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Lastunen KS, Leppäniemi AK, Mentula PJ. Pre-hospital management and patient-related factors affecting access to the surgical care of appendicitis - a survey study. Scand J Prim Health Care 2024; 42:399-407. [PMID: 38497923 PMCID: PMC11332302 DOI: 10.1080/02813432.2024.2329214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/06/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND AND AIMS Long pre-hospital delay substantially increases the likelihood of perforated appendicitis. This study aimed to find patient-related factors affecting this delay. METHODS A survey was conducted for patients with acute appendicitis after appendectomy. The participants were asked about their path to the surgical center and socioeconomic status. Variables affecting delays and the rate of complicated appendicitis were analyzed. RESULTS The study included 510 patients; 157 (31%) had complicated appendicitis with a median prehospital delay of 42 h. In patients with uncomplicated appendicitis, the delay was 21 h, p < .001. Forty-six (29%) patients with complicated appendicitis were not referred to the hospital after the first doctor's visit. The multivariate analysis discovered factors associated with long pre-hospital delay: age 40-64 years (OR 1.63 (95% CI 1.06-2.52); compared to age 18-39), age more than 64 years (OR 2.84 (95% CI 1.18-6.80); compared to age 18-39), loss of appetite (OR 2.86 (95% CI 1.64-4.98)), fever (OR 1.66 (95% CI 1.08-2.57)), non-referral by helpline nurse (OR 2.02 (95% CI 1.15-3.53)) and non-referral at first doctors visit (OR 2.16 (95% CI 1.32-3.53)). Age 40-64 years (OR 2.41 (95% CI 1.50-3.88)), age more than 64 years (OR 8.79 (95% CI 2.19-35.36)), fever (OR 1.83 (95% CI 1.15-2.89)) and non-referral at first doctors visit (OR 1.90 (95% CI 1.14-3.14)) were also risk factors for complicated appendicitis. CONCLUSIONS Advanced age, fever and failure to suspect acute appendicitis in primary care are associated with prolonged pre-hospital delay and complicated appendicitis.
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Affiliation(s)
- Kirsi Serenella Lastunen
- Department of Gastrointestinal Surgery, Helsinki University Hospital and the University of Helsinki, Helsinki, Finland
| | - Ari Kalevi Leppäniemi
- Department of Gastrointestinal Surgery, Helsinki University Hospital and the University of Helsinki, Helsinki, Finland
| | - Panu Juhani Mentula
- Department of Gastrointestinal Surgery, Helsinki University Hospital and the University of Helsinki, Helsinki, Finland
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Fujii T, Tanaka A, Katami H, Shimono R. Utility of the American Association for the Surgery of Trauma Appendicitis Severity Grade in Predicting Prognosis in Children. Cureus 2024; 16:e65129. [PMID: 39171002 PMCID: PMC11338628 DOI: 10.7759/cureus.65129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
INTRODUCTION The American Association for the Surgery of Trauma (AAST) proposed a grade classification (I (mild) to V (severe)) to predict the risks and outcomes of acute appendicitis. However, its utility in children remains unknown. We investigated the relationship between the AAST grade and disease severity in children. METHODS We retrospectively evaluated 93 patients aged ≤16 years who underwent surgery for acute appendicitis between 2012 and 2020. The AAST computed tomography (CT), operative, and pathologic grades were analyzed. We collected data for demographics, length of stay (LOS), and complications. Trend tests were performed to compare the AAST grade and outcomes. Bland-Altman plots were used to evaluate the correlation between grades. Multiple regression analysis was performed to identify the factors related to LOS. RESULTS AAST grades included CT (n=55), operative (n=93), and pathologic (n=93) grades. The number of complications and LOS increased significantly with the increase of every three-grade. Bland-Altman plots revealed that each of the three-grade correlated with each other. Multiple regression analysis identified AAST operative grades III-V as risk factors for prolonged LOS. CONCLUSION Higher CT, operative, and pathologic grades were found to be significantly associated with an increased number of complications and prolonged LOS in pediatric patients. We further concluded that the AAST grading system could be useful in predicting the prognosis of acute appendicitis in children.
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Affiliation(s)
| | - Aya Tanaka
- Pediatric Surgery, Kagawa University, Takamatsu, JPN
| | - Hiroto Katami
- Pediatric Surgery, Kagawa University, Takamatsu, JPN
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Suzuki T, Matsumoto A, Akao T, Matsumoto H. Interval appendectomy as a safe and feasible treatment approach after conservative treatment for appendicitis with abscess: a retrospective, single-center cohort study. Updates Surg 2023; 75:2257-2265. [PMID: 37987979 PMCID: PMC10710379 DOI: 10.1007/s13304-023-01679-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023]
Abstract
Emergency appendectomy (EA) is the gold standard management for acute appendicitis (AA). However, whether EA or interval appendectomy (IA) after conservative treatment is the optimal approach in AA with abscess remains controversial. This study compared IA and EA in patients presenting with AA accompanied by abscess. This was a retrospective single-center study including 446 consecutive patients undergoing appendectomy between April 2009 and March 2023. AA with abscess was defined as a pericecal abscess observed by computed tomography or abdominal ultrasonography, and patients with signs of peritoneal irritation were excluded. Perioperative outcomes were compared between the patients who directly underwent EA and those who underwent IA after conservative treatment. Among 42 patients (9.4%) with AA and abscess, 34 and 8 patients underwent IA and EA, respectively. The rates of ileocecal resection and postoperative complications were lower in the IA group than in the EA group (3% vs. 50%, P < 0.001 and 9% vs. 75%, P < 0.001, respectively). Colonoscopy before IA was performed in 16 of the 17 patients aged ≥ 40 years in the IA group, and one patient underwent ileocecal resection because of suspicious neoplasm in the root of the appendix. IA after conservative treatment might be considered as the useful therapeutic option for AA with abscess. Colonoscopy during the waiting period between the initial diagnosis and IA should be considered in patients aged ≥ 40 years who may have malignant changes. Implementing IA as a first-line treatment will be beneficial to both patients and healthcare providers.
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Affiliation(s)
- Toshiyuki Suzuki
- Department of Surgery, Hanyu General Hospital, Hanyushi Saitama, 348-8505, Japan.
| | - Akiyo Matsumoto
- Department of Surgery, Hanyu General Hospital, Hanyushi Saitama, 348-8505, Japan
| | - Takahiko Akao
- Department of Surgery, Hanyu General Hospital, Hanyushi Saitama, 348-8505, Japan
| | - Hiroshi Matsumoto
- Department of Surgery, Hanyu General Hospital, Hanyushi Saitama, 348-8505, Japan
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Brillantino A, Iacobellis F, Brusciano L, Abu-Omar A, Muto G, Amadu AM, Foroni F, Antropoli M, Antropoli C, Castriconi M, Renzi A, Pirolo L, Giuliani A, Scarano E, Docimo L, Scaglione M, Romano L. Accuracy of computed tomography in staging acute appendicitis and its impact on surgical outcome and strategy: a multi-center retrospective case-control study. LA RADIOLOGIA MEDICA 2023; 128:415-425. [PMID: 36940006 DOI: 10.1007/s11547-023-01619-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/07/2023] [Indexed: 03/21/2023]
Abstract
INTRODUCTION The aims of this study were to evaluate the concordance between AAST-CT appendicitis grading criteria, first published in 2014, and surgical findings and to assess the impact of CT staging on the choice of surgical approach. METHODS This was a multi-center retrospective case-control study including 232 consecutive patients undergoing surgery for acute appendicitis and who had undergone preoperative CT evaluation between 1 January 2017 and 1 January 2022. Appendicitis severity was classified in 5 grades. For each degree of severity, the surgical outcome between patients undergoing open and surgical approach was compared. RESULTS An almost perfect agreement (k = 0.96) was found between CT and surgery in staging acute appendicitis. The vast majority of patients with grade 1 and 2 appendicitis underwent laparoscopic surgical approach and showed low morbidity rate. In patients with grade 3 and 4 appendicitis, laparoscopic approach was adopted in 70% of cases and was associated, if compared to open, with a higher prevalence of postoperative abdominal collections (p = 0.05; fisher's exact test) and a significantly lower prevalence of surgical site infections (p = 0.0007; fisher's exact test). All the patients with grade 5 appendicitis were treated by laparotomy. CONCLUSIONS AAST-CT appendicitis grading system seems to show a relevant prognostic value and a potential impact on the choice of surgical strategy, directing toward a laparoscopic approach in patients with grade 1 and 2, an initial laparoscopic approach, replaceable by the open one, for grade 3 and 4 and an open approach in patients with grade 5.
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Affiliation(s)
- Antonio Brillantino
- Department of Surgery, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy.
| | - Francesca Iacobellis
- Department of General and Emergency Radiology, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Luigi Brusciano
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania Luigi Vanvitelli Naples, Via Luigi Pansini N° 5, 80131, Naples, Italy
| | - Ahmad Abu-Omar
- Department of Radiology, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
| | - Gianluca Muto
- Diagnostic Imaging Department, Hospitaux Universitaires de Genève, Geneva, Switzerland
| | - Antonio Matteo Amadu
- Diagnostic Imaging 1 Unit, University Hospital of Sassari, 07100, Sassari, Italy
| | - Fabrizio Foroni
- Surgery Department, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Massimo Antropoli
- Surgery Department, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Carmine Antropoli
- Surgery Department, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Maurizio Castriconi
- Surgery Department, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Adolfo Renzi
- Surgery Department, "Buonconsiglio Fatebenefratelli" Hospital, Naples, Italy
| | - Luigi Pirolo
- Radiology Department, "Buonconsiglio Fatebenefratelli" Hospital, Naples, Italy
| | | | - Enrico Scarano
- Radiology Department, "San Carlo" Hospital, Potenza, Italy
| | - Ludovico Docimo
- Division of General, Mininvasive and Obesity Surgery, University of Study of Campania Luigi Vanvitelli Naples, Via Luigi Pansini N° 5, 80131, Naples, Italy
| | - Mariano Scaglione
- Department of Radiology, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK.,Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale San Pietro 112, 07199, Sassari, Italy
| | - Luigia Romano
- Radiology Department, A. Cardarelli Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
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Reinke CE, Wang H, Thompson K, Paton BL, Sherrill W, Ross SW, Schiffern L, Matthews BD. Impact of COVID-19 on common non-elective general surgery diagnoses. Surg Endosc 2023; 37:692-702. [PMID: 35298704 PMCID: PMC8927521 DOI: 10.1007/s00464-022-09154-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/17/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, public health and hospital policies were enacted to decrease virus transmission and increase hospital capacity. Our aim was to understand the association between COVID-19 positivity rates and patient presentation with EGS diagnoses during the COVID pandemic compared to historical controls. METHODS In this cohort study, we identified patients ≥ 18 years who presented to an urgent care, freestanding ED, or acute care hospital in a regional health system with selected EGS diagnoses during the pandemic (March 17, 2020 to February 17, 2021) and compared them to a pre-pandemic cohort (March 17, 2019 to February 17, 2020). Outcomes of interest were number of EGS-related visits per month, length of stay (LOS), 30-day mortality and 30-day readmission. RESULTS There were 7908 patients in the pre-pandemic and 6771 in the pandemic cohort. The most common diagnoses in both were diverticulitis (29.6%), small bowel obstruction (28.8%), and appendicitis (20.8%). The lowest relative volume of EGS patients was seen in the first two months of the pandemic period (29% and 40% decrease). A higher percentage of patients were managed at a freestanding ED (9.6% vs. 8.1%) and patients who were admitted were more likely to be managed at a smaller hospital during the pandemic. Rates of surgical intervention were not different. There was no difference in use of ICU, ventilator requirement, or LOS. Higher 30-day readmission and lower 30-day mortality were seen in the pandemic cohort. CONCLUSIONS In the setting of the COVID pandemic, there was a decrease in visits with EGS diagnoses. The increase in visits managed at freestanding ED may reflect resources dedicated to supporting outpatient non-operative management and lack of bed availability during COVID surges. There was no evidence of a rebound in EGS case volume or substantial increase in severity of disease after a surge declined.
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Affiliation(s)
- Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC, 28205, USA.
| | - Huaping Wang
- Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC, 28205, USA
| | - Kyle Thompson
- Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC, 28205, USA
| | - B Lauren Paton
- Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC, 28205, USA
| | - William Sherrill
- Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC, 28205, USA
| | - Samuel W Ross
- Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC, 28205, USA
| | - Lynnette Schiffern
- Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC, 28205, USA
| | - Brent D Matthews
- Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Plaza, Suite 300, Charlotte, NC, 28205, USA
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Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study. Eur J Trauma Emerg Surg 2023; 49:17-32. [PMID: 36693948 PMCID: PMC9925585 DOI: 10.1007/s00068-022-02191-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/27/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications. MATERIAL AND METHODS We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41-0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11-0.96), p = 0.045] complications could be detected when using energy devices. CONCLUSIONS Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.
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Duraiswamy S, Sanchez SE, Flum DR, Paasche-Orlow MK, Kenzik KM, Tseng JF, Drake FT. Caveat emptor: The accuracy of claims data in appendicitis research. Surgery 2022; 172:1050-1056. [PMID: 35985898 DOI: 10.1016/j.surg.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND International Classification of Disease, ninth/tenth revision codes are used to identify patients with appendicitis and classify severity of disease for research and hospital reimbursement. We sought to determine accuracy of International Classification of Disease, ninth/tenth revision codes in classifying appendicitis as uncomplicated versus complicated (defined as perforated, necrotic, or abscess) compared with the clinical gold standard: surgeon characterization of the appendix in the operative report. METHODS Retrospective review of operative reports and discharge International Classification of Disease, ninth/tenth revision codes for patients ≥18 years old who underwent noninterval, nonincidental appendectomy between January 2012 and December 2019 at a tertiary referral center. Sensitivity, specificity, and positive predictive value were calculated for International Classification of Disease, ninth/tenth revision codes to classify appendicitis accurately as complicated compared with surgeon description. ICD-9/10 codes and surgeon description were categorized into complicated/uncomplicated based on the American Association for the Surgery of Trauma grading system. RESULTS In the study, 1,495 patients with acute appendicitis underwent appendectomy. Per surgeon description, 200 (13%) were complicated and 1,295 (87%) uncomplicated. Compared with surgeon description, discharge International Classification of Disease, ninth/tenth revision codes did not accurately identify complicated appendicitis: sensitivity = 0.68, positive predictive value = 0.77. As a sensitivity analysis, the cohort was stratified by public versus private payers, and the results did not change. CONCLUSION International Classification of Disease, ninth/tenth revision codes do not accurately identify surgeon-described complicated appendicitis. Nearly one-third of the cases of complicated appendicitis were coded as uncomplicated. Such misclassification negatively impacts reimbursement for complicated appendicitis care and could lead to misleading results in research and quality improvement activities that rely on these codes.
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Affiliation(s)
- Swetha Duraiswamy
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA.
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA
| | - David R Flum
- Department of Surgery, University of Washington Medical Center, Seattle, WA
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA
| | - Kelly M Kenzik
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA
| | - Frederick Thurston Drake
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA. https://twitter.com/F_ThurstonDrake
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The Diagnostic Differentiation Challenge in Acute Appendicitis: How to Distinguish between Uncomplicated and Complicated Appendicitis in Adults. Diagnostics (Basel) 2022; 12:diagnostics12071724. [PMID: 35885627 PMCID: PMC9322371 DOI: 10.3390/diagnostics12071724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
(1) Background: How to best define, diagnose and differentiate uncomplicated from complicated acute appendicitis remains debated. Hence, the aim of this review was to present an overview of the current knowledge and emerging field of acute appendicitis with a focus on the diagnostic differentiation of severity currently subject to ongoing investigations. (2) Methods: We conducted a PubMed search using the MeSH terms “appendicitis AND severity” and “appendicitis AND classification”, with a focus on studies calling appendicitis as ‘uncomplicated’ or ‘complicated’. An emphasis on the last 5 years was stressed, with further studies selected for their contribution to the theme. Further studies were retrieved from identified full-text articles and included per the authors’ discretion. (3) Results: The assumption that appendicitis invariably will proceed to perforation has been outdated. Both uncomplicated and complicated appendicitis exist with likely different pathophysiology. Hence, this makes it important to differentiate disease severity. Clinicians must diagnose appendicitis, but, in the next step, also differentiate between uncomplicated and complicated appendicitis in order to allow for management decisions. Diagnostic accuracy without supportive imaging is around 75–80% and, based on clinical judgement and blood tests alone, the negative appendectomy rate has been described as high as 36%. More research is needed on available biomarkers, and the routine use of imaging still remains debated. Scoring systems have the potential to improve diagnostic accuracy, but no scoring system has yet been validated for differentiating disease severity. Currently, no universally agreed definition exists on what constitutes a complicated appendicitis. (4) Conclusions: Uncomplicated and complicated appendicitis appear to have different pathophysiology and should be treated differently. The differentiation between uncomplicated and complicated appendicitis remains a diagnostic challenge.
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Aicher BO, Betancourt-Ramirez A, Grossman MD, Heise H, Schroeppel TJ, Hernandez MC, Zielinski MD, Kongkaewpaisan N, Kaafarani HMA, Wagner A, Grabo D, Scott M, Peck G, Chang G, Matsushima K, Cullinane DC, Cullinane LM, Stocker B, Posluszny J, Simonoski UJ, Catalano RD, Vasileiou G, Yeh DD, Agrawal V, Truitt MS, Pickett M, Dultz L, Muller A, Ong AW, San Roman JL, Barth N, Fackelmayer O, Velopulos CG, Hendrix C, Estroff JM, Gambhir S, Nahmias J, Jeyamurugan K, Bugaev N, O'Meara L, Kufera J, Diaz JJ, Bruns BR. Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study. Am Surg 2022; 88:953-958. [PMID: 35275764 DOI: 10.1177/0003134820960022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. METHODS Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. RESULTS There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. CONCLUSION The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.
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Affiliation(s)
- Brittany O Aicher
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | | | - Michael D Grossman
- Department of Surgery, Southside Hospital, Northwell Health, Bay Shore, Bay Shore, NY
| | - Holly Heise
- Department of Surgery, UCHealth Memorial Hospital Central Trauma Center, Colorado Springs, Colorado
| | - Thomas J Schroeppel
- Department of Surgery, UCHealth Memorial Hospital Central Trauma Center, Colorado Springs, Colorado
| | | | | | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Afton Wagner
- Department of Surgery, West Virginia University Medicine, Morgantown, West Virginia
| | - Daniel Grabo
- Department of Surgery, West Virginia University Medicine, Morgantown, West Virginia
| | - Michael Scott
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Gregory Peck
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Gloria Chang
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, California
| | | | | | - Benjamin Stocker
- Department of Surgery, Northwestern Memorial Hospital, Chicago, Illinois
| | - Joseph Posluszny
- Department of Surgery, Northwestern Memorial Hospital, Chicago, Illinois
| | - Ursula J Simonoski
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Richard D Catalano
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Georgia Vasileiou
- Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
| | - Daniel Dante Yeh
- Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
| | - Vaidehi Agrawal
- Department of Surgery, Methodist Dallas Medical Center, Dallas, Texas
| | - Michael S Truitt
- Department of Surgery, Methodist Dallas Medical Center, Dallas, Texas
| | - MaryAnne Pickett
- Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, Texas
| | - Linda Dultz
- Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, Texas
| | - Alison Muller
- Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | - Adrian W Ong
- Department of Surgery, Reading Hospital, West Reading, Pennsylvania
| | | | | | | | | | | | | | - Sahil Gambhir
- Department of Surgery, University of California, Irvine, Irvine, California
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Irvine, California
| | | | - Nikolay Bugaev
- Department of Surgery, Tufts University, Boston, Massachusetts
| | - Lindsay O'Meara
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Joseph Kufera
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - Brandon R Bruns
- R Adams Cowley Shock Trauma Center, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland
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Duraiswamy S, Ignacio A, Weinberg J, Sanchez SE, Flum DR, Paasche-Orlow MK, Kenzik KM, Tseng JF, Drake FT. Comparative Accuracy of ICD-9 vs ICD-10 Codes for Acute Appendicitis. J Am Coll Surg 2022; 234:377-383. [PMID: 35213502 DOI: 10.1097/xcs.0000000000000058] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND ICD codes are used to identify patients with appendicitis and to classify disease severity for reimbursement and research purposes. We sought to compare the accuracy of ICD-9 vs ICD-10 codes in classifying appendicitis as uncomplicated vs complicated (defined as perforated, necrotic, or abscess) compared with the clinical gold standard: surgeon characterization of the appendix in the operative report. STUDY DESIGN This is a retrospective review of operative reports and discharge ICD-9/10 codes for patients 18 years or older who underwent noninterval, nonincidental appendectomy from January 2012 to December 2019 at a tertiary referral center. Sensitivity, specificity, and positive predictive value were calculated for ICD-9/10 codes to classify appendicitis as complicated when compared with surgeon description. Chi-square testing was used to compare agreement between ICD-9/10 codes and surgeon description. RESULTS A total of 1,585 patients underwent appendectomy. ICD-9 codes had higher sensitivity than ICD-10 codes for complicated appendicitis (sensitivity 0.84 and 0.54, respectively) and a similar positive predictive value (0.77 and 0.76, respectively). Overall, 91% of ICD-9 codes agreed with surgical description of disease, but 84.4% of ICD-10 codes agreed with surgical description (p < 0.01). Among cases classified as complicated by the surgeon, 84% (79/94) had an accurate ICD-9 code for complicated disease, but only 53.8% (57/106) of cases had an accurate ICD-10 code (p < 0.01). CONCLUSIONS Compared with ICD-9 codes, ICD-10 codes were less accurate in characterizing severity of appendicitis. The ICD-10 coding schema does not provide an accurate representation of disease severity. Until this system is improved, significant caution is needed for people who rely on these data for billing, quality improvement, and research purposes.
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Affiliation(s)
- Swetha Duraiswamy
- From the Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA (Duraiswamy, Sanchez, Tseng, Thurston Drake)
| | - Amanda Ignacio
- the Department of Biostatistics, Boston University School of Public Health, Boston, MA (Ignacio, Weinberg)
| | - Janice Weinberg
- the Department of Biostatistics, Boston University School of Public Health, Boston, MA (Ignacio, Weinberg)
| | - Sabrina E Sanchez
- From the Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA (Duraiswamy, Sanchez, Tseng, Thurston Drake)
| | - David R Flum
- the Department of Surgery, University of Washington Medical Center, Seattle, WA (Flum)
| | - Michael K Paasche-Orlow
- the Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA (Paasche-Orlow)
| | - Kelly M Kenzik
- the Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL (Kenzik)
| | - Jennifer F Tseng
- From the Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA (Duraiswamy, Sanchez, Tseng, Thurston Drake)
| | - Frederick Thurston Drake
- From the Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA (Duraiswamy, Sanchez, Tseng, Thurston Drake)
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11
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Social Vulnerability and Appendicitis: Single-Institution Study in a High Insurance State. J Surg Res 2022; 275:35-42. [PMID: 35219249 DOI: 10.1016/j.jss.2022.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/21/2021] [Accepted: 01/25/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Multiple factors signifying higher social vulnerability, including lower socioeconomic status and minority race, have been associated with presentation with complicated appendicitis (CA). In this study, we compared the Social Vulnerability Index (SVI) of our population by appendicitis severity (uncomplicated appendicitis [UA] versus CA). We hypothesized that SVI would be similar between patients with UA and CA presenting to our institution, a safety-net hospital in a state with high healthcare insurance coverage. METHODS We included all patients at our hospital aged 18 y and older who underwent appendectomy for acute appendicitis between 2012 and 2016. SVI values were determined based on the 2010 census data using ArcMap software. We used nonparametric univariate statistics to compare the SVI of patients with CA versus UA and multivariable regression to model the likelihood of operative CA. RESULTS A total of 997 patients met inclusion criteria, of which 177 had CA. The median composite SVI score for patients with CA was lower than for patients with UA (80% versus 83%, P = 0.004). UA was associated with higher socioeconomic (83% versus 80%, P = 0.007), household/disability (68% versus 55%, P = 0.037), and minority/language SVI scores (91% versus 89%, P = 0.037). On multivariable analysis controlling for age, sex, ethnicity, insurance status, relevant comorbidities, and chronicity of symptoms, there was an inverse association between SVI and the likelihood of CA (odds ratio 0.59, 95% confidence interval 0.4-0.87, P = 0.008). CONCLUSIONS In the setting of high healthcare insurance and a medical center experienced in caring for vulnerable populations, patients presenting with UA have a higher composite SVI, and thus greater social vulnerability, than patients presenting with CA.
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12
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Waddimba AC, Newman P, Shelley JK, McShan EE, Cheung ZO, Gibson JN, Bennett MM, Petrey LB. Pain management after laparoscopic appendectomy: Comparative effectiveness of innovative pre-emptive analgesia using liposomal bupivacaine. Am J Surg 2021; 223:832-838. [PMID: 34610868 DOI: 10.1016/j.amjsurg.2021.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/06/2021] [Accepted: 09/20/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Laparoscopic appendectomy is standard of care for appendicitis in the US. Pain control that limits opioids is an important area of research given the opioid epidemic. This study examined post-appendectomy inpatient opioid use and pain scores following intraoperative use of liposomal bupivacaine (LB) versus non-liposomal bupivacaine. METHODS This was a retrospective cohort study of 155 adults who underwent laparoscopic appendectomy for acute appendicitis. Patients were divided into four cohorts based on the analgesia administered: (i) bupivacaine hydrochloride (BH)± epinephrine; (ii) undiluted LB; (iii) LB diluted with normal saline; and (iv) LB diluted with BH. RESULTS Baseline demographic/clinical attributes, intra-operative findings, and post-operative pain scores were equivalent across cohorts. Post-operative pre-discharge opioid use was higher in the BH vs. LB cohorts (mean 60.4 vs. 46.0, 35.5, and 30.4 morphine milligram equivalents, respectively; p < 0.001). CONCLUSIONS Pre-emptive analgesia with LB during laparoscopic appendectomy can reduce inpatient opioid use without significantly increasing post-operative pain scores.
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Affiliation(s)
- Anthony C Waddimba
- Health Systems Science; Department of Surgery; Baylor University Medical Center; Dallas, TX, United States; Baylor Scott & White Research Institute; Dallas, TX, United States.
| | - Pete Newman
- Division of Trauma, Critical Care, & Acute Care Surgery; Department of Surgery; Baylor University Medical Center; Dallas, TX, United States; Texas College of Osteopathic Medicine; University of North Texas Health Science Center; Fort Worth, TX, United States
| | - Jordin K Shelley
- Division of Trauma, Critical Care, & Acute Care Surgery; Department of Surgery; Baylor University Medical Center; Dallas, TX, United States; Texas College of Osteopathic Medicine; University of North Texas Health Science Center; Fort Worth, TX, United States
| | - Evan E McShan
- Baylor Scott & White Rehabilitation Institute; Dallas, TX, United States
| | - Zi-On Cheung
- College of Medicine; Texas A & M University Health Science Center; Dallas Campus, TX, United States
| | - Jennifer N Gibson
- General Medical Education; Department of Surgery; Baylor University Medical Center; Dallas, TX, United States
| | - Monica M Bennett
- Baylor Scott & White Research Institute; Dallas, TX, United States
| | - Laura B Petrey
- Division of Trauma, Critical Care, & Acute Care Surgery; Department of Surgery; Baylor University Medical Center; Dallas, TX, United States.
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13
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Zaikos TD, Boudiab EM, Peshel EC, Wu AA, Dyer E, Haut ER, Salimian KJ. Acute appendicitis severity during the early COVID-19 pandemic period. Trauma Surg Acute Care Open 2021; 6:e000809. [PMID: 34466662 PMCID: PMC8392736 DOI: 10.1136/tsaco-2021-000809] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/04/2021] [Indexed: 12/29/2022] Open
Abstract
Background The early COVID-19 pandemic period significantly strained the US healthcare system. During this period, consultations and admissions for acute medical conditions decreased, which was associated with an increase in disease-specific morbidity and mortality. Therefore, we sought to determine what, if any, effect the early COVID-19 pandemic period had on the presentation, management, and histopathologic severity of acute appendicitis. Methods We performed a retrospective, observational study to compare the frequencies with which patients presented with acute appendicitis, the proportion of whom were managed surgically, and the distribution of histopathologic disease severity among all resected appendix specimens during the early COVID-19 pandemic period (March 6-June 30, 2020) to equivalent time periods for the 3 preceding/pre-pandemic years (2017-2019). Results Compared with equivalent pre-pandemic time periods, during the COVID-19 pandemic period there was no significant difference in the number of patients who presented for acute appendicitis, there was a decreased rate of surgical management (81% vs 94%; p=0.014), and there was an overall increase in the incidence of perforated appendicitis (31% vs 16%; p=0.004), including by histopathologic diagnosis (25% vs 11%; p=0.01). Discussion Despite potential patient hesitancy to present for care, the early COVID-19 pandemic period was associated with no significant change in the number of patients presenting with acute appendicitis; however, there was a significant increase in the incidence of perforated appendicitis. This study highlights the need to encourage patients to avoid late presentation for acute surgical conditions and for the robust planning for the medical management of otherwise surgical abnormalities during episodes of restricted or limited resources. Level of evidence Level III.
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Affiliation(s)
- Thomas D Zaikos
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Emanuela C Peshel
- Department of General Surgery, Beaumont Health, Royal Oak, Michigan, USA
| | - Annie A Wu
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ethan Dyer
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Elliott R Haut
- Divsion of Acute Care Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA.,Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kevan J Salimian
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
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14
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Reinke CE, Lim RB. Minimally Invasive Acute Care Surgery. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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15
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Reinke CE, Lim RB. Minimally invasive acute care surgery. Curr Probl Surg 2021; 59:101031. [DOI: 10.1016/j.cpsurg.2021.101031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/16/2021] [Indexed: 12/07/2022]
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16
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Brown C, Waterman J, El Hitti E, Luton O, Joseph A, Pollitt MJ, Thippeswamy K, Robinson DBT. Appendicitis in the COVID-19 era: a modern challenge for experienced hands. Ann R Coll Surg Engl 2021; 103:481-486. [PMID: 34192486 PMCID: PMC10334878 DOI: 10.1308/rcsann.2021.0089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION The first wave of COVID-19 was accompanied by global uncertainty. Delayed presentation of patients to hospitals ensued, with surgical pathologies no exception. This study aimed to assess whether delayed presentations resulted in more complex appendicectomies during the first wave of COVID-19. METHODS Operation notes for all presentations of appendicitis (n=216) within a single health board (three hospitals) during two three-month periods (control period (pre-COVID) vs COVID pandemic) were analysed, and the severity of appendicitis was recorded as per the American Association for the Surgery of Trauma (AAST) grading system. RESULTS Presentations of appendicitis were delayed during the COVID period with a median duration of symptoms prior to hospital attendance of two days versus one day (p=0.003) with individuals presenting with higher median white cell count than during the control period (14.9 vs 13.3, p=0.031). Use of preoperative CT scanning (OR 3.013, 95% CI 1.694-5.358, p<0.001) increased significantly. More complex appendicectomies (AAST grade >1) were performed (OR 2.102, 95% CI 1.155-3.826, p=0.015) with a greater consultant presence during operations (OR 4.740, 95% CI 2.523-8.903, p<0.001). Despite the greater AAST scores recorded during the COVID period, no increase in postoperative complications was observed (OR 1.145, 95% CI 0.404-3.244, p=0.798). CONCLUSIONS Delayed presentations during the COVID-19 pandemic were associated with more complex cases of appendicitis. Important lessons can be learnt from the changes in practice employed as a result of this global pandemic.
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Affiliation(s)
| | | | | | - O Luton
- Royal Glamorgan Hospital, UK
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17
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Emergency General Surgery (EGS) Risk Stratification Scores. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-020-00281-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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18
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Scott JW, Staudenmayer K, Sangji N, Fan Z, Hemmila M, Utter G. Evaluating the association between American Association for the Surgery of Trauma emergency general surgery anatomic severity grades and clinical outcomes using national claims data. J Trauma Acute Care Surg 2021; 90:296-304. [PMID: 33214490 DOI: 10.1097/ta.0000000000003030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) encompasses a heterogeneous population of acutely ill patients, and standardized methods for determining disease severity are essential for comparative effectiveness research and quality improvement initiatives. The American Association for the Surgery of Trauma (AAST) has developed a grading system for the anatomic severity of 16 EGS conditions; however, little is known regarding how well these AAST EGS grades can be approximated by diagnosis codes in administrative databases. METHODS We identified adults admitted for 16 common EGS conditions in the 2012 to 2017q3 National Inpatient Sample. Disease severity strata were assigned using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes based on AAST EGS anatomic severity grades. We evaluated whether assigned EGS severity (multiple strata or dichotomized into less versus more complex) were associated with in-hospital mortality, complications, length of stay, discharge disposition, and costs. Analyses were adjusted for age, sex, comorbidities, hospital traits, geography, and year. RESULTS We identified 10,886,822 EGS admissions. The number of anatomic severity strata derived from ICD-9/10-CM codes varied by EGS condition and by year. Four conditions mapped to four strata across all years. Two conditions mapped to four strata with ICD-9-CM codes but only two or three strata with ICD-10-CM codes. Others mapped to three or fewer strata. When dichotomized into less versus more complex disease, patients with more complex disease had worse outcomes across all 16 conditions. The addition of multiple strata beyond a binary measure of complex disease, however, showed inconsistent results. CONCLUSION Classification of common EGS conditions according to anatomic severity is feasible with International Classification of Diseases codes. No condition mapped to five distinct severity grades, and the relationship between increasing grade and outcomes was not consistent across conditions. However, a standardized measure of severity, even if just dichotomized into less versus more complex, can inform ongoing efforts aimed at optimizing outcomes for EGS patients across the nation. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- John W Scott
- From the Department of Surgery (J.W.S., N.S., M.H.), and Center for Health Outcomes and Policy (J.W.S., N.S., Z.F., M.H.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (K.S.), Stanford University, Stanford; and Outcomes Research Group (G.U.), University of California Davis, Sacramento, California
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19
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Appendicitis in the Pregnant Patient: Risk, Diagnosis, Management, and Outcomes. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-020-00278-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Current opinion on emergency general surgery transfer and triage criteria. J Trauma Acute Care Surg 2021; 89:e71-e77. [PMID: 32467469 DOI: 10.1097/ta.0000000000002806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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21
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Fernández-Moreno MC, Pérez Santiago L, Martí Fernández R, León Espinoza C, Ortega Serrano J. Is laparoscopic approach still a risk factor for postappendectomy intra-abdominal abscess? J Trauma Acute Care Surg 2021; 90:163-169. [PMID: 33003018 DOI: 10.1097/ta.0000000000002957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The impact of laparoscopic appendectomy (LA) on the incidence of intra-abdominal abscess (IAA) remains controversial. We aimed to identify risk factors for postappendectomy IAA and assess the impact of appendectomy approach in postoperative morbidity. METHODS A retrospective single-center study including consecutive patients who underwent appendectomy for acute appendicitis between 2015 and 2018 was performed. Demographic, clinical, intraoperative, and perioperative variables were collected. Univariate and multivariate analyses was performed to detect independent risk factors for IAA. Comparison of LA and open appendectomy was conducted, and propensity score model (PSM) was used to overcome differences between groups. Independent risk factors for IAA were identified by univariate and multivariate analyses in the PSM cohort. RESULTS A total of 532 appendectomies were included. The median age was 35 years. Three hundred two patients (56.7%) underwent LA. The most frequent operative finding was American Association for the Surgery of Trauma (AAST) grade 1 appendicitis in 303 patients (57%). Peritonitis was found in 109 patients (20.5%). Postoperative morbidity and mortality were 14.4% and 0%, respectively. Intra-abdominal abscess rate was 6.2%. An AAST grade of ≥2, a preoperative C-reactive protein level of >100 mg/dL, and diabetes mellitus were identified as independent risk factors for IAA in the multivariate analysis. Comparing LA and open appendectomy, there were no differences in IAA rates. After PSM, LA showed lower morbidity and shorter hospital stay. CONCLUSIONS Laparoscopic appendectomy is a safe approach and not related to a higher risk of IAA. Patients with an AAST grade of ≥2, a preoperative C-reactive protein level of >100, and diabetes mellitus have higher risk for postappendectomy IAA. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- María-Carmen Fernández-Moreno
- From the Department of Surgery (M.-C.F.-M., L.P.S., R.M.F., C.L.E., J.O.S.), Hospital Clínico Universitario de Valencia; and Biomedical Research Institute (INCLIVA) (J.O.S.), University of Valencia, Valencia, Spain
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22
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Kabir SMU, Bucholc M, Walker CA, Sogaolu OO, Zeeshan S, Sugrue M. Quality Outcomes in Appendicitis Care: Identifying Opportunities to Improve Care. Life (Basel) 2020; 10:life10120358. [PMID: 33352906 PMCID: PMC7767194 DOI: 10.3390/life10120358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/07/2020] [Accepted: 12/16/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Appendicitis is one of the most common causes of acute abdominal pain requiring surgical intervention, but the variability of diagnosis and management continue to challenge the surgeons. Aim: This study assessed patients undergoing appendectomy to identify opportunities to improve diagnostic accuracy and outcomes. METHODS An ethically approved retrospective cohort study was undertaken between March 2016 and March 2017 at a single university hospital of all consecutive adult and paediatric patients undergoing appendectomy. Demographic data including age, gender, co-morbidities, presentation and triage timings along with investigation, imaging and operative data were analysed. Appendicitis was defined as acute based on histology coupled with intraoperative grading with the American Association for the Surgery of Trauma (AAST) grades. Complications using the Clavien-Dindo classification along with 30-day re-admission rates and the negative appendectomy rates (NAR) were recorded and categorised greater and less than 25%. The use of scoring systems was assessed, and retrospective scoring performed to compare the Alvarado, Adult Appendicitis Score (AAS) and the Appendicitis Inflammatory Response (AIR) score. Results: A total of 201 patients were studied, 115 male and 86 females, of which 136/201 (67.6%) were adults and 65/201 (32.3%) paediatric. Of the adult group, 83 were male and 53 were female, and of the paediatric group, 32 were male and 33 were female. Median age was 20 years (range: 5 years to 81 years) and no patient below the age of 5 years had an appendectomy during our study period. All patients were admitted via the emergency department and median time from triage to surgical review was 2 h and 38 min, (range: 10 min to 26 h and 10 min). Median time from emergency department review to surgical review, 55 min (range: 5 min to 6 h and 43 min). Median time to operating theatre was 21 h from admission (range: 45 min to 140 h and 30 min). Out of the total patients, 173 (86.1%) underwent laparoscopic approach, 28 (13.9%) had an open approach and 12 (6.9%) of the 173 were converted to open. Acute appendicitis occurred in 166/201 (82.6%). There was no significant association between grade of appendicitis and surgeons' categorical NAR rate (p = 0.07). Imaging was performed in 118/201 (58.7%); abdominal ultrasound (US) in 53 (26.4%), abdominal computed tomography (CT) in 59 (29.2%) and both US and CT in 6 (3%). The best cut-off point was 4 (sensitivity 84.3% and specificity of 65.7%) for AIR score, 9 (sensitivity of 74.7% and specificity of 68.6%) for AAS, and 7 (sensitivity of 77.7% and specificity of 71.4%) for the Alvarado score. Twenty-four (11.9%) were re-admitted, due to pain in 16 (58.3%), collections in 3 (25%), 1 (4.2%) wound abscess, 1 (4.2%) stump appendicitis, 1 (4.2%) small bowel obstruction and 1 (4.2%) fresh rectal bleeding. CT guided drainage was performed in 2 (8.3%). One patient had release of wound collection under general anaesthetic whereas another patient had laparoscopic drain placement. A laparotomy was undertaken in 3 (12.5%) patients with division of adhesions in 1, the appendicular stump removed in 1 and 1 had multiple collections drained. CONCLUSION The negative appendectomy and re-admission rates were unacceptably high and need to be reduced. Minimising surgical variance with use of scoring systems and introduction of pathways may be a strategy to reduce NAR. New systems of feedback need to be introduced to improve outcomes.
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Affiliation(s)
- Syed Mohammad Umar Kabir
- Donegal Clinical Research Academy and Department of Surgery Letterkenny University Hospital, Letterkeny, Co. F92 AE81 Donegal, Ireland; (S.M.U.K.); (O.O.S.); (S.Z.)
| | - Magda Bucholc
- Intelligent Systems Research Centre, University of Ulster, Magee Campus, Londonderry BT48 7JL, UK;
| | - Carol-Ann Walker
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, X728 HG Letterkenny, Ireland;
| | - Opeyemi O. Sogaolu
- Donegal Clinical Research Academy and Department of Surgery Letterkenny University Hospital, Letterkeny, Co. F92 AE81 Donegal, Ireland; (S.M.U.K.); (O.O.S.); (S.Z.)
| | - Saqib Zeeshan
- Donegal Clinical Research Academy and Department of Surgery Letterkenny University Hospital, Letterkeny, Co. F92 AE81 Donegal, Ireland; (S.M.U.K.); (O.O.S.); (S.Z.)
| | - Michael Sugrue
- Donegal Clinical Research Academy and Department of Surgery Letterkenny University Hospital, Letterkeny, Co. F92 AE81 Donegal, Ireland; (S.M.U.K.); (O.O.S.); (S.Z.)
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, X728 HG Letterkenny, Ireland;
- Correspondence: ; Tel.: +353-74-918-8823; Fax: +353-74-918-8816
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23
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Prospectively Assigned AAST Grade versus Modified Hinchey Class and Acute Diverticulitis Outcomes. J Surg Res 2020; 259:555-561. [PMID: 33248670 DOI: 10.1016/j.jss.2020.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/08/2020] [Accepted: 10/28/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) recently developed a classification system to standardize outcomes analyses for several emergency general surgery conditions. To highlight this system's full potential, we conducted a study integrating prospective AAST grade assignment within the electronic medical record. METHODS Our institution integrated AAST grade assignment into our clinical workflow in July 2018. Patients with acute diverticulitis were prospectively assigned AAST grades and modified Hinchey classes at the time of surgical consultation. Support vector machine-a machine learning algorithm attuned for small sample sizes-was used to compare the associations between the two classification systems and decision to operate and incidence of complications. RESULTS 67 patients were included (median age of 62 y, 40% male) for analysis. The decision for operative management, hospital length of stay, intensive care unit admission, and intensive care unit length of stay were associated with both increasing AAST grade and increasing modified Hinchey class (all P < 0.001). AAST grade additionally showed a correlation with complication severity (P = 0.02). Compared with modified Hinchey class, AAST grade better predicted decision to operate (88.2% versus 82.4%). CONCLUSIONS This study showed the feasibility of electronic medical record integration to support the full potential of AAST classification system's utility as a clinical decision-making tool. Prospectively assigned AAST grade may be an accurate and pragmatic method to find associations with outcomes, yet validation requires further study.
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Mouch CA, Cain-Nielsen AH, Hoppe BL, Giudici MP, Montgomery JR, Scott JW, Machado-Aranda DA, Hemmila MR. Validation of the American Association for the Surgery of Trauma grading system for acute appendicitis severity. J Trauma Acute Care Surg 2020; 88:839-846. [PMID: 32459449 DOI: 10.1097/ta.0000000000002674] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The American Association for the Surgery of Trauma (AAST) developed an anatomic grading system to assess disease severity through increasing grades of inflammation. Severity grading can then be utilized in risk-adjustment and stratification of patient outcomes for clinical benchmarking. We sought to validate the AAST appendicitis grading system by examining the ability of AAST grade to predict clinical outcomes used for clinical benchmarking. METHODS Surgical quality program data were prospectively collected on all adult patients undergoing appendectomy for acute appendicitis at our institution between December 2013 and May 2018. The AAST acute appendicitis grade from 1 to 5 was assigned for all patients undergoing open or laparoscopic appendectomy. Primary outcomes were occurrence of major complications, any complications, and index hospitalization length of stay. Multivariable models were constructed for each outcome without and with inclusion of the AAST grade as an ordinal variable. We also developed models using International Classification of Diseases, 9th or 10th Rev.-Clinical Modification codes to determine presence of perforation for comparison. RESULTS A total of 734 patients underwent appendectomy for acute appendicitis. The AAST score distribution included 561 (76%) in grade 1, 49 (6.7%) in grade 2, 79 (10.8%) in grade 3, 33 (4.5%) in grade 4, and 12 (1.6%) in grade 5. The mean age was 35.3 ± 14.7 years, 47% were female, 20% were nonwhite, and 69% had private insurance. Major complications, any complications, and hospital length of stay were all positively associated with AAST grade (p < 0.05). Risk-adjustment model fit improved after including AAST grade in the major complications, any complications, and length of stay multivariable regression models. The AAST grade was a better predictor than perforation status derived from diagnosis codes for all primary outcomes studied. CONCLUSION Increasing AAST grade is associated with higher complication rates and longer length of stay in patients with acute appendicitis. The AAST grade can be prospectively collected and improves risk-adjusted modeling of appendicitis outcomes. LEVEL OF EVIDENCE Prospective/Epidemiologic, Level III.
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Affiliation(s)
- Charles A Mouch
- From the Department of Surgery (C.A.M., J.R.M., J.W.S., D.A.M.-A., M.R.H.), and Center for Health Outcomes and Policy (A.H.C.-N., B.L.H., M.P.G., J.W.S., M.R.H.), University of Michigan, Ann Arbor, Michigan
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Bessoff KE, Choi J, Bereknyei Merrell S, Nassar AK, Spain D, Knowlton LM. Creation and implementation of a novel clinical workflow based on the AAST uniform anatomic severity grading system for emergency general surgery conditions. Trauma Surg Acute Care Open 2020; 5:e000552. [PMID: 32953998 PMCID: PMC7481073 DOI: 10.1136/tsaco-2020-000552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/01/2020] [Accepted: 08/16/2020] [Indexed: 01/04/2023] Open
Abstract
Objective Emergency general surgery (EGS) conditions encompass a variety of diseases treated by acute care surgeons. The heterogeneity of these diseases limits infrastructure to facilitate EGS-specific quality improvement (QI) and research. A uniform anatomic severity grading system for EGS conditions was recently developed to fill this need. We integrated this system into our clinical workflow and examined its impact on research, surgical training, communication, and patient care. Methods The grading system was integrated into our clinical workflow in a phased fashion through formal education and a written handbook. A documentation template was also deployed in our electronic medical record to prospectively assign severity scores at the time of patient evaluation. Mixed methods including a quantitative survey and qualitative interviews of trainees and attending surgeons were used to evaluate the impact of the new workflow and to identify obstacles to its adoption. Results We identified 2291 patients presenting with EGS conditions during our study period. The most common diagnoses were small bowel obstruction (n=470, 20.5%), acute cholecystitis (n=384, 16.8%), and appendicitis (n=370, 16.1%). A total of 21 qualitative interviews were conducted. Twenty interviewees (95.2%) had a positive impression of the clinical workflow, citing enhanced patient care and research opportunities. Fifteen interviewees (75.0%) reported the severity grading system was a useful framework for clinical management, with five participants (25.0%) indicating the system was useful to facilitate clinical communication. Participants identified solutions to overcome barriers to adoption of the clinical workflow. Conclusions The uniform anatomic severity grading system can be readily integrated into a clinical workflow to facilitate prospective data collection for QI and research. The system is perceived as valuable by users. Educational initiatives that focus on increasing familiarity with the system and its benefits will likely improve adoption of the classification system and the clinical workflow that uses it. Level of evidence Level III.
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Affiliation(s)
- Kovi E Bessoff
- General Surgery, Stanford University, Stanford, California, USA
- Students and Surgeons writing About Trauma, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Jeff Choi
- General Surgery, Stanford University, Stanford, California, USA
- Students and Surgeons writing About Trauma, Department of Surgery, Stanford University, Stanford, CA, USA
| | | | - Aussama Khalaf Nassar
- Students and Surgeons writing About Trauma, Department of Surgery, Stanford University, Stanford, CA, USA
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - David Spain
- Students and Surgeons writing About Trauma, Department of Surgery, Stanford University, Stanford, CA, USA
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Lisa Marie Knowlton
- General Surgery, Stanford University, Stanford, California, USA
- Students and Surgeons writing About Trauma, Department of Surgery, Stanford University, Stanford, CA, USA
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The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study. J Trauma Acute Care Surg 2020; 86:601-608. [PMID: 30601458 DOI: 10.1097/ta.0000000000002175] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). METHODS This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. RESULTS 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. CONCLUSION This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. LEVEL OF EVIDENCE Prognostic/Epidemiologic retrospective multicenter trial, level III.
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Di Saverio S, Podda M, De Simone B, Ceresoli M, Augustin G, Gori A, Boermeester M, Sartelli M, Coccolini F, Tarasconi A, De' Angelis N, Weber DG, Tolonen M, Birindelli A, Biffl W, Moore EE, Kelly M, Soreide K, Kashuk J, Ten Broek R, Gomes CA, Sugrue M, Davies RJ, Damaskos D, Leppäniemi A, Kirkpatrick A, Peitzman AB, Fraga GP, Maier RV, Coimbra R, Chiarugi M, Sganga G, Pisanu A, De' Angelis GL, Tan E, Van Goor H, Pata F, Di Carlo I, Chiara O, Litvin A, Campanile FC, Sakakushev B, Tomadze G, Demetrashvili Z, Latifi R, Abu-Zidan F, Romeo O, Segovia-Lohse H, Baiocchi G, Costa D, Rizoli S, Balogh ZJ, Bendinelli C, Scalea T, Ivatury R, Velmahos G, Andersson R, Kluger Y, Ansaloni L, Catena F. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg 2020; 15:27. [PMID: 32295644 PMCID: PMC7386163 DOI: 10.1186/s13017-020-00306-3] [Citation(s) in RCA: 471] [Impact Index Per Article: 117.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy. METHODS This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients. CONCLUSIONS The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.
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Affiliation(s)
- Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy.
| | - Mauro Podda
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Belinda De Simone
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan-Bicocca, Milan, Italy
| | - Goran Augustin
- Department of Surgery, University Hospital Centre of Zagreb, Zagreb, Croatia
| | - Alice Gori
- Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health District, Bologna, Italy
| | - Marja Boermeester
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Antonio Tarasconi
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
| | - Nicola De' Angelis
- Department of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Paris, France
| | - Dieter G Weber
- Trauma and General Surgeon Royal Perth Hospital & The University of Western Australia, Perth, Australia
| | - Matti Tolonen
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Arianna Birindelli
- Department of General Surgery, Azienda Socio Sanitaria Territoriale, di Valle Camonica, Italy
| | - Walter Biffl
- Queen's Medical Center, University of Hawaii, Honolulu, HI, USA
| | - Ernest E Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Michael Kelly
- Acute Surgical Unit, Canberra Hospital, ACT, Canberra, Australia
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Jeffry Kashuk
- Department of Surgery, University of Jerusalem, Jerusalem, Israel
| | - Richard Ten Broek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Carlos Augusto Gomes
- Department of Surgery Hospital Universitario, Universidade General de Juiz de Fora, Juiz de Fora, Brazil
| | | | - Richard Justin Davies
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK
| | - Dimitrios Damaskos
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | - Ari Leppäniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP, Brazil
| | - Ronald V Maier
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA, USA
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Gabriele Sganga
- Department of Emergency Surgery, "A. Gemelli Hospital", Catholic University of Rome, Rome, Italy
| | - Adolfo Pisanu
- Department of General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Gian Luigi De' Angelis
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, Parma, Italy
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry Van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Francesco Pata
- Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | | | - Andrey Litvin
- Department of Surgery, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Fabio C Campanile
- Department of Surgery, San Giovanni Decollato Andosilla Hospital, Viterbo, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Gia Tomadze
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, TSMU, Tbilisi, Georgia
| | - Rifat Latifi
- Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery, New York Medical College, Valhalla, NY, USA
| | - Fakri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - David Costa
- Hospital universitario de Alicante, departamento de Cirugia General, Alicante, Spain
| | - Sandro Rizoli
- Department of Surgery, St. Michael Hospital, University of Toronto, Toronto, Canada
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
| | | | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
| | - George Velmahos
- Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Luca Ansaloni
- Department of General Surgery and Trauma, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Department, Maggiore Hospital of Parma, Parma, Italy
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Hernandez MC, Finnesgard EJ, Aho JM, Zielinski MD, Schiller HJ. Reduced Opioid Prescription Practices and Duration of Stay after TAP Block for Laparoscopic Appendectomy. J Gastrointest Surg 2020; 24:418-425. [PMID: 30671804 DOI: 10.1007/s11605-018-04100-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/28/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND We evaluated whether TAP blocks performed at the time of appendectomy resulted in reduced total oral morphine equivalent (OME) prescribed and fewer 30-day opioid prescription (OP) refills. STUDY DESIGN Single institution review of historical data (2010-2016) was performed. Adults (≥ 18 years) that underwent appendectomy for appendicitis with uniform disease severity (AAST EGS grades I, II) were included. Opioid tolerance was defined as any preoperative OP ordered 1-3 months prior to appendectomy or < 1 month unrelated to appendicitis; opioid naïve patients were without OP. Intraoperative TAP blocks (admixture of liposomal/regular bupivacaine) were performed at surgeon discretion. Risk factors for discharge prescription > 200 OME were assessed using logistic regression and quantified using odds ratios (OR) and 95% confidence intervals (CI). RESULT There were 960 patients with uniform appendicitis severity. During appendectomy, 145 (15%) patients received TAP blocks. There were 46 patients that were opioid tolerant (5%) and the majority of the cohort received discharge OP (n = 914, 95%) with a median prescription OME volume of 225 [150-300]. Only 76 patients required 30-day opioid prescription refill. On regression, factors associated with a discharge prescription > 200 OME included ≥ 65 years of age (OR 0.64 (95%CI 0.41-0.98)) and no TAP block (OR 1.7 (95%CI 1.2-2.5)) but not preoperative opioid utilization. CONCLUSIONS TAP blocks in low-grade appendicitis were associated with reduced OME prescribed, hospital duration of stay, and fewer refills without impacting operative time or total hospital costs.
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Affiliation(s)
- Matthew C Hernandez
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55901, USA.
| | | | - Johnathon M Aho
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55901, USA
| | - Martin D Zielinski
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55901, USA
| | - Henry J Schiller
- Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55901, USA
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Sceats LA, Trickey AW, Morris AM, Kin C, Staudenmayer KL. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA Surg 2019; 154:141-149. [PMID: 30427983 DOI: 10.1001/jamasurg.2018.4282] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking. Objective To compare the outcomes of nonoperatively managed appendicitis against appendectomy. Design, Setting, and Participants This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018. Exposures Appendectomy (control arm) or nonoperative management (treatment arm). Main Outcomes and Measures Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index. Results Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P < .001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P = .02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P < .001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P < .001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P = .003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days. Conclusions and Relevance According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.
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Affiliation(s)
- Lindsay A Sceats
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Arden M Morris
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Cindy Kin
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Kristan L Staudenmayer
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Stanford University, Stanford, California
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Gee KM, Jones RE, Babb JL, Preston SC, Beres AL. Clinical and Imaging Correlates of Pediatric Mucosal Appendicitis. J Surg Res 2019; 242:111-117. [PMID: 31075655 DOI: 10.1016/j.jss.2019.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/20/2019] [Accepted: 04/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Mucosal appendicitis is a controversial entity that is histologically distinct from transmural appendicitis. There is mixed opinion regarding mucosal inflammation as a spectrum of appendicitis versus a negative appendectomy. The ability to distinguish these diagnoses preoperatively is of importance to prevent unnecessary surgery. We hypothesize that patients with mucosal appendicitis can be discriminated from those with transmural disease based on specific preoperative clinical and imaging findings. MATERIALS AND METHODS After IRB approval, all patients who underwent laparoscopic appendectomy at our institution during 2015 were reviewed in the electronic medical record. Patients with mucosal appendicitis were identified and matched 2:1 to a random cohort of nonperforated transmural appendicitis cases. Demographic and clinical data were collected, including history, examination, laboratory, and imaging findings. Preoperative factors associated with mucosal appendicitis were modeled using binomial logistic regression analysis. RESULTS Of 1153 appendectomies performed during 2015, 103 patients had pathologic diagnosis of mucosal appendicitis. When compared with patients with mucosal infection, leukocytosis >10,000 per microliter led to 5.9 times higher likelihood of transmural pathology (P = 0.000). Noncompressibility on ultrasound was associated with 7.3 times higher likelihood of transmural disease (P = 0.015). Echogenic changes were predictive of transmural appendicitis, conferring 3.9 times the risk (P = 0.007). Presence of free fluid led to 2.3 times the rate of transmural pathology (P = 0.007). Finally, for every millimeter decrease in appendiceal diameter, patients were half as likely to exhibit transmural disease (P = 0.000). Together, these variables can successfully predict presence of mucosal appendicitis on final pathology report at a rate of 82.1%, and explain 60% of the variance in diagnosis of mucosal versus transmural appendicitis (P = 0.000). CONCLUSIONS Mucosal appendicitis remains a controversial pathologic entity, but is not associated with greater complications compared with transmural appendicitis when treated with laparoscopic appendectomy. Transmural disease can be predicted by leukocytosis, noncompressible appendix, presence of free fluid, larger appendiceal diameter and echogenicity.
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Affiliation(s)
- Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ruth Ellen Jones
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jacqueline L Babb
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephanie C Preston
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery, Children's Health, Dallas, Texas.
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Validation of the American Association for the Surgery of Trauma emergency general surgery score for acute appendicitis—an EAST multicenter study. J Trauma Acute Care Surg 2019; 87:134-139. [PMID: 31259871 DOI: 10.1097/ta.0000000000002319] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Nearly 3 million patients are hospitalized every year for emergent gastrointestinal (GI) surgical problems and nearly one third of those will require surgery. This article reviews the scope of GI surgical emergencies within the context of emergency general surgery (EGS), costs of care, overview of several common GI surgical problems, and traditional and emerging treatment modalities. This article also argues for ongoing work in the area of risk assessment for EGS, and describes quality metrics as well as outcomes of care for these patients.
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McGillen PK, Drake FT, Vallejo A, Brahmbhatt TS, Sanchez SE. Retrospective Analysis of Post-Operative Antibiotics in Complicated Appendicitis. Surg Infect (Larchmt) 2019; 20:359-366. [PMID: 30932747 DOI: 10.1089/sur.2018.223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: There is no consensus regarding the ideal post-operative antibiotic strategy for surgically managed complicated appendicitis. The goal of this study was to investigate different antibiotic regimens used for this purpose at our institution and their association with post-operative outcomes. Methods: The 1,102 patients underwent appendectomy from 2012 to 2016. A detailed chart review was performed on the 188 with complicated appendicitis based on standardized definitions. Descriptive and inferential statistics were used to analyze post-operative antibiotic use and complications. Results: Of the 188 cases of complicated appendicitis, 143 (76%) were classified as perforated by the operative surgeon. These patients were significantly more likely to be started on antibiotics after appendectomy (83.9% versus 33.3%; p < 0.001) and have a greater length of stay (LOS) (p = 0.006). The development of a surgical site infection (SSI) was significantly associated with a clinical diagnosis of diabetes (p = 0.04); the presence of free fluid, abscess, or perforation on pre-operative imaging (p = 0.002, 0.039, and 0.012, respectively); and a decision by the surgeon to leave a drain (p = 0.001). On multiple logistic regression analysis adjusted for free fluid on pre-operative imaging and an intra-operative decision to leave a drain, patients receiving one day or three or more days of antibiotics had higher odds of developing an SSI than patients who did not receive any post-operative antibiotics. Conclusions: In this cohort, operative surgeons accurately identified patients with complicated appendicitis who did not require post-operative antibiotics. For patients deemed to require them, two days of treatment was associated with reduced odds of SSI compared with shorter or longer antibiotic courses. The optimal course of antibiotics remains to be identified, but these findings suggest that longer post-operative courses do not avert SSI compared with two days of antibiotics. A prospective trial could clarify the optimal duration and route of antibiotic therapy in the setting of surgical complicated appendicitis.
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Affiliation(s)
- Patrick K McGillen
- 1 Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - F Thurston Drake
- 1 Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Andrew Vallejo
- 1 Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Tejal S Brahmbhatt
- 1 Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
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Validation of the American Association for the Surgery of Trauma emergency general surgery grade for skin and soft tissue infection. J Trauma Acute Care Surg 2019; 84:939-945. [PMID: 29794690 DOI: 10.1097/ta.0000000000001860] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Skin and soft tissue infections (SSTIs) present with variable severity. The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery (EGS) grading system for several diseases. We aimed to determine whether the AAST EGS grade corresponds with key clinical outcomes. METHODS Single-institution retrospective review of patients (≥18 years) admitted with SSTI during 2012 to 2016 was performed. Patients with surgical site infections or younger than 18 years were excluded. Laboratory Risk Indicator for Necrotizing Fasciitis score and AAST EGS grade were assigned. The primary outcome was association of AAST EGS grade with complication development, duration of stay, and interventions. Secondary predictors of severity included tissue cultures, cross-sectional imaging, and duration of inpatient antibiotic therapy. Summary and univariate analyses were performed. RESULTS A total of 223 patients were included (mean ± SD age of 55.1 ± 17.0 years, 55% male). The majority of patients received cross sectional imaging (169, 76%) or an operative procedure (155, 70%). Skin and soft tissue infection tissue culture results included no growth (51, 24.5%), monomicrobial (83, 39.9%), and polymicrobial (74, 35.6%). Increased AAST EGS grade was associated with operative interventions, intensive care unit utilization, complication severity (Clavien-Dindo index), duration of hospital stay, inpatient antibiotic therapy, mortality, and hospital readmission. CONCLUSION The AAST EGS grade for SSTI demonstrates the ability to correspond with several important outcomes. Prospective multi-institutional study is required to determine its broad generalizability in several populations. LEVEL OF EVIDENCE Prognostic, level IV.
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Abstract
INTRODUCTION Threatened, perforated, and infarcted bowel is managed with conventional resection and anastomosis (hand sewn [HS] or stapled [ST]). The SHAPES analysis demonstrated equivalence between HS and ST techniques, yet surgeons appeared to prefer HS for the critically ill. We hypothesized that HS is more frequent in patients with higher disease severity as measured by the American Association for the Surgery of Trauma Emergency General Surgery (AAST EGS) grading system. METHODS We performed a post hoc analysis of the SHAPES database. Operative reports were submitted by volunteering SHAPES centers. Final AAST grade was compared with various outcomes including duration of stay, physiologic/laboratory data, anastomosis type, anastomosis failure (dehiscence, abscess, or fistula), and mortality. RESULTS A total of 391 patients were reviewed, with a mean age (±SD) of 61.2 ± 16.8 years, 47% women. Disease severity distribution was as follows: grade I (n = 0, 0%), grade II (n = 106, 27%), grade III (n = 113, 29%), grade IV (n = 123, 31%), and grade V (n = 49, 13%). Increasing AAST grade was associated with acidosis and hypothermia. There was an association between higher AAST grade and likelihood of HS anastomosis. On regression, factors associated with mortality included development of anastomosis complication and vasopressor use but not increasing AAST EGS grade or anastomotic technique. CONCLUSION This is the first study to use standardized anatomic injury grades for patients undergoing urgent/emergent bowel resection in EGS. Higher AAST severity scores are associated with key clinical outcomes in EGS diseases requiring bowel resection and anastomosis. Anastomotic-specific complications were not associated with higher AAST grade; however, mortality was influenced by anastomosis complication and vasopressor use. Future EGS studies should routinely include AAST grading as a method for reliable comparison of injury between groups. LEVEL OF EVIDENCE Prognostic, level III.
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Validation of a new American Association for the Surgery of Trauma (AAST) anatomic severity grading system for acute cholecystitis. J Trauma Acute Care Surg 2019; 84:650-654. [PMID: 29271871 DOI: 10.1097/ta.0000000000001762] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) established anatomic grading to facilitate risk stratification and risk-adjusted outcomes in emergency general surgery. Cholecystitis severity was graded based on clinical, imaging, operative, and pathologic criteria. We aimed to validate the AAST anatomic grading system for acute cholecystitis. METHODS This is a retrospective cohort study including consecutive patients admitted with acute cholecystitis at an urban, tertiary medical center between 2013 and 2016. Grade 1 is acute cholecystitis, Grade 2 is gangrenous or emphysematous cholecystitis, Grade 3 is localized perforation, and Grades 4 and 5 have regional and systemic peritonitis, respectively. Concordance between the AAST grade and outcome including mortality, length of stay (LOS), ICU use, readmission, and complications were assessed using logistic regression. RESULTS A total of 315 patients were included. There was very good inter-rater (two independent raters) reliability for anatomic grading, κ = 1.00, p < 0.005. The majority of patients were Grade 1 or Grade 2 (94%). Incidence of complications, LOS, ICU use, and any adverse event increased with increasing anatomic grade. When compared to Grade 1 disease, patients with Grade 2 were more likely to undergo cholecystectomy (OR 4.07 [1.93-8.56]). Grade 3 patients were at higher risk of adverse events (OR 3.83 [1.34-10.94]), longer LOS (OR 1.73 [1.03-2.92]), and ICU use (OR 8.07 [2.43-26.80]). CONCLUSIONS AAST severity scores were independently associated with clinical outcomes in patients with acute cholecystitis. Despite low-grade disease, complications were common, and therefore a refinement of the scoring system may be necessary for more granular prediction. LEVEL OF EVIDENCE Epidemiologic/prognostic, level III.
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Association of postoperative organ space infection after intraoperative irrigation in appendicitis. J Trauma Acute Care Surg 2019; 84:628-635. [PMID: 29271870 DOI: 10.1097/ta.0000000000001773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The benefit of intraoperative irrigation on postoperative abscess rates compared to suction alone is unclear. The American Association for the Surgery of Trauma grading system provides distinct disease severity stratification to determine if prior analyses were biased by anatomic severity. We hypothesized that for increasing appendicitis severity, patients receiving (high, ≥2 L) intraoperative irrigation would have increased postoperative organ space infection (OSI) rate compared to (low, <2 L) irrigation. METHODS Single-institution review of adults (>18 years) undergoing appendectomy for appendicitis during 2010-2016. Demographics, operative details, irrigation volumes, duration of stay, and complications (Clavien-Dindo classification) were collected. American Association for the Surgery of Trauma grades were assigned by two independent reviewers based on operative findings. Summary, univariate, and area under the receiver operating curve analyses were performed. RESULTS Patients (n = 1187) were identified with a mean (SD) age of 41.6 (18.4) years (45% female). Operative approach included laparoscopy (n = 1122 [94.5%]), McBurney incision (n = 10 [0.8%]), midline laparotomy (n = 16 [1.3 %]), and laparoscopy converted to laparotomy (n = 39 [3.4%)]. The mean (SD) volume of intraoperative irrigation was 410 (1200) mL. Complication rate was 26.1%. Median volume of intraoperative irrigation in patients who developed postoperative OSI was 3 [0-4] compared to 0 [0-0] in those without infection (p < 0.0001). Area under the receiver operating curve analysis determined that 2 or more liters of irrigation was associated with postoperative OSI (c statistic: 0.83, 95% confidence interval, 0.76-0.89; p < 0.001). CONCLUSION Irrigation is used for increasingly severe appendicitis with wide variation. Irrigation volumes of 2 L or greater are associated with postoperative OSI. Improving standardization of irrigation volume (<2 L) may prevent morbidity associated with this high-volume disease. LEVEL OF EVIDENCE Therapeutic, level IV.
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The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction. J Trauma Acute Care Surg 2019; 84:372-378. [PMID: 29117026 DOI: 10.1097/ta.0000000000001736] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study. METHODS Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed. RESULTS There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade. CONCLUSION The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms. LEVEL OF EVIDENCE Prognostic, level III.
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Madni TD, Nakonezny PA, Barrios E, Imran JB, Clark AT, Taveras L, Cunningham HB, Christie A, Eastman AL, Minshall CT, Luk S, Minei JP, Phelan HA, Cripps MW. Prospective validation of the Parkland Grading Scale for Cholecystitis. Am J Surg 2019; 217:90-97. [DOI: 10.1016/j.amjsurg.2018.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/06/2018] [Accepted: 08/13/2018] [Indexed: 12/24/2022]
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Hernandez MC, Birindelli A, Bruce JL, Buitendag JJP, Kong VY, Beuran M, Aho JM, Negoi I, Clarke DL, Di Saverio S, Zielinski MD. Application of the AAST EGS Grade for Adhesive Small Bowel Obstruction to a Multi-national Patient Population. World J Surg 2018; 42:3581-3588. [PMID: 29770872 DOI: 10.1007/s00268-018-4671-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) has demonstrated to be a valid tool in North American patient populations. Using a multi-national patient cohort, we retrospectively assessed the validity the AAST ASBO grading system and estimated disease severity in a global population in order to correlate with several key clinical outcomes. METHODS Multicenter retrospective review during 2012-2016 from four centers, Minnesota USA, Bologna Italy, Pietermaritzburg South Africa, and Bucharest Romania, was performed. Adult patients (age ≥ 18) with ASBO were identified. Baseline demographics, physiologic parameters, laboratory results, operative and imaging details, outcomes were collected. AAST ASBO grades were assigned by independent reviewers. Univariate and multivariable analyses with odds ratio (OR) and 95% confidence intervals (CIs) were performed. RESULTS There were 789 patients with a median [IQR] age of 58 [40-75] years; 47% were female. The AAST ASBO grades were I (n = 180, 23%), II (n = 443, 56%), III (n = 87, 11%), and IV (n = 79, 10%). Successful non-operative management was 58%. Conversion rate from laparoscopy to laparotomy was 33%. Overall mortality and complication and temporary abdominal closure rates were 2, 46, and 4.7%, respectively. On regression, independent predictors for mortality included grade III (OR 4.4 95%CI 1.1-7.3), grade IV (OR 7.4 95%CI 1.7-9.4), pneumonia (OR 5.6 95%CI 1.4-11.3), and failing non-operative management (OR 2.4 95%CI 1.3-6.7). CONCLUSION The AAST EGS grade can be assigned with ease at any surgical facility using operative or imaging findings. The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research. Disease severity and outcomes varied between countries. LEVEL OF EVIDENCE III Study type Retrospective multi-institutional cohort study.
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Affiliation(s)
- Matthew C Hernandez
- Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Arianna Birindelli
- Department of Surgery, Maggiore Hospital, Bologna, Italy
- Department of Surgery, NHS, Queen Elizabeth University Hospital, Birmingham, UK
| | - John L Bruce
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Johannes J P Buitendag
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Victory Y Kong
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Mircea Beuran
- Department of General Surgery, Emergency Hospital of Bucharest, Carol Davila University of Medicine and Pharmacy of Bucharest, Bucharest, Romania
| | - Johnathon M Aho
- Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ionut Negoi
- Department of General Surgery, Emergency Hospital of Bucharest, Carol Davila University of Medicine and Pharmacy of Bucharest, Bucharest, Romania
| | - Damian L Clarke
- University of KwaZulu Natal, Department of Surgery, Pietermaritzburg Metropolitan Complex, Pietermaritzburg, South Africa
| | - Salomone Di Saverio
- Department of Surgery, Maggiore Hospital, Bologna, Italy
- Department of Surgery, NHS, Queen Elizabeth University Hospital, Birmingham, UK
- Addenbrookes Hospital, Cambridge University Hospitals, NHS, University of Cambridge, Cambridge, UK
| | - Martin D Zielinski
- Division of Trauma, Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Hornor MA, Liu JY, Hu QL, Ko CY, Wick E, Maggard-Gibbons M. Surgical Technical Evidence Review for Acute Appendectomy Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg 2018; 227:605-617.e2. [PMID: 30316962 DOI: 10.1016/j.jamcollsurg.2018.09.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Melissa A Hornor
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; American College of Surgeons, Chicago, IL.
| | - Jessica Y Liu
- American College of Surgeons, Chicago, IL; Department of Surgery, Emory University, Atlanta, GA
| | - Q Lina Hu
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
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Hernandez MC, Finnesgaard E, Aho JM, Kong VY, Bruce JL, Polites SF, Laing GL, Clarke DL, Zielinski MD. Appendicitis: Rural Patient Status is Associated with Increased Duration of Prehospital Symptoms and Worse Outcomes in High- and Low-Middle-Income Countries. World J Surg 2018; 42:1573-1580. [PMID: 29134308 DOI: 10.1007/s00268-017-4344-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Appendicitis is a significant economic and healthcare burden in low-, middle-, and high-income countries. We aimed to determine whether urban and rural patient status would affect outcomes in appendicitis in a combined population regardless of country of economic status. We hypothesize that patients from rural areas and both high- and low-middle-income countries would have disproportionate outcomes and duration of symptoms compared to their urban counterparts. METHODS Adults (≥18 years) with appendicitis during 2010-2016 in South Africa and USA were reviewed using multi-institutional data. Baseline demographic, operative details, durations of stay, and complications (Clavien-Dindo index) were collected. AAST grades were assigned by two independent reviewers based on operative findings. Summary, univariate, and multivariable analyses of rural and urban patients in both countries were performed. RESULTS There were 2602 patients with a median interquartile range [IQR] of 26 [18-40] years; 45% were female. Initial management included McBurney incisions (n = 458, 18%), laparotomy (n = 915, 35%), laparoscopic appendectomy (n = 1185, 45%), and laparoscopy converted to laparotomy (n = 44, 2%). Comparing rural versus urban patient status, there were increased overall median [IQR] AAST grades (3 [1-5] vs. 2 [1-3], p = 0.001), prehospital duration of symptoms (2 [1-5] vs. 2 [1-3], p = 0.001), complications (44.3 vs. 23%, p = 0.001), and need for temporary abdominal closure (20.3 vs. 6.9%, p = 0.001). CONCLUSION Despite socioeconomic status and country of origin, patients from more rural environments demonstrate poorer outcomes notwithstanding significant differences in overall disease severity. The AAST grading system may serve a potential benchmark to recognize areas with disparate disease burdens. This information could be used for strategic improvements for surgeon placement and availability.
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Affiliation(s)
- Matthew C Hernandez
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Eric Finnesgaard
- Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN, 55905, USA
| | - Johnathon M Aho
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Biomedical Engineering and Physiology, Mayo Clinic College of Medicine, Rochester, MN, 55905, USA
| | - Victor Y Kong
- Department of Surgery, Pietermaritzburg Metropolitan Hospital Complex, University of KwaZulu-Natal, Durban, South Africa
| | - John L Bruce
- Department of Surgery, Pietermaritzburg Metropolitan Hospital Complex, University of KwaZulu-Natal, Durban, South Africa
| | - Stephanie F Polites
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Grant L Laing
- Department of Surgery, Pietermaritzburg Metropolitan Hospital Complex, University of KwaZulu-Natal, Durban, South Africa
| | - Damian L Clarke
- Department of Surgery, Pietermaritzburg Metropolitan Hospital Complex, University of KwaZulu-Natal, Durban, South Africa
| | - Martin D Zielinski
- Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Murphy BL, Hernandez MC, Naik ND, Glasgow AE, Kong VY, Clarke DL, Saleem HY, Racz JM, Habermann EB, Zielinski MD. Validation of the American Association for the Surgery of Trauma's emergency general surgery breast infection grading system. J Surg Res 2018; 228:263-270. [PMID: 29907220 DOI: 10.1016/j.jss.2018.03.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/01/2018] [Accepted: 03/15/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The American Association for the Surgery of Trauma (AAST) developed emergency general surgery (EGS) grading systems for multiple diseases to standardize classification of disease severity. The grading system for breast infections has not been validated. We aimed to validate the AAST breast infection grading system. METHODS Multi-institutional retrospective review of all adult patients with a breast infection diagnosis at Mayo Clinic Rochester 1/2015-10/2015 and Pietermaritzburg South African Hospital 1/2010-4/2016 was performed. AAST EGS grades were assigned by two independent reviewers. Inter-rater reliability was measured using the agreement statistic (kappa). Final AAST grade was correlated with patient and treatment factors using Pearson's correlation coefficient. RESULTS Two hundred twenty-five patients were identified: grade I (n = 152, 67.6%), II (n = 44, 19.6%), III (n = 25, 11.1%), IV (n = 0, 0.0%), and V (n = 4, 1.8%). At Mayo Clinic Rochester, AAST grades ranged from I-III. The kappa was 1.0, demonstrating 100% agreement between reviewers. Within the South African patients, grades included II, III, and V, with a kappa of 0.34, due to issues of the grading system application to this patient population. Treatment received correlated with AAST grade; less severe breast infections (grade I-II) received more oral antibiotics (correlation [-0.23, P = 0.0004]), however, higher AAST grades (III) received more intravenous antibiotics (correlation 0.29, P <0.0001). CONCLUSIONS The AAST EGS breast infection grading system demonstrates reliability and ease for disease classification, and correlates with required treatment, in patients presenting with low-to-moderate severity infections at an academic medical center; however, it needs further refinement before being applicable to patients with more severe disease presenting for treatment in low-/middle-income countries.
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Affiliation(s)
- Brittany L Murphy
- Department of Surgery, Mayo Clinic, Rochester, Minnesota; The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.
| | | | - Nimesh D Naik
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Amy E Glasgow
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.
| | - Victor Y Kong
- Peitermartizburg Metropolitan Complex, Kwa-Zulu Natal, South Africa.
| | - Damian L Clarke
- Peitermartizburg Metropolitan Complex, Kwa-Zulu Natal, South Africa.
| | - Humza Y Saleem
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, Minnesota; The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota.
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The American Association for the Surgery of Trauma Emergency General Surgery Anatomic Severity Scoring System as a predictor of cost in appendicitis. Surg Endosc 2018; 32:4798-4804. [PMID: 29777350 DOI: 10.1007/s00464-018-6230-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 05/09/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND The World Society for Emergency Surgery determined that for appendicitis managed with appendectomy, there is a paucity of evidence evaluating costs with respect to disease severity. The American Association for the Surgery of Trauma (AAST) disease severity grading system is valid and generalizable for appendicitis. We aimed to evaluate hospitalization costs incurred by patients with increasing disease severity as defined by the AAST. We hypothesized that increasing disease severity would be associated with greater cost. METHODS Single-institution review of adults (≥ 18 years old) undergoing appendectomy for acute appendicitis during 2010-2016. Demographics, comorbidities, operative details, hospital stay, complications, and institutional cost data were collected. AAST grades were assigned by two independent reviewers based on operative findings. Total cost was ascertained from billing data and normalized to median grade I cost. Non-parametric linear regression was utilized to assess the association of several covariates and cost. RESULTS Evaluated patients (n = 1187) had a median [interquartile range] age of 37 [26-55] and 45% (n = 542) were female. There were 747 (63%) patients with Grade I disease, 219 (19%) with Grade II, 126 (11%) with Grade III, 50 (4%) with Grade IV, and 45 (4%) with Grade V. The median normalized cost of hospitalization was 1 [0.9-1.2]. Increasing AAST grade was associated with increasing cost (ρ = 0.39; p < 0.0001). Length of stay exhibited the strongest association with cost (ρ = 0.5; p < 0.0001), followed by AAST grade (ρ = 0.39), Clavien-Dindo Index (ρ = 0.37; p < 0.0001), age-adjusted Charlson score (ρ = 0.31; p < 0.0001), and surgical wound classification (ρ = 0.3; p < 0.0001). CONCLUSIONS Increasing anatomic severity, as defined by AAST grade, is associated with increasing cost of hospitalization and clinical outcomes. The AAST grade compares favorably to other predictors of cost. Future analyses evaluating appendicitis reimbursement stand to benefit from utilization of the AAST grade.
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Collins CM, Davenport DL, Talley CL, Bernard AC. Appendicitis Grade, Operative Duration, and Hospital Cost. J Am Coll Surg 2018; 226:578-583. [DOI: 10.1016/j.jamcollsurg.2017.12.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 11/26/2022]
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Younis M, Hernandez M, Ray-Zack M, Haddad NN, Choudhry A, Reddy P, Zielinski MD. Validation of AAST EGS Grade for Acute Pancreatitis. J Gastrointest Surg 2018; 22:430-437. [PMID: 29340918 DOI: 10.1007/s11605-017-3662-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 12/18/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods. METHODS Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014-1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems. RESULTS There were 297 patients with a mean (±SD) age of 55 ± 17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay. CONCLUSIONS The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system. LEVEL OF EVIDENCE IV Study Type: Single institutional retrospective review.
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Affiliation(s)
- Moustafa Younis
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Matthew Hernandez
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Mohamed Ray-Zack
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Nadeem N Haddad
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Asad Choudhry
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Pooja Reddy
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Martin D Zielinski
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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Yousef Y, Youssef F, Dinh T, Pandya K, Stagg H, Homsy M, Baird R, Laberge JM, Poenaru D, Puligandla P, Shaw K, Emil S. Risk stratification in pediatric perforated appendicitis: Prospective correlation with outcomes and resource utilization. J Pediatr Surg 2018; 53:250-255. [PMID: 29223673 DOI: 10.1016/j.jpedsurg.2017.11.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/08/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE Despite a wide spectrum of severity, perforated appendicitis in children is typically considered a single entity in outcomes studies. We performed a prospective cohort study to define a risk stratification system that correlates with outcomes and resource utilization. METHODS A prospective study was conducted of all children operated for perforated appendicitis between May 2015 and December 2016 at a tertiary free-standing university children's hospital. Surgical findings were classified into one of four grades of perforation: I. localized or contained perforation, II. Contained abscess with no generalized peritonitis, III. Generalized peritonitis with no dominant abscess, IV. Generalized peritonitis with one or more dominant abscesses. All patients were treated on a clinical pathway that involved all points of care from admission to final follow-up. Outcomes and resource utilization measures were analyzed using Fisher's exact test, Kruskal-Wallis test, One-way ANOVA, and logistic regression. RESULTS During the study period, 122 patients completed treatment, and 100% had documented follow-up at a median of 25days after operation. Grades of perforation were: I, 20.5%; II, 37.7%; III, 10.7%; IV, 31.1%. Postoperative abscesses occurred in 12 (9.8%) of patients, almost exclusively in Grade IV perforations. Hospital stay, duration of antibiotics, TPN utilization, and the incidence of postoperative imaging significantly increased with increasing grade of perforation. CONCLUSION Outcomes and resource utilization strongly correlate with increasing grade of perforated appendicitis. Postoperative abscesses, additional imaging, and additional invasive procedures occur disproportionately in patients who present with diffuse peritonitis and abscess formation. The current stratification allows risk-adjusted outcome reporting and appropriate assignment of resource burden. LEVEL OF EVIDENCE I (Prognosis Study).
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Affiliation(s)
- Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Fouad Youssef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Trish Dinh
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kartikey Pandya
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Hayden Stagg
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael Homsy
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert Baird
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jean-Martin Laberge
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Dan Poenaru
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pramod Puligandla
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kenneth Shaw
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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Hernandez M, Murphy B, Aho JM, Haddad NN, Saleem H, Zeb M, Morris DS, Jenkins DH, Zielinski M. Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines. Surgery 2018; 163:739-746. [PMID: 29325783 DOI: 10.1016/j.surg.2017.10.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/28/2017] [Accepted: 10/25/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Acute cholecystitis presents with heterogeneous severity. The Tokyo Guidelines 2013 is a validated method to assess cholecystitis severity, but the variables are multifactorial. The American Association for the Surgery of Trauma (AAST) developed an anatomically based severity grading system for surgical diseases, including cholecystitis. Because the Tokyo Guidelines represent the gold standard to estimate acute cholecystitis severity, we wished to validate the AAST emergency general surgery scoring system and compare the performance of both systems for several patient outcomes. METHODS Adults (≥18 years) with acute cholecystitis during 2013-2016 were identified. Baseline demographic characteristics, comorbidity severity as defined by Charlson Comorbidity Index score, procedure types, and AAST and Tokyo Guidelines 2013 grades were abstracted. Outcomes included duration of stay, 30-day mortality, and complications. Comparison of the Tokyo Guidelines and AAST grading system was performed using receiver operating characteristic (AUROC) curve C statistics. RESULTS There were 443 patients, with a mean (±standard deviation) age of 64.8 (±18) years, 59% male. The median (interquartile ratio) Charlson Comorbidity score was 3 (0-6). Management included laparoscopic (n = 307, 69.3%), open (n = 26, 6%), laparoscopy converted to laparotomy (n = 53, 12%), and cholecystostomy (n = 57, 12.7%). Comparison of AAST with Tokyo Guidelines AUROC C statistics indicated (P < .05) mortality (0.86 vs 0.73), complication (0.76 vs 0.63), and cholecystostomy tube utilization (0.80 vs 0.68). CONCLUSION Emergency general surgery grading systems improve disease severity assessment, may improve documentation, and guide management. Discrimination of disease severity using the AAST grading system outperforms the Tokyo Guidelines for key clinical outcomes. The AAST grading system requires prospective validation and further comparison.
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Affiliation(s)
- Matthew Hernandez
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Brittany Murphy
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - Johnathan M Aho
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nadeem N Haddad
- Division Trauma and Emergency Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Humza Saleem
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - Muhammad Zeb
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | - David S Morris
- Division of General Surgery, Trauma, and Critical Care, Intermountain Medical Center, Murray, UT, USA
| | - Donald H Jenkins
- Division Trauma and Emergency Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Martin Zielinski
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
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