Results of appendectomy

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Madeline shows off her appendectomy scar.

This exhibit should really be titled "The risks and benefits of appendectomy," and this is the discussion that I have with my patients before surgery.

The Risks of Appendicitis

First, you have been diagnosed with appendicitis. That diagnosis doesn't actually mean you have appendicitis. (see exhibit "How often is the Doctor wrong?")

With all the signs and symptoms in order, and being examined by a surgeon who is experienced, there is still a 3-5% chance that you have some other illness that ismimicking appendicitis, such as "mesentericadeninitis" an infection of the lymph glands near the cecum and appendix.

Doctors will frequently add in an X-ray study, such as a CT scan or an ultrasound examination. This lowers the chances that the appendix will be normal at operation to 1-2%.

For a long time, the rate of normal appendix removal was thought to be the price paid to "get the appendix out before it ruptured." There is some truth in that, but the overwhelming majority of studies show that the time before coming in to the hospital was much more important in terms of ruptured appendix rate, than was the time in the hospital. In other words, most ruptured appendices are ruptured before the patient came to the hospital.

That said, the risks of having a ruptured appendix, individually, are still higher than the risks for the removal of a normal appendix. In addition, patients who have appendectomy and who are found to have a "normal" appendicitis quite frequently are cured of their symptoms with appendectomy - the appendix was distended or full of stool, but inflammation had not set up yet. Also, after appendectomy you will never get appendicitis again.

We currently believe that left untreated, appendicitis will progress to rupture. When the appendix ruptures one of three things can happen - The body can wall off the infection and take care of it itself; the infection can be "walled off" and create an abscess in the area; the infection can spread throughout the abdomen as a generalized peritonitis.

Finally, patients with appendicitis frequently report having had a prior attack that they either walked off, or that the work up was negative and they got better. This is a large point - because the standard of care for appendicitis is the emergent removal of the appendix, we no longer know what the natural history of appendicitis is - we cannot predict who will rupture and who will get better. Our surgical dogma is that "within 24 hours of developing the symptoms of appendicitis, the appendix is either ruptured, in the surgical pan, or both."

There have been recently published trials of antibiotic therapy for cases of uncomplicated acute appendicitis that were randomized with appendectomy. The IV antibiotic group had a lower rate of complications, but 40% of the non-operative treatment group needed to have appendectomy within a year.

And remember that these trials were done at academic medical centers, where the complication rate for appendectomy is higher than for community hospitals, as they found an 8% and higher complication rate for appendectomy for uncomplicated appendicitis. (see exhibit "Some thoughts on complications ofAppendectomy") This is extraordinarily high.

The Risks of Surgery

Having a operation, any operation, is a big deal. There are risks to any surgery. The overall risk of a "complication" from appendectomy depends upon where you are having the surgery. If you are having your appendix out by me in Maine or in Alaska, the overall complication rate is about 2%. If you are having your appendix out at Mayo Clinic, your chance of a complication is about 30%.

Any surgery carries a risk of infection and of bleeding. The risks of these complications are around 1% (higher, frequently much higher, at academic institutions) The risks of these complications, particularly infectious complications rises significantly if the appendix has ruptured.

Other risks of surgery include scarring and hernias - any time you make an incision there will be a scar, and anytime you go through the muscles and fascia of the abdomen there is a risk of hernia. The risk of a scar is 100%. The risk of a hernia is about a percent.

There is a risk of blot clots (called DVT's) and of a blood clot going to the lung (called a PE, or a Pulmonary Embolism) The risk of this is about 1 in a thousand. The risk is increased if you have a big pelvic infection, if you have a long operation, if you are old or obese, or if blood clots run in your family. Dan Blocker, "Hoss" on Bonanza, died in 1972 at the age of 43 of a PE after an appendectomy for a ruptured appendix.

There are rare occurrences with surgery that cannot be predicted, but that include an adverse reaction to the anesthesia, leakage from the stump of the appendix, a prolongedileum, or poor bowel function after surgery, adhesions and bowel obstructions, and injury to the bowel during surgery. These risks are all very small, <1%, but not zero.