Wednesday, August 9, 2017

What to do when a normal looking appendix is found at surgery for appendicitis

For patients undergoing surgery with a presumptive diagnosis of appendicitis in Norway and other parts of Europe, the protocol is if the appendix looks grossly normal in the operating room, it is usually not removed.

This approach was mentioned as part of a paper on the readmission of post-appendectomy patients from Oslo University Hospital. Most of the patients underwent laparoscopy based on clinical diagnosis with only 160 having CT scans and 67 having ultrasounds.

Of the 710 patients in the Oslo series, 94% of the appendectomies were done laparoscopically, and 111 had a normal appearing appendix at laparoscopy. The appendix was not removed in 88. The other 23 patients had appendectomies for various reasons, and those appendices were normal at pathology.

The cumulative rate of operating for what turned out to be a normal appendix (88 + 23 cases) was 15.6%, which the authors attributed to “the low use of preoperative CT” due to concerns about radiation exposure. That over 100 patients had unnecessary general anesthesia and surgery was apparently not a concern.

In the United States and the Netherlands, more than 90% of adult patients who have surgery for appendicitis undergo preoperative imaging, and the rate of removal of a normal appendix is less than 5% in most series. Preoperative imaging can also rule out diseases like Crohn’s and Yersinia enterocolitis that can mimic the signs and symptoms of appendicitis.

When the preoperative diagnosis is appendicitis and a normal appearing appendix is founded surgery, should you take it out or not?

My practice was to remove any appendix that looked grossly normal for two reasons. One, many appendices that look normal are found to be inflamed when examined histologically. Two, the presence of characteristic scars of an appendectomy might be interpreted by subsequent treating physicians as evidence that an appendectomy had been done. Patients may not remember whether they had an appendectomy or not which could lead to confusion if abdominal pain recurs years after surgery was performed.

But is my way of handling this supported by any evidence?

As is true of nearly every issue in medicine, papers can be found to support just about any side of a debate.

The Norwegian investigators cited a 1998 study from Sweden of 1043 patients who had diagnostic laparoscopies for suspected acute appendicitis. Of the 211 patients who did not have an appendectomy, 181 were women and 86 of them had gynecologic diagnoses. After two years of follow-up, none of the 211 patients required appendectomy. One could argue that if a patient never had appendicitis in the first place, odds are it would probably not develop in the two years after the appendix was left in place.

A paper from the UK about the morbidity of a negative appendectomy analyzed 467 laparoscopic appendectomies for appendicitis; 143 or 30.6% of the specimens removed were negative for appendicitis [an alarmingly high percentage]. The complication rate for the negative appendix patients was 11.9%—not significantly different from those who had inflamed appendices (16.6%). However most of the complications in the negative group were minor and treated with bedside procedures or antibiotics. Only four patients required invasive procedures and two of those were for port site abscesses.

The methods section of the paper did not state whether the appendix was routinely placed in a bag before extracting it from the abdomen as is customary in the US.

Proponents of removing a normal looking appendix cite papers finding rates of inflammation or other significant findings on pathologic examination ranging from 29% to 58% and even 76% including three neuroendocrine tumors in the latter study.

The World Society for Emergency Surgery recently published guidelines for the diagnosis and treatment of acute appendicitis. The list of authors includes a number of renowned surgical experts including EE Moore, Andrew Peitzman, Ron Maier, Rao Ivatury, Thomas Scalea, and many others.

Statement 6.4 of the WSES guidelines states, "If the appendix looks 'normal' during surgery and no other disease is found in a symptomatic patient, we recommend removal in any case."

If that's not enough to convince you to remove a normal looking appendix during surgery for suspected appendicitis, maybe the following will.

I conducted a 24 hour Twitter poll on August 3 and 4. Of 562 votes cast, 83% said they would remove a normal appearing appendix when operating for the presumed diagnosis of appendicitis.

I rest my case.

A number of people too numerous to mention contributed to the discussion of this topic on Twitter. I appreciate their input.


Unknown said...

Thanks again Dr. S for your keen insights. I would write up the results of that Twitter poll - it will soon represent the highest level evidence we have on this topic.

Skeptical Scalpel said...

Thanks for the suggestion. Maybe I'll see if the New England Journal of Medicine will accept it.

artiger said...

I think one very important thing is to address this issue in the preoperative discussion. My preference is to remove the appendix regardless (which is what I would want as a patient). It is what I recommend for the reasons noted above, amongst a few others, but I would yield to patient preference if he/she was adamantly against it. We can't cover every possible unexpected finding but it is certainly reasonable to cover a normal appendix.

Korhomme said...

In may day, the diagnosis was entirely clinical, and the operations were open.

We were taught, by Zita*, that appendicitis starts in the mucosa and then spreads outwards towards the serosa. The appendix, Zita said, should be removed and opened to confirm or refute the presence of inflammation.

If the appendix was (apparently) normal, then look for mesenteric adenitis or a Meckel's diverticulum (or female problems). Rarely, there might be a 'closed loop' obstruction of the right colon; or a 'dry perforation' of a duodenal ulcer.

In any event, we were advised to remove the appendix, as an 'appendix' scar would be potentially confusing in the future.

*Zita was Sir Zachary Cope, author of the 'Acute Abdomen in Rhyme' and a book on abdominal surgery.

Debra Gottsleben said...

Didn't think of the possibility of confusion but that is a very valid concern. I'm shocked at the number of people who have no idea what medical procedure was done on them. So it is a real problem.
I do like the idea that it was discussed with the patient beforehand. I'm not sure why someone would be so attached to their appendix that they'd say if it looks normal keep it there esp. if some of the concerns expressed were told to them.
Very interesting post.

jim thornton said...

Discussing what to do with a normal appendix with the patient. Are you out of your mind?

Skeptical Scalpel said...

I agree the possibility of finding a normal appendix should be discussed with the patient preoperatively.

@bnwomeh, a pediatric surgeon, tweeted that 100% of parents in his practice say to take it out if it looks normal.

Cope's book "Early Diagnosis of the Acute Abdomen" is a classic. Not many books get to 22 editions.

It is amazing how many people don't remember they had surgery. This sort of thing happened to me many times.

During the history, me: Have you ever had any surgery?
Patient: No.

During the physical exam, me: What's this big scar on your abdomen from?
Patient: Oh that. I had a splenectomy when I got stabbed.

Jim, I LOL'ed at that one.

William Reichert said...

I liked the post on appendicitis but I was puzzled by the reasoning at the end of the post. You stated that you polled a large number of surgeons and 83% agreed with you to remove a normal looking appendix if encountered at surgery. This poll result was then presented as evidence that removal is the right thing to do. In my experience in life as well as in medicine, taking a vote on an issue is no guarantee that the
result of the vote is necessarily best. Just because a lot of doctors do something is not evidence that what they do is indicated. IMHO medicine is rife with examples of this situation.The reality is that quite often we as physicians do not know what the right thing to do is.I admit , though , that a physician who exudes confidence in his own judgement is very reassuring.

Skeptical Scalpel said...

William as always thanks for commenting. I wasn't serious when I referred to the Twitter poll. I agree that the matter is not settled.

There will likely never be a randomized trial because at least here in the US, there aren't enough normal appendices being taken out. Also the increased use of antibiotics may impact the number of appendectomies.

William Reichert said...

Apropos of your response and building upon it, I would like to point out that there is a movement in the USA to make medicine "evidence based". Of course this is impossible as IMHO probably only 10% of what physicians do can be said to be backed by evidence directly directed at the specific clinical situation that the physician is faced with
during any individual encounter. What we are left with is a
physician's "clinical judgment" to respond to the remaining
90% of issues. Perhaps not scientific but the best we have to go on. So in that sense, while not scientific, your twitter poll
still should carry a lot of weight for real world medical practice.
When I was a fellow at Strong Memorial we were taught that clinical judgment tempered by an awareness of "scientific evidence" was considered to be "the party line".
I have always had a soft spot in my heart for that phrase
as it combines both elements while reminding me always that,
when all is said and done ,the truth is always just about to be
discovered shortly. In the meantime, the party line will have to suffice.

frankbill said...

What has changed from removing appendices when you doing other surgery as stated in this pub.
September 1962
Incidental Appendectomy in Gallbladder Surgery

Air Knot Artist said...

I recently took care of a patient with appendicitis, but he developed C diff colitis after we took his appendix out, presumably from a dose of peri-operative Zosyn. While I wouldn't have done anything different for this patient, this case made me looka little deeper into the association between C diff colitis after appendectomy. I found some interesting things that have made me less gung-ho about removing an appendix if it appeared normal upon operation.

A retrospective chart analysis of 507 patients hospitalized for C diff showed that of the 388 patients who had an intact appendix, only 5% developed fulminant infection and colectomy. For the other 119 patients, who had a prior appendectomy, 10.9% developed fulminant infection and colectomy. The conclusion from this study was that appendectomy may be a risk factor for increased severity of C diff infection.

This is suggesting that the appendix has an immunologic role in replenishing colonic flora after antibiotics wipe out C diff from the colon, decreasing rates of recurrent C diff infections that could lead to fulminant C diff colitis requiring colectomy.

In another retrospective chart review of 55 pathologic specimens of pseudomembranous colitis, 24 of the 55 (43.6%) of pathologic specimens had prior appendectomies. For comparison, lifetime incidence of the general population for appendectomies is 17.6%. This also suggests an association between prior appendectomy and severe C diff colitis that can lead to colectomy.

One must weigh the higher risks of fulminant C diff after appendectomies, against the confusing picture of abdominal scars for patients who don’t know if they ever had their appendix taken out. Personally, I know my medical history well and feel confident conveying it to any possible future surgeon. Thus, if my appendix looks normal on upon laparoscopy, I would like to keep my appendix.

Lady Anne said...

When I had a hysterectomy in 1979, I was informed post-op that my appendix had been removed. It doesn't seem to serve any particular function, and as long as the surgeon is in there it might as well come out anyway. One less thing for me to worry about, at any rate.

Skeptical Scalpel said...

Frankbill, what changed is that in the 70s, we realized that incidental appendectomies added time to cases and were not worth the effort especially if insurance would not reimburse for the procedure. More importantly, patients did not remember that they had appendectomies with their hysterectomies or cholecystectomies so when they developed abdominal pain later, it was confusing to their doctors.

Air Knot, I have heard these arguments before. The studies you mentioned are retrospective and the patients are highly selected, but I admit that there may be some validity to the studies. People have been trying to find some justification for the presence of an appendix for years. You are welcome to keep yours just as Lady Anne is happy to have hers removed. This is a patient-centered blog.

Korhomme said...

Interesting comments here.

When I was 7 months old I had a laparotomy for an intussception — in the days long before hydrostatic reduction. My appendix was removed. This was in the time when many surgeons performed an 'encore', removing the appendix to prevent future problems. In those days there was no effective antibiotic treatment for appendicitis or peritonitis; a 20% rate of normal appendicectomies was considered acceptable and appropriate — the implication was that at a lesser rate, you were missing some cases of real appendicitis.

Years later, my mother had a cholecystectomy performed by the same surgeon. And yes, he removed her appendix as well.

William Reichert refers to 'expert opinion' though he doesn't call it as such. This comes low down on the progression from meta-analysis, double-blind trials etc. Yet, for much of what we do (did, in my case) trials would be difficult or simply unethical. Yet although we know that 'expert opinion' isn't all that reliable so often there is no other option.

Skeptical Scalpel said...

I agree. Even in the era of "evidence-based medicine," estimates are that about 95% of what we do as surgeons is based on low levels of evidence and expert opinion.

William Reichert said...

To make the same point but a using a different example, from Air Knot's story which was briefly:
507 patients had C Diff. Those with previous appendectomy did worse than those without.
This is similar to:
Of 507 people who were admitted to a hospital, those who
had been admitted previously did worse than those that had never been admitted previously.
Therefore, hospitalization is bad for your health?.
Is that conclusion convincing? I hope not.But it is possible, of course.
Re: the first example, maybe those who never had had appendix removed never had had previous appendicitis due to a better immune system.Hence they did better.
People who live in million dollar homes earn more money than the homeless. DOES THAT MEAN if you put people in a million dollar homes, will they soon start to earn a lot of money ?
I doubt it. But it is possible.
Medicine is rife with studies that show correlations of unproven causal significance. Is that what we should call
an "evidenced based study" I hope not but it makes for fascinating news stories, studies that most people take as "scientific". Sadly.

Skeptical Scalpel said...

William, thanks for pointing out that association is not necessarily causation with some good examples.

Rugger said...

We all know that most appendicitis is diagnosed by CT scan these days, and we all occasionally get that patient with RLQ pain that has the reading of "cant clearly identify the appendix" (which probably means it is normal).
Well that is a good time for me to fall back on all the new literature that states we can now treat appendicitis with just antibiotics (which I mostly don't agree with except in this case).

Skeptical Scalpel said...

Rugger, that's a good idea.

artiger said...

If nothing else, we can at least count on antibiotics to buy us some sleep time between 10pm and 6am.

Skeptical Scalpel said...

I suppose so, but I never waited. I grabbed them in the middle of the night.

stacey said...

Reading this with interest. I developed appendicitis during chemotherapy.. walked in for a treatment feeling a little "crappy". RLQ tenderness, low grade fever but no elevated white cells because, well... immune suppressed...etc.. Onc sent me down the hall to my surgeon. He poked on my RLQ and I came off the table. We didn't bother with a CT. He sat me up and said, "Generally, about 10% of the appendices we remove are normal, but given your immune status, we don't have the luxury of waiting to see if antibiotics work. He described the possible dangers of surgery in my condition, but then he said, if it is appendicitis and we don't take it out...Welp, peritonitis and you die. Afterwards I saw a copy of the path report he sent to the oncologist. Grossly normal on the outside, but ugly on the inside. (Ok not exact verbiage) So, he saw a "normal looking appy" but took it out! And I am glad. That was 18 years ago.

Skeptical Scalpel said...

Dear Ms. Gordon,

Thank you for supporting my opinion that a normal-looking appendix should be removed when operating for presumed appendicitis. I hope your cancer is cured or at least in remission. Best wishes.


Korhomme said...

Ms Gordon; as I indicated above, Zita said that the inflammation of appendicitis starts on the inside, then spreads outwards. Your surgeon was entirely correct to remove your appendix; the diagnosis of acute appendicitis was confirmed by the pathological finding that it was "ugly" on the inside.

Best wishes

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