American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Health Care Professionals Have Differing Opinions on Pediatric Appendectomy

Minneci PC, Hade EM, Lawrence AE, et al. Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis. JAMA. 2020.

Livingston EH. Success of Antibiotic Therapy vs Laparoscopic Appendectomy for Uncomplicated Appendicitis in Children: A Matter of Perspective. JAMA. 2020.

The carefully performed study reported by Minneci and coauthors clearly identifies differences of opinion on the potential utility of nonoperative management of uncomplicated appendicitis in patients younger than 17 years old. Outcomes in more than 1,000 patients were recorded. Significantly fewer disability days were reported during the first year after the index admission in the nonoperative treatment group. The success rate of nonoperative treatment defined as avoidance of appendectomy for one year after the index admission was 67.1 percent. Surgeons involved in the study had defined “success” as 70 percent avoidance of appendectomy at one year.

Of interest is the observation that families, pediatricians, emergency physicians, and nurses who were part of the research team and were questioned regarding the value of nonoperative treatment preferred a success rate of 50 percent. The authors noted that preference for operative treatment might increase with increasing use of one-day stay laparoscopic appendectomy. They also acknowledged that the findings of the study were limited by a 25 percent rate of loss to follow-up during the first year.

In the accompanying editorial, Livingston stresses the importance of carefully defining an acceptable success rate using insights from all stakeholders. This study clearly shows that a preference for operative management depends on who is asked. Surgeons caring for these patients need to be aware of differing viewpoints and preferences when counseling patients and families.

Mounting Evidence Shows That Early Endoscopic Retrograde Cholangiopancreatography Has Limited Clinical Benefit

Schepers NJ, Hallensleben NDL, Besselink MG, et al. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): A multicentre randomised controlled trial. Lancet. 2020;396(10245):167-176.

Higgins M, Divino C. Judicious use of ERCP in gallstone pancreatitis. Lancet. 2020;396(10245):144-145.

This article reports the results of a randomized controlled trial comparing early (within 24 hours of admission) endoscopic retrograde cholangiopancreatography with sphincterotomy with conservative supportive care for patients with severe gallstone pancreatitis. A total of 232 patients were diagnosed with severe gallstone pancreatitis based on standard clinical scores and C-reactive protein levels. These patients had no clinical evidence of cholangitis. The composite endpoint of mortality and major complications was assessed in 230 patients; the data analysis showed that early ERCP has no significant clinical benefit. Although cholangitis was diagnosed during follow-up in more patients in the conservative group, subgroup analysis disclosed that most of the affected patients had prolonged cholestasis. The authors concluded that early ERCP was unnecessary unless cholangitis or prolonged complete biliary obstruction with cholestasis was present.

The editorial comment by Higgins and Divino noted that earlier studies that recommended early ERCP were limited by varying definitions of “severe gallstone pancreatitis.” They agreed that mounting clinical evidence supports the omission of ERCP unless prolonged complete biliary obstruction or cholangitis are diagnosed.

Myocardial Infection Common in COVID-19 Patients

Knight DS, Kotecha T, Razvi Y, et al. COVID-19: Myocardial injury in survivors. Circulation. 2020.

This report provided data on 828 patients treated inhospital for COVID-19 infection at a single center in the U.K. Myocardial injury was diagnosed using high-sensitivity troponin levels. Patients were offered cardiac magnetic resonance imaging after discharge to determine the extent of persistent myocardial damage. Elevated troponin levels were noted in 71 percent of patients. Magnetic resonance imaging was performed in 51 patients. Evidence of cardiac damage with no discernable cause was observed in 66 percent of this group.

The authors concluded that myocardial damage from COVID infection was common. These findings provide additional evidence of widespread, persistent damage in multiple organ systems of patients with COVID infection. This damage apparently persists for various intervals after clinical recovery from the virus. The presence of persistent cardiac damage has potentially important implications for patients who may require surgical intervention for non-COVID disorders following recovery. Preoperative evaluation of organ damage is advisable when planning a surgical procedure in these patients.

Fibrinolysis Shutdown and Thrombosis Are Common Conditions in Patients with Severe COVID-19

Wright FL, Vogler TO, Moore EE, et al. Fibrinolysis Shutdown Correlation with Thromboembolic Events in Severe COVID-19 Infection. J Am Coll Surg. 2020;231(2):193-203 e191.

Seheult JN, Seshadri A, Neal MD. Robotic Approach to Paraesophageal Hernia Repair Results in Low Long-Term Recurrence Rate and Beneficial Patient-Centered Outcomes. J Am Coll Surg. 2020;231(2):203-204.

Wright and coauthors provided additional evidence of the association of fibrinolysis shutdown with thromboembolic events in patients with severe COVID-19 infection, building on previously published work. In this most recent study, thrombo-elastography was performed on 44 patients; evidence of fibrinolysis shutdown was present in more than half of this cohort. Fibrinolysis shutdown was strongly associated with thromboembolic events, including venous thrombosis, thrombosis of vascular access catheters, pulmonary embolus and renal failure. The authors conclude that fibrinolysis shutdown is an important contributor to the coagulopathy of COVID-19 infection.

These findings suggest a potential value of fibrinolytic agents, such as tissue plasminogen activator, for treatment of affected patients. However, the editorial comment by Seheult and coauthors that accompanies the article stresses that evidence of fibrinolysis shutdown was present even though other measured variables, such as D-dimer levels, suggested hyperfibrinolysis. Additional studies are needed to further elucidate the etiologies of COVID-19 coagulopathy and provide insights regarding potentially valuable therapeutic approaches.

Additional Readings

Science Advances, Low-cost measurement of facemask efficacy for filtering expelled droplets during speech

CNN, Researchers created a test to determine which masks are the least effective