The American Journal of Surgery 215 (2018) 483e486

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The American Journal of Surgery

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Early versus delayed appendectomy: A comparison of outcomes

Kyle Seudeal a, b, Hira Abidi a, b, Saad Shebrain a, b, *
a
Western Michigan University School of Medicine, 1000 Oakland Dr, Kalamazoo, MI 49008, USA
b
Bronson Methodist Hospital, 601 John St, Kalamazoo, MI 49007, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: The optimal timing for performing appendectomy in adults remains controversial.
Received 6 July 2017 Method: A one-year retrospective review of adult patients with acute appendicitis who underwent
Received in revised form appendectomy. The cohort was divided by time-to-intervention into two groups: patients who under-
17 October 2017
went appendectomy within 8 h (group 1), and those who had surgery after 8 h (group 2). Outcome
Accepted 26 October 2017
measures including perioperative morbidity and mortality, post-operative length of stay, and the 30-day
readmission rate were compared between the two groups.
Keywords:
Results: A total of 116 patients who underwent appendectomy met the inclusion criteria: 75 patients
Appendicitis
Early appendectomy
(65%) in group 1, and 41 (35%) in group 2. There were no differences between group 1 & 2 in periop-
Delayed appendectomy erative complications (6.7% vs. 9.8%, P ¼ 0.483), postoperative length of stay (median [IQR]; 19.5 [11.5
Complication e40.5] vs. 20.0 [11.25e58.5] hours, P ¼ 0.632), or 30-day readmission rate (2.7% vs. 4.9%, P ¼ 0.543).
Morbidity There were no deaths in either group.
Outcome Conclusion: Delayed appendectomy performed more than 8 h was not associated with increased peri-
operative complications, postoperative length of stay, 30-day readmission rate, or mortality.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction greater than 24 h led to increased incidence of gangrenous

Appendicitis remains one of the most common causes of acute
abdomen, and, traditionally, immediate appendectomy has been
the gold-standard treatment. The concern with delay in surgical
management is that the progression of appendicitis, over time, will
likely result in perforation with subsequent increased risk of
morbidity and mortality. Current research, however, has been
inconclusive in this regard.
A retrospective review of over 1000 patients treated for acute
appendicitis found that delayed appendectomy was unsafe and led
to increased rates of complications in patients with intervention
delayed more than 48 h. The risk of progressive pathology was 13
times higher in the group in which appendectomy was delayed for
longer than 71 h.1 A subsequent review of over 4000 patients
treated for acute appendicitis found that appendectomy delayed
6 h or more was associated with a significant increase risk of sur-
gical site infection.2 One study found that appendectomy delayed
more than 12 h led to increased complication risk, and delays
appendicitis.3
In contrast, a large retrospective study from the American Col-
lege of Surgeons National Quality Improvement Program (NSQIP)
database found that appendectomy delayed more than 12 h was
associated with increased operative time and postoperative stay,
but not morbidity or mortality.4 A retrospective study found that
length of postoperative stay, complication rate, and readmission
rate were not significantly affected when appendectomy was
delayed more than 8 h after initial presentation.5
The aim of this study was to compare the outcomes including
morbidity, mortality, postoperative length of stay, and 30-day
readmission rate in patients with acute appendicitis who under-
went appendectomy within 8 h of arrival to the emergency
department, and those who had surgery after 8 h. Our hypothesis
was that a delay in performing appendectomy was associated with
adverse outcomes.
2. Methods and materials

After institutional review board approval, a retrospective review

* Corresponding author. Western Michigan University School of Medicine, 1000
Oakland Dr, Kalamazoo, MI 49008, USA.
E-mail addresses: kseudeal@gmail.com (K. Seudeal), hira.abidi@med.wmich.edu
(H. Abidi), saad.shebrain@med.wmich.edu (S. Shebrain).
of all patients with the diagnosis of acute appendicitis at a single
university-affiliated community hospital from March 2015 to
March 2016 was performed. Patients with a diagnosis of

https://doi.org/10.1016/j.amjsurg.2017.10.057
0002-9610/© 2017 Elsevier Inc. All rights reserved.
484 K. Seudeal et al. / The American Journal of Surgery 215 (2018) 483e486

appendicitis were identified based on ICD-9 codes (540, 540.0,
540.1, 540.9) and ICD-10 codes (K35, K35.3, K35.3, K35.8).
All patients undergoing appendectomy during the study period
who met the inclusion criteria were included in the analysis. In-
clusion criteria for the subjects were (1) patients between the age
of 18e90 years at time of appendectomy, (2) patients diagnosed
with appendicitis by ultrasound, computed tomography (CT) scan,
magnetic resonance image (MRI), or by clinical suspicion, and (3)
patients who underwent appendectomy during the same hospi-
talization in which they were diagnosed. Exclusion criteria were (1)
patients discharged from the hospital before undergoing appen-
dectomy (i.e. interval appendectomy, patients leaving against
medical advice), and (2) pregnant patients who were diagnosed
with acute appendicitis.
The study population was divided into two groups by time-to-
intervention: the early appendectomy (group 1) included patients
who underwent surgery within 8 h, and the delayed appendectomy
(group 2) included patients who had surgery after 8 h. The two
study groups were then then compared for differences in the un-
derlying characteristics including demographic, clinical, radio-
graphic and perioperative data. Outcome measures included
mortality and morbidity, postoperative length of stay, and 30-day
readmission rate.
Data was collected manually via patient chart review within the
electronic medical record. Statistical analysis was performed using
SAS Enterprise Guide 7.1. Statistical significance was considered for
P < 0.05. Categorical variables are presented as frequencies and
percentages, and continuous variables were reported as means and
standard deviation (SD) or, if the data were skewed, as medians and
interquartile ranges (IQR). Categorical data were tested using the
Pearson c2 test. Differences in means between groups were
compared using the unpaired Student t-test or Mann-Whitney rank
sum test.
3. Results
During the one-year study period, a total of 116 patients met the
inclusion criteria for the study population. Seventy-five patients
(65%) underwent appendectomy within 8 h of arrival to the ED, and
41 patients (35%) after 8 h. The overall mean (SD) age was 42.2
(17.5) years. Male patients accounted for 54% (n ¼ 63) of the pop-
ulation. The median (IQR) time from onset of abdominal pain to
arrival to the ED was 24 (12e48) hours. The median (IQR) time from
arrival to ED to skin incision was 6 (3.3e10) hours.
Table 1 presents detailed overall patient characteristics and
comparison between the two study groups. There was no signifi-
cant difference between the two groups. All patients presented
with abdominal pain. Overall, 93% (108/116) of patients underwent
a preoperative computed tomography (CT) scan of the abdomen
and pelvis. The most common finding in the CT scan was the
presence of peri-appendiceal inflammation in 94% (102/108) of
patients, followed by the presence of fecalith in 35% (38/102). No
statistically significant difference was identified between the two
groups regarding the CT scan findings. Abdominal ultrasound was
used in 15 patients, and magnetic resonance imaging (MRI) was
used in one patient.
Table 2 presents detailed overall perioperative data and com-
parison between the two study groups. We found no significant

Table 1
Overall patient demographic, clinical and radiologic data and comparison between early appendectomy (group 1) and delayed appendectomy (group 2).

Overall (n ¼ 116) Early Appendectomy (Group 1) Delayed Appendectomy (Group 2) p-value

(8 h, n ¼ 75) (>8 h, n ¼ 41)

Background Demographics
Age in years, mean (SD) 42.2 (17.5) 42.6 (18) 41.4 (16.7) 0.585
Gender (Male/Female) 63/53 39/36 24/17 0.561
Body Mass Index (Kg/m2), mean (SD) 28.9 (6.7) 29 (6.7) 28.5 (7) 0.796
Prior abdominal surgeries, n (%) 41 (35) 23 (30.7) 18 (44) 0.1622
Medical Comorbidities
CAD, n (%) 3 (2.6) 1 (1.3) 2 (4.9) 0.285
CVA, n (%) 2 (1.7) 1 (1.3) 1 (2.4) 0.667
CHF, n (%) 3 (2.6) 1 (1.3) 2 (4.9) 0.285
COPD, n (%) 4 (3.4) 1 (1.3) 3 (7.3) 0.126
Diabetes, n (%) 11 (9.5) 6 (8) 5 (12.2) 0.516
Chronic Kidney Disease, n (%) 3 (2.6) 2 (2.7) 1 (2.4) 0.941
Clinical and Imaging Data
Timing from onset of abdominal pain to arrival to 24 (12e48) 24 (12e48) 24 (15e48) 0.314
ED in hours, median (IQR)
Symptoms associated with abdominal pain
Fever, n (%) 14 (12.1) 10 (13.3) 4 (9.8) 0.768
Nausea, n (%) 65 (56) 41 (54.7) 24 (58.5) 0.701
Anorexia, n (%) 24 (21) 18 (24) 6 (14.6) 0.338
Diarrhea, n (%) 11 (9.5) 9 (12) 2 (4.9) 0.323
Physical Examination/labs
Temperature in Celsius, mean (SD) 36.9 (0.6) 36.9 (0.6) 36.9 (0.6) 0.911
Localized peritonitis, n (%) 112 (96.6) 73 (97.3) 39 (95.1) 0.688
Diffuse peritonitis, n (%) 4 (3.4) 2 (2.7) 2 (4.9) 0.534
White blood count (x109/L), mean (SD) 13.9 (4.5) 13.8 (4.2) 13.5 (5.1) 0.513
Radiologic Data
Abdomen and Pelvis CT Scan, n (%) 108 (93) 68 (91) 40 (97.5) 0.163
CT scan Findings
Peri-appendiceal inflammation, n (%) 102 ((94) 67 (98.5) 35 (87.5) 0.560
Fecolith, n (%) 38 (35) 27 (40) 11 (27.5) 0.408
Phlegmon/Abscess, n (%) 4 (3.7) 1 (1.5) 3 (7.5) 0.126
Pneumoperitoneum, n (%) 4 (3.7) 1 (1.5) 3 (7.5) 0.661
Ultrasound, n (%) 15 (13) 9 (12) 6 (5.2) 0.687
MRI, n (%) 1 (0.9) 1 (1.3) 0 (0) 1.000

CAD ¼ coronary artery disease, CVA ¼ cerebrovascular accident, CHF ¼ congestive heart failure, COPD ¼ chronic obstructive pulmonary disease, ED ¼ Emergency Department,
CT ¼ computerized tomography, MRI ¼ magnetic resonance Image.
 K. Seudeal et al. / The American Journal of Surgery 215 (2018) 483e486 485

Table 2
Overall perioperative data between early appendectomy (group 1) and delayed appendectomy (group 2).

Perioperative Data Overall (N ¼ 116) Early Appendectomy (Group 1) Delayed Appendectomy (Group 2) p-value
(8 h, n ¼ 75) (>8 h, n ¼ 41)

Time in hours from arrival at ED to Incision, median (IQR) 6 (3.3e10) 4 (2e5.5) 12 (9.9e14.4) 0.001
Time in hours between onset of symptoms 32.75 (18e57) 26 (16e52) 41 (31e82) 0.001
to skin incision, median (IQR)
Operative Time in minutes, mean (SD) 56 (25) 55 (21) 63 (31) 0.699
Pre-operative antibiotics, n (%) 113 (97) 73 (97.3) 40 (97.5) 0.941
Post-operative Antibiotics usage, n (%) 42 (36) 25 (33.3) 17 (41.5) 0.386
Pathologic diagnosis
Acute nonperforated appendicitis, n (%) 104 (90) 69 (92) 35 (85.4) 0.69
Perforated appendicitis, n (%) 8 (6.7) 3 (4) 5 (12.2) 0.54
Other pathology, n (%)
Normal appendix, n (%) 1 (0.9) 1 (1.3) 0 (0)
Carcinoid, n (%) 1 (0.9) 1 (1.3) 0 (0)
Adenocarcinoma, ruptured, n (%) 1 (0.9) 0 (0) 1 (2.4)
Sessile serrated adenoma, n (%) 1 (0.9) 1 (1.3) 0 (0)

differences between the two groups regarding the operative time
(P ¼ 0.699), pathologic diagnosis of non-perforated and perforated
appendicitis (P ¼ 0.691, P ¼ 0.540), and administration of pre- and
postoperative antibiotics (P ¼ 0.941, P ¼ 0.386). The two groups
differ significantly regarding the time from arrival to ED to skin
incision (P < 0.001), and the time from onset of symptoms to skin
incision (P < 0.001). Diagnosis of acute appendicitis was confirmed
in 96.7% (112/116) of patients, eight of them had perforated
appendicitis. Histopathologic examination in four patients showed
one normal appendix, one carcinoid tumor, one ruptured appen-
diceal neoplasm, and one sessile serrated adenoma. One hundred-
thirteen patients (97%) received preoperative antibiotics and only
42 patients (36%) received postoperative antibiotics. Laparoscopic
appendectomy was performed in 115 patients (99.14%). The
remaining patient underwent a conversion to open procedure.
Table 3 presents overall outcomes and comparison between the
two study groups. There were no deaths in the study population.
Overall, nine patients (6.7%) had postoperative complications
including one post-operative bleeding (0.9%), two surgical site in-
fections (2.6%), one pneumonia (1.7%), one urinary tract infection
(0.9%), and multiple organ system failure in two patients (1.7%).
Four patients (3.4%) were readmitted within 30 days of surgery.
There were no significant differences in the measured outcomes
between the two groups regarding perioperative morbidity (6.7% vs
9.8%, P ¼ 0.483) and 30-day readmission rate (2.7% vs. 4.9%,
P ¼ 0.543). There was no significant difference in the postoperative
length of stay (median [IQR] 19.5 [11.5e40.5] hours vs 20.0
[11.25e58.5] hours, P ¼ 0.632) between the two groups.
4. Discussion
In this study, we found that a delay of more than 8 h in per-
forming appendectomy was not associated with increased
perioperative morbidity, postoperative length of stay, or the 30-day
readmission rate. Our findings are concordant with recent studies
suggesting that short delays of less than 12e24 h in performing
appendectomy have not been associated with an increase in
morbidity or mortality.1,5,6 A large, population-based study using
the American College of Surgeons National Surgical Quality
Improvement Program (NSQIP) database supports this semi-
elective approach, suggesting that appendectomy may be delayed
up to 24e48 h without a significant increase in adverse outcome.7
In that study, no difference was seen in the complication rate for
those undergoing appendectomy within one day of admission;
however, there was a two-fold increase in complication rates for
any patient in which time-to-operation was delayed more than
48 h. Prior smaller studies have found similar results.8,9
In contrast to the studies supporting safe delay of appendec-
tomy, there have been studies that demonstrate a negative impact
on outcomes with short delays of even 6e12 h in intervention.2 A
recent study from the UK found no increased rate of complicated
appendicitis when appendectomy was performed within 48 h.10
However, an in-hospital delay of greater than 48 h was associated
with a significantly increased risk of developing complicated
appendicitis.
Unplanned readmission within 30 days of performing appen-
dectomy in our study was 3.4% (n ¼ 4), which is comparable to the
3.7% reported in a large study.11 Reasons for readmission were
either infection, bleeding, inadequate pain control, nausea, vomit-
ing, or ileus. Intra-abdominal infections and nonspecific abdominal
pain are the most common reasons for readmission.
In certain circumstances, when a delay to operative intervention
is justified, patients with acute appendicitis should be maintained
on intravenous fluids and intravenous antibiotics during the wait-
ing period.4 Patients who are admitted with acute appendicitis
overnight can be safely managed nonoperatively until surgery can

Table 3
Outcomes and comparison between early appendectomy (group 1) and delayed appendectomy (group 2).

Perioperative Data Overall (N ¼ 116) Early Appendectomy (Group 1) Delay Appendectomy (Group 2) p-value
(8 h, n ¼ 75) (>8 h, n ¼ 41)

Perioperative Mortality 0 0 0 e
Perioperative Morbidity, n (%) 9 (7.8) 5 (6.7) 4 (9.8) 0.483
Bleeding, n (%) 1 (0.9) 1 (1.3) 0 (0) 0.460
Infection-SSI, n (%) 3 (2.6) 2 (2.7) 1 (2.4) 0.941
Pneumonia, n (%) 2 (1.7) 1 (1.3) 1 (2.4) 0.663
Urinary Tract Infection, n (%) 1 (0.9) 0 (0) 1 (2.4) 0.176
MODS, n (%) 2 (1.7) 1 (1.3) 1 (2.4) 0.663
PLOS in hours, median (IQR) 19.75 (11.50e41.80) 19.5 (11.50e40.5) 20.0 (11.25e58.50) 0.632
Readmission Within 30 days, n (%) 4 (3.4) 2 (2.7) 2 (4.9) 0.534

SSI ¼ surgical site infection, PLOS ¼ postoperative length of stay, MODS ¼ multiple organ dysfunction syndrome, IQR ¼ interquartile range.
486 K. Seudeal et al. / The American Journal of Surgery 215 (2018) 483e486
be performed the next morning. It is, however, prudent to have a
system in place to accommodate these cases in the morning. Our
institution provides operative block time in the early morning for
clinically-stable surgical cases admitted overnight; this has helped
to preserve overnight hospital resources for more acute and urgent
cases. In addition, many studies have shown that most patients
with uncomplicated, acute appendicitis can undergo laparoscopic
appendectomy and be discharged home within 24 h of admission.
Although some believe that operative intervention may be
avoided altogether in certain cases of uncomplicated acute
appendicitis,12 more investigation is needed to identify which pa-
tients might be predicted to do well without operative manage-
ment. The patients who will ultimately require appendectomy
should have a time interval from diagnosis to operation of less than
48 h and, ideally, less than 24 h.
In addition to all limitations of retrospective studies, our study
has a small sample size, which adversely reduces its ability to
detect potential significant effects of many independent variables
on the measured outcomes. This study was performed at a single
institution over a one-year period, therefore limiting the general-
izability of the results, and adding the potential for selection bias.
Randomized controlled trials are difficult to conduct given the
current standard practice of providing immediate operative care to
patients with acute appendicitis. However, given the increasing
number of supporting studies, a paradigm shift from immediate to
brief delay in intervention may be established in the management
of this common surgical condition.
5. Conclusion
This retrospective review of patients with acute appendicitis
suggests that appendectomy delay of 8 h was not associated with
increased postoperative length of stay, nor increase in mortality,
morbidity, or 30-day readmission rate.
Acknowledgment
The authors would like to thank Duncan Vos, MS for providing
advice about the analyzed data, and Laura Bauler, PhD, for
reviewing the draft of this manuscript.
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