The use of pre-operative computed tomography in the assessment of the acute abdomen

Outpatient secondary care pathways for head and neck cancer referral result in patient delays for cancer treatment

INTRODUCTION

The majority of head and neck cancer referrals are received through primary care. A proportion of cancer referrals are received through secondary care specialties. Local delivery plan (LDP) targets in Scotland for cancer investigation are set at 31 days for diagnosis and 62 days to start treatment. The aim was to audit referrals made through non-primary care pathways compared with the standard primary care pathways against LDP targets.

METHODS

New head and neck cancer patients between 1 January 2014 and 1 January 2019 were included. Pathway points were recorded between referral to outpatient clinic, time to multidisciplinary team discussion (MDT) and finally MDT to treatment.

RESULTS

1,276 new patient referrals were received over a 5-year period. Of these, 136 (10%) were referred via non-primary care pathways. The mean time for urgent suspicion of cancer (USoC) referrals to start treatment was 77 days (15 days over target) and for outpatient secondary care referrals was 102 days (40 days over target) (p<0.05). When treatment intent was considered, 841/1,131 (75%) of patients referred via primary care were treated curatively compared with 49/99 (49%) (p<0.05) of patients referred through the secondary outpatient pathway.

CONCLUSION

Patients with head and neck cancer referred from other outpatient specialties face delays commencing cancer treatment and are also associated with a greater likelihood of being treated with palliative intent.

Markers of sarcopenia increase 30-day mortality following emergency laparotomy: A systematic review

BACKGROUND AND OBJECTIVE

Decreased skeletal muscle mass and quality are one of the several markers used for sarcopenia diagnosis and are generally associated with increased rates of post-operative infections, poorer recovery and increased mortality. The aim of this review was to evaluate methods applied to detect markers of sarcopenia and the associated outcomes for patients undergoing emergency laparotomy.

METHODS

This review was conducted with reference to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. MEDLINE, Embase and Google Scholar databases were searched. Studies detecting patients with sarcopenia or skeletal muscle decline markers and the associated outcomes after emergency laparotomy surgery were considered. The Newcastle-Ottawa Scale was used to evaluate publication quality.

RESULTS

Out of 103 studies, which were screened, 19 full-text records were reviewed and 7 studies were ultimately analyzed. The study cohort sizes ranged from n = 46 to n = 967. The age range was 36-95 years. There were 1107 females (53%) and 973 males (47%) across all 7 studies. All studies measured psoas muscle mass and three studies assessed psoas muscle quality using computerized tomography (CT) imaging. No study assessed muscle strength or function, while five studies showed an association between low muscle mass and increased mortality rates after emergency laparotomy. Among the three studies, which assessed muscle quality, two of three studies showed poorer 30-day survival rates.

CONCLUSIONS

The existing literature is limited, however it indicates that low psoas muscle mass and quality markers are associated with increased 30-day mortality rates after emergency laparotomy. Therefore, muscle markers can be used as a new feasible tool to identify most at risk patients requiring further interventions.

Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies

Secondary peritonitis and intra-abdominal sepsis are a global health problem. The life-threatening systemic insult that results from intra-abdominal sepsis has been extensively studied and remains somewhat poorly understood. While local surgical therapy for perforation of the abdominal viscera is an age-old therapy, systemic therapies to control the subsequent systemic inflammatory response are scarce. Advancements in critical care have led to improved outcomes in secondary peritonitis. The understanding of the effect of secondary peritonitis on the human microbiome is an evolving field and has yielded potential therapeutic targets. This review of secondary peritonitis discusses the history, classification, pathophysiology, diagnosis, treatment, and future directions of the management of secondary peritonitis. Ongoing clinical studies in the treatment of secondary peritonitis and the open abdomen are discussed.

Patients undergoing primary surgery for oral and oropharyngeal cancer: how many are referred on the two-week wait pathway and by whom?

INTRODUCTION

Available data suggest that the two-week wait referral pathway is ineffective at expediting diagnosis of cancer due to large numbers of inappropriate referrals. This study aimed to compare the referral pathway of 125 patients who had undergone primary surgery for oral and oropharyngeal cancer with 100 who had been two-week wait referrals.

MATERIALS AND METHODS

This was a case note review.

RESULTS

Of the 125 patients who underwent surgery; 47 (38%) were referred via the 2WW pathway. GPs had referred 25 (53%) of the 47 patients and general dental practitioners 22 (47%). The tumour stage was similar regardless of referral pathway (two-week wait or routine). GPs recognised that the two-week wait pathway was needed in 49% of the patients they had referred, whereas the equivalent figure for GDPs was 40%. Of the 100 2WW patients, 52 were biopsied. Of these, nine (9%) were diagnosed with a malignancy. GPs referred 61% of the 100 two-week wait patients and accurately diagnosed five of the cancers (although two were basal cell carcinomas), general dental practitioners the remainder (including one basal cell carcinoma). Overall, 41% of the patients referred on the two-week wait pathway by GPs needed a biopsy, compared with 69% of those referred by general dental practitioners.

CONCLUSIONS

While the criteria for referral on the two-week wait pathway lack discrimination and the majority of referrals proved benign, nearly 40% of surgically treated patients were referred via this pathway, suggesting that it does serve a useful purpose. More patients with cancer were referred by GPs, but more two-week wait referrals by general dental practitioners warranted biopsy.

Generalist versus Abdominal Subspecialist Radiologist Interpretations of Abdominopelvic Computed Tomography Performed on Patients with Abdominal Pain and its Impact on the Therapeutic Approach

Introduction:

Abdominal pain is one of the most common patient complaints in the emergency department (ED) and abdominopelvic computed tomography (ACT) scan plays an important role in evaluation of these patients.

Objective:

The aim of this study was to determine the differences between interpretations by generalist radiologists and abdominal subspecialist radiologists regarding the abdominopelvic computed tomography (ACT) of patients who were admitted to the Emergency Department (ED) and to investigate its effect on the patients’ therapeutic approach.

Methods:

The records of 16452 patients who were admitted to the emergency department with complaint of abdominal pain between January 2015 and April 2017 were reviewed, retrospectively. Out of these patients, 245 (1.5%) underwent ACT for differential diagnosis and among them, 137 (0.8%) patients had their ACT reports evaluated by generalist radiologists in 45 minutes and by abdominal subspecialist radiologist 8–12 hours later and were included in the study. Patients were divided into three groups according to the effect of ACT reports on the performed treatment. Group 1: no effect on planned treatment, group 2: minor effect on planned treatment, which did not result in a change in the treatment process and group 3: major effect on planned treatment approach, which resulted in a change in the treatment process. These changes included at least one of the two criteria: changing the indication of surgery from emergency surgery to elective surgery and/or discharge of the patient from the ED, when actually hospitalization was required.

Results:

Out of the 137 patients, 87 (63.5%) were male, 50 (36.5%) were female and the patients’ mean age was 56 (27–93) years. There were 117 (85.4%) patients in group 1, 15 (10.9%) patients in group 2, and 5 (3.7%) patients in group 3. We determined minor inconsistency between the reports in group 2 and major inconsistency in group 3. Patients in group 3 suffered from delayed surgical intervention due to inconsistency of the CT reports resulting in prolonged hospital stay and increased morbidity. In 17 patients (four patients in Group 1 and 13 patients in Group 2) treatment plan was changed due to CT results; and while surgical treatment was planned for them prior to CT scan, they were discharged with medical treatment after that and overtreatment was prevented.

Conclusion:

Contribution of abdominal radiologists to evaluation of ACT images in the ED would reduce the inconsistency in ACT reports and prevent the patients from receiving insufficient treatment or overtreatment.

The Diagnostic Utility and Clinical Impact of After-Hours CT Scans of the Abdomen and Pelvis Investigating Abdominal Pain

Introduction

The aim of this study was to evaluate the diagnostic utility and impact on clinical management of after-hours CT scans investigating abdominal pain in surgical patients.

Methods

After-hours CT A/P reports investigating the acute surgical abdomen were compared with clinical outcomes and histopathological findings to assess sensitivity and specificity of CT reporting. Comparisons between CT reports and clinical notes were made. CT scans were categorised as having direct effects on clinical management, ruling out a serious pathology, ruling out a nonserious pathology, or having no effect. Discrepancies between information in case-notes and information provided to radiologists were also analysed.

Results

79 clinical notes were located. After-hours CT demonstrated 91% sensitivity and 82% reporting specificity using clinical outcomes as the standard. In the 26 patients with histopathological findings, CT reports demonstrated 91% sensitivity. In 79.7% of cases, CT scanning had an impact on management. In 35.4% of cases, an indication for scanning was not documented with variation in clinical information in 8.9% of cases.

Discussion

This study demonstrates after-hours CT A/P reports result in significant impacts on clinical management of surgical patients with acute abdominal pain. Improvements in providing information when requesting scans are however needed to facilitate accurate reporting.

Sex differences in the splenic flexure

INTRODUCTION Anecdotally, surgeons claim splenic flexure mobilisation is more difficult in male patients. There have been no scientific studies to confirm or disprove this hypothesis. The implications in colorectal surgery could be profound. The aim of this study was to assess quantitatively whether there is an anatomical difference in the position of the splenic flexure between men and women using computed tomography (CT). METHODS Portal venous phase CT performed for preoperative assessment of colorectal malignancy was analysed using the hospital picture archiving and communication system. The splenic flexure was compared between men and women using two variables: anatomical height corresponding to the adjacent vertebral level (converted to ordinal values between 1 and 17) and distance from the midline. RESULTS In total, 100 CT images were analysed. Sex distribution was even. The mean ages of the male and female patients were 68.1 years and 66.7 years respectively (p=0.630). The mean vertebral level for men was 8.88, equating to the inferior half of the T11 vertebral body (range: 1-17 [superior half of T9 to inferior half of L2]), and 11.36 for women, equating to the inferior half of the T12 vertebral body (range: 4-16 [superior half of T10 to superior half of L2]). This difference was statistically significant (p=0.0001) and is equivalent to one whole vertebra. The mean distance from the midline was 160.8mm (range: 124-203mm) for men and 138.2mm (range: 107-185mm) for women (p<0.0001). CONCLUSIONS The splenic flexure is both higher and further from the midline in men than in women. This provides one theory as to why mobilising the splenic flexure may be more difficult in male patients.

The accuracy of interpretation of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain: results of a UK national audit

AIM

To evaluate major/minor discrepancy rates for provisional (initial) and addendum (supplementary senior review) emergency computed tomography (CT) reports in patients presenting with non-traumatic abdominal pain.

MATERIALS AND METHODS

Ethical approval for this type of study is not required in the UK. All radiology departments with an approved lead for audit registered with the Royal College of Radiologists were invited to participate in this retrospective audit. The first 50 consecutive patients (25 surgical, 25 non-surgical) who underwent emergency abdominal CT for non-traumatic abdominal pain in 2013 were included. Statistical analyses were performed to identify organisational and report/patient-related variables that might be associated with major discrepancy.

RESULTS

One hundred and nine (58%) of 188 departments supplied data to the study with a total of 4,931 patients (2,568 surgical, 2,363 non-surgical). The audit standard for provisional report major discrepancy was achieved for registrars (target <10%, achieved 4.6%), for on-site consultants (target <5%, achieved 3.1%) and consultant addendum (target <5%, achieved 2.9%). Off-site reporters failed to meet the standard target (<5%, achieved 8.7% overall and 12.7% in surgical patients). The standard for patients coming to harm was not met in the surgical group (target <1%, achieved 1.5%) and was narrowly missed overall (target <1%, achieved 1%).

CONCLUSION

This study should be used to provide impetus to improve aspects of out-of-hours CT reporting. Clear benefits of CT interpretation/review by on-site and more senior (consultant) radiologists have been demonstrated.

Relative accuracy of emergency CT in adults with non-traumatic abdominal pain

OBJECTIVE

CT examination prior to emergency laparotomy has become ubiquitous in contemporary clinical practice, but the relative accuracy of CT in this context has not been widely reported. The aim of this study was to determine the accuracy and strength of agreement between the perceived pre-operative CT diagnosis and operative findings.

METHODS

Data from patients undergoing pre-operative CT prior to emergency laparotomy from January 2013 to June 2014 in a large teaching hospital were analysed. The CT diagnosis was compared with operative findings using the χ(2) test and weighted kappa statistic (Kw). Results were further analysed related to the time of day the CT was reported, anatomical location and grade of the reporting radiologist.

RESULTS

361 patients [median age 67 years (18-98 years); 180 males] underwent CT prior to emergency laparotomy. CT reports were deemed accurate in 318 (88.1%) cases and inaccurate in 43 (11.9%) cases, which resulted in 5 negative laparotomies in this latter cohort (11.6%, χ(2) 37.50, df 1; p < 0.0001). Accuracy and strength of agreement varied with anatomical location of the pathology; upper gastrointestinal (UGI) 75.5%, Kw 0.673 (0.531-0.815; p < 0.001); small bowel 89.9%, Kw 0.781 (0.687-0.875, p < 0.001); lower gastrointestinal (LGI) 90.4%, Kw 0.821 (0.749-0.893; p < 0.001). CT examinations reported within normal working hours had higher strength of agreement [Kw 0.832 (0.768-0.896), p < 0.001] than CTs reported out of hours [Kw 0.789 (0.721-0.857), p < 0.001], but there was no significant difference in overall accuracy (89.9 vs 86.0%; χ(2) 1.306, df 1, p = 0.253). Reporter seniority was not associated with improved diagnostic accuracy (χ(2) 1.825, df 1; p = 0.177).

CONCLUSION

CT agreement with emergency operative pathology was good to excellent, but the strength of agreement varied in relation to anatomical location of pathology.

ADVANCES IN KNOWLEDGE

Overall accuracy was 88.1% with good to excellent agreement between pre-operative CT and emergency laparotomy findings in adult patients with non-traumatic abdominal pain in the acute setting. Diagnostic accuracy of CT reporting varies with anatomical location of pathology.

Surgical management of peritonitis secondary to acute superior mesenteric artery occlusion

Diagnosis of acute arterial mesenteric ischemia in the early stages is now possible using modern computed tomography with intravenous contrast enhancement and imaging in the arterial and/or portal phase. Most patients have acute superior mesenteric artery (SMA) occlusion, and a large proportion of these patients will develop peritonitis prior to mesenteric revascularization, and explorative laparotomy will therefore be necessary to evaluate the extent and severity of intestinal ischemia, and to perform bowel resections. The establishment of a hybrid operating room in vascular units in hospitals is most important to be able to perform successful intestinal revascularization. This review outlines current frontline surgical strategies to improve survival and minimize bowel morbidity in patients with peritonitis secondary to acute SMA occlusion. Explorative laparotomy needs to be performed first. Curative treatment is based upon intestinal revascularization followed by bowel resection. If no vascular imaging has been carried out, SMA angiography is performed. In case of embolic occlusion of the SMA, open embolectomy is performed followed by angiography. In case of thrombotic occlusion, the occlusive lesion can be recanalized retrograde from an exposed SMA, the guidewire snared from either the femoral or brachial artery, and stented with standard devices from these access sites. Bowel resections and sometimes gall bladder removal due to transmural infarctions are performed at initial laparotomy, leaving definitive bowel reconstructions to a planned second look laparotomy, according to the principles of damage control surgery. Patients with peritonitis secondary to acute SMA occlusion should be managed by both the general and vascular surgeon, and a hybrid revascularization approach is of utmost importance to improve outcomes.

Free air on plain film: Do we need a computed tomography too?

Context:

Standard teaching is that patients with pneumoperitoneum on plain X-ray and clinical signs of abdominal pathology should undergo urgent surgery. It is unknown if abdominal computed tomography (CT) provides additional useful information in this scenario.

Aims:

The aim of this study is to determine whether or not CT scanning after identification of pneumoperitoneum on plain X-ray changes clinical management or outcomes.

Settings and Design:

Retrospective study carried out over 4 years at a tertiary care academic medical center. All patients in our acute care surgery database with pneumoperitoneum on plain X-ray were included. Patients who underwent subsequent CT scanning (CT group) were compared with patients who did not (non-CT group).

Statistical Analysis Used:

The Wilcoxon rank-sum test, t-test and Fisher's exact test were used as appropriate to compare the groups.

Results:

There were 25 patients in the non-CT group and 18 patients in the CT group. There were no differences between the groups at presentation. All patients in the non-CT group underwent surgery, compared with 83% (n = 15) of patients in the CT group (P = 0.066). 16 patients in the non-CT and 11 patients in the CT group presented with peritonitis and all underwent surgery regardless of group. For patients undergoing surgery, there were no differences in outcomes between the groups. After X-ray, patients undergoing CT required 328.0 min to arrive in the operating room compared with 136.0 min in the non-CT group (P = 0.007).

Conclusions:

In patients with pneumoperitoneum on X-ray and peritonitis on physical exam, CT delays surgery without providing any measurable benefit.

Lessons for surgeons in the final moments of Air France Flight 447

BACKGROUND

All surgeons make mistakes, and learning from critical incidents may help improve performance. The present study aimed to highlight lessons for surgeons from analysis of the final moments of Air France Flight 447. All of the authors work in teams and situations where safety, technical performance, and non-technical skills are critical. This review was born out of discussions regarding the events of Flight 447; specifically, whether the airline disaster was relevant to their work, and whether they could learn anything from it.

METHODS

The study is based on review of the crash reports of Flight 447, which lost flight speed indication after formation of ice prevented air from entering flight speed indicators during a storm. Following a subsequent stall, the aircraft fell at a rate of >10,000 feet/min until it crashed into the Atlantic Ocean, killing 228 passengers and crew.

RESULTS

There were errors in decision making, reasoning, communication, and teamwork. Such non-technical skills failures have been recognized previously and can be addressed by existing non-technical skills training. A reliance on autopilot meant that the pilots were unfamiliar with high-altitude flying when the autopilot is disengaged. They were unprepared for and affected by such a sudden and serious problem; an event called "surprise and startle" by the accident investigation. The absence of the senior pilot (who was on a scheduled break) in the critical final minutes slowed error recognition and recovery.

CONCLUSIONS

Unintended consequences of modern safety strategies may be under-recognized and can lead to adverse events. Both simulation-based and non-simulation-based training should include "surprise and startle" events beyond the scenarios trainees might expect. Likewise, in the face of increasing reliance on modern technology, surgeons should ensure that they would be able to perform procedures in the absence of such technologies. Specific training may improve surgeons' non-technical skills, and recognition of such skills could also be used to help select future surgeons.

Clinical value of CT in early diagnosis and treatment of acute abdomen

It is critical to select a fast and accurate method for the early diagnosis and treatment of acute abdomen. CT displays important application value in the early diagnosis and treatment of acute abdomen because of its convenient and intuitive features, advantages in terms of sensitivity and specificity compared with other methods, and the relatively low economic cost. In this paper, we summarize the application value of abdominal CT in the early diagnosis and treatment of acute abdomen by analyzing the characteristics of acute abdomen, comparing CT examination with other methods, and presenting several specific cases.

Acutely incarcerated abdominal wall hernia: what if it is a consequence?

PURPOSE

The aim of this study was to emphasize the importance of differential diagnosis in patients with acutely incarcerated abdominal wall hernia (AWH).

METHODS

The medical records of patients who underwent emergency surgery with preoperative diagnosis of acutely incarcerated AWH and in whom acutely incarcerated AWH was the consequence of increased intraabdominal pressure due to other abdominal emergencies were reviewed. The following data were collected: demographics, the duration between the onset of symptoms and admission, clinical findings, biochemical test results that were abnormal, radiological findings, preoperative and intraoperative diagnosis, operative findings, surgical procedure, different diagnosis made in the postoperative period, reoperation, morbidity, mortality, and the length of hospital stay.

RESULTS

Ten patients were included to the study. The primary pathology was found to be perforated peptic ulcer disease in three, bowel obstruction due to neoplastic mass in three, complicated appendicitis in two, acute mesenteric ischemia in one, and acute diverticulitis in one. The correct diagnosis was made during emergency surgery for hernia repair, whereas the primary pathology was identified postoperatively in two patients.

CONCLUSIONS

Patients who are diagnosed to have acutely incarcerated AWH preoperatively should undergo further diagnostic workup, if any level of clinical suspicion for differential diagnosis is present. Moreover, the surgeon should consider general abdominal exploration if contradictory findings are encountered during the exploration of the hernia sac, even if preoperative diagnostic studies reveal no gross pathology or non-specific findings.

Diagnostic value of CT versus BUS in detection of acute appendicitis

AIM: To compare the diagnostic value of CT versus BUS in detection of acute appendicitis.

METHODS: Clinical data for 120 patients with pathologically verified acute appendicitis who underwent CT ( n = 60) or BUS ( n = 60) were retrospectively analyzed to compare the value of CT and BUS in diagnosis and differential diagnosis of this disease. The sensitivity of the two modalities in the diagnosis of acute appendicitis was compared.

RESULTS: The sensitivity of CT and BUS in the diagnosis of acute appendicitis was 93% and 60%, respectively. The diagnostic accuracy of CT for acute appendicitis was significantly better than that of BUS (P < 0.05). However, there was no significant difference in diagnostic accuracy between CT and BUS for other pathologic types of appendicitis.

CONCLUSION: CT should be the first choice for acute appendicitis, especially in patients with a negative BUS examination.

The acute abdomen in the older person

The acute abdomen is a common condition in older people. Half of all presentations to hospital require admission, with a third requiring immediate surgery. The Royal College of Surgeons of England have reported a worryingly high mortality rate in the over 80s undergoing emergency surgery, with a 3-fold difference in mortality throughout the England, Wales and Northern Ireland. The aim of this article is to highlight the issues that older people face in relation to acute abdominal pathology.