All surgeons strive to operate on the inflamed appendix before
perforation takes place but when, as Andersson et al suggest1, the resolve
to play safe results in 20 - 30% of excised appendices proving to be
normal, then the question has to be asked whether "the Gordian knot of
appendicitis diagnosis (should be) untied with the scalpel " 2.
Studies over the past 30 years have shown that only 30 - 40%of
patients admitted with acute abdominal pain need an
emergency operation. Another 30%, sent in with possible appendicitis,
settle without treatment, and others prove to have medical or non-surgical
causes for pain. To identify these groups - and so avoid operating on them
- investigation and "active observation" is required. This regime has now
been thoroughly tested in children and adults, and shown to be practical
and safe. In 8 reports on over 1000 patients having an appendicectomy for
possible appendicitis (either on admission or after observation) the
negative appendicectomy rate was 6.8%. Where perforation rates were given,
92% were diagnosed on admission: the other 8% were recognised after
observation and all made a good recovery 3. In a previous study Andersson
confirmed that low numbers of negative appendicectomies are not associated
with a high perforation rate 4.
As in many situations in medicine, a balance has to be struck here
between undue haste and unwise delay. It is reassuring to know that
infertility rarely follows perforated appendicitis. This finding, taken
with the results of careful observation of the patient with debatable
signs, should allow many unproductive laparotomies to be avoided.
Peter F Jones
Emeritus Clinical Professor of Surgery
University of Aberdeen
1 Andersson R, Lambe M, Bergstrom R. Fertility patterns after
appendicectomy: historical cohort study. BMJ 1999; 318:963-7. (10 April).
2 Hoffmann J, Rasmussen OO. Aids in the diagnosis of acute
appendicitis. Br J Surg 1989; 76: 774-9.
3 Jones PF, Bagley FH. Acute appendicitis. In: Jones PF, Krukowski
ZH, Youngson GG, eds. Emergency Abdominal Surgery. 3rd edition. London:
Chapman and Hall, 1998: 49 - 52.
4 Andersson RE, Hugander A, Thulin AJG. Diagnostic accuracy and
perforation rate in appendicitis: association with age and sex of the
patient and with appendicectomy rate. Eur J Surg 1992; 158: 37 - 41.
Rapid Response:
Perforated appendicitis and infertility
Editor
All surgeons strive to operate on the inflamed appendix before
perforation takes place but when, as Andersson et al suggest1, the resolve
to play safe results in 20 - 30% of excised appendices proving to be
normal, then the question has to be asked whether "the Gordian knot of
appendicitis diagnosis (should be) untied with the scalpel " 2.
Studies over the past 30 years have shown that only 30 - 40%of
patients admitted with acute abdominal pain need an
emergency operation. Another 30%, sent in with possible appendicitis,
settle without treatment, and others prove to have medical or non-surgical
causes for pain. To identify these groups - and so avoid operating on them
- investigation and "active observation" is required. This regime has now
been thoroughly tested in children and adults, and shown to be practical
and safe. In 8 reports on over 1000 patients having an appendicectomy for
possible appendicitis (either on admission or after observation) the
negative appendicectomy rate was 6.8%. Where perforation rates were given,
92% were diagnosed on admission: the other 8% were recognised after
observation and all made a good recovery 3. In a previous study Andersson
confirmed that low numbers of negative appendicectomies are not associated
with a high perforation rate 4.
As in many situations in medicine, a balance has to be struck here
between undue haste and unwise delay. It is reassuring to know that
infertility rarely follows perforated appendicitis. This finding, taken
with the results of careful observation of the patient with debatable
signs, should allow many unproductive laparotomies to be avoided.
Peter F Jones
Emeritus Clinical Professor of Surgery
University of Aberdeen
1 Andersson R, Lambe M, Bergstrom R. Fertility patterns after
appendicectomy: historical cohort study. BMJ 1999; 318:963-7. (10 April).
2 Hoffmann J, Rasmussen OO. Aids in the diagnosis of acute
appendicitis. Br J Surg 1989; 76: 774-9.
3 Jones PF, Bagley FH. Acute appendicitis. In: Jones PF, Krukowski
ZH, Youngson GG, eds. Emergency Abdominal Surgery. 3rd edition. London:
Chapman and Hall, 1998: 49 - 52.
4 Andersson RE, Hugander A, Thulin AJG. Diagnostic accuracy and
perforation rate in appendicitis: association with age and sex of the
patient and with appendicectomy rate. Eur J Surg 1992; 158: 37 - 41.
Competing interests: No competing interests