Focus on identifying and closing knowledge gaps in acute appendicitis

Surgical science that informs patient care has evolved along two principal pathways: retrospective review of what has already occurred, and trials that test interventions designed to improve outcomes. The current environment of evidence-based practice favors rigorous investigations such as the prospective, randomized and controlled trial. These studies are tightly focused and intensely investigate only patients who fulfill entry criteria. As valuable as those investigations are in advancing science and patient care, they may not reflect the breadth of current practice that includes patients with characteristics that would prevent inclusion in a prospective randomized controlled trial (RCT). Indeed, for any given surgical condition, there are broad variations in approaches to care, delivery methods and outcomes that merit investigation. These variations are important to recognize and explore as they may disclose the question that a prospective RCT is ideally suited to answer. This special issue of the European Journal of Trauma and Emergency Surgery is devoted to a method of inquiry that bridges the gap between retrospective database review and RCT—the snapshot audit.

Snapshot audits are prospective, observation and time-constrained assessments of current care practices for specific clinical conditions [1]. All patients with the condition of interest are included in the analysis, thereby capturing a “snapshot” of care including outcomes during a specified follow-up period. Suitable for virtually any condition of interest, the snapshot audit identifies the spectrum of delivered care and provides an “environmental scan” across care settings, patient populations and geographic locations. While this issue curates snapshot audit analyses into the management of a common surgical condition—acute appendicitis—the spectrum of analyses highlights the vast body of knowledge that is collectable using this unique approach. Of course, the snapshot audit approach has been used in a variety of other settings, including most recently, in COVIDSurg, to garner a global perspective into the excess postoperative morbidity and mortality associated with surgical intervention for patients with active COVID-19 infection [2–4] and inform practice [5]. Similarly, ESTES has supported other snapshot audits into key emergency general surgery conditions, and more are under development or ready to launch. Your participation is invited!

In this issue of the European Journal of Trauma and Emergency Surgery, Bass, Kaplan, Mohseni and their ESTES colleagues describe the “snapshot audit” as a pragmatic approach to observational inquiry in surgical disease [1] that complements retrospective registry analysis and prospective RCTs. They also catalog their experience in applying this approach to achieve two specific goals: (1) identifying knowledge gaps regarding the optimal treatment for appendicitis as a hypothesis-generating launch-pad for future interventional RCTs, and (2) describing the gap between evidence-based practice guidelines [6] and “real world” selective application as a lens through which to assess the variability in surgical outcomes. Tackling some of the controversies in current care of the patient with acute appendicitis, the ESTES SnapAppy collaborative explores technical aspects of surgical management (including the use of staplers and energy devices at key portions of the operation), operating surgeon experience, mentorship and graded trainee autonomy, and contemporary surgical outcomes following appendectomy across Europe, North America and the Middle East, particularly in the context of an evolving COVID pandemic [7–10].

Despite nearly a century of surgical investigation, several knowledge gaps and clinical management controversies remain (Table 1). Ongoing debate explores operative timing, antibiotic duration and surgical technique, where appendectomy fits in the spectrum of graded autonomy that is central to surgical training and even whether surgical intervention is mandatory.

Table 1.

Knowledge gaps and controversies in the current management of acute appendicitis

Knowledge gap or controversy	References
Decision making: Operative versus nonoperative
Optimal timing of appendectomy and implications of in-hospital delay	[11–13]
Safety and efficacy of nonoperative management of acute appendicitis	[14–20]
Indications for interval appendectomy following successful nonoperative management	[21–23]
Operative techniques
Technical modifications such as methods of handling the mesoappendix and appendiceal base	[24, 25]
Intraoperative peritoneal saline lavage versus aspiration of periappendiceal/pelvic fluid/abscess	[26, 27]
Perioperative medicine
Need for postoperative antibiotics and the route of their administration	[18]
System logistics and their implications for surgical care
Optimal management of acute appendicitis during and after the SARS-CoV-2 pandemic	[28–30]
The place of appendicitis in core surgical training
Operating surgeon experience and surgical outcomes following emergency appendectomy	[31–33]

These interwoven inquiries may serve as a template for how professional medical organizations and individuals collaborate around relevant clinical issues to help assess current care, and design future investigations to improve outcomes. For those unfamiliar with the snapshot audit, consider this issue an introduction to it and the breadth of questions that may be asked and answered. For those already accustomed, consider this issue an invitation to design a collaborative snapshot audit focused on a topic relevant to ESTES members as well as our colleagues around the globe.

Hayato Kurihara, MD FEBS(EmSurg) FACS

President, European Society for Trauma and Emergency Surgery

Jonathan Tilsed, MS FRCS(Eng) FRCS(GenSurg) FEBS(EmSurg)

Vice-President, European Society for Trauma and Emergency Surgery

Data availability statement

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Declarations

Conflict of interest

HK—no conflict of interest to disclose; JT—no conflict of interest to disclose.