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Okidi R, Sambo VDC, Okello I, Ekwem DA, Ekwang S, Obalim F, Kyegombe W. Associated factors of mortality and morbidity in emergency and elective abdominal surgery: a two-year prospective cohort study at lacor hospital, Uganda. BMC Surg 2024; 24:144. [PMID: 38730310 PMCID: PMC11088035 DOI: 10.1186/s12893-024-02433-z] [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: 02/22/2023] [Accepted: 05/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND The mortality rate associated with open abdominal surgery is a significant concern for patients and healthcare providers. This is particularly worrisome in Africa due to scarce workforce resources and poor early warning systems for detecting physiological deterioration in patients who develop complications. METHODS This prospective cohort study aimed to follow patients who underwent emergency or elective abdominal surgery at Lacor Hospital in Uganda. The participants were patients who underwent abdominal surgery at the hospital between April 27th, 2019 and July 07th, 2021. Trained research staff collected data using standardized forms, which included demographic information (age, gender, telephone contact, and location), surgical indications, surgical procedures, preoperative health status, postoperative morbidity and mortality, and length of hospital stay. RESULTS The present study involved 124 patients, mostly male, with an average age of 35 years, who presented with abdominal pain and varying underlying comorbidities. Elective cases constituted 60.2% of the total. The common reasons for emergency and elective surgery were gastroduodenal perforation and cholelithiasis respectively. The complication rate was 17.7%, with surgical site infections being the most frequent. The mortality rate was 7.3%, and several factors such as preoperative hypotension, deranged renal function, postoperative use of vasopressors, and postoperative assisted ventilation were associated with it. Elective and emergency-operated patients showed no significant difference in survival (P-value = 0.41) or length of hospital stay (P-value = 0.17). However, there was a significant difference in morbidity (p < 0.001). CONCLUSION Cholelithiasis and gastroduodenal perforation were key surgical indications, with factors like postoperative ventilation and adrenaline infusion linked to mortality. Emergency surgeries had higher complication rates, particularly surgical site infections, despite similar hospital stay and mortality rates compared to elective surgeries.
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Affiliation(s)
- Ronald Okidi
- Department of Surgery, Lacor Hospital, P.O. Box 180, Gulu, Uganda.
- Faculty of Medicine, Gulu University, Gulu, Uganda.
| | | | - Isaac Okello
- Department of Surgery, Lacor Hospital, P.O. Box 180, Gulu, Uganda
| | | | - Solomon Ekwang
- Department of Surgery, Lacor Hospital, P.O. Box 180, Gulu, Uganda
| | - Fiddy Obalim
- Department of Surgery, Lacor Hospital, P.O. Box 180, Gulu, Uganda
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Clinch D, Dorken-Gallastegi A, Argandykov D, Gebran A, Proano Zamudio JA, Wong CS, Clinch N, Haddow L, Simpson K, Imbert E, Skipworth RJE, Moug SJ, Kaafarani HMA, Damaskos D. Validation of the emergency surgery score (ESS) in a UK patient population and comparison with NELA scoring: a retrospective multicentre cohort study. Ann R Coll Surg Engl 2024; 106:439-445. [PMID: 38478020 PMCID: PMC11060857 DOI: 10.1308/rcsann.2023.0105] [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] [Accepted: 11/24/2023] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION Accurate risk scoring in emergency general surgery (EGS) is vital for consent and resource allocation. The emergency surgery score (ESS) has been validated as a reliable preoperative predictor of postoperative outcomes in EGS but has been studied only in the US population. Our primary aim was to perform an external validation study of the ESS in a UK population. Our secondary aim was to compare the accuracy of ESS and National Emergency Laparotomy Audit (NELA) scores. METHODS We conducted an observational cohort study of adult patients undergoing emergency laparotomy over three years in two UK centres. ESS was calculated retrospectively. NELA scores and all other variables were obtained from the prospectively collected Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA) database. The primary and secondary outcomes were 30-day mortality and postoperative intensive care unit (ICU) admission, respectively. RESULTS A total of 609 patients were included. Median age was 65 years, 52.7% were female, the overall mortality was 9.9% and 23.8% were admitted to ICU. Both ESS and NELA were equally accurate in predicting 30-day mortality (c-statistic=0.78 (95% confidence interval (CI), 0.71-0.85) for ESS and c-statistic=0.83 (95% CI, 0.77-0.88) for NELA, p=0.196) and predicting postoperative ICU admission (c-statistic=0.76 (95% CI, 0.71-0.81) for ESS and 0.80 (95% CI, 0.76-0.85) for NELA, p=0.092). CONCLUSIONS In the UK population, ESS and NELA both predict 30-day mortality and ICU admission with no statistically significant difference but with higher c-statistics for NELA score. Both scores have certain advantages, with ESS being validated for a wider range of outcomes.
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Affiliation(s)
- D Clinch
- Royal Infirmary of Edinburgh, UK
| | | | | | - A Gebran
- Massachusetts General Hospital, USA
| | | | - CS Wong
- Royal Alexandra Hospital, UK
| | - N Clinch
- Royal Infirmary of Edinburgh, UK
| | - L Haddow
- Royal Infirmary of Edinburgh, UK
| | | | - E Imbert
- Royal Infirmary of Edinburgh, UK
| | | | - SJ Moug
- Royal Alexandra Hospital, UK
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Lagazzi E, Proaño-Zamudio JA, Argandykov D, Rafaqat W, Abiad M, Romijn AS, van Ee EPX, Velmahos GC, Kaafarani HMA, Hwabejire JO. Burden of Social and Behavioral Determinants of Health on Infectious Complications in Emergency General Surgery. Surg Infect (Larchmt) 2023; 24:869-878. [PMID: 38011709 DOI: 10.1089/sur.2023.192] [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: 11/29/2023] Open
Abstract
Background: Infectious complications lead to worse post-operative outcomes and are used to compare hospital performance in pay-for-performance programs. However, the impact of social and behavioral determinants of health on infectious complication rates after emergency general surgery (EGS) remains unclear. Patients and Methods: All patients undergoing EGS in the 2019 Nationwide Readmissions Database were included. The primary outcome of the study was the rate of infectious complications within 30 days, defined as a composite outcome including all infectious complications occurring during the index hospitalization or 30-day re-admission. Secondary outcomes included specific infectious complication rates. Multivariable regression analyses were used to study the impact of patient characteristics, social determinants of health (insurance status, median household income in the patient's residential zip code), and behavioral determinants of health (substance use disorders, neuropsychiatric comorbidities) on post-operative infection rates. Results: Of 367,917 patients included in this study, 20.53% had infectious complications. Medicare (adjusted odds ratio [aOR], 1.3; 95% confidence interval [CI], 1.26-1.34; p < 0.001), Medicaid (aOR, 1.24; 95% CI,1.19-1.29; p < 0.001), lowest zip code income quartile (aOR, 1.17; 95% CI, 1.13-1.22; p < 0.001), opioid use disorder (aOR,1.18; 95% CI,1.10-1.29; p < 0.001), and neurodevelopmental disorders (aOR, 2.16; 95% CI, 1.90-2.45; p < 0.001) were identified as independent predictors of 30-day infectious complications. A similar association between determinants of health and infectious complications was also seen for pneumonia, urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA) sepsis, and catheter-association urinary tract infection (CAUTI). Conclusions: Social and behavioral determinants of health are associated with a higher risk of developing post-operative infectious complications in EGS. Accounting for these factors in pay-for-performance programs and public reporting could promote fairer comparisons of hospital performance.
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Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Humanitas Research Hospital, Rozzano, Italy
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - May Abiad
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anne-Sophie Romijn
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Division of Trauma and Emergency Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Elaine P X van Ee
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Leiden University Medical Center, Leiden, The Netherlands
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Elsherbiny M, Hasanin A, Kasem S, Abouzeid M, Mostafa M, Fouad A, Abdelwahab Y. Comparison of different ratios of propofol-ketamine admixture in rapid-sequence induction of anesthesia for emergency laparotomy: a randomized controlled trial. BMC Anesthesiol 2023; 23:329. [PMID: 37789329 PMCID: PMC10546635 DOI: 10.1186/s12871-023-02292-w] [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: 07/11/2023] [Accepted: 09/25/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND We aimed to compare the hemodynamic effect of two ratios of propofol and ketamine (ketofol), namely 1:1 and 1:3 ratios, in rapid-sequence induction of anesthesia for emergency laparotomy. METHODS This randomized controlled study included adult patients undergoing emergency laparotomy under general anesthesia. The patients were randomized to receive either ketofol ratio of 1:1 (n = 37) or ketofol ratio of 1:3 (n = 37). Hypotension (mean arterial pressure < 70 mmHg) was managed by 5-mcg norepinephrine. The primary outcome was total norepinephrine requirements during the postinduction period. Secondary outcomes included the incidence of postinduction hypotension, and the intubation condition (excellent, good, or poor). RESULTS Thirty-seven patients in the ketofol-1:1 and 35 patients in the ketofol 1:3 group were analyzed. The total norepinephrine requirement was less in the ketofol-1:1 group than in the ketofol-1:3 group, P-values: 0.043. The incidence of postinduction hypotension was less in the ketofol-1:1 group (4 [12%]) than in ketofol-1:3 group (12 [35%]), P-value 0.022. All the included patients had excellent intubation condition. CONCLUSION In patients undergoing emergency laparotomy, the use of ketofol in 1:1 ratio for rapid-sequence induction of anesthesia was associated with less incidence of postinduction hypotension and vasopressor consumption in comparison to the 1:3 ratio with comparable intubation conditions. CLINICAL TRIAL REGISTRATION NCT05166330. URL: https://clinicaltrials.gov/ct2/show/NCT05166330 .
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Affiliation(s)
- Mona Elsherbiny
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Sahar Kasem
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Abouzeid
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Fouad
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Yaser Abdelwahab
- Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
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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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Mihailov R, Firescu D, Constantin GB, Mihailov OM, Hoara P, Birla R, Patrascu T, Panaitescu E. Mortality Risk Stratification in Emergency Surgery for Obstructive Colon Cancer-External Validation of International Scores, American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (SRC), and the Dedicated Score of French Surgical Association (AFC/OCC Score). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13513. [PMID: 36294094 PMCID: PMC9603747 DOI: 10.3390/ijerph192013513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/14/2022] [Accepted: 10/16/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The increased rates of postoperative mortality after emergency surgery for obstructive colon cancer (OCC) require the use of risk-stratification scores. The study purpose is to external validate the surgical risk calculator (SRC) and the AFC/OCC score and to create a score for risk stratification. PATIENTS AND METHODS Overall, 435 patients with emergency surgery for OCC were included in this retrospective study. We used statistical methods suitable for the aimed purpose. RESULTS Postoperative mortality was 11.72%. SRC performance: strong discrimination (AUC = 0.864) and excellent calibration (11.80% predicted versus 11.72% observed); AFC/OCC score performance: adequate discrimination (AUC = 0.787) and underestimated mortality (6.93% predicted versus 11.72% observed). We identified nine predictors of postoperative mortality: age > 70 years, CHF, ECOG > 2, sepsis, obesity or cachexia, creatinine (aN) or platelets (aN), and proximal tumors (AUC = 0.947). Based on the score, we obtained four risk groups of mortality rate: low risk (0.7%)-0-2 factors, medium risk (12.5%)-3 factors, high risk (40.0%)-4 factors, very high risk (84.4%)-5-6 factors. CONCLUSIONS The two scores were externally validated. The easy identification of predictors and its performance recommend the mortality score of the Clinic County Emergency Hospital of Galați/OCC for clinical use.
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Affiliation(s)
- Raul Mihailov
- Clinic Surgery Department, Dunarea de Jos University, 800216 Galati, Romania
| | - Dorel Firescu
- Clinic Surgery Department, Dunarea de Jos University, 800216 Galati, Romania
| | | | | | - Petre Hoara
- General Surgery Department, Carol Davila University, 050474 Bucharest, Romania
| | - Rodica Birla
- General Surgery Department, Carol Davila University, 050474 Bucharest, Romania
| | - Traian Patrascu
- General Surgery Department, Carol Davila University, 050474 Bucharest, Romania
| | - Eugenia Panaitescu
- Medical Informatics and Biostatistics Department, Carol Davila University, 050474 Bucharest, Romania
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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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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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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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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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Christou CD, Naar L, Kongkaewpaisan N, Tsolakidis A, Smyrnis P, Tooulias A, Tsoulfas G, Papadopoulos VN, Velmahos GC, Kaafarani HMA. Validation of the Emergency Surgery Score (ESS) in a Greek patient population: a prospective bi-institutional cohort study. Eur J Trauma Emerg Surg 2021; 48:1197-1204. [PMID: 34296323 PMCID: PMC8297717 DOI: 10.1007/s00068-021-01734-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 06/19/2021] [Indexed: 02/05/2023]
Abstract
Purpose The Emergency Surgery Score (ESS) is a reliable point-based score that predicts mortality and morbidity in emergency surgery patients. However, it has been validated only in the U.S. patients. We aimed to prospectively validate ESS in a Greek patient population. Methods All patients who underwent an emergent laparotomy were prospectively included over a 15-month period. A systematic chart review was performed to collect relevant preoperative, intraoperative, and postoperative variables based on which the ESS was calculated for each patient. The relationship between ESS and 30-day mortality, morbidity (i.e., the occurrence of at least one complication), and the need for intensive care unit (ICU) admission was evaluated and compared between the Greek and U.S. patients using the c-statistics methodology. The study was registered on "Research Registry" with the unique identifying number 5901. Results A total of 214 patients (102 Greek) were included. The mean age was 64 years, 44% were female, and the median ESS was 7. The most common indication for surgery was hollow viscus perforation (25%). The ESS reliably and incrementally predicted mortality (c-statistics = 0.79 [95% CI 0.67–0.90] and 0.83 [95% CI 0.74–0.92]), morbidity (c-statistics = 0.83 [95% CI 0.76–0.91] and 0.79 [95% CI 0.69–0.88]), and ICU admission (c-statistics = 0.88 [95% CI 0.81–0.96] and 0.84 [95% CI 0.77–0.91]) in both Greek and U.S. patients. Conclusion The correlation between the ESS and the surgical outcomes was statistically significant in both Greek and U.S. patients undergoing emergency laparotomy. ESS could prove globally useful for preoperative patient counseling and quality-of-care benchmarking.
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Affiliation(s)
- Chrysanthos Dimitris Christou
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Leon Naar
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Alexandros Tsolakidis
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Smyrnis
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andreas Tooulias
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Tsoulfas
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios Nikolaos Papadopoulos
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Constantinos Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Haytham Mohamed Ali Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
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Burcharth J, Falkenberg A, Schack A, Ekeloef S, Gögenur I. The effects of early enteral nutrition on mortality after major emergency abdominal surgery: A systematic review and meta-analysis with Trial Sequential Analysis. Clin Nutr 2021; 40:1604-1612. [PMID: 33744604 DOI: 10.1016/j.clnu.2021.02.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/21/2021] [Accepted: 02/26/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Early oral or enteral nutrition (EEN) has been proven safe, tolerable, and beneficial in elective surgery. In emergency abdominal surgery no consensus exists regarding postoperative nutrition standard regimens. This review aimed to assess the safety and clinical outcomes of EEN compared to standard care after emergency abdominal surgery. METHODS The review protocol was performed according to the Cochrane Handbook and reported according to PRISMA. Clinical outcomes included mortality, specific complication rates, length of stay, and serious adverse events. Risk of bias was assessed by Cochrane risk of bias tool and Downs and Black. GRADE assessment of each outcome was performed, and Trial Sequential Analysis was completed to obtain the Required Information Size (RIS) of each outcome. RESULTS From a total of 4741 records screened, a total of five randomized controlled trials and two non-randomized controlled trials were included covering 1309 patients. The included studies reported no safety issues regarding the use of EEN. A significant reduction in the mortality rate of EEN compared with standard care was seen (OR 0.59 (CI 95% 0.34-1.00), I2 = 0%). Meta-analyses on sepsis and postoperative pulmonary complications showed non-significant tendencies in favor of EEN compared with standard care. GRADE assessment of all outcomes was evaluated 'low' or 'very low'. Trial Sequential Analysis revealed that all outcomes had insufficient RIS to confirm the effects of EEN. CONCLUSION EEN after major emergency surgery is correlated with reduced mortality, however, more high-quality data regarding the optimal timing and composition of nutrition are needed before final conclusions regarding the effects of EEN can be made.
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Affiliation(s)
- Jakob Burcharth
- Department of Surgery, Zealand University Hospital, Denmark.
| | | | - Anders Schack
- Department of Surgery, Zealand University Hospital, Denmark
| | - Sarah Ekeloef
- Department of Surgery, Zealand University Hospital, Denmark
| | - Ismail Gögenur
- Department of Surgery, Zealand University Hospital, Denmark
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13
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El Hechi MW, Maurer LR, Levine J, Zhuo D, El Moheb M, Velmahos GC, Dunn J, Bertsimas D, Kaafarani HM. Validation of the Artificial Intelligence-Based Predictive Optimal Trees in Emergency Surgery Risk (POTTER) Calculator in Emergency General Surgery and Emergency Laparotomy Patients. J Am Coll Surg 2021; 232:912-919.e1. [PMID: 33705983 DOI: 10.1016/j.jamcollsurg.2021.02.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/19/2021] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Predictive Optimal Trees in Emergency Surgery Risk (POTTER) tool is an artificial intelligence-based calculator for the prediction of 30-day outcomes in patients undergoing emergency operations. In this study, we sought to assess the performance of POTTER in the emergency general surgery (EGS) population in particular. METHODS All patients who underwent EGS in the 2017 American College of Surgeons NSQIP database were included. The performance of POTTER in predicting 30-day postoperative mortality, morbidity, and 18 specific complications was assessed using the c-statistic metric. As a subgroup analysis, the performance of POTTER in predicting the outcomes of patients undergoing emergency laparotomy was assessed. RESULTS A total of 59,955 patients were included. Median age was 50 years and 51.3% were women. POTTER predicted mortality (c-statistic = 0.93) and morbidity (c-statistic = 0.83) extremely well. Among individual complications, POTTER had the highest performance in predicting septic shock (c-statistic = 0.93), respiratory failure requiring mechanical ventilation for 48 hours or longer (c-statistic = 0.92), and acute renal failure (c-statistic = 0.92). Among patients undergoing emergency laparotomy, the c-statistic performances of POTTER in predicting mortality and morbidity were 0.86 and 0.77, respectively. CONCLUSIONS POTTER is an interpretable, accurate, and user-friendly predictor of 30-day outcomes in patients undergoing EGS. POTTER could prove useful for bedside counseling of patients and their families and for benchmarking of EGS care.
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Affiliation(s)
- Majed W El Hechi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA
| | | | | | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA
| | | | - Dimitris Bertsimas
- Interpretable AI, Boston, MA; Massachusetts Institute of Technology, Cambridge, MA
| | - Haytham Ma Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA.
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14
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El Hechi M, Kongkaewpaisan N, Naar L, Aicher B, Diaz J, O'Meara L, Decker C, Rodriquez J, Schroeppel T, Rattan R, Vasileiou G, Yeh DD, Simonoski U, Turay D, Cullinane D, Emmert C, McCrum M, Wall N, Badach J, Goldenberg-Sandau A, Carmichael H, Velopulos C, Choron R, Sakran J, Bekdache K, Black G, Shoultz T, Chadnick Z, Sim V, Madbak F, Steadman D, Camazine M, Zielinski M, Hardman C, Walusimbi M, Kim M, Rodier S, Papadopoulos V, Tsoulfas G, Perez J, Kaafarani HMA. The Emergency Surgery Score accurately predicts the need for postdischarge respiratory and renal support after emergent laparotomies: A prospective EAST multicenter study. J Trauma Acute Care Surg 2021; 90:557-564. [PMID: 33507026 DOI: 10.1097/ta.0000000000003016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL). METHODS This is a post hoc analysis of a 19-center prospective observational study. Between April 2018 and June 2019, all adult patients undergoing EL were enrolled. Preoperative, intraoperative, and postoperative variables were systematically collected. In this analysis, patients were excluded if they died during the index hospitalization, were discharged to hospice, or transferred to other hospitals. A composite variable, the need for RRS, was defined as the need for one or more of the following at hospital discharge: tracheostomy, ventilator dependence, or dialysis. Emergency Surgery Score was calculated for all patients, and the correlation between ESS and RRS was examined using the c-statistics method. RESULTS From a total of 1,649 patients, 1,347 were included. Median age was 60 years, 49.4% were men, and 70.9% were White. The most common diagnoses were hollow viscus organ perforation (28.1%) and small bowel obstruction (24.5%); 87 patients (6.5%) had a need for RRS (4.7% tracheostomy, 2.7% dialysis, and 1.3% ventilator dependence). Emergency Surgery Score predicted the need for RRS in a stepwise fashion; for example, 0.7%, 26.2%, and 85.7% of patients required RRS at an ESS of 2, 12, and 16, respectively. The c-statistics for the need for RRS, the need for tracheostomy, ventilator dependence, or dialysis at discharge were 0.84, 0.82, 0.79, and 0.88, respectively. CONCLUSION Emergency Surgery Score accurately predicts the need for RRS at discharge in EL patients and could be used for preoperative patient counseling and for quality of care benchmarking. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Affiliation(s)
- Majed El Hechi
- From the Division of Trauma, Emergency Surgery & Surgical Critical Care (M.E.H., N.K., L.N., H.M.A.K.), Massachusetts General Hospital, Boston, Massachusetts; Division of Acute Care and Ambulatory Surgery (N.K.), Siriraj Hospital, Mahidol University, Bangkok, Thailand; R Adams Cowley Shock Trauma Center (B.A., J.D., L.O.), University of Maryland Medical Center, Baltimore, Maryland; Department of Surgery, UCHealth Memorial Hospital Central Trauma Center (C.D., J.R., T.S.), Colorado Springs, Colorado; The Dewitt Daughtry Family Department of Surgery Ryder Trauma Center/Jackson Memorial Hospital (R.R., G.V., D.D.Y.), Miami, Florida; Department of Surgery, Loma Linda University Medical Center (U.S., D.T.), Department of Surgery, Loma Linda, California; Marshfield Clinic (D.C., C.E.), Marshfield, Wisconsin; University of Utah (M.C., N.W.), Salt Lake City, Utah; Department of Surgery, Cooper University Hospital (J.B., A.G.-S.), Camden, New Jersey; Department of Surgery, University of Colorado Anschutz Medical Campus (H.C., C.V.), Aurora, Colorado; Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine (R.C., J.S.), Baltimore, Maryland; Department of Surgery, Eastern Maine Medical Center (K.B.), Bangor, Maine; Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital (G.B., T.S.), Dallas, Texas; Department of Surgery, Staten Island University Hospital, Northwell Health (Z.C., V.S.), Staten Island, New York; Department of Surgery, University of Florida College of Medicine-Jacksonville (F.M., D.S.), Jacksonville, Florida; Mayo Clinic (M.C., M.Z.), Rochester, Minnesota; Miami Valley Hospital (C.H., M.W.), Dayton, Ohio; New York University School of Medicine (M.K., S.R.), New York, New York; Department of Surgery, Papageorgiou General Hospital/Aristotle University School of Medicine (V.P., G.T.), Greece; and Department of Surgery, Hackensack University Medical Center (J.P.), Hackensack, New Jersey
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15
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Fagan G, Barazanchi A, Coulter G, Leeman M, Hill AG, Eglinton TW. New Zealand and Australia emergency laparotomy mortality rates compare favourably to international outcomes: a systematic review. ANZ J Surg 2021; 91:2583-2591. [PMID: 33506977 DOI: 10.1111/ans.16563] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/16/2020] [Accepted: 12/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Almost 20 000 people undergo an emergency laparotomy each year in New Zealand and Australia. Common indications include small and large bowel obstruction, and intestinal perforation. Considered a high-risk procedure, emergency laparotomy is associated with significantly high morbidity and mortality. The aim of this review was to identify and compare 30-day, 90-day and 1-year mortality rates following emergency laparotomy in New Zealand and Australia. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Electronic searches were performed in Medline, Embase, PubMed and Scopus in April 2020. RESULTS Thirty-three papers met the inclusion criteria. Studies ranged in size from 58 to 75 280 patients. Weighted mean 30-day mortality was 8.40% (8.39-8.41). Mortality rates increased with longer postoperative follow up with 90-day weighted mortality rate of 14.14% (14.13-14.15) and the weighted mortality rate at 1 year of 24.60% (24.56-24.66). There was significant variability in mortality rates between countries. CONCLUSION There is a wide variability of 30-day, 90-day and 1-year mortality rates internationally. Lowering postoperative mortality rates following emergency laparotomy through quality improvement initiatives could result in up to 120 lives in New Zealand and over 250 lives in Australia being saved each year. The continued work of the Australian and New Zealand Emergency Laparotomy Audit - Quality Improvement is crucial to improving emergency laparotomy mortality rates further in New Zealand and Australia.
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Affiliation(s)
- Georgina Fagan
- Department of Surgery, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Ahmed Barazanchi
- Department of Surgery, University of Auckland, Middlemore Hospital, Auckland, New Zealand
| | - Grant Coulter
- Department of Surgery, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Matthew Leeman
- Department of Surgery, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Andrew G Hill
- Department of Surgery, University of Auckland, Middlemore Hospital, Auckland, New Zealand
| | - Tim W Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Christchurch, New Zealand
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Hajibandeh S, Hajibandeh S, Antoniou GA, Antoniou SA. Meta-analysis of mortality risk in octogenarians undergoing emergency general surgery operations. Surgery 2021; 169:1407-1416. [PMID: 33413918 DOI: 10.1016/j.surg.2020.11.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 10/31/2020] [Accepted: 11/16/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study aimed to quantify the risk of perioperative mortality in octogenarians undergoing emergency general surgical operations and to compare such risk between octogenarians and nonoctogenarians. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards to identify studies reporting the mortality risk in patients aged over 80 years undergoing emergency general surgery operations. The primary outcome measure was 30-day mortality, which was stratified based on American Society of Anesthesiologists (ASA) status and procedure type. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Random-effects models were applied to calculate pooled outcome data. RESULTS Analysis of 66,701 octogenarians from 22 studies showed that the risk of 30-day mortality was 26% (95% confidence interval 18%-34%) for all operations: 29% (95% confidence interval 25%-33%) for emergency laparotomy; 9% (95% confidence interval 1%-23%) for nonlaparotomy emergency operations; 21% (95% confidence interval 13%-30%) for colon resection; 17% (95% confidence interval 11%-25%) for small bowel resection; 9% (95% confidence interval 7%-11%) for adhesiolysis; 6% (95% confidence interval 5.9%-6.8%) for perforated ulcer repair; 3% (95% confidence interval 2.6%-4%) for appendicectomy; 3% (95% confidence interval 2.8%-3.3%) for cholecystectomy; and 5% (95% confidence interval 0.2%-14%) for hernia repair. When stratified based on the patient's ASA status, the risk was 11% (95% confidence interval 4%-20%) for ASA 2 status, 22% (95% confidence interval 10%-36%) for ASA 3 status, 39% (95% confidence interval 29%-48%) for ASA 4 status, and 94% (95% confidence interval 77%-100%) for ASA 5 status. The risk was higher in octogenarians compared with nonoctogenarians (odds ratio: 4.07, 95% confidence interval 2.40-6.89), patients aged 70 to 79 (odds ratio: 1.21, 95% confidence interval 1.13-1.31), and patients aged 50 to 79 (odds ratio: 2.03, 95% confidence interval 1.68-2.45). CONCLUSION The risk of perioperative mortality in octogenarians undergoing emergency general surgical operations is high. The risk of perioperative death in this group is higher than in younger patients. Laparotomy, bowel resection, and ASA status above 3 carry the highest risk.
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Affiliation(s)
- Shahab Hajibandeh
- Department of General Surgery, Glan Clwyd Hospital, the Betsi Cadwaladr University Health Board, Rhyl, United Kingdom.
| | - Shahin Hajibandeh
- Department of General Surgery, Hereford County Hospital, Wye Valley NHS Trust, United Kingdom
| | - George A Antoniou
- Department of Vascular & Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Northern Care Alliance NHS Group, Manchester, United Kingdom; Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, United Kingdom
| | - Stavros A Antoniou
- Surgical Service, Mediterranean Hospital of Cyprus, Limassol, Cyprus; Medical School, European University Cyprus, Nicosia, Cyprus
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Patients' perceptions of barriers to enhanced recovery after emergency abdominal surgery. Langenbecks Arch Surg 2020; 406:405-412. [PMID: 33215245 DOI: 10.1007/s00423-020-02032-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 11/15/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE The patient-perceived barriers towards an optimized short-term recovery after major emergency abdominal surgery are unknown. The purpose was to investigate which patient-perceived barriers dominated concerning nutrition, mobilization, and early discharge after major emergency abdominal surgery. METHODS An explorative study, which focused on patient-perceived barriers for early discharge, mobilization, and nutrition, was performed within an enhanced recovery perioperative setting in major emergency abdominal surgery. Patients were asked daily from postoperative day (POD) 1 to POD 7 of their self-perceived barriers towards getting fully mobilization and resuming normal oral intake. From POD 3 to POD 7, patients were asked regarding self-perceived barriers towards early discharge. RESULTS A total of 101 patients that underwent major emergency abdominal surgery were included for final analysis from March 2017 to August 2017. The main patient self-perceived barrier towards sufficient nutrition was dominated by food aversion (including loss of appetite). The main patient self-perceived barrier towards sufficient mobilization throughout the study period was fatigue. The patient self-perceived barriers towards early discharge were more diffuse and lacked a dominant variable throughout the study period; however, fatigue was the most pronounced barrier throughout the study period. The leading initial variables were postoperative ileus, insufficient nutrition, and epidural catheter. The leading later variables besides fatigue included awaiting normalization of biochemistry values, pain, and the perception of insufficient oral intake. CONCLUSIONS The major patient-perceived factors that limited postoperative recovery after major emergency abdominal surgery included food aversion regarding normalization of oral intake and fatigue regarding mobilization and early discharge.
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Evaluating and improving current risk prediction tools in emergency laparotomy. J Trauma Acute Care Surg 2020; 89:382-387. [PMID: 32301890 DOI: 10.1097/ta.0000000000002745] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Emergency laparotomy (EL) encompasses a high-risk group of operations, which are increasingly performed on a heterogeneous population of patients, making preoperative risk assessment potentially difficult. The UK National Emergency Laparotomy Audit (NELA) recently produced a risk predictive tool for EL that has not yet been externally validated. We aimed to externally validate and potentially improve the NELA tool for mortality prediction after EL. METHODOLOGY We reviewed computer and paper records of EL patients from May 2012 to June 2017 at Middlemore Hospital (New Zealand). The inclusion criteria mirrored the UK NELA. We examined the NELA, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Acute Physiology and Chronic Health Evaluation II (APACHE-II), and American College of Surgeons National Surgical Quality Improvement Programs risk predictive tools for 30-day mortality. The Hosmer-Lemeshow test was used to assess calibration, and the c statistic, to evaluate discrimination (accuracy) of the tools. We added the modified frailty index (mFI) and nutrition to improve the accuracy of risk predictive tools. RESULTS A total of 758 patients met the inclusion criteria, with an observed 30-day mortality of 7.9%. The NELA was the only well calibrated tool, with predicted 30-day mortality of 7.4% (p = 0.22). When combined with mFI and nutritional status, the c statistic for NELA improved from 0.83 to 0.88. American College of Surgeons National Surgical Quality Improvement Programs, APACHE-II, and P-POSSUM had lower c statistics, albeit also showing an improvement (0.84, 0.81, and 0.74, respectively). CONCLUSION We have demonstrated the NELA tool to be most predictive of mortality after EL. The NELA tool would therefore facilitate preoperative risk assessment and operative decision making most precisely in EL. Future research should consider adding mFI and nutritional status to the NELA tool. LEVEL OF EVIDENCE Level IV; Retrospective observational cohort study.
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El Hechi M, Kongkaewpaisan N, El Moheb M, Aicher B, Diaz J, OʼMeara L, Decker C, Rodriquez J, Schroeppel T, Rattan R, Vasileiou G, Yeh DD, Simonosk U, Turay D, Cullinane D, Emmert C, McCrum M, Wall N, Badach J, Goldenberg-Sanda A, Carmichael H, Velopulos C, Choron R, Sakran J, Bekdache K, Black G, Shoultz T, Chadnick Z, Sim V, Madbak F, Steadman D, Camazine M, Zielinski M, Hardman C, Walusimbi M, Kim M, Rodier S, Papadopoulos V, Tsoulfas G, Perez J, Kaafarani H. The emergency surgery score (ESS) and outcomes in elderly patients undergoing emergency laparotomy: A post-hoc analysis of an EAST multicenter study. Am J Surg 2020; 221:1069-1075. [PMID: 32917366 DOI: 10.1016/j.amjsurg.2020.08.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/21/2020] [Accepted: 08/28/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION We sought to evaluate whether the Emergency Surgery Score (ESS) can accurately predict outcomes in elderly patients undergoing emergent laparotomy (EL). METHODS This is a post-hoc analysis of an EAST multicenter study. Between April 2018 and June 2019, all adult patients undergoing EL in 19 participating hospitals were prospectively enrolled, and ESS was calculated for each patient. Using the c-statistic, the correlation between ESS and mortality, morbidity, and need for ICU admission was assessed in three patient age cohorts (65-74, 75-84, ≥85 years old). RESULTS 715 patients were included, of which 52% were 65-74, 34% were 75-84, and 14% were ≥85 years old; 51% were female, and 77% were white. ESS strongly correlated with postoperative mortality (c-statistic:0.81). Mortality gradually increased from 0% to 20%-60% at ESS of 2, 10 and 16 points, respectively. ESS predicted mortality, morbidity, and need for ICU best in patients 65-74 years old (c-statistic:0.81, 0.75, 0.83 respectively), but its performance significantly decreased in patients ≥85 years (c-statistic:0.72, 0.64, 0.67 respectively). CONCLUSION ESS is an accurate predictor of outcome in the elderly EL patient 65-85 years old, but its performance decreases for patients ≥85. Consideration should be given to modify ESS to better predict outcomes in the very elderly patient population.
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Affiliation(s)
- Majed El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA; Division of Acute Care and Ambulatory Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Brittany Aicher
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jose Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Lindsay OʼMeara
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Cassandra Decker
- UCHealth Memorial Hospital Central Trauma Center, Colorado Springs, CO, USA
| | - Jennifer Rodriquez
- UCHealth Memorial Hospital Central Trauma Center, Colorado Springs, CO, USA
| | - Thomas Schroeppel
- UCHealth Memorial Hospital Central Trauma Center, Colorado Springs, CO, USA
| | - Rishi Rattan
- The DeWitt Daughtry Family Department of Surgery Ryder Trauma Center/ Jackson Memorial Hospital, Miami, FL, USA
| | - Georgia Vasileiou
- The DeWitt Daughtry Family Department of Surgery Ryder Trauma Center/ Jackson Memorial Hospital, Miami, FL, USA
| | - D Dante Yeh
- The DeWitt Daughtry Family Department of Surgery Ryder Trauma Center/ Jackson Memorial Hospital, Miami, FL, USA
| | | | - David Turay
- Loma Linda University Medical Center, Loma Linda, CA, USA
| | | | | | | | | | | | | | | | | | - Rachel Choron
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph Sakran
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - George Black
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
| | - Thomas Shoultz
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
| | - Zachary Chadnick
- Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Vasiliy Sim
- Staten Island University Hospital, Northwell Health, Staten Island, NY, USA
| | - Firas Madbak
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Daniel Steadman
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | | | | | | | | | - Mirhee Kim
- New York University School of Medicine, New York, NY, USA
| | - Simon Rodier
- New York University School of Medicine, New York, NY, USA
| | - Vasileios Papadopoulos
- Papageorgiou General Hospital/Aristotle University School of Medicine, Thessaloniki, Greece
| | - Georgios Tsoulfas
- Papageorgiou General Hospital/Aristotle University School of Medicine, Thessaloniki, Greece
| | - Javier Perez
- Hackensack University Medical Center, Hackensack, NJ, USA
| | - Haytham Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
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Hansted AK, Møller MH, Møller AM, Wetterslev J, Rosenberg J, Jorgensen LN, Waldau T, Vester‐Andersen M. Long-term mortality in the Intermediate care after emergency abdominal surgery (InCare) trial-A post-hoc follow-up study. Acta Anaesthesiol Scand 2020; 64:1100-1105. [PMID: 32386082 DOI: 10.1111/aas.13613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients undergoing emergency abdominal surgery are at high risk of post-operative complications. Although post-operative treatment at an intermediate care unit may improve early outcome, there is a lack of studies on the long-term effects of such therapy. The aim of this study was to assess the long-term effect of intermediate care versus standard surgical ward care on mortality in the Intermediate Care After Emergency Abdominal Surgery (InCare) trial. METHODS We included adult patients undergoing emergency major laparoscopy or laparotomy with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 10 or more, who participated in the InCare trial from October 2010 to November 2012. In the InCare trial, patients were randomized to either post-operative intermediate care or standard surgical ward care. The primary outcome was time to death within 6 years after surgery. We assessed mortality with Coxregression analysis. RESULTS A total of 286 patients were included. The all-cause 6-year landmark mortality was 52.8% (76 of 144 patients) in the intermediate care group and 47.9% (68 of 142 patients) in the ward care group. There was no statistically significant difference in mortality risk between the two groups (hazard ratio 1.06 (95% confidence interval 0.76-1.47), P = .73). CONCLUSION We found no statistically significant difference in 6-year mortality between patients randomized to post-operative intermediate care or ward care after emergency abdominal surgery. However, we detected an absolute mortality risk reduction of 5% in favour of ward care, possibly due to random error.
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Affiliation(s)
- Anna K. Hansted
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES) Department of Anaesthesiology Herlev HospitalUniversity of Copenhagen Herlev Denmark
| | - Morten H. Møller
- Department of Intensive Care 4131 RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Ann M. Møller
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES) Department of Anaesthesiology Herlev HospitalUniversity of Copenhagen Herlev Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit Dpt. 7812 RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Jacob Rosenberg
- Department of Surgery Herlev HospitalUniversity of Copenhagen Copenhagen Denmark
| | - Lars N. Jorgensen
- Digestive Disease Center Bispebjerg HospitalUniversity of Copenhagen Copenhagen Denmark
| | - Tina Waldau
- Department of Intensive Care Herlev HospitalUniversity of Copenhagen Herlev Denmark
| | - Morten Vester‐Andersen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES) Department of Anaesthesiology Herlev HospitalUniversity of Copenhagen Herlev Denmark
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Nugent E, O'Connell E, Ooi E, McCawley N, Burke JP, McNamara DA. Impact of service delivery factors on patient outcomes in emergency general surgery. Surgeon 2020; 19:156-161. [PMID: 32444339 DOI: 10.1016/j.surge.2020.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 04/16/2020] [Accepted: 04/20/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) is a high-risk process and is associated with poor outcomes and high mortality. This study aimed to evaluate the service delivery factors in a tertiary referral centre which may influence patient outcomes in emergency general surgery. METHODS Data on consecutive patients undergoing emergency laparotomy in a tertiary referral centre were prospectively collected from July 2017-July 2018. An extensive review of patient charts and IT systems was performed to extract demographic, clinical and care pathway data. Transfers for surgery from within the institution or within the centralised hospital network were recorded. RESULTS The unadjusted 30-day mortality rate in 163 patients undergoing emergency laparotomy was 13%. On multivariate analysis, 30-day mortality was significantly associated with p-POSSUM predicted mortality (p = 0.003), p-POSSUM predicted morbidity (p = 0.01), SORT mortality (p = 0.004), ICU admission (p = 0.02), ASA grade (p < 0.001) and transfer from non-surgical services (p < 0.001). 19.2% of patients were transferred from a referring hospital for emergency laparotomy. There was no association between inter-hospital transfer and 30-day mortality while increased mortality was observed in patients admitted to non-surgical services who required laparotomy (p < 0.001). CONCLUSION Inter-hospital transfer for emergency laparotomy was not associated with increased mortality. Increased mortality was observed in patients admitted to non-surgical services who subsequently required emergency laparotomy. Configuration of emergency general surgery services must accommodate safe and effective transfer of patients, both between and within hospitals.
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Affiliation(s)
- Emmeline Nugent
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - Emer O'Connell
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.
| | - Emma Ooi
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - Niamh McCawley
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - John P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Deborah A McNamara
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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22
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Thahir A, Pinto-Lopes R, Madenlidou S, Daby L, Halahakoon C. Mortality risk scoring in emergency general surgery: Are we using the best tool? J Perioper Pract 2020; 31:153-158. [PMID: 32368947 DOI: 10.1177/1750458920920133] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND It is imperative that an accurate assessment of risk of death is undertaken preoperatively on all patients undergoing an emergency laparotomy. Portsmouth-Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) is one of the most widely used scores. National Emergency Laparotomy Audit (NELA) presents a novel, validated score, but no direct comparison with P-POSSUM exists. We aimed to determine which would be the best predictor of mortality. METHODS We analysed all the entries on the online NELA database over a four-and-a-half-year period. The Hosmer-Lemeshow goodness of fit test was performed to assess model calibration. For the outcome of death and for each scoring system, a non-parametric receiver operator characteristic analysis was done. The sensitivity, specificity, area under receiver operator characteristic curve and their standard errors were calculated. RESULTS Data pertaining to 650 patients were included. There were 59 deaths, giving an overall observed mortality rate of 9.1%. Predicted mortality rate for the P-POSSUM score and NELA score were 15.2% and 7.8%, respectively. The discriminative power for mortality was highest for the NELA score (C-index = 0.818, CI: 0.769-0.867, p < 0.001), when compared to P-POSSUM (C-index = 0.769, CI: 0.712-0.827, p < 0.001). CONCLUSIONS The NELA score showed good discrimination in predicting mortality in the entire cohort. The P-POSSUM over-predicted observed mortality and the NELA score under-predicted observed mortality.
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Affiliation(s)
- Azeem Thahir
- Department of General Surgery of 2592Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Rui Pinto-Lopes
- Department of General Surgery of 2592Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Stavroula Madenlidou
- Department of General Surgery of 2592Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Laura Daby
- Department of General Surgery of 2592Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Chandima Halahakoon
- Department of General Surgery of 2592Colchester Hospital University NHS Foundation Trust, Colchester, UK
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23
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Parkin CJ, Moritz P, Kirkland O, Doane M, Glover A. Utility of the American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator in predicting mortality in an Australian acute surgical unit. ANZ J Surg 2020; 90:746-751. [DOI: 10.1111/ans.15892] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/09/2020] [Accepted: 03/19/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Cameron J. Parkin
- Department of Surgery and Surgical Education Research and Training InstituteRoyal North Shore Hospital, Northern Sydney Local Health District Sydney New South Wales Australia
- Northern Clinical School, Faculty of Medicine and HealthSydney Medical School, The University of Sydney Sydney New South Wales Australia
| | - Peter Moritz
- Department of Surgery and Surgical Education Research and Training InstituteRoyal North Shore Hospital, Northern Sydney Local Health District Sydney New South Wales Australia
| | - Olivia Kirkland
- Department of Surgery and Surgical Education Research and Training InstituteRoyal North Shore Hospital, Northern Sydney Local Health District Sydney New South Wales Australia
| | - Matthew Doane
- Northern Clinical School, Faculty of Medicine and HealthSydney Medical School, The University of Sydney Sydney New South Wales Australia
- Department of AnaesthesiaRoyal North Shore Hospital, Northern Sydney Local Health District Sydney New South Wales Australia
| | - Anthony Glover
- Department of Surgery and Surgical Education Research and Training InstituteRoyal North Shore Hospital, Northern Sydney Local Health District Sydney New South Wales Australia
- Northern Clinical School, Faculty of Medicine and HealthSydney Medical School, The University of Sydney Sydney New South Wales Australia
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Emergency Surgery Mortality (ESM) Score to Predict Mortality and Improve Patient Care in Emergency Surgery. Anesthesiol Res Pract 2019; 2019:6760470. [PMID: 31662742 PMCID: PMC6778951 DOI: 10.1155/2019/6760470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/31/2019] [Accepted: 09/06/2019] [Indexed: 11/18/2022] Open
Abstract
Background Emergency surgery has poor outcomes with high mortality. Numerous studies have reported the risk factors for postoperative death in order to stratify risk and improve perioperative care; nevertheless, a predictive model based upon these risk factors is lacking. Objective We aimed to identify the risk factors of postoperative mortality and to construct a new model for predicting mortality and improving patient care. Methods We included adult patients undergoing emergency surgery at Srinagarind Hospital between January 2012 and December 2014. The patients were randomized: 80% to the Training group for model construction and 20% to the Validation group. Patient data were extracted from medical records and then analyzed using univariate and multivariate logistic regression. Results We recruited 758 patients, and the mortality rate was 14.5%. The Training group comprised 596 patients, and the Validation group comprised 162. Based upon a multivariate analysis in the Training group, we constructed a model to predict postoperative mortality-an Emergency Surgery Mortality (ESM) score based on the coefficient of each risk factor from the multivariate analysis. The ESM score comprised 7 risk factors, i.e., coagulopathy, ASA class 5, bicarbonate <15 mEq/L, heart rate >100/min, systolic blood pressure <90 mmHg, renal comorbidity, and general surgery, for a total score of 11. An ESM score ≥4 was predictive of postoperative mortality with an AUC of 0.83. The respective sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value, and accuracy for an ESM score ≥4 predictive of postoperative mortality was 70.2%, 94.9%, 13.8, 0.3, 69.4%, 95.1%, and 91.4%. The performance of the ESM score in the Validation group was comparable. Conclusions An ESM score comprises 7 risk factors for a total score of 11. An ESM score ≥4 is predictive of postoperative mortality with a high AUC (0.83), sensitivity (70.2%), and specificity (94.9%). Four risk factors are preoperatively manageable for decreasing the probability of postoperative mortality and improving quality of patient care.
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25
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Yeo LSH, Goo TT, Tan KY. Geriatric emergency laparotomy patients in a general hospital in Singapore. ANZ J Surg 2019; 89:E47. [PMID: 30756499 DOI: 10.1111/ans.14950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/07/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Lynn Soo Hoon Yeo
- Department of Anaesthesia, Khoo Teck Puat Hospital/Woodlands Health Campus, Singapore
| | - Tiong Thye Goo
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore
| | - Kok Yang Tan
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore
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26
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Tocaciu S, Thiagarajan J, Maddern GJ, Wichmann MW. Mortality after emergency abdominal surgery in a non‐metropolitan Australian centre. Aust J Rural Health 2018; 26:408-415. [DOI: 10.1111/ajr.12428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Shreya Tocaciu
- Department of General Surgery Mount Gambier General Hospital Mount Gambier South Australia Australia
| | - Jayaraman Thiagarajan
- Department of Anaesthesia Mount Gambier General Hospital Mount GambierSouth Australia Australia
| | - Guy J. Maddern
- Department of General Surgery Mount Gambier General Hospital Mount Gambier South Australia Australia
- Discipline of Surgery The Queen Elizabeth Hospital University of Adelaide Adelaide South Australia Australia
| | - Matthias W. Wichmann
- Department of General Surgery Mount Gambier General Hospital Mount Gambier South Australia Australia
- Discipline of Surgery The Queen Elizabeth Hospital University of Adelaide Adelaide South Australia Australia
- Flinders University Rural Medical School Flinders University Adelaide South Australia Australia
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27
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Han K, Lee JM, Achanta A, Kongkaewpaisan N, Kongwibulwut M, Eid AI, Kokoroskos N, van Wijck S, Meier K, Nordestgaard A, Rodriguez G, Jia Z, Lee J, King D, Fagenholz P, Saillant N, Mendoza A, Rosenthal M, Velmahos G, Kaafarani HMA. Emergency Surgery Score Accurately Predicts the Risk of Post-Operative Infection in Emergency General Surgery. Surg Infect (Larchmt) 2018; 20:4-9. [PMID: 30272533 DOI: 10.1089/sur.2018.101] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Emergency Surgery Score (ESS) was validated recently as an accurate and user-friendly post-operative mortality risk calculator specific for Emergency General Surgery (EGS). ESS is calculated by adding one to three integer points for each of 22 pre-operative variables (demographics, co-morbidities, and pre-operative laboratory values); increasing scores accurately and gradually predict higher mortality rates. We sought to evaluate whether ESS can predict the occurrence of post-operative infectious complications in EGS patients. PATIENTS AND METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2007-2015, all EGS patients were identified by using the "emergent" ACS-NSQIP variable and a concomitant surgery Current Procedural Terminology code for "digestive system." Patients with any missing ESS variables or those who died within 72 hours from the surgical procedure were excluded. A composite variable, post-operative infection, was created and defined as the post-operative occurrence of one or more of the following: superficial, deep incisional or organ/space surgical site infection, surgical site disruption, pneumonia, sepsis, septic shock, or urinary tract infection. ESS was calculated for all included patients, and the correlation between ESS and post-operative infection was examined using c-statistics. RESULTS Of a total of 4,456,809 patients, 90,412 patients were included. The mean age of the population was 56 years, 51% were female, and 70% were white; 22% developed one or more post-operative infections, most commonly sepsis/septic shock (12.2%), surgical site infection (9%), and pneumonia (5.7%). The ESS gradually and consistently predicted infectious complications; post-operative infections developed in 7%, 24%, and 49% of patients with an ESS of 1, 5, and 10, respectively. The c-statistics for overall post-operative infection, post-operative sepsis/septic shock, and pneumonia were 0.73, 0.75, and 0.80, respectively. CONCLUSION The ESS accurately predicts the occurrence of post-operative infectious complications in EGS patients and could be used for pre-operative clinical decision-making as well as quality benchmarking of infection rates in EGS.
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Affiliation(s)
- Kelsey Han
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Jae Moo Lee
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Aditya Achanta
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Manasnun Kongwibulwut
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Ahmed I Eid
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Nikolaos Kokoroskos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Suzanne van Wijck
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Karien Meier
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Ask Nordestgaard
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Gabriel Rodriguez
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Zhenyi Jia
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Jarone Lee
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - David King
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - April Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Martin Rosenthal
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
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Havens JM, Seshadri AJ, Salim A, Christopher KB. Red cell distribution width predicts out of hospital outcomes in critically ill emergency general surgery patients. Trauma Surg Acute Care Open 2018; 3:e000147. [PMID: 29766132 PMCID: PMC5931307 DOI: 10.1136/tsaco-2017-000147] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/06/2018] [Accepted: 03/02/2018] [Indexed: 01/01/2023] Open
Abstract
Introduction Red cell distribution width (RDW) is associated with mortality and bloodstream infection risk in critically ill patients. We hypothesized that an increase in RDW at hospital discharge in critically ill patients who received emergency general surgery (EGS) would be associated with increased mortality after hospital discharge. Methods We performed a two-center observational study of patients treated in medical and surgical intensive care units. We studied 1567 patients, who received critical care between 1998 and 2012 who underwent EGS and survived hospitalization. The exposure of interest was RDW within 24 hours of hospital discharge and categorized a priori in quintiles as ≤13.3%, 13.3% to 14.0%, 14.0% to 14.7%, 14.7% to 15.8%, 15.8% to 17.0% and >17.0%. The primary outcome was 90-day all-cause mortality. Adjusted ORs were estimated by multivariable logistic regression models with inclusion of covariate terms for age, race, gender, Deyo-Charlson Index, sepsis and number of organs with acute failure. Results The cohort patients were 51.4% male and 23.2% non-white. 23.9% had sepsis and the mean age was 58 years. 90-day postdischarge mortality was 6.8%. Patients with a discharge RDW 15.8% to 17.0% or RDW >17.0% have an adjusted OR of 90-day postdischarge mortality of 3.64 (95% CI 1.04 to 12.68; p=0.043) or 4.58 (95% CI 1.32 to 15.93; p=0.02), respectively, relative to patients with a discharge RDW ≤13.3%. Further, patients with a discharge RDW ≥15.8 have an adjusted OR of 30-day hospital readmission of 2.12 (95% CI 1.17 to 3.83; p=0.013) relative to patients with a discharge RDW ≤13.3%. Conclusions In EGS patients requiring critical care who survive hospitalization, an elevated RDW at the time of discharge is a robust predictor of all-cause patient mortality and hospital readmission after discharge. Level of evidence Level II, prognostic retrospective study.
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Affiliation(s)
- Joaquim Michael Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anupamaa J Seshadri
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ali Salim
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kenneth B Christopher
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,The Nathan E. Hellman Memorial Laboratory Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Hussain A, Mahmood F, Teng C, Jafferbhoy S, Luke D, Tsiamis A. Patient outcome of emergency laparotomy improved with increasing "number of surgeons on-call" in a university hospital: Audit loop. Ann Med Surg (Lond) 2017; 23:21-24. [PMID: 29021897 PMCID: PMC5633340 DOI: 10.1016/j.amsu.2017.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 09/13/2017] [Accepted: 09/17/2017] [Indexed: 12/27/2022] Open
Abstract
AIM Emergency laparotomy is a commonly performed high-mortality surgical procedure. The National Emergency Laparotomy Network (NELA) published an average mortality rate of 11.1% and a median length of stay equivalent to 16.3 days in patients undergoing emergency laparotomy. This study presents a completed audit loop after implementing the change of increasing the number of on-call surgeons in the general surgery rota of a university hospital. The aim of this study was to evaluate the outcomes of emergency laparotomy in a single UK tertiary centre after addition of one more consultant in the daily on-call rota. METHODS This is a retrospective study involving patients who underwent emergency laparotomy between March to May 2013 (first audit) and June to August 2015 (second audit). The study parameters stayed the same. The adult patients undergoing emergency laparotomy under the general surgical take were included. Appendicectomy, cholecystectomy and simple inguinal hernia repair patients were excluded. Data was collected on patient demographics, ASA, morbidity, 30-day mortality and length of hospital stay. Statistical analysis including logistic regression was performed using SPSS. RESULTS During the second 3-month period, 123 patients underwent laparotomy compared to 84 in the first audit. Median age was 65(23-93) years. 56.01% cases were ASA III or above in the re-audit compared to 41.9% in the initial audit. 38% patients had bowel anastomosis compared to 35.7% in the re-audit with 4.2% leak rate in the re-audit compared to 16.6% in the first audit. 30-day mortality was 10.50% in the re-audit compared to 21% and median length of hospital stay 11 days in the re-audit compared to 16 days. The lower ASA grade was significantly associated with increased likelihood of being alive, as was being female, younger age and not requiring ITU admission post-operatively. However, having a second on-call consultant was 2.231 times more likely to increase the chances of patients not dying (p = 0.031). CONCLUSION Our audit-loop suggests that adding a second consultant to the daily on-call rota significantly reduces postoperative mortality and morbidity. Age, ASA and ITU admission are other independent factors affecting patient outcomes. We suggest this change be applied to other high volume centres across the country to improve the outcomes after emergency laparotomy.
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Affiliation(s)
- Anwar Hussain
- SpR Colorectal Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Fahad Mahmood
- Core Trainee General Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Chui Teng
- FY1 General Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Sadaf Jafferbhoy
- SpR General Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - David Luke
- Consultant colorectal Surgeon, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Achilleas Tsiamis
- Consultant colorectal Surgeon, Department of Colorectal Surgery, University Hospital of North Midlands, UK
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30
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Ho YM, Cappello J, Kousary R, McGowan B, Wysocki AP. Benchmarking against the National Emergency Laparotomy Audit recommendations. ANZ J Surg 2017; 88:428-433. [DOI: 10.1111/ans.14164] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 06/17/2017] [Accepted: 06/25/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Yiu Ming Ho
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
- Department of Medicine; Griffith University School of Medicine; Gold Coast Queensland Australia
| | - Julie Cappello
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
| | - Ramin Kousary
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
| | - Brian McGowan
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
| | - Arkadiusz P. Wysocki
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
- Department of Medicine; Griffith University School of Medicine; Gold Coast Queensland Australia
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31
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Tengberg LT, Cihoric M, Foss NB, Bay-Nielsen M, Gögenur I, Henriksen R, Jensen TK, Tolstrup MB, Nielsen LBJ. Complications after emergency laparotomy beyond the immediate postoperative period - a retrospective, observational cohort study of 1139 patients. Anaesthesia 2016; 72:309-316. [PMID: 27809332 DOI: 10.1111/anae.13721] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 12/25/2022]
Abstract
Mortality and morbidity occur commonly following emergency laparotomy, and incur a considerable clinical and financial healthcare burden. Limited data have been published describing the postoperative course and temporal pattern of complications after emergency laparotomy. We undertook a retrospective, observational, multicentre study of complications in 1139 patients after emergency laparotomy. A major complication occurred in 537/1139 (47%) of all patients within 30 days of surgery. Unadjusted 30-day mortality was 20.2% and 1-year mortality was 34%. One hundred and thirty-seven of 230 (60%) deaths occurred between 72 h and 30 days after surgery; all of these patients had complications, indicating that there is a prolonged period with a high frequency of complications and mortality after emergency laparotomy. We conclude that peri-operative, enhanced recovery care bundles for preventing complications should extend their focus on continuous complication detection and rescue beyond the first few postoperative days.
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Affiliation(s)
- L T Tengberg
- Copenhagen University Hospital, Hvidovre, Denmark
| | - M Cihoric
- Copenhagen University Hospital, Hvidovre, Denmark
| | - N B Foss
- Copenhagen University Hospital, Hvidovre, Denmark
| | | | - I Gögenur
- Copenhagen University Hospital, Køge, Denmark
| | - R Henriksen
- Copenhagen University Hospital, Hillerød, Denmark
| | - T K Jensen
- Copenhagen University Hospital, Herlev, Denmark
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32
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COCORULLO G, FALCO N, TUTINO R, FONTANA T, SCERRINO G, SALAMONE G, LICARI L, GULOTTA G. Open versus laparoscopic approach in the treatment of abdominal emergencies in elderly population. G Chir 2016; 37:108-112. [PMID: 27734793 PMCID: PMC5119696 DOI: 10.11138/gchir/2016.37.3.108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM To evaluate the role of laparoscopy in the treatment of surgical emergency in old population. PATIENTS AND METHODS Over-70 years-old patients submitted to emergency abdominal surgery from January 2013 to December 2014 were collected and grouped according to admission diagnoses. These accounted small bowel obstruction, colonic acute disease, appendicitis, ventral hernia, gastro-duodenal perforation, biliary disease. In each group it was analyzed the operation time (OT), the morbidity rate and the mortality rate comparing open and laparoscopic management using T-test and Chi-square test. RESULTS 159 over 70-years-old patients underwent emergency surgery in the General and Emergency surgery Operative Unit (O.U.) of the Policlinic of Palermo. 75 patients were managed by a laparoscopic approach and 84 underwent traditional open emergency surgery. T-Test for OT and Chi-square test for morbidity rate and mortality rate showed no differences in small bowel emergencies (p=0,4; 0,25 0,9; p>0,95) and in gastro-duodenal perforation (p=0,9; p>0.9; p>0.95). In cholecystitis, laparoscopy group showed lower OT (T-Test: p= 0,0002) while Chi-square test for morbidity rate (0,1 CONCLUSIONS The collected data showed the feasibility of laparoscopic management as an alternative to open surgery in surgical emergencies in elderly population.
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Affiliation(s)
- G. COCORULLO
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
| | - N. FALCO
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
| | - R. TUTINO
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
| | - T. FONTANA
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
| | - G. SCERRINO
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
| | - G. SALAMONE
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
| | - L. LICARI
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
| | - G. GULOTTA
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
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Abstract
Intraabdominal infections represent a diagnostic and therapeutic challenge in the elderly population. Atypical presentations, diagnostic delays, additional comorbidities, and decreased physiologic reserve contribute to high morbidity and mortality, particularly among frail patients undergoing emergency abdominal surgery. While many infections are the result of age-related inflammatory, mechanical, or obstructive processes, infectious complications of feeding tubes are also common. The pillars of treatment are source control of the infection and judicious use of antibiotics. A patient-centered approach considering the invasiveness, risk, and efficacy of a procedure for achieving the desired outcomes is recommended. Structured communication and time-limited trials help ensure goal-concordant treatment.
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