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Initial experience with same day discharge after laparoscopic

appendectomy for nonperforated appendicitis

Pablo Aguayo, MD,* Hanna Alemayehu, MD, Amita A. Desai, MD, Jason
D. Fraser, MD, and Shawn D. St. Peter, MD
Department of Pediatric Surgery, The Children’s Mercy Hospital, Kansas city, Missouri

article info abstract

Article history: Background: Although many laparoscopic procedures are performed on an outpatient basis, patients who have
Received 2 January 2014 undergone a laparoscopic appendectomy have typically stayed at least overnight. Recently, data in both the
Received in revised form 25 pediatric and adult literature suggest that same day discharge (SDD) for acute nonperforated appendicitis is
February 2014 Accepted 5 safe and associated with high patient and parent satisfaction. We have recently begun attempting SDD for
March 2014 Available online nonperforated appendicitis, and this study is an analysis of our initial experience.
xxx
Methods: A retrospective chart review of all patients who underwent laparoscopic appen-dectomy for
Keywords: nonperforated appendicitis at our institution from January 2012 to July 2013 was performed. Demographics,
Same day discharge length of stay, hospital course, and outcomes were measured. Data are expressed as mean standard deviation.
Nonperforated appendicitis Comparative analysis was performed using a t-test.
Children
Results: A total of 588 laparoscopic appendectomies for nonperforated appendicitis were performed over an
18-mo period. Approximately 28% (n ¼ 128) were discharged on the day of surgery. Of the remaining
patients, 12.9% (n ¼ 59) stayed overnight for medical reasons, 0.4% (n ¼ 2) stayed for social reasons, 3.9%
(n ¼ 18) stayed because the operation ended late in the evening, and 82.8% (n ¼ 381) stayed because of
clinical care habits. Compared with patients who stayed overnight, there was no statistically significant
difference in read-mission rates (0.7% versus 1.9%, P ¼ 0.6%), follow-up before scheduled appointment
(5.4% versus 5.4%, P ¼ 1.0), and complication rate (0.7% versus 2.6%, P ¼ 0.3). Patients whose operation
ended later in the day had a longer hospital stay. We observed a trend toward more SDDs, the further we got
from the initiation of our protocol.

Conclusions: SDD is safe for children undergoing laparoscopic appendectomy for non-perforated
appendicitis. The two main barriers to SDD were time of day for the operation and provider habit, both of
which improved as more practitioners felt comfortable with the concept. SDD requires extensive education
within the hospital system, and we have initiated an aggressive prospective protocol to improve the results.

ª 2014 Elsevier Inc. All rights reserved.

* Corresponding author. Department of Pediatric Surgery, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108.
Tel.: þ1 816 234 3575; fax: þ1 816 983 6885. E-mail
address: [email protected] (P. Aguayo).
0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jss.2014.03.012
2 j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5

1. Introduction three-incision laparoscopic appendectomy was performed by one of seven

attending pediatric surgeons. The number of incisions for each case was
Appendicitis continues to be the most common gastrointes-tinal disorder based on surgeon preference and patient variables. All operations were
requiring urgent surgery in the pediatric popu-lation. Since the performed with the assistance of a resident or fellow.
introduction of laparoscopy as an approach to the treatment of
appendicitis, there have been multiple randomized controlled trials The current treatment algorithm at our institution for postoperative
demonstrating the safety and benefits of laparoscopy over the open management after laparoscopic appendectomy includes the following:
approach [1]. These studies have consistently shown that one of the major Trocar sites are injected with 0.25% bupivacaine hydrochloride
bene-fits of laparoscopy over the open approach is a decreased length of (Marcaine; AstraZeneca, London, England) intraoperatively. Patients
hospital stay. Despite these reported benefits, health care providers receive parenteral ketorolac tromethamine (Toradol; ACI Pharmaceuticals,
continue to mimic postoperative treatment patterns that are used for the New York, NY) during the procedure and every 6 h thereafter. All patients
open approach. received a prescription for oxycodone plus acetaminophen (Roxicet;
Roxane Laboratories Inc, Columbus, OH) at a standard dose of 0.15
Recently, there have been a series of publications demon-strating that mg/kg every 4 h to be taken as needed. Patients are immediately started
same day discharge (SDD) after laparoscopic appendectomy for acute on a regular diet and intravenous nar-cotics are discontinued
nonperforated appendicitis is safe and is associated with patient and postoperatively. Before discharge to home, patients and their families are
family satisfaction [2,3]. We have recently begun attempting SDD for provided written in-structions regarding diet, activity, and analgesic use.
nonperforated appendicitis, and this study is an analysis of our initial
experience. Demographic data were collected and included age, weight, and
gender. Data on length of operation, number of incisions used, length of
postoperative stay, and the time of day the operation was performed were
obtained. The total number and type of postoperative complications and
2. Methods need for follow-up before scheduled clinic appointment were recorded.
For patients who were not discharged on the day of their opera-tion, the
A retrospective chart review was performed after approval from the reason for overnight stay was recorded. The time of day that the operation
Institutional Review Board (IRB No 12070374). The study population ended for each case was also recorded.
included all patients who underwent a laparoscopic appendectomy for
nonperforated appendicitis between January 2012 and July 2013 at a Data are presented as mean standard deviation. Data comparisons
single institution. At our institution, perforation is defined as a hole in the were made using a two-tailed Student t-test for continuous variables.
appendix or fecalith in the abdomen [4]. All patients’ families were Significance was defined as a P 0.05.
informed of the possibility of SDD before any surgical inter-vention.
Patients found to have perforated appendicitis, defined in our center as
either a hole in the appendix or stool in the abdomen [4], were admitted to 3. Results
the hospital and were not included in this analysis.
We identified 588 patients who underwent laparoscopic ap-pendectomy
for nonperforated appendicitis; of which, 128 (28%) belonged to SDD
All patients received a single dose of ceftriaxone plus metronidazole group, whereas 460 patients belonged
before their appendectomy. A single, two, or

Fig. 1 e Time of case end and same day discharges. SDD [ same day discharge; ONS [ overnight stay.
 j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5 3

intra-abdominal abscesses, one for pancreatitis, two for persistent pain and
Table e Demographic data. constipation, and one for persistent nausea.
SDD ONS P Value
Age (y) 11.9 ( 3.3) 11.5 ( 3.4) 0.194 The time of day that the operation ended is recorded in Figure 2.
Gender (M) 66% 61% 0.219
Weight (kg) 49.7 ( 23.2) 47.6 ( 20.1) 0.339

4. Discussion
to overnight stay (ONS) group. The distribution of those with SDD versus
those with ONS are shown in Figure 1. There were no statistically A recent meta-analysis of 44 randomized controlled trials in adults and
significant differences with regards to de-mographics between the two children comparing laparoscopic versus open appendectomy demonstrated
groups (Table). Of the 128 pa-tients in the SDD group, 74 (57.8%) multiple benefits to the lapa-roscopic approach. These benefits include a
underwent a three-incision appendectomy, 11 (8.6%) a two-incision shorter length of hospital stay, faster return to normal activity, less post-
appendectomy, and 43 (33.6%) a single incision laparoscopic operative pain, and decreased wound infection rates when the
appendectomy. Mean operative time in the SDD group was 27.5 11.2 min laparoscopic approach was used [1]. The average length of stay after
versus 32.4 13.9 min in the ONS group. The average postoperative length laparoscopic appendectomy in a randomized clin-ical trial from 2000, 21
of stay for the SDD group was 7.3 2.5 h versus 22 11.3 h in the ONS y after the first laparoscopic appen-dectomy was performed in Germany,
group. was 1.9 d [5]. Data from more recent studies show that currently the
average length of stay for uncomplicated appendicitis remains essentially
Of those patients in the ONS group, 59 (12.9%) stayed for medical the same, between 1.1 and 2.2 d [6e8]. In a recent randomized trial in our
reasons, which included pain uncontrolled by oral analgesics, nausea, center, the mean length of stay was 22 h for both three-port and single-site
emesis, or for observation because of known comorbid conditions. laparoscopic appendectomy for non-perforated appendicitis [9].
Nursing records from 18 patients (3.9%) reflected the need for overnight Conversely, elective laparoscopic cholecystectomy, which was introduced
observation because of late arrival on the floor after their appendectomy. in the United States in 1985 and was once associated with a 2- to 8-d
Late arrival of these 18 patients appears to be those that were going to be postoperative hospital stay is now routinely performed as an outpatient
discharged after 9:00 PM. Two (0.4%) stayed for social reasons, whereas procedure.
the remaining 381 (82.8%) stayed because of clinical care habits.

There were no statistically significant differences between the two Over the last 5 y, several groups have attempted a SDD strategy for
groups in postoperative complications or unplanned return visits. A total the postoperative management of uncomplicated appendicitis in both the
of six patients (5%) from the SDD group sought an unplanned visit. Four adult and pediatric population [2,3,10]. They report SDD rates of
of these patients were seen for incisional pain and two for umbilical 35%e78% with a mean postoperative length of stay of approximately 5 h.
wound infection or drainage. One of the patients (0.8%) from the SDD Our present study demonstrated an overall SDD rate of 28% with an
group was admitted for overnight observation at the parent’s request. A average length of stay of 7.3 h.
total of 25 patients (5.4%) in the ONS group were seen before their
scheduled follow-up appointment. Eighteen were eval-uated for persistent At the time of this study, there were a total of seven attending pediatric
pain, one for feeding intolerance, five for wound infections, and one for surgeons that shared call and were involved with this study. At our
constipation. Of the ONS group patients, 6 (1.3%) were readmitted. Two institution, we have 24 h per day, 7 d per week in-house call coverage by
were readmitted for at least one pe-diatric surgery fellow and one resident. There are a total of

Fig. 2 e Time of case end and same day discharges.

4 j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5

three pediatric surgery fellows and anywhere from two to four junior length of stay was approximately 6 h for those patients admitted to a
residents that rotate with us throughout the year. During the hours of 6:00 surgical ward compared with 3 h for those who were discharged from the
AM and 4:00 PM we also have an average of three nurse practitioners that ambulatory surgery suite [2]. His-torically, an ambulatory surgery ward
assist with inpatient and outpatient clinical responsibilities. for patients undergoing appendectomy at our institution has not been used.
All pa-tients are admitted to a surgical ward after a short recovery period
In addition, we have a reserved operating room every weekday for in the post anesthesia care unit. We attribute the longer postoperative stay
add-on cases. Because of this, we generally do not schedule any in part because of this. We also noted that the later the appendectomy was
appendectomies after 9:00 PM or before 7:30 AM. performed, the less likely that the patient would be discharged to home
Although our SDD rate is lower than in reported studies, we were able that same day (Fig. 2). Patients in our present study who had their appen-
to demonstrate a trend toward more SDDs as we progressed from the dectomy performed between the hours of 12:00e3:00 PM were more than
introduction of our protocol (Fig. 1). The reason for this is multifactorial twice as likely to be discharged as those who had their appendectomy
but at its core can be attributed to the need for a paradigm shift. For the performed between 3:00e6:00 PM. We also observed that none of the
previous 20 y, most patients who underwent an appendectomy were patients who had their opera-tion completed after 9:00 PM were
admitted to the hospital for at least one night. This was the standard discharged that same day. We speculate that the delay may be due to the
practice at our institution and the standard by which all of our emergency fact that practice patterns, or clinical care habits, among nurses may be
department physicians, referring pediatricians, and nurses based on their difficult to break and unlike ambulatory surgery nurses, sur-gical ward
postoperative management ex-pectations. These expectations were then nurses may not feel as comfortable sending pa-tients home after shorter
conferred to the families who assumed that overnight observation in the postoperative intervals. As we move forward with a prospective study, we
hospital was medically indicated. In fact, what we observed was that only will be consulting with our nursing supervisors on the feasibility of
13% of the patients in our study who were admitted overnight stayed for admitting un-complicated, postoperative appendectomy patients to an
medical reasons, the remaining 87% stayed for nonmedical reasons. extended stay recovery area even if they were already admitted to a
surgical ward preoperatively.

Realizing that patient and family expectations would need to be

carefully managed in order for our patients to achieve the full benefits of
laparoscopic appendectomy, a concerted edu-cation effort by our surgical Ultimately, the most important factor to consider when implementing
team was instituted. The families were presented with one of two a fast-track discharge protocol is whether or not patients experience any
postoperative management strategies based on whether or not the patient adverse outcomes or require earlier follow-up as a direct result of early
had a non-perforated appendicitis. Families were instructed that in the discharge. The reported rate of urgent postoperative visits among SDD
absence of an appendiceal hole, their child could be discharged to home patients in the literature ranges between 7.4% and 13.7%. The reported
after they tolerated any oral intake and their pain was adequately rate of readmissions is 2.5% [2,3]. In the present study, we observed a 5%
controlled without the need for intravenous nar-cotics. This instruction urgent visit rate and a <1% readmission rate among those patients who
was given to the family and patient by someone from our surgical team were in the SDD group. The only patient who was readmitted was
either in the emergency department or surgical inpatient wards as soon as admitted for pain control at the request of the parents. These data support
a diagnosis of appendicitis was made. The instruction was repeated by one the findings that SDD is safe.
of our attending pediatric surgeons in the preoperative holding area and
again immediately postoperatively after the attending surgeons discussed
the outcome of the case with the family in the surgery waiting area.
5. Conclusions

SDD after laparoscopic appendectomy is safe but can be challenging to

Instruction on expedited SDD was also given to our surgical ward implement. A concerted effort to educate health care providers as to the
nurses. Initially, they were asked to contact the resident on-call once the safety of this postoperative management strategy and to manage the
patient met discharge criteria. The resident would then place the discharge expectations of the families is critical to its success. Despite the longer
orders and instructions into an electronic medical record. What we observa-tion time in the ONS group, there was no significant difference in
observed was that the nurses were not calling the resident for reasons that either urgent follow-up or in the rate of postoperative complications
are not clear. In an attempt to circumvent this delay, several months into between the two groups.
our protocol, we began entering the discharge orders and instructions
immediately after the operation was completed with instruction to call if
there was a problem with discharge. This changed our scheme from opt-in
for SDD with ONS as default to opt-out for SDD with SDD as default.
This step was critical in expediting patient discharge. Acknowledgment

Authors’ contributions: P.A. conceptualized the study, super-

Our length of stay was found to be 50% longer than that reported in
vised data acquisition and analysis, wrote the initial manu-
other studies. In two retrospective studies of prospectively collected data,
the hospital used an extended stay ambulatory surgery suite staffed with script, critically reviewed and revised the manuscript, and
ambulatory sur-gery nurses [2,9]. One of those studies demonstrated that approved it in its final form. H.A. and A.A.D. acquired data,
performed the initial data analysis, critically reviewed and
revised the manuscript, and approved it in its final form.
J.D.F
 j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e5 5

and S.D.P. conceptualized the study, supervised data acqui-sition and [4] St. Peter SD, Sharp SW, Holcomb GW III, et al. An evidence based
analysis, critically reviewed and revised the manuscript, and approved it definition for perforated appendicitis derived from a prospective,
in its final form. randomized trial. J Pediatr Surg 2008;43:2242.

[5] Lintula H, Kokki H, Vanamo K. Single-blind randomized clinical trial

Disclosure of laparoscopic versus open appendectomy in children. Br J Surg
2001;88:510.
The authors reported no proprietary or commercial interest in any product [6] Ingraham AM, Cohen ME, Bilimoria KY. Effects of delay to operation
mentioned or concept discussed in this article. on outcomes in adults with acute appendicitis. Arch Surg
2010;145:886.
[7] Stilling NM, Fristrup C, Gabers T, et al. Acceptable outcome after
laparoscopic appendectomy in children. Dan Med J 2013;60:A4564.
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