KOTALUOTO Operative Treatment of Acute Appendicitis Wound healing , severe complications and mortality

The diagnostics of appendicitis are everyday routine for surgeons at emergency units. In many cases, the diagnosis of appendicitis is straightforward and the decision regarding surgery simple. However, the diagnosis can be challenging, and despite advanced diagnostic imaging, the rate of removal of healthy appendices in suspected cases of appendicitis (negative appendectomies) remains high. Earlier studies have shown a connection between negative appendectomies and increased complications and mortality. Appendectomy-related mortality in Finland is not well defined. Severe complications related to appendectomy have not been studied in Finland previously, and few studies have been published worldwide. Appendectomy is the most frequently performed emergency operation in the field of alimentary tract surgery worldwide. The open technique of appendectomy was developed over a hundred years ago and has remained more or less unchanged over the years. During the last two decades, laparoscopic appendectomy has increased in popularity and is presently the method of choice in many centres. Worldwide, open appendectomy is still a valid technique, as laparoscopy requires a higher level of skill as well as complex instrumentation and more resources. Open appendectomy wounds have traditionally been closed with a few interrupted, nonabsorbable sutures in the fear of wound infection, which is the most common complication of appendectomy. This wound closure method results in a suboptimal cosmetic outcome, with the inconvenience of stich removal to the patient and a burden to the health care system. Absorbable intradermal suturing has become a common wound closure method. In children, intradermal absorbable suturing is already accepted as a routine method for appendectomy wound closure. This thesis consists of four independent articles. The aim of the first two was to investigate the feasibility of intradermal absorbable suturing in appendectomy wound closure in adults. In the first study (I), we randomized 200 appendectomy patients into two wound closure groups: traditional non-absorbable interrupted sutures and absorbable intradermal continuous suturing. The result was that the methods were equal in regard to the frequency of wound infection; however, mild wound complications (dehiscence) were significantly more frequent in the non-absorbable suture group. In the second study (II), we examined the cosmetic outcome of the two wound closure methods. The patients included in the first study were evaluated by means of both subjective and objective scar assessment, which showed a statistically significant benefit for absorbable intradermal wound closure in terms of cosmetic outcome. In the third study (III), the aim was to define severe complications related to appendectomies based on the Patient Insurance Centre’s register data. We found that patient complains related to appendectomy are rare (0.2%). The complaints were more frequently related to laparoscopic operations than to open surgery. This difference equalised towards the end of the study period as the percentage of laparoscopic operations increased. Severe complications were more often related to laparoscopic surgery, a complicated infection, negative appendectomy and aging. We concluded that, with better diagnostics, some of the severe complications may be avoided. The increased complication rate related to laparoscopic appendectomies during the study period correlated with the adoption of a new technique. In the fourth (IV) study, we investigated the mortality related to appendectomies in Finland based on the register data of the National Institute of Health and Welfare and Statistics Finland. Over the study period of two decades, the appendectomy-related mortality in Finland was 2.1/1,000 operations. The mortality decreased to less than half of the baseline level over the study period. At the same time, the rate of negative appendectomies decreased and the percentage of laparoscopic surgery increased. Mortality was related to male sex, aging, complicated infection, negative appendectomy and open appendectomy. We concluded that better diagnostics may have decreased the appendectomy-related mortality in Finland. Appendectomy wounds have been traditionally closed in an old-fashioned way in the fear of wound infection. In this thesis, we were able to prove that a more modern wound closure method with absorbable intradermal suturing is safe in terms of wound infection and yields a better cosmetic outcome in appendectomy wounds. Another tradition has been to accept a relatively high rate of negative appendectomies. In our studies on complications and mortality, we were able to conclude that an attempt at better diagnostics may decrease both severe complications and mortality. The importance of knowing the present figures is that they act as a valid reference value when examining the benefits of conservative treatment of acute appendicitis. Our results encourage the use of laparoscopic procedures and a proper diagnostic workup in the operative treatment of appendicitis.