Ann & Robert H. Lurie Children's Hospital of Chicago, IL; Geisinger Medical Center, Danville, PA.
Ann & Robert H. Lurie Children's Hospital of Chicago, IL. Electronic address: https://twitter.com/JonathanVacek.
Surgery. 2022 Apr;171(4):1022-1026. doi: 10.1016/j.surg.2021.10.006. Epub 2021 Nov 10.
There is wide variability and considerable controversy regarding the classification of appendicitis and the need for postoperative antibiotics. This study aimed to assess interrater agreement with respect to the classification of appendicitis and its influence on the use of postoperative antibiotics amongst surgeons and surgical trainees.
A survey comprising 15 intraoperative images captured during appendectomy was distributed to surgeons and surgical trainees. Participants were asked to classify severity of disease (normal, inflamed, purulent, gangrenous, perforated) and whether they would prescribe postoperative antibiotics. Statistical analysis included percent agreement, Krippendorff's alpha for interrater agreement, and logistic regression.
In total, 562 respondents completed the survey: 206 surgical trainees, 217 adult surgeons, and 139 pediatric surgeons. For classification of appendicitis, the statistical interrater agreement was highest for categorization as gangrenous/perforated versus nongangrenous/nonperforated (Krippendorff's alpha = 0.73) and lowest for perforated versus nonperforated (Krippendorff's alpha = 0.45). Fourteen percent of survey respondents would administer postoperative antibiotics for an inflamed appendix, 44% for suppurative, 75% for gangrenous, and 97% for perforated appendicitis. Interrater agreement of postoperative antibiotic use was low (Krippendorff's alpha = 0.28). The only significant factor associated with postoperative antibiotic utilization was 16 or more years in practice.
Surgeon agreement is poor with respect to both subjective appendicitis classification and objective utilization of postoperative antibiotics. This survey demonstrates that a large proportion (59%) of surgeons prescribe antibiotics after nongangrenous or nonperforated appendectomy, despite a lack of evidence basis for this practice. These findings highlight the need for further consensus to enable standardized research and avoid overtreatment with unnecessary antibiotics.
阑尾炎的分类以及术后使用抗生素的问题存在广泛的差异和相当大的争议。本研究旨在评估外科医生和外科住院医师在阑尾炎分类方面的评分者间一致性，并评估其对术后抗生素使用的影响。
本研究向外科医生和外科住院医师发放了一份包含 15 张阑尾切除术术中图像的调查问卷。参与者被要求对疾病严重程度（正常、炎症、化脓、坏疽、穿孔）进行分类，并决定是否开具术后抗生素。统计分析包括百分比一致性、评分者间一致性的 Krippendorff's alpha 以及逻辑回归。
共有 562 名受访者完成了调查：206 名外科住院医师、217 名成人外科医生和 139 名儿科外科医生。在阑尾炎分类方面，对于坏疽/穿孔与非坏疽/非穿孔的分类，评分者间的统计一致性最高（Krippendorff's alpha=0.73），而穿孔与非穿孔的一致性最低（Krippendorff's alpha=0.45）。14%的受访者会在阑尾炎炎症期开具术后抗生素，44%会在化脓期开具，75%会在坏疽期开具，97%会在穿孔期开具。术后抗生素使用的评分者间一致性较低（Krippendorff's alpha=0.28）。唯一与术后抗生素使用相关的显著因素是 16 年以上的从业经验。
外科医生在主观的阑尾炎分类和客观的术后抗生素使用方面一致性较差。本调查表明，很大一部分（59%）外科医生在非坏疽或非穿孔性阑尾炎手术后开具抗生素，尽管这种做法缺乏证据基础。这些发现强调需要进一步达成共识，以实现标准化研究并避免不必要的抗生素过度治疗。
