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letter
. 2022 Oct 26;110(2):280. doi: 10.1093/bjs/znac367

Author response to: Comment on: DIAgnostic iMaging or Observation in early equivocal appeNDicitis (DIAMOND): open-label, randomized clinical trial

Kirsi S Lastunen 1,, Ari K Leppäniemi 2, Panu J Mentula 3
PMCID: PMC10364514  PMID: 36285889

Dear Editor

We thank Dr Javanmard-Emamghissi for her interest in our paper1. Dr Javanmard-Emamghissi asked whether we had considered the impact of observation on patient flow and bed occupancy in the emergency department (ED), and whether these patients would have been suited for ambulatory care. The effect of observation on crowding in the ED was discussed briefly in our article, but we did not measure or record it in this study. For safety reasons, we wanted to keep patients in hospital during the observation period. In the end, the study proved that observation did not increase the number of perforations, which indicates that ambulatory care could be a reasonable option in the future.

We find the numbers in Dr Javanmard-Emamghissi’s comments confusing because 61 per cent (not 25 per cent) of patients in the observation group were operated on after observation. Of the observed patients, 46 per cent had imaging within 30 days and 50 per cent within 1 year (not 40 per cent). Thus, the observation protocol significantly reduced diagnostic imaging without evidence of harmful effects of the delay in care. Furthermore, the reduction in surgical treatment released resources for other surgical emergencies.

Observation of patients with right iliac fossa pain is closely related to the initial non-operative management of appendicitis. The main difference is that the latter is usually based on a definitive radiological diagnosis of uncomplicated appendicitis. This study showed that a definitive diagnosis might not be necessary if patients are selected based on clinical scoring and observed closely. By modifying the observation protocol, it might even be possible to increase the number of patients not requiring surgery.

Contributor Information

Kirsi S Lastunen, Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

Ari K Leppäniemi, Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

Panu J Mentula, Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.

Reference

  • 1. Lastunen KS, Leppäniemi AK, Mentula PJ. DIAgnostic iMaging or Observation in early equivocal appeNDicitis (DIAMOND): open-label, randomized clinical trial. Br J Surg 2022;109:588–594 [DOI] [PMC free article] [PubMed] [Google Scholar]

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