Perioperative outcomes and appendiceal malignancy in elderly patients with acute appendicitis: a comparative retrospective cohort study

Acute appendicitis (AA) is increasingly diagnosed in elderly patients as life expectancy rises. Because elderly patients often present atypically and are prone to complications, we compared perioperative outcomes between patients younger than 65 and those aged 65 years and older. We included 488 patients who underwent appendectomy between January 2023 and January 2025, divided into Group 1 (18–64 years, n = 445) and Group 2 (≥ 65 years, n = 43). Demographics, comorbidities, symptoms, surgical characteristics, postoperative outcomes, and histopathology were compared. A multivariable logistic regression assessed whether age is an independent predictor of complications. Significance was set at p < 0.05. Laparoscopic appendectomy (325 patients, 66.6%) was associated with shorter operative times, fewer complications, and shorter stays (all p < 0.05). Elderly patients more often presented with diffuse abdominal pain (25.6% vs. 8.1%, p < 0.001) and had higher complication rates (65.1% vs. 21.6%, p < 0.001), longer stays ( p < 0.001), and higher readmission (18.6% vs. 2.2%, p < 0.001). Appendiceal malignancy was more frequent in the elderly (9.3% vs. 2.0%; p = 0.005). On multivariable analysis, advanced age was the strongest independent predictor of complications (adjusted OR 6.40; 95% CI 3.14–13.04; p < 0.001). Elderly patients with AA frequently present atypically, which may delay surgery and lead to more advanced disease. Advanced age was independently associated with higher perioperative morbidity. Given the significantly higher malignancy rate in the elderly (9.3% vs. 2.0%; p = 0.005), non-operative management may risk leaving life-threatening neoplasms undetected. However, given the small number of neoplasm cases ( n = 4), these inferences are hypothesis-generating and should be interpreted cautiously.