The Rising Morbidity of Appendectomy For Acute Appendicitis


The Rising Morbidity of Appendectomy For Acute Appendicitis

Jeffrey D. Sedlack, M.D., FACS

The author received no external financial support for this study, and has no external financial contracts or conflicts.

Abstract:

BACKGROUND: High morbidity rates have been reported recently in comparisons of open and laparoscopic appendectomy, raising the question of whether the surgical community is still performing this common procedure well.

STUDY DESIGN: .The English language literature was searched for reports of series of appendectomies between 1892 and 2008. Reported morbidity and mortality rates for appendectomy were evaluated over time.

RESULTS: 399,996 patients were identified over the 116 year period. Mortality from appendectomy showed a predictable, steady decline. The morbidity from appendectomy showed steady improvement until 1962. Since 1962 there has been a statistically significant rise of morbidity from appendectomy, to morbidity rates as high as 29%. The rise in morbidity since 1960 was especially pronounced at teaching hospitals.

DISCUSSION: There has been a statistically significant rise in the morbidity from appendectomy since 1960. The rising morbidity was independent of laparoscopic surgery, and is particularly pronounced at teaching hospitals.


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It may be argued that the “Century of Surgery” began in 1886 when Reginald Fitz reported on the pathology of the appendix in acute appendicitis.[1] The decades following this seminal event saw the development of safer surgery in the abdomen, and the development of progressively more complex procedures for intra-abdominal disease. Yet despite the passage of more than a century, appendectomy remains one of the most common surgeries performed in the United States and around the world.

For surgeons, performing one’s first appendectomy as an intern is a significant rite of passage, remembered forever. William A. Nolan, in his book, “The Making of A Surgeon,” vividly describes this experience in a way that forty years later still resonates.[2] His description of the surgery, however, is also replete with error, injury, and complications for his patient; the direct result of an inexperienced surgeon.

The Institute of Medicine reported on an extraordinary rate of error in Medicine and Surgery.[3] This report, as well as well publicized anecdotes of error, call into question the underlying quality of our patient care, as well as highlight the delicate balance between risk to patients, on the one hand, and the obligation to teach the next generation of physicians, on the other.

Since appendectomy is such a common surgical procedure, and one that is such an integral part of the training process for surgeons, This study attempts to determine how well modern surgeons are performing in achieving patients safety with a common surgical procedure.

STUDY DESIGN

This study is a retrospective statistical analysis of Western Literature reports on the morbidity and mortality of appendectomy for appendicitis over time.

The western, English language literature was carefully searched for peer reviewed medical literature documenting morbidity and mortality for acute appendicitis. These data were extracted from these papers, as well as the time frame discussed for each series. The data were then evaluated using traditional statistical analysis (Analyze-It statistical software program, Analyze-It, LTD, London, England, 2008), simple and polynomial regression analysis, and between groups statistical meta-analysis to evaluate the performance of appendectomy by the surgical community over time, using reported morbidity and mortality as indicators of quality.

In addition, the performance of modern teaching hospitals for appendectomy was evaluated over time and compared with both historical controls and with reports from modern community, or non-teaching facilities.

RESULTS

A total of 76 peer reviewed articles were identified that discussed rates of morbidity and/or mortality in series of patients undergoing appendectomy for acute appendicitis. These reports covered patient experiences from 1892 through 2005 and reported on 399997 appendectomies for acute appendicitis. The literature and morbidity and mortality data are summarized in Table I.

The mortality data was plotted over time, using study midpoint year as the time data for each series. Polynomial regression analysis was performed on the data, and the plot, with the regression curve (p<0.0001) is shown as figure 1. There was a clear, and precipitous decline in mortality from appendectomy between 1920 and 1940 that was followed by a fairly level, nearly zero, mortality rate for this procedure since that time. There was one outlier in the modern data from the VA consortium study which reported a 24% mortality rate in VA patients with acute appendicitis in 1995.

The morbidity data was also plotted over time, again using study midpoint year as the time marker for each series. Polynomial regression analysis was again perforomed on this data, and the regression curve, with confidence intervals are shown in figure 2. There was a clear, statistically significant decline in operative morbidity for appendectomy between 1895 and about 1960. After 1960, however, the morbidity for appendectomy began to rise to an average morbidity for appendectomy since the development of laparoscopic surgery in 1990 of 18%.

The series reported since 1960 were then divided into teaching hospitals, and community, or non-teaching hospitals. Historical controls were also generated of grouped morbidity of appendectomies prior to 1960, 1950, and 1940. These data are summarized in Table 2. The groups were compared using Pearson Х2 analysis. There was a significantly greater morbidity for appendectomies at teaching hospitals than non-teaching hospitals (p<0.0001), for teaching hospitals compared with appendectomies prior to 1960 (p<0.0001), and prior to 1950 (p<0.0001). Appendectomies performed prior to 1940 were associated with a significantly higher morbidity than for modern teaching hospitals (p<0.01).

DISCUSSION

The safe surgical treatment of appendicitis is of paramount importance, given the frequency of the operation, and the relative youth and health of the typical appendicitis patient. The data demonstrate significant success in achieving a low morbidity for appendectomy until 1960, and then progressively less success, such that major medical centers are now reporting morbidity rates as high as 30%.

There are a number of possible explanations for this increasing morbidity, such as differing standards of calculating, or reporting complications, severity of disease, and so on. By and large, though, review of the reporting standards for each series, and the complications reported are remarkably uniform over time. The development of antibiotics around 1940 appears to have made a significant difference in the mortality rate from appendicitis, but less of an effect on the infectious complication rates reported. It is hard to argue that the severity of appendiceal disease has worsened over time, given that there has been a clear decline over time in the rate of perforated appendicitis seen, and given that up to 10% of pre 1940 perforated appendicitis was caused by either tuberculosis or Actinomycosis. In addition, the pre-1940 or 1950 appendectomies were performed without muscle relaxation, ventilators, antibiotics, CT scanners, heparin, or reliable suture.

Similarly, since appendicitis is a community disease, generally cared for at the presenting hospital, it is also difficult to maintain that there is a significant difference in patient populations between community and teaching hospitals. One obvious possible explanation for the significantly different morbidity rates between the two types of centers is the level of training or experience of the operating surgeons. There is no data available from these reported studies of teaching hospital experiences with appendectomy that describes the level of training of the operating surgeon for the appendectomy, and it would be helpful to include this information in future reports in the literature of laparoscopic or open appendectomy experiences.

The successful surgical treatment of acute appendicitis is a landmark triumph in the surgical treatment of a common disease. The combined findings of a steadily rising morbidity from appendectomy since 1960, and a significantly increased risk of morbidity from appendectomy at teaching hospitals are troubling, and should prompt an evaluation of how appendicitis is managed in our hospitals, and who should be performing appendectomy.


Figure 1 Morbidity (%) of Appendectomy over time

Figure 2 Mortality from appendicitis/appendectomy (%) over time


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