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2015 ; 15
(ä): 69
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Surgical decision-making in acute appendicitis
#MMPMID26032861
Sandell E
; Berg M
; Sandblom G
; Sundman J
; Fränneby U
; Boström L
; Andrén-Sandberg Å
BMC Surg
2015[Jun]; 15
(ä): 69
PMID26032861
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BACKGROUND: Acute appendicitis is one of the most common acute abdominal
conditions. Among other parameters, the decision to perform surgical exploration
in suspected appendicitis involves diagnostic accuracy, patient age and
co-morbidity, patient's own wishes, the surgeon's core medical values, expected
natural course of non-operative treatment and priority considerations regarding
the use of limited resources. Do objective clinical findings, such as radiology
and laboratory results, have greater impact on decision-making than "soft"
clinical variables? In this study we investigate the parameters that surgeons
consider significant in decision-making in cases of suspected appendicitis;
specifically we describe the process leading to surgical intervention in real
settings. The purpose of the study was to explore the process behind the decision
to undertake surgery on a patient with suspected appendicitis as a model for
decision-making in surgery. METHODS: All appendectomy procedures (n = 201) at the
Department of Surgery at Karolinska University Hospital performed in 2009 were
retrospectively evaluated. Every two consecutive patients seeking for abdominal
pain after each case undergoing surgery were included as controls. Signs and
symptoms documented in the medical records were registered according to a
standardized protocol. The outcome of this retrospective review formed the basis
of a prospective registration of patients undergoing appendectomy. During a
three- month period in 2011, the surgeons who made the decision to perform acute
appendectomy on 117 consecutive appendectomized patients at the Karolinska
University Hospital, Huddinge, and Södersjukhuset, were asked to answer a
questionnaire about symptoms, signs and diagnostic measures considered in their
treatment decision. They were also asked which three symptoms, signs and
diagnostic measures had the greatest impact on their decision to perform
appendectomy. RESULTS: In the retrospective review, tenderness in the right fossa
had the greatest impact (OR 76) on treatment decision. In the prospective
registration, the most frequent symptom present at treatment decision was pain in
the right fossa (94 %). Tenderness in the right fossa (69 %) was also most
important for the decision to perform surgery. Apart from local status, image
diagnostics and blood sample results had the greatest impact. CONCLUSION: Local
tenderness in the right fossa, lab results and the results of radiological
investigations had the greatest impact on treatment decision.
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