Delayed appendicitis care linked to higher perforation risk

Clinical takeaway: Patients with suspected appendicitis should be assessed by a surgical team as early as possible, as delays before surgical evaluation were associated with a progressively higher risk of perforation, a complication linked to substantially worse outcomes.

Appendicitis is the world's most common abdominal surgical emergency, and perforation can lead to infection, longer hospital stays, repeat procedures, and other complications. While prior research has suggested that short in-hospital delays may be safe, less has been known about the impact of delays before patients reach surgical assessment.

In the prospective AlliGatOr study, investigators analyzed outcomes for more than 45,000 patients who underwent emergency appendectomy at 1,377 hospitals across 112 countries. Overall, 32% of patients had perforated appendicitis. Perforation rates increased steadily as pre-hospital delays lengthened, rising from 23% among patients assessed within 12 hours of symptom onset to 26% at 12 to 23 hours, 34% at 24 to 47 hours, 42% at 48 to 71 hours, and 48% among those waiting 72 hours or longer. After adjustment for patient and health system factors, patients waiting at least 72 hours faced an approximately 85% higher risk of perforation than those assessed within 12 hours.

Perforation carried important downstream consequences. Patients with perforated appendicitis had more than double the risk of postoperative complications, while surgical-site infections occurred in 11% versus 3% of nonperforated cases. Mean hospital stay was also longer, at 4.3 versus 2.0 days.

The study also highlighted major global disparities in care. CT use ranged from 59% in high-income countries to 6% in low-income countries, while use of minimally invasive surgery ranged from 96% to 7%, respectively. Preoperative CT imaging was associated with a 31% lower likelihood of unnecessary appendectomy.

“These findings suggest that getting patients to surgical assessment within 24 hours of symptom onset should be a key target for healthcare systems worldwide in order to improve both patient outcomes and experiences,” said senior author Dr Dmitri Nepogodiev.

Source: Anyomih TTK, et al. (2026 Sep 23) Lancet Global Health. Pre-hospital time and risk of perforation in patients with acute appendicitis in 112 countries (AlliGatOr): an international, prospective, observational cohort study