A Comprehensive Systematic Review of Relationship between Surgery Waiting Time and Perforation Rate in Acute Appendicitis

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