EAST 26 th 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/end colostomy/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 post operative 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 PCT (Complicated) 33% 62% CRP WBC 57% 62% 89% 94% 87% 75% 0.64 (95% CI 0.61-0.69

0.75 (95% CI 0.71-0.78

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: – 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 – 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?

• • • • • • • 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!