This presentation was delivered to the WMRC in March 2017. The first paper was published in BJS in Dec 2019. The data was collected from March 2017. The planning began in 2015. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11440

1. The Right Iliac Fossa pain
Treatment Audit (The RIFT audit)
RIFT Audit Group - WMRC
J Matthews, S Jain, S Bhanderi, G Morley, D Nepogodiev,
J Glasbey, R Tyler, I Mohamed, R Wilkin, A Bhangu
Acknowledgements - E Griffiths, T Pinkney, O Gee, D Morton
RIFTstudy@gmail.com
@WMRC_UK #RIFTaudit

2. Timeline
November 30th
2016
March
2017
April
2017
End of
2017
June
2017

3. Background
Appendicitis
Gynae
Urology
Non specific
pain
Gastro
RIF Pain

4. “Sit Rep”
UK + ROI
Potentially 283 teams (? Less)
>3070 emails
>200 drafted documents
Adult 186 contacts
Paeds 24 contacts
REDCap 157 complete forms
>500 collaborators
? >4000 patients to be audited
?

5. “Sit Rep”
Regions Count of Involved Count of Region %
East Midlands 10 11 91
East of England 17 17 100
Jersey 1 1 100
Kent, Surrey and Sussex 12 18 67
London North Central and East 10 13 77
London North West 5 9 56
London South 10 11 91
North East 6 14 43
North West 13 28 46
Northern Ireland 7 10 70
Paediatric Surgery 24 27 89
ROI 16 16 100
Scotland 18 28 64
South West 10 14 71
Thames Valley 5 5 100
Wales 10 15 67
Wessex 7 9 78
West Midlands 15 18 83
Yorkshire and the Humber 13 18 72
Iberian peninusula 1 ?
Italy 65 ?
Grand Total 210 283 74

6. Aims and Standards
1) An initial laparoscopic approach should be used for appendicectomy unless
contraindicated
– [WSES Statement 5.1]
– [EAES Operative recommendations]
– (National Re-audit)
2) The normal appendicectomy rate should be <20%. For centres with higher or lower rates,
risk stratification data will allow interpretation of this rate in light of baseline case-mix.
1) The primary aim of this study is to determine the negative appendicectomy rate for
patients presenting with right iliac fossa pain.
2) Secondary aims of this study are:
i. to validate predictive risk scores for acute appendicitis;
ii. determine the laparoscopic appendicectomy rate in 2017;
iii. model variation in pathways for management of undifferentiated right iliac fossa pain;
iv. determine readmission rates for non-operated patients with RIF pain.
Risk stratification data using Alvarado/ AIR score will allow interpretation of individual
centres’ rates of negative and laparoscopic appendicectomy in light of their baseline case-
mix. A separate centre survey will profile local policy and service delivery for management
of RIF pain.

7. Potential Outcomes
1. New trainee collaborative networks
2. National re-audit of laparoscopy rate
3. National Re-audit of negative appendectomy rate
4. International comparison
5. Paediatric management
6. Variation between centres
7. Management differences depending on gender
8. “Incidence” of RIF pain
9. “Incidence” of Acute Appendicitis
10. “Incidence” of other pathologies and operations
11. “Incidence” of USS, CT and MRI + Findings
12. “Incidence” of risk score clinical usage
13. Calculated Risk Scores
14. Sensitivity + Specificity + PPV + NPV of the Risk Scores
15. Validated risk scores
16. Proposed pathways and guidance

8. Method - Scores
Data Point Alvarado AIR
Nausea Or vomiting 1 1
Anorexia 1
RIF Pain 2 1
Migration to RIF 1
Rebound or Gaurding 1 1 - 3
Temperature 1 1
WCC 2 1 - 2
Leukocytosis 1
Polymorphs 1 - 2
CRP 1 -2
Total Score 10 12

11. RIFTstudy@gmail.com
@WMRC_UK #RIFTaudit
Any questions?
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12. References
National Surgical Research Collaborative. Multicentre observational study of performance variation in
provision and outcome of emergency appendicectomy. Br J Surg [Internet]. 2013 Aug 1 [cited 2016 Sep
23];100(9):1240–52. Available from: http://onlinelibrary.wiley.com/doi/10.1002/bjs.9201/abstract
Di Saverio S, Birindelli A, Kelly MD, Catena F, Weber DG, Sartelli M, et al. WSES Jerusalem guidelines for
diagnosis and treatment of acute appendicitis. World Journal of Emergency Surgery [Internet].
2016;11:34. Available from: http://dx.doi.org/10.1186/s13017-016-0090-5
Gorter RR, Eker HH, Gorter-Stam MAW, Abis GSA, Acharya A, Ankersmit M et al. Diagnosis and
management of acute appendicitis. EAES consensus development conference 2015. Surgical Endoscopy
[Internet]. 2016 Nov;30(11):4668-4690. Available from:
http://link.springer.com/article/10.1007/s00464-016-5245-7
Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of
pathogenesis, diagnosis, and management. The Lancet [Internet]. 2015 Sep;386(10000):1278–87.
Available from: http://linkinghub.elsevier.com/retrieve/pii/S0140673615002755