Journal Club 21/11/03

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Journal Club 21/11/03

• At laparoscopy for ?appendicitis, should a normal
  looking Appendix be removed, when there is no
  other pathology?

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IINTERACTVE PART!

• ADULTS PAEDS
• Matthews Take Shi Take
• Donnellan Take Adams - Leave
• Crowe Take Dilley - Take
• Grieve Leave Henry - Take
• Keogh Take Curry - Leave
• Janindra Take Varja - Take

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INTRODUCTION

• Removing a normal appendix
• Wound infection increased
• Prolongs OT time and cost
• Increases anaesthetic risk
• Adhesions locally and possible BO
• Case report long appendiceal stump represented
  with appendicitis 2/12 post normal removal
• ?Further urological reconstruction
• Removing normal appendix continued pain more
  likely if normal appendix removed

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INTRODUCTION

• Question of whether a normal appendix is
  normal. Will it eventuate into frank
  appendicitis at a later date?
• Should the normal appendix be removed at
  operation for appendicitis? B Grunewald and J
  Keating. Prospective study
• Surgeons PPV 91 for acute appendicitis
• Of 132 appendixes thought to be inflamed, only
  120 were histopathologically confirmed
• Not inflamed 32/43 74. False rate of 26
• Champault et al showed 92 accuracy in diagnosing
  acute appendicitis at laparoscopy
• Lau et al showed 19 of normal appendixes were
  found to be inflamed at histopathology

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CHOOSING THE ARTICLE

• Medline 1966 Present
• Meshed Appendicitis and Laparoscopy
• Limited to Human and English 351

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PAPER 1

• Should an Appendix that looks Normal be removed
  at Diagnostic Laparoscopy for Acute Right Iliac
  Fossa Pain?
• SH Teh, S OCeallaigh, JGK McKeon, MK ODonohoe,
  WA Tanner and FBV Keane
• European Journal of Surgery 2000 166 388-389

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AIMS

• To find out whether the removal of the appendix
  from patients in whom laparoscopy for acute right
  iliac fossa pain shows no abnormality is
  justified to avoid the risk of missing acute
  appendicitis

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STUDY DESIGN

• Retrospective study
• Notes reviewed on 254 patients that had emergency
  laparoscopy for acute abdominal pain (Jan 90-
  July 97 Dublin)
• INCLUDED Pts with signs of appendicitis
• Normal appendix at laparoscopy
• Appendix left at OT
• Total of 41 patients (36 women)
• FU either with telephone or via GP or both

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RESULTS

• 34/41 Pts available for FU (Mean 2yrs (0.8-
  3.3yrs))
• 7 lost (young mobile population)
• 21/34 were symptom free
• 13/34 RIF pain (12 in 1st 6/12, 11 women)
• X2 underwent appendicectomies normal at path
  but still had persistent pain
• X2 underwent laparoscopy normal and pain
  resolved
• X5 USS -X4 Colonoscopy
• IBS x2 -Ovarian cyst x2
• UC x1 -PUD x1 x7 ?Diagnosis

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PAPER 2

• A Normal Appendix found during diagnostic
  laparoscopy should not be removed.
• WT Van den Broek, AB Bijnen, P de Ruiter and DJ
  Gouma
• British Journal of Surgery 2001, 88, 251-254

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METHOD/ STUDY DESIGN

• Prospective study (94-97) Median FU 4.4 yrs
• GP referral for ?appendicitis
• 109 diagnostic laparoscopies on a selective group
  of pts
• Where there was doubt of clinical diagnosis of
  appendicitis
• Removed if inflamed or unsure
• All were seen at 6/52 OPD.
• Subsequent telephone FU 1999

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RESULTS

• 1050 Pts (51 women 37 men 12 children)
• 202 were discharged
• 471 open appendix (45)
• 13 -ve appendicectomy rate
• 377 (67 w 22 m 11 ch) laparoscopy
• 268 had appendicectomies (71)
• 94 LAPAROSCOPICALLY 174 OPEN
• 15 -ve appendix rate
• 109 left Group 1 Other pathology (74 Gynae)
• Group 2 no other pathology

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RESULTS

• Group 2 (44 Pts) normal appendix and no other
  pathology
• 7 of the 44 represented to ED with abdo pain
  Median 8/12
• 3 were readmitted
• 1 elective appendicectomy for chronic pain
  normal appendix symptoms remained
• 2 appendicectomy for ?appendicitis one was
  normal, the other had laparoscopic removal of
  inflamed appendix.
• Group 1 and 2 no difference in recurrence of
  symptoms or treatment

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RESULTS After telephone FU

• 3 abroad 1 dead not appendicitis
• 41 for FU
• 3 Recurrent lower abdo pain
• 3 sought medical specialist
• x2 Diagnosed with IBS
• No false ves post op
• 1 appendix removed 1 no higher than normal
  population

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CONCLUSIONS

• LEAVE IT
• Good recruitment and attempt to FU enough pts. 2
  papers very similar no of pts.
• No control/randomised
• No false negatives
• Question of whether Normal appendixes no
  appendicitis or if mild appendicitis which
  settled with antibiotics

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STRENGTHS/ WEAKNESSES / APPLICABLE

• Retrostudy and Prospective
• ?Being involved in study altered pts perception
  ?Not sure if aware in study