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Effect of Delay to Operation on Outcomes in Patients with Acute Appendicitis: a Systematic Review and Meta-analysis

  • Review Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Many studies have investigated the association between time interval and incidence of complicated appendicitis and post-operative surgical site infection (SSI), but the results are controversial.

Methods

A systematic search of the electronic databases identified studies that investigated the association of appendectomy delay with complicated appendicitis and SSI among patients with acute appendicitis. Qualitative and quantitative meta-analysis of the results was conducted.

Results

Twenty-one studies were included in the final analysis. Meta-analysis showed no significant difference in complicated appendicitis incidence between patients in the 6–12 h, > 12 and < 6 h groups (OR 1.07, 95% CI 0.89–1.30, p = 0.47; OR 1.04, 95% CI 0.88–1.22, p = 0.64). Comparison of the 6–12 h category with the < 6 h category of in-hospital delay revealed significant associations between longer in-hospital delay and increased risk of post-operative SSI (OR 1.40, 95% CI 1.11–1.77, p = 0.004). Patients in the 24–48 h category had 1.99- and 1.84-fold (p < 0.05) higher odds of developing complicated appendicitis compared to patients in the < 24 h category for pre-hospital delay and total delay, respectively (OR 1.99, 95% CI 1.35–2.94, p = 0.0006; OR 1.84, 95% CI 1.05–3.21, p = 0.03). When pre-hospital and total delay time extended to more than 48 h, the odds of risk increased 4.62- and 7.57-fold, respectively (OR 4.62, 95% CI 2.99–7.13, p < 0.00001; OR 7.57, 95% CI 6.14–9.35, p = < 0.00001).

Conclusion

Complicated appendicitis incidence was associated with overall elapsed time from symptom onset to admission or operation; short appendectomy in-hospital delay did not increase the risk of complicated appendicitis but was associated with a slightly increased risk of SSI. Prompt surgical intervention is warranted to avoid additional morbidity, enabling quicker recovery in this population.

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References

  1. Anderson JE, Bickler SW, Chang DC, Talamini MA. Examining a common disease with unknown etiology: trends in epidemiology and surgical management of appendicitis in California, 1995–2009. World J Surg 2012;36:2787–2794.

    Article  PubMed  Google Scholar 

  2. Cueto J, D'Allemagne B, Vázquez-Frias JA, Gomez S, Delgado F, Trullenque L, Fajardo R, Valencia S, Poggi L, Ballí J, Diaz J, González R, Mansur JH, Franklin ME. Morbidity of laparoscopic surgery for complicated appendicitis: an international study. Surg Endosc 2006;20:717–720.

    Article  CAS  PubMed  Google Scholar 

  3. Yaghoubian A, de Virgilio C, Lee SL. Appendicitis outcomes are better at resident teaching institutions: a multi-institutional analysis. Am J Surg 2010;200:810–813.

    Article  PubMed  Google Scholar 

  4. Gandy RC, Truskett PG, Wong SW, Smith S, Bennett MH, Parasyn AD. Outcomes of appendicectomy in an acute care surgery model. Med J Aust 2010;193:281–284.

    PubMed  Google Scholar 

  5. Van Zwalenburg C The relation of mechanical distention to the etiology of appendicitis. Ann Surg 1905;41:437–450;

    Article  PubMed  PubMed Central  Google Scholar 

  6. Ditillo MF, Dziura JD, Rabinovici R. Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 2006;244:656–660.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults. A prospective study. Ann Surg 1995;221:278–281.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Bickell NA, Aufses AH Jr, Rojas M, Bodian C. How time affects the risk of rupture in appendicitis. J Am Coll Surg 2006;202:401–406.

    Article  PubMed  Google Scholar 

  9. Teixeira PG, Sivrikoz E, Inaba K, Talving P, Lam L, Demetriades D. Appendectomy timing: waiting until the next morning increases the risk of surgical site infections. Ann Surg 2012;256:538–543.

    Article  PubMed  Google Scholar 

  10. Eldar S, Nash E, Sabo E, Matter I, Kunin J, Mogilner JG, Abrahamson J. Delay of surgery in acute appendicitis. Am J Surg 1997;173:194–198.

    Article  CAS  PubMed  Google Scholar 

  11. Blomqvist PG, Andersson RE, Granath F, Lambe MP, Ekbom AR. Mortality after appendectomy in Sweden, 1987–1996. Ann Surg 2001;233:455–460.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Abou-Nukta F, Bakhos C, Arroyo K, Koo Y, Martin J, Reinhold R, Ciardiello K. Effects of delaying appendectomy for acute appendicitis for 12–24 h. Arch Surg 2006;141:504–506.

    Article  PubMed  Google Scholar 

  13. Eastridge BJ, Hamilton EC, O’Keefe GE, Rege RV, Valentine RJ, Jones DJ, Tesfay S, Thal ER. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg 2003;186:169–174.

    Article  PubMed  Google Scholar 

  14. Andersson R, Hugander A, Thulin A, Nyström PO, Olaison G. Indications for operation in suspected appendicitis and incidence of perforation. BMJ 1994;308:107–110.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Ciani S, Chuaqui B. Histological features of resolving acute, non-complicated phlegmonous appendicitis. Pathol Res Pract 2000;196:89–93.

    Article  CAS  PubMed  Google Scholar 

  16. Stahlfeld K, Hower J, Homitsky S, Madden J. Is acute appendicitis a surgical emergency? Am Sur 2007;73:626–629.

    Google Scholar 

  17. Kearney D, Cahill RA, O'Brien E, Kirwan WO, Redmond HP. Influence of delays on perforation risk in adults with acute appendicitis. Dis Colon Rectum 2008;51:1823–1827.

    Article  CAS  PubMed  Google Scholar 

  18. Ingraham AM, Cohen ME, Bilimoria K, Ko C, Hall BL, Russell TR, Nathens AB. Effect of delay to operation on outcomes in adults with acute appendicitis. Arch Surg 2010;145:886–892.

    Article  PubMed  Google Scholar 

  19. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000;283:2008–2012.

    Article  CAS  PubMed  Google Scholar 

  20. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010;8:336–341.

    Article  PubMed  Google Scholar 

  21. Wells G, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. Available at: http://www.ohri.ca/programs/clinical epidemiology/oxford web.ppt. Accessed October 2013.

  22. Hernandez AV, Pasupuleti V, Benites-Zapata VA, Thota P, Deshpande A, Perez-Lopez FR. Insulin resistance and endometrial cancer risk: A systematic review and meta-analysis. Eur J Cancer; 2015; 51(18):2747–2758.

    Article  CAS  PubMed  Google Scholar 

  23. Macaskill P, Walter SD, Irwig L. A comparison of methods to detect publication bias in meta-analysis. Stat Med 2001;20:641–654.

    Article  CAS  PubMed  Google Scholar 

  24. Augustin T, Cagir B, Vandermeer TJ. Characteristic of perforated appendicitis: effect of delay is confounded by age and gender. J Gastrointest Surg 2011;15(7):1223–1231.

    Article  PubMed  Google Scholar 

  25. Boomer LA, Cooper JN, Deans KJ, Minneci PC, Leonhart K, Diefenbach KA, Kenney BD, Besner GE. Does delay in appendectomy affect surgical site infection in children with appendicitis? J Pediatr Surg 2014;49:1026–1029.

    Article  PubMed  Google Scholar 

  26. 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;35:1626–1633.

    Article  PubMed  Google Scholar 

  27. Eko FN, Ryb GE, Drager L, Goldwater E, Wu JJ, Counihan TC. Ideal time of surgery for acute uncomplicated appendicitis. N Am J Med Sci 2013;5:22–27.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Fahim F, Shirjeel S A comparison between presentation time and delay in surgery in simple and advanced appendicitis. J Ayub Med Coll Abbottabad 2005;17:37–39.

    PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  30. Hansson LE, Laurell H, Gunnarsson U. Impact of time in the development of acute appendicitis. Dig Surg 2008;25:394–399.

    Article  PubMed  Google Scholar 

  31. Jeon BG, Kim HJ, Jung KH, Lim HI, Kim SW, Park JS, Kim KH, Kim ID. Appendectomy: Should it Be Performed So Quickly? Am Surg 2016;82:65–74.

    PubMed  Google Scholar 

  32. Kim HK, Kim YS, Lee SH, Lee HH. Impact of a delayed laparoscopic appendectomy on the risk of complications in acute appendicitis: a retrospective study of 4,065 patients. Dig Surg 2017;34:25–29.

    Article  PubMed  Google Scholar 

  33. Lee JM, Kwak BS, Park YJ. Is a one night delay of surgery safe in patients with acute appendicitis? Ann Coloproctol 2018;34:11–15.

    Article  PubMed  PubMed Central  Google Scholar 

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

    Article  PubMed  Google Scholar 

  35. Maroju NK, Robinson Smile S, Sistla SC, Narasimhan R, Sahai A. Delay in surgery for acute appendicitis. Anz J Surg 2004;74:773–776.

    Article  PubMed  Google Scholar 

  36. Sammalkorpi HE, Leppäniemi A, Mentula P. high admission C-reactive protein level and longer in-hospital delay to surgery are associated with increased risk of complicated appendicitis. Langenbecks Arch Surg 2015;400:221–228.

    Article  PubMed  Google Scholar 

  37. Saar S, Talving P, Laos J, Põdramägi T, Sokirjanski M, Lustenberger T, Lam L, Lepner U. Delay between onset of symptoms and surgery in acute appendicitis increases perioperative morbidity: a prospective study. World J Surg 2016;40:1308–1314.

    Article  PubMed  Google Scholar 

  38. Yardeni D, Hirschl RB, Drongowski RA, Teitelbaum DH, Geiger JD, Coran AG. Delayed versus immediate surgery in acute appendicitis: do we need to operate during the night? J Pediatr Surg 2004;39:464–469.

    Article  PubMed  Google Scholar 

  39. Stevenson MD, Dayan PS, Dudley NC, Bajaj L, Macias CG, Bachur RG, Sinclair K, Bennett J, Mittal MK, Donneyong MM, Kharbanda AB; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Time From Emergency department evaluation to operation and appendiceal perforation. Pediatrics 2017;139: e20160742.

    Article  PubMed  Google Scholar 

  40. United Kingdom National Surgical Research Collaborative, Bhangu A Safety of short, in-hospital delays before surgery for acute appendicitis: multicentre cohort study, systematic review, and meta-analysis. Ann Surg 2014;259:894–903.

    Google Scholar 

  41. Prystowsky JB, Pugh CM, Nagle AP. Current problems in surgery Appendicitis. Curr Probl Surg 2005;42:688–742.

    Article  PubMed  Google Scholar 

  42. Andersson RE. 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;31:86–92.

    Article  PubMed  Google Scholar 

  43. Salminen P, Paajanen H, Rautio T, Nordström P, Aarnio M, Rantanen T, Tuominen R, Hurme S, Virtanen J, Mecklin JP, Sand J, Jartti A, Rinta-Kiikka I, Grönroos JM. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: The APPAC Randomized Clinical Trial. JAMA 2015;313:2340–2348.

    Article  CAS  PubMed  Google Scholar 

  44. Di Saverio S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, Sugrue M, De Moya M, Gomes CA, Bhangu A, Agresta F, Moore EE,Soreide K, Griffiths E, De Castro S, Kashuk J, Kluger Y, Leppaniemi A, Ansaloni L, Andersson M, Coccolini F, Coimbra R,Gurusamy KS, Campanile FC, Biffl W, Chiara O, Moore F, Peitzman AB, Fraga GP, Costa D, Maier RV, Rizoli S, Balogh ZJ,Bendinelli C, Cirocchi R, Tonini V, Piccinini A, Tugnoli G, Jovine E, Persiani R, Biondi A, Scalea T, Stahel P, Ivatury R, Velmahos G, Andersson R. WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World J Emerg Surg 2016;11:34.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Andersson RE. Does delay of diagnosis and treatment in appendicitis cause perforation? World J Surg 2016;40:1315–1317.

    Article  PubMed  Google Scholar 

  46. Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015; 386(10000):1278–1287.

    Article  PubMed  Google Scholar 

  47. Di Saverio S, Sibilio A, Giorgini E, Biscardi A, Villani S, Coccolini F, Smerieri N, Pisano M, Ansaloni L, Sartelli M, Catena F, Tugnoli G. The NOTA Study (Non Operative Treatment for Acute Appendicitis): prospective study on the efficacy and safety of antibiotics (amoxicillin and clavulanic acid) for treating patients with right lower quadrant abdominal pain and long-term follow-up of conservatively treated suspected appendicitis. Ann Surg 2014;260:109–117.

    Article  PubMed  Google Scholar 

  48. Flum DR. Clinical practice. Acute appendicitis-appendectomy or the “antibiotics first” strategy. N Engl J Med 2015;372:1937–1943.

    Article  PubMed  Google Scholar 

  49. Nagaraja V, Eslick GD, Cox MR. The acute surgery unite model versus the traditional “on call” model: a systematic review and meta-analysis. World J Surg 2014;38:1381–1387

    Article  PubMed  Google Scholar 

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Acknowledgements

We thank all the authors of studies included in this review. The authors would also like to thank the Health and Family Planning Commission of Mianyang City for their support.

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Authors and Affiliations

  1. Department of General Surgery, The Third Hospital of Mianyang, The Mental Health Center of Sichuan, No. 190 East Section of Jiannan Road, Youxian District, Sichuan, 621000, China

    Jian Li, Run Xu, Deng-Min Hu, Yao Zhang, Tu-Ping Gong & Xue-Lian Wu

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  1. Jian Li
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  2. Run Xu
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  3. Deng-Min Hu
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  4. Yao Zhang
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Contributions

Jian Li and Run Xu designed the study. Jian Li was directly involved in the full implementation of this study and was a major contributor in writing the manuscript. Deng-Min Hu, Yao Zhang, and Jian Li were jointly involved in studies collection, quality assessment, and data extraction. Tu-Ping Gong, Xue-Lian Wu, and Jian Li provided substantial contributions to the data analysis. All authors read and approved the final manuscript.

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Correspondence to Jian Li.

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The authors declare that they have no competing interests.

Ethics Statement

This systematic review and meta-analysis accomplished all of the ethics requirements according to the Helsinki declaration and all international statements.

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Li, J., Xu, R., Hu, DM. et al. Effect of Delay to Operation on Outcomes in Patients with Acute Appendicitis: a Systematic Review and Meta-analysis. J Gastrointest Surg 23, 210–223 (2019). https://doi.org/10.1007/s11605-018-3866-y

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