Appendicitis in children: an ongoing debate

The aim of the study by Lee et al. (ref) was to evaluate determinants (co-morbidities) and outcomes of in-hospital delay in treatment of children with acute appendicitis. This retrospective evaluation was done using a database of 683,016 children hospitalised with appendicitis between 2000 and 2008 in the USA. Out of these, 17,737 children (2.6 %) experienced a delay in treatment of 2 days or more (Median 3 days; IQR 2–5 days). The underlying hypothesis is that ‘Increased time interval from the onset of symptoms to intervention is associated with increased rate of rupture’ as the authors state in their introduction. This hypothesis, however, has never been proven, and has even been disputed by several investigators [1–3]. It has been demonstrated that the majority of patients with ruptured appendicitis have the perforation already at the time of presentation at the hospital [3]. Several authors envisage two types of appendicitis: simple (non-perforated) appendicitis, with no tendency to progress, and complex (perforated) appendicitis, in which perforation occurs early in the course of the disease [3, 4]. The authors reported significant differences between the groups with and without delay in terms of age, sex, ethnicity and presence of co-morbidities (Table 1). Significantly more patients with a delay in treatment (57.3 %) had a complicated disease course, including perforation, than was seen in the early treatment group (28.9 %) (Table 3). Not surprisingly, therefore, the authors demonstrate an association between delayed treatment and adverse outcome, such as mortality, length of stay and increased cost (Table 4). The implicit but not proven assumption of the authors is that perforation of the appendix occurred during the delay between admission and treatment and, therefore, could have been prevented. There is no argument that early diagnosis and treatment (whether operative or antibiotic) of acute appendicitis actually results in reduction of pain, anxiety, complications and costs.