Sample Peer Review
Physician/Professional Peer Review Service Report Sample (PPRS)
PPRS #2007-03 GSG
Peer Review is privileged and confidential. Reports are protected under Iowa Code and are therefore, not subject to discoverability within a court of law. Reports are produced to assure quality care and to reduce morbidity and mortality within the healthcare organization.
This reviewer is a board certified general surgeon who has been in a community based surgical practice for 21 years, the past 15 as a member of a multi specialty practice with three general surgeons. My practice encompasses the full range of general surgical services expected in rural practice. I have been performing laparoscopic procedures since 1991 including cholecystectomy, appendectomy, hernia repair and colon resection with an approximate volume of 75 cases/year. I have performed general surgery case review several times in the past for the Institute of Quality Healthcare Resource Center.
CASE SUMMARY: This case is a 53 year-old man who presented with a two day history of mid abdominal pain which migrated to the right lower quadrant. His pain was worse with cough, deep breath or motion. His past medical history was significant for hypertension and hyperlipidemia. His only medication was Atenolol 50 mg daily with no drug allergies. His only abdominal operation was a pyloromyotomy as an infant. His physical exam showed a fever of 37.7° C and an abdominal exam with exquisite tenderness with localized rebound tenderness over McBurney’s point. His WBC was 18,300 with 97.9% neutrophils. The evaluating surgeon’s impression was acute appendicitis and the treatment plan was Unasyn 3.0 gram IVPB q 6 hr and laparoscopic appendectomy. Finding at operation was perforated appendicitis at the distal third (by path report) with fibrinopurulent exudate but no abscess or mention of fecal contamination. Postoperative care included four days or Unasyn. The patient went home on his fourth postoperative day but returned three days later with an ileus, a CT scan documented pelvic abscess and a WBC of 24,000. This was initially treated with Levaquin 500 mg IVPB q day and Flagyl 500 mg IVPB q 6 hr. CT guided percutaneous drainage was performed on the fourth day of hospitalization. TPN was initiated for profound hypoalbuminemia via a PICC line. Stool was noted in the drain two days later and exploratory laparotomy was performed. Operative findings showed a left subphrenic abscess and a pelvic abscess with a leak from the appendiceal stump. Drainage of the abscesses with antibiotic irrigation was performed and cecostomy tube was to control the open appendiceal stump. The patient made a slow progressive recovery and was discharged on his 14th postoperative day.
QUESTIONS:
1. Based on the presenting signs and symptoms, was the procedure indicated, was the intra-operative care of the original care appropriate?
The history and physical exam of this patient are consistent with the diagnosis of acute appendicitis. The patient’s age, >40, duration of symptoms >48 hours and WBC <15,000 are all indicators of possible appendiceal perforation. Preoperative antibiotic is appropriate in this setting to decrease wound infection and postoperative abscess rates . The choice of antibiotics should include both gram negative and anaerobic bacilli coverage. Zosyn and Invanz would be first line choices as wound therapy in the absence of penicillin allergy with the combination of other quinolone and metronidazole for penicillin allergic patients . In the reviewer’s institution, Unasyn is effective for only 70% of E. coli isolates and therefore is a less optimal choice.
The decision to proceed with a laparoscopic appendectomy (LA) versus an open appendectomy (OA) is somewhat controversial. Depending on the study reviewed, the benefits of LA versus OA are usually decreased length of stay and decreased wound infection. A compilation of studies in ACS Principles and Practice 2006 Chapter 5:31 page 820 Table 1 shows an increase of postoperative abscess following LA (2.4%) versus OA (1%) although no statistical analysis is offered. Other studies do not confirm this finding and one study demonstrated a decrease in the postop abscess rate when LA was performed by skilled laparoscopic surgeons despite the severity of disease (acute, gangrenous or perforated) . There seems to be agreement in literature for three situations of clear benefit of LA versus OA - woman of childbearing age, obesity and uncertain diagnosis. The greatest factor for making the decision of LA versus OA is the skill and experience of the surgeon which cannot be ascertained by this single case review.
This reviewer could not find any recent study involving LA and prophylactic drains. While the benefit is clear for a defined pocket of purulence, it is less clear in this situation. It has been my practice to leave a drain in the pelvis if there is any suggestion of contamination or pus without a defined abscess when the patient has a gangrenous or perforated appendix due to the increased risk of abscess . This drain is removed when the drainage is clear and the patient has no signs of ongoing infection (fever, leukocytosis).
Copious irrigation of the abdomen is one of the mainstays for preventing postop abscess following appendectomy . While the surgeon documents nearly 6 liters of saline were used for irrigation, only 2 liters are documented on the supply sheet. Also 38 minutes of total operating time for a laparoscopic appendectomy that is perforated is fairly short to irrigate and aspirate that amount of fluid from the right colic gutter and the pelvis in this reviewer’s experience.
2. Was the postop care appropriate and timely including but not limited to antibiotic administration and surgical intervention?
The choice of surgical intervention, laparoscopic appendectomy, is appropriate in this setting given the operative findings if the surgeon has the operative skills and experience. While this reviewer would have selected Zosyn or Invanz initially, in this patient and continued treatment postoperatively, Unasyn is acceptable if the bacterial isolates for your institution are usually susceptible. There are no cultures intra-operatively of either the intraabdominal fluid or the perforated appendix to assist in this determination although this is not routinely done unless there is evidence of frank contamination or pus.
The duration of antibiotic therapy is a more significant issue. This patient received four days of Unasyn 3 gm IVPB q 6 hr. While this may have been adequate therapy given the fact the patient was afebrile at time of discharge, no follow-up CBC could be found in the chart to document a successful response to therapy. One study cited a 68% rate of postop septic complications in afebrile patients with WBC >10,000 when antibiotics were stopped versus 8% in those with WBC <10,000 at antibiotic discontinuance . Thus, a CBC should have been performed to determine success of the therapy before stopping the antibiotic. Also, switching to oral antibiotics, particularly ciprofloxacin and metronidazole, is as effective as IV antibiotics when the patient is afebrile. Patient response to therapy is more important than a specific duration of time and the trend is to limit antibiotics in this setting to less than 7 days. If the patient has not responded, then a search for a source of ongoing infection should be performed. The reviewer also questions the degree of resolution of this patient’s ileus as all bowel activity seemed induced by medication or cathartic. The patient had one meal of full liquids prior to discharge which seems a limited trial in this patient. Also, hiccoughs in this setting usually denotes gastric distention from ileus or diaphragmatic irritation which suggests potential complications or slow resolution of his ileus.
This reviewer’s practice is to see patients on postop day 5 to 7 as this is usually the time complications will occur with the wound(s) and rarely longer than 1 week from discharge with this type of patient8.
3. Can the reviewer suggest any modification in procedure execution that may decrease the chance of such a complication?
This complication seems to be the result of surgical technique rather than the decision making process. A leak from the appendiceal stump appears to be the initiating factor of this patient’s postoperative complication. This reviewer always uses an Endo GIA stapling device to secure the appendiceal stump due to its ease of use, its reliability of closure and the ability to handle inflammation of the appendiceal base if present8 . While the downside is cost (compared to endoloops) and the need for a 12 mm port, I believe the benefit far outweighs these factors. Also, I never use electrocautery on the exposed mucosa of the appendiceal stump. It is unnecessary as the exposed mucosa does not increase infectious complications (just as in stapled colonic anastomosis). Also, the application of electrocautery can cause necrosis of the stump allowing the endoloops to “fall off” leaving an opening to the cecum usually at 3-5 days postop8 , which is most likely the cause of the appendiceal stump leak in this case. I believe these two changes would have prevented this complication given the information in the chart.
4. Does the reviewer have any overall recommendations that would improve the care of similar patients in the future?
Other than changes of technique listed above, all other items would be again to minimize or identify the complication earlier in the patient’s postop course. Choice of antibiotic and duration of treatment are discussed above. It would seem prudent to perform a postop WBC at some point postop to confirm success of the antibiotic therapy. Cultures are helpful to identify the bacteria and their sensitivities to the antibiotic regimen. This reviewer did not find cultures from the time the CT guided drains were placed which seemed unusual given the fact that pus was aspirated and sent for cytology. There seemed to be a three day delay from diagnosis to intervention on readmission for his pelvic abscess for drain placement. While the patient had EKG changes on his readmission to the hospital presumably due to hypokalemia, it seemed unusual that a 53 year-old man with hypertension, hyperlipidemia and a family history of heart disease did not have a preop EKG on his first admission. Earlier initiation of parenteral nutrition may have been of benefit once the diagnosis of intraabdominal abscess was established with the presumption of a long delay of establishing adequate enteral nutrition. Lastly, the operative times for the patient’s second operation documented anesthesia start time at 1615 and surgery start time at 1725 - a 70 minute delay with no other apparent interventions taking place.
References
Cochrane Database Sys Rev 2006 Andersen BR et al
ACS Principles and Practices 2006 Chapter 8:15 Antibiotics pg 1535.
ACS Principles and Practices Chapter 5:31 Appendectomy pg 820.
Laparoscopic versus Open Appendectomy: Outcomes Comparison Based Administrative Database, Ann Surg 239(1): 43-52 2004 Gulier, u et al.
Results of Laparoscopic versus Conventional Appendectomy in Complicated Appendicitis Dis Colon Rectum 2001; 44(11)1700-5 Wallstein, C. et al.
Intraabdominal Abscess Rate After Laparoscopic Appendectomy Katkhouda, N et al AM Surg 2000; 180(6) 456-9.
Risk Factors for Post-appendectomy Intraabdominal Abscess Aust NF & Surg. 1999 69 (5):373-4.
Complications of Laparoscopic Surgery John Flowers Chap 6 Appendectomy pg 161-181 1995 Quality Medical Publishing.
Duration of Antimicrobial Therapy for Intraabdominal Infections Infect Med 21 (10) 506-510 2004 T. Hedrick, et al.
Securing the appendiceal stump in laparoscopic appendectomy: evidence for routine stapling. Surg. Endosc 2006; 20 (9): 1473-6
Kazemier, 6. et al.
Importance of appendix stump management in laparoscopic appendectomy. Klima, S. Zentraib: Chir 1998 123 suppl 4:90-3.
Mastery of Surgery; 5th edition 2007 Chapter 130 Laparoscopic Appendectomy 1434-8 Awad, F.
Time = 5 hours
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