Risk stratification tools in emergency general surgery. Havens JM, Columbus AB, Seshadri AJ, Brown CVR, Tominaga GT, Mowery NT, Crandall M. Trauma Surg Acute Care Open. 2018 Apr 29;3(1):e000160.
Several studies have previously confirmed that the risk of mortality and morbidity of Emergency General Surgery (EGS) is several folds higher than its elective counterpart; some strongly advocated that, as a result, EGS needs to be benchmarked separately. A crucial component of meaningful EGS benchmarking is risk adjustment. The authors of this paper examined the currently available risk assessment tools that could be applied to the EGS patient population to predict the risk of postoperative mortality and morbidity.
In a elegantly designed and systematic methodology, the authors assessed 14 existing risk prediction models. Specifically, they evaluated each tool’s performance on 6 criteria: 1) accurate quantification of morbidity and mortality risk in the EGS population, 2) the use of readily obtainable objective data, 3) the applicability prior to a surgical intervention, 4) the applicability to non-operative cases, 5) the potential use for auditing purposes, and 6) the presence of an application that facilitates use in clinical practice.
Based on this systematic methodology, the authors concluded that the Emergency Surgery Acuity Score (ESS) and the ACS-NSQIP Universal Surgical Risk Calculator are the most applicable and appropriate for EGS.
Reduced Rate of Dehiscence After Implementation of a Standardized Fascial Closure Technique in Patients Undergoing Emergency Laparotomy. Tolstrup MB, Watt SK, Gögenur I. Ann Surg. 2017 Apr;265(4):821-826.
The optimal method of abdominal closure in emergency laparotomy remains unclear. The authors of this paper sought to study whether the implementation of a standardized technique of fascial in emergent midline laparotomies at their institution decreased the rate of wound dehiscence.
The fascial closure technique adopted was a "small steps" one using continuous suturing with a slowly absorbable (polydioxanone) suture material in a wound-suture ratio of minimum 1?:?4. That technique has been suggested to decrease the rate of ventral hernias in the elective setting. A total of 494 patients that had the “small steps” fascial closure between 2014 and 2015 were compared to 1079 patients from the historical cohort between 2009 and 2013: the rate of dehiscence was reduced from 6.6% to 3.8% with the “small steps” technique (P = 0.03), despite the fact that the patient population after 2014 was one of more comorbidities. The study is the first one to suggest the superiority of the “small steps” technique in emergency laparotomy by decreasing the short-term risk of fascial dehiscence.
Bile Spillage as a Risk Factor for Surgical Site Infection after Laparoscopic Cholecystectomy: A Prospective Study of 1,001 Patients. Peponis T, Eskesen TG, Mesar T, Saillant N, Kaafarani HMA, Yeh DD, Fagenholz PJ, de Moya MA, King DR, Velmahos GC. J Am Coll Surg. 2018 Jun;226(6):1030-1035.
Bile spillage occurs frequently in laparoscopic cholecystectomy, especially in the setting of acute cholecystitis and the non-elective resection of the gallbladder. It is currently thought that such spillage is largely inconsequential, even though that hypothesis has not been tested. The authors aimed to study the impact of bile spillage on the risk of postoperative surgical site infections (SSI) in laparoscopic cholecystectomy.
All adult patients who were admitted to a single academic hospital for a laparoscopic (or laparoscopic converted to open) cholecystectomy over a seven year-period were prospectively included. At the end of the procedure, the operating surgeons received an email inquiring if there was any bile or stone spillage during the procedure. Patients were assessed clinically during hospitalization and 2 to 4 weeks after discharge, specifically with regard to the occurrence of postoperative SSIs. Of 1,001 patients, bile was spilled intraoperatively in 591 patients (59.0%), with hydrops noted in 10.5% and empyema in 14.6% of the cases. In 20.2% of patients, bile spillage was accompanied by stone spillage. In multivariable analyses adjusting for most relevant patient and procedure risk variables, the authors found that bile spillage increased the risk of SSIs more than 2 folds (OR 2.29, p-value <0.05).
The importance of the study emanates from its suggestion that bile spillage in laparoscopic cholecystectomy, one of the most common procedures performed by acute care surgeons, is not free and might have a negative impact on patient outcome. As such, surgeons should take extra caution to avoid it during laparoscopic cholecystectomy.