Abstract
Apparently acute appendicitis as a disease has been around at least for thousands of years, as evidence from Egyptian mummies show, but it was not until renaissance that appendix as an anatomic entity was defined (1). It took few hundred years more until Fitz (2) in 1886 published an article on the diagnosis and management of acute appendicitis and McBurney (3) in 1894 described the muscle splitting incision. It was also Charles McBurney (4) who in 1891 described the exact point of maximal tenderness in acute appendicitis, known as the “McBurney’s point.” Diagnosis based on clinical examination followed by open appendectomy became the standard for the next 100 years, and was the most common surgical emergency we as surgical residents encountered. And we thought that “the case is closed,” no need for further research or innovations. What little did we know …
First of all, it is not going away. The lifetime cumulative incidence of acute appendicitis in Western world is about 9%, and it seems to increase both in developed and developing countries (5, 6). Second, it is not an innocent disease. The case fatality rate in Sweden in 1987–1996 was 2.44/1000 appendectomies with highest rates among the elderly and when perforated (7). How can we improve the outcome?
We need to diagnose (and treat) the disease earlier. Decreasing pre-hospital delay requires educational efforts both toward the public and to the primary health-care providers so that the patients with suspected appendicitis will be evaluated with minimal delay. In-hospital delay can be improved by better diagnostics, whether supporting clinical evaluation with imaging techniques such as ultrasound or low-dose computed tomography, or relying on various diagnostic scores (8 –10). Organizing our emergency surgery system better has been shown to improve outcome (11). Outpatient laparoscopic appendectomy is also feasible and safe, and could result in major savings in resources (12).
The treatment options are still controversial; surgery or antibiotics, laparoscopic or open surgery, just to mention two. Most Western academic centers prefer laparoscopic over open appendectomy, and there are numerous studies that seem to support the superiority of the laparoscopic approach (13). However, the differences in outcome are not that drastic and under many rural and third-world conditions open appendectomy is a perfectly accepted option. On the other hand, the laparoscopic techniques are constantly developed using a single-incision approach (14) or gasless laparoscopy (15), for example. Even “new” diseases are discovered, such as the stump appendicitis, although obviously it can also occur after incomplete open appendectomy (16).
There are several randomized trials (and more coming) comparing antibiotic treatment with appendectomy in patients with acute uncomplicated appendicitis and even some meta-analyses (17, 18). So, the jury is still out …
Finally, the manifestation and natural progression of acute appendicitis varies considerably and perhaps in the future the treatment can be tailored to the patient’s genetic profile (19). While waiting for that, we still need to do research to find the best practices, as shown in some of the articles in this issue of the Scandinavian Journal of Surgery.