A 30-day prospective audit of all inpatient complications following acute care surgery: How well do we really perform?

The Clinical Frailty Scale (CFS) as an Independent Prognostic Factor for Patients ≥80 Years with Small Bowel Obstruction (SBO)

BACKGROUND

SBO is a potentially life-threatening condition that often affects older patients. Frailty, more than age, is expected to play a crucial role in predicting SBO prognosis in this population. This study aims to define the influence of Clinical Frailty Scale (CFS) on mortality and major complications in patients ≥80 years with diagnosis of SBO at the emergency department (ED).

METHODS

All patients aged ≥80 years admitted to our ED for SBO from January 2015 to September 2020 were enrolled. Frailty was assessed through the CFS, and then analyzed both as a continuous and a dichotomous variable. The endpoints were in-hospital mortality and major complications.

RESULTS

A total of 424 patients were enrolled. Higher mortality (20.8% vs 8.6%, p<0.001), longer hospital stay (9 [range 5-14] days vs 7 [range 4-12] days, p=0.014), and higher rate of major complications (29.9% vs 17.9%, p=0.004) were associated with CFS ≥7. CFS score and bloodstream infection were the only independent prognostic factors for mortality (OR 1.72 [CI: 1.29-2.29], p<0.001; OR 4.69 [CI: 1.74-12.6], p=0.002, respectively). Furthermore, CFS score, male sex and surgery were predictive factors for major complications (OR 1.41 [CI: 1.13-1.75], p=0.002; OR 1.67 [CI: 1.03-2.71], p=0.038); OR 1.91 [CI: 1.17-3.12], p=0.01; respectively). At multivariate analysis, for every 1-point increase in CFS score, the odds of mortality and the odds of major complications increased 1.72-fold and 1.41-fold, respectively.

CONCLUSION

The increase in CFS is directly associated with an increased risk of mortality and major complications. The presence of severe frailty could effectively predict an increased risk of in-hospital death regardless of the treatment administered. The employment of CFS in elderly patients could help the identification of the need for closer monitoring and proper goals of care.

Frailty assessment as independent prognostic factor for patients ≥65 years undergoing urgent cholecystectomy for acute cholecystitis

BACKGROUND

To evaluate, in a prospective observational cohort study of adults ≥65 years old, the frailty status at the emergency department (ED) admission for the in-hospital death risk stratification of patients needing urgent cholecystectomy.

METHODS

Clinical variables and frailty status assessed in the ED were evaluated for the association with major complications and the need for open surgery. The parameters evaluated were frailty, comorbidities, physiological parameters, surgical approach, and laboratory values at admission. Logistic regression analysis was used to identify independent risk factors for poor outcomes.

RESULTS

The study enrolled 358 patients aged ≥65 years [median age 74 years]; 190 males (53.1%)]. Overall, 259 patients (72.4%) were classified as non-frail, and 99 (27.6%) as frail. The covariate-adjusted analysis revealed that frailty (P< 0.001), and open surgery (P = 0.015) were independent predictors of major complications. Frailty, peritonitis, constipation at ED admission, and Charlson Comorbidity Index ≥ 4 were associated with higher odds of open surgical approach (2.06 [1.23 - 3.45], 2.49 [1.13 - 5.48], 11.59 [2.26 - 59.55], 2.45 [1.49 - 4.02]; respectively).

DISCUSSION

In patients aged ≥65 years undergoing urgent cholecystectomy, the evaluation of functional status in the ED could predict the risk of open surgical approach and major complications. Frail patients have an increased risk both for major complications and need for "open" surgical approach.

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

Time interval between self-expandable metal stent placement or creation of a decompressing stoma and elective resection of left-sided obstructive colon cancer

BACKGROUND

The optimal timing of resection after decompression of left-sided obstructive colon cancer is unknown. Revised expert-based guideline recommendations have shifted from an interval of 5 - 10 days to approximately 2 weeks following self-expandable metal stent (SEMS) placement, and recommendations after decompressing stoma are lacking. We aimed to evaluate the recommended bridging intervals after SEMS and explore the timing of resection after decompressing stoma.

METHODS

This nationwide study included patients registered between 2009 and 2016 in the prospective, mandatory Dutch ColoRectal Audit. Additional data were collected through patient records in 75 hospitals. Only patients who underwent either SEMS placement or decompressing stoma as a bridge to surgery were selected. Technical SEMS failure and unsuccessful decompression within 48 hours were exclusion criteria.

RESULTS

510 patients were included (182 SEMS, 328 decompressing stoma). Median bridging interval was 23 days (interquartile range [IQR] 13 - 31) for SEMS and 36 days (IQR 22 - 65) for decompressing stoma. Following SEMS placement, no significant differences in post-resection complications, hospital stay, or laparoscopic resections were observed with resection after 11 - 17 days compared with 5 - 10 days. Of SEMS-related complications, 48 % occurred in patients operated on beyond 17 days. Compared with resection within 14 days, an interval of 14 - 28 days following decompressing stoma resulted in significantly more laparoscopic resections, more primary anastomoses, and shorter hospital stays. No impact of bridging interval on mortality, disease-free survival, or overall survival was demonstrated.

CONCLUSIONS

Based on an overview of the data with balancing of surgical outcomes and timing of adverse events, a bridging interval of approximately 2 weeks seems appropriate after SEMS placement, while waiting 2 - 4 weeks after decompressing stoma further optimizes surgical conditions for laparoscopic resection with restoration of bowel continuity.

The importance of laboratory tests and Body Mass Index in the diagnosis of acute appendicitis

&lt;b&gt;Background:&lt;/b&gt; Acute appendicitis is the most common cause of acute abdomen. Delay in diagnosis increases the mortality and morbidity. &lt;br&gt;&lt;b&gt;Aim: &lt;/b&gt;In this study, we aimed to investigate whether the body mass index is useful in diagnosis and whether the neutrophil /lymphocyte and platelet/lymphocyte ratios can help in determining the inflammation level of acute appendicitis. &lt;br&gt;&lt;b&gt;Meterial and Methods:&lt;/b&gt; Cases of appendectomy performed between June 2012 and December 2018 in our clinic were analyzed retrospectively. Based on the pathology results of the cases included in the study, 4 groups were formed, i.e.: Group 1 (initial stage), Group 2 (catarrhal stage), Group 3 (phlegmonous-gangrenous stage) and Group 4 (perforation). The study compared age, body mass index, leukocyte values, red cell distribution width (RDW), neutrophil/lymphocyte ratio (NLR), platelet /lymphocyte ratio (PLR), and mean platelet volume (MPV) between groups. &lt;br&gt;&lt;b&gt; Results:&lt;/b&gt; 828 cases were included in the study. When compared between groups, the values of Group 3 and Group 4 were higher than those of Group 1 and Group 2 for PLR and NLR. There was no difference in RDW and MPV values in the blood. When Body Mass Index (BMI) was compared between groups, it was found to be significantly higher with increasing histopathological stage. &lt;br&gt;&lt;b&gt;Conclusion:&lt;/b&gt; In acute appendicitis, the blood leukocyte value, elevated PLR and NLR are helpful in diagnosis. We aimed to emphasize that the diagnosis of acute appendicitis is delayed in patients with a BMI above 30 and/or at age of over 40 years, with the perforation rate being determined more frequently.

Post-Operative All-Cause Mortality in Elderly Patients Undergoing Abdominal Emergency Surgery: Role of Charlson Comorbidity Index

(1) Background: The Charlson comorbidity index (CCI) score has been shown to predict 10-year all-cause mortality, but its validity is a matter of debate in surgical patients. We wanted to evaluate CCI on predicting all-cause mortality in elderly patients undergoing emergency abdominal surgery (EAS); (2) Methods: This retrospective single center study included all patients aged 65 years or older consecutively admitted from January 2017 to December 2019, who underwent EAS and were discharged alive. CCI was calculated by using of the International Classification of Diseases, 9th Revision, Clinical Modification codes. Our outcome was all-cause death recorded during the 20.8 ± 8.8 month follow-up; (3) Results: We evaluated 197 patients aged 78.4 ± 7.2 years of whom 47 (23.8%) died. Mortality was higher in patients who underwent open abdominal surgery than in those treated with laparoscopic procedure (74% vs. 26%, p < 0.001), and in those who needed colon, small bowel, and gastric surgery. Mean CCI was 4.98 ± 2.2, and in subjects with CCI ≥ 4 survival was lower. Cox regression analysis showed that CCI (HR 1.132, 95% CI 1.009-1.270, p = 0.035), and open surgery (HR 10.298, 95%CI 1.409-75.285, p = 0.022) were associated with all-cause death independently from age and sex; (4) Conclusions: Calculation of CCI, could help surgeons in the preoperative stratification of risk of death after discharge in subjects aged ≥65 years who need EAS. CCI ≥ 4, increases the risk of all-causes mortality independently from age.

A special acute care surgery model for dealing with dilemmas involved in emergency department in China

There was a fast growth in the number and the formation of emergency department (ED) visits in China during the twenty-first century. As a result, engaging special medical model will be essential to decompressing the ED visits. To do this, it will be important to understand which specific aspects to focus interventions on for the greatest impact. To characterize the emergency surgery patients who were seen and discharged from ED. Retrospective cohort study of hospitalized emergency surgery patients currently under the care from specialists presenting to an urban, university affiliated hospital between 01 January 2018 and 1 January 2019. This study will highlight some of the controversies and challenges and key lessons learned. During the study period there were 231,229 ED visits; 4100 of these patients were admitted for Acute care surgery (ACS) service. Multivariate analysis identified age ≧ 65 (p = 0.023; odds ratio, OR = 2.66), ACS model (p = 0.000, OR = 0.18), ICU stay (p = 0.000, OR = 118.73) as factors associated with in-hospital mortality. There was a increase in length of stay between young and elderly postoperative patients when stratifying patients by age (11.67 ± 9.48 vs 13.95 ± 9.11 p < 0.05). ED overcrowding is not just an ED problem. ED overcrowding is a systems problem requiring a systematic facility-wide multidisciplinary response. Continuous and high-quality surveillance data across China are needed to estimate the acute care surgery model which used to deal with ED overcrowding.

Complications of appendectomy and cholecystectomy in acute care surgery: A systematic review and meta-analysis

INTRODUCTION

Acute care surgery (ACS) was initiated two decades ago to address timeliness and quality in emergency general surgery. We hypothesized that ACS has improved the management of acute appendicitis and biliary disease.

METHODS

A comprehensive systematic review and meta-analysis of outcome studies for emergent appendectomy and cholecystectomy from 1966 to 2017, comparing studies prior to and following ACS implementation, were performed.

RESULTS

Of 1,704 studies, 27 were selected for analysis (appendicitis, 16; biliary pathology, 7; both, 4). Following ACS introduction, the complication rate was significantly reduced in both appendectomy and cholecystectomy (risk ratios, 0.70; 95% confidence interval [CI], 0.57-0.85; I = 9.2% and relative risk, 0.62; 95% CI, 0.41-0.94; I = 63.5%) respectively. There was a significant reduction in the time from arrival in emergency until admission and from admission to operation (-1.37 hours: 95% CI, -1.93 to -0.80; -2.51 hours: 95% CI, -4.44 to -0.58) in the appendectomy cohort. Time to operation was shorter in the cholecystectomy group (-6.46 hours; 95% CI, -9.54 to -3.4). Length of hospital stay was reduced in both groups (appendectomy, -0.9 day; cholecystectomy, -1.09 day). There was a reduction in overall cost in cholecystectomy group (-US $854.37; 95% CI, -1,554.1 to -154.05). No statistical significance was detected for wound infection, abscess, conversion of laparoscopy to open technique, rate of negative appendectomy, after hours, readmission, and cost.

CONCLUSION

The implementation of ACS models in general surgery emergency care has significantly improved system and patient outcomes for appendicitis and biliary pathology.

LEVEL OF EVIDENCE

Systematic review and meta-analysis of a retrospective study, level III.