Thanks, Deb. You're making me blush. Thank you all. I know I'm standing between you and the end of the session. So there are a lot of slides and a lot of references. I don't freak out. It's okay. I was kind of channeling my inner Dr. Naylor. But this is a QR code. It is a link to all of the bibliographies from all three talks today. And then give it a couple weeks, we'll have it, the same QR code linked to the Dr. Naylor-styled bibliography. So without further ado, left click. Thank you. I was thinking about getting one of those techie tags and putting a big X over it. Right click, left click, oh dear. Left, I am, I promise you, I'm pushing the left. I'm clicking it, I promise you, I'm clicking it. Do you want me to do it for you? I can do it that way. All right. Sorry, guys. I have no financial disclosures other than the usual. I work for the state. I work for the federal government. And all this is my own personal reflections and not reflecting the state of Maryland, nor the federal government, nor the Society of Critical Care Medicine. Okay, we'll do it this way. Again, here's the QR code. Our learning objectives is we're going to go over major EGS publications stratified by topics. There are a few focused details and summaries of select articles. And then the rest will be just categorized with some short summaries. And then you guys can review that on your own time and come to your own conclusions. First, we'll begin with the EGS burden of disease. As we all know, emergency general surgery has a huge burden of disease on the population. These are a few articles looking at different aspects of the burden from VTEs to patients with organ transplants, kidney failure, and looking at the major NISQIP papers. Coinbrite looked at over 300,000 EGS patients in over a six-year time span in the NISQIP database. And not surprising, 5.2% of these patients had unplanned readmissions. So we're not just looking at the high burden of cost on the index admission, but these patients also tend to have a higher burden as a readmission. Unfortunately, most of these risk factors that they identified are not modifiable, such as older age, higher ASA scores, sepsis, higher or lower BMIs, high-risk procedures, and long hospital stays or discharge to a facility. As we all take care of these patients, we know that they tend to be sicker. But still, it highlights an area that we have to really work on and look for the modifiable risk factors. There are lots of disparities in care. Here are a few articles looking at the different types of disparities from younger patients who are Medicare beneficiaries, which you don't expect most younger patients to have, to patients who are incarcerated, which was a great yeast multicenter study. So Zhang et al, focusing on the emergency general surgery rates among Medicare beneficiaries, they actually, again, took the nationally inpatient sample and looked at some major operations, such as AAA repair, colectomies for cancer, and incisional repair. They stratified by elective versus emergency procedures, and not surprising, the emergency procedure patients' population did worse. But what they did find, too, was that the patients who were Medicare beneficiaries but were younger and otherwise healthier had persistently higher rates of emergency general surgery. What that says about our society and that these younger patients are dependent on Medicare is a different story, but that was an interesting finding, and you can look at that article. Several EGS risk calculators out there, one of which is the quad SOFA score. So using the QSOFA score not just for your critically ill patients, but also for stratifying your emergency general surgery patients for outcomes and a validation of the World Society of Emergency Surgery system for scoring diverticulitis. Focusing on frailty, there are several articles that looked at frailty as being an independent risk factor for worse outcomes, and use of different frailty scores and incorporating the NISDA database. Frail patients do have worse outcomes, but not operating on frail patients and then having them get even sicker is also a bad idea. So even though they may have a higher risk, some of these patients are still deserving of an operation. Age is associated with increased morbidity after laparoscopic appendectomy, as shown here by Stevens et al. But what they also found was that it is nonlinear, right? And the patients who had increasing age, they tend to do poorly, but within the VASCWP database, the probability of outcomes was actually lower. Even though these two scores look similar, the scale on the VASCWP score is lower, and so whether that has to do with transfers or how patients are cared for within the VA system, again, for you to draw your conclusions. A few more articles on frailty and costs, and older patients do incur higher costs to a higher length of stay, sometimes related to placement, higher risk of complications. And then we can't talk about emergency general surgery patients without looking at models of care. So several articles here looking at acute care surgery model within different groups, and if you kind of look through some of these articles, show that the acute care surgery models have better outcomes, and other models show that there's really no difference in outcomes, and a lot of that has to do with the heterogeneity of our patient population and also local resources. But one study by a group in Texas, of which Dr. Ariel Santos is a part of, looked at their laparoscopic appendectomy outcomes with respect to transition in their time zone from when they had general surgeons doing elective surgery, taking call, versus having a dedicated acute care surgeon who had no other elective applications taking call. And they found that once they switched over to the acute care surgery model, they did have better outcomes, even for patients requiring, quote unquote, a simple appendectomy. Transfers. There is always, we all have this bias that the patients who are transferred have worse outcomes, but what is the data? Here are a few articles that look at this. Some find that there are differences, and others there are not. One particular article I wanted to bring to your attention is the group by Turcotte et al. They looked at 30,000 subjects who were transferred with a higher MELD score. So these are patients with high MELD, liver cirrhosis, liver dysfunction, older, they were white, they were obese, they were septic, and they compared these against the control patients. And then once they've been actually independently controlled for all the other comorbidities between the transferred and non-transferred patient population, it was actually interesting that they did not find the transfer status as being independently associated with post-operative complications, mortality, or length of stay. What they did find, though, is that a lot of these transferred patients were at higher risk of re-operation. And the weekend effect, again, here are two articles, one showing that the weekend effect did seem to make a difference, and one that it does not, and maybe more related to the resources that are available to those separate institutions. The second part of this is actually looking at the disease-specific portions of EGS surgery. So this will be stratified by disease topics. A number of articles looking at predictive factors for complicated appendicitis, ranging from radiographic models to using the delta-deltas of the neutrophils, neutrophil-to-lymphocyte ratios, et cetera, and you can read into that some more. One article that I thought was interesting and not something that you would normally read and thought was interesting and not something that you would usually think of is for those who live in warmer climates, there actually may be an independent association with warmer weather that's independent of season. Why that is, we don't know. This was in the JAMA, and they found that looking at a cohort study stratifying for the climate changes and what have you, people who lived in warmer temperatures had increased appendicitis. Go figure. Maybe we should all move to Michigan or somewhere cold, or Alaska. Acute cholecystitis. Here are a few articles looking at the Estes trial, which is a snapshot of clinical practice. We have, we teach in terms of clinical practice of acute cholecystitis, but how much do we actually adhere to the published international guidelines? There was, bring to your attention here, Schuster et al., they did a revision of the WASC grading for acute cholecystitis and compared this to physiologic measures of severity, and I thought that this was a nice table to incorporate or to include for your reference here. A few more topics on acute cholecystitis. Percolitubes. How often do we send patients out with percolitubes? Too old, too frail, too sick to have their gallbladder taken out, right? So what happens to them afterwards? Do they ever get this removed? Chen et al. actually looked at the outcomes following patients who got a percolitube for acalculus versus calculus cholecystitis, and here, what they find is that the patients with acalculus cholecystitis, a fair number of them, don't end up needing to have their gallbladder out, which sort of is, makes sense from a physiologic standpoint, but here you have the data to support that. Choledocholithiasis and common valve duct zone management. The perpetual debate to go to the OR with intraoperative CBD exploration, intraoperative cholangiography, or do you get an ERCP before you do a lap coli? So a few articles that look at that, and you can see which way you want to do it for your own practice. Interesting, Koukouroskos et al, they took a look at transaminases as a way of predicting whether or not the patients would actually have choledocolithiasis at the time of lap chole. And so this is sort of not just taking a look at the ALKFOS, but they did a scoring system utilizing the ALKFOS, the ASTs, and then the t-BILI. And not surprising, but with a concrete lab value, you can say that patients with a higher score may have a higher risk of having common bile duct stone, and depending on your institution and your resource availability, you can go down that management pathway. Can't talk about EGS without talking about pancreatitis, especially with Dr. Diaz sitting in the audience. So there are a few articles here looking at early cholecystectomy with protocols on pancreatitis and management of gallstone pancreatitis. The Manktra trial was looking at, again, compliance with evidence-based guidelines in acute biliary pancreatitis and found that there was actually still a wide variability. So we have our standards, but there is still obviously room for improvement, and as we understand more about the disease process, perhaps also more, a better way to tailor our treatment. This group here described with a nice pictorial here of doing a, what they call a laparoscopic assisted pancreatic necrosectomy technique. So if you look at the diagram and read through the techniques, it's actually very similar to what we do with the VARDS, but instead they use the laparoscope and describe a slightly smaller incision in their operation. So that's more of a technical paper. Colorectal disease, lots to say about elective versus emergent colectomies and their outcomes in terms of increased risk for patients. This one here by Sito et al. looked at the difference between emergency and elective colorectal surgeries and found that most EGS colorectal surgeries are for diverticular disease as opposed to cancer, but importantly that when cancer is involved, while the EGS patients may have more complications, but due to their emergent presentation, their overall complication rates were not that different compared to the elective procedure. So we're doing a good job, I think, in the EGS world for these patients. And again, not surprisingly, because these patients come to us sicker, we also tend to have a higher stoma rate and lower anastomotic rates. Failure to rescue after reoperation. This is looking at 90-day mortality, and one of the things that we find is that perioperative organ failure at the time of reoperation is a potentially modifiable risk factors. So this has to do with more scrutinizing the patients after their index operation for colorectal resection. And in colorectal cancer, EGS surgeons do just as good of a job as the elective cancer surgeons for resections in emergency colon cancer patients. Diverticulitis, here are a few articles that are great for reviews, as well as an update of the WSES guidelines for the management of diverticulitis. Looking at operative versus non-operative management, I'll have a little bit more to say about that when we get to the drugs portion of this talk. This article by Hudnall et al. is a nice review of the surgical techniques for peptic ulcer disease, which is largely a medically treated patient population until they present emergently with a perforation. And then I would bring to your attention that Gormanson et al. found a lot of variations in post-operative management. Here are a couple of articles looking at intestinal ischemia and management. Bala et al. published the updated guidelines for the WSES, World Society of Emergency Surgery for the Management of Acute Mesenteric Ischemia. So whether or not you can figure out if a patient has acute mesenteric ischemia as well. Likewise, with small bowel obstruction, and looking at the use of water-soluble contrast is an update to the original trial. So, this article by Morris describes using bowel ischemia score to predict which patients who present with small bowel obstruction will actually proceed to need surgery. And this is based, as well as bowel resection, this is based on the CT score with wall thickening, reduced bowel enhancement, looking at the mesentery, and looking for any presence of ascites. Large bowel obstruction, similarly, looking at the different options, stent or not stent, operate or not operate in some of these patients who present with obstructing colon cancer. Sigmoid volvulus, looking at some patients who present with sigmoid volvulus, and what are their outcomes, and when should we perform definitive surgery, even in the high-risk patient population. Damage control in the open abdomen. Altmeier did a systemic review and meta-analysis of damage control surgery in the non-trauma patients. And there have been a few looking at the development of EC fistulas and what have you. I just kind of wanted to move on to this one here. Diaz et al., as part of the Meridian Study Consortium, looked at intra-abdominal infections that were patients who were managed with the open abdomen, and found that these patients actually had a higher risk of secondary infections. So prolonged duration of antibiotics in patients with open abdomen do not necessarily help because then these patients on the prolonged antibiotics had a higher risk of secondary infection, especially compared to those with a closed abdomen. A few articles looking at ventral hernias and risk factors associated with EC fistula hernia repair and cirrhotics and incarcerated hernias. Their Parthenote trial is looking at absorbable mesh and preventing peristomal hernias. I'm not quite sure what happened to this slide there, but this was an interesting one. Cepi et al. described a technique of managing ruptured umbilical hernias in the cirrhotic patients by incorporating fibrin glue as one of their layers of closure and found that they actually did not have a worse leak rate or a wound dehescence rate. Here we go. So fibrin glue, super glue, may actually help you in the cirrhotic patient who presents with a ruptured umbilical hernia. So this is also a technical description paper. MIS and robotic surgery is something that we usually think of in the elective world, but there is a lot of interest in using this in the emergency world. So here are a few studies looking at the feasibility factor. Still not ready for primetime, but certainly working its way out there. Medications pro peri. So anticoagulants and EGS surgery. To DOAC or not to DOAC? Or in the case of the M.O.O.N.E. paper, they called it the NOAC, but NOAC, DOAC, your oral anticoagulant. And this was found to be associated with a lower rate of postoperative bleeding and transfusions. But that being said, in this area, whether it's temporal or related to the medication use, we do see that they do have a higher increased risk of complications, but not increased risk of postoperative bleeding. Antibiotics or not. So a lot of interest, maybe some of it stemming from the COVID pandemic as a side effect, but using antibiotics or not using antibiotics in the treatment of acute appendicitis and also mild acute diverticulitis was a hot topic this year. So a few studies looking at that. In Salmonin, they looked at antibiotics versus placebo with uncomplicated appendicitis and found that resolution of symptoms was relatively similar and there was no statistical significance. Small study, but certainly challenging the paradigm that everybody that's nonoperative with appendicitis must be treated with antibiotics, right? And then the importance of antibiotic de-escalation in emergency surgery and we really do need to have antibiotic stewardship. Opioids and pain management. So we'll kind of roll through some of these here. COVID has had a lot of impact across the world for so many different aspects, including AGS. I have a few articles here looking at the impact on the REGS surgery and a lot of it had to do with resources. In some places the outcomes were similar and other places the outcomes were worse. But one thing that we did learn from all this is that there is a lot of variation and there are some disease processes where maybe you don't actually have to operate for you to make your own decisions. However, burnout and resilience is an important piece of that and the World Society for Emergency Surgery looked at the impact of COVID on staff burnout and in the AGS world. So there's that for you. And then just one last thing coming down the pipeline. Interoperative fluorescence for laparoscopic cholecystectomy to assist with visualization of critical structures and the use of therapy and rehab to help our AGS patients do better. The Ice Age trial is something that will be coming into the future. This is a prelim publication of a pilot study for feasibility. We're looking at intensive physical therapy for the first five days after AGS procedures and there will be a multi-center trial coming up from this soon to see if that will help decrease our complications. Again, always looking for the modifiables. So again, thank you so much for your time.

emergency general surgery

burden of disease

risk calculators

frailty

management

COVID-19