Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG), an EAST Multicenter Study. Yeh DD, Eid AI, Young KA, Wild J, Kaafarani HMA, Ray-Zack M, Kana'an T, Lawless R, Cralley AL, Crandall M; EAST Appendicitis Study Group. Ann Surg. 2019 Oct 28.
For over a century, acute appendicitis has been considered a surgical emergency and early surgery was indicated to prevent progression to perforation and other complications. Several European studies have challenged this belief and reported on antibiotics-only treatment for simple appendicitis as an accepted alternative to surgical appendectomy. However, these studies had their limitations—some presented data on simple appendicitis only, and others reported exceptionally high rates of open appendectomy and long length of stay, which is not consistent with current practice in the United States. This study by Yeh et. al sought to describe the experience in the United States as related to the presentation, treatment, and outcomes of patients presenting with uncomplicated, perforated, or gangrenous appendicitis. This study also challenges the idea that perforation and gangrene are the result of a delay in treatment of acute appendicitis. This was an Eastern Association for the Surgery of Trauma prospective, multi-institutional, observational study that enrolled adult patients with appendicitis from January 2017 to June 2018.
Overall, 3597 patients were enrolled at 28 institutions. The median age was 37 years, 53% were male, 90% underwent computed tomography (CT) imaging, 91% were treated with appendectomy (98% laparoscopic), and median hospital stay was 1 day. The 30-day rate of emergency department visit and readmission was 10% and 6%, respectively. Initially, 219 patients were treated with antibiotics, 16% of whom required appendectomy during their index hospitalization; 5% underwent appendectomy within 30 days for a cumulative failure rate of 21%. Of the patients that failed antibiotics-only treatment, 77% had acute non-perforated appendicitis, 16% had perforated, and 7% had gangrenous appendicitis. By regression analysis, age, symptoms lasting more than 48 hours, temperature, white blood cell count, Alvarado score, and appendicoliths were predictive of complicated appendicitis. Comorbidities, smoking, and emergency department time to appendectomy of > 6 or > 12 hours were not predictive of complicated appendicitis.
The authors concluded that most patients in the United States presenting with appendicitis received CT imaging, underwent laparoscopic appendectomy, and stayed in the hospital for 1 day. One in 5 patients initially treated with antibiotics alone required an appendectomy within 30 days. A delay in appendectomy at the hospital did not increase the risk of perforation or gangrene. Of note is the low incidence of negative appendectomy (2%) attributed to the use of preoperative imaging. These findings should be taken into consideration when deciding on surgery versus antibiotics only for the treatment of appendicitis. Perhaps patients with the aforementioned risk factors for complicated appendicitis should be offered surgical appendectomy rather than treated with antibiotics alone. For the rest, especially considering the potential complications associated with surgery and anesthesia, treating with antibiotics only seems reasonable. When considering appendectomy, delaying the surgery to be performed during daylight hours may be more practical without increasing the risk of complications.
Impact of Operative Management on Recurrence of Adhesive Small Bowel Obstruction: A Longitudinal Analysis of a Statewide Database. Medvecz AJ, Dennis BM, Wang FL, Lindsell CJ, Guillamondegui OD. J Am Coll Surg. 2020 Jan 16.
Historically, management of adhesive small bowel obstruction (ASBO) was to “never let the sun rise or set” on an SBO. However, in recent years, non-operative management has been accepted as initial treatment. Gastric decompression, as well as contrast follow-through studies, have resulted in successful non-operative management of bowel obstruction in about 75% of cases. This study from the Tennessee Hospital Association sought to evaluate the risk of recurrence after operative or non-operative management of adhesive small bowel obstruction, as well as the morbidity and mortality associated with each approach.
In this study, the authors retrospectively analyzed patients with adhesive small bowel obstruction at their index admission and subsequent readmissions within any hospital in the state of Tennessee (2007-2009). The primary outcome was the incidence of ASBO recurrence using the Andersen-Gill approach for modeling recurrent time-to-event data. Secondary outcomes included mortality, complications, and time-to-recurrence.
Overall, 6,191 patients with ASBO were included in the analysis of which 70% were initially treated non-operatively (median follow up: approximately 10 years for both groups). Patients who were initially managed surgically had lower overall recurrence compared with those who were treated non-operatively (19.0% vs. 25.6%, p<0.005). The risk for recurrence was lower if the most recent episode was managed operatively (HR: 0.27). For patients with multiple recurrences, each additional admission for recurrence increased the risk of recurrence following operative (HR 2.3) and non-operative (HR 1.18) management. In-hospital mortality was greater for the operative compared to non-operative groups (3.7% vs. 2.6%, respectively, p=0.025) as was overall morbidity. Median time to recurrence was longer for those who underwent operative management (729 vs 550 days, p=0.009).
The authors concluded that initial operative treatment of adhesive small bowel obstruction is associated with decreased risk of recurrence which is consistent with other recently published studies. The time to recurrence was also longer in those who underwent operative management. However, when deciding whether to operate it is important to consider the potential morbidity and mortality associated with surgery. Perhaps earlier surgical intervention should be considered to minimize the risk of recurrence in patients with no significant risk factors. However, the patient's clinical condition at presentation, comorbidities, and number of previous abdominal surgeries might influence our decision for operative versus non-operative management. This paper does not stratify patients according to baseline risk, nor do the authors describe the operative approach, whether laparoscopic or open, which may have an impact on outcomes. This information should be considered when weighing the risks of surgery versus recurrence, especially among complex patients.
Prevention of Fascial Dehiscence with Onlay Prophylactic Mesh in Emergency Laparotomy: A Randomized Clinical Trial. Lima HVG, Rasslan R, Novo FCF, Lima TMA, Damous SHB, Bernini CO, Montero EFS, Utiyama EM. J Am Coll Surg. Jan 2020; 230(1): 76–87.
Fascial dehiscence (FD) is a serious early complication of emergency laparotomy, occurring around 15% of the time. Mesh can reduce FD, but we worry about it getting contaminated during dirty abdominal surgery.
This prospective randomized trial in Sao Paulo Brazil randomized emergency laparotomy patients at high risk of developing FD to fascial closure with running #0 PDS suture versus the same closure with an onlay polypropylene mesh that overlapped the wound 3cm in all directions and was fixed with multiple running absorbable suture to eliminate dead space between mesh and fascia (adding 50 minutes to the OR time). The randomization envelope was opened after fascia closure, to determine whether mesh would be used. All mesh patients got a drain, so there was no blinding postoperatively. The authors tried to maintain a 4:1 suture to wound length ratio using small bites in the fascial closure, but only managed to do this in about half the cases. There are no differences in the 52 patients randomized to suture alone versus the 63 who also got mesh. There were 75% colon and 15% gastroduodenal operations. Half had an ostomy. About 60% were clean contaminated, 15% contaminated, and 25% were dirty procedures. FD was detected by surgeon exam and CT on POD 30. This study was presented at the American College of Surgeons meeting in San Francisco in October 2019.
FD developed in 7 patients, all in the suture group, all diagnosed by exam and confirmed by CT. None were diagnosed exclusively by CT. Four underwent fascial reclosure and mesh onlay. Three with intact skin were treated conservatively. The patients with dehiscence had a longer ICU and overall length of stay. Seven patients in the mesh group had mesh exposure; two of these underwent partial mesh removal (3 cm x 1 cm and 5 cm x 2 cm); the rest healed within 3 months. The mesh group had a higher surgical site infection (21% v 8%), seroma (19% v 6%) and non-healing incisional wound (24% v 6%). These complications did not require any procedures.
This is an important prospective randomized study showing that onlay mesh is safe in emergency contaminated laparotomy and eliminates the serious complication of FD, but at the cost of almost an hour of OR time and increased rates of the less serious complications of increased surgical site infection, seroma and slowly healing incisional wounds.
Delayed interhospital transfer of critically ill patients with surgical sepsis. Loftus TJ, Wu, Q, Wang Z, Lysak N, Moore FA, Bihorac A, Efron PA, Mohr AM, Brakenridge SC. J Trauma Acute Care Surg. Jan 2020; 88(1): 169–175.
Surgical sepsis is highly morbid. Early source control, adequate resuscitation and antibiotics are important. This was a prospective cohort study of patients treated at the University of Florida Gainesville, the only tertiary care center within 90 miles, with over a million people in the catchment area, comparing Group 1 (patients admitted directly to UF or transferred within 24 hours of presenting at an outside facility) versus Group 2 (patients transferred later than 24 hours). The study was presented at the AAST meeting in Dallas in Sep 2019.
Patients admitted to the surgical ICU with a diagnosis of sepsis were included. About 40% had an intrabdominal infection, 15% had pneumonia and 15% had necrotizing soft tissue infections. Within Group 1 (239 patients), the patients who were directly admitted to UF were similar to the patients who were transferred within 24 hours (median 1 hour at the outside facility), allowing the authors to combine these groups in the comparison. There were 69 patients in Group 2 (delayed transfer, averaging almost 2 days at the outside facility). Group 2 patients were about four years older and had higher comorbidity index, lower Glasgow coma scores, higher SOFA scores and Apache 2 scores.
About two-thirds of all patients underwent a source control procedure. Time to source control was 1 hour in Group 1 and 12 hours in Group 2. At UF, patients received protocols for fluid resuscitation, pressure support, antibiotics, breathing trials, transfusions, nutrition, and management of delirium. Group 2 had about double the mortality rate (15%), ICU length of stay (14 days), total length of stay (24 days), and nosocomial infections (40%) as Group 1. They were also half as likely to be discharged home (22%). The hospital length-of-stay difference was maintained on multivariate analysis.
This was not a randomized controlled study, and Group 2 started out sicker, so it is not surprising that this group did worse. There must be a bias, as only patients at outside facilities that were deteriorating would be considered for transfer. However, it suggests that early transfer to a tertiary care center may help seriously sick patients.