The STITCH Trial. Small bites versus large bites for closure of abdominal midline incisions.

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“Incisional hernia is a frequent complication of abdominal operations with an incidence of 10–23%, which can increase to 38% in specific risk groups. In the USA 4 million to 5 million laparotomies are done annually, suggesting that at least 400 000–500 000 incisional hernias can be expected to occur every year. Incisional hernia is associated with pain and discomfort, resulting in a decreased quality of life. Moreover, incarceration and strangulation of abdominal contents can take place, for which emergency surgery is indicated, with associated morbidity and mortality. About 348 000 operations for incisional hernia are done every year in the USA with US$3·2 billion in annual associated costs. Prevention of
incisional hernia is therefore of paramount importance.”

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Cardiopulmonary resuscitation and outcomes with in-hospital cardiac arrest

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“In-hospital cardiac arrest is an important public health problem, affecting approximately 300 000 adults annually in the United States, with a high mortality rate.1 2 The survival rate after in-hospital cardiac arrest in the US improved from 2000 to 2010 and has remained plateaued after 2010, with approximately 25% of patients surviving to hospital discharge.
Achieving return of spontaneous circulation is the first step toward long term survival and favorable functional recovery. However, for nearly half of patients with in-hospital cardiac arrest, resuscitative efforts are terminated without achievement of return
of spontaneous circulation.”

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Hypoglycemia associated with renal failure

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“Hypoglycemia associated with renal failure is more common than generally thought. Its occurrence is often a marker of multisystem failure and has an ominous prognostic implication. Its pathogenesis is frequently complex and involves one or several mechanisms. In the evaluation of uremic hypoglycemia, the first step should be the exclusion of obvious causes such as insulin, oral hypoglycemic agent therapy, and the use of drugs known to cause hypoglycemia. Propranolol, salicylates, and disopyramide are among the most commonly implicated agents.”

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The role of CT in decision for acute appendicitis treatment

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“Although medical treatment has proven to be a successful method of treatment of uncomplicated acute appendicitis, there is still controversy over which treatment to apply. It is intended that the computed tomography (CT) appendicitis score, which carries the information of all CT parameters, gives us an idea about the severity of acute appendicitis, such as the Alvarado score.”

“A retrospective analysis was conducted on 138 patients with acute appendicitis who underwent CT between 2015 and 2019. In this study, medical treatment group (n = 60) versus surgical treatment group (n = 78) and successful antibiotic treatment group (n = 23) versus unsuccessful antibiotic treatment group (n = 14) were compared.”

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Article of interest: A randomized trial comparing antibiotics with appendectomy for appendicitis

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CODA Collaborative, Flum DR, Davidson GH, et al. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020 Nov 12;383(20): 1907-1919.

Full-text for Emory users.

Figure 2. Cumulative Incidence of Appendectomy in the Antibiotics Group. Plus signs indicate censoring because the participant withdrew or was lost to follow-up.

Background: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis.

Methods: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith.

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Article of interest: A randomized trial comparing antibiotics with appendectomy for appendicitis.

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CODA Collaborative, Flum DR, et al. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med. 2020 Oct 5. [Epub ahead of print.]

Full-text for Emory users.

Results: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50).

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Negative appendectomy rate over 18 years of technological advances

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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)