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Article 1
Hospital Variation in Mortality after Emergency Bowel Resections: The Role of Failure-to-Rescue.
Mehta, Ambar; Efron, David; Stevens, Kent; Manukyan, Mariuxi C; Joseph, Bellal; Sakran, Joseph V. J Trauma Acute Care Surg. 2018 May;84(5):702-710.
Few studies exist which have evaluated the hospital-level variation in mortality related to emergency general surgeries and investigated the role of failure to rescue.
Failure to rescue is defined as death after a postoperative complication. As healthcare continues to increase the focus on quality improvement initiatives to improve patients’ surgical outcomes, these QI programs can be tailored to specific institutions in order to address FTR and to reduce variations in outcomes.
Mehta et al. performed a retrospective study using the Agency for Healthcare Research and Quality Nationwide Inpatient Sample (NIS) in 2010 and 2011 to capture all outcomes after emergency bowel resections occurring at a hospital. They used the AAST criteria to define emergency small and large bowel resections. Patients ranged from 18-105 years of age and procedures not performed on day 0 or 1 of admission were excluded. 21,564 patients from 457 hospitals were included in the analysis.
The overall unadjusted mortality rate was 7.7% with a complication rate of 38.3% and FTR rate of 17.2%. Myocardial infarction (29.4%), pneumonia (25.3%) and pulmonary failure (24.3%) all had the greatest rates of FTR. Risk adjusted mortality rates by hospital varied significantly with a 10.9-fold variation between the top and bottom quintiles of hospitals. Complications rates were similar across hospitals. There were significant differences in mortality and FTR when comparing hospitals with teaching affiliations to those without.
This study suggests that addressing failure to rescue can serve as a quality marker to reduce surgical morbidity and mortality after emergency bowel procedures.
Article 2
Emergency General Surgery in Geriatric Patients: A Statewide Analysis of Surgeon and Hospital Volume with Outcomes. Mehta, Ambar; Duluth, Linda A.; Joseph, Bellal; Canner, Joseph K.; Stevens, Kent; Jones, Christian; Haut, Elliot R.; Efron, David T.; Sakran, Joseph V. J Trauma Acute Care Surg. 2018 Jun;84(6):864-875.
The proportion of patients over the age of 65 years continues to increase. There are few studies that focus on outcomes among the geriatric population who undergo emergency general surgery (EGS).
Mehta et al. queried the Maryland Health Services Cost Review Commission database from 2012 to 2014 for selected EGS procedures in patients 65 years or older. Median annual volumes of EGS procedures in geriatric patients were used to create categories for both surgeons and hospitals. Eight or less procedures were considered low volume. Outcomes were evaluated and compared between the categories. 3,832 patients were identified. Cholecystectomy, open large bowel resection and adhesiolysis comprised the most common procedures performed.
The overall mortality rate was 4.7%, complication rate of 27%, FTR of 15% and 30-day readmission rate 11.5%. There were 302 surgeons operating at 44 hospitals. Variations existed in annual geriatric-EGS volume among both surgeons and hospitals. Patients operated on by low volume surgeons had higher risk-adjusted outcomes compared to high volume surgeons. Mortality was higher in the low volume group as were failure to rescue rates, but in-hospital complications were similar. In contrast, patients operated on by low volume hospitals compared to high volume hospitals did not demonstrate higher rates for any outcome.
Low geriatric-EGS volume surgeons were associated with 86% higher odds or mortality and 74% higher odds of failure to rescue in elderly patients. This study demonstrates the need for protocols directed at caring for the geriatric patient which includes surgeon experience with this population. Further study in Quality improvement programs need to be developed in order to improve outcomes in geriatric patients undergoing EGS procedures.
Article 3
Geriatric rescue after surgery (GRAS) score to predict failure-to-rescue in geriatric emergency general surgery patients. Khan A, Azim A, O’Keefe T, Jehan F, Kulvatunyou N, Santino C, Tang A, Vercruysse G, Gries L, Joseph B. Am J Surg. 2018 Jan;215(1):53-57.
Failure-to-rescue (FTR), or death after a postoperative complication, is thought to explain excess surgical mortality across hospitals, and is an emerging performance measure and target for quality improvement. Geriatric patients are a growing subset of the population that is particularly vulnerable to adverse outcomes after emergency general surgery (EGS). In this retrospective analysis of 725 patients age >65 years undergoing EGS, the authors sought to determine which patient-level factors were associated with FTR, and develop a simple scoring system (GRAS score) for predicting FTR among geriatric EGS patients.
The authors found an overall in-hospital mortality rate of 15.3% and an FTR rate of 11.5%. FTR rates were highest in patients that developed sepsis (42.8%), DIC (37.3%), and pneumonia (33.2%). Patient-level factors including age > 80, ASA class >3, serum albumin <3.5, congestive heart failure, chronic renal failure, and chronic obstructive pulmonary disease were found to be independent predictors of FTR. These factors formed the basis of the GRAS score which could be used to accurately predict (AUROC 0.787) the risk of FTR in this patient population.
Minimizing the risk of FTR is essential for improving outcomes in the geriatric patient population. Earlier identification of geriatric patients at high risk for postoperative complications could enable appropriate resource allocation and timely clinical interventions, potentially increasing the chance of “rescue.” While this study is limited by the retrospective study design and the fact that the authors could not account for operative severity in their analysis, it does highlight the importance of a multidisciplinary approach to the preoperative, intraoperative and postoperative management of geriatric EGS patients. The GRAS score may be an important initial step not only for risk stratifying patients, but determining realistic goals of care. Prospective validation of this tool is warranted to determine if the GRAS score can reliably predict FTR and improve patient outcomes in other care settings.
Article 4
Hartmann’s Procedure of Primary Anastomosis for Generalized Peritonitis due to Perforated Diverticulitis: A Prospective Multicenter Randomized Trial (DIVERTI). Bridoux V, Regimbeau JM, Ouaissi M, Mathonnet M, Mauvais F, Houivet E, Schwarz L, Mege D, Sielezneff I, Sabbagh C, Tuech JJ. J Am Coll Surg. 2017 Dec;225(6):798-805.
Acute diverticulitis is one of the most common indications for emergency colectomy, with up to 25% of patients requiring an emergent colon resection. Single stage resection and anastomosis is often used to manage acute diverticulitis in the absence of peritonitis, but the optimal surgical approach for more severe disease is controversial. Either Hartmann’s procedure or primary anastomosis (with or without diverting stoma) are acceptable surgical options for diverticular peritonitis. Recent data suggest that morbidity and mortality may be lower after primary anastomosis but there is limited Level 1 evidence supporting this approach.
In this well-designed multicenter trial, Dr. Bridoux and colleagues randomized adult patients with purulent or fecal peritonitis (Hinchey III and IV) to either primary anastomosis (PA) with a protective diverting ostomy or Hartmann’s procedure (HP). Their primary endpoint was mortality rate after PA or HP and ostomy reversal while secondary endpoints included morbidity, operating time, ICU length of stay and stoma reversal rates. A total of 102 patients were enrolled (despite a target sample size of 246). Intention-to-treat analysis showed no significant difference in mortality or complications between the two groups but stoma reversal rates were significantly higher after PA than HP (4% of patients in the PA group had a definitive stoma compared to 35.4% in the HP group). For those that underwent ostomy reversal, the operative time was significantly longer in the HP group but there was no difference in morbidity or overall complications.
There are several limitations to this study. The accrual rate was only 41% due to challenges with recruitment. The proportion of patients with Hinchey IV peritonitis in this study was quite low which is concerning for selection bias. It is also difficult to account for the variability in the operative techniques for both PA and HP, as well as the timing of ostomy reversal in both groups. It is worth noting that 15 patients in the PA arm did not undergo diverting stoma which was a deviation from the protocol. However, overall morbidity and serious complications were significantly lower in this subgroup of patients, and it remains to be seen whether PA without diverting stoma should be considered in all patients with severe diverticular peritonitis.
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