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Rehné Jensen L, Snitkjær C, Kokotovic D, Korgaard Jensen T, Burcharth J. Understanding early deaths after major emergency abdominal surgery: An observational study of 754 patients. World J Surg 2024; 48:1797-1807. [PMID: 38886168 DOI: 10.1002/wjs.12254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/09/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Major emergency abdominal surgery is associated with severe postoperative complications and high short- and long-term mortality. Despite recent advancements in standardizing multidisciplinary care bundles, a subgroup of patients continues to face a heightened risk of short-term mortality. This study aimed to identify and describe the high-risk surgical patients and risk factors for short-term postoperative mortality. METHODS In this study, we included all patients undergoing major emergency abdominal surgery over 2 years and collected data on demographics, intraoperative variables, and short-term outcomes. The primary outcome measure was short-term mortality and secondary outcome measures were pre, intra, and postoperative risk factors for premature death. Multivariable binary regression analysis was performed to determine possible risk factors for short-term mortality. RESULTS Short-term mortality within 14 days of surgery in this cohort of 754 consecutive patients was 8%. Multivariable analysis identified various independent risk factors for short-term mortality throughout different phases of patient care. These factors included advanced age, preoperative history of myocardial infarction or ischemic heart disease, chronic obstructive pulmonary disease, liver cirrhosis, chronic kidney disease, and vascular bowel ischemia or perforation of the stomach or duodenum during the primary surgery. CONCLUSION Patients at high risk of early mortality following major emergency abdominal surgery exhibited distinct perioperative risk factors. This study underscores the importance of clinicians identifying and managing these factors in high-risk patients to ensure optimal care.
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Affiliation(s)
- Lasse Rehné Jensen
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Christian Snitkjær
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Dunja Kokotovic
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
| | - Thomas Korgaard Jensen
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Burcharth
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev and Gentofte, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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2
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Passi NN, Gupta A, Lusby E, Scott S, Sehmbi H, Hare S, Oliver CM. Analgesia for emergency laparotomy: a systematic review. Br J Hosp Med (Lond) 2024; 85:1-9. [PMID: 38941975 DOI: 10.12968/hmed.2023.0409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Aims/Background Poorly controlled pain is common after emergency laparotomy. It causes distress, hinders rehabilitation, and predisposes to complications: prolonged hospitalisation, persistent pain, and reduced quality of life. The aim of this systematic review was to compare the relative efficacies of pre-emptive analgesia for emergency laparotomy to inform practice. Methods We performed a search of MEDLINE, MEDLINE In-Process, Embase, PubMed, Web of Science and SCOPUS for comparator studies of preoperative/intraoperative interventions to control/reduce postoperative pain in adults undergoing emergency laparotomy (EL) for general surgical pathologies. Exclusion criteria: surgery including non-abdominal sites; postoperative sedation and/or intubation; non-formal assessment of pain; non-English manuscripts. All manuscripts were screened by two investigators. Results We identified 2389 papers. Following handsearching and removal of duplicates, 1147 were screened. None were eligible for inclusion, with many looking at elective and/or laparoscopic surgeries. Conclusion Our findings indicate there is no evidence base for pre-emptive analgesic strategies in emergency laparotomy. This contrasts substantially with elective cohorts. Potential reasons include variation in practice, management of physiological derangement taking priority, and perceived contraindications to neuraxial techniques. We urge a review of contemporary practice, with analysis of clinical data, to generate expert consensus.
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Affiliation(s)
- Neha N Passi
- Department of Anaesthesia, Whipps Cross Hospital, London, UK
| | - Aayushi Gupta
- Department of Anaesthesia, Royal Free Hospital, London, UK
| | - Eimear Lusby
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Sara Scott
- Department of Anaesthesia, Queen Elizabeth Hospital, Gateshead, UK
| | - Herman Sehmbi
- London Health Sciences Centre, Western University, London, Canada
| | - Sarah Hare
- Department of Anaesthesia, Medway Maritime Hospital, Gillingham, Kent, UK
| | - Charles M Oliver
- Centre for Perioperative Medicine, University College London, London, UK
- Department of Anaesthesia, University College London Hospital, London, UK
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Ashmore DL, Wilson T, Halliday V, Lee M. Malnutrition in emergency general surgery: a survey of National Emergency Laparotomy Audit Leads. J Hum Nutr Diet 2024; 37:663-672. [PMID: 38436051 DOI: 10.1111/jhn.13293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/17/2024] [Accepted: 02/05/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Patients who are malnourished and have emergency general surgery, such as a laparotomy, have worse outcomes than those who are not malnourished. It is paramount to identify these patients and minimise this risk. This study aimed to describe current practices in identifying malnutrition in patients undergoing a laparotomy, specifically focusing on screening, assessment, nutrition pathways and barriers encountered by clinicians. METHODS Following piloting and validity assessment, anaesthetic and surgical National Emergency Laparotomy Audit (NELA) Leads at hospitals across England and Wales were emailed an invitation to a survey. Responses were gathered using Qualtrics. Descriptive analysis and correlation with laparotomy volume and professional role were performed in SPSSv26. University of Sheffield ethical approval was obtained (UREC 046205). The results from the survey are reported according to the CHERRIES guidelines. RESULTS The survey was completed by 166/289 NELA Leads from 117/167 hospitals (57.4% and 70.1% response rates, respectively). Participants reported low rates of nutritional screening (42/166; 25.3%) and assessment (26/166; 15.7%) for malnutrition preoperatively. More than one third of respondents (40.1%) had no awareness of local screening tools; indeed, the Malnutrition Universal Screening Tool (MUST) was used by approximately half of respondents (56.6%). Contrary to guidelines, NELA Leads report albumin levels continue to be used to determine malnutrition risk (73.5%; 122/166). Postoperative nutrition pathways were common (71.7%; 119/166). Reported barriers to nutritional screening and assessment included a lack of time, training and education, organisational support and ownership. Participants indicated nutrition risk is inadequately identified and is an important missing data item from NELA. There was no significant correlation with hospital laparotomy volume in relation to screening or assessment for malnutrition, the use of nutritional support pathways or organisational barriers. There was interprofessional agreement across a number of domains, although some differences did exist. CONCLUSIONS Wide variation exists in the current practice of identifying malnutrition risk in NELA patients. Barriers include a lack of time, knowledge and ownership. Nutrition pathways that encompass the preoperative phase and incorporation of nutrition data in NELA may support improvements in care.
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Affiliation(s)
- Daniel L Ashmore
- School of Medicine and Population Health, Faculty of Health, University of Sheffield, Sheffield, UK
- Department of General Surgery, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Timothy Wilson
- Department of General Surgery, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Vanessa Halliday
- School of Medicine and Population Health, Faculty of Health, University of Sheffield, Sheffield, UK
| | - Matthew Lee
- School of Medicine and Population Health, Faculty of Health, University of Sheffield, Sheffield, UK
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Kanstrup CTB, Svarre KJ, Rasmussen MC, Serup CM, Lundstrøm LH, Kleif J, Bertelsen CA. The effects of troponin screening among patients undergoing acute high-risk abdominal surgery: A retrospective cohort study. Acta Anaesthesiol Scand 2024; 68:476-484. [PMID: 38213306 DOI: 10.1111/aas.14371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/29/2023] [Accepted: 12/14/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Acute high-risk abdominal (AHA) surgery is associated with a high short-term mortality rate. This might be partly attributed to myocardial injury after non-cardiac surgery (MINS) defined by elevated postoperative troponin levels. The myocardial injury is often asymptomatic; thus, troponin screening seems to be the best diagnostic method. We aimed to assess whether implementing troponin screening with subsequent individualised interventions as standard care is associated with reduced mortality after AHA surgery. We also explored the treatment implications in the screening period. METHODS A retrospective cohort of 558 patients undergoing surgery from February 2018 to March 2021 was included. The patients undergoing surgery before March 2019 served as the historical control group, while the screening group consisted of patients undergoing surgery from March 1, 2019. Troponin I was to be measured 6-12 h postoperatively and in the morning of the succeeding 4 days. Patients with myocardial injury were assessed, and treatment was individualised after multiple disciplinary consultations. The primary outcome was the unadjusted 30-day mortality rates. Inverse probability treatment weighting was used to adjust for selection bias. RESULTS We included 558 patients: 382 in the screening group and 176 in the historical control group. In the screening group, 15 patients (3.9%) died before the first blood sampling, and in 31 patients (8.1%), troponin screening was omitted, leaving only 336 patients screened. Myocardial injury was diagnosed in 81 patients (24.1%) of the 336 patients. Of these, 59 (72.8%) had a cardiac consultation. No interventions or alterations in relation to myocardial injury were done in 67 patients (82.7%). The 30-day mortality was 13.8% (95% CI 8.7%-18.9%) in the control group and 11.1% (95% CI 8.0%-14.3%) in the screening group. The absolute risk difference was -2.7% (95% CI -8.7%-3.3%; p = .38), which was unchanged after adjustment. The difference remained unchanged after 90 days and 1 year. CONCLUSION The implementation of postoperative troponin screening was not associated with reduced mortality after AHA surgery. Research on the prevention and treatment of MINS is warranted before the implementation of standard troponin screening.
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Affiliation(s)
- Charlotte T B Kanstrup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Graduate School, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristina Johansen Svarre
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maja Christine Rasmussen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Mattesen Serup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Jakob Kleif
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Claus Anders Bertelsen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Harji DP, Griffiths B, Stocken D, Pearse R, Blazeby J, Brown JM. Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis. Br J Surg 2024; 111:znae057. [PMID: 38513265 PMCID: PMC10957158 DOI: 10.1093/bjs/znae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes. METHODS The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling. RESULTS Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001). DISCUSSION Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.
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Affiliation(s)
- Deena P Harji
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ben Griffiths
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Rupert Pearse
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical research Centre, Bristol, UK
| | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Kanstrup CTB, Serup CM, Svarre KJ, Rasmussen MC, Lundstrøm LH, Kleif J, Bertelsen CA. Association between troponin I levels and mortality among patients undergoing acute high-risk abdominal surgery-A cohort study. World J Surg 2024; 48:361-370. [PMID: 38284768 DOI: 10.1002/wjs.12035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/20/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Myocardial injury after noncardiac surgery (MINS) is associated with 30-day mortality in heterogeneous surgical populations but is barely described after acute high-risk abdominal surgery. The impact of dynamic changes has not previously been investigated. The objectives were to determine the incidence of MINS in this population, the association between mortality and MINS, and whether plasma troponin I (TnI) dynamics have any impact on mortality. METHODS A prospective cohort study of 341 patients undergoing acute high-risk gastrointestinal surgery was conducted. Plasma TnI was measured at the first four postoperative days. MINS was defined as any increased TnI level >59 ng/L. TnI dynamic required either two succeeding measurements of TnI >59 ng/L with a >20% increase/fall or one measurement of TnI >59 ng/L with a succeeding measurement of TnI <59 ng/L with a >50% decrease. Adjusted mortality rates were calculated using inverse probability of treatment weighting and competing risk analyses. RESULTS The incidence of MINS was 23.8% and dynamic TnI changes occurred in 15.6% of the patients. The unadjusted 30-day and 1-year mortality were 19.8% and 35.9% in patients with MINS, compared with 2.7% and 11.6%, respectively, in patients without MINS (p < 0.001). After adjusting, the differences remained significant. There was no difference in mortality between patients with or without dynamic changes in TnI level. CONCLUSION MINS occurred frequently and was associated with increased mortality. TnI monitoring might help identify patients with increased risk of mortality and improve care. Research on preventive measures and treatments is warranted. TRIAL REGISTRATION NUMBER AND AGENCY ClinicalTrials.gov Identifier: NCT05933837, retrospective registered.
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Affiliation(s)
- Charlotte Tiffanie Bendtz Kanstrup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Graduate School, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Mattesen Serup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristina Johansen Svarre
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maja Christine Rasmussen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Jakob Kleif
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Claus Anders Bertelsen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Timan TJ, Ekerstad N, Karlsson O, Sernert N, Prytz M. One-year mortality rates after standardized management for emergency laparotomy: results from the Swedish SMASH study. BJS Open 2024; 8:zrad133. [PMID: 38284401 PMCID: PMC10823779 DOI: 10.1093/bjsopen/zrad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/21/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Patients who require an emergency laparotomy suffer from high mortality and morbidity rates. Studies have shown that the standardization of perioperative management reduces complications in the short term. The aim of the present study was to report long-term mortality rates for the SMASH (Standardized perioperative Management of patients operated with acute Abdominal Surgery in a High-risk and emergency setting) study, as well as short- and long-term outcomes for different age groups within the SMASH study. METHODS A prospective intervention study was introduced in 2018, with the aim of investigating the introduction of a standardized protocol for emergency laparotomy. For 42 months, intervention patients were managed according to the protocol and outcomes were then compared with those of historical controls. RESULTS A total of 1344 unique patients were included (681 in the intervention group and 663 in the control group). The 90-day mortality rate was 14.1 per cent in the intervention group and 20.8 per cent in the control group (P = 0.002) and the 1-year mortality rate in adjusted analyses was 19.7 and 27.8 per cent respectively (P =< 0.001). An age-related subgroup analysis showed that the oldest patients (76 years and older, 260 in the intervention group and 240 in the control group) had a 1-year mortality rate of 29.6 and 43.8 per cent respectively (P = 0.004) and a mean duration of hospital stay of 9.9 and 11.6 days respectively (P = 0.027). Among older adults (61-75 years), the mean duration of hospital stay was 11.7 days in the intervention group compared with 15.1 days in the control group (P = 0.009) and the mean duration of ICU care was reduced to 4.49 days compared with 7.29 days (P = 0.046). CONCLUSION The standardized protocol associated with an emergency laparotomy appears to be beneficial, even in the long term. For elderly patients, it appears to reduce mortality rates and the durations of hospital stay and ICU care.
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Affiliation(s)
- Terje Jansson Timan
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Anaesthesiology and Intensive Care, NU Hospital Group, Trollhättan, Sweden
| | - Niklas Ekerstad
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Health, Medicine, and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden
| | - Ove Karlsson
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
| | - Ninni Sernert
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
| | - Mattias Prytz
- Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Surgery, NU Hospital Group, Trollhättan, Sweden
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Uchino H, Nguyen-Powanda P, Tokuno J, Kouyoumdjian A, Fiore JF, Grushka J. Enhanced recovery protocols in trauma and emergency abdominal surgery: a scoping review. Eur J Trauma Emerg Surg 2023; 49:2401-2412. [PMID: 37505285 DOI: 10.1007/s00068-023-02337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Enhanced recovery protocols (ERP) have been shown to improve patient outcomes and is now regarded as standard of care in elective surgical setting. However, the literature addressing the use of ERP in trauma and emergency abdominal surgery (EAS) is limited and heterogenous. A scoping review was conducted to comprehensively assess the literature on ERP in trauma laparotomy and EAS. METHODS Three bibliographic databases were searched for studies addressing ERP in trauma laparotomy and EAS. We extracted the study characteristics including study design, country, year, surgical procedures, ERP components used, and outcomes. Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. RESULTS After screening of 1631 articles for eligibility, 39 studies were included in the review. There has been an increase in the number of articles in the field, with 44% of the identified studies published between 2020 and 2022. Fourteen different protocols were identified, with varying components for each operative phase (preoperative; 29, intraoperative; 20, postoperative; 27). The majority of the studies addressed the effectiveness of ERP on clinical outcomes (31/39: 79%). Only two studies (5%) included purely trauma populations. CONCLUSIONS Studies on ERP implementations in the EAS populations were published across a range of countries, with improved outcomes. However, a clear gap in ERP research on trauma laparotomy was identified. This scoping review indicates that standardization of care through ERP implementation has potential to improve the quality of care in both EAS and trauma laparotomy.
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Affiliation(s)
- Hayaki Uchino
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada.
| | - Philip Nguyen-Powanda
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Junko Tokuno
- Steinberg Centre for Simulation and Interactive Learning, McGill University, Montreal, QC, Canada
| | - Araz Kouyoumdjian
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Jeremy Grushka
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
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Xiao M, Liu X. Laparoscopic Appendectomy Combined with an "Antimicrobial-Free" Strategy for Acute Uncomplicated Appendicitis. J Laparoendosc Adv Surg Tech A 2023; 33:1134-1140. [PMID: 37733260 DOI: 10.1089/lap.2023.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
Objective: To explore the efficacy and safety of enhanced recovery protocol (ERP) combined with laparoscopic appendectomy (LA) in the treatment of acute uncomplicated appendicitis (AUA) without antibiotics. Methods: In this study, a total of 160 patients with AUA who underwent LA between January 2018 and December 2021 were included and divided into the antibiotic group (n = 80) or the no-antibiotic group (n = 80). The patients in the antibiotic group received the ERP combined with antimicrobials during the perioperative period, while those in the no-antibiotic group only received the ERP during the perioperative period. The clinical data of these patients were collected to compare the inflammation level and stress state before and after surgery. In addition, the incidence of postoperative complications and the recovery speed of the patients were compared between groups. Results: There were no significant differences in the inflammation level and stress state before or after surgery, the incidence of postoperative complications or the recovery speed between the antibiotic group and the no-antibiotic group (P > .05). Conclusion: The use of ERP combined with LA as an antimicrobial-free treatment scheme in the perioperative period was found to be safe and effective for patients with AUA. Therefore, this approach is clinically valuable.
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Affiliation(s)
- Mingsheng Xiao
- Department of Gastrointestinal Surgery, The Fifth People's Hospital of Chongqing, Nanan, Chongqing, China
| | - Xiao Liu
- Department of Gastrointestinal Surgery, The Fifth People's Hospital of Chongqing, Nanan, Chongqing, China
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10
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Aggarwal A, Irrinki S, Kurdia KC, Khare S, Naik N, Tandup C, Savlania A, Dahiya D, Kaman L, Sakaray Y. Modified Enhanced Recovery After Surgery (ERAS) Protocol Versus Non-ERAS Protocol in Patients Undergoing Emergency Laparotomy for Acute Intestinal Obstruction: A Randomized Controlled Trial. World J Surg 2023; 47:2990-2999. [PMID: 37740758 DOI: 10.1007/s00268-023-07176-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a multimodal approach with promising results in improving patient outcome. Only recently, is evidence emerging highlighting how similar principles of care can be applied to patients undergoing emergency abdominal surgery. METHODS A randomized controlled trial was conducted from November 2021 to April 2022 at PGIMER Chandigarh, which is a leading tertiary care hospital in northern India. 60 patients with acute intestinal obstruction requiring emergency laparotomy were randomized and assigned to ERAS or Non-ERAS group. ERAS protocol with some modifications was applied. Primary endpoints were post-operative hospital stay. Secondary end points were morbidity, 30-day readmission and mortality rate. Data analysis was done using SPSS 22.0. Independent t test or Mann-Whitney test and Chi-square or Fisher-exact test were used for analysis. RESULTS A significant 3-day reduction in hospital stay was observed in ERAS compared to non-ERAS group (median (interquartile range) 5.50 (4.75-8.25) vs 8.0 (6.0-11.0) p = 0.003) with no difference in 30-day readmission rate, mortality rate and complication rate (according to Clavien-Dindo classification). ERAS group was associated with early recovery of gastrointestinal functions including time to first passage of flatus (p < 0.001), stools (p = 0.014), early ambulation (p < 0.001), time to first fluid diet (p < 0.001), solid diet (p = 0.001) and reduced nasogastric tube reinsertion rates (p = 0.01) despite its early removal. CONCLUSION ERAS with some modifications can be applied in patients with intestinal obstruction. Thus, we can expedite post-operative recovery and early regain of gastrointestinal function with decreased hospital stay, comparable morbidity and mortality. Further studies are needed to assess ERAS role in emergency gastrointestinal surgeries. Trial registration Ctri.gov Identifier: CTRI/2022/04/042156.
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Affiliation(s)
- Ankit Aggarwal
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Santosh Irrinki
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Kailash C Kurdia
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Siddhant Khare
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Naveen Naik
- Department of Anaesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Cherring Tandup
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Ajay Savlania
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Divya Dahiya
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Lileswar Kaman
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Yashwant Sakaray
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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11
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Kokotovic D, Jensen TK. Acute abdominal pain and emergency laparotomy: bundles of care to improve patient outcomes. Br J Surg 2023; 110:1594-1596. [PMID: 37449877 DOI: 10.1093/bjs/znad224] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Dunja Kokotovic
- Department of Gastrointestinal Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Thomas Korgaard Jensen
- Department of Gastrointestinal Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev, Herlev, Denmark
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12
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Ceresoli M, Braga M, Zanini N, Abu-Zidan FM, Parini D, Langer T, Sartelli M, Damaskos D, Biffl WL, Amico F, Ansaloni L, Balogh ZJ, Bonavina L, Civil I, Cicuttin E, Chirica M, Cui Y, De Simone B, Di Carlo I, Fette A, Foti G, Fogliata M, Fraga GP, Fugazzola P, Galante JM, Beka SG, Hecker A, Jeekel J, Kirkpatrick AW, Koike K, Leppäniemi A, Marzi I, Moore EE, Picetti E, Pikoulis E, Pisano M, Podda M, Sakakushev BE, Shelat VG, Tan E, Tebala GD, Velmahos G, Weber DG, Agnoletti V, Kluger Y, Baiocchi G, Catena F, Coccolini F. Enhanced perioperative care in emergency general surgery: the WSES position paper. World J Emerg Surg 2023; 18:47. [PMID: 37803362 PMCID: PMC10559594 DOI: 10.1186/s13017-023-00519-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023] Open
Abstract
Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients' outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.
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Affiliation(s)
- Marco Ceresoli
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy.
- General and Emergency Surgery Department, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, Italy.
| | - Marco Braga
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
- General and Emergency Surgery Department, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, Italy
| | - Nicola Zanini
- General Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, UAE
| | - Dario Parini
- General Surgery Department - Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Thomas Langer
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Dimitrios Damaskos
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Francesco Amico
- John Hunter Hospital Trauma Service and School of Medicine and Public Health, The University of Newcastle, Newcastle, AU, Australia
| | - Luca Ansaloni
- General Surgery, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Ian Civil
- University of Auckland, Auckland, New Zealand
| | | | - Mircea Chirica
- Department of Digestive Surgery, CHU Grenoble Alpes, Grenoble, France
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Belinda De Simone
- Unit of Emergency and Trauma Surgery, Villeneuve St Georges Academic Hospital, Villeneuve St Georges, France
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | | | - Giuseppe Foti
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
- Department of Critical Care and Anesthesia, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Michele Fogliata
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
- General and Emergency Surgery Department, Fondazione IRCCS San Gerardo dei Tintori, Via Pergolesi 33, 20900, Monza, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences (FCM), University of Campinas (Unicamp), Campinas, Brazil
| | | | | | | | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Gießen, Germany
| | | | - Andrew W Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppäniemi
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Andrei Litvin, CEO AI Medica Hospital Center, Kaliningrad, Russia
| | - Ingo Marzi
- Department of Trauma, Hand, and Reconstructive Surgery, Goethe University, Frankfurt University Hospital, Frankfurt am Main, Germany
| | - Ernest E Moore
- Director of Surgery Research, Ernest E. Moore Shock Trauma Center, Distinguished Professor of Surgery, University of Colorado, Denver, CO, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Emmanouil Pikoulis
- Third Department of Surgery, Attikon University Hospital, Athene, Greece
| | - Michele Pisano
- General Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Edward Tan
- Former Chair Department of Emergency Medicine, HEMS Physician, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Giovanni D Tebala
- Digestive and Emergency Surgery Department, Azienda Ospedaliera S.Maria, Terni, Italy
| | - George Velmahos
- Harvard Medical School - Massachusetts General Hospital, Boston, USA
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, Head of Service and Director of Trauma, Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | - Vanni Agnoletti
- Anesthesia and Critical Care Department, Bufalini Hospital, Cesena, Italy
| | - Yoram Kluger
- Department of General Surgery, The Rambam Academic Hospital, Haifa, Israel
| | - Gianluca Baiocchi
- General Surgery, University of Brescia, ASST Cremona, Cremona, Italy
| | - Fausto Catena
- General Surgery Department, Bufalini Hospital, Cesena, Italy
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13
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Cheng DT, Miyata N, Asomah F. An 8-year retrospective review of emergency laparotomy outcomes in a Queensland rural hospital. Aust J Rural Health 2023; 31:991-998. [PMID: 37635294 DOI: 10.1111/ajr.13034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023] Open
Abstract
OBJECTIVE Emergency laparotomy (EL) is a major operation performed in critically unwell patients. The National Emergency Laparotomy Audit (NELA), undertaken in the UK since 2013 has shown progressive improvement in clinical outcomes, specifically reduced mortality, and length of stay (LOS) through the implementation of perioperative key performance indicators (KPIs) (ANZ J Surg. 2021;91:2575, Br J Surg. 2015;102:57, Br J Surg. 2017;104:463, JAMA Surg. 2019;154:e190145). The objective is to generate a rural hospital EL audit (MELA) to evaluate local outcomes and clinical standards of practice with regional, national, and international benchmarks. METHODS A review of medical records between January 2014 and December 2021 of patients who undergo an EL. Data collected include patient demographics, clinical information, compliance to KPIs and the primary outcomes of 30-day mortality and LOS. DESIGN This is a descriptive quantitative study. The inclusion and exclusion criteria were similar to those defined in NELA and ANZELA-QI. SETTING AND PARTICIPANTS The general surgeons at the rural hospital provide emergency surgery services for the North-West Queensland community. MAIN OUTCOME MEASURES To review local clinical outcomes of 30-day mortality, LOS, and adherence to perioperative KPIs. RESULTS Overall, 84 patients met inclusion criteria. The median age (IQR) was 61 (48.8-70.3) years. The 30-day mortality was 3.6% and mean LOS was 12.8 (±13.4) days which was secondary to the low-risk patients within the data set. Compliance to KPIs (≥80%) was achieved in five of eight standards assessed. CONCLUSION Local outcomes appear to be comparable to national and international benchmarks and a similar rural setting. The audited cohort outperformed the national standard in adherence to perioperative KPIs.
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Affiliation(s)
- Dong Tony Cheng
- Department of General Surgery, Mount Isa Base Hospital, Mount Isa, Queensland, Australia
| | - Nariyoshi Miyata
- Department of General Surgery, Mount Isa Base Hospital, Mount Isa, Queensland, Australia
- Mount Isa Base Hospital, Mount Isa, Queensland, Australia
| | - Francis Asomah
- Mount Isa Base Hospital, Mount Isa, Queensland, Australia
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14
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Hansted AK, Storm N, Burcharth J, Diasso PDK, Ninh M, Møller MH, Vester-Andersen M. Validation of the NELA risk prediction model in emergency abdominal surgery. Acta Anaesthesiol Scand 2023; 67:1194-1201. [PMID: 37353882 DOI: 10.1111/aas.14294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 05/25/2023] [Accepted: 05/28/2023] [Indexed: 06/25/2023]
Abstract
Risk prediction models are frequently used to identify high-risk patients undergoing emergency laparotomy. The National Emergency Laparotomy Audit (NELA) developed a risk prediction model specifically for emergency laparotomy patients, which was recently updated. In this study, we validated the updated NELA model in an external population. Furthermore, we compared it with three other risk prediction models: the original NELA model, the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) model, and the American Society of Anesthesiologists Physical Status (ASA-PS). We included adult patients undergoing emergency laparotomy at Zealand University Hospital, from March 2017 to January 2019, and Herlev Hospital, from November 2017 to January 2020. Variables included in the risk prediction models were collected retrospectively from the electronic patient records. Discrimination of the risk prediction models was evaluated with area under the curve (AUC) statistics, and calibration was assessed with Cox calibration regression. The primary outcome was 30-day mortality. Out of 1226 included patients, 146 patients (11.9%) died within 30 days. AUC (95% confidence interval) for 30-day mortality was 0.85 (0.82-0.88) for the updated NELA model, 0.84 (0.81-0.87) for the original NELA model, 0.81 (0.77-0.84) for the P-POSSUM model, and 0.76 (0.72-0.79) for the ASA-PS model. Calibration showed underestimation of mortality risk for both the updated NELA, original NELA and P-POSSUM models. The updated NELA risk prediction model performs well in this external validation study and may be used in similar settings. However, the model should only be used to discriminate between low- and high-risk patients, and not for prediction of individual risk due to underestimation of mortality.
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Affiliation(s)
- Anna K Hansted
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital-Herlev Hospital, Copenhagen, Denmark
| | - Nicolas Storm
- Department of Surgery, Copenhagen University Hospital-Herlev Hospital, Copenhagen, Denmark
| | - Jakob Burcharth
- Department of Surgery, Copenhagen University Hospital-Herlev Hospital, Copenhagen, Denmark
- Department of Surgery, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Pernille D K Diasso
- Department of Surgery, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mian Ninh
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital-Herlev Hospital, Copenhagen, Denmark
| | - Morten H Møller
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital-Herlev Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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15
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Smart N. Editor's choice - September 2023. Colorectal Dis 2023; 25:1752. [PMID: 37758690 DOI: 10.1111/codi.16748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Affiliation(s)
- Neil Smart
- Royal Devon & Exeter Hospital, Devon, UK
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16
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott MJ. Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient. World J Surg 2023; 47:1881-1898. [PMID: 37277506 PMCID: PMC10241556 DOI: 10.1007/s00268-023-07039-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
- Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Research Department of Targeted Intervention, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, S 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anaesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Kaiser Permanente Research, Department of Research & Evaluation, 100 South Los Robles Ave, 2nd Floor, Pasadena, CA 91101 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Queen’s Medical Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, Queen’s Medical Centre, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, School of Medical Sciences, Orebro University Hospital, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine, and Department of Anesthesiology, Weill-Cornell Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
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17
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Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023; 47:1850-1880. [PMID: 37277507 PMCID: PMC10241558 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA 9110 USA
| | - Nicholas P. Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104 USA
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18
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Tian BWCA, Stahel PF, Picetti E, Campanelli G, Di Saverio S, Moore E, Bensard D, Sakakushev B, Galante J, Fraga GP, Koike K, Di Carlo I, Tebala GD, Leppaniemi A, Tan E, Damaskos D, De'Angelis N, Hecker A, Pisano M, Maier RV, De Simone B, Amico F, Ceresoli M, Pikoulis M, Weber DG, Biffl W, Beka SG, Abu-Zidan FM, Valentino M, Coccolini F, Kluger Y, Sartelli M, Agnoletti V, Chirica M, Bravi F, Sall I, Catena F. Assessing and managing frailty in emergency laparotomy: a WSES position paper. World J Emerg Surg 2023; 18:38. [PMID: 37355698 DOI: 10.1186/s13017-023-00506-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/27/2023] [Indexed: 06/26/2023] Open
Abstract
Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.
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Affiliation(s)
- Brian W C A Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Philip F Stahel
- Department of Orthopedic Surgery and Department of Neurosurgery, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | | | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | - Ernest Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Denis Bensard
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Boris Sakakushev
- Research Institute of Medical University Plovdiv/University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Gustavo P Fraga
- Faculdade de Ciências Médicas (FCM), Unicamp Campinas, Campinas, SP, Brazil
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, Cannizzaro Hospital, Via Messina 829, 95126, Catania, Italy
| | - Giovanni D Tebala
- Oxford University Hospitals NHSFT John Radcliffe Hospital, Headley Way, HeadingtonOxford, OX3 9DU, UK
| | - Ari Leppaniemi
- General Surgery Department, Helsinki University Hospital, Helsinki, Finland
| | - Edward Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Dimitris Damaskos
- General and Emergency Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nicola De'Angelis
- Hôpital Henri Mondor, Université Paris Est, Service de Chirurgie Digestive et Hépato-Bilio-Pancréatique, Créteil, France
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital, Giessen, Germany
| | - Michele Pisano
- General and Emergency Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Ron V Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Belinda De Simone
- Department of Emergency Surgery, Centre Hospitalier Intercommunal de Villeneuve-Saint-Georges, Villeneuve-Saint-Georges, France
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walt Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Solomon Gurmu Beka
- School of Medicine and Health Science, University of Otago, Wellington Campus, Wellington, New Zealand
| | - Fikri M Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
| | - Mircea Chirica
- Service de Chirurgie Digestive, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Ibrahima Sall
- Department of General Surgery, Military Teaching Hospital, Hôpital Principal Dakar, Dakar, Senegal.
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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19
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Kokkinakis S, Kritsotakis EI, Paterakis K, Karali GA, Malikides V, Kyprianou A, Papalexandraki M, Anastasiadis CS, Zoras O, Drakos N, Kehagias I, Kehagias D, Gouvas N, Kokkinos G, Pozotou I, Papatheodorou P, Frantzeskou K, Schizas D, Syllaios A, Palios IM, Nastos K, Perdikaris M, Michalopoulos NV, Margaris I, Lolis E, Dimopoulou G, Panagiotou D, Nikolaou V, Glantzounis GK, Pappas-Gogos G, Tepelenis K, Zacharioudakis G, Tsaramanidis S, Patsarikas I, Stylianidis G, Giannos G, Karanikas M, Kofina K, Markou M, Chrysos E, Lasithiotakis K. Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy. J Trauma Acute Care Surg 2023; 94:847-856. [PMID: 36726191 DOI: 10.1097/ta.0000000000003904] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Accurate preoperative risk assessment in emergency laparotomy (EL) is valuable for informed decision making and rational use of resources. Available risk prediction tools have not been validated adequately across diverse health care settings. Herein, we report a comparative external validation of four widely cited prognostic models. METHODS A multicenter cohort was prospectively composed of consecutive patients undergoing EL in 11 Greek hospitals from January 2020 to May 2021 using the National Emergency Laparotomy Audit (NELA) inclusion criteria. Thirty-day mortality risk predictions were calculated using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), NELA, Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM), and Predictive Optimal Trees in Emergency Surgery Risk tools. Surgeons' assessment of postoperative mortality using predefined cutoffs was recorded, and a surgeon-adjusted ACS-NSQIP prediction was calculated when the original model's prediction was relatively low. Predictive performances were compared using scaled Brier scores, discrimination and calibration measures and plots, and decision curve analysis. Heterogeneity across hospitals was assessed by random-effects meta-analysis. RESULTS A total of 631 patients were included, and 30-day mortality was 16.3%. The ACS-NSQIP and its surgeon-adjusted version had the highest scaled Brier scores. All models presented high discriminative ability, with concordance statistics ranging from 0.79 for P-POSSUM to 0.85 for NELA. However, except the surgeon-adjusted ACS-NSQIP (Hosmer-Lemeshow test, p = 0.742), all other models were poorly calibrated ( p < 0.001). Decision curve analysis revealed superior clinical utility of the ACS-NSQIP. Following recalibrations, predictive accuracy improved for all models, but ACS-NSQIP retained the lead. Between-hospital heterogeneity was minimum for the ACS-NSQIP model and maximum for P-POSSUM. CONCLUSION The ACS-NSQIP tool was most accurate for mortality predictions after EL in a broad external validation cohort, demonstrating utility for facilitating preoperative risk management in the Greek health care system. Subjective surgeon assessments of patient prognosis may optimize ACS-NSQIP predictions. LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level II.
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Affiliation(s)
- Stamatios Kokkinakis
- From the Department of General Surgery (S.K., K.P., G.-A.K., V.M., A.K., M.P., E.C., K.L.), University Hospital of Heraklion, University of Crete, School of Medicine; Laboratory of Biostatistics, University of Crete, School of Medicine (E.I.K.); Department of Surgical Oncology, University Hospital of Heraklion, University of Crete, School of Medicine (C.S.A., O.Z.), Heraklion; Department of Surgery, University General Hospital of Patras, School of Medicine (N.D., I.K., D.K.), University of Patras, Patras, Greece; Department of Surgery, General Hospital of Nicosia, School of Medicine (N.G., G.K., I.P., P.P., K.F.), University of Cyprus, Nicosia, Cyprus; First Department of Surgery (D.S., A.S.) and Second Propaedeutic Department of Surgery (I.M.P.), Laikon General Hospital, National and Kapodistrian University of Athens; Department of Surgery, University General Hospital Attikon, School of Medicine (K.N., M.P., N.V.M., I.M.), University of Athens, Athens; Department of Surgery (E.L., G.D.), General Hospital of Volos, Volos, Greece; Department of Surgery (D.P., V.N.), General Hospital of Trikala, Trikala; Department of Surgery (G.K.G., G.P.-G., K.T.), University Hospital of Ioannina, Ioannina, Greece; Department of Surgery, Ippokrateion General Hospital of Thessaloniki, School of Medicine (G.Z., S.T., I.P.), Aristotle University of Thessaloniki, Thessaloniki; Second Department of Surgery (G.S., G.G.), Evangelismos General Hospital, Athens; and Department of Surgery, University General Hospital of Alexandroupolis, School of Medicine (M.K., K.K., M.M.), University of Thrace, Alexandroupolis, Greece
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20
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Timan TJ, Karlsson O, Sernert N, Prytz M. Standardized perioperative management in acute abdominal surgery: Swedish SMASH controlled study. Br J Surg 2023; 110:710-716. [PMID: 37071812 PMCID: PMC10364510 DOI: 10.1093/bjs/znad081] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/24/2023] [Accepted: 03/03/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Acute high-risk abdominal surgery is common, as are the attendant risks of organ failure, need for intensive care, mortality, or long hospital stay. This study assessed the implementation of standardized management. METHODS A prospective study of all adults undergoing emergency laparotomy over an interval of 42 months (2018-2021) was undertaken; outcomes were compared with those of a retrospective control group. A new standardized clinical protocol was activated for all patients including: prompt bedside physical assessment by the surgeon and anaesthetist, interprofessional communication regarding location of resuscitation, elimination of unnecessary factors that might delay surgery, improved operating theatre competence, regular epidural, enhanced recovery care, and frequent early warning scores. The primary endpoint was 30-day mortality. Secondary endpoints were duration of hospital stay, need for intensive care, and surgical complications. RESULTS A total of 1344 patients were included, 663 in the control group and 681 in the intervention group. The use of antibiotics increased (81.4 versus 94.7 per cent), and the time from the decision to operate to the start of surgery was reduced (3.80 versus 3.22 h) with use of the new protocol. Fewer anastomoses were performed (22.5 versus 16.8 per cent). The 30-day mortality rate was 14.5 per cent in the historical control group and 10.7 per cent in the intervention group (P = 0.045). The mean duration of hospital (11.9 versus 10.2 days; P = 0.007) and ICU (5.40 versus 3.12 days; P = 0.007) stays was also reduced. The rate of serious surgical complications (grade IIIb-V) was lower (37.6 versus 27.3 per cent; P = <0.001). CONCLUSION Standardized management protocols improved outcomes after emergency laparotomy.
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Affiliation(s)
- Terje J Timan
- University of Gothenburg, Sahlgrenska Academy, Institute of Clinical Sciences, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Anaesthesiology and Intensive Care, NU Hospital Group, Trollhättan, Sweden
| | - Ove Karlsson
- University of Gothenburg, Sahlgrenska Academy, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Ninni Sernert
- University of Gothenburg, Sahlgrenska Academy, Institute of Clinical Sciences, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
| | - Mattias Prytz
- University of Gothenburg, Sahlgrenska Academy, Institute of Clinical Sciences, Gothenburg, Sweden
- Department of Research and Development, NU Hospital Group, Trollhättan, Sweden
- Department of Surgery, NU Hospital Group, Trollhättan, Sweden
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21
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Atkins E, Birmpili P, Glidewell L, Li Q, Johal AS, Waton S, Boyle JR, Pherwani AD, Chetter I, Cromwell DA. Effectiveness of quality improvement collaboratives in UK surgical settings and barriers and facilitators influencing their implementation: a systematic review and evidence synthesis. BMJ Open Qual 2023; 12:bmjoq-2022-002241. [PMID: 37037588 PMCID: PMC10106059 DOI: 10.1136/bmjoq-2022-002241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/14/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND High-quality surgical care is vital to deliver the excellent outcomes patients deserve following surgical treatment. Quality improvement collaboratives (QICs) are based on a multicentre model for improving healthcare. They are increasingly used but their effectiveness in the context of surgical services is unclear. This review assessed effectiveness of QICs in National Health Service (NHS) surgical settings, and identified factors that influenced implementation. METHODS A systematic search of MEDLINE and EMBASE, as well as grey literature, was conducted in January 2022 to identify evaluations of QICs in NHS surgical settings. Data were extracted on the intervention, setting, study results and factors that were identified as facilitators or barriers. These were coded using the Consolidated Framework for Implementation Research (CFIR). The quality of study reports was assessed using Quality Improvement Minimum Criteria Set. RESULTS Fifteen reports on 10 QICs met inclusion criteria. The evaluations used study designs of different strength, with one using a stepped-wedge randomised controlled trial (RCT). Eight studies reported the QIC had been successful in achieving their principal aims, which covered a mix of patient outcomes and process indicators. The study based on the RCT found the QIC was not successful (no improvement in patient outcomes). Each article reported a range of facilitators and barriers to effectiveness of implementation of the QIC, which were spread across the CFIR domains (intervention, outer setting, inner setting, individuals and process). There were few barriers reported in the intervention domain that related to the QIC. There was no clear relationship between numbers of facilitators and barriers reported and effectiveness. CONCLUSIONS Studies have reported QICs to be effective in increasingly complex contexts, but their results must be treated with caution. The evaluations often used weak study designs and the quality of reports was variable. Evaluation with strong study design should be integral to future QICs. PROSPERO REGISTRATION NUMBER CRD42022324970.
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Affiliation(s)
- Eleanor Atkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | | | - Qiuju Li
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, School of Hygiene and Tropical Medicine, London, UK
| | - Amundeep S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Sam Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Jon R Boyle
- Department of Vascular Surgery, Cambridge University Hospitals, Cambridge, UK
| | - Arun D Pherwani
- Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, School of Hygiene and Tropical Medicine, London, UK
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22
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Associations Between Care Bundles and Postoperative Outcomes After Major Emergency Abdominal Surgery: A Systematic Review and Meta-Analysis. J Surg Res 2023; 283:469-478. [PMID: 36436282 DOI: 10.1016/j.jss.2022.10.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 09/05/2022] [Accepted: 10/15/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Care bundles were found to improve postoperative outcomes in elective surgery. However, in major emergency general surgery studies show a divergent impact on mortality and length of stay. This meta-analysis aimed to evaluate associations between care bundles and mortality, complications, and length of stay when applied in major emergency general surgery. METHODS A systematic literature search in PubMed and Embase was performed on the May 1, 2021. Only comparative studies on care bundles in major emergency general surgery were included. Meta-analysis and trial sequential analysis were performed on 30-d mortality. We undertook a narrative approach of long-term mortality, complications, and length of stay. RESULTS Meta-analysis of 13 studies with 35,771 patients demonstrated that care bundles in emergency surgery were not associated with a significant reduction in odds of 30-d mortality (odds ratio = 0.8, 95% confidence interval 0.62-1.03). Trial sequential analysis confirmed that the meta-analysis was underpowered with a minimum of 78,901 patients required for firm conclusions. Seven studies reported complication rates whereof six reported lower complication rates using care bundles. CONCLUSIONS Care bundles were reported to decrease postoperative complications in five out of seven studies and seven out of 11 studies reported a shortening in length of stay.
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23
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Smyth R, Darbyshire A, Mercer S, Khan J, Richardson J. Trends in emergency colorectal surgery: a 7-year retrospective single-centre cohort study. Surg Endosc 2023; 37:3911-3920. [PMID: 36729232 DOI: 10.1007/s00464-023-09876-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/06/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND Emergency colorectal resections carry a higher morbidity and mortality than elective surgery. The use of minimally invasive surgery has now become widespread in elective colorectal surgery, with improved patient outcomes. Laparoscopy is being increasingly used for emergency colorectal resections, but its role is still being defined. Our aim was to observe the uptake of laparoscopy for emergency colorectal surgery in our centre. METHOD A retrospective single-centre cohort study was performed using local National Emergency Laparotomy Audit data from January 2014-December 2020. All patients who had a colorectal resection were included. Trends in the number and type of resections were recorded. Primary outcome was the proportion of cases started and completed laparoscopically. Secondary outcomes included rate of conversion to open, length of stay and 30-day mortality. RESULTS A total 523 colorectal resections were performed. The number of cases attempted and completed laparoscopically steadily increased over the study period (28.3% to 63.3% and 16.3% to 35.4%, respectively). The mean rate of conversion to open was 43.8%. The greatest expansion in laparoscopy was for cases of intestinal obstruction, perforation and peritonitis, and for those undergoing Hartmann's procedure and right hemicolectomy. 30‑day mortality for cases completed laparoscopically was much lower than those converted or started with open surgery (2.1% vs 11.7% and 17.5%, respectively). Laparoscopic approach was independently associated with reduced length of stay. CONCLUSION Laparoscopy has been successfully adopted for emergency colorectal resections in our centre, with half of cases felt to be suitable for minimally invasive surgery.
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Affiliation(s)
- Rachel Smyth
- MRCS Colorectal Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK.
| | - Alexander Darbyshire
- MRCS Upper GI Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - Stuart Mercer
- FRCS Upper GI Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - Jim Khan
- FRCS Colorectal Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - John Richardson
- FRCS Colorectal Surgery, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
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24
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Intraoperative Surgical Strategy in Abdominal Emergency Surgery. World J Surg 2023; 47:162-170. [PMID: 36221004 DOI: 10.1007/s00268-022-06782-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emergency abdominal surgery is associated with a high rate of postoperative complications and death. Pre- and immediate postoperative bundle-care strategies have improved outcome, but so far, no standardized intraoperative strategies have been proposed. We introduced a quality improvement model of specific intra- and postoperative strategies for the heterogenous group of patients undergoing emergency abdominal surgery. The objective was to evaluate a quality improvement strategy, using an intraoperative, multidisciplinary time-out model in emergency abdominal surgery to apply one of three surgical strategies; definitive-palliative-or damage control surgery. METHODS All patients scheduled for any gastrointestinal emergency procedure were stratified dynamically according to standardized criteria for performing definitive-palliative-or damage control surgery. Pre- intra- and postoperative data were collected according to the intraoperative strategy applied. Postoperative complications were displayed according to the Clavien-Dindo-score and the CCI (Comprehensive Complication Index). 30-90-day- and 1-year mortality was presented. RESULTS We included 436 consecutive patients undergoing emergency laparotomy or laparoscopy in 2019. Intraoperative strategy was definitive in 326(75%)-palliative in 90(21%) and damage control approach in 20(4%) patients. CCI was 21(0,45), 30(17,54) and 78(54,100) in the definitive-, the palliative-, and the damage control group, respectively. 30-day mortality was; 11.7%, 26.7% and 30%, and the 1-year mortality was 16.9%, 56.7% and 40% in the definitive- the palliative- and the damage control group, respectively. CONCLUSIONS We present a multidisciplinary, intraoperative decision-making standard as a potential quality improvement tool of ensuring individualized intra- and postoperative treatment for every emergency surgical patient and for future research-protocols.
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25
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Bala M. Structured Decision-Making during Emergency Abdominal Surgery. World J Surg 2023; 47:171-172. [PMID: 36383233 DOI: 10.1007/s00268-022-06830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, General Surgery, Hebrew University of Jerusalem, Jerusalem, Israel.
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26
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Lasithiotakis K, Kritsotakis EI, Kokkinakis S, Petra G, Paterakis K, Karali GA, Malikides V, Anastasiadis CS, Zoras O, Drakos N, Kehagias I, Kehagias D, Gouvas N, Kokkinos G, Pozotou I, Papatheodorou P, Frantzeskou K, Schizas D, Syllaios A, Palios IM, Nastos K, Perdikaris M, Michalopoulos NV, Margaris I, Lolis E, Dimopoulou G, Panagiotou D, Nikolaou V, Glantzounis GK, Pappas-Gogos G, Tepelenis K, Zacharioudakis G, Tsaramanidis S, Patsarikas I, Stylianidis G, Giannos G, Karanikas M, Kofina K, Markou M, Chrysos E. The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece. World J Surg 2023; 47:130-139. [PMID: 36109368 PMCID: PMC9483423 DOI: 10.1007/s00268-022-06723-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). METHODS This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. RESULTS There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). CONCLUSION In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.
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Affiliation(s)
- Konstantinos Lasithiotakis
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece. .,Department of General Surgery, University Hospital of Crete, 71110, Heraklion, Greece.
| | | | - Stamatios Kokkinakis
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Georgia Petra
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Konstantinos Paterakis
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Garyfallia-Apostolia Karali
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Vironas Malikides
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Charalampos S. Anastasiadis
- Department of Surgical Oncology, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Odysseas Zoras
- Department of Surgical Oncology, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Nikolas Drakos
- Department of Surgery, School of Medicine, University General Hospital of Patras, University of Patras, Patras, Greece
| | - Ioannis Kehagias
- Department of Surgery, School of Medicine, University General Hospital of Patras, University of Patras, Patras, Greece
| | - Dimitrios Kehagias
- Department of Surgery, School of Medicine, University General Hospital of Patras, University of Patras, Patras, Greece
| | - Nikolaos Gouvas
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Georgios Kokkinos
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Ioanna Pozotou
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Panayiotis Papatheodorou
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Kyriakos Frantzeskou
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Syllaios
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ifaistion M. Palios
- Second Propaedeutic Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Nastos
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Markos Perdikaris
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Nikolaos V. Michalopoulos
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Ioannis Margaris
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Evangelos Lolis
- Department of Surgery, General Hospital of Volos, Volos, Greece
| | | | | | | | | | | | - Kostas Tepelenis
- Department of Surgery, University Hospital of Ioannina, Ioannina, Greece
| | - Georgios Zacharioudakis
- Department of Surgery, School of Medicine, Ippokrateio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Savvas Tsaramanidis
- Department of Surgery, School of Medicine, Ippokrateio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Patsarikas
- Department of Surgery, School of Medicine, Ippokrateio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Georgios Giannos
- 2nd Department of Surgery, Evangelismos General Hospital, Athens, Greece
| | - Michael Karanikas
- Department of Surgery, School of Medicine, University General Hospital of Alexandroupolis, University of Thrace, Alexandroupolis, Greece
| | - Konstantinia Kofina
- Department of Surgery, School of Medicine, University General Hospital of Alexandroupolis, University of Thrace, Alexandroupolis, Greece
| | - Markos Markou
- Department of Surgery, School of Medicine, University General Hospital of Alexandroupolis, University of Thrace, Alexandroupolis, Greece
| | - Emmanuel Chrysos
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
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Smart N. Editor's choice - Jan 2023. Colorectal Dis 2023; 25:4-5. [PMID: 36719028 DOI: 10.1111/codi.16480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Ylimartimo AT, Nurkkala J, Koskela M, Lahtinen S, Kaakinen T, Vakkala M, Hietanen S, Liisanantti J. Postoperative Complications and Outcome After Emergency Laparotomy: A Retrospective Study. World J Surg 2023; 47:119-129. [PMID: 36245004 PMCID: PMC9726776 DOI: 10.1007/s00268-022-06783-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency laparotomy (EL) is a common urgent surgical procedure with high risk for postoperative complications. Complications impair the prognosis and prolong the hospital stay. This study explored the incidence and distribution of complications and their impact on short-term mortality after EL. METHODS This was a retrospective single-center register-based cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The primary outcome was operation-related or medical complication after EL. The secondary outcome was mortality in 90-day follow-up. Multivariate logistic regression analyses were used to identify independent risk factors for complications. RESULTS A total of 389 (58%) patients developed complications after EL, including 215 (32%) patients with operation-related complications and 361 (54%) patients with medical complications. Most of the complications were Clavien-Dindo classification type 4b (28%) and type 2 (22%). Operation-related complications occurred later compared to medical complications. Respiratory complications were the most common medical complications, and infections were the most common operation-related complications. The 30- and 90-day mortalities were higher in both the medical (17.2%, 26.2%) and operation-related complication groups (13.5%, 24.2%) compared to patients without complications (10.5% and 4.8%, 14.8% and 8.0%). Low albumin, high surgical urgency, excessive alcohol consumption and medical complications were associated with operation-related complications. Older age, high ASA class and operation-related complications were associated with medical complications. CONCLUSIONS This study demonstrated that EL is associated with a high risk of complications and poor short-term outcome. Complications impair the prognosis regardless of which kind of EL is in question.
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Affiliation(s)
- Aura T. Ylimartimo
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O. Box 21, 90029 OYS Oulu, Finland
| | - Juho Nurkkala
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Marjo Koskela
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O. Box 21, 90029 OYS Oulu, Finland
| | - Sanna Lahtinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Timo Kaakinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Merja Vakkala
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Siiri Hietanen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland
| | - Janne Liisanantti
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
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Implementing Bundle Care in Major Abdominal Emergency Surgery: Long-Term Mortality and Comprehensive Complication Index. World J Surg 2023; 47:106-118. [PMID: 36171351 PMCID: PMC9726819 DOI: 10.1007/s00268-022-06763-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Major abdominal emergency surgery (MAES) has a high risk of postoperative mortality and a high complication rate. The aim of this study was to evaluate whether the implementation of a perioperative care bundle reduced long-term mortality and the Comprehensive Complication Index (CCI) after MAES. METHODS This study was a single-centre retrospective cohort study. Data in the intervention group were collected prospectively and compared with a historical cohort from the same centre. It includes adult patients undergoing MAES. We implemented a care bundle under the name Abdominal Surgery Acute Protocol (ASAP). We initiated fast-track initiatives and standardised optimised care in before, during and after surgery. Data were analysed using survival analysis and multiple regression. RESULTS We included 120 patients in the intervention cohort and 258 in the historical cohort. The one-year mortality rate was 21.7% in the intervention cohort compared to 28.3% in the standard care cohort. Adjusted odds ratio of one-year mortality 0.81 (CI95% 0.41-1.56). The 30-day mortality was lowered from 19.0 to 6.7% (p = 0.003). The CCI in the intervention cohort was 8.7 (IQR 0-34) compared to 21 (IQR 0-36) in the control cohort (p = 0.932) The length of stay increased by two days (p = 0.021). Most cases had 71-80% protocol compliance. CONCLUSION Implementing bundle care in major abdominal emergency surgery lowered the 30-day postoperative mortality. The difference in mortality was preserved over time although not significant after one year. The changes in the Comprehensive Complication Index were not statistically significant.
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Onen BC, Semulimi AW, Bongomin F, Olum R, Kurigamba G, Mbiine R, Kituuka O. Surgical Apgar score as a predictor of outcomes in patients following laparotomy at Mulago National Referral Hospital, Uganda: a prospective cohort study. BMC Surg 2022; 22:433. [PMID: 36529732 PMCID: PMC9759870 DOI: 10.1186/s12893-022-01883-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Postoperative complications and mortality following laparotomy have remained high worldwide. Early postoperative risk stratification is essential to improve outcomes and clinical care. The surgical Apgar score (SAS) is a simple and objective bedside prediction tool that can guide a surgeon's postoperative decision making. The objective of this study was to evaluate the performance of SAS in predicting outcomes in patients undergoing laparotomy at Mulago hospital. METHOD A prospective observational study was conducted among eligible adult patients undergoing laparotomy at Mulago hospital and followed up for 4 months. We collected data on the patient's preoperative and intraoperative characteristics. Using the data generated, SAS was calculated, and patients were classified into 3 groups namely: low (8-10), medium (5-7), and high (0-4). Primary outcomes were in-hospital major complications and mortality. Data was presented as proportions or mean (standard deviation) or median (interquartile range) as appropriate. We used inferential statistics to determine the association between the SAS and the primary outcomes while the SAS discriminatory ability was determined from the receiver-operating curve (ROC) analysis. RESULTS Of the 151 participants recruited, 103 (68.2%) were male and the mean age was 40.6 ± 15. Overall postoperative in-hospital major complications and mortality rates were 24.2% and 10.6%, respectively. The participants with a high SAS category had an18.4 times risk (95% CI, 1.9-177, p = 0.012) of developing major complications, while those in medium SAS category had 3.9 times risk (95% CI, 1.01-15.26, p = 0.048) of dying. SAS had a fair discriminatory ability for in-hospital major complications and mortality with the area under the curve of 0.75 and 0.77, respectively. The sensitivity and specificity of SAS ≤ 6 for major complications were 60.5% and 81.14% respectively, and for death 54.8% and 81.3%, respectively. CONCLUSION SAS of ≤ 6 is associated with an increased risk of major complications and/or mortality. SAS has a high specificity with an overall fair discriminatory ability of predicting the risk of developing in-hospital major complications and/or death following laparotomy.
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Affiliation(s)
- Bruno Chan Onen
- grid.11194.3c0000 0004 0620 0548Department of Surgery, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Andrew Weil Semulimi
- grid.11194.3c0000 0004 0620 0548Lung Institute, Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Felix Bongomin
- grid.442626.00000 0001 0750 0866Department of Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, P.O. Box 166, Gulu, Uganda
| | - Ronald Olum
- grid.11194.3c0000 0004 0620 0548School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Gideon Kurigamba
- grid.416252.60000 0000 9634 2734Department of Surgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Ronald Mbiine
- grid.11194.3c0000 0004 0620 0548Department of Surgery, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Olivia Kituuka
- grid.11194.3c0000 0004 0620 0548Department of Surgery, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
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Tankel J, Chayen D, Einav S. Fluid balance following laparotomy for hollow viscus perforation: A study of morbidity and mortality. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Nally DM, Lonergan PE, O’Connell EP, McNamara DA, Elwahab SA, Bass G, Burke E, Cagney D, Canas A, Cronin C, Cullinane C, Devane L, Fearon N, Fowler A, Fullard A, Hechtl D, Kelly M, Lenihan J, Murphy E, Neary C, O'Connell R, O'Neill M, Ramkaran C, Troy A, Tully R, White C, Yadav H. Increasing the use of perioperative risk scoring in emergency laparotomy: nationwide quality improvement programme. BJS Open 2022; 6:6649489. [PMID: 35876188 PMCID: PMC9309802 DOI: 10.1093/bjsopen/zrac092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 06/07/2022] [Accepted: 06/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Emergency laparotomy is associated with high morbidity and mortality. The early identification of high-risk patients allows for timely perioperative care and appropriate resource allocation. The aim of this study was to develop a nationwide surgical trainee-led quality improvement (QI) programme to increase the use of perioperative risk scoring in emergency laparotomy. Methods The programme was structured using the active implementation framework in 15 state-funded Irish hospitals to guide the staged implementation of perioperative risk scoring. The primary outcome was a recorded preoperative risk score for patients undergoing an emergency laparotomy at each site. Results The rate of patients undergoing emergency laparotomy receiving a perioperative risk score increased from 0–11 per cent during the exploratory phase to 35–100 per cent during the full implementation phase. Crucial factors for implementing changes included an experienced central team providing implementation support, collaborator engagement, and effective communication and social relationships. Conclusions A trainee-led QI programme increased the use of perioperative risk assessment in patients undergoing emergency laparotomy, with the potential to improve patient outcomes and care delivery.
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Affiliation(s)
- Deirdre M Nally
- Department of Surgical Affairs, Royal College of Surgeons in Ireland , Dublin , Ireland
- Department of Surgery, Mater Misericordiae University Hospital , Dublin , Ireland
| | - Peter E Lonergan
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland , Dublin , Ireland
- Department of Urology, St. James’s Hospital , Dublin , Ireland
- Department of Surgery, Trinity College , Dublin , Ireland
| | | | - Deborah A McNamara
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland , Dublin , Ireland
- Department of Surgery, Beaumont Hospital , Dublin , Ireland
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Ylimartimo AT, Koskela M, Lahtinen S, Kaakinen T, Vakkala M, Liisanantti J. Outcomes in patients requiring intensive care unit (ICU) admission after emergency laparotomy - a retrospective study. Acta Anaesthesiol Scand 2022; 66:954-960. [PMID: 35686388 PMCID: PMC9545255 DOI: 10.1111/aas.14103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 12/01/2022]
Abstract
Purpose Outcomes after emergency laparotomy (EL) are poor. These patients are often admitted to an intensive care unit (ICU). This study explored outcomes in patients who were admitted to an ICU within 48 h after EL. Materials and Methods This retrospective single‐center registry study included all patients over 16 years of age that underwent an EL and were admitted to an ICU within 48 h after surgery in Oulu University Hospital, Finland between January 2005 and May 2015. Survival was followed until the end of 2019. Results We included 525 patients. Hospital mortality was 13.3%, 30‐day mortality was 17.3%, 90‐day mortality was 24.2%, 1‐year mortality was 33.0%, and 5‐year mortality was 59.4%. Survivors were younger (57 [45–70] years) than the non‐survivors (73 [62–80] years; p < .001). According to the Cox regression model, death during the follow‐up was associated with age, APACHE II‐score, lower postoperative CRP levels and platelet count of the first postoperative day, and the admission from the post‐anesthesia care unit (PACU) to the ICU instead of direct ICU admission. Conclusion Age, high APACHE II‐score, low CRP and platelet count, and admission from the PACU to the ICU associated with mortality after EL in patients admitted to an ICU within 48 h after EL.
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Affiliation(s)
- Aura T Ylimartimo
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine.,Oulu University Hospital, Department of Surgery
| | - Marjo Koskela
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine.,Oulu University Hospital, Department of Surgery
| | - Sanna Lahtinen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine.,Oulu University Hospital, Department of Anesthesiology
| | - Timo Kaakinen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine.,Oulu University Hospital, Department of Anesthesiology
| | - Merja Vakkala
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine.,Oulu University Hospital, Department of Anesthesiology
| | - Janne Liisanantti
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine.,Oulu University Hospital, Department of Anesthesiology
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Quality Improvement in Emergency General Surgery. J Am Coll Surg 2022; 234:1254-1255. [PMID: 35258486 DOI: 10.1097/xcs.0000000000000159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hansen JB, Humble CAS, Møller AM, Vester-Andersen M. The prognostic value of surgical delay in patients undergoing major emergency abdominal surgery: a systematic review and meta-analysis. Scand J Gastroenterol 2022; 57:534-544. [PMID: 35019790 DOI: 10.1080/00365521.2021.2024250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mortality following major emergency abdominal surgery is high. Surgical delay is regarded as an important modifiable prognostic factor. Current care-bundles aim at reducing surgical delay, most often using a six-hour cut-off. We aimed to investigate the evidence supporting the in-hospital delay cutoffs currently used. METHODS MEDLINE, EMBASE and the Cochrane Library were searched. We included studies assessing in-hospital surgical delay in major emergency abdominal surgery patients. Studies were only included if they performed adjusted analysis. Surgical delay beyond six hours was the primary cutfrom interest. The primary outcome was mortality at longest follow-up. Meta-analyses were conducted if possible. RESULTS Eleven observational studies were included with 16,772 participants. Two studies evaluated delay in unselected major emergency abdominal surgery patients. Three studies applied a six-hour cutoff, but only a study on acute mesenteric ischemia showed an association between delay and mortality. Meta-analysis showed no association with mortality at this cutoff. An association was seen between hourly delay and mortality risk estimate, 1.02 (95% confidence interval [CI], 1.00 - 1.03), and on subgroup analysis of hourly delay in perforated peptic ulcer patients, risk estimate, 1.02 (95% CI, 1.0 - 1.03). All risk estimates had a very low Grading of Recommendations Assessment, Development, and Evaluation score. CONCLUSION Little evidence supports a six-hour cutoff in unselected major emergency abdominal surgical patients. We found an association between hourly delay and increased mortality; however, evidence supporting this was primarily in patients undergoing surgery for perforated peptic ulcer. This review is limited by the quality of the individual studies.
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Affiliation(s)
- Jannick Brander Hansen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - Caroline Anna Sofia Humble
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark.,Centre of Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ann Merete Møller
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
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Young E, Khoo TW, Trochsler MI, Maddern GJ. Factors influencing interhospital transfer delays in emergency general surgery: a systematic review and narrative synthesis. ANZ J Surg 2022; 92:1314-1321. [PMID: 35437859 DOI: 10.1111/ans.17718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/09/2022] [Accepted: 04/02/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Emergency general surgery is an emerging public health issue globally, with substantial healthcare burden. Interhospital transfer of critically unwell surgical patients has been the mainstay of bridging gaps in surgical coverage in regional and rural locations, despite evidence of greater morbidity and mortality. Delays in transfer invariably occurs and compounds the situation. Our aim was to examine the factors influencing interhospital transfer delays in emergency general surgical patients. METHODS A systematic search of PubMED and EmBase, was performed by two researchers from 2020 to 23rd Feb 2021, for English articles related to interhospital transfer delays in emergency general surgical patients, with an age of >16. Articles were critically appraised and data were extracted into a pre-specified data extraction form. No data was suitable for statistical analysis and a narrative synthesis was performed instead. RESULTS Six relevant articles were identified from the search. All studies were retrospective cohort studies with moderate to high risk of bias. Lack of consultant surgeon input, after hours transfer, need for intensive care bed and poor transfer documentation may have a role in interhospital transfer delays. Patients with public health insurance, multiple comorbidities and non-emergency medical conditions experience longer transfer request time and may be at risk of precipitating interhospital transfer delays. Transfer delays are seen in transfers over longer distances. CONCLUSION There is a paucity of knowledge on what and how factors influence interhospital transfer delays in emergency general surgical patients. Well-designed prospective cohort studies are required to bridge this knowledge gap.
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Affiliation(s)
- Edward Young
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Teng-Wei Khoo
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Markus Ivo Trochsler
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
| | - Guy John Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, South Australia, Australia
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Shahait AD, Dolman H, Mostafa G. Postoperative Outcomes After Emergency Laparotomy in Nontrauma Settings: A Single-Center Experience. Cureus 2022; 14:e23426. [PMID: 35481305 PMCID: PMC9033638 DOI: 10.7759/cureus.23426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction: Emergency laparotomy (EL) is a common operation that deals with a wide range of pathologies. Preoperative optimization is often lacking due to the urgent nature of the disease process with a reported mortality rate of up to 44%. This study examines the mortality of EL at an academic acute care surgery medical center. Methods: A retrospective analysis of nontrauma EL from January 2008 to December 2013 was conducted. Data included demographics, clinical features, preoperative laboratory studies, comorbidities, time to surgery, ICU admission, and 30-day mortality. Results: A total of 234 patients (123 males, 52.6%) were included in the study. EL was performed within four hours (immediate) of presentation in 93 (39.7%) patients, within 4-12 hours (early) in 53 (25.4%) patients, and within 12-24 hours (late) in 63 (30.1%) patients. Overall mortality was 16 (6.8%) at 30 days. Mortality was significantly higher with chronic obstructive pulmonary disease (p = 0.014), blood transfusion (p < 0.001), ICU admission (p < 0.001), ventilator days > four (p = 0.013), hyperlipidemia (p = 0.014), heart rate > 90 beats/minute (p = 0.003), temperature > 38°C or < 35°C (p = 0.013), and systolic blood pressure < 90 mmHg (p < 0.001). Conclusion: EL can be performed with lower mortality than previously reported. Specific predictors of mortality are identified and can be used for risk assessment.
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Aggarwal G, Scott M, Peden CJ. Emergency Laparotomy. Anesthesiol Clin 2022; 40:199-211. [PMID: 35236580 DOI: 10.1016/j.anclin.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Emergency laparotomy is a high-risk surgical procedure with mortality and morbidity up to 10 times higher than for a similar procedure performed electively. An enhanced recovery approach has been shown to improve outcomes. A focus on rapid correction of underlying deranged acute physiology and proactive management of conditions associated with aging such as frailty and delirium are key. Patients are at high risk of complications and prevention and avoidance of failure to rescue are essential to improve outcomes. Other enhanced recovery components such as opioid-sparing analgesia and early postoperative mobilization are beneficial.
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Affiliation(s)
- Geeta Aggarwal
- Royal Surrey Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX, UK.
| | - Michael Scott
- Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Surgical Outcomes Research Centre, University College London, London, UK
| | - Carol J Peden
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Clinical Quality the Blue Cross Blue Shield Association, Chicago, IL 60601, USA
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Stephens TJ, Beckingham IJ, Bamber JR, Peden CJ. What Influences the Effectiveness of Quality Improvement in Perioperative Care: Learning From Large Multicenter Studies in Emergency General Surgery? Anesth Analg 2022; 134:559-563. [PMID: 35180173 DOI: 10.1213/ane.0000000000005879] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Timothy J Stephens
- From the William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Adult Critical Care Unit, The Royal London Hospital, Surgery and Critical Care, Barts Health NHS Trust, London, United Kingdom
| | - Ian J Beckingham
- Department of Hepatico-Pancreatico-Biliary Surgery, Nottingham University Hospitals NHS Foundation Trust, Nottingham, United Kingdom
| | - Jonathan Riddell Bamber
- Department of Medicine, Faculty of Medical Sciences, University College London, London, United Kingdom
| | - Carol J Peden
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California.,Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania
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Ng P, Lee JKD, Tan KY. Finding value with prehabilitation in older persons receiving surgery. Curr Opin Support Palliat Care 2022; 16:19-24. [PMID: 34812752 DOI: 10.1097/spc.0000000000000581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Patients presenting for surgery are increasingly older and frail. Prehabilitation offers the best hope of preemptive functional optimisation to improve postoperative outcomes. Systematic reviews and meta-analyses show signals of improved function and reduced complications and length of stay, but are hampered by small trials with heterogeneous nature of interventions. RECENT FINDINGS The value proposition for prehabilitation is strengthened by applying the following considerations to the evidence. Multimodal prehabilitation programmes incorporating elements of exercise, nutrition, and psychological preparation have a sound physiological basis and will help standardise care delivery and evidence gathering. Targeting prehabilitation resources at high-risk patients may yield higher returns. Effective prehabilitation programmes must be individualised and pragmatic to address known barriers to adherence. The evidence for functional improvement is clear and this aligns with the values of older patients. A comprehensive analysis of value incorporates functional, quality of life, and cost outcomes in addition to conventional morbidity and mortality measures. SUMMARY Multimodal prehabilitation delivered by a multidisciplinary team improves functional outcomes following surgery. Function is an integral part of multidimensional value assessment including clinical and experiential measures. Future value enhancements include addressing frailty and overcoming barriers through targeted programme design.
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Affiliation(s)
| | | | - Kok Yang Tan
- Department of Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
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Ross SW, Reinke CE, Ingraham AM, Holena DN, Havens JM, Hemmila MR, Sakran JV, Staudenmayer KL, Napolitano LM, Coimbra R. Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues. J Am Coll Surg 2022; 234:214-225. [PMID: 35213443 DOI: 10.1097/xcs.0000000000000044] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.
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Affiliation(s)
- Samuel W Ross
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Caroline E Reinke
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Angela M Ingraham
- University of Wisconsin School of Medicine and Public Health, Madison, WI (Ingraham)
| | - Daniel N Holena
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Holena)
| | - Joaquim M Havens
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA (Havens)
| | - Mark R Hemmila
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Joseph V Sakran
- Johns Hopkins University School of Medicine, Baltimore, MD (Sakran)
| | | | - Lena M Napolitano
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Loma Linda, CA (Coimbra)
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42
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Scott MJ. Perioperative Fluid Management. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00016-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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43
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One-Year Outcomes Following Emergency Laparotomy: A Systematic Review. World J Surg 2021; 46:512-523. [PMID: 34837122 DOI: 10.1007/s00268-021-06385-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Emergency laparotomies (EL) are associated with significant morbidity and mortality. To date, 30-day mortality has been predominately reported, and been the focus of various national emergency laparotomy audits. Only a few studies have reported on the long-term mortality associated with EL. The aim of this study was to review the one-year mortality following EL. METHOD A systematic review was conducted using PRISMA guidelines to identify studies published in the last 10 years reporting on long-term mortality associated with EL. The data abstracted included: patient demographics, pathology or type of operation performed for EL, post-operative mortality at 7-day, 30-day, 90-day, 1-year, beyond 1-year and inpatient, functional outcomes and risk factors associated with mortality. A quality assessment of included studies was performed. RESULTS Fifteen studies reporting long-term outcomes associated with EL were identified, including the results of 48,023 patients. The indications and/or pathologies for ELs varied. The 30-day mortality after EL ranged from 5.3% to 21.8%, and the one-year mortality ranged from 15.1 to 47%. The mortality in the six studies focusing on elderly patients ranged from 30 to 47%. CONCLUSION The long-term mortality rate associated with EL is substantial. Further study is required to understand the 1-year mortality described in the studies and translate these findings for meaningful application into the clinical care of these patients.
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Ong MW, Goh SSN, Tung WMJ, Lim WW, Hu HH, Lim CY, Ng P, Tan KY, Goo TTJ. Initial emergency laparotomy outcomes following a transdisciplinary perioperative care pathway in Singapore. Acute Med Surg 2021; 8:e702. [PMID: 34745640 PMCID: PMC8552521 DOI: 10.1002/ams2.702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/03/2021] [Accepted: 10/07/2021] [Indexed: 11/10/2022] Open
Abstract
Aim Emergency laparotomy (EL) is a common surgery associated with high morbidity and mortality. An enhanced care pathway incorporates evidence-based care bundles with the aim of providing standardized perioperative care. Prior to 2019, EL management in our institution was not standardized. This study aims to assess whether implementation of a transdisciplinary perioperative Emergency Laparotomy (ELAP) pathway improves clinical and efficiency outcomes of EL. Methods A prospective single-center audit was undertaken between 1 January and 31 December, 2019 following the implementation of the ELAP pathway. Comparisons were made with retrospective data from the preimplementation period between 1 January and 31 December, 2017. Demographics and clinical and efficiency outcomes were compared for patients (age > 16 years old) requiring EL for acute abdominal conditions. Results There were 152 and 162 patients from preimplementation and postimplementation periods, respectively. There was a nonsignificant reduction of 30-day mortality in the intervention group receiving perioperative pathway care compared with the preintervention group (3.1% versus 5.3%, respectively; P = 0.40). There was a decrease in postoperative complications in the intervention group, in particular for Clavien-Dindo IV complications (11.2% versus 3.1%, p < 0.01). Efficiency outcomes improved postimplementation with increased consultant surgeon and anesthetist presence in operating theater and postoperative geriatric assessment for elderly patients. There was an overall reduction in cost of hospital stay from S$32,128 to $27,947 (p = 0.24). Conclusion Implementation of a transdisciplinary perioperative care pathway was associated with significant reduction in postoperative complications, improvement in 30-day mortality and efficiency outcomes at reduced hospital costs for patients following EL in our institution.
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Affiliation(s)
- Marc Weijie Ong
- Department of General Surgery Khoo Teck Puat Hospital Singapore City Singapore
| | - Serene Si Ning Goh
- Department of General Surgery Khoo Teck Puat Hospital Singapore City Singapore
| | - Wei Min James Tung
- Lee Kong Chian School of Medicine Nanyang Technological University Singapore City Singapore
| | - Woan Wui Lim
- Department of General Surgery Khoo Teck Puat Hospital Singapore City Singapore
| | - Hilda Haoling Hu
- Department of Anaesthesia Khoo Teck Puat Hospital Singapore City Singapore
| | - Choong Yan Lim
- Department of Geriatric Medicine Khoo Teck Puat Hospital Singapore City Singapore
| | - Priscilla Ng
- Department of Geriatric Medicine Khoo Teck Puat Hospital Singapore City Singapore
| | - Kok Yang Tan
- Department of General Surgery Khoo Teck Puat Hospital Singapore City Singapore
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45
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Outcomes and associated factors among patients undergone emergency laparotomy: A retrospective study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Twahirwa I, Niyonshuti N, Uwase C, Rickard J. Comparison of Outcomes of Emergency Laparotomies Performed During Daytime Versus Nights and Weekends in Rwandan University Teaching Hospitals. World J Surg 2021; 46:61-68. [PMID: 34581844 DOI: 10.1007/s00268-021-06327-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency laparotomy is a common procedure with high morbidity and mortality. The aim of this study was to assess if the time of surgery (day versus night and weekend) affects the morbidity and mortality in a low-resource setting. METHODS A retrospective study was conducted in 2 university teaching hospitals in Rwanda. Patient characteristics, time of laparotomy, operative details and postoperative outcomes were recorded. Chi-square and Wilcoxon rank sum tests were used to determine factors and outcomes associated with time of surgery. Logistic regression was used to determine factors associated with mortality. RESULTS In 309 patients, who underwent emergency laparotomy, 147 (48%) patients were operated during the daytime, 123 (40%) patients were operated during the night shift and 39 (12%) patients were operated on the weekend. Common diagnoses were intestinal obstruction (n = 141, 46%), peritonitis (n = 101, 33%) and abdominal trauma (n = 40, 13%). The overall mortality rate was 16% with 14% in patients operated during day and 17% in patients operated during night and weekends (p = 0.564). Overall, the morbidity rate was 30% with 27% in patients operated during the day compared with 32% in patients operated during night/weekends (p = 0.348). After controlling for confounding factors, there was no association between time of operation and mortality or morbidity. CONCLUSION Morbidity and mortality associated with emergency laparotomy are high but the time of day for emergency laparotomy did not affect outcome in Rwandan referral hospitals.
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Affiliation(s)
- Isaie Twahirwa
- University of Rwanda, Kigali, Rwanda
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Norbert Niyonshuti
- University of Rwanda, Kigali, Rwanda
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Clement Uwase
- University of Rwanda, Kigali, Rwanda
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jennifer Rickard
- University of Rwanda, Kigali, Rwanda.
- University Teaching Hospital of Kigali, Kigali, Rwanda.
- University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA.
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Degett TH, Christensen J, Dalton SO, Bossen K, Frederiksen K, Iversen LH, Gögenur I. Prediction of the postoperative 90-day mortality after acute colorectal cancer surgery: development and temporal validation of the ACORCA model. Int J Colorectal Dis 2021; 36:1873-1883. [PMID: 33982139 DOI: 10.1007/s00384-021-03950-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to develop and validate a model to predict 90-day mortality after acute colorectal cancer surgery. METHODS The model was developed in all patients undergoing acute colorectal cancer surgery in 2014-2016 and validated in a patient group operated in 2017 in Denmark. The outcome was 90-day mortality. Tested predictor variables were age, sex, performance status, BMI, smoking, alcohol, education level, cohabitation status, tumour localization and primary surgical procedure. Variables were selected according to the smallest Akaike information criterion. The model was shrunken by bootstrapping. Discrimination was evaluated with a receiver operated characteristic curve, calibration with a calibration slope and the accuracy with a Brier score. RESULTS A total of 1450 patients were included for development of the model and 451 patients for validation. The 90-day mortality rate was 19% and 20%, respectively. Age, performance status, alcohol, smoking and primary surgical procedure were the final variables included in the model. Discrimination (AUC = 0.79), calibration (slope = 1.04, intercept = 0.04) and accuracy (brier score = 0.13) were good in the developed model. In the temporal validation, discrimination (AUC = 0.80) and accuracy (brier score = 0.13) were good, and calibration was acceptable (slope = 1.19, intercept = 0.52). CONCLUSION We developed prediction model for 90-day mortality after acute colorectal cancer surgery that may be a promising tool for surgeons to identify patients at risk of postoperative mortality.
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Affiliation(s)
- Thea Helene Degett
- Center for Surgical Science (CSS), Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600, Koge, Denmark. .,Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark.
| | - Jane Christensen
- Statistics and Data analysis, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Susanne Oksbjerg Dalton
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Clinical Oncology & Palliative Care, Zealand University Hospital, Naestved, Denmark
| | | | - Kirsten Frederiksen
- Statistics and Data analysis, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Lene Hjerrild Iversen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science (CSS), Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600, Koge, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
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Cozza V, Barberis L, Altieri G, Donatelli M, Sganga G, La Greca A. Prediction of postoperative nausea and vomiting by point-of-care gastric ultrasound: can we improve complications and length of stay in emergency surgery? A cohort study. BMC Anesthesiol 2021; 21:211. [PMID: 34465303 PMCID: PMC8407058 DOI: 10.1186/s12871-021-01428-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 08/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative nausea and vomiting and postoperative ileus are common after major digestive surgery and represent one of the significant problems in Acute Care Surgery. The delivery model of emergency surgery needs to be improved in order to foster a patient-centered care. The multimodal approach suggested by Enhanced Recovery After Surgery (ERAS®) Guidelines is gaining widespread acceptance but is difficult to apply to emergency surgery. Ultrasound examination of the gastric antrum allows a reliable assessment of gastric contents and volume and might help contribute to improve perioperative care in the emergency setting. Methods Gastric ultrasound examinations were performed preoperatively and postoperatively on forty-one patients undergoing emergency abdominal surgery. Gastric cross-sectional area (CSA) was measured, in order to estimate the gastric volume. The data obtained were used to evaluate a possible relationship between delayed gastric emptying and postoperative adverse event. Results Gastric antrum detection rate varied from 31.8% in open up to 78.9% in laparoscopic surgeries (p = 0.003). Six patients experienced adverse outcomes, had an antiemetic therapy administered and/or a nasogastric tube inserted. Mean CSA was significantly higher in this group (12.95 cm2 vs 6.12 cm2; p = 0.040). Conclusions Sensitivity of gastric ultrasound varies depending on surgical technique. A dilated gastric antrum is significantly related to postoperative adverse outcomes and a careful ultrasound follow-up might help tailor postoperative nutrition and antiemetic therapy. In patients who experienced adverse events, antral CSA showed an average increase of more than 50% over a period of 72 h after surgery. A relative measure could be used to predict the risk of postoperative ileus. Overall, gastric ultrasound seems to be a promising diagnostic tool and a useful way to integrate ERAS® protocol in emergency abdominal surgery.
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Affiliation(s)
- Valerio Cozza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | | | - Gaia Altieri
- Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Antonio La Greca
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Roma, Italy
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Jansson Timan T, Hagberg G, Sernert N, Karlsson O, Prytz M. Mortality following emergency laparotomy: a Swedish cohort study. BMC Surg 2021; 21:322. [PMID: 34380437 PMCID: PMC8356422 DOI: 10.1186/s12893-021-01319-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/04/2021] [Indexed: 01/05/2023] Open
Abstract
Background Emergency laparotomy (EL) is a central, high-risk procedure in emergency surgery. Patients in need of an EL present an acute pathology in the abdomen that must be operated on in order to save their lives. Usually, the underlying condition produces an affected physiology. The perioperative management of this critically ill patient group in need of high-risk surgery and anaesthesia is challenging and related to high mortality worldwide. However, outcomes in Sweden have yet to be studied. This retrospective cohort study explores the perioperative management and outcome after 710 ELs by investigating mortality, overall length of stay (LOS) in hospital, need for care at the intensive care unit (ICU), surgical complications and a general review of perioperative management. Methods Medical records after laparotomy was retrospectively analysed for a period of 38 months (2014–2017), the emergency cases were included. Children (< 18 years), aortic surgery, second look and other expected reoperations were excluded. Demographic, management and outcome data were collected after an extensive analysis of the cohort. Results A total of 710 consecutive operations, representing 663 patients, were included in the cohort (mean age 65.6 years). Mortality (30 days/1 year) after all operations was 14.2% and 26.6% respectively. The mean LOS in hospital was 12 days, while LOS in the ICU was five days. Of all operations, 23.8% patients were admitted at any time to the ICU postoperatively and the 30-day mortality seen among ICU patients was 37.9%. Mortality was strongly correlated to existing comorbidity, high ASA classification, ICU care and faecal peritonitis. The mean/median time from notification to operate until the first incision was 3:46/3:02 h and 87% of patients had their first incision within 6 h of notification. Conclusions In this present Swedish study, high mortality and morbidity were observed after emergency laparotomy, which is in agreement with other recent studies. Trial registration: The study has been registered with ClinicalTrials.gov (NCT03549624, registered 8 June 2018).
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Affiliation(s)
- Terje Jansson Timan
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Department of Research and Development, NU-Hospital Group, Trollhättan, Sweden. .,Department of Anesthesiology and Intensive Care Unit, NU-Hospital Group, Trollhättan, Sweden.
| | - Gustav Hagberg
- Department of Surgery, NU-Hospital Group, Trollhättan, Sweden
| | - Ninni Sernert
- Department of Research and Development, NU-Hospital Group, Trollhättan, Sweden.,Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ove Karlsson
- Department of Anesthesiology and Intensive Care Unit, NU-Hospital Group, Trollhättan, Sweden.,Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Prytz
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Research and Development, NU-Hospital Group, Trollhättan, Sweden.,Department of Surgery, NU-Hospital Group, Trollhättan, Sweden
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Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial. Br J Anaesth 2021; 127:521-531. [PMID: 34389168 DOI: 10.1016/j.bja.2021.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/27/2021] [Accepted: 06/23/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND More than 50% of patients have a major complication after emergency gastrointestinal surgery. Intravenous (i.v.) fluid therapy is a life-saving part of treatment, but evidence to guide what i.v. fluid strategy results in the best outcome is lacking. We hypothesised that goal-directed fluid therapy during surgery (GDT group) reduces the risk of major complications or death in patients undergoing major emergency gastrointestinal surgery compared with standard i.v. fluid therapy (STD group). METHODS In a randomised, assessor-blinded, two-arm, multicentre trial, we included 312 adult patients with gastrointestinal obstruction or perforation. Patients in the GDT group received i.v. fluid to near-maximal stroke volume. Patients in the STD group received i.v. fluid following best clinical practice. Postoperative target was 0-2 L fluid balance. The primary outcome was a composite of major complications or death within 90 days. Secondary outcomes were time in intensive care, time on ventilator, time in dialysis, hospital stay, and minor complications. RESULTS In a modified intention-to-treat analysis, we found no difference in the primary outcome between groups: 45 (30%) (GDT group) vs 39 (25%) (STD group) (odds ratio=1.24; 95% confidence interval, 0.75-2.05; P=0.40). Hospital stay was longer in the GDT group: median (inter-quartile range), 7 (4-12) vs 6 days (4-8.5) (P=0.04); no other differences were found. CONCLUSION Compared with pressure-guided i.v. fluid therapy (STD group), flow-guided fluid therapy to near-maximal stroke volume (GDT group) did not improve the outcome after surgery for bowel obstruction or gastrointestinal perforation but may have prolonged hospital stay. CLINICAL TRIAL REGISTRATION EudraCT number 2015-000563-14; the Danish Scientific Ethics Committee and the Danish Data Protection Agency (REG-18-2015).
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