Management of Acute Apendicitis in the New Millennium

The prevalence of acute appendicitis in The Netherlands is 16460 times a year, 8647 man and 7813 women in 2006 and is still increasing. The chance of undergoing an appendectomy is higher in women than in men, 23 versus 12 percent, this is in contradiction with the chance of developing acute appendicitis, 7 versus 9 percent, due to the number of incidental and unnecessary appendectomies. In spite of the high incidence of acute appendicitis the percentage appendices without signs of infl ammation during surgery remains high, between 5% and 30%. These data show the challenge to the clinician to diagnose acute appendicitis. Adjacent to this are the costs involved with the diagnosis and treatment representing a returning point of discussion. The mean costs of negative appendectomy are 2712 Euro, also the complication rate is relatively high: six percent. The new health care system (DBC) in The Netherlands is implemented to reduce costs and have a manageable system. In this health care system the counted insurance costs of laparoscopic appendectomy are slightly higher than the costs of open appendectomy. However the costs of negative appendectomy can be saved by optimizing the preoperative workup and avoiding unnecessary appendectomies. One of the arguments to choose for open appendectomy is represented by the lower direct costs. Otherwise laparoscopy is pre-eminently suitable for diagnostic purpose and the appendix can left in situ in case of a normal appendix, avoiding the possible complications and costs of appendectomy. Computer Tomography (CT) has proven to be a reliable non-invasive diagnostic tool, although discussion is still going on about the most accurate CT technique and about the exposure of radiation to the patients. However in The Netherlands in daily practice CT is not often used resulting in a high percentage of unnecessary appendectomies, especially in fertile women. The discussion remains if this is justifi ed. Arguments used to avoid CT are costs, radiation exposure and good quality of ultrasonography. Implementation of CT in daily practice can also be limited by the learning curve of the radiologist. Especially in hours of duty, the quality of CT diagnosis can be less suffi cient. One of the last questions is whether histopathology of the infl amed appendix without other macroscopic abnormalities is necessary. In literature primary malignancy of the appendix is reported to be rare. Carcinoid tumors of the appendix are the most common single appendicular malignancies, with a prevalence of 0.3-0.9 percent of patients undergoing appendectomy. This thesis tries to make treatment of patients suspected of acute appendicitis tailor made.