Effect of Delay to Operation on Outcomes in Patients with Acute Appendicitis: a Systematic Review and Meta-analysis
- 187 Downloads
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.
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.
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).
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.
KeywordsAcute appendicitis Appendectomy Delay Surgical site infection
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.
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.
Compliance with Ethical Standards
The authors declare that they have no competing interests.
This systematic review and meta-analysis accomplished all of the ethics requirements according to the Helsinki declaration and all international statements.
- 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.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
- 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.CrossRefGoogle 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.
- 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.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.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.CrossRefGoogle 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
- 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.CrossRefGoogle 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.CrossRefGoogle 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.CrossRefGoogle Scholar