Study of outcomes of perforated appendicitis in adults: a prospective cohort study

Acute appendicitis remains the most common general surgical emergency seen in most hospitals and the most common cause of acute abdomen requiring surgical intervention.

The aim was to study the intraoperative features and postoperative outcomes of appendicular perforation in adults.

First, to study the incidence, clinical presentation, and complications of perforated appendicitis in a tertiary care hospital. Second, to study morbidity and mortality in an operated case of perforated appendicitis.

This prospective observational study was conducted at a tertiary care centre in a government setup from August 2017 to July 2019. Data were collected from patients (N=126) who had an intraoperative finding of perforated appendicitis. The inclusion criteria are as follows: patients over the age of 12 with a perforated appendix, as well as any patients with intraoperative findings like perforated appendicitis, gangrenous perforated appendicitis, or a disintegrated appendix. The exclusion criteria are as follows: all patients with appendicitis below 12 years of age with perforated appendicitis; all patients with appendicitis with intraoperative findings of acute nonperforated appendicitis; and all patients with intraoperative findings of an appendicular lump or mass.

Perforation was found in 13.8% of the cases of acute appendicitis in this study. With a mean age of 32.5 years, the most common age of presentation in perforated appendicitis was 21-30 years. The most prevalent presenting symptom in all patients (100%) was abdominal pain, followed by vomiting (64.3%) and fever (38.9%). Patients with perforated appendicitis had a 72.2% complication rate. Peritoneal pollution of more than 150 ml was linked to a 100% increase in morbidity and mortality (54.5%). The mean duration of the hospital stay in patients with a perforated appendix was 7.28±5 days. Surgical site infection (42%) was the most common early complication, followed by wound dehiscence (16.6%), intestinal obstruction (1.6%), and faecal fistula (1.6%). The most common late complications were intestinal obstruction (2.4%), intra-abdominal abscess (1.6%), and incisional hernia (1.6%). The mortality rate in patients with perforated appendicitis was 4.8%.

To conclude, prehospital delay was an important factor contributing to appendicular perforation and leading to adverse outcomes. A higher rate of morbidity and prolonged duration of hospital stay were seen in patients with delayed presentation, with features of generalised peritonitis and perforation of the base of the appendix. Delayed presentations in as elderly population with underlying co-morbid conditions associated with severe peritoneal contamination were associated with higher mortality (26%) in perforated appendicitis. Conventional surgery and open procedures remain the preferred approach in a government setup like ours where laparoscopy may not be available during odd hours. Since this study was done over a short duration, certain long-term outcomes could not be assessed. Hence, there is still a need for further studies.