The use of risk stratification tools for perioperative and postoperative morbidity and mortality

Havens JM, Columbus AB, Seshadri AJ, et al. Risk stratification tools in emergency general surgery. Trauma Surg Acute Care Open. 2018 Apr 29;3(1):e000160.

Free full-text.

The use of risk stratification tools (RST) aids in clinical triage, decision making and quality assessment in a wide variety of medical fields. Although emergency general surgery (EGS) is characterized by a comorbid, physiologically acute patient population with disparately high rates of perioperative morbidity and mortality, few RST have been explicitly examined in this setting. We examined the available RST with the intent of identifying a tool that comprehensively reflects an EGS patients perioperative risk for death or complication.

Continue reading

Guidelines for the perioperative management of anticoagulants

One discussion this week focused on the perioperative management of NOACs.


Reference:  DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 -. Record No. 227537, Periprocedural management of patients on long-term anticoagulation; [updated 2018 Oct 10, cited 2018 Oct 12; [about 26 screens]. Emory login required.

Summary: The information below is from DynaMed Plus (2018). To view full information on the topic, click on the citation above.

Vitamin K antagonists in patients undergoing major surgery or procedures

  • Consider continuing vitamin K antagonist (VKA) therapy in patients who require minor dental procedures, minor dermatological procedures, or cataract surgery.
  • In those having a minor dental procedure, consider coadministering an oral hemostatic agent or stopping the VKA 2 to 3 days before the procedure.
  • In those undergoing implantation of a pacemaker or an implantable cardioverter device, consider continuing VKA therapy.
  • In those having a major surgery or procedure, stop VKA therapy 5 days before surgery.
  • Resume VKA therapy 12-24 hours after surgery when there is adequate hemostasis.

Bridging therapy in patients undergoing major surgery or procedures

  • If at low risk for thrombosis, consider omitting bridging therapy.
  • If at moderate risk for thrombosis, assess individual patient- and surgery-related factors when considering bridging therapy.
  • If at high risk for thrombosis consider bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH).
  • For those receiving bridging therapy with UFH, stop UFH 4-6 hours before surgery.
  • For those receiving bridging therapy with therapeutic-dose LMWH, stop LMWH 24 hours before surgery.
  • For those receiving bridging therapy with UFH or therapeutic-dose LMWH and undergoing non-high-bleeding-risk surgery, consider resuming heparin 24 hours after surgery.
  • For those receiving bridging therapy with UFH or therapeutic-dose LMWH and undergoing high-bleeding-risk surgery, consider resuming heparin 48-72 hours after surgery.

Continue reading

Step-up vs open necrosectomy for pancreatitis: the PANTER trial’s 2019 followup

One discussion this week included the question of step-up approach versus open necrosectomy for pancreatitis.


Summary: 

BACKGROUND: The 2010 randomized PANTER trial in (infected) necrotizing pancreatitis found a minimally invasive step-up approach to be superior to primary open necrosectomy for the primary combined endpoint of mortality and major complications, but long-term results are unknown.

NEW FINDINGS: With extended follow-up, in the step-up group, patients had fewer incisional hernias, less exocrine insufficiency and a trend towards less endocrine insufficiency. No differences between groups were seen for recurrent or chronic pancreatitis, pancreatic endoscopic or surgical interventions, quality of life or costs.

IMPACT: Considering both short and long-term results, the step-up approach is superior to open necrosectomy for the treatment of infected necrotizing pancreatitis.

Continue reading

Clinical guideline for management of sigmoid volvulus

One discussion this week included revolvulus after colonic decompression.


Reference: Vogel JD, et al. Clinical practice guidelines for colon volvulus and acute colonic pseudo-obstruction. Diseases of the Colon and Rectum. 2016 Jul;59(7):589-600. doi: 10.1097/DCR.0000000000000602

Summary: Volvulus occurs in the sigmoid colon or cecum in >95% of cases, with the remainder involving either the transverse colon or the splenic flexure of the colon. Sigmoid volvulus affects patients who are older, with more comorbid medical and neuropsychological conditions, compared with those with cecal volvulus.

Continue reading

Restrictive vs liberal red-cell transfusion strategy: the Transfusions Requirements in Critical Care (TRICC) trial

One discussion this week included the TRICC trial.

Reference: Herbert PC, et al…the Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. NEJM. 1999 Feb 11;340(6):409-417.

Summary:  The aim of the study was to determine whether a restrictive strategy of red-cell transfusion and a liberal strategy produced equivalent results in critically ill patients, we compared the rates of death from all causes at 30 days and the severity of organ dysfunction.

Methods: Between 1994 and 1997, the trial enrolled 838 critically ill patients with euvolemia after initial treatment who had hemoglobin concentrations of less than 9.0 g per deciliter within 72 hours after admission to the intensive care unit and randomly assigned 418 patients to a restrictive strategy of transfusion, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g per deciliter and hemoglobin concentrations were maintained at 7.0 to 9.0 g per deciliter, and 420 patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g per deciliter and hemoglobin concentrations were maintained at 10.0 to 12.0 g per deciliter.

Results: The use of a threshold for red-cell transfusion as low as 7.0 g of hemoglobin per deciliter, combined with maintenance of hemoglobin concentrations in the range of 7.0 to 9.0 g per deciliter, was at least as effective as and possibly superior to a liberal transfusion strategy (threshold, 10.0 g per deciliter; maintenance range, 10.0 to 12.0) in critically ill patients with normovolemia. There was a trend toward decreased 30-day mortality among patients who were treated according to the restrictive transfusion strategy. The significant differences in mortality rates during hospitalization, rates of cardiac complications, and rates of organ dysfunction all favored the restrictive strategy.

TRICC trial

Overall, 30-day mortality was similar in the two groups (18.7 percent vs. 23.3 percent, P= 0.11). However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill — those with an Acute Physiology and Chronic Health Evaluation II score of < or =20 (8.7 percent in the restrictive-strategy group and 16.1 percent in the liberal-strategy group; P=0.03) — and among patients who were less than 55 years of age (5.7 percent and 13.0 percent, respectively; P=0.02), but not among patients with clinically significant cardiac disease (20.5 percent and 22.9 percent, respectively; P=0.69). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.3 percent vs. 28.1 percent, P=0.05).

Conclusion:  On the basis of the trial’s results, the authors recommend that critically ill patients receive red-cell transfusions when their hemoglobin concentrations fall below 7.0 g per deciliter and that hemoglobin concentrations should be maintained between 7.0 and 9.0 g per deciliter. The diversity of the patients enrolled in this trial and the consistency of the results suggest that these conclusions may be generalized to most critically ill patients, with the possible exception of patients with active coronary ischemic syndromes.

 

Enterocutaneous fistulas: causes, management, and Emory authors

One discussion this week involved enterocutaneous fistulas.

Reference: Haak CI, Galloway JR, Srinivasan J. Enterocutaneous fistulas: a look at causes and management. Current Surgery Reports. 2014 Oct;2:71.

Summary: Despite advances in medical technology and surgical care, the management of enterocutaneous fistulas (ECF) remains one of the most challenging problems faced by physicians. Success depends on an expert multidisciplinary team, access to long-term enteral and parenteral nutrition support, advanced wound care, optimal medical management and meticulous, methodical, surgical decision-making and technique.

Team members involved in the care of these complex patients include: general and reconstructive surgeons, nutritional support staff, bedside and enterostomal nursing, social workers, radiologists, internists, psychiatrists and physical therapists, among others. While mortality rates have improved over the past four decades, leading institutions with dedicated surgeons and full multidisciplinary teams well versed in the management of these patients continue to publish very high morbidity rates, in excess of 85%.

Strict adherence to the following principles of management is paramount: (1) identification of the fistula; (2) resuscitation and sepsis control with correction of electrolyte imbalances; (3) protection of the skin and control of fistula output; (4) nutritional support; (5) radiographic investigation; and (6) definitive management, potentially with operative repair.

ECF

Overall mortality for ECF ranges from 10 to 30%. Medical management leads to spontaneous closure in approximately 30% of patients in most series. Most patients ultimately require definitive surgical closure which carries a 30 day operative mortality rate of 3–5% and a 1 year mortality rate of 7–19% from fistula-related complications.

Operative success in closing the fistula and keeping it closed is 75–89%. After definitive surgery, simple fistulas recur 5% of the time, while complex fistulas recur up to 30% of the time in most series.

Unfortunately, the incidence of ECF appears to be rising as surgeons attempt increasingly complex operations in older patients with higher acuity and multiple comorbidities. A dedicated, multidisciplinary approach is paramount in restoring gastrointestinal tract continuity while limiting morbidity, mortality, and fistula recurrence.

The STITCH trial: a summary

One discussion this week mentioned the STITCH trial.

Reference: Deerenberg EB, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised control trial. Lancet. 2015 Sep 26;386(10000):1254-1260. doi: 10.1016/S0140-6736(15)60459-7.

Summary: Incisional hernia is a frequent complication of abdominal operations with an incidence of 10–23%, which can increase to 38% in specific risk groups. It is associated with pain and discomfort, resulting in a decreased quality of life. Incarceration and strangulation of abdominal contents can take place, for which emergency surgery is indicated, with associated morbidity and mortality. The authors (2015) estimate about 348,000 operations for incisional hernia are done every year in the US with $3.2 billion in annual associated costs.

This trial is registered at Clinicaltrials.gov, number NCT01132209 and with the Nederlands Trial Register, number NTR2052.

METHODS: The STITCH trial was a prospective, multicentre, double-blind, randomised controlled trial conducted at surgical and gynaecological departments in 10 hospitals in the Netherlands between October 2009 – May 2012. The 560 patients who were scheduled to undergo elective abdominal surgery with midline laparotomy were randomly assigned to receive small tissue bites of 5 mm every 5 mm or large bites of 1 cm every 1 cm.  The primary outcome was the occurrence of incisional hernia; a reduced incidence in the small bites group was expected

RESULTS: Patients in the small bites group had fascial closures sutured with more stitches than those in the large bites group (mean number of stitches 45 [SD 12] vs 25 [10]; p<0.0001), a higher ratio of suture length to wound length (5.0 [1.5] vs 4.3 [1.4]; p<0.0001) and a longer closure time (14 [6] vs 10 [4] min; p<0.0001). At 1 year follow-up, 57 (21%) of 277 patients in the large bites group and 35 (13%) of 268 patients in the small bites group had incisional hernia (p=0.0220, covariate adjusted odds ratio 0.52, 95% CI 0.31-0.87; p=0.0131). Rates of adverse events did not differ significantly between groups.

CONCLUSIONS: In this study, the small bites suture technique is more effective than the traditional large bites technique for prevention of incisional hernia in midline incisions and is not associated with a higher rate of adverse events. The small bites technique should become the standard closure technique for midline incisions.

The Child-Pugh score and its impact on surgical morbidity and mortality (check out the references if nothing else)

One discussion this week involved the impact of the Child-Pugh scoring system. A special thank you to Dr. Sellers for providing the wealth of original documents for this post. We love hearing you talk about liver disease and portal hypertension!


References:

Cheung A., Cheung A. The Child-Pugh score: prognosis in chronic liver disease and cirrhosis [Classics Series]. 2 Minute Medicine, The Classics in Medicine: Summaries of the Landmark Trials. 2013 Jul 16. Retrieved May 17, 2019 from https://www.2minutemedicine.com

Garrison RN, et al. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Annals of Surgery. 1984 Jun;199(6):648-655.

Malinchoc M, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000 Apr;31(4):864-871.

Mansour A, et al. Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997 Oct;122(4):730-735. discussion 735-736.

Pugh RN, et al. Transection of the oesophagus for bleeding oesophageal varices. The British Journal of Surgery. 1973 Aug;60(8):646-649.

Teh SH, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007 Apr;132(4):1261-1269.

Summary: The Child-Pugh score consists of five clinical features and is used to assess the prognosis of chronic liver disease and cirrhosis. It was originally developed in 1973 to predict surgical outcomes in patients presenting with bleeding esophageal varices. It has since been modified, refined, and become a widely used tool to assess prognosis in patients with chronic liver disease and cirrhosis.

The score considers five factors, three of which assess the synthetic function of the liver (i.e., total bilirubin level, serum albumin, and international normalized ratio, or INR) and two of which are based on clinical assessment (i.e., degree of ascites and degree of hepatic encephalopathy). Critics of the Child-Pugh score have noted its reliance on clinical assessment, which may result in inconsistency in scoring. Others have suggested that its broad classifications of disease are impractical when determining priority for liver transplantation; nevertheless, it remains widely used.

child pugh

In their 1997 study, Mansour et al found the mortality in Child’s class A was 10%, compared to 30% in Class B and 82% in Class C patients.

The Model for End-Stage Liver Disease (MELD) is a newer scoring system that has been developed to address some of the concerns with the Child-Pugh score, and the two systems are often used in conjunction to determine liver transplantation priority.

The utility of the Model for End-stage Liver Disease (MELD) in predicting mortality after surgery other than liver transplantation is unknown. In determining the risk factors for postoperative mortality in patients with cirrhosis, Teh et al (2007) found that only MELD score, American Society of Anesthesiologists class, and age predicted mortality at 30 and 90 days, 1 year, and long-term, independently of type or year of surgery. Emergency surgery was the only independent predictor of duration of hospitalization postoperatively. Thirty-day mortality ranged from 5.7% (MELD score, <8) to more than 50% (MELD score, >20). The relationship between MELD score and mortality persisted throughout the 20-year postoperative period.

Liver transplantation in alcoholic liver disease: is a period of sobriety necessary?

One discussion this week included early liver transplantation in patients with alcoholic liver disease (ALD).


Reference: Godfrey EL, Stribling R, Rana A. Liver transplantation for alchoholic liver disease: an update. Clinics in Liver Disease. 2019 Feb;23(1):127-139. doi: 10.1016/j.cld.2018.09.007.

Summary (quoted from the article): ALD, a major cause of global morbidity and mortality, is expected to continue to increase in the global health burden. Although several new therapies have become available for other causes of liver disease, very few effective therapies exist for ALD other than liver transplantation. To ensure good outcomes and appropriate allocation of scarce donated organs, stringent selection criteria must be used to determine who is eligible to receive a graft, and effective, integrated alcohol use treatment must be used to prevent relapse.

Continue reading

Negative appendectomy rate over 18 years of technological advances

One discussion this week included the rate of negative appendectomy.

Reference: Raja AS, et al. Negative appendectomy rate in the era of CT: an 18-year perspective. Radiology. 2010 Aug;256(2):460-465. doi: 10.1148/radiol.10091570.

Summary: In a retrospective study of records from 1990-2007, researchers from Harvard sought to estimate the correlation between the negative appendectomy rate (NAR) and the rate of preoperative computed tomography (CT) in patients suspected of having acute appendicitis who presented to the emergency department.

The findings showed NAR decreased significantly from 23.0% to 1.7% (P < .0001), the annual number of appendectomies decreased significantly from 217 per year to 119 per year (P = .0003), and the proportion of patients undergoing appendectomy who underwent preoperative CT increased significantly from 1% to 97.5% (P < .0001).

Data from this study also suggest that the use of preoperative CT has been associated with a decrease in the female-to-male NAR ratio from 1.9:1 in 1990 to 0.9:1 in 2007, implying that the use of CT may have been helpful in decreasing the number
of negative appendectomies in women.

NAR

(Raja et al, 2010, p.464)