Managing acute appendicitis

Editor—Like many others will have been, I was astonished at the assertion in Benjamin and Patel's leader that mortality from negative appendicectomy (1.5%) exceeded that of appendicectomy for acute appendicitis (0.2%).¹ It is clear from reading their source document, that this is a seriously misleading statistic, the figure of 1.5% representing the mortality of comorbidity rather than that of the appendicectomy itself.²

In a study of all 805 deaths from appendicitis or appendicectomy in Scotland (population 5 million) over 10 years to 1963, mortality from appendicectomy for appendicitis was 0.62%, and that from negative appendicectomy was 0.06%. Seventy one of the 605 patients (11.7%) for whom clinical records could be studied had previously been treated non-operatively for suspected appendicitis, and 55 of them died from gangrenous or perforated appendicitis.³ For patients aged 12-29, in whom diagnostic difficulty is greatest, mortality from appendicectomy for appendicitis and for negative appendicectomy was 0.16% and 0.02%; the death rate from missed appendicitis—difficult to calculate exactly—was at least 0.04%.

Attempting to project these results to the then competing management strategies I described as conservative (operating on around 60% of patients admitted with possible appendicitis) and radical (operating on 80% of such admissions) for patients in the age group 12-29,⁴ I estimated that avoidable mortality (death from missed appendicitis plus that from negative appendicectomy) from the two approaches was virtually identical at 1.13 and 1.07 patients per 10 000 admissions—figures which then represented 0.6 avoidable deaths per year in Scotland. It is hard to believe that all the advances described by Benjamin and Patel since then can have done all that much to improve these statistics.

Two other observations are relevant.

Firstly, appendicectomy but not appendicitis runs in families.

Secondly, conservative surgeons become radical surgeons when dealing with medical and nursing colleagues and their families when they present with possible appendicitis. In this field at least, surgery—like general practice—combines the skills of a behavioural with those of a biomedical science.

Jones ends his review of the contemporary management of suspected acute appendicitis by saying that we can be sure that emphasis on technology at the expense of clinical evaluation will diminish, rather than improve, the quality of care for patients with acute abdominal pain—a truth that surely has much wider applications.⁵