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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-
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.
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
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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?