The burden of the knowledge-to-action gap in acute appendicitis
Authors: Cioffi Stefano Piero Bernardo , Altomare Michele , Podda Mauro , Spota Andrea , Granieri Stefano , Reitano Elisa , Zamburlini Beatrice , Virdis Francesco , Bini Roberto , Gupta Shailvi , Torzilli Guido , Mingoli Andrea , Chiara Osvaldo , Cimbanassi Stefania ,   The REsiDENT-1 research group, Abruzzese Giulia Arianna , Albanesi Francesca , Andreatta Erika , Baldari Ludovica , Benuzzi Laura , Bevilaqua Emanuele , Bonomi Alessandro Michele , Brachetti Greta , Cannavale Giulia , Chierici Andrea Piero , Cirelli Riccardo , Colletti Gaia , D’abrosca Vera , Danelli Piergiorgio , Del Prete Luca , Di Capua Francesco , Di Vittorio Francesca , Ferrari Davide , Ferrario Luca , Fiore Laura , Frattaruolo Colomba , Froiio Caterina , Gibelli Ludovica , Giusti Irene , Giustizieri Ugo , Grandi Samuele , Iacob Giulio , Kersik Alessia , Lombardi Pietro , Longhi Marco , Lorusso Leonardo , Manara Michele , Manzo Elena , Marin Jacopo Nicolo , Maspero Marianna , Messina Valentina , Milito Pamela , Molteni Mattia , Monti Eleonora , Nicastro Vincenzo , Novelli Giorgio , Paleino Sissi , Pavesi Silvia , Perali Carolina , Pezzoli Isabella , Ragozzino Roberta , Santolamazza Giuliano , Scaravilli Luca , Tornatore Gilda , Toti Francesco , Tripodi Vincenzo , Vaterlini Elisa , Vignati Barbara , Maina Cecilia , Borghi Alessandra , Luc Marco Realis , Pizzini Paolo , Masserano Riccardo , Maistri Marta , Traballi Laura , Cammarata Francesco , Boero Alvino , Socci Davide , Carbonaro Margherita , Pellegrini Martina 
Published: October 2023

Background

The burden of emergency general surgery (EGS) is higher compared to elective surgery. Acute appendicitis (AA) is one of the most frequent diseases and its management is dictated by published international clinical practice guidelines (CPG). Adherence to CPG has been reported as heterogeneous. Barriers to clinical implementation were not studied. This study explored barriers to adherence to CPG and the clinico-economic impact of poor compliance.

Methods

Data were extracted from the three-year data lock of the REsiDENT-1 registry, a prospective resident-led multicenter trial. We identified 7 items from CPG published from the European Association of Endoscopic Surgery (EAES) and the World Society of Emergency Surgery (WSES). We applied our classification proposal and used a five-point Likert scale (Ls) to assess laparoscopic appendectomy (LA) difficulty. Descriptive analyses were performed to explore compliance and group comparisons to assess the impact on outcomes and related costs. We ran logistic regressions to identify barriers and facilitators to implementation of CPG.

Results

From 2019 to 2022, 653 LA were included from 24 centers. 69 residents performed and coordinated data collection. We identified low compliance with recommendations on peritoneal irrigation (PI) (25.73%), abdominal drains (AD) (34.68%), and antibiotic stewardship (34.17%).

Poor compliance on PI and AD was associated to higher infectious complications in uncomplicated AA. Hospitalizations were significantly longer in non-compliance except for PI in uncomplicated AA, and costs significantly higher, exception made for antibiotic stewardship in complicated AA. The strongest barriers to CPG implementation were complicated AA and technically challenging LA for PI and AD. Longer operative times and the use of PI negatively affected antibiotic stewardship in uncomplicated AA. Compliance was higher in teaching hospitals and in emergency surgery units.

Conclusions

We confirmed low compliance with standardized items influenced by environmental factors and non-evidence-based practices in complex LA. Antibiotic stewardship is sub-optimal. Not following CPG may not influence clinical complications but has an impact in terms of logistics, costs and on the non-measurable magnitude of antibiotic resistance. Structured educational interventions and institutional bundles are required.