Health: Appendicitis: To operate or not to operate

This year about 700,000 appendectomies will be performed in North America. And although the lowly appendix does not get the attention associated with other problems, each year nearly 3,000 people will die of appendicitis. But do all cases require surgery?

We’ve come a long way since the French surgeon Dupuytren ridiculed the idea that the appendix could be the cause of infection. Later, Henry Sands, a New York surgeon, simply stitched up a hole in an appendix! It’s also hard to believe that another surgeon, just straightened out the kinks in the appendix! If these patients survived, it was the Almighty who saved them.

The appendix is a fingerlike tube about four inches long that’s situated in the lower right side of the abdomen. It’s usually bacteria, viruses, parasites, or fungi that block the opening of the appendix, triggering infection and pain.

Today, once the diagnosis has been made, the gold standard for treatment is immediate surgical removal of the appendix. For years this has involved an abdominal operation. Now, removal is often performed by laparoscopic keyhole surgery. But whatever the decision, the key is to remove the appendix before it ruptures, resulting in peritonitis, and possible death.

Some studies show that surgery may not always be required for all cases of appendicitis. For instance, a study in Finland, conducted between 2009 and 2012, analyzed cases of uncomplicated appendicitis. These involved patients without perforation, abscess formation and inflammation located to the appendix. Some were treated successfully by antibiotics and did not require surgery during a one year follow-up period. Others, where antibiotics failed, required surgery but did not have any significant complications due to the delay.

A later study in 2018 concluded that six out of ten patients who were treated with antibiotics for uncomplicated acute appendicitis remained free of disease for five years. Further studies have also concluded that using antibiotics is a feasible alternative to surgery.

I would add some other important considerations. Where you’re located when appendicitis strikes is important. Years ago, I was a young surgeon on a ship transporting 800 displaced people from Germany to Canada. There was no anesthetist on board. The antibiotic option would have been an easy decision if I had encountered a passenger with appendicitis.

But even if a surgeon is in a well-equipped hospital, the decision is never easy. Every surgeon knows the abdomen can contain a surprise package that can result in embarrassing findings. So what he or she believes is a docile appendix may be about to rupture with dire consequences. Or the diagnosis may be a twisted gangrenous ovarian cyst or cancerous bowel.

It’s been nearly 300 years since Claudius Amyand removed the first appendix at St. George’s Hospital in London, England. Now, every year, about 700,000 North Americans will develop appendicitis, 13,000 people a week, 1,836 a day, 77 an hour, or one per minute.

It’s always a tragedy when someone dies of preventable disease. Today one person in a thousand dies due to a non-perforated appendix. It’s five in a thousand if perforated.

So don’t make these errors. If you develop abdominal pain, do not self-diagnose and assume you’ve just overindulged at dinner. Don’t believe the pain is due to constipation and take a laxative. This is the wrong decision if pain happens to be due to a bowel obstruction. And do not decide to eat a meal.

The logical decision is to get medical advice quickly. When sudden pain strikes the lower right abdomen, see your doctor, and if pain is severe, go to the hospital emergency.

Remember, “If you decide to treat yourself you have a fool for a patient!”

Dr. W. Gifford-Jones can be reached at info@docgiff.com

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