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The appendix, the tissue committee and the small hospital
The
Appendix, the Tissue Committee and the Small Hospital G. L. WATKINS, M.D., Farmington, Missouri
recent years a great dea1 of study and effort has been directed toward the probIem of the unjustified operation. HospitaIs have set up tissue committees as advocated by the American CoIIege of Surgeons to monitor and help improve the quality of surgery performed. The probIems encountered in anaIyzing the effectiveness of a tissue committee are many and varied. This is a study of this problem as it pertains to appendectomies performed in a smaI1 seventy-five-bed rura1 hospital. It is hoped that this wiI1 heIp answer the question of what constitutes an acceptabIe percentage of error in the diagnosis of acute appendicitis.
I
N
MATERIALS AND METHODS Since the most common major operation performed in the community hospita1 is an appendectomy this operation was chosen for audit. It was further seIected because of the avaiIabiIity of tissue for study in a11 cases. Adequate records were avaiIabIe from 1947 and the investigation was carried through 1937, a tota of eIeven years. There were I ,382 primary appendectomies performed during this period of time. AI1 cases in which operation was performed primariIy to remove the appendix were chosen regardIess of time under observation in the hospital prior to surgery. This incIuded diagnoses ranging from “subacute appendicitis” to “acute perforative appendicitis.” AIso included in this group is the interva1 appendix which will be referred to in this study as chronic recurrent appendicitis. The criteria for the diagnosis of acute appendicitis was a report by the pathologist of Ieukocytic infiItration. The histoIogica1 diagnosis of Iymphoid hyperwithout Ieukoplasia, pinworm infestation cytic infiItration, intraIumina1 fecaIith, fatty infiltration, fibrosed appendix, obIiterative
appendicitis, scarred appendix and so forth, were considered to be normaI appendices. The tissue committee was not established until January, 1954, and consequentIy the study was divided into two parts: appendectomies from January, 1947 through 1953, and those from January, 1954 through 1957. These divisions wiI1 hereafter be referred to as groups I and II, respectiveIy. RESULTS In group I, 916 primary appendectomies were performed and 38.7 per cent proved histoIogicaIIy to be normaI. A preoperative diagnosis of chronic recurrent appendicitis was made in 13 per cent in this series. In group II, 466 primary appendectomies were performed, 29 per cent of which were considered normal, an improvement of aImost IO per cent. A preoperative diagnosis of chronic recurrent appendicitis was made in only four, or Iess than I per cent in this group. In genera1 the diagnosis of chronic recurrent appendicitis has not met with the approva1 of the tissue committee and this has resuIted in the virtua1 disappearance of the interva1 appendectomy from the schedule board. It is recognized, however, that in some instances a preoperative diagnosis of chronic recurrent appendicitis in group I might under similar circumstances have been caIIed “subacute appendicitis” or “early acute appendicitis ” in group II. Whether this is too severe a poIicy might be open to question [I] but it, is beIieved that adopting a more Iiberal one might encourage an excessive number of elective appendectomies. It wouId appear from the record of each individua1 operator that some progress has been made. (TabIe I.) The tighter operative criteria and the Iower
693
American Journal of Surgery, Volume 96, November,
1998
Watkins TABLE I RECORD OF INDIVIDUAL SURGEONS
TABLE III SOURCES OF DIAGNOSTIC ERROR
-
hup Surgeon
CCroup*I (*954-,957)
I (1947-1953)
No. of ippendectomies
No. of
?er cent Norma1
i ippendectomies
Classification
Intrinsic disease (42) : Mesenteric lymphadenitis. Lymphoid hyperplasia. Pinworm infestation.. Chronic recurrent appendicitis.
‘er cent Normal
_ I20
I.....
8 ......... Others .....
3’7 65 64 42 55 ‘05 44 IO4
TotaI ......
916
2 ......... 3 ......... 4 ......... $ .........
6
......... 7 .........
3I 43 I4 42 29 36 35 57 46 38.7
-
12
25 250 66 16 7 56 None None
21
466
29
HistoIogicaIIy negative “ Disease X ” No disease.
-
8.1 8.3
Per cent of Acute Appendices
13. I 11.7
percentage of error in group II has not Ied to an increase in the percentage of perforative appendicitis. (TabIe II.) SOURCES
: 42 39
.I
of these were associated with enIarged Iymph nodes. Pinworm infestation (Enterobius vermicuIaris) was found in seventeen appendices. In the entire eIeven-year series there were forty-two instances of E. vermicuIaris, 43 per cent of which were associated with acute appendicitis. AIthough Ashburn [J] couId not demonstrate any causa1 connection between oxyuriasis of the appendix and acute appendicitis, the IikeIihood of an appendix in which the Iumen is HIed with pinworms giving rise to IocaIized pain in the right Iower quadrant cannot be discounted. The four primary diagnoses of chronic recurrent appendicitis are also pIaced with the intrinsic disease group. The tweIve extrinsic pathoIogica1 conditions eventuating in primary appendectomy formed a very smaI1 fraction of the over-a11 percentage
-
Group I. ........... Group II ............
(81)
I
TABLE II INCIDENCE OF PERFORATIVE APPENDICITIS
Per cent of A11 Appendectomies
14 7 ‘7 4
Extrinsic disease (I 2) : Salpingitis. Renal. Ovarian........................ GastrointestinaI. Pancreatitis. Tuberculous peritonitis.
30 23 31 43 40
46
No. of Patients
OF ERROR
What are the sources of error and what steps can be taken to reduce them? In the group II series one finds 135 cases (29 per cent) in which there was no Ieukocytic infiltration. Careful survey of the records made it possible to divide these into three general cIassifications. (Table III.) There were forty-two intrinsic Iesions which couId have caused symptoms suggestive of appendicitis. Fourteen patients had the socaIIed “mesenteric Iymphadenitis” in which the regiona Iymph nodes were described as “reddened” or “swoIIen.” Many of these had an antecedent upper respiratory infection. Lymphoid hyperpIasia was described by the pathoIogist in seven instances, and these patients presented rather typica symptoms and clinica findings of acute appendicitis [2]. Four
TABLE IV COMPARISONOF
DIAGNOSTIC
FEATURES
I
(GROUP I
Acute Appendix
Males. Females. Vomiting. White bIood cel1 count of 12,000 or over.
694
I
CASES)
t
“ Disease X,, (42)
I 51
II
No Disease
I-
::
2: 69
24
77
58
33
The
Appendix,
Tissue
Committee
of error. This leaves the third cIassification, the eighty-one cases of histoIogicaIIy normal appendices in which nothing was found to account for the symptoms. It is in this group that most of the improvement should take pIace if the percentage of error is to he diminished further. Comparisons between these cases and the 331 acute appendices of group II are interesting. (,TabIe IV.) Sixty-eight per cent were females; vomiting \vas a symptom in less than 50 per cent. In forty-two the symptoms seemed fairIy typical with upper abdomina1 pain, nausea, and frequentIJ vomiting with IocaIized tenderness and muscle guard described in the right Iower quadrant. These symptoms more often than not were associated with Ieukocytosis. These patients invariabIy recovered rapidIy after appendectomy even though the appendix was entireI?- normal histologically. They are classiX” [d]. In the remaining fied as “disease thirty-nine of the eighty-one histoIogicaIIy normal appendices the symptoms commonI?; \vcre present from three days to three weeks or longer, nausea and vomiting were infrequent, and the white blood count was often within normal limits. If operation couId have been avoided in these thirty-nine cases, and if half of the extrinsic group could have been eIiminatcd by I more prolonged and carefu1 examination, a diagnostic error of about 21 per cent could have been attained.
Small
Hospital
and the over-a11 betterment of the diagnostic accuracy indicates some support of the committee. Xloreover, the recognition of perforative appendicitis as a serious disease, the philosophy and vigor of the surgeon, the uneasiness that often comes to a patient and p,hFsician alike during a period of lvatchful w,altrng, and finally the probity of the individua1 surgeon are factors that w-III never be signific>tntl\. inBuenced by rules of a committee. If a11 piimary appendectomies arc included and the problem reaIisticaIIy approached it is doubtful that a diagnostic error of less than 20 per cent will ever be consistently achieved. SUMMARY I. Al1 primary appendectomies performed over an eIeven-year period in a small sevcntyfive-bed hospita1 have been studied. 2. Nine hundred sixteen of these were performed before the establishment of a tissue committee with a diagnostic error of 38.07 per cent. 3. Four hundred sixty-six appendectomies were performed after organization of the tissue committee with a diagnostic error of 29 per cent. 4. Sources of error are discussecl and suggestions made for improvement. REFERENCES
MCLENKAN, I. and WATT, J. Ii. Justification for appendectomy m chronic appendicitis. Brat. M. J., 2: 736738, 1954. 2. NATHANS, A. F., MERESTEIX, H. and BROWS, S. S. Lymph&d hyperplasia of the appendix. Pediatrics, 12: 516 -524, 1953. 3. ASHBURN, L. L. Appendiceal oxyuriasis. Am. J. I.
COMMENTS
Considering the avaiIabiIity of material, few studies of the probIem have been made, and diagnostic errors variousIy caIcuIated range from 13.3 to 25.9 per cent [d-6]. Improvement in the percentage of error in this study is in part due to change in staff personne1 and it is difficult to determine how effectiveIy the tissue committee has functioned. However, the almost compIete disappearance of the preoperative diagnosis of chronic recurrent appendicitis
and
Path., ~7: 841-856, 1941. 4. THIEME, E. P. Concerning the problems of a tissue committee reviewing the diagnosis of acute appendicitis. Surgery, 36: 960-965, 1954. 5. LAWTON, W. E., LUTZ, J. E. and BRADI:ORD, B., JR. The tissue committee. v. The normal appendix. West Virginia M. J., 5 I : 345-348, 1935. 6. MEAGHEK, S. W., CKANDON, J. H. and CAMPBELI., J. A. Appendicitis in children. Neu) England J. Med., 250: 895-900, 1954.
695
Appendix, the Tissue Committee and the Small Hospital G. L. WATKINS, M.D., Farmington, Missouri
recent years a great dea1 of study and effort has been directed toward the probIem of the unjustified operation. HospitaIs have set up tissue committees as advocated by the American CoIIege of Surgeons to monitor and help improve the quality of surgery performed. The probIems encountered in anaIyzing the effectiveness of a tissue committee are many and varied. This is a study of this problem as it pertains to appendectomies performed in a smaI1 seventy-five-bed rura1 hospital. It is hoped that this wiI1 heIp answer the question of what constitutes an acceptabIe percentage of error in the diagnosis of acute appendicitis.
I
N
MATERIALS AND METHODS Since the most common major operation performed in the community hospita1 is an appendectomy this operation was chosen for audit. It was further seIected because of the avaiIabiIity of tissue for study in a11 cases. Adequate records were avaiIabIe from 1947 and the investigation was carried through 1937, a tota of eIeven years. There were I ,382 primary appendectomies performed during this period of time. AI1 cases in which operation was performed primariIy to remove the appendix were chosen regardIess of time under observation in the hospital prior to surgery. This incIuded diagnoses ranging from “subacute appendicitis” to “acute perforative appendicitis.” AIso included in this group is the interva1 appendix which will be referred to in this study as chronic recurrent appendicitis. The criteria for the diagnosis of acute appendicitis was a report by the pathologist of Ieukocytic infiItration. The histoIogica1 diagnosis of Iymphoid hyperwithout Ieukoplasia, pinworm infestation cytic infiItration, intraIumina1 fecaIith, fatty infiltration, fibrosed appendix, obIiterative
appendicitis, scarred appendix and so forth, were considered to be normaI appendices. The tissue committee was not established until January, 1954, and consequentIy the study was divided into two parts: appendectomies from January, 1947 through 1953, and those from January, 1954 through 1957. These divisions wiI1 hereafter be referred to as groups I and II, respectiveIy. RESULTS In group I, 916 primary appendectomies were performed and 38.7 per cent proved histoIogicaIIy to be normaI. A preoperative diagnosis of chronic recurrent appendicitis was made in 13 per cent in this series. In group II, 466 primary appendectomies were performed, 29 per cent of which were considered normal, an improvement of aImost IO per cent. A preoperative diagnosis of chronic recurrent appendicitis was made in only four, or Iess than I per cent in this group. In genera1 the diagnosis of chronic recurrent appendicitis has not met with the approva1 of the tissue committee and this has resuIted in the virtua1 disappearance of the interva1 appendectomy from the schedule board. It is recognized, however, that in some instances a preoperative diagnosis of chronic recurrent appendicitis in group I might under similar circumstances have been caIIed “subacute appendicitis” or “early acute appendicitis ” in group II. Whether this is too severe a poIicy might be open to question [I] but it, is beIieved that adopting a more Iiberal one might encourage an excessive number of elective appendectomies. It wouId appear from the record of each individua1 operator that some progress has been made. (TabIe I.) The tighter operative criteria and the Iower
693
American Journal of Surgery, Volume 96, November,
1998
Watkins TABLE I RECORD OF INDIVIDUAL SURGEONS
TABLE III SOURCES OF DIAGNOSTIC ERROR
-
hup Surgeon
CCroup*I (*954-,957)
I (1947-1953)
No. of ippendectomies
No. of
?er cent Norma1
i ippendectomies
Classification
Intrinsic disease (42) : Mesenteric lymphadenitis. Lymphoid hyperplasia. Pinworm infestation.. Chronic recurrent appendicitis.
‘er cent Normal
_ I20
I.....
8 ......... Others .....
3’7 65 64 42 55 ‘05 44 IO4
TotaI ......
916
2 ......... 3 ......... 4 ......... $ .........
6
......... 7 .........
3I 43 I4 42 29 36 35 57 46 38.7
-
12
25 250 66 16 7 56 None None
21
466
29
HistoIogicaIIy negative “ Disease X ” No disease.
-
8.1 8.3
Per cent of Acute Appendices
13. I 11.7
percentage of error in group II has not Ied to an increase in the percentage of perforative appendicitis. (TabIe II.) SOURCES
: 42 39
.I
of these were associated with enIarged Iymph nodes. Pinworm infestation (Enterobius vermicuIaris) was found in seventeen appendices. In the entire eIeven-year series there were forty-two instances of E. vermicuIaris, 43 per cent of which were associated with acute appendicitis. AIthough Ashburn [J] couId not demonstrate any causa1 connection between oxyuriasis of the appendix and acute appendicitis, the IikeIihood of an appendix in which the Iumen is HIed with pinworms giving rise to IocaIized pain in the right Iower quadrant cannot be discounted. The four primary diagnoses of chronic recurrent appendicitis are also pIaced with the intrinsic disease group. The tweIve extrinsic pathoIogica1 conditions eventuating in primary appendectomy formed a very smaI1 fraction of the over-a11 percentage
-
Group I. ........... Group II ............
(81)
I
TABLE II INCIDENCE OF PERFORATIVE APPENDICITIS
Per cent of A11 Appendectomies
14 7 ‘7 4
Extrinsic disease (I 2) : Salpingitis. Renal. Ovarian........................ GastrointestinaI. Pancreatitis. Tuberculous peritonitis.
30 23 31 43 40
46
No. of Patients
OF ERROR
What are the sources of error and what steps can be taken to reduce them? In the group II series one finds 135 cases (29 per cent) in which there was no Ieukocytic infiltration. Careful survey of the records made it possible to divide these into three general cIassifications. (Table III.) There were forty-two intrinsic Iesions which couId have caused symptoms suggestive of appendicitis. Fourteen patients had the socaIIed “mesenteric Iymphadenitis” in which the regiona Iymph nodes were described as “reddened” or “swoIIen.” Many of these had an antecedent upper respiratory infection. Lymphoid hyperpIasia was described by the pathoIogist in seven instances, and these patients presented rather typica symptoms and clinica findings of acute appendicitis [2]. Four
TABLE IV COMPARISONOF
DIAGNOSTIC
FEATURES
I
(GROUP I
Acute Appendix
Males. Females. Vomiting. White bIood cel1 count of 12,000 or over.
694
I
CASES)
t
“ Disease X,, (42)
I 51
II
No Disease
I-
::
2: 69
24
77
58
33
The
Appendix,
Tissue
Committee
of error. This leaves the third cIassification, the eighty-one cases of histoIogicaIIy normal appendices in which nothing was found to account for the symptoms. It is in this group that most of the improvement should take pIace if the percentage of error is to he diminished further. Comparisons between these cases and the 331 acute appendices of group II are interesting. (,TabIe IV.) Sixty-eight per cent were females; vomiting \vas a symptom in less than 50 per cent. In forty-two the symptoms seemed fairIy typical with upper abdomina1 pain, nausea, and frequentIJ vomiting with IocaIized tenderness and muscle guard described in the right Iower quadrant. These symptoms more often than not were associated with Ieukocytosis. These patients invariabIy recovered rapidIy after appendectomy even though the appendix was entireI?- normal histologically. They are classiX” [d]. In the remaining fied as “disease thirty-nine of the eighty-one histoIogicaIIy normal appendices the symptoms commonI?; \vcre present from three days to three weeks or longer, nausea and vomiting were infrequent, and the white blood count was often within normal limits. If operation couId have been avoided in these thirty-nine cases, and if half of the extrinsic group could have been eIiminatcd by I more prolonged and carefu1 examination, a diagnostic error of about 21 per cent could have been attained.
Small
Hospital
and the over-a11 betterment of the diagnostic accuracy indicates some support of the committee. Xloreover, the recognition of perforative appendicitis as a serious disease, the philosophy and vigor of the surgeon, the uneasiness that often comes to a patient and p,hFsician alike during a period of lvatchful w,altrng, and finally the probity of the individua1 surgeon are factors that w-III never be signific>tntl\. inBuenced by rules of a committee. If a11 piimary appendectomies arc included and the problem reaIisticaIIy approached it is doubtful that a diagnostic error of less than 20 per cent will ever be consistently achieved. SUMMARY I. Al1 primary appendectomies performed over an eIeven-year period in a small sevcntyfive-bed hospita1 have been studied. 2. Nine hundred sixteen of these were performed before the establishment of a tissue committee with a diagnostic error of 38.07 per cent. 3. Four hundred sixty-six appendectomies were performed after organization of the tissue committee with a diagnostic error of 29 per cent. 4. Sources of error are discussecl and suggestions made for improvement. REFERENCES
MCLENKAN, I. and WATT, J. Ii. Justification for appendectomy m chronic appendicitis. Brat. M. J., 2: 736738, 1954. 2. NATHANS, A. F., MERESTEIX, H. and BROWS, S. S. Lymph&d hyperplasia of the appendix. Pediatrics, 12: 516 -524, 1953. 3. ASHBURN, L. L. Appendiceal oxyuriasis. Am. J. I.
COMMENTS
Considering the avaiIabiIity of material, few studies of the probIem have been made, and diagnostic errors variousIy caIcuIated range from 13.3 to 25.9 per cent [d-6]. Improvement in the percentage of error in this study is in part due to change in staff personne1 and it is difficult to determine how effectiveIy the tissue committee has functioned. However, the almost compIete disappearance of the preoperative diagnosis of chronic recurrent appendicitis
and
Path., ~7: 841-856, 1941. 4. THIEME, E. P. Concerning the problems of a tissue committee reviewing the diagnosis of acute appendicitis. Surgery, 36: 960-965, 1954. 5. LAWTON, W. E., LUTZ, J. E. and BRADI:ORD, B., JR. The tissue committee. v. The normal appendix. West Virginia M. J., 5 I : 345-348, 1935. 6. MEAGHEK, S. W., CKANDON, J. H. and CAMPBELI., J. A. Appendicitis in children. Neu) England J. Med., 250: 895-900, 1954.
695