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Article 1
The Role of Magnetic Resonance Cholangiopancreatography in the Diagnosis of Choledocholithiasis: Do Benefits Outweigh the Costs? Ward W, Fluke L, Hoagland B, Zarow G, Held J, Ricca R. American Surgeon. 2015 July; 81: 720-25.
Workup for choledocholithiasis traditionally includes endoscopic retrograde cholangiopancreatography (ERCP). Magnetic resonance cholangiopancreatography (MRCP) is commonly employed before ERCP because of its minimal risk profile. The aim of this study was to determine the usefulness of preprocedural MRCP and whether it affects clinical management of patients with suspected choledocholithiasis.
This is a retrospective, IRB-approved, single institution study. Chart review was performed of all patients suspected of choledocholithiasis who underwent MRCP within 48 hours of admission or ERCP within 72 hours. Roux-en-Y gastric bypass patients were excluded. Demographics, lab data, and imaging studies were reviewed.
MRCP was used in 107 patients over a 4 year period. The diagnostic criteria for obtaining MRCP was not supplied. There was no choledocholithiasis in 88 (82%) of these patients. Twelve patients had subsequent ERCP and 6 of those were found to have choledocholithiasis. There were 19 MRCP-positive patients. The sensitivity of MRCP for diagnosing choledocholithiasis was 75% and the specificity was 86%.
ERCP was used in 131 patients with suspected choledocholithiasis without preprocedural MRCP. Choledocholithiasis was found in 116 patients (92%), no CBD stones in 12 patients, and 3 with a non-stone diagnosis. Diameter of the common bile duct > 6mm was not significantly predictive of choledocholithiasis when assessed by MRCP or by ultrasound. MRCP-confirmed choledocholithiasis cases were associated with higher alkaline phosphatase, alanine aminotransferase, and total bilirubin when compared to negative MRCP studies. Length of stay was no different between ERCP-only patient, MRCP-only patient, and patients who received both MRCP and ERCP. This study demonstrates that screening MRCP can effectively rule out choledocholithiasis and it spurs the concept of formal guidelines for use of MRCP in biliary obstruction.
Article 2
Management of Acute Appendicitis in Ambulatory Surgery: Is It Possible? How to Select Patients? Lefrancois M, Lefevre JH, Chafai N, Pitel S, Kerger L, Agostini J, Canard G, Tiret E.
Ann Surg. 2015 Jun; 261(6):1167-72.
Appendectomy for acute appendicitis remains one of the most common emergency general surgery procedures performed. The procedure is often performed in young, healthy patients who do well immediately postoperatively. In the era of resource utilization, transitioning traditional inpatient surgery to ambulatory surgery is an opportunity to reduce the overall cost of care. The surgical group from Hospital Saint-Antoine in Paris, France sought to determine clinical criteria that are associated with successful discharge at day 1. Their goal was to apply the criteria to prospectively select patients for ambulatory surgery (hospital stay less than 12 hours). A two year retrospective review of all laparoscopic appendectomies was performed at a single institution. All patients diagnosed with acute appendicitis by CT or ultrasound were included in the study. Univariate and multivariate analysis of preoperative variables were performed to create the Saint-Antoine Score ranging from 0-5. Patients received 1 point each for BMI < 28 kg/m2, WBC < 15,000/uL, CRP < 30mg/L, no radiological signs of perforation, and appendix diameter ≤ 10 mm. Patients with a score of 4 or more were considered for ambulatory surgery in the prospective group. Patients were included if they agreed to early discharge, the ambulatory surgery unit was available, and no contraindications for ambulatory surgery were present.
During the prospective period, 38 patients underwent laparoscopic appendectomy in ambulatory surgery group. Only 1 (3%) patient was not discharged from the recovery room. A total of 146 patients underwent laparoscopic appendectomy in the conventional group. 45 of these patients qualified for the ambulatory group but were excluded due to the unavailability of the ambulatory surgical unit. 58% of the conventional surgery group was discharged on day 1. Rate of early discharge was significantly associated with the Saint-Antoine Score with 0% at a score of 0, 14% with a score of 1, 30% with a score of 2, 62% with a score of 3, 71% with a score of 4, and 92% with a score of 5. There were no differences in surgical morbidity, rehospitalization, or pathological confirmation of acute appendicitis between the groups. Of note, there was no increased morbidity if laparoscopic appendectomy was postponed to the following day. While this is a small study, the hospital’s surgical group has prospectively validated preoperative scoring criteria in patients with acute appendicitis to predict ambulatory surgery success without increasing surgical morbidity.
Article 3
Use of Magnetic Resonance Cholangiopancreatography in Clinical Practice: Not as Good as We Once Thought. Aydelotte J, Ali J, Huynh P, Coopwood T, Uecker J, Brown C. J Am Coll Surg. 2015 Jul;221(1):215-9.
Magnetic Resonance Cholangiopancreatography (MRCP) is thought to be a highly diagnostic test with sensitivities and specificities reported in the 80%-90% range in the literature. The aim of this study was to compare MRCP with endoscopic retrograde cholangiopancreatography (ERCP) regarding sensitivity, negative predictive value, and accuracy of specific pathology. All patients over a 6 year period who underwent MRCP followed by ERCP within 48 hours were evaluated. Results were viewed as positive or negative for either stone or non-stone disease.
ERCP was performed in 110 patients, 81 of which had a preprocedural MRCP. At least one lesion was seen on MRCP in 53 patients: 36 with stone disease, 14 with mass or stricture, and 3 pancreas or pancreatic duct abnormalities. Specificity was 94.4% and positive predictive value was 98.0%. The remaining 28 patients that did not have a distinct lesion identified on MRCP went on to have ERCP, mostly because of dilated bile ducts. Of these 28, 13 had pathology diagnosed on ERCP: 6 with stricture of a biliary duct, 2 with transected pancreatic ducts, 1 with cystic duct leak, and 4 with choledocholithiasis. Sensitivity was 80% and negative predictive value was 54%. MRCP’s sensitivity for choledocholithiasis was 90%, however it was only 65% for non-stone pathology. Negative predictive value for choledocholithiasis was 64% and 47% for non-stone pathology.
This study questions the reported high sensitivity of MRCP in biliary tract disease. It is reasonable to correlate the results between MRCP and ERCP within an institution to optimize practice strategies and employ other methods of investigating the biliary tract, such as intraoperative.
Article 4
Trial of short-course antimicrobial therapy for intraabdominal infection. Sawyer R, Claridge J, Nathens A, Rotstein O, Duane T, Evans H, Cook C, O'Neill P, Mazuski J, Askari R, Wilson M, Napolitano L, Namias N,Miller P, Dellinger E, Watson C, Coimbra R, Dent D, Lowry S, Cocanour C, West M, Banton K, Cheadle W, Lipsett P, Guidry C, Popovsky K. N Engl J Med. 2015 May 21;372(21):1996-2005.
Complicated intra-abdominal infection remains a common problem. Source control and antibiotics are necessary to control intra-abdominal infectious processes. The duration of antibiotic therapy after source control is debated, despite recommendations by the Surgical Infection Society and the Infectious Diseases Society of America to continue antibiotic for “4-7 days, depending on the clinical response.”
The Study to Optimize Peritoneal Infection Therapy (STOP-IT) was undertaken from 8/2008-8/2013 to address this question. The study population included adults with complex intra-abdominal infection AND temperature ≥ 38ºC or leukocytosis ≥ 11,000 white cells per cubic mm or GI dysfunction secondary to peritonitis. All patients had undergone an intervention to obtain source control of intra-abdominal infection. Patients were randomized to 4-days of antibiotics (Experimental) or antibiotics until 48-hours after resolution (Control, maximum 10-days of antibiotics) of systemic inflammation (all patients had adequate source control as judged by a local investigator).
The two study groups were similar regarding demographics. More patients in the Experimental group (81.8%) received the designated amount of antibiotics than those in the Control (72.7%) group (p=0.02). Primary outcomes included surgical site infection, recurrent intra-abdominal infection, or death. There was no difference in outcomes between the two groups (Experimental 21.8%, Control 22.3%). Experimental group patients received fewer days of antibiotics than control patients (median 4 days versus 8 days) with no difference in extra-abdominal infection, C. diff, or resistant pathogen infection. Experimental patients and significantly more antibiotic free days than those in the Control group (25 days versus 21 days). Control patients had significantly longer times to diagnosis of surgical site infection (15.1 days versus 8.8 days) and recurrent intra-abdominal infection (15.1 days versus 10.8 days) compared to Experimental patients.
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