Abstract
Background : This study was carried out to see the feasibility of early discharge from the hospital after open appendicectomy, so that it will reduce the burden on hospital and hospital staff and also benefit the patients.

Methods : Cases of emergency as well as interval appendicectomy who were the native of city were studied excluding cases of perforated and gangrenous appendix. All patients were discharged within 48 hours after starting liquids and followed for removal of stitches on the 8th day. Different problems like wound infections, fever etc and feasibility of 2 doses antibiotics were also studied.

Results : Post operative infection rate was 4%. Only 2 patients came back before 8 days. They were treated but there was no need for readmission. Except wound infection no other complication was noted. No patients had problems related with early discharge.
Early discharge is beneficial and feasible for local patients. Only two doses of antibiotics with local instillation of antibiotics in the wound significantly reduced post operative infection rate and are safe and feasible.

Introduction
Acute appendicitis is the most common emergency for general surgeons. The standard accepted treatment for appendicitis is appendicectomy. It is common practice in many institutions to discharge the patients after removal of stitches, that is usually on 7th day. Because of increase in number of patients, at the same time number of beds remaining constant, there is increase of pressure on surgeon as well as on hospital and hospital staff, especially working in general hospitals. Floor beds is a common problem in many general hospitals in India. Though laparoscopy is available in most of the big cities, the common lower middle class patients cannot afford it because of obvious financial constraints.

This prospective study was planned mainly to study the feasibility of early discharge (within 48 hrs) after open appendicectomy. The study included cases of non complicated appendicitis (non perforated and non gangrenous). The cases studied were within the area of city Municipal Corporation, only with the intention that if some problem arises after discharge they should be able to reach the hospital immediately.

From this study we have come to the conclusion that cases of non complicated appendicitis can be safely discharged within 48 hrs after appendicectomy. If the patient tolerates liquids, discharge from the hospital becomes very safe. It becomes economical to the patients as well as helps to alleviate hospital burden. Only two doses of antibiotics (one preoperative and another post operative) are enough to take care of these patients of actually inflamed and recurrent appendicitis.

Material and Methods
This prospective study was done within the four year period (October 2000 to December 2004) at Government Medical College and Hospital, Nagpur. Those patients who were the residents of city corporation area only were included in this study. Patients and their relatives were explained about the plan of early discharge and willingness was obtained. Patient of either sex and of any age were included in the study. Patients who were found to have only acutely inflamed appendix or cases of recurrent and interval appendicectomy were included in the study. Patients with perforated or gangrenous appendix, patients not willing for early discharge, leaving outside corporation area and the patients with morbid conditions like diabetes mellitus, cardiovascular disease, pregnancy etc. were excluded from the study.

After admission the cases were thoroughly examined and fully investigated. An intravenous dose of ciprofloxacin (500 mg) and metronidazole (400 mg) was administered. They were operated under general or spinal anaesthesia which was decided by the anaesthesiologist. All males were operated by McBurney’s incision and females by the Lanz incision. Appendicectomy was carried out by standard method. At the time of closure of wound 0.25% bupivacaine (apprx 5-10 ml) was infiltrated locally in the wound edges. Local antibiotics in the form of Ciplox drops (O.3%-apprx 5 ml) was instilled in the wound layers. Inj Diclofenac sodium 75 mg was given 8 hourly (only 3 doses). 2nd dose of antibiotics was administered after 8 hrs postoperatively. Intravenous fluids were given. Along with the regular postoperative monitoring, patients were especially looked for pain, vomiting and bowel sounds. Clear fluids were started before 24 hrs in many of the patients. After they tolerated liquids, all of them were discharged within 48 hrs after surgery. They were called to follow-up on 8th postoperative day for removal of stitches. They were given clear instruction about the diet and were asked to report in the hospital, if fever, vomiting, pain at site, distension of abdomen and constipation etc. develops.

Observations
From this study also it was clear that the appendicitis is a disease of young people, mostly belonging to second and third decade. 76% patients belonged to this age group. There was male preponderance (58%). Out of 100 patients, 84 were operated as an emergency, ¹⁶ were operated as elective appendicectomy. Majority of them were operated under spinal anaesthesia. Appendicular stump was managed by ligation and invagination in 80% cases and simple ligation was done in 20% due to caecal wall oedema. Post operative infection rate was 4% (4 cases). In 56% patients bowel sounds appeared within 24 hrs and they were given clear fluids quite early. In 24% patients, there was vomiting inspite of presence of bowel sounds. In those patients, oral fluids were given little late, after control of vomiting but still within 24 hrs.(after apprx16 hrs postoperatively). In 20% patients bowel sounds did not return, hence they were given liquids after 24 hrs. 56% patients were discharged at 24 hrs, 24% within 24-36 hrs and 20% within 36 to 48 hrs. The mean hospital stay was 32 hrs.

After discharge 4 patients came back before 8 days. Two complained of headache, which was treated. Two had fever for which wound was examined, stitch abscess was present. Stitch was removed and pus drained. There was superficial wound gape of 1 cm length. They were advised dressings on OPD basis. On 8th day two patients had wound infection at the time of stitch removal. Those were treated with dressings only. There was no any other complication. No patient had any problem related with early discharge.

With this regimen there was a significant amount of financial saving for the patient as well as significant saving of revenue of the hospital and helped in increasing turn over of patients. For the patient, the satisfaction of living in home atmosphere, prevention of cross infection and hospital acquired infection and cost effective treatment were the benefits.

Discussion
In the present study, because of local infiltration of bupivacaine about 80% patients were very comfortable in the immediate post operative period (6-8 hrs). Only 20% patients required injectable analgesics (Diclofenac Sodium) in the immediate postoperative period. So it helps in the early mobilization of the patients and early discharge. Similar intraoperative infiltration was done by Ramesh et al1 in 130 patients. In his study 23% patients required postoperative analgesia. Colberts et al² in 1998, in a study on analgesia after open appendicectomy concluded that subcutaneous and peritoneal bupivacaine is superior to skin infiltration alone. Foulds KA et al³ in a study done in the year 2000 concluded that intraoperative local anaesthesia in children during open appendicectomy reduced the hospital stay. Salman et al⁴ in the year 2000 evaluated the efficacy of Tenoxicam (20 mg IV), fentanyl (100 mg) and bupivacaine (2.5 mg/ml- 5 ml) in the patients undergoing a day care minor operative laparoscopy. He concluded that Tenoxicam was found ineffective and bupivacaine was superior to other groups in reducing pain and was superior to other analgesics.

Ramesh et al¹ did not give any antibiotics in non complicated cases of appendicitis with 8.4% wound infection rate, while in the present series it was 4% with two doses of antibiotics (Ciprofloxacin + metronidazole) along with local instillation of ciprofloxacin drops. Kumar Krishnan et al⁵ also in their study of two groups (one with Gentamycin + metronidazole and another Ciprofloxacin + metronidazole) concluded that ciprofloxacin + metronidazole is a good combination to decrease the wound infection rate. T M Tsang et al⁶ studied the efficiency of single dose gentamycin and metronidazole preoperatively and in another group, 3 doses postoperatively. The infection rate was 1.9% and 1.8% respectively.

So he concluded that the single preoperative dose of gentamycin and metronidazole is effective in controlling post appendicectomy wound infection in uncomplicated cases.

Kowski et al⁷ reviewed literature of 25 yrs on preventing wound infection after appendicectomy. On that basis he said, topical antiseptics has no significant effect but topical antibiotics are beneficial. Galland RB⁸ in 1983 found that inspite of using topical antiseptics like povidone –iodine infection rate was still high. He also concluded that topical antiseptic has no benefit in preventing post appendicectomy wound infection. Stringer et al⁹ used topical cefamandol in all appendicectomy wounds and he got excellent result and lowest complication rate, of less than 1%. In the present series we can conclude that topical antibiotics in addition with systemic antibiotics significantly reduce the post appendicectomy wound infection.

The readmission rate after early discharge was between 1.5 and 2.5% as quoted by Ramesh et al¹ and Salman et al⁴ respectively. In the present series it was 0%. Velhote et al10 quoted the mean hospital stay of 24 hrs, Lord et al¹¹ quoted 46 hrs, Ramesh et al¹ 36 hrs, Salman et al⁴ 62 hrs and in the present series it was 32 hrs. Salman adopted the criteria for early discharge as 1) stable vital signs 2) active bowel sounds and 3) ambulation and ability to tolerate fluid and food without discomfort. Lord et al11 concluded early discharge is safe and feasible. Foulds et al³ observed in children that intraoperative local anaesthesia during open appendicectomy reduced the hospital stay. The wound infection rate after early discharge was 4% in present series, 4.5% quoted by Salman et al,⁴ 8.4% by Ramesh et al,¹ 8% by Velhote et al.¹⁰ We observed that the local instillation of antibiotics drops reduces wound infection rate. This regimen of early discharge is beneficial for both patients and hospital agencies and staff by reducing cost of treatment and reducing burden on hospital staff. So we conclude this programme of early discharge after open appendicectomy for local patients, with only two doses of antibiotics, with the instillation of antibiotic drops in wound is safe and feasible. It reduces, the overuse or misuse of IV fluids, antibiotics, analgesics. It also reduces hospital acquired infection rate and most important is, it gives satisfaction to a patient of living in home atmosphere. It can be practised safely in non gangrenous and non perforated appendicitis.

References

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