Outcomes in Older Patients with Grade III Cholecystitis and Cholecystostomy Tube Placement: A Propensity Score Analysis. Dimou FM, Adhikari D, Mehta HB, Riall TS. J Am Coll Surg. 2017 Apr;224(4):502-511.e1.
Percutaneous cholecystostomy tubes decompress the inflamed gallbladder in patients that are too critically ill to safely undergo cholecystectomy. The Tokyo Guidelines for the Management of Acute Cholecystitis (2007, revised 2013), advocated their use as a temporizing measure to allow drainage of bile and resolution of biliary obstruction and inflammation until definitive surgery can be safely performed. There is a paucity of data pertaining to the long-term outcomes of using these tubes, especially in the geriatric population.
The authors wanted to evaluate the efficacy of adhering to the non-operative approach advocated in the Tokyo Guidelines in geriatric patients presenting to their urban, tertiary-level University hospital with grade III cholecystitis (acute cholecystitis with organ dysfunction, leukocytosis and/or thrombocytopenia). They compared outcomes in geriatric patients who did and did not have a cholecystostomy tube placed as initial treatment. Performing a retrospective review of the Medicare (CMS) inpatient and out-patient claims database from 1996 to 2010; they found 8,818 critically ill patients aged 66 or older were admitted, of which 565 (6.4%) patients had a Cholecystostomy tube placed. Then they performed a 1:3 propensity match sampling and compared the cohort to 1689 comparable controls who underwent cholecystectomy during their hospitalization. The results revealed that elderly patients who had a cholecystostomy tube placed had similar in-hospital mortality (24% vs. 22.6%) compared to the controls. However they had higher 30-day, 90-day and 2-year mortality (Hazard Ratio=1.26, 1.26 and 1.19 respectively). They also had longer length of stay (LOS) as well as higher readmission rates at 30-days, 90-days and 2-years (HR= 2.93, 3.48 and 3.08 respectively). In addition, they were also less likely to undergo a definitive cholecystectomy in the next 2-years after placement, and the median time to operation, if performed post-cholecystostomy tube placement was 4.6 months.
This study showed that >90% of severely ill elderly Medicare patients that should have been candidates for conservative treatment with a cholecystostomy tube did not receive it. The limitations of the study are that they were unable to determine the actual medical treatment differences in the two groups (e.g. duration of symptoms, ICU management, length of antibiotic use or if there were difficulties in tube management like dislodgement leading to failure of conservative management) from claims data alone. In addition, the initial Tokyo guidelines were published in 2007, the study period was from 1996-2010, so the actual implementation of the recommendations was only for the last 4 years of the study. The authors conclude that more data is needed to identify which subset of patients will most benefit from cholecystostomy tube placement.
Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction. Zielinski MD, Haddad NN, Cullinane DC, Inaba K, Yeh DD, Wydo S, Turay D, Pakula A, Duane TM, Watras J, Widom KA, Cull J, Rodriguez CJ, Toschlog EA, Sams VG, Hazelton JP, Graybill JC, Skinner R, Yune JM. J Trauma Acute Care Surg. 2017 Jul;83(1):47-54.
Mechanical small bowel obstruction (SBO) is a common condition requiring hospital admission. A surgeon has to decide which patients will develop a complete strangulating obstruction and operate on them in a timely fashion to prevent the morbidity of bowel perforation and/or bowel resection. Diagnostic fluoroscopic studies using enteric contrast can opacify the small bowel and help not only to delineate the point and degree of obstruction, but also determine whether the contrast media traverses the obstruction and makes its way to the colon. The use of Gastrografin (GG) a hyperosmolar oral contrast agent can be both diagnostic and may have therapeutic potential. While several RCTs and a few meta-analyses on the use of GG in SBO have been published, there is no consensus regarding type of hyperosmolar contrast, timing of contrast administration, timing of follow-up radiographs and its utility in preventing operations for SBO.
This was an EAST-sponsored multi-institutional trail conducted at 14 hospitals. It was a prospective, observational, non-randomized study comparing standardized adhesive SBO treatment protocols with and without the use of GG challenge. The selection of SBO treatment algorithm (GG-protocol vs. non-GG protocol) was left to the discretion of the surgeon. They excluded SBO patient with obvious peritonitis, internal or external herniae, abdomino-pelvic malignancy, previous abdominal operation within 6 weeks, hypotension/sepsis, closed loop obstruction, pneumatosis intestinalis or presence of portal venous gas. 316 patients with a mean age of 58 +/- 18 years were enrolled. There were 173 in the GG group and 143 in the non-GG cohort. The groups had similar characteristics except for a lower rate of mesenteric edema on CT scan in the GG-group. They applied area under the curve (AUROC) as well as logistic multivariable regression analysis and found that 118 (68%) passed the GG challenge and there was only a 20.8% rate of operative exploration in that cohort compared to 44.1% in the non-GG group. The GG group patients also had a decreased rate of bowel resection (6.9% vs. 21% p<0.0001), but longer median duration of time to surgical exploration (3 vs 2 days p=0.005). The rate of missed strangulating obstruction was also less in the GG group (0.6% vs 7.7% p<0.001). The GG group had an overall shorter hospital length of stay (LOS) by about 24 hours, and both groups had similar rate of complications (12.5% vs 17.9% p=0.22).
The limitations of this study include lack of randomization and blinding and the clinical proclivity of the surgeon to forgo the GG challenge and essentially enroll the patient in the non-GG arm, also three of the institutions did not have GG availability and defaulted to the non-GG protocol group. There was also a higher incidence of mesenteric edema on CT scan in the non-GG group perhaps contributing to their higher operative rate. Nevertheless, this is a large study to explicate on this frequent diagnostic dilemma for a surgeon and it provides evidence and proof of concept that using a standardized Gastrografin administration protocol can reduce the number of operations for SBO without an increase in complications.
Operation versus antibiotics--The "appendicitis conundrum" continues: A meta-analysis. Sakran JV, Mylonas KS, Gryparis A, Stawicki SP, Burns CJ, Matar MM, Economopoulos KP. J Trauma Acute Care Surg. 2017 Jun; 82(6):1129-1137.
Although appendectomy is the most common surgical procedure performed worldwide, the management of acute appendicitis continues to evolve. Despite its frequent occurrence, acute, non-perforated appendicitis presents a diagnostic and therapeutic challenge to the acute care surgeon. Clinicians have proposed that certain cases of uncomplicated appendicitis in adults may be safely managed non-operatively with antibiotics. Public debate ensued after the publication of the APPAC Trial in JAMA in 2015 and PROSPERO Metanalysis in Annals of Surgery in 2017. These studies showed that approximately 3 out of 4 patients potentially could be successfully treated with antibiotics.
To identify those patients who will most benefit from a conservative approach, the authors of this study did a systematic review in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) methodology of eligible studies comparing operative and antibiotic treatment of adult patients with uncomplicated and non-perforated acute appendicitis from 1992 to 2012. They applied the modified Jadad scale to identify five high-quality randomized controlled trials with an intent-to-treat analysis of treatment efficacy. Two blinded reviewers independently evaluated the five articles and performed the data synthesis. Of the five studies, four were multi-institutional. 1430 adult patients were identified with n=727 for antibiotic group and n=703 for the operative cohort. Their results showed that 586/727 (80.6%) of patients had complete symptom resolution initially after antibiotics. However 122/586 (20.8%) developed a recurrence of their appendicitis within 1-year of follow-up. They also found that although treatment complications were higher in the operative group (23.6% vs 7.7%, RR 0.32, p<0.001), treatment efficacy was much lower at 1 year-follow-up for the antibiotics group (63.8% vs 93%, RR0.68, p<0.001). No major differences found in terms of length of stay, duration of pain, time off from work and most importantly, incidence of perforation of the appendix. Monotherapy with Ertapenem resulted in the highest risk of subsequent perforation; otherwise, no difference identified among the various antibiotic regimens used.
The authors conclude that there is still lack of consensus on its management, and “best practice” for this condition remains debatable. The limitations of this meta-analysis are reflective of the 5 studies themselves. However, given this data, surgeons can quote an 80% initial success rate for non-operative management of uncomplicated appendicitis with another 20% requiring surgery within a year of treatment. Overall complications are higher with surgery, but so is treatment efficacy. There is no difference in risk of rupture of the inflamed appendix. An individualized, risk-aware approach should be taken with discussion of all possible treatment options with the patient.
Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated disease: An Eastern Association for the Surgery of Trauma multicenter trial. Ferrada P, Callcut R, Zielinski MD, Bruns B, Yeh DD, Zakrison TL, Meizoso JP, Sarani B, Catalano RD, Kim P, Plant V, Pasley A, Dultz LA, Choudhry AJ, Haut ER; EAST Multi-Institutional Trials Committee. J Trauma Acute Care Surg. 2017 Jul;83(1):36-40.
With the widespread use of broad-spectrum antibacterial agents, antibiotic-resistant C. difficile infection is becoming more prevalent. Occasionally it can cause fulminant pan-colitis called C. difficile-associated disease (CDAD), which is a life threatening condition, associated with multi-organ failure, sepsis, ileus and megacolon. Delay in surgical treatment carries a high mortality risk. The definitive surgical treatment is total abdominal colectomy (TC), which is a high morbidity procedure in critically ill patients. It can also leave patients with a permanent ileostomy with its accompanying problems. In 2011, an alternative procedure was proposed: temporary loop ileostomy (LI), colonic washout with vancomycin and reversal of the ileostomy once the colitis had subsided, the so-called “Pittsburgh protocol”. However, their positive results were not uniformly replicated and there were concerns about recurrence of CDAD without a TC.
The objective of this study was to compare these two procedures. They conducted an EAST-sponsored retrospective analysis of data from 10 centers collected from 2010 to 2014. They found 100 patients required surgery for CDAD, 2 died during their procedure leaving a cohort of 98 patients. They were critically ill patients with multiple comorbidities; 54% were on vasopressors, 47% had renal failure and 36% had respiratory failure. Median age was 64.5 years and most of them were male. Using an electronic research data capture tool, Mann-Whitney and Fischer exact tests to compare TC with LI, they found that the patients who underwent each procedure had similar APACHE II scores. 55% were on Metronidazole, 45% on Vancomycin and 30% were getting both. Univariate predictors of mortality were age, lactate, timing of operation, vasopressor use, and acute renal failure. LI was performed in 21 and TC in 77 patients. Average blood loss was also lower in the LI group compared to the TC group (30 mL vs 250 mL; p<0.001). Adjusted mortality was significantly lower in the LI group (17.2% vs 39.7%; p=0.002). The overall mortality was 32% and 75% had a perioperative complication.
The limitations of the study are those inherent to extrapolation of data collected retrospectively from a small sample size. Patients were not randomized (possible selection bias), and a propensity score analysis was performed to account for that. LI was performed in only 21 patients and 5 of those patients required an unplanned re-operation with 3/5 requiring conversion to a TC. However, this is still the first multi-centric study that directly compares outcomes of LI vs TC for CDAD. It showed that LI has less than half the mortality of TC with significantly less operative blood loss and is a lesser physiologic insult to critically ill patients. The authors propose that given its more favorable outcome, LI should be considered the first line surgical treatment for CDAD in patients without contraindications.