Surgical Technical Evidence Review for Acute Appendectomy Conducted for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Hornor MA, Liu JY, Hu QL, Ko CY, Wick E, Maggard-Gibbons M. J Am Coll Surg. 2018 Dec;227(6):605-617.
Appendectomy is one of the most common surgical procedures and so it is imperative to have a guideline to improve surgical care and recovery. The Safety Program for Improving Surgical Care and Recovery (ISCR) was created as a collaborative project by AHQR, American College of Surgeons and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality by creating enhanced recovery pathways (ERPs) in several specialties like colorectal, orthopaedic, gynecology and emergency general surgery. This is the first literature review to cover an Enhanced Recovery Pathway for appendectomy.
A surgical technical evidence review was done which covered 13 components for appendectomy:
- Though minimal information is available, patient-centered preoperative education and counseling likely improves knowledge retention with minimal risk.
- Appropriate antibiotics should be given as soon as possible after diagnosis of acute appendicitis; it may require redosing within 60 minutes before incision.
- Nonoperative management is a reasonable first-line treatment for complicated appendicitis i.e. with phlegmon or abscess. Well-circumscribed periappendiceal abscess can be treated by percutaneous drainage initially. However, operative management is a safe alternative to nonoperative management in expert hands.
- Risk stratification for VTE must be done using validated VTE risk assessment tool such as Caprini Score. Intermittent pneumatic compression (IPC) should be provided for low risk patients; and, IPC and VTE chemoprophylaxis for moderate and high-risk patients.
- Short surgical delay up to 12 to 24 hours is safe in uncomplicated acute appendicitis and does not increase complication; however, if resources allow for immediate appendectomy, it may lead to faster patient symptom resolution.
- Laparoscopic appendectomy represents the first choice in complicated and uncomplicated appendicitis offering several advantages: less pain, lower incidence of SSI, decreased LOS, earlier return to work and overall cost.
- There is no evidence to support routine use of abdominal drain as it prolongs length of stay and increases complications
- There is no strong evidence to support routine placement of Foley catheter. Further research is recommended whether it reduces iatrogenic bladder injury or increases UTI.
- Routine NGT placement is not recommended and should be done only in selected patients with severe gastric symptoms.
- Same day discharge for uncomplicated appendicitis is safe if discharge criteria are met.
- Patients with acute or gangrenous non-perforated appendicitis should only receive prophylactic antibiotics. Postoperative antibiotics are recommended in the presence of perforation.
- Early oral feeding for uncomplicated appendicitis is considered a standard of care.
- Early mobilization is recommended postoperatively for as long as no contraindication exists.
This is an excellent initiative for one of the most common surgical procedure and highly recommended to be read by every surgeon who performs appendectomy. I suggest there should be a periodic update of the review to include the latest research particularly in areas that are currently evolving such non-operative management, radiographic imaging, interval appendectomy and multi-modality pain control.
Trauma and emergency general surgery patients should be extubated with an open abdomen. Taveras LR, Imran JB, Cunningham HB, Madni TD, Taarea R, Tompeck A, Clark AT, Provenzale N, Adeyemi FM, Minshall CT, Eastman AL, Cripps MW. J Trauma Acute Care Surg. 2018 Dec;85(6):1043-1047.
Open abdomen (OA) and temporary abdominal closure (TAC) are widely utilized as part of damage control laparotomy in trauma and emergency general surgery (EGS) cases.Traditionally, patients with open abdomen are kept intubated postoperatively leading to prolonged mechanical ventilation and increased susceptibility to ventilator associated pneumonia or VAP. This is a retrospective review of all trauma and emergency general surgery patients managed with OA and TAC from January 2014 to February 2016.It excludes patients who died within 24 hours and with non-survivable head injury. The number of extubation events, ventilator free hours and adverse events such as need for reintubation were measured. Fifty-two patients (20 trauma and 32 EGS) were included in the study. The indications for OA and TAC were: planned second look operation (48.1%), concern for intraabdominal hypertension (23.1%), severe intra-abdominal hemorrhage (15.4%), intra-abdominal contamination (7.7%) and necrotizing abdominal wall infection (5.8%).
Twenty-five patients (19 EGS, 6 trauma) had at least one extubation events with median ventilator free hours at 101 hours (interquartile range, 39 – 260.46). The majority of patient extubated were EGS patients (59.4% vs 30% of trauma patients) alluding to less pulmonary compromise among EGS patient. Also, SOFA scores for EGS patients who were successfully extubated were significantly lower. The patients that were never extubated with open abdomen had a higher rate of VAP (30.8% vs 3.8%, p=0.01). One patient required re-intubation for respiratory dysfunction after a trial of extubation.
Based on this study, extubation of patients with open abdomen is feasible and safe and can potentially decrease VAP rates. It is imperative to constantly assess patient using the mechanical ventilation liberation protocol instituted in this study. In addition, this can potentially decrease cost and need for sedation. Over-utilization of damage control laparotomy seem to be trending and the appropriateness of this approach must be addressed in future studies.
Another study related to this article is The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy Loftus TJ, Efron PA, Bala TM, Rosenthal MD, Croft CA, Walters MS, Smith R, Moore F, Mohr A, Brakenridge S. J Trauma Acute Care Surg. 2019 Apr;86(4):670-678.
This study compared 78 historical control patients with 60 protocol patients. The latter were managed using a protocol designed to include patient selection, operative technique, resuscitation strategies like 3% hypertonic saline, early relaparotomy with sequential fascial closure and critical care provision. Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations and higher fascial closure rates with no difference in complications.
Malnutrition at intensive care unit admission predicts mortality in emergency general surgery patients. Havens JM, Columbus AB, Seshadri AJ, Olufajo, OA, Mogensen KM, Rawn JD, Salim A, Christopher KB. JPEN J Parenter Enteral Nutr. 2018 Jan;42(1):156-163.
It has been well described that patients undergoing emergency general surgical (EGS) procedures are 2-3 times more likely to experience a significant complication with a much more significant increase in mortality when compared to non-EGS procedures of the similar type.Precipitated by the fact that there is not as of yet a well-defined study looking at malnutrition as one of the contributing factors, this study hypothesized that malnutrition is independently associated with mortality in EGS patients requiring treatment in the intensive care unit (ICU), by observing the increase 90-day mortality risk.
This was an observational study of patients treated at a single tertiary care academic institution serving eastern Massachusetts.1361 patients were identified who underwent an EGS procedure within 48 hours of admission to an ICU from January 2005 – December 2011 after excluding those who did not undergo a nutritional assessment.Malnutrition was categorized into groups of non-specific malnutrition, any type of protein-energy malnutrition (i.e. mild, moderate, severe, marasmus, or kwashiorkor) or absent. After adjusting for age, sex, race, Deyo-Charlson Index, sepsis and the number of organ failures, patients with nonspecific or protein-energy malnutrition demonstrated a 1.5-fold and 3-fold increase in mortality than in patients without malnutrition.The adjusted odds of 90-day mortality demonstrated this similarly with good statistical discrimination, and good calibration within a 95% confidence interval.
Interestingly, in those patients who survived to discharge, nutrition status was also a predictor of 30-day unplanned hospital readmission.This study demonstrated that critically ill EGS patients with any degree of malnutrition was associated with a statistically significant increase off of 90-day mortality. Identification of this population in EGS patients could help “red-flag” opportunities for increased follow-up, vigilance, and interventional initiatives in spite survival from the ICU.
Patient preferences for surgery or antibiotics for the treatment of acute appendicitis. Hanson AL, Crosby RD, Basson MD. JAMA Surg. 2018 May 1;153(5):471-478.
As appendicitis and its management has become a hot button topic with respect to surgical versus medical management among physicians, consideration about patient’s informed decision regarding pursing either therapy has not yet been widely evaluated.A team at the University of North Dakota conducted an online survey to evaluate “how patients might choose between surgical and nonsurgical therapy for acute uncomplicated appendicitis and to identify targets to make antibiotic treatment more appealing.”This is performed with revealing data from new trials that suggest antibiotics may preclude surgical intervention.
A voluntary, uncompensated, web survey was conducted through dissemination by various methods (email, posters, and social media) from April through June of 2016 asking individuals to imagine that they have or their child has acute uncomplicated appendicitis.After providing information regarding laparoscopic, open, and antibiotic therapy, they were queried as to their preference. Of the 1728 respondents, 1482 respondents (85.8%) chose laparoscopic appendectomy, 84 (4.9%) chose open appendectomy, and 162 (9.4%) chose antibiotics alone.Similar trends were seen if choosing the therapy for their child.Interestingly, those with an education beyond college, identified as non-Hispanic white, were more likely to choose antibiotics.This was in exception to one group that had an education beyond college, surgeons, who were less likely to choose antibiotics.As with any large cohort survey study, there are many limitations that would affect the outcomes seen, however as we begin to hone in on the optimal therapy for various forms of appendicitis, it is important to realize that patient preference after informed consent will play a significant impact on the resultant therapy chosen due to long standing prejudices.