PDF(Pubmed)
Abstract：
BACKGROUND: 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.
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.
摘要：
背景：急性阑尾炎是一种常见的外科急症，和标准的诊断和管理方法已被编入几个实践指南。遵守这些指南可以深入了解独立的外科实践模式和机构资源限制，这是最佳实践的障碍。我们探索了最近的ESTESSnapAppy观察性队列研究的数据，以确定当代实践中的指南依从性，以确定缩小证据与实践差距的机会。
方法：我们对ESTESSnapAppy观察性队列研究进行了预先计划的分析，识别,在患者层面，与，或与WSES耶路撒冷指南中急性阑尾炎的诊断和治疗以及我们队列中的败血症生存运动的偏离。依从性与术后并发症的发生率相关。
结果：自入院之日起（2020年11月1日和2021年5月28日），对四千六百十三（4613）名连续的成人和青少年急性阑尾炎患者进行了90天的随访。患者对指南要素的依从性允许患者被分组为完全依从性的患者（所有5个要素：13％），部分合规（1-4个元素：87％）或不合规（0个元素：0.2％）。我们发现接受不合规和部分合规护理的患者术后并发症发生率过高，与接受完全符合指南的护理的人相比(36%和16%，与7.3%相比，p<0.001)。
结论：所观察到的参与机构的诊断和治疗实践在符合现有指南的关键建议方面表现出差异性。总的来说,实践与术前抗生素手术部位感染预防管理的建议一致，手术时间到了,和手术方法。然而,诊断成像模式的选择仍有改进的机会，术后抗生素管理及时停止预防性抗生素，以及在健康的年轻成年人中实施非复杂性阑尾炎的动态治疗途径。
方法：我们对ESTESSnapAppy观察性队列研究进行了预先计划的分析，识别,在患者层面，与，或与WSES耶路撒冷指南中急性阑尾炎的诊断和治疗以及我们队列中的败血症生存运动的偏离。依从性与术后并发症的发生率相关。
结果：自入院之日起（2020年11月1日和2021年5月28日），对四千六百十三（4613）名连续的成人和青少年急性阑尾炎患者进行了90天的随访。患者对指南要素的依从性允许患者被分组为完全依从性的患者（所有5个要素：13％），部分合规（1-4个元素：87％）或不合规（0个元素：0.2％）。我们发现接受不合规和部分合规护理的患者术后并发症发生率过高，与接受完全符合指南的护理的人相比(36%和16%，与7.3%相比，p<0.001)。
结论：所观察到的参与机构的诊断和治疗实践在符合现有指南的关键建议方面表现出差异性。总的来说,实践与术前抗生素手术部位感染预防管理的建议一致，手术时间到了,和手术方法。然而,诊断成像模式的选择仍有改进的机会，术后抗生素管理及时停止预防性抗生素，以及在健康的年轻成年人中实施非复杂性阑尾炎的动态治疗途径。
