November 2023 - Emergency General Surgery

Article 1
Reclaiming the management of common duct stones in acute care surgery. Bosley ME, Ganapathy AS, Sanin GD, Cambronero GE, Neff LP, Syriani FA, Gaffley MW, Evangelista ME, Westcott CJ, Miller PR, Nunn AM. J Trauma Acute Care Surg. 2023 Oct 1;95(4):524-528.

Laparoscopic common bile duct exploration (LCBDE) offers a single-anesthetic treatment for common bile duct stones with comparable risks to the more widespread method of endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy. Despite its benefits, including decreased hospital stay and cost, LCBDE is not in widespread use secondary to its perceived complexity and the need for specialized equipment. Acute care surgery (ACS) services can streamline the management of biliary diseases, reducing hospital stays and enhancing outcomes. This retrospective cohort study published by Bosley et. Al aimed to compare an ACS-driven approach to the traditional LC with ERCP, hypothesizing that a protocol including LCBDE would reduce hospital stay without increasing complications.

The authors conducted a 4-year retrospective review on adult patients treated for choledocholithiasis at a single tertiary care center including only patients who required either LCBDE or LC followed by ERCP for ductal clearance.  LCBDEs were performed transcystically using a fluoroscopic balloon sphincteroplasty approach. Of 1,197 cholecystectomies, 180 met the study criteria. 71 patients underwent LCBDE, while 109 had ERCP before or after cholecystectomy. LCBDE was successful in 70.4% of cases, and failed LCBDE patients then underwent ERCP without issues. There was a substantial difference in length of stay, with the LCBDE group staying ~2 days less (48.8 [29–77.7] hours vs. 84.3 [62.2–116.8] hours, p < 0.01).  but the LCBDE group had an increased operative time (166 [141–194] minutes vs. 108 [79–134] minutes, p < 0.01). There were no bleeding or post-procedure pancreatitis complications in the LCBDE group, while one patient in the LC + ERCP group experienced post-ERCP pancreatitis. Readmission and emergency visits within 30 days were similar for both groups.\

This work demonstrates that Acute Care Surgeon performed LCBDE is successful, safe, and results in a substantial decrease in length of stay. Moreover, the authors noted a shift to a “surgery first” mentality over the study period which resulted in many negative intraoperative cholangiograms, thereby avoiding costly MRCP or ERCP.  While study's retrospective nature and focus on a single institution may limits its broader applicability, it presents further evidence that LCBDE can successfully be incorporated into the skill set of acute care surgeons with a net benefit to patients, providers, and healthcare institutions.

Article 2
Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study. O'Meara L, Zhang A, Baum JN, Cooper A, Decker C, Schroeppel T, Cai J, Cullinane DC, Catalano RD, Bugaev N, LeClair MJ, Feather C, McBride K, Sams V, Leung PS, Olafson S, Callahan DS, Posluszny J, Moradian S, Estroff J, Hochman B, Coleman NL, Goldenberg-Sandau A, Nahmias J, Rosenbaum K, Pasley JD, Boll L, Hustad L, Reynolds J, Truitt M, Vesselinov R, Ghneim MJ. J Trauma Acute Care Surg. 2023 Oct 1;95(4):510-515.

A variety of clinical conditions require anticoagulation to decrease risk of complications or disease progression. This has historically been maintained with warfarin or anti-platelet agents depending of the disease process and patient risk factors. Direct oral anticoagulants (DOAC) are newer agents that has surged in popularity over the last decade as they offer several advantages over warfarin including more predictable pharmacodynamics and no need for routine laboratory monitoring. However, specific reversal agents have only more recently become available and come with significant cost. The risk of major bleeding in the non-surgical population have shown equivalence in major hemorrhage risk. Further study in trauma populations has not demonstrated a difference in bleeding outcomes between warfarin and DOAC. The bleeding outcomes between these modalities in the emergency general surgery (EGS) population is not well studied.
 
Omeara and colleagues performed a prospective observational multicenter trial at 21 institutions.  Inclusion criteria were all EGS patients that were confirmed to have taken a DOAC, warfarin, or antiplatelet (AP) therapy (aspirin, clopidogrel, ticagrelor) within 24 hours prior undergoing emergent general surgery. Comparison was made between patients on a DOAC and patients on either warfarin or AP (warfarin/AP). 413 patients were enrolled in the study with 63% in the warfarin/AP group (warfarin n=40, AP therapy n=221) and 37% on DOAC therapy(n=152). The DOAC group was older with higher rates of atrial fibrillation, heart failure and stroke. The DOAC group was more likely to have emergency surgery for hernia and small bowel obstruction, while the warfarin/AP group was more likely to have surgery for appendicitis and cholecystitis.  AAST Disease severity grade was worse in the DOAC group. Preoperative use of reversal agents was utilized in 38.2% in the DOAC group vs 16.5% in the warfarin/AP group (although warfarin patients had a 52.5% preoperative FFP transfusion and a 42.5% preoperative PCC use).  Primary outcomes of the study were intraoperative and postoperative bleeding complications. The authors did not identify any statistically significant differences between the two groups in regard to intraoperative or postoperative bleeding. However, on further analysis using multivariate regression they found that a history of chemotherapy, and operative indications of mesenteric ischemia (occlusive and nonocclusive) and diverticulitis were independent predictors of bleeding risk.
 
This study concludes that there is no increased bleeding risk of DOACs compared to patients on warfarin or AP.  This is consistent with prior literature in other patient populations that demonstrate no increased risk of bleeding from DOACs compared to other forms of anticoagulation. While careful risk stratification is important in the perioperative decision-making process, it would appear that active DOAC use should not preclude emergent operative operation.

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