Preoperative delay in uncomplicated appendicitis: the PERFECT trial
Authors: Dimitrios Moris, Marcelo Cerullo, Theodore Pappas
Journal: The Lancet (2024)

Karoliina Jalava and colleagues presented findings from a multicentre, randomised clinical trial designed to evaluate the non-inferiority of in-hospital early (within 8 h) versus delayed (within 24 h) appendicectomy in patients with uncomplicated appendicitis.1Jalava K Sallinen V Lampela H et al.Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, non-inferiority, randomised controlled trial.Lancet. 2023; 402: 1552-1561Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar The authors showed delayed appendicectomy was non-inferior with respect to risk of appendiceal perforation. We would like to congratulate the authors for this potentially practice-changing trial. We have a few comments regarding the study's design and some of its conclusions. Uncomplicated appendicitis is well described as a very heterogeneous entity. Uncomplicated appendicitis could refer to mild appendiceal inflammation that would probably resolve with antibiotics or even spontaneously; however, it also encapsulates a disease process characterised by more complex inflammation accompanied by transmural ischaemia or necrosis that is unlikely to resolve with antibiotics and thus, will require surgery.2Moris D Paulson EK Pappas TN Diagnosis and management of acute appendicitis in adults: a review.JAMA. 2021; 326: 2299-2311Crossref PubMed Scopus (82) Google Scholar We were struck by the fact that more than half of the patients in each treatment group did not receive antibiotics, which is considered to be part of the standard of care in patients with appendicitis,2Moris D Paulson EK Pappas TN Diagnosis and management of acute appendicitis in adults: a review.JAMA. 2021; 326: 2299-2311Crossref PubMed Scopus (82) Google Scholar especially in patients who will not undergo surgery until the next day. In our hospital system, for example, these patients are usually started on intravenous antibiotics in the emergency department. Moreover, the curious scarcity of antibiotics coverage was apparently not related to increased complication or perforation rate, which we are concerned might imply that most of the patients included in the trial had simple appendiceal inflammation that would be unlikely to require surgical management at all. This could also explain why delaying surgery was not related to clinical deterioration, and thus confounding the primary conclusions of the study. The authors also indicate that delaying surgery might lead to better or more efficient use of hospital resources, largely due to the decreased need for night-time surgery. We appreciate that efficient use of resources is highly relevant for systems constrained by small numbers of perioperative staff and little operating suite availability overnight; however, in systems such as tertiary care centres with uninterrupted staffing and supplies that can be furnished and maintained around the clock, a decreased need for night-time surgery might not be as relevant. Admitting patients to undergo an appendicectomy the next day might lead to day-time backlog of elective cases, which might be deprioritised.3Ott KC Vacek JC McMahon MA et al.Expedited surgical care of appendicitis is associated with improved resource utilization.J Surg Res. 2023; 282: 93-100Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Even with higher costs associated with staff coverage and equipment availability overnight, the purported financial benefit might be obviated by the next-day burden brought by disrupting elective (and therefore less urgent) case scheduling.4Goldstein BA Cerullo M Krishnamoorthy V et al.Development and performance of a clinical decision support tool to inform resource utilization for elective operations.JAMA Netw Open. 2020; 3e2023547 Crossref Scopus (12) Google Scholar Appendicectomy, especially in the setting of uncomplicated appendicitis, has become an outpatient operation, with patients usually being discharged from the recovery room. Appendicectomy becoming an outpatient operation has led to a substantial reduction of cost and optimisation of hospital resources.5Bernard ET Davenport DL Collins CM Benton BA Bernard AC Time is money: quantifying savings in outpatient appendectomy.Trauma Surg Acute Care Open. 2018; 3e000222 Crossref Scopus (7) Google Scholar Thus, the cost of overnight admission in anticipation of a day-time operation should not be underestimated, especially in a period where health-care systems worldwide are struggling with high health-care costs.3Ott KC Vacek JC McMahon MA et al.Expedited surgical care of appendicitis is associated with improved resource utilization.J Surg Res. 2023; 282: 93-100Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar We believe that the results of the PERFECT trial further support the emerging paradigm shift to postpone night-time appendicectomy in patients with uncomplicated appendicitis; however, night-time appendicectomy should be offered in selected patients with simple appendicitis, taking into account the cost of prolonged hospital stay and optimal allocation of hospital resources. We declare no competing interests. Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, non-inferiority, randomised controlled trialIn patients with presumed uncomplicated acute appendicitis, scheduling appendicectomy within 24 h does not increase the risk of appendiceal perforation compared with scheduling appendicectomy within 8 h. The results can be used to allocate operating room resources, for example postponing night-time appendicectomy to daytime. Full-Text PDF