Arkadiusz Peter Wysocki describes for SIIC his article published in ANZ Journal of Surgery 85(7/8):521-524, July 2015

Queensland, Australia (special for SIIC)
Death following appendicectomy is a rare event with a wide reported range around the world. Mortality is age dependent. However, when stratified for disease severity, the impact of chronological age is diminished. The main causes of death following appendicectomy for acute appendicitis are cardiovascular disease and sepsis. Hospital volume and laparoscopic versus open appendicectomy seem to not affect mortality risk. Many perforations occur prior to hospital admission and are not related to a delay to surgery. Patients undergoing surgery for acute appendicitis may at times undergo procedures other than simple appendicectomy e.g. abscess drainage, caecectomy or right hemicolectomy. Some are managed nonoperatively. Whether mortality following appendicectomy alone is equivalent to mortality in the setting of acute appendicitis in the current decade has not been explored. The authors have reviewed the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database in order to determine whether patients who died with a primary diagnosis of acute appendicitis underwent appendicectomy alone.

Deaths are reported to ANZASM by the hospital if the patient was an in-patient at the time of death and under the care of a surgeon, whether or not a surgical procedure was performed. Patients who were readmitted and died within 30 days of surgery are included. The data is provided by treating surgeons using a standard form. Prospectively collected data through ANZASM (2009 to 2012) was analyzed.

A total of 13,039 surgically-related deaths had been reported to ANZASM. The data collection tool was complete for 2,997 patients who died under the care of a gastrointestinal surgeon and 26 patients were identified as having died with a primary diagnosis of acute appendicitis.

Of the 26 patients none had a terminal malignancy. Sex distribution was almost equal. Median age was 83 years. Median length of stay was eight days. The median number of comorbidities was 3. Median American Society of Anesthesiologists (ASA) class was 4. Twelve (out of 16 with available data) underwent a diagnostic abdominal Computed Tomography (CT) scan. Four patients were managed with antibiotics alone, predominantly due to family refusal of surgery.

Twenty-two patients underwent at least one operation. The median duration of symptoms prior to presentation was four days (in the nine patients with available data). An operation almost always occurred on the day of admission. In 16 patients the first operation was a laparotomy. Only four appendicectomies were performed via laparoscopy or a McBurney approach. In two patients, the operative approach for the appendicectomy could not be determined from the available data. Ultimately, the first operation performed was: appendicectomy (16), right hemicolectomy (5), and abscess drainage (1). The median Disease Severity Score was 4. One in three had an unplanned return to theatre (7 / 22). All reoperations were by means of laparotomy for the purpose of adhesiolysis, enterotomy repair, ileostomy formation or right hemicolectomy.

This study demonstrates a significant proportion of adults who died with a primary diagnosis of acute appendicitis had advanced appendicitis and did not undergo simple appendicectomy. Interestingly, a small number of patients died without surgical intervention. This study confirms prior findings that death in the setting of acute appendicitis occurs predominantly in elderly patients with multiple comorbidities.

Methodological strengths: inclusion of all adults who died with a primary diagnosis of acute appendicitis regardless of whether they underwent an operation or the surgical approach; inclusion of all Australian states and territories and access to systematically collected data entered by surgeons using a self-reporting tool as opposed to an administrative database.

Limitations: denominator variation; inability to capture patients who underwent surgery for suspected appendicitis but other pathology was identified; including only deaths while under the care of a surgeon; and possible self-reporting bias.

Those who died in the setting of appendicitis are elderly patients with multiple comorbidities who presented late with advanced disease and many underwent surgery other than simple appendicectomy alone. Some patients were so infirm their carer’s instructed the surgical team to not operate on their loved ones. Most underwent a preoperative abdominal Computed Tomography scan presumably due to advanced age and the possibility of coexisting caecal adenocarcinoma. The vast majority of patients underwent surgery on the day of admission (i.e. delay to diagnosis and treatment seems not to be frequent) but one third had an unplanned return to theatre possibly due to concerns of ongoing sepsis. The majority of patients were treated in a Critical Care Unit but died a median of eight days following admission.

The current study suggests in hospital mortality from acute appendicitis in Australian hospitals is rare and typically occurs in the setting of complex disease rather than following simple appendicectomy.