The results of rapid source control laparotomy or open abdomen for acute diverticulitis.

INTRODUCTION: Rapid source control laparotomy (RSCL) for the management of non-traumatic intra-abdominal emergencies has increased over the past 25 years when it was advocated for trauma patients. Little data, however, support its widespread use. We hypothesize that the patients with RSCL will have poorer outcomes than those treated with primary fascial closure (PFC). METHODS: Patients operated for acute diverticulitis from 2014 to 2016 using The American College of Surgeons sponsored National Surgical Quality Improvement Program (NSQIP) data were reviewed. Two groups were identified: PFC, patients with their closed fascia but skin left open (PFC) and RSCL, patients with their left open fascia after the initial operation. The primary outcome of the study was 30-day mortality, with secondary analyses evaluating complications, discharge location and length of stay. Univariate analysis was initially performed followed by propensity score matching. RESULTS: A total of 460 patients were surgically treated for Hinchey IV diverticulitis of whom 101 (21.9%) had RSCL. The length of stay of the RSCL patients was significantly longer (15 versus 12 days, p, 0.02) than patients in the PFC group. Similarly, the discharge destination for the PFC group was twice as likely to be discharged home as the RSCL group. CONCLUSION: RSCL for acute diverticulitis is a widely used but is associated with prolonged hospitalizations resulting in high rates of discharge to skilled nursing or rehabilitation facilities. Its routine use for diverticulitis should be limited.

Are the Benefits of Rapid Source Control Laparotomy Realized after Acute Colonic Perforation?

Background: The indications for damage-control laparotomy (DCL) in patients with intra-abdominal injuries have evolved from its use in trauma patients with hypothermia, coagulopathy, and acidosis to use in general surgical patients with acute intestinal perforations. Whereas some patients may be acidotic, most are not hypothermic or afflicted with coagulopathies. Recent study suggests the benefits to patients of rapid source-control laparotomy (RSCL) are not realized in patients with acute abdominal emergencies. Methods: Three years of data (2014-2016) from The American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) were assessed. The patient populations were separated into RSCL patients who had their fascia left open after the initial source control operation and those who had primary fascial closure (PFC). The principal outcome of interest in this study was death within thirty days. A secondary analysis was performed evaluating complications and length of stay. Results: Of the 1,381 patients who qualified for the study, 396 (28.7%) were managed with RSCL and the remaining 985 patients had PFC. After a univariable analysis, propensity score matching was performed. The median hospital length of stay was 20 days (95% confidence interval [CI] 18-22) versus 14 (95% CI 13-16; p < 0.001) in RSCL and PFC, respectively. A larger number of patients having RSCL went to a rehabilitation facility than those having PFC (18.7%; versus 11.2%; p = 0.014). The 30-day mortality rate in patients in the RSCL group was significantly higher than in the PFC group ((32.6% versus 16.9%; p < 0.001). Conclusion: These data provide strong evidence that RSCL may not be beneficial for routine use in perforated colon surgery.

Hospital Enforcement of Early Cholecystectomy for Acute Cholecystitis.

International guidelines state that early laparoscopic cholecystectomy (ELC) is appropriate for all severity grades of acute cholecystitis and leads to reduced hospital stays and costs. A multicenter prospective randomized controlled trial recommends ELC over delayed laparoscopic cholecystectomy (DLC) management because in addition to reduced hospital stays and costs, ELC also leads to reduced patient morbidity. Therefore, ELC is standard of care for acute cholecystitis. We hypothesize that 1) international guidelines are not presently followed and that 2) a quality improvement (QI) project enforcing ELC for acute cholecystitis will increase rates of ELC management. A retrospective chart review of all surgical consults for cholecystitis from January 2016 to December 2018 was undertaken. A total of 307 patients diagnosed with acute cholecystitis were included. ELC was defined as cholecystectomy within hospital admission. Pre-QI ELC versus DLC rates were 77.4 per cent (233/301) versus 22.6 per cent (68/301). Eight DLC patients (11.8%) returned to the ED after discharge secondary to persistent signs and symptoms of cholecystitis and 62.5 per cent (5/8) received an immediate cholecystectomy before their elective surgery date. After QI initiatives, ELC rates rose to 100 per cent (6/6). These data show there was a lack of consistent ELC management of acute cholecystitis.

Operating Room Foot Traffic: A Risk Factor for Surgical Site Infections.

Extensive studies on foot traffic in the operating room (OR) have shown little correlation between surgical site infections (SSIs) and traffic of OR personnel in and out of the OR. While evidence supports the relation between foot traffic in the OR, airborne bacteria, and subsequent SSIs in orthopedic surgical procedures, the studies were conducted over four years and in more than 8,000 patients. The direct relation this finding has to general surgery patients has yet to be proven; however, protocols to reduce foot traffic may have a beneficial effect for the OR team.

Gastroduodenal Surgery: A Persistent and Continuing Challenge.

The number of patients being treated surgically for gastroduodenal disease has decreased over the past five decades as a result of focus on medical treatment. However, perforated and bleeding peptic ulcer disease (PUD) continues to represent a significant percentage of patients who require emergency surgery. The aim of this study was to characterize these critically ill surgical patients treated for gastroduodenal disease in our hospital. A retrospective, single-center, consecutive cohort study of all patients identified from the hospital National Surgical Quality Improvement Program database who were admitted to our institution requiring emergent surgical intervention over the past two years was conducted. Of 423 patients, 33 (7.8%) had operative procedures for complications of PUD, of which 19 patients (57.6%) had perforation; nine patients (27.3%) had hemorrhage; one patient (3.0%) had both perforation and hemorrhage; two patients (6.1%) had distal gastrectomies for ulcers refractory to medical management alone, and two patients (6.1%) had gastrectomies for malignant gastric neoplasms. There is a significant population of patients who present with life-threatening complications of PUD, despite the decline in PUD worldwide. These patients are critically ill and require careful and diligent management for good outcomes.

Rapid Source-Control Laparotomy: Is There a Mortality Benefit in Septic Shock?

BACKGROUND: In the 1990s, damage control laparotomy (DCL) became a proved approach to treat intra-abdominal injuries caused by trauma. In the ensuing two decades, this approach has been applied to non-traumatic abdominal processes as well. Although the benefits of DCL are clear, the benefit of rapid source-control laparotomy (RSCL) for non-traumatic abdominal diseases is much less clear. However, two recent cohort analyses identified significant increases in the mortality rate with RCSL compared with primary fascial closure (PFC). The purpose of this study was to assess the efficacy of RSCL in patients with septic shock. METHODS: The 2015 National Surgical Quality Improvement Project (NSQIP) database was queried for 11 International Statistical Classifications of Diseases (ICD)-10 codes associated with septic shock. Collected data included age, gender, body mass index (BMI), wound class, American Society of Anesthesiologists (ASA) class, operative time, number of risk factors, and presence or absence of post-operative pneumonia. The risk factors were diabetes mellitus, alcohol or tobacco abuse, blood dyscrasias, disseminated cancer, and cardiac, gastrointestinal, pulmonary, hepatobiliary, or renal dysfunction. The primary outcomes were rate of re-operation, prevalence of post-operative pneumonia, hospital length of stay (LOS), and death by 30 days. RESULTS: The RSCL and PFC cohorts were each comprised of 56 patients matched for propensity scores for ICD-10 code. There were no significant differences in wound or ASA class, BMI, gender, or number of risk factors between the two cohorts. The operative time for RSCL was significantly shorter than for PFC (median 84 vs. 128 min, respectively; p = 0.002). There was no significant difference in re-operation rate, prevalence of post-operative pneumonia, LOS, or mortality rate between the two cohorts. CONCLUSIONS: Although this analysis showed no clear advantage to RSCL in the management of septic shock, it may be a means to salvage certain patients. The best way to assess the relative value of RSCL is a prospective trial.

Rapid Source-Control Laparotomy: Is There a Mortality Benefit?

BACKGROUND: The purpose of this study was to determine the influence rapid source-control laparotomy (RSCL) has on the mortality rate in non-trauma patients with intra-abdominal infection. The hypothesis was that RSCL reduces deaths and hospital lengths of stay (LOS) in patients compared with definitive repair and primary fascial closure (PFC). METHODS: The International Classification of Diseases-10 codes for sepsis, gastric and duodenal ulcer perforation or hemorrhage, incisional or ventral hernia with obstruction, intestinal volvulus, ileus with obstruction, diverticulitis with perforation or abscess, vascular disorder of intestine, non-traumatic intestinal perforation, peritoneal abscess, and unspecified peritonitis were used to query the 2015 National Surgical Quality Improvement Project (NSQIP) database for all patients treated with either RSCL or PFC. The two groups of patients were compared on the basis of LOS and deaths. Collected data included age, gender, body mass index (BMI), site classification, American Society of Anesthesiologists (ASA) class, operative time, number of risk factors, and pre-operative septic state. RESULTS: After adjusting for the aforementioned variables, propensity score-matched cohorts (n = 210 in each cohort) were used to evaluate the influence of incision closure type on LOS and mortality rate. The odds of death (31.4% vs. 21.4%) with RSCL was 1.78 (95% confidence interval 1.08-2.95; p = 0.02) times that of PFC. Closure type was not significantly associated with an increased LOS (median 14 vs. 11 days; p = 0.35). CONCLUSIONS: This retrospective cohort analysis demonstrated that RSCL is associated with higher odds of death in general surgical patients with intra-abdominal infection. There is a need for further studies to delineate what, if any, physiologic parameters indicate a need for RSCL.

Risk stratification of survival in injured patients with cardiopulmonary resuscitation within the first hour of arrival to trauma centre: retrospective analysis from the national trauma data bank.

BACKGROUND: The purpose of this study was to evaluate overall survival and associated survival factors for patients with trauma who had cardiopulmonary resuscitation (CPR) within 1 hour after arrival to a hospital. METHODS: Retrospective patient data was retrieved from the 2007-2010 edition of the US National Trauma Data Bank. Inhospital survival was the primary outcome; only patients with a known outcome were included in the analysis. Summary statistics and univariate analyses were first reported. Eighty per cent of the patients were then randomly selected and used for multivariate logistic regression analysis. The identified risk factors were further assessed for discrimination and calibration with the remaining patients with trauma using area under the curve (AUC) analysis and a Hosmer-Lemeshow test. RESULTS: From 19 310 total cases that were reviewed, only 2640 patients required CPR within 1 hour of hospital arrival and met the additional inclusion criteria. Of these patients, 2309 (87.5%) died and 331 (12.5%) survived to discharge. There were statistical differences for race (p=0.003), initial systolic BP (p<0.001), initial pulse (p<0.001), cause of injury (p<0.001), presence of head injury (p=0.02), Injury Severity Score (ISS) (p<0.001), Glasgow Coma Scale (GCS) total score (p<0.001) and GCS motor score (p<0.001); though not all were clinically significant. The multiple logistic regression model (AUC=0.72) identified lower ISS, higher GCS motor score, Caucasian race, American College of Surgeons (ACS) level 2 trauma designation and higher initial SBP as the most predictive of survival to hospital discharge. CONCLUSION: Approximately 13% of patients who had CPR within an hour of arrival to a trauma centre survived their injury. Therefore, implementation of an aggressive first hour in-hospital resuscitation strategy may result in better survival outcomes for this patient population.

Laparoscopic versus open liver resection: a meta-analysis of long-term outcome.

BACKGROUND: Laparoscopic liver resection is growing in popularity, but the long-term outcome of patients undergoing laparoscopic liver resection for malignancy has not been established. This paper is a meta-analysis and compares the long-term survival of patients undergoing laparoscopic (LHep) versus open (OHep) liver resection for the treatment of malignant liver tumours. METHODS: A PubMed database search identified comparative human studies analysing LHep versus OHep for malignant tumours. Clinical and survival parameters were extracted. The search was last conducted on 18 March 2012. RESULTS: In total, 1002 patients in 15 studies were included (446 LHep and 556 OHep). A meta-analysis of overall survival showed no difference [1-year: odds ratio (OR) 0.71, 95% confidence interval (CI) 0.42 to 1.20, P = 0.202; 3-years: OR 0.76, 95% CI 0.56 to 1.03, P = 0.076; 5-years: OR 0.8, 95% CI 0.59 to 1.10, P = 0.173]. Subset analyses of hepatocellular carcinoma (HCC) and colorectal metastases (CRM) were performed. There was no difference in the 1-, 3-, and 5-year survival for HCC or in the 1-year survival for CRM, however, a survival advantage was found for CRM at 3 years (LHep 80% versus OHep 67.4%, P = 0.036). CONCLUSIONS: Laparoscopic surgery should be considered an acceptable alternative for the treatment of malignant liver tumours.

Epinephrine, cortisol, endotoxin, nutrition, and the neutrophil.

BACKGROUND: Neutrophil dysfunction has been documented after injury in animals and human beings. This review evaluates the relative effects of the hormonal and endotoxin response to injury on immune resistance. METHOD: Review of the pertinent English-language literature. RESULTS: In volunteers given total parenteral nutrition, neutrophils demonstrate a robust response to leukotriene B4 but none to zymosan/activated serum or the bacterial metabolite formyl-methionyl-leucyl-phenylalanine (FMLP). This finding suggests subclinical exposure to activated complement and FMLP that does not occur during enteral feeding. Additional evidence of neutrophil activation is the release of lactoferrin to the same degree with the two routes of feeding. When normal volunteers are challenged with endotoxin, uniform impairment of the neutrophil response to chemotactic stimuli except LTB4 is demonstrated. Epinephrine increases the total circulating neutrophil pool for a few hours, whereas when cortisol is administered, the neutrophil counts continue to increase through 6 h. A combined epinephrine and cortisol infusion extends the half-life of neutrophils. The role of genomic and central nervous system control through the vagus nerve also is reviewed. CONCLUSION: Normal volunteers have provided insight into the stress response to infection that is understood only partially.

Report card on Surgical Care Improvement Project (SCIP): nationwide inpatient sample infection data 2001-2006.

BACKGROUND: The administration of appropriate antibiotics in a timely fashion with discontinuation post-operatively is the first of the Surgical Care Improvement Project (SCIP) initiatives and was expected to reduce post-operative infections significantly. This study aimed at determining whether SCIP has had an effect on surgical site infections (SSIs). METHODS: A retrospective cohort study was conducted to evaluate the infection rates of adult patients (age≥18 years) having elective cholecystectomies, laparoscopic cholecystectomies, and colectomies from 2001-2006 using the Nationwide Inpatient Sample (NIS) database. The population consisted of all patients older than 18 years who had colon resection or cholecystectomy and were discharged from a hospital included in the NIS. Annual infection rates were determined for each of the operations. RESULTS: Post-operative infections rose steadily and significantly (p<0.0001) in colon surgery from 2001 to 2006. A significant increase in SSIs also was seen in open (p=0.0001) and laparoscopic (p<0.0001) cholecystectomy from 2001 to 2006. Length of stay was significantly longer in infected than in non-infected patients. CONCLUSION: The factors that contributed to the observed increase in the infection rate should be identified to improve the SCIP initiatives.

Current risks of occupational blood-borne viral infection.

BACKGROUND: Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other viruses remain occupational risks for both surgeons and patients in the operating room environment. In the past, this concern attracted great attention, but recently, this subject has been given much less attention. METHODS: Review of the literature over the past 50 years on occupational risks of viral infection in the operating room. RESULTS: Transmission of HIV still looms as a potential pathogen in the operating room, but no case has been documented in the United States. Infection with HBV can be prevented by a safe and effective vaccine. Chronic HCV infection is present in more than three million U.S. residents and remains a risk that can be managed only by adhering to strict infection control practices and avoiding blood exposure. CONCLUSIONS: The risks of viral infection in the operating room remain the same as a decade ago even though attention to this issue has waned. The avoidance of blood exposure to prevent transmission of both known and unknown blood-borne pathogens continues to be a goal for all surgeons.

Is impaired immunity a consequence of surgery in patients infected by the human immunodeficiency virus?

BACKGROUND: Surgery affects immune function adversely in a variety of clinical settings. To date, there are no data assessing immune function in patients infected with the human immunodeficiency virus (HIV) who have had surgery. METHODS: A retrospective review was performed of 67 patients, of whom 46% were female, who underwent surgery while being treated for HIV infection. These patients were identified from a database collected over a ten-year period. The CD4(+) cell counts were analyzed according to the degree of immunosuppression (> or =500, 200-499, and <200 cells/mm(3), respectively). Viral titers also were assessed. RESULTS: Of the 17 patients with CD4(+) cell counts >500/mm(3) prior to surgery, 64.7% had unchanged counts after surgery (95% confidence interval [CI] 32.9%, 81.6%), whereas 35.2% of patients had lower CD4(+) counts after surgery (95% CI 14.2%, 61.7%). In patients with preoperative CD4(+) counts between 200 and 500/mm(3), 9.7% (95% CI 2.0%, 25.8%) had their counts decrease to <200 cells/mm(3), whereas in 29% (95% CI 14.2%, 48.0%) of patients, the counts increased to within the normal range. In the most immunosuppressed group (CD4(+) counts <200/mm(3)), 15.8% of patients (95% CI 3.4%, 39.6%) had their CD4(+) counts increase to the intermediate range. In the majority of patients, the viral titers remained unchanged, whereas 18.8% (n = 6) (95% CI 7.2%, 36.4%) had a decline in their titers. CONCLUSIONS: Surgery does not affect immune function adversely in HIV-infected patients, as judged by CD4(+) cell counts or viral titers.

Intravenous iron following cardiac surgery does not increase the infection rate.

BACKGROUND: Intravenous iron (FeIV) has been used increasingly, alone or in combination with recombinant erythropoietin, to promote red cell production as part of a blood conservation program. Given the important role that iron plays in the growth of bacteria, it has been hypothesized that this use of FeIV may promote surgical site infection. However, this hypothesis has not yet been tested appropriately. To assess this hypothesis, postoperative infection rates in patients undergoing cardiothoracic surgery were analyzed. METHODS: Data were collected on 863 patients undergoing cardiopulmonary bypass surgery in 2001. Patients were either enrolled voluntarily in a blood conservation program in which they received either postoperative FeIV and erythropoietin (n=302), as indicated, or blood transfusions and no FeIV (n=561), as indicated, to correct postoperative anemia. Infections were defined according to the U.S. Centers for Disease Control and Prevention guidelines. RESULTS: Thirty-nine infections developed. The overall infection rate was 4.52%, with an infection rate of 3.97% in the iron-treated group (n=12) and a rate of 4.81% in the untreated group (n=27). When the impact of gender, age, diabetes mellitus, operating time, type of surgery, and blood transfusions were controlled for, FeIV did not increase the risk of infection (odds ratio of 1.031 for each increment of 125 mg of FeIV; 95% confidence interval 0.908, 1.170; p=0.64). CONCLUSIONS: There was no impact of FeIV on the subsequent infection rate in a cardiac surgery patient cohort, indicating its safety for use in the postoperative setting.

The current infectious risks of transfusions.

BACKGROUND: Red blood cell transfusions have been widely associated with the transmission of human immunodeficiency virus (HIV) especially prior to 1985 when testing for HIV was not available. Currently the blood supply is much safer because of very sensitive testing for HIV as well as hepatitis C. However, new infectious agents emerge constantly and pose a threat to our blood supply. Current and potential threats are reviewed in this manuscript. METHODS: Review of pertinent English language literature. RESULTS: Transmission of infectious agents from blood transfusion is rare. Protozoans pose one the greatest threats because there are no assays available that can reliably detect their presence and because of worldwide travel. Viruses potentially pose a significant threat to the blood supply. The West Nile virus has recently been transmitted by a blood transfusion that was negative by assay for WNV. Severe acute respiratory syndrome (SARS) poses a threat to the blood supply but has never been transmitted in a transfusion. Prions also have been transmitted by a blood transfusion. CONCLUSIONS: Several infectious agents pose potential threats. The current risk of a blood transfusion is very low but the potential threat is ever present.