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      Gynecologic pathologies in our appendectomy series and literature review

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          Abstract

          Purpose

          Appendectomy applied from the diagnosis of acute appendicitis is one the most common operations in surgery. The rates of negative appendectomy are still high. The rates of negative appendectomy in males and females differ and are higher in females. In our study, these differences, particularly in females, were studied and possible solutions were discussed.

          Methods

          Between October 2002 and October 2009, among women receiving urgent appendectomies, those whose primary cause was gynecological pathology were studied retrospectively. All our women subjects were examined by preoperative gynecologists. After gynecological consultation, the patients were evaluated by a general surgeon due to lack of urgent ultrasonography, computed tomography (CT) and diagnostic laparoscopy and the patient received appendectomy due to acute appendicitis.

          Results

          In our series of 1,969 appendectomies, the rate of female/male is 811/1,158. It was determined that the primary cause in 47 (47/811; 5.8%) women with applied appendectomy was gynecological pathology. As a gynecological pathology, it was observed that the most common cause was ovarian cyst ruptures at a rate of 72.3%. The negative appendectomy rate in males was found to be 14.94% (173/1,158), and in females it was 22.56% (183/811). The difference between them is significant (P < 0.01). Of these women, 5.8% were gynecologically-induced and 16.76% were unrelated to gynecological causes.

          Conclusion

          We believe that gynecological consultation before appendectomy in women is necessary, but not sufficient. It is also important that at least one of the facilities, such as us, CT, magnetic resonance imaging, and diagnostic laparoscopy should be available in surgical use for the diagnosis of negative appendicitis.

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          Most cited references21

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          A practical score for the early diagnosis of acute appendicitis.

          We conducted a retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analyzed for specificity, sensitivity, predictive value, and joint probability. The total joint probability, the sum of a true-positive and a true-negative result, was chosen as a diagnostic weight indicative of the accuracy of the test. Eight predictive factors were found to be useful in making the diagnosis of acute appendicitis. Their importance, according to their diagnostic weight, was determined as follows: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain. Based on this weight, we devised a practical diagnostic score that may help in interpreting the confusing picture of acute appendicitis.
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            Introduction of appendiceal CT: impact on negative appendectomy and appendiceal perforation rates.

            OBJECTIVE To evaluate the impact of appendiceal computed tomography (CT) availability on negative appendectomy and appendiceal perforation rates. Appendiceal CT is 98% accurate. However, its impact on negative appendectomy and appendiceal perforation rates has not been reported. The authors reviewed the medical records of 493 consecutive patients who underwent appendectomy between 1992 and 1995, 209 consecutive patients who underwent appendectomy in 1997 (59% of whom had appendiceal CT), and 206 patients who underwent appendiceal CT in 1997 without subsequent appendectomy. Before appendiceal CT, 98/493 patients (20%) taken to surgery had a normal appendix. After CT availability, 15/209 patients (7%) taken to surgery had a normal appendix; 7 patients did not have CT, 5 patients had surgery despite a negative CT, and 3 patients had a false-positive CT. Negative appendectomy rates were lowered overall (20% to 7%), in men (11% to 5%), in women (35% to 11%), in boys (10% to 5%), and in girls (18% to 12%). Appendiceal perforation rates dropped from 22% to 14% after CT availability. CT excluded appendicitis in 206 patients in 1997 who avoided appendectomy and identified alternative diagnoses in 105 of these patients (51%). The availability of appendiceal CT coincided with a drop in the negative appendectomy rate from 20% to 7% in all patients, and to only 3% in patients with a positive CT. Perforation rates decreased from 22% to 14%. Appendiceal CT can be advocated in nearly all female and many male patients.
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              A normal appendix found during diagnostic laparoscopy should not be removed.

              Diagnostic laparoscopy has been introduced as a new diagnostic tool for suspected appendicitis. While the normal appendix used to be removed routinely, laparoscopy allows us to leave a normal looking appendix in place. This latter strategy is, however, not generally accepted. The long-term results of not removing a normal looking appendix were evaluated. This was a prospective evaluation of 109 diagnostic laparoscopies for suspected appendicitis in which a normal looking appendix was left in place. After a median follow-up of 4.4 years a telephone questionnaire was performed. There were no false-negative laparoscopies. In 65 patients (60 per cent) another diagnosis was obtained (group 1). In 44 patients (40 per cent) no diagnosis was obtained (group 2). After a median interval of 8 months, 15 patients presented to the emergency department for symptoms possibly involving the appendix, during the median follow-up of 4.4 years. This resulted in readmission of nine patients, of whom eight were reoperated. In only one patient (1 per cent) was a histologically proven appendicitis found and the appendix removed. Some 105 patients were eligible for follow-up. Of the 100 patients interviewed (95 per cent), nine patients (9 per cent) (six in group 1 and three in group 2) still had recurrent pain in the right lower abdominal quadrant. There were no differences between patients with or without another diagnosis obtained during preceding laparoscopy. It is safe to leave a normal looking appendix in place when a diagnostic laparoscopy for suspected appendicitis is performed, even if another diagnosis cannot be found at laparoscopy.
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                Author and article information

                Journal
                J Korean Surg Soc
                JKSS
                Journal of the Korean Surgical Society
                The Korean Surgical Society
                2233-7903
                2093-0488
                April 2011
                12 April 2011
                : 80
                : 4
                : 267-271
                Affiliations
                Department of Surgery, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey.
                [1 ]Department of Surgery, Buca Seyfi Demirsoy Large State Hospital, Izmir, Turkey.
                [2 ]Department of Pathology, Buca Seyfi Demirsoy Large State Hospital, Izmir, Turkey.
                Author notes
                Correspondence to: Omer Engin. Department of Surgery, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey. Tel: +90-232-2505-050, Fax: +90-232-2614444, omerengin@ 123456hotmail.com
                Article
                10.4174/jkss.2011.80.4.267
                3204677
                22066046
                0b1f6b9e-bc60-4bb6-aae8-94a515200111
                Copyright © 2011, the Korean Surgical Society

                Journal of the Korean Surgical Society is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 19 January 2010
                : 30 August 2010
                Categories
                Original Article

                Surgery
                acute appendicitis,gynecologic,negative appendectomy,ovarian cyst
                Surgery
                acute appendicitis, gynecologic, negative appendectomy, ovarian cyst

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