Appendectomy outcomes in the modern era

Finally we have some data on the current rate of complications of appendectomy for uncomplicated appendicitis. But that’s not all. This new paper, published online in the journal Surgery, reveals much about the diagnosis, technique, and outcomes of appendectomy in the United States.

Using data from 115 hospitals participating in the National Surgical Quality Improvement Program, researchers at UCLA analyzed the results of 7778 adult patients undergoing appendectomy for simple appendicitis in 2016.

More negative data about the nonoperative management of simple appendicitis

If you think I am the only one urging restraint in the adoption of nonoperative management of patients with uncomplicated appendicitis, you are wrong. A pediatric surgeon and a research fellow from Harvard and Massachusetts General Hospital have recently published their thoughts on the matter online in Annals of Surgery.

They call their opinion piece “Ulysses Syndrome” because they liken the fate of those undergoing nonoperative management to the “10-year ordeal filled with unexpected peril and ample misfortune” that befell Ulysses while attempting to go home.

Here are a few highlights.

Perforated appendix not seen on CT scan

From an email received two days ago. Posted with permission and edited for length and clarity.

I came across your blog while looking for information on something puzzling that happened to my sister. I read the blog on CT scans and appendicitis* and went through all of the comments section. I couldn't find a case like my sister’s.

She has been sick off and on for the last two months. It began with what seemed like a bad stomach virus, fever, throwing up, diarrhea, gas pain, bloating, and stomach cramps. She brushed it off as a 24 hour type thing, stayed home from work a few days, and felt better but never returned to normal. She would have intermittent stomach upset and began to have weight loss. About 3 weeks ago, she went to see her GP who ran some tests (antibody tests, no CBC, chem 7 or normal work up) and diagnosed her with gluten intolerance.

Nonoperative treatment of appendicitis in children: Is it safe?

After writing my 21st post about appendicitis back in November, I swore I would not write about it again for the foreseeable future.

Well, the future is now because investigators from the United Kingdom and Canada just published a meta-analysis including 10 papers and 413 children about the efficacy and safety of nonoperative treatment for appendicitis in children.

They concluded that nonoperative management is effective in 96% of children with acute uncomplicated appendicitis during their initial hospitalizations with just 17 (4%) children requiring appendectomy before discharge. An additional 68 (16.4%) developed recurrent appendicitis later, and 19 of these patients were treated with the second course of antibiotics. The other 49 underwent appendectomy with histologic evidence of recurrent appendicitis.

Another 11 patients underwent appendectomy in the follow-up period for various reasons. In all, 77 (18.6%) patients initially treated with antibiotics eventually underwent appendectomy.

Although the initial hospital length of stay for appendectomy was shorter than that of patients treated with antibiotics, complication rates were similar.

These findings were met with headlines like "Antibiotics, not surgery, could treat appendicitis in children, study suggests" from The Guardian and "Is Surgery Always Needed for Kids' Appendicitis?" from US News.

What are the problems with this paper?

A medical oncologist weighs in on the treatment of appendicitis

It was an interesting fortnight for the debate about the treatment of appendicitis.

On November 1, David Agus, a medical oncologist and Director of the University Of Southern California's Center for Applied Molecular Medicine, had some thoughts about how appendicitis should be treated. He cited the Finnish randomized trial of antibiotics vs. surgery and said a 70% cure rate was good enough.

In a brief article on the Fortune magazine website, Agus wondered why appendectomy "continues to reign supreme." He said it was "because 24/7 we’re taught you have to take it out if there’s appendicitis” and that the healthcare community is "stubborn and pigheaded" [pigheaded means stubborn] and that we focus on treatment instead of prevention.

Antibiotics vs. surgery for appendicitis: Critique of a meta-analysis

A meta-analysis can be useful when looking at a topic that has been studied by several different groups of investigators. The pooling of data from different published papers can sometimes bolster a conclusion about the effectiveness of a treatment.

However, a meta-analysis is only as good as the studies it includes, and the biases of those performing the meta-analysis can color the results.

Last month, a meta-analysis concerning antibiotics vs. surgery for the treatment of uncomplicated acute appendicitis by investigators from Nottingham University Hospitals was published in the World Journal of Surgery.

The authors concluded that “antibiotic therapy represents a safe, efficacious and viable treatment option for the treatment of uncomplicated acute appendicitis.” I disagree.

Five randomized trials involving 1430 subjects were included in the meta-analysis. After one year of follow-up, the efficacy of treatment for those receiving antibiotics was 62.2% compared with those undergoing appendectomy whose treatment efficacy was 88%. Depending on the inclusion or exclusion of a particularly weak study there was said to be a 39-52% risk reduction for complications in the antibiotic group.

This meta-analysis has so many problems that it is hard to know where to start.

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?

Appendicitis: Continuing debate about treatment

The other day on Twitter, Kenny Goldberg (@kghealth), a health reporter at KPBS News in San Diego, asked me, "Why all the stories on antibiotics vs. surgery for appendicitis? Are appendectomies inherently dangerous?" My answer was "Great question. The answer is a resounding 'No.' The complication rate is very low."

Yet the papers keep coming.

A new systematic review of all the randomized controlled studies on appendicitis found important shortcomings in all of them. Here are a few:

Bias in selecting patients was a problem in all six of the studies reviewed. Diagnostic criteria for inclusion in the studies were not standardized. Some of the studies enrolled patients with clinically diagnosed appendicitis only. Since some patients may not have had appendicitis, they would probably have improved regardless of how they were treated.

Patients were treated with a variety of antibiotics, Since most of the studies were done in Europe, open appendectomy was the more common surgical intervention. Laparoscopic appendectomy results in fewer complications and shorter lengths of stay than the traditional open procedure.

Follow-up in five of the six studies was one year with only one study following patients as long as a median of 17 months. Rates of recurrent appendicitis necessitating appendectomy ranged from 24% to 60% with an average of 35.4%. What will the recurrence rates be at 3 years? 5 years?

The authors concluded that although more evidence for treating appendicitis with antibiotics has emerged, the comparative effectiveness of that strategy is still unknown. They recommend that patients should be enrolled in clinical trials or registries to help answer this therapeutic question.

The second recent paper involves two issues I have commented about many times—research and medical reporting.

It's a study of 102 pediatric patients between the ages of 7 and 17 with uncomplicated appendicitis as judged by CT scan parameters. After informed consent was discussed, parents were permitted to choose the therapeutic arm, antibiotics or laparoscopic surgery.

Of the 629 patients who presented with acute appendicitis during the study period, only 102 (21%) met the study's inclusion criteria of whom 37 were selected for antibiotic therapy by their parents.

During the median follow-up period of 21 months, 9 (24.3%) patients initially treated with antibiotics had to undergo appendectomy.

I blogged about this study's preliminary results when they were published back in 2014. If you would like more details about its limitations, read that post.

The inadequacies of medical reporting on this paper were rather glaring. Under the headline "Not all kids with appendicitis need surgery. Antibiotics can work just fine," the Boston Globe's new website Stat News said the following:

“'Their parents began to question whether they needed surgery [for appendicitis],' said [lead author] Dr. Peter Minneci, a pediatric surgeon at Nationwide in Columbus, Ohio. Minneci decided to answer the question with a controlled study." Sorry folks, this wasn't a controlled study.

The New York Times reported: "The surgery group had more complications and two of those who chose antibiotics had to be readmitted to the hospital for appendectomies in the first 30 days." This is misleading because although 5 of 65 patients in the surgery group had postoperative complications compared to none of the 9 who eventually had appendectomies in the antibiotic group, the difference was not statistically significant (p = 1.0, Fisher's exact test).

But the most interesting thing about this paper was an entire page explaining why allowing parents to select the therapy was a better method than randomizing patients to one group or the other. It's very clever and must be read to be appreciated.

Here is an excerpt: "The patient choice design allows a therapy to be aligned with the preferences of the patient and his or her family, thereby minimizing the potential negative effects of preferences."

I don't know about you, but if I or anyone in my family had appendicitis, my preference would be for a laparoscopic appendectomy.

Appendicitis and shared decision-making

Staying with the current theme of appendicitis on my blog, here is a summary of recent developments. A JAMA Surgery Viewpoint suggested that because of the findings of a Finnish randomized trial, surgeons now should give patients with appendicitis a choice between an appendectomy or treatment with antibiotics.

The paper acknowledged my criticisms of the Finnish study which found that simple appendicitis could be treated successfully with antibiotics in almost 75% of patients.

I respect the authors of the JAMA Surgery article and am happy they referenced the blog post noting my concerns about that Finnish trial: the trial compared antibiotics to open appendectomy—an operation with more complications than the more commonly performed laparoscopic appendectomy; the antibiotic used in the Finnish trial is not a first line choice in the United States; patients were followed for only one year.

The JAMA surgery paper answered three questions I posed in a previous post. One, the Viewpoint authors consider antibiotic therapy for appendicitis mainstream. Two, surgeons must assume that patients might opt for antibiotics despite at least a 25-30% chance of suffering a recurrence of appendicitis. Three, an informed consent discussion now should include a mention of antibiotics as an option.

I disagree with the Viewpoint authors’ assertion that antibiotics are as safe and effective as surgery for treating appendicitis. Based on one flawed study, antibiotic therapy cannot yet compare to the many years of excellent results of laparoscopic appendectomy.

Here are some other problems.

My blog cited in JAMA Surgery paper: Progress for bloggers

About a year and a half ago, I blogged that a medical student on Twitter used a blog post of mine as evidence. In January, the Canadian Journal of Anesthesia published an article I wrote under my pseudonym called “Why I blog and tweet.”

Last month, medical blogging took another step toward legitimacy. A JAMA Surgery Viewpoint formally cited my post critiquing the Finnish randomized trial of antibiotics versus surgery for the treatment of acute appendicitis.

Here is the first page with the portion of the piece discussing what I had written in the blog post.

Click on figure to enlarge.

Here is how citation appears in the JAMA Surgery article.

If you haven't read my entire post about the randomized trial, click here.

Last year I said this: “Journals may have to adapt and become more like blogs. In the future, medical information may be disseminated by blogs and comments rather than journal articles and letters to the editor.”

We have already seen prominent publications such as the New England Journal of Medicine starting online forums and the BMJ hosting blogs (at least 36 so far) and rapid responses to published papers.

The sea change in the way medical research is disseminated may be happening sooner than I thought.

A curious trend in appendectomies by residents

Some experts are worried that laparoscopic cholecystectomy is so prevalent that future surgeons may have difficulty doing open cases. I was going to blog about the possibility that open appendectomy would become the next operation that next generation surgeon might have trouble with. But while looking at some data [link added 12/4/15] collected by the RRC for Surgery, I was struck by something else.

Since 1999, the total number of appendectomies (open and laparoscopic) performed by surgical residents who completed 5 years of training has risen by 65.1% compared to the total number of appendectomies done in the US, which has increased only 16.4%. Here are the numbers:

Except for the academic year ending in 2006, the average total appendectomy rate per resident has risen every year since 2000. The chart below displays that change and the changes in the numbers of open and laparoscopic appendectomies.

Click on chart to enlarge

The difference in the average combined number of appendectomies between the two academic years ending 2000 and 2014 is significant, p < 0.0001.

Do doctors charge too much?

We all know that some doctors’ fees are excessive. I have blogged about this myself citing a neurosurgeon’s $117,000 charge for assisting on a case.

We also know that doctor bashing is a popular sport right now.

In an otherwise reasonable article about high-deductible health insurance on Vox.com, reporter Sarah Kliff’s second paragraph read as follows:

The bolded text was hyperlinked to a Washington Post piece about a study that showed wide variations in hospital charges for appendectomies in California. The study was not about physician fees. No matter how difficult the case was, no surgeon would ever have been paid $186,955 for performing an appendectomy.

Yesterday, I twice asked Ms. Kliff to please correct this grossly misleading paragraph. She acknowledged my request that evening, but as of 9 AM today, nothing had been changed.

Even if Ms. Kliff had correctly identified the hospitals as the culprits, using appendectomy as an example of why patients should shop for the lowest prices was a poor choice.

Nearly every patient with appendicitis does not know he has it until he has gone to an emergency room, seen an ED physician, and had some tests. I doubt most people in this situation would A) ask how much it’s going to cost to have an appendectomy and B) decide to go to another hospital for care. The fact is, hospitals are so secretive about their charges that a patient would be unable to comparison shop especially if the emergency department visit occurred outside of normal working hours.

Even trying to find out the charges for elective surgery remains difficult in 2015.

Physicians—particularly surgeons—have taken a lot of heat recently. We don’t need articles like this to inflame patients (and journalists) even more than they already are.

ADDENDUM 9:45 AM 10/15/15

The article was just changed. The bolded mistaken passage was corrected, but the next sentence (underlined in red) remains the same. Still blaming those "really expensive doctors."

In 22% of kids with appendicitis, antibiotics do not prevent perforation

Those clambering aboard the "antibiotics for appendicitis" bandwagon should read this interesting paper about appendicitis in children.

A group of emergency physicians from Maimonides Medical Center in Brooklyn, New York found that "Increasing in-hospital time delay from ED presentation to OR appendectomy is associated with increased risk for developing appendicitis perforation in children who present with CT-documented uncomplicated appendicitis."

Children with simple appendicitis who were taken to the operating room longer than 9 hours from the time of ED presentation were much more likely to develop a perforation than those who had surgery in less than 9 hours.

During the four years of the study, 404 consecutive children ≤ 18 years of age had a CT scan diagnosis of acute appendicitis; 156 (38.6%) had evidence of perforation at the time of presentation and were not included in the final analysis.

Questions about antibiotics vs. surgery for acute appendicitis

A study from Finland suggesting that antibiotics may be a viable alternative to surgery for acute appendicitis has created a stir. As you might have expected, I had some concerns about the paper which you can read in my blog post here.

On Twitter, many surgeons have commented on both the paper and my post. Several interesting questions come to mind.

Based on this and other similar studies, is the treatment of acute appendicitis with antibiotics now a mainstream alternative to surgery?

Should surgeons now mention the Finnish study results during their informed consent discussions with patients?

Antibiotics for appendicitis? No thanks

The long-awaited Finnish randomized controlled trial of antibiotics vs. surgery for appendicitis was just published in JAMA. Depending on your perspective, 73% of patients were successfully treated with antibiotics or 27% of patients failed antibiotics and needed surgery.

The good news is that it was a large multicenter study involving 273 patients randomized to surgery and 257 to antibiotics. Patients included in the study had uncomplicated appendicitis as diagnosed by CT scan.

The bad news is that the paper has many limitations.

Of the patients who underwent appendectomy as the primary treatment, only 15 (5.5%) had laparoscopic surgery. The authors state that open appendectomy was selected as the protocol operative technique because laparoscopic instruments may not be available worldwide and apparently many surgeons in Finland are not experienced in performing laparoscopic appendectomies.

Antibiotics vs. surgery for appendicitis: It's time for a randomized trial

Maybe you've heard that there is a growing debate about whether antibiotics are as good or better than surgery for treating appendicitis.

So far there have been several studies from Europe showing that antibiotics may be safely used to treat appendicitis in many cases. However, the studies have involved small numbers of patients and have exhibited some flaws in their methods. A few studies from the US have been published, but they were not randomized or prospective.

I have blogged about some of these studies on three occasions. If you would like to read these posts, click on their titles.

Antibiotics instead of surgery for appendicitis? I'm still not convinced

Antibiotics instead of surgery for appendicitis? No way

Antibiotics instead of surgery for appendicitis? I don’t think so.

A group of surgeons in Washington State are putting together what will be the first randomized prospective trial of antibiotics vs. surgery for appendicitis in the United States. In order to obtain a grant from the Patient-Centered Outcomes Research Institute to help fund the project, the investigators must demonstrate that people in this country would be willing to participate in such a study.

To help determine the level of interest, they have written a brief explanation of why this study is being proposed. It parallels my thinking on the subject.

At the end of their post is a link to survey involving one question:

If you had appendicitis, would you be willing to join a study that would randomize you (a 50% chance, or flip of a coin) to “surgery ” or “antibiotics?”

You don't have to read the Washington researchers' post to take the survey.

You may click here to answer that question. Thanks.

Antibiotics instead of surgery for appendicitis? I'm still not convinced

Two recent papers have added more fuel to the debate about whether appendicitis can be managed without surgery.

The first paper is a prospective observational study from Italy involving 159 patients over the age of 14 who were thought to have uncomplicated appendicitis. Nonoperative management with oral antibiotics was planned for all of the patients.

Nonoperative management failed within 7 days in 19 (11.9%) patients, all of whom underwent immediate surgery. Appendicitis was found in 17 patients, and 2 had tubo-ovarian abscesses

The abstract says "After 2 years, the overall recurrence rate was 13.8% (22/159)." This is blatantly misleading. The overall recurrence rate was 19 recurrences within 7 days plus 22 more recurrences between 7 days and 2 years for a total of 41 (25.8%) recurrences with 27/159 (17%) of the patients requiring surgery.

If you look at this paper more carefully, you will find the following from Table 3:

Antibiotics instead of surgery for appendicitis? No way

A retrospective study from California claims that the nonoperative management of simple appendicitis may be safe and is worth studying further.

Why am I not convinced? Because every time this subject comes up, the paper purporting to show that antibiotics are superior or even equal to surgical treatment is flawed. The trend continues with the current paper du jour which appears online in the Journal of the American College of Surgeons.

This study looked at the records of over 231,000 patients with uncomplicated appendicitis during the years 1997 to 2008. Only 3236 (1.5%) of those patients were treated non-operatively, and 10.3% of them had either a failure of antibiotic treatment or a recurrence of appendicitis during follow-up with 3% of those having perforations. Mortality rates were very low (appendectomy 0.1%, antibiotics 0.3%) and not significantly different, and hospital charges were similar in the groups matched with propensity scoring. Length of stay was significantly longer for those treated with antibiotics 3.2 days vs. 2.1 days, p < 0.001.

Sounds great, right?

I will not go into detail about the some of the important problems with this paper such as the fact that before the statistical manipulation with propensity scoring, the baseline characteristics of the patients in both groups were significantly different in all but one category. In table 1 of the paper, the number of patients available for follow-up was exactly the same as the number entering the study. That means that not a single patient was lost to follow-up, which is hard to believe since people occasionally move out of state. The reasons that patients did not undergo appendectomy could not be determined from the administrative database used.

Here are the key issues.

The paper was based on discharge diagnoses. Even with the use of CT scans for diagnosis, some cases of what seem to be simple appendicitis turn out to be more extensive at surgery. Had these patients been treated with antibiotics, the results would have been disastrous. And as a paper from the UK reported, administrative databases are notoriously unreliable for use in clinical studies.

The biggest problem with the paper touting antibiotics for appendicitis is that it includes patients over the course of the 11 years from 1997 to 2008. During that time and continuing to the present, the surgical technique of appendectomy has evolved.

If you look at the same database used by the authors (California Office of Statewide Health Planning and Development Patient Discharge), you will find that in 1999, appendectomies were done laparoscopically in 7574 of 36,740 cases or 21% of the time. Fast-forward to 2012, and note the converse—laparoscopic appendectomy was performed in 35,393 (79%) of 44,582 appendectomies.

Why is this important? The average length of stay for laparoscopic appendectomy for simple appendicitis is one day or fewer. This is less than half of the time stated in the comparison with antibiotic treatment.

In the January 2014 issue of the Journal of Trauma, a study reported 345 patients who had a laparoscopic appendectomy for uncomplicated appendicitis. Of those patients, 305 (88%) were discharged home from the post anesthesia care unit. The average time from admission to operation was five hours, and the average time spent in the PACU was just under 3 hours. The reasons that the 40 (12%) patients were admitted were lack of transportation in 19, pre-existing comorbidities in 15, and postoperative morbidity in 6. Only 4 of the patients who were discharged directly from the PACU required readmission. Thus, total complications (postop morbidity plus readmission) numbered 10 (2.8%).

Treating appendicitis with antibiotics also exposes patients to the risks of C. difficile colitis and other side effects of the drugs. The complications associated with laparoscopic appendectomy for simple appendicitis are few, and more importantly, the appendix is gone forever.

The authors concluded: "While the rate of treatment failure was 5.9% in non-operative patients, it was only 0.1% in operative patients. With concerns over controlling 30-day readmission and rising healthcare costs, these shortcomings may be substantial barriers to the consideration of non-operative approaches."

A randomized trial of antibiotics vs. surgery for uncomplicated appendicitis is underway in Finland. Judging from the wording of the abstract describing the trial, the authors are markedly biased toward the use of antibiotics. Despite this, let's hope it sheds some much needed light on this subject.

I don't understand why investigators, especially surgeons, continue to push antibiotics as an alternative to appendectomy. For simple appendicitis, laparoscopic surgery is quick, safe, and definitive.

Transgastric appendectomy. Would you have one?

A study in the British Journal of Surgery says that removing an inflamed appendix via the stomach is feasible and "promising." This is what is known as NOTES or natural orifice transluminal endoscopic surgery.

The paper (full text plus videos under "Supporting Information" tab) describes the first 15 cases done at the University of Heidelberg in Germany.

There is so much wrong with this paper and the concept in general that it is hard to know where to start.

During the year from April 2010 to April 2011, 111 patients were offered the chance to have this procedure done and only 15 agreed to do so. It appears that patients have a lot more common sense than some physicians think. The patients were carefully selected. Those with BMIs > 30 and with perforated appendicitis were excluded

The procedure was done by inserting an endoscope through the mouth and then through the stomach wall,  but if you read only the abstract, you would miss the fact that a separate trocar was inserted via the umbilicus to facilitate the operation. Therefore, it is not a pure NOTES procedure. The NOTES crowd would call this a "hybrid" procedure.

Several complications occurred. The first case had to be converted to an open appendectomy because of "severe inflammation." This was not explained in the paper but was revealed in the typically uncritical MedPage Today article about it.

Two patients developed postoperative pelvic abscesses requiring what they called "laparoscopic revision" which is their euphemism for second operations. A second operation is very uncommon in patients without perforated appendicitis.

In one patient, a technical problem necessitated ligation of the stump of the appendix through the umbilical port. Another patient had bleeding which had to be controlled by clips. For an obese patient (curious, as only patients with BMIs < 30 were said to have been included), the appendix had to be cut into two pieces because it would not fit through the opening in the gastric wall.

The median duration of the NOTES cases was 105 minutes with a range of 59 to 150 minutes. The average time for a standard three-port laparoscopic appendectomy is about 25 to 35 minutes which means that the NOTES takes three times as long.

The median hospital stay was 3 days with a range on 1 to 8 days. The usual length of stay for a standard laparoscopic appendectomy in the United States is < 24 hours.

The heavily edited videos are worth a look, especially the fourth one, which shows that it takes at least 10 snips of the tiny endoscopic scissors before the appendix is completely divided.

Because of the two patients in the series who developed abscesses, the authors advise caution for those with purulent appendicitis and suggest doing a standard laparoscopic appendectomy instead. The problem is that the surgeon would not know that a patient has purulent appendicitis until she has looked and made what would then have been an unnecessary hole in the stomach.

Most standard laparoscopic appendectomy scars are invisible anyway. If just one patient suffered a leak of the stomach wall closure which would cause sepsis and other major complications, that would strongly negate the minimal cosmetic gain from the trans-gastric operation.

The study ended two years ago but was just published. I always wonder about that. What took so long? Was it rejected by other journals? You would think the authors would want this sort of breakthrough brought to light as soon as possible. Have they done more cases since then? What were the outcomes?

After reading the paper and seeing the videos, is there a surgeon in the world who would want a trans-gastric appendectomy performed on herself or a loved one? An unscientific Twitter poll indicated they would decline. One surgeon said, "Not sure if I'd answer 'No' or 'Hell No,' and I do NOTES research."

Here's the bottom line. Unless you have promised your patient trouble, only the most ardent proponent of NOTES could call these results "promising".

Pregnant woman dies after ovary removed instead of appendix

On June 10, 2013 a 32-year-old "heavily" pregnant woman was reported to have died after having an ovary removed instead of her inflamed appendix. As the infected appendix festered, she became septic and succumbed to multiple organ failure. This tragedy occurred in the UK in late 2011, but has just come to light.

How could this have happened?

Let me count the ways.

The surgery was performed by two trainee surgeons. Their level of experience was not stated.

The senior staff, called consultants in the UK, had gone home for the day.

The operation to remove the appendix was apparently done as an open procedure, not laparoscopic, which is acceptable if done correctly. The articles say that the surgeons had to take out the organ by feel and not under direct vision, which is not proper.

Although an ovary can be enlarged during pregnancy, under no circumstances does an ovary look or feel like an appendix. As in another case described below, inflammation can cause confusion at times, but not to this degree.

The woman was discharged a week after the initial surgery but returned with pain some 10 days after the removal of the wrong organ. During that time period, no one had checked the pathology report. The mistake was discovered by a doctor reviewing the patient's records during the readmission.

An abscess was drained but the she died on the operating table during a futile attempt to at last remove the appendix.

Last week, the CEO of the hospital sent a written apology to the family promising to correct the dreaded "system errors." Too little, too late.

Yes, there were system errors.

But what about human errors?

Trainees were allowed to undertake a supposedly routine operation without supervision. However, as this case shows, an appendectomy during pregnancy can be very difficult. The uterus is in the way, and its increasing size may displace the appendix from its normal position. This type of surgery cannot be done by "feel" alone.

Commentary from UK physicians on Twitter suggests that all the facts of the case, such as what communications took place between the trainees and their supervisor, have not been made public. They also point out that it is not mandatory for a consultant to be present in the operating room for every case as is true of the resident-attending surgeon relationship in the US.

But I doubt that many US surgeons would allow residents to operate independently on a pregnant patient with appendicitis. At the very least, the attending would have been in the OR, if not scrubbed.

Did the trainees ask the consultant for help when they found themselves doing an appendectomy by feel?

The surgeons did not look at the pathology report, a major omission. But what about the pathologist? If a pathologist receives a specimen labeled "appendix," and he finds only an ovary, wouldn't the prudent pathologist pick up the phone and call the surgeon?

There is also "failure to rescue." When the patient was readmitted, earlier recognition of sepsis and more timely intervention might have saved her life.

I am aware of a similar case in which an inflamed piece of fat was removed by two unsupervised trainees who mistook it for the inflamed appendix. On the following day, the pathologist called the attending surgeon to tell her that the appendix was not present in the specimen. The patient was promptly taken back to surgery. He wasn't too happy, but he was alive.

The hospital's investigation of this case should have taken a few days at most. If the media reports are true, disciplinary measures and remediation should have been promptly instituted. An apology should have been offered far sooner than it was.

“An extensive trust-wide action plan was drawn up following Mrs De Jesus’ death in 2011 to ensure that such a tragic incident will not happen again" and "… to improve systems and patient safety," said the hospital's CEO.

As I have blogged before, system changes can be instituted, but can be defeated easily by carelessness, inattention and lapses of common sense by one or more individuals.

Stories about this from the UK media here and here. Search this blog for "system error" to view other posts on system errors.

ADDENDUM April 15, 2014
For some follow-up on this sad story, click here.