Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
Division of Trauma & Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Örebro, Sweden.
Eur J Trauma Emerg Surg. 2023 Feb;49(1):45-56. doi: 10.1007/s00068-022-02208-2. Epub 2023 Jan 31.
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.
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.
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).
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.
急性阑尾炎是一种常见的外科急症，其诊断和治疗的标准方法已在多个实践指南中进行了编纂。这些指南的遵守情况提供了有关独立手术实践模式和机构资源限制作为最佳实践障碍的见解。我们探讨了来自最近的 ESTES SnapAppy 观察性队列研究的数据，以确定当代实践中指南的遵守情况，以确定缩小证据与实践差距的机会。
我们对 ESTES SnapAppy 观察性队列研究进行了预先计划的分析，在患者层面上，确定了我们队列中与 WSES 耶路撒冷指南对急性阑尾炎的诊断和管理以及拯救脓毒症运动的一致性或偏离。然后将合规性与术后并发症的发生率相关联。
4613 例连续的成人和青少年急性阑尾炎患者从入院日期（2020 年 11 月 1 日和 2021 年 5 月 28 日）开始随访 90 天。根据指南要素，患者可以分为完全合规（所有 5 个要素：13%）、部分合规（1-4 个要素：87%）或不合规（0 个要素：0.2%）。与接受完全合规护理的患者相比，接受不合规和部分合规护理的患者术后并发症发生率更高（36%和 16%，与 7.3%相比，p<0.001）。
参与机构的观察性诊断和治疗实践在遵守现有指南的关键建议方面存在差异。一般来说，实践与术前抗生素预防手术部位感染的应用、手术时间和手术方法的建议一致。然而，在选择诊断成像方式、术后抗生素管理以及时停止预防性抗生素以及为健康年轻成年人实施简单阑尾炎的门诊治疗途径方面仍有改进的机会。
