A review of appendectomy cases at a single teaching hospital, Baghdad, Iraq

INTRODUCTION

Acute appendicitis is the most common cause of acute abdominal pain and appendectomy is the most frequently performed emergency surgery in the world.^1,2 Although acute appendicitis mortality is low, morbidity remains high.^3,4 The complication rate is related mainly with appendiceal perforation.³ and increases 10 times after appendiceal perforation.^2,5,6 Diagnosis of acute appendicitis is established primarily on patient's history and physical examination supported by laboratory and imaging exams.^7-10 Delay in the diagnosis and treatment is by far the main cause of appendiceal perforation.^11-16

Several factors have been considered to influence the incidence of negative appendectomy. The experience of the surgeon is of great importance. Some investigators have also considered the availability of various diagnostic tests (abdominal ultrasonography and CT) as being very useful in minimizing the incidence of negative appendectomy.¹⁷

Certain unexpected/unusual lesions of the appendix may warrant further clinical attention or follow-up. Data about incidence of appendicitis and related pathological presentation is lacking from Iraq, especially with lack of proper documentation. This study reviewed appendectomies for presumed acute appendicitis over a 4-year period, and entailed auditing of all such surgeries performed in our hospital. By this means we set out to determine the incidence of various pathological findings to different demographic characteristics.

METHODS

Patients in this study were admitted to Al-Karama teaching hospital. The records of all those who underwent appendectomy from 1st of June 2012 to 31st of May 2016 for presumed acute appendicitis were retrieved from the hospital database. All those who had appendectomy performed on a non-emergency basis or as a part of other surgical procedures (e.g. right hemicolectomy for carcinoma of the caecum and incidental appendectomy) were excluded. the records of 243 patients were retrieved in this retrospective study and all the medical notes, operative records, and pathology reports were reviewed.

The diagnosis of acute appendicitis was confirmed if there was infiltration with polymorphs in the muscular is propria of the appendix in some suspected cases, otherwise was confirmed by clinical intraoperative findings. Perforation was defined either intra-operatively by the surgeon, or described in the pathology report. Peri-appendicitis, fibrous obliteration, and serositis were regarded as negative appendectomies. Study defined the reproductive age-group as females aged 11 to 50 years, and the extremes of age as being less than 11 or greater than 70 years. Statistical analysis was performed using the Statistical Package for the Social Sciences (Windows version 10.0; SPSS Inc, Chicago [IL], US). Categorical Results with P value of less than 0.05 were considered statistically significant.

RESULTS

During the 4-year period, there were 243 emergency appendectomies. The number performed each year remained similar and the average number performed annually was around 60. There were 184 patients with clinically and pathologically confirmed acute appendicitis; 95 were male and 89 were female, giving a sex ratio of 1.067 to 1. The median age of the patients with acute appendicitis was 29 (male27.3, female 30.7; range (4-67) years. The median length of hospital stay was 2 (range, 1-22) days.

Figure 1 summarizes the results of the study. Out of the total 243, 47 appendices were normal, making the overall NAR 19.3%; 14.0% in males and 24.6% in females (P<0.001).

Notably, female patients of reproductive age (11-50 years) had a higher NAR than those in the non-reproductive rate was 22.5% (24.8% in males versus 20.1% in females; P=0.68).

When study compared the perforation rate in different age-groups, patients at the extremes of age were more likely to have a perforation (25.2% versus 16.3%; P=0.002). On performing analyses, patients with a normal appendix tended to have a lower mean preoperative white cell count (P<0.001). Patients with a perforated appendicitis tended to have higher body temperatures and pulse rates on admission (P=0.004 and 0.003, respectively). Preoperative imaging was not associated with a lower NAR or perforation rate (p=0.205 and 0.218).

The 30-day mortality rate for patients who underwent appendectomy was negligible.

Appendiceal pathology other than acute appendicitis was found in 12 patients, making an overall percentage of 4.9%. The majority of these were inflammatory appendiceal lesions (8/12, 66.6%); 3 of them had appendiceal diverticulitis and 5 had granulomatous appendicitis. Of the 4 neoplastic appendiceal lesions, 3 were in males, and their ages ranged from 19,48 and 61years, 2 of neoplastic appendiceal pathology were carcinoid tumour, (0.8% of all appendectomies), and mucinous cystadenoma, pseudomyxomaperitonei were each found in one patient.

In 47 patients with a normal appendix, extra-appendiceal pathology was found in 11 (4.5% of all appendectomies); 6 (6.7% of all female patients) had a gynaecological pathology, including: ovarian cysts, endometriosis and pelvic inflammatory disease.

Meckels diverticulitis was found in three of the patients. one of the patients was found to have a perforated peptic ulcer and other patient was found to have ascariasis of the terminal ileum.

DISCUSSION

This study showed that the incidence of acute appendicitis remained similar throughout the 4-year period, which is consistent with the study performed.

Negative appendectomy and perforation of an inflamed appendix are the two main adverse outcomes in managing suspected acute appendicitis. They are usually the result of a low operative threshold and prolonged observation, respectively. Although this is a simple logic, the decision to operate or not is always a challenge even to a senior surgeon. The quoted NAR was 15 to 25%, but could be as high as 40% in female patients.¹⁸

The NAR in this study was 18.2%, which was within the expected range. Since the appendix is in close proximity to the reproductive organs in females, many common gynaecological conditions like dysmenorrhoea and ovarian cyst complications can masquerade as acute appendicitis, thus accounting for their higher NAR.^19,20

Patients of extreme age are more likely to have a delayed diagnosis due to atypical presentations and less efficient communication.

Preoperative imaging has been advocated so as to minimise the chance of a negative appendectomy. Some studies even suggested that routine preoperative imaging could reduce the NAR, but others were contradictory.^21-23

Routine preoperative imaging is not practical because (1) it could never replace taking a thorough history and physical routine preoperative examination; (2) it may overload the radiology department with abdominal pain patients, and (3) it could lead to delayed treatment and hence increased chance of perforation.

Study suggest preoperative imaging be offered more liberally to the two patient groups that we have discussed.

In this study demonstrates limited role of preoperative imaging in reducing the NAR and perforation rate, A properly designed prospective study in collaboration with radiologists to standardise imaging and reporting could be helpful.

The appendectomy mortality rate in our study was negligible comparable to that in a Swedish study, in which 117, 424 patients were recruited and the average 30-day mortality was 0.19%.²⁴

In this cohort, 4.9% of the patients had atypical appendicular pathology; some of whom required further clinical attention and surveillance. It is important that surgeons have some idea of how to deal with such atypical findings.

Prevalence of appendiceal diverticulitis was 1.2% lower than around 2% as quoted in the literature.⁹ Many authorities consider appendiceal diverticulitis to be no different from ordinary appendicitis, although the former usually affects older subjects. In our series, the mean age of patients with appendiceal diverticulitis was 10 years older than those with acute appendicitis. The onset of abdominal pain could be more sub-acute and intermittent, and the respective perforation and mortality rates are 4 and 30 times more than those in the acute appendicitis.²⁵

Granulomatous appendicitis was another inflammatory lesion encountered in this series, though the quoted point prevalence in western countries is 2%, it includes infection by fungi, Yersinia pseudotuberculosis, mycobacterium tuberculosis, parasites, Crohn”s disease, foreign body reactions, and sarcoidosis.²⁶

After exclusion of these causes, idiopathic granulomatous appendicitis is a benign disease. However, follow-up is suggested because the differentiation of appendiceal Crohn”s and granulomatous appendicitis is difficult, and there are reports that granulomatous appendicitis may be a forerunner of Crohn’s disease.²⁷

Concerning the neoplastic appendiceal lesions, carcinoid tumour was the most common and contributed to 0.8% of the cases in this study, which is also comparable to the rate quoted in the literature (0.3-0.9%).^19,20 Most studies agree that appendectomy is the only required procedure in patients with carcinoid tumours of less than 2 cm in diameter, as they generally have a favourable prognosis. Right hemicolectomy should be considered if the tumour diameter exceeds 2 cm, there is evidence of mesoappendiceal extension and lymphovascular permeation, the tumour involves the base of appendix or caecum with positive margins, there is a high mitotic index and Ki67 levels, or goblet cell carcinoid is present.²⁸

Nonetheless, laparotomy and right hemicolectomy are procedures associated with morbidity. Surgeons should therefore have a higher operative threshold for patients with advanced age and high operative risks in view of low recurrence rate, and the smoldering nature of carcinoid disease.²⁹

In cases of appendiceal carcinoma and other non-carcinoid tumours, oncological resection with right hemicolectomy is the treatment of choice regular colonoscopic surveillance for metachronous tumour is recommended in patients with primary neoplastic appendiceal diseases, including carcinoid tumours.³⁰

Concerning the pseudomyxomaperitonei, it is a rare condition secondary to the release of mucinous tumour cells from the appendix, usually by means of a ruptured mucocele.²⁶ Its treatment includes radical peritonectomy and hyperthermic intra-peritoneal chemotherapy.³¹

CONCLUSION

Appendectomy continues to be a very common surgical procedure. Study suggest a more liberal utilization of preoperative imaging in females of reproductive age, and patients at the extreme age.

Long-term follow-up should be offered to patients with granulomatous appendicitis and neoplastic appendiceal diseases, as there may be a potential for development of Crohn”s disease and carcinoma.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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