van Dijk ST, van Dijk AH, Dijkgraaf MG, Boermeester MA. Meta-analysis of in-hospital delay before surgery as a risk factor for complications in patients with acute appendicitis. Br J Surg. 2018 Jul;105(8):933-945. doi: 10.1002/bjs.10873. PMID: 29902346; PMCID: PMC6033184.

2. in-hospital delay before surgery

Article Summary

Emergency appendicectomy is the standard of care in the treatment of acute appendicitis. However, some studies have reported higher morbidity and error rates when working or operating at night. So, if patient presents at nighttime with acute appendicitis. Do we have to perform a night-time surgery immediately? This systematic review aimed to assess in-hospital delay before surgery as risk factor for complicated appendicitis and postoperative morbidity in patients with acute appendicitis.

PubMed and EMBASE databases were searched from 1990 to 2016.Two types of study, prospective and retrospective studies were selected in this review. The studies were excluded if they analysed patient treated without surgery, the sample size less than ten patients, or the studies that did not define in-hospital delay et cetera. All the selected articles were reviewed by two reviewers independently. Data collected for each article included: study design and setting; age and number of patients; definitions of delay and complicated appendicitis; diagnostic modality for complicated appendicitis; outcome measures reported.

The primary outcome measure was complicated appendicitis after surgery (like perforated or gangrenous appendicitis); other outcomes were postoperative surgical-site infection and morbidity.

Forty-five studies with 152, 314 patients were included in this review. No Randomized controlled trials were found. All studies were observational. 40 were retrospective and five were prospective cohort studies.

After analysis, they found:

For complicated appendicitis,

• a delay of 7–12 h was not significantly associated with complicated appendicitis compared with a delay of 0–6 h
• a delay of 13–24 h was also not significantly associated with complicated appendicitis compared with a delay of 0–12 h

For surgical-site infection or wound infection, none of the studies reported a significantly higher risk for a delayed surgery. The similar results also apply for the postoperative intra-abdominal abscess and postoperative morbidity analysis.

Generally, the sensitivity analysis showed that in uncomplicated appendicitis there is no increased risk of complications when appendicectomy is delayed. Moreover, studies including only children showed comparable results, and thus children may not be exceptions to these conclusions.

There are some limitations of this review:

• All studies were observational cohort studies, leading to a selection bias inherent to non-randomized studies.
• The method of diagnosing complicated appendicitis, definition of complicated appendicitis and the timing of the in-hospital delay were factors that varied between studies.
• The most important limitation was that most study results were unadjusted for confounders. As clinically ill patients are more likely to have complicated appendicitis and more likely to be operated on earlier, selection bias is an important issue.

In conclusion, the traditional belief of increasing numbers of perforations during the course of appendicitis seems not to be true. Most cases of appendicitis probably rupture at an early stage. Thus, only a few perforations could be prevented by very early surgery after the onset of symptoms and arrival at the hospital. However, for patients with clinical or radiological signs of complicated appendicitis, delaying surgical treatment is not advocated. In addition, appendicectomy should not be delayed unnecessarily to minimize the discomfort of patients, but a delay of up to 24 h seems to be safe when there are reasons for delay.