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Predictive factors for failure of nonoperative management in perforated appendicitis

Maxfield, Mark W. MD; Schuster, Kevin M. MD; Bokhari, Jamal MD; McGillicuddy, Edward A. MD; Davis, Kimberly A. MD, MBA

Journal of Trauma and Acute Care Surgery: April 2014 - Volume 76 - Issue 4 - p 976–981
doi: 10.1097/TA.0000000000000187
Original Articles

BACKGROUND Identifying patients on admission with perforated appendicitis who have phlegmon or abscess initially selected for but likely to fail nonoperative management may avoid delays in definitive treatment.

METHODS Patients older than 15 years presenting to a university tertiary care hospital with perforated appendicitis and abscess or phlegmon and planned nonoperative management were reviewed. Comorbidities, clinical findings, laboratory markers, radiographic findings, and nonsurgical treatments associated with failure of nonoperative management were recorded.

RESULTS Eighty-nine patients were identified, and 69 were managed successfully to discharge without operation. Length of stay was greater in the failure group (11 days vs. 5 days, p = 0.001), and intensive care unit care was more common (10% vs. 0%, p = 0.049). On univariate and multivariate analyses, smoking (odds ratio [OR], 13.20; 95% confidence interval [CI], 1.13–142; p = 0.039), tachycardia (OR, 4.93; 95% CI, 1.21–20.06; p = 0.026), and generalized abdominal tenderness (OR, 5.52; 95% CI, 1.40–21.73; p = 0.015) were associated with failure of nonoperative management. On computed tomographic scan, the failure group had higher rates of abscess (75% vs. 55%, p = 0.110), and their abscesses were more likely smaller than 50 mm (OR, 2.83; 95% CI, 1.01–7.92; p = 0.043).

CONCLUSION Patients with perforated appendicitis and phlegmon or abscess who smoke or present with tachycardia, generalized abdominal tenderness, and abscesses smaller than 50 mm are more likely to fail nonoperative management and should be considered for early operation. These findings should be validated prospectively.

LEVEL OF EVIDENCE Therapeutic study, level III.

From the Departments of Surgery (M.W.M., K.M.S., E.A.M., K.A.D.), and Radiology (J.B.), Yale School of Medicine, New Haven, Connecticut.

Submitted: November 26, 2013, Revised: January 2, 2014, Accepted: January 2, 2014.

This study was part of the poster presentation at the New England Surgical Society 93rd annual meeting, September 21–23, 2012, in Rockport, Maine.

Address for reprints: Kevin M. Schuster, MD, Department of Surgery, Yale School of Medicine, 330 Cedar St, BB310, PO Box 208062, New Haven, CT 06520-8062; email:

© 2014 Lippincott Williams & Wilkins, Inc.