Clinical practice selectively follows acute appendicitis guidelines
Authors: Bass Gary Alan , Mohseni Shahin , Ryan Éanna J. , Forssten Maximilian Peter , Tolonen Matti , Cao Yang , Kaplan Lewis J. ,   ESTES SnapAppy Group, Ahl Hulme Rebecka , Biloslavo Alan , Kurihara Hayato , Martinez-Casas Isidro , Pereira Jorge , Pourlotfi Arvid , Louri Nayef , Cao Yang , Nedham Fatema , Walsh Thomas Noel , Hashem Jamal , Corbally Martin , Farhan Abeer , Al Hamad Hamad , Elhennawy Rawan , AlKooheji Mariam , AlYusuf Manar , Aknouche Wissal , Zeidan Anas A. , Alsaffar Yusuf S. , Lipping Edgar , Talving Peep , Saar Sten , Graumann Katrina , Kibuspuu Liis , Harkov Eduard , Aaltonen Gisele , Sillman Iines S. , Haapanen Sami , Lampela Hanna , Sammalkorpi Henna , Eskola Sofia , Laakso Altti , Back Johan , Kettunen Ulla , Nummi Antti M. , Szwedyc Anika , Nykänen Taina , Rantala Rolle , Mäkäräinen-Uhlbäck Elisa J. , Meriläinen Sanna A. , Huhta Heikki I. , Rintala Jukka M. J. , Laitakari Kirsi E. M. , Lietzen Elina , Salminen Paulina , Rapola Risto K. A. , Zangouri Vahid , Karami Mohammad Y. , Tahmasebi Sedigheh , Akrami Majid , Golchini Alireza , Bahrami Faranak , Johnston Sean M. , Lim Sean T. , Ahonkhai Irele Ifijeh , Eltagani Eltahir , Ryan Odhran K. , O’Driscoll-Collins Ailbhe , O’Neill Aine , Penny Zakiya , Kelly Orlaith , Cullinane Carolyn , Reynolds Ian , Heneghan Helen , Martin Sean , Winter Des , Davey Matthew , Alkhattab Maha , Lowery Aoif J. , Kerin Michael J. , Hogan Aisling M , Davey Martin S , Oh Ke En , Kabir Syed Mohammad Umar , Huan Huilun , Aziz Charlotte , Sugrue Michael , Ryan Jessica M. , Connelly Tara M. , Alhazmi Mohammad , Al-Mukhaizeem Youssef , Cooke Fiachra , Neary Peter M. , Hill Arnold D. K. , Boland Michael R. , Lloyd Angus J. , Fallon Frances , Cleere Eoin F. , Toale James , Boland Patrick A. , Devine Michael , Keady Conor , Hunter Sarah , Barry M. Kevin , Kelly Michael E. , O’Dowling Aidan T. , Creavin Ben , Kavanagh Dara O. , Neary Paul , Ridgway Paul F F. , McCarrick Cathleen A. , Bolger Jarlath , Maguire Barry , Keogh Cian , Chawla Surbhi , Conneely John , McCormack Emilie , Shanahan Ben , Raftery Nicola , Rice Darragh , McInerney Niall , Stakelum Aine , Mares Jan , Tan Jonavan , Hanna Mark , Balasubramanian Ishwarya , Fleming Christin , Barsky Guy , Shaked Gad , Giudici Simone , Ceolin Martina , Mei Simona , Mazzarella Francesca , Zucca Annalisa , Terranova Susanna , de Manzini Nicolo , Visconti Diego , Doria Emanuele , Santarelli Mauro , Scotton Giovanni , Notte Francesca , Bertelli Giacomo , Malpaga Anna , Armatura Giulia , Frena Antonio , Tartaglia Dario , Coccolini Federico , Cremonini Camilla , Cicuttin Enrico , Mazzoni Alessio , Chiarugi Massimo , Azevedo Constança M. , Mendes Filipa D. , Faria Luis Q. , Nazario Carlos , Machado Daniela , Semiao Miguel , Casimiro Carlos , Pinto Jose , Pavão Tiago , Pereira Raquel , Barbosa Bruno , Tenreiro Nadia , Ferreira Catia , Guidi Goncalo , Martins Daniela C. , Leal Clara , Vieira Bruno B. , Castro Luís S. , Faria Aldara , Figueira Alberto , Sousa Mauro , Rodrigues Pedro , Roquette Rodrigo , Ribeiro Ricardo , Cardoso Paulo , Domingues Joana , Manso Maria Isabel , Pereira Rute , Revez Tatiana , Dumbrava Bogdan D. , Turcu Florin , Hutopila Ionut , Banescu Bogdana , Filip Gerald , Copaescu Catalin , Alba Valmorisco Marcos , Manzano Martín Isabel , Martín García de Arboleya Rocio , Ortega Seda José , Rodríguez González Pablo , Becerra Toro Jose Antonio , Rodríguez Lara Enrique , González Minchón Jose Antonio , Segura-Sampedro Juan José , Jerí-McFarlane Sebastián , Gil-Catalán Alejandro , Craus-Miguel Andrea , Fernández-Vega Laura , González-Argenté Xavier , Estaire-Gómez Mercedes , Camacho Fernández-Pacheco Borja , Vitón-Herrero Rebeca , Jimenez-Higuera Elisa , Barbero Alejandro , Valverde José M. , Colás-Ruiz Enrique , Escales-Oliver Maria del Mar , Claramonte-Bellmunt Olga , Castro-Suárez Marta , Pagés-Valle Naila , Cifuentes-Ródenas José Andrés , Merayo Alvarez Marta , Michi Campos Jose Luis , García González Luis Alejandro , Carrasco Aguilera Beatriz , Iturbe Menéndez Jaime , Rodicio Miravalles Jose Luis , Rodríguez Haro Carmen , Núñez O’Sullivan Sara , García Virosta Mariana , Hernández O’Reilly María , Balciscueta-Coltell Izaskun , Lorenzo-Perez Javier , Martinez-Alcaide Sonia , Martinez-Ramos Susana , Sebastian-Fuertes Maria , Gomez-Romer Laura , Pelloni Maria M. , Rahy-Martín Aida Cristina , Yepes-Cano Andrés Felipe , Reguera-Rosal Julio , Lopez-Ruiz Jose A. , Marenco Beatriz , Retamar-Gentil Marina , Romero-Vargas Estela , Gil-Olarte Angeles , Landaluce-Olavarria Aitor , Estraviz-Mateos Begoña , De Francisco-Rios Jose Mario , Sainz-Lete Aitor , Emaldi-Abasolo Ane , Leon-Valarezo Manolo , Lopes Moreira Claudia C. , Lizarazu Perez Aintzane , Rodriguez Gonzalez Araceli , Augusto Ponce Iñigo , Goena Iglesias Ignacio Maria , González-Prado Cristina , Cabriada Guillermo , López Beatriz , Otero Michelle C. , Muñoz-Plaza Nerea , Palomo Alberto , Mendoza-Moreno Fernando , Díez-Alonso Manuel , García-Moreno-Nisa Francisca , Matías-García Belén , Ovejero-Merino Enrique , Quiroga-Valcárcel Ana , Sánchez-Guillén Luis , Oller-Navarro Inmaculada , Soler-Silva Álvaro , Sanchís-López Antonio Francisco , Blanco-Antona Francisco , Muñoz-Bellvis Luis , López-Sánchez Jaime , Garrosa-Muñoz Sonsoles , Barón-Salvador Beatriz , Nieto-Arranz Juan Manuel , Campos-Serra Andrea , Gràcia-Roman Raquel , Muñoz-Campaña Anna , Zerpa-Martin Carla , Torrecilla-Portoles Andrea , Landa Tessa , Durán Muñoz-Cruzado Virginia , Pareja-Ciuró Felipe , Aparicio-Sánchez Daniel , Perea del Pozo Eduardo , Dios-Barbeito Sandra , García-Sánchez Carlos , García-Moriana Antonio Jesús , Turrado-Rodriguez Victor , Termes-Serra Roser , Gonzalez-Atienza Paula , Morales-Sevillano Xavier , Torroella Alba , Ginestà César , Escartín Alfredo , Gomez Ferney , Pinillos Ana , Ortega Jaume , Lopez Guillermo , Gutierrez Eric , Membrilla-Fernandez Estela , Ocho-Segarra Francisco , González-Castillo Ana María , Pelegrina-Manzano Amalia , Guzmán-Ahumada Juan , Sancho-Insenser Juan Jose , García-Jiménez María Lourdes , Castro-Diez Laura , González-Bermúdez Manuel , Torres-Díaz Mónica , Madarro Pena Carla , Blanco Rodríguez Angélica , Trivedi Dhanisha , Reda Souheil , Edvardsson Hans , Strömmer Lovisa , Caragounis Eva-Corina , Sillén Karin , Warfvinge Sofia , Bergstedt Fredrik , Enström Philip , Olsson Harald , Rosemar Anders , Young Nathalie , Popowicz Agnieszka , Lerström Johanna , Jäderbo Johanna , Hammarqvist Folke , Zacharias Hanna , Wikström Maria B. , Stene Hurtsén Anna , Bayadsi Haytham , Jansson Emma , Brunstrom Nils , Malers Ellen B. , Loftås Per I. , Möller Anders , Atanasova Elena , Zwicky Simone N. , Schnüriger Beat , Rutka Olga , Kattakayam Arjun T. , Alam Mushfique , Taylor John V. , Mihailescu Andrei , Karip Eszter T. , Zeb Ehtisham , O’Connor Adam , Pokusevski Goran , Khan Mansoor , Florance Charlotte , Swaminathan Christie , Jaunoo Shameen , Sajid Mohammed , Duffy Caoimhe C. , Rees John , Seamon Mark J. , Martin Niels D. , McCurry Ian J. , Vail Emily A. , Bormann Bradford C. , Cullinane Daniel C. , Sawhney Jaswin S. , Dreifus Jonathan , Sheppard Forest R. , Coimbra Raul , Albini Paul , Edwards Sara 
Published: January 2023

Abstract
Introduction
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.