The appendix: to snip or not to snip?

MEDICAL MATTERS:Why are appendectomies less common now?

WHEN BUILDING a past history with a new patient, it is quite striking how many older people have had a tonsillectomy or appendectomy. Both surgical interventions were far more common in the past than they are now. I recently came across a research paper on the health of recruits entering the RAF in the 1950s, which showed that more than a third of young men had had a tonsillectomy while about 10 per cent had undergone an appendectomy by the time they reached 20.

Separate research noted that while appendectomy ran in families, appendicitis (inflammation of the appendix) did not. Another hint that appendectomy was sometimes influenced by non-biomedical factors was that surgeons were more likely to remove appendices from nurses and from colleagues’ children.

So was there (and is there still) a social element to the decision to carry out either of these operations? Not quite at the “too posh to push” level prevalent in women of a certain status keen to have a more suitably timed birth, but perhaps in those 50:50 cases where “watchful waiting” is an option, the decision to whip out a child’s tonsils or appendix has been nudged by certain social pressures.

Where tonsillitis is concerned, at least antibiotics are an option before the scalpel is sharpened. But until researchers suggested using antibiotics as a first-line treatment in appendicitis, definitive treatment meant removing the offending organ.

Last week's Lancethad a most interesting paper by French researchers in which they compared antibiotic treatment of uncomplicated acute appendicitis with an emergency appendectomy.

They decided to use the occurrence of peritonitis (the spread of infection to the abdominal cavity) some 30 days after treatment as a measure of success or failure. When the management of appendicitis with antibiotics was successful, the incidence of post-treatment peritonitis was zero. However, if antibiotics failed, the organ space surgical site infection rate was very high, at 14 per cent compared with 1.7 per cent in the appendectomy group. Rather than label the results as an out-and-out failure of the antibiotic option, the researchers concluded that finding certain predictive markers on a Cat scan of the abdomen may improve the targeting of antibiotic treatment for acute appendicitis.

Other diagnostic advances mean that up to two-thirds of patients with suspected appendicitis can now be spared an operation. And for those who undergo surgery, the invention of the laparoscope has significantly changed the management of acute appendicitis. This “miniature telescope” is inserted through the belly button, allowing the surgeon to directly view the appendix. If the appendix is inflamed, it can be removed, using instruments passed through the laparoscope. If it is normal, unnecessary surgery is avoided. This advance has halved the number of wound infections and reduced post-operative pain, the length of hospital stay and the time taken to return to work.

Times have changed for tonsillectomy also. Once bordering on the ubiquitous, the latest guidelines from the American Academy of Otolaryngology limit the operation to children with the most severe and frequently recurrent throat infections. In truth, the number of tonsillectomies had already dropped considerably, to the point where paediatricians are noting an increase in children whose tonsils obstruct the throat enough to affect breathing while they sleep.

One man who had no option but to choose an appendectomy was Leningrad surgeon Leonid Rogozov. In 1961 this member of the sixth Soviet Antarctic expedition noticed symptoms of weakness, nausea and, later, pain in his upper abdomen, which shifted to the right lower side. He was the only doctor at the snowbound base, and the weather meant he could not be airlifted out – so he successfully carried out an auto-appendectomy. It certainly puts social pressures to operate in a different light.