Comment on ‘Is it necessary to block an entire appendix to exclude acute appendicitis?’, a previously published article by Newton ACS Wong

Abstract

Sir: This comment is in regard to the Histopathology article by Newton ACS Wong entitled 'Is it necessary to block an entire appendix to exclude acute appendicitis?'. This paper examined at least 267 cases where the entire appendix was blocked and concluded that if initial appendiceal sections are normal, it is unlikely that blocking the entire appendix will identify a significant acute appendicitis. This is not entirely in line with our experience.In our smaller study, all remaining portions of 55 appendicectomy specimens with initially unremarkable histology, received between March 2020 to August 2022, were embedded. All slides showing any changes in diagnosis were independently reviewed by two pathologists (C.K., C.B.). Minimal mucosal inflammation, defined as neutrophils confined to the mucosa only, was excluded from the study as its clinical significance is contentious. 1,2 The 55 appendicectomies included 42 females (76%) and 13 males (24%). Four cases revealed clinically significant changes (7%), and these included acute appendicitis, Enterobius vermicularis, sessile serrated lesion without dysplasia and endometriosis.It was difficult to estimate the additional cost incurred for embedding the rest of appendices, but we used a schedule of charges used in our institution for external requests for research purposes; the additional cost amounted to $8830 for the above 55 cases (approximately $160 for a case). This could be criticised as being an excessive estimate, but it may not be an unreasonable figure if the extra time required by scientific staff to process additional sections is taken into account. It is reassuring to see that our extrapolated additional cost is similar to Newton ACS Wong's costings.A previous study by Jones et al. 3 has illustrated that 2% (24 of 1225) of all appendix specimens removed for suspected acute appendicitis showed clinically significant unexpected findings. A common finding was Enterobius, which accounted for 10 cases but, additionally, three cases of endometrioisis were identified as well as cases of Schistosomiasis, Crohn's disease, neuroendocrine tumour and adenocarcinoma.