Causes of Short-Term Mortality After Appendectomy

A Population-Based Case-Controlled Study

Manne N. Andersson, MD; Roland E. Andersson, MD, PhD


Annals of Surgery. 2011;254(1):103-107. 

In This Article

Abstract and Introduction


Objective: This case control study is a detailed analysis of the causes of death and the risk factors of short-term mortality after appendectomy.
Summary Background Data: Although death is a rare event after appendectomy, we found a 7-fold excess mortality after appendectomy overall and a 9-fold excess mortality after negative appendectomy, compared to the background population in a previous study from Sweden, in accordance with others.
Materials and Methods: All patients who died within 30 days after appendectomy, and controls matched to age, sex and period, were identified of 119,060 patients who were operated with appendectomy in 1987 to 1996 from the Swedish National Inpatient Registry. Causes of death and differences between the cases and controls in comorbidity and appendectomy diagnoses were analyzed on the basis of a review of hospital records. Only patients and controls with appendectomy as the only surgical intervention and without prevalent malignant diagnosis were included in the analysis to avoid bias.
Results: A total of 179 patients who died within 30 days and 400 matched controls remained for the analyses. Nonproductive and negative exploration was strongly associated with mortality [odds ratio (OR), 5.11; confidence interval (CI), 2.09–12.48; P < 0.001 and OR, 2.38; CI, 1.24–4.57; P = 0.009, respectively] in contrast to perforated appendicitis (OR, 1.60; CI, 0.95–2.70; P = 0.078) after adjustment for age, sex, and comorbidity. Chronic obstructive pulmonary disease (OR, 3.31; CI, 1.05–10.45, P = 0.041), renal insufficiency (OR, 2.32; CI, 1.26–4.27; P = 0.007), and diabetes mellitus were also independent risk factors (OR, 2.39; CI, 1.12–5.12; P = 0.025). Cardiovascular or thromboembolic disease was responsible for the death in more than 50% of the cases, whereas appendicitis was responsible in only 17.9%.
Conclusions: Appendicitis is only responsible for a small portion of the deaths after appendectomy. Comorbidity and negative appendectomy are strongly associated with mortality, suggesting that comorbidity, diagnostic failure, and the anesthesiosurgical trauma may play an important role.


Acute appendicitis is a common abdominal emergency in the industrialized world, with a lifetime risk of 6% to 9% in the United States.[1] The diagnosis is difficult, and errors with delayed or missed diagnosis and negative explorations are common.

The management of patients with suspicion of appendicitis is controversial. Advocates of early exploration claim that an aggressive surgical approach is a necessity to forestall perforation and the associated increased morbidity and mortality.[2] Others argue that a low threshold for surgical exploration due to suspected appendicitis does not prevent perforations but leads to an increased number of negative explorations, with associated potentially avoidable morbidity and mortality.[3]

Avoiding mortality has through history been the ultimate goal in the management of patients with suspected appendicitis and is still important, although mortality after appendectomy has dropped dramatically. The risk factors and the causes of mortality after appendectomy are, however, not well studied. Mortality after appendicitis and appendectomy is related to appendicitis, with an increased risk after perforated appendicitis due to peritonitis and sepsis, but comorbidity and the stress and trauma from the anesthesia and the surgical intervention itself may also be involved. However, the impact of comorbidity and the anesthesiosurgical trauma on mortality after appendectomy has not been studied previously.

In a previous study, we analyzed 30-day mortality after appendectomy from January 1987 through November 1996 in Sweden, based on 117,424 patients from the Swedish National Inpatient Register, and found a 7-fold excess mortality for all appendectomy diagnoses. Surprisingly, negative appendectomy was associated with a 9-fold excess mortality.[4] A high mortality after negative appendectomy has also been reported by others.[5,6] This motivated us to do an in-depth analysis of the causes of mortality, with a special emphasis on patients operated with negative appendectomy.


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