1. (Inter)National, Multicentred
Appendicectomy Audit
Aneel Bhangu
General Surgery Registrar
West Midlands Research Collaborative

2. 1. First things first
•Why we did it
•What we found
•Future trials
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3. National Collaborative
• 3rd National meeting
• National Research Collaborative
• Simple, easy, accessible idea
• “All” trainees and hospitals
• Many questions
– Feasibility, Structure, Organisation

4. Aim
• Aim: a national (international),
multicentred, audit of appendicectomy
• Primary outcome: negative rate
• Secondary outcomes: laparoscopy
rates, adverse event rates
• Inclusion: appendicectomy, all ages
• Exclude: diagnostic lap

5. Method
• Protocol – reviewed by Prof Alderson
• 2 week 5 centre pilot in West Mids
• 2 month multi-centred audit
• 30 centres will recruit approximately 1000
patients
– LSRG, WMRC, Mersey, EoE, Trent, Sparcs, PSTRN
– Hong Kong, Aus, New Zealand

6. General Surgical Research Collaboratives
Newcastle Surgical
Scottish Surgical Research Collaborative
Registrars Research
Group

7. Data collection
• May 1st- June 30th, 30 day FU
• Access Database with guidance notes
• Strict confidentiality - only anonymised data
submitted via nhs.net
• Audit registration
• Centrally collated
• Authorship model

8. To date
• Over 60 centres registered
• 30 have confirmed via unit questionnaire or audit
registration form
• 15*30 = 450 patients to date
• Database
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9. Results
• 95 centres
• 3326 patients
• 89 UK centres
• 6 international centres
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10. Results II
• (Initial) open appendicectomy: 33.7% (range 3.3-36.8%
in centres>25 appendicectomies)
• Initial lap approach: 66.3% (8.7-100%)
• Lap conversion in 6.9% (of total)
• A consultant was present in theatre: 23.8% (1.9-84.6%)
• Histologically normal appendix: 20.6% (3.3-36.8%).
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11. Centre specific normal appendicectomy rate Centre specific 30 day adverse event rate
Centre specific provision of initial laparoscopic approach Consultant presence in the operating theatre
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12. Centre specific normal appendicectomy rate Centre specific 30 day complication rate
Centre specific provision of initial laparoscopic approach Consultant presence in the operating theatre
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13. What we did well
• Communication networks
• Speed
• Volume
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14. Where we could have improved
• Definitions and outcomes
• Even wider communication
• Data collection tools (teething problems only)
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15. Summary of aims
• Aim to perform a high quality, multi-centred audit
• Aim to establish a national collaborative
research network
• Build an RCT from this

16. Future trials
1. Lap v open appendicectomy
2. Lap normal appendix
3. Right iliac fossa pain of uncertain cause
4. Operative versus antibiotic treatment
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17. Lap normal appendix
• Rationale: no evidence to guide practice at present.
• What we can add: a multicenter trial
• Difficulties:
– need to randomize everyone to capture target market.
Combining as an arm of another study is feasible, but will
increase sample size significantly.
– Needs one year FU.
– Endpoint: Reducing LoS; readmissions; adverse events.
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18. lap v open appendicectomy
• Rationale:
– 0-100% lap rate from 95 centres in the national audit
– Current 62 RCTs from a Cochrane review mostly single centre
(only 3 were >3 centres)
– Mostly used length of stay as primary outcome
• What we can add:
– a multicenter, national RCT with adverse events as an outcome.
– Could aim for 1000 patients which may help stablise use of lap
rates in the UK and beyond.
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19. Difficulties
• High volume centres with lap pathways/ centres with
high lap rates unlikely to participate, leaving medium size
centres who currently have mixed rates.
• Learning curves for trainees.
• Need to convince the community of the need for another
trial on this topic.
• This idea could be trimmed down to selected patients
rather than all-comers (e.g. those with risk factors for
post-op adverse events)
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20. RIF pain of uncertain cause
• Rationale: management of undifferentiated RIF pain
(and undifferentiated acute abdominal pain) is very
topical and very under-researched.
• Design: Early diagnostic lap v imaging and observation.
– May be best in females or reproductive age alone.
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21. • What we can add: a multicenter trial – only around 2
small RCTs currently done on this topic (but this proves
feasibility). Could randomize the imaging/observation
arm too.
• Difficulties:
– Units would need to ensure pathways to access theatre and
imaging within 24 hours.
– surgeons may be reluctant to randomize?
– Potentially slow recruitment?
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22. operative versus antibiotic
treatment of appendicitis
• Rationale: recent interest and meta-analysis of this as a
future treatment. Meta-analysis showed 80% avoid
appendicectomy by 12 months.
• What we can add:
– no RCT has been done in the UK.
– Nigel Hall is planning to start a feasibility study in paediatric
patients, to test whether randomization in the UK climate is
feasible.
• Difficulties: high quality meta-analysis has showed
outcomes (but not in UK). Will UK surgeons accept this?
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24. • Questions and discussion
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