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Article 1
Validation of the American Association for Surgery of Trauma emergency general surgery grade for skin and soft tissue infection. Ray-Zack MD, Hernandez MC, Younis M, Hoch WB, Soukup DS, Haddad NN, Zielinski MD. J Trauma Acute Care Surg. 2018 Jun;84(6):939-945.
The AAST has published an anatomic grading system for 16 Emergency General Surgery conditions. This study seeks to validate the grading system for skin and soft tissue infections (SSTI) and compare it to the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC).
The authors retrospectively reviewed adult patients admitted with SSTI between 2012 and 2016. Two reviewers reviewed imaging, pathology, and clinical documentation to assign a AAST SSTI Grade for 223 patients. Need for operative intervention followed SSTI Grade (Grade I 0%, Grade II 8.6%, Grade III 88.1%, Grade IV 100%, and Grade V 100%; p<0.0001). Complications also increases with AAST SSTI Grade (20.8%, 31.4%, 60.4%, 71.4%, and 100%; p<0.0001). Although mortality was only seen in Grade III thru V, it also increased with Grade (5.9%, 7.1%, and 9.5%; p =0.0453). Only 37% of the cohort had lab values needed to calculate LRINEC score. In this subset SSTI Grade more accurately predicted complications [0.98 (0.96-1.0) vs 0.64 (0.53-0.75) p=0.0001], 90-day mortality [0.99 (0.98-1.0) vs 0.66 (0.55-0.770 p=0.0001], and readmission [0.80 (0.77-0.84) vs 0.69(0.67-0.74) p=0.002].
This study is the first to use the AAST SSTI Grade and demonstrates its association between increasing Grade and key clinical outcomes.
Article 2
Transfer status: A Significant risk factor for mortality in emergency general surgery patients requiring colon resection. DeWane MP, Davis KA, Schuster KM, Erwin SP, Maung AA, Becher RD. J Trauma Acute Care Surg. 2018 Aug;85(2):348-353.
When compared to elective operations, patients requiring emergency surgeries are noted to have higher morbidity and mortality. Several factors have been suggested that contribute to these observations, one such factor is time to surgery. In this study the authors examine the effects of transfer status on patients requiring colon resection; specifically, they examined the type of referring institution; emergency department (ED), inpatient unit at referring hospital, or nursing home.
Using NSQIP data from 2010 to 2012 they identified 14,266 emergent colectomies, of these patients 3,203 (22%) were transferred. Transferred patients were significantly more likely to be male, older, have more comorbidities and be partially dependent. Transferred patients also had higher rates of preoperative septic shock (26.9 % for nursing home vs 11.6% for non-transferred, p < 0.001). When compared to non-transferred patients, patients transferred from ED, inpatient, and SNF had significant differences in LOS, prolonged intubation (17.1%, 27.8%, 35.2%, and 36.2%, p<0.001), pneumonia (7.96%, 10.26%, 13.69%, and 16.83%, p<0.001), thromboembolic complications (4.17%, 4.77%, 6%, and 6.79%, p=0.0004), and 30-day mortality (12.8%, 19.4%, 25.7%, and 34.25%, p < 0.001). When compared to non-transferred patients, those transferred from another ED (OR, 1.27; 95% CI 1.04-1.54), in patient unit (OR, 1.41; 95% CI 1.21-1.66), or nursing home (OR, 1.83; 95% CI, 1.51-2.23) had higher odds of death. Interestingly there was no difference in dehiscence or SSI.
This study shows that delay related to transfer increases the morbidity and mortality of patients undergoing emergent colectomy, and that mortality is inversely related to the acuity of the referring hospital. The authors acknowledged that transferred patients have more comorbidities, and less functional independence that may have contributed to differences in outcome, and suggest more research in this area to improve triage and transfer processes.
Article 3
The GroinPain Trial: A Randomized Controlled Trial of Injection Therapy Versus Neurectomy for Postherniorrhaphy Inguinal Neuralgia. Verhagen T, Loos MJA, Scheltinga MRM, Roumen Roumen. Ann Surg. 2018 May;267(5):841-845.
Chronic inguinal pain is seen in up to 11% of patients undergoing herniorraphy. Treatment options include regional blocks, tender point injection (TPI), selective neurectomy, and 3 nerve neurectomy. This is the first randomized control study comparing tender point injection to tailored neurectomy. Primary endpoint was a 50% reduction in pain using Visual Analog Scale (VAS) at 6 months. Patients were permitted to crossover to neurectomy.
The authors randomized 54 patients. Of the patients in the TPI group 22% had improved pain at 6 months (VAS 39 to 8, P=0.03), and 70% of the patients crossed over to the neurectomy group after 3 injections without relief. In patients randomized to neurectomy, 71% of patients had clinical success (VAS 53 to 17, P=0.02). In patients that failed TPI and crossed over to tailored neurectomy, 58% were successfully treated (60 to 14, P=0.001).
Based on this study the authors concluded that TPI should be considered as part of the treatment algorithm for inguinodynia following Lichtenstein hernia repair. Tailored neurectomy should be offered if unsuccessful. The authors did note that these findings may not be applicable to patients whom had undergone laparoscopic or endoscopic hernia repair.
Article 4
Surgeon-driven variability in emergency general surgery outcomes: Does it matter who is on call? Udyavar R, Cornwell EE, Havens JM, Hashmi ZG, Scott JW, Sturgeon D, Uribe-Leitz T, Lipsitz SR, Salim A, Haider AH. Surgery. 2018 Nov;164(5):1109-1116.
Emergency general surgery (EGS) patients are at higher risk for complications, in-hospital mortality, longer hospital stays, and reoperations. Factors that vary by surgeon, however, have not been examined in the context of EGS, despite the fact that practice patterns, training, and experience differ among surgeons for these cases. This study seeks to quantify the amount of variability in complications, in-hospital mortality, and unplanned 30-day readmissions after EGS that is attributable to surgeon-level characteristics and determine whether this proportion of explained variation differs across disease processes and procedure types.
In this study, the Florida State Inpatient Database was queried for adult patients that underwent EGS procedures as identified by ICD-9-CM codes (partial colectomy, small bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, and laparotomy). These 7 procedures account for 80% of all non-trauma emergency general surgery procedures performed nationwide. The analysis was restricted to operating physician.
Outcomes for this analysis were in-hospital mortality, unplanned 30-day readmissions, and in-hospital complications. The latter were defined by a set of ICD-9 diagnosis codes that capture common postoperative complication such as pulmonary embolism, sepsis, myocardial infarction, acute renal failure, and cardiac arrest. A total of 569,767 EGS cases performed by 2,149 surgeons across 225 hospitals.
Surgeon random effects in isolation explained nearly one third of the unexplained variability in mortality for all EGS procedures, a finding that was statistically significant across procedure type. Nearly half of the between-surgeon variability in mortality among patients undergoing repair for peptic ulcer disease (PUD) was due to surgeon random effects. Lysis of adhesions was also significantly influenced by surgeon effect, with 35.45% of the variation in mortality for this procedure explained by the individual surgeon effect. Surgeon random effects appeared to explain a much smaller proportion of the variability in complications (0.08%) and readmissions (2.28%), with the highest contribution of surgeon random effects to complications found among patients undergoing colectomy (2.27%) and to readmissions found among patients undergoing PUD repair (6.78%). Patients treated at academic facilities had higher odds of mortality, complications, and readmissions, even when adjusting for cases in which a transfer from an outside facility took place. For other covariates, such as race and insurance, there was no difference in the relationship to readmissions when taking surgeon random effects into consideration. The results indicate that surgeons in the lowest tercile of EGS volume over this study period were associated with a higher odds of mortality but lower odds of readmissions.
Collecting and reporting surgeon-level statistics on mortality, complications, and readmissions after EGS may represent a valuable quality control technique to improve the overall quality of emergency surgical care. Developing and implementing proficiency standards for surgeons participating in the care of emergency general surgery patients may reduce this surgeon-driven variability in outcomes.
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