GENERAL SURGERY
Twenty-Five Percent of Patients with
Appendicitis and Periappendiceal Abscess
Fail Percutaneous Drainage Alone and
Require an Operation during the Index
Hospital Stay
Isaiah R Turnbull, MD, PhD, FACS, Christopher B Horn, MD,
Jarot Guerra, MD, Laurie J Punch, MD,
John E Mazuski, MD, PhD, Grant V Bochicchio, MD, MPH
Washington University School of Medicine, St Louis, MO
INTRODUCTION: Percutaneous drainage is the recommended
treatment for appendicitis with periappendiceal abscess. Prior
retrospective studies suggest that this strategy is successful in
more than 90% of cases. To determine efficacy of percutaneous
drainage in a large sample, we measured the incidence of surgery
after drainage during the index hospital stay in patients with peri-
appendiceal abscess using the National Inpatient Sample (NIS).
METHODS: The NIS from 2010 to 2014 was queried for patients
with appendicitis with periappendiceal abscesses (ICD-9 540.1).
Minors and elective admissions were excluded. Percutaneous
drainage was identified by ICD-9 549.1; we measured the inci-
dence and risk factors for subsequent surgical operation. Fre-
quencies were analyzed by c2 and continuous variables by
Students t-test.
RESULTS: We identified 2,209 patients with appendicitis and
appendiceal abscesses who underwent percutaneous drainage; 25%
(n561) patients failed percutaneous drainage alone and required
operative intervention during index hospitalization. Patients who
failed drainage were younger (4919 vs 5118 years; p .009);
more likely to be Hispanic (18.4% vs 12.3%; p<.001); had more
inpatient diagnoses (7.55.8 vs 6.14.9; p<.001) and underwent
drainage earlier in their stay (0.91.8 vs 1.612.14 days;
p<.001). Failure was also associated with increased total charges
($81,930$117,925 vs $41,383$37,282; p<.001) and longer
length-of-stay (8.79.0 vs 6.14.7 days; p <.001).
CONCLUSIONS: Approximately a quarter of patients fail manage-
ment of appendiceal abscess with percutaneous drainage alone. Risk
factors for failure include patient complexity and Hispanic race. Fail-
ure of drainage is associated with higher total charges and increased
hospital stay; however, there is no significant mortality difference.
A Nomogram for Prediction of Mortality in
Patients who Undergo Surgery for Fulminant
Clostridium Difficile Colitis: Results from the
American College of Surgeons-NSQIP
Database
Maria Abou Khalil, MD, Sahir Rai Bhatnagar,
Carol-Ann Vasilevsky, MD, FACS, Nancy A Morin, MD, FACS,
Liane S Feldman, MD, FACS, Yves Longtin, MD,
Gabriela Ghitulescu, Julio Faria, Marylise Boutros
Lady Davis Institute, Jewish General Hospital, Montreal, QC
INTRODUCTION: The objective of this study was to develop a
clinically applicable nomogram to quantify the risk of 30-day
e80
mortality for patients who undergo surgery for fulminant C. diffi-
cile colitis (FCDC).
METHODS: After institutional board approval, the American Col-
lege of Surgeons-NSQIP database (2005 to 2015) was used to
include adult patients who underwent emergency surgery (Amer-
ican Society of Anesthesiologists 3) for FCDC. CPT codes
were limited to total abdominal colectomies (TAC) and diverting
loop ileostomies lavage (DLI). A priori preoperative predictors
of mortality were selected from the literature: age, immunosuppres-
sion, sepsis, acute renal failure, dialysis, intubation, and laboratory
values. Logistic regression models using stepwise regression were
fitted and the predictive accuracy of different models were
measured by calculating the area under the receiver operating char-
acteristic (ROC) curve.
RESULTS: Of 583 patients with FCDC, 557 (96%) and 26 (4%)
underwent TAC and DLI. Overall mortality was 44% and similar
in both groups. The best model included 5 preoperative categorical
predictors odds ratio [95% CI]: shock (SIRS 0.86 [0.29-2.48];
Sepsis 1.26 [0.53-3.02]; septic shock 2.49 [1.11-5.60]), immuno-
suppression 1.84 [1.11-3.04], creatinine (Cr 1.13-2.26mg/dL
0.52 [0.3-1.00], Cr >2.26 mg/dL 0.80 [0.33-1.28]), low platelets
2.52 [1.67-3.81]) and age >65 years 4.39 [2.02-9.52]. The 5 inde-
pendent covariates were then used to create adjusted estimates, each
on a weighted scale of 0-100. The total score, on a 331-point scale,
is used to directly obtain the probability of death.
CONCLUSIONS: A clinically applicable nomogram using preoper-
ative variables can be used to predict postoperative mortality for pa-
tients with FCDC and help guide preoperative decision-making.
A Novel Rapidly Biodegradable Implantable
Elastomeric Visceral Shield for Safe and
Efficient Abdominal Fascial Closure
Omer Kaymakcalan, MD, Julia L Jin, Nicole G Ricapito, PhD,
Zhexun Sun, Sarah J Karinja, Andrew I Abadeer, Jaime L Bernstein,
David A Putnam, PhD, Jason A Spector, MD, FACS
Weill Cornell Medical College, New York, NY; Cornell
University, Ithaca, NY
INTRODUCTION: Current practice in laparotomy closure is to use
the Glassman Visceral Retainer or metal malleable retractor to shield
the bowel. These tools however must be removed prior to placement
of the final fascial sutures, leaving the bowel at risk for injury when
visualization is poorest. We have synthesized a biocompatible, flex-
ible and rapidly degrading elastomer, CC-DHA, that can withstand
surgical needle puncture for use as an implantable barrier to
completely shield the bowel during closure.
METHODS: Midline laparotomy was performed in 32 C57BL/6
mice with a CC-DHA disk or saline control placed on the viscera.
Three, 6, 9, and 24 hours and 14 days postoperatively, mice were
sacrificed and evaluated. Mice sacrificed at 3 hours underwent
bodily fluid testing for CC-DHA degradation products. Mechani-
cal testing was performed to study (GS-21) needle puncture force
of the CC-DHA disks.
http://dx.doi.org/10.1016/j.jamcollsurg.2017.07.738
ISSN 1072-7515/17