The effect of prolonged antibiotics on postoperative complications for common bile duct stones: A post hoc analysis of an EAST multicenter study.

BACKGROUND: Antimicrobial guidance for common bile duct (CBD) stones is limited. We sought to examine the effect of antibiotic duration on infectious complications in patients with choledocholithiasis and/or gallstone pancreatitis. METHODS: We performed a post hoc analysis of a prospective, observational, multicenter study of patients undergoing same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019. We excluded patients with cholangitis and/or cholecystitis. Patients were divided into groups based on duration of antibiotics: prophylactic (<24 hours) or prolonged (≥24 hours). We analyzed these two groups in the preoperative and postoperative periods. Outcomes included infectious complications, acute kidney injury (AKI), and hospital length of stay (LOS). RESULTS: There were 755 patients in the cohort. Increasing age, CBD diameter, and a preoperative endoscopic retrograde cholangiopancreatography (odds ratio, 1.91; 95% confidence interval, 1.34-2.73; p < 0.001) significantly predicted prolonged preoperative antibiotic use. Increasing age, operative duration, and a postoperative endoscopic retrograde cholangiopancreatography (odds ratio, 4.8; 95% confidence interval, 1.85-13.65; p < 0.001) significantly predicted prolonged postoperative antibiotic use. Rates of infectious complications were similar between groups, but LOS was 2 days longer for patients receiving overall prolonged antibiotics (p < 0.0001). Patients with AKI received two more days of overall antibiotic therapy (p = 0.02) compared with those without AKI. CONCLUSION: Rates of postoperative infectious complications were similar among patients treated with a prolonged or prophylactic course of antibiotics. Prolonged antibiotic use was associated with a longer LOS and AKI. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Risk factors for complications after cholecystectomy for common bile duct stones: An EAST multicenter study.

BACKGROUND: We sought to prospectively identify risk factors for biliary complications and 30-day readmission after cholecystectomy for choledocholithiasis and gallstone pancreatitis across multiple US hospitals. METHODS: We performed a prospective, observational study of patients who underwent same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019 at 12 US centers. Patients with prior history of endoscopic retrograde cholangiopancreatography or diagnosis of cholangitis were excluded. We used logistic regression to determine associations between preoperative demographics, labs, and imaging on primary outcomes: postoperative biliary complications and 30-day readmission. RESULTS: There were 989 patients in the cohort. There were 16 (1.6%) patients with postoperative biliary complications, including intra-abdominal abscesses, endoscopic retrograde cholangiopancreatography-induced pancreatitis, and biliary leaks. Increasing operative time (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .02), worsening leukocytosis (odds ratio 1.16, 95% confidence interval 1.07-1.25, P = .0002), and jaundice (odds ratio 3.25, 95% confidence interval 1.01-10.42, P = .04) were associated with postoperative biliary complications. There were 36 (3.6%) patients readmitted within 30 days owing to a surgical complication. A prior postoperative biliary complication (odds ratio 7.8, 95% confidence interval 1.63-37.27, P = .01), male sex (odds ratio 2.42, 95% confidence interval 1.2-4.87, P = .01), and index operative duration (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .03) were associated with 30-day readmission. CONCLUSION: Among patients undergoing cholecystectomy for common bile duct stones, jaundice, worsening leukocytosis, and longer operations are associated with postoperative biliary complications. A prior biliary complication is also predictive of a 30-day readmission. Surgeons should recognize these factors and avoid prematurely discharging at-risk patients given their propensity to develop complications and require readmission.

A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography.

INTRODUCTION: Arteriography is the current "gold standard" for the detection of extremity vascular injuries. Less invasive than operative exploration, conventional arteriography (CA) still has a 1% to 3% risk of morbidity and may delay definitive repair. Recent improvements in computed tomography (CT) technology has since broadened the application of CT to include the diagnosis of cervical, thoracic, and now extremity vascular injury. We hypothesized that CT angiography (CTA) provides equivalent injury detection compared with the more invasive CA, but is more rapidly completed and more cost effective. METHODS: A prospective evaluation of patients, ages 18 to 50, with potential extremity vascular injuries was performed during 2006-2007. Ankle-brachial indices (ABI) of injured extremities were measured on presentation in all patients without hard signs of vascular injury. Patients whose injured extremity ABI was <0.9 were enrolled and underwent CTA followed by either CA or operative exploration if CTA findings were limb threatening. Interventionalists were blinded to CTA findings before performing and reading CAs. RESULTS: Twenty-one patients (mean age, 26.1 +/- 7.1 years) had 22 extremity CTAs after gunshot (82%), stab (9%), or pedestrian struck by automobile (9%) injuries to either upper (32%) or lower (68%) extremities. Eleven of 22 (50%) extremities had associated orthopedic injuries while the mean ABI of the study population was 0.72 +/- 0.21. Twenty-one of 22 (96%) CTAs were diagnostic and all CTAs were confirmed by either CA alone (n = 18), operative exploration (n = 2), or both CA and operative exploration (n = 2). Diagnostic CTAs had 100% sensitivity and specificity for clinically relevant vascular injury detection. Unlike rapidly obtained CTA, CA required 131 +/- 61 minutes (mean +/- SD) to complete. In our center, CTA saves $12,922 in patient charges and $1,166 in hospital costs per extremity when compared with CA. CONCLUSIONS: With acceptable injury detection, rapid availability, and a favorable cost profile, our results suggest that CTA may replace CA as the diagnostic study of choice for vascular injuries of the extremities.

Outcomes of complicated appendicitis: Is conservative management as smooth as it seems?

BACKGROUND: This study characterized the failure rate of non-operative management (NOM) for complicated appendicitis (CA; perforation, abscess, phlegmon), and compared outcomes among patients undergoing acute appendectomy (AA), elective interval appendectomy (EIA), and unplanned appendectomy after failing to improve with NOM. METHODS: Adults treated at one facility between 2007 and 2014 were retrospectively studied. RESULTS: Ninety-five patients presented with CA. Sixty individuals underwent AA. The remaining 35 patients initially underwent NOM: 14 underwent EIA, nine (25.7%) failed NOM, 12 never underwent surgery. All patients failing NOM had an open operation with most (55.6%) requiring bowel resection. AA and EIA were comparable in surgical approach, bowel resection and post-operative readmission. However, AA demonstrated a lower incidence of bowel resection (3.3% vs 17.1%, P = 0.048) when compared to all patients initially undergoing NOM. CONCLUSIONS: Due to the high incidence of failed NOM and the morbidity associated with failure, AA may be appropriate for CA.