The document summarizes a national multicenter audit of appendicectomy procedures conducted in the United Kingdom. Over 3,300 appendicectomy cases were collected from 95 centers. Key findings included an initial laparoscopic approach rate of 66.3% and a histologically normal appendix rate of 20.6%. The audit demonstrated the feasibility of a large multicenter collaborative research network. Future randomized controlled trials are proposed, including comparing laparoscopic versus open appendicectomy and evaluating the treatment of appendicitis with antibiotics versus an operative approach.

1. (Inter)National, Multicentred
Appendicectomy Audit
Aneel Bhangu
General Surgery Registrar
West Midlands Research Collaborative

2. 1. First things first
•Why we did it
•What we found
•Future trials
2

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

4. 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

5. 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

6. General Surgical Research Collaboratives
Newcastle Surgical
Scottish Surgical Research Collaborative
Registrars Research
Group

7. 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

8. To date
• Over 60 centres registered
• 30 have confirmed via unit questionnaire or audit
registration form
• 15*30 = 450 patients to date
• Database
8

9. Results
• 95 centres
• 3326 patients
• 89 UK centres
• 6 international centres
9

10. 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%).
10

11. Centre specific normal appendicectomy rate Centre specific 30 day adverse event rate
Centre specific provision of initial laparoscopic approach Consultant presence in the operating theatre
11

12. Centre specific normal appendicectomy rate Centre specific 30 day complication rate
Centre specific provision of initial laparoscopic approach Consultant presence in the operating theatre
12

13. What we did well
• Communication networks
• Speed
• Volume
13

14. Where we could have improved
• Definitions and outcomes
• Even wider communication
• Data collection tools (teething problems only)
14

15. 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

16. Future trials
1. Lap v open appendicectomy
2. Lap normal appendix
3. Right iliac fossa pain of uncertain cause
4. Operative versus antibiotic treatment
16

17. 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.
17

18. 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.
18

19. 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)
19

20. 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.
20

21. • 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?
21

22. 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?
22

23. 23

24. • Questions and discussion
24