October 2020 - Emergency General Surgery

October 2020
EAST Monthly Literature Review


"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee

This issue was prepared by EAST Emergency General Surgery Committee Members Seth Bellister, MD and Alejandro Luis, MD, FACS.

Thank you to Haemonetics for supporting the EAST Monthly Literature Review.


In This Issue: Emergency General Surgery 

Scroll down to see summaries of these articles

Article 1 reviewed by Seth Bellister, MD
Prospective validation of the Emergency Surgery Score in emergency general surgery: An Eastern Association for the Surgery of Trauma multicenter study. Kaafarani H, Kongkaewpaisan N, Aicher B, et al. J Trauma Acute Care Surg. 2020 Jul;89(1):118-124.

Article 2 reviewed by Seth Bellister, MD
REBOA Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience.  Hatchimonji JS, Chipman AM, McGreevy DT, Hörer TM, Burruss S, Han S, Spalding MC, Fox CJ, Moore EE, Diaz JJ, Cannon JW. J Surg Res. 2020 Jul 21;256:149-155.

Article 3 reviewed by Alejandro Luis, MD, FACS
Laparoscopy at all costs? Not now during COVID-19 outbreak and not for acute care surgery and emergency colorectal surgery: A practical algorithm from a hub tertiary teaching hospital in Northern Lombardy, Italy. Di Saverio S, Khan M,  Pata F, Ietto G, De Simone B, Zani E, Carcano G. J Trauma Acute Care Surg. 2020 Jun;88(6):715-718.

Article 4 reviewed by Alejandro Luis, MD, FACS
Prospective validation of the Emergency Surgery Score in emergency general surgery: An Eastern Association for the Surgery of Trauma multicenter study. Kaafarani H, Kongkaewpaisan N, Aicher B, et al. J Trauma Acute Care Surg. 2020 Jul;89(1):118-124.

Article 1
Prospective validation of the Emergency Surgery Score in emergency general surgery: An Eastern Association for the Surgery of Trauma multicenter study. Kaafarani H, Kongkaewpaisan N, Aicher B, et al. J Trauma Acute Care Surg. 2020 Jul;89(1):118-124.

Summary

This is a prospective, multicenter, observational trial of 1,649 patients from 19 centers of the Emergency Surgery Score (ESS).  The population included all patients over 18 undergoing emergency laparotomies, excluding trauma, vascular, and gynecologic causes for laparotomy. The ESS is a 29-point scoring system that can be performed at the bedside from demographic data, comorbidities, and lab values.  Overall, 30-day mortality in this study was 14.8%. Using the ESS, the observed mortality increased from 3.5%, 50%, and 85.7% at 3, 12, and 17 points. The overall 30-day complication rate was 53.4% with scores of 1, 6, and 13 correlating to complication rates of 21%, 57.1% and 88.9%.  The ESS was also useful in predicting postoperative ICU stay with scores of 1, 6, and 13 predicting ICU admission of 17.4%, 60%, and 95.6%. 

Critique

The introduction briefly addresses the issues with other risk calculators including ACS-NSQIP. Head to head comparison of the ESS to ACS-NSQIP may have been a nice addition to this study that seemed to be alluded to, however not delivered. The ESS will certainly assist clinicians, patients, and family members in understanding severity of disease and expected postoperative course.

For such a large multicenter trial, there was an admirable fidelity of data with 81.4% of patients having a complete set of ESS variables.  This contributed to narrow confidence intervals throughout the results.  This makes for exciting possibilities in when counselling a patient.  Unfortunately, the ESS is limited to only laparotomies. This addresses only one area of practice that commonly faces the emergency surgeon. 

Take-home Point

This ESS is a validated tool that may be used preoperatively at the bedside as part of a shared decision making model. The lack of electronic application/calculator makes this tool less accessible than the others.

Article 2
REBOA Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience.  Hatchimonji JS, Chipman AM, McGreevy DT, Hörer TM, Burruss S, Han S, Spalding MC, Fox CJ, Moore EE, Diaz JJ, Cannon JW. J Surg Res. 2020 Jul 21;256:149-155.

Summary

REBOA continues to be an emerging technology with significant interest broadening applications. This retrospective multicenter cohort study evaluates the use of REBOA in non-compressible thoracic hemorrhage from nontraumatic etiologies.  A total of 37 patients across six centers with stated expertise in REBOA placement reported their data. Indication for REBOA placement included GI hemorrhage, ruptured AAA, ruptures splenic artery aneurysm, sacral decubitus ulcer and unknown. Most of the catheters were placed by attending trauma surgeons (54%).  The overall deployment was zone 1 in over 77% of cases.  Additionally, most of these cases were performed in the operating room.  The mortality of patients in which the REBOA balloon was inflated was 37% with zone 1 deployments having a higher mortality (37%) than zone 3 (0%).  Median time to hemorrhage control was 20 minutes. Mean balloon inflation time was 35.3 +- 17.7 minutes.

Critique

This study looks to expand on the emergency surgeon’s armamentarium in life threatening hemorrhage.  It is difficult to assess how to apply these data as they very much represent the avant garde of this technology. 

Complicating the issue is the clear benefit of experience in outcomes of REBOA placement that this study endorses.  When combined with the data suggesting survivors had higher nadir pH levels after inflation it stands to reason that centers wherein REBOA placement occurs relatively more frequently may recognize the need for REBOA and deploy earlier than less experienced centers. This also would support a learning curve for centers looking to use these data in their own practice.  

One of the benefits posited by this study is the ability to plan REBOA insertion. Indications for REBOA placement other than trauma may avoid austere environments, like the emergency center.  Placement of the REBOA catheter without deployment using the 7 Fr sheath seems to be a relatively safe procedure.  Only one access complication is reported in this study.    

Take Home
This is a thought-provoking early report from a lower impact journal. The optimal application of REBOA remains controversial.  This study demonstrates an additional potential application of this technology in centers with a high volume of non-traumatic life-threatening hemorrhage.

Article 3
Laparoscopy at all costs? Not now during COVID-19 outbreak and not for acute care surgery and emergency colorectal surgery: A practical algorithm from a hub tertiary teaching hospital in Northern Lombardy, Italy. Di Saverio S, Khan M,  Pata F, Ietto G, De Simone B, Zani E, Carcano G. J Trauma Acute Care Surg. 2020 Jun;88(6):715-718.

Summary
COVID has permeated and transcended almost every facet of our lives on a global scale.  The authors of this paper plead their case for the very deliberate and restrictive use of laparoscopy in COVID + patients, and alternatives to laparoscopic approaches to include non-operative, as well as open surgical intervention as the preferred alternatives.  While the authors do not advocate for a total abandoning of laparoscopy in the age of COVID, they do point out the added costs of laparoscopy as well as potential high risk exposure of operating room staff to aerosolized virus.
 
The authors’ experience in Lombardy, Italy with emergency surgical procedures has essentially been replicated by all centers across the globe.  While the initial uncertainty as well as fear surrounding operating on COVID + cases has subsided, serious concerns remain about laparoscopy during the COVID age, as there is a significant paucity of data.  Several “letters to the editor” have postulated safe laparoscopic alternatives to common emergency surgical cases such as perforated peptic ulcer disease, acute appendicitis, acute cholecystitis, complicated diverticulitis, as well as bowel obstructions.
    
Article 4 
Prospective validation of the Emergency Surgery Score in emergency general surgery: An Eastern Association for the Surgery of Trauma multicenter study. Kaafarani H, Kongkaewpaisan N, Aicher B, et al. J Trauma Acute Care Surg. 2020 Jul;89(1):118-124.

Summary
 
Emergency Surgery Score (ESS) has been retrospectively validated as an accurate tool to predict 30-day postoperative mortality, morbidity, and the need for postoperative critical care in the EGS patient. The authors of this study aimed to validate this score in a prospective fashion as well as the scores ability to predict 30-day mortality, postoperative complications, and the need for postoperative ICU admission for critical EGS patients.
 
In this one year, multicenter, prospective, observational study 1649 patients were studied who underwent exploratory laparotomy (EL) for small bowel obstruction, mesenteric ischemia, perforated viscous, and complicated diverticulitis. Variables collected included demographic information, 30-day mortality, ICU admission postoperatively, need for reoperation, length of hospital stay, readmission, as well as 21 defined postoperative complications.  The study found that the most common diagnoses for which patients underwent EL was hollow viscous perforation (29.5%), small bowel obstruction (22.1%), strangulated or incarcerated hernia (13%), and bowel/mesenteric ischemia (12.3%).

  • ESS calculated that in this population of patients, the 30-day mortality was approximately 15% with a c-statistic of 0.84 (95% CI [0.82-0.87]). The observed mortality increased from 3.5%, 50%, and 85.7% with ESS scores of 3,12, and 17 points respectively.
  • ESS calculated that 53% had at least one postoperative complication with a c-statistic of 0.74 (95% CI [0.72-0.77]) The observed complication scores of 1, 6, and 13 corresponded with complication rates of 21%, 57%, and 89% respectively.  
  • ESS calculated that approximately 57% required postoperative ICU admission, with hemodynamic compromise as the most common cause.  ESS predicted which patients required postoperative ICU admission with scores of 1,6, and 13 correlating with ICU admission rates of 17%, 60%, and 95% respectively. The c-statistic was 0.80 (95% CI [0.78-0.82).

In conclusion, the study was able to demonstrate the ability of the ESS to predict 30-day mortality, 30-day postoperative complications, and the requirement for postoperative ICU admission.  This allows the acute care surgeon to address potential pitfalls when discussing operative alternatives with patients and their families, as well as providing them with a tool to benchmark the quality of care of EGS patients.

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 This Literature Review is being brought to you by the EAST Manuscript and Literature Review Committee. Have a suggestion for a review or an additional comment on articles reviewed? Please email litreview@east.orgPrevious issues available on the EAST website.