Revisiting delayed appendectomy in patients with acute appendicitis

Table 1 Clinical trials and meta-analyses comparing primary antibiotic treatment vs surgery for acute appendicitis

Ref.	Publishing year	Study design	Patients in NOM (n)	Age (yr)	Initially successful	Recurrence rate
Harnoss et al[10]	2017	Meta-analysis	1312	13-75	89.2%	1-yr: 27.4%
Podda et al[11]	2019	Meta-analysis	1743	Unrestricted	91.5%	1-yr: 19.2%
Eriksson et al[13]	1995	RCT	20	≥ 18	95%	1-yr: 37%
APPAC study[14,15]	2015	Multicentre RCT	257	≥ 18	94%	1-yr: 27%; 5-yr: 39.1%;
Minneci et al[16]	2016	Prospective cohort	37	7-17	94.6%	30-d: 5.4%; 1-yr: 18.9%
Georgiou et al[72]	2017	Meta-analysis	413	< 18	97%	Adjusted: 14%
Joo et al[73]	2017	Prospective observational	20	Pregnant women	85%	10%

The table is not an exhaustive list and the scope has been restricted to references that are discussed in the main text. NOM: Nonoperative management; RCT: Randomised controlled trial.

Table 2 Effects of delaying appendectomy on incidence of complicated appendicitis

Ref.	Publishing year	Age (yr)	Patients (n)	Delay	Conclusion
Li et al[21]	2019	≥ 18	421	In-hospital	No differences were found between patients with uncomplicated and complicated AA
Lee et al[22]	2018	2–85	1076	In-hospital	Advanced pathology was not associated with in-hospital delay
Aiken et al[23]	2020	≥ 18	1372	In-hospital	No differences between delayed cases and nondelayed cases for rate of perforation
Bhangu et al[24]	2014	Unrestricted	2510	In-hospital	Short delays of less than 24 h were not associated with increased rates of complex pathology
Stevenson et al[25]	2017	< 18	955	In-hospital	Short time delays from ED evaluation to operation did not independently increase the odds of perforation
Almström et al[26]	2017	< 15	2756	In-hospital	In-hospital delay was not associated with an increased rate of histopathologic perforation
Hornby et al[27]	2014	Unrestricted	2403	In-hospital	Appendicitis is not more likely to lead to perforation if a short delay prior to surgery is allowed
Jeon et al[28]	2016	Unrestricted	4148	In-hospital	Hospital delays were not associated with significantly increased risks of perforation
van Dijk et al[30]	2018	Unrestricted	20668	In-hospital	Delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis
Abdul Jawad et al[33]	2020	≥ 18	3004	In-hospital	≥ 24-h delay from ED triage to appendectomy is not associated with an increased rate of severity upgrade from simple to complicated appendicitis
Abou-Nukta et al[34]	2006	18-90	309	In-hospital	Delaying appendectomies for AA for 12 to 24 h after presentation does not significantly increase the rate of perforations
Busch et al[74]	2011	Adult	1675	In-hospital	In-hospital delay of more than 12 h is an independent risk factor for perforation
Giraudo et al[75]	2013	3–90	723	In-hospital	Delayed appendectomy after 24 h from onset increases the rate of complicated AA
Meltzer et al[76]	2019	< 18	857	In-hospital	Every hour increase in the time from ED triage to incision was independently associated with a 2% increase in the odds of perforation
Papandria et al[77]	2014	< 18	1388	In-hospital	An increased risk of perforation was found beginning on hospital day 2
Saar et al[79]	2016	≥ 18	266	Total	Extended time interval from the onset of initial symptoms to appendectomy is associated with increased rates of complicated AA
Elniel et al[80]	2018	16–87	190	Total	A significant increase in the likelihood of a perforated appendicitis occurs after 72 h of symptom onset
Canal et al[81]	2020	Unrestricted	9224	Total	A longer length of preoperative stay significantly increases the risk of perforation
Bickell et al[82]	2005	Unrestricted	219	Total	Risk of rupture in ensuing 12-h periods rises to 5% after 36 h of untreated symptoms
Li et al[83]	2019	Unrestricted	4889	Total	Complicated appendicitis incidence was associated with overall elapsed time from symptom onset to admission or operation

The table is not an exhaustive list and the scope has been restricted to references that are discussed in the main text. AA: Acute appendicitis; ED: Emergency department.

Table 3 Effects of delaying appendectomy on incidence of postoperative complications

Ref.	Publishing year	Age (yr)	Patients (n)	Delay	Conclusion
Aiken et al[23]	2020	≥ 18	1372	In-hospital	No differences between delayed cases and nondelayed cases for POCs
Almström et al[26]	2017	< 15	2756	In-hospital	Timing of surgery was not an independent risk factor for POCs
van Dijk et al[30]	2018	Unrestricted	20668	In-hospital	Delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for postoperative SSI
Kim et al[35]	2018	Unrestricted	397	In-hospital	The time from CT to operation has no effect on the results of appendicitis
Boomer et al[36]	2016	< 18	1338	In-hospital	A 16-h delay from ED presentation or a 12-h delay from hospital admission to appendectomy was not associated with an increased risk for SSI
Fair et al[37]	2015	Unrestricted	69926	In-hospital	There was a 2-fold increase in complication rate for patients delayed longer than 48 h
Lee et al[84]	2012	< 18	683016	In-hospital	In-hospital delay beyond 2 d is associated with significant negative outcomes with regard to complications
Teixeira et al[85]	2012	Unrestricted	4108	In-hospital	Appendectomy delay was associated with a significantly increased risk of SSI in patients with nonperforated appendicitis

The table is not an exhaustive list and the scope has been restricted to references that are discussed in the main text. CT: Computed tomography; ED: Emergency department; POCs: Postoperative complications; SSI: Surgical-site infection.