Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Not all is lost: Functional recovery in older adults following emergency general surgery

BACKGROUND

Although functional decline and death are common long-term outcomes among older adults following emergency general surgery (EGS), we hypothesized that patients' post-discharge function may wax and wane over time. Periods of fluctuation in function may represent opportunities to intervene to prevent further decline. Our objective was to describe the functional trajectories of older adults following EGS admission.

METHODS

This was a population-based retrospective cohort study of all independent, community-dwelling older adults (age ≥ 65) in Ontario with an EGS admission (2006-2016). A multistate model was used to examine patients' functional trajectories over the five years following discharge. Patients were followed as they transitioned back and forth between functional independence, use of chronic home care (in-home assistance for personal care, homemaking, or medical care for at least 90 days), nursing home admission, and death.

RESULTS

We identified 78,820 older adults with an EGS admission (mean age 77, 53% female). In the 5 years following admission, 32% (n = 24,928) required new chronic home care, 21% (n = 5,249) of whom had two or more episodes of chronic home care separated by periods of independence. The average time spent in chronic home care was 11 months, and 50% (n = 12,679) of chronic home care episodes ended with a return to independence. For patients requiring chronic home care at any time, the probability of returning to independent living over the subsequent five years ranged from 36-43% annually.

CONCLUSIONS

Not all is lost for older adults who experience functional decline following EGS admission. Half of those who require chronic home care will recover to independence, and one-third will have a durable recovery, remaining independent after five years. Fluctuations in function in the years following EGS may represent a unique opportunity for interventions to promote rehabilitation and recovery among older adults.

LEVEL OF EVIDENCE

Level III, epidemiological.

Long-term survival in high-risk older adults following emergency general surgery admission

BACKGROUND

Emergency general surgery (EGS) conditions are increasingly common among nursing home residents. While such patients have a high risk of in-hospital mortality, long-term outcomes in this group are not well described, which may have implications for goals of care discussions. In this study, we evaluate long-term survival among nursing home residents admitted for EGS conditions.

METHODS

We performed a population-based, retrospective cohort study of nursing home residents (65 years or older) admitted for one of eight EGS diagnoses (appendicitis, cholecystitis, strangulated hernia, bowel obstruction, diverticulitis, peptic ulcer disease, intestinal ischemia, or perforated viscus) from 2006 to 2018 in a large regional health system. The primary outcome was 1-year survival. To ascertain the effect of EGS admission independent of baseline characteristics, patients were matched to nursing home residents without an EGS admission based on demographics and baseline health. Kaplan-Meier analysis was used to evaluate survival across groups.

RESULTS

A total of 7,942 nursing home residents (mean age, 85 years) were admitted with an EGS diagnosis and matched to controls. One quarter of patients underwent surgery, and 18% died in hospital. At 1 year, 55% of cases were alive, compared with 72% of controls (p < 0.001). Among those undergoing surgery, 61% were alive at 1 year, compared with 72% of controls (p < 0.001). The 1-year survival probability was 57% in patients who did not require mechanical ventilation, 43% in those who required 1 to 2 days of ventilation, and 30% in those who required ≥3 days of ventilation.

CONCLUSION

Although their risk of in-hospital mortality is high, most nursing home residents admitted for an EGS diagnosis survive at least 1 year. While nursing home residents presenting with an EGS diagnosis should be cited realistic odds for the risk of death, long-term survival is achievable in the majority of these patients.

LEVEL OF EVIDENCE

Epidemiological, level III.

Patient reported outcomes in an elder-friendly surgical environment: Prospective, controlled before-after study

Introduction

The Acute Care for the Elderly (ACE) model has demonstrated clinical benefit, but there is little evidence regarding quality of life after discharge. The Elder-friendly Approaches to the Surgical Environment (EASE) study was conducted to assess implementation of an ACE unit on an acute surgical service. Improved clinical and economic outcomes have been demonstrated, but post-discharge patient reported outcomes have not yet been reported.

Methods

Prospective, concurrently controlled, before-after study at two tertiary care hospitals in Alberta, Canada. The SF-12, EQ-5D, Canadian Malnutrition Screening Tool (CMST) and patient satisfaction were collected from elderly (≥ 65 years old) patients, 6 weeks and 6 months after discharge from an acute care surgical service. A difference-in-difference (DID) method was used to analyze between-site effects.

Results

At six weeks, patient satisfaction was high at 68%-86%, with significant improvement Pre-to Post-EASE at the control site (p < 0.001), but not the intervention site (p = 0.06). For the intervention site, within-site adjusted pre-post effects were nonsignificant for all patient reported outcomes [EQ-Index Score β coefficient (SE): 0.042 (0.022); EQ-Visual Analog Scale: 0.10 (2.14); SF-12 Physical Component Score: -0.57 (0.84); SF-12 Mental Component Score: 1.17 (0.84); CMST Score: -0.39 (0.34)]. DID analyses were also non significant for all outcomes except for SF-12 Mental Component Score (p < 0.001).

Conclusion

The clinically and economically beneficial EASE interventions do not appear to compromise quality of life, risk for malnutrition, or patient satisfaction in the post-discharge period. Further research with larger sample size is needed with comparisons to pre-intervention and the early post-discharge period.

Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade

As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.

Alive and at home: Five-year outcomes in older adults following emergency general surgery

BACKGROUND

While the short-term risks of emergency general surgery (EGS) admission among older adults have been studied, little is known about long-term functional outcomes in this population. Our objective was to evaluate the relationship between EGS admission and the probability of an older adult being alive and residing in their own home 5 years later. We also examined the extent to which specific EGS diagnoses, need for surgery, and frailty modified this relationship.

METHODS

We performed a population-based, retrospective cohort study of community-dwelling older adults (age, ≥65 years) admitted to hospital for one of eight EGS diagnoses (appendicitis, cholecystitis, diverticulitis, strangulated hernia, bowel obstruction, peptic ulcer disease, intestinal ischemia, or perforated viscus) between 2006 and 2018 in Ontario, Canada. Cases were matched to controls from the general population. Time spent alive and at home (measured as time to nursing home admission or death) was compared between cases and controls using Kaplan-Meier analysis and Cox models.

RESULTS

A total of 90,245 older adults admitted with an EGS diagnosis were matched with controls. In the 5 years following an EGS admission, cases experienced significantly fewer months alive and at home compared with controls (mean time, 43 vs. 50 months; p < 0.001). Except for patients operated on for appendicitis and cholecystitis, all remaining patient subgroups experienced reduced time alive and at home compared with controls (p < 0.001). Cases remained at elevated risk of nursing home admission or death compared with controls for the entirety of the 5-year follow-up (hazard ratio, 1.17-5.11).

CONCLUSION

Older adults who required hospitalization for an EGS diagnosis were at higher risk for death or admission to a nursing home for at least 5 years following admission compared with controls. However, most patients (57%) remained alive and living in their own home at the end of this 5-year period.

LEVEL OF EVIDENCE

Epidemiological, level III.

Factors associated with refractory pain in emergency patients admitted to emergency general surgery

BACKGROUND

Oligoanalgesia in emergency departments (EDs) is multifactorial. A previous study reported that emergency providers did not adequately manage patients with severe pain despite objective findings for surgical pathologies. Our study aims to investigate clinical and laboratory factors, in addition to providers' interventions, that might have been associated with oligoanalgesia in a group of ED patients with moderate and severe pains due to surgical pathologies.

METHODS

We conducted a retrospective study of adult patients who were transferred directly from referring EDs to the emergency general surgery (EGS) service at a quaternary academic center between January 2014 and December 2016. Patients who were intubated, did not have adequate records, or had mild pain were excluded. The primary outcome was refractory pain, which was defined as pain reduction <2 units on the 0-10 pain scale between triage and ED departure.

RESULTS

We analyzed 200 patients, and 58 (29%) had refractory pain. Patients with refractory pain had significantly higher disease severity, serum lactate (3.4±2.0 mg/dL vs. 1.4±0.9 mg/dL, P=0.001), and less frequent pain medication administration (median [interquartile range], 3 [3-5] vs. 4 [3-7], P=0.001), when compared to patients with no refractory pain. Multivariable logistic regression showed that the number of pain medication administration (odds ratio [OR] 0.80, 95% confidence interval [95% CI] 0.68-0.98) and ED serum lactate levels (OR 3.80, 95% CI 2.10-6.80) were significantly associated with the likelihood of refractory pain.

CONCLUSIONS

In ED patients transferring to EGS service, elevated serum lactate levels were associated with a higher likelihood of refractory pain. Future studies investigating pain management in patients with elevated serum lactate are needed.

The Silent Majority of Emergency General Surgery: An Assessment of Consult and Operative Volumes

BACKGROUND

Defining the work performed by emergency general surgery (EGS) surgeons has relied on quantifying surgical interventions, failing to include nonsurgical management performed. The purpose of this study was to identify the extent of operative and nonoperative patient management provided by an EGS service line in response to consults from other hospital providers.

METHODS

This is a retrospective descriptive study of all adult patients with an EGS consult request placed from July 1, 2014 to June 30, 2016 at a 1000-bed tertiary referral center. Consult requests were classified by suspected diagnosis and linked to patient demographic and clinical information. Operative and nonoperative cases were compared.

RESULTS

About 4998 EGS consults were requested during the 2-y period, of which 69.6% were placed on the first day of the patient encounter. Disposition outcomes after consultation included admission to the EGS service (27.6%) and discharge from the emergency department (25.3%). Small bowel obstruction, appendicitis, and cholecystitis decisively comprised the top three diagnoses for overall consults and those requiring admission to the EGS service. For every consult requiring an operation (n = 1400), 2.6 consults were managed without an operation (n = 3598).

CONCLUSIONS

EGS surgeons are asked to evaluate and manage a variety of potentially surgical diagnoses. As most consults do not require surgical intervention, operative volume is a poor surrogate for quantifying EGS productivity. The role of this service is vital to patient triage and disposition, particularly in the emergency department setting. Institutions should consider the volume of their nonoperative consultations when evaluating EGS service line workload and in guiding staffing needs.

The rate of short-term revisits after diagnosis of non-specific abdominal pain is similar for surgeons and emergency physicians - results from a single tertiary hospital emergency department

Background

Acute abdominal pain can be a diagnostic challenge even for experienced surgeons. Delayed diagnosis can lead to higher morbidity, mortality and increased costs. While readmission rate has been used to evaluate quality of surgical care, studies addressing the issue in emergency departments (ED) are rare. The role of emergency physicians in the care of patients with abdominal pain is increasing in many European countries, including Finland. It is not known whether this has an effect on the number of readmissions.

Here we evaluate whether the increasing role of emergency physicians in examining patients presenting with abdominal pain has affected the rate of short-term revisits among patients with non-specific abdominal pain (NSAP).

Methods

We identified consecutive ED patients receiving a diagnosis of NSAP 1.1. 2015–31.12.2016 in the ED of Tampere University Hospital. Those revisiting the ED within 48 h were selected for further analysis. Data were obtained from electronic medical records. We compared the outcomes of those initially examined by surgeons and by emergency physicians.

Results

During the study period, 173,630 patients visited our ED, of whom 6.1% (n = 10,609) were discharged with a diagnosis of NSAP. Only 3.0% of patients revisited the ED, 0.7% required hospitalization and 0.06% immediate surgery. The short-term revisit rates among those originally examined by surgeons and by emergency physicians were similar, 2.8 and 3.2% respectively (p = 0.193).

Conclusions

The rate of short-term revisits in patients with NSAP was altogether low. The increasing role of emergency physicians in the care of acute abdominal patients did not affect the revisit rate.

Risk factors for mortality after emergency laparotomy: scoping systematic review

BACKGROUND

Emergency laparotomy (EL) is a common procedure with high mortality leading to several efforts to record and reduce mortality. Risk scores currently used by quality improvement programmes either require intraoperative data or are not specific to EL. To be of utility to clinicians/patients, estimation of preoperative risk of mortality is important. We aimed to explore individual preoperative risk factors that might be of use in developing a preoperative mortality risk score.

METHODS

Two independent reviewers identified relevant articles from searches of MEDLINE, EMBASE and Cochrane databases from January 1980 to January 2018. We selected studies that evaluated only preoperative predictive factors for mortality in EL patients.

RESULTS

The search yielded 6648 articles screened, with 22 studies included examining 157 728 patients. The combined post-operative 30-day mortality was 13%. All, but one small study, were at low risk of bias. A meta-analysis of results was not possible due to the heterogeneity of populations and outcomes. Age, American Society of Anesthesiologists, preoperative sepsis, dependency status, current cancer and comorbidities were associated with increased mortality. Acute physiological derangements seen in renal, albumin and complete blood count assays were strongly associated with mortality. Delay to surgery and diabetes did not influence mortality. Higher body mass index was protective.

CONCLUSION

Preoperatively, risk factors identified can be used to develop and update risk scores specific for EL mortality. This scoping review focused on the preoperative setting which helps tailor treatment decisions. It highlights the need for further research to test the relevance of newer risk factors such as frailty and nutrition.

Multidisciplinary survey of current and future use of emergency laparotomy risk assessment scores in New Zealand

Risk prediction is an important part of the management of emergency laparotomy (EL) patients. This study aims to investigate the current use of and future directions for EL risk prediction scores. New Zealand members of the Royal Australasian College of Surgery (RACS), Australian and New Zealand College of Anaesthetists (ANZCA) and College of Intensive Care Medicine (CICM) were invited to participate in an anonymous online survey. Responses were received from 316 clinicians (45 RACS, 253 ANZCA and 19 CICM), with 73% of them having >10 years' experience as a consultant. Risk assessment scores were utilised by respondents for approximately 30% of EL cases. The most common EL risk scores used were Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality (P-POSSUM) and American College of Surgeons National Surgical Quality Improvement Programs (ACS-NSQIP). When used, respondents used risk assessment mostly preoperatively (RACS 100%, ANZCA 98% and CICM 78%), although P-POSSUM and ACS-NSQIP scores require intraoperative data (which can only be estimated crudely preoperatively by the clinician). Respondents on average 'somewhat agreed' that risk assessment scores should only include preoperative variables. The most common reasons for using P-POSSUM and ACS-NSQIP scores were familiarity and ease of use and availability of online/app calculators. The most important outcomes that the respondents would like to predict were quality of life and 30-day mortality rather than long-term impact from EL. These findings suggest that developing a new score may be required to improve utilisation and help in decision-making. This may require tailoring risk scores specifically for EL, and designing them to predict what is preferred by the clinicians making the decisions.

Percentage of Mortal Encounters Transferred in Emergency General Surgery

BACKGROUND

Despite the frequent occurrence of interhospital transfers in emergency general surgery (EGS), rates of transfer of complications are undescribed. Improved understanding of hospital transfer patterns has a multitude of implications, including quality measurement. The objective of this study was to describe individual hospital transfer rates of mortal encounters.

MATERIALS AND METHODS

A retrospective review was undertaken from 2013 to 2015 of the Maryland Health Services Cost Review Commission database. Two groups of EGS encounters were identified: encounters with death following transfer and encounters with death without transfer. The percentage of mortal encounters transferred was defined as the percentage of EGS hospital encounters with mortality initially presenting to a hospital transferred to another hospital before death at the receiving hospital.

RESULTS

Overall, 370,242 total EGS encounters were included, with 17,003 (4.6%) of the total EGS encounters with mortality. Encounters with death without transfer encompassed 15,604 (91.8%) of mortal EGS encounters and encounters with death following transfer 1399 (8.2%). EGS disease categories of esophageal varices or perforation, necrotizing fasciitis, enterocutaneous fistula, and pancreatitis had over 10% of these total mortal encounters with death following transfer. For individual hospitals, percentage of mortal encounters transferred ranged from 0.8% to 35.2%. The percentage of mortal encounters transferred was inversely correlated with annual EGS hospital volume for all state hospitals (P < 0.001, r = -0.57).

CONCLUSIONS

Broad variability in individual hospital practices exists for mortality transferred to other institutions. Application of this knowledge of percentage of mortal encounters transferred includes consideration in hospital quality metrics.

Interhospital Transfers with Wide Variability in Emergency General Surgery

Interhospital transfer of emergency general surgery (EGS) patients is a common occurrence. Modern individual hospital practices for interhospital transfers have unknown variability. A retrospective review of the Maryland Health Services Cost Review Commission database was undertaken from 2013 to 2015. EGS encounters were divided into three groups: encounters not transferred, encounters transferred from a hospital, and encounters transferred to a hospital. In total, 380,405 EGS encounters were identified, including 12,153 (3.2%) encounters transferred to a hospital, 10,163 (2.7%) encounters transferred from a hospital, and 358,089 (94.1%) encounters not transferred. For individual hospitals, percentage of encounters transferred to a hospital ranged from 0 to 30.05 per cent, encounters transferred from a hospital from 0.02 to 14.62 per cent, and encounters not transferred from 69.25 to 99.95 per cent of total encounters at individual hospitals. Percentage of encounters transferred from individual hospitals was inversely correlated with annual EGS hospital volume ( P < 0.001, r = -0.59), whereas percentage of encounters transferred to individual hospitals was directly correlated with annual EGS hospital volume ( P < 0.001, r = 0.51). Individual hospital practices for interhospital transfer of EGS patients have substantial variability. This is the first study to describe individual hospital interhospital transfer practices for EGS.

Prothrombin Complex Concentrate Reversal of Coagulopathy in Emergency General Surgery Patients

BACKGROUND

Coagulopathy can delay or complicate surgical diseases that require emergent surgical treatment. Prothrombin complex concentrates (PCC) provide concentrated coagulation factors which may reverse coagulopathy more quickly than plasma (FFP) alone. We aimed to determine the time to operative intervention in coagulopathic emergency general surgery patients receiving either PCC or FFP. We hypothesize that PCC administration more rapidly normalizes coagulopathy and that the time to operation is diminished compared to FFP alone.

METHODS

Single institution retrospective review was performed for coagulopathic EGS patients during 2/1/2008 to 8/1/2016. Patients were divided into three groups (1) PCC alone (2) FFP alone and (3) PCC and FFP. The primary outcome was the duration from clinical decision to operate to the time of incision. Summary and univariate analyses were performed.

RESULTS

Coagulopathic EGS patients (n = 183) received the following blood products: PCC (n = 20, 11%), FFP alone (n = 119, 65%) and PCC/FFP (n = 44, 24%). The mean (± SD) patient age was 71 ± 13 years; 60% were male. The median (IQR) Charlson comorbidity index was similar in all three groups (PCC = 5(4-6), FFP = 5(4-7), PCC/FFP = 5(4-6), p = 0.33). The mean (± SD) dose of PCC administered was similar in the PCC/FFP group and the PCC alone group (2539 ± 1454 units vs. 3232 ± 1684, p = .09). The mean (±SD) time to incision in the PCC alone group was significantly lower than the FFP alone group (6.0 ± 3.6 vs. 8.8 ± 5.0 h, p = 0.01). The mean time to incision in the PCC + FFP group was also significantly lower than the FFP alone group (7.1 ± 3.6 vs. 8.8 ± 5.0, p = 0.03). The incidence of thromboembolic complications was similar in all three groups.

CONCLUSIONS

PCC, alone or in combination with FFP, reduced INR and time to surgery effectively and safely in coagulopathic EGS patients without an apparent increased risk of thromboembolic events, when compared to FFP use alone.

LEVEL OF EVIDENCE

IV single institutional retrospective review.

Emergency pediatric surgery: Comparing the economic burden in specialized versus nonspecialized children's centers

BACKGROUND

The American College of Surgeons has developed a verification program for children's surgery centers. Highly specialized hospitals may be verified as Level I, while those with fewer dedicated resources as Level II or Level III, respectively. We hypothesized that more specialized children's centers would utilize more resources.

STUDY DESIGN

We performed a retrospective study of the Maryland Health Services Cost Review Commission (HSCRC) database from 2009 to 2013. We assessed total charge, length of stay (LOS), and charge per day for all inpatients with an emergency pediatric surgery diagnosis, controlling for severity of illness (SOI). Using published resources, we assigned theoretical level designations to each hospital.

RESULTS

Two hospitals would qualify as Level 1 hospitals, with 4593 total emergency pediatric surgery admissions (38.5%) over the five-year study period. Charges were significantly higher for children treated at Level I hospitals (all P<0.0001). Across all SOI, children at Level I hospitals had significantly longer LOS (all P<0.0001).

CONCLUSION

Hospitals defined as Level II and Level III provided the majority of care and were able to do so with shorter hospitalizations and lower charges, regardless of SOI. As care shifts towards specialized centers, this charge differential may have significant impact on future health care costs.

LEVEL OF EVIDENCE

Level III Cost Effectiveness Study.

Surgeon variation in operating times and charges for emergency general surgery

BACKGROUND

Patients and hospitals face significant financial burdens from emergency general surgeries (EGSs), which have been termed a public health crisis in the United States. We evaluated hospitalization charges, operating charges, and variations in operating time by surgeon volume for three common EGS procedures.

METHODS

Using Maryland's Health Services Cost Review Commission database, we performed a retrospective study of laparoscopic appendectomies, laparoscopic cholecystectomies, and open bowel resections performed by general surgeons among adult patients from July 2012 to September 2014. We compared operating charges to total hospitalization charges and quantified variations in operating time for each procedure. We then divided patients into quartiles based on their surgeon's procedure-specific case volume and used hierarchical linear regressions to calculate differences in both operating time and charges between quartiles.

RESULTS

We identified 3194 appendectomies, 4143 cholecystectomies, and 1478 bowel resections. Operating charges accounted for one-quarter (26.9%) of total hospitalization charges and widespread variation existed in operating time (appendectomies: median 79 min [interquartile range 66-100 min], cholecystectomies: 96 min [76-125 min], bowel resections: 155 min [117-209 min]). After adjustment, low-volume surgeons relative to high-volume surgeons did not operate statistically longer for appendectomies (+1%, 95% confidence interval [CI]: -2% to 5%) but operated +16% (95% CI: 12%-20%) longer for cholecystectomies (+14 min) and +40% (95% CI: 30%-50%) longer for bowel resections (+59 min). Adjusted median operating charges from low-volume surgeons relative to high-volume surgeons were $554 (26.7%), $621 (22.0%), and $1801 (47.0%) greater for appendectomies, cholecystectomies, and bowel resections, respectively.

CONCLUSIONS

Operating charges contributed substantially to total EGS hospitalization charges, where low-volume surgeons operated longer and had higher operative charges relative to high-volume surgeons. Reducing variations in operating times and charges represents an opportunity to alleviate the financial burden from EGS procedures.

Clinical patterns of presentation and attenuated inflammatory response in octo- and nonagenarians with perforated gastroduodenal ulcers

BACKGROUND

Perforated gastrodudenal ulcer (PGDU) is an operative emergency with high mortality rates. The growing elderly population increasingly presents with need for geriatric acute operative care. Current knowledge of age-specific characteristics in presentation, diagnosis, and outcome for PGDU in the elderly is scarce.

METHODS

We reviewed a consecutive, population-based cohort of patients with PGDU, octa- and nonagenarians were compared with younger patients for variation in patterns of presentation and outcomes. Patterns and outcomes observed included 30-day mortality, serious complications (Clavien-Dindo 3 and 4), and duration of stay.

RESULTS

Of the 244 patients, 127 were women (52%); median age was 68 years; and 59 patients (24.2%) were ≥80 years. Two thirds had gastric ulcers (n = 168; 67.2%). On admission, hemoglobin levels, white blood cell count, and serum levels of C-reactive protein, bilirubin, and albumin differed significantly between the age groups. Diagnosis, treatment, and the occurrence of severe complications did not differ with age. The median hours of delay to definitive treatment did not differ significantly for all ages, but patients ≥80 years had a greater proportion (44.1% compared with 25.8%) of delay >12 hours (odds ratio 2.26, 95% confidence interval 1.22-4.17; P = .008). Overall mortality was 38 (15.6%); no deaths occurred in patients <55 years. Over one half of deaths occurred in those ≥80 years (odds ratio 4.76, 2.30-9.83; P < .001). Duration of hospital stay was significantly greater in elderly survivors, and fewer were discharged within a week.

CONCLUSION

Octa- and nonagenarians with PGDU present with fewer signs of peritonitis and have an attenuated inflammatory response. The very elderly have twice the risk of long delays to definitive treatment and almost 5 times increased risk of mortality.

Acute Care Surgery: Defining the Economic Burden of Emergency General Surgery

BACKGROUND

Trauma centers (TCs) have been shown to provide lifesaving, but more expensive, care when compared with non-TCs (NTC). Limited data exist about the economic impact of emergency general surgery (EGS) patients on health care systems. We hypothesized that the economic burden would be higher for EGS patients managed at TCs vs NTCs.

METHODS

The Maryland Health Services Cost Review Commission database was queried from 2009 to 2013. The American Association for the Surgery of Trauma EGS ICD-9 codes were used to define the top 10 EGS diagnoses. Demographic characteristics, TC designation, severity of illness, and hospital charge data were collected. Differences in total charges between TCs and NTCs were analyzed by Wilcoxon test using SAS 9.3 software (SAS Institute).

RESULTS

A total of 435,623 patients were included. Median age was 61 years (interquartile range 47 to 76 years) and 55.9% were female. Median length of stay was 4 days; 90.3% were admitted via emergency department; and overall mortality was 5.1%. Overall median charges were $11,081 for TC vs $8,264 for NTC (p < 0.0001). Minor, moderate, major, and extreme severities of illness all had higher charges at TC vs NTC with no ICU admissions, respectfully ($5,908 vs $5,243; $7,051 vs $6,003; $10,501 vs $8,777; and $23, 997 vs $18,381; p < 0.001). Care at TCs was nearly twice as expensive if patients were admitted to the ICU, even when stratifying by severity of illness.

CONCLUSIONS

Emergency general surgery patients treated at TCs incurred increased costs compared with NTCs, independent of patient severity. These costs nearly doubled for those admitted to the ICU. As acute care surgery grows as a specialty, additional investigation is required to better understand the reasons for this cost differential.

Emergency general surgery in the geriatric patient

BACKGROUND

Emergency general surgery in the elderly is a particular challenge to the surgeon in charge of their care. The aim was to review contemporary aspects of managing elderly patients needing emergency general surgery and possible alterations to their pathways of care.

METHODS

This was a narrative review based on a PubMed/MEDLINE literature search up until 15 September 2015 for publications relevant to emergency general surgery in the geriatric patient.

RESULTS

The number of patients presenting as an emergency with a general surgical condition increases with age. Up to one-quarter of all emergency admissions to hospital may be for general surgical conditions. Elderly patients are a particular challenge owing to added co-morbidity, use of drugs and risk of poor outcome. Frailty is an important potential risk factor, but difficult to monitor or manage in the emergency setting. Risk scores are not available universally. Outcomes are usually severalfold worse than after elective surgery, in terms of both higher morbidity and increased mortality. A care bundle including early diagnosis, resuscitation and organ system monitoring may benefit the elderly in particular. Communication with the patient and relatives throughout the care pathway is essential, as indications for surgery, level of care and likely outcomes may evolve. Ethical issues should also be addressed at every step on the pathway of care.

CONCLUSION

Emergency general surgery in the geriatric patient needs a tailored approach to improve outcomes and avoid futile care. Although some high-quality studies exist in related fields, the overall evidence base informing perioperative acute care for the elderly remains limited.