David R. Flum

Nonsteroidal Anti-inflammatory Drugs and the Risk for Anastomotic Failure: A Report From Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP)

IMPORTANCE Nonsteroidal anti-inflammatory drugs (NSAIDs) have many physiologic effects and are being used more commonly to treat postoperative pain, but recent small studies have suggested that NSAIDs may impair anastomotic healing in the gastrointestinal tract. OBJECTIVE To evaluate the relationship between postoperative NSAID administration and anastomotic complications. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 13,082 patients undergoing bariatric or colorectal surgery at 47 hospitals in Washington State from January 1, 2006, through December 31, 2010, using data from the Surgical Care and Outcomes Assessment Program linked to the Washington State Comprehensive Abstract Reporting System. EXPOSURE NSAID administration beginning within 24 hours after surgery. MAIN OUTCOMES AND MEASURES We used multivariate logistic regression modeling to assess the risk for anastomotic complications (reoperation, rescue stoma, revision of an anastomosis, and percutaneous drainage of an abscess) through 90 days after bariatric and colorectal surgery involving anastomoses. RESULTS Of the 13,082 patients (mean [SD] age, 58.1 [15.8] years; 60.7% women), 3158 (24.1%) received NSAIDs. The overall 90-day rate of anastomotic leaks was 4.3% for all patients (151 patients [4.8%] in the NSAID group and 417 patients [4.2%] in the non-NSAID group; P=.16). After risk adjustment, NSAIDs were associated with a 24% increased risk for anastomotic leak (odds ratio, 1.24 [95% CI, 1.01-1.56]; P=.04). This association was isolated to nonelective colorectal surgery, for which the leak rate was 12.3% in the NSAID group and 8.3% in the non-NSAID group (odds ratio, 1.70 [95% CI, 1.11-2.68]; P=.01). CONCLUSIONS AND RELEVANCE Postoperative NSAIDs were associated with a significantly increased risk for anastomotic complications among patients undergoing nonelective colorectal resection. To determine the role of NSAIDs in colorectal surgery, future evaluations should consider specific formulations, the dose effect, mechanism, and other relevant outcome domains, including pain control, cardiac complications, and overall recovery.

Prophylactic Cholecystectomy in Transplant Patients: A Decision Analysis

Prophylactic laparoscopic cholecystectomy should be performed in solid organ transplant patients with asymptomatic cholelithiasis. Modeled, decision analytic techniques were used to evaluate the different management strategies for asymptomatic cholelithiasis in cardiac and pancreas/renal transplant recipients. The clinical outcomes of expectant management, pretransplantation prophylactic cholecystectomy, and posttransplantation prophylactic cholecystectomy were analyzed for each population. The probabilities and outcomes were derived form a pooled analysis of published studies. One- and two-way sensitivity and cost analyses were performed. Prophylactic posttransplantation cholecystectomy is favored for cardiac transplant recipients with asymptomatic cholelithiasis, resulting in 5:1000 deaths versus 80:1000 for pretransplantation cholecystectomy and 44:1000 for expectant management. In distinction, expectant management for asymptomatic cholelithiasis is favored in pancreas/renal transplant patients, resulting in 2:1000 deaths compared with 5:1000 for prophylactic cholecystectomy. After heart transplantation, a strategy of routine, prophylactic cholecystectomy is anticipated to result in a cost savings of

Comparative Effectiveness of Skin Antiseptic Agents in Reducing Surgical Site Infections: A Report from the Washington State Surgical Care and Outcomes Assessment Program

17,779 per quality-adjusted life-year. Prophylactic posttransplantation cholecystectomy is the preferred management strategy for cardiac transplant patients with incidental gallstones, resulting in decreased mortality and significant cost savings per quality-adjusted life-year. Expectant management is the preferred strategy for pancreas and/or kidney transplant recipients with asymptomatic cholelithiasis.

Pulmonary function in the morbidly obese

BACKGROUND Surgical site infections (SSI) are an important source of morbidity and mortality. Chlorhexidine in isopropyl alcohol is effective in preventing central venous-catheter associated infections, but its effectiveness in reducing SSI in clean-contaminated procedures is uncertain. Surgical studies to date have had contradictory results. We aimed to further evaluate the relationship of commonly used antiseptic agents and SSI, and to determine if isopropyl alcohol has a unique effect. STUDY DESIGN We performed a prospective cohort analysis to evaluate the relationship of commonly used skin antiseptic agents and SSI for patients undergoing mostly clean-contaminated surgery from January 2011 through June 2012. Multivariate regression modeling predicted expected rates of SSI. Risk adjusted event rates (RAERs) of SSI were compared across groups using proportionality testing. RESULTS Among 7,669 patients, the rate of SSI was 4.6%. The RAERs were 0.85 (p = 0.28) for chlorhexidine (CHG), 1.10 (p = 0.06) for chlorhexidine in isopropyl alcohol (CHG+IPA), 0.98 (p = 0.96) for povidone-iodine (PVI), and 0.93 (p = 0.51) for iodine-povacrylex in isopropyl alcohol (IPC+IPA). The RAERs were 0.91 (p = 0.39) for the non-IPA group and 1.10 (p = 0.07) for the IPA group. Among elective colorectal patients, the RAERs were 0.90 (p = 0.48) for CHG, 1.04 (p = 0.67) for CHG+IPA, 1.04 (p = 0.85) for PVI, and 1.00 (p = 0.99) for IPC+IPA. CONCLUSIONS For clean-contaminated surgical cases, this large-scale state cohort study did not demonstrate superiority of any commonly used skin antiseptic agent in reducing the risk of SSI, nor did it find any unique effect of isopropyl alcohol. These results do not support the use of more expensive skin preparation agents.

Short- and Long-Term Mortality After Appendectomy in Sweden 1987–2006: Influence of Appendectomy Diagnosis, Sex, Age, Co-morbidity, Surgical Method, Hospital Volume, and Time Period—A National Population Based Cohort Study

BACKGROUND Only limited data exist on the relationship of lung function to patients with extreme obesity. To assess the relationship between lung function tests and clinical characteristics in a cohort of morbidly obese patients undergoing evaluation for bariatric procedures in a university hospital in the United States. METHODS Consecutive patients undergoing clinical evaluation were reviewed. The variables included demographic, anthropometric, clinical, and pulmonary function data. RESULTS A total of 229 patients underwent a standardized preoperative evaluation. Of these 229 patients, 136 (59%) had evaluable data and 102 (75%) were women. The mean +/- standard deviation age was 45 +/- 10 years, the mean weight was 164 +/- 42 kg, and the mean body mass index was 57 +/- 13 kg/m2. Smoking or asthma was reported in 38% and 24% of patients, respectively. The mean forced vital capacity and forced expiratory volume in 1 s was 80% +/- 17% of predicted and 76% +/- 19% of predicted, respectively. Of the 136 patients, 29% had a measured forced expiratory volume in 1 s/forced vital capacity of >or=.08 below the predicted ratio. The mean total lung capacity was 86% +/- 14% of predicted; 26% of subjects had a total lung capacity <80% of predicted. Multivariate logistic regression analysis demonstrated an association of obstructive ventilatory defects with male gender (odds ratio [OR] 2.35, 95% confidence interval [CI] 1.00-5.50) and current or previous smoking (OR 2.41, 95% CI 1.10-5.30), but not body mass index. Restrictive defects were associated with body mass index (OR 1.06, 95% CI 1.01-1.10), in particular, obesity hypoventilation syndrome (OR 3.7, 95% CI 1.2-11.1). CONCLUSION The mean preoperative spirometry, lung volumes, and gas exchange values were within the established reference ranges. Restrictive ventilatory defects were less common than obstructive ventilatory patterns and were most prominently associated with obesity hypoventilation syndrome.

Single institution and statewide performance of ultrasound in diagnosing appendicitis in pregnancy.

This article is Roland Andersson’s most recent addition to his important body of work focused on appendicitis and appendectomy [1]. Using a large Swedish database, Andersson has reaffirmed what previous studies in the Unites States [2] and the United Kingdom [3] have also demonstrated: negative exploration for suspected appendicitis and subsequent so-called negative appendectomy (NA), often considered by surgeons to be a harmless procedure, may not be benign and may be a marker of something worse. There are several important outcomes in appendectomy patients. Although we disagree with Andersson that “avoiding mortality is the ultimate goal in the management of patients with suspected appendicitis” (emphasis added), the data presented in this paper suggest that both long-term and short-term mortality may be adversely affected when patients who are incorrectly diagnosed with appendicitis undergo appendectomy. Compared to patients with nonperforated appendicitis, the risk of death after NA was increased in the short term [hazard ratio (HR) 3.32, 95 % CI 2.21–4.94] and in the long term (HR 1.76, 95 % CI 1.54–2.00). Indeed, these HRs were larger than those for perforated appendicitis (compared to nonperforated appendicitis). Interestingly, at 5 years, the standardized mortality ratio (SMR) showed that mortality for patients who underwent appendectomy for nonperforated and perforated appendicitis fell below societal baseline (SMRs of 0.71 and 0.92, respectively). By contrast, for NA the SMR remained elevated at 5 years, at 1.27. Readers will certainly be interested in how it is that appendectomy for appendicitis is associated with a reduction in 5-year mortality compared to that for the general Swedish population. In our judgment, it likely arises from two sources. As Andersson discusses in his article, there is likely a “healthy patient bias,” by which individuals judged healthy enough to undergo an operation were preferentially selected for surgical treatment of their suspected appendicitis (instead of applying antibiotics or observation). Another potential contributor arises from the fact that long-term mortality was calculated from 90 days to 5 years—excluding those patients who died within 89 days of surgery. Sicker patients who were less able to withstand surgery may have died early, which would have left healthier patients in the remaining cohort measured out to 5 years. In terms of the increased 5-year mortality observed among NA patients, the data presented here establish a clear association between NA and an increasing number of co-morbid conditions, which can affect survival. Additionally, if we recognize NA as a marker of missed diagnoses, in which appendicitis was suspected but instead there was an occult but potentially serious intraabdominal process, the finding of increased long-term mortality may represent the sequelae of these unrecognized processes. Andersson’s analysis accounted for the presence of additional diagnoses identified at the time of operation by categorizing those separately from the “entirely negative appendectomy,” but ongoing processes missed by the surgeon at the time of laparotomy or laparoscopy (e.g., ulcerative colitis, Crohns disease, other colitides) may contribute to the long-term reduction in mortality seen in NA patients. In summary, although these data cannot be used to prove that NA, in and of itself, is harmful, there is certainly no evidence to suggest that it is harmless. There are other important findings. Most notably, Andersson found no association between hospital volume and postoperative mortality at 30 days or at 5 years. Additionally, he found that short-term mortality of laparoscopic appendectomy was not different than that of open appendectomy. However, at 5 years, the HR of laparoscopic versus open procedures was lower, at 0.83 (95 % CI 0.73–0.94). Andersson suggests that the reduction in mortality compared to open procedures likely arises from selection bias (healthier patients are more often chosen for laparoscopic than for open surgery), not, as other investigators have suggested, that long-term benefits accrue to patients because the laparoscopic approach causes less systemic stress response than open surgery. Given that patients were nonrandomly allocated to laparoscopic or open procedures, it is difficult to choose one interpretation over the other. It bears mentioning as well that data collection began in 1987. Early laparoscopic surgery outcomes were perhaps not as good as later outcomes from surgeons more experienced with laparoscopy. Conversely, patients from the earlier era, which we are told had higher baseline mortality, are more likely to be included in the open category, which would tend to bias the results toward laparoscopy. The central message of this article is that, as Andersson writes, diagnostic accuracy is critical. Just because appendectomy is relatively well-tolerated by patients and not prone to serious complication does not mean that it should be undertaken without careful consideration. One cannot determine from these data whether NA itself is harmful or if it is a marker of underlying poor health or other conditions that ultimately lead to worse outcomes. As a marker of something else, we would not expect these outcomes to change with a better diagnostic workup focused specifically on appendicitis—unless the improved workup leads to a correct alternative diagnosis for patients who can then be started on appropriate therapy. A prospective trial of ultrasonography in patients with suspected appendicitis showed that alternative diagnoses can be frequently detected by experienced, highly-qualified sonographers [4]. For these reasons, and although we recognize that this strategy may not be appropriate in all of the many diverse health care settings around the world, our group has advocated the routine use of advanced diagnostic imaging (ultrasonography, computed tomography, magnetic resonance imaging) as a means of safely reducing NAs in patients suspected of having appendicitis. This is especially critical in reproductive-age women, but analysis of a large cohort of patients in Washington state demonstrated that the use of preoperative imaging in men is also associated with a significant reduction in NAs [5]. At the same time, as Andersson pointed out in a recent letter to the British Medical Journal [6], there are almost certainly some cases of appendicitis that are self-resolving. As we achieve greater sensitivity in diagnosing appendicitis, we will likely increase the number of patients treated whose disease might otherwise resolve spontaneously. These competing interests—improving diagnostic accuracy to reduce the number of unnecessary (and potentially harmful) operations and, simultaneously, not over-treating patients with appendicitis that may be self-limiting—represent the newest challenges in the management of this disease. As is true in much of medicine, when we learn more, we find that we actually know less. This is certainly the case with appendicitis, a beguiling condition with many questions still to be answered.

Selective vs Nonselective Nonsteroidal Anti-inflammatory Drugs and Anastomotic Leakage After Colorectal Surgery—Reply

Abstract Objective: Assess the performance of ultrasound (US) in pregnant patients presenting with acute abdominal pain concerning for appendicitis. Methods: Descriptive analysis of pregnant patients who underwent an US for acute abdominal pain over a 6-year period using data from a statewide quality improvement collaborative and a single center. Results: Statewide, 131 pregnant patients underwent an appendectomy and 85% had an US. In our single-center case series, 49 pregnant patients underwent an US for acute abdominal pain and four patients had appendicitis (8%). Of those, three were definitively diagnosed with US. The appendix was visualized by US in five patients (3 appendicitis/2 normal). Mean gestational age was 11 weeks for visualization of the appendix versus 20 weeks for non-visualization (p < 0.001). Concordance between US and pathology was similar statewide and at our institution (43%). Conclusions: US appears to play a central role in the evaluation of appendicitis in pregnant women, especially in the first trimester, and often contributes to definitive disposition. US performed less well in excluding appendicitis; however, in certain clinical settings, providers appeared to trust US findings. From these results, we developed a multidisciplinary imaging pathway for pregnant patients who present with acute abdominal pain concerning for appendicitis.