Open Versus Laparoscopic Appendectomy: A Post Hoc Analysis of the EAST Appendicitis MUSTANG Study.

Background: We sought to understand which factors are associated with open appendectomy as final operative approach. We hypothesize that higher American Association for the Surgery of Trauma (AAST) Emergency General Surgery (EGS) grade is associated with open appendectomy. Patients and Methods: Post hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated and Gangrenous (MUSTANG) prospective appendicitis database was performed. All adults (age >18) undergoing appendectomy were stratified by final operative approach: laparoscopic or open appendectomy (including conversion from laparoscopic). Univariable analysis was performed to compare group characteristics and outcomes, and multivariable logistic regression was performed to identify demographic, clinical, or radiologic factors associated with open appendectomy. Results: A total of 3,019 cases were analyzed. One hundred seventy-five (5.8%) patients underwent open appendectomy, including 127 converted from laparoscopic to open. The median age was 37 (25) years and 53% were male. Compared with the laparoscopic group, open appendectomy patients had more comorbidities, higher proportion of symptoms greater than 96 hours, and higher AAST EGS grade. Moreover, on intraoperative findings, the open appendectomy group had a higher incidence of perforated and gangrenous appendicitis with purulent contamination, abscess/phlegmon, and purulent abdominal/pelvic fluid. On multivariable analysis controlling for comorbidities, clinical and imaging AAST grade, duration of symptoms, and intra-operative findings, only AAST Clinical Grade 5 appendicitis was independently associated with open appendectomy (odds ratio [OR], 5.63; 95% confidence interval [CI], 1.24-25.55; p = 0.025). Conclusions: In the setting of appendicitis, generalized peritonitis (AAST Clinical Grade 5) is independently associated with greater odds of open appendectomy.

Severe Short Bowel Syndrome: Prognosis for Nutritional Independence Through Management by a Multidisciplinary Nutrition Service and Surgery.

INTRODUCTION: Short bowel syndrome (SBS) is a debilitating condition associated with significant morbidity and mortality. Historically, SBS patients require indefinite parenteral nutrition (PN) and endure lifelong nutritional challenges. The purpose of this study was to review the outcomes, specifically nutritional independence, of a multidisciplinary nutrition service. METHODS: A retrospective analysis of SBS patients followed by our surgical nutrition service was performed. Patients without 1-year follow-up were excluded. Demographics and nutritional parameters were collected at 4 intervals: initial presentation, 1-year, 2-year, and 5-year follow-up. Short bowel syndrome anatomical subtypes identified through operative reports were characterized as end jejunostomy, jejunocolonic, or jejuno-ileocolonic with ileo-cecal valve intact. Intestinal failure was defined by the requirement of PN, while intestinal insufficiency was defined by enteral support requirement. Clinical outcomes examined included mortality, fistula closure, and nutritional independence. RESULTS: The study cohort comprised 89 patients, 50 of whom had ≤ 100 cm intestinal length. Mean age was 57 ± 17y, 55 (62%) were female, and median initial intestinal length was 77 [60-120] cm. Short bowel syndrome was complicated by fistulas in 47 (53%) of patients. Overall mortality was 13%, and 67 (75%) were liberated from PN. A total of 58 (65%) underwent operative intervention and fistula closure was achieved in 37 of 47 (79%) patients. CONCLUSIONS: Short bowel syndrome patients can experience significant benefit under treatment by a multidisciplinary nutrition service. By incorporating surgical intervention, the majority of patients previously relegated to lifelong PN have the opportunity to become nutritionally independent within 5 years.

Teduglutide for the treatment of low-output enterocutaneous fistula - A pilot randomized controlled study.

BACKGROUND & AIMS: Enterocutaneous fistula (ECF) is a complication of surgery or inflammatory bowel disease associated with disproportionately high healthcare costs, morbidity, and mortality. We performed this proof-of-concept, feasibility, open-label, pilot randomized, crossover study to assess the efficacy and safety of the use of teduglutide (TED) to treat ECF. METHODS: Adults (age >18) with low-output (<200 mL/d) ECF were randomized to 2 months of continuing standard-of-care (SOC) followed by crossover to 2 months of SOC + TED or the reverse order. The primary efficacy endpoint was decrease in fistula volume by 20% of baseline 3-day average. Secondary efficacy endpoints were: fistula resolution and health-related quality of life questionnaire scores. RESULTS: Six out of 10 planned subjects were randomized and completed the study, which was terminated early due to slow enrollment during the Covid-19 pandemic. Overall subject compliance with daily TED injections was high (98%). Five of six enrolled subjects met the definition for the primary efficacy endpoint; these clinical responses were not observed during the SOC arm in these subjects. One subject experienced complete fistula closure during TED treatment. Adverse events during treatment were uncommon, minor, and usually resolved despite ongoing treatment. Quality of life survey responses were highly variable and did not correlate with fistula changes. CONCLUSIONS: Two months of teduglutide treatment was feasible, well-tolerated, and resulted in observable decreases in ECF drainage in the majority of subjects, including spontaneous closure in one subject. This therapy shows promise, but larger, multicenter confirmatory trials are required. CLINICALTRIALS: GOV: (NCT02889393).

A Weaning Protocol for Venovenous Extracorporeal Membrane Oxygenation With a Review of the Literature.

Several articles have discussed the weaning process for venoarterial extracorporeal membrane oxygenation; however, there is no published report to outline a standardized approach for weaning a patient from venovenous extracorporeal membrane oxygenation (ECMO). This complex process requires an organized approach and a thorough understanding of ventilator management and ECMO physiology. The purpose of this article is to describe the venovenous ECMO weaning protocol used at our institution as well as provide a review of the literature.

Multicenter review of diaphragm pacing in spinal cord injury: successful not only in weaning from ventilators but also in bridging to independent respiration.

BACKGROUND: Ventilator-dependent spinal cord-injured (SCI) patients require significant resources related to ventilator dependence. Diaphragm pacing (DP) has been shown to successfully replace mechanical ventilators for chronic ventilator-dependent tetraplegics. Early use of DP following SCI has not been described. Here, we report our multicenter review experience with the use of DP in the initial hospitalization after SCI. METHODS: Under institutional review board approval for humanitarian use device, we retrospectively reviewed our multicenter nonrandomized interventional protocol of laparoscopic diaphragm motor point mapping with electrode implantation and subsequent diaphragm conditioning and ventilator weaning. RESULTS: Twenty-nine patients with an average age of 31 years (range, 17-65 years) with only two females were identified. Mechanism of injury included motor vehicle collision (7), diving (6), gunshot wounds (4), falls (4), athletic injuries (3), bicycle collision (2), heavy object falling on spine (2), and motorcycle collision (1). Elapsed time from injury to surgery was 40 days (range, 3-112 days). Seven (24%) of the 29 patients who were evaluated for the DP placement had nonstimulatable diaphragms from either phrenic nerve damage or infarction of the involved phrenic motor neurons and were not implanted. Of the stimulatable patients undergoing DP, 72% (16 of 22) were completely free of ventilator support in an average of 10.2 days. For the remaining six DP patients, two had delayed weans of 180 days, three had partial weans using DP at times during the day, and one patient successfully implanted went to a long-term acute care hospital and subsequently had life-prolonging measures withdrawn. Eight patients (36%) had complete recovery of respiration, and DP wires were removed. CONCLUSION: Early laparoscopic diaphragm mapping and DP implantation can successfully wean traumatic cervical SCI patients from ventilator support. Early laparoscopic mapping is also diagnostic in that a nonstimulatable diaphragm is a convincing evidence of an inability to wean from ventilator support, and long-term ventilator management can be immediately instituted. LEVEL OF EVIDENCE: Therapeutic study, level V.

Prevalence of sleep apnea in morbidly obese patients who presented for weight loss surgery evaluation: more evidence for routine screening for obstructive sleep apnea before weight loss surgery.

The incidence of obstructive sleep apnea has been underestimated in morbidly obese patients who present for evaluation for weight loss surgery. This retrospective study shows that the incidence of obstructive sleep apnea in this patient population is greater than 70 per cent and increases in incidence as the body mass index increases. Obstructive sleep apnea (OSA) is a common comorbidity in obese patients who present for evaluation for gastric bypass surgery. The incidence of sleep apnea in obese patients has been reported to be as high as 40 per cent. A retrospective review of our prospectively collected database was performed. All patients being evaluated for weight loss surgery for obesity were screened preoperatively for OSA using a sleep study. The overall incidence of sleep apnea in our patients was 78 per cent (227 of 290). All 227 were diagnosed by formal sleep study. There were 63 (22%) males and 227 (78%) females. The mean age was 43 years (range, 17-75 years). The mean body mass index (BMI) was 52 kg/m2 (range, 31-94 kg/m2). The prevalence of OSA in the severely obese group (BMI 35-39.9 kg/m2) was 71 per cent. For the morbidly obese group (BMI 40-40.9 kg/m2), the prevalence was 74 per cent and for the superobese group (BMI 50-59.9 kg/m2) 77 per cent. Those with a BMI 60 kg/m2 or greater, the prevalence of OSA rose to 95 per cent. The incidence of sleep apnea in patients presenting for weight loss surgery was greater than 70 per cent in our study. Patients presenting for weight loss surgery should undergo a formal sleep study to diagnose OSA before bariatric surgery.