ORIGINAL ARTICLE

Effects of Delaying Appendectomy

for Acute Appendicitis for 12 to 24 Hours
Fadi Abou-Nukta, MD; Charles Bakhos, MD; Kervin Arroyo, MD; Young Koo, DDS;
Jeremiah Martin, MD; Randolph Reinhold, MD; Kenneth Ciardiello, MD

Objective: To determine whether delaying appendectomy for 12 hours to avoid disturbing the operating room
schedule and to minimize the number of operations during the night negatively affects the outcome of patients
with acute appendicitis.

Main Outcome Measures: Length of stay, operative

time, and the rate of perforations and complications.
Interventions: Laparoscopic or open appendecto-

mies.
Results: There were 309 patients included in our study.

Design: Retrospective study.

Setting: Large teaching community hospital.
Patients: The medical records of 380 patients who underwent appendectomies between January 1, 2002, and
December 31, 2004, were reviewed. Patients proven to
have an inflamed appendix on the pathological report were
divided into 2 groups. The early group comprised patients who had undergone appendectomies within 12
hours of presentation to the emergency department, including patients with generalized sepsis. The late group
comprised patients who had undergone appendectomies more than 12 to 24 hours after presentation.

There were no statistically significant differences between the early and late groups in the length of stay, operative time, the percentage of advanced appendicitis, or
the rate of complications.
Conclusions: In selected patients, delaying appendectomies for acute appendicitis for 12 to 24 hours after presentation does not significantly increase the rate of perforations, operative time, or length of stay. It decreases the
use of the nursing staff, anesthesia team, and surgical house
staff during the night shifts, and it decreases the interruption of the regular operating room schedule.

Arch Surg. 2006;141:504-507

PPENDECTOMY FOR ACUTE

appendicitis is the most

common nonelective procedure performed by general surgeons.1 It has generally been accepted that an appendectomy
should be performed within a few hours
of diagnosis and that a delay in the operation may lead to an increase in the morbidity.2-4 Recent articles5-7 on the negative impact of sleep deprivation on clinical
performance suggest the value of limiting operations and procedures during the
night and early morning hours to absolute emergencies. In this study, we assess
whether appendectomy for acute appendicitis can be safely delayed for 12 to 24
hours to be performed during the day shift.
Author Affiliations:
Department of Surgery,
Hospital of Saint Raphael,
New Haven, Conn.

METHODS
Between January 1, 2002, and December 31,
2004, 380 appendectomies were performed in

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504

our hospital. We included patients who underwent appendectomies after a preoperative

diagnosis of acute appendicitis that was confirmed by pathological examination. We excluded patients who were younger than 18
years, patients who underwent negative appendectomies, incidental appendectomies, or
interval appendectomies, and patients who had
errors or delays of more than 24 hours in the
diagnosis (Table 1).
Patients included in the study were divided into 2 groups. The early group comprised patients who underwent appendectomies within 12 hours after presentation to the
emergency department. The late group comprised patients who underwent appendectomies between 12 and 24 hours after presentation. There were several reasons for the delay
in the operation: the time between admission
to the emergency department and surgical consultation, the lack of operating room availability, a delay in the diagnosis owing to an atypical presentation, and the surgeons decision to
delay the surgical procedure. Oral intake was
stopped for patients in both groups. Intrave-

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nous hydration using crystalloid fluids and intravenous antibiotics were administered at the time of diagnosis. The medical records of patients from both groups were compared for age,
white blood cell counts, and temperature on presentation as
well as length of stay, operative time, and pathological diagnosis. We differentiated between nonadvanced appendicitis and
advanced appendicitis (gangrenous or perforated). The rate of
complications was also recorded.
Our hospital is a teaching community hospital with residents of all levels on call in house and supervised by attending
surgeons who are either in house or on call. At all times, our
operating rooms are staffed and readily available for emergency operations.
The t test and Fisher exact test were used to analyze the statistical difference between the 2 groups. We calculated a sample
size of 152 patients in each group to detect an increase of 10%
in the rate of advanced appendicitis, with a power of 80%.4 A
P value of less than .05 was considered significant.
RESULTS

Three hundred nine patients were included in the study.

There were 165 men and 144 women. The average age
was 40 years (age range, 18-90 years). There were 233
patients in the early group and 76 patients in the late
group. The mean SD time between presenting to the
emergency department and surgery was 6.7 2.7 hours
for the early group and 16.73.6 hours for the late group.
Both groups were comparable with respect to age, sex,
white blood cell count, and temperature (Table 2).
There were no statistically significant differences between the 2 groups in the length of stay (P = .17), operative time (P=.93 for laparoscopic surgery; P=.14 for open
surgery), rate of advanced appendicitis (P=.56), and complication rate (P = .74) (Table 3).
In reviewing the time of presentation to the emergency department and the time of operation, 54% of patients were admitted to the emergency department during the day hours (7 AM7 PM) vs 46% during the evening
and night hours (7 PM7 AM). This percentage was slightly
reversed when noting the time of operation: 57% during the evening and night hours vs 43% during the day
hours.
COMMENT

Acute appendicitis, the term we use today and the pathophysiological abnormality we understand in the 21st century, is attributed to Reginald H. Fitz,8 the Shattuck Professor of Pathological Anatomy from Harvard University,
Boston, Mass, who presented a paper in 1886 describing the natural history and progression of the disease. He
also recognized the vital importance of early diagnosis
and immediate surgical intervention.
The adoption of his conclusions by surgeons in North
America in the following 15 years led to a decrease in
the mortality of acute appendicitis from 50% to 15%.9 Today, appendectomy for acute appendicitis is the most common nonelective surgical procedure performed in the
Western world.1 It is typically done within hours of diagnosis to prevent the complications of gangrene and perforation.2 However, medicine and surgery have wit(REPRINTED) ARCH SURG/ VOL 141, MAY 2006
505

Table 1. Exclusion Criteria

Exclusion Criteria
Age 18 y
Negative appendectomy
Incidental appendectomy
Interval appendectomy
Error or delay 24 h in the diagnosis

Table 2. Comparisons in Age, Sex, White Blood Cell Count,

and Temperature*

Characteristic
Age, mean SD, y
Sex, No.
Male
Female
WBC count, mean SD, per L
Temperature, mean SD, C

Early Group
(n = 233)

Late Group
(n = 76)

P
Value

41.0 16.9

39.6 15.9

.85

129
104
13.6 3.9
37.3 0.5

36
40
14.1 3.8
37.4 0.6

.20
.30
.78

Abbreviation: WBC, white blood cell.

*Early group indicates patients who underwent surgical procedures less
than 12 hours after presentation to the emergency department. Late group
indicates patients who underwent surgical procedures between 12 and
24 hours after presentation to the emergency department.

Table 3. Endpoints Between the Early and Late Groups*

End point
Time to surgery, mean SD, h
Length of stay, mean SD, d
Advanced appendicitis, No. (%)
Operative time, mean SD, min
Laparoscopic surgery
Open surgery
Complications, No. (%)
Abscess
Wound infection

Early
Group

Late
Group

P
Value

6.7 2.7
2.5 2.3
75 (32)

16.7 3.6
2.9 1.8
28 (37)

NA
.17
.56

81.0 31.0
77.0 31.0

81.5 31.0
86.0 33.0

.93
.14

1 (1)
1 (1)

.74

6 (2)
2 (1)

Abbreviation: NA, not applicable.

*Early group indicates patients who underwent surgical procedures less
than 12 hours after presentation to the emergency department. Late group
indicates patients who underwent surgical procedures between 12 and
24 hours after presentation to the emergency department.

nessed tremendous improvements in the last few decades,

with dramatic improvement in the quality of antibiotics. The use of antibiotics has become standard in the treatment of surgical infections, changing what otherwise
would have needed an emergent operation to that with
the option of an elective operation.2 The last 2 decades
have also seen historic improvement in the quality of radiological studies available. Computed tomographic scans
and ultrasonography are readily available in most US hospitals, and we are more able today than ever in the past
to achieve a more accurate preoperative diagnosis of several surgical entities, including appendicitis.10
One of the most prominent changes that marked the
last few years has been the emphasis on the potential negaWWW.ARCHSURG.COM

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tive impact of prolonged work hours for residents.5,6 Several studies have shown the negative effects of sleep deprivation on clinical performance,7 mood, and cognitive
abilities.11 These changes suggest the need to limit operations and procedures performed during the night hours
to absolute emergencies that cannot be safely delayed until the morning hours, when a well-rested surgeon and
surgical team are available.
Surana et al4 studied the effects of delaying an appendectomy for acute appendicitis. They found no statistical difference in the rate of complications between children who underwent appendectomies within 6 hours of
diagnosis and those who underwent appendectomies between 6 and 18 hours of diagnosis (2.3% to 4.2%, respectively; P=.28). A similar study by Yardeni et al2 on
the effects of delaying appendectomies by 6 to 24 hours
in children showed no significant increase in the rate perforation, operative time, or complications when compared with children who underwent the appendectomies within 6 hours. Furthermore, some studies suggest
that the rate of perforation is due to a delay in patient
presentation rather than to a delay in treatment.12,13 In
our study, the early and late groups had similar clinical
outcomes. The late group had a slightly longer length of
stay than the early group (2.9 days vs 2.5 days, respectively), but that included the average delay of 10 hours
(0.4 day). The difference in the rate of advanced appendicitis was not statistically significant in the late group
compared with the early group (37% vs 32%, respectively). Both groups had a similar rate of complications,
including intra-abdominal abscesses and wound infections ranging from less than 1% to 2%.
Our study was underpowered when considering an increase of 10% in the rate of advanced appendicitis. However, on a post hoc analysis, our sample sizes were enough
to detect an increase of 10% in the rate of complications, with a study power of 80%.
An approach to the treatment of acute appendicitis that
includes the early administration of intravenous antibiotics and fluid hydration followed by the performance
of appendectomy during the day hours does not increase the rate of complications, and it does not significantly increase the length of stay or rate of advanced appendicitis. In addition, this practice pattern decreases the
need for operating during the late night hours or the interruption of the regular operating room schedule. Finally, it aids in focusing resources and operating room
availability to life-threatening emergencies.
Accepted for Publication: December 15, 2005.
Correspondence: Fadi Abou-Nukta, MD, Department of
Surgery, Hospital of Saint Raphael, 330 Orchard St, New
Haven, CT 06511 (fadinukta@yahoo.com).
Previous Presentation: This paper was presented at the
86th Annual Meeting of the New England Surgical Society; September 30, 2005; Bretton Woods, NH; and is
published after peer review and revision. The discussions that follow this article are based on the originally
submitted manuscript and not the revised manuscript.
Acknowledgment: We thank Tassos Kyriakides, PhD,
Veterans Affairs Connecticut Healthcare System, West
Haven, who served as a statistical reviewer.
(REPRINTED) ARCH SURG/ VOL 141, MAY 2006
506

REFERENCES
1. Pittman-Waller VA, Myers JG, Stewart RM, et al. Appendicitis: why so complicated?
analysis of 5755 consecutive appendectomies. Am Surg. 2000;66:548-554.
2. Yardeni D, Hirschl RB, Drongowski RA, Teitelbaum DH, Geiger JD, Coran AG.
Delayed vs immediate surgery in acute appendicitis: do we need to operate during the night? J Pediatr Surg. 2004;39:464-469.
3. Eldar S, Nash E, Sabo E, et al. Delay of surgery in acute appendicitis. Am J Surg.
1997;173:194-198.
4. Surana R, Quinn F, Puri P. Is it necessary to perform appendicectomy in the middle
of the night in children? BMJ. 1993;306:1168.
5. Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep deprivation on surgeons dexterity on laparoscopy simulator. Lancet. 1998;352:1191.
6. Steinbrook R. The debate over residents work hours. N Engl J Med. 2002;347:
1296-1302.
7. Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA.
2002;287:955-957.
8. Fitz RH. Perforating inflammation of the vermiform appendix, with special reference to its early diagnosis and treatment. Trans Assoc Am Physicians. 1886;
1:107-144.
9. Seal A. Appendicitis: a historical review. Can J Surg. 1981;24:427-433.
10. Jones K, Pena AA, Dunn EL, Nadalo L, Mangram AJ. Are negative appendectomies still acceptable? Am J Surg. 2004;188:748-754.
11. Wesnes KA, Walker MB, Walker LG, et al. Cognitive performance and mood after a weekend on call in a surgical unit. Br J Surg. 1997;84:493-495.
12. Colson M, Skinner KA, Dunnington G. High negative appendectomy rates are no
longer acceptable. Am J Surg. 1997;174:723-727.
13. Temple CL, Huchcroft SA, Temple WJ. The natural history of appendicitis in adults:
a prospective study. Ann Surg. 1995;221:278-281.

DISCUSSION
John Sutton, MD, Lebanon, NH: Its interesting that you chose
the point of entry in the ER [emergency room] as the time course
for this, because in actuality thats implying that everybodys
appendicitis started as they walked through the door. Although it would be harder to actually historically perhaps track
the onset of symptoms, it might make a big difference in terms
of who is being determined as being an early or a late patient
in this group.
The second comment I have is, you tell us that because we
can delay this now, we dont have to interrupt the day schedule and we dont have to operate in the middle of the night, so
my question is, when they come in, do we choose to not interrupt the day schedule and operate at night or do we choose
to operate at night to not interrupt the day schedule?
Dr Abou-Nukta: We chose presenting to the emergency department as our T0 [time 0] because it was the only time recorded in the computer, so it was standardized among the 300
patients. Initially, we looked at the number of days in terms of
symptoms, and we found that it was difficult to accurately describe in numbers. We did know how to interpret several days
vs couple days vs a few days. So we thought to try to standardize the time, and we chose the ER as T0.
Now, about interrupting the OR [operating room] schedule, some surgeons will schedule the 5:30 or 6 AM and be done
before the beginning of the OR schedule or add it on at the end
of the day.
Sheridan Oldham, MD, Waterville, Me: Id like to ask the
authors if they had considered another title, perhaps, Surgeon Convenience and Elective OR Surgery Schedule First, Patients Second. I was disturbed when I saw this paper. You state
that one of the reasons is the most feared complicationthe
reason for early operationis to prevent perforation. I would
say that the reason for early operation is to prevent pain and
suffering, which is our ethical obligation to our patients. I think
that 78 patients at St Raphael Hospital had a delayed operation for known appendicitis is an embarrassment, and if you
are teaching surgical residents to care for patients in that way,

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shame on you. I am concerned that the publication of this material in the proceedings of this distinguished surgical society
sends a very wrong message that was alluded to by the previous questioner.
Dr Abou-Nukta: Im sorry that you were disturbed, but
I assure you, nothing was personal. The title of my paper is
merely a question. Asking questions is the basis for starting any
scientific project. This is not the first paper to ask this. In 1993,
Surana published a paper in the British Medical Journal which
had the same idea. They compared 6 hours vs 6 to 18 hours
and found no increase in the rate of complications. Yardeni published a paper in the Journal of Pediatric Surgery in 2004 which
asked the same question with a very similar title. I disagree with
you that the primary reason appendectomy is an emergent operation is to relieve pain and suffering. If that is the case, then
we should perform emergency cholecystectomies on patients
with acute cholecystitis. Now, about the pain and suffering. In
2000, I was diagnosed with appendicitis in the middle of the
night. The surgeon was called. They told him the results of the
CT [computed tomography] scan and it was now 2 oclock in
the morning, and they said that the surgeon would be here first
thing in the morning to do your appendectomy. I said, Okay,
can I have some morphine and go to sleep? The day after,
I woke up and I was taken to surgery. I dont think it prolonged my pain and suffering, and Im glad that it actually did
not increase my risk of complications.
Orlando Kirton, MD, Hartford, Conn: To follow up on the
first 2 discussants, looking at what is written in our meeting
booklet, it says:
Objective: To determine if delaying appendectomy for 12 hours
to avoid disturbing the operating room schedule and to minimize the number of operations during the night negatively affects the outcome of patients with acute appendicitis.
Seventy-seven percent of your patient cohort actually had
their operation early and the remainder late. Was this due to
unavailable OR time or unavailable surgeon?
My second observation which would have helped us was if
all the patients had an abnormal CAT [computed axial tomography] scan. You alluded that CAT scans have changed your
overall approach to the diagnosis of appendicitis. If that was
the case, you can better triage which patients you may want to
delay vs not. Did every patient in this review receive a CAT scan?
Dr Abou-Nukta: The reason in the delay was, first of all,
we chose T0 as the time of admission to a room in the emer-

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gency department, so sometimes it is a few hours before the

surgeon is called because the emergency department attending sees the patient first, gets some laboratories, and then a surgeon is called. Some of the other delay was having an OR available, and in only a few cases it had to do with reversal of
Coumadin and the patient had to be reversed. Now the thing
about the use of CT scans. In my conclusions, I say in selected
patients. Actually, I wanted to reiterate that in our conclusion,
we say, in selected patients. We are not saying if someone is
having severe pain or in generalized peritonitis or the patient
is very ill to delay until the morning. This should be elected in
someone who is having right lower-quadrant pain and mildly
elevated white count, having some tenderness in the right lower
quadrant, with findings of early appendicitis on CT. I think that
is a very different decision than in someone with signs of perforation.
Robert Touloukian, MD, New Haven, Conn: Simple question. Is this an affirmation for the referring physician to delay
referral until the morning?
Dr Abou-Nukta: No. It has to be after the patient has been
evaluated and the diagnosis is confirmed, then to selectively
choose patients to wait until the morning.
Richard Barth, MD, Hanover, NH: Did you find that there
were any more complications in the patients that were operated on at night?
Dr Abou-Nukta: No.
Dr Barth: So isnt that one of the reasons why you are trying to avoid surgery at night?
Dr Abou-Nukta: Oh, Im sorry. You meant the patients who
had surgery at night?
Dr Barth: Yes.
Dr Abou-Nukta: No, we didnt look at that. We looked only
at the time between the presentation and the surgery, but not
who was operated on at night vs who was operated on during
the day.
Dr Barth: Did you find that surgery at night wasnt safe for
these patients?
Dr Abou-Nukta: We did not look at the rate of complications in patients operated upon at night vs during the day.
A. Ronald Grimm, MD, Canaan, NH: In 1984, I was called
in at 2 oclock in the morning to help someone with an appendectomy. It was a 12-year-old girl. The anesthetist was tired,
had a long day, and didnt notice when she stopped breathing
and died.

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