Current status of laparoscopic emergency surgery in Korea: multicenter restrospective cohort study

Purpose

Laparoscopic surgery is a choice in several emergency settings. However, there has been no nationwide study or survey that has compared the clinical use of laparoscopic emergency surgery (LES) versus open abdominal emergency surgery (OES) in Korea. Therefore, we examined the state of LES across multiple centers in Korea and further compared this data with the global state based on published reports.

Methods

Data of 2,122 patients who received abdominal emergency surgery between 2014 and 2019 in three hospitals in Korea were collected and retrospectively analyzed. Several clinical factors were investigated and analyzed.

Results

Of the patients, 1,280 (60.3%) were in the OES group and 842 (39.7%) were in the LES group. The most commonly operated organ in OES was the small bowel (25.8%), whereas that for LES was the appendix. In appendectomy and cholecystectomy, 93.7% and 88.0% were in the LES group. In small bowel surgery, gastric surgery, and large bowel surgery, 89.4%, 92.0%, and 79.1% were in the OES group. The severity-related factors of patient status demonstrated statistically significant limiting factors of selection between LES and OES.

Conclusion

Although our study has several limitations, compared to the LES data from other countries, the general LES state was similar in appendectomies, cholecystectomies, and small bowel surgeries. However, in gastric and colorectal surgeries, the LES state was different from those of other countries. This study demonstrated the LES state and limiting factors of selection between LES and OES in various operated organs. Further studies are required to analyze these differences and the various limiting factors.

Improved Outcomes in Treating Acute Biliary Disorders With a Shift-Based Acute Care Surgery Model

BACKGROUND

As Acute Care Surgery and shift-based models increase in popularity, there is evidence of better outcomes for many types of emergency general surgery patients. We explored the difference in outcomes for patients with acute biliary disorders, treated by either Acute Care Surgery (ACS) model or traditional call model (TRAD) during the same period.

METHODS

Retrospective review of patients undergoing laparoscopic cholecystectomy for acute biliary disease 2017-2018. Demographics, clinical presentation, operative details, and outcomes were compared.

RESULTS

Demographics, clinical presentation, and complication rates were similar between groups. Time from surgical consult to operating room (Δ = -15.34 hours [-24.57, -6.12], P = .001), length of stay (Δ = -1.4 days [-2.45, -.35], P = .009), and total charges were significantly decreased in ACS group compared to TRAD (Δ$2797.76 [-4883.12, -712.41], P = .009).

CONCLUSIONS

Acute biliary disease can be managed successfully in an ACS shift-based model with reduced overall hospital charges and equivalent outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Successful Implementation of a Trauma and Acute Care Surgery Model in Ecuador

BACKGROUND

For years, surgical emergencies in Ecuador were managed on a case-by-case basis without significant standardization. To address these issues, the Regional Hospital Vicente Corral Moscoso adapted and implemented a model of "trauma and acute care surgery" (TACS) to the reality of Cuenca, Ecuador.

METHODS

A cohort study was carried out, comparing patients exposed to the traditional model and patients exposed to the TACS model. Variables assessed included number of surgical patients attended to in the emergency department, number of surgical interventions, number of surgeries performed per surgeon, surgical wait time, length of stay and in-hospital mortality.

RESULTS

The total number of surgical interventions increased (3919.6-5745.8, p ≤ 0.05); by extension, the total number of surgeries performed per surgeon also increased (5.37-223.68, p ≤ 0.05). We observed a statistically significant decrease in surgical wait time (10.6-3.2 h for emergency general surgery, 6.3-1.6 h for trauma, p ≤ 0.05). Length of stay decreased in trauma patients (9-6 days, p ≤ 0.05). Higher mortality was found in the traditional model (p ≤ 0.05) compared to the TACS model.

CONCLUSIONS

The implementation of TACS model in a resource-restrained hospital in Latin America had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients and length of stay in trauma patients. We also noted a statistically significant decrease in mortality. Savings to the overall system and patients can be inferred by decreased mortality, length of stay and surgical wait times. To our knowledge, this is the first implementation of a TACS model described in Latin America.

Acute Diverticulitis Outcomes in the Acute Care Surgery Model

BACKGROUND

The acute care surgery (ACS) model has been widely implemented, with single institution studies demonstrating improved outcomes but multicenter studies questioning the efficiency. Acute care surgery programs care for sicker and more economically disadvantaged patients. This study compares outcomes between ACS and traditional models in the management of diverticulitis across an entire state.

STUDY DESIGN

The Virginia Health Information administrative database for adults discharged with diverticulitis from January 2008 through September 2015, was reviewed. Patient characteristics were analyzed and compared between ACS and traditional models. Outcome differences were compared using logistic regression.

RESULTS

We reviewed 23,943 admissions, with 2,330 (9.7%) patients cared for in ACS programs. The ACS patients were more likely to be uninsured (10.6% vs 6.8%, p < 0.0001) or covered by Medicaid (5.5% vs 3.4%, p < 0.0001), and the ACS hospitals cared for a higher percentage of minority patients than in the traditional programs (30.4% vs 19.8%, p < 0.0001). Operative rates were higher in ACS hospitals (14.7% vs 11.8%, p < 0.0001), as were rates of complicated diverticulitis (24.5% vs 20.3%, p < 0.0001). The ACS patients had significantly higher rates of comorbidities. After adjusting for patient comorbidities and demographics, ACS patients had a higher rate of complications (odds ratio [OR] 1.36, p = 0.0017). However, there was no difference in mortality, length of stay, or costs. When comparing only operative patients, there were no outcome differences after adjusting for patient factors.

CONCLUSIONS

Acute care surgery patients present to the hospital with more severe disease, higher rates of medical comorbidities, and lower socioeconomic status. Once patient factors are accounted for, outcomes are equivalent for operative patients in either model. Acute care surgery hospitals provide high quality and efficient care to sicker and more complex patients than traditional programs.

Statewide assessment of surgical outcomes and the acute care surgery model

BACKGROUND

The acute care surgery (ACS) model has been widely implemented with single institution studies demonstrating improved outcomes. Recent multicenter studies have raised questions about the economics and efficacy of ACS. This study compares traditional and ACS outcomes across an entire state.

METHODS

A retrospective review of Virginia's Health Information administrative database was completed. Adults admitted with appendicitis or cholecystitis between 2008 and 2014 were included. Hospital administration was contacted to determine surgical model. To compare patient characteristics, t-test and chi-square analyses were used. Total charges and length of stay (LOS) differences between ACS and traditional were examined using generalized linear models, whereas logistic regression was used for the presence of complications and 30-day mortality.

RESULTS

Overall, the ACS model showed an increased proportion of uninsured patients with a higher rate of comorbidities. In the appendicitis subgroup, (n = 22,011; ACS n = 1993), ACS patients had higher total charges ($30,060 versus $28,460, P = 0.013), longer LOS (3.31 versus 2.92 d, P < 0.001), and higher chance of complications (odds ratio [OR] = 1.2, P = 0.016) and mortality (OR = 2.4, P = 0.029). After adjustment for comorbidities and insurance, mortality was no longer significantly different. In the cholecystitis group (n = 6936; ACS n = 777), ACS patients had a longer LOS (4.55 versus 4.13 d; P = 0.009) without significant differences in mortality, complications, or cost. There were no significant differences after adjustment for patient characteristics.

CONCLUSIONS

ACS patients in Virginia have a higher rate of medical comorbidities and uninsured status, with slightly worse outcomes than the traditional model for appendicitis. Further studies to determine which patients benefit the most from ACS are warranted.