Management of a macroscopically normal appendix during surgery for suspected appendicitis: Evidence for clinical practice, healthcare resource use and surgical policy
Raya Al Shaaibi, Hilal Al Miskry, Nawal Al Sharji, Abdullah Al AlawiBackground
Whether a macroscopically normal appendix identified during surgery for suspected acute appendicitis should be removed or left in situ remains controversial. Although unnecessary appendectomy may expose patients to avoidable operative risks and healthcare costs, failure to remove an appendix with occult inflammation may lead to delayed diagnosis, disease progression, and subsequent complications. This systematic review and meta-analysis aimed to determine the incidence of histologically confirmed appendicitis and other clinically significant pathology in macroscopically normal appendices removed during surgery for suspected appendicitis.
Methods
A systematic review was conducted in accordance with the PRISMA 2020 statement and prospectively registered in PROSPERO (CRD42023397449). PubMed, MEDLINE, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Library, the WHO International Clinical Trials Registry Platform, and Google Scholar were systematically searched for eligible studies published up to 1 March 2023. Experimental and observational studies reporting histopathological findings in macroscopically normal appendices removed during surgery for suspected appendicitis were included. Random-effects meta-analysis was performed to estimate the pooled incidence of histologically confirmed appendicitis and overall clinically significant pathology.
Results
Eighteen studies involving 1,780 patients with macroscopically normal appendices removed during diagnostic laparoscopy or open surgery for suspected appendicitis met the inclusion criteria. The pooled incidence of histologically confirmed acute appendicitis was 25% (95% CI 0.15–0.33), while the pooled incidence of overall clinically significant pathology was 28% (95% CI 0.20–0.37). Although appendicitis accounted for the vast majority of abnormal histological findings, other important pathologies, including neuroendocrine tumours and appendiceal neoplasms, were also identified. Considerable between-study heterogeneity was observed.
Conclusions
Macroscopic assessment alone does not reliably exclude appendiceal pathology, with approximately one in four macroscopically normal appendices showing histologically confirmed appendicitis. Appendectomy may therefore be considered when no alternative cause of symptoms is identified, although decisions should be individualised given the heterogeneity and observational nature of the evidence. Clinical guidelines should also consider healthcare capacity, access to follow-up, and the potential resource consequences of both unnecessary surgery and missed disease. Prospective studies incorporating patient-centred outcomes, healthcare utilisation, and economic evaluation are needed to inform context-specific surgical policy.
Registration : PROSPERO CRD42023397449