THE APPENDIX: A SURGICAL VICTIM?

It is perhaps a poorly kept secret that most surgeons are knife happy when it comes to treating appendicitis. Patients have long complained about surgeons’ penchant to ascribe any tummy pain to appendicitis and knock the thing off. A recent article in the World Journal of Surgery strongly questions the rationale of doing the operation in many cases.For more than a century, surgeons have learnt to recognize acute appendicitis by its triad of pain, vomiting and fever and operate as soon as it is diagnosed. The condition has always been considered a surgical emergency, because of the high risk of mortality if the organ perforates. Once it ruptures, infection spreads all over the abdomen and into the bloodstream, leading to septicemia and death. It has always been a given that an inflamed appendix would perforate with time and emergency operation would be the safest option to prevent catastrophe.
Roland Andersson, Associate Professor of Surgery, Linkoping University, Sweden, says that this is simply not true. Studying trials conducted on over 56,000 patients, Andersson found that inflamed appendices do not progress to perforate with time. Instead, they start of as a perforation. “Perforations are simply not preventable”, says Andersson. According to him, “The results presented in a number of studies suggest that spontaneous resolution of appendicitis is common, that the risk of perforation has been exaggerated and that in-hospital delay is safe.”
Many surgeons philosophize that it is better to remove an uninflamed (normal) appendix than to risk a rupture, with a ten-fold risk of dying. A study of over 100,000 Swedish patients has shown that appendectomy itself increases the mortality rate by several fold compared to normal population, especially if the appendix is shown to be normal. In other words, appendectomy is not a trivial operation that should be easily offered to any and every suspected case of ‘appendicitis’. Andersson published these findings in this article.

So, how would these recent scientific findings influence surgeons’ treatment policies? Moshe Schein, author of the book Common Sense Abdominal Emergency Surgery, says, “ A good number of patients improve without surgery, so where is the need to rush? In typical cases, I would operate the next morning. In atypical cases, if the patient is re-examined clinically or by CT scan, the diagnosis is rarely missed or wrongly made”. Schein, like Andersson, stresses the need to diagnose the disease clearly before attempting to treat it.
Today, in the US, it is normal for any suspected case of acute appendicitis to be sent first for a CT scan, even before a surgeon sees the patient. In India, especially in the rural areas, this is a far cry! Private nursing homes vie with each other in offering surgery at the cheapest possible rate in order to increase their case load. What is often forgotten is that the very concept of non-operative treatment becomes overshadowed by the need to operate. Surgeons rationalize, not entirely without merit, that an appendectomy can be done in the same cost that a CT scan would incur. So patients are mentally primed to spend the minimum in the treatment of the disease. Therefore the diagnosis is largely a result of the surgeon’s hunch or intelligent guesswork, without any investigation to support it. Surgeons say, even now, that the diagnosis is entirely clinical and can be confirmed only by operation. Modern surgery clearly does not support this contention, with high diagnostic rates seen with CT scans.

In recent times it has become commonplace to remove the appendix by the keyhole (laparoscopic) method rather than by conventional, open approach. This technique has given a high rate of correct diagnosis of the disease and has almost eliminated the incidence of wound infections, the most common complication of open surgery. Laparoscopy is, however, frowned upon by the majority of conservative surgeons who claim equivalent results with open operations. Irrespective of such conservative objections, the quick recovery after keyhole appendectomy is impressive, though the reports about Hollywood actress Lindsay Lohan take this to unreal levels. Lohan allegedly underwent the operation earlier this month and partied with alcohol and drinks the very next day. In suspicious cases of appendicitis, the diagnosis is something else (like a small intestinal pathology, tuberculosis, ectopic pregnancy, etc.) at various times. Putting in a laparoscope, with its magnified camera vision, increases the diagnostic accuracy without increasing the size of the incision. This is just the opposite to open surgery, where the smaller the incision the less is the visual diagnosis and ease of surgery.
In coming days, these evidence-based observations could curb surgeons’ enthusiasm for wielding the knife. Appendectomy being the commonest of operations for the resident to develop hand skills, the number of such adventures can also be expected to reduce. Moreover, surgeons would be cautious to avoid lawsuits alleging rash action resulting in operative complications, when non-surgical treatment would have, arguably, succeeded.

Patients will surely feel more relieved to know this, though surgeons may not be ecstatic to see another bread-winning procedure slipping out of hand!

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