To Örebro University

BACKGROUND: Small bowel obstruction (SBO) is a common surgical emergency associated with substantial morbidity, hospital length of stay (LOS), and healthcare cost. The World Society of Emergency Surgery (WSES) Bologna guidelines provide evidence-informed recommendations for managing adhesive SBO, promoting timely surgical intervention (or non-operative management (NOM) when ischaemia, strangulation, or peritonitis are absent). However, guideline adoption and its impact on outcomes remain under studied. Compliance with the Bologna guidelines was evaluated to determine the impact of compliance on outcomes.

METHODS: SnapSBO, a prospective, multicentre, time-bound, observational cohort study, captured data on patients with adhesive SBO across diverse healthcare settings and patient populations. Patient care was categorized into: successful NOM, surgery after an unsuccessful appropriate trial of NOM (NOM-T), and direct to surgery (DTS). Compliance with diagnostic, therapeutic, and postoperative Bologna guideline recommendations was assessed as either complete or partial. Primary outcomes included adherence to the Bologna guidelines, LOS, complications, and the incidence of the composite metric 'optimal outcomes' (LOS ≤5 days, discharge without complications, and no readmission within 30 days).

RESULTS: Among 982 patients with adhesive SBO, successful NOM occurred in 561 (57.1%), 224 (22.8%) underwent NOM-T, and 197 (20.1%) proceeded DTS. The mean(s.d.) LOS was 5.3(9.0), 12.9(11.4), and 7.7(8.0) days respectively (P < 0.001). Optimal outcomes were achieved in 61.0%, 16.1%, and 37.6% respectively (P < 0.001) and full guideline compliance was observed in 17.2%, 10.1%, and 0.4% respectively.

CONCLUSION: Patients with adhesive SBO whose care was aligned with the Bologna guidelines had a shorter LOS and a greater incidence of optimal outcomes. Addressing evidence-to-practice gaps through implementation strategies that consider contextual factors will enhance guideline adoption and patient outcomes.

BACKGROUND: European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature.

METHODS: Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society.

RESULTS: Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training.

CONCLUSIONS: This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

INTRODUCTION: Acute appendicitis is a common surgical emergency, and the standard approach to diagnosis and management has been codified in several practice guidelines. Adherence to these guidelines provides insight into independent surgical practice patterns and institutional resource constraints as impediments to best practice. We explored data from the recent ESTES SnapAppy observational cohort study to determine guideline compliance in contemporary practice to identify opportunities to close evidence-to-practice gaps.

METHODS: We undertook a preplanned analysis of the ESTES SnapAppy observational cohort study, identifying, at a patient level, congruence with, or deviation from WSES Jerusalem guidelines for the diagnosis and management of acute appendicitis and the Surviving Sepsis Campaign in our cohort. Compliance was then correlated with the incidence of postoperative complications.

RESULTS: Four thousand six hundred and thirteen (4613) consecutive adult and adolescent patients with acute appendicitis were followed from date of admission (November 1, 2020, and May 28, 2021) for 90 days. Patient-level compliance with guideline elements allowed patients to be grouped into those with full compliance (all 5 elements: 13%), partial compliance (1-4 elements: 87%) or noncompliance (0 elements: 0.2%). We identified an excess postoperative complication rate in patients who received noncompliant and partially compliant care, compared with those who received fully guideline-compliant care (36% and 16%, versus 7.3%, p < 0.001).

CONCLUSIONS: The observed diagnostic and treatment practices of the participating institutions displayed variability in compliance with key recommendations from existing guidelines. In general, practice was congruent with recommendations for preoperative antibiotic surgical site infection prophylaxis administration, time to surgery, and operative approach. However, there remains opportunities for improvement in the choice of diagnostic imaging modality, postoperative antibiotic stewardship to timely discontinue prophylactic antibiotics, and the implementation of ambulatory treatment pathways for uncomplicated appendicitis in the healthy young adult.

INTRODUCTION: Surgical skill, a summation of acquired wisdom, deliberate practice and experience, has been linked to improved patient outcomes. Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery, coupled with the steep learning curve required to achieve trainer-recognition of independent competency, 'real-world' clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. The principle of graded autonomy matches trainees with clinical conditions that they can manage independently, and increased complexity drives attending input or assumption of the technical aspects of care, and therefore, one cannot detect an impact of operator experience on outcomes.

MATERIALS AND METHODS: This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study (ClinicalTrials.gov Trial #NCT04365491), including all consecutive patients aged ≥ 15 who underwent appendectomy for appendicitis during a three-month period in 2020-2021. Patient- and surgeon-specific variables, as well as 90-day postoperative outcomes, were collected. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to (adjusted for patient-associated confounders) assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, adjusted for patient-associated confounders. The primary outcome of interest was any complications within 90 days.

RESULTS: A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger (Median (IQR) 33 [24-46] vs 38 [26-55] years, p < 0.001), had lower ASA classifications (ASA ≥ 3: 6.6% vs 11.6%, p < 0.001) and fewer comorbidities compared to those operated on by attendings. Additionally, trainees operated alone on fewer patients with appendiceal perforation (AAST severity grade ≥ 3: 8.7% vs 15.6%, p < 0.001). Regression analyses revealed no association between operator experience and complications (IRR 1.03 95%CI 0.83-1.28 for trainee vs attending; IRR 1.13 95%CI 0.89-1.42 for supervised trainee vs attending) or hLOS.

CONCLUSION: The linkage of case complexity with operator experience within the context of graduated autonomy is a central tenet of surgical training. Either subconsciously, or by design, patients operated on by trainees were younger, fitter and with earlier stage disease. At least in part, these explain why clinical outcomes following appendectomy do not differ depending on the experience of the operating surgeon.

BACKGROUND: Race is associated with differences in quality of care process measures and incidence of venous thromboembolism (VTE) in trauma patients. We aimed to investigate if racial disparities exist in the administration of VTE prophylaxis in trauma patients.

METHODS: We queried the Trauma Quality Improvement Project database from 2017 to 2019. Patients ages ≥16 years old with ISS ≥15 were included. Patients with no signs of life on arrival, any AIS ≥6, hospital length of stay <1 day, anticoagulant use before admission, or without recorded race were excluded. Patients were grouped by race: white, black, Asian, American Indian, and Native Hawaiian or Pacific Islander. The association between VTE prophylaxis administration and race was determined using a Poisson regression model with robust standard errors to adjust for confounders.

RESULTS: A total of 285,341 patients were included. Black patients had the highest rates of VTE prophylaxis exposure (73.8%), shortest time to administration (1.6 days), and highest use of low molecular weight heparin (56%). Black patients also had the highest incidence of deep vein thrombosis (2.8%) and pulmonary embolism (1.4%). Black patients were 4% more likely to receive VTE prophylaxis than white patients [adj. IRR (95% CI): 1.04 (1.03-1.05), P < .001]. American Indians were 8% less likely to receive VTE prophylaxis [adj. IRR (95% CI): .92 (.88-.97), P < .001] than white patients. No differences between white and Asian or Native Hawaiian or Pacific Islander patients existed.

DISCUSSION: While black patients had the highest incidence of DVT and PE, they had higher administration rates and earlier initiation of VTE prophylaxis. Further work can elucidate modifiable causes of these differences.

BACKGROUND: The Brain Trauma Foundation recommends intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (TBI). Race is associated with worse outcomes after TBI. The reasons for racial disparities in clinical decision-making around ICP monitor placement remain unclear.

STUDY DESIGN: We queried the TQIP database from 2017 to 2019 and included patients 16 years or older, with blunt severe TBI, defined as a head abbreviated injury score 3 or greater. Exclusion criteria were missing race, those without signs of life on admission, length of stay 1 day or less, and AIS of 6 in any body region. The primary outcome was ICP monitor placement, which was calculated using a Poisson regression model with robust SEs while adjusting for confounders.

RESULTS: A total of 260,814 patients were included: 218,939 White, 29,873 Black, 8,322 Asian, 2,884 American Indian, and 796 Native Hawaiian or Other Pacific Islander. Asian and American Indian patients had the highest rates of midline shift (16.5% and 16.9%). Native Hawaiian or Other Pacific Islanders had the highest rates of neurosurgical intervention (19.3%) and ICP monitor placement (6.5%). Asian patients were found to be 19% more likely to receive ICP monitoring (adjusted incident rate ratio 1.19; 95% CI 1.06 to 1.33; p = 0.003], and American Indian patients were 38% less likely (adjusted incident rate ratio 0.62; 95% CI 0.49 to 0.79; p < 0.001), compared with White patients, respectively. No differences were detected between White and Black patients.

CONCLUSIONS: ICP monitoring use differs by race. Further work is needed to elucidate modifiable causes of this difference in the management of severe TBI.

INTRODUCTION: The COVID-19 (SARS-CoV-2) pandemic drove acute care surgeons to pivot from long established practice patterns. Early safety concerns regarding increased postoperative complication risk in those with active COVID infection promoted antibiotic-driven non-operative therapy for select conditions ahead of an evidence-base. Our study assesses whether active or recent SARS-CoV-2 positivity increases hospital length of stay (LOS) or postoperative complications following appendectomy.

METHODS: Data were derived from the prospective multi-institutional observational SnapAppy cohort study. This preplanned data analysis assessed consecutive patients aged ≥ 15 years who underwent appendectomy for appendicitis (November 2020-May 2021). Patients were categorized based on SARS-CoV-2 seropositivity: no infection, active infection, and prior infection. Appendectomy method, LOS, and complications were abstracted. The association between SARS-CoV-2 seropositivity and complications was determined using Poisson regression, while the association with LOS was calculated using a quantile regression model.

RESULTS: Appendectomy for acute appendicitis was performed in 4047 patients during the second and third European COVID waves. The majority were SARS-CoV-2 uninfected (3861, 95.4%), while 70 (1.7%) were acutely SARS-CoV-2 positive, and 116 (2.8%) reported prior SARS-CoV-2 infection. After confounder adjustment, there was no statistically significant association between SARS-CoV-2 seropositivity and LOS, any complication, or severe complications.

CONCLUSION: During sequential SARS-CoV-2 infection waves, neither active nor prior SARS-CoV-2 infection was associated with prolonged hospital LOS or postoperative complication. Despite early concerns regarding postoperative safety and outcome during active SARS-CoV-2 infection, no such association was noted for those with appendicitis who underwent operative management.

INTRODUCTION: Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications.

MATERIAL AND METHODS: We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs).

RESULTS: Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41-0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11-0.96), p = 0.045] complications could be detected when using energy devices.

CONCLUSIONS: Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.

BACKGROUND: Risk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture.

METHODS: All geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders.

RESULTS: 96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome.

CONCLUSIONS: Geriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.

Purpose: For some surgical conditionns and scientific questions, the "real world" effectiveness of surgical patient care may be better explored using a multi-institutional time-bound observational cohort assessment approach (termed a "snapshot audit") than by retrospective review of administrative datasets or by prospective randomized control trials. We discuss when this might be the case, and present the key features of developing, deploying, and assessing snapshot audit outcomes data.

Methods: A narrative review of snapshot audit methodology was generated using the Scale for the Assessment of Narrative Review Articles (SANRA) guideline. Manuscripts were selected from domains including: audit design and deployment, statistical analysis, surgical therapy and technique, surgical outcomes, diagnostic testing, critical care management, concomitant non-surgical disease, implementation science, and guideline compliance.

Results: Snapshot audits all conform to a similar structure: being time-bound, non-interventional, and multi-institutional. A successful diverse steering committee will leverage expertise that includes clinical care and data science, coupled with librarian services. Pre-published protocols (with specified aims and analyses) greatly helps site recruitment. Mentored trainee involvement at collaborating sites should be encouraged through manuscript contributorship. Current funding principally flows from medical professional organizations.

Conclusion: The snapshot audit approach to assessing current care provides insights into care delivery, outcomes, and guideline compliance while generating testable hypotheses.