Every hour counts: Global study links assessment delays to higher risk of burst appendix
A global study of appendicitis has found longer time to surgical assessment was associated with a progressively higher risk of perforation to the appendix, or a 'burst appendix'.
Published in The Lancet Global Health, the University of Birmingham-led study, involving Australian researchers, provides new insights into where delays matter most in this common emergency condition.
The Appendicitis Global Outcomes (AlliGatOr) study which involved more than 45,000 patients from 1,377 hospitals across 112 countries, also identified major differences between countries in the use of CT imaging and minimally invasive surgery.
Co-author and the Australian national lead on the study, University of Newcastle Honorary Professor Amanda Dawson, said the research found the longer patients waited before being assessed by a surgeon, the higher their risk of perforation.
Appendicitis is the most common abdominal surgical emergency worldwide. Some patients develop perforation, or a burst appendix, which is associated with infection, longer hospital stays, and increased risk of complications.
Perforation increased from around 23 per cent among patients reaching surgical assessment within 12 hours of symptom onset to 48 per cent among those reaching assessment after 72 hours or more. Perforation was itself associated with more than twice the risk of complications after surgery.
"The clock that matters starts when symptoms begin and stops when a surgeon examines you — not when you reach theatre,” general surgeon Professor Dawson said.
Across 112 countries, perforation rose from about one in four in patients assessed within 12 hours to nearly one in two in those assessed after three days or more.
"Our 38 Australian sites spanned every state and the ACT, from tertiary referral and children's hospitals to outer-metropolitan growth corridors and small rural hospitals. Same condition, same 24-hour target, very different odds of meeting it.
"What this study shows is that the harm accrues before a surgeon ever sees you.
“How long it takes to reach a surgeon is not the same in all of those places, and that is now a measurable thing to fix.
"This study produced two things: a finding, and more than 350 Australians who now know how to run a study. For many of them — medical students including University of Newcastle Joint Medical Program (JMP) students, interns, residents — this was the first trial they had ever worked on and the first paper their name will appear on," Professor Dawson (pictured right) said.
"A registrar recording cases in Gosford worked to the same protocol, the same training and the same authorship terms as a registrar in Birmingham or in Hawassa, Ethiopia. That is what a collaborative does — it distributes research capability rather than concentrating it in a handful of academic centres.
"These trainees and students are the surgeons of the future — the site leads of the next study, and the national leads of the one after that. They will spend their careers using evidence like this, and they now know how to build it. The paper will be cited for a decade; they will still be operating in 30 years.”
What delays to treatment matter most?
The researchers examined two distinct periods in the patient pathway: pre-hospital time, defined as the time from symptom onset to first surgical assessment, and in-hospital time, defined as the time from surgical assessment to surgery. This allowed the team to examine where delays were most strongly associated with perforation.
Longer time before surgical assessment was associated with greater perforation risk. By contrast, longer time between surgical assessment and surgery was not associated with higher perforation risk, probably reflecting clinical triage, whereby patients with more severe disease are prioritised for earlier surgery.
The study also highlights major global inequalities in access to diagnosis and treatment:
- CT was used in 58.6 per cent of patients in high-income countries compared with 5.6 per cent in low-income countries. CT imaging was also associated with fewer unnecessary operations.
- Minimally invasive surgery was used in 95.8 per cent of patients in high-income countries compared with 7.3 per cent in low-income countries.
These findings highlight substantial differences in diagnostic and operative capacity between income settings.
The research team recommend two key priorities for improving outcomes:
- Earlier access to surgical assessment, through stronger referral pathways, reduced barriers to care, and improved public awareness; and
- Stronger diagnostic and operative capacity, including appropriate access to CT imaging and minimally invasive surgery.
The research was conducted through the AlliGatOr (Appendicitis Global Outcomes) Collaborative, coordinated by the NIHR Global Health Research Unit on Global Surgery at the University of Birmingham.
Contact
- Media and Communication Specialist Carmen Swadling
- Email: carmen.swadling@newcastle.edu.au
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