Surgical critical care: Is work-life expectancy increasing? An analysis of American Board of Surgery recertification rates across subspecialties

The practice of surgical critical care (SCC) has traditionally necessitated additional in-house, extended night and weekend clinical commitments, which can be viewed as less desirable for many surgeons. Therefore, the authors have observed that some SCC surgeons elect to transition their practice to focus solely on general surgery (GS) rather than continuing practicing both SCC and GS. We hypothesized that surgeons with a practice focused on SCC are more likely to make the transition to a GS practice than those who have certification in other subspecialties that are certified through the American Board of Surgery.

Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer

Introduction

Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI).

Methods

This was a secondary analysis of a multicenter, case–control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts.

Results

A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53).

Conclusion

For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary.

Study type

Original article, case series.

Level of evidence

III.

Laparoscopic omental patch for perforated peptic ulcer disease reduces length of stay and complications, compared to open surgery: A SWSC multicenter study

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p < 0.05) as was unplanned re-operation (4.7% vs 14%, p < 0.05). Lap reduced LOS (6 vs 8 days, p < 0.001). Ileus was more in Lap (42% vs 18 p < 0.001) operative time was 14 min higher in Lap(p < 0.01) and admission to OR time was 4 h higher in Lap(<0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.

The southwestern surgical congress multi-center trial on suspected common duct stones

BACKGROUND

Choledocholithiasis is present in up to 15% of cholecystectomy patients. Treatment can be surgical, endoscopic, or via interventional radiology. We hypothesized significant heterogeneity between hospitals exists in the approach to suspected common duct stones.

METHODS

A retrospective review of patients that had a preoperative MRCP, endoscopic ultrasound, endoscopic retrograde cholangiopancreatogram (ERCP), or intra-operative cholangiogram was performed. Comparisons were by Wilcoxon-Mann-Whitney tests with significance of p < 0.05 for paired variables and p < 0.017 for multiple comparisons.

RESULTS

Twelve participating institutions identified 1263 patients (409 men and 854 women) with a median age of 49 years (IQR: 31-94). Liver function tests (LFT's) were elevated in 939 patients (75%), median bilirubin level 1.75 mg/dl (IQ: 0.8-3.7 mg/dl) and median common duct size 7 mm (IQR 5-10 mm). The most common initial procedure was cholecystectomy with IOC at seven institutions, endoscopy at four and MRCP at one.

CONCLUSION

Significant variation exists within the surgical community regarding suspected common duct stones. These results underscore the need for a protocol for common duct stones to minimize multiple, redundant interventions.