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January 2, 2002

Misdiagnosis of Appendicitis—Reply

Author Affiliations

Copyright 2002 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2002

JAMA. 2002;287(1):43-44. doi:10.1001/jama.287.1.40

In Reply: In our study we found stable rates of negative appendectomy over time, but found a higher rate of misdiagnosis in women of reproductive age undergoing LA when compared with age- and sex-matched patients undergoing open appendectomy. We agree with Dr Sauerland that there is potential for selection bias in observational studies, and we cautioned that this finding is likely the result of several factors.

Women of reproductive age, especially those with atypical presentations, are more likely to be misdiagnosed and are more likely to undergo a laparoscopic procedure compared with patients with more straightforward clinical presentations. It is therefore expected that patients undergoing LA have a higher rate of misdiagnosis compared with both the general population and with age- and sex-matched patients in whom the presentation is more classic. Furthermore, unlike the formalized trial protocols cited by Sauerland, in general practice there is no agreement regarding the appropriate management of a normal-appearing appendix found during a laparoscopic procedure. Leaving the normal-appearing appendix in situ has been challenged by a study suggesting that a surgeon's inspection of a "normal" appendix offers only a 28% negative predictive value.1 An additional factor in understanding the high rate of misdiagnosis with LA is the issue of miscoding. The code for an incidental LA is most likely applied when the appendix is removed incidental to another procedure. It is less clear, however, if an LA would be considered incidental if other nonoperative pathology was identified during the diagnostic component of the LA. We were unable to assess the frequency of this occurrence in the database.

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