Presentation on theme: "Standard of Care T. Topp, MDcd, FRCSC, FACS Head, Division of General Surgery."— Presentation transcript:
Standard of Care T. Topp, MDcd, FRCSC, FACS Head, Division of General Surgery
In the USA, failure to timely diagnose acute appendicitis is the ____ most common cause for malpractice lawsuit. A. 1st B. 2nd C. 3rd D. 4th
The Diagnosis of Acute Uncomplicated Appendicitis mandates: A. An Emergent Operation (<8 hrs from diagnosis) B. An Urgent Operation (<24-36 hrs from diagnosis) C. No operation, as the disease can be managed medically.
Audience Survey: What proportion of your non-pregnant patients in whom you suspect acute appendicitis do you obtain an CT scan? A. 0-33% B % C % D. 100%
You are operating on CT proven appendicitis, but at surgery the appendix (and everything else) looks normal. Do you: A. Convert to open (or extend your open incision) and do a formal laparotomy. B. Just take out the appendix. C. Leave the appendix in, go home and blame it all on a bad virus going around. D. A & B.
Legal: professional care and skill that might reasonably have been provided by a colleague in similar circumstances. Appropriate measure is the level of reasonableness. Not a standard of perfection. The Court determines that reasonable standard through the evidence of experts.
Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis Susan Krajewski, MD, MPH* Jacqueline Brown, MD† P. Terry Phang, MD‡ Manoj Raval, MD, MSc‡ Carl J. Brown, MD, MSc‡ Can J Surg, Vol. 54, No. 1, February 2011
Numerous studies have correlated perforation with duration of symptoms and delays in presentation. similar rates of perforation between patients in the CT group and those in the clinical evaluation group (23.4% v. 16.3%, p = 0.15).
Management of Acute Appendicitis: The Impact of CT Scanning on the Bottom Line Cedric V Pritchett, MD, MPH, Nick C Levinsky, BS, Yoonhee P Ha, MSc, Allard E Dembe, SCD, Steven M Steinberg, MD, FACS J Am Coll Surg 2010;210:699–707 Increases cost of care Decreases contribution to margin Prolongs patient’s stay in the emergency department Delays time to operation
Surgical delay correlates with appendiceal rupture Peritonitis Sepsis Death How Time Affects the Risk of Rupture in Appendicitis; Nina A Bickell, MD, MPH, Arthur H Aufses Jr, MD, FACS, Mary Rojas, PhD, Carol Bodian, DrPhJ Am Coll Surg 2006;202:401–406
Perioperative: reduction of SSI’s For uncomplicated (non-perforated) acute appendicitis, duration of postoperative antibiotics is unclear Post-operative antibiotic use in nonperforated appendicitis; Dinhkim Le, M.D., Wendy Rusin, A.C.N.P., Britani Hill, M.D., John Langell, M.D., Ph.D.; The American Journal of Surgery (2009) 198, 748–752
Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open- label, non-inferiority, randomised controlled trial. Vons C - Lancet - 7-MAY-2011; 377(9777): 243 pts 120 antibiotics alone, & 120 appendicectomy group 30 day post-intervention peritonitis: abx group = 8% appy group = 2% Nb. In appy group, despite CT-proven ‘uncomplicated’ appendicitis, 18% were ‘complicated’ at appendicectomy.
Antibiotic Group 14/120 patients (12%) had appy in first 30 days 30/102 (29%) had appy between 31 and 365 days 26 of these had acute appendicitis
Histologically Inflamed Histologically Normal Clinically Inflamed 47 (55%)1 (1%) Clinically Normal 14 (17%)23 (27%)