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Donohue SJ, Reinke CE, Evans SL, Jordan MM, Warren YE, Hetherington T, Kowalkowski M, May AK, Matthews BD, Ross SW. Laparoscopy is associated with decreased all-cause mortality in patients undergoing emergency general surgery procedures in a regional health system. Surg Endosc 2022; 36:3822-3832. [PMID: 34477959 DOI: 10.1007/s00464-021-08699-1] [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: 05/24/2021] [Accepted: 08/24/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the use of laparoscopic surgery for common emergency general surgery (EGS) procedures within an integrated Acute Care Surgery (ACS) network. We hypothesized that laparoscopy would be associated with improved outcomes. METHODS Our integrated health care system's EGS registry created from AAST EGS ICD-9 codes was queried from January 2013 to October 2015. Procedures were grouped as laparoscopic or open. Standard descriptive and univariate tests were performed, and a multivariable logistic regression controlling for open status, age, BMI, Charlson Comorbidity Index (CCI), trauma tier, and resuscitation diagnosis was performed. Laparoscopic procedures converted to open were identified and analyzed using concurrent procedure billing codes across episodes of care. RESULTS Of 60,604 EGS patients identified over the 33-month period, 7280 (12.0%) had an operation and 6914 (11.4%) included AAST-defined EGS procedures. There were 4813 (69.6%) surgeries performed laparoscopically. Patients undergoing a laparoscopic procedure tended to be younger (45.7 ± 18.0 years vs. 57.2 ± 17.6, p < 0.001) with similar BMI (29.7 ± 9.0 kg/m2 vs. 28.8 ± 8.3, p < 0.001). Patients in the laparoscopic group had lower mean CCI score (1.6 ± 2.3 vs. 3.4 ± 3.2, p ≤ 0.0001). On multivariable analysis, open surgery had the highest association with inpatient mortality (OR 8.67, 4.23-17.75, p < 0.0001) and at all time points (30-, 90-day, 1-, 3-year). At all time points, conversion to open was found to be a statistically significant protective factor. CONCLUSION Use of laparoscopy in EGS is common and associated with a decreased risk of all-cause mortality at all time points compared to open procedures. Conversion to open was protective at all time points compared to open procedures.
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Affiliation(s)
- Sean J Donohue
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Susan L Evans
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Mary M Jordan
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Yancey E Warren
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Timothy Hetherington
- Carolinas Medical Center, Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Marc Kowalkowski
- Carolinas Medical Center, Center for Outcomes Research and Evaluation, Charlotte, NC, USA
| | - Addison K May
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Brent D Matthews
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Samuel W Ross
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
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Ross SW, Reinke CE, Ingraham AM, Holena DN, Havens JM, Hemmila MR, Sakran JV, Staudenmayer KL, Napolitano LM, Coimbra R. Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues. J Am Coll Surg 2022; 234:214-225. [PMID: 35213443 DOI: 10.1097/xcs.0000000000000044] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.
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Affiliation(s)
- Samuel W Ross
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Caroline E Reinke
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Angela M Ingraham
- University of Wisconsin School of Medicine and Public Health, Madison, WI (Ingraham)
| | - Daniel N Holena
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Holena)
| | - Joaquim M Havens
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA (Havens)
| | - Mark R Hemmila
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Joseph V Sakran
- Johns Hopkins University School of Medicine, Baltimore, MD (Sakran)
| | | | - Lena M Napolitano
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Loma Linda, CA (Coimbra)
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Inukai K, Usui A, Yamada M, Amano K, Mukai N, Tsunetoshi Y, Nakata Y, Yokota J. Open abdominal management for perforative peritonitis with septic shock: a retrospective analysis on usefulness of a standardized treatment protocol. Eur J Trauma Emerg Surg 2019; 47:93-98. [PMID: 30949740 DOI: 10.1007/s00068-019-01132-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Damage control surgery (DCS) with open abdominal management (OAM) has been increasingly expanded to include critically ill non-trauma patients. However, there is limited data regarding the usefulness of this protocol for the treatment of severe perforative peritonitis (PP), especially with septic shock (SS). Here, we retrospectively evaluated the usefulness of our OAM protocol for PP with SS. METHODS We retrospectively reviewed patients with from June 2015 to September 2018. The proposed protocol was composed of the following steps: (1) rapid control of contamination; (2) temporary abdominal closure; (3) repeated washout of the abdominal cavity; and (4) delayed definitive surgery. For temporary abdominal closure, a negative pressure wound therapy device was used. The end points were the morbidity and 30-day mortality rates. Logistic backward regression was performed to identify factors associated with complications. RESULTS The mortality rate was 4% (1/25) and the overall morbidity rate of surviving patients was 58.3% (14/24). The mean duration of the first DCS was 67.36 ± 22.83 min. The median durations of ventilation and intensive care unit stay were 5 and 7 days, respectively. Although not significant, morbidity might be associated with age, diabetes mellitus, initial operative time, and OAM duration. CONCLUSIONS A standardized protocol for OAM may improve the outcomes of patients with SS due to PP. This damage control approach can be applied for the treatment of severe abdominal sepsis.
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Affiliation(s)
- Koichi Inukai
- Department of Acute Care Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, 593-8304, Japan.
| | - Akihiro Usui
- Department of Acute Care Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, 593-8304, Japan
| | - Motohiko Yamada
- Department of Acute Care Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, 593-8304, Japan
| | - Koji Amano
- Department of Acute Care Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, 593-8304, Japan
| | - Nobutaka Mukai
- Department of Acute Care Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, 593-8304, Japan
| | - Yusuke Tsunetoshi
- Department of Acute Care Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, 593-8304, Japan
| | - Yasuki Nakata
- Department of Acute Care Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, 593-8304, Japan
| | - Junichiro Yokota
- Department of Acute Care Surgery, Sakai City Medical Center, 1-1-1 Ebaraji-cho, Nishi-ku, Sakai, Osaka, 593-8304, Japan
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Abstract
BACKGROUND Damage-control surgery with open abdomen (OA) is described for trauma, but little exists regarding use in the emergency general surgery. This study aimed to better define the following: demographics, indications for surgery and OA, fascial and surgical site complications, and in-hospital/long-term mortality. We hypothesize that older patients will have increased mortality, patients will have protracted stays, they will require specialized postdischarge care, and the indications for OA will be varied. METHODS A prospective observational study of emergency general surgery OA patients from June 2013 to June 2014 was performed. Demographics, clinical/operative variables, comorbidities, indications for procedure and OA, wound/fascial complications, and disposition were collected. Patients were stratified into age groups (≤ 60, 61-79, and ≥ 80 years). Six-month and 1-year mortality was determined by query of the Social Security Death Index. RESULTS A total of 338 laparotomies were performed, of which 96 (28%) were managed with an OA. Median age was 61 years (interquartile range [IQR], 0-68 years), and 51% were male. The median Charlson Comorbidity Index was 2 (IQR, 1.5-5.1), and the median hospital stay was 25 days (IQR, 15-50 days). The most common indications for operation were perforated viscus/free air (20%), mesenteric ischemia (17%), peritonitis (16%), and gastrointestinal hemorrhage (12%). The most common indication for OA was damage control (37%). In the 63 patients with fascial closure, there were 9 (14%) wound infections and 6 (10%) fascial dehiscences. A total of 30% of the patients died in the hospital, and an additional six patients died 6 months after discharge. Patients in the oldest age stratum were more likely to die at 6 months than those in the lower strata. CONCLUSION Older patients were more likely to die by 6 months, the median hospital stay was 3 weeks, and there were multiple indications for OA management. With a 6-month mortality of 36% and 70% of survivors requiring postdischarge care, this population represents a critically ill population meriting additional study. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Abstract
OBJECTIVE ICU needs of nontrauma emergency general surgery patients are poorly described. This study was designed to compare ICU utilization of emergency general surgery patients admitted to an acute care emergency surgery service with other general surgery patients. Our hypothesis is that tertiary care emergency general surgery patients utilize more ICU resources than other general surgical patients. DESIGN Retrospective database review. SETTING Academic, tertiary care, nontrauma surgical ICU. PATIENTS All patients admitted to the surgical ICU over age 18 between March 2004 and June 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Six thousand ninety-eight patients were evaluated: 1,053 acute care emergency surgery, 1,964 general surgery, 1,491 transplant surgery, 995 facial surgery/otolaryngology, and 595 neurosurgery. Acute care emergency surgery patients had statistically significantly longer ICU lengths of stay than other groups: acute care emergency surgery (13.5 ± 17.4 d) versus general surgery (8.7 ± 12.9), transplant (7.8 ± 11.6), oral-maxillofacial surgery (5.5 ± 4.2), and neurosurgery (4.47 ± 9.8) (all p< 0.01). Ventilator usage, defined by percentage of total ICU days patients required mechanical ventilation, was significantly higher for acute care emergency surgery patients: acute care emergency surgery 73.4% versus general surgery 64.9%, transplant 63.3%, oral-maxillofacial surgery 58.4%, and neurosurgery 53.1% (all p < 0.01). Continuous renal replacement therapy usage, defined as percent of patients requiring this service, was significantly higher in acute care emergency surgery patients: acute care emergency surgery 10.8% versus general surgery 4.3%, transplant 6.6%, oral-maxillofacial surgery 0%, and neurosurgery 0.5% (all p < 0.01). Acute care emergency surgery patients were more likely interhospital transfers for tertiary care services than general surgery or transplant (24.5% vs 15.5% and 8.3% respectively, p < 0.001 for each) and more likely required emergent surgery (13.7% vs 6.7% and 3.5%, all p < 0.001). Chronic comorbidities were similar between acute care emergency surgery and general surgery, whereas transplant had fewer. CONCLUSIONS Emergency general surgery patients have increased ICU needs in terms of length of stay, ventilator usage, and continuous renal replacement therapy usage compared with other services, perhaps due to the higher percentage of transfers and emergent surgery required. These patients represent a distinct population. Understanding their resource needs will allow for better deployment of hospital resources.
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Post hoc ergo propter hoc: the story of the Resuscitation Outcomes Consortium. J Trauma Acute Care Surg 2013; 74:8-16. [PMID: 23271071 DOI: 10.1097/ta.0b013e31827dc6d3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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