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Becnel M, Danner I, Santos MDL, Escobedo LJ, Mohrbacher M, Young J, Patterson R. The utility of a CT grading scale in deciding on surgical intervention for patients with suspected small bowel obstruction. Surg Open Sci 2024; 20:70-76. [PMID: 38946861 PMCID: PMC11214169 DOI: 10.1016/j.sopen.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/09/2024] [Accepted: 05/24/2024] [Indexed: 07/02/2024] Open
Abstract
Background A grading system was developed for computerized tomography (CT) scans evaluating patients with suspected small bowel obstruction (SBO). We hypothesized that patients with a higher grade of suspected SBO on CT scan would be more likely to require surgical intervention. Methods Retrospective chart review of patients who presented to the Emergency Room (ER) who had a CT of the abdomen and pelvis for suspected SBO. Patients were divided into 5 groups: Grade 1 (SBO unlikely), Grade 2 (probable partial or early SBO), Grade 3 (probable high grade SBO), Grade 4 (SBO with changes concerning for ischemia) and Not Graded. Results The CT scans of 655 patients were graded. Of the 22 patients with a grade 1 SBO, only 1 went for surgery (4.5 %). For grade 2 patients, 23 out of 299 had an operation (7.7 %), for grade 3 it was 84 out of 299 (28.1 %) and for grade 4 SBO, 25 out of 35 patients (71.4 %) had surgery. The p value is <0.00001. The three most common intraoperative findings were SBO obstruction from adhesions alone (48 % of cases), followed by incarcerated hernias (12 %) and ischemic bowel (9 %). Only 8 cases out of 133 operations (6 % of total) had no findings at time of surgery other than dilated bowel. Conclusions The CT grading scale for SBO developed at our institution shows excellent correlation between grade and going for surgery, with few negative results, and can be a useful tool among other factors for general surgeons when deciding whether or not to operate on a patient with suspected SBO.
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Affiliation(s)
- Marianne Becnel
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Ikaikaolahui Danner
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Maria De Los Santos
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Lindsay J. Escobedo
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Marie Mohrbacher
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Jacob Young
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
| | - Robert Patterson
- Noorda College of Osteopathic Medicine, 2162 South 180 East, Provo, UT 84606, USA
- Intermountain Health American Fork Hospital, 170 N 1100 E, American Fork, UT 84043, USA
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Eze VN, Parry T, Boone D, Mallett S, Halligan S. Prognostic factors to identify resolution of small bowel obstruction without need for operative management: systematic review. Eur Radiol 2024; 34:3861-3871. [PMID: 37938387 PMCID: PMC11166786 DOI: 10.1007/s00330-023-10421-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/06/2023] [Accepted: 09/24/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES To identify imaging, clinical, and laboratory variables potentially prognostic for surgical management of small bowel obstruction. METHODS Two researchers systematically reviewed indexed literature 2001-2021 inclusive for imaging, clinical, and laboratory variables potentially predictive of surgical management of small bowl obstruction and/or ischaemia at surgery, where performed. Risk of bias was assessed. Contingency tables for variables reported in at least 5 studies were extracted and meta-analysed to identify strong evidence of association with clinical outcomes, across studies. RESULTS Thirty-one studies were ultimately included, reporting 4638 patients (44 to 313 per study). 11 (35%) studies raised no risk of bias concerns. CT was the modality reported most (29 studies, 94%). Meta-analysis of 21 predictors identified 5 strongly associated with surgical intervention, 3 derived from CT (peritoneal free fluid, odds ratio [OR] 3.24, 95%CI 2.45 to 4.29; high grade obstruction, OR 3.58, 95%CI 2.46 to 5.20; mesenteric inflammation, OR 2.61, 95%CI 1.94 to 3.50; abdominal distension, OR 2.43, 95%CI 1.34 to 4.42; peritonism, OR 3.97, 95%CI 2.67 to 5.90) and one with conservative management (previous abdominopelvic surgery, OR 0.58, 95%CI 0.40 to 0.85). Meta-analysis of 10 predictors identified 3 strongly associated with ischaemia at surgery, 2 derived from CT (peritoneal free fluid, OR 3.49, 95%CI 2.28 to 5.35; bowel thickening, OR 3.26 95%CI 1.91 to 5.55; white cell count, OR 4.76, 95%CI 2.71 to 8.36). CONCLUSIONS Systematic review of patients with small bowel obstruction identified four imaging, three clinical, and one laboratory predictors associated strongly with surgical intervention and/or ischaemia at surgery. CLINICAL RELEVANCE STATEMENT Via systematic review and meta-analysis, we identified imaging, clinical, and laboratory predictors strongly associated with surgical management of small bowel obstruction and/or ischaemia. Multivariable model development to guide management should incorporate these since they display strong evidence of potential utility. KEY POINTS • While multivariable models incorporating clinical, laboratory, and imaging factors could predict surgical management of small bowel obstruction, none are used widely. • Via systematic review and meta-analysis we identified imaging, clinical, and laboratory variables strongly associated with surgical management and/or ischaemia at surgery. • Development of multivariable models to guide management should incorporate these predictors, notably CT scanning, since they display strong evidence of potential utility.
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Affiliation(s)
- Vivienne N Eze
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Tom Parry
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Darren Boone
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Sue Mallett
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Steve Halligan
- Centre for Medical Imaging, University College London UCL, Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK.
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Talwar G, McKechnie T, Patel J, Qiu R, Wu K, Lee Y, Hong D, Doumouras A, Bogach J, Eskicioglu C. Assessing the Modified Frailty Index and Post-Operative Outcomes in Adhesive Small Bowel Obstruction: A Retrospective Cohort Study. J Surg Res 2024; 297:71-82. [PMID: 38447338 DOI: 10.1016/j.jss.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/18/2023] [Accepted: 12/16/2023] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Studies identifying predictors of postoperative outcomes in adhesive small bowel obstruction are limited. This study investigates the efficacy of the modified frailty index (mFI)to predict postoperative morbidity and mortality among patients undergoing surgery for adhesive small bowel obstruction. METHODS A multicentre retrospective cohort study including patients undergoing surgery for adhesive small bowel obstruction after failed trial of nonoperative management between January 2015 and December 2020 was performed. Impact of frailty status using the mFI, stratified as frail (≥0.27) and robust (<0.27), on postoperative morbidity, mortality, length of stay, and discharge destination was evaluated using multiple logistic regression. RESULTS Ninety-two robust patients (mean age 62.4 y, 68% female) and 41 frail patients (mean age 81.7 y, 63% female) were included. On simple stratification, frail patients had significantly increased 30-d morbidity (overall morbidity 80% versus 49%) and need for higher level of care on discharge (41% versus 9%). However, on multiple regression, functional dependence but not the mFI, was independently associated with worse 30-d overall morbidity (odds ratio [OR] 3.97, confidence interval [CI] 1.29-12.19) and lower likelihood of returning to preoperative disposition (OR 0.21, CI 0.05-0.91). The delay in operation beyond 5 d was independently associated with worse 30-d outcomes including overall morbidity and mortality (OR 7.54, CI 2.13-26.73) and decreased return to preoperative disposition (OR 0.14, CI 0.04-0.56). CONCLUSIONS The mFI, although promising, was not independently predictive of outcomes following surgery for adhesive small bowel obstruction. Further adequately powered studies are required.
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Affiliation(s)
- Gaurav Talwar
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Janhavi Patel
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Reva Qiu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kathy Wu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Aristithes Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Jessica Bogach
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
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Talwar G, McKechnie T, Lee Y, Kazi T, El-Sayes A, Bogach J, Hong D, Eskicioglu C. Modified frailty index predicts postoperative morbidity in adhesive small bowel obstruction: analyzing the National Inpatient Sample 2015-2019. J Gastrointest Surg 2024; 28:205-214. [PMID: 38445910 DOI: 10.1016/j.gassur.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/08/2023] [Accepted: 10/25/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND There are limited data identifying predictors of postoperative outcomes in adhesive small bowel obstruction (ASBO). This study used the National Inpatient Sample (NIS) to assess the efficacy of the modified frailty index (mFI) to predict postoperative morbidity among patients undergoing an operation for ASBO. METHODS A retrospective analysis of the NIS between September 1, 2015, and December 31, 2019, was performed to identify adult patients who underwent nonelective operative intervention for ASBO. The mFI was used to stratify patients as either frail (mFI value ≥ 0.27) or robust (mFI value < 0.27). The primary outcomes were overall in-hospital postoperative morbidity and mortality. The secondary outcomes were system-specific morbidity, length of stay (LOS), total in-hospital healthcare cost, and discharge disposition. Univariable and multivariable regressions were used. RESULTS Overall, 23251 robust patients and 6122 frail patients were included. Adjusted analyses demonstrated that frail patients had increased in-hospital mortality (adjusted odds ratio [aOR], 2.16; 95% CI, 1.80-2.60), postoperative morbidity (aOR, 1.63; 95% CI, 1.52-1.74), postoperative LOS (adjusted mean difference [aMD], 0.97 days; 95% CI, 0.73-1.21), and total in-hospital healthcare costs (aMD, $18,921; 95% CI, $14,608-$23,235) and were less likely to be discharged home (aOR, 0.59; 95% CI, 0.55-0.63). The findings were unchanged on subgroup analysis of patients undergoing open operation and those older than 65 years of age. CONCLUSION The mFI may predict postoperative outcomes for ASBO. Stratifying patients based on frailty may assist clinicians and patients in making informed decisions, setting realistic expectations, and proactively planning postoperative disposition.
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Affiliation(s)
- Gaurav Talwar
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tania Kazi
- Faculty of Health Sciences Undergraduate Medical Education, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Abdullah El-Sayes
- Faculty of Health Sciences Undergraduate Medical Education, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Bogach
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, Juravinski Hospital, Hamilton, Ontario, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, Department of Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
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Wassmer CH, Revol R, Uhe I, Chevallay M, Toso C, Gervaz P, Morel P, Poletti PA, Platon A, Ris F, Schwenter F, Perneger T, Meier RP. A new clinical severity score for the management of acute small bowel obstruction in predicting bowel ischemia: a cohort study. Int J Surg 2023; 109:1620-1628. [PMID: 37026805 PMCID: PMC10389338 DOI: 10.1097/js9.0000000000000171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/28/2022] [Indexed: 04/08/2023]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a nonviable small bowel remains a challenge. Through a prospective cohort study, the authors aimed to validate risk factors and scores for intestinal resection, and to develop a practical clinical score designed to guide surgical versus conservative management. PATIENTS AND METHODS All patients admitted for an acute SBO between 2004 and 2016 in the center were included. Patients were divided in three categories depending on the management: conservative, surgical with bowel resection, and surgical without bowel resection. The outcome variable was small bowel necrosis. Logistic regression models were used to identify the best predictors. RESULTS Seven hundred and thirteen patients were included in this study, 492 in the development cohort and 221 in the validation cohort. Sixty-seven percent had surgery, of which 21% had small bowel resection. Thirty-three percent were treated conservatively. Eight variables were identified with a strong association with small bowel resection: age 70 years of age and above, first episode of SBO, no bowel movement for greater than or equal to 3 days, abdominal guarding, C-reactive protein greater than or equal to 50, and three abdominal computer tomography scanner signs: small bowel transition point, lack of small bowel contrast enhancement, and the presence of greater than 500 ml of intra-abdominal fluid. Sensitivity and specificity of this score were 65 and 88%, respectively, and the area under the curve was 0.84 (95% CI: 0.80-0.89). CONCLUSION The authors developed and validated a practical clinical severity score designed to tailor management of patients presenting with an SBO.
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Affiliation(s)
| | - Rebecca Revol
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Isabelle Uhe
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Mickaël Chevallay
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Christian Toso
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Pascal Gervaz
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Philippe Morel
- Department of Surgery, University Hospitals of Geneva and Medical School
| | | | | | - Frederic Ris
- Department of Surgery, University Hospitals of Geneva and Medical School
| | - Frank Schwenter
- Department of Surgery, Montreal University Hospital CHUM, Université de Montréal, Montréal, Quebec, Canada
| | - Thomas Perneger
- Division of Clinical Epidemiology, Faculty of Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
| | - Raphael P.H. Meier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Maraux L, Dammaro C, Gaillard M, Lainas P, Derienne J, Maitre S, Chague P, Rocher L, Dagher I, Tranchart H. Predicting the Need for Surgery in Uncomplicated Adhesive Small Bowel Obstruction: A Scoring Tool. J Surg Res 2022; 279:33-41. [PMID: 35717794 DOI: 10.1016/j.jss.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 03/08/2022] [Accepted: 05/22/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Nonoperative treatment can be attempted for uncomplicated adhesive small bowel obstruction (ASBO), but carries a risk of delayed surgery. Highlighting initial parameters predicting risk of failure of nonoperative management would be of great interest. METHODS Patients initially managed conservatively for uncomplicated ASBO were retrospectively analyzed. Univariate and multivariate analysis were performed to identify predictive failure's factors. Based on the risk factors, a score was created and then prospectively validated in a different patients' population. RESULTS Among 171 patients included, 98 (57.3%) were successfully managed conservatively. In a multivariate analysis, three independent nonoperative management failure's factors were identified: Charlson Index ≥4 (P = 0.016), distal obstruction (P = 0.009), and maximum small bowel diameter over vertical abdominal diameter ratio >0.34 (P = 0.023). A score of two or three was associated with a risk of surgery of 51.4% or 70.3% in the retrospective analysis and 62.2% or 75% in the validation cohort, respectively. CONCLUSIONS This clinical-radiological score may help guide surgical decision-making in uncomplicated ASBO. A high score (≥2) was predictive of failure of nonoperative management. This tool could assist surgeons to determine who would benefit from early surgery.
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Affiliation(s)
- Lucien Maraux
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Carmelisa Dammaro
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Martin Gaillard
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Panagiotis Lainas
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Joseph Derienne
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Sophie Maitre
- Department of Radiology, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, Orsay, France
| | - Pierre Chague
- Department of Radiology, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, Orsay, France
| | - Laurence Rocher
- Department of Radiology, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, Orsay, France
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France
| | - Hadrien Tranchart
- Department of Minimally Invasive Digestive Surgery, Antoine-Béclère Hospital, Paris-Saclay University, Orsay, France.
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McFadden NR, Brown SK, Howard SM, Utter GH. Validity of the American Association for the Surgery of Trauma Intestinal Obstruction Grading System. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Aicher BO, Betancourt-Ramirez A, Grossman MD, Heise H, Schroeppel TJ, Hernandez MC, Zielinski MD, Kongkaewpaisan N, Kaafarani HMA, Wagner A, Grabo D, Scott M, Peck G, Chang G, Matsushima K, Cullinane DC, Cullinane LM, Stocker B, Posluszny J, Simonoski UJ, Catalano RD, Vasileiou G, Yeh DD, Agrawal V, Truitt MS, Pickett M, Dultz L, Muller A, Ong AW, San Roman JL, Barth N, Fackelmayer O, Velopulos CG, Hendrix C, Estroff JM, Gambhir S, Nahmias J, Jeyamurugan K, Bugaev N, O'Meara L, Kufera J, Diaz JJ, Bruns BR. Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study. Am Surg 2022; 88:953-958. [PMID: 35275764 DOI: 10.1177/0003134820960022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. METHODS Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. RESULTS There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. CONCLUSION The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.
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Affiliation(s)
- Brittany O Aicher
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | | | - Michael D Grossman
- Department of Surgery, Southside Hospital, Northwell Health, Bay Shore, Bay Shore, NY
| | - Holly Heise
- Department of Surgery, UCHealth Memorial Hospital Central Trauma Center, Colorado Springs, Colorado
| | - Thomas J Schroeppel
- Department of Surgery, UCHealth Memorial Hospital Central Trauma Center, Colorado Springs, Colorado
| | | | | | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Afton Wagner
- Department of Surgery, West Virginia University Medicine, Morgantown, West Virginia
| | - Daniel Grabo
- Department of Surgery, West Virginia University Medicine, Morgantown, West Virginia
| | - Michael Scott
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Gregory Peck
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Gloria Chang
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, California
| | | | | | - Benjamin Stocker
- Department of Surgery, Northwestern Memorial Hospital, Chicago, Illinois
| | - Joseph Posluszny
- Department of Surgery, Northwestern Memorial Hospital, Chicago, Illinois
| | - Ursula J Simonoski
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Richard D Catalano
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Georgia Vasileiou
- Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
| | - Daniel Dante Yeh
- Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
| | - Vaidehi Agrawal
- Department of Surgery, Methodist Dallas Medical Center, Dallas, Texas
| | - Michael S Truitt
- Department of Surgery, Methodist Dallas Medical Center, Dallas, Texas
| | - MaryAnne Pickett
- Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, Texas
| | - Linda Dultz
- Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, Texas
| | - Alison Muller
- Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | - Adrian W Ong
- Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | | | | | | | | | | | | | - Sahil Gambhir
- Department of Surgery, University of California, Irvine, Irvine, California
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Irvine, California
| | | | - Nikolay Bugaev
- Department of Surgery, Tufts University, Boston, Massachusetts
| | - Lindsay O'Meara
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Joseph Kufera
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Brandon R Bruns
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
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Scott JW, Staudenmayer K, Sangji N, Fan Z, Hemmila M, Utter G. Evaluating the association between American Association for the Surgery of Trauma emergency general surgery anatomic severity grades and clinical outcomes using national claims data. J Trauma Acute Care Surg 2021; 90:296-304. [PMID: 33214490 DOI: 10.1097/ta.0000000000003030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) encompasses a heterogeneous population of acutely ill patients, and standardized methods for determining disease severity are essential for comparative effectiveness research and quality improvement initiatives. The American Association for the Surgery of Trauma (AAST) has developed a grading system for the anatomic severity of 16 EGS conditions; however, little is known regarding how well these AAST EGS grades can be approximated by diagnosis codes in administrative databases. METHODS We identified adults admitted for 16 common EGS conditions in the 2012 to 2017q3 National Inpatient Sample. Disease severity strata were assigned using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes based on AAST EGS anatomic severity grades. We evaluated whether assigned EGS severity (multiple strata or dichotomized into less versus more complex) were associated with in-hospital mortality, complications, length of stay, discharge disposition, and costs. Analyses were adjusted for age, sex, comorbidities, hospital traits, geography, and year. RESULTS We identified 10,886,822 EGS admissions. The number of anatomic severity strata derived from ICD-9/10-CM codes varied by EGS condition and by year. Four conditions mapped to four strata across all years. Two conditions mapped to four strata with ICD-9-CM codes but only two or three strata with ICD-10-CM codes. Others mapped to three or fewer strata. When dichotomized into less versus more complex disease, patients with more complex disease had worse outcomes across all 16 conditions. The addition of multiple strata beyond a binary measure of complex disease, however, showed inconsistent results. CONCLUSION Classification of common EGS conditions according to anatomic severity is feasible with International Classification of Diseases codes. No condition mapped to five distinct severity grades, and the relationship between increasing grade and outcomes was not consistent across conditions. However, a standardized measure of severity, even if just dichotomized into less versus more complex, can inform ongoing efforts aimed at optimizing outcomes for EGS patients across the nation. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- John W Scott
- From the Department of Surgery (J.W.S., N.S., M.H.), and Center for Health Outcomes and Policy (J.W.S., N.S., Z.F., M.H.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (K.S.), Stanford University, Stanford; and Outcomes Research Group (G.U.), University of California Davis, Sacramento, California
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10
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Abstract
Nearly 3 million patients are hospitalized every year for emergent gastrointestinal (GI) surgical problems and nearly one third of those will require surgery. This article reviews the scope of GI surgical emergencies within the context of emergency general surgery (EGS), costs of care, overview of several common GI surgical problems, and traditional and emerging treatment modalities. This article also argues for ongoing work in the area of risk assessment for EGS, and describes quality metrics as well as outcomes of care for these patients.
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11
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Validation of the American Association for the Surgery of Trauma emergency general surgery grade for skin and soft tissue infection. J Trauma Acute Care Surg 2019; 84:939-945. [PMID: 29794690 DOI: 10.1097/ta.0000000000001860] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Skin and soft tissue infections (SSTIs) present with variable severity. The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery (EGS) grading system for several diseases. We aimed to determine whether the AAST EGS grade corresponds with key clinical outcomes. METHODS Single-institution retrospective review of patients (≥18 years) admitted with SSTI during 2012 to 2016 was performed. Patients with surgical site infections or younger than 18 years were excluded. Laboratory Risk Indicator for Necrotizing Fasciitis score and AAST EGS grade were assigned. The primary outcome was association of AAST EGS grade with complication development, duration of stay, and interventions. Secondary predictors of severity included tissue cultures, cross-sectional imaging, and duration of inpatient antibiotic therapy. Summary and univariate analyses were performed. RESULTS A total of 223 patients were included (mean ± SD age of 55.1 ± 17.0 years, 55% male). The majority of patients received cross sectional imaging (169, 76%) or an operative procedure (155, 70%). Skin and soft tissue infection tissue culture results included no growth (51, 24.5%), monomicrobial (83, 39.9%), and polymicrobial (74, 35.6%). Increased AAST EGS grade was associated with operative interventions, intensive care unit utilization, complication severity (Clavien-Dindo index), duration of hospital stay, inpatient antibiotic therapy, mortality, and hospital readmission. CONCLUSION The AAST EGS grade for SSTI demonstrates the ability to correspond with several important outcomes. Prospective multi-institutional study is required to determine its broad generalizability in several populations. LEVEL OF EVIDENCE Prognostic, level IV.
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13
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Abstract
INTRODUCTION Threatened, perforated, and infarcted bowel is managed with conventional resection and anastomosis (hand sewn [HS] or stapled [ST]). The SHAPES analysis demonstrated equivalence between HS and ST techniques, yet surgeons appeared to prefer HS for the critically ill. We hypothesized that HS is more frequent in patients with higher disease severity as measured by the American Association for the Surgery of Trauma Emergency General Surgery (AAST EGS) grading system. METHODS We performed a post hoc analysis of the SHAPES database. Operative reports were submitted by volunteering SHAPES centers. Final AAST grade was compared with various outcomes including duration of stay, physiologic/laboratory data, anastomosis type, anastomosis failure (dehiscence, abscess, or fistula), and mortality. RESULTS A total of 391 patients were reviewed, with a mean age (±SD) of 61.2 ± 16.8 years, 47% women. Disease severity distribution was as follows: grade I (n = 0, 0%), grade II (n = 106, 27%), grade III (n = 113, 29%), grade IV (n = 123, 31%), and grade V (n = 49, 13%). Increasing AAST grade was associated with acidosis and hypothermia. There was an association between higher AAST grade and likelihood of HS anastomosis. On regression, factors associated with mortality included development of anastomosis complication and vasopressor use but not increasing AAST EGS grade or anastomotic technique. CONCLUSION This is the first study to use standardized anatomic injury grades for patients undergoing urgent/emergent bowel resection in EGS. Higher AAST severity scores are associated with key clinical outcomes in EGS diseases requiring bowel resection and anastomosis. Anastomotic-specific complications were not associated with higher AAST grade; however, mortality was influenced by anastomosis complication and vasopressor use. Future EGS studies should routinely include AAST grading as a method for reliable comparison of injury between groups. LEVEL OF EVIDENCE Prognostic, level III.
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14
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Validation of a new American Association for the Surgery of Trauma (AAST) anatomic severity grading system for acute cholecystitis. J Trauma Acute Care Surg 2019; 84:650-654. [PMID: 29271871 DOI: 10.1097/ta.0000000000001762] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) established anatomic grading to facilitate risk stratification and risk-adjusted outcomes in emergency general surgery. Cholecystitis severity was graded based on clinical, imaging, operative, and pathologic criteria. We aimed to validate the AAST anatomic grading system for acute cholecystitis. METHODS This is a retrospective cohort study including consecutive patients admitted with acute cholecystitis at an urban, tertiary medical center between 2013 and 2016. Grade 1 is acute cholecystitis, Grade 2 is gangrenous or emphysematous cholecystitis, Grade 3 is localized perforation, and Grades 4 and 5 have regional and systemic peritonitis, respectively. Concordance between the AAST grade and outcome including mortality, length of stay (LOS), ICU use, readmission, and complications were assessed using logistic regression. RESULTS A total of 315 patients were included. There was very good inter-rater (two independent raters) reliability for anatomic grading, κ = 1.00, p < 0.005. The majority of patients were Grade 1 or Grade 2 (94%). Incidence of complications, LOS, ICU use, and any adverse event increased with increasing anatomic grade. When compared to Grade 1 disease, patients with Grade 2 were more likely to undergo cholecystectomy (OR 4.07 [1.93-8.56]). Grade 3 patients were at higher risk of adverse events (OR 3.83 [1.34-10.94]), longer LOS (OR 1.73 [1.03-2.92]), and ICU use (OR 8.07 [2.43-26.80]). CONCLUSIONS AAST severity scores were independently associated with clinical outcomes in patients with acute cholecystitis. Despite low-grade disease, complications were common, and therefore a refinement of the scoring system may be necessary for more granular prediction. LEVEL OF EVIDENCE Epidemiologic/prognostic, level III.
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15
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The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction. J Trauma Acute Care Surg 2019; 84:372-378. [PMID: 29117026 DOI: 10.1097/ta.0000000000001736] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study. METHODS Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed. RESULTS There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade. CONCLUSION The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms. LEVEL OF EVIDENCE Prognostic, level III.
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17
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Madni TD, Nakonezny PA, Barrios E, Imran JB, Clark AT, Taveras L, Cunningham HB, Christie A, Eastman AL, Minshall CT, Luk S, Minei JP, Phelan HA, Cripps MW. Prospective validation of the Parkland Grading Scale for Cholecystitis. Am J Surg 2019; 217:90-97. [DOI: 10.1016/j.amjsurg.2018.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/06/2018] [Accepted: 08/13/2018] [Indexed: 12/24/2022]
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18
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Hernandez MC, Birindelli A, Bruce JL, Buitendag JJP, Kong VY, Beuran M, Aho JM, Negoi I, Clarke DL, Di Saverio S, Zielinski MD. Application of the AAST EGS Grade for Adhesive Small Bowel Obstruction to a Multi-national Patient Population. World J Surg 2018; 42:3581-3588. [PMID: 29770872 DOI: 10.1007/s00268-018-4671-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) has demonstrated to be a valid tool in North American patient populations. Using a multi-national patient cohort, we retrospectively assessed the validity the AAST ASBO grading system and estimated disease severity in a global population in order to correlate with several key clinical outcomes. METHODS Multicenter retrospective review during 2012-2016 from four centers, Minnesota USA, Bologna Italy, Pietermaritzburg South Africa, and Bucharest Romania, was performed. Adult patients (age ≥ 18) with ASBO were identified. Baseline demographics, physiologic parameters, laboratory results, operative and imaging details, outcomes were collected. AAST ASBO grades were assigned by independent reviewers. Univariate and multivariable analyses with odds ratio (OR) and 95% confidence intervals (CIs) were performed. RESULTS There were 789 patients with a median [IQR] age of 58 [40-75] years; 47% were female. The AAST ASBO grades were I (n = 180, 23%), II (n = 443, 56%), III (n = 87, 11%), and IV (n = 79, 10%). Successful non-operative management was 58%. Conversion rate from laparoscopy to laparotomy was 33%. Overall mortality and complication and temporary abdominal closure rates were 2, 46, and 4.7%, respectively. On regression, independent predictors for mortality included grade III (OR 4.4 95%CI 1.1-7.3), grade IV (OR 7.4 95%CI 1.7-9.4), pneumonia (OR 5.6 95%CI 1.4-11.3), and failing non-operative management (OR 2.4 95%CI 1.3-6.7). CONCLUSION The AAST EGS grade can be assigned with ease at any surgical facility using operative or imaging findings. The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research. Disease severity and outcomes varied between countries. LEVEL OF EVIDENCE III Study type Retrospective multi-institutional cohort study.
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Affiliation(s)
- Matthew C Hernandez
- Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Arianna Birindelli
- Department of Surgery, Maggiore Hospital, Bologna, Italy
- Department of Surgery, NHS, Queen Elizabeth University Hospital, Birmingham, UK
| | - John L Bruce
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Johannes J P Buitendag
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Victory Y Kong
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Mircea Beuran
- Department of General Surgery, Emergency Hospital of Bucharest, Carol Davila University of Medicine and Pharmacy of Bucharest, Bucharest, Romania
| | - Johnathon M Aho
- Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ionut Negoi
- Department of General Surgery, Emergency Hospital of Bucharest, Carol Davila University of Medicine and Pharmacy of Bucharest, Bucharest, Romania
| | - Damian L Clarke
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Salomone Di Saverio
- Department of Surgery, Maggiore Hospital, Bologna, Italy
- Department of Surgery, NHS, Queen Elizabeth University Hospital, Birmingham, UK
- Addenbrookes Hospital, Cambridge University Hospitals, NHS, University of Cambridge, Cambridge, UK
| | - Martin D Zielinski
- Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Ozturk E, van Iersel M, Stommel MM, Schoon Y, Ten Broek RR, van Goor H. Small bowel obstruction in the elderly: a plea for comprehensive acute geriatric care. World J Emerg Surg 2018; 13:48. [PMID: 30377439 PMCID: PMC6196030 DOI: 10.1186/s13017-018-0208-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 09/24/2018] [Indexed: 12/16/2022] Open
Abstract
Small bowel obstruction is one of the most frequent emergencies in general surgery, commonly affecting elderly patients. Morbidity and mortality from small bowel obstruction in elderly is high. Significant progress has been made in the diagnosis and management of bowel obstruction in recent years. But little is known whether this progress has benefitted outcomes in elderly patients, particularly those who are frail or have a malignancy as cause of the obstruction, and when considering quality of life and functioning as outcomes. In this review, we discuss the specific challenges and needs of elderly in diagnosis and treatment of small bowel obstruction. We address quality of life aspects and explore how the concept of geriatric assessment can be utilized to improve decision-making and outcomes for elderly patients with a small bowel obstruction.
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Affiliation(s)
- Ekin Ozturk
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Marianne van Iersel
- 2Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn Mwj Stommel
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Yvonne Schoon
- 2Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands.,3Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard Rpg Ten Broek
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Harry van Goor
- 1Department of Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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20
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Bower KL, Lollar DI, Williams SL, Adkins FC, Luyimbazi DT, Bower CE. Small Bowel Obstruction. Surg Clin North Am 2018; 98:945-971. [PMID: 30243455 DOI: 10.1016/j.suc.2018.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.
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Affiliation(s)
- Katie Love Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA.
| | - Daniel I Lollar
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Sharon L Williams
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Farrell C Adkins
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - David T Luyimbazi
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Curtis E Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
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Ten Broek RPG, Krielen P, Di Saverio S, Coccolini F, Biffl WL, Ansaloni L, Velmahos GC, Sartelli M, Fraga GP, Kelly MD, Moore FA, Peitzman AB, Leppaniemi A, Moore EE, Jeekel J, Kluger Y, Sugrue M, Balogh ZJ, Bendinelli C, Civil I, Coimbra R, De Moya M, Ferrada P, Inaba K, Ivatury R, Latifi R, Kashuk JL, Kirkpatrick AW, Maier R, Rizoli S, Sakakushev B, Scalea T, Søreide K, Weber D, Wani I, Abu-Zidan FM, De'Angelis N, Piscioneri F, Galante JM, Catena F, van Goor H. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg 2018; 13:24. [PMID: 29946347 PMCID: PMC6006983 DOI: 10.1186/s13017-018-0185-2] [Citation(s) in RCA: 212] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023] Open
Abstract
Background Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups. Methods The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion. Recommendations Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention. Discussion This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.
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Affiliation(s)
- Richard P G Ten Broek
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.,39Department of Surgery, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Pepijn Krielen
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Walter L Biffl
- 4Acute Care Surgery, The Queen's Medical Center, Honolulu, Hawaii USA
| | - Luca Ansaloni
- 3General Emergency and Trauma Surgery, Bufalini hospital, Cesena, Italy
| | - George C Velmahos
- 5Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | | | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM), Unicamp Campinas, São Paulo, Brazil
| | | | | | - Andrew B Peitzman
- 10Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | | | | | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus Haifa, Haifa, Israel
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | - Zsolt J Balogh
- 16Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | | | - Ian Civil
- 18Department of Vascular and Trauma Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Raul Coimbra
- 19Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Mark De Moya
- Trauma, Acute Care Surgery Medical College of Wisconsin/Froedtert Trauma Center Milwaukee, Milwaukee, Wisconsin USA
| | - Paula Ferrada
- 21Virginia Commonwealth University, Richmond, VA USA
| | - Kenji Inaba
- 22Division of Trauma & Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA USA
| | - Rao Ivatury
- 21Virginia Commonwealth University, Richmond, VA USA
| | - Rifat Latifi
- 23Department of General Surgery, Westchester Medical Center, Westchester, NY USA
| | - Jeffry L Kashuk
- 24Department of General Surgery, Assuta Medical Centers, Tel Aviv, Israel
| | | | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Sandro Rizoli
- 27Trauma & Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Boris Sakakushev
- 28Department of General Surgery, University of Medicine Plovdiv, Plovdiv, Bulgaria
| | - Thomas Scalea
- 29R Adams Crowley Shock Trauma Center, University of Maryland, Baltimore, USA
| | - Kjetil Søreide
- 30Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,31Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Dieter Weber
- 32Department of General Surgery, Royal Perth Hospital, The University of Western Australia and The University of Newcastle, Perth, Australia
| | - Imtiaz Wani
- 33Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Fikri M Abu-Zidan
- 34Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Nicola De'Angelis
- 35Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | | | - Joseph M Galante
- 37Trauma and Acute Care Surgery and Surgical Critical Care Trauma, Department of Surgery, University of California, Davis, USA
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore hospital, Parma, Italy
| | - Harry van Goor
- 1Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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The American Association for the Surgery of Trauma Emergency General Surgery Anatomic Severity Scoring System as a predictor of cost in appendicitis. Surg Endosc 2018; 32:4798-4804. [PMID: 29777350 DOI: 10.1007/s00464-018-6230-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 05/09/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND The World Society for Emergency Surgery determined that for appendicitis managed with appendectomy, there is a paucity of evidence evaluating costs with respect to disease severity. The American Association for the Surgery of Trauma (AAST) disease severity grading system is valid and generalizable for appendicitis. We aimed to evaluate hospitalization costs incurred by patients with increasing disease severity as defined by the AAST. We hypothesized that increasing disease severity would be associated with greater cost. METHODS Single-institution review of adults (≥ 18 years old) undergoing appendectomy for acute appendicitis during 2010-2016. Demographics, comorbidities, operative details, hospital stay, complications, and institutional cost data were collected. AAST grades were assigned by two independent reviewers based on operative findings. Total cost was ascertained from billing data and normalized to median grade I cost. Non-parametric linear regression was utilized to assess the association of several covariates and cost. RESULTS Evaluated patients (n = 1187) had a median [interquartile range] age of 37 [26-55] and 45% (n = 542) were female. There were 747 (63%) patients with Grade I disease, 219 (19%) with Grade II, 126 (11%) with Grade III, 50 (4%) with Grade IV, and 45 (4%) with Grade V. The median normalized cost of hospitalization was 1 [0.9-1.2]. Increasing AAST grade was associated with increasing cost (ρ = 0.39; p < 0.0001). Length of stay exhibited the strongest association with cost (ρ = 0.5; p < 0.0001), followed by AAST grade (ρ = 0.39), Clavien-Dindo Index (ρ = 0.37; p < 0.0001), age-adjusted Charlson score (ρ = 0.31; p < 0.0001), and surgical wound classification (ρ = 0.3; p < 0.0001). CONCLUSIONS Increasing anatomic severity, as defined by AAST grade, is associated with increasing cost of hospitalization and clinical outcomes. The AAST grade compares favorably to other predictors of cost. Future analyses evaluating appendicitis reimbursement stand to benefit from utilization of the AAST grade.
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Younis M, Hernandez M, Ray-Zack M, Haddad NN, Choudhry A, Reddy P, Zielinski MD. Validation of AAST EGS Grade for Acute Pancreatitis. J Gastrointest Surg 2018; 22:430-437. [PMID: 29340918 DOI: 10.1007/s11605-017-3662-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 12/18/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods. METHODS Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014-1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems. RESULTS There were 297 patients with a mean (±SD) age of 55 ± 17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay. CONCLUSIONS The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system. LEVEL OF EVIDENCE IV Study Type: Single institutional retrospective review.
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Affiliation(s)
- Moustafa Younis
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Matthew Hernandez
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Mohamed Ray-Zack
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Nadeem N Haddad
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Asad Choudhry
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Pooja Reddy
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Martin D Zielinski
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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