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Safe to go home the same day after appendix surgery

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Adult patients with acute, non-perforated appendicitis can be discharged safely on the day of surgery without higher rates of postoperative complication or readmission rates compared with those hospitalised after surgery, found a large US analysis.

“The results are not surprising and rather reaffirm the practice that patients may be discharged on the same day as the surgery if the treating team feels it is appropriate,” said senior author Dr Armen Aboulian of Kaiser Permanente Woodland Hills Medical Centre in California.

“The decision for a patient to be discharged is based on numerous things and many teams, including the operating surgeon, the anesthesiologist, the recovery room team and any other consultants that may have been involved,” Aboulian said. “It is a complex decision but with this study, we showed that if patients are discharged without spending the night, they do well and do not end up returning to the emergency room at higher rates.”

Reuters Health reports that the researchers studied more than 12,000 patients from Kaiser Permanente medical centres in Southern California with acute appendicitis who underwent laparoscopic – sometimes called “keyhole surgery” – appendix removal between 2010 and 2014.

Roughly half of the patients were discharged from the hospital on the same day and half were hospitalised overnight. About 2% of those discharged on the same day were readmitted to the hospital within 30 days, compared to 3% of the overnight group.

Complications like wound infection and postoperative visits to the emergency treatment or diagnostic imaging studies were equally common in both groups. Wound infection happened in 2.2% of the group that went home and 2.7% of the hospitalised group, for example. Imaging was done on 11% of the group that went home and 12.3% of those who stayed overnight.

The patients who stayed overnight after their surgery were a bit older, on average, and slightly more likely to have diabetes or high blood pressure, the authors note.

The biggest difference between groups was in hospital costs. Those discharged on the same day had an average cost of $1,994 compared to $2,343 for overnight stays, as reported.

“Currently in the Southern California Kaiser Permanente Medical System, approximately 60% of patients with non-perforated appendicitis leave the hospital on the same day as the surgery,” Aboulian is quoted in the report as saying. “However, this is not the traditional approach and even through the time period of our study, there has been an annual increase in the tendency to discharge on the day of the surgery.”

“These changes are part of the art of medicine and continued education that is engrained in the American medical system,” he said. It’s hard to say if and why earlier hospital discharge leads to better outcomes, other than reduced healthcare expenses, he said.

“For example, getting a good night sleep in your own bed without the disturbance of the IV beeping or the 5 AM vitals check is difficult to obtain as a measurable metric,” Aboulian said. “However, previous studies have shown that an earlier discharge does correlate to a faster recovery and an earlier return to normal activities such as work.”

Surgeons may offer same-day hospital discharge, but patients and family should not request it, he said.

Abstract
Background: Small studies done during the past decade have demonstrated same-day discharge after appendectomy as an option for non-perforated appendicitis. Here we have examined a large cohort to confirm that same-day discharge in acute non-perforated appendicitis is a safe option.
Study Design: This was a retrospective study of patients from 14 Southern California Region Kaiser Permanente medical centers. All patients older than 18 years of age with acute, non-perforated appendicitis who underwent a laparoscopic appendectomy between 2010 and 2014 were included. We compared patients discharged on the day of surgery with patients hospitalized for 1 night. We examined readmission rates, complication rates, postoperative emergency department visits, postoperative diagnostic or therapeutic radiology visits, reoperations, and cost of treatment.
Results: The cohort was composed of 12,703 patients; 6,710 patients were in the same-day discharge group and 5,993 patients were in the hospitalized group. Patients in the same-day discharge group had a lower rate of readmission within 30 days when compared with the hospitalized group (2.2% vs 3.1%; p < 0.005). In both groups, postoperative rates of visits to emergency or radiology department for diagnostic or therapeutic imaging studies were statistically similar. Postoperative general surgery department visits were slightly higher in the hospitalized group (85% vs 81%; p < 0.001).
Conclusions: Adult patients with acute, non-perforated appendicitis can be discharged safely on the day of surgery without higher rates of postoperative complication or readmission rates compared with those hospitalized after surgery. In addition, same-day discharge in this patient group is cost-effective.

Authors
Andrew Scott, Shant Shekherdimian, Joshua D Rouch, Greg D Sacks, Aaron J Dawes, Wendy Y Lui, Letitia Bridges, Tracy Heisler, Steven R Crain, Mang-King W Cheung, Armen Aboulian

Reuters Health report
Journal of the American College of Surgeons abstract


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