Skip to main content

Delayed Surgery for Perforated Appendicitis is Feasible in Children Without Compromising the Outcome in Selected Cases


Background and aim

The relationship between time to surgery and risk of postoperative complications and re-intervention has not been conclusively investigated in pediatric perforated appendicitis (PA). The aim of this study was to determine whether time to appendectomy (TTA) is a risk factor for postoperative complications and re-intervention in a cohort of children undergoing appendectomy for PA.


A total of 254 children (age: 8.7 ± 3.7 years) undergoing appendectomy for PA were retrospectively evaluated and stratified into Group I–III according to the Clavien-Dindo classification for postoperative complications (Group I n = 218, 86%; Group II n = 7, 3%; Group III n = 29, 11%).


The TTA was comparable between all groups (group I: 8.8 ± 9.2 h; group II: 7.8 ± 5.3 h; group III: 9.5 ± 9.6 h; overall: 8.8 ± 9.1 h; p = 0.885). A C-reactive protein (CRP) value at admission of  ≥128.6 mg/l indicated a higher risk for developing Grade II complications with no need for re-intervention (OR: 3.963; 95% CI: 1.810–8.678; p = 0.001) and Grade III complications with the need for re-intervention (OR: 3.346; 95% CI: 1.456–7.690; p = 0.004). This risk was independent of the TTA (OR: 1.007; 95% CI: 0.980–1.035; p = 0.613).


Appendectomy can be delayed by an average time delay of about 9 h in children with PA without increasing the risk of postoperative complications and re-intervention, also in patients at high risk defined by the initial CRP level ≥ 128.6 mg/l. This data may support the correct risk-adjusted scheduling of surgical interventions in times of limited capacity.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

Data availability

This published article contains all analyzed data.


  1. Cameron DB, Williams R, Geng Y et al (2018) Time to appendectomy for acute appendicitis: a systematic review. J Pediatr Surg 53:396–405.

    Article  PubMed  Google Scholar 

  2. Frongia G, Mehrabi A, Ziebell L et al (2016) Predicting postoperative complications after pediatric perforated appendicitis. J Invest Surg 29:185–194.

    CAS  Article  PubMed  Google Scholar 

  3. Henry MCW, Walker A, Silverman BL et al (2007) Risk factors for the development of abdominal abscess following operation for perforated appendicitis in children: a multicenter case-control study. Arch Surg 142:236–241.

    Article  PubMed  Google Scholar 

  4. Pittman-Waller VA, Myers JG, Stewart RM et al (2000) Appendicitis: why so complicated? Analysis of 5755 consecutive appendectomies. Am Surg 66:548–554

    CAS  PubMed  Google Scholar 

  5. Fike FB, Mortellaro VE, Juang D et al (2011) The impact of postoperative abscess formation in perforated appendicitis. J Surg Res 170:24–26.

    Article  PubMed  Google Scholar 

  6. Feng C, Anandalwar S, Sidhwa F et al (2016) Beyond perforation: Influence of peritoneal contamination on clinical severity and resource utilization in children with perforated appendicitis. J Pediatr Surg 51:1896–1899.

    Article  PubMed  Google Scholar 

  7. Almström M, Svensson JF, Patkova B et al (2017) In-hospital surgical delay does not increase the risk for perforated appendicitis in children: a single-center retrospective cohort study. Ann Surg 265:616–621.

    Article  PubMed  Google Scholar 

  8. Drake FT, Mottey NE, Farrokhi ET et al (2014) Time to appendectomy and risk of perforation in acute appendicitis. JAMA Surg 149:837–844.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Yardeni D, Hirschl RB, Drongowski RA et al (2004) Delayed versus immediate surgery in acute appendicitis: Do we need to operate during the night? J Pediatr Surg 39:464–469.

    Article  PubMed  Google Scholar 

  10. Abbas PI, Peterson M, Stephens LJ et al (2016) Evaluating the effect of time process measures on appendectomy clinical outcomes. J Pediatr Surg 51:810–814.

    Article  PubMed  Google Scholar 

  11. Meier C-M, Latz H, Kraemer J et al (2017) Acute appendicitis in children: Can surgery be postponed? Short-term results in a cohort of 225 children. Langenbecks Arch Surg 402:977–986.

    Article  PubMed  Google Scholar 

  12. Newman K, Ponsky T, Kittle K et al (2003) Appendicitis 2000: variability in practice, outcomes, and resource utilization at thirty pediatric hospitals. J Pediatr Surg 38:372–379.

    Article  PubMed  Google Scholar 

  13. Boomer LA, Cooper JN, Deans KJ et al (2014) Does delay in appendectomy affect surgical site infection in children with appendicitis? J Pediatr Surg 49:1026–1029.

    Article  PubMed  Google Scholar 

  14. Boomer LA, Cooper JN, Anandalwar S et al (2016) Delaying appendectomy does not lead to higher rates of surgical site infections: a multi-institutional analysis of children with appendicitis. Ann Surg 264:164–168.

    Article  PubMed  Google Scholar 

  15. Dunlop JC, Meltzer JA, Silver EJ, Crain EF (2012) Is nonperforated pediatric appendicitis still considered a surgical emergency? A survey of pediatric surgeons. Acad Pediatr 12:567–571.

    Article  PubMed  Google Scholar 

  16. St Peter SD, Sharp SW, Holcomb GW, Ostlie DJ (2008) An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg 43:2242–2245.

    Article  PubMed  Google Scholar 

  17. Clavien PA, Barkun J, de Oliveira ML et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196.

    Article  PubMed  Google Scholar 

  18. Narsule CK, Kahle EJ, Kim DS et al (2011) Effect of delay in presentation on rate of perforation in children with appendicitis. Am J Emerg Med 29:890–893.

    Article  PubMed  Google Scholar 

  19. Mandeville K, Monuteaux M, Pottker T, Bulloch B (2015) Effects of timing to diagnosis and appendectomy in pediatric appendicitis. Pediatr Emerg Care 31:753–758.

    Article  PubMed  Google Scholar 

  20. Gurien LA, Wyrick DL, Smith SD, Dassinger MS (2016) Optimal timing of appendectomy in the pediatric population. J Surg Res 202:126–131.

    Article  PubMed  Google Scholar 

  21. Hornby ST, Shahtahmassebi G, Lynch S et al (2014) Delay to surgery does not influence the pathological outcome of acute appendicitis. Scand J Surg 103:5–11.

    CAS  Article  PubMed  Google Scholar 

  22. Shelton JA, Brown JJS, Young JA (2014) Preoperative C-reactive protein predicts the severity and likelihood of complications following appendicectomy. Ann R Coll Surg Engl 96:369–372.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  23. Fraser JD, Aguayo P, Sharp SW et al (2010) Physiologic predictors of postoperative abscess in children with perforated appendicitis: subset analysis from a prospective randomized trial. Surgery 147:729–732.

    Article  PubMed  Google Scholar 

  24. Kokoska ER, Silen ML, Tracy TF et al (1999) The impact of intraoperative culture on treatment and outcome in children with perforated appendicitis. J Pediatr Surg 34:749–753.

    CAS  Article  PubMed  Google Scholar 

  25. Garey CL, Laituri CA, Little DC et al (2011) Outcomes of perforated appendicitis in obese and nonobese children. J Pediatr Surg 46:2346–2348.

    Article  PubMed  Google Scholar 

Download references


No funding was received for this study.

Author information

Authors and Affiliations



Each of the authors substantially contributed to the study, fulfills the COPE requirements for authorship, and approved the manuscript in its’ final version.

Corresponding author

Correspondence to G. Frongia.

Ethics declarations

Conflict of interest

Authors have no conflict of interests to declare. No financial support was received for this article.

Ethical approval

The local ethical committee approved the study protocol.

Informed consent

Due to the retrospective nature of this study, no patient’s informed consent was necessary.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Frongia, G., Dostal, F., Ziebell, L. et al. Delayed Surgery for Perforated Appendicitis is Feasible in Children Without Compromising the Outcome in Selected Cases. World J Surg 46, 1980–1986 (2022).

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: