Ambulatory management of gastrointestinal emergencies: what are the current literature data?

Proctologic emergency consultation during COVID-19: Comparative cross-sectional cohort study

INTRODUCTION

Proctologic issues entail a frequent reason for consultation in the emergency department (ED). We aim to analyze how the SARS-COV-2 pandemic has impacted in the demand for proctological consultations.

MATERIAL AND METHOD

Descriptive comparative retrospective study of cross-sectional cohorts of patients attending the ED for proctological complaints from March to April in 2020 and 2019. Demographic variables, comorbidities, reasons for consultation and diagnosis, treatment and readmission were included. Four periods were analyzed according to the different stages of the pandemic derived limitations.

RESULTS

A total of 191 patients were reviewed, 58 in 2020 and 133 in 2019 with an average age of 48 years (SD 20.1) and 112 (58.6%) males. The average number of daily consultations was 2.18 patients in 2019 versus 0.95 in 2020 (p=0.025) meaning a 56% reduction in consultations for proctological reasons. This difference in average consultations was significant in both periods of lockout (p=0.001) and previous de-escalation (p=0.014). The diagnosis distribution was similar between both periods; however, perianal abscesses doubled their rate in 2020, 22.4% versus 11.3% (p=0.045). There was an increasing need for surgery, 31% vs 15% (p=0.011) with no difference in outpatients regimen after emergency surgery (12.5% vs 7.5%, p=0.201). Three patients in 2020 required readmission to the ED (5.2% vs 12.9%, p=0.086).

CONCLUSION

There was a decrease of a 56% in proctologic emergency consultation, however, the need for surgery was twice more frequent during the study period. Reflection on the use of emergencies for proctological reasons is warranted.

Same-day discharge after appendectomy for acute appendicitis: a systematic review and meta-analysis

PURPOSE

Patients presenting with acute appendicitis are usually hospitalized for a few days for appendectomy and postoperative recovery. Shortening length of stay may reduce costs and improve patient satisfaction. The purpose of this study was to assess the safety of same-day discharge after appendectomy for acute appendicitis.

METHODS

A systematic review was performed according to PRISMA guidelines. A literature search of EMBASE, Ovid MEDLINE, Web of Science, Cochrane Central, and Google Scholar was conducted from inception to April 14, 2020. Two reviewers independently screened the literature and selected studies that addressed discharge on the same calendar day as the appendectomy. Risk of bias was assessed with the ROBINS-I tool. Main outcomes were hospital readmission, complications, and unplanned hospital visits in the postoperative course. A random effects model was used to pool risk ratios for the main outcomes.

RESULTS

Of the 1912 articles screened, 17 comparative studies and 8 non-comparative studies met the inclusion criteria. Most only included laparoscopic procedure for uncomplicated appendicitis. Most studies were considered at moderate or serious risk of bias. In meta-analysis, same-day discharge (vs. overnight hospitalization) was not associated with increased rates of readmission, complication, and unplanned hospital visits. Non-comparative studies demonstrated low rates of readmission, complications, and unplanned hospital visits after same-day discharge.

CONCLUSION

This study suggests that same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis is safe without an increased risk of readmission, complications, or unplanned hospital visits. Hence, same-day discharge may be further encouraged in selected patients.

TRIAL REGISTRATION

PROSPERO registration no. CRD42018115948.

Proctologic emergency consultation during COVID-19: Comparative cross-sectional cohort study

INTRODUCTION

Proctologic issues entail a frequent reason for consultation in the emergency department (ED). We aim to analyze how the SARS-COV-2 pandemic has impacted in the demand for proctological consultations.

MATERIAL AND METHOD

Descriptive comparative retrospective study of cross-sectional cohorts of patients attending the ED for proctological complaints from March to April in 2020 and 2019. Demographic variables, comorbidities, reasons for consultation and diagnosis, treatment and readmission were included. Four periods were analyzed according to the different stages of the pandemic derived limitations.

RESULTS

A total of 191 patients were reviewed, 58 in 2020 and 133 in 2019 with an average age of 48 years (SD 20.1) and 112 (58.6%) males. The average number of daily consultations was 2.18 patients in 2019 versus 0.95 in 2020 (p=0.025) meaning a 56% reduction in consultations for proctological reasons. This difference in average consultations was significant in both periods of lockout (p=0.001) and previous de-escalation (p=0.014). The diagnosis distribution was similar between both periods; however, perianal abscesses doubled their rate in 2020, 22.4% versus 11.3% (p=0.045). There was an increasing need for surgery, 31% vs 15% (p=0.011) with no difference in outpatients regimen after emergency surgery (12.5% vs 7.5%, p=0.201). Three patients in 2020 required readmission to the ED (5.2% vs 12.9%, p=0.086).

CONCLUSION

There was a decrease of a 56% in proctologic emergency consultation, however, the need for surgery was twice more frequent during the study period. Reflection on the use of emergencies for proctological reasons is warranted.

Current and Projected Financial Burden of Emergency General Surgery for Adults in Scotland's Single Payer Healthcare System: A Cost Analysis of Hospital Admissions

OBJECTIVE

To calculate the current and projected financial burden of EGS hospital admissions in a single-payer healthcare system.

SUMMARY OF BACKGROUND DATA

EGS is an important acute care service, which demands significant healthcare resources. EGS admissions and associated costs have increased over time, associated with an aging demographic. The National Health Service is the sole provider of emergency care in Scotland.

METHODS

Principal, high and low Scottish population projections were obtained for 2016 until 2041. EGS admission data were projected using an ordinary least squares linear regression model. An exponential function, fitted to historical length of hospital stay (LOS) data, was used to project future LOS. Historical hospital unit cost per bed day was projected using a linear regression model. EGS cost was calculated to 2041 by multiplying annual projections of population, admission rates, LOS, and cost per bed day.

RESULTS

The adult (age >15) Scottish population is projected to increase from 4.5 million to 4.8 million between 2016 and 2041. During this time, EGS admissions are expected to increase from 83,132 to 101,090 per year, cost per bed day from £786 to £1534, and overall EGS cost from £187.3 million to £202.5 million.

CONCLUSIONS

The future financial burden of EGS in Scotland is projected to increase moderately between 2016 and 2041. This is in sharp contrast to previous studies from settings such as the United States. However, if no further reductions in LOS or cost per bed day are made, especially for elderly patients, the cost of EGS will rise dramatically.

Surgeon's Definition of Complicated Appendicitis: A Prospective Video Survey Study

Aim

Definition of the type of appendicitis is based on examination of the peritoneum and appendix. Gomes et al. proposed a laparoscopic grading system of acute appendicitis (grades 1 and 2, noncomplicated appendicitis, grade 3-5 complicated appendicitis). The aim of this study was to evaluate the reproducibility of this score.

Patients and methods

All patients managed for acute appendicitis between January 2016 and June 2016 were included in this single-center prospective study. Laparoscopic appendectomy procedures were filmed by analogy to Sugerbaker's peritoneal carcinomatosis score (9 quadrants, all of the abdomen was filmed). The videos were then analyzed by seven staff surgeons blinded to each other and the operative report. The primary endpoint was to determine the concordance between staff surgeons for grading of appendicitis using the laparoscopic grading system of acute appendicitis described by Gomes et al.

Results

A total of 40 patients were included in this study. A concordance was observed between the seven staff surgeons in 85% of cases. For regional peritonitis, the mean ± (SD) number of quadrants in which the staff surgeons reported signs of peritonitis was 1.44 ± 0.63. For diffuse peritonitis, the mean (SD) number of quadrants in which the staff surgeons reported signs of peritonitis was 2.59 ± 0.51. On ROC curve analysis, two quadrants was the best cut-off between grade 4B (local peritonitis) and five (diffuse peritonitis) acute appendicitis (AUC = 0.92, Se = 100%, Sp = 92%, p = 0.005).

Conclusion

The classification used to determine the type of appendicitis is reproducible.

Clinical significance

To give a definition of complicated appendicitis.

How to cite this article

Mariage M, Sabbagh C, et al. Surgeon's Definition of Complicated Appendicitis: A Prospective Video Survey Study. Euroasian J Hepatogastroenterol 2019;9(1):1-4.

Should ambulatory appendectomy become the standard treatment for acute appendicitis?

Background

Appendectomy is increasingly performed as a 'short stay' or 'ambulatory' procedure, yet there is no consensus for selection of patients with acute appendicitis for ambulatory surgery (AS). We aimed to compare characteristics and outcomes of complicated and uncomplicated appendectomies performed in ambulatory vs. conventional settings, and to determine factors associated with unexpected re-consultations and re-hospitalizations.

Methods

The authors reviewed a consecutive series of 185 laparoscopic appendectomies. Whenever possible, patients were offered AS, defined as 'discharge on the same working day.' Multivariable regressions were performed to determine associations of unexpected re-consultations and re-hospitalizations with surgery type (ambulatory or conventional) and patient characteristics (age, gender, obesity, symptoms, appendicolith, perforations, appendix diameter, serologic results, American Society of Anesthesiologists score, and Saint-Antoine score).

Results

From the initial cohort, 117 patients (63.2%) were eligible for AS, of which 8 had peri- or post-operative contraindications. Therefore, 109 patients (58.9%) were operated by AS, with median length of stay 8.5 h (range, 3.3-20.5). Ambulatory cases had a lower incidence of complications (11.9%) than conventional cases (25.0%) (p = 0.029). Uni- and multi-variable regressions revealed that unexpected re-consultations were not significantly associated with any of the pre- or peri-operative variables but that unexpected re-hospitalizations were 4 times more likely for patients with appendicolith (OR, 4.32; p = 0.04).

Conclusions

Ambulatory surgery could be considered as a standard procedure for both complicated and uncomplicated acute appendicitis. Appendicolith was found to be an independent risk factor for unexpected re-hospitalization and should therefore trigger closer monitoring.