Increased surgical morbidity of psychiatric patients submitted to appendectomy

Morbidade cirúrgica aumentada de pacientes psiquiátricos submetidos à apendectomia

CARTA AOS EDITORES

Increased surgical morbidity of psychiatric patients submitted to appendectomy

Morbidade cirúrgica aumentada de pacientes psiquiátricos submetidos à apendectomia

Dear Editor,

The general medical care offered to psychiatric patients tends to be worse than the one offered to the general population. It includes inappropriate management of highly prevalent diseases such as diabetes mellitus and systemic hypertension as well as a significant delay in the diagnosis of emergent clinical and surgical conditions leading to increased morbidity and mortality.^1-2

In this preliminary report, we aim at presenting our evaluation of the hypothesis that patients with major psychiatric disorders submitted to appendectomy had delayed diagnosis and/or worse outcome when compared to control subjects. We searched for all records of patients over age 18 who underwent a surgical procedure (appendectomy) in a general hospital in the period from May, 2005 to August, 2006, all of them with real appendicitis evidenced by anatomopathologic exam carried out after the surgery. Appendectomy was selected due to the high incidence of appendicitis in the general population.³ We performed a chart review and the following data were evaluated: 1) the presence of a major psychiatric diagnosis according to DSM-IV criteria; 2) time elapsed from the onset of clinical symptoms to the surgical procedure (in days); 3) length of hospital stay (in days); and 4) number of postoperative complications. Coincidently only female psychiatric patients were identified (n = 10) based on retrospective psychiatric diagnosis (medical record and family information). Three patients had schizophrenia, four patients had recurrent depressive disorder, and three patients had bipolar disorder. The control group was comprised of female patients without current psychiatric disorders and/or receiving psychiatric treatment, who underwent the same surgical procedure at the same period (n = 81). A non-parametric test (Mann-Whitney) was used to compare the values between the groups. The results are shown in Table 1.

Our results show that psychiatric patients had a longer interval between the onset of their symptoms and the surgical procedure. This may suggest that the patients postponed the search for medical care. An alternative explanation would be that their clinical symptoms could be erroneously attributed to their psychiatric disorder. A delayed diagnosis could be associated with more postoperative complications.^2-3 In line with this, psychiatric patients had more complications than controls, although the length of hospital stay was the same for both groups. Other reasons for the increased morbidity in psychiatric patients in the postoperative period include: metabolic disorders related to the underlying disease or secondary to the use of psychiatric medications that have metabolic effects such as hyperglycemia, weight gain, and insulin resistance; inappropriate management of the psychiatric medication during the pre-, peri- and postoperative period, and the poor relationship among the members of the medical team (surgeons and psychiatrics).^2,4

An interesting point that should be mentioned is the non-inclusion of psychiatric patients in most studies that evaluate surgical indexes and features related to the morbidity and mortality of surgical procedures.⁵

Despite the evident limitations of our study (small sample, information obtained retrospectively and lack of laboratory or other clinical data possibly related to the outcome), the present results highlight the neglect of general medical problems in psychiatric patients.

Felipe Filardi da Rocha; Flávia Mello Soares; Humberto Correa

Department of Psychiatry, School of Medicine,

Universidade Federal de Minas Gerais (UFMG),

Belo Horizonte (MG), Brazil

Renata Figueiredo Rocha

Service of Surgery, Santa Casa de Misericórdia Hospital,

Belo Horizonte (MG), Brazil

Antônio Lúcio Teixeira

Department of Internal Medicine, School of Medicine,

Universidade Federal de Minas Gerais (UFMG),

Belo Horizonte (MG), Brazil

References

1. Schneiderman G. Surgery and psychiatric practice. Can J Psychiatry. 1998;43(7):750.

2. Tsuang MT, Woolson RF. Mortality in patients with schizophrenia, mania, depression and surgical conditions. A comparison with general population mortality. Br J Psychiatry. 1977;130:162-6.

3. Cooke BK, Magas LT, Virgo KS, Feinberg B, Adityanjee A, Johnson FE. Appendectomy for appendicitis in patients with schizophrenia. Am J Surg. 2007;193(1):41-8.

4. Rocha FF, Bezerra BPS. Síndrome metabólica e transtornos psiquiátricos: uma associação que não pode ser esquecida. Arq Bras Endocrinol Metab. 2006;50(6):1138-9.

5. Abreu RA, Speranzini MB, Fernandes LC, Matos D. Feasibility analysis of loop colostomy closure in patients under local anesthesia1. Acta Cir Bras. 2006;21(5):275-8.

Financing: None

Conflict of interests: None

Publication Dates

• Publication in this collection
  06 July 2007
• Date of issue
  June 2007