The American Association for the Surgery of Trauma grading scale for 16 emergency general surgery conditions: Disease-specific criteria characterizing anatomic severity grading. Tominaga GT, Staudenmayer KL, Shafi S, et al. J Trauma Acute Care Surg. 2016 Sep;81(3):593-602.
The American Association for the Surgery of Trauma (AAST) Committee on Patient Assessment previously developed a scale for the extent of emergency general surgical (EGS) diseases, grading the presenting problem from I to V based on anatomic findings of disease within or beyond the organ of origin. This consensus paper takes that abstract work further, describing the explicit findings expected with the spectrum of severity of 16 common EGS problems: acute appendicitis, breast infection, acute cholecystitis, acute diverticulitis, esophageal perforation, hernia, infectious colitis, intestinal obstruction, intestinal arterial ischemia, acute pancreatitis, pelvic inflammatory disease, perirectal abscess, perforated peptic ulcer, pleural space infection, soft tissue infection, and surgical site infection. For each of problem, the group evaluated the clinical, imaging, operative, and pathologic findings expected for each of the grades, recognizing that some conditions may not require operative management and therefore the operative and pathology findings would be noncontributory. In addition to the authors’ opinions, the paper includes other grading systems’ descriptions where available, such as the Hinchey classification for diverticulitis.
In addition to the extensive yet understandable definitions given for each class of each disease, the authors include a comparison of this relatively new classification scheme to previously available (and quite disparate) classifications of individual diseases. They describe validation of the grading scale in diverticulitis as having high inter-rater reliability, but note that the scale has not been validated for other diseases. They additionally admit that this scale alone isn’t expected to be associated with outcome differences, but rather may be one factor included in comparing outcomes based partially on disease severity.
The authors make clear throughout the article that this grading scale is intended as a research tool, not necessarily as a part of the clinical diagnostic toolkit. There’s no doubt that basing the scales for widely varying diseases on similar anatomic criteria simplifies the process of establishing in which class an EGS process belongs, and allows the application of the grading system to diseases not explicitly described here. The authors are to be commended for applying the AAST EGS grading scale to more than a dozen diseases to obtain reasonable explicit definitions for their severities, and indeed it is expected this article will become extensively cited as a reference for standardizing disease severity classification in research. It will be particularly interesting to see this scheme included in data collection and outcomes research for EGS diseases and interventions.
Appendicitis in Diabetics: Predictors of Complications and Their Incidence. Bach L, Donovan A, Loggins W, Thompson S, Richmond B. Am Surg. Aug;82(8):753-8.
If there’s one diagnosis emergency general surgeons are expected to be proficient at making, it’s that of acute appendicitis. However, the experienced surgeon has long recognized that surprisingly few patients with appendicitis have a “textbook” presentation, and that comorbid disease and age can easily confuse what those outside the field believe should be a “straightforward” diagnosis. Dr. Lindsay Bach and colleagues from West Virginia University explored the presentation and outcomes of diabetic patients who developed acute appendicitis when compared with their nondiabetic counterparts, and in this article describe their findings with the apparent goal of decreasing delays in diagnosis and risk of complications.
The retrospective review of 339 patients—only 36 of whom were diabetic—at a single medical center over 2 years highlights the presenting findings (based on the Alvarado score criteria) and the outcome measures (length of stay, perforation, and perioperative complications) for patients with and without pre-existing diabetes. The diabetic and nondiabetic cohorts were not matched, with the former older and with more chronic illnesses than the latter. Even though Alvarado scores on presentation did not significantly differ between the two groups, diabetics had a significantly lower level of leukocytosis and were more likely to present with a perforated appendix. Though diabetics also fared worse after surgery, multivariate analysis suggests this is largely associated with the other existing comorbid diseases rather than independently with diabetes.
This noninterventional retrospective analysis appears to offer little new actionable information for the practicing surgeon; perhaps the most obvious takeaway point is the warning not to rule out appendicitis in the diabetic patient with a minimal leukocytosis, but it seems quite likely the patient will still have an appropriate workup despite this finding. The complications of a surgical procedure are already known to be higher incidence in patients with diabetes its associated comorbidities, and it’s no surprise that this occurs for “simple” appendicitis as well. If anything, the question most raised by this study of a small number of diabetic patients with appendicitis is whether the higher perforation rate at presentation is indeed due to delay in diagnosis. It’s not answered by this manuscript, but could be an important finding suggesting more vigilance regarding appendicitis evaluation in diabetic patients in the future.
Laparoscopic lavage is superior to colon resection for perforated purulent diverticulitis—a meta-analysis. Angenete E, Bock D, Rosenberg J, Haglind E. Int J Colorectal Dis. 2017 Feb;32(2):163-169.
Ah, a routine laparoscopic washout, drain placement, and antibiotics instead of a laparotomy with Hartmann’s procedure, concern about not seeing the ureter, leaving the midline wound open, and, after the patient makes it through their postoperative course, planning for their colostomy reversal with all the same concerns; it’s a fantastic hope for a shorter hospital course and fewer complications, a hope that both patient and surgeon share, and one that’s received plenty of attention by the emergency surgeon. Finally Dr. Eva Angenete and her Scandanavian colleagues present the first meta-analysis comparing laparoscopic lavage with colon resection as treatment for purulent diverticulitis.
The authors report a well-designed PRISMA- and GRADE-based systematic review and meta-analysis, but found only three randomized controlled trials suitable for analysis, and unsurprisingly found those to still differ significantly in patient population. Nonetheless, the authors proceeded with combining data where possible to perform a limited meta-analysis of 358 patients with diverticulitis, 185 of whom had a laparoscopic lavage and 173 of whom underwent either a colon resection with primary anastomosis or a Hartmann’s procedure. The only statistically significant difference found between meta-groups was an increased rate of reoperation within 12 months in patients who underwent colon resection by combining two of the three studies; it is, of course, entirely possible that this increase is due to ostomy reversals, though such data are not available.
As systematic reviews and meta-analyses go, the design of this study is meticulous and deserves great praise; the limitation, however, is that there needs to be adequate analysis of a problem before a useful meta-analysis can be performed. The three studies which were able to be included were, of course, quite heterogeneous, and obtaining actionable results from such a group is nearly impossible. This manuscript won’t change our practice—if you didn’t think laparoscopic lavage was a good idea before, this certainly won’t convince you—but does remind us that this technique continues to be studied, and that those studies still have work to do.
How Does Cholecystectomy Influence Recurrence of Idiopathic Acute Pancreatitis? Stevens CL, Abbas SM, Watters DAK. J Gastrointest Surg. 2016 Dec;20(12):1997-2001.
Pancreatitis + Gall Stones = Gallstone pancreatitis. But what if there are no stones? “Idiopathic” pancreatitis, that which occurs in the absence of a clear inciting event and with no stones on imaging, may be the result of a passed gallstone, “microlithiasis” or “sludge”, or for some unidentified reason. This occurs in up to 30% of cases of acute pancreatitis, and the appropriate treatment strategy for reducing recurrence of such cases is unknown. The most current gastroenterology guidelines recommend “further assessment,” but don’t rely upon high quality evidence and don’t make a recommendation regarding cholecystectomy. Dr. Claire Stevens and her colleagues from Geelong, Australia, retrospectively examined the records of more than 2,000 patients presenting to their hospital with acute pancreatitis, identifying 195 patients without cholelithiasis and with no other apparent cause of their pancreatitis. About 1/6 of these had cholecystectomy following that event, and another 1/6 had cholecystectomy following one or more recurrences; the remaining 2/3 had follow-up care but no cholecystectomy.
Overall, the recurrence rate of pancreatitis was 20% in those who underwent cholecystectomy and more than 40% in those who did not. Importantly, Dr. Stevens and colleagues additionally break down episodes of recurrence in patients who don’t receive cholecystectomy until after their second, third, or later episodes of pancreatitis; though the numbers become too small to determine rates of recurrence with high confidence, the same pattern persists. The group uses these data to help analyze appropriate timing for cholecystectomy following idiopathic pancreatitis, finding it best served the patient to undergo surgery following their initial episode rather than waiting.
This is a retrospective evaluation at a single center, with the appropriate caveats therein, but does encourage those who would recommend cholecystectomy even in the absence of radiographically proven stones. Only a small randomized trial is available (which supports this finding as well), but given these data it’s unlikely more convincing findings will be produced—we should likely offer cholecystectomy to patients with “idiopathic” pancreatitis who are fit to undergo the procedure.