A Comprehensive Systematic Review of Relationship between Surgery Waiting Time and Perforation Rate in Acute Appendicitis
Keywords:
Acute appendicitis, surgical waiting time, perforation, in-hospital delay, appendectomy timing, risk stratificationAbstract
Introduction: Acute appendicitis is one of the most common surgical emergencies worldwide, with appendiceal perforation representing a critical complication associated with significant morbidity. The relationship between surgical waiting time and perforation risk remains controversial, with conflicting evidence regarding the safety of in-hospital delay. This systematic review aims to evaluate the association between waiting time for appendectomy and perforation rates in acute appendicitis, identify population-specific risks, and synthesize evidence for clinical practice guidance.
Methods: A systematic review was conducted using comprehensive literature screening. Studies were included if they examined patients with acute appendicitis, reported measurable waiting time intervals, documented perforation outcomes, and employed appropriate comparative study designs. Data extraction encompassed waiting time definitions, perforation criteria, study population characteristics, statistical relationships, perforation rates by time categories, confounding factors, and secondary outcomes. Harvard citation style was applied throughout.
Results: Eighty-nine studies published were analyzed, comprising retrospective cohorts (n=67), prospective cohorts (n=12), randomized controlled trials (n=2), cross-sectional studies (n=7), and one systematic review. Sample sizes ranged from 50 to 683,590 patients. Overall perforation rates varied from 7.5% to 72.5%, with most studies reporting 10-30%. For pre-hospital delay (symptom duration), consistent positive association with perforation was demonstrated, with odds ratios increasing from 2.84 for >24-hour delay to 6.6 for >36-hour symptoms (Bickell et al., 2006; Sadot et al., 2013). However, for in-hospital delay, findings were discordant. The PERFECT randomized controlled trial found no significant difference in perforation rates between <8-hour (8%) and <24-hour (9%) surgical windows (absolute risk difference 0.6%, 95% CI -2.1 to 3.2; Jalava et al., 2023). Conversely, pediatric studies demonstrated significant associations, with every hour of delay increasing perforation odds by 2% (AOR 1.02, 95% CI 1.00-1.04; Meltzer et al., 2016). High-risk subgroups including elderly patients, those with appendicoliths, and patients with marked inflammatory markers demonstrated accelerated perforation risk with in-hospital delay (Jeon et al., 2018; Hanson et al., 2019).
Discussion: The relationship between surgical waiting time and appendiceal perforation is fundamentally dichotomous. Pre-hospital delay consistently predicts perforation at presentation, representing irreversible disease progression. In contrast, in-hospital delay of up to 24 hours appears safe for carefully selected adults with uncomplicated appendicitis, likely attributable to preoperative antibiotics and modern diagnostic accuracy. However, this safety window does not extend uniformly across populations. Pediatric patients demonstrate time-dependent perforation risk even within 24 hours, potentially reflecting anatomical and physiological differences in disease progression (Serres et al., 2017; Stevenson et al., 2017). Elderly patients present with attenuated symptoms yet accelerated perforation, warranting expedited surgical intervention (F. Rondelli et al., 2019). The presence of appendicolith confers 2.2-fold increased risk of progression to complicated appendicitis within 12 hours, mandating prioritized surgical scheduling (M. Prayle et al., 2023). Secondary outcomes including length of stay and surgical site infections showed inconsistent associations with in-hospital delay, further supporting risk-stratified rather than universal timing protocols.
Conclusion: This systematic review demonstrates that the impact of surgical waiting time on appendiceal perforation is critically dependent on the temporal phase examined and patient-specific risk factors. Pre-hospital delay is a robust predictor of perforation, whereas in-hospital delay up to 24 hours is acceptable for low-risk adults with uncomplicated appendicitis. However, pediatric patients, elderly individuals, and those with appendicoliths or severe inflammatory markers require expedited surgery within 12 hours of presentation. We recommend implementation of risk-stratified triage protocols incorporating clinical, laboratory, and radiological parameters to optimize surgical timing. Future research should focus on prospective validation of composite risk stratification models and investigation of antibiotic therapy optimization during waiting periods. Healthcare institutions should prioritize public education to reduce pre-hospital delay while allocating resources for timely surgical intervention in high-risk populations.
References
A. Annisa. “HUBUNGAN JUMLAH LEUKOSIT PRE OPERASI DENGAN KEJADIAN KOMPLIKASI PASCA OPERASI APENDEKTOMI PADA PASIEN APENDISITIS PERFORASI DI RSUP DR. M. DJAMIL PADANG PERIODE TAHUN 2015-2016,” 2018.
A. Ehlers, F. T. Drake, Meera Kotagal, V. Vlad, Simianu, Chethana Achar, Nidhi Agrawal, S. Joslyn, and D. Flum. “Factors Influencing Delayed Hospital Presentation in Patients with Appendicitis: The APPE Survey.” Journal of Surgical Research, 2016.
A. Ingraham, Mark E. Cohen, K. Bilimoria, C. Ko, B. Hall, T. Russell, and A. Nathens. “Effect of Delay to Operation on Outcomes in Adults with Acute Appendicitis.” Archives of Surgery, 2010.
A. Koyuncu, A. Yavuz, H. Buluş, and M. Dogan. “Association Between Delay in Surgical Treatment and Perforation in Acute Appendicitis,” 2016.
A. Nasution. “HUBUNGAN ANTARA JUMLAH LEUKOSIT DENGAN APENDISITIS AKUT DAN APENDISITIS PERFORASI DI RSU DOKTER SOEDARSO PONTIANAK TAHUN 2011,” 2013.
A. Setiadi, Ros Sumarny, Delina Hasan, and Alfina Rianti. “Analisis Efektivitas Penggunaan Antibiotik Profilaksis Dan Faktor Risiko Infeksi Daerah Operasi Pada Pasien Bedah Apendisitis Di RS X.” Syntax Literate : Jurnal Ilmiah Indonesia, 2021.
Abdul Muthalib Pattiiha, and P. A. M. Selomo. “PERBANDINGAN SKOR RIPASA DAN SKOR LABEDA PADA TINGKAT KEPARAHAN MORFOLOGI APPENDISITIS AKUT DI TERNATE.” Kieraha Medical Journal, 2022.
Akhmad Kheru, N. Sudiadnyani, and Puji Lestari. “Perbedaan Jumlah Leukosit Pasien Apendisitis Akut Dan Perforasi.” JURNAL ILMIAH KESEHATAN SANDI HUSADA, 2022.
Alden Jiraldi Akemah, I. Nyoman, Mangku Karmaya, and Gede Wardana. “PREVALENSI APENDISITIS AKUT BERDASARKAN POSISI ANATOMIS APENDIKS VERMIFORMIS, USIA, DAN JENIS KELAMIN DI RUMAH SAKIT STELLA MARIS MAKASSAR PERIODE 2018-2020.” E-Jurnal Medika Udayana, 2023.
Allen Anderson Pattipeilohy, Ketut Wiargitha, and Wayan Sudarsa. “Kadar Fibrinogen Sebagai Faktor Prediktor Apendisitis Komplikasi.” JBN (Jurnal Bedah Nasional), 2023.
Álvaro Sanabria, Luis Carlos Domínguez, V. Vega, Camilo Osorio, A. Serna, and Charles Bermúdez. “Tiempo de Evolución de La Apendicitis y Riesgo de Perforación.” Revista Colombiana de Cirugía, 2013.
Alvian Rachman Santosa, P. Selomo, and A. Husen. “Hubungan Onset Nyeri Perut Dengan Komplikasi Perforasi Pada Pasien Apendisitis Di RSUD Dr. H. CHASAN BOESOIRIE.” Malahayati Nursing Journal, 2025.
Amelia Ambar Nurani, and Yonathan Adi Purnomo. “Hubungan Usia Dan Jumlah Lekosit Terhadap Tingkat Keparahan Apendisitis Akut Di RS Sumber Waras Periode 2020-2023.” Tarumanagara Medical Journal, 2024.
Amirah Amalia, F. Hasan, I. Wahyuni, Mohamad Riza El Anshori, and Zahra Nurusshofa. “Hubungan Tingginya Nilai ANC (Absolute Neutrophil Count) Dengan Kejadian Apendisitis Akut Dan Perforasi Di RS Islam Jakarta Pondok Kopi Pada Tahun 2018-2020.” Sanus Medical Journal, 2023.
Annisa Amalina, Avit Suchitra, and Deddy Saputra. “Hubungan Jumlah Leukosit Pre Operasi Dengan Kejadian Komplikasi Pasca Operasi Apendektomi Pada Pasien Apendisitis Perforasi Di RSUP Dr. M. Djamil Padang.” Jurnal Kesehatan Andalas, 2018.
Arif Nugroho, Ariandi Setiawan, and A. D. Widodo. “Correlation of Surgical Site Infection with Empirical Antibiotic Therapy in Children with Perforated Appendicitis,” 2021.
asrahadi tengku. “KORELASI POLA KUMAN DAN FAKTOR HOST TERHADAP RESIKO KEJADIAN APENDIKS PERFORASI,” 2017.
Ayang Sophia, M. H. Mustaqim, and Fakhrul Rizal. “PERBANDINGAN KADAR LEUKOSIT DARAH PADA PASIEN APENDISITIS AKUT DAN APENDISITIS PERFORASI DI RSUD MEURAXA BANDA ACEH,” 2020.
B. Jeon, Hyukjung Kim, Kuk Hyun Jung, Hye In Lim, Sang Wook Kim, Jin soo Park, K. H. Kim, and I. Kim. “Appendectomy: Should It Be Performed So Quickly?” The American Surgeon, 2016.
B. Jeon, Hyukjung Kim, and S. Heo. “CT Scan Findings Can Predict the Safety of Delayed Appendectomy for Acute Appendicitis.” Journal of Gastrointestinal Surgery, 2018.
Baldah Deyan Sofiana, Ferdian Hidayat, and M. Anwar. “Karakteristik Penderita Peritonitis Di RSUD Dr. H. Chasan Boesoirie.” Kieraha Medical Journal, 2022.
Basilis Papaziogas, P. Tsiaousis, Ioannis Koutelidakis, A. Giakoustidis, S. Atmatzidis, and K. Atmatzidis. “Effect of Time on Risk of Perforation in Acute Appendicitis.” Acta Chirurgica Belgica, 2009.
Basrah Journal, Jasim Mohemed Ayuib, and Adnan Y Al-Adab. “DELAY IN SURGERY FOR ACUTE APPENDICITIS .39,” 2010.
Brett A. Fair, J. Kubasiak, I. Janssen, J. Myers, K. Millikan, D. Deziel, and M. Luu. “The Impact of Operative Timing on Outcomes of Appendicitis: A National Surgical Quality Improvement Project Analysis.” American Journal of Surgery, 2015.
C. Narsule, Eden J. Kahle, Daniel S. Kim, A. C. Anderson, and F. Luks. “Effect of Delay in Presentation on Rate of Perforation in Children with Appendicitis.” American Journal of Emergency Medicine, 2011.
Caecilia Lelia Rahmawati, R. Pinzon, and Trisasi Lestari. “EVALUASI IMPLEMENTASI CLINICAL PATHWAY APPENDICITIS ELEKTIF DI RS BETHESDA YOGYAKARTA,” 2017.
Chia-Lin Chou, S. Weng, Li-Chin Cheng, Yu-Feng Tian, and C. Tseng. “Predictors of Perforated Acute Appendicitis: A Retrospective Study from a Single Institution,” 2014.
Christi Evana Doda, Topan Sugara, and F. The. “HUBUNGAN LAMA PERAWATAN PASCA APENDEKTOMI PADA PASIEN APENDISITIS AKUT DAN APENDISITIS PERFORASI DI RSUD Dr. H. CHASAN BOESOIRIE TAHUN 2019-2022.” PREPOTIF : JURNAL KESEHATAN MASYARAKAT, 2025.
Cokorda Putra, and Sang Nyoman Suryana. “Gambaran Prediktor Perforasi Pada Penderita Apendisitis Di Rumah Sakit Umum Ari Canti Gianyar, Bali, Indonesia Tahun 2018,” 2020.
Courtney Clyde, T. Bax, A. Merg, M. MacFarlane, P. Lin, S. Beyersdorf, and M. McNevin. “Timing of Intervention Does Not Affect Outcome in Acute Appendicitis in a Large Community Practice.” American Journal of Surgery, 2008.
D. Cameron, Regan F. Williams, Yimin Geng, A. Gosain, M. Arnold, Y. Guner, M. Blakely, et al. “Time to Appendectomy for Acute Appendicitis: A Systematic Review.” Journal of Pediatric Surgery, 2017.
D. Fung, R. McLean, and I. McCallum. “PTU-229 Time to Appendicectomy; Is It Predictive of Morbidity?” 2015.
D. Kearney, R. Cahill, E. O'brien, W. Kirwan, and H. Redmond. “Influence of Delays on Perforation Risk in Adults with Acute Appendicitis.” Diseases of the Colon & Rectum, 2008.
D. Woolridge. “Childhood Appendicitis: Is Time Really of the Essence?” Journal of Emergency Medicine, 2017.
Dalia Izma Tuasamu, Is Ikhsan Hataul, C. I. Devi, and O. W. Angkejaya. “HUBUNGAN ANTARA LAMA NYERI PRA OPERASI DENGAN LAMA PERAWATAN POST OPERASI PADA PASIEN APENDISITIS PERFORASI YANG DILAKUKAN LAPAROTOMI APENDEKTOMI DI RSUD DR M HAULUSSY AMBON TAHUN 2018-2019.” PAMERI Pattimura Medical Review, 2022.
Danny Zefanya Mooy, I. G. Suwedagatha, and N. Golden. “Faktor-Faktor Risiko Yang Berperan Terhadap Terjadinya Infeksi Luka Operasi Pada Pasien Post Appendectomy Di RSUP Sanglah Denpasar,” 2020.
Dayu Satriya Wibawa, Aditya Bhayusakti, Dwimantoro, Hotimah Masdan Salim, and David Sajid Muhammad. “Profil Deskriptif Pasien Dengan Apendisitis Akut Di Rumah Sakit Islam Jemursari.” Jurnal Kesehatan Islam : Islamic Health Journal, 2024.
Dominic J. Papandria, S. Goldstein, D. Rhee, Jose H. Salazar, Jamir D. Arlikar, Amany I Gorgy, G. Ortega, Yiyi Zhang, and F. Abdullah. “Risk of Perforation Increases with Delay in Recognition and Surgery for Acute Appendicitis.” Journal of Surgical Research, 2013.
E. Amelia. “Kesesuaian Dan Efektivitas Antibiotik Perioperatif Terkait Luka Operasi Pasca Apendiktomi,” 2015.
E. Bozkurt, and M. F. Celayir. “Treatment of Acute Appendicitis: Urgent Surgery or Emergent Surgery?” Ulusal Travma Ve Acil Cerrahi Dergisi-Turkish Journal of Trauma & Emergency Surgery, 2020.
E. Sadot, N. Wasserberg, R. Shapiro, A. Keidar, B. Oberman, and S. Sadetzki. “Acute Appendicitis in the Twenty-First Century: Should We Modify the Management Protocol?” Journal of Gastrointestinal Surgery, 2013.
F. Javed, S. Saleem, Ayesha Rehman, Nazim Hayat, Z. Rashid, T. Ahmad, and I. Ahmad. “Early Versus Delayed Appendectomy for Uncomplicated Acute Appendicitis.” 2020.
F. Rondelli, M. De Rosa, Paolo Stella, M. Boni, G. Ceccarelli, R. Balzarotti, A. Polistena, A. Sanguinetti, W. Bugiantella, and N. Avenia. “Perforated Vs Nonperforated Acute Appendicitis: Evaluation of Short-Term Surgical Outcomes in an Elderly Population.” Minerva Chirurgica, 2019.
F. T. Drake. “Is Appendicitis a Ticking Time Bomb? Time to Treatment and Risk of Perforation After Patients Reach the Hospital,” 2013.
F. T. Drake, Neli E. Mottey, Ellen T. Farrokhi, M. Florence, Morris G. Johnson, C. Mock, S. Steele, R. Thirlby, and D. Flum. “Time to Appendectomy and Risk of Perforation in Acute Appendicitis.” JAMA Surgery, 2014.
F. Yulianto, R. Sakinah, M. Kamil, and Tri Wahono. “Faktor Prediksi Perforasi Apendiks Pada Penderita Apendisitis Akut Dewasa Di RS Al-Ihsan Kabupaten Bandung Periode 2013–2014,” 2016.
Febria Valentine Aritonang, Sanjaya Soebagio, and Yan Aditya. “Perbedaan Jumlah Leukosit Darah Antara Pasien Apendisitis Akut Dan Apendisitis Perforasi Sebagai Prediktor Diagnosis Di RSUD Pulang Pisau, Kalimantan Tengah, Indonesia.” Intisari Sains Medis, 2022.
Festy Ladyani, and N. F. Dewi. “DIFFERENCES IN LEUKOCYTE RATE BETWEEN ACUTE NONPERFORATED AND PERFORATED APPENDICITIS IN HOSPITALISED PATIENTS BANDAR LAMPUNG-INDONESIA.” Malahayati International Journal of Nursing and Health Science, 2019.
Fitria Anggaina A. Mustafa, Ferdian Hidayat, and Prita Aulia M. Selomo. “Correlation Between Alvarado Score with Surgical Findings in Acute Appendicitis Patients at RSUD Dr. H. Chasan Boesoirie Ternate.” AVERROUS: Jurnal Kedokteran Dan Kesehatan Malikussaleh, 2024.
Fraz Fahim, and S. Shirjeel. “A Comparison Between Presenatation Time and Delay in Surgery in Simple and Advanced Appendicitis.” Journal of Ayub Medical College, 2005.
Furat Shani Aoda, Sura Saeed Abood, and I. Noori. “Factors Associated with Increased Risk of Perforation of Acute Appendicitis.” Annals of Medicine &Amp; Surgery, 2025.
G. Frongia, F. Dostál, L. Ziebell, N. R. Vuille-dit-Bille, T. Müller, J. Schenk, A. Mehrabi, and P. Günther. “Delayed Surgery for Perforated Appendicitis Is Feasible in Children Without Compromising the Outcome in Selected Cases.” World Journal of Surgery, 2022.
G. Giraudo, F. Baracchi, L. Pellegrino, H. Dal Corso, and F. Borghi. “Prompt or Delayed Appendectomy? Influence of Timing of Surgery for Acute Appendicitis.” Surgery Today (Print), 2013.
Gloria A. Thomas, Ishak Lahunduitan, and Adrian Tangkilisan. “ANGKA KEJADIAN APENDISITIS DI RSUP PROF. DR. R. D. KANDOU MANADO PERIODE OKTOBER 2012 – SEPTEMBER 2015,” 2016.
Gunnar Andrésson, and Árný Kristínardóttir. “Risk of Developing Perforations and Abscesses for Patients With Appendicitis, With Regards to Duration of Symptoms. A Retrospective Cohort Study.” 2021.
H. Baker. “Research in Brief.” The Lancet Gastroenterology and Hepatology, 2023.
H. Marisa. “Batas Angka Leukosit Antara Appendisitis Akut Dan Appendisitis Perforasi Di RSUD Tugurejo Semarang Periode Januari 2009 - Juli 2011,” 2012.
Helman Kurniadi, Ros Sumarny, Timbul Partogi Haposan Simorangkir, and Syamsudin Abdillah. “Faktor-Faktor Yang Berhubungan Dengan Komplikasi Apendisitis Dan Efektivitas Penggunaan Antibiotik Profilaksis Pada Pasien Apendektomi Di RSPAD Gatot Soebroto.” Jurnal Sains Dan Kesehatan, 2023.
Hendra Kastiaji. “HUBUNGAN ONSET GEJALA KLINIS DAN NILAI LEUKOSIT TERHADAP APENDISITIS PERFORASI DI BANDA ACEH TAHUN 2016,” 2017.
Hendrik M. J. M. J. Tampi, Heber B. Sapan, and Richard M. Sumangkut. “Hubungan Kadar Fibrinogen Dengan Apendisitis Akut,” 2016.
Heru Ardila Putra, T. O. R. Wahid, and Wiwit Ade Fidiawati. “HUBUNGAN MULAI NYERI PERUT DENGAN TINGKAT KEPARAHAN APENDISITIS AKUT ANAK BERDASARKAN KLASIFIKASI CLOUD DI RSUD ARIFIN ACHMAD PROVINSI RIAU,” 2015.
Hyun Kyu Kim, Yong-Seok Kim, Soo Ho Lee, and H. Lee. “Impact of a Delayed Laparoscopic Appendectomy on the Risk of Complications in Acute Appendicitis: A Retrospective Study of 4,065 Patients.” Digestive Surgery, 2016.
I. K. T. Widarsa, and Cokorda Istri Padmi. “Akurasi Total Hitung Leukosit Dan Durasi Simtom Sebagai Prediktor Perforasi Apendisitis Pada Penderita Apendisitis Akut,” 2018.
I. Ozguner, B. I. Buyukayavuz, and M. C. Savaş. “The Influence of Delay on Perforation in Childhood Appendicitis. A Retrospective Analysis of 58 Cases.” Saudi Medical Journal, 2004.
I. W. Wismaya, Paul L Tahalele, and Titien Rahayu. “The Difference In Neutrophil/Lymphocyte Ratio In Patients With Acute Appendicitis Without And With Perforation,” 2019.
Iday Hidayat, Reny Tri Febriani, and Sismala Harningtyas. “Hubungan Antara Jumlah Leukosit Dengan Diagnosa Apendisitis Pada Pasien Apendiktomy Di Kamar Operasi Rumah Sakit Persada Hospital Malang.” Borneo Journal of Medical Laboratory Technology, 2024.
Ilhamsyah Pakpahan Icuk. “PERBANDINGAN AKURASI SKOR TZANAKIS DENGAN SKOR ALVARADO DALAM PENEGAKAN DIAGNOSIS APENDISITIS AKUT DI RSUP Dr. M DJAMIL PADANG DAN SEMEN PADANG HOSPITAL,” 2016.
Ilil Maidatuz Zulfa. “Studi Komparatif Efektivitas Seftriakson Dibanding Kombinasi Seftriakson-Metronidazole Dan Sefuroksim-Metronidazole Pada Pasien Apendisitis Yang Menjalani Apendiktomi,” 2020.
Irmayanti Johar Bima, Rachmat Faisal Syamsu, Sigit Dwi Pramono, Reeny Purnamasari, Sri Juliani, Hermiaty Nasruddin, and R. AndiFatihahRizkiSalsabilah. “Hubungan Jenis Kelamin, Usia Dan Jumlah Leukosit Pada Pasien Apendisitis Perforasi Dan Apendisitis Non Perforasi.” Wal'afiat Hospital Journal, 2021.
Islam MN, Sarkar P, Islam MS, Kudrat-e-khuda I M, Hussain MT, Datta KK, and Benarjee S. “Timing of Surgery and the Risk of Complications in Acute Appendicitis.” Journal of Diabetic Association Medical College, Faridpur, 2023.
Isra Febriana Sari, M. Zulfikar, and Muhammad Ali Palanro. “PROFIL PERITONITIS GENERALISATA DI RSU ANUTAPURA DAN UPT. RSUD UNDATA PALU PERIODE 2018-2020.” Medika Alkhairaat : Jurnal Penelitian Kedokteran Dan Kesehatan, 2022.
Isye Maudina Effendi, Nuzirwan Acang, and Buti Azfiani. “Pola Pasien Apendisitis Akut Yang Dilakukan Tindakan Pembedahan Di RS Al-Islam Periode 1 Januari-31 Desember 2017,” 2019.
J. Tay, and J. Ortega. “Factores Asociados a La Perforación Apendicular En Pacientes Con Apendicitis Aguda. Experiencia En El Nuevo Sanatorio Durango,” 2013.
James A. Meltzer, S. Kunkov, Jennifer H. Chao, E. Tay, J. George., David Borukhov, S. Alerhand, P. Harrison, J. Hom, and E. Crain. “Association of Delay in Appendectomy With Perforation in Children With Appendicitis.” Pediatric Emergency Care, 2016.
januar az zahrani, Amry Junus, and F. A. Yulianto. “Relationship Between Age and Perforation in Acute Appendicitis Patient at Rsud Al Ihsan Bandung in 2016,” 2017.
Japanes Aiwi. “POLA KASUS DAN PENATALAKSANAAN PERITONITIS AKUT DI BANGSAL BEDAH RSUP DR. M. DJAMIL PADANG PERIODE JANUARI 2013-DESEMBER 2013,” 2014.
Jian Li, Run Xu, D. Hu, Yao Zhang, Tuping Gong, and Xue-Lian Wu. “Effect of Delay to Operation on Outcomes in Patients with Acute Appendicitis: A Systematic Review and Meta-Analysis.” Journal of Gastrointestinal Surgery, 2018.
Joko Suprayitno, Reno Budiman, and Tommy Ruchimat. “Peran Fibrinogen Serum Sebagai Prediktor Perforasi Pada Pasien Apendisitis Akut Di RSUP Dr. Hasan Sadikin Bandung 2018,” 2020.
Jong Wan Kim, D. Shin, D. Kim, Jeong Yeon Kim, Sung Gil Park, and Jun Ho Park. “Effects of Timing of Appendectomy on the Risks of Perforation and Postoperative Complications of Acute Appendicitis.” World Journal of Surgery, 2018.
Jumarni Katrin Imelda Selan, Bambang Hadi Kartiko, and Devi Marlita Martana. “FAKTOR - FAKTOR YANG MEMPENGARUHI LAMA HARI RAWAT PASIEN APENDIKTOMI DI RUMAH SAKIT UMUM PUSAT SANGLAH KOTA DENPASAR.” JURNAL KESEHATAN, SAINS, DAN TEKNOLOGI (JAKASAKTI), 2023.
Junghyun Lee, and Chami Im. “Time-to-Surgery Paradigms: Wait Time and Surgical Outcomes in Critically Ill Patients Who Underwent Emergency Surgery for Gastrointestinal Perforation.” BMC Surgery, 2024.
K. Jalava, V. Sallinen, H. Lampela, H. Malmi, A. Leppäniemi, and P. Mentula. “Role of Delay and Antibiotics on PERForation Rate While Waiting appendicECTomy (PERFECT): A Protocol for a Randomized Non-Inferiority Trial.” BJS Open, 2021.
K. Lastunen, A. Leppäniemi, and P. Mentula. “Perforation Rate After a Diagnosis of Uncomplicated Appendicitis on CT.” BJS Open, 2021.
K. Mandeville, M. Monuteaux, T. Pottker, and B. Bulloch. “Effects of Timing to Diagnosis and Appendectomy in Pediatric Appendicitis.” Pediatric Emergency Care, 2015.
K. Stahlfeld, J. Hower, S. Homitsky, and J. Madden. “Is Acute Appendicitis a Surgical Emergency?” The American Surgeon, 2007.
K. Westfall, and A. Charles. “Risk of Perforation in the Era of Nonemergent Management for Acute Appendicitis.” The American Surgeon, 2019.
Karoliina Jalava, V. Sallinen, H. Lampela, H. Malmi, I. Steinholt, K. M. Augestad, A. Leppäniemi, and P. Mentula. “Role of Preoperative in-Hospital Delay on Appendiceal Perforation While Awaiting Appendicectomy (PERFECT): A Nordic, Pragmatic, Open-Label, Multicentre, Non-Inferiority, Randomised Controlled Trial.” The Lancet, 2023.
Keith A. Hanson, Daron Jacob, A. Alhaj Saleh, and S. Dissanaike. “In-Hospital Perforation Risk in Acute Appendicitis: Age Matters.” American Journal of Surgery, 2019.
Khaled Abdul Jawad, A. Cioci, Eva M. Urrechaga, Hang Zhang, Saskya Byerly, R. Rattan, G. Pust, et al. “Impact of Delay in Appendectomy on the Outcome of Appendicitis: A Post Hoc Analysis of an EAST Multicenter Study.” Surgical Infections, 2020.
L. Hansson, H. Laurell, and U. Gunnarsson. “Impact of Time in the Development of Acute Appendicitis.” Digestive Surgery, 2008.
Lathvi Masyithah, Armenia Armenia, and A. Almahdy. “Hubungan Ketepatan Switch Therapy Terhadap Kesembuhan Luka, Lama Rawatan Dan Biaya Pengobatan Antibiotik Pasien Appendisitis,” 2016.
Laura A. Harmon, Matthew L. Davis, D. Jupiter, R. Frazee, and Justin L Regner. “Computed Tomography to Operating Room in Less Than 3 Hours Minimizes Complications from Appendicitis.” American Journal of Surgery, 2016.
Lera Lera, Azis Beru Gani, Zulfahmidah Zulfahmidah, Febie Irsandy Syahruddin, and Berry Erida Hasbi. “HUBUNGAN DIAMETER APPENDIX VERMIFORMIS BERDASARKAN HASIL USG DENGAN GRADING APENDISITIS PADA PASIEN APENDEKTOMI DI RSUD MASSENREMPULU TAHUN 2023.” Jurnal Kesehatan Tambusai, 2024.
Li Jiang, Z. Liu, Xiaojun Tong, Yang Deng, Jianwen Liu, Xuefei Yang, F. S. Chan, and J. K. Fan. “Does the Time from Symptom Onset to Surgery Affect the Outcomes of Patients with Acute Appendicitis? A Prospective Cohort Study of 255 Patients.” Asian Journal of Endoscopic Surgery, 2020.
Lucy Patmasari, Hendra Herizal, and Syamel Muhammad. “Karakteristik Penderita Apendisitis Yang Dioperasi Di Divisi Bedah Anak RSUP Dr. M. Djamil Padang Periode 2019-2020.” Jurnal Ilmu Kesehatan Indonesia, 2022.
Luis Augusto Cruz Díaz, César Colquehuanca Hañari, and Alejandro Walter Machado Núñez. “TIEMPO DE ENFERMEDAD Y PREMEDICACIÓN COMO RIESGO PARA APENDICITIS PERFORADA EN EL HOSPITAL DE VENTANILLA 2017.” Revista de La Facultad de Medicina Humana, 2019.
M. Busch, F. Gutzwiller, Sonja Aellig, Rolf Kuettel, U. Metzger, and U. Zingg. “In-Hospital Delay Increases the Risk of Perforation in Adults with Appendicitis.” World Journal of Surgery, 2011.
M. Elniel, J. Grainger, E. Nevins, N. Misra, and P. Skaife. “72 h Is the Time Critical Point to Operate in Acute Appendicitis.” Journal of Gastrointestinal Surgery, 2018.
M. Kurniadi, I. M. Nur, and Zulmansyah Zulmansyah. “Karakteristik Apendisitis Berdasarkan Gambaran Histopatologi Di Rumah Sakit Al-Islam Bandung,” 2019.
M. Prayle, A. Taib, A. Kler, D. Kanakalingam, and P. Asaad. “508 Appendicoliths – Time to Operate: The Temporal Relationship Between Pre-Operative CT Confirmed Appendicolith and Time to Develop Complicated Appendicitis.” British Journal of Surgery, 2023.
M. Sayuti. “KARAKTERISTIK PERITONITIS PERFORASI ORGAN BERONGGA DI RSUD CUT MEUTIA ACEH UTARA.” AVERROUS: Jurnal Kedokteran Dan Kesehatan Malikussaleh, 2020.
M. Sayuti, Anna Millizia, and Hasanatul Khairiyah. “Prevalensi Dan Karakteristik Apendisitis Perforasi Di Rumah Sakit Wilayah Kota Lhokseumawe Tahun 2020-2022.” GALENICAL : Jurnal Kedokteran Dan Kesehatan Mahasiswa Malikussaleh, 2023.
M. Shiddiq. “SUHU TUBUH DAN NILAI GRANULOSIT PRAOPERASI PASIEN APENDISITIS AKUT BERKOMPLIKASI DI RSUD DOKTER SOEDARSO PONTIANAK TAHUN 2012,” 2013.
M. Stevenson, P. Dayan, Nanette C. Dudley, L. Bajaj, C. Macias, R. Bachur, Kelly A. Sinclair, et al. “Time From Emergency Department Evaluation to Operation and Appendiceal Perforation.” Pediatrics, 2017.
Mangema Junias R.S. “Hubungan Antara Skor Alvarado Dan Temuan Operasi Appendisitis Akut Di Rumah Sakit Pendidikan Fakultas Kedokteran Universitas Sumatera Utara,” 2009.
Maria F. Dien Esquivel, Reza Belaghi, R. Webster, and Gali Shapira-Zalstberg. “Image-Guided Abscess Drainage in Children with Perforated Appendicitis – Can It Wait?” Pediatric Radiology, 2023.
Markus Almström, J. Svensson, Barbora Pátková, A. Svenningsson, and T. Wester. “In-Hospital Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children: A Single-Center Retrospective Cohort Study.” Annals of Surgery, 2017.
Maru Kim, S. Kim, and H. Cho. “Effect of Surgical Timing and Outcomes for Appendicitis Severity.” Annals of Surgical Treatment and Research, 2016.
Maru Kim, and S. Oh. “Effect of Time Delays for Appendectomy as Observed on Computed Tomography in Patients with Noncomplicated Appendicitis.” American Journal of Emergency Medicine, 2016.
Masato Fujino, Shingo Ochiai, and Tadao Kubota. “A 48-Hour Symptom Threshold Predicts Perforated Appendicitis: Development of a Clinical Risk Model.” World Journal of Surgery, 2025.
Mati Durongrittichai. “Factors Related Between Acute Appendicitis and Ruptured Appendicitis in Pathum Thani Hospital - ความแตกต่างระหว่างไส้ติ่งอักเสบเฉียบพลันและไส้ติ่งอักเสบทะลุในโรงพยาบาลปทุมธานี,” 2015.
Mirza Nuchalida. “Kegawatdaruratan Bedah Abdomen Anak Di Rumah Sakit Islam Banjarnegara Selama Pandemi Covid-19.” Jurnal Health Sains, 2021.
Mirza Nuchalida, Agus Ujianto, and Niko Yuandi. “Kegawatdaruratan Bedah Abdomen Anak Di Rumah Sakit Islam Banjarnegara Selama Pandemi Covid-19.” Jurnal Health Sains, 2021.
Mizar Erianto, Zulhafis Mandala, and Rio Chairul Anam. “Hubungan Jumlah Kadar Limfosit Dan Neutrofil Segmen Pada Apendisitis Akut,” 2020.
Mohd Reza Bahlia. “Perbandingan Suhu Dan Kadar Leukosit Pada Pasien Appendisitis Akut Dengan Pasien Appendisitis Perforasi.” COMSERVA Indonesian Jurnal of Community Services and Development, 2022.
Muzzamil Muzzamil, M. Mansur, and M. Suryadi. “Analisis Variasi Pengelolaan Appendicitis Acuta Di Rumah Sakit Wava Husada Malang,” 2014.
N. Bickell, A. Aufses, Mary Rojas, and C. Bodian. “How Time Affects the Risk of Rupture in Appendicitis.” Journal of the American College of Surgeons, 2006.
N. Kulvatunyou, S. A. Zimmerman, B. Joseph, R. Friese, Lynn Gries, T. O'keeffe, John A. Stroster, and A. Tang. “Risk Factors for Perforated Appendicitis in the Acute Care Surgery Era-Minimizing the Patient's Delayed Presentation Factor.” Journal of Surgical Research, 2019.
N. Romadhona. “GAMBARAN PASIEN APENDISITIS AKUT DI BAGIAN BEDAH RS AL ISLAM BANDUNG PERIODE 1 JULI - 31 DESEMBER 2009,” 2015.
Natario Natario, and Anak Agung Ngurah Pretangga. “Profil Deskriptif Pasien Dengan Apendisitis Akut Di Rumah Sakit Sekunder Periode Juni Hingga Desember 2020.” Intisari Sains Medis, 2021.
Niko Yuandi, Mirza Nuchalida, Agus Ujianto, Meta Safila, and Suripto Riayani. “Manifestasi Klinis Apendisitis Akut Pada Anak Di Rumah Sakit Islam Banjarnegara.” Jurnal Health Sains, 2021.
Nopi Sani, Arti Febriyani, and Yuni Fidia Hermina. “KARATERISTIK PASIEN APENDISITIS AKUT DI RUMAH SAKIT UMUM DAERAH DR. H. ABDUL MOELOEK PROVINSI LAMPUNG,” 2020.
Nurnadhirah Mirantika, Danial Danial, and Bambang Suprapto. “Hubungan Antara Usia, Lama Keluhan Nyeri Abdomen, Nilai Leukosit, Dan Rasio Neutrofil Limfosit Dengan Kejadian Apendisitis Akut Perforasi Di RSUD Abdul Wahab Sjahranie Samarinda.” Jurnal Sains Dan Kesehatan, 2021.
Orhan Üreyen, Abidin Gazi Alagöz, Murat Kale, İlhan Dursun, Emrehan İnci̇, and Enver Ilhan. “Gece Ve Gündüz Başvuruya Göre Akut Apandisit.” İzmir Tıp Fakültesi Dergisi, 2022.
P. Teixeira, E. Sivrikoz, K. Inaba, P. Talving, L. Lam, and D. Demetriades. “Appendectomy Timing: Waiting Until the Next Morning Increases the Risk of Surgical Site Infections.” Annals of Surgery, 2012.
P. Youatou Towo, A. Ramadan, W. Ngatchou, J. N. Djiele, A. Etienne, E. Capelluto, and P. Mols. “Predictors of Early Outcome After Acute Appendicitis: Is Delaying Surgery for Acute Appendicitis an Option? A Retrospective Study.” European Journal of Trauma and Emergency Surgery, 2012.
Parth Maheshwari, and S. Basu. “eP75 The Effect of Time of Intra-Abdominal Drain Insertion on Surgical Outcomes in Patients Undergoing Emergency Laparotomy.” British Journal of Surgery, 2025.
Paula Castro, Julián Rincón, C. Sánchez, I. Molina, and G. Buitrago. “Presurgical Time and Associated Factors as Predictors of Acute Perforated Appendicitis: A Prospective Cohort Study in a Teaching Pediatric Hospital in Colombia.” BMC Pediatrics, 2022.
Paulette I. Abbas, M. Peterson, Lindsay J Stephens, J. R. Rodriguez, Timothy C. Lee, M. Brandt, and Monica E. Lopez. “Evaluating the Effect of Time Process Measures on Appendectomy Clinical Outcomes.” Journal of Pediatric Surgery, 2016.
Prita Aulia M Selomo. “LEUKOSIT PRA OPERASI DENGAN TINGKAT KEPARAHAN MORFOLOGI APENDISITIS AKUT DI RUMAH SAKIT KOTA TERNATE.” Kieraha Medical Journal, 2021.
Puti Reno Rauda, Fidiariani Sjaaf, and Budi Yulhasfi Febrianto. “Karakteristik Apendisitis Pada Usia Muda Dan Usia Lanjut Di RS Siti Ramah Padang Tahun 2023.” Scientia Journal, 2024.
R. Chhetri, S. Baral, Neeraj Thapa, B. Kc, D. Pandit, and B. Buda. “Will Delay in Surgery Affect Outcome in Acute Appendicitis,” 2019.
R. Galletti, Vinicius Oliveira Fernandes, N. Novo, and Willy Marcus França. “Timing of Surgery and Complications of Acute Appendicitis: A Retrospective Study.” Surgical Science, 2019.
R. Ko, Se Jin Park, and H. Kim. “Relationship Between the Time Required for Transfer and Outcomes in Patients with Appendicitis.” Medicine, 2019.
R. Puji. “PERBEDAAN JUMLAH LEUKOSIT BERDASARKANJENIS KELAMIN, USIA, DAN STATUS GIZIPADA PENDERITA APENDISITIS PERFORASIDI RSUP DR. M. DJAMIL PADANG,” 2015.
R. Riauka, P. Ignatavičius, Žygimantas Tverskis, and Ž. Dambrauskas. “ACUTE APPENDICITIS: DELAYED SURGERY DOES NOT INCREASE THE NUMBER OF POSTOPERATIVE COMPLICATIONS,” 2018.
Rahmatushubhan Rahmatushubhan. “HUBUNGAN USIA DENGAN KEJADIAN APENDISITIS PERFORASIDI RSUP DR. M. DJAMIL TAHUN 2013,” 2016.
Ranika Paramita, Dedi Afandi, Ennimay Ennimay, Budi Hartono, and Asfeni Asfeni. “HUBUNGAN IMPLEMENTASI CLINICAL PATHWAY APPENDICITIS ACUTE TERHADAP AVERANGE LENGTH OF STAY DI AULIA HOSPITAL PEKANBARU.” Jurnal Kesehatan Tambusai, 2025.
Roosanie Patria Murti. “Hubungan Kadar HCRP Dan Jumlah Leukosit Terhadap Derajat Beratnya Appendicitis Akut Anak Berdasarkan Klasifikasi Cloud,” 2015.
Rosa Margarita Terrón-Arriaga, Agustín Luna Tovar, Nubia Andrea Ramírez BuenSuceso Conde, Claudia Cabau-Talarn, J. L. Perez Hernandez, M. Palermo, R. Vilallonga, and M. R. Rodríguez-Luna. “Perioperative Morbidity in Acute Appendicitis: Is Delayed Appendectomy Still an Option?” Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A, 2021.
S. Arain, S. Ali, A. Memon, and S. Siddiqui. “Delayed Appendectomy in Adults with Acute Appendicitis. Safe or Unsafe,” 2014.
S. M. A. Hakim, Habibullah Sarkar, and Manzurur Rahman Shah Chowdhury. “Risk Factors of Perforation of Appendix and Unfavorable Outcome in Delayed Presentation of Acute Appendicitis: A Cross-Sectional Analysis.” TAJ Journal of Teachers Association, 2018.
S. Maharani, Mizar Erianto, Ringgo Alfarisi, and Joan Willy. “FAKTOR-FAKTOR YANG MEMPENGARUHI LAMA HARI RAWAT INAP PASIEN POST APENDIKTOMI DI RSUD DR. H. ABDUL MOELOEK KOTA BANDAR LAMPUNG TAHUN 2018.” Human Care Journal, 2020.
S. Musunuru, Herb Chen, L. Rikkers, and S. Weber. “Computed Tomography in the Diagnosis of Acute Appendicitis: Definitive or Detrimental?” Journal of Gastrointestinal Surgery, 2007.
S. Saar, P. Talving, Juhan Laos, T. Põdramägi, M. Sokirjanski, T. Lustenberger, L. Lam, and U. Lepner. “Delay Between Onset of Symptoms and Surgery in Acute Appendicitis Increases Perioperative Morbidity: A Prospective Study.” World Journal of Surgery, 2016.
S. Siregar, Agi satria Putranto, and Aria Kekalih. “Hiperbilirubinemia Sebagai Prediksi Terhadap Appendisitis Perforasi,” 2020.
Salma Abu Foul, E. Egozi, A. Assalia, Y. Kluger, and A. Mahajna. “Is Early Appendectomy in Adults Diagnosed with Acute Appendicitis Mandatory? A Prospective Study.” World Journal of Emergency Surgery, 2019.
Seong-Keun Park, Min-Su Park, and K. Lee. “Relationship Between the Hospital Visit-to-Operation Time Interval and the Risk of Appendiceal Perforation and Clinical Outcomes,” 2018.
Septi Auliza Refolinda, Mizar Eriantono, Ringgo Alfarisi, and Joan Willy. “Perbedaan Lamanya Rawat Inap Pasien Post Appendektomi Pada Appendiksitis Akut Dan Appendiksitis Perforasi,” 2020.
Shifa Khamila, and Peter Ian Limas. “PERBANDINGAN KARAKTERISTIK PASIEN APENDISITIS SEBELUM DAN SAAT PANDEMI COVID-19 DI RS HAJI DARJAD SAMARINDA PERIODE 2019-2020.” Ebers Papyrus, 2023.
Shuo-Lun Lai, Chin-Hao Chang, Po-Chu Lee, Cheng-Maw Ho, Jin-Ming Wu, Hong-Shiee Lai, and Been-Ren Lin. “Impact of Preoperative Factors and Waiting Time on Post-Appendectomy Complications: A Retrospective Study.” Perioperative Medicine, 2024.
Siti Fathekhatul Khairiyyah, and Peter Ian Limas. “Analisis Jumlah Leukosit, Lama Gejala Dan Suhu Tubuh Sebagai Prediktor Lamanya Operasi Pada Kasus Apendisitis Akut.” Tarumanagara Medical Journal, 2020.
Stefano Agnesi, Gabriele Mauro Di Lucca, Fabio Benedetti, L. Fattori, L. Degrate, L. Roccamatisi, M. Braga, and M. Ceresoli. “Effect of in-Hospital Delay on Acute Appendicitis Severity: Does Time Really Matter?” Updates in Surgery, 2024.
Stephanie K. Serres, D. Cameron, Charity C. Glass, Dionne A. Graham, D. Zurakowski, Mahima Karki, Seema P. Anandalwar, and S. Rangel. “Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children.” JAMA Pediatrics, 2017.
T. Aiken, James R Barrett, C. Stahl, Patrick B. Schwartz, Shreyans Udani, A. Acher, G. Leverson, and D. Abbott. “Operative Delay in Adults with Appendicitis: Time Is Money.” Journal of Surgical Research, 2020.
T. Augustin, B. Cagir, and T. Vandermeer. “Characteristics of Perforated Appendicitis: Effect of Delay Is Confounded by Age and Gender.” Journal of Gastrointestinal Surgery, 2011.
T. Fatmawati. “STUDI PENGGUNAAN OBAT PADA PENDERITA APENDISITIS AKUT DI BAGIAN BEDAH RSU Dr. SAIFUL ANWAR MALANG,” 2009.
T. Oyetunji, R. Rentea, Katrina L. Weaver, and R. Hendrickson. “Preoperative Imaging Does Not Predict Rupture in Acute Appendicitis.” Journal of Emergency Medicine, 2017.
Teressa S. Liwu, Novi H. Rampengan, and Suryadi N. N. Tatura. “HUBUNGAN STATUS GIZI DENGAN BERAT RINGANNYA CAMPAK PADA ANAK,” 2016.
Vini Puspasari Puspasari, and Asri Ahram Efendi. “HUBUNGAN ANTARA KADAR LEUKOSIT PRE OPERASI DENGAN KEJADIAN KOMPLIKASI PERFORASI PADA PASIEN APENDISITIS AKUT YANG DIOPERASI DI RSUD UNDATA PROVINSI SULAWESI TENGAH TAHUN 2012,” 2017.
W. Bonadio. “Back to the Future: Does in-Hospital Delay to Appendectomy for Pediatric Uncomplicated Appendicitis Increase Risk for Perforation?” Journal of Pediatric Surgery, 2015.
W. Bonadio, Jared Brazg, Nadya Telt, Marybelle Pe, Ferrin Doss, L. Dancy, and Maili Alvarado. “Impact of In-Hospital Timing to Appendectomy on Perforation Rates in Children with Appendicitis.” Journal of Emergency Medicine, 2015.
W. C. Sesa, and M. Sabir. “PERBANDINGAN ANTARA SUHU TUBUH, KADAR LEUKOSIT, DAN PLATELET DISTRIBUTION WIDTH (PDW) PADA APENDISITIS AKUT DAN APENDISITIS PERFORASI DI RUMAH SAKIT UMUM ANUTAPURA PALU TAHUN 2014,” 2017.
W. França, R. P. Galletti, and V. Fernandes. “Estudo Retrospectivo Das Complicações Da Apendicite Aguda Relacionadas Com a Demora Para o Tratamento Operatório,” 2016.
W. Wibowo, T. O. R. Wahid, and Huriatul Masdar. “Hubungan Onset Keluhan Nyeri Perut Dan Jumlah Leukosit Dengan Tingkat Keparahan Apendisitis Akut Pada Anak.” Health & Medical Journal, 2020.
W. Wijaya, Mizar Eranto, and Ringgo Alfarisi. “Perbandingan Jumlah Leukosit Darah Pada Pasien Appendisitis Akut Dengan Appendisitis Perforasi,” 2020.
Wahyuning Ati Ashari, E. Suswati, and Erfan Efendi. “The Relationship of Delayed Appendectomy to the Incidence of Surgical Site Infection (SSI) in Acute Appendicitis Patients: A Narrative Review.” Media Penelitian Dan Pengembangan Kesehatan, 2021.
Yan Zhang, Yang-Yu Zhao, J. Qiao, and R. Ye. “Diagnosis of Appendicitis During Pregnancy and Perinatal Outcome in the Late Pregnancy.” Chinese Medical Journal, 2009.
Ying-xin Wang. “The Analysis of Delayed Appendectomy in the Treatment of Patients with Acute Nonperforated Appendicitis,” 2017.
Z. Assefa, and Awetash G/yesuse. “ACUTE APPENDICITIS IN CHILDREN ADMITTED TO ZEWDITU MEMORIAL HOSPITAL.” Ethiopian Medical Journal, 2014.
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