Compliance to guidelines in the management of acute appendicitis: how fare have we gone? A perspective from the largest Italian surgical educational network

Abstract text (incl. references and figure legends)

IntroductionAcute appendicits (AA) is one of the most common surgical emergencies worldwide. Recent international guidelines (GL) defined various aspects of AA diagnosis and management, based on high-quality evidence, whereas some other are still controversial. We aimed to assess compliance with GL on a multicenter cohort of adult patients affected by AA.MethodsData were retrieved from the Resident-1 multicenter trainee-led Italian registry.We explored the adherence to GL on 7 selected clinical items(Tab1).We compared different subgroups considering procedures approached by residents vs surgeons, in university vs non-university hospitals, and in dedicated emergency surgery services vs non dedicated ones.Results653 patients with AA treated with laparoscopic appendectomy (LA) were recruited from 60 residents in 21 centres in the largest Northern Italian educational network.We identified low compliance to four items: no peritoneal lavage in 25.7%, no drain placement in 53.3%, no postoperative antibiotics for uncomplicated AA in 38.1% and antibiotics administered for ≤5 days for complicated AA in 34.2%.Procedures performed in ES services and university hospitals were associated with higher compliance concerning drain placement and no lavage. ConclusionWe identified poor compliance with four items among which two were based on moderate and two on high quality evidence, all with strong recommendation. Low compliance to drain placement and postoperative antibiotics regimens are red flags linked to non-negligible impact on postoperative pain, length of stay, efficacy of antibiotics therapies and resistance. The diffusion of dedicated ES services and the adoption of more evidence-based surgical practices are core issues to address. Specific clinical bundles are needed to fill these gaps and an international snapshot is necessary to explore the phenomenon worldwide.

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