(Inter)National, Multicentred Appendicectomy Audit

Aneel BhanguGeneral Surgery Registrar

West Midlands Research Collaborative

1. First things first

•Why we did it•What we found•Future trials

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National Collaborative

• 3rd National meeting• National Research Collaborative• Simple, easy, accessible idea• “All” trainees and hospitals• Many questions

– Feasibility, Structure, Organisation

Aim

• Aim: a national (international), multicentred, audit of appendicectomy

• Primary outcome: negative rate• Secondary outcomes: laparoscopy rates,

adverse event rates• Inclusion: appendicectomy, all ages• Exclude: diagnostic lap

Method• Protocol – reviewed by Prof Alderson• 2 week 5 centre pilot in West Mids• 2 month multi-centred audit• 30 centres will recruit approximately 1000

patients – LSRG, WMRC, Mersey, EoE, Trent, Sparcs, PSTRN– Hong Kong, Aus, New Zealand

Scottish Surgical Registrars Research

Group

Newcastle Surgical Research Collaborative

General Surgical Research Collaboratives

Data collection• May 1st- June 30th, 30 day FU• Access Database with guidance notes• Strict confidentiality - only anonymised data

submitted via nhs.net• Audit registration• Centrally collated• Authorship model

To date

• Over 60 centres registered • 30 have confirmed via unit questionnaire or audit

registration form• 15*30 = 450 patients to date• Database

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Results

• 95 centres• 3326 patients• 89 UK centres• 6 international centres

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Results II

• (Initial) open appendicectomy: 33.7% (range 3.3-36.8% in centres>25 appendicectomies)

• Initial lap approach: 66.3% (8.7-100%)

• Lap conversion in 6.9% (of total)

• A consultant was present in theatre: 23.8% (1.9-84.6%)

• Histologically normal appendix: 20.6% (3.3-36.8%).

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What we did well

• Communication networks • Speed• Volume

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Where we could have improved

• Definitions and outcomes• Even wider communication • Data collection tools (teething problems only)

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Summary of aims

• Aim to perform a high quality, multi-centred audit• Aim to establish a national collaborative

research network• Build an RCT from this

Future trials

1. Lap v open appendicectomy

2. Lap normal appendix

3. Right iliac fossa pain of uncertain cause

4. Operative versus antibiotic treatment

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Lap normal appendix

• Rationale: no evidence to guide practice at present.

• What we can add: a multicenter trial

• Difficulties: – need to randomize everyone to capture target market.

Combining as an arm of another study is feasible, but will increase sample size significantly.

– Needs one year FU.

– Endpoint: Reducing LoS; readmissions; adverse events.

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lap v open appendicectomy

• Rationale: – 0-100% lap rate from 95 centres in the national audit

– Current 62 RCTs from a Cochrane review mostly single centre (only 3 were >3 centres)

– Mostly used length of stay as primary outcome

• What we can add: – a multicenter, national RCT with adverse events as an outcome.

– Could aim for 1000 patients which may help stablise use of lap rates in the UK and beyond.

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Difficulties

• High volume centres with lap pathways/ centres with high lap rates unlikely to participate, leaving medium size centres who currently have mixed rates.

• Learning curves for trainees.

• Need to convince the community of the need for another trial on this topic.

• This idea could be trimmed down to selected patients rather than all-comers (e.g. those with risk factors for post-op adverse events)

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RIF pain of uncertain cause

• Rationale: management of undifferentiated RIF pain (and undifferentiated acute abdominal pain) is very topical and very under-researched.

• Design: Early diagnostic lap v imaging and observation. – May be best in females or reproductive age alone.

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• What we can add: a multicenter trial – only around 2 small RCTs currently done on this topic (but this proves feasibility). Could randomize the imaging/observation arm too.

• Difficulties: – Units would need to ensure pathways to access theatre and

imaging within 24 hours.

– surgeons may be reluctant to randomize?

– Potentially slow recruitment?

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operative versus antibiotic treatment of appendicitis

• Rationale: recent interest and meta-analysis of this as a future treatment. Meta-analysis showed 80% avoid appendicectomy by 12 months.

• What we can add: – no RCT has been done in the UK.

– Nigel Hall is planning to start a feasibility study in paediatric patients, to test whether randomization in the UK climate is feasible.

• Difficulties: high quality meta-analysis has showed outcomes (but not in UK). Will UK surgeons accept this?

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• Questions and discussion

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