EAST 2018 oncallchristianjonesmd jonessurgery jonessurgerycom christianjonesmd Christian Jones MD MS FACS Division of Acute Care Surgery Department of Surgery ID: 752341
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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 MedicineSlide2
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.Slide3
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):33-40Slide4
Acute
Chole
: Complications by OR DaySlide5
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 spotSlide6
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):2545-2555Slide7
“Cure” rate (no continued or recurrent e/o infection)Slide8
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 hardSlide9
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):36-40Slide10
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%Slide11
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 seenSlide12
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):1082-1086Slide13
Statistically Significant
PICO
OpSiteSSI (30 days)8.3%32.0%LOS*6.1 days14.7 daysSlide14
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.Slide15
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):1129-1137Slide16
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*. Slide17
Operation versus antibiotics––The “appendicitis conundrum”
continues
Sakran JV et al. Journal of Trauma and Acute Care Surgery, 82(6):1129-1137Slide18
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.Slide19
Thank you.
@jonessurgery
on-call@christianjones.mdSlide20
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.Slide21
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
.