Author Affiliations: Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland (Drs Abdullah, Papandria, and Camp).
Dr Andersson's letter to us and his work1 have presented an interesting challenge to a widely held belief that the natural history of acute appendicitis is progression to perforation, absent early intervention. In support of his hypothesis, one argument he makes is reflected in studies that suggest that conservative observation vs aggressive surgical therapy does not result in an increased rate of perforated appendicitis. However, we would respond that the progression to perforation is one that likely unfolds over the course of days, not just hours. This is supported by our clinical experience, in which children with appendicitis who had more than 5 days of symptoms are more likely to be treated using an interval appendectomy pathway (with patients treated initially with antibiotics who return for an elective appendectomy). Beyond clinical experience, the majority of evidence in the literature describes increased rates of perforated appendicitis to be associated with delays in surgical intervention in both adults2,3 and children.4 Thus, we respectfully disagree with Dr Andersson's view that the proportion of perforations is a bad measure of the quality of care, although we look forward to further inquiry on this subject.
Abdullah F, Papandria D, Camp M. Proportion of Cases of Perforated Appendicitis: A Bad Measure of Quality of Care—Reply. Arch Surg. 2011;146(7):885–886. doi:10.1001/archsurg.2011.169
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