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Implications of Removing a Normal AppendixBijnen C.L.a · van den Broek W.T.a · Bijnen A.B.a · de Ruiter P.a · Gouma D.J.b
aDepartment of Surgery, Medical Center Alkmaar, and bDepartment of Surgery, Academic Medical Center, Amsterdam, The Netherlands
Background: The diagnosis of acute appendicitis remains difficult, and therefore 15–30% of the removed appendices appear to be normal. The aim of this study is to investigate the morbidity, mortality and costs of removing a normal appendix in patients with suspected appendicitis. Patients and Methods: A retrospective study was performed on patients who underwent a negative appendectomy for suspected appendicitis in the period 1991–1999 with a median follow-up of 4.4 years. Patients who underwent an elective appendectomy or appendectomy for other reasons were excluded. Results: In 285 patients (70% women, 30% men) a normal appendix was removed. In 192 (67%) patients a muscle-splitting incision was performed, in 6 (2%) a median laparotomy, and in 51 (18%) the normal appendix was removed by laparoscopy. In 36 patients (13%) a diagnostic laparoscopy was converted to a muscle-splitting incision. Complications occurred in 16 (6%) patients, in 5 (2%) a reoperation was needed. The mean hospital stay was 4.4 (SE 2.8) days, in case of complication 7.4 (SE 4.2) days. The mean extra hospital costs of a negative appendectomy were EUR 2,712. Conclusion: The removal of a normal appendix has considerable complications and costs. In an attempt to prevent these costs, extra diagnostic tools should be considered. Expensive diagnostic tools as diagnostic laparoscopy should be used selectively in order to not further exceed costs.
© 2003 S. Karger AG, Basel
Bronx Lebanon Hospital Center, Bronx, N.Y.
‘The point of greatest tenderness is, in the average adult, almost exactly 2 inches from the anterior iliac spine, on a line drawn from this process through the umbilicus’ – Charles McBurney (1845–1913).
We are grateful to Dr. Bijnen and his colleagues from the Netherlands for reminding us that removing a normal appendix is associated with some morbidity and wastage of financial resources. This of course is not surprising because in surgery the more we do – and the more invasive what we do is, and the more unnecessary what we do is – the more complications we are going to generate.
In this series a normal appendix was found in 16% of the patients. This conforms to the ‘classical’ notion that a negative appendectomy rate of 15–20% is the ‘norm’ . Traditionally surgeons who achieved a lower rate of ‘white’ appendixes were blamed for being ‘too conservative’, risking a higher rate of perforations, and those with a higher rate of negative appendectomies were accused of being ‘too aggressive’. I should mention, however, that when measuring the morbidity of ‘negative appendectomies’ only cases representing appendectomies performed during truly non-therapeutic laparotomies/laparoscopies should be included. By including a few cases of cecal diverticulitis and omental infarction the authors inflated their series since the laparotomy in such instances was indicated, necessary and therapeutic, with the potential morbidity resulting from the necessary procedure rather than from the incidental appendectomy.
The management of patients with suspected appendicitis has traditionally focused on the prevention of perforation by early operation, but at the expense of a high proportion of unnecessary operations. But despite an increased use of modern diagnostic modalities, the rate of perforation has not declined [1, 2]. Population-based studies document that diagnostic accuracy decreases as the rate of appendectomy increases, but the rate of perforation does not change [2, 3]. This suggests that perforation is a different disease: patients come to hospital with perforation – they do not perforate while we investigate them or observe them [2, 4].
While it is unlikely that we can modify the rate of perforated appendicitis, I believe that we can decrease the number of unnecessary negative appendectomies. It has been said that ‘a fool with a tool is still a fool’: indiscriminate and nonselective usage of modern diagnostic technologies is only going to worsen the situation: in a study of 63,707 non-incidental appendectomy patients the proportion of patients undergoing laparoscopic appendectomy who were misdiagnosed was significantly higher than that of open appendectomy patients (19.6 vs. 15.5%, p < 0.001) . What is needed is common sense and rational deployment of available diagnostic modalities. Frankly, managing at least 1 case of adult (i.e. >13 years old) acute appendicitis per week, I do not recall when I last removed a normal one during a non-therapeutic laparotomy, or missed an abnormal one. And this is how I do it:
This is what I do when all decisions are left to me, but on my side of the Atlantic the diagnostic algorithm is increasingly dictated by dogmatic emergency room personal who perform CT scans in lieu of clinical examination and plain abdominal X-rays. Such indiscriminate use of CT scanning leads to a new syndrome which I call ‘CT appendicitis’: you admit a patient with right lower quadrant pain and ambiguous clinical findings for observation. Meanwhile the emergency room doctor orders a CT, which is reported by the radiologist in the following morning. At this stage, the patient feels much better, his abdomen is benign, and he wants to go home but the radiologist claims that the appendix is grossly inflamed. Should we treat the CT digital image or the patient?
As Dr. Bijnen and colleagues assert here, negative appendectomy is not an innocuous procedure. By applying sound clinical judgment and selective usage of noninvasive diagnostic procedures we can and should remove less normal appendixes. Be it as it may, ‘There are two things in life that I will never understand: women and acute appendicitis’ .References
01 Flum DR, Morris A, Koepsell T, Dellinger EP: Has misdiagnosis of appendicitis decreased over time? A population-based analysis. JAMA 2001;286:1748–1753.
02 Watters JM, Andersson REB: Acute appendicitis; in Schein M, Marshall J (eds): Source Control. Heidelberg, Springer, 2002, chapt 14.
03 Andersson RE, Hugander A, Thulin AJG: Diagnostic accuracy and perforation rate in appendicitis: Association with age and sex of the patient and with appendectomy rate. Eur J Surg 1992;158:37–41.
04 Kraemer M, Kremer K, Leppert R, Yang Q, Ohmann C, Fuchs KH: Perforating appendicitis: Is it a separate disease? Acute Abdominal Pain Study Group. Eur J Surg 1999;165:473–480.
05 Schein M (ed): Aphorisms and Quotations for the Surgeon. London, Tfm, 2002.