|
Article 1
Recurring emergency general surgery: Characterizing a vulnerable population. Lunardi N, Mehta A, Ezzeddine H, Canner JK, Hamidi M, Jehan F, Joseph BA, Nathens AB, Efron DT, Diaz J Jr, Sakran JV. J Trauma Acute Care Surg. 2019 Mar;86(3):464-470.
Acute cate surgeons are increasingly taking care of acutely ill patients that require emergent surgical intervention. Emergency general surgeries (EGSs) is associated with increased risk of morbidity and mortality with a 3—day post-operative mortality rate as high as 13%. Limited data exist for long-term outcomes after EGSs in the United States. This study by Lunardi eta al. aimed to characterize the incidence of inpatient readmissions and additional operations within 6 months of an EGS procedure.
This retrospective observational study included adults (≥18 years old) undergoing one of seven common EGS procedures which were appendectomies, cholecystectomies, small bowel resections, large bowel resections, control of gastrointestinal ulcers and bleeding, peritoneal adhesiolysis, and exploratory laparotomies. They examined patients discharged alive between 2010-2015 in the National Readmissions Database. Outcomes examined were the rates of all-cause inpatient readmissions and of undergoing a second EGS procedure, both within 6 months. Multivariable logistic regression models were used to identify risk factors of reoperation, adjusting for patient, clinical, and hospital factors.
The study involved 706,678 patients undergoing an EGS procedure. 131,291 (18.6%) patients had an inpatient readmission within 6 months. Among those readmitted, 15,178 (11.6%) underwent a second EGS procedure at a median of 45 days (interquartile range, 15-95). After adjustment, notable predictors of reoperation included male sex; private, nonprofit hospitals; private, investor-owned hospitals; discharge to short-term hospital; discharge with home health care; and index procedure of control of GI ulcer and bleeding, laparotomy, or large bowel resection.
This study demonstrated that one fifth of patients undergoing an EGS procedure had an inpatient readmission within 6 months, where one in nine of those underwent a second EGS procedure. Half of all second EGS procedures occurred within 6 weeks of the index procedure. identifying patients with the highest health care needs may identify patients at risk for subsequent reoperation in nonemergency settings. Future prospective studies will be able to further distinguish between recurring procedures caused by the natural disease course from preventable etiologies.
Article 2
Management of adhesive small bowel obstruction: A distinct paradigm shift in the United States. Matsushima K, Sabour A, Park C, Strumwasser A, Inaba K, Demetriades D.J Trauma Acute Care Surg. 2019 Mar;86(3):383-391.
Recent studies show that early operative intervention in patients who fail nonoperative management of adhesive small bowel obstruction (ASBO) is associated with improved outcomes. The study by Matsushima et al retrospectively examined the trend in practice pattern and outcomes of patients with ASBO in the United States.
The authors examined data from the National Inpatient Sample data from 2003 to 2013. They study included patients (age ≥18 years) who were discharged with primary diagnosis codes consistent with ASBO. The authors examined data for changes in mortality and hospital length of stay in addition to any trends in rate and timing of operative interventions.
During the study period, 1,930,289 patients were identified with the diagnosis of ASBO. Over the course of the study period, the rate of operative intervention declined (46.10-42.07%, p = 0.003), and the timing between admission and operative intervention was significantly shortened (3.09-2.49 days, p < 0.001). In addition, in-hospital mortality rate decreased significantly (5.29-3.77%, p < 0.001). In the multiple logistic regression analysis, the relative risk of mortality decreased by 5.6% per year (odds ratio, 0.944; 95% confidence interval, 0.937-0.951; p < 0.001). Hospital length of stay decreased from 10.39 to 9.06 days (p < 0.001).
Over the last decade, fewer patients with ASBO were managed operatively, whereas those requiring an operation underwent one earlier in their hospitalization. Although further studies are warranted, our results suggest that recent changes in practice pattern may have contributed to improved outcomes. The study is limited by using the National Inpatient Sample which is an administrative data base nit structured for research. The study was also not able to evaluate the impact of the use of laparoscopic intervention. The improvement in outcomes over the study period may also be attributed to improvements in resuscitation, medical optimization and post-operative ICU care.
Article 3
Gallstone pancreatitis: Admission versus normal cholecystectomy-a randomized trial (Gallstone PANC Trial). Mueck KM, Wei S, Pedroza C, Bernardi K, Jackson ML, Liang MK, Ko TC, Tyson JE, Kao KS. Ann Surg. 2019 Sep;270(3):519-527.
Studies in the past have supported awaiting resolution of acute gallstone pancreatitis prior to cholecystectomy due to reported higher morbidity and mortality with surgery performed prior to 48 hours after admission. However, there is retrospective data now putting this practice into question.
To test the hypothesis that early cholecystectomy during the index admission for “mild” gallstone pancreatitis is feasible and can result in a shorter 30-day total hospital length of stay without an increase in complications, a group from the Department of Surgery at the University Of Texas Health Sciences Center performed a single-center, parallel-group, randomized study. Predicted mild pancreatitis was defined as a “Bedside Index of Severity in Acute Pancreatitis (BISAP) score of 0-2 and without evidence of organ failure or local or systemic complications. The intervention studied was a laparoscopic cholecystectomy with intraoperative cholangiogram within 24 hours of presentation regardless of biochemical or clinical resolution of symptoms with the control being those patients for whom a resolution was obtained, as defined by “resolution of abdominal pain and down-trending laboratory values,” with the potential bias of also the team determining the patient was “appropriate for surgery.”
A total of 49 patients were randomized to early cholecystectomy and 48 to control cholecystectomy. Similarities were insured in age, race/ethnicity, body mass index, ASA classification, comorbid conditions, and duration of symptoms between the treatment groups. The 30-day LOS was significantly shorter in the early group (median LOS 50h) when they compared against the control group with a median LOS of 77 h. Complication rates were low in both groups (6% versus 2%, p=0.617), and included recurrence or progression of the pancreatitis and cystic duct stump leak in the early group.
The trial demonstrated that early laparoscopic cholecystectomy between 12-24 hours of admission is possible at a busy safety-net hospital and did decrease 30-day hospital LOS. Not surprisingly the need for ERCP was identified as less as well. The literature is limited to small retrospective cohort studies to suggest that there are worsened outcomes along with the high risk of selection bias. One potential barrier to early cholecystectomy the authors concede is accurately predicting the severity of pancreatitis, and this was the reason why this study unfortunately had several protocol changes that could inherently complicate the results.
This is the first study that evaluates laparoscopic cholecystectomy within the first 24 hours after admission in a safety-net hospital population. There is a recent randomized trial that evaluated intervention at 48 hours, but this study goes even further to push it to within the first 24. Unfortunately, still more research is necessary to identify which patients would actually benefit from this strategy of intervention, but the authors concede it is probably important to try to establish granularity in the grading of acute pancreatitis at admission to identify predictors of complications with the early intervention first.\
Article 4
Defining the burden of emergency general surgery in transplant patients: A nationwide examination. Bhatti UF, Shah AA, Williams AM, Zuberi MK, Butt Z, Biesterveld B, Alam HB, Idrees K. J Surg Res. 2020 Jan;245:315-320.
Organ transplantation is becoming more common. With the advancement of the medical and surgical management of these patient, long-term graft survival continues to improve. Surgical intervention on this expanding population is complicated by their altered anatomy and immunosuppression. The burden of emergency general surgical (EGS) need not related to their transplant in this subtype of patient is largely understudied and we know even less in their outcomes.
The authors performed a retrospective cohort study of the Nationwide Inpatient Sample (NIS) from 2007-2011 in 35,573 adult patients who were post-operative liver, kidney, pancreas, and intestinal transplant and identified emergency general surgical conditions. The most common AAST-defined clinical conditions that this cohort encountered were need for resuscitation, bowel obstruction, biliary maladies, and hernias.
Notably 30% of the total transplanted patients developed an EGS condition. Of this population, the liver transplant recipients (52%) most commonly developed an EGS condition. They identified that, overall, transplant patients with an EGS condition had a nine-fold higher likelihood of mortality and a threefold higher likelihood of complications over those transplant patients who did not develop and EGS condition. Post-transplant patients with EGS conditions were observed to have an average of 13 days longer risk-adjusted length of stay with a $60,000 higher cost of care when comparing to their non-EGS controls. There were several limitations noted which included the fact that EGS diagnoses do not have agreed upon severity scores. This being a cross-sectional database, there weren’t a lot of clinical parameters to help with better understanding the mechanisms contributing to the noted trends, including immunosuppression modalities and co-morbid conditions. Additionally, it remained unclear who was managing these patients.
This is the largest retrospective review of transplant patient with AAST-defined EGS conditions in the US. As many institutions have varying policies on who manages EGS conditions in this population, in many instances, the Acute Care Surgeon will be the one to step up to the plate. Understanding the literature in this patient population can be helpful in the clinical decision making and perioperative risk stratification for these patients.
|