EAST 26th Annual Scientific Assembly
Scientific Papers That Should Have
Changed Your Practice
January 16, 2013
Emergency General Surgery
Philip S. Barie, MD, MBA, FIDSA FCCM, FACS
Professor of Surgery and Public Health
Weill Cornell Medical College
Acute Diverticulitis
Outcomes of Elective Operation after
Diverticulitis (DD)
• National Inpatient Sample
• Comparison with elective colectomies for
other indications
– Cancer
– IBD
• 74,879 adults (Age > 18)
– DD 51%; CC 43%; IBD 6%
• Multivariable analysis
Van Arendonk et al. Arch Surg 2012; Dec 17 [epub ahead of print]
Outcomes of Elective Operation after
Diverticulitis-2
• Compared with CC, patients with DD were significantly
more likely to have:
– in-hospital mortality (AOR 1.90; 95% CI 1.37-2.63)
– Postoperative infection (1.67; 1.48-1.89)
– Ostomy placed (1.87; 1.65-2.11)
• Adjusted total hospital charges for patients with DD (vs. CC)
were $6,679 higher (95% CI, $5,722-$7,635)
• Length of stay for patients with DD (vs. CC) was 1 day
longer (95% CI, 0.86-1.14; p <0.001)
• Patients with IBD had the highest in-hospital mortality,
complication rates, ostomy placement, longest length of
stay, and highest hospital charges.
• Consider when recommending interval colectomy for DD
Van Arendonk et al. Arch Surg 2012; Dec 17 [epub ahead of print]
Primary Anastomosis vs. Hartmann for
Perforated Left Colon Diverticulitis with
Peritonitis
• Prospective randomized trial
• 62 Patients, 4 centers
– 32 H, 30 PA with loop ileostomy
– Planned stoma reversal 3 mos.
• Analyzed by intention-to-treat
• Primary end point: Overall complication rate
• Early termination for differences in SECONDARY
end points (interim analysis)
Oberkofler et al. Ann Surg 2012;256:819-826.
Primary Anastomosis vs. Hartmann for Perforated
Left Colon Diverticulitis with Peritonitis-2
• Demographics:
– Hinchey III: 76% vs. 75%, Hinchey IV: 24% vs. 25%
• Outcomes:
–
–
–
–
Overall complication rate comparable (80% vs. 84%, p = 0.813)
Mortality comparable (13% vs. 9%)
Stoma reversal rate higher after PA (90% vs. 57%, p = 0.005)
Serious complications lower after PA (Grades IIIb-IV: 0 vs. 20%, p =
0.046)
– Operating time shorter for PA (73 min vs. 183 min, p < 0.001),
– LOS shorter after PA (6 d vs. 9 d, p = 0.016)
– Hospital cost lower for PA $16,717 vs. $24,014)
Oberkofler et al. Ann Surg 2012;256:819-826.
Open vs. Laparoscopic Emergency
Operation for Acute Diverticulitis
• NSQIP subsample
• 1,186 patients, 2005-2009
• Emergency partial colectomy/endcolostomy/Hartmann pouch
– Laparoscopic vs. open
• Propensity-matched retrospective analysis
Turley et al. Dis Colon Rectum 2013;56:72-82.
Open vs. Laparoscopic Emergency
Operation for Acute Diverticulitis-2
• Unadjusted data:
–
–
–
–
Laparoscopic group
Fewer overall complications (26% vs. 41.7%, p = 0.008)
Shorter mean LOS (8.9 vs. 11.6 days, p = 0.0008)
Operative times not different
• Adjusted for cofounders:
Laparoscopy was NOT associated with decreased
morbidity or mortality.
Turley et al. Dis Colon Rectum 2013;56:72-82.
Complicated Intra-abdominal
Infection
Complicated Intra-Abdominal Infection
Observational Study (CIAO) in Europe
• Observational study
– 2,152 patients
– January-June 2012
– 68 Centers
• Age 54 years (range: 4-98 years)
• 46.3% female
• Mortality rate 7.5% (163/2,152)
Sartelli et al. World J Emerg Surg 2012;7:36.
Complicated Intra-Abdominal Infection
Observational Study (CIAO) in Europe-2
• Multivariable analysis of mortality:
– Age
– Intestinal non-appendiceal source of infection
– Delayed initial intervention (>24 hours)
– Severe sepsis/septic shock in the immediate postoperative period
– Need for ICU admission
Sartelli et al. World J Emerg Surg 2012;7:36.
Acute Appendicitis
Diagnostic/Therapeutic Delay and
Perforation-Appendicitis Risk
• Cross-sectional analysis 1998-2008
– National Inpatient Sample
– Kids’ Inpatient Database
• Discharge diagnosis of acute appendicitis
– Surgery within 7 d of admission
• Excluded
– Elective admissions
– Drainage procedure before appendectomy
Papandria et al. J Surg Res Dec 27 {Epub ahead of print]
Diagnostic/Therapeutic Delay and
Perforation-Appendicitis Risk
• Analysis as a function of age and LOS before
appendectomy
• 683,590 patients
– 30.3% perforation rate
• >80% of operations on day of admission
– 18% days 2-4
– <1% after day 4
Papandria et al. J Surg Res Dec 27 {Epub ahead of print]
Diagnostic/Therapeutic Delay and
Perforation-Appendicitis Risk
• Day 1 operation
– Perforation rate 29%
• Day 2-4 operation
– Perforation rate 33%
• By day 8, 79%
• Odds of perforation
– Adults: 1.20 (day 2-4), 4.76 (by day 8)
– Children 1.08 (day 2-4), 15.42 (by day 8)
Papandria et al. J Surg Res Dec 27 {Epub ahead of print]
Volume-Outcome Relationships in
Acute Appendicitis
• Taiwanese national population-based study
• 65,339 patients with first-time discharges for
acute appendicitis
• Outcome: Perforated?
• Conditional logistic regression model
• Morbidity rates:
– Low-volume surgeons 28%
– High-volume surgeons 36%
– Very high-volume surgeons 21%
Wei et al. PLoS One 2012:7:e52539.
Volume-Outcome Relationships in
Acute Appendicitis
• Adjusted odds ratios for low-volume surgeons
– Practice location, hospital teaching status, hospital
volume, age, gender, Charlson Index
• Adjusted odds ratios for low-volume surgeons
– Vs. medium-volume: AOR 1.09
– Vs. high-volume AOR 1.16
– Vs. very high-volume AOR 1.54
Wei et al. Plos One 2012: 7:e52539.
Acute Appendicitis
Disease Severity Score
• Literature review and consensus expert
opinion
– Grade 1: Inflamed (uncomplicated)
– Grade 2: Gangrenous
– Grade 3: Localized free fluid
– Grade 4: Perforated (localized abscess)
– Grade 5: Perforated (generalized peritonitis)
• Retrospective validation on a cohort of 918
consecutive patients
Garst et al. J Trauma Acute Care Surg 2013;74:32-36
Acute Appendicitis
Disease Severity Score
• Distribution of pathology:
– Grade 1: 62.4%
– Grade 2: 13.0%
– Grade 3: 18.7%
– Grade 4: 4.4%
– Grade 5: 1.5%
Perforation rate 24.6%
• Retrospective validation in a cohort of 918
consecutive patients
Garst et al. J Trauma Acute Care Surg 2013;74:32-36
Acute Appendicitis
Disease Severity Score
• Step-wise increase in risk for increasing grade
(AUROC > 0.75 in all cases)
– Mortality
– LOS
– In-hospital AND post-discharge complications
• Covariates did not improve the accuracy of the
models
– Age, gender, operative technique
Garst et al. J Trauma Acute Care Surg 2013;74:32-36
Biomarkers in Acute Appendicitis?
• Systematic review/meta-analysis of studies
reporting use of procalcitonin (PCT) vs. other
biomarkers
– WBC count
– CRP concentration
– PCT concentration
• 7 Studies
– 1,011 Suspected cases
– 636 Confirmed cases
Yu et al. Br J Surg 2013;100:322-329.
Biomarkers in Acute Appendicitis-2
Biomarker
Sens.
Spec.
Discrimination (AUROC)
PCT
33%
PCT
62%
(Complicated)
89%
94%
0.64 (95% CI 0.61-0.69
CRP
57%
87%
0.75 (95% CI 0.71-0.78
WBC
62%
75%
0.72 (95% CI 0.68-0.76)
Yu et al. Br J Surg 2013;100:322-329.
Antibiotic Treatment vs. Appendectomy for
Uncomplicated Appendicitis?
• 5 RCTs, 980 patients
– 510 Antibiotic treatment
– 470 Appendectomy
• 7 Outcome parameters:
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–
–
–
–
–
Overall complication rate
Treatment failure rate (index hospitalization
Overall treatment failure rate
Length of stay (LOS)
Duration of pain; Utilization of pain medication
Time lost (work/school)
• Fixed and random effects meta-analyses performed using
odds ratios (ORs) and weighted or standardized mean
differences (WMDs or SMDs)
Mason et al. Surg Infect (Larchmt) 2012;13:74-84.
Antibiotic Treatment vs. Appendectomy for
Uncomplicated Appendicitis-2
• In 3 of the 7 outcome analyses, the summary point
estimates favored antibiotics over appendectomy
– Complications (OR 0.54; 95% CI 0.37-0.78; p=0.001) a
– Reduction in sick leave/disability (SMD -0.19; CI -0.33- 0.06; p=0.005)
– Decreased pain medication utilization (SMD -1.55; CI -1.96-1.14; p<0.0001)
• For overall treatment failure, the summary point
estimate favored appendectomy
– 40.2% failure rate for antibiotics versus 8.5% for
appendectomy (OR 6.72; CI 0.08-12.99; p<0.001)
• Initial treatment failure, LOS, and pain duration were
similar
Mason et al. Surg Infect (Larchmt) 2012;13:74-84.
Antibiotic Treatment vs. Appendectomy for
Uncomplicated Appendicitis-3
• Authors’ conclusions:
• Non-operative management of uncomplicated
appendicitis with antibiotics was associated
with significantly fewer complications, better
pain control, and shorter sick leave
• Overall, non-operative management of
uncomplicated appendicitis had inferior
efficacy because of the high rate of recurrence
in comparison with appendectomy.
Mason et al. Surg Infect (Larchmt) 2012;13:74-84.
Timing of Appendectomy
• Retrospective study of effect of timing of
appendectomy on outcomes
• 723 Patients, 2003-2009
– Histologically confirmed appendicitis
• Three groups
– Surgery <12 h (Early appendectomy [EA], n=518)
– Surgery 12-24 h (Early-delayed appy [EDA], n=140)
– Surgery >24 h (Delayed appendectomy [DA], n=65)
Giraudo et al. Surg Today 2012 Aug 30 [Epub ahead of print]
Timing of Appendectomy-2
• Operative time similar
• Postoperative complications highest in DA group
– P <0.012 vs. EA group
– P <0.003 vs. EDA group
• Mortality limited to DA group (2/65, 3%)
• Gangrenous appendicitis significantly higher in DA
group (p < 0.05).
Giraudo et al. Surg Today 2012 Aug 30 [Epub ahead of print]
More on Timing of Appendectomy
• Single-center review
• 4,529 patients admitted with appendicitis
– July 2003 to June 2011
– 4,108 underwent operation
– Age, gender, admission WBC count, surgical approach
(open vs. laparoscopic), time to appendectomy, and
pathology report were abstracted
– Primary outcomes included perforation and SSI.
– Logistic regression was performed to identify
independent predictors of perforation and investigate
the association between TTA and SSI
Teixeira er al.Ann Surg 2012256:438-453.
More on Timing of Appendectomy-2
• Logistic regression identified 3 independent predictors
of perforation
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–
–
–
Age 55 years or older; OR (95% CI): 1.66 (1.21-2.29)
WBCl count > 16,000; OR 1.38 (1.15-1.64)
Female gender; OR 1.20 (1.02-1.41)
Delay to appendectomy was not associated with higher
perforation rate.
• Controlling for age, leukocytosis, gender, laparoscopy,
and perforation, TTA of more than 6 h:
– Increase in SSI; OR 1.54 (1.01-2.34)
– Increase in SSI from 1.9% to 3.3% with non-perforated
appendicitis; OR 2.16 (1.03-4.52)
Teixeira er al.Ann Surg 2012256:438-453.
Negative Appendectomy as a Quality
Metric-Definitions Matter
• 2 definitions:
– Absence of inflammation
– Absence of neutrophil infiltration of wall
• Effect on diagnostic accuracy assessed
– 1,306 patients, 1996-2010
– Divided into 3 5-year cohorts
• 1996-2000 CT use rare
• 2001-2005 Progressive CT implementation
• 2006-2010 CT use prevalent
– Alvarado score vs. computed tomography
Mariadason et al. Ann R Coll Surg Engl2012;94:395-401.
Negative Appendectomy as a Quality
Metric-Definitions Matter-2
• Changing the definition to lack of neutrophil
infiltration increased the negative appendectomy
rate
– 1996-2000, 9% to 16%
– 2001-2005, 3% to 9% (CT rate 81%)
– 2002-2006, 3% to 7% (CT rate 92%)
• Positive predictive values
– Alvarado score 98.6%
– CT 99.0%
Mariadason et al. Ann R Coll Surg Engl2012;94:395-401.
Negative Appendectomy as a Quality
Metric-Definitions Matter-2
• Authors’ conclusions (not all data shown):
– Definition of negative appendectomy determines the
negative appendectomy rate
– Routine CT unnecessary for male patients with positive
Alvarado score
– Early/mild appendicitis may resolve without surgery
– CT may contribute to unnecessary surgery
– Alvarado scoring allows selective use of CT in suspected
appendicitis
Mariadason et al. Ann R Coll Surg Engl2012;94:395-401.
Impact of CT on Negative
Appendectomy Rate
• Population-based study
• State of Washington
• 50+ hospitals state-wide, mostly in the
community
• Prospective study of 19,327 patients
– Age >15 years
– 48% female
Drake et al. Ann Surg 2012; 256:586-594.
Impact of CT on Negative
Appendectomy Rate (NAR)-2
• Negative appendectomy rate 5.4%
– If imaged: 4.5%
– If not imaged: 15.4%
• True for males and females
– Males 3% vs. 10%
– Females 7% vs. 25%
• Multivariable analysis
– Adjusted for age, gender, WBC count
– If not imaged, NAR OR 3.7, 95% CI 3.0-4.4
Drake et al. Ann Surg 2012; 256:586-594.
Laparoscopic vs. Open Appendectomy
in Pregnancy
• Systematic review/meta-analysis
• 11 studies, 3,415 women
– 2,816 open, 599 laparoscopic
• Fetal loss rate higher for laparoscopic
appendectomy
– RR 1.91, 95% CI 1.31-2.77
• Preterm labor not influenced
– RR 1,44, 95% CI 0.68-3.06
Wilasrusmeeet al. Br J Surg 2012;99:1478-1490.
Laparoscopic vs. Open Appendectomy
in Elderly Patients
• Retrospective study
• ACS/NSQIP database 2005-2009
• 3,674 patients age > 65 years
– Appendectomy for acute appendicitis
• Propensity analysis
Moazzez et al. Surg Endosc 2012;Oct 6. [Epub ahead of print.
Laparoscopic vs. Open Appendectomy
in Elderly Patients-2
• Propensity-matched analysis (open
appendectomy):
– Higher superficial incisional SSI (4% vs. 1%), p
<0.001
– Lower organ/space SSI (1% vs. 3%, p <0.01)
Moazzez et al. Surg Endosc 2012;Oct 6. [Epub ahead of print]
Irrigate or Aspirate?
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•
•
•
•
•
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RCT in children with perforated appendicitis
Power analysis: 200 patients (200 enrolled)
Randomized to irrigation/aspiration vs. aspiration
Minimum of 0.5 L 0.9% NaCl as irrigant
Pre-/postoperative antibiotic use regulated
Primary end point: Intraperitoneal abscess
Intention-to-treat analysis
– 1 “suction only” patient received irrigation also
St Peter et al. Ann Surg 2012;256:581-585.
Irrigate or Aspirate-2
• Demographics identical
• Abscess rate:
– Suction only 19%
– Irrigation/aspiration 18%
• Duration of hospitalization identical
• Hospital charges identical
St Peter et al. Ann Surg 2012;256:581-585.
Thank You!