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%)