Introduction: The surgical treatment of appendicitis is one of the greatest triumphs of modern medicine. The pioneering work of McBurney and others led to earlier, more aggressive and accurate diagnosis and treatment of what was formerly a lethal disease. As surgical technology has improved, particularly in the last decade, one must ask whether these improvements have helped an already successful therapy.
Methods: A retrospective analysis of American published data from 1919 to 2006 was performed. Thirty-five peer reviewed publications were included containing adequately described data, and were reviewed to evaluate morbidity, mortality, infection rate, age and sex in the surgical treatment of acute appendicitis. Statistical regression analysis was then performed to evaluate trends in morbidity and mortality rates from appendectomy.
Results: There was a progressive decline in published morbidity rates for appendectomy from 1919 to the 1960’s. There has been a statistically significant increase in published morbidity rates since the 1980’s. The rise in morbidity observed since the 1980's does not appear to be from the increased frequency of laparoscopic appendectomy, as published morbidity for both procedures is high. There was, however, a trend to a correlation between operating time and morbidity. Many other factors also appear to influence the rising published morbidity, including: an increase in patients with other co-morbidities, increased time to intervention, and an increase in patients’ body mass index. Mortality following appendectomy was greater than 35% prior to 1919, fell to around 5% by the 1940’s, and further fell to nearly 0% by the 1960’s.
Conclusions: There was a significant increase in operative morbidity from appendectomy since the 1980’s. Several factors potentially influence this increase in morbidity: the dilution of the operative experience due to the increase in laparoscopy for straightforward cases, improved reporting of complications, and fewer false positive appendectomies due to better clinical acumen and imaging. This study is obviously limited by differences in reporting, potential changes over time in what constitutes “a complication” of surgery, and improved, and more readily available, diagnostic testing for problems after surgery. Further studies are warranted using a standardized method, such as institutional conditional length of stay, to identify operative morbidity over time to determine whether morbidity is truly rising from appendicitis.