EAST 26 th Annual Scientific Assembly - PowerPoint Presentation

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EAST 26th Annual Scientific AssemblyScientific Papers That Should Have Changed Your PracticeJanuary 16, 2013 Emergency General Surgery

Philip S. Barie, MD, MBA, FIDSA FCCM, FACS

Professor of Surgery and Public Health

Weill

C

ornell Medical College

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Acute Diverticulitis

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Outcomes of Elective Operation after Diverticulitis (DD)National Inpatient SampleComparison with elective colectomies for other indicationsCancerIBD74,879 adults (Age

>

18)

DD 51%; CC 43%; IBD 6%

Multivariable analysis

Van

Arendonk

et al. Arch

Surg

2012;

D

ec 17 [

epub

ahead of print]

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Outcomes of Elective Operation after Diverticulitis-2Compared with CC, patients with DD were significantly more likely to have:in-hospital mortality (AOR 1.90; 95% CI 1.37-2.63)Postoperative infection (1.67; 1.48-1.89)Ostomy placed (1.87; 1.65-2.11)

A

djusted total hospital charges for patients with DD (vs. CC) were $6,679 higher (95% CI, $5,722-$7,635)

Length of stay for patients with DD (vs. CC) was 1 day longer (95% CI, 0.86-1.14;

p

<0.001)

Patients with IBD had the highest in-hospital mortality, complication rates,

ostomy placement, longest length of stay, and highest hospital charges. Consider when recommending interval colectomy for DD

Van

Arendonk

et al. Arch

Surg

2012;

D

ec 17 [

epub

ahead of print]

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Primary Anastomosis vs. Hartmann for Perforated Left Colon Diverticulitis with Peritonitis

Prospective randomized trial

62 Patients, 4 centers

32 H, 30 PA with loop

ileostomy

Planned stoma reversal 3 mos.

Analyzed by intention-to-treat

Primary end point: Overall complication rateEarly termination for differences in SECONDARY end points (interim analysis)

Oberkofler

et al. Ann

Surg

2012;256:819-826.

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Primary Anastomosis vs. Hartmann for Perforated Left Colon Diverticulitis with Peritonitis-2

Demographics:

Hinchey III: 76% vs. 75%, Hinchey IV: 24% vs. 25%

Outcomes:

Overall complication rate comparable (80% vs. 84%,

p

= 0.813)

Mortality comparable (13% vs. 9%)

S

toma reversal rate higher after PA (90% vs. 57%,

p

= 0.005)

S

erious complications lower after PA (Grades IIIb-IV: 0 vs. 20%, p = 0.046)Operating time shorter for PA (73 min vs. 183 min, p < 0.001), LOS shorter after PA (6 d vs. 9 d, p = 0.016)Hospital cost lower for PA $16,717 vs. $24,014)

Oberkofler

et al. Ann

Surg

2012;256:819-826.

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Open vs. Laparoscopic Emergency Operation for Acute DiverticulitisNSQIP subsample1,186 patients, 2005-2009Emergency partial colectomy/end-colostomy/Hartmann pouchLaparoscopic vs. open

Propensity-matched retrospective analysis

Turley et al.

Dis

C

olon Rectum 2013;56:72-82.

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Open vs. Laparoscopic Emergency Operation for Acute Diverticulitis-2Unadjusted data:Laparoscopic group Fewer overall complications (26% vs. 41.7%, p = 0.008)

S

horter mean LOS (8.9 vs. 11.6 days,

p

= 0.0008)Operative times not different

Adjusted for cofounders:

Laparoscopy was NOT associated with decreased morbidity or mortality.

Turley et al. Dis

C

olon Rectum 2013;56:72-82.

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Complicated Intra-abdominal Infection

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Complicated Intra-Abdominal Infection Observational Study (CIAO) in EuropeObservational study2,152 patientsJanuary-June 201268 CentersAge 54 years (range: 4-98 years)46.3% female

M

ortality rate 7.5% (163/2,152)

Sartelli

et al. World J

Emerg

Surg 2012;7:36.

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Complicated Intra-Abdominal Infection Observational Study (CIAO) in Europe-2Multivariable analysis of mortality:AgeIntestinal non-appendiceal source of infection

Delayed initial intervention (>24 hours)

Severe sepsis/septic shock in the immediate post-operative period

Need for ICU admission

Sartelli

et al. World J

Emerg

Surg 2012;7:36.

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Acute Appendicitis

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Diagnostic/Therapeutic Delay and Perforation-Appendicitis RiskCross-sectional analysis 1998-2008National Inpatient SampleKids’ Inpatient DatabaseDischarge diagnosis of acute appendicitisSurgery within 7 d of admission

Excluded

Elective admissions

Drainage procedure before appendectomy

Papandria

et al. J

Surg

Res Dec 27 {Epub ahead of print]

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Diagnostic/Therapeutic Delay and Perforation-Appendicitis RiskAnalysis as a function of age and LOS before appendectomy683,590 patients30.3% perforation rate>80% of operations on day of admission18% days 2-4<1% after day 4

Papandria

et al. J

Surg

Res Dec 27 {

Epub

ahead of print]

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Diagnostic/Therapeutic Delay and Perforation-Appendicitis RiskDay 1 operationPerforation rate 29%Day 2-4 operationPerforation rate 33%By day 8, 79%Odds of perforationAdults: 1.20 (day 2-4), 4.76 (by day 8)

Children 1.08 (day 2-4), 15.42 (by day 8)

Papandria

et al. J

Surg

Res Dec 27 {

Epub

ahead of print]

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Volume-Outcome Relationships in Acute AppendicitisTaiwanese national population-based study65,339 patients with first-time discharges for acute appendicitisOutcome: Perforated?Conditional logistic regression modelMorbidity rates:Low-volume surgeons 28%

High-volume surgeons 36%

Very high-volume surgeons 21%

Wei et al.

PLoS

One 2012:7:e52539.

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Volume-Outcome Relationships in Acute AppendicitisAdjusted odds ratios for low-volume surgeonsPractice location, hospital teaching status, hospital volume, age, gender, Charlson IndexAdjusted odds ratios for low-volume surgeonsVs. medium-volume: AOR 1.09Vs. high-volume AOR 1.16

Vs. very high-volume AOR 1.54

Wei et al.

Plos

One 2012: 7:e52539.

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Acute Appendicitis Disease Severity ScoreLiterature review and consensus expert opinionGrade 1: Inflamed (uncomplicated)Grade 2: GangrenousGrade 3: Localized free fluidGrade 4: Perforated (localized abscess)

Grade 5: Perforated (generalized peritonitis)

Retrospective validation on a cohort of 918 consecutive patients

Garst

et al. J Trauma Acute Care

Surg

2013;74:32-36

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Acute Appendicitis Disease Severity ScoreDistribution of pathology:Grade 1: 62.4%Grade 2: 13.0% Grade 3: 18.7% Perforation rate 24.6%Grade 4: 4.4%Grade 5: 1.5%

Retrospective validation in a cohort of 918 consecutive patients

Garst

et al. J Trauma Acute Care

Surg

2013;74:32-36

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Acute Appendicitis Disease Severity ScoreStep-wise increase in risk for increasing grade (AUROC > 0.75 in all cases)MortalityLOSIn-hospital AND post-discharge complicationsCovariates did not improve the accuracy of the models

Age, gender, operative technique

Garst

et al. J Trauma Acute Care

Surg

2013;74:32-36

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Biomarkers in Acute Appendicitis?Systematic review/meta-analysis of studies reporting use of procalcitonin (PCT) vs. other biomarkersWBC countCRP concentrationPCT concentration7 Studies

1,011 Suspected cases

636

C

onfirmed cases

Yu et al. Br J

Surg

2013;100:322-329.

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Biomarkers in Acute Appendicitis-2Biomarker Sens. Spec. Discrimination (AUROC)PCT 33% 89% 0.64 (95% CI 0.61-0.69PCT 62% 94%(Complicated)

CRP 57% 87% 0.75 (95% CI 0.71-0.78

WBC 62% 75% 0.72 (95% CI 0.68-0.76)

Yu et al. Br J

Surg

2013;100:322-329.

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Antibiotic Treatment vs. Appendectomy for Uncomplicated Appendicitis?5 RCTs, 980 patients510 Antibiotic treatment470 Appendectomy

7 Outcome parameters:

O

verall complication rate

Treatment failure rate (index hospitalization

O

verall treatment failure rate

Length of stay (LOS)Duration of pain; Utilization of pain medicationTime lost (work/school) Fixed and random effects meta-analyses performed using odds ratios (ORs) and weighted or standardized mean differences (

WMDs

or

SMDs

)

Mason et al.

Surg Infect (Larchmt) 2012;13:74-84.

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Antibiotic Treatment vs. Appendectomy for Uncomplicated Appendicitis-2In 3 of the 7 outcome analyses, the summary point estimates favored antibiotics over appendectomyComplications (OR 0.54; 95% CI 0.37-0.78; p

=0.001) a

R

eduction in sick leave/disability (SMD -0.19; CI -0.33- -0.06;

p=0.005)

D

ecreased pain medication utilization (SMD -1.55; CI -1.96- -1.14;

p<0.0001) For overall treatment failure, the summary point estimate favored appendectomy40.2% failure rate for antibiotics versus 8.5% for appendectomy (OR 6.72; CI 0.08-12.99; p

<0.001)

Initial treatment failure, LOS, and pain duration were similar

Mason et al.

Surg

Infect (

Larchmt) 2012;13:74-84.

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Antibiotic Treatment vs. Appendectomy for Uncomplicated Appendicitis-3Authors’ conclusions:Non-operative management of uncomplicated appendicitis with antibiotics was associated with significantly fewer complications, better pain control, and shorter sick leaveOverall, non-operative management of uncomplicated appendicitis had inferior efficacy because of the high rate of recurrence in comparison with appendectomy.

Mason et al.

Surg

Infect (

Larchmt

) 2012;13:74-84.

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Timing of AppendectomyRetrospective study of effect of timing of appendectomy on outcomes723 Patients, 2003-2009Histologically confirmed appendicitisThree groupsSurgery <12 h

(Early appendectomy [EA],

n

=518)

Surgery 12-24 h

(Early-delayed

appy

[EDA], n=140)Surgery >24 h (Delayed appendectomy [DA], n=65)

Giraudo

et al.

Surg

Today 2012 Aug 30 [

Epub

ahead of print]

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Timing of Appendectomy-2Operative time similarPostoperative complications highest in DA groupP <0.012 vs. EA groupP <0.003 vs. EDA groupMortality limited to DA group (2/65, 3%)Gangrenous appendicitis significantly higher in DA group (

p

< 0.05).

Giraudo

et al.

Surg

Today 2012 Aug 30 [

Epub ahead of print]

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More on Timing of AppendectomySingle-center review4,529 patients admitted with appendicitis July 2003 to June 20114,108 underwent operation Age, gender, admission WBC count, surgical approach (open vs. laparoscopic), time to appendectomy, and pathology report were abstractedPrimary outcomes included perforation and SSI.

Logistic regression was performed to identify independent predictors of perforation and investigate the association between TTA and SSI

Teixeira

er

al.Ann

Surg 2012256:438-453.

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More on Timing of Appendectomy-2Logistic regression identified 3 independent predictors of perforationAge 55 years or older; OR (95% CI): 1.66 (1.21-2.29) WBCl count > 16,000; OR 1.38 (1.15-1.64)

F

emale gender; OR 1.20 (1.02-1.41)

Delay to appendectomy was not associated with higher perforation rate.

Controlling for age, leukocytosis

, gender, laparoscopy, and perforation, TTA of more than 6

h

: Increase in SSI; OR 1.54 (1.01-2.34)Increase in SSI from 1.9% to 3.3% with non-perforated appendicitis; OR 2.16 (1.03-4.52)

Teixeira

er

al.Ann

Surg 2012256:438-453.

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Negative Appendectomy as a Quality Metric-Definitions Matter 2 definitions:Absence of inflammationAbsence of neutrophil infiltration of wallEffect on diagnostic accuracy assessed

1,306 patients, 1996-2010

Divided into 3 5-year cohorts

1996-2000 CT use rare

2001-2005 Progressive CT implementation

2006-2010 CT use prevalent

Alvarado score vs. computed tomography

Mariadason et al. Ann R

Coll

Surg

Engl2012;94:395-401.

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Negative Appendectomy as a Quality Metric-Definitions Matter-2Changing the definition to lack of neutrophil infiltration increased the negative appendectomy rate1996-2000, 9% to 16%2001-2005, 3% to 9% (CT rate 81%)2002-2006, 3% to 7% (CT rate 92%)

Positive predictive values

Alvarado score 98.6%

CT 99.0%

Mariadason

et al. Ann R

Coll

Surg Engl2012;94:395-401.

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Negative Appendectomy as a Quality Metric-Definitions Matter-2Authors’ conclusions (not all data shown):Definition of negative appendectomy determines the negative appendectomy rateRoutine CT unnecessary for male patients with positive Alvarado scoreEarly/mild appendicitis may resolve without surgery

CT may contribute to unnecessary surgery

Alvarado scoring allows selective use of CT in suspected appendicitis

Mariadason

et al. Ann R

Coll

Surg Engl2012;94:395-401.

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Impact of CT on Negative Appendectomy RatePopulation-based studyState of Washington50+ hospitals state-wide, mostly in the communityProspective study of 19,327 patientsAge >15 years48% female

Drake et al. Ann

Surg

2012; 256:586-594.

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Impact of CT on Negative Appendectomy Rate (NAR)-2Negative appendectomy rate 5.4%If imaged: 4.5%If not imaged: 15.4%True for males and femalesMales 3% vs. 10%

Females 7% vs. 25%

Multivariable analysis

Adjusted for age, gender, WBC count

If not imaged, NAR OR 3.7, 95% CI 3.0-4.4

Drake et al. Ann

Surg

2012; 256:586-594.

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Laparoscopic vs. Open Appendectomy in PregnancySystematic review/meta-analysis11 studies, 3,415 women2,816 open, 599 laparoscopicFetal loss rate higher for laparoscopic appendectomyRR 1.91, 95% CI 1.31-2.77Preterm labor not influencedRR 1,44, 95% CI 0.68-3.06

Wilasrusmeeet

al. Br J

Surg

2012;99:1478-1490.

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Laparoscopic vs. Open Appendectomy in Elderly PatientsRetrospective studyACS/NSQIP database 2005-20093,674 patients age > 65 yearsAppendectomy for acute appendicitisPropensity analysis

Moazzez

et al.

Surg

Endosc

2012;Oct 6. [

Epub ahead of print.

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Laparoscopic vs. Open Appendectomy in Elderly Patients-2Propensity-matched analysis (open appendectomy):Higher superficial incisional SSI (4% vs. 1%), p <0.001

Lower organ/space SSI (1% vs. 3%,

p

<0.01)

Moazzez

et al.

Surg

Endosc 2012;Oct 6. [

Epub

ahead of print]

Slide38

Irrigate or Aspirate?RCT in children with perforated appendicitisPower analysis: 200 patients (200 enrolled)Randomized to irrigation/aspiration vs. aspirationMinimum of 0.5 L 0.9% NaCl as irrigant

Pre-/postoperative antibiotic use regulated

Primary end point:

I

ntraperitoneal abscess

Intention-to-treat analysis

1 “suction only” patient received irrigation also

St Peter et al. Ann Surg

2012;256:581-585.

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Irrigate or Aspirate-2Demographics identicalAbscess rate:Suction only 19%Irrigation/aspiration 18%Duration of hospitalization identicalHospital charges identical

St Peter et al. Ann

Surg

2012;256:581-585.

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Thank You!