Article 1
Prognostic Value of Water-Soluble Contrast Challenge for Nonadhesive Small Bowel Obstruction. Lanier MH, Ludwig DR, Ilahi O, Mellnick V. J. Am Coll Surg. 2022 Feb 1;234(2):121-128.
Small bowel obstruction (SBO) is a common condition accounting for 15% of hospital admissions. Over the past 2 decades, there has been a large body of evidence supporting the use of water-soluble contrast challenges (WSCC) to predict failure of conservative management for adhesive SBO (ASBO). Nonadhesive SBO (NASBO) management is often excluded from the studies and guidelines that support the use of WSCC. The authors of this study recognized that their institution was applying WSCC principles to their NASBO population. The purpose of this study was to evaluate the prognostic value of the WSCC in the NASBO population. The authors hypothesized that WSCC may be helpful to facilitate discharge in the NASBO population.
This was a single center, retrospective chart review study for patients admitted with ASBO or NASBO and who underwent WSCC between 2016 and 2019. All patients were adults who received an initial CT of the abdomen and pelvis and subsequently received a small bowel follow-through. Imaging and charts were reviewed for nonadhesive etiologies but ultimately an SBO was considered an ASBO if an underlying cause could not be identified or ASBO was favored on CT. Ultimately, 53 ASBO and 53 NASBO cases met inclusion criteria. The two most common causes of NASBO were malignancy (49%) and hernia (45%). A total of 33 interventions were required during the initial hospitalization (21 NASBO vs 12 ASBO; p=0.059). NASBO was associated with a higher any-cause 30-day readmission (40% vs 23%; p-0.059) and readmission for recurrent SBO (17% vs 4%; p=0.026).
There was no difference in transit time of the small bowel follow through between groups, but the authors completed a subgroup analysis focusing on those patients with a colonic transit time of <36 hours. This group was analyzed because previous literature suggests that those with rapid colonic transit time are more likely to benefit from the WSCC. In this subgroup, NASBO was associated with a higher rate of any-cause 30-day readmission (29% vs 12%; p=0.044) and for requiring surgical intervention on the first admission or within 30 days of discharge (34% vs 12%; p=0.014). There was no difference in outcomes between ASBO or NASBO patients with a prolonged colonic transit time of >36 hours. Multivariate analysis identified NASBO (p=0.03) and transit time of >36 hours (p<0.001) as the only independent predictors for surgical intervention.
Overall, this study does show a potential use for WSCC in the NASBO population. The authors concluded that given most patients in both the ASBO and the NASBO groups were managed successfully and safely with conservative management, the use of WSCC in patients with NASBO is supported. In particular, WSCC may be an appropriate option for those patients deemed high risk or for those whom surgery may have a substantial impact on their quality of life. Importantly, they do acknowledge the higher rate of readmission and subsequent interventions for the NASBO group, and they suggest additional consideration be given for decompressive gastrostomy tube placement for patients proceeding to hospice for malignant SBO.
Article 2
National adherence to the ASGE-SAGES guidelines for managing suspected choledocholithiasis: An EAST Multicenter Study. Tracy BM, Poulose BK, Paterson CW, Mendoza AE, Gaitanidis A, Saxe JM, Young AJ, Zielinski MD, Sims CA, Gelbard RB. J Trauma Acute Care Surg. 2022 Feb 1;92(2):305-312.
Cholelithiasis with concomitant common bile duct (CBD) stones is a common problem seen by virtually every emergency general surgery service. In 2010, the American Society for Gastrointestinal Endoscopy (ASGE) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed an algorithm for risk stratification of suspected choledocholithiasis. The guidelines are based on clinical and radiographic criteria. Specifically, this algorithm groups predictors into “very strong, strong, and moderate” tiers. The very strong predictors include a visualized CBD stone and a bilirubin greater than 4mg/dL. Strong predictors included a CBD >6mm and a bilirubin 1.8mg/dL to 4 mg/dL. Moderate predictors include any abnormal liver function tests (LFT) other than bilirubin, age >55 years old, and a clinical diagnosis of acute biliary pancreatitis (ABP). The ASGE-SAGES guideline designates a high-risk patient as having any “very strong” predictor or both “strong” predictors, a low-risk patient as having no positive predictors, and an intermediate-risk patient as having any other combination of predictors. The recommended evaluation/treatment was based on this risk designation. The high-risk group should undergo endoscopic retrograde cholangiopancreatography (ERCP). The intermediate group should receive additional biliary imaging, such as magnetic resonance cholangiopancreatography (MRCP) or intraoperative cholangiography (IOC). The low-risk group does not require additional workup.
This was an EAST multi-center study that included 12 academic medical centers and 844 patients. Its goal was to evaluate adherence to the 2010 ASGE-SAGES guidelines and to assess its accuracy in predicting choledocholithiasis. Data was gathered in a prospective, observational, manner from 2016 to 2019, with a post hoc analysis. Demographics, relevant lab work, imaging results, interventions, and outcomes were measured. Overall, this study found 44.8% of all care deviated from the guidelines. More specifically, 64.3% of those cases stratified to the high-risk group deviated from the guidelines. 63.4% of these deviations included obtaining an MRCP. Despite the increased imaging, this group also had a significantly higher rate of common bile duct explorations (6% vs 0.2%; p=0.01). The intermediate-risk group deviated 29% of the time, most commonly by proceeding directly with cholecystectomy. In this intermediate-risk group, deviation was associated with an increased rate of 30-day readmission (2.9% vs 2.2%; p=0.02), most commonly for biliary complications. Liver function tests (LFT) were independently associated with choledocholithiasis for this group. Curiously, adherence to the guidelines for the intermediate risk was associated with a decreased odds of choledocholithiasis. The low-risk group deviated 78.9% of the time, most commonly by obtaining an IOC. Univariate analysis identified clinical ABP to be associated with increased deviation and abnormal LFTs to be associated with decreased deviation from the guidelines. Multivariate analysis identified age >55 YO as a predictor for guideline nonadherence. Importantly, deviation from the guidelines was not associated with an increased length of stay or postoperative biliary leaks. This study did have many limitations, most notably, the data was collected from 2016-2019 but the ASGE-SAGES guidelines were updated in 2019. Among the changes, ABP was removed as a risk factor for choledocholithiasis. It is unclear how these changes may have impacted practices. Additionally, the study did not identify if any institutions routinely performed IOC.
Overall, this study serves as an excellent example that clinical practices often differ, for a variety of reasons, from the stated guidelines. In this case, almost half of patients were treated discordantly from the 2010 ASGE-SAGES guidelines. Given the practice patterns and that adherence to the guidelines for the intermediate-risk group resulted in a decreased odds of finding choledocholithiasis, the authors conclude that the guidelines warrant additional revisions to better reflect the clinical variable in predicting choledocholithiasis. Additional studies will be needed to most fully assess the cause for the deviations and outcomes associated with the deviations.
Article 3
Damage Control Surgery in Patients with Non-traumatic Abdominal Emergencies: A Systematic Review and Meta-Analysis. Haltmeier T, Falke M, Quaile O, Candinas D, Schnuriger B. J Trauma Acute Surg. 2021 Dec 6.
After the wide-spread adoption of damage control surgery (DCS) in the trauma population, the same principles carried over to patients undergoing laparotomy for emergency general surgery. However, the indications and benefits remain controversial. The authors of this study sought to perform the first systematic review and meta-analysis to evaluate the effect of DCS on mortality in the non-trauma population. Two separate meta-analyses were performed: one comparing mortality in patients undergoing DCS versus non-DCS, and another comparing the observed versus expected mortality in DCS as reported in the studies using validated assessments such the APACHE score.
Twenty-one studies that met criteria for analysis were identified and included 1,238 patients undergoing DCS and 936 undergoing non-DCS. Most studies (16) were retrospective, and no RCT’s were identified. Meta-analysis using eight of the identified studies that reported mortality found no statistically significant difference between the two groups. However, in a subgroup of only propensity matched studies, mortality was higher in the DCS group. As the authors point out, only two studies used matched analyses, and matched for different variables in each study. The second Meta-analysis included 14 studies and found a significantly lower observed versus expected mortality rate in patients undergoing DCS. The authors do cite several limitations of the study, including retrospective nature of most of the studies, different outcomes prediction scores to evaluate observed: expected mortality rates, and heterogeneity of the studies. While the non-trauma role of DCS remains unclear, the results of this meta-analysis do suggest a benefit with a lower observed mortality rate.
Article 4
Effect of Antibiotic Duration in Emergency General Surgery Patients with Intra-Abdominal Infection Managed with Open versus Closed Abdomen. Diaz JJ, Zielinski MD, Chipman AM, O'Meara L, Schroeppel T, Cullinane D, Shoultz T, Barnes SL, May AK, Maung AA. J Am Coll Surg. 2022 Apr 1;234(4):419-427.
The previously published STOP-IT trial was practice changing and supported the use of a shorter course of antibiotics for intraabdominal infections. As the authors of this study point out, the trial did not include patients undergoing damage control surgery (DCS), and data in the existing literature about antibiotic use in this patient population is lacking. This prospective observational multicenter study sought to determine the effect of antibiotic duration in EGS patients managed with DCS compared to those managed with non-DCS. The primary outcome was development of a secondary infection, defined as an SSI, pneumonia, UTI, or bloodstream infection, and mortality.
In total, 752 patients met the criteria and were included in the analysis. Mortality, secondary infection rates, and duration of antibiotics were all higher in the DCS group. As you would expect, these patients were more physiologically deranged on presentation. When evaluating the secondary infections, the DCS group had a significantly higher rate of infections compared to non-DCS patients. Interestingly, the rates of SSI’s and pneumonia seem similar in both groups, but the rates of UTI and bloodstream infection are higher in the DCS group, which seems to be the main driver of the statistically significant difference. Patients who developed a secondary infection had longer ventilator days, ICU LOS and hospital LOS.
While this study does highlight the implications that secondary infections have on patient outcomes, it is difficult to determine the effect DCS and antibiotics have on these outcomes due to the differences in baseline characteristics of the patients in each group. This well-done study does, however, add to the existing body of literature that suggests that a longer duration of antibiotics may not ultimately prevent infectious complications, and that careful consideration should be used when using DCS in emergency general surgery.
