Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg. 2015;261:619-629. [PMID: 25742461 DOI: 10.1097/sla.0000000000001180]

Laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma: Stratified analysis based on tumor burden score

The role of laparoscopic liver resection (LLR) for intrahepatic cholangiocarcinoma (ICC) remains debated. This study aimed to evaluate the short- and long-term outcomes of LLR vs. open liver resection (OLR) in ICC stratified by tumor burden score (TBS). ICC patients who underwent LLR or OLR were included from a multicenter database between July 2009 and October 2022. Patients were stratified into two cohorts based on whether the TBS was > 5.3. A 1:3 propensity score matching (PSM) analysis was performed between LLR and OLR in each cohort. Cox regression analysis was used to identify prognostic factors for ICC. A total of 626 patients were included in this study, 304 and 322 patients were classified into the low- and high-TBS groups, respectively. In the low-TBS group, after PSM, LLR was associated with less blood loss, lower CCI, fewer complications and shorter hospital stay (all p < 0.05). Kaplan-Meier curves revealed that LLR had better OS (p = 0.032). Multivariate Cox regression analysis showed that surgical procedure was an independent prognostic factor for ICC (HR: 0.445; 95% CI: 0.235-0.843; p = 0.013). In the high-TBS group, after PSM, LLR were associated with reduced blood loss, lower CCI, fewer complications and shorter hospital stay (all p < 0.05), while OS (p = 0.98) and DFS (p = 0.24) were similar between the two groups. TBS is an important prognostic factor for ICC. LLR is a safe and feasible option for ICC and leads to faster postoperative recovery. LLR can offer ICC a comparable and even better long-term prognosis than OLR.

Improving quality of care in traumatic spinal column/spinal cord injuries (TSC/SCI) in Iran: a policy brief

STUDY DESIGN

Descriptive study.

OBJECTIVES

The National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) is a registry system to survey Traumatic Spinal Column/Spinal Cord Injuries (TSC/SCIs) patients and obtain the required data for quality-of-care assessment.

SETTING

Iran.

METHODS

In 2022, the pre-hospital, in-hospital, and post-hospital Quality of Care (QoC) of registered patients with TSC/SCIs in 8 referral hospitals in Iran were studied.

RESULTS

Based on the study reports, TSCI/SCIs and their complication management were highly influenced by the health system's performance. In particular, the health system structure and medical process were identified to affect patient outcomes. According to the QoC study reports, several recommendations, including goal setting by emergency medical service providers to transport patients with possible spinal injury to first care facilities in <1 h and to an equipped care facility in <8 h, the dedication of operating room available 24/7 for patients with TSC/SCIs in referral centers, the distinction between early vs late surgery in patients with TSC/SCIs by healthcare insurance to increase the propensity for early surgery, operating a specialized SCI care unit with trained physicians and personnel in the management of acute complications following SCI and early rehabilitation in referral hospitals were specified.

CONCLUSION

This article provides a policy brief of this report. The role of the health system and medical process, as well as addressing TSC/SCIs health concerns by policymakers and stakeholders in the Ministry of Health and the parliament, to improve the QoC for patients with TSC/SCIs are discussed.

Clinical outcomes of the implementation of acute care surgery system in South Korea: a multi-centre, retrospective cohort study

BACKGROUND

In emergency general surgery (EGS), rapid judgement and prompt emergency surgery play a significant role in determining the patient's prognosis. This study aimed to evaluate whether implementing the acute care surgery (ACS) system in Korea has improved the clinical outcomes of patients.

METHODS

This retrospective cohort study was conducted at three tertiary hospitals in Korea. The study included patients aged 18-99 years who required EGS due to acute abdomen or abdominal trauma. A window period of 4 months was set after the implementation of the ACS system, and the clinical outcomes before and after the implementation were compared.

RESULTS

A total of 2146 patients were enrolled in the study, with 1008 in the pre-ACS group and 1138 in the post-ACS group. After propensity score matching, 901 patients were selected in the pre-ACS group and 906 patients were selected in the post-ACS group. The time from emergency room admission to operating room transfer was reduced in the post-ACS group, with a mean of 452.2 ± 347.0 min compared to 522.1 ± 416.5 min in the pre ACS group (P = 0.001). Moreover, the complication rates were reduced in the post-ACS group (38.3% vs. 31.3%, P = 0.006).

CONCLUSIONS

The implementation of the ACS system can lead to faster surgical decision-making and the prompt execution of emergency surgery for patients, thereby reducing postoperative complications.

Frailty and body composition predict adverse outcomes after emergency general surgery admission: a multicentre observational cohort study

INTRODUCTION

Emergency surgical admissions represent the most unwell patients admitted to any hospital. Frailty and body composition independently identify risk of adverse outcomes but are seldom combined to predict outcomes in emergency patients. We aim to determine the relationships between frailty, body composition analyses (BCA) and mortality in an undifferentiated emergency general surgical patient population.

METHOD

A prospective, multicentre observational cohort study of patients admitted with emergency surgical pathology was conducted in eight hospitals. BCA were performed at L3 vertebrae using computed tomography images to quantify sarcopenia and myosteatosis. Sex-specific BCA cut-off values were determined by our previous study. Reported Edmonton Frail Scale (REFS) values ≥8 identified frailty. The primary outcomes were all-cause 30-day and 1-year mortality. Multivariable logistic regression was utilised to explore predictive relationships between frailty, BCA, mortality and independent discharge.

RESULTS

A total of 194 patients were included; 24% were frail, 25% were sarcopenic and 23% myosteatotic. Some 61% of patients underwent an emergency laparotomy. Frail patients were more likely to be sarcopenic (20.4% vs 40.4%; p = 0.011) and myosteatotic (27.2% vs 51.1%; p = 0.004). Thirty-day and 1-year mortality was 5.2% and 15.5%, respectively; 30-day mortality was two times higher in the frail group (4.1% vs 8.5%; p = 0.414), and three times higher at 1 year (10.2% vs 31.9%; p = 0.001). Age (odds ratio [OR] 1.06; p = 0.001), sarcopenia (OR 2.88; p = 0.047) and frailty (OR 4.13; p = 0.001) were associated with 1-year mortality. Only 55.3% of frail patients were discharged home independently compared with 88.4% non-frail patients (p < 0.001). One-year mortality was greater in those with frailty and/or BCA abnormalities than in those without (28.8% vs 9.6%; p = 0.003).

CONCLUSION

Frailty, sarcopenia and myosteatosis contribute significantly to adverse outcomes.

STUDY REGISTRATION

NCT03534765.

Outcomes in emergency surgery following the implementation of an acute care surgery model: a retrospective observational study

Purpose

Over the past 3 years, approximately 23,000 emergency surgeries were performed annually in South Korea, accounting for >1% of all surgeries nationwide. With the growing necessity for treating these emergency cases with dedication and proficiency, acute care surgery (ACS) teams were appointed at various hospitals. Regarding the implications of the ACS team, many studies showed promising results with a shorter time from the emergency department (ED) to the operating room (OR), shorter length of stay, and fewer complications. This study aimed to demonstrate the overall effect of ACS implementation at a single institution in South Korea.

Methods

This was a single-center, retrospective observational study. Patients aged >18 years who visited the emergency room and received emergency surgery between July 2014 and December 2016 (pre-ACS) and between July 2017 and December 2019 (post-ACS) were included.

Results

Among 958 patients, 497 were in the pre-ACS group and 461 in the post-ACS group. After propensity score matching by age, sex, underlying disease, and Emergency Surgery Acuity Score, 405 patients remained in each group. Our analysis showed a reduction in time from ED presentation to operation (547.8 ± 401.0 minutes vs. 476.6 ± 313.2 minutes, P = 0.005) and complication rates (24.7% vs. 16.8%, P < 0.001) in the post-ACS group. There were no significant differences in total operation duration, length of hospital stay, and mortality between the groups.

Conclusion

As expected, time from ED to OR and complication rates were significantly reduced in the post-ACS group. Implementing an ACS team dedicated to emergency surgery provides better clinical outcomes.

Short-Term Surgical Outcomes After Robotic Liver Surgery: A Propensity-Score Matched Analysis With Conventional Open Liver Surgery at a High-Volume Centre in Denmark

BACKGROUND

The aim of this study was to investigate the perioperative outcomes of robotic liver surgery (RLS) and Open liver surgery (OLS) in a centre with a high number of operations.

METHODS

A 1:1 propensity score matched (PSM) analysis of a retrospective database of RLS and OLS was performed. Cumulative sum (CUSUM) analysis was performed to identify learning curves.

RESULT

After PSM analysis, operative time was significantly longer in the RLS group (p < 0.001). Estimated blood loss was significantly lower in the RLS group (p < 0.001). Transfusion rates were significantly lower in the RLS group. The length of hospital stay was shorter in the RLS group (3.5vs6.3 days, p < 0.001). Readmission rates were significantly lower in the RLS group (p < 0.049). CUSUM analysis showed a learning curve for at least 8 low-intermediate RLS procedures and 27 advanced-Expert RLS procedures.

CONCLUSIONS

RLS has many advantages, including being safe to perform, less blood loss and faster postoperative recovery compared with OLS.

The implementation of the acute care surgery model in the management of patients with acute appendicitis - A 5-year single-center, retrospective experience: An observational study

We conducted this study to assess the effects of the acute care surgery (ACS) model in the management of patients with acute appendicitis (AA) based on our 5-year single-center, retrospective experience. The current single-center, retrospective, observational study was conducted in a consecutive series of the patients with AA who had been surgically treated at a tertiary referral hospital in Seoul, Korea, between January 2016 and December 2020. At our institution, the ACS model was first introduced in March 2018. Therefore, our clinical series of the patients were divided into 2 groups: the pre-ACS group (March 2014 to February 2018) and the post-ACS group (March 2018 to December 2022). Key time intervals include emergency department registration to request for surgical consultation, request for surgical consultation to decision on surgery, decision-to-operating room, time to decision on surgery and length of emergency department stay. Moreover, outcomes include rates of perforation and complications and discharge within 24 or 48 hours. We compared key time intervals, outcomes, and length of hospital stay between the 2 groups. A total of 900 patients with AA were finally included in the current study, 447 and 453 of whom were divided into the pre-ACS group (n = 447) and the post-ACS group (n = 453), respectively. There were significant differences in key time intervals, outcomes, and length of hospital stay between the 2 groups (P < .05). In conclusion, our results showed that the implementation of the ACS model was effective in improving key time intervals, rates of perforation, and discharge within 24 or 48 hours in the patients with AA.

Management of acute perianal abscess: is surgeon specialization associated with improved outcomes?

BACKGROUND

Acute surgical units (ASU) are increasingly being adopted and in our system are staffed by colorectal and non-colorectal general surgeons. This study aims to evaluate whether surgeon specialization was associated with improved outcomes in perianal abscess.

METHODS

Patients with perianal abscess admitted to the ASU between 2016 and 2020 were identified from a prospective database and their medical records reviewed. Patients with IBD, treatment for fistula-in-ano within the preceding year, or perianal sepsis of non-cryptoglandular origin were excluded. Patients admitted under an ASU colorectal (CR) consultant were compared with those under a non-CR general surgeon in a retrospective cohort study. Primary outcome was perianal abscess recurrence. For those without initial fistula, hazard of recurrent abscess or fistula was analysed. Multivariable Cox PH regression analysis was performed.

RESULTS

Four-hundred and eight patients were included (150 CR, 258 non-CR). The CR group more frequently had a fistula identified at index operation (34.0% versus 10.9%, P < 0.0001). However, Cox multivariable analysis found no difference in hazard of recurrent abscess between groups (HR 1.12, 95% CI 0.65-1.95, P = 0.681)). Abscess recurred in 18.7% CR and 15.5% non-CR. Subsequent fistula developed in 14.7% in both groups. For patients without initial fistula, there was no difference between groups in hazard of recurrent abscess or fistula (HR 1.18, 95% CI 0.69-2.01, P = 0.539).

CONCLUSION

Surgeon specialization was not associated with improved outcomes for ASU patients with perianal abscess, albeit with potential selection bias. CR surgeons were more proactive identifying fistulas; this raises the possibility that drainage alone may be adequate treatment.

Missed nursing care in emergency departments: a cross-sectional descriptive study

BACKGROUND

Missed care refers to the omission or delay in performing any aspect of patient's care (either a part of the care or the entire care). Currently, missed care has become a growing concern at the international level, which threatens the quality and safety of care and cases many unwanted consequences. This study aims to investigate the frequency and types of missed nursing care in the emergency departments of selected hospitals affiliated to Tehran University of Medical Sciences.

METHODS

This is a cross-sectional and descriptive- observational study that was conducted with the aim of determining the frequency and types of missed nursing care in the emergency departments of selected hospitals affiliated to Tehran University of Medical Sciences from January 2020 to June 2020. The research community included all nursing care offered in the designated areas, as well as all nurses working in the emergency departments of selected hospitals. Finally, 146 nurses were selected by census method. The information was collected by self-reporting method and the researcher's observation. Demographic information questionnaire, a researcher-made checklist were used to determine the frequency and types of missed nursing care. 384 observations were made for each item. Descriptive statistics methods were used to analyze the data.

RESULTS

The area of checking equipment and emergency trolley(mean = 81.80) had the lowest and the area of patient communication(mean = 55.72) had the highest level of missed care.

CONCLUSIONS

The level of missed nursing care in the emergency departments of selected hospitals affiliated to Tehran University of Medical Sciences was found to be high and the highest amount was related to the field of communication with the patient. Therefore, it is recommended that the details of missed nursing care in each area should be considered by nursing managers.

The burden of the knowledge-to-action gap in acute appendicitis

BACKGROUND

The burden of emergency general surgery (EGS) is higher compared to elective surgery. Acute appendicitis (AA) is one of the most frequent diseases and its management is dictated by published international clinical practice guidelines (CPG). Adherence to CPG has been reported as heterogeneous. Barriers to clinical implementation were not studied. This study explored barriers to adherence to CPG and the clinico-economic impact of poor compliance.

METHODS

Data were extracted from the three-year data lock of the REsiDENT-1 registry, a prospective resident-led multicenter trial. We identified 7 items from CPG published from the European Association of Endoscopic Surgery (EAES) and the World Society of Emergency Surgery (WSES). We applied our classification proposal and used a five-point Likert scale (Ls) to assess laparoscopic appendectomy (LA) difficulty. Descriptive analyses were performed to explore compliance and group comparisons to assess the impact on outcomes and related costs. We ran logistic regressions to identify barriers and facilitators to implementation of CPG.

RESULTS

From 2019 to 2022, 653 LA were included from 24 centers. 69 residents performed and coordinated data collection. We identified low compliance with recommendations on peritoneal irrigation (PI) (25.73%), abdominal drains (AD) (34.68%), and antibiotic stewardship (34.17%). Poor compliance on PI and AD was associated to higher infectious complications in uncomplicated AA. Hospitalizations were significantly longer in non-compliance except for PI in uncomplicated AA, and costs significantly higher, exception made for antibiotic stewardship in complicated AA. The strongest barriers to CPG implementation were complicated AA and technically challenging LA for PI and AD. Longer operative times and the use of PI negatively affected antibiotic stewardship in uncomplicated AA. Compliance was higher in teaching hospitals and in emergency surgery units.

CONCLUSIONS

We confirmed low compliance with standardized items influenced by environmental factors and non-evidence-based practices in complex LA. Antibiotic stewardship is sub-optimal. Not following CPG may not influence clinical complications but has an impact in terms of logistics, costs and on the non-measurable magnitude of antibiotic resistance. Structured educational interventions and institutional bundles are required.

Robot-assisted minimally invasive liver surgery in elderly patients: A single-centre, propensity score- matched study

BACKGROUND

The aim was to evaluate the short-term results of robot-assisted minimally invasive liver surgery(Robot-assisted liver surgery (RLS)) in elderly patients.

METHODS

Between November 2019 and July 2022, RLS was performed on 100 consecutive patients. Patients were divided into a middle-aged group (Group1:＜75years) and an elderly group(Group2:≧75years). A propensity score matching(PSM) analysis with a ratio of 1:1 was performed.

RESULTS

After PSM, there were 28 patients in each group. There were no significant differences in clinicopathologic characteristics, type of resection and intraoperative variables. Postoperative complications and length of hospital stay were comparable in Groups 1 and 2. In a comparison between minor and major hepatectomy in Group 2, there were no significant differences in any of the factors.

CONCLUSIONS

The study showed that RLS for patients over 75years had similar short-term outcomes as for younger patients down to middle-aged, especially the risk of perioperative complications was comparable.

Effects of indocyanine green fluorescence imaging of laparoscopic anatomic liver resection for HCC: a propensity score-matched study

BACKGROUND

Recently, indocyanine green (ICG) fluorescence imaging has been increasingly used in laparoscopic anatomic liver resection. The aim of this study was to investigate the efficacy of ICG-guided laparoscopic anatomic liver resection in hepatocellular carcinoma (HCC) compared with traditional laparoscopic anatomic liver resection.

METHODS

A retrospective study was performed on patients with pathologically diagnosed HCC who successfully underwent laparoscopic anatomical liver resection from January 2019 to December 2021. The outcomes were compared between the two groups before and after the propensity score matching (PSM).

RESULTS

A total of 110 patients were included in this study, including 50 patients in the ICG-guided group and 60 patients in the traditional group. Compared with the traditional group, the ICG-guided group had a shorter operative duration (P = 0.040), less intraoperative blood loss (P = 0.044), a lower incidence of postoperative complications (P = 0.023), and a shorter postoperative hospitalisation (P < 0.001). After PSM, significant differences remained between the two groups for the duration of postoperative hospitalisation (P = 0.018) and postoperative complications (P = 0.042). There was no significant difference in the recurrence rate between the two groups before and after PSM.

CONCLUSION

Laparoscopic anatomic liver resection guided by ICG fluorescence imaging can reduce the duration of postoperative hospitalisation for patients and the incidence of postoperative complications. However, it has no impact on the long-term outcome of patients.

Clinical significance of acute care surgery system as a part of hospital medical emergency team for hospitalized patients

Purpose

Acute care surgery (ACS) has been practiced in several tertiary hospitals in South Korea since the late 2000s. The medical emergency team (MET) has improved the management of patients with clinical deterioration during hospitalization. This study aimed to identify the clinical effectiveness of collaboration between ACS and MET in hospitalized patients.

Methods

This was an observational before-and-after study. Emergency surgical cases of hospitalized patients were included in this study. Patients hospitalized in the Department of Emergency Medicine or Department of Surgery, directly comanaged by ACS were excluded. The primary outcome was in-hospital mortality rate. The secondary outcome was the alarm-to-operation interval, as recorded by a Modified Early Warning Score (MEWS) of >4.

Results

In total, 240 patients were included in the analysis (131 in the pre-ACS group and 109 in the post-ACS group). The in-hospital mortality rates in the pre- and post-ACS groups were 17.6% and 22.9%, respectively (P = 0.300). MEWS of >4 within 72 hours was recorded in 62 cases (31 in each group), and the median alarm-to-operation intervals of each group were 11 hours 16 minutes and 6 hours 41 minutes, respectively (P = 0.040).

Conclusion

Implementation of the ACS system resulted in faster surgical intervention in hospitalized patients, the need for which was detected early by the MET. The in-hospital mortality rates before and after ACS implementation were not significantly different.

The State of Global Trauma and Acute Care Surgery/Surgical Critical Care

Trauma is a leading cause of morbidity and mortality globally, with a significant burden attributable to the low- and middle-income countries (LMICs), where more than 90% of injury-related deaths occur. Road injuries contribute largely to the economic burden from trauma and are prevalent among adolescents and young adults. Trauma systems vary widely across the world in their capacity of providing basic and critical care to injured patients, with delays in treatment being present at multiple levels at LMICs. Strengthening existing systems by providing cost-effective and efficient solutions can help mitigate the injury burden in LMICs.

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

"Peas in a Pod": Clustering minorly injured trauma patients together during their hospitalization results in decreased hospital costs and fewer inpatient complications

BACKGROUND

Trauma patient care is complex. Clustering these patients within the hospital seems intuitive. This study's purpose was to explore the benefits of trauma patient clustering, hypothesizing these patients will have decreased costs and better outcomes.

METHODS

This was an analysis of all adult (18-99 years) trauma patients admitted from 1/2017-1/2019 without an intensive care unit stay. Patients were grouped into those admitted to the trauma unit (TU) versus non-trauma units (NTU). Outcomes evaluated between groups were baseline demographics, direct costs, complication rates (using our TQIP registry), and discharge location. T-test, median test, and chi squared test were used. Linear regression was performed. Significance was set at p < 0.05.

RESULTS

1481 patients (684 TU and 797 NTU) were analyzed. TU patients were younger. Injury Severity Score, mortality, and hospital length of stay were similar between groups. Direct hospital costs were decreased for TU patients ($4941(±$4740) versus $5639(±$4897), p = 0.006). Fewer TU patients experienced inpatient complications (7.8% versus 13.5%, p < 0.001). More TU patients were discharged to home (78.9% versus 73.8%, p = 0.02). Linear regression analysis demonstrated admission to NTUs predicted a direct cost increase of $766.35 (p < 0.001).

CONCLUSIONS

Clustering minorly injured trauma patients on a dedicated unit resulted in reduced costs, decreased complications, and higher likelihood for discharge to home.

Centralization of Major Trauma Influences Liver Availability for Transplantation in Northern Italy: Lesson Learned from COVID-19 Pandemic

Background: During the COVID-19 pandemic, the centralization of patients allowed trauma and transplants referral centers to continue their routine activity, ensuring the best access to health care. This study aims to analyze how the centralization of trauma is linked with liver allocation in Northern Italy. Methods: Cluster analysis was performed to generate patient phenotype according to trauma-related variables. Comparison between clusters was performed to evaluate differences in damage control strategy procedures (DCS) performed and the 30-day graft dysfunction. Results: During the pandemic period, the centralization of major trauma has deeply impaired the liver procurement and allocation between the transplant centers in the metropolitan area of Milan (Niguarda: 22 liver procurement; other transplant centers: 2 organ procurement). Two clusters were identified the in Niguarda’s series: cluster 1 is represented by 17 (27.4%) trauma donors, of which 13 (76.5%) were treated with DCS procedures, and 4 (23.5%) did not; cluster 2 is represented by 45 trauma donors (72.6%), of which 22 (48.8%) underwent DCS procedures. A significant difference was found in the number of DCS procedures performed between clusters (3.18 ± 2.255 vs. 1.11 ± 1.05, p = 0.0001). Comparative analysis did not significantly differ in the number of transplanted livers (cluster1/cluster2 94.1%/95.6% p = 0.84) and the 30-day graft dysfunction rate (cluster1/cluster2 0.0%/4.8% p = 0.34). Conclusions: The high level of care guaranteed by first-level trauma centers could reduce the loss of organs suitable for donation, maintaining the good outcomes of transplanted ones, even in case of multiple organ injuries. The pandemic period underlined that the centralization of major trauma impairs the liver allocation between transplant centers.

External Validation of Two Established Clinical Risk Scores Predicting Outcome after Local Treatment of Colorectal Liver Metastases in a Nationwide Cohort

Optimized surgical techniques and systemic therapy have increased the number of patients with colorectal liver metastases (CRLM) eligible for local treatment. To increase postoperative survival, we need to stratify patients to customize therapy. Most clinical risk scores (CRSs) which predict prognosis after CRLM resection were based on the outcome of studies in specialized centers, and this may hamper the generalizability of these CRSs in unselected populations and underrepresented subgroups. We aimed to externally validate two CRSs in a population-based cohort of patients with CRLM. A total of 1105 patients with local treatment of CRLM, diagnosed in 2015/2016, were included from a nationwide population-based database. Survival outcomes were analyzed. The Fong and more recently developed GAME CRS were externally validated, including in pre-specified subgroups (≤70/>70 years and with/without perioperative systemic therapy). The three-year DFS was 22.8%, and the median OS in the GAME risk groups (high/moderate/low) was 32.4, 46.7, and 68.1 months, respectively (p < 0.005). The median OS for patients with versus without perioperative therapy was 47.6 (95%CI [39.8, 56.2]) and 54.9 months (95%CI [48.8, 63.7]), respectively (p = 0.152), and for below/above 70 years, it was 54.9 (95%CI [49.3−64.1]) and 44.2 months (95%CI [37.1−54.3]), respectively (p < 0.005). The discriminative ability for OS of Fong CRS was 0.577 (95%CI [0.554, 0.601]), and for GAME, it was 0.596 (95%CI [0.572, 0.621]), and was comparable in the subgroups. In conclusion, both CRSs showed predictive ability in a population-based cohort and in predefined subgroups. However, the limited discriminative ability of these CRSs results in insufficient preoperative risk stratification for clinical decision-making.

Predictors of interhospital transfer delays in acute surgical patient deaths in Australia: a retrospective study

BACKGROUND

Interhospital transfers in Australia facilitate access to acute surgical services, however transfer delays can occur. The aims of this study were to examine Australian mortality audit data on acute surgical patients who were transferred after presenting with a surgical emergency, and to identify modifiable predictors of transfer delay.

METHODS

Surgical admissions between 1 January 2001 and 18 August 2020 were retrospectively extracted from the Australian and New Zealand Audit of Surgical Mortality database. Relevant factors and themes of interest were collated. Results were presented as odds ratios (OR) and 95% confidence intervals (CI), with statistical significance defined as P <0.05.

RESULTS

After exclusion, a final 8270 cases were analysed. Non-modifiable predictors identified were female gender (OR 1.34, 95% CI 1.05-1.70, P = 0.0184), comorbidities (OR 1.50, 95% CI 1.40-161, P <0.0001) and major non-trauma non-vascular specialty (OR 1.54 to 7.77, depending on specialty, P < 0.05). Modifiable predictors were inadequate clinical assessment (OR 49.48, 95% CI 32.91-74.38, P <0.0001), poor communication (OR 6.62, 95% CI 3.70-11.85, P <0.0001) and multiple transfers (OR 6.30, OR 95% 4.31-9.21, P <0.0001). Age, lack of bed and after-hours transfer did not predict transfer delays. Metropolitan transfers was protective against transfer delays (OR 0.64, 95% CI 0.47-0.86, P = 0.0035).

CONCLUSION

In the view of the receiving surgeon or assessor, all transfer delays potentially contributed to patient deaths, and may have been preventable. Strategies directed at modifiable factors could minimize delays. Increased surgical services in non-metropolitan regions could reduce need for transfer. Prospective data is required to examine if the same predictors are observed in surgical patients who survive.

The Impact of Concurrent Multi-Service Coverage on Quality and Safety in Trauma Care

BACKGROUND

At many trauma centers in the United States, one acute care surgeon is responsible for overnight coverage of both the emergency general surgery (EGS) and trauma services. The impact of this scheduling phenomenon on the quality and safety of trauma care has not been studied.

METHODS

Overnight (12:00 AM to 7:00 AM) trauma admissions to an academic Level 1 trauma center from 2013-2015 were studied after the institution adopted this scheduling phenomenon. Admissions were divided into two groups based on whether the admitting surgeon covered only the trauma service, or both the trauma and EGS services ("multi-service coverage"). Four major outcomes (e.g., mortality and complications), six quality metrics (e.g., time to first OR visit and unplanned transfers to the ICU), and procedural utilization patterns were compared.

RESULTS

A total of 1046 admissions were included. There were no differences in any major outcomes between the two exposure groups, including any National Trauma Data Bank-defined complication (OR 1.1, 95% CI 0.8-1.5, P= 0.5). Quality metrics dependent on the admitting surgeon remained unchanged, including attending presence at the highest-level trauma activations within 15 min of arrival (93% versus 86%, P= 0.07) and time to urgent operative intervention (68 min versus 82 min, P= 0.9). There were no differences in the number of laboratory and imaging studies (4.1 versus 4.1, P= 0.9) or bedside interventions (1.8 versus 2.1, P= 0.4) performed per patient by the admitting surgeon. Multivariate logistic regression did not identify multi-service coverage as an independent risk factor for adverse patient outcomes or quality metrics.

CONCLUSIONS

Trauma admissions under a surgeon covering multiple services simultaneously had similar outcomes, quality metrics, and procedural utilization patterns compared to trauma admissions under surgeons covering only the trauma service. Despite concerns that multiple-service coverage may overburden one acute care surgeon, time-dependent quality metrics and studies done during the initial workup of trauma patients remained unchanged. These findings suggest that simultaneous trauma and EGS service coverage by one acute care surgeon does not adversely impact trauma patient care.

Work Characteristics of Acute Care Surgeons at a Swiss Tertiary Care Hospital: A Prospective One-Month Snapshot Study

BACKGROUND

Multiple acute care surgery (ACS) working models have been implemented. To optimize resources and on-call rosters, knowledge about work characteristics is required. Therefore, this study aimed to investigate the daily work characteristics of ACS surgeons at a Swiss tertiary care hospital.

METHODS

Single-center prospective snapshot study. In February 2020, ACS fellows prospectively recorded their work characteristics, case volume and surgical case mix for 20 day shifts and 16 night shifts. Work characteristics were categorized in 11 different activities and documented in intervals of 30 min. Descriptive statistics were applied.

RESULTS

A total of 432.5 working hours (h) were documented and characterized. The three main activities 'surgery,' 'patient consultations' and 'administrative work' ranged from 30.8 to 35.9% of the documented working time. A total of 46 surgical interventions were performed. In total, during day shifts, there were 16 elective and 15 emergency interventions, during night shifts 15 emergency interventions. For surgery, two peaks between 10:00 a.m.-02:00 p.m. and 08:00 p.m.-11:00 p.m. were observed. A total of 225 patient were consulted, with a first peak between 08:00 a.m. and 11:00 a.m. and a second, wider peak between 02:00 p.m. and 02:00 a.m.

CONCLUSION

The three main activities 'surgery,' 'patient consultations' and 'administrative work' were comparable with approximately one third of the working time each. There was a bimodal temporal distribution for both surgery and patient consultations. These results may help to improve hospital resources and on-call rosters of ACS services.

Comparative Analysis of Models of Care and Its Impact on Emergency Cholecystectomy Outcomes

Background: The implementation of the acute surgical unit (ASU) model has been demonstrated to improve care outcomes for the emergency general surgery patient in comparison to the traditional "on call" model. Currently, only few studies have evaluated surgical outcomes of the ASU model in patients with acute biliary pathologies. This is the first comparative study of two different emergency surgery structures in the acute management of patients with acute cholecystitis and biliary colic. Methods: A retrospective review of patients who underwent emergency cholecystectomy for acute cholecystitis and biliary colic at two tertiary hospitals between April 2018 and March 2019 was conducted. Primary outcomes included length of hospital stay, time from admission to definitive surgery, and postoperative complications. Secondary outcomes include proportion of cases performed during daylight hours, length of operating time, rate of conversion to open cholecystectomy, and consultant surgeon involvement. Results: A total of 339 patients presented with acute biliary symptoms and were managed operatively. Univariate analysis identified a shorter mean time to surgery in the traditional group compared to the ASU group (29.2 hours versus 43.1 hours; P < .001). There was no difference in mean length of stay, operation duration between models, and postoperative complication rates between groups, with the majority of surgeries performed during daylight hours. The ASU group had a greater proportion of consultant-led cases (48.2% versus 2.5%, P < .001) compared to the traditional group. Conclusion: Patients with acute biliary pathology requiring laparoscopic cholecystectomy achieve equivalent surgical outcomes irrespective of the model of acute surgical care.

The acute surgical unit: An updated systematic review and meta-analysis

OBJECTIVE

To systematically review comparative studies on the acute surgical unit (ASU) model.

METHODS

Searches were performed of Cochrane, Embase, Medline and grey literature. Eligible articles were comparative studies of the Acute Surgical Unit (ASU) model published 01/01/2000-12/03/2020. Amongst patients with any diagnosis, primary outcomes were length of stay, after-hours operating, complications and cost. Secondary outcomes were time to surgical review, time to theatre, mortality and re-admission for patients with any diagnosis, and cholecystectomy during index admission for patients with biliary disease. Additional analyses were planned for specific cohorts, such as patients with appendicitis or cholecystitis.

RESULTS

Searches returned 9,677 results from which 77 eligible publications were identified, representing 150,981 unique patients. Cohorts were adequately homogenous for meta-analysis of all outcomes except cost. For patients with any diagnosis, compared with the Traditional model, the introduction of an ASU model was associated with reduced length of stay (mean difference [MD] 0.68 days; 95% confidence interval [CI] 0.38-0.98), after-hours operating rates (odds ratio [OR] 0.56; 95% CI 0.46-0.69) and complications (OR 0.48, 95% CI 0.33-0.70). Regarding cost, two studies reported savings following ASU introduction, while one found no difference. Amongst secondary outcomes, for patients with any diagnosis, ASU commencement was associated with reduced time to surgical review, time to theatre and mortality. Re-admissions were unchanged. For patients with biliary disease, ASU establishment was associated with superior rates of index cholecystectomy.

CONCLUSION

Compared to the Traditional structure, the ASU model is superior for most metrics. ASU introduction should be promoted in policy for widespread benefit.

Structures, processes and models of care for emergency general surgery in Ontario: a cross-sectional survey

BACKGROUND

Emergency general surgery (EGS) patients require urgent surgical evaluation and intervention for various conditions, such as infectious or obstructive diseases of the gastrointestinal tract. We aimed to characterize the structures and processes that are relevant to the delivery of EGS care across Ontario hospitals and to evaluate the availability of critical resources at hospitals with formal EGS models.

METHODS

Between August 2019 and July 2020, we conducted a cross-sectional survey of Ontario hospitals that offered urgent general surgery (defined as the ability to provide nonelective surgical intervention within 24 to 48 hours of presentation) to adults. People with intimate knowledge of their hospital's EGS program completed a Web-based or telephone survey characterizing the program's organizational structure and staffing, operating room availability, interventional radiology and interventional endoscopy availability, intensive care unit availability and staffing, and regional participation. Their responses were compiled and comparisons were made between hospitals with and without formal EGS models of care, as well as between hospitals based on size and academic status.

RESULTS

Of the 114 Ontario hospitals identified, 109 responded (95.6% response rate). A third (34.6%; n = 37/107) of hospitals had EGS models of care. Thirty-four of these (91.9%) were large (> 100-bed) institutions that would be likely to have increased resources. However, even for hospitals of similar size, those with EGS models had increased staffing levels compared to those without (clinical associates 17.6% [n = 3/17] v. 10.0% [n = 2/20]; nurse practitioners or physician assistants 27.8% [n = 5/18] v. 14.3% [n = 3/21]). They also had better access to diagnostic and interventional equipment (24/7 access to computed tomography 94.1% [n = 16/17] v. 69.2% [n = 18/26]), interventional radiology (88.9% [n = 16/18] v. 42.3% [n = 11/26]), endoscopy (100% [n = 18/18] v. 69.2% [n = 18/26]) and endoscopic retrograde cholangiopancreatography (77.8% [n = 14/18] v. 42.3% [n = 11/26]), as well as dedicated operating room time (72.2% [n = 13/18] v. 0% [n = 0/25]).

INTERPRETATION

The structures and processes available to care for patients requiring EGS in Ontario were highly variable between hospitals. Hospitals with formal EGS models were more likely to have access to key resources.

Impact of an Acute Care Surgery Model on the Management of Acute Appendicitis in South Korea: A Retrospective Cohort Study

Background

The acute care surgery (ACS) system is a new model for the prompt management of diseases that require rapid treatment in patients with acute abdomen. This study compared the outcomes and characteristics of the ACS system and traditional on-call system (TROS) for acute appendicitis in South Korea.

Methods

This single-center, retrospective study included all patients (aged ≥18 years) who underwent surgery for acute appendicitis in 2016 and 2018. The TROS and ACS system were used for the 2016 and 2018 groups, respectively. We retrospectively obtained data on each patient from the electrical medical records. The independent samples t-test and Mann-Whitney U-test were used for continuous and nonnormally distributed data, respectively.

Results

In total, 126 patients were included. The time taken to get from the emergency room admission to the operating room, operation times, and postoperative complication rates were similar between both groups. However, the length of the hospital stay was shorter in the ACS group than in the TROS group (4.3 ± 3.2 days vs. 7.2 ± 9.6 days, p=0.039).

Conclusions

Since the introduction of the ACS system, the length of hospital stay for surgical patients has decreased. This may be due to the application of an integrated medical procedure, such as a new clinical pathway, rather than differences in the surgical techniques.

Minimally invasive versus open radical resection surgery for hilar cholangiocarcinoma: Comparable outcomes associated with advantages of minimal invasiveness

Background

Minimally invasive surgery (MIS) provides a new approach for patients with hilar cholangiocarcinoma (HCCA). However, whether it can achieve similar outcomes to traditional open surgery (OS) remains controversial.

Methods

To assess the safety and feasibility of MIS for HCCA, a systematic review and meta-analysis was performed to compare the outcomes of MIS with OS. Seventeen outcomes were assessed.

Results

Nine studies involving 382 patients were included. MIS was comparable in blood transfusion rate, R0 resection rate, lymph nodes received, overall morbidity, severe morbidity (Clavien–Dindo classification > = 3), bile leakage rate, wound infection rate, intra-abdominal infection rate, days until oral feeding, 1-year overall survival, 2-year overall survival and postoperative mortality with OS. Although operation time was longer (mean difference (MD) = 93.51, 95% confidence interval (CI) = 64.10 to 122.91, P < 0.00001) and hospital cost (MD = 0.68, 95% CI = 0.03 to 1.33, P = 0.04) was higher in MIS, MIS was associated with advantages of minimal invasiveness, that was less blood loss (MD = -81.85, 95% CI = -92.09 to -71.62, P < 0.00001), less postoperative pain (MD = -1.21, 95% CI = -1.63 to -0.79, P < 0.00001), and shorter hospital stay (MD = -4.22, 95% CI = -5.65 to -2.80, P < 0.00001).

Conclusions

The safety and feasibility of MIS for HCCA is acceptable in selected patients. MIS is a remarkable alternative to OS for providing comparable outcomes associated with a benefit of minimal invasiveness and its application should be considered more.

How to Treat Hepatocellular Carcinoma in Elderly Patients

Hepatocellular carcinoma (HCC) is the primary tumour of the liver with the greatest incidence, particularly in the elderly. Additionally, improvements in the treatments for chronic liver diseases have increased the number of elderly patients who might be affected by HCC. Little evidence exists regarding HCC in old patients, and the elderly are still underrepresented and undertreated in clinical trials. In fact, this population represents a complex subgroup of patients who are hard to manage, especially due to the presence of multiple comorbidities. Therefore, the choice of treatment is mainly decided by the physician in the clinical practice, who often tend not to treat elderly patients in order to avoid the possibility of adverse events, which may alter their unstable equilibrium. In this context, the clarification of the optimal treatment strategy for elderly patients affected by HCC has become an urgent necessity. The aim of this review is to provide an overview of the available data regarding the treatment of HCC in elderly patients, starting from the definition of "elderly" and the geriatric assessment and scales. We explain the possible treatment choices according to the Barcelona Clinic Liver Cancer (BCLC) scale and their feasibility in the elderly population.

Acute Care Surgery Models Worldwide: A Systematic Review

Background

The Acute Care Surgery (ACS) model was developed as a dedicated service for the provision of 24/7 nontrauma emergency surgical care. This systematic review investigated which components are essential in an ACS model and the state of implementation of ACS models worldwide.

Methods

A literature search was conducted using PubMed, MEDLINE, EMBASE, Cochrane library, and Web of Science databases. All relevant data of ACS models were extracted from included articles.

Results

The search identified 62 articles describing ACS models in 13 countries. The majority consist of a dedicated nontrauma emergency surgical service, with daytime on-site attending coverage (cleared from elective duties), and 24/7 in-house resident coverage. Emergency department coverage and operating room access varied widely. Critical care is fully embedded in the original US model as part of the acute care chain (ACC), but is still a separate unit in most other countries. While in most European countries, ACS is not a recognized specialty yet, there is a tendency toward more structured acute care.

Conclusions

Large national and international heterogeneity exists in the structure and components of the ACS model. Critical care is still a separate component in most systems, although it is an essential part of the ACC to provide the best pre-, intra- and postoperative care of the physiologically deranged patient. Universal acceptance of one global ACS model seems challenging; however, a global consensus on essential components would benefit any healthcare system.

Developing a toolbox for identifying when to engage senior surgeons in emergency general surgery: A multicenter cohort study

BACKGROUND

Having a senior surgeon present for high-risk patients is an important safety measure in emergency surgery, but 24-h consultant cover is not efficient. We aimed to develop a user-friendly toolbox (risk identification, outcome prediction and patient stratification) to support when to involve a senior surgeon.

MATERIALS AND METHODS

We included 11,901 general surgery patients (10.0% emergencies) in a multicenter prospective cohort in China (2015-2016). Patient information and surgeons' seniority were compared between emergency and elective surgery with the same procedure codes. Risk indicators common in these two surgical timings and specific to emergency surgery were identified, and their clinical importance was evaluated by a working group of 48 experienced surgeons. Predictive models for mortality and morbidity were built using logistic regression models. Stratification rules were created to balance patients' risk and surgeons' caseload with an Acute Call Team (ACT) model.

RESULTS

Emergency patients had significantly higher risks of mortality (3.6% vs 0.6%) and morbidity (7.8% vs 4.3%) than elective patients, but disproportionally fewer senior surgeons (59.9% vs 91.4%) were present. Using three risk indicators (American Society of Anesthesiologists score, age, blood urea nitrogen), C-statistic (95% CI) for prediction of emergency mortality was high [0.90 (0.84-0.96)]. It was less complex but equally accurate as two existing and validated models (0.86 [0.79-0.93] and 0.86 [0.77-0.95]). Using five indicators, C-statistic (95% CI) was moderate for prediction of overall morbidity [0.77 (0.72-0.83)], but high for severe morbidity [0.92 (0.88-0.97)]. Based on stratification rules of the ACT model, patient mortality and morbidity were 0.5% and 5.3% in the low-risk stratum (composing 64.6% of emergency caseload), and 15.9% and 29.0% in the very high-risk stratum (6.9% of caseload).

CONCLUSION

These findings show the practical feasibility of using a risk assessment tool to direct senior surgeons' involvement in emergency general surgery.

Acute Care Surgery Service Is Essential During a Nonsurgical Catastrophic Event, the COVID-19 Pandemic

BACKGROUND

The role of an acute care surgery (ACS) service during the COVID-19 pandemic is not well established.

METHODS

A retrospective review of the ACS service performance in an urban tertiary academic medical center. The study was performed between January and May 2020. The demographics, clinical characteristics, and outcomes of patients treated by the ACS service 2 months prior to the COVID surge (pre-COVID group) and during the first 2 months of the COVID-19 pandemic (surge group) were compared.

RESULTS

Trauma and emergency general surgery volumes decreased during the surge by 38% and 57%, respectively; but there was a 64% increase in critically ill patients. The proportion of patients in the Department of Surgery treated by the ACS service increased from 40% pre-COVID to 67% during the surge. The ACS service performed 32% and 57% of all surgical cases in the Department of Surgery during the pre-COVID and surge periods, respectively. The ACS service managed 23% of all critically ill patients in the institution during the surge. Critically ill patients with and without confirmed COVID-19 infection treated by ACS and non-ACS intensive care units during the surge did not differ in demographics, indicators of clinical severity, or hospital mortality:13.4% vs. 13.5% (P = .99) for all critically ill patients; and 13.9% vs. 27.4% (P = .12) for COVID-19 critically ill patients.

CONCLUSION

Acute care surgery is an "essential" service during the COVID-19 pandemic, capable of managing critically ill nonsurgical patients while maintaining the provision of trauma and emergent surgical services.

LEVEL OF EVIDENCE

III.

STUDY TYPE

Therapeutic.

Simultaneous colorectal and parenchymal-sparing liver resection for advanced colorectal carcinoma with synchronous liver metastases: Between conventional and mini-invasive approaches

The optimal timing of surgery in case of synchronous presentation of colorectal cancer and liver metastases is still under debate. Staged approach, with initial colorectal resection followed by liver resection (LR), or even the reverse, liver-first approach in specific situations, is traditionally preferred. Simultaneous resections, however, represent an appealing strategy, because may have perioperative risks comparable to staged resections in appropriately selected patients, while avoiding a second surgical procedure. In patients with larger or multiple synchronous presentation of colorectal cancer and liver metastases, simultaneous major hepatectomies may determine worse perioperative outcomes, so that parenchymal-sparing LR should represent the most appropriate option whenever feasible. Mini-invasive colorectal surgery has experienced rapid spread in the last decades, while laparoscopic LR has progressed much slower, and is usually reserved for limited tumours in favourable locations. Moreover, mini-invasive parenchymal-sparing LR is more complex, especially for larger or multiple tumours in difficult locations. It remains to be established if simultaneous resections are presently feasible with mini-invasive approaches or if we need further technological advances and surgical expertise, at least for more complex procedures. This review aims to critically analyze the current status and future perspectives of simultaneous resections, and the present role of the available mini-invasive techniques.

The emergence of the physician assistant role in a Canadian acute care surgery setting

BACKGROUND

The role of physician assistants (PAs) in surgical care in Canada is expanding. Similarly, the acute care surgery (ACS) model continues to evolve, and PAs are increasingly being considered as members of ACS teams. However, their exact impact and contribution has not been well studied. Our study describes the contribution of a PA who worked full time on weekdays on an ACS team in a Canadian academic tertiary hospital.

METHODS

To quantify the PA's contributions, an ACS database was created in September 2016. Data on the number of ACS patient encounters, the number of ACS surgical consults, the number of ACS admissions, the PA's involvement in the operating room, the number of PA patient encounters and the number of multidisciplinary meetings were prospectively collected. We report data for 365 consecutive days from Dec. 30, 2016, to Dec. 29, 2017.

RESULTS

The ACS team had 11 651 patient encounters during the year, with a mean of 31.92 per day. The mean number of surgical consults per day was 5.89, and a mean of 2.08 surgical procedures were performed per day. The PA was involved in 53.5% of all patient encounters, despite working only during daytime hours on weekdays. Multidisciplinary meetings were conducted by the PA 94.9% of the time. Alternate level of care patients were seen by the PA 96.2% of the time. The PA was directly involved in 2.0% of the operating room procedures during the study period.

CONCLUSION

Integrating a PA on an ACS team adds value to patient care by providing consistency and efficient management of ward issues and patient care plans, including multidisciplinary discharge planning, timely emergency department consultations and effective organization of the ACS team members.

Identifying the fundamental structures and processes of care contributing to emergency general surgery quality using a mixed-methods Donabedian approach

BACKGROUND

Acute Care Surgery (ACS) was developed as a structured, team-based approach to providing round-the-clock emergency general surgery (EGS) care for adult patients needing treatment for diseases such as cholecystitis, gastrointestinal perforation, and necrotizing fasciitis. Lacking any prior evidence on optimizing outcomes for EGS patients, current implementation of ACS models has been idiosyncratic. We sought to use a Donabedian approach to elucidate potential EGS structures and processes that might be associated with improved outcomes as an initial step in designing the optimal model of ACS care for EGS patients.

METHODS

We developed and implemented a national survey of hospital-level EGS structures and processes by surveying surgeons or chief medical officers regarding hospital-level structures and processes that directly or indirectly impacted EGS care delivery in 2015. These responses were then anonymously linked to 2015 data from the American Hospital Association (AHA) annual survey, Medicare Provider Analysis and Review claims (MedPAR), 17 State Inpatient Databases (SIDs) using AHA unique identifiers (AHAID). This allowed us to combine hospital-level data, as reported in our survey or to the AHA, to patient-level data in an effort to further examine the role of EGS structures and processes on EGS outcomes. We describe the multi-step, iterative process utilizing the Donabedian framework for quality measurement that serves as a foundation for later work in this project.

RESULTS

Hospitals that responded to the survey were primarily non-governmental and located in urban settings. A plurality of respondent hospitals had fewer than 100 inpatient beds. A minority of the hospitals had medical school affiliations.

DISCUSSION

Our results will enable us to develop a measure of preparedness for delivering EGS care in the US, provide guidance for regionalized care models for EGS care, tiering of ACS programs based on the robustness of their EGS structures and processes and the quality of their outcomes, and formulate triage guidelines based on patient risk factors and severity of EGS disease.

CONCLUSIONS

Our work provides a template for team science applicable to research efforts combining primary data collection (i.e., that derived from our survey) with existing national data sources (i.e., SIDs and MedPAR).

Impact of anthropometric data on technical difficulty of laparoscopic liver of resections of segments 7 and 8: the CHALLENGE index

BACKGROUND

The high technical difficulty of using a laparoscopic approach to reach the posterosuperior liver segments is mainly associated with their poor accessibility. This study was performed to analyze correlations between anthropometric data and intraoperative outcomes.

STUDY DESIGN

All patients who underwent segmentectomy or wedge laparoscopic liver resection (LLR) of segments seven and/or eight from June 2012 to November 2019 were retrospectively analyzed. The exclusion criteria were intrahepatic cholangiocarcinoma, associated resection, multiple concomitant LLR, redo resection, and lack of preoperative imaging. Anthropometric data were correlated with intraoperative outcomes.

RESULTS

Forty-one patients (wedge resection, n = 32; segmentectomy, n = 9) were analyzed. A strong correlation was found between the craniocaudal liver diameter (CCliv) and liver volume (r = 0.655, p < 0.001). The anteroposterior liver diameter was moderately correlated with both the laterolateral abdominal diameter (LLabd) (r = 0.372, p = 0.008) and anteroposterior abdominal diameter (r = 0.371, p = 0.008). The body mass index (BMI) was not correlated with liver diameters. Women had a longer CCliv (p = 0.002) and shorter LLabd (p < 0.001) than men. The liver and abdominal measurements were combined to reduce this sex-related disparity. The CCliv/LLabd ratio (CHALLENGE index) was significantly correlated with the time of transection (r = 0.382, p = 0.037) and blood loss (r = 0.352, p = 0.029). The association between the CHALLENGE index and intraoperative blood loss was even stronger when considering only anatomical resection (r = 0.577, p = 0.048). A CHALLENGE index of > 0.4 (area under the curve, 0.757; p = 0.046) indicated a higher bleeding risk. The BMI predicted no intraoperative outcomes.

CONCLUSION

Anthropometric data rather than the BMI can help anticipate the difficulty of LLR of segments seven and eight.

The economic footprint of acute care surgery in the United States: Implications for systems development

BACKGROUND

Acute care surgery (ACS) comprises trauma, surgical critical care, and emergency general surgery (EGS), encompassing both operative and nonoperative conditions. While the burden of EGS and trauma has been separately considered, the global footprint of ACS has not been fully characterized. We sought to characterize the costs and scope of influence of ACS-related conditions. We hypothesized that ACS patients comprise a substantial portion of the US inpatient population. We further hypothesized that ACS patients differ from other surgical and non-surgical patients across patient characteristics.

METHODS

We queried the National Inpatient Sample 2014, a nationally representative database for inpatient hospitalizations. To capture all adult ACS patients, we included adult admissions with any International Classification of Diseases-9th Rev.-Clinical Modification diagnosis of trauma or an International Classification of Diseases-9th Rev.-Clinical Modification diagnosis for one of the 16 AAST-defined EGS conditions. Weighted patient data were presented to provide national estimates.

RESULTS

Of the 29.2 million adult patients admitted to US hospitals, approximately 5.9 million (20%) patients had an ACS diagnosis. ACS patients accounted for US $85.8 billion, or 25% of total US inpatient costs (US $341 billion). When comparing ACS to non-ACS inpatient populations, ACS patients had higher rates of health care utilization with longer lengths of stay (5.9 days vs. 4.5 days, p < 0.001), and higher mean costs (US $14,466 vs. US $10,951, p < 0.001. Of all inpatients undergoing an operative procedure, 27% were patients with an ACS diagnosis. Overall, 3,186 (70%) of US hospitals cared for both trauma and EGS patients.

CONCLUSION

Acute care surgery patients comprise 20% of the inpatient population, but 25% of total inpatient costs in the United States. In addition to being costly, they overall have higher health care utilization and worse outcomes. This suggests that there is an opportunity to improve clinical trajectory for ACS patients that in turn, can affect the overall US health care costs.

LEVEL OF EVIDENCE

Epidemiologic, level III.

Incidence and Cost of Deep Vein Thrombosis in Emergency General Surgery Over 15 Years

BACKGROUND

Deep vein thromboses (DVTs) are a significant sequela of surgery and are associated with significant of morbidity and mortality in the United States. Operative emergency general surgery (EGS) cases have been demonstrated to have a greater burden of DVT than other types of surgery.

MATERIALS AND METHODS

DVT in EGS cases were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2015 Q3 based on ICD-9 code specification. National incidence of DVT in EGS was calculated using the National Inpatient Sample-Healthcare Cost and Utilization Project sampling methodology, and propensity score matching was used to assess costs associated with DVT.

RESULTS

Among 15,148,352 sample-weighted hospitalizations, 0.623% (94,392) experienced DVT. Incidence of DVT was greatest in GI ulcer surgery (1.705%) and lowest in appendectomy (0.095%). Patients with a perioperative DVT incurred $22,301 more in hospital-related costs than their counterparts who did not have a DVT. Although rates of DVT remained stable over the period analyzed, DVT-associated costs increased at a 2.09% annual rate in excess of inflation during the period analyzed. This increase in costs was most significant for laparotomy, which increased at a rate of 8.09% annually.

CONCLUSIONS

DVT continues to be a significant burden on resources in EGS in spite of efforts with DVT prophylaxis. Considering the increase in costs and little change in incidence, further research on cost-effective management of DVT in EGS is warranted.

Evaluating outcomes following emergency laparotomy in the North of England and the impact of the National Emergency Laparotomy Audit - A retrospective cohort study

BACKGROUND

Emergency laparotomy is associated with high morbidity and mortality. Current trends suggest improvements have been made in recent years, with increased survival and shorter lengths of stay in hospital. The National Emergency Laparotomy Audit (NELA) has evaluated participating hospitals in England and Wales and their individual outcomes since 2013. This study aims to establish temporal trends for patients undergoing emergency laparotomy and evaluate the influence of NELA.

METHODS

Data for emergency laparotomies admitted to NHS hospitals in the Northern Deanery between 2001 and 2016 were collected, including demographics, co-morbidities, diagnoses, operations undertaken and outcomes. The primary outcome of interest was in-hospital death within 30 days of admission. Cox-regression analysis was undertaken with adjustment for covariates.

RESULTS

There were 2828 in-hospital deaths from 24,291 laparotomies within 30 days of admission (11.6%). Overall 30-day mortality significantly reduced during the 15-year period studied from 16.3% (2001-04), to 8.1% during 2013-16 (p < 0.001). After multivariate adjustment, laparotomies undertaken in more recent years were associated with a lower mortality risk compared to earlier years (2013-16: HR 0.73, p < 0.001). There was a significant improvement in 30-day postoperative mortality year-on-year during the NELA period (from 9.1 to 7.1%, p = 0.039). However, there was no difference in postoperative mortality for patients who underwent laparotomy during NELA (2013-16) compared with the preceding three years (both 8.1%, p = 0.526).

DISCUSSION

30 day postoperative mortality for emergency laparotomy has improved over the past 15-years, with significantly reduced mortality risk in recent years. However, it is unclear if NELA has yet had a measurable effect on 30-day post-operative mortality.

Association of Operative Repair Type and Trauma Center Designation With Outcomes in Ruptured Abdominal Aortic Aneurysm Repair

OBJECTIVE

Open repair of ruptured abdominal aortic aneurysm (rAAA) has shown improved outcomes at trauma centers. Whether the benefit of trauma center designation extends to endovascular repair of rAAA is unknown.

METHODS

Retrospective cohort study using the California Office of Statewide Health Planning and Development 2007 to 2014 discharge database to identify patients with rAAA. Data included demographic and admission factors, discharge disposition, International Classification of Diseases, Ninth Revision, Clinical Modification codes, and hospital characteristics. Hospitals were categorized by trauma center designation and teaching hospital status. The effect of repair type and trauma center designation (level I, level II, or other-other trauma centers and nondesignated hospitals) was evaluated to determine rates and risks of 9 postoperative complications, in-hospital mortality, and 30-day postdischarge mortality.

RESULTS

Of 1941 rAAA repair patients, 61.2% had open and 37.8% had endovascular; 1.0% had both. Endovascular repair increased over the study interval. Hospitals were 12.0% level I, 25.0% level II, and 63.0% other. A total of 48.7% of hospitals were teaching hospitals (level I, 100%; level II, 42.2%; and other, 41.8%). Endovascular repair was significantly more common at teaching hospitals (41.5% vs 34.3%, P < .001) and was the primary repair method at level I trauma centers (P < .001). Compared with open repair, endovascular repair was protective for most complications and in-hospital mortality. The risk for in-hospital mortality was highest among endovascular patients at level II trauma centers (hazard ratio 1.67, 95% confidence interval [CI]: 0.95-2.92) and other hospitals (hazard ratio 1.66, 95% CI: 1.01-2.72).

CONCLUSIONS

Endovascular repair overall was associated with a lower risk of adverse outcomes. Endovascular repair at level I trauma centers had a lower risk of in-hospital mortality which may be a result of their teaching hospital status, organizational structure, and other factors. The weight of the contributions of such factors warrants further study.

Association between operating room access and mortality for life-threatening general surgery emergencies

BACKGROUND

Few diseases truly require emergency surgery today. We investigated the relationship between access to operating room (OR) and outcomes for patients with life-threatening emergency general surgery (LT-EGS) diseases at US hospitals.

METHODS

In 2015, we surveyed 2,811 US hospitals on EGS practices, including how OR access is assured (e.g., OR staffing, block time). There were 1,690 (60%) hospitals that responded. We anonymously linked survey data to 2015 Statewide Inpatient Sample data (17 states) using American Hospital Association identifiers. Adults admitted with life-threatening diagnoses (e.g., necrotizing fasciitis, perforated viscus) who underwent operative intervention the same calendar day as hospital admission were included. Primary outcome was in-hospital mortality. Univariate and multivariable regression analyses, clustered by treating hospital and adjusted for patient factors, were performed to examine hospital-level OR access variables.

RESULTS

Overall, 3,620 patients were admitted with LT-EGS diseases. The median age was 63 years (interquartile range, 51-75), with half having three or more comorbidities (50%). Thirty-four percent had one or more major systemic complication, and 5% died. The majority got care at hospitals with less than 1 day of EGS block time but with policies to ensure emergency access to the OR. After adjusting for age, sex, race, insurance status, comorbidities, systemic complications, and surgical complications, we found that less presence of an in-house EGS surgeon, compared with around the clock, was associated with increased mortality (rarely/never in-house surgeon: odds ratio, 2.4; 95% confidence interval [CI],1.1-5.3; sometimes in-house surgeon: odds ratio, 1.6; 95% CI, 1.1-2.3). In addition, after controlling for other factors, on-call overnight recovery room nurse, compared with in-house, was associated with an increased mortality (odds ratio, 2.2; 95% CI, 1.5-3.1).

CONCLUSION

Round-the-clock availability of personnel, specifically emergency general surgeons and recovery room nurses, is associated with decreased mortality. These findings have implications for the creation of EGS patient triage criteria and Acute Care Surgery Centers of Excellence.

LEVEL OF EVIDENCE

Therapeutic, level III.

Safety and feasibility of laparoscopic liver resection for patients with large or multiple intrahepatic cholangiocarcinomas: A propensity score based case-matched analysis from a single institute

Only a few high-volume centers have reported the efficacy of laparoscopic liver resection (LLR) for patients with intrahepatic cholangiocarcinoma (ICC). The minimally invasive approach is still controversial for ICC, especially when dealing with large (≥5 cm) or multiple (≥2) ICCs.Patients with large and multiple ICCs who underwent LLR or open hepatectomy (OH) between January 2012 and June 2017 were included. Furthermore, 1:2 propensity score matching (PSM) was performed between the LLR group and the OH group. Short- and long-term outcomes were compared between the different techniques.After PSM, LLR resulted in significantly longer operation time (median 225 minutes vs 190 minutes, P = .006) and pringle maneuver time (median 50 minutes vs 32.5 minutes, P = .001). There was no statistically significant difference in postoperative hospital stay between the different approaches (median 6 days vs 7 days, P = .092). The grade III/IV complication rates were comparable between the groups (5.6% vs 11.1%, P = .868). In the PSM subset, there was no significant difference in terms of overall survival (P = .645) or disease-free survival (P = .827) between patients in the LLR group and in the OH group.The present study showed that patients who underwent LLR for large or multiple ICCs could obtain similar short- and long-term outcomes compared with those who underwent OH, and lymph node dissection (LND) was technically difficult but feasible during LLR.

General Surgeons Australia's 12-point plan for emergency general surgery

In the last decade, emergency general surgery (EGS) in Australia and New Zealand has seen a transition from the traditional on-call system to the acute surgical unit (ASU) model. The importance and growing demand for EGS has resulted in the implementation of the General Surgeons Australia's 12-point plan for emergency surgery. Since its release, the 12-point plan has been used as a benchmark of a well-functioning ASU, both locally and abroad. This study aims to provide a descriptive review on the relevance of the 12-point plan to the ASU model and review the current evidence to support this framework. The review concludes that the establishment of the ASU model has met the aims set out by the Royal Australasian College of Surgeons for EGS. The 12-point plan is relevant and has good evidence to support its framework.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Pro-con debate on regionalization of emergency general surgery: controversy or common sense?

More than three million patients every year develop emergency general surgical (EGS) conditions and this number is rising. EGS diseases range from straightforward to potentially life-threatening, and if severe or complex may require extensive resources. Given the looming surgeon shortage and concerns about access to care, regionalization of EGS care, in a manner similar to trauma care, has been proposed. We present a unique pro-con debate highlighting the salient arguments for and against regionalization of EGS care in the USA.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology

This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.

The Acute Care Surgery model in the world, and the need for and implementation of trauma and emergency surgery units in Spain

The Acute Care Surgery model groups trauma and emergency surgery with surgical critical care. Conceived and extended during the last 2 decades throughout North America, the magnitude and clinical idiosyncrasy of emergency general surgery have determined that this model has been expanded to other parts of the world. In our country, this has led to the introduction and implementation of the so-called trauma and emergency surgery units, with common objectives as those previously published for the original model: to decrease the rates of emergency surgery at night, to allow surgeons linked to elective surgery to develop their activity in their own disciplines during the daily schedule, and to become the perfect link and reference for the continuity of care. This review summarizes how the original model was born and how it expanded throughout the world, providing evidence in terms of results and a description of the current situation in our country.

Minimally invasive surgery for hilar cholangiocarcinoma: state of art and future perspectives

BACKGROUND

Hilar cholangiocarcinoma (HCCA) occurs in the core section of the biliary system and has a strong tendency to broadly invade the surrounding vascular system, perineural tissue and major liver parenchyma. Thus, minimally invasive resection can only be achieved in limited cases. This article reviews the current laparoscopic and robotic surgery techniques for HCCA and analyses the difficulties and limitations of the current minimally invasive surgical techniques for HCCA.

METHODS

A systematic literature search was conducted using multiple electronic databases. All studies involving minimally invasive resections of HCCA were included (up to November 2017).

RESULTS

Twelve studies were included, of which eight concerned laparoscopic surgery of HCCA and four involved robotic surgery for HCCA. For laparoscopic surgery, most of the surgical procedures were limited to partial hepatectomy or even bile duct resection; the post-operative morbidity rate was approximately 38.9% (range 0-100%); those with fewer complications were mostly restricted to Bismuth type I or type II carcinomas. For robotic surgery, only one study concerned caudate lobectomy of HCCA, with a reported median operative time of 703 min and post-operative morbidity of 90%.

CONCLUSIONS

Minimally invasive surgery for HCCA is restricted to highly selected cases and is deemed technically achievable in experienced hands. However, technical and instrumental improvement is needed to reduce the relevant morbidity and popularize the use of minimally invasive surgery to treat HCCA.