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Shared decision‐making and nonoperative management of appendicitis

Dear Editor, We read with great interest Dr Talan’s letter to the editor regarding our study entitled “Risk of appendiceal cancer in patients undergoing appendectomy for appendicitis in the era of increasing nonoperative management.” Dr Talan discusses interesting aspects of the study and focuses on the appropriate use of this information in the context of shared decision‐making and informed consent, one of the most critical aspects of the surgeon‐patient relationship. One comment is focused on the applicability of the information that patients aged greater than 50 are at increased risk of appendiceal cancer in the context of the known incidence pattern of acute appendicitis. While the age range of acute appendicitis in adults tends to peak between 20 and 40 years of age, the median age of diagnosis for appendiceal cancer is reported to be late 50s to early 60s. However, recent studies have demonstrated that the rates of appendiceal cancer have not only increased over time but that the age of diagnosis has significantly decreased as well. Therefore, while cancer risk may be lower in those under age 50 relative to an older population, there is still risk of appendiceal cancer and we must be vigilant and fully discuss risks and benefits of nonoperative management with these patients. Dr Talan also comments on the likelihood of cancer being later diagnosed in patients who choose to undergo nonoperative management before having increased morbidity and mortality from progressed cancer. To this point, is important to note that while the incidence of malignancy found in appendectomy specimens is approximately 1% overall, up to 39% of appendiceal cancer cases have been diagnosed as a result of surgery performed for a preoperative diagnosis of acute appendicitis; further, there may be low detection with colonoscopy after nonoperative management as fewer than 2% of cases have been reported to be identified on screening colonoscopies. Appendiceal cancer is most often diagnosed at late stages, with the majority of patients presenting with distant disease. Another issue raised is the increased risk of morbidity and mortality in cases of elderly patients who undergo operative treatment for acute appendicitis. This is certainly important to consider, as the elderly population is also the population at increased risk of malignancy. However, the increased morbidity and mortality seen in the cohort of age greater than 65 is often attributed to the fact that elderly patients tend to present later and have higher rates of complicated appendicitis with perforation and intraabdominal contamination. A recent study evaluating appendiceal cancer in the elderly demonstrated that over 26% of patients aged greater than 65 who had appendiceal cancer were initially misdiagnosed with inflammatory appendicitis, and those with an initial misdiagnosis were significantly more likely to have a lower stage of disease. This raises the concern that older patients may be at higher risk of missing an opportunity for a curative intervention when appropriate treatment can be limited to a minimally invasive surgery. While it is correctly suggested that in some elderly patients who are at high surgical risk a nonoperative approach is appropriate, there is increasing evidence that follow‐up imaging or interval appendectomy should be considered. Ultimately, future studies with long‐term follow‐up of patients who undergo nonoperative management for uncomplicated acute appendicitis are needed to further elucidate the outcomes of this management approach. Furthermore, as imaging capabilities improve, we may gain the ability to better discern between cases of true uncomplicated acute appendicitis and those of underlying malignancy. Until then, we must make best use of the information available to engage our patients in shared decision‐making processes that are as well informed as possible.