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| Year : 2009 | Volume
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| Issue : 3 | Page : 167-170 |
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| Acute appendicitis: Is removal of a normal appendix still existing and can we reduce its rate? |
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Gamal Khairy
Division of General Surgery, Department of Surgery, PO Box 7805, Riyadh - 11472, Saudi Arabia
Click here for correspondence address and email
| Date of Submission | 15-Jun-2008 |
| Date of Acceptance | 24-Nov-2008 |
| Date of Web Publication | 24-Jul-2009 |
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 Abstract | | |
Background/Aim: To determine the incidence of negative appendectomies and to identify factors that may reduce the risk of having the normal appendices removed surgically. Design: Cross-sectional study. Setting: College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia. Materials and Methods: The surgical and histological data of 852 patients who underwent appendicectomy were reviewed. All incidental or interval appendicectomies were excluded. Only patients who were admitted and whose appendices were removed and subjected to histology were included (585 patients). The data on patients who had a normal appendix on histology further analyzed to include demographics, specific investigations, operative findings of the appendix and additional operative findings that need other surgical procedures. Results: A normal appendix was removed in 54 (9.2%) of the patients. Only 5.5% of those patients had a computed tomography (CT) scan preoperatively and 3.7% had diagnostic laparoscopy. In 21 patients, additional operative and histological findings were obtained that might have caused the right lower abdominal pain. Conclusion: In spite of the advances in the diagnostic and imaging techniques, the rates of negative findings on appendicectomy have not decreased much. Clinical judgment is still the most important factor in the management of patients with suspected acute appendicitis. The routine use of CT scan or diagnostic laparoscopy for all patients who are suspected to have appendicitis is neither cost-effective nor safe. Keywords: Acute appendicitis, laparoscopy, computed tomography
How to cite this article:
Khairy G. Acute appendicitis: Is removal of a normal appendix still existing and can we reduce its rate?. Saudi J Gastroenterol 2009;15:167-70 |
Appendectomy remains the most frequently performed emergency abdominal surgical procedure. [1] The lifetime risk of acute appendicitis for men and women is 8.6% and 6.7%, respectively. However, the lifetime risk of having an appendectomy is 12% for men and 25% for women. [2],[3],[4]
Appendicitis remains a difficult diagnosis, [5] and the most accurate means of its diagnosis remains a source of debate. Several diagnostic tools and scoring systems to diagnose early appendicitis have been developed, characterized as noninvasive, understandable and cost effective. [6],[7] It is imperative that patients with appendicitis go to the operating room early as there is a significant increase in the morbidity and mortality in those experiencing appendiceal rupture. [8],[9],[10],[11],[12] This has led to 10-30% of the normal appendices being removed at open operation. [2],[13],[14],[15] The cost to both the patient and the health care system of those so-called "negative appendicectomies" (NAs) is considerable [2],[16],[17] and a complication rate of up to 6.1% following removal of normal appendices was reported. [18] The use of laparoscopy did not reduce the rate of NA. [19] The aim of this study is to determine the incidence of negative appendectomies in our practice and to identify factors that may reduce the risk of having the normal appendices removed surgically.
| Materials and Methods | |  |
A retrospective chart analysis was performed for all the patients who underwent appendectomy at the King Khalid University Hospital, Riyadh, in the period 1998-2003. All incidental and interval appendectomies were excluded. Only patients who were admitted for suspected acute appendicitis and whose appendices were physically removed and subjected to histology were included. The appendicectomy was carried out using either the standard or the modified gridiron incision. When there was a discrepancy between the surgeon's operative diagnosis and the pathologist's diagnosis, based on gross and histological examination of the appendix, the pathologist's diagnosis was assumed to be correct. Acute appendicitis was diagnosed on histological grounds according to the following criteria: Macroscopic signs include intravascular injection of serosa, fibrinous and purulent film, edematous, necrotic changes of the wall and blood or pus on opening the appendix. Microscopic signs include focal or expanded erosion, ulceration, abscess, fistula and necrosis or perforation. The data of patients who had normal appendix on histology were analyzed with regard to demographics (e.g., age, sex), specific investigation (preop computed tomography [CT], diagnostic laparoscopy), operative finding (of the appendix), additional operative and histological pathology and other surgical procedures needed to be performed.
| Results | | |
Out of the 852 patients who were reviewed, 585 patients were found to be eligible for entry in the study. [Table 1] shows the histopathological results of patients who underwent appendicectomy. A normal appendix was removed in 54 (9.2%) patients, 39 women (72%) and 15 men (27.2%). The mean age of those who had normal appendices was 23 + 8.67 years (range 12-60 years). Only three (5.5%) of those patients had a CT scan preoperatively and two (3.7%) had diagnostic laparoscopy. At operation, the surgeons considered 11 of the 54 normal appendices to be acutely inflamed. In 21 patients, additional operative and histological findings were obtained that might have caused the right lower abdominal pain and treated if necessary [Table 2]. In six patients (11%), the underlying cause needed operative intervention [Table 2].
| Discussion | | |
The diagnosis of appendicitis is not always straight forward. Approximately 20-33% of the patients suspected of having acute appendicitis present with atypical findings. [20],[21] The indication for operation is usually based on a combination of clinical and laboratory findings. [22],[23],[24] The important aspect of this diagnostic dilemma is the fear of perforated appendicitis, which can lead to increased morbidity and prolonged hospital stay. Traditionally, the most effective way to decrease the rate of perforation is to have a lower threshold for taking the patient to the operating room at the expense of increasing the negative appendectomy rate. [25]
The overall NA rate in the present series is 9.2%, which is comparable with previously reported rates elsewhere. [26],[27],[28] However, some recent studies reported rates between 15% and 35%. [29],[30],[31],[32] More than 70% of our patients who had NA were females and their mean age was 23 years + 8.67. The findings are in line with the reported difficulties involved in making the correct diagnosis in females. [33] Similarly, others confirmed that the incidence of misdiagnosis increased for women of reproductive age. [34] Accordingly, some investigators advised routine diagnostic laparoscopy in women of child-bearing age with suspected appendicitis, but in men its use is not recommended. [35],[36] However, in a recent publication, Ekeh et al . [19] concluded that laparoscopic appendicectomy was associated with an increased rate of NA.
In the present series, the surgeon considered 11 of the 43 patients with NA to have acute appendicitis. Such disagreement between the surgeon and the pathologist was reported before. [37] Also, 5.5% of our patients had NA in spite of having a preoperative CT scan. This diagnostic tool has not been shown conclusively to improve the outcome in terms of negative findings on appendicectomy and complicated appendicitis. [38],[39] One of the earliest studies supporting the use of routine appendiceal CT was published by Rao et al. in 1998, [40] who concluded that routine appendiceal CT should be performed to reduce the use of hospital resources. A follow-up study by the same research group demonstrated a decrease in the NA rate from 20% to 7%. [41] Many studies that have been published since then do not support the liberal use of CT scan in the diagnosis of appendicitis. Perez et al. showed no improvement in the NA with the increased use of CT. [42] Clinical assessment without radiological imaging was shown to be superior and patients went to the operative room in a shorter time than those having preoperative CT. [43] However, some recent publications [44],[45] show the significant benefit of using a preoperative CT scan in reducing the rate of NA.
In the current series, 3.7% of those who had NA underwent diagnostic laparoscopy. Some previous reports showed that the use of laparoscopy improved the accuracy of diagnosis in acute appendicitis. The incidence rate of removing a normal appendix has been reduced to 8-20% in those patients undergoing the laparoscopic procedure [46],[47] compared with 10-33% in patients undergoing an open procedure. [48],[49] Others reported a further lower NA rate for laparoscopic appendicectomy (4-13%), claiming that a normal appendix can be safely left in place. [50],[51],[52] However, such a policy may expose the patient to potentially harmful investigation and risks missing the diagnosis of an early appendicitis. [53] Others advocated the removal of the normal-appearing appendix because at histopathology examination the normal-appearing appendix might show increased cytokines, indicating an inflammatory response. [54]
In conclusion, in spite of the advances in the diagnostic and imaging techniques, the rates of the negative findings on appendicectomy have not decreased much. Clinical judgment is still the most important factor in the management of patients with suspected acute appendicitis. The routine use of CT scan or diagnostic laparoscopy for all patients who are suspected to have acute appendicitis is neither cost-effective nor safe. However, the use of these two diagnostic procedures in selected controversial cases can enhance the accuracy of diagnosis, reduce the cost and reduce the rate of NA.
| References | | |
| 1. | David RF, Thomas DK. Evaluating diagnostic accuracy in appendicitis using administrative data. J Sur Res 2005;123:257-61.  |
| 2. | Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis. Arch Surg 2002;137:799-804. |
| 3. | Rothrock SG, Pagane J. Acute appendicitis in children: Emergency department diagnosis and management. Ann Emerg Med 2000;6:39-51. |
| 4. | Shelton T, McKinlay R, Schawrtz RW. Acute appendicitis: Current diagnosis and treatment. Curr Surg 2003;60:502-5. |
| 5. | Beasly SW. Can we improve diagnosis of acute appendicitis? BMJ 2000;321:907-10. |
| 6. | Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15:557-64. |
| 7. | Christian F, Christian GP. A simple scoring system to reduce the negative appendicectomy rate. Am R Coll Surg Engl 1992;74:281-5. |
| 8. | Bendeck SE, Nino-Murcia M, Berry GJ, Jeffrey RB Jr. Imaging for suspected appendicitis: Negative appendectomy and perforation rates. Radiology 2002;225:131-6. |
| 9. | Fuchs JR, Schlamberg JS, Shortsleeve MJ, Schuler JG. Impact of abdominal CT imaging on the management of appendicitis: An update. J Surg Res 2002;6:131-6. |
| 10. | Gwynn LK. The diagnosis of acute appendicitis: Clinical assessment versus computed tomography evaluation. J Emerg Med 2001;21:119-3. |
| 11. | McDonald GP, Pendarvis DP, Wilmoth R, Daley BJ. Influence of preoperative computed tomography on patients undergoing appendectomy. Am Surg 2001;67:1017-21. |
| 12. | Oliak D, Sinow R, French S, Udani VM, Stamos MJ. Computed tomography scanning for the diagnosis of perforated appendicitis. Am Surg 1999;65:959-64. |
| 13. | Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910-25. |
| 14. | Andersson RE, Hugander A, Thulin AJ. 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. |
| 15. | Pieper R, Kager L. The incidence of acute appendicitis and appendectomy: an epidemiologic study of 971 cases. Acta Chirurgia Scandinavica 1982;148:45-9. |
| 16. | Bijnen CL, Van Den Broek WT, Bijnen AB, De Ruiter P, Gouma DJ. Implications of removing a normal appendix. Dig Surg 2003;20:115-121. |
| 17. | McGory ML, SZingmond DS, Tillou A, Hiatt JR, Cryer HM. Negative appendectomy in pregnant women is associated with substantial risk of fetal loss. J Am Coll Surg 2007;205:534-40. |
| 18. | Gough IR, Morris MI, Pertnikovs EI, Murry MR, Smith MB, Bestmann MS. Consequences of removal of a normal appendix. Med J Aust 1983;1:370-2. |
| 19. | Ekeh Ap, Woznaik CJ, Monson B, Crawford J, McCarthy MC. Laparoscopy in the contemporary management of acute appendicitis. Am J Surg 2007;193:310-3. |
| 20. | Lewis FR, Holcroft JW, Boey J, Dumphy JE. Appendicitis: A critical review of diagnosis and treatment in 1000 cases. Arch Surg 1975;110:677-84. |
| 21. | Berry J. Jr, Malt RA. Appendicitis near its centenary. Ann Surg 1984;200:567-75. |
| 22. | Korner H, Dondenaa K, Soreide JA, Nysted A, Vatten L. The history is important in patients with suspected acute appendicitis. Dig Surg 2000;17:364-9. |
| 23. | Bergeron E, Richer B., Gharib R, Giard A. Appendicitis is a place for clinical judgement. Am J Surg 1999;177:460-2. |
| 24. | Andersson RE, Hugander AP, Ghazi SH, Ravn H, Offenbartl SK, Nystrom PO, et al . Diagnostic value of disease history, clinical presentation, and inflammatory parameters of appendicitis. World J Surg 1999;23:133-40. |
| 25. | Velanovich V, Satava R. Balancing the normal appendectomy rate with the perforated appendicitis rate: Implications for quality assurance. Am Surg 1992;58:264-9. |
| 26. | Richter M, Laffer U, Ayer G, Blessing H, Biaggi J, Bruttin JM, et al . Is appendectomy really performed too frequently? Results of the prospective multicenter study of the Swiss Society of General Surgery. Swiss Surg 2000;6:101-7. |
| 27. | Van Breda Vriesman AC, Kole BJ, Puylaert JB. Effect of ultrasonography and optional computed tomography on the outcome of appendectomy. Eur Radiol 2003;12:22-78-82. |
| 28. | Douglas CD, Macpherson NE, Davidson PM, Gani JS. Randomized controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ 2000;321:919-22. |
| 29. | Koch A, Marusch F, Schmidt U, Gastinger I, Lippert H. Appendicitis in the last decade of the 20 th century. Zentralbl Chir 2002;127:290-6. |
| 30. | Bisard D, Rosenfield JC, Estrada F, Reed JF 3rd. Institutioning a clinical guideline practice to decrease the rate of normal appendectomies. Am Surg 2003;69:796-8. |
| 31. | Rettenbacher T. Hollerweger A, Greitzmann N, Gotwald T, Schwamberger K, Ulmer H, et al . Appendicitis: Should diagnostic imaging be performed if the clinical presentation is highly suggestive of the disease. Gastroenterolgy 2002;123:992-8. |
| 32. | Althoubaity FK. Suspected acute appendicitis in female patients trends in diagnosis in emergency department in a university hospital in Western Region of Saudi Arabia. Saudi Med J 2006;27:1667-73. |
| 33. | Walker SJ, West CR, Colmer MR. Acute appendicitis: Does removal of a normal appendix matter, what is the value of diagnostic accuracy and is surgical delay important? Ann R Col Surg Engl 1995;77:358-63. |
| 34. | Marcia LM, David Z, Darshani N, Melinda AM, Clifford Y. Negative appendectomy rate: Influence of CT scans. Am Surg 2005;71:803-8. |
| 35. | Borgstein PJ, Gordijn RV, Eysbouts QA, Questa MA. Acute appendicitis: A clear-cut case in men, a guessing game in young women. Surg Endosc 1997;11:923-7. |
| 36. | Mutter D, Vix M, Bui A, Evrard S, Tasseti V, Breton JF, et al . Laparoscopy not recommended for routine appendectomy in men: Results of a prospective randomized study. Surgery 1996;120:71-4. |
| 37. | Andersson R, Hugander A, Thulin A, Nystrom PO, Olaison G. Indications for operation in suspected appendicitis and incidence of perforation. Br Med J 1994;308:107-10. |
| 38. | Morris KT, Kavanagh M, Hansen P, Whiteford MH, Deveney K, Standage B. The rational use of computed tomography scans in the diagnosis of appendicitis. Am J Surg 2002:183:547-50. |
| 39. | Paulson EK, Kalady MF, Pappas TN. Suspected appendicitis. N Engl Med 2003;348:236-42. |
| 40. | Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CJ. Effect of computed tompgraphy of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998;338:141-6. |
| 41. | Rao PM, Rhea JT, Ratmer DW, Venus LG, Novelline RA. Introduction of appendiceal CT: Impact on negative appendectomy and appendiceal perofration rates. Ann Surg 1999;229:344-9. |
| 42. | Perez J, Barone JE, Wilbanks TO, Jorgensson D, Corvo PR. Liberal use of computed tomography scanning does not improve diagnostic accuracy in appendicitis. Am J Surg 2003;185:194-7. |
| 43. | Hong JJ, Cohn SM, Ekeh AP, Newman M, Salama M, Leblang SD; Et al . A prospective randomized study of clinical assessment versus computed tomography for the diagnosis of acute appendicitis. Surg Infect 2003;4;231-9. |
| 44. | Kim K, Lee CC, Song KJ, Kim W, Suh G, Singer AJ. The impact of helical computed tomography on the negative appendectomy rate: A multi-center comparison. J Emerg Med 2008;34:3-6. |
| 45. | Chooi WK, Brow AJ, Zetler P, Wiseman S, Cooperberg P. Imaging of acute appendicitis and its impact on negative appendectomy and perforation rates: the St. Paul's experience. Can Assoc Radiol J 2007;58:220-4. |
| 46. | Lau WY, Fan ST, Yiu TF, Chu KW, Wong SH. Negative findings at appendectomy. Am J Surg 1984;148:375-8. |
| 47. | Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? A population-based analysis. JAMA 2001;286:1748-53. |
| 48. | Nguyen DB, Silen W, Hodin RA. Appendectomy in the pre and post laparoscopic eras. J Gastrointest Surg 1999;3:67-73. |
| 49. | Jess P, Bjerregaard B, Brynitz S, Holst-Christensen J, Kalaja E, Lund-Kristensen J. Acute appendicitis: Prospective trial concerning diagnostic accuracy and complications. Am J Surg 1981;141:232-4. |
| 50. | Barrat C, Catheline JM, Rizk N, Champault GG. Does laparoscopy reduce the incidence of unnecessary appendectomies? Surg Laparosc Endosc 1999;9:27-31. |
| 51. | Van den Broek WT, Bijnen AB, Van Eerten PV, De Ruiter P, Gouma DJ. Selective use of diagnostic laparoscopy in patients with suspected appendicitis. Surg Endosc 2000;14:938-41. |
| 52. | Moberg AC, Ahlberg G, Leijonmarck CE, Montgomery A, Reiertsen O, Rosseland AR, et al . Diagnostic laparoscopy in 1,043 patients with suspected acute appendicitis. Eur J Surg 1998;164:833-40. |
| 53. | Grabham JA, Sutton C, Nicolson ML. A case for the removal of the normal appendix at laparoscopy for suspected acute appendicitis. Ann R coll Surg Engl 1999;81:279-80. |
| 54. | Wang Y, Reen DJ, Puri P. Is a histologically normal appendix following emergency appendicectomy always normal? Lancet 1996;347:1076-9. |
Correspondence Address:
Gamal Khairy
Division of General Surgery, Department of Surgery, PO Box 7805, Riyadh - 11472
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1319-3767.51367
[Table 1], [Table 2] |
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