Quantifying lives lost due to variability in emergency general surgery outcomes: Why we need a national emergency surgery quality improvement program. Hashmi ZG, Jarman MP, Havens JM, Scott JW, Goralnick E, Cooper Z, Salim A, Haider AH. J Trauma Acute Care Surg. 2021 Apr 1;90(4):685-693.
Summary: This study sought to compare the in-hospital mortality rates for emergency General surgery patient among hospitals and benchmark individual hospitals into quintiles of reliability-adjusted mortality rate using standardized techniques. Data from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS) were collected from 2006 to 2014. The authors then calculated the relative risk of mortality at each hospital quintile relative to best-performing quintile followed by calculating the number of estimated excess deaths at each hospital quintile versus the best-performing quintile. For All EGS cohort, in-hospital mortality varied from 0.3% to 4.1%. There was a greater than twofold difference between reliability-adjusted mortality rates for patients treated at hospitals among the best-performing versus the worst-performing quintile. The highest mortality rate was observed among the worst quintile of hospitals treating Operative EGS patients (2.4%), whereas the lower rate was among the best-performing hospitals treating All EGS patients. The highest relative risk was observed among patients undergoing the high-burden operative EGS procedures at the worst-performing hospital quintile. An estimated 158,177 excess EGS deaths occurred at lower-performing hospital quintiles. Overall, 47% of excess deaths occurred at the worst-performing hospitals, while 27% of all excess deaths occurred among the operative cohort.
Take away: There is significant variability in the mortality rate between Low performing hospitals versus high performing hospitals with an estimated 200,000 excess death in emergency General surgery patients treated at low performing hospitals. This study suggests the necessity of a national quality improvement initiative specific for emergency General surgery to enable structure and processes associated with optimal outcomes to achieve zero preventable death in emergency general surgery patients.
Managing acute uncomplicated appendicitis in frail geriatric patients: A second hit may be too much.
Mohamad C, Ditillo M, Khurrum M, Gries L, Asmar S, Douglas M, Bible L, Kulvatunyou N, Joseph B.
J Trauma Acute Care Surg. 2021 Mar 1;90(3):501-506.
Summary: This study sought to examine long-term outcomes of frail geriatric patients with acute uncomplicated appendicitis (AUA) treated initially with appendectomy versus initial non operative management with antibiotics. A 1-year analysis of the Nationwide Readmissions Database included all frail geriatric patients (age, ≥65 years) with a diagnosis of AUA. Modified 5 factor frailty score was used to assess frailty. An equal number of patients that underwent initial appendectomy or non-operative management with antibiotics were compared. Both groups had similar overall frailty scores and average age. 18% of patients treated non operatively initially had failure and 95% of these required eventually an appendectomy. Patient that were treated initially non operatively had significantly higher rates of Clostridium difficile colitis, number hospitalizations, hospital length of stay and higher overall cost. Patient who failed initial non operative management had higher overall complication rate, mortality rate as well as diagnosis of appendiceal neoplasms.
Take away: While some patients are suitable for initial non operative management of acute uncomplicated appendicitis with antibiotics, frail geriatric patients may benefit from initial appendectomy. In this study, Failure of initial non-operative management for AUA was associated with increased hospital stay, overall cost as well as complication rates and mortality in these patients.
Outcomes of same admission cholecystectomy and endoscopic retrograde cholangiopancreatography for common bile duct stones: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study. Tracy BM, Paterson CW, Kwon E, Mlaver E, Mendoza A, Gaitanidis A, Rattan R, Mulder MB. J Trauma Acute Care Surg. 2021 Apr 1;90(4):673-679.
Summary: This is a post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study that sought to identify optimal timing of cholecystectomy after ERCP for choledocholithiasis looking at biliary complications and length of stay. The study prospectively followed patient who underwent cholecystectomy after ERCP for CBD stone. They compared patient who underwent cholecystectomy within 24 hours of ERCP (early group), 24-72 hours after ERCP (early group) and after 72 hours of ERCP (late group). Total of 349 patients were studied, 33.8% (n = 118) were categorized as immediate, 50.4% (n = 176) as early, and 15.8% (n = 55) as late group. The rate of CBD exploration was higher in the late group compared with immediate group (9.1% vs. 0.9%, p = 0.01). Rates of open conversion were lower in the immediate group compared with the early group (0.9% vs. 10.8%, p < 0.01) and in the immediate group compared with the late group (0.9% vs. 10.9%, p < 0.001). There was a 21% decreased in Postoperative length of stay and 23% decrease in hospital length of stay in the immediate group.
Take away: In this study, performing a cholecystectomy within 24 hours after ERCP for choledocholithiasis was associated with decreased postoperative length, total hospital length of stay as well as rates of common bile duct exploration and conversion to open cholecystectomy. An EAST Practice Management guideline regarding timing of cholecystectomy after ERCP would be beneficial based on the results of the study.