ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Validation of Appendectomy Allan J. Ryan To cite this article: Allan J. Ryan (1979) Validation of Appendectomy, Postgraduate Medicine, 65:1, 19-21, DOI: 10.1080/00325481.1979.11715015 To link to this article: http://dx.doi.org/10.1080/00325481.1979.11715015
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 22 August 2017, At: 01:12
POSTGRADUATE MEDICINE 1/79
VALIDATION OF APPENDECTOMY Can it be done? Downloaded by [Australian Catholic University] at 01:12 22 August 2017
Allan J. Ryan, MD
My father would be amazed to learn that the benefits of appendectomy vs the risks have not yet been established in controlled trials. When he started surgical practice in the early 1900s there were no formal surgical training programs, most surgeons did not wear gloves, and pus was still thought "laudable." He did not know that in 1843 Willard Parker had successfully drained an appendiceal abscess. He and his colleagues did know, however, of Reginald Fitz's report in 1886 clearly establishing appendicitis as a clinical and pathologic entity, and of his report of 72 cases in 1889, in which he recommended early operation as well as interval appendectomy. In 1888 Henry Sands removed an appendix before perforation occurred, and in 1889
his assistant, Charles McBurney, described the diagnostic point of abdominal tenderness that still bears his name. Although appendectomy became common after 1890, in many cases operation was not done until perforation had occurred and peritonitis had developed. This happened in my own case as a boy, despite my father's calling another surgeon to see me within 24 hours after onset of symptoms. Prominent victims of appendicitis during the pre-antibiotic era included Harry Houdini and Rudolph Valentino. As late as 1936, well over 16,000 deaths from appendicitis occurred. Today mortality from appendicitis, including the most complicated cases, is less than I%. Virtually every patient with a diagnosis of appendicitis has an appendectomy urgently, or drainage of an abscess followed by appendectomy.
VOL 65/NO 1/JANUARY 1979/POSTGRADUATE MEDICINE
The Office of Technology Assessment (OTA) has recently issued a document questioning the general acceptance by physicians of 12 common procedures, including four that are surgical: tonsillectomy, hysterectomy, coronary bypass, and appendectomy. The first three have been the subject of several studies, none of which could be described in strict scientific terms as controlled. Nonoperative management of appendicitis, using acupuncture, moxibustion, and other measures, has been practiced in the Peoples' Republic of China, but not in a controlled fashion. Nonoperative management of acute appendicitis was enforced in the US Navy submarine service during World War II after appendectomy had been attempted at sea by medical corpsmen in two cases with less than satisfactory results (but no deaths). How many cases were managed with anticontinued
Downloaded by [Australian Catholic University] at 01:12 22 August 2017
biotics alone has not to my knowledge been reported. People do sometimes recover spontaneously from attacks of acute appendicitis. I have operated on young people who had repeated attacks of right lower quadrant abdominal pain and who had either not been seen by a physician or, if they had been seen, did not have findings that appeared to justify a diagnosis of appendicitis. In each instance, at operation on the occasion of a recurrent attack, the appendix was found either posterior to the cecum or tucked into a mass of scar tissue behind the terminal ileum. One of these patients had been given a diagnosis of regional ileitis by the late Burrill Crohn, who gave the disease its classic description. The patient was cured after removal of a gangrenous appendix from a mass of scar tissue behind the terminal ileum. I suspect that cases of this sort gave rise to the old diagnosis of perityphlitis. I have also seen recurrent appendicitis in the overlong stump of an appendix previously partially removed. Thus, I have the strong feeling that even if acute appendicitis can be caused to subside by nonoperative means-especially with the antibiotics now available-it will recur in time. This does not leave us with a very good measure for evaluating the success of a controlled study of appendectomy. How long would follow-up have to continue to assure that another, and perhaps more
threatening, attack did not occur? I have removed an acutely inflamed appendix from a 6-month-old infant and from a 92-year-old woman. What about removal of the appendix incidental to another abdominal operative procedure-a prophylactic measure practiced for years? Since appendicitis is common and there are times and places inconvenient for an acute attack, this seems a reasonable procedure that does not add appreciably to the general operative risk in appropriate cases. I have removed an acutely inflamed appendix in five women in various stages of pregnancy and have seen one woman with acute appendicitis during labor who was operated on safely after delivery. In the remarkable three-year journey of Lewis and Clark to the Pacific and back (1803-1806), the only man lost from the party died of what was probably a ruptured appendix. My father told me that he believed the diagnosis of acute appendicitis to be the most difficult one for a surgeon to make accurately, and my experience has confirmed his. There are so many other frequently indistinguishable abdominal events- regional ileitis, Meckel's diverticulum, infarction of the omentum, mesenteric lymphadenitis, and the various problems that afflict the ovaries and fallopian tubes-that being right 100% of the time is impossible. I have found the appendix under the liver, near the umbilicus, and in the
VOL 65/NO 1/JANUARY 1979/POSTGRADUATE MEDICINE
left lower quadrant of the abdomen. If the surgeon can be right 90% of the time, his or her surgical judgment is good. Since a sine qua non for all surgery today is the patient's informed consent, I would like to support the OT A's proposal for a controlled study of appendectomy (operative vs nonoperative treatment), providing each potential candidate for the trial is made familiar with the type of information I have related here, plus a careful description of peritonitis, pelvic and subhepatic abscess, and other possible complications of appendiceal rupture and abscess. I wonder how long filling up the nonoperative group would take. If my father were still alive, I think he would say it would be a very long time.