Okay. Nothing to disclose. I want to first by saying thank you to SCCM and the section for this opportunity and also that I grouped these articles by topic and tried to highlight takeaway points throughout so that you can kind of capture the high yield information. I also will post a list of the references on the section Twitter account. So join our section, follow us on Twitter, and you can download the references. First topic is acute appendicitis. And this article compares outcomes of operative to non-operative management of acute appendicitis in older adults in the U.S. And the reason why this was done was because previous studies looked at younger population of people in their 30s with no comorbidities. And so these authors sought to determine if the risk-benefit profile in older adults mirrored that of younger adults. And what they found was that there was fewer short-term complications with non-operative management, no change in mortality, increased length of stay, and greater costs. What was actually interesting about this article, though, was that they found this was somewhat routine already compared to younger adults. And up to 20 percent are already being treated with antibiotics alone. I think one of the limitations from this study compared to previous articles on this topic is that they weren't really able to identify the presence of a fecal lyft and things of that nature. But regardless, the takeaway point here is that this imbalance, this relative balance between risk and benefit demonstrated in previous studies was not duplicated. And that we really need a more comprehensive study that represents this demographic. The next three will relate to biliary disease. The first one was named one of the best articles of 2023 in the Journal of Acute Care and Trauma Surgery. And it's called Reclaiming the Management of Common Bile Duck Stones in Acute Care Surgery. And commonly, currently across the, I think, the nation pretty much, more commonly common bile duck stones are actually treated with ERCP and cholecystectomy. But there is an alternative solution, and that's a laparoscopic exploration, which can be done under one anesthesia event. And so acute care surgeons are really in a nice place to kind of improve the patient outcomes and efficiency of care with these patients. And so these authors hypothesized that implementation of a catheter-based laparoscopic exploration would result in decreased length of stay and an equivalent complication profile. These were kind of the eight steps that they summarized their technique. And it starts with simple interventions and escalates to more complex maneuvers. What they found actually was that there was successful clearance of the duct in 70% of patients with a nearly two-day decreased length of stay and no change in complications. And there was just two limitations, I would say, or the main one being that the decision to make, to do the exploration laparoscopically was based on the surgeon's independent judgment and not like a defined algorithm, which I think probably limits this in some ways. But regardless, the technique is both possible and safe and can really expand the footprints for ACS surgeons and also translate to rural and community hospitals as well, which is important. The next one talks about biliary hyperkinesia and was published in the Journal of the American College of Surgeons. The typically functional gallbladder disorders are defined as biliary symptoms with a low EF, but there is certainly a controversial subset with a high EF. And there's some recent studies looking at the success of choastasectomy to relieve symptoms of patients with a high EF, but there's really no consensus. And so this article tries to determine the optimal cutoff for EF on a HIDA with CCK, at which choastasectomy would helpfully postoperatively resolve symptoms. And actually what they found was that cutoff was 81%. They found that those patients had a complete resolution of their symptoms without any recurrence. I think this study was limited by probably, you know, small patient volume, and also there was inconsistent documentation on admission of what exactly the symptoms were. They were kind of assumed to be pain and things like that, but they really had to do a better job probably at really defying the top symptoms. But regardless, the majority of patients with hyperkinesia will benefit from a choastasectomy, which can really help us decrease patients' return visits to the ER. We've all seen these patients, and improve patient satisfaction scores as well. The third article in this section is, wait and see is justified for ERCP and endoscopic sphincterotomy in elderly patients with convaleduct stones. I think this is a common dilemma we all face on call. These patients are at high surgical risk. But also the common teaching is that choastasectomy should be done to prevent recurrent or future more serious biliary events. But how do we know if it's working? And so these authors looked at the long-term applications, sorry, outcomes of this strategy this kind of wait-and-see strategy in patients that were specifically 75 years old or greater. This took place in Finland. They looked at patients that were 75 years old or greater. What's interesting about this article is that they were able to, because it's in Finland, access their national healthcare database and actually look at outcomes of patients who may have presented at other hospitals and gotten subsequent operation outside of the initial hospital, which is, I think, unique to their healthcare system. What they actually found were that routine choastasectomy is not indicated. Only 11% of patients actually had a secondary biliary event. And only 4% actually needed, or less than 4% needed an operation, which was not associated with a higher mortality. What I also found interesting was that the duration, the most common time for these patients to present was actually 307 days later, which I thought was long. I was surprised. So in summary, the wait-and-see policy for ERCP is a safe population, safe option for this population, and you can leave the gallbladder in with a relatively low risk of biliary events. They do talk about, though, that probably there needs to be more studies about the economic impact of this decision, depending on where you live and such. Okay, and next topic, coagulation. This is a yeast multicenter trial ACEs study that really asks who bleeds more in emergency general surgery. And although we have improved access and there's more options for reversal agents for DOACs, their use is still limited by availability, by cost, by fear of thrombosis, and even efficacy. And so these authors looked to determine the prevalence of perioperative bleeding complication in patients who had DOACs versus traditional anticoagulants who required emergent surgery. And for this article, traditional was defined as coumadin and anti-platelet agents. And they were able to look at this and compare these two, and what they actually found was there was no difference in perioperative bleeding in hospital mortality between these two patient populations. They did find that a history of chemotherapy because of the platelet dysfunction and indication of surgery did increase your risk of perioperative bleeding, and severity of illness was associated with the postoperative, sorry, increase in hospital mortality. Regardless, in summary, they really say that this should not dictate the timing of surgery. The timing of surgery really should be still based on patient physiology and indication, and regardless of what kind of blood thinners they're on. I think one limitation to the study is that they confirmed the patient took their medication within 24 hours of surgery based on the patient's recollection or a surrogate decision maker. And these patients are generally older, and so there was some inconsistency on their memory and if they took it or not, which drug it was. And so that may have limited the comparison, but I still think it's a good article. The next one, it looks at 10A level monitoring for patients on Lovenox for VTE prophylaxis in emergency general surgery patients. And we all know our patients are at increased risk, particularly emergency patients. And typically, dosing regimens are kind of a one-size-fit-all, particularly for general surgery. I think we know that that has some issues with it, particularly for trauma patients, for example, and that same kind of issue remains in our EGS patients. And so this article tries to determine the efficacy of a standard Lovenox dosing approach in achieving adequate prophylactic 10A levels in EGS patients. What they found was they started with an initial dose that was based on BMI, and that's kind of an evidence-based way to pick your dose for Lovenox. And then using 10A levels, they adjusted their dose to either a higher dose or a more frequent dose, and it was one of these categories here. What they found actually was that 80% of these patients never actually met their target range, and even after adjusting their dose, they still remained under their range. And therefore, we probably don't have an optimal dosing regimen for these patients. So similar to trauma, we really need to spend more time looking at how to best dose Lovenox and check Lovenox efficacy in these patients for VTE prophylaxis. And the optimal strategy probably includes these four items. We just have to better define what those details are. Hernia. The first article looks at two technical ways for us to prevent subsequent hernia from developing in our high-risk patients. You know, two things talked in the literature are prophylactic synthetic mesh and taking small fascial bites, about 0.5 centimeters. And so these authors looked to assess the efficacy of these interventions, particularly in a high-risk population, which is one of those three factors. Of note, they also decided to use biologic mesh instead of synthetic mesh in this study, which is interesting. They randomized patients to biologic mesh or no mesh and small bites or large bites. And what they found was that there was no difference. There was no difference in the complications, the abdominal wall quality of life scores, the cosmetic scores, and patient satisfaction scores. And so there really is no, you know, clear evidence that biologic mesh or small bites will effectively prevent hernias in this patient population, which is a lot of our patients. And so we probably need to better define which patients this can help and which patients we need different studies on. The next one looks at predictors of acute incisional hernia incarceration. So the problem with these patients is that those that are at higher risk for developing a hernia or having a recurrent hernia also make them high surgical risk patients. And so there's been a trend nationally to have more nonoperative management of hernias, which has led nationwide to increasing the numbers of emergent hernia repairs. And so how can we better fix this process? And so they sought to identify factors, patient factors and hernia features measured on CT at the time of a diagnosis, which were associated with a future increased risk of incarceration events. And actually what they found was a few things. Let me go back actually. They found that there's small bowel contents, hernia, a smaller hernia defect, a larger hernia sac height, and more acute angle, as well as increased subcutaneous adipose tissue all increased the risk of subsequent acute incarceration. I think this picture shows some of these and how they measured them on CAT scan. Importantly, I think the angle was interesting as well as the depth and where to measure it from. And so they kind of summarized that imaging characteristics present on a time of initial diagnosis can predict acute incarceration and help really influence who we decide to fix emergently, urgently, or electively. I think one thing this study was limited by was they only looked at the CAT scan at the initial diagnosis, and so if patients had subsequent imaging between initial and incarceration, they didn't look at the kind of changes in between for longitudinal information. But nonetheless, I think if you're seeing somebody in the ER or in clinic, this can really influence decision-making trees and referral patterns. The next topic is perioperative care, and particularly the first article looks at artificial intelligence for predicting risk. The Potter Risk Calculator is an AI-based risk calculator that was developed specifically for EGS patients. So these authors look at, compare Potter's risk assessment to a surgeon's risk assessment, and then to see how Potter can influence a surgeon's risk estimation. What they did is they found 150 cases of patients that were undergoing emergent laparotomy, and then they found 30 surgeons that were blinded to Potter's risk assessment, and they gave them 10 unique cases and said, please write down your predicted mortality and complication rate. Then they gave them 10 new cases and allowed them to interact with the Potter calculator, and then put their same assessment down. And then they found in almost all things, the surgeon with Potter's influence were better at predicting outcomes, and they were more consistently reporting outcomes, with the exception of infectious outcomes, so sepsis and surgical site infections. And so this risk calculator can positively and effectively enhance surgeon judgment and help us provide better decision-making, but also give risks to families and patients at the bedside in real time. The next one looks at 30-day readmissions after emergency general surgery, and tries to identify any factors that might be modifiable, so we can make an impact and decrease 30-day mortality, sorry, readmissions. And what they actually found was that overall the general 30-day readmission rate for the nine most common EGS procedures was only 5%. And these are the risk factors they found that were more likely to predict admission, and they were age over 40, ASA greater than 3, which is actually the highest predictor, sepsis on admission, extremes of VMI, high-risk procedures, initial length of stay, and discharge to SNF, which aren't really modifiable. But they do discuss a lot about what we can do as a kind of a system and community is try to develop better post-operative coordination and discharge surveillance so that patients aren't coming back to the hospital for admission with things that could be addressed in the outpatient setting. So how can we better have telehealth, for example, appointments while they're at their SNF to adjust symptoms earlier so they don't come back and get readmitted to the hospital where it's an increased cost to the hospital and patient. Okay, the next two are clinical reviews that were written specifically for acute care surgeons. The first one is Contemporary Management of Acute Appendicitis, and their first recommendation is to use grading systems that are agnostic to underlying etiology to communicate about these patients and also make decisions. The first one is a revised Atlantic criteria, which looks at the degree of parenchymal injury, and the second is the AAST and atomic severity grading system. Other take-home messages in this article, which I thought were interesting, were, again, enteral feeding is important and should be started within 24 hours. If patients aren't clinically progressing as expected by 72 hours, a repeat CAT scan should be performed to look for complications. For biliary pancreatitis that's mild, patients should have a lap coli prior to discharge, and it can be as early as 24 hours after admission. However, if it's necrotizing pancreatitis, you should have a colistectomy within eight weeks of discharge, and you should get preoperative imaging first. And the last point, which I thought was interesting, was they compared different operative techniques for necrosectomy, and although we've kind of talked about step-up before and endoscopic necrosectomy approaches, they really are favoring, in this article, transgastric necrosectomies through laparoscopic or robotic techniques, and I think they think there's more to come on this kind of front, but it was something that caught my attention and something to look for as more things are published. The next one is common bariatric surgical emergencies, and this is sort of like a guide made for those who are seeing these patients in the middle of the night and off hours, which are emergency general surgeons. And it's to help, you know, with diagnostic evaluations, help guide your interventions and perioperative management decisions. They really kind of hone in on 10 things. Work up common problems. If it looks like a PE, it could be a PE, so work it up. Get a really thorough bariatric history. This is even including, you know, details of the first surgery, complications, contact information. In the early postoperative period, the most common complication is a leak, and that can be from a staple line or an asthmosis, and they can present quite insidiously, with sometimes the only sign is just a persistent leukocytosis and no abdominal complaints, so don't overlook that subtle finding. Pulmonary symptoms can be both pulmonary pathology and abdominal pathology, since we're in the foregut, and so work up both if you have a patient who has pulmonary symptoms. Postoperative bowel obstructions is an internal hernia until proven otherwise, and that's ruled out by surgical expiration. Be familiar with the sleeve gastrectomy, because it's the fastest-growing procedure for bariatric surgeries, and so you're more likely to experience a patient or meet a patient that had a sleeve. And for leaks, an upper GI can often miss some leaks, and so if you get an immediate postoperative post-upper GI CAT scan, you can actually catch a higher number of patients with a leak. And lastly, acutely decompensating patient belongs in the OR, as we all know, but patients who are stable but don't have symptom resolution do need exploration, but it can be in the form of a laparoscopic approach, robotic, or even endoscopic approach in a more controlled setting. And here's, this article has a lot of like tables and quick reference charts that I recommend everyone look at for kind of quick reference of the bedside in the middle of the night. And the last article, which is like near and dear to my heart, is Robotic Acute Care Surgery Program, and how this group of authors were able to implement it successfully and show improved outcomes. So basically, their goal here was to expand access for all EGS patients while providing them equal opportunity for improved outcomes, you know, despite the day of the week or the time of the day. And they kind of outlined their steps of success. The first one was to identify stakeholders and create a common mission so that they were successful and could also define the outcomes to measure. Using the stakeholders, they built a kind of high-functioning dedicated team and really made sure that the surgeon led the culture of positive change going forward. The next was preclinical preparation, and this was through a variety of platforms, you know. There was simulator training. There was, you know, podcasts, all different things. But their kind of point here is that make it tailored to the team members' needs and not just a generic pathway. And the next, the last part was really making sure to integrate this program into your existing service line, however that might be, and into like the logistics of the OR and hospitals so that you don't run into any roadblocks as you get going, and you really continue momentum. The last part was trying to define a training program for surgeons that made them, you know, competent. They can master skills, and then apply it to a new patient population, which is sicker. And the operations are more complex sometimes. And so they started with general cases, elective cases, things that were short, you know, gallbladders, inguinal hernias. And then the next step was going to more complex procedures during normal daytime hours. So they had resources. They had people to call for help. And then finally to offer these cases at all times of the day and night. The last thing I recommended was really doing some post-case reviews and really collecting good data to share with administration because they very quickly were able to show improved outcomes at a decreased cost. And that's all I have for acute care surgery. Up next is critical care. Yes. I think. Thank you.

surgical care

appendicitis

biliary disease

AI risk calculator

DOACs

robotic surgery