The Safety of In-Hospital Delay and the Utility of dNLR in Elderly Patients With Acute Appendicitis.

Abstract

Elderly patients with acute appendicitis face high rates of complicated disease, yet the impact of in-hospital timing and the utility of simple biomarkers remain debated. We aimed to assess whether in-hospital timing influences severity and to evaluate the derived neutrophil-to-lymphocyte ratio (dNLR) as a risk-stratification tool. A retrospective study of 412 patients (184 aged ≥ 65 years; 228 younger controls) undergoing appendectomy (2010-2019) was conducted. We analyzed Patient Interval (symptom onset to admission) and Hospital Interval (admission to incision). Appendicitis was graded as uncomplicated or complicated (gangrenous/perforated). Multivariable regression and categorical sensitivity analyses (0-6, 6-12, 12-18, > 18 h) were used to identify predictors of severity. Elderly patients had higher rates of complicated appendicitis (29.4% vs. 9.2%) and morbidity (13.0% vs. 1.3%). While night-shift admission increased time to diagnosis, it did not increase complications. Hospital Interval was shorter in the elderly (13.5 vs. 15.4 h) but was not an independent predictor of complications and showed no adverse trend across time categories. In the elderly, dNLR ≥ 4.0 independently predicted complicated disease (AUC 0.65) alongside age, fever, and Patient Interval. Mortality spiked to 8.3% in patients ≥ 85 years, driven by medical complications. Disease severity in geriatric appendicitis appears to be largely determined prior to admission. Within the limitations of this observational design, short in-hospital delays for optimization or logistical reasons were not associated with increased perforation or morbidity. Furthermore, a dNLR ≥ 4.0 helps identify high-risk patients, suggesting that an "optimize then operate" approach-prioritizing physiological stabilization may be a safe and reasonable strategy for clinically stable elderly patients. Research Registry (UIN: researchregistry11765).