Papers That Should Change Your Practice of Emergency General Surgery

Papers That Should Change Your Practice of Emergency General Surgery

EAST 2018

on-call@christianjones.md @jonessurgery jonessurgery.com christianjones.md

Christian Jones, MD, MS, FACS

Division of Acute Care Surgery, Department of Surgery

Johns Hopkins University School of Medicine

Practices to adopt?

Take out gall bladders on hospital day 2.

Use antibiotics for skin abscesses s/p I&D.Do loop ileostomies for C. diff. colitis.Use the skin vac for laparotomies.… and an honorable mention.

The Sooner, the Better? The Importance of Optimal Timing of Cholecystectomy in Acute Cholecystitis: Data from the National Swedish Registry for Gallstone Surgery, GallRiks.

My Blohm, Johanna Österberg, Gabriel Sandblom, Lars Lundell, Mats Hedberg, and Lars Enochsson

Journal of Gastrointestinal Surgery

, January 2017, 21(1):33-40

Acute

Chole

: Complications by OR Day

The Sooner, the Better? The Importance of Optimal Timing of Cholecystectomy in Acute

Cholecystitis

Blohm M et al. Journal of Gastrointestinal Surgery, 21(1):33-40

Late is bad

Higher mortality on admission day

Hospital day 2 may be the sweet spot

A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses

Robert S. Daum, Loren G. Miller, Lilly Immergluck, Stephanie Fritz, C. Buddy Creech,David Young, Neha Kumar, Michele Downing, Stephanie Pettibone, Rebecca Hoagland, Samantha J. Eells, Mary G. Boyle, Trisha Chan Parker, and Henry F. Chambers, M.D., for the DMID 07-0051 Team

New England Journal of Medicine

, June 2017, 376(26):2545-2555

“Cure” rate (no continued or recurrent e/o infection)

A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses

Daum

RS et al. New England Journal of Medicine, 376(26):2545-2555

Antibiotics help even in simple abscesses

Adverse reactions do occur, but rarely

Patient risk vs community risk is hard

Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated disease: An Eastern Association for the Surgery of Trauma multicenter trial.

Paula Ferrada, Rachael Callcut, Martin D. Zielinski, Brandon Bruns, Daniel Dante Yeh, Tanya L. Zakrison, Jonathan P.Meizoso, Babak Sarani, Richard D. Catalano, Peter Kim, Valerie Plant, Amelia Pasley, Linda A. Dultz, Asad J. Choudhry, Elliott R. Haut, and EAST Multi-Institutional Trials Committee

Journal of Trauma and Acute Care Surgery

, July 2017, 83(1):36-40

Not Much Difference?

Age

NSSystolic BPNS

Diastolic BP

NS

Heart

rate

NS

WBC

NS

Hgb

NS

pH

NS

INR

NS

Lactate

NS

Base deficit

NS

APACH

E II

NS

Gender

NS

Admitting service

NS

Preoperative antibiotics

NS

Preoperative

pressors

NS

Preoperative renal failure

NS

Preoperative respiratory failure

NS

Postoperative

pneumonia

NSPostoperative sepsisNSPostoperative renal failureNS

Outcome

Favors (p < 0.05)Intraop EBLLIIntraop transfusionLIIntraop crystalloidLIAdjusted overall mortalityLIAdjusted mortality if requiring reoperationLI

39.7%  17.2%

Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated

disease

Ferrada P et al. Journal of Trauma and Acute Care Surgery, 83(1):36-40

Even sick patients can get LI

F

ailure of LI not associated with

incr

mortality

There are still things not seen

Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following Abdominal Operations

A Randomized, Controlled, Open-label Trial: The P.I.C.O. Trial

Donal Peter O’Leary, Colin Peirce, Breffini Anglim, Michael Burton, Elizabeth Concannon, Marguerite Carter, Kevin Hickey, and John Calvin Coffey

Annals of Surgery

, June 2017, 265(6):1082-1086

Statistically Significant

PICO

OpSiteSSI (30 days)8.3%32.0%LOS*6.1 days14.7 days

Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following

Abdominal

OperationsO’Leary DP et al. Annals of Surgery, 265(6):1082-1086

The skin

vac

is associated with a decreased rate of surgical site infections in undifferentiated stapled laparotomy wounds.

Operation versus antibiotics––The “appendicitis conundrum” continues: A meta-analysis

Joseph V. Sakran, Konstantinos S. Mylonas, Alexandros Gryparis, Stanislaw P. Stawicki, Christopher J. Burns, Maher M. Matar, and Konstantinos P. Economopoulos

Journal of Trauma and Acute Care Surgery

, June 2017, 82(6):1129-1137

Yes, they’re different.

Antibiotics OnlyEfficacy: 64%Complications: 8%

OR

Efficacy: 93%

Complications: 24%

Longer time off work

Perforations: 11%

Antibiotics Failure

Perforations: 52%

3x more wound infections

No difference in LOS, sick leave taken, subsequent bowel obstruction

, or incisional

hernia*.

Operation versus antibiotics––The “appendicitis conundrum”

continues

Sakran JV et al. Journal of Trauma and Acute Care Surgery, 82(6):1129-1137

Practices to adopt?

Take out gall bladders on hospital day 2.Use antibiotics for skin abscesses s/p I&D.

Do loop ileostomies for C. diff. colitis.Use the skin vac for laparotomies.… and an honorable mention.

Thank you.

@jonessurgery

on-call@christianjones.md

References

Blohm M, Österberg J, Sandblom G, Lundell L, Hedberg M, Enochsson L. The Sooner, the Better? The Importance of Optimal Timing of Cholecystectomy in Acute Cholecystitis: Data from the National Swedish Registry for Gallstone Surgery, GallRiks.

J Gastrointest Surg. 2017;21(1):33-40. doi:10.1007/s11605-016-3223-y.Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med. 2017;376(26):2545-2555. doi:10.1056/NEJMoa1607033.Ferrada P, Callcut R, Zielinski MD, et al. Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated disease: An Eastern Association for the Surgery of Trauma multicenter trial. J Trauma Acute Care Surg. 2017;83(1):36-40. doi:10.1097/TA.0000000000001498.O’Leary DP, Peirce C, Anglim B, et al. Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following Abdominal Operations. Ann Surg. 2017;265(6):1082-1086. doi:10.1097/SLA.0000000000002098.Sakran J V., Mylonas KS, Gryparis A, et al. Operation versus antibiotics––The “appendicitis conundrum” continues. J Trauma Acute Care Surg. 2017;82(6):1129-1137. doi:10.1097/TA.0000000000001450.

Copyright & Acknowledgments

Johns Hopkins logo and PowerPoint template are presumed to be the property of Johns Hopkins University, and used here representing the work of myself, a Johns Hopkins employee.Image

of PICO negative pressure device on slide 13 from included reference (O’Leary 2017) and used here under the conditions of Fair Use for educational purposes onlyImage of transparent dressing on slide 13 downloaded from http://www.tagumedica.com/Wordpress/?product=opsite-post-op-post-operatorios-con-almohadilla on 10 January 2018, used here under the conditions of Fair Use for educational purposes onlyImage of balanced scale on slide 17 is in the public domain, downloaded from https://commons.wikimedia.org/wiki/File:Balanced_scale_of_Justice.svg on 9 January 2018Twitter icon on slide 19 is a trademark of Twitter, downloaded with permission from https://about.twitter.com/en_us/company/brand-resources.html and used according to the Twitter Brand Guidelines v. 2.0Email icon on slide 19 is in the public domain, downloaded from https://commons.wikimedia.org/wiki/File:Aiga_mail.svg on 9 January 2018

All other work is the sole creation of Christian Jones (

on-call@christianjones.md)

, and hereby released into the public domain, with no rights reserved. This is version 20180110-1. The latest version is always available at

http://jonessurgery.com/papers2018

.