World Journal of Surgery

, Volume 35, Issue 7, pp 1626–1633 | Cite as

In-hospital Delay Increases the Risk of Perforation in Adults with Appendicitis

  • Mirjam Busch
  • Florian S. Gutzwiller
  • Sonja Aellig
  • Rolf Kuettel
  • Urs Metzger
  • Urs ZinggEmail author



The influence of in-hospital delay (time between admission and operation) on outcome after appendectomy is controversial.


A total of 1,827 adult patients underwent open or laparoscopic appendectomy for suspected appendicitis in eleven Swiss hospitals between 2003 and 2006. Of these, 1,675 patients with confirmed appendicitis were included in the study. Groups were defined according in-hospital delay (≤12 vs. >12 h).


Delay > 12 h was associated with a significantly higher frequency of perforated appendicitis (29.7 vs. 22.7%; P = 0.010) whereas a delay of 6 or 9 h was not. Size of institution, time of admission, and surgical technique (laparoscopic vs. open) were independent factors influencing in-hospital delay. Admission during regular hours was associated with higher age, higher frequency of co-morbidity, and higher perforation rate compared to admission after hours. The logistic regression identified four independent factors associated with an increased perforation rate: age (≤65 years vs. >65 years, odds ratio (OR) 4.5, P < 0.001); co-morbidity (Charlson index > 0 vs. Charlson index = 0, OR 2.3, P < 0.001); time of admission (after hours vs. regular hours, OR 0.8, P = 0.040), in-hospital delay (>12 vs. ≤12 h, OR 1.5, P = 0.005). Perforation was associated with an increased reintervention rate (13.4 vs. 1.6%; P < 0.001) and longer length of hospital stay (9.5 vs. 4.4 days; P < 0.001).


In-hospital delay negatively influences outcome after appendectomy. In-hospital delay of more than 12 h, age over 65 years, time of admission during regular hours, and the presence of co-morbidity are all independent risk factors for perforation. Perforation was associated with a higher reintervention rate and increased length of hospital stay.


Appendicitis Laparoscopic Appendectomy Open Appendectomy Perforated Appendicitis Perforation Rate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors are grateful to David I. Watson, M.D., and Sarah Thompson, M.D., for critical review of the manuscript. The authors are also grateful to the surgeons who contributed patient records for this study. The study was funded by the ‘Outcome’ Association Zurich, Switzerland.

Conflict of interest



  1. 1.
    Kearney D, Cahill RA, O’Brien E et al (2008) Influence of delays on perforation risk in adults with acute appendicitis. Dis Colon Rectum 51:1823–1827PubMedCrossRefGoogle Scholar
  2. 2.
    SCOAP Collaborative, Cuschieri J, Florence M, Flum DR et al (2008) Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program. Ann Surg 248:557–563PubMedGoogle Scholar
  3. 3.
    Hale DA, Jaques DP, Molloy M et al (1997) Appendectomy. Improving care through quality improvement. Arch Surg 132:153–157PubMedGoogle Scholar
  4. 4.
    Sleem R, Fisher S, Gestring M et al (2009) Perforated appendicitis: is early laparoscopic appendectomy appropriate? Surgery 146:731–737PubMedCrossRefGoogle Scholar
  5. 5.
    Pittman-Waller VA, Myers JG, Stewart RM et al (2000) Appendicitis: why so complicated? Analysis of 5755 consecutive appendectomies. Am Surg 66:548–554PubMedGoogle Scholar
  6. 6.
    Colson M, Skinner KA, Dunnington G (1997) High negative appendectomy rates are no longer acceptable. Am J Surg 174:723–726PubMedCrossRefGoogle Scholar
  7. 7.
    Eldar S, Nash E, Sabo E et al (1997) Delay of surgery in acute appendicitis. Am J Surg 173:194–198PubMedCrossRefGoogle Scholar
  8. 8.
    Temple CL, Huchcroft SA, Temple WJ (1995) The natural history of appendicitis in adults. A prospective study. Ann Surg 221:278–281PubMedCrossRefGoogle Scholar
  9. 9.
    Fahim F, Shirjeel S (2005) A comparison between presentation time and delay in surgery in simple and advanced appendicitis. J Ayub Med Coll Abbottabad 17:37–39PubMedGoogle Scholar
  10. 10.
    Maroju NK, Robinson Smile S, Sistla SC et al (2004) Delay in surgery for acute appendicitis. ANZ J Surg 74:773–776PubMedCrossRefGoogle Scholar
  11. 11.
    Von Titte SN, McCabe CJ, Ottinger LW (1996) Delayed appendectomy for appendicitis: causes and consequences. Am J Emerg Med 14:620–622CrossRefGoogle Scholar
  12. 12.
    Omundsen M, Dennett E (2006) Delay to appendicectomy and associated morbidity: a retrospective review. ANZ J Surg 76:153–155PubMedCrossRefGoogle Scholar
  13. 13.
    Hardin DM Jr (1999) Acute appendicitis: review and update. Am Fam Physician 60:2027–2034PubMedGoogle Scholar
  14. 14.
    Preston CA, Karch SB (1989) The influence of gender and use of barium enema on morbidity in acute appendicitis. Am J Emerg Med 7:253–255PubMedCrossRefGoogle Scholar
  15. 15.
    Antevil J, Rivera L, Langenberg B et al (2004) The influence of age and gender on the utility of computed tomography to diagnose acute appendicitis. Am Surg 70:850–853PubMedGoogle Scholar
  16. 16.
    Agafonoff S, Hawke I, Khadra M et al (1987) The influence of age and gender on normal appendicectomy rates. ANZ J Surg 57:843–846CrossRefGoogle Scholar
  17. 17.
    Franz MG, Norman J, Fabri PJ (1995) Increased morbidity of appendicitis with advancing age. Am Surg 61:40–44PubMedGoogle Scholar
  18. 18.
    Lunca S, Bouras G, Romedea NS (2004) Acute appendicitis in the elderly patient: diagnostic problems, prognostic factors and outcomes. Rom J Gastroenterol 13:299–303PubMedGoogle Scholar
  19. 19.
    Hansson LE, Laurell H, Gunnarson U (2008) Impact of time in the development of acute appendicitis. Dig Surg 25:394–399PubMedCrossRefGoogle Scholar
  20. 20.
    Abou-Nukta F, Bakhos C, Arroyo K et al (2006) Effects of delaying appendicectomy for acute appendicitis for 12 to 24 hours. Arch Surg 141:504–507PubMedCrossRefGoogle Scholar
  21. 21.
    Bickell N, Aufses AH, Rojas M et al (2006) How time affects the risk of rupture in acute appendicitis. J Am Coll Surg 202:401–406PubMedCrossRefGoogle Scholar
  22. 22.
    Chung CH, Ng CP, Lai KK (2000) Delays by patients, emergency physicians, and surgeons in the management of acute appendicitis: retrospective study. Hong Kong Med J 6:254–259PubMedGoogle Scholar
  23. 23.
    Papaziogas B, Tsiaousis P, Koutelidakis I et al (2009) Effect of time on risk of perforation in acute appendicitis. Acta Chir Belg 109:75–80PubMedGoogle Scholar
  24. 24.
    Charlson ME, Pompei P, Ales KL et al (1987) A new method of classifying prognostic co-morbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383PubMedCrossRefGoogle Scholar
  25. 25.
    Ditillo MF, Dziura JD, Rabinovici R (2006) Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 244:656–660PubMedCrossRefGoogle Scholar
  26. 26.
    Burns RP, Cochran JL, Russell WL et al (1985) Appendicitis in mature patients. Ann Surg 201:695–704PubMedCrossRefGoogle Scholar
  27. 27.
    Andersson RE (2007) 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 early diagnosis. World J Surg 31:86–92. doi: 10.1007/s00268-006-0056-y PubMedCrossRefGoogle Scholar
  28. 28.
    Cullinane M, Gray AJG, Hargraves CMK et al (2003) The 2003 report of the national confidential inquiry into perioperative deaths, pp 1–128. Accessed April 2011
  29. 29.
    Simillis C, Symeonides P, Shorthouse AJ et al (2010) A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery 147:818–829PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2011

Authors and Affiliations

  • Mirjam Busch
    • 1
  • Florian S. Gutzwiller
    • 2
  • Sonja Aellig
    • 2
  • Rolf Kuettel
    • 2
  • Urs Metzger
    • 1
  • Urs Zingg
    • 1
    • 3
    Email author
  1. 1.Department of SurgeryTriemli Hospital ZurichZurichSwitzerland
  2. 2.“Outcome” Association ZurichZurichSwitzerland
  3. 3.University Hospital BaselBaselSwitzerland

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