Hello, and welcome. My name is Niels Martin. I will be providing the Emergency General Surgery portion of this year's Surgery Year in Review. As a means of disclosure, I have selected the following 27 articles based two-fold. One on my cache of prospectively collected landmark articles, and two based on a retrospective review of the table of contents from several top surgical journals, all from the past year. I then grouped the articles based on their EGS topic area. So the first EGS topic area that we will discuss is the management of appendicitis. There were two good quality articles that I found. The first is a single center study performed in Dublin, Ireland that randomized adult patients with uncomplicated appendicitis into receiving antibiotics only versus a surgical appendectomy. The authors enrolled 186 patients, and in the antibiotic only group, there was a 25.3% failure rate within the first year. Additionally, there was no difference in length of stay, and the surgical group did have higher expenses, but the quality of life assessment scores were significantly higher in the surgical group than in the antibiotics alone group at both 3 months and 12 months postoperatively. The authors therefore concluded that surgical intervention should be the mainstay of treatment for patients with acute, uncomplicated appendicitis. Now in this second study, which was a one year cohort study using the Healthcare Cost and Utilization Projects Nationwide Readmissions Database that is maintained by the Agency for Healthcare Research and Quality, the authors included all patients with acute, uncomplicated appendicitis who were age 65 or greater. Additionally, they excluded patients with a modified frailty index below .4, thus ensuring they had both an elderly and comorbid population. Ultimately, they included over 5,000 patients, of which 23.7% were treated non-operatively. However, as you can see, 17.7% had a failure and had recurrent symptoms. Those patients requiring that delayed appendectomy underwent propensity matching with the initial cohort. Patients undergoing delayed appendectomy had longer hospital length of stays, incurred higher healthcare costs, and experienced more complications and mortality. The authors therefore concluded that appendectomy offers an evident advantage of complete and long-term resolution of the appendicitis and related symptoms in this vulnerable population. Now the next section is Bilirian Pancreatic Papers. There were several. In the first study, which was a single center randomized controlled trial called the Gallstone Panc trial, the patients had either a cholecystectomy between 24 hours of admission, or they waited for resolution of their pancreatitis symptoms. Ultimately, the authors found no increase in complications, but a shorter hospital length of stay and a non-statistically significant cost savings of $1,200 for those patients who underwent early cholecystectomy. Therefore the moral of this is do not delay for a mild pancreatitis. In the next paper, 350 patients were prospectively identified in an East multi-center trial who had both a cholecystectomy and an ERCP in the same admission. The authors found that immediate ERCP was associated with a shorter post-op and hospital length of stay. Additionally, common bile duct explorations and the need to convert to an open cholecystectomy occurred more frequently when surgery was delayed. So again, the moral of this paper is do not delay surgery and ensure that your ERCP is done in a timely manner. Pushing further into this topic, this study compared definitive single-stage laparoscopic cholecystectomy with an intraoperative ERCP versus those who had progressively longer periods between the two procedures. This multi-institutional study had over 350 patients and showed that performing a cholecystectomy and ERCP together shortened the post-op length of stay and the hospital length of stay. Further, conversion to an open-ap cholecystectomy or the need for common bile duct exploration occurred more commonly when surgery was delayed. Next up, patients who present for an interval cholecystectomy after a percutaneous cholecystostomy tube. When is the optimal time for surgery? These authors used a nationwide readmission database and found over 2,700 patients who had a percutaneous cholecystostomy tube followed by an interval cholecystectomy join a separate admission. They found an increase in operative complications if surgery was performed within one month of placement of that percutaneous cholecystostomy. However, they also found an increase in percutaneous cholecystostomy-related complications and need for interventions if surgery was performed beyond eight weeks. Therefore, these authors suggested that the most favorable time for an interval cholecystectomy after a percutaneous cholecystostomy tube placement was between four and six weeks after the tube was placed. Should you operate on perforated cholecystitis or should you drain it and do an interval cholecystectomy? These authors reviewed over 650 NISQUIP patients who presented with perforated cholecystitis over a 12-year period. The authors found that patients who underwent cholecystectomy during the index admission had a significantly higher 30-day morbidity and mortality rate as well as longer postoperative hospitalizations. Their findings, therefore, suggested to do an interval cholecystectomy if your initial report is perforated cholecystitis from your ultrasonographer or radiologic imaging reader. Once the gallbladder is out, how much antibiotics is prudent? For uncomplicated cholecystitis, I think we have the answer, it's one and done. But how about if there are retained common bile duct stones? The authors here performed a post hoc analysis of a prospective observational multicenter e-study of patients undergoing same admission cholecystectomy for choledocolithiasis and gallstone pancreatitis. They found that the rates of postoperative infectious complications were similar among patients treated with prolonged versus just prophylactic antibiotics, the definition of which was at 24 hours. They further found that prolonged antibiotics, however, were associated with a longer length of stay and a higher incidence of acute kidney injury. And finally, in this multicenter randomized controlled trial of patients with mild to moderate acute pancreatitis, they were randomized to receive either immediate or conventional oral feeding. They had over 131 patients enrolled and their conventional group took 2.8 days to achieve the start of feeding, whereas of course in the experimental arm it was 0 days. The authors found a significantly shorter hospital length of stay in the immediate feeding group suggesting that we should be feeding patients with mild to moderate pancreatitis at admission. Moving on to the next section, bleeding in acute care surgery, there is one relevant paper here from the last year. Many of our peers and other surgical specialties have been using TXA to decrease intraoperative blood loss for quite some time. In this meta-analysis, the authors found 57 articles inclusive of orthopedics, OBGYN, OMFS and ENT, cardiac and plastic surgery. Ultimately, the authors surmised that a single dose of IV TXA reduced the perioperative blood loss by an average of 153 cc's per case, equating to a 72% decreased odds of transfusion. So perhaps the bigger general surgery and acute care surgery community should also be considering TXA in some of our bigger, more complex cases. Alright, how about COVID-19 and surgery? One paper here, and I'm hoping that this paper becomes much less relevant with time. Here the authors evaluated how much time should elapse after an acute COVID-19 infection before proceeding with elective surgery. This was an international, multi-center, prospective cohort study organized by the National Institute of Health in the UK. Outcomes were stratified by two-week intervals and over 137,000 patients were included. Ultimately, the findings concluded that the risks of post-operative morbidity and mortality were greatest within the first six weeks of infection and that surgery should be delayed thereafter. And this was even the case in patients who had asymptomatic COVID-19 infections. Alright, next big category, small bowel obstruction management. In the first study, which was a single institution retrospective study, the authors stratified patients by time between time of admission and the institution of a gastrographin challenge. And they evaluated the duration of stay. They ultimately found that if a gastrographin challenge was performed within 12 hours of admission, based on the receiver-operator curves, they were able to predict a less than five-day length of stay for non-operative patients and even a shorter length of stay preoperatively for patients who required an operation. Thus, they concluded that a gastrographin challenge within 12 hours of admission should probably be the standard we all look to achieve. Next, this study, the authors reviewed patients who presented to a single emergency department over a three-year period before and after initiation of a protocol to observe patients with a small bowel obstruction in an observation unit as opposed to admitting them to the hospital. A total of 125 patients were included, just about half in each group. Interestingly, I found the exclusion criteria very helpful in this study as they were indications for immediate surgery, as you can see in the top left. Ultimately, the post-intervention group had a 51% decrease in median length of stay, which equated to 36 hours shorter length of stay. And for those with a non-operative resolution, the readmission rate decreased also from 16 to 8%, showing that they weren't just discharging patients who would bounce back. Finally, in this section, this was a single center study of 116 patients where they evaluated the ability of CT scan to predict the cause of a small bowel obstruction as either being a single band versus matted adhesions, with the premise that delineation of this could influence surgical pathway. The studies were independently reviewed by a radiologist and compared to the ultimate surgical outcome. Several radiological findings were included in the regression model, as you can see listed on the left, and they had a pretty good receiver-operator curve. So our radiologists may actually be more helpful than we think in determining the early trajectory of surgical patients. Alright, next section, looking at tracheostomies and airway management. In this first study, which was a retrospective study from a large academic institution, the authors reviewed nearly 350 airway rapid response team activations, looking at the outcomes and the technical needs within those events. The authors found that nearly half of these events involved tracheostomies, and that establishing recannulation of a tracheostomy tract was the most common procedure performed. There was a significant cohort that required transfer to an operating room, and 3% required creation of a new surgical airway. The authors ultimately concluded that there is a real need for surgical expertise on airway response teams. The next everlasting question of the perfect timing of when to place a tracheostomy. This study was a meta-analysis, looking at early, as defined by less than or equal to seven days from admission, versus late tracheostomy patients in those with pneumonia. Ultimately, the authors included 17 trials, inclusive of over 300,000 patients. The authors ultimately found that a significant odds ratio towards early tracheostomy in terms of ventilator-associated pneumonia, duration of mechanical ventilation, ventilator-free days, and mortality. So early tracheostomy is still good. All right, looking at predictors of outcome and measures of frailty. Several papers here. The first one was a retrospective study done within a large regional health system over 12 years, looking at nursing home-specific patients who were admitted to an acute care hospital with one of eight various emergency general surgery diagnoses. There were nearly 8,000 patients included, and a matched control cohort was created from the same local nursing home population who did not require surgery. As you can see from the Kaplan-Meier plots for operative cases at the top and non-operative cases at the bottom, EGS care of nursing home patients carries significant risk of mortality, but it was not futile. The authors therefore concluded that nursing home status alone should not preclude aggressive surgical management in this population. All right, next paper. These authors created an emergency surgery scoring system to predict 30-day mortality in EGS patients. This was done using 10 years of NISQIP data. Of over 6 million patients in the database, 173,000 had emergency procedures. The mean age of this group was 60 and the mortality rate was 9.7, which is not insignificant. The weighted scoring algorithm involved the variables seen here in table 1 on your left. The C-statistic performed relatively well, ranging from 0.81 to 0.97, depending on the type of emergency procedure. So perhaps we may one day see this calculator incorporated into our EMRs. This next study similarly used and generated a risk analysis using both the NISQIP and VAQIP data. These investigators not only tested the risk analysis index, but also incorporated an operative stress score. These two assessments integrated well together, giving a broader stratification of outcome, not just on frailty indices, but also on how to incorporate the stress of surgery and surgical recovery in their assessment. Looking beyond mortality now, this study looked at predictors of inpatient readmission following emergency surgery. This was a post hoc analysis of a multi-center prospect of observational trial. The authors obviously excluded all deaths and hospice discharges from their index admission cohort. Ultimately, they included over 1,300 patients. And there was a 17.4% readmission rate. The most common original admission diagnoses included hollow viscous perforation and small bowel obstruction. The predictors of readmission included disseminated cancer, a greater than 10% weight loss in the prior 6 months, dyspnea at baseline, wound complications, and discharge to a nursing home. Now building off those prior three studies, these authors used the same single institution data and used a frailty assessment and operative severity score to ultimately predict early post-operative loss of independence, which similarly can be used in preoperative outcome prediction and management of expectations. Age and frailty assessments did directly correlate with a loss of independence and mortality. Loss of independence should be an additional factor in preoperative discussions. All right for the purposes of time, I will give you this bibliography, however there are a couple other important sections just to go through briefly. This one is on guidelines, pathways, and processes. There were several good papers here in emergency general surgery, including fast track pathways in emergency general surgery, reducing operating room costs, preoperative patient activation or preparation to improve outcomes, and guidelines to mitigate C. diff infections. There was one good paper on surgical disparities. This elucidated contemporary racial disparities in surgical care. I believe this is a topic that warrants ongoing discussion as we improve our processes and was worthy of mention in this year in review. And finally, to round out this discussion, of course ending on a supportive note for our community of intensivists, this paper looked at a process to support team members after an intraoperative death, which I think is an important aspect of supportive care. So I want to thank you for your time and attention. I hope you found this review helpful. More so, I hope you will reference this bibliography and further your own individual practices. Thank you again.

emergency general surgery

appendicitis management

bilirian pancreatic papers

small bowel obstruction management

support after intraoperative deaths