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Original Paper

Received: February 18, 2002


Dig Surg 2003;20:115121
Accepted: July 22, 2002
DOI: 10.1159/000069386

Implications of Removing a Normal


Appendix
C.L. Bijnen a W.T. van den Broek a A.B. Bijnen a P. de Ruiter a D.J. Gouma b
a Department of Surgery, Medical Center Alkmaar, and b Department of Surgery, Academic Medical Center,

Amsterdam, The Netherlands

Key Words costs. In an attempt to prevent these costs, extra diag-


Appendectomy W Morbidity W Costs, appendectomy W nostic tools should be considered. Expensive diagnostic
Diagnostic tools tools as diagnostic laparoscopy should be used selec-
tively in order to not further exceed costs.
Copyright 2003 S. Karger AG, Basel

Abstract
Background: The diagnosis of acute appendicitis re-
mains difficult, and therefore 1530% of the removed Introduction
appendices appear to be normal. The aim of this study is
to investigate the morbidity, mortality and costs of re- Appendectomy is the most commonly performed acute
moving a normal appendix in patients with suspected abdominal operation because of the relatively high life-
appendicitis. Patients and Methods: A retrospective time risk for men (8.6%) and women (6.7%) to develop
study was performed on patients who underwent a neg- appendicitis [1]. The indication for operation is usually
ative appendectomy for suspected appendicitis in the based on a combination of clinical and laboratory find-
period 19911999 with a median follow-up of 4.4 years. ings [24]. If a normal appearing appendix is found dur-
Patients who underwent an elective appendectomy or ing exploration, it is generally removed in order to avoid
appendectomy for other reasons were excluded. Re- future diagnostic confusion. As a result, 1530% of the
sults: In 285 patients (70% women, 30% men) a normal removed appendices do not have histological signs of
appendix was removed. In 192 (67%) patients a muscle- inflammation [57]. To improve the diagnostic accuracy
splitting incision was performed, in 6 (2%) a median lap- for appendicitis, diagnostic modalities such as ultrasound
arotomy, and in 51 (18%) the normal appendix was (US), computed tomography (CT) scan and diagnostic
removed by laparoscopy. In 36 patients (13%) a diagnos- laparoscopy have been introduced. These tools though
tic laparoscopy was converted to a muscle-splitting inci- have their own limitations, risks and costs. Sensitivity
sion. Complications occurred in 16 (6%) patients, in 5 rates for ultrasound vary between 75 and 90% and speci-
(2%) a reoperation was needed. The mean hospital stay ficity rates between 84 and 100%, but the efficacy of ultra-
was 4.4 (SE 2.8) days, in case of complication 7.4 (SE 4.2) sound is observer-dependent and because of the relatively
days. The mean extra hospital costs of a negative appen- low sensitivity rates, it is not useful in ruling out appendi-
dectomy were EUR 2,712. Conclusion: The removal of a citis [812]. Combining laboratory tests (C-reactive pro-
normal appendix has considerable complications and tein and white cell count) with US increased the diagnos-

2003 S. Karger AG, Basel A.B. Bijnen


ABC 02534886/03/02020115$19.50/0 Medisch Centrum Alkmaar, Department of Surgery
Fax + 41 61 306 12 34 Wilhelminalaan 12
E-Mail karger@karger.ch Accessible online at: NL1815 JD Alkmaar (The Netherlands)
www.karger.com www.karger.com/dsu Tel. +31 72 548 24 12, Fax +31 72 548 21 71, E-Mail wtbroek@xs4all.nl
Table 1. Other diagnoses obtained in patients from whom a normal appendix was removed: summarized for the 3
different age groups

n Age group (years) Treatment


014 1550 1 51

Mesenteric lymphadenitis 21 19 2 0
Fecalith 12 11 1 0
Meckels diverticle 1 0 1 0 resection diverticle
ovulation bleeding 5 1 4 0
Salpingitis 4 0 3 1 antibiotics
Ovarian cyst 5 1 4 0 ovariectomy (n = 3)
Torsion of adnex 3 0 3 0 adnex extirpation (n = 3)
Leiomyoma of uterus 3 0 3 0
Retrograde menstruation 1 0 1 0
Endometriosis 2 0 2 0
Adhesions 7 2 5 0
Diverticulitis cecum 3 0 3 0 perforation, cecum oversewn (n = 1)
Urinary tract infection 2 1 1 0 antibiotics
Gastroenteritis 1 1 0 0
Pneumococcal peritonitis 1 0 1 0 antibiotics
Crohns disease 1 0 1 0 conservative
Local infarction of omentum 1 0 1 0 local resection
Total 73 36 36 1

tic accuracy from 70.9 to 87.1% in a retrospective study of Patients and Methods
2,351 patients [13]. The sensitivity of a CT scan is higher
A retrospective chart analysis was performed of all patients who
(0.871), with a similar specificity rate of between 0.83
underwent a negative appendectomy for suspected appendicitis in
and 1, and is less observer-dependent [1418]. However, the Medical Center Alkmaar in the period from 1991 to 1999. The
CT scan is relatively expensive and exposes the patient, diagnosis normal appendix was confirmed by histopathological
often a fertile woman, to a relatively high radiation dose. investigation using serial cuts of the entire appendix, which was per-
Laparoscopy is another reliable diagnostic tool for appen- formed routinely on all removed appendices. Patient records were
retrieved by searching the hospital administration database for all
dicitis with the advantage of obtaining other (mostly
performed appendectomies and the pathological database for histo-
gynecological) diagnoses and the possibility of concomi- logically normal appendices. Also patients who underwent appendec-
tant therapeutic intervention. Reported negative appen- tomy for suspected appendicitis and who had been treated for anoth-
dectomy rates for laparoscopic appendectomy are rela- er possible cause of the right lower quadrant pain were included.
tively low: 413%, as a normal appendix can be safely left Patients who underwent an elective appendectomy or an appendec-
tomy for reasons other than suspected appendicitis were excluded.
in place [1925]. When open appendectomy is performed,
The variables: age, gender, hospital stay, type of operation, other
the preceding laparoscopy can be considered as an extra obtained diagnoses, complications, reoperations and patients recov-
diagnostic procedure with the accompanying risks of an ery were noted and analyzed using the SPSS computer program. The
invasive procedure. 2 test was used when appropriate. A p value of ! 0.01 was considered
To determine the usefulness and the cost-efficiency of significant.
Costs were calculated by retrieving the costs in the year 2000 in
these added investigations and to evaluate whether it is
our community hospital for: routine laboratory investigation; ultra-
justified to perform additional diagnostic procedures, sound; CT scan; visit to the emergency ward; consultation of a sur-
more should be known about the consequences of remov- geon; hospital admission; outpatient clinic visits; fee of the surgeon
ing a normal appendix. in case of operation; anesthesiologists fee, and histopathological
The aim of this study is therefore to investigate the investigation.
morbidity, mortality and costs (preoperative and inhospi-
tal) of removing a normal appendix in patients with sus-
pected appendicitis.

116 Dig Surg 2003;20:115121 Bijnen/van den Broek/Bijnen/de Ruiter/


Gouma
Table 2. Complications and treatment after
negative appendectomy in a group of Complication n Treatment
285 patients
Wound infection 5 reoperation: drainage of abscess (n = 2)
Incarceration of ileoinguinal nerve 1 reoperation: release of nerve
Ileus due to adhesion 1 reoperation: adhesiolysis
Postoperative ileus 2 nasogastric tube (n = 1)
reoperation: explorative laparotomy (n = 1)a
Urine retention 2 catheterization
Infiltrate RLQ 1 readmission, i.v. antibiotics
Postoperative hemorrhageb 1 administration of 6 packed cells
Hypertrophic scar 1 local excision
Awareness during anesthesia 1
Large hematoma 1
Total 16
Reoperation 5

RLQ = Right lower quadrant.


a Explorative laparotomy because of signs of peritonitis, during operation fecal impaction
was found.
b Child with idiopathic thrombocytopenia.

Results Table 3. The costs of the different diagnostic and treatment proce-
dures for patients who are referred to the emergency ward for sus-
pected appendicitis
Of the 1,821 patients operated for suspected appendi-
citis, a normal appendix was removed in 285 (16%) Cost, EUR
patients (200 women or 70%, and 85 men or 30%). The
mean age was 26 (SE 14) years. Visit emergency ward 29
Patients were divided into 3 groups: group 1 (children), Consultation surgeon or resident 14
Routine laboratory examination 14
age 014 years, n = 65, 24 males, 41 females; group 2
Ultrasound 63
(adults, including women of the childbearing age), age 15 CT scan 88
50 years, n = 208, 55 men, 153 women, and group 3 (elderly) Operation room costs diagnostic laparoscopy 267
age 150 years, n = 12, 6 men, 6 women. Most patients were Surgeon fee diagnostic laparoscopy 47
women in the age group 1550 years (p ! 0.01). Anesthesiologist fee diagnostic laparoscopy 30
One-day admission 469
In 192 (67%) patients a muscle-splitting incision was
Operation room costs appendectomy 363
performed, in 6 (2%) a median laparotomy, and in 51 Surgeon fee appendectomy 163
(18%) the appendix was removed by laparoscopy. In 36 Anesthesiologist fee appendectomy 54
patients (13%) a diagnostic laparoscopy was converted to Extra costs laparoscopic appendectomy
a muscle-splitting incision. Despite a preceding diagnostic 3 Endoloop EJ 10C 93
Endocatch 108
laparoscopy, a normal appendix was removed due to
Outpatient clinic control 44
doubt in the diagnosis, wrong diagnosis (misinterpreta- Histopathologic examination 24
tion), no other diagnosis found during laparoscopy, or no
visualization of the appendix.
In 73 (26%) patients, another diagnosis was obtained
that might have caused the right lower abdominal pain
and was treated if necessary (table 1). In group 1 more tion. Thus, a total of 276 unnecessary operations were
other diagnoses were obtained (36%) compared to groups performed.
2 (17%) and 3 (8%; p ! 0.01). The most common diag- Complications occurred in 16 (6%) patients during a
noses in children were mesenteric lymphadenitis and median follow-up period of 4.4 (SE 2.7) years (table 2). In
fecaliths. In 3% of the patients of groups 1 (n = 2) and 2 5 (2%) a reoperation was needed. All patients recovered
(n = 7), the underlying cause needed operative interven- well from these complications. The mortality was 0. The

Implications of Removing a Normal Dig Surg 2003;20:115121 117


Appendix
mean hospital stay was 4.4 (SE 2.8) days. This was longer One way to reduce the percentage of negative appen-
in case of a complication: 7.4 (SE 4.2) vs. 4.2 (SE 2.7) days dectomies is to first observe all patients in whom the diag-
(p ! 0.01). There was no difference in hospital stay nosis is not clinically evident [28, 29]. This, however,
between open appendectomy (4.4 days) and laparoscopic could lead to a delay in the diagnosis and treatment of
appendectomy (4.3 days). The costs of the different diag- appendicitis. Another solution could be the use of extra
nostic and therapeutic procedures in our hospital are diagnostic tools. The cost-efficiency of the routine use of
shown in table 3. Routine costs are EUR 57 for a patient such diagnostic procedures depends upon their sensitivi-
who visits the emergency ward for suspected appendicitis: ty, specificity and costs. For example, if we aim for budget
visit emergency ward (EUR 29); consultation surgeon or neutrality and calculate EUR 2,712 as additional costs for
resident (EUR 14), and routine laboratory examination the removal of a normal appendix, a maximum of 2,712/
(EUR 14). An ultrasound will add EUR 63 to these costs, 63 (43) ultrasounds, 2,712/88 (31) CT scans or 2,712/
a CT scan EUR 88, and a diagnostic laparoscopy with 2 1,282 (2) diagnostic laparoscopies could be used in order
days admission will add EUR 1,282. The hospital cost of a to prevent one negative appendectomy.
negative appendectomy, including 4.4 days admission, a These are of course theoretical estimates, as many oth-
routine control visit at the outpatient clinic, and histo- er factors such as the potential consequences of a perfora-
pathological examination will be EUR 2,712 and in case tion due to delayed operation are not taken into account.
of laparoscopic appendectomy EUR 2,913. The illustrates, however, that especially if one uses diag-
nostic laparoscopy without removing the appendix lapa-
roscopically, the cost-efficiency could greatly increase by a
Discussion selective application to a subset of patients in whom the
diagnosis is not clinically evident.
Removal of a normal appendix at operation for sus- Routine CT scan for patients with suspected appendi-
pected appendicitis could be considered an appendecto- citis improved patient care and reduced the use of hospi-
my en passant during a diagnostic procedure. In the tal resources and total costs in another study [30]. It
present study, the mean hospital stay of patients undergo- remains questionable, however, if it is justified to routine-
ing a negative appendectomy was 4.4 days, and the com- ly impose a large group of females in the childbearing age
plication rate was 6%, as previously found (6.1%) by oth- to a considerable radiation dose.
ers [26]. Also the reoperation rate is not negligible, namely The majority of negative appendectomies were per-
2%. These percentages are higher than in the case of diag- formed in women aged 1550 years. This reflects the dif-
nostic laparoscopy alone (mean hospital stay 2 days, com- ferential diagnostic difficulty in fertile females. For this
plication rate 0.3%, and reoperation rate 0%), as recorded reason, others advise routinely performing a diagnostic
in a previous study [27]. Unfortunately, in 87 patients a laparoscopy in women of the childbearing age with sus-
normal appendix was removed despite a preceding lapa- pected appendicitis, but in men its use is not recom-
roscopy. So in terms of mean hospital stay (2 vs. 4 days), mended [21, 31]. However, a considerable number of nor-
complications (0.3 vs. 6%) and reoperation rate (0 vs. mal appendices were also removed in pre-menarche chil-
2%), a diagnostic laparoscopy is preferable over perform- dren and men. Also in these latter subsets the diagnosis is
ing a negative appendectomy, but better judgement and apparently not always obvious. The feasibility of identi-
adequate management of the normal-looking non-in- fying such subsets, not based on gender, is demonstrated
flamed appendix during laparoscopy are needed. in a separate study [32].
We calculated that the removal of a normal appendix Others advocate removal of a normal-appearing ap-
will cost EUR 2,712. According to the Dutch network and pendix found in case of suspected appendicitis because at
national database for pathology (PALGA), 2,285 negative histopathological examination the normal-appearing ap-
appendectomies are performed yearly in the Netherlands. pendix might show increased cytokines, indicating an
Thus the negative appendectomies will cost the society inflammatory response [33]. Also neuroproliferation is
EUR 6,196,920/year. The economic loss due to sick leave shown in the normal-appearing appendix and should be a
after hospital discharge is more difficult to calculate but reason for removing it [34]. In a prospective study in
should be added to this amount. So there are at least two which a normal-appearing appendix found during diag-
important reasons for trying to lower the number of nega- nostic laparoscopy for suspected appendicitis was left in
tive appendectomies, namely preventing complications place, recurrent abdominal pain was low both in the direct
and reducing costs. postoperative period as in long-term follow-up, suggesting

118 Dig Surg 2003;20:115121 Bijnen/van den Broek/Bijnen/de Ruiter/


Gouma
that it is safe to leave a normal appendix in place and that appendectomies. Ultrasonography should be the investi-
the above-mentioned findings might not be of clinical gation of first choice because it is relatively cheap and
importance [32]. Furthermore, the morbidity and costs of noninvasive. If appendicitis cannot be confirmed at ultra-
removing a normal appendix found in this study are rea- sonography, the negative effects of the ionizing radiation
sons not to remove a normal-appearing appendix. of the CT scan should be weighed against the negative
Thus, we conclude that due to 6% morbidity and 2% effects of diagnostic laparoscopy, which is relatively ex-
reoperation rates, removing a normal appendix is not a pensive, invasive and needs hospital admission. Expen-
harmless operation. Also, because a negative appendecto- sive and invasive diagnostic tools such as laparoscopy
my is more expensive (EUR 2,712) than available diag- should be used selectively and not as a routine.
nostic tools, these tools should be used to avoid negative

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Implications of Removing a Normal Dig Surg 2003;20:115121 119


Appendix
Invited Commentary
Moshe Schein
Bronx Lebanon Hospital Center, Bronx, N.Y.

The point of greatest tenderness is, in the average nologies is only going to worsen the situation: in a study of
adult, almost exactly 2 inches from the anterior iliac 63,707 non-incidental appendectomy patients the propor-
spine, on a line drawn from this process through the tion of patients undergoing laparoscopic appendectomy
umbilicus Charles McBurney (18451913). who were misdiagnosed was significantly higher than that
We are grateful to Dr. Bijnen and his colleagues from of open appendectomy patients (19.6 vs. 15.5%, p !
the Netherlands for reminding us that removing a normal 0.001) [1]. What is needed is common sense and rational
appendix is associated with some morbidity and wastage deployment of available diagnostic modalities. Frankly,
of financial resources. This of course is not surprising managing at least 1 case of adult (i.e. 113 years old) acute
because in surgery the more we do and the more inva- appendicitis per week, I do not recall when I last removed
sive what we do is, and the more unnecessary what we do a normal one during a non-therapeutic laparotomy, or
is the more complications we are going to generate. missed an abnormal one. And this is how I do it:
In this series a normal appendix was found in 16% of
the patients. This conforms to the classical notion that a 1 Male patients with typical presentation. I do an open appendec-
negative appendectomy rate of 1520% is the norm [1]. tomy immediately or the next morning
Traditionally surgeons who achieved a lower rate of 2 Male patients with atypical presentation. I do serial re-examina-
tions if not better or still atypical, I do a CT
white appendixes were blamed for being too conserva-
3 Females in the reproductive age with typical presentation. I al-
tive, risking a higher rate of perforations, and those with a ways start with a transvaginal ultrasound (US) which frequently
higher rate of negative appendectomies were accused of detects ovarian pathology and fluid in the cul-de-sac to explain
being too aggressive. I should mention, however, that the clinical picture. If US not contributory they are sent for a CT
when measuring the morbidity of negative appendecto- 4 Females with atypical presentation, see 2 and 3
5 As the above approaches differentiate between those who need an
mies only cases representing appendectomies performed
operation and those who do not need one, I do not see any sense
during truly non-therapeutic laparotomies/laparoscopies in using laparoscopy as a pure diagnostic tool. Laparoscopy per
should be included. By including a few cases of cecal di- se represents a costly and invasive operation and despite asser-
verticulitis and omental infarction the authors inflated tions that normal appendixes discovered during laparoscopy
their series since the laparotomy in such instances was should be left alone, many surgeons still feel uncomfortable with
this approach. Thus, commonly negative laparoscopy means
indicated, necessary and therapeutic, with the potential
negative appendectomy. Instead, in my practice the lapscopes
morbidity resulting from the necessary procedure rather sole objective is to better determine the correct incision in
than from the incidental appendectomy. patients with clinical peritonitis who need an operation, but do
The management of patients with suspected appendi- not need a CT: is it appendicitis, perforated ulcer or sigmoid
citis has traditionally focused on the prevention of perfo- diverticulitis?
ration by early operation, but at the expense of a high pro-
portion of unnecessary operations. But despite an in- This is what I do when all decisions are left to me, but
creased use of modern diagnostic modalities, the rate of on my side of the Atlantic the diagnostic algorithm is
perforation has not declined [1, 2]. Population-based increasingly dictated by dogmatic emergency room per-
studies document that diagnostic accuracy decreases as sonal who perform CT scans in lieu of clinical examina-
the rate of appendectomy increases, but the rate of perfo- tion and plain abdominal X-rays. Such indiscriminate use
ration does not change [2, 3]. This suggests that perfora- of CT scanning leads to a new syndrome which I call CT
tion is a different disease: patients come to hospital with appendicitis: you admit a patient with right lower quad-
perforation they do not perforate while we investigate rant pain and ambiguous clinical findings for observation.
them or observe them [2, 4]. Meanwhile the emergency room doctor orders a CT,
While it is unlikely that we can modify the rate of per- which is reported by the radiologist in the following morn-
forated appendicitis, I believe that we can decrease the ing. At this stage, the patient feels much better, his abdo-
number of unnecessary negative appendectomies. It has men is benign, and he wants to go home but the radiolo-
been said that a fool with a tool is still a fool: indiscrimi- gist claims that the appendix is grossly inflamed. Should
nate and nonselective usage of modern diagnostic tech- we treat the CT digital image or the patient?

120 Dig Surg 2003;20:115121 Bijnen/van den Broek/Bijnen/de Ruiter/


Gouma
As Dr. Bijnen and colleagues assert here, negative References
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plying sound clinical judgment and selective usage of non- dicitis decreased over time? A population-based analysis. JAMA 2001;286:
17481753.
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less normal appendixes. Be it as it may, There are two (eds): Source Control. Heidelberg, Springer, 2002, chapt 14.
3 Andersson RE, Hugander A, Thulin AJG: Diagnostic accuracy and perfo-
things in life that I will never understand: women and ration rate in appendicitis: Association with age and sex of the patient and
acute appendicitis [5]. with appendectomy rate. Eur J Surg 1992;158:3741.
4 Kraemer M, Kremer K, Leppert R, Yang Q, Ohmann C, Fuchs KH: Perfo-
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5 Schein M (ed): Aphorisms and Quotations for the Surgeon. London, Tfm,
2002.

Implications of Removing a Normal Dig Surg 2003;20:115121 121


Appendix
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