Clinical practice selectively follows acute appendicitis guidelines

INTRODUCTION

Acute appendicitis is a common surgical emergency, and the standard approach to diagnosis and management has been codified in several practice guidelines. Adherence to these guidelines provides insight into independent surgical practice patterns and institutional resource constraints as impediments to best practice. We explored data from the recent ESTES SnapAppy observational cohort study to determine guideline compliance in contemporary practice to identify opportunities to close evidence-to-practice gaps.

METHODS

We undertook a preplanned analysis of the ESTES SnapAppy observational cohort study, identifying, at a patient level, congruence with, or deviation from WSES Jerusalem guidelines for the diagnosis and management of acute appendicitis and the Surviving Sepsis Campaign in our cohort. Compliance was then correlated with the incidence of postoperative complications.

RESULTS

Four thousand six hundred and thirteen (4613) consecutive adult and adolescent patients with acute appendicitis were followed from date of admission (November 1, 2020, and May 28, 2021) for 90 days. Patient-level compliance with guideline elements allowed patients to be grouped into those with full compliance (all 5 elements: 13%), partial compliance (1-4 elements: 87%) or noncompliance (0 elements: 0.2%). We identified an excess postoperative complication rate in patients who received noncompliant and partially compliant care, compared with those who received fully guideline-compliant care (36% and 16%, versus 7.3%, p < 0.001).

CONCLUSIONS

The observed diagnostic and treatment practices of the participating institutions displayed variability in compliance with key recommendations from existing guidelines. In general, practice was congruent with recommendations for preoperative antibiotic surgical site infection prophylaxis administration, time to surgery, and operative approach. However, there remains opportunities for improvement in the choice of diagnostic imaging modality, postoperative antibiotic stewardship to timely discontinue prophylactic antibiotics, and the implementation of ambulatory treatment pathways for uncomplicated appendicitis in the healthy young adult.

A Prospective Meta-Analysis (PMA) Could Harmonize the Studies Focusing on Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

With the rapid development of novel surgical devices such as Resuscitative Endovascular Balloon Occlusion of theAorta (REBOA) and the eagerness of clinicians to use them, there is a risk that their usage in clinical practice exceedsthe evidence-based principles required for their introduction. This might be truer in the fields, such as trauma surgery,where the patient population and the disease (injury) burden are very heterogeneous and time-sensitive,and thus not fitting for the more gold standard investigation methods. The studies that are currently being publishedconsidering the use of REBOA in clinical settings have significant limitations and raise concerns in terms of the risk ofbiases that might influence the gold-standard evidence-based synthesis. This paper elaborates on the merits of aProspective Meta-Analysis (PMA) in reducing such biases.

Surgical management of acute appendicitis during the European COVID-19 second wave: safe and effective

INTRODUCTION

The COVID-19 (SARS-CoV-2) pandemic drove acute care surgeons to pivot from long established practice patterns. Early safety concerns regarding increased postoperative complication risk in those with active COVID infection promoted antibiotic-driven non-operative therapy for select conditions ahead of an evidence-base. Our study assesses whether active or recent SARS-CoV-2 positivity increases hospital length of stay (LOS) or postoperative complications following appendectomy.

METHODS

Data were derived from the prospective multi-institutional observational SnapAppy cohort study. This preplanned data analysis assessed consecutive patients aged ≥ 15 years who underwent appendectomy for appendicitis (November 2020-May 2021). Patients were categorized based on SARS-CoV-2 seropositivity: no infection, active infection, and prior infection. Appendectomy method, LOS, and complications were abstracted. The association between SARS-CoV-2 seropositivity and complications was determined using Poisson regression, while the association with LOS was calculated using a quantile regression model.

RESULTS

Appendectomy for acute appendicitis was performed in 4047 patients during the second and third European COVID waves. The majority were SARS-CoV-2 uninfected (3861, 95.4%), while 70 (1.7%) were acutely SARS-CoV-2 positive, and 116 (2.8%) reported prior SARS-CoV-2 infection. After confounder adjustment, there was no statistically significant association between SARS-CoV-2 seropositivity and LOS, any complication, or severe complications.

CONCLUSION

During sequential SARS-CoV-2 infection waves, neither active nor prior SARS-CoV-2 infection was associated with prolonged hospital LOS or postoperative complication. Despite early concerns regarding postoperative safety and outcome during active SARS-CoV-2 infection, no such association was noted for those with appendicitis who underwent operative management.

The revised cardiac risk index is associated with morbidity and mortality independent of injury severity in elderly patients with rib fractures

BACKGROUND

Risk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture.

METHODS

All geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders.

RESULTS

96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome.

CONCLUSIONS

Geriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.

The mortality burden of frailty in hip fracture patients: a nationwide retrospective study of cause-specific mortality

PURPOSE

Frailty is a condition characterized by a reduced ability to adapt to external stressors because of a reduced physiologic reserve, which contributes to the high risk of postoperative mortality in hip fracture patients. This study aims to investigate how frailty is associated with the specific causes of mortality in hip fracture patients.

METHODS

All adult patients in Sweden who suffered a traumatic hip fracture and underwent surgery between 2008 and 2017 were eligible for inclusion. The Orthopedic Hip Frailty Score (OFS) was used to classify patients as non-frail (OFS 0), pre-frail (OFS 1), and frail (OFS ≥ 2). The association between the degree of frailty and both all-cause and cause-specific mortality was determined using Poisson regression models with robust standard errors and presented using incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs), adjusted for potential sources of confounding.

RESULTS

After applying the inclusion and exclusion criteria, 127,305 patients remained for further analysis. 23.9% of patients were non-frail, 27.7% were pre-frail, and 48.3% were frail. Frail patients exhibited a 4 times as high risk of all-cause mortality 30 days [adj. IRR (95% CI): 3.80 (3.36-4.30), p < 0.001] and 90 days postoperatively [adj. IRR (95% CI): 3.88 (3.56-4.23), p < 0.001] as non-frail patients. Of the primary causes of 30-day mortality, frailty was associated with a tripling in the risk of cardiovascular [adj. IRR (95% CI): 3.24 (2.64-3.99), p < 0.001] and respiratory mortality [adj. IRR (95% CI): 2.60 (1.96-3.45), p < 0.001] as well as a five-fold increase in the risk of multiorgan failure [adj. IRR (95% CI): 4.99 (3.95-6.32), p < 0.001].

CONCLUSION

Frailty is associated with a significantly increased risk of all-cause and cause-specific mortality at 30 and 90 days postoperatively. Across both timepoints, cardiovascular and respiratory events along with multiorgan failure were the most prevalent causes of mortality.

Common bile duct stones management: A network meta-analysis

BACKGROUND

Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute care setting. Consequently, this systematic review and network meta-analysis, comparing one-stage (CBD exploration or intraoperative endoscopic retrograde cholangiopancreatography [ERCP] with simultaneous cholecystectomy) and two-stage (precholecystectomy or postcholecystectomy ERCP) procedures, was undertaken with the main outcomes of interest being postprocedural complications and hospital length of stay (LOS).

METHODS

PubMed, SCOPUS, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were methodically queried for articles from 2010 to 2021. The search terms were a combination of medical subject headings terms and the subsequent terms: gallstone; common bile duct (stone); choledocholithiasis; cholecystitis; endoscopic retrograde cholangiography/ERCP; common bile duct exploration; intraoperative, preoperative, perioperative, and postoperative endoscopic retrograde cholangiography; stone extraction; and one-stage and two-stage procedure. Studies that compared two procedures or more were included, whereas studies not recording complications (bile leak, hemorrhage, pancreatitis, perforation, intra-abdominal infections, and other infections) or LOS were excluded. A network meta-analysis was conducted to compare the four different approaches for managing CBD stones.

RESULTS

A total of 16 studies (8,644 participants) addressing the LOS and 41 studies (19,756 participants) addressing postprocedural complications were included in the analysis. The one-stage approaches were associated with a decrease in LOS compared with the two-stage approaches. Common bile duct exploration demonstrated a lower overall risk of complications compared with preoperative ERCP, but there were no differences in the overall risk of complications in the remaining comparisons. However, differences in specific postprocedural complications were detected between the four different approaches managing CBD stones.

CONCLUSION

This network meta-analysis suggests that both laparoscopic CBD exploration and intraoperative ERCP have equally good outcomes and provide a preferable single-anesthesia patient pathway with a shorter overall length of hospital stay compared with the two-stage approaches.

LEVEL OF EVIDENCE

Systematic Review/Meta Analysis; Level III.

Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study

Background

Hip fractures often occur in frail patients with several comorbidities. In those undergoing emergency surgery, determining the optimal anesthesia modality may be challenging, with equipoise concerning outcomes following either spinal or general anesthesia. In this study, we investigated the association between mode of anesthesia and postoperative morbidity and mortality with subgroup analyses.

Methods

This is a retrospective study using all consecutive adult patients who underwent emergency hip fracture surgery in Orebro County, Sweden, between 2013 and 2017. Patients were extracted from the Swedish National Hip Fracture Registry, and their electronic medical records were reviewed. The association between the type of anesthesia and 30-day and 90-day postoperative mortality, as well as in-hospital severe complications (Clavien-Dindo classification ≥3a), was analyzed using Poisson regression models with robust SEs, while the association with 1-year mortality was analyzed using Cox proportional hazards models. All analyses were adjusted for potential confounders.

Results

A total of 2437 hip fracture cases were included in the study, of whom 60% received spinal anesthesia. There was no statistically significant difference in the risk of 30-day postoperative mortality (adjusted incident rate ratio (IRR) (95% CI): 0.99 (0.72 to 1.36), p=0.952), 90-day postoperative mortality (adjusted IRR (95% CI): 0.88 (0.70 to 1.11), p=0.281), 1-year postoperative mortality (adjusted HR (95% CI): 0.98 (0.83 to 1.15), p=0.773), or in-hospital severe complications (adjusted IRR (95% CI): 1.24 (0.85 to 1.82), p=0.273), when comparing general and spinal anesthesia.

Conclusions

Mode of anesthesia during emergency hip fracture surgery was not associated with an increased risk of postoperative mortality or in-hospital severe complications in the study population or any of the investigated subgroups.

Level of evidence: Therapeutic/Care Management, level III

Developing and validating a scoring system for measuring frailty in patients with hip fracture: a novel model for predicting short-term postoperative mortality

Objectives

Frailty is common among patients with hip fracture and may, in part, contribute to the increased risk of mortality and morbidity after hip fracture surgery. This study aimed to develop a novel frailty score for patients with traumatic hip fracture that could be used to predict postoperative mortality as well as facilitate further research into the role of frailty in patients with hip fracture.

Methods

The Orthopedic Hip Frailty Score (OFS) was developed using a national dataset, retrieved from the Swedish National Quality Registry for Hip Fractures, that contained all adult patients who underwent surgery for a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017. Candidate variables were selected from the Nottingham Hip Fracture Score, Sernbo Score, Charlson Comorbidity Index, 5-factor modified Frailty Index, as well as the Revised Cardiac Risk Index and ranked based on their permutation importance, with the top 5 variables being selected for the score. The OFS was then validated on a local dataset that only included patients from Orebro County, Sweden.

Results

The national dataset consisted of 126,065 patients. 2365 patients were present in the local dataset. The most important variables for predicting 30-day mortality were congestive heart failure, institutionalization, non-independent functional status, an age ≥85, and a history of malignancy. In the local dataset, the OFS achieved an area under the receiver-operating characteristic curve (95% CI) of 0.77 (0.74 to 0.80) and 0.76 (0.74 to 0.78) when predicting 30-day and 90-day postoperative mortality, respectively.

Conclusions

The OFS is a significant predictor of short-term postoperative mortality in patients with hip fracture that outperforms, or performs on par with, all other investigated indices.

Level of evidence

Level III, Prognostic and Epidemiological.

The significance of direct transportation to a trauma center on survival for severe traumatic brain injury

INTRODUCTION

While timely specialized care can contribute to improved outcomes following traumatic brain injury (TBI), this condition remains the most common cause of post-injury death worldwide. The purpose of this study was to investigate the difference in mortality between regional trauma centers in Sweden (which provide neurosurgical services round the clock) and non-trauma centers, hypothesizing that 1-day and 30-day mortality will be lower at regional trauma centers.

PATIENTS AND METHODS

This retrospective cohort study used data extracted from the Swedish national trauma registry and included adults admitted with severe TBI between January 2014 and December 2018. The cohort was divided into two subgroups based on whether they were treated at a trauma center or non-trauma center. Severe TBI was defined as a head injury with an AIS score of 3 or higher. Poisson regression analyses with both univariate and multivariate models were performed to determine the difference in mortality risk [Incidence Rate Ratio (IRR)] between the subgroups. As a sensitivity analysis, the inverse probability of treatment weighting (IPTW) method was used to adjust for the effects of confounding.

RESULTS

A total of 3039 patients were included. Patients admitted to a trauma center had a lower crude 30-day mortality rate (21.7 vs. 26.4% days, p = 0.006). After adjusting for confounding variables, patients treated at regional trauma center had a 28% [adj. IRR (95% CI): 0.72 (0.55-0.94), p = 0.015] decreased risk of 1-day mortality and an 18% [adj. IRR (95% CI): 0.82 (0.69-0.98)] reduction in 30-day mortality, compared to patients treated at a non-trauma center. After adjusting for covariates in the Poisson regression analysis performed after IPTW, admission and treatment at a trauma center were associated with a 27% and 17% reduction in 1-day and 30-day mortality, respectively.

CONCLUSION

For patients suffering a severe TBI, treatment at a regional trauma center confers a statistically significant 1-day and 30-day survival advantage over treatment at a non-trauma center.

What trauma patients need: the European dilemma

There is a need for implementation and maturation of an inclusive trauma system in every country in Europe, with patient centered care by dedicated surgeons. This process should be initiated by physicians and medical societies, based on the best available evidence, and supported and subsequently funded by the government and healthcare authorities. A systematic approach to organizing all aspects of trauma will result in health gain in terms of quality of care provided, higher survival rates, better functional outcomes and quality of life. In addition, it will provide reliable data for both research, quality improvement and prevention programs. Severely injured patients need surgeons with broad technical and non-technical competencies to provide holistic, inclusive and compassionate care. Here we describe the philosophy of the surgical approach and define the necessary skills for trauma, both surgical and other, to improve outcome of severely injured patients. As surgery is an essential part of trauma care, surgeons play an important role for the optimal treatment of trauma patients throughout and after their hospital stay, including the intensive care unit (ICU). However, in most European countries, it might not be obvious to either the general public, patients or even the physicians that the surgeon must assume this responsibility in the ICU to optimize outcomes. The aim of this paper is to define key elements in terms of trauma systems, trauma-specific surgical skills and active critical care involvement, to organize and optimize trauma care in Europe.

Statin Therapy Is Associated With Decreased 90-Day Postoperative Mortality After Colon Cancer Surgery

BACKGROUND

There have been conflicting reports regarding a protective effect of statin therapy after colon cancer surgery.

OBJECTIVE

This study aimed to evaluate the association between statin therapy and the postoperative mortality following elective colon cancer surgery.

DESIGN

This population-based cohort study is a retrospective analysis of prospectively collected data from the Swedish Colorectal Cancer Register.

SETTINGS

Patient inclusion was achieved through a nationwide register.

PATIENTS

All adult patients undergoing elective surgery for colon cancer between January 2007 and September 2016 were included in the study. Patients who had received and collected a prescription for statins pre- and postoperatively were allocated to the statin-positive cohort.

MAIN OUTCOME MEASURES

The primary and secondary outcomes of interest were 90-day all-cause mortality and 90-day cause-specific mortality.

RESULTS

A total of 22,337 patients underwent elective surgery for colon cancer during the study period, of whom 6,494 (29%) were classified as statin users. Statin users displayed a significant survival benefit despite being older, having a higher comorbidity burden, and being less fit for surgery. Multivariate analysis illustrated significant reductions in the incidence risk for 90-day all-cause mortality (Incidence Rate Ratio = 0.12, p < 0.001) as well as 90-day cause-specific deaths due to sepsis, due to multiorgan failure, or resulting from a cardiovascular and respiratory origin.

LIMITATIONS

The limitations of this study include its observational retrospective design, restricting the ability to perform standardized follow-up of statin therapy. Confounding from other uncontrolled variables cannot be excluded.

CONCLUSIONS

Statin users had a significant postoperative benefit regarding short-term mortality following elective colon cancer surgery in the current study; however, further research is needed to ascertain whether this relationship is causal. See Video Abstract at http://links.lww.com/DCR/B738.

LA TERAPIA CON ESTATINAS SE ASOCIA CON UNA DISMINUCIN DE LA MORTALIDAD POSOPERATORIA A LOS DAS DESPUS DE LA CIRUGA DE CNCER DE COLON

ANTECEDENTES:Ha habido informes contradictorios con respecto al efecto protector de la terapia con estatinas después de la cirugía de cáncer de colon.OBJETIVO:Este estudio tuvo como objetivo evaluar la asociación entre la terapia con estatinas y la mortalidad postoperatoria después de la cirugía electiva por cáncer de colon.DISEÑO:Este estudio de cohorte poblacional es un análisis retrospectivo de datos recopilados prospectivamente del Registro Sueco de Cáncer Colorrectal.AJUSTES:La inclusión de pacientes se logró mediante la inclusión a través de un registro a nivel nacional.PACIENTES:Se incluyeron en el estudio todos los pacientes adultos sometidos a cirugía electiva por cáncer de colon en el período de enero de 2007 y septiembre de 2016. Los pacientes que habían recibido y recogido una receta de estatinas antes y después de la operación fueron asignados a la cohorte positiva de estatinas.PRINCIPALES MEDIDAS DE DESENLACES:Los desenlaces primarios y secundarios de interés fueron la mortalidad por cualquier causa a los 90 días y la mortalidad por causas específicas a los 90 días.RESULTADOS:Un total de 22.337 pacientes se sometieron a cirugía electiva por cáncer de colon durante el período de estudio, de los cuales 6.494 (29%) se clasificaron como usuarios de estatinas. Los usuarios de estatinas mostraron un beneficio significativo en la supervivencia a pesar de ser mayores, de tener una mayor carga de comorbilidad y de estar menos acondicionado para la cirugía. El análisis multivariado ilustró reducciones significativas en el riesgo de incidencia de mortalidad por cualquier causa a 90 días (índice de tasa de incidencia = 0,12, p < 0,001), así como muertes específicas ena 90 días debidas a sepsis, falla multiorgánica o dea enfermedades de origen cardiovascular y respiratorio.LIMITACIONES:Las limitaciones de este estudio incluyen su diseño observacional retrospectivo, que restringe la capacidad de realizar un seguimiento estandarizado de la terapia con estatinas. No se puede excluir confusión a partir de otras variables no controladas.CONCLUSIONES:Los usuarios de estatinas tuvieron un beneficio posoperatorio significativo con respecto a la mortalidad a corto plazo después de cirugía electiva por cáncer de colon en el estudio actual, sin embargo, se necesita más investigación para confirmar si eexiste una relación es causal. Consulte Video Resumen en http://links.lww.com/DCR/B738.

OUP accepted manuscript

Background

Healthcare requires patient feedback to improve outcomes and experience. This study undertook a systematic review of the depth, variability, and digital suitability of current patient-reported outcome measures (PROMs) in patients undergoing laparoscopic cholecystectomy.

Methods

A PROSPERO-registered (registration number CRD42021261707) systematic review was undertaken for all relevant English language articles using PubMed version of MEDLINE, Scopus, and Web of Science electronic databases in June 2021. The search used Boolean operators and wildcards and included the keywords: laparoscopic cholecystectomy AND patient outcome OR patient-reported outcome OR patient-reported outcome measure OR PRO OR PROM. Medical Subjects Heading terms were used to search PubMed and Scopus. Articles published from 1 January 2011 to 2 June 2021 were included.

Results

A total of 4960 individual articles were reviewed in this study, of which 44 were found to evaluate PROMs in patients undergoing laparoscopic cholecystectomy and underwent methodological index for non-randomized studies (MINORS) grading. Twenty-one articles spanning 19 countries and four continents met all inclusion criteria and were included in the qualitative data synthesis. There was significant heterogeneity in PROMs identified with eight different comprehensive PROM tools used in the 21 studies. There was wide variation in the time points at which PROMs were recorded. Fourteen of 21 studies recorded PROMs before and after surgery, and 7 of 21 recorded PROMs only after surgery. Follow-up intervals ranged from 3 days to 2 years after surgery.

Conclusions

This study identified that while post-laparoscopic cholecystectomy PROMs are infrequently measured currently, tools are widely available to achieve this in clinical practice. PROMs may not capture all the outcomes but should be incorporated into future cholecystectomy outcome research. The EQ-5D™ (EuroQoL Group, Rotterdam, the Netherlands) provides a simple platform for the modern digital era.

The interaction between pre-admission β-blocker therapy, the Revised Cardiac Risk Index, and mortality in geriatric hip fracture patients

BACKGROUND

An association between β-blocker (BB) therapy and a reduced risk of major cardiac events and mortality in patients undergoing surgery for hip fractures has previously been demonstrated. Furthermore, a relationship between an increased Revised Cardiac Risk Index (RCRI) score and a higher risk of postoperative mortality has also been detected. The purpose of the current study was to investigate the interaction between BB therapy and RCRI in relation to 30-day postoperative mortality in geriatric patients after hip fracture surgery.

METHODS

All patients older than 65 years who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008, and December 31, 2017, except for pathological fractures, were included in this retrospective cohort study. Patients were divided into cohorts based on their RCRI score (RCRI 1, 2, 3, and ≥4) and whether they had ongoing BB therapy at the time of admission. A Poisson regression model with robust standard errors of variance was used, while adjusting for confounders, to evaluate the association between BB therapy, RCRI, and 30-day mortality.

RESULTS

A total of 126,934 cases met the study inclusion criteria. β-Blocker therapy was associated with a 65% decrease in the risk of 30-day postoperative mortality in the whole study population (adjusted incidence rate ratio [95% confidence interval], 0.35 [0.32-0.38]; p < 0.001). The use of BB also resulted in a significant reduction in 30-day postoperative mortality within all RCRI cohorts. However, the most pronounced effect of BB therapy was seen in patients with an RCRI score greater than 0.

CONCLUSION

β-Blocker therapy is associated with a reduction in 30-day postoperative mortality, irrespective of RCRI score. Furthermore, patients with an elevated cardiac risk appear to have a greater benefit of BB therapy.

LEVEL OF EVIDENCE

Therapeutic/care management, level II.

Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index

PURPOSE

Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients.

METHODS

All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference.

RESULTS

259,399 patients met the study's inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01-1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05-1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11-1.90), p = 0.006], compared to RCRI 0.

CONCLUSION

An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population.

The consequences of out-of-hours hip fracture surgery: insights from a retrospective nationwide study

Purpose

The study aimed to investigate the association between out-of-hours surgery and postoperative mortality in hip fracture patients. Furthermore, internal fixation and arthroplasty were compared to determine if a difference could be observed in patients operated with these techniques at different times during the day.

Methods

All patients above 18 of age years in Sweden who underwent hip fracture surgery between 2008 and 2017 were eligible for inclusion. Pathological fractures, non-operatively managed fractures, or cases whose time of surgery was missing were excluded. The cohort was subdivided into on-hour (08:00–17:00) and out-of-hours surgery (17:00–08:00). Poisson regression with adjustments for confounders was used to evaluate the association between out-of-hours surgery and both 30-day and 90-day postoperative mortality.

Results

Out-of-hours surgery was associated with a 5% increase in the risk of both 30-day [adj. IRR (95% CI) 1.05 (1.00–1.10), p = 0.040] and 90-day [adj. IRR (95% CI) 1.05 (1.01–1.09), p = 0.005] mortality after hip fracture surgery compared to on-hour surgery. There was no statistically significant association between out-of-hours surgery and postoperative mortality among patients who received an internal fixation. Arthroplasties performed out-of-hours were associated with a 13% increase in 30-day postoperative mortality [adj. IRR (95% CI) 1.13 (1.04–1.23), p = 0.005] and an 8% increase in 90-day postoperative mortality [adj. IRR (95% CI) 1.08 (1.01–1.15), p = 0.022] compared to on-hour surgery.

Conclusion

Out-of-hours surgical intervention is associated with an increase in both 30- and 90-day postoperative mortality among hip fracture patients who received an arthroplasty, but not among patients who underwent internal fixation.

The Association Between Revised Cardiac Risk Index and Postoperative Mortality Following Elective Colon Cancer Surgery: A Retrospective Nationwide Cohort Study

INTRODUCTION

Despite improvements in the perioperative care during the last decades for oncologic colon resection, there is still a substantial risk for postoperative complications and mortality. Opportunities exist for improvement in preoperative risk stratification in this patient population. We hypothesize that the Revised Cardiac Risk Index, a user-friendly tool, could better identify patients with high postoperative mortality risks.

METHODS

A retrospective analysis of operated patients between the years 2007 and 2017 was undertaken, using the prospectively recorded Swedish Colorectal Cancer Registry, which has a 99.5% national coverage for all cases of colon cancer. Patients were cross-referenced with the Swedish National Board of Health and Welfare dataset, a government registry of mortality and comorbidity data. Revised Cardiac Risk Index (RCRI) scores were calculated for each patient and stratified into four groups (RCRI 1, 2, 3, ⩾ 4). A Poisson regression model with robust standard errors of variance was employed to correlate the 90-day postoperative survival with each level of the Revised Cardiac Risk Index.

RESULTS

A total of 24,198 patients met the study inclusion criteria. 90-day postoperative mortality increased from 2.4% in patients with RCRI 1 to 10.1% in patients with RCRI ⩾ 4 (p < 0.001). Adjusted 90-day postoperative mortality increased linearly with an increasing RCRI, where an RCRI of 2, 3, and ≥ 4 respectively led to a 46%, 80%, and 167% increased risk of mortality compared to RCRI 1 (p < 0.001).

CONCLUSIONS

A strong association between an increasing Revised Cardiac Risk Index score and increased 90-day postoperative mortality risk was detected. The Revised Cardiac Risk Index may facilitate risk stratification of patients undergoing elective colon cancer surgery.

Statin Use and Long-Term Mortality after Rectal Cancer Surgery

BACKGROUND

The current study aimed to assess the association between regular statin therapy and postoperative long-term all-cause and cancer-specific mortality following curative surgery for rectal cancer. The hypothesis was that statin exposure would be associated with better survival.

METHODS

Patients with stage I-III rectal cancer undergoing surgical resection with curative intent were extracted from the nationwide, prospectively collected, Swedish Colorectal Cancer Register (SCRCR) for the period from January 2007 and October 2016. Patients were defined as having ongoing statin therapy if they had filled a statin prescription within 12 months before and after surgery. Cox proportional hazards models were employed to investigate the association between statin use and postoperative five-year all-cause and cancer-specific mortality.

RESULTS

The cohort consisted of 10,743 patients who underwent a surgical resection with curative intent for rectal cancer. Twenty-six percent (n = 2797) were classified as having ongoing statin therapy. Statin users had a considerably decreased risk of all-cause (adjusted hazard ratio (HR) 0.66, 95% confidence interval (CI): 0.60-0.73, p < 0.001) and cancer-specific (adjusted HR 0.60, 95% CI: 0.47-0.75, p < 0.001) mortality up to five years following surgery.

CONCLUSIONS

Statin use was associated with a lower risk of both all-cause and rectal cancer-specific mortality following curative surgical resections for rectal cancer. The findings should be confirmed in future prospective clinical trials.

Postoperative mortality in hip fracture patients stratified by the Revised Cardiac Risk Index: a Swedish nationwide retrospective cohort study

Objectives

The Revised Cardiac Risk Index (RCRI) is a tool that can be used to evaluate the 30-day risk of postoperative myocardial infarction, cardiac arrest and mortality. This study aims to confirm its association with postoperative mortality in patients who underwent hip fracture surgery.

Methods

All adults who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017 were included in this study. The database was retrieved by cross-referencing the Swedish National Quality Register for hip fractures with the Swedish National Board of Health and Welfare registers. The outcomes of interest were the association between the RCRI score and mortality at 30 days, 90 days and 1 year postoperatively.

Results

134 915 cases were included in the current study. There was a statistically significant linear trend in postoperative mortality with increasing RCRI scores at 30 days, 90 days and 1 year. An RCRI score ≥4 was associated with a 3.1 times greater risk of 30-day postoperative mortality (adjusted incidence rate ratio (IRR) 3.13, p<0.001), a 2.5 times greater risk of 90-day postoperative mortality (adjusted IRR 2.54, p<0.001) and a 2.8 times greater risk of 1-year postoperative mortality (adjusted HR 2.81, p<0.001) compared with that observed with an RCRI score of 0.

Conclusion

An increasing RCRI score is strongly associated with an elevated risk 30-day, 90-day and 1-year postoperative mortality after primary hip fracture surgery. The objective and easily retrievable nature of the variables included in the RCRI calculation makes it an appealing choice for risk stratification in the clinical setting.

Levels of evidence

Level III.

Beta-Blocker Therapy Is Associated With Increased 1-Year Survival After Hip Fracture Surgery: A Retrospective Cohort Study

The high mortality rates seen within the first postoperative year after hip fracture surgery have remained relatively unchanged in many countries for the past 15 years. Recent investigations have shown an association between beta-blocker (BB) therapy and a reduction in risk-adjusted mortality within the first 90 days after hip fracture surgery. We hypothesized that preoperative, and continuous postoperative, BB therapy may also be associated with a decrease in mortality within the first year after hip fracture surgery.

Cardiac risk stratification in emergency resection for colonic tumours

Background

Despite advances in perioperative care, the postoperative mortality rate after emergency oncological colonic resection remains high. Risk stratification may allow targeted perioperative optimization and cardiac risk stratification. This study aimed to test the hypothesis that the Revised Cardiac Risk Index (RCRI), a user-friendly tool, could identify patients who would benefit most from perioperative cardiac risk mitigation.

Methods

Patients who underwent emergency resection for colonic cancer from 2007 to 2017 and registered in the Swedish Colorectal Cancer Registry (SCRCR) were analysed retrospectively. These patients were cross-referenced by social security number to the Swedish National Board of Health and Welfare data set, a government registry of mortality, and co-morbidity data. RCRI scores were calculated for each patient and correlated with 90-day postoperative mortality risk, using Poisson regression with robust error of variance.

Results

Some 5703 patients met the study inclusion criteria. A linear increase in crude 90-day postoperative mortality was detected with increasing RCRI score (37.3 versus 11.3 per cent for RCRI 4 or more versus RCRI 1; P < 0.001). The adjusted 90-day all-cause mortality risk was also significantly increased (RCRI 4 or more versus RCRI 1: adjusted incidence rate ratio 2.07, 95 per cent c.i. 1.49 to 2.89; P < 0.001).

Conclusion

This study documented an association between increasing cardiac risk and 90-day postoperative mortality. Those undergoing emergency colorectal surgery for cancer with a raised RCRI score should be considered high-risk patients who would most likely benefit from enhanced postoperative monitoring and critical care expertise.

Patients over 65 years with Acute Complicated Calculous Biliary Disease are Treated Differently-Results and Insights from the ESTES Snapshot Audit

BACKGROUND

Accrued comorbidities are perceived to increase operative risk. Surgeons may offer operative treatments less often to their older patients with acute complicated calculous biliary disease (ACCBD). We set out to capture ACCBD incidence in older patients across Europe and the currently used treatment algorithms.

METHODS

The European Society of Trauma and Emergency Surgery (ESTES) undertook a snapshot audit of patients undergoing emergency hospital admission for ACCBD between October 1 and 31 2018, comparing patients under and ≥ 65 years. Mortality, postoperative complications, time to operative intervention, post-acute disposition, and length of hospital stay (LOS) were compared between groups. Within the ≥ 65 cohort, comorbidity burden, mortality, LOS, and disposition outcomes were further compared between patients undergoing operative and non-operative management.

RESULTS

The median age of the 338 admitted patients was 67 years; 185 patients (54.7%) of these were the age of 65 or over. Significantly fewer patients ≥ 65 underwent surgical treatment (37.8% vs. 64.7%, p < 0.001). Surgical complications were more frequent in the ≥ 65 cohort than younger patients, and the mean postoperative LOS was significantly longer. Postoperative mortality was seen in 2.2% of patients ≥ 65 (vs. 0.7%, p = 0.253). However, operated elderly patients did not differ from non-operated in terms of comorbidity burden, mortality, LOS, or post-discharge rehabilitation need.

CONCLUSIONS

Few elderly patients receive surgical treatment for ACCBD. Expectedly, postoperative morbidity, LOS, and the requirement for post-discharge rehabilitation are higher in the elderly than younger patients but do not differ from elderly patients managed non-operatively. With multidisciplinary perioperative optimization, elderly patients may be safely offered optimal treatment.

TRIAL REGISTRATION

ClinicalTrials.gov (Trial # NCT03610308).

β-Adrenergic blockade in patients with dementia and hip fracture is associated with decreased postoperative mortality

Purpose

Dementia, present in 20% of hip fracture patients, is associated with an almost threefold increase in postoperative mortality risk. These patients have a substantially higher incidence of cardiovascular, respiratory, and cerebrovascular mortality after hip fracture surgery compared to patients without dementia. This study aimed to investigate the association between beta-blocker therapy and postoperative mortality in patients with dementia undergoing hip fracture surgery.

Methods

This nationwide study included all patients in Sweden with the diagnosis of dementia who underwent emergency surgery for a hip fracture between January 2008 and December 2017. Cases where the hip fracture was pathological or conservatively managed were not included. Poisson regression analysis with robust standard errors was performed while controlling for confounders to determine the relationship between beta-blocker therapy and all-cause, as well as cause-specific, postoperative mortality.

Results

A total of 26,549 patients met the study inclusion criteria, of whom 8258 (31%) had ongoing beta-blocker therapy at time of admission. After adjusting for clinically relevant variables, the incidence of postoperative mortality in patients receiving beta-blocker therapy was decreased by 50% at 30 days [adj. IRR (95% CI) 0.50 (0.45–0.54), p < 0.001] and 34% at 90 days [adj. IRR (95% CI) 0.66 (0.62–0.70), p < 0.001]. Cause-specific mortality analysis demonstrated a significant reduction in the incidence of postoperative cardiovascular, respiratory, and cerebrovascular death within 30 and 90 days postoperatively.

Conclusion

Beta-blocker therapy is associated with decreased postoperative mortality in hip fracture patients with dementia up to 90 days after surgery. This finding warrants further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01723-y.

Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study

Background

Epidural analgesia (EA) has been the standard of care after major abdominal surgery for many years. This study aimed to correlate EA with postoperative complications, short- and long-term mortality in patients with and without EA after open surgery (OS) and minimally invasive surgery (MIS) for colorectal cancer.

Methods

Patient, clinical and outcome data were obtained from the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry. All adult patients diagnosed with colorectal cancer without metastases who underwent elective curative MIS or OS for colorectal cancer between January 2016 and December 2018 and who had data recorded in both registries, were included in the study. Data were analyzed for OS and MIS procedures separately. A Poisson regression model was used to investigate the association between EA and the outcomes of interest.

Results

Five thousand seven hundred sixty-two patients were included in the study, 2712 in the MIS and 3050 patients in the OS group. After adjusting for patient specific and clinically relevant variables in the regression model, no statistically significant difference in risk for complications; 30-day, 90-day, and up to 3-year mortality following either MIS or OS could be detected between the EA+ and EA-cohorts.

Conclusions

In this large study cohort, EA as part of the comprehensive care provided was not associated with a reduction in postoperative complications risk or improved 30-day, 90-day, or 3-year survival after MIS or OS for colorectal cancer.

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No reduction in postoperative complications with epidural analgesia.

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No reduction in short-term mortality with epidural analgesia after colorectal surgery.

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No reduction in long-term mortality with epidural analgesia in colorectal cancer.

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.

METHODS

Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1.

RESULTS

Twelve components of preoperative care were considered. Consensus was reached after three rounds.

CONCLUSIONS

These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.