The histopathological spectrum of 1,929 appendectomy specimens over 22 years in Palestine: a multi-branch descriptive audit

Abstract Histopathological examination of the resected appendix confirms clinical suspicion and detects unexpected disease, yet population-level data on the appendiceal disease spectrum from the eastern Mediterranean, and Palestine specifically, remain limited. To describe the histopathological spectrum, demographic distribution and clinicopathological correlations of appendectomy specimens received over 22 calendar years at a multi-branch pathology service in Palestine. We conducted a retrospective observational study of appendectomy specimens accessioned between 2005 and 2026 across a multi-branch laboratory network. To ensure the cohort reflected appendectomy practice, every specimen forming part of, or belonging to, a larger bowel or pelvic resection was excluded. Of 2,326 specimens accessioned, 397 non-appendectomy or non-appendiceal specimens were excluded, yielding 1,929 appendectomy specimens. Diagnoses were standardized against a structured reference taxonomy; every specimen assigned a neoplastic diagnosis was re-reviewed by a panel of pathologists against the archived slides using the fifth-edition WHO classification and the PSOGI consensus, and non-appendiceal or non-neoplastic lesions were reclassified accordingly. Proportions with 95% confidence intervals were computed; associations were tested with the chi-square test and the secular trend in complicated appendicitis with the Cochran-Armitage test. Among 1,929 appendectomy specimens, patients were 1,125 male (58.3%) and 804 female (41.7%) (M: F = 1.40), median age 23 years. Acute appendicitis (uncomplicated) accounted for 1,467 specimens (76.0%), predominantly acute suppurative appendicitis (1,453; 75.3%); complicated acute appendicitis comprised 109 (5.7%), a complication rate of 6.9% among acute cases. The negative-appendectomy rate was 15.1% overall and was highest in children (20.3%). After panel review, incidental appendiceal neoplasia was confirmed in 23 specimens (1.2%; 95% CI 0.8–1.8): low-grade appendiceal mucinous neoplasm (LAMN) in 13 (0.7%), adenocarcinoma in 7 (0.4%; five conventional and two mucinous) and well-differentiated neuroendocrine tumor in 3 (0.2%). Diagnosis category was strongly associated with age (chi-square = 117.3, df = 15, p < 0.001) but not with sex (chi-square = 7.5, df = 5, p = 0.19); the proportion of complicated cases showed no significant secular trend ( p = 0.80). In this 1,929-specimen appendectomy series - to our knowledge the largest reported from Palestine - incidental appendiceal neoplasia was identified in 1.2% of specimens (95% CI 0.8–1.8), predominantly of low-grade mucinous type rather than adenocarcinoma, while acute suppurative appendicitis dominated the remaining spectrum (75.3%). Because approximately one in eighty-four specimens harbored a clinically unsuspected neoplasm carrying management consequences, and because such lesions are not reliably apparent on macroscopic or intra-operative assessment, it is this neoplastic yield - rather than the histological confirmation of inflammation, which does not alter management - that supports the continued role of routine histopathological examination following appendectomy.