectomy, on the other hand, those patients with gangrenous appendicitis had the shortest length of hospital stay among all other patients with complicated appendicitis.
Uncomplicated appendicitis can safely be treated with a low complication rate, complicated appendicitis with perforation, abscess formation, and generalized peritonitis is still associated with an increased postoperative morbidity .
In our study, we observed that most of patients with complicated appendicitis developed postoperative complications in the form of surgical site infection and ileus, and wound seroma which is statistically significant (X2=131.82, p value 0.00). Most of them did well and treated conservatively and discharge without second operation.
Acute appendicitis is one of the most common non-traumatic cause of acute surgical abdominal emergency in our locality. Complicated appendicitis is not uncommon type of appendicitis, and it must be taken into consideration as they represent nearly one-third of cases of appendicitis and they need a special pre and postoperative care because they have a high rate of postoperative complication in comparison to patients with non-complicated appendicitis.
We think that the most important cause of complicated appendicitis is the delay of patients in seeking medical treatment, so we recommend education and early medical consultation.
Elderly people they have late presentation, delayed diagnosis as the clinical picture is not classical with comorbidity they have led to a high rate of complicated appendicitis.
Conflict of Interest
The author declares no conflict of interest.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
I would like to express my special thanks of gratitude to Prof. Mahfood Falih Hassan (University of Basrah) for his assistance in statistical analysis.