Early appendicectomy has been the treatment of choice for acute appendicitis. The report of a confidential inquiry into perioperative deaths (CEPOD) in the United Kingdom has shown that there is increased reluctance to involve senior members of the staff in the night, resulting in a lower standard of care which is reflected by inappropriate preoperative management, inappropriate operation, and deaths related to surgery.' It is generally accepted that delay in appendicectomy is associated with increased risk of perforation, complications, and prolonged hospitalisation. Advances in preoperative fluid and electrolyte management, anaesthesia, and antimicrobial prophylaxis, especially against anaerobes, have resulted in decreased morbidity in appendicitis.2 It is increasingly realised that sleep deprivation in surgical and anaesthetic junior hospital staff causes significant reduction in performance of mental and physical skills.3 With these factors in mind we compared the outcome in children with appendicitis who underwent early appendicectomy with that in those whose operation was delayed overnight. Materials, methods, and results We audited outcome in patients who had emergency appendicectomy between January 1987 and December 1991. Patients were divided into two groups: those who had an appendicectomy within six hours of admission and those observed overnight and who had an appendicectomy 6-18 hours after admission. It is hospital policy that all patients with acute appendicitis who cannot be operated on before midnight are operated on the following morning.Antibiotics were given before operation in all patients. Amoxycillin with clavulinic acid was given for up to 48 hours to patients with acute appendicitis and gentamicin with metronidazole for up to seven days to patients with perforated appendicitis. All wounds were. closed primarily in layers with absorbable subcuticular sutures. We estimated that 230 patients would be needed in each group to obtain a sample with 80% power and 10% difference in incidence of perforation (20% v 30%). The Z test, two tailed for age and one tailed for perforation and complications, was used for statistical analysis.This study included 695 patients-451 (257 boys) operated on within six hours and 244 (128 boys) operated on 6-18 hours after admission. Mean (SD) age was 9 9 (2 7) years and 10 1 (2 8) years respectively (p=0 363). Diagnoses included acute appendicitis in 325 (72%) patients, perforated-appendix in 81 (18%), and normal appendix in 45 (10%) in the group operated on within six hours and 169 (69%), 50 (21%), and 25 (10%) in the group whose operation was delayed. The difference in the rate of perforation was not significant (p=0-21; 95% confidence interval -3 7% to 8&7%).Postoperative complications occurred in 18 patients (4%) in the group operated on within six hours and 12 (5%) patients in the group operated on 6-18 hours after admission ( The average hospital stay for the group operated on within six hours was 3-5 (range 2-18) days compared with 4 1 (2-21) days for t...
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