Skip to main content
Top
Published in: BMC Surgery 1/2015

Open Access 01-12-2015 | Research article

Surgical decision-making in acute appendicitis

Authors: Eva Sandell, Maria Berg, Gabriel Sandblom, Joar Sundman, Ulf Fränneby, Lennart Boström, Åke Andrén-Sandberg

Published in: BMC Surgery | Issue 1/2015

Login to get access

Abstract

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.
Literature
1.
go back to reference Cooper JG, West RM, Clamp SE, Hassan TB. Does computer-aided clinical decision support improve the management of acute abdominal pain? A systematic review. Emerg Med J. 2011;28:553–7.CrossRefPubMed Cooper JG, West RM, Clamp SE, Hassan TB. Does computer-aided clinical decision support improve the management of acute abdominal pain? A systematic review. Emerg Med J. 2011;28:553–7.CrossRefPubMed
3.
go back to reference Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276:1589–94.CrossRefPubMed Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276:1589–94.CrossRefPubMed
4.
go back to reference Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis. N Eng J Med. 2003;348:236–42.CrossRef Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis. N Eng J Med. 2003;348:236–42.CrossRef
5.
go back to reference Trentzsch H, Werner J, Jauch KW. Acute abdominal pain in the emergency department – a clinical algorithm for adult patients. Zentralbl Chir. 2011;136:118–28 (in German).CrossRefPubMed Trentzsch H, Werner J, Jauch KW. Acute abdominal pain in the emergency department – a clinical algorithm for adult patients. Zentralbl Chir. 2011;136:118–28 (in German).CrossRefPubMed
6.
go back to reference Croskerry P. The cognitive imperative: thinking about how we think. Aca Emerg Me. 2000;7:1223–31.CrossRef Croskerry P. The cognitive imperative: thinking about how we think. Aca Emerg Me. 2000;7:1223–31.CrossRef
7.
go back to reference Croskerry P, Nimmo GR. Better clinical decision making and reducing diagnostic error. J R Coll Physicians Edinb. 2011;41:155–62.CrossRefPubMed Croskerry P, Nimmo GR. Better clinical decision making and reducing diagnostic error. J R Coll Physicians Edinb. 2011;41:155–62.CrossRefPubMed
8.
go back to reference Farnan JM, Johnson JK, Meltzer DO, Humphrey HJ, Arora VM. Resident uncertainty in clinical decision making and impact on patient care: a qualitative study. Qual Saf Health Care. 2008;17:122–6.CrossRefPubMed Farnan JM, Johnson JK, Meltzer DO, Humphrey HJ, Arora VM. Resident uncertainty in clinical decision making and impact on patient care: a qualitative study. Qual Saf Health Care. 2008;17:122–6.CrossRefPubMed
9.
go back to reference Young JS, Smith RL, Guerlain S, Nolley B. How residents think and make medical decisions: implications for education and patient safety. Am Surg. 2007;73:548–53.PubMed Young JS, Smith RL, Guerlain S, Nolley B. How residents think and make medical decisions: implications for education and patient safety. Am Surg. 2007;73:548–53.PubMed
10.
go back to reference Wray CJ, Kao LS, Millas SG, Tsao K, Ko TC. Acute appendicitis: controversies in diagnosis and management. Curr Probl Surg. 2013;50:54–86.CrossRefPubMed Wray CJ, Kao LS, Millas SG, Tsao K, Ko TC. Acute appendicitis: controversies in diagnosis and management. Curr Probl Surg. 2013;50:54–86.CrossRefPubMed
11.
go back to reference Cole MA, Maldonado N. Evidence-based management of suspected appendicitis in the emergency department. Emerg Med Pract. 2011;13:1–29.PubMed Cole MA, Maldonado N. Evidence-based management of suspected appendicitis in the emergency department. Emerg Med Pract. 2011;13:1–29.PubMed
12.
go back to reference Antevil J, Rivera L, Langenberg B, Brown CV. The influence of age and gender on the utility of computed tomography to diagnose acute appendicitis. Am Surg. 2004;70(10):850–3. Antevil J, Rivera L, Langenberg B, Brown CV. The influence of age and gender on the utility of computed tomography to diagnose acute appendicitis. Am Surg. 2004;70(10):850–3.
13.
go back to reference Rosen MP, Ding A, Blake MA, Baker ME, Cash BD, Fidler JL, et al. ACR Appropriateness Criteria® right lower quadrant pain–suspected appendicitis. J Am Coll Radiol. 2011;8:749–55.CrossRefPubMed Rosen MP, Ding A, Blake MA, Baker ME, Cash BD, Fidler JL, et al. ACR Appropriateness Criteria® right lower quadrant pain–suspected appendicitis. J Am Coll Radiol. 2011;8:749–55.CrossRefPubMed
14.
go back to reference Ohle R, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med. 2011;9:139.CrossRefPubMedPubMedCentral Ohle R, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review. BMC Med. 2011;9:139.CrossRefPubMedPubMedCentral
15.
go back to reference Fenyö G. Routine use of a scoring system for decision-making in suspected acute appendicites in adults. Acta Chir Scand. 1987;153:545–51.PubMed Fenyö G. Routine use of a scoring system for decision-making in suspected acute appendicites in adults. Acta Chir Scand. 1987;153:545–51.PubMed
16.
go back to reference Kaplan RM, Frosch DL. Decision making in medicine and health care. Annu Rev Clin Psychol. 2005;1:525–56.CrossRefPubMed Kaplan RM, Frosch DL. Decision making in medicine and health care. Annu Rev Clin Psychol. 2005;1:525–56.CrossRefPubMed
17.
go back to reference Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9:1184–204.CrossRefPubMed Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9:1184–204.CrossRefPubMed
Metadata
Title
Surgical decision-making in acute appendicitis
Authors
Eva Sandell
Maria Berg
Gabriel Sandblom
Joar Sundman
Ulf Fränneby
Lennart Boström
Åke Andrén-Sandberg
Publication date
01-12-2015
Publisher
BioMed Central
Published in
BMC Surgery / Issue 1/2015
Electronic ISSN: 1471-2482
DOI
https://doi.org/10.1186/s12893-015-0053-x

Other articles of this Issue 1/2015

BMC Surgery 1/2015 Go to the issue