Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative.

BACKGROUND: Emergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements. METHODS: We collected data at 10 hospitals from July 2019 to December 2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative versus nonoperative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits. RESULTS: Of the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were White, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5% (95% confidence interval [CI], 3.2-3.7), morbidity rate was 27.6% (95% CI, 27.0-28.3), and the readmission rate was 15.1% (95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high- and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial nonoperative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals. CONCLUSION: A multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Comparison of stapling techniques and management of the mesoappendix in laparoscopic appendectomy.

Many techniques for laparoscopic appendectomy have been proposed with few comparative studies. We performed a retrospective review of all patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from 2006 to 2011. Techniques were: (1) transection of the mesoappendix and appendix with a single staple line (SSL); (2) transection of the mesoappendix and appendix with multiple staple lines (MSL); and (3) transection of the mesoappendix with ultrasonic shears and the appendix with a single staple line (USSL). A total of 565 cases were reviewed (149 SSL, 259 MSL, and 157 USSL). Patients treated with the SSL technique had decreased operative duration (P<0.001) and length of stay (P=0.003) despite equivalent disease presentations. Multivariate analysis demonstrated decreased operative duration with the SSL technique (P=0.001). Use of a SSL for transection of the mesoappendix and appendix is both a safe and efficient technique that results in reduced operative duration with excellent surgical outcomes.

Selective laparoscopic approach in suspected gallbladder malignancy.

BACKGROUND AND OBJECTIVES: We examined patients with clinical findings that are concerning for gallbladder malignancy to determine the incidence of pathology-confirmed malignancy and to discover factors that may be used to determine which patients may be initially treated with a laparoscopic approach. METHODS: All patients referred to a surgical oncologist with preoperative findings that are concerning for gallbladder malignancy who had not undergone previous surgical resection from 2005 to 2011 were reviewed. Variables collected included demographics, imaging, operative findings, and final pathology. Patients were grouped into 3 categories based on preoperative findings: gallbladder mass, irregular wall thickening, and abnormal intraoperative findings on previous diagnostic laparoscopy. RESULTS: Twenty-nine of 4474 patients evaluated for gallbladder pathology during the study period met the inclusion criteria. Preoperative imaging included computed tomography, ultrasonography, and magnetic resonance imaging. Twelve patients had multiple imaging studies. Eight patients were initially treated with a laparoscopic approach with 3 conversions to an open procedure. Forty-eight percent of patients had pathology-confirmed malignancy. Patients without a discrete mass on imaging were more likely to have benign disease (P = .04). CONCLUSIONS: Our results demonstrate that >50% of patients with suspicious preoperative findings had benign pathology, suggesting that the initial laparoscopic approach in selected patients may be appropriate.