Clinical practice selectively follows acute appendicitis guidelines
Gary Alan Bass, Shahin Mohseni, Éanna J. Ryan, Maximilian Peter Forssten, Matti Tolonen, Yang Cao, Lewis J. Kaplan, ESTES SnapAppy Group, Rebecka Ahl Hulme, Alan Biloslavo, Hayato Kurihara, Isidro Martínez-Casas, Jorge Pereira, Arvid Pourlotfi, Nayef Louri, Yang Cao, Fatema Nedham, T. N. Walsh, Jamal Hashem, Martin Corbally, Abeer Farhan, Hamad Al Hamad, Rawan Elhennawy, Mariam AlKooheji, Manar AlYusuf, Wissal Aknouche, Anas A. Zeidan, Yusuf S. Alsaffar, Edgar Lipping, Peep Talving, Sten Saar, Katrina Graumann, Liis Kibuspuu, Eduard Harkov, Gisele Aaltonen, Iines S. Sillman, Sami Haapanen, Hanna Lampela, Henna Sammalkorpi, Sofia Eskola, Altti Laakso, Johan Back, Ulla Kettunen, Antti Nummi, Anika Szwedyc, Taina Nykänen, Rolle Rantala, Elisa Mäkäräinen, Sanna Meriläinen, Heikki Huhta, Jukka Rintala, K. Laitakari, Elina Lietzén, Paulina Salminen, Risto K. A. Rapola, Vahid Zangouri, Mohammad Y. Karami, Sedigheh Tahmasebi, Majid Akrami, Alireza Golchini, Faranak Bahrami, Sean M. Johnston, Sean T. Lim, Irele Ifijeh Ahonkhai, Eltahir Eltagani, Odhran K. Ryan, Ailbhe O’Driscoll-Collins, A O’Neill, Zakya Penny, Orlaith Kelly, Carolyn Cullinane, Ian S. Reynolds, Helen Heneghan, Seán Martin, D. C. Winter, Matthew Davey, Maha Alkhattab, Aoïfe Lowery, Michael J. Kerin, Aisling Hogan, Martin S. Davey, Ke En Oh, Syed Mohammad Umar Kabir, Huilun Huan, Charlotte Aziz, Michael F. Sugrue, Jessica Ryan, Tara M. Connelly, Mohammad Alhazmi, Youssef Al-Mukhaizeem, Fiachra Cooke, Peter Neary, Arnold Hill, Michael R. Boland, Angus Lloyd, Frances Fallon, Eoin F. Cleere, James Toale, Patrick A. Boland, Michael Devine
Abstract
INTRODUCTION: Acute appendicitis is a common surgical emergency, and the standard approach to diagnosis and management has been codified in several practice guidelines. Adherence to these guidelines provides insight into independent surgical practice patterns and institutional resource constraints as impediments to best practice. We explored data from the recent ESTES SnapAppy observational cohort study to determine guideline compliance in contemporary practice to identify opportunities to close evidence-to-practice gaps. METHODS: We undertook a preplanned analysis of the ESTES SnapAppy observational cohort study, identifying, at a patient level, congruence with, or deviation from WSES Jerusalem guidelines for the diagnosis and management of acute appendicitis and the Surviving Sepsis Campaign in our cohort. Compliance was then correlated with the incidence of postoperative complications. RESULTS: Four thousand six hundred and thirteen (4613) consecutive adult and adolescent patients with acute appendicitis were followed from date of admission (November 1, 2020, and May 28, 2021) for 90 days. Patient-level compliance with guideline elements allowed patients to be grouped into those with full compliance (all 5 elements: 13%), partial compliance (1-4 elements: 87%) or noncompliance (0 elements: 0.2%). We identified an excess postoperative complication rate in patients who received noncompliant and partially compliant care, compared with those who received fully guideline-compliant care (36% and 16%, versus 7.3%, p < 0.001). CONCLUSIONS: The observed diagnostic and treatment practices of the participating institutions displayed variability in compliance with key recommendations from existing guidelines. In general, practice was congruent with recommendations for preoperative antibiotic surgical site infection prophylaxis administration, time to surgery, and operative approach. However, there remains opportunities for improvement in the choice of diagnostic imaging modality, postoperative antibiotic stewardship to timely discontinue prophylactic antibiotics, and the implementation of ambulatory treatment pathways for uncomplicated appendicitis in the healthy young adult.