Incidental Appendectomy in the Symptomatic Patient

I read at first with great interest, and finally with great concern, the article by Flum and Koepsell¹ regarding the consequences of misdiagnosed appendicitis. The authors used a large national database of inpatients to determine characteristics of patients who underwent appendectomy for appendicitis vs patients who underwent nonincidental appendectomy. The authors suggest in their introduction that clinicians consider the diagnosis of appendicitis "straightforward." This clinician disagrees. The diagnosis has remained elusive (15% rate of misdiagnosis in the current series) despite decades of medical advances because the clinical course is often atypical and requires a high index of suspicion and exploration when any doubt exists. The authors observed a longer length of hospital stay, greater hospital charges, and a higher case-fatality rate in the nonincidental appendectomy population. It was concluded that these discrepancies were a direct result of removal of a normal appendix. As an example, the authors suggest that in a child (age <5 years) the hospital length of stay was increased 4-fold when a normal appendix was removed (5.4 days vs 24.1 days), because the appendix was removed. Further, in that same population, removal of a normal appendix resulted in a case-fatality rate 38 times greater than that in children with an appendectomy for appendicitis (5.05 vs 0.13). Is there any reason to suspect that these observations were due to anything other than the associated comorbid disease or the actual primary diagnosis rather than the removal of the appendix? To truly isolate the impact of removing a normal appendix, the comparison group should be those patients with suspected appendicitis who undergo exploration and do not have the appendix removed.