By Rita Rubin
USA TODAY
Appendectomies are the most common emergency general surgical procedure in the USA, but a new study suggests many are unneeded. According to conventional medical wisdom dating back to the late 19th century, if you don't remove an inflamed appendix, it could burst and lead to potentially life-threatening complications such as an abscess or peritonitis. The study, out today in the Archives of Surgery, implies that perforated, or ruptured, appendicitis is a different disease from non-perforating appendicitis. In other words, some inflamed appendixes won't burst, no matter how long you wait to remove them. "I don't think the disease is as straightforward as we thought, and I believe it needs to be revisited," says senior author Edward Livingston, chief of gastrointestinal and endocrine surgery at the University of Texas Southwestern Medical Center in Dallas. Though the cause of appendicitis isn't known, Livingston's study links non-rupturing — but not ruptured — disease to viral infections, an association supported by reports of clusters, or outbreaks, of appendicitis cases. Using U.S. hospital discharge data from 1970 to 2006, the authors found that annual rates of non-rupturing appendicitis fell and rose along with influenza. The researchers are not saying that the flu causes appendicitis, because over the course of a year, seasonal influenza peaks in the winter, while non-rupturing appendicitis is slightly more common in the summer. But in an accompanying "invited critique" of the study, Rebecca Britt, a surgeon at Eastern Virginia Medical School in Norfolk, speculates that influenza might set up the immune system for infection by another, as-yet-unidentified virus that causes appendicitis. According to some theories, Livingston and his coauthors write, a viral infection could damage the appendix's mucous membrane, leading to a bacterial infection. Some studies suggest simply treating appendicitis with antibiotics — which were unavailable when the first appendectomy was performed more than a century ago — could eliminate the need to remove the appendix. Livingston is planning a trial in which all participants would first be treated with antibiotics for their non-rupturing appendicitis. Only those who don't improve in 12 to 24 hours would have an appendectomy. He practices what he preaches. Three years ago, Livingston says, his son, then 14, awakened him and his wife, an internist, at 2 a.m. with what appeared to be a classic case of appendicitis. The doctors told their son to go back to bed, and he was fine the next day. Rodney Mason, an associate professor of surgery at USC, is a believer. At a professional meeting in November, he reported on 70 patients whose "uncomplicated" appendicitis was treated satisfactorily with antibiotics. To answer skeptics who question whether the patients really had appendicitis, he notes that CT scans confirmed that diagnosis.