BALANCING OVERTREATMENT AND DELAY: NEGATIVE APPENDECTOMY AND PERFORATION IN A FIVE-YEAR COHORT OF ACUTE APPENDICITIS

Abstract

Background: Acute appendicitis is a common surgical emergency. The negative appendectomy rate (NAR) and perforation rate are complementary quality metrics reflecting the balance between diagnostic over-caution and delayed intervention. Methods: A five-year retrospective cohort study was conducted at Lady Reading Hospital, Peshawar (2021–2025), including all consecutive patients undergoing emergency appendectomy. Multivariable logistic regression identified independent predictors of NAR and perforation. Postoperative outcomes were graded by Clavien Dindo classification. Results: Of 500 patients (mean age 27.4 ± 14.2 years; 60.0% male), preoperative imaging was used in 40.0%. Histopathology confirmed appendicitis in 415 patients (83.0%), yielding a NAR of 17.0%. Of confirmed cases, 300 (60.0%) were simple, 70 (14.0%) gangrenous, and 45 (9.0%) perforated. The overall complication rate was 6.0% with no mortality. Perforation was associated with significantly higher morbidity versus simple disease (complication rate 33.3% vs. 4.0%; median stay 6 vs. 2 days; 30-day readmission 28.9% vs. 5.0%). Female gender (OR 2.1, 95% CI 1.3–3.5; p = 0.002) and absence of preoperative imaging (OR 1.8, 95% CI 1.1–3.0; p = 0.021) independently predicted negative appendectomy. Age ≥50 years (OR 4.5, 95% CI 2.0–10.1), symptom duration ≥48 hours (OR 6.2, 95% CI 3.1–12.4), and diabetes mellitus (OR 3.0, 95% CI 1.2–7.5) independently predicted perforation (all p < 0.05). Conclusion: A NAR of 17.0% and perforation rate of 9.0% identify clear targets for quality improvement. Standardized clinical scoring with selective imaging protocols and efforts to reduce diagnostic delay are recommended.