Article 1
Common Bile Duct Stones Management: A Network Meta-analysis. Mohseni S, Bass GA, Forssten MP, Casas IM, Martin M, Davis KA, Haut ER, Sugrue M, Kurihara H, Sarani B, Cao Y, Coimbra R. J Trauma Acute Care Surg. 2022 Nov 1;93(5):e155-e165.
Common bile duct stones are a frequent problem managed by acute care surgeons. Despite the prevalence of this issue, no single agreed upon approach for management exists. Many institutions utilize the two-stage approach employed since the introduction of endoscopic retrograde cholangiopancreatography (ERCP) in 1968. The authors point out the importance of establishing evidence-based approaches for management of common bile duct stones that improve resource allocation, reduce disease and procedure specific complications, and improve patient throughput in this era of consistently high censuses that strain healthcare systems.
The authors performed a systemic review and network meta-analysis comparing different treatment options for CBD stones, specifically comparing one-stage and two-stage approaches. The procedures compared were pre-operative ERCP (preERCP), post-operative ERCP (postERCP), laparoscopic common bile duct explorations (CBDE) and intraoperative ERCP (iERCP). The primary outcomes of interest were postprocedural complications and hospital length of stay (LOS). 16 studies (8,644 participants) addressing hospital LOS and 41 studies (19,756) addressing post-procedural complications were included in the analysis.
The author’s analysis found a lower overall risk of complications and a reduced LOS by two days in patients undergoing CBDE compared to preERCP. The risk of bile leak was 3 times higher in CBDE patients compared to preERCP. However, no difference existed when comparing the CBDE and postERCP cohorts. iERCP was superior to both pre and postERCP according to the rank probabilities for complications. There was a statistically significant reduction in LOS when comparing iERCP to preERCP. iERCP had a significantly shorter LOS than CBDE. CBDE was superior to iERCP regarding the risk of hemorrhage, pancreatitis, and perforation.
There were several limitations to the study including the lack of distinction between choledochotomy vs cholecystoscopy for CBDE. Likewise, there was no distinction between iERCP performed using the rendezvous or traditional technique.
This is the first study comparing common post procedural complications and LOS across all four available interventions for management of CBD stones. Based on this review, CBDE and iERCP provide equally good outcomes and a shorter LOS when compared to 2-stage approaches. This review does not address the likelihood of challenges associated with coordination of services required for iERCP. However, based on individual hospital resources, a 1-stage approach to common bile duct stones may provide benefit to both patients and hospital systems.
Article 2
Is Previous Postoperative Infection an Independent Risk Factor for Postoperative Infection after Second Unrelated Abdominal Operation? Feldt SL, Keskey R, Krishnan P, Hyman NH, Shogan BD. J Am Coll Surg. 2022 Aug 1;235(2):285-292.
Post operative infections after gastrointestinal surgery can result in significant resource utilization, increased healthcare costs, and increased length of stay. The authors of this study surmised that given the prevalence of antibiotic resistance, previous postoperative infection is a significant risk factor for the development of infection after a second unrelated surgery. They suggest that individualization of antibiotic prophylaxis in patients with a previous postoperative infection is warranted.
The authors designed a single-center, retrospective cohort study of patients who had undergone 2 elective, unrelated abdominal surgeries between January 1, 2012, and July 21, 2018. Out of 758 patients, 15.0% (n = 114) had a confirmed postoperative infection after their first operation. Of these 114 patients, 22.8% (n = 26) had a postoperative infection after their second operation. Of the 644 patients who did not have an infection after the initial operation, only 9.5% (n = 61) had a postoperative infection after their second operation. There were no significant differences in the demographics and comorbidities between the two cohorts.
Multivariable logistic regression demonstrated that development of an infection after the first operation was independently associated with development of an infection after the second operation (OR 2.49; 95% CI 1.46 to 4.25). Notably, a minimally invasive surgery approach was protective against a postoperative infection in the second operation (OR 0.2; 95% CI 0.10 to 0.41). Antibiotic resistance was more common after the second operation compared with infections after the first operation (64.1% and 82.3%, p = 0.036). Resistance to the class of antibiotics given as preoperative prophylaxis was observed more frequently after second operations (32.1% and 49.0%, p = 0.078).
The authors of this study note several limitations. Culture results were not available for every patient. Additionally, this was a retrospective study design. The authors specifically looked at patients who had undergone elective operations so the results may not be generalizable to the typical emergency general surgery cohort. Given that a substantial number of EGS patients present with a history of prior gastrointestinal surgery, it would be beneficial for future studies to determine if tailoring antibiotic prophylaxis based on prior culture data would reduce post operative infections in the EGS patient population.
Article 3
Broad vs Narrow Spectrum Antibiotics in Common Bile Duct Stones: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma Multicenter Study. Tracy BM, Valdez CL, Paterson CW, Hochman BR, Kwon E, Sims CA, Rattan R, Yeh DD, Gelbard RB. J Am Coll Surg. 2022 Sep 1;235(3):411-419.
Surgical site infections account for the largest number of healthcare-associated infections and are the most common complication after cholecystectomy. Patients presenting with choledocholithiasis (CDL) and acute biliary pancreatitis (ABP) are at increased risk for developing this complication. There is little data to support the use of broad spectrum (BS) vs narrow spectrum (NS) antibiotics in these patients. Bile cultures in patients with early cholecystitis and choledocholithiasis tend to be monomicrobial, yet bile cultures from patients with acute cholangitis are often polymicrobial. This accounts for the wide variability of prescribing patterns amongst providers.
The authors performed a post-hoc analysis of a prospective, observational, multicenter study of patients undergoing same-admission cholecystectomy for choledocholithiasis and/or acute biliary pancreatitis. A presumptive diagnosis of ABP was made by elevated serum amylase or lipase > 3 times the upper limit of normal. A presumptive diagnosis of CDL was made by elevated serum bilirubin with or without abdominal US demonstrating a dilated CBD or presence of gallstones. They compared the use of BS antibiotics and NS antibiotics between the two cohorts primarily looking at the incidence of SSIs, but also secondary outcomes including LOS, AKI and 30-day readmission rates. The cohort had 891 patients: 51.7% received BS antibiotics and 48.3% received NS antibiotics. They found overall antibiotic duration was longer in the broad-spectrum group (6 vs 4 days, p = 0.01), but there were similar rates of SSIs between the two groups (1.1% vs 1.2%). They also noted a higher rate of AKI (5% vs 1.4%, p = 0.001) and LOS (p < 0.001) in the BS group.
These results highlight there are no contemporary studies investigating the use of various antibiotics in this patient population. The authors recognize the limitations of this study which involve the fact they did not include disease severity or note intra-operative bile spillage. The BS group tended to have preoperative ERCP, contributing to both increased length of stay and possibly increase risk of bactibilia. Patients with other healthcare associated infections which could affect the duration and type of antimicrobial therapy were not excluded from the study, which could also affect use of antibiotics and LOS. In conclusion, although rates of SSI infections are low for patients undergoing same admission cholecystectomy, use of BS antibiotics should be used judiciously as there is an increased risk of LOS and AKI in these patients.
Article 4
Analyzing Impact of Multimorbidity on Long-Term Outcomes after Emergency General Surgery: A Retrospective Observational Cohort Study. Rosen CB, Roberts SE, Wirtalla CJ, Ramadan OI, Keele LJ, Kaufman EJ, Halpern SD, Kelz RR. J Am Coll Surg. 2022 Nov 1;235(5):724-735.
Emergency general surgery patients are a heterogenous group, who tend to experience poorer outcomes than patients receiving similar elective operations. Many EGS patients are older and tend to have multiple medical co-morbidities. This adds to the complexity in pre-operative counseling and decision making. A large amount of EGS patients is multi-morbid which has been identified as a global health challenge. There are specific combinations of comorbidities, known as Qualifying Comorbidity Sets (QSCs) that are used to label patients as multimorbid.
This study is a nationwide, retrospective observational cohort study using the national Centers for Medicare and Medicaid claims data. All patients underwent an operative intervention for an EGS condition (e.g., cholecystectomy, partial colectomy, appendectomy). Patients were then classified as multimorbid based on the presence of the Qualifying Comorbidity Set (QSC) which is a specific set of conditions known to be associated with increased risk of in-hospital mortality. Of the 174, 891 patients identified, 45.5% were identified as multimorbid; they had a mean of 7.86 comorbid conditions compared with a mean of 3.2 comorbid conditions. Multimorbid patients had higher rates of mortality, both in-hospital (5.9% vs 0.7%, odd ratio 3.05, p < 0.001) and through 6 months (17.1% vs 3.4%, OR 2.33, p < 0.001). These patients also had higher rates of readmission at 1 month (22.9% vs 11.4%, OR 1.48, p < 0.001), 2 months (12.2% vs 2%, p < 0.001), 3 months (13.8% vs 2.4%, p < 0.001) and at 6 months (17.1% vs 3.4%, p < 0.001). They were less likely to be discharged home and hence have higher rates of discharge to rehabilitation and nursing facilities as well as increased utilization of home oxygen and other assistive devices. The longer length of stay was also associated with higher healthcare costs.
The authors note a major limitation of this study is they only included patients who underwent operative intervention for EGS conditions. A majority of these patients could have been managed conservatively. They also note this data is claims based and relies on appropriate coding, although they controlled for this through clustering analysis. Despite this, this study highlights the need to have honest discussions with our multimorbid patients prior to emergency general surgeries. Discussions should include not just peri-operative risk but also recovery afterwards including inability to return home and changes to their quality of life.
Article 5
Lighting the Way with Fluorescent Cholangiography in Laparoscopic Cholecystectomy: Reviewing 7 Years of Experience. Broderick RC, Li JZ, Huang EY, Blitzer RR, Lee AM, Serra JL, Bouvet M, Sandler BJ, Jacobsen GR, Horgan S. J Am Coll Surg. 2022 Nov 1;235(5):713-723.
Laparoscopic cholecystectomy is one of the most commonly performed surgical procedures in the US. Despite the frequency, complications do occur with bile duct injuries being the most feared. The critical view of safety was first coined in 1995 and has become a crucial step for safe laparoscopic cholecystectomy. Intraoperative cholangiography has been used to help improve visualization but there remains significant debate about its use in the prevention of bile duct injury. Fluorescent cholangiography (FC) with indocyanine green is a relatively new imaging study with real time visualization of the biliary system.
The authors performed a retrospective review of a prospectively maintained database of patients undergoing cholecystectomy at a single academic institution from October 2013 to September 2021. Data points included age, sex, BMI, operative time, drain placement, blood loss and use of FC. Planned open cholecystectomies, transvaginal cholecystectomies and cholecystectomies part of an oncologic resection were excluded. Outcomes included rates of bile duct injury (CBDI), bile leak, LOS, 30-day ED visits, 30-day readmission, and 30-day morbidity and mortality. A total of 1,841 patients were identified; of these 828 underwent FC. Operative time (99 vs 68 min), LOS (1.4 days vs 0.4 days), open conversion (8% vs 3%), ED visits (13% vs 8%) and drain placements (12% vs 3%) were all decreased in the FC protocol group.
This study is retrospective and follows surgeon outcomes over the course of 7 years. The decrease rate of complications, drain placement, and operative time could be attributed to natural surgeon experience however the authors did account for this. Through univariate and multivariate analysis, they discovered both experience and use of FC demonstrated a protective odds ratio against longer LOS and operative times. This suggests FC can augment the learning curve, accelerating surgeons’ progression. The limitations of this study include the retrospective nature of the data and it is single institution study. As more hospitals get access to fluorescent cholangiography technology, studies will be needed to elucidate its true potential in cholecystectomy.
