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November 1, 2007

AppendectomyNegative Appendectomy No Longer Ignored

Arch Surg. 2007;142(11):1023-1025. doi:10.1001/archsurg.142.11.1023

Early appendectomy has been the treatment of choice for patients with confirmed or suspected acute appendicitis. The surgical residents have been taught that although observation may reduce the rate of unnecessary appendectomy, such a policy will increase the rate of perforation, which undoubtedly results in increased morbidity and mortality. Whereas appendectomy has been a safe procedure with a mortality rate of 0.4% to 0.08% for uncomplicated appendicitis,1,2 in some series perforated appendicitis is associated with an unacceptable mortality rate as high as 12%.1 For patients with acute appendicitis, therefore, the perforation rate has been used as an index of quality of care. In a recent study, the association between time from the onset of symptoms and risk of appendiceal rupture was retrospectively studied in 219 patients who had undergone appendectomy for pathologically proven appendicitis.3 The risk was negligible within the first 24 hours, climbed to 6% by 36 hours, and then rose by 5% for each ensuing 12-hour period until day 4. Based on these data, most surgeons offer early appendectomy to patients with suspected acute appendicitis. The policy on early surgical intervention for suspected appendicitis results in relatively high rates of negative appendectomy, quoted as between 15% and 25%.4,5 The error rate can increase up to 40% in young women or in elderly patients.6 Deaths from a normal appendectomy in young adults were extremely rare (0.02%).1 A retrospective computer-based study in Sweden, however, revealed a 30-day mortality rate of 0.19% after appendectomy for nonsurgical abdominal pain and showed that appendectomy for a normal appendix was associated with an excess rate of deaths.2 In a nationwide analysis in the United States including 261 134 patients with appendectomy, negative appendectomy was associated with a significantly longer hospital stay and total admission charges compared with patients with appendicitis.4 In the 5 years following lower abdominal surgery, appendectomy was associated with a lower rate of hospital readmission (0.9%) directly related to adhesions compared with other procedures, such as total colectomy (8.8%) and ileostomy (10.6%).7 However, appendectomy accounted for as high as 30% of all procedures, and 7% of all patients contributed to the overall burden of adhesion-related readmissions. Could we continue to allow such a high rate of negative appendectomy?

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