SAN FRANCISCO – Implementing an outpatient laparoscopic appendectomy protocol for uncomplicated appendicitis allowed 88% of 345 cases at one institution to be performed without hospitalizing the patient overnight.
The outpatients went home an average of 171 minutes after completion of the surgery.
Forty patients were admitted (12%) because of pre-existing comorbidities in 15 patients, postoperative morbidity in 6, and a lack of transportation or assistance for 19, Dr. Richard C. Frazee and his associates reported.
Only 4 of the 305 patients who underwent the procedure as outpatients were admitted after going home, for an overall outpatient success rate of 87%, he said at the annual meeting of the American Association for the Surgery of Trauma. Reasons for readmission included fever, nausea and vomiting, partial small bowel obstruction, or deep vein thrombosis.
Morbidity affected 7% of patients in the form of urinary retention, wound infection, operative enterotomy, cecal serosal injury, deep vein thrombosis, or exacerbation of chronic obstructive pulmonary disease. One laparoscopic appendectomy was converted to open surgery; none of the patients died.
This is not the first time Dr. Frazee has presented his institution’s experience with the outpatient laparoscopic appendectomy protocol; he shared similar findings from an earlier series at the same meeting a few years ago. In an interview, he expressed some frustration that more hospitals haven’t adopted similar protocols.
By his rough calculation, 20% of all laparoscopic uncomplicated appendectomies performed in the United States each year cause perforations requiring hospitalization and 80% of the rest are successful outpatient procedures. That means 242,760 patients each year would not be hospitalized overnight for this surgery. Separate data show that the average U.S. length of hospitalization for laparoscopic appendectomy is 2 days, at an average cost of $1,900 per day. Nationwide adoption of an outpatient protocol potentially could avoid over $921 million in annual costs.
"It is time for us to create a change in the standard of care for uncomplicated appendicitis," said Dr. Frazee, chief of acute care surgery at Scott & White Healthcare in Temple, Tex.
His interest in the subject started when his son, an otherwise healthy young adult, complained about having to stay in the hospital after a laparoscopic appendectomy. Dr. Frazee conducted a review of 119 laparoscopic appendectomies at his institution and found that 35% of patients went home the same day, 61% were admitted for a day, and the few others were hospitalized longer. Morbidity was seen in 8%.
He and his colleagues developed an outpatient protocol in July 2010, under which patients undergoing uncomplicated laparoscopic appendectomies would not be admitted unless they were pregnant or younger than 17 years, or if a perforated or gangrenous appendicitis was discovered during the surgery. To qualify for same-day discharge, outpatients had to be able to tolerate intake of liquids, ambulate, urinate, and have adequate respiratory effort. They also had to be hemodynamically stable, have pain controlled with oral analgesics, have nausea and vomiting controlled, show no alteration in mental status from baseline, have the approval of their physician, and have appropriate supervision and assistance at home.
An initial review compared 116 patients treated under the protocol in 2010-2011 with historical controls and found a significant reduction in length of stay without increased morbidity. Under the protocol, 85% of patients were outpatients, compared with 35% in the control group. Postoperative morbidity affected 5% in the protocol group and 8% in the control group, and no patients were readmitted (Am. Surg. 2012;215:101-5).
Since then, the outpatient protocol has been the standard of care at his institution. The current report covers 166 men and 179 women treated under the protocol from July 2010 through December 2012. They had a mean age of 35 years and a mean body mass index of 31 kg/m2. Thirty-two percent had a history of prior abdominal surgery. Comorbidities at baseline included hypertension in 29%, diabetes in 11%, coronary artery disease in 4%, and chronic obstructive pulmonary disease in 1%.
Outpatients were sent home from the day surgery unit or the post–anesthetic care unit. Thirty percent were dismissed between 6 a.m. and noon, 15% went home between noon and 6 p.m., 25% were dismissed between 6 p.m. and midnight, and 30% went home between midnight and 6 a.m.
The investigators now are conducting a follow-up study to assess patient satisfaction with the protocol. "Our impression is that they like going home the same day," but a study will confirm whether this is true or not, he said.
Dr. Frazee reported having no financial disclosures.