GTFO appendix

February 9, 2012 10:05 AM

Pre-emptive appendectomy? Difficulty filter: living and working in remote corners of Africa.

YANMD, but maybe YAAD. In any case, I live in Africa and my work sometimes takes me to some of the remotest parts of some of the remotest countries here. Places where if I woke up one night with appendicitis it could easily be 48+ hours before I could see anything approaching even a 2nd-world-standards hospital. I'm around the same age that both my father and grandfather were when they contracted appendicitis, and while I don't gather from my net-surfing that its a genetic thing, suffice to say I'm thinking about it more often.

Maybe its way too simple of a question, but I'm wondering if a doctor would look at me like I have 2 heads if I asked about having it taken out as a preventative measure. Is there any pressing reason not to get it out, considering?

posted by allkindsoftime to Health & Fitness (13 answers total)

I know two people who had it done in the exact circumstances you describe. However, your insurance might not pay for a prophylactic surgery.
posted by Sidhedevil at 10:08 AM on February 9, 2012

I spoke to my doctor about a prophylactic appendectomy and a prophylactic gallbladder removal -- I have a health condition that meant waiting for an emergency to have surgery was extra-risky. I got the gallbladder out no problem, as I had some stones already and was nearing the age when my mother and sister both starting having problems with theirs.
The appendectomy, though, he advised against, since I was getting to the age when it's less likely to be a problem. (I think he said after 30 the risk goes way down.) Given your family history and situation, though, you probably stand a better chance of getting it approved. Certainly, a doctor you've got a decent relationship with won't look at you like you're completely crazy. (Mine did kind of cock his head to the side, a la the RCA dog, and asked me why I wanted the surgery, but then listened to my explanation and treated me like a rational person.)
I think the most pressing concern is that it's significant abdominal surgery, which few people want to have unnecessarily. But definitely talk to your doctor -- and if s/he does look at you like you have 2 heads, get a new doctor.
posted by katemonster at 10:12 AM on February 9, 2012

If the doctor is someone whose practice includes a decent number of patients who do back-of-the-beyond aid work like you, they are not going to think you're nuts for wanting this. Given your work, you may not have a regular doctor, so ask around your compatriots to see if they have any particular recommendations.
posted by rtha at 10:23 AM on February 9, 2012

Response by poster: Apparently "prophylactic" was the word my google-fu was missing. Thanks.
posted by allkindsoftime at 10:31 AM on February 9, 2012

Best answer: Everyone going to Antarctica has had to have a prophylactic appendectomy since the time that the only doctor there developed appendicitis and had to perform an appendectomy on himself.

FYI, this is no longer true. In fact, if you've had an appendectomy in the last few months, I believe you need special clearance to go to Antarctica, because of the risk of post-op complications.

So, while it sounds like this might well be a good idea for you, do make sure that you allow some time post-surgery to make sure there are no complications before you go back into the remoter regions. It would be pretty ironic if you got a prophylactic appendectomy and then got into trouble because of that. (This actually happened to someone I know, who had a prophylactic wisdom-tooth extraction before going into the field, and then had to be evacuated because of complications from the oral surgery.)
posted by fermion at 11:13 AM on February 9, 2012 [1 favorite]

Actually, given that science now thinks that the appendix has a purpose--providing a safe haven for good germs so they can repopulate your gut if necessary--you might be better off keeping it despite the risk of a harrowing journey to receive care. If you contracted something like cholera it would wipe out your good bacteria and, without your appendix, your recovery would be longer.
posted by carmicha at 11:18 AM on February 9, 2012

Best answer: I think this is a dumb idea, and some "back of a napkin" sums demonstrate why.

The current incidence of appendicitis in the US is 1 per 1000 per year. The mortality rate from an acute appendectomy is improving with laparoscopic techniques, but is in the region of 1 in 635 to 1 in 1500. Most of those deaths are due to surgical risk and comorbidities, not appendicitis itself, meaning that elective appendectomy is probably not that much safer. The risk of other serious complications is about 1 in 20.

If you were going to be spending a whole year in a place with no health care, where every case of appendicitis was uniformly fatal, then this might just be a worthwhile proposition. But actually a majority of cases of appendicitis can be safely managed conservatively with antibiotics (linked study is about management of appendicitis for nuclear submariners). If, and this is a big if, you are having a laparoscopy for some other condition, then given your job, you might ask to have your appendix removed at the same time. Otherwise I would steer clear.
posted by roofus at 12:34 PM on February 9, 2012 [1 favorite]

Best answer: roofus, I found your numbers surprising so I read the article you linked to with the 1 in 1500 stat (Tiwari et al). Note that in uncomplicated appendicitis cases, a laparoscopic approach (using cameras instead of a big incision) is typically used.

Table 2 in the article gives these figures:

Mortality rate for all severity levels, laparoscopic appendectomy: 0.07%

Mortality rate for minor severity level, laparoscopic appendectomy: 0.00% (using a group of almost 17,000 uncomplicated appendicitis cases as the study group. Of note, morbidity was about 1.5% for this group but may include minor morbidities).

Given those figures, I'm not sure why you think the 1 in 1500 number would apply to this poster. In a case where he doesn't even have appendicitis and might not have any co-morbidities, why would you suggest that prophylactic appendectomy wouldn't be even safer than these projections? In typical appendicitis cases, surgeons may not infrequently do the cases after hours, in the middle of the night, when staffing and skills have been time and again shown to contribute to increased morbidity and mortality for many kinds of medical procedures and treatments (i.e. if you're going to have a heart attack, you're more likely to survive if you have it during the daytime).

Your point about managing appendicitis conservatively is a reasonable one, but to be able to treat it, you have to be able to diagnose it, and the diagnosis of appendicitis is tricky even for experienced physicians with a wealth of tests at their disposal. I'm not necessarily in favor of the idea of having prophylactic appendectomy in this case, but I certainly would be hesitant about the idea of having my suspected appendicitis diagnosed and treated in some "of the remotest parts of some of the remotest countries" - they aren't well known for being served by highly trained physicians, those types of places are lucky if they have a nurse or a midwife in the area.
posted by treehorn+bunny at 1:04 PM on February 9, 2012

Best answer: Everyone going to Antarctica has had to have a prophylactic appendectomy since the time that the only doctor there developed appendicitis and had to perform an appendectomy on himself.

This is no longer the case. They used to do it for Antarctic winter-overs and for astronauts but if you actually crunch the numbers it doesn't make sense in either case for a member of the general population. I don't know how heritable appendicitis is, but your family history may changes those calculations.

The alternative, as roofus mentions is learning the protocol for aggressive non-surgical treatment and preparing yourself and other members of your team (if applicable) to administer it. Do I recall correctly that you work for an organisation with extensive operations in rural Africa? Maybe there are doctors they work with that specialise in expedition medicine that can:

a) Have a frank and informed discussion with you based on the latest science as to what the options are. (Most ordinary GPs do not have the experience to do this, and are not trained to consider "What if the patient can't get to a modern hospital?")
b) Refer you to relevant expedition medic programmes that can train you to correctly diagnose appendicitis (and other things!) and carry out stabilising treatment if required pre-hospital.
c) Be on call via satellite phone / whatever to assist in remote diagnosis in the future.
d) If you decided to get a prophylactic appendectomy, they can refer you to a surgeon. Not only are they more likely to entertain the idea of such a referral in the first place, but a referral from them will carry more weight with a surgeon.
posted by atrazine at 4:44 PM on February 9, 2012 [1 favorite]

Best answer: treehorn+bunny the "minor severity level" category in the Tiwari paper is not minor appendicitis, but an opaque composite of age, sex, race, admission status, admission source, socioeconomic status, and other unspecified stuff. The OP is 33 and drives around Africa, so he probably is low risk, but we don't know what category he gets into. The mortality even from a diagnostic laparoscopy is in the 1 in 10,000 range, with about a 1 in 300 chance of bowel or vascular injury. These numbers don't favour elective intervention.

PS Appendicitis has low heritability of 0.21.
posted by roofus at 5:54 PM on February 9, 2012

Best answer: roofus, IANA Surgeon, but regardless, if they did it laparoscopically, that suggests it was an uncomplicated case - and it sounds like what we're talking about here is an uncomplicated case in an uncomplicated patient. As you're clearly aware, many medical decisions involve a risk versus benefit equation that may change depending on the risk tolerance of the patient and that of the physician. Although the numbers may not be convincing to you, the OP may have a different opinion (or not, since he apparently likes your answer). Either way, it's far from overwhelmingly dangerous. By the numbers, you wouldn't expect women to have elective C-sections, yet they happen all the time.

atrazine, the paper cited by roofus about a protocol for non-surgical treatment of appendicitis involves identifying appendicitis using ultrasound. This requires electricity, an ultrasound machine, and a highly trained ultrasonographer - any one of these 3 things are in short supply in a remote part of a remote country. I order ultrasounds for appendicitis commonly as a part of my work in the emergency department, and in adults, a significant percentage of them are indeterminate.
posted by treehorn+bunny at 10:57 PM on February 9, 2012

There are a number of things that can cause appendicitis: fecalith, gallstones, tumor, parasites, IBD &al. Can you recall why your father and grandfather developed appendicitis? If tumor or gallstones, then that might shift your index of suspicion toward thinking you might be predisposed. If it was parasites, then perhaps the only thing putting you at increased risk of appendicitis would be your line of work.
posted by The White Hat at 7:49 AM on February 10, 2012

If you're really worried, you could sign up with Global Rescue. I don't know a lot about them but they seem to come up in articles in Outside magazine fairly frequently.
posted by mingshan at 9:32 AM on February 10, 2012