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Appendicectomy in older patients with acute appendicitis is not an indication for routine colonoscopy

  • Hytham K. S. HamidEmail author
  • Ahmed O. Hamedelneel
Letter to the Editor

Dear Editor:

In the recent article by Mohamed et al. [1], the authors concluded that post-appendicectomy patients aged ≥ 55 years should be offered colonoscopy to exclude coexistent caecal pathology. Considering the small number of positive findings in the study, the results should be more cautiously interpreted, and few potential limitations warrant attention.

First, the overall caecal cancer incidence rate (0.7%) in the study is comparable with local rates reported in average-risk patients undergoing colonoscopy or CT colonography [2, 3]. This rate would not justify routine colonoscopy in post-appendicectomy patients, which is associated with increased financial burden and morbidity, and would rather confirm that the recommended screening interval of 5 years is safe. Indeed, unnecessary colonoscopy is among five low value interventions with the highest negative impact on health budgets in the UK [4]. Performing a preoperative CT in older patients with suspected appendicitis to exclude clinically relevant cancer is a reliable and cost-effective alternative to colonoscopy [5], and is recommended in the commissioning guide endorsed by the RCSEng and the ASGBI [6].

Second, two of seven patients were diagnosed with caecal cancer 6 and 8 years after surgery, which are less likely to be relevant to the time of appendicectomy. Furthermore, in order for the incident cancer rate to be more accurate, it would be relevant to query the local cancer registry for additional cases reported during the study period as not all patients would have available follow-up investigations, and to provide data about the percentage of non-residents in the presented cohort.

In conclusion, until further evidence is available, a more selective approach in which only older patients with complicated appendicitis, mass lesion, or equivocal preoperative CT, and endoscopy-naive patients would undergo follow-up colonoscopy seems more appropriate.

Notes

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethical approval

Not necessary.

References

  1. 1.
    Mohamed I, Chan S, Bhangu A, Karandikar S (2019) Appendicitis as a manifestation of colon cancer: should we image the colon after appendicectomy in patients over the age of 40 years? Int J Color Dis.  https://doi.org/10.1007/s00384-018-03224-8
  2. 2.
    Logan RF, Patnick J, Nickerson C, Coleman L, Rutter MD, von Wagner C, English Bowel Cancer Screening Evaluation Committee (2012) Outcomes of the Bowel Cancer Screening Programme (BCSP) in England after the first 1 million tests. Gut 61(10):1439–1446CrossRefGoogle Scholar
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    Lung PF, Burling D, Kallarackel L, Muckian J, Ilangovan R et al (2014) Implementation of a new CT colonography service: 5 year experience. Clin Radiol 69:597–605CrossRefGoogle Scholar
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    Malik HT, Marti J, Darzi A, Mossialos E (2018) Savings from reducing low-value general surgical interventions. Br J Surg 105(1):13–25CrossRefGoogle Scholar
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    Saunders JH, Miskovic D, Bowman C, Panto P, Menon A (2014) Colorectal cancer is reliably excluded in the frail and elderly population by minimal preparation CT. Tech Coloproctol 18(2):137–143CrossRefGoogle Scholar
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    Association of Surgeons of Great Britain and Ireland, Royal College of Surgeons of England (2014) Commissioning guide: Emergency general surgery (acute abdominal pain). RCS, LondonGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of SurgerySoba University HospitalKhartoumSudan
  2. 2.Department of Accident and EmergencySt Helens and Knowsley Hospitals NHS TrustPrescotUK

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