Impact of surgical timing on outcomes in adult acute appendicitis: a ten-year retrospective cohort from an Egyptian tertiary center

Mohamed K. Abdelaal; Emad Mostafa Abdelhafez; Mohamed M. Debes

doi:10.18203/2349-2902.isj20254103

Authors

Mohamed K. Abdelaal Department of General Surgery, Benha University Hospital, Benha, Egypt
Emad Mostafa Abdelhafez Department of General Surgery, Benha University Hospital, Benha, Egypt
Mohamed M. Debes Department of General Surgery, Benha University Hospital, Benha, Egypt

DOI:

https://doi.org/10.18203/2349-2902.isj20254103

Keywords:

Acute appendicitis, Appendectomy outcomes, Postoperative complications, Perforation, Surgical timing

Abstract

Background: Acute appendicitis is the most common cause of emergency abdominal surgery, yet the optimal timing for appendectomy remains debated. Advances in imaging, antibiotics and perioperative care have led many centers to accept short delays for stable patients, although the safety of delays beyond 24 hours remains uncertain, particularly in low- and middle-income countries.

Methods: A retrospective cohort study was conducted at Benha University Hospital from January 2014 to June 2024. Consecutive patients aged 18 years or older with imaging-confirmed acute appendicitis who underwent appendectomy during the index admission were included. Time to surgery was categorized as ≤12 hours, >12–24 hours, >24–48 hours and >48 hours. The primary outcome was a composite of 30-day major postoperative complications. Secondary outcomes included perforation, conversion to open surgery, length of hospital stay and 30-day mortality. Multivariable regression adjusted for demographic, clinical, radiologic and operative factors.

Results: A total of 2,784 patients were analyzed. Surgery within 12–24 hours showed no increase in complications compared to ≤12 hours. Delays beyond 24 hours were associated with significantly higher perforation rates, more postoperative complications and longer hospital stays. The adverse effect of delay was more pronounced in patients with complicated appendicitis.

Conclusions: Appendectomy performed within 24 hours is safe for stable adults, whereas delays beyond 24 hours increase morbidity, particularly in complicated cases. Early surgical prioritization is recommended to optimize outcomes.

Metrics

Metrics Loading ...

References

Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990;132(5):910–25. DOI: https://doi.org/10.1093/oxfordjournals.aje.a115734

Ferris M, Quan S, Kaplan BS. The global incidence of appendicitis: a systematic review of population-based studies. BMJ. 2017;357:1703.

Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis and management. Lancet. 2015;386(10000):1278–87. DOI: https://doi.org/10.1016/S0140-6736(15)00275-5

Fitz RH. Perforating inflammation of the vermiform appendix: with special reference to its early diagnosis and treatment. Am J Med Sci. 1886;92:321–46.

Bendeck SE, Nino-Murcia M, Berry GJ, Jeffrey RB. Imaging for suspected appendicitis: negative appendectomy and perforation rates. Radiology. 2002;225(1):131–6. DOI: https://doi.org/10.1148/radiol.2251011780

Coursey CA, Nelson RC, Patel MB. Making the diagnosis of acute appendicitis: do more preoperative CT scans mean fewer negative appendectomies. A 10-year study. Radiology. 2010;255(1):32–41. DOI: https://doi.org/10.1148/radiol.09082298

Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis. Ann Surg. 2006;243(5):656–60. DOI: https://doi.org/10.1097/01.sla.0000231726.53487.dd

Ingraham AM, Cohen ME, Bilimoria KY. Effect of delay to operation on outcomes in adults with acute appendicitis. Ann Surg. 2010;252(5):895–900. DOI: https://doi.org/10.1001/archsurg.2010.184

Teixeira PG, Sivrikoz E, Inaba K. Appendectomy timing: waiting until the next morning increases the risk of surgical site infections. J Trauma. 2009;66(4):1035–9.

Busch M, Gutzwiller FS, Aellig S, Kuettel R, Metzger U, Zingg U. In-hospital delay increases the risk of perforation in adults with appendicitis. World J Surg. 2011;35(7):1626–33. DOI: https://doi.org/10.1007/s00268-011-1101-z

Kim M, Kim SJ, Cho HJ. Impact of surgical timing on outcomes in acute appendicitis: a multicenter cohort study. Ann Surg. 2018;268(4):650–7.

Eko FN, Ryb GE, Drager L, Goldwater E, Wu JJ, Counihan TC. Overnight versus same-day surgery for acute appendicitis: a multicenter analysis. Am J Surg. 2013;206(6):911–5.

Papandria D, Goldstein SD, Rhee D. Risk of perforation increases with delay in recognition and surgery for acute appendicitis. J Surg Res. 2013;184(2):723–9. DOI: https://doi.org/10.1016/j.jss.2012.12.008

Di Saverio S, Podda M, De Simone B. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15:27.

Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg. 2004;91(1):28–37. DOI: https://doi.org/10.1002/bjs.4464

Bhangu A, Søreide K, Di Saverio S. Global variation in the management of appendicitis. Colorectal Dis. 2015;17(7):671–9.

Petroze RT, Nzayisenga A, Rusanganwa V, Ntakiyiruta G, Calland JF. Comprehensive national analysis of emergency general surgery in Rwanda: epidemiology, mortality and opportunities for improvement. World J Surg. 2014;38(8):1885–91.

Khalil M, Morshed G, Aboelenen A, Fikry A. Clinical profile and outcomes of acute appendicitis in Egypt: a retrospective study. Egypt J Surg. 2019;38(1):23–9.

El Nakeeb A, Salah T, Sherief M. Impact of COVID-19 on the management of acute appendicitis in a tertiary Egyptian center. Egypt J Surg. 2022;41(4):1212–20.

Anwar M, Mahmoud A, Ahmed A. Predictors of failure of nonoperative management of acute appendicitis: an Egyptian experience. Egypt J Surg. 2024;43(1):55–62.

Calpin C, Soliman M, Zhu H. Delay to appendectomy and outcomes: a systematic review and meta-analysis. JAMA Surg. 2024;159(2):101–10.

Agnesi F, De Simone B, Sartelli M. Timing of appendectomy in adults: results from a prospective multicenter observational study. Ann Surg. 2024;279(3):456–64.

Augustin T, Cagir B, Vandermeer TJ. Characteristics of perforated appendicitis: effect of delay is confounded by age and gender. J Gastrointest Surg. 2011;15(7):1223–31. DOI: https://doi.org/10.1007/s11605-011-1486-x

Yardeni D, Hirschl RB, Drongowski RA. Delayed versus immediate surgery in acute appendicitis: do outcomes differ? J Pediatr Surg. 2004;39(3):464–9. DOI: https://doi.org/10.1016/j.jpedsurg.2003.11.020

El Nakeeb A. Acute appendicitis during COVID-19: changes in presentation and outcomes in Egypt. Egypt J Surg. 2022;41(4):1212–20.

Anwar M. Nonoperative management failure predictors in acute appendicitis: a prospective study. Egypt J Surg. 2024;43(1):55–62.

Hussein M, Abdelrahman M, Taha A. Outcomes of laparoscopic appendectomy in obese Egyptian patients: does timing matter. Egypt J Surg. 2022;41(2):312–9.

Di Saverio S, Podda M, De Simone B. Diagnosis and treatment of acute appendicitis: WSES Jerusalem guidelines 2020. World J Emerg Surg. 2020;15:27. DOI: https://doi.org/10.1186/s13017-020-00306-3

Jaschinski T, Mosch C, Eikermann M, Neugebauer EA. Laparoscopic versus open appendectomy in adults. Cochrane Database Syst Rev. 2018;11:1546. DOI: https://doi.org/10.1002/14651858.CD001546.pub4

Andersson R. The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg. 2007;31(1):86–92. DOI: https://doi.org/10.1007/s00268-006-0056-y