Friday, February 5, 2016

What? A woman with no appendix undergoes attempted appendectomy

A surgeon found no appendix when he operated on a 69-year-old woman with abdominal pain in Saskatchewan. She had been admitted with chronic diarrhea and right-sided pain. A colonoscopy showed what was thought to be impacted stool in the orifice of her appendix, a finding often associated with appendicitis.

Laparoscopic surgery was done through three small incisions, and after an hour of searching, the appendix was not located.

After the operation, the doctor claimed the patient did not tell him she had had an appendectomy possibly during either gallbladder or tubal ligation surgery in the past. On one of those occasions, she may have had an incidental appendectomy—removal of a normal appendix to theoretically prevent appendicitis in the future. It's an operation rarely done today.

She was discharged after a brief hospital stay. There was a bit of a fuss about "unnecessary surgery" and what, if anything, the surgeon told the patient after the procedure. A phone conversation with him was secretly recorded by the patient's daughter. An investigation is underway.

You might be interested in two questions. Can you get appendicitis again after you've had an appendectomy? Other than previous surgery, is there another explanation for a patient who does not have an appendix?

Some people don't remember whether they've had their appendices removed, especially if it was done many years ago or at the time of another procedure. Maybe this patient was never told that she had had an appendectomy.

Even if she had had undergone an appendectomy, she could have had another attack of appendicitis.

There is an entity called "stump appendicitis" which occurs when the appendix is only partially removed during surgery.

A 2006 literature review found 36 cases of stump appendicitis (1). Considering there are more than 250,000 appendectomies done every year in the US, stump appendicitis is a rare. Here's what it looks like on a CT scan. (2)

And here is a photo of appendicitis in a rather long stump about to be removed during laparoscopic surgery. (3)

Another possibility is duplication of the appendix which has been reported to occur in 0.004-0.009% of the population. (4) Either or both of the two appendices can become inflamed.

Maybe our 69-year-old lady never had an appendectomy. Congenital absence of the appendix occurs in 1 of 100,000 people. However, she probably wouldn't have had an appendiceal orifice if her appendix was absent when she was born. (5) This is what absence of the appendix looks like at surgery. (6)

Bottom line: Appendicitis can recur or may not be present in some individuals.

Acknowledgment: Thanks to my Twitter follower @davepaskar for stimulating me to write this post.

References available upon request.


Anonymous said...

Anonymous Europe:Hi, I just woke up after being on call yesterday.:) As I read this, one thing that came to mind was Meckel's Diverticulum...?
Nice pictures by the way.:) If the daughter recorded a phone conversation without the doctor knowing, should not she be prosecuted?

Skeptical Scalpel said...

Of course Meckel's but here in the US they're usually seen on the CTs that we get on everyone. It's rare to see a surprise Meckel's anymore.

About the recording, laws are different in each state of the US. Some allow secret recording and some don't. This happened in Canada. I guess secret recordings are ok in Saskatchewan.

Carlota said...

Well, I once found and unsuspected entire appendix (not appendicitis) in a young male who told me that he had had his appendix removed 10 years before.
Surgery is often surprising!

Anonymous said...

Good post, and as usual very educational. I found the original CBC article on the incident to be both inflammatory and trying to make the incident about the race of the patient. There are many very reasonable explanations why this may have happened, and I appreciate you pointing those out.

Skeptical Scalpel said...

Carlota, mistakenly thinking you had your appendix removed is something I hadn't thought of.

Anon, you (or someone else) mentioned that on Twitter. That's why I wrote it.

George Gasman said...

I have to wonder what other diagnostics were available in this case: CT? White count? Fever? What did the physical exam reveal?

In the presence of any of those, an appy would be a logical thing to do, particularly in the presence of a suggestive colonoscopy.

This will be interesting to follow, especially with the sensationalistic reporting of the CBC in mind.

Skeptical Scalpel said...

George, as usual these articles leave out a number of important details. I'm not sure we will ever hear what happened in this case because the sensationalism part of it is now over. I doubt the CBC will follow-up. I hope a Canadian reader of my blog will update us if anything else is published.

artiger said...

If this had happened in the US, there would have been even more sensationalism than what was seen here. Still, it might have helped if the surgeon had taken some time after the operation and had a long discussion with the patient, answered as many questions as he could, and tried to provide something of an explanation to the patient. I refer to it as damage control. My take from the article is that the patient felt ignored, and that was preventable.

I try to visit with my ambulatory surgery patients' family members immediately after the surgery, and with the patient him/herself prior to discharge. Is this not common? Maybe I'm just old fashioned.

Oldfoolrn said...

Perhaps diagnostic studies or better awareness is present today. One of the most disastrous surgical interventions I have witnessed involved an appendectomy during an unrecognized exacerbation of Crohn's Disease. Fistula and sepsis being the end result.

Skeptical Scalpel said...

Artiger, I agree. You must talk to the patient and family after any operation.

Old, that's a classic problem. Despite the radiation, a pre-op CT would have helped.

frankbill said...

Who pays for this mistake. Doctor Performs Surgery on Wrong Newborn Baby.

Skeptical Scalpel said...

Frank, if the hospital and surgeon are smart, they would waive the bills, but I think I read somewhere that the surgeon had sent a bill. Not a good idea.

frankbill said...

Shouldn't the surgeon have know that he was performing unneeded surgery?

Skeptical Scalpel said...

There's not enough information to answer that question. If he had done a CT scan, he might have seen a normal appendix. Maybe it wasn't available to him. I don't know.

frankbill said...

Guess I should have made it clearer I was referring to the link about the Doctor that Performed Surgery on Wrong Newborn. The surgeon cut the flap of skin beneath the newborn's tongue. The newborn did not need the procedure, which had been intended for another child.

artiger said...

In regard to the wrong patient surgery Frank mentioned above, I have to wonder why the time out didn't prevent this. Maybe it was skipped, but that would be surprising at an academic medical center.

The surgeon did apologize and admit the mistake, which, although it doesn't excuse the action, is a bit refreshing.

Skeptical Scalpel said...

Frank, there are many questions about that case. I may blog about it.

Artiger, that's one of the questions. What happened to everyone else. That apology didn't work. The family already has a lawyers.

artiger said...

Just to clarify, the purpose of an apology is not avoidance of litigation. It's to express sympathy and remorse. And perhaps to lessen the jury award.

Just joking on that last part...or maybe not.

Skeptical Scalpel said...

I agree that an apology is meant to express that one is sorry. I was pointing out that people are saying the apologies can prevent lawsuits, but that's not always so.

I predict that this case may result in a suit, but plaintiff will not prevail because despite all the press and indignation about the case, the damages are nil.

frankbill said...

But the plaintiff may prevail. In any case the surgeon's lawyer is going to win and the surgeon is going to loose something.

Skeptical Scalpel said...

I thought about it some more. I think the hospital and the surgeon will settle the case for small amounts - low 5 figures - just to avoid dredging the whole mess up again.

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