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Article 1
Hartmann's Procedure vs Primary Anastomosis with Diverting Loop Ileostomy for Acute Diverticulitis: Nationwide Analysis of 2,729 Emergency Surgery Patients. Lee JM, Chang JBP, Hechi ME, Kongkaewpaisan N, Bonde A, Mendoza AE, Saillant NN, Fagenholz PJ, Velmahos G, Kaafarani HM. J AM Coll Surg. 2019 Jul;229(1):48-55.
This study sought to use the ACS NSQIP colectomy procedure targeted Database to compare the 30-day mortality and morbidity outcomes of patients undergoing emergent Hartmann`s procedure (HP) vs primary anastomosis with a diverting loop ileostomy (PADLI) for acute diverticulitis. All patients with age 18 years or older who underwent emergent colectomy for acute diverticulitis from the database for years 2012 to 2016 were included and the following were then systematically excluded – All colectomies with indication other than acute diverticulitis were excluded, patients with inflammatory bowel disease, those who underwent mechanical or antibiotic bowel preparation and those with non-urgent or elective colectomies were excluded.
On univariate analysis HP patients had a higher 30-day mortality, however the 30-day morbidity was similar between the HP and PADLI patients. HP patients more often had postoperative pneumonia, unplanned intubation, and failure to wean off the ventilator for more than 48 hours. PADLI patients had worse outcomes in superficial surgical site infections and were discharged more frequently to home. On multivariable logistic regression analysis, PADLI was not associated with any independent increase in 30-day mortality or overall, 30-day morbidity. In conclusion, after controlling for the patient population differences, PADLI appears to be a safe alternative to HP for select patient populations.
Article 2
Outcomes of Open Abdomen versus Primary Closure following Emergent Laparotomy for Suspected Secondary Peritonitis: A Propensity-Matched Analysis. Kao AM, Cetrulo LN, Baimas-George M, Prasad T, Heniford BT, Davis BR, Kasten KR. J Trauma Acute Care Surg. 2019 Sep;87(3):623-629.
This is a study assessing the benefit of open abdomen (OA) with temporary abdominal closure vs Primary closure (PC) in patients with a non-trauma indication for an exploratory laparotomy. The most notable complication of an open abdomen is formation of an entero-atmospheric fistula and hence it is important to have appropriate indications and technical recommendations for performing temporary abdominal closure. The study has a well-defined hypothesis that the use of OA for surgical management of suspected secondary peritonitis is associated with higher in-hospital complication and mortality rates when compared with PC.
The propensity-matched analysis of emergent laparotomies performed for suspected secondary peritonitis showed a benefit for PC over OA management in terms of in-hospital mortality rates. The study also showed a positive association of OA management and rates of Gastro-intestinal and infectious complications. Also, the OA approach was associated with increased LOS and hospital costs. In conclusion the data suggests that OA approach may not provide the benefit as perceived of a planned relook laparotomy and instead a selective approach of PC with “ on demand” re laparotomy may be the method with lower complication rates, better mortality rates and lower health care costs.
Article 3
Outcomes in Adhesive Small Bowel Obstruction from a Large Statewide Database: What to Expect after Non-Operative Management. Wessels LE, Calvo RY, Dunne CE, Bowie JM, Butler WJ, Bansal V, Sise CB, Sise MJ. J Trauma Acute Care Surg. 2019 Apr;86(4):651-657.
The purpose of this study was to evaluate the risk factors for operative intervention and mortality at readmission in patients with adhesive small bowel obstruction (ASBO) who were initially managed nonoperatively using a large population-based database. The database used was a unique one, which was the California Office of Statewide Health Planning and Development patient discharge database which enabled long term follow-up and allowed for identification of subsequent admissions to other hospitals in California.
In terms of study definitions, the term index admission was defined as the first admission containing a diagnosis for ASBO without a concomitant code for surgical intervention. The primary outcomes being evaluated were operative management for ASBO and mortality occurring during the first readmission following index admission.
The study showed that the younger patients with no comorbidities were more at risk for an operative intervention. Also, the risk for mortality appeared to be associated with any operative management subtype compared to non-operative management. Patients who were managed operatively at their first readmission had a longer interval before their second readmission and were less likely to have a second readmission. In conclusion, certain factors that may be considered in addition to clinical factors include, patients age, time to recurrence, comorbidities, and initial hospital length of stay to determine the need for operative intervention.
Article 4
Geriatric rescue after surgery (GRAS) score to predict failure-to-rescue in geriatric emergency general surgery patients. Khan M, Azim A, O'Keeffe T, Jehan F, Kulvatunyou N, Santino C, Tang A, Vercruysse G, Gries L, Joseph B. Am J Surg. 2018 Jan;215(1):53-57.
As the US population ages the need to better understand factors influencing the surgical outcomes in that group intensifies. The geriatric population, patients 65 or older, are susceptible to major complications from bread and butter surgery and this is increased in the emergent situation. Failure to rescue (FTR) is defined as mortality after developing a major postoperative complication. While research has focused on the hospital factors associated with the phenomenon, studies have demonstrated that patient factors also play a role.
This is a retrospective chart review that attempts to identify patient characteristics that increase the likelihood of FTR which can then be used to create a simple score for clinical use. This study proposes the bedside score, the Geriatric-Rescue-After-Surgery (GRAS) score, to predict FTR in geriatric patients undergoing emergency general surgery.
All patients 65 and older who had undergone emergency surgical evaluation by 8 identified surgeons from 2013 to 2015 at a single center were reviewed. Excluded from analysis were patients who died within 24 hours post-surgery, and patients with preoperative sepsis, disseminated intravascular coagulation, or missing data. Types of surgery in the study population included appendectomy, cholecystectomy, hernia repair, bowel resection, and bowel diversion. Data collected included demographics, admission vitals and laboratory, and ASA score. Co-morbidities were also documented. Outcome measure was FTR. There were 725 patients analyzed. The mean age was 74.4. When adjusted for risk, reviewers found that Age > 80, ASA class >3, serum Albumin <3.5, CHF, CRF, and COPD as independent predictors of FTR. Weights were assigned to each factor to create a GRAS score. GRAS scores of 0-2 were associated with low risk while scores > 6 were associated with a high risk of FTR. Using AUROC the GRAS score as presented showed excellent discriminative power at 0.787.
The study is the first of its kind to develop a simple score to assess FTR after emergency surgery in this patient population. It demonstrates that patient factors such as nutritional status contributes to FTR. While further studies are warranted that can prospectively validate this score, the study presents an important step in better understanding emergency surgery in geriatric patients.
Article 5
Risk Factors and Outcomes for Sepsis after Appendectomy in Adults. Ninh A, Wood K, Bui AH, Leitman IM. Surg Infect (Larchmt). 2019 Dec;20(8):601-606.
Acute Care Surgeons will often encounter patients with appendicitis. Operative intervention, while undergoing review, is still the accepted standard of care. Sepsis is a known complication of any infectious process, and while uncommon, may occur in patients after appendectomy. Morbidity and mortality in those patients remain high. The mean rate of sepsis after appendectomy ranges from 1.2% to 1.6%. The infrequency of this occurrence increases the need for the surgeon to recognize the risk factors associated with sepsis after appendectomy.
This is a retrospective review of the NSQIP database from 2012 to 2015. Data collected included demographics and pre-operative comorbidities. Primary outcome was development of sepsis after surgery. Patients with pre-existing SIRS or sepsis were excluded from analysis. There were 72 538 appendectomies performed. The median age was 37 with 50.1% female and 14.5 % of patients aged 60 or greater. Sepsis occurred in 311 (0.43%) of patients. Using multivariable logistic regression patients who were 60 years or greater, African American, morbidly obese, had acute renal failure or was on dialysis, disseminated malignancy, a dirty or infected incision, and who underwent open appendectomy were more likely to develop sepsis. Interestingly, patients with sepsis were less likely to be female. The researchers proposed a pro-inflammatory state as contributing to the increased complications in the patients described. They conclude that an interval appendectomy may be a solution but do not offer real supporting evidence for this conclusion. The study provides a useful method to help identify patients at risk for post appendectomy sepsis which is important for the ACS surgeon.
Article 6
Hospital Operative Volume Is an Essential Quality Indicator for General Surgery Operations Performed Emergently in Geriatric Patients. Becher RD, DeWane MP, Sukumar N, Stolar MJ, Gill TM, Becher RM, Maung AA, Schuster KM, Davis KA. J AM Coll Surg. 2019 Jun;228(6):910-923.
By 2030 there will be about 72.1 million older persons in the U.S., twice the number from 2007. Emergency surgery in that population will necessitate expanding quality metrics to ensure best outcomes. The American College of Surgeons has led the charge in working to improve outcomes in geriatric surgical patients with the formation of the Coalition for Quality in Geriatric Surgery (CQGS). Similar to accreditation requirements that use volume as an indicator of proficiency and improved outcomes, the number of operations performed may be a quality indicator. The present study sought to evaluate this question by investigating the impact of hospital emergency operative volume on mortality for geriatric patients and “the procedure-specific hospital volume at which geriatric patients undergoing an emergency operation achieve at or better than average mortality risk”.
This is a retrospective cohort study of geriatric patients undergoing emergency operations in California from January 2010 to December 2011. Patients were defined as geriatric if they were 65 or older and operations were identified from the California State Inpatient Database. Ten procedures were picked for review as the most common; appendectomy; cholecystectomy; colectomy; inguinal & femoral hernia repair (analyzed together); lysis of adhesions (LOA; no bowel resections were performed in the LOA group); excision of necrotizing soft tissue infection (NSTI); repair of perforated peptic ulcer disease (either gastric or duodenal ulcers); small bowel resection; umbilical hernia repair; and ventral hernia repair. For analysis, hospitals performing less than three of the identified operations were excluded.
Four hundred and twenty-five hospitals were identified as acute care hospitals but only 299 were included in evaluation. A total of 41 680 patients underwent emergency surgical operations. The 3 most common procedures were cholecystectomy (17 427), colectomy (6727), and appendectomy (4857). The least common operations were umbilical hernia repair (268), excision of NSTI (666), and repair of perforated peptic ulcer disease (871). Mortality decreased significantly as volume increased across all operations. Hospital operative volume was the most important characteristic with respect to survival benefit. With respect to procedure, once a specific threshold is reached, all hospitals performed better. Based on the results of this study, it would seem that the need for accreditation of acute care hospitals exist; at least for centers where emergency surgery is performed on patients 65 or older, similar to the systems created for verification of trauma centers.
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