Safety of short, in-hospital delays before surgery for acute appendicitis: Multicentre cohort study, systematic review, and meta-analysis

Aneel Bhangu*, I. G. Panagiotopoulou, N. Chatzizacharias, M. Rana, K. Rollins, F. Ejtehadi, B. Jha, Y. W. Tan, N. Fanous, G. Markides, A. Tan, C. Marshal, S. Akhtar, D. Mullassery, A. Ismail, C. Hitchins, S. Sharif, L. Osborne, N. Sengupta, C. ChallandD. Pournaras, K. Bevan, J. King, J. Massey, I. Sandhu, J. M. Wells, D. A. Teichmann, A. Peckham-Cooper, M. Sellers, S. E. Folaranmi, B. Davies, S. Potter, D. Egbeare, C. Kallaway, S. Parsons, E. Upchurch, A. Lazaridis, D. Cocker, D. King, N. Behar, S. P. Loukogeorgakis, R. Kalaiselvan, S. Marzouk, E. J. H. Turner, S. Kaptanis, V. Kaur, G. Shingler, A. Bennett, S. Shaikh, M. Aly, J. Coad, T. Khong, Z. Nouman, J. Crawford, P. Szatmary, H. West, A. MacDonald, J. Lambert, K. Gash, K. A. Hanks, E. Griggs, L. Humphreys, A. Torrance, J. Hardman, L. Taylor, D. Rex, J. Bennett, N. Crowther, B. McAree, S. Flexer, P. Mistry, P. Jain, M. Hwang, J. Richardson, N. Oswald, A. Wells, H. Newsome, P. Martinez, C. A. B. Alvarez, J. León, D. Carradice, R. Gohil, M. Mount, A. Campbell, S. Iype, E. Dyson, T. Groot-Wassink, A. R. Ross, C. Jones, P. Charlesworth, N. Baylem, J. Voll, T. Sian, L. Creedon, G. Hicks, J. Goring, V. Ng, S. Tiboni, T. Palser, B. Rees, P. Ravindra, C. Neophytou, H. Dent, T. Lo, L. Broom, M. O'Connell, R. Foulkes, D. Griffith, K. Butcher, O. McLaren, A. Tai, H. Yano, H. D. T. Torrance, O. Moussa, D. Mittapalli, D. Watt, S. Basson, J. Gilliland, S. Pilgrim, A. Wilkins, J. Yee, H. Cain, M. Wilson, J. Pearson, E. Turnbull, A. Brigic, N. A. Yassin, J. Clarke, S. Mallappa, P. Jackson, C. Jones, B. Lakshminarayanan, A. Sharma, R. Velineni, K. Fareed, G. Yip, A. Brown, N. Patel, M. Ghisel, N. Tanner, H. Jones, J. Witherspoon, M. Phillips, M. F. Ho, S. Ng, T. Mak, N. Campain, D. Mukhey, W. K. Mitchell, F. Amawi, E. Dickson, S. Aggarwal, L. K. Satherley, F. Asprou, C. Keys, M. Steven, M. Johnstone, J. Muhlschlegel, E. Hamilton, J. Yin, M. Dilworth, A. Wright, P. Spreadborough, P. Marriott, M. Singh, K. Mockford, J. Morgan, W. Ball, J. Royle, J. Lacy-Colson, W. Lai, S. Griffiths, S. Mitchell, C. Parsons, A. S. Joel, P. F. Mason, G. J. Harrison, J. Steinke, H. Rafique, C. Battersby, W. Hawkins, D. Gurram, C. A. Hateley, A. Penkethman, C. Lambden, A. Conway, P. Dent, D. Yacob, O. A. Oshin, A. Hargreaves, G. Gossedge, J. Long, M. Walls, K. Futaba, T. Pinkney, S. Puig, D. Nepogodiev, P. Marriott, A. Boddy, A. Jones, C. Tennuci, N. Battersby, R. Wilkin, C. Lloyd, E. Sein, K. McEvoy, L. Whisker, S. Austin, A. Colori, P. Sinclair, M. Loughran, A. Lawrence, J. Horsnell, J. Bagenal, A. Pisesky, S. Mastoridis, K. Solanki, I. Siddiq, L. Merker, P. Sarmah, C. Richardson, D. Hanratty, L. Evans, M. Mortimer, A. Bhalla, D. Bartlett, D. Beral, N. S. Blencowe, J. Cornish, J. B. Haddow, N. J. Hall, M. Johnstone, S. Pilgrim, S. Trong, R. Velineni

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

134 Scopus citations


OBJECTIVE: To determine safety of short in-hospital delays before appendicectomy. BACKGROUND: Short organizational delays before appendicectomy may safely improve provision of acute surgical services. METHODS: The primary endpoint was the rate of complex appendicitis (perforation, gangrene, and/or abscess). The main explanatory variable was timing of surgery, using less than 12 hours from admission as the reference. The first part of this study analyzed primary data from a multicentre study on appendicectomy from 95 centers. The second part combined this data with a systematic review and meta-analysis of published data. RESULTS: The cohort study included 2510 patients with acute appendicitis, of whom 812 (32.4%) had complex findings. Adjusted multivariable binary regression modelling showed that timing of operation was not related to risk of complex appendicitis [12-24 hours odds ratio (OR) 0.98 (P = 0.869); 24-48 hours OR 0.88 (P = 0.329); 48+ hours OR 0.82 (P = 0.317)]. However, after 48 hours, the risk of surgical site infection and 30-day adverse events both increased [adjusted ORs 2.24 (P = 0.039) and 1.71 (P = 0.024), respectively]. Meta-analysis of 11 nonrandomized studies (8858 patients) revealed that delay of 12 to 24 hours after admission did not increase the risk of complex appendicitis (OR 0.97, P = 0.750). CONCLUSIONS: Short delays of less than 24 hours before appendicectomy were not associated with increased rates of complex pathology in selected patients. These organizational delays may aid service provision, but planned delay beyond this should be avoided. However, where optimal surgical systems allow for expeditious surgery, prompt appendicectomy will still aid fastest resolution of pain for the individual patient.

Original languageEnglish
Pages (from-to)894-903
Number of pages10
JournalAnnals of surgery
Issue number5
StatePublished - May 2014
Externally publishedYes


  • appendicectomy
  • appendicitis
  • surgical outcomes
  • timing of surgery


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