When Appendicitis Extends Beyond Appendectomy: Bowel Resection and Morbidity in Complicated Appendicitis

Background Surgery is considered definitive management for acute uncomplicated appendicitis, with non-operative management an acceptable alternative, but its role in complicated appendicitis remains controversial. Despite guideline recommendations favoring surgery in complicated appendicitis, there remains a trend toward non-operative management due to concern for greater postoperative complications. We aimed to compare in-hospital outcomes with surgical intervention for uncomplicated and complicated appendicitis in a contemporary national cohort. Materials and Methods We used the 2019-2022 National Inpatient Sample to identify adult emergency hospitalizations with surgery for acute appendicitis. We compared hospitalizations with surgery for uncomplicated appendicitis against complicated appendicitis examining patient characteristics, extent of resection, length of stay, in-hospital outcomes using survey-weighted multivariable regression. Results We identified 406 110 emergency weighted hospitalizations for acute appendicitis; 325 995 included emergency surgery, of which 178 690 (55%) were for uncomplicated and 147 305 (45%) for complicated appendicitis. Compared with uncomplicated appendicitis, surgery for complicated appendicitis more often required unplanned bowel resections (3% vs 1%, P < .001) and had approximately threefold higher rates of gastrointestinal, infectious and wound complications (all P < .001). Complicated appendicitis was associated with longer length of stay (3.9 vs 1.7 days, P < .001) while in-hospital mortality did not differ between the groups. Discussion Surgical management for complicated appendicitis more frequently requires additional bowel resection and is associated with higher postoperative complication rates than surgery for uncomplicated appendicitis, despite similar mortality. These highlight the operative complexity of complicated appendicitis and underscore the need for careful perioperative counseling and shared decision-making regarding operative risks and expected outcomes.