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Pouke A, Ylimartimo A, Nurkkala J, Lahtinen S, Koskela M, Vakkala M, Kaakinen T, Raatiniemi L, Liisanantti J. Socio-economic factors and rural-urban differences in patients undergoing emergency laparotomy. Ann Med Surg (Lond) 2024; 86:5704-5710. [PMID: 39359844 PMCID: PMC11444583 DOI: 10.1097/ms9.0000000000002498] [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: 06/18/2024] [Accepted: 08/07/2024] [Indexed: 10/04/2024] Open
Abstract
Background Emergency laparotomy (EL) is a common surgical procedure with high rates of mortality and complications. Socio-economic circumstances and regional differences have an influence on the utilization of care and outcomes in many diagnostic groups, but there are only a few studies focusing on their effect in EL population. The aim of this study was to examine the socio-economic and regional differences in the rate of EL within one tertiary care hospital district. Methods Retrospective single-center study of 573 patients who underwent EL in Oulu University Hospital between May 2015 and December 2017. The postal code area of each patient's home address was used to determine the socio-economic status and rurality of the location of residence. Results The age-adjusted rate of EL was higher in patients from low-income areas compared to patients from high-income areas [1.46 ((95% CI 1.27-1.64)) vs. 1.15 (95% CI, 0.96-1.34)]. The rate of EL was higher in rural areas compared to urban areas [1.29 (95% CI 1.17-1.41 vs. 1.42 (1.18-1.67)]. Peritonitis was more common in patients living in low-income areas. There were no differences in operation types or mortality between the groups. Conclusions The study findings suggest that there are socio-economic and regional differences in the need of EL. The patients living in low-income areas had a higher rate of EL and a higher rate of peritonitis. These differences cannot be explained by patient demographics or comorbidities alone.
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Affiliation(s)
- Anne Pouke
- Research Unit of Translational Medicine, MRC Oulu, Oulu University
- Department of Anesthesiology, Oulu University Hospital
| | - Aura Ylimartimo
- Research Unit of Translational Medicine, MRC Oulu, Oulu University
- Department of Gastrointestinal Surgery, Oulu University Hospital, Oulu, Finland
| | - Juho Nurkkala
- Research Unit of Translational Medicine, MRC Oulu, Oulu University
| | - Sanna Lahtinen
- Research Unit of Translational Medicine, MRC Oulu, Oulu University
- Department of Anesthesiology, Oulu University Hospital
| | - Marjo Koskela
- Research Unit of Translational Medicine, MRC Oulu, Oulu University
- Department of Gastrointestinal Surgery, Oulu University Hospital, Oulu, Finland
| | - Merja Vakkala
- Research Unit of Translational Medicine, MRC Oulu, Oulu University
- Department of Anesthesiology, Oulu University Hospital
| | - Timo Kaakinen
- Research Unit of Translational Medicine, MRC Oulu, Oulu University
- Department of Anesthesiology, Oulu University Hospital
| | - Lasse Raatiniemi
- Research Unit of Translational Medicine, MRC Oulu, Oulu University
| | - Janne Liisanantti
- Research Unit of Translational Medicine, MRC Oulu, Oulu University
- Department of Anesthesiology, Oulu University Hospital
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Daba AB, Beshah DT, Tekletsadik EA. Magnitude of in-hospital mortality and its associated factors among patients undergone laparotomy at tertiary public hospitals, West Oromia, Ethiopia, 2022. BMC Surg 2024; 24:193. [PMID: 38902650 PMCID: PMC11188532 DOI: 10.1186/s12893-024-02477-1] [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: 11/18/2023] [Accepted: 06/10/2024] [Indexed: 06/22/2024] Open
Abstract
INTRODUCTION Laparotomy surgery, which involves making an incision in the abdominal cavity to treat serious abdominal disease and save the patient's life, causes significant deaths in both developed and developing countries, including Ethiopia. The number studies examining in-hospital mortality rates among individuals that undergone laparotomy surgery and associated risk factors is limited. OBJECTIVE To assess the magnitude of in-hospital mortality and its associated factors among patients undergone laparotomy at tertiary hospitals, West Oromia, Ethiopia, 2022. METHODS An institutional based retrospective cross-sectional study was conducted from January 1, 2017, to December 31, 2021. Data were collected using systematic random sampling and based on structured and pretested abstraction sheets from 548 medical records and patient register log. Data were checked for completeness and consistency, coded, imported using Epi-data version 4.6, cleaned and analyzed using SPSS version 25 software. Variables with p < 0.2 in the Bi-variable logistic regression analysis were included in the multivariate logistic regression analysis. The fit of the model was checked by the Hosmer‒Lemeshow test. Using the odds ratio adjusted to 95% CI and a p value of 0.05, statistical significance was declared. RESULTS A total of 512 patient charts were reviewed, and the response rate was 93.43%. The overall magnitude of in-hospital mortality was 7.42% [95% CI: 5.4-9.8]. American society of Anesthesiology physiological status greater than III [AOR = 7.64 (95% CI: 3.12-18.66)], systolic blood pressure less than 90 mmHg [AOR = 6.11 (95% CI: 1.98-18.80)], preoperative sepsis [AOR = 3.54 (95% CI: 1.53-8.19)], ICU admission [AOR = 4.75 (95% CI: 1.50-14.96)], and total hospital stay greater than 14 days [(AOR = 6.76 (95% CI: 2.50-18.26)] were significantly associated with mortality after laparotomy surgery. CONCUSSION In this study, overall in- hospital mortality was high. Early identification patient's American Society of Anesthesiologists physiological status and provision of early appropriate intervention, and pays special attention to patients admitted with low systolic blood pressure, preoperative sepsis, intensive care unit admission and prolonged hospital stay to improve patient outcomes after laparotomy surgery.
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Affiliation(s)
- Aliyi Benti Daba
- Institute of health science, Wallaga University, Nekemte, Ethiopia.
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3
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Marcolin P, Mazzola Poli de Figueiredo S, Oliveira Trindade B, Bueno Motter S, Brandão GR, Mao RMD, Moffett JM. Prophylactic mesh augmentation in emergency laparotomy closure: a meta-analysis of randomized controlled trials with trial sequential analysis. Hernia 2024; 28:677-690. [PMID: 38252397 DOI: 10.1007/s10029-023-02943-4] [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: 10/13/2023] [Accepted: 12/08/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Prophylactic mesh augmentation in emergency laparotomy closure is controversial. We aimed to perform a meta-analysis of randomized controlled trials (RCT) evaluating the placement of prophylactic mesh during emergency laparotomy. METHODS We performed a systematic review of Cochrane, Scopus, and PubMed databases to identify RCT comparing prophylactic mesh augmentation and no mesh augmentation in patients undergoing emergency laparotomy. We excluded observational studies, conference abstracts, elective surgeries, overlapping populations, and trial protocols. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. Risk of bias was assessed using the revised Cochrane risk-of-bias tool (RoB 2). The review protocol was registered at PROSPERO (CRD42023412934). RESULTS We screened 1312 studies and 33 were thoroughly reviewed. Four studies comprising 464 patients were included in the analysis. Mesh reinforcement was significantly associated with a decrease in incisional hernia incidence (OR 0.18; 95% CI 0.07-0.44; p < 0.001; I2 = 0%), and synthetic mesh placement reduced fascial dehiscence (OR 0.07; 95% CI 0.01-0.53; p = 0.01; I2 = 0%). Mesh augmentation was associated with an increase in operative time (MD 32.09 min; 95% CI 6.39-57.78; p = 0.01; I2 = 49%) and seroma (OR 3.89; 95% CI 1.54-9.84; p = 0.004; I2 = 0%), but there was no difference in surgical-site infection or surgical-site occurrences requiring procedural intervention or reoperation. CONCLUSIONS Mesh augmentation in emergency laparotomy decreases incisional hernia and fascial dehiscence incidence. Despite the risk of seroma, prophylactic mesh augmentation appears to be safe and might be considered for emergency laparotomy closure. Further studies evaluating long-term outcomes are still needed.
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Affiliation(s)
- P Marcolin
- School of Medicine, Universidade Federal da Fronteira Sul, Passo Fundo, RS, Brazil.
| | | | - B Oliveira Trindade
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - S Bueno Motter
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - G R Brandão
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - R-M D Mao
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - J M Moffett
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
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Snitkjær C, Rehné Jensen L, í Soylu L, Hauge C, Kvist M, Jensen TK, Kokotovic D, Burcharth J. Impact of clinical frailty on surgical and non-surgical complications after major emergency abdominal surgery. BJS Open 2024; 8:zrae039. [PMID: 38788680 PMCID: PMC11126315 DOI: 10.1093/bjsopen/zrae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 03/03/2024] [Accepted: 03/24/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Major emergency abdominal surgery is associated with a high risk of morbidity and mortality. Given the ageing and increasingly frail population, understanding the impact of frailty on complication patterns after surgery is crucial. The aim of this study was to evaluate the association between clinical frailty and organ-specific postoperative complications after major emergency abdominal surgery. METHODS A prospective cohort study including all patients undergoing major emergency abdominal surgery at Copenhagen University Hospital Herlev, Denmark, from 1 October 2020 to 1 August 2022, was performed. Clinical frailty scale scores were determined for all patients upon admission and patients were then analysed according to clinical frailty scale groups (scores of 1-3, 4-6, or 7-9). Postoperative complications were registered until discharge. RESULTS A total of 520 patients were identified. Patients with a low clinical frailty scale score (1-3) experienced fewer total complications (120 complications per 100 patients) compared with patients with clinical frailty scale scores of 4-6 (250 complications per 100 patients) and 7-9 (277 complications per 100 patients) (P < 0.001). A high clinical frailty scale score was associated with a high risk of pneumonia (P = 0.009), delirium (P < 0.001), atrial fibrillation (P = 0.020), and infectious complications in general (P < 0.001). Patients with severe frailty (clinical frailty scale score of 7-9) suffered from more surgical complications (P = 0.001) compared with the rest of the cohort. Severe frailty was associated with a high risk of 30-day mortality (33% for patients with a clinical frailty scale score of 7-9 versus 3.6% for patients with a clinical frailty scale score of 1-3, P < 0.001). In a multivariate analysis, an increasing degree of clinical frailty was found to be significantly associated with developing at least one complication. CONCLUSION Patients with frailty have a significantly increased risk of postoperative complications after major emergency abdominal surgery, especially atrial fibrillation, delirium, and pneumonia. Likewise, patients with frailty have an increased risk of mortality within 90 days. Thus, frailty is a significant predictor for adverse events after major emergency abdominal surgery and should be considered in all patients undergoing major emergency abdominal surgery.
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Affiliation(s)
- Christian Snitkjær
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
| | - Lasse Rehné Jensen
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
| | - Liv í Soylu
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
| | - Camilla Hauge
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
| | - Madeline Kvist
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
| | - Thomas K Jensen
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
| | - Dunja Kokotovic
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
| | - Jakob Burcharth
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital—Herlev and Gentofte, Herlev, Denmark
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Dessalegn M, Negesse A, Deresse T, Yigzaw Birhanu M, Agedew E, Dires G. Perioperative mortality rate and its predictors after emergency laparatomy at Debre Markos comprehensive specialized hospital, Northwest Ethiopia: 2023: retrospective follow-up study. BMC Surg 2024; 24:114. [PMID: 38627671 PMCID: PMC11020798 DOI: 10.1186/s12893-024-02401-7] [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: 11/03/2023] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Emergency laparatomy is abdominal surgery associated with a high rate of mortality. There are few reports on rates and predictors of postoperative mortality, whereas disease related or time specific studies are limited. Understanding the rate and predictors of mortality in the first 30 days (perioperative period) is important for evidence based decision and counseling of patients. This study aimed to estimate the perioperative mortality rate and its predictors after emergency laparatomy at Debre Markos Comprehensive Specialized Hospital, Northwest Ethiopia, 2023. METHODS This was a Hospital-based retrospective follow-up study conducted at Debre Markos Comprehensive Specialized Hospital in Ethiopia among patients who had undergone emergency laparatomy between January 1, 2019 and December 31, 2022. Sample of 418 emergency laparatomy patients selected with simple random sampling technique were studied. The data were extracted from March 15, 2023 to April 1, 2023 using a data extraction tool, cleaned, and entered into Epi-Data software version 3.1 before being exported to STATA software version 14.1 for analysis. Predictor variables with P value < 0.05 in multivariable Cox regression were reported. RESULTS Data of 386 study participants (92.3% complete charts) were analyzed. The median survival time was 18 days [IQR: (14, 29)]. The overall perioperative mortality rate in the cohort during the 2978 person-days of observations was 25.5 per 1000 person-days of follow-up [95% CI: (20.4, 30.9))]. Preoperative need for vasopressor [AHR: 1.8 (95% CI: (1.11, 2.98))], admission to intensive care unit [AHR: 2.0 (95% CI: (1.23, 3.49))], longer than three days of symptoms [AHR: 2.2 (95% CI: (1.15, 4.02))] and preoperative sepsis [AHR: 1.8 (95% CI: (1.05, 3.17))] were identified statistically significant predictors of perioperative mortality after emergency laparatomy. CONCLUSIONS The perioperative mortality rate is high. Preoperative need for vasopressors, admission to intensive care unit, longer than three days of symptoms and preoperative sepsis were predictors of increased perioperative mortality rate.
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Affiliation(s)
- Megbar Dessalegn
- Department of Surgery, School of Medicine, Debre Markos University, Debre Markos, Ethiopia.
| | - Ayenew Negesse
- Department of Human Nutrition, Health Science College, Debre Markos University, Debre markos, Ethiopia
| | - Tilahun Deresse
- Department of Surgery, School of Medicine, Debre Birhan University, Debre Markos, Ethiopia
| | - Molla Yigzaw Birhanu
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Eskeziyaw Agedew
- College of Health Sciences, Debre Markos University, Debre markos, Ethiopia
| | - Gedefaw Dires
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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6
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Tolstrup MB, Skovsen AP, Gögenur I. Determining a multidisciplinary intraoperative strategy in emergency surgery for bowel obstruction and its impact on outcomes. Langenbecks Arch Surg 2024; 409:110. [PMID: 38570353 DOI: 10.1007/s00423-024-03292-1] [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: 11/06/2023] [Accepted: 03/20/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE Bowel obstruction accounts for around 50% of all emergency laparotomies. A multidisciplinary (MDT) standardized intraoperative model was applied (definitive, palliative, or damage control surgery) to identify patients suitable for a one-step, definitive surgical procedure favoring anastomosis over stoma, when undergoing surgery for bowel obstruction. The objective was to present mortality according to the strategy applied and to compare the rate of laparoscopic interventions and stoma creations to a historic cohort in surgery for bowel obstruction. METHODS In a retrospective cohort study, we included patients undergoing emergency surgery for bowel obstruction during a 1-year period at two Copenhagen University Hospitals (2019 and 2021). The MDT model consisted of a 30- and 60-min time-out with variables such as functional and hemodynamic status, presence of malignancy, and surgical capabilities (lap/open). Pre-, intra-, and postoperative data were collected to investigate associations to postoperative complications and mortality. Stoma creation rates and laparoscopies were compared to a historic cohort (2009-2013). RESULTS Three hundred sixty-nine patients underwent surgery for bowel obstruction. Intraoperative surgical strategy was definitive in 77.0%, palliative in 22.5%, and damage control surgery in 0.5%. Thirty-day mortality was significantly lower in the definitive patient population (4.6%) compared to the palliative population (21.7%) (p < 0.000). Compared to the historic cohort, laparoscopic surgery for bowel obstruction increased from 5.0 to 26.4% during the 10-year time span, the rate of stoma placements was reduced from 12.0 to 6.1%, p 0.014, and the 30-day mortality decreased from 12.9 to 4.6%, p < 0.000. CONCLUSION An intraoperative improvement strategy can address the specific surgical interventions in patients undergoing surgery for bowel obstruction, favoring anastomosis over stoma whenever resection was needed, and help adjust specific postoperative interventions and care pathways in cases of palliative need.
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Affiliation(s)
- Mai-Britt Tolstrup
- Department of Gastrointestinal Surgery, Copenhagen University Hospital Hilleroed, Dyrehavevej 29, 3400, Hillerød, Denmark.
| | - Anders Peter Skovsen
- Department of Gastrointestinal Surgery, Copenhagen University Hospital Hilleroed, Hillerød, Denmark
| | - Ismail Gögenur
- Department of Gastrointestinal Surgery, Copenhagen University Hospital Roskilde and Koege, Roskilde, Denmark
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Harji DP, Griffiths B, Stocken D, Pearse R, Blazeby J, Brown JM. Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis. Br J Surg 2024; 111:znae057. [PMID: 38513265 PMCID: PMC10957158 DOI: 10.1093/bjs/znae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes. METHODS The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling. RESULTS Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001). DISCUSSION Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.
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Affiliation(s)
- Deena P Harji
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ben Griffiths
- Department of Colorectal Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Rupert Pearse
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical research Centre, Bristol, UK
| | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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8
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Í Soylu L, Kokotovic D, Gögenur I, Ekeloef S, Burcharth J. Short and long-term readmission after major emergency abdominal surgery: a prospective Danish study. Eur J Trauma Emerg Surg 2024; 50:295-304. [PMID: 37646801 PMCID: PMC10923996 DOI: 10.1007/s00068-023-02352-3] [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: 05/04/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Major emergency abdominal surgery is associated with severe in-hospital complications and loss of performance. After discharge, a substantial fraction of patients are readmitted emergently; however, limited knowledge exists of the long-term consequences. The aim of this study was to examine the risks and causes of short-term (30-day) and long-term (180-day) readmission among patients undergoing major emergency abdominal surgery. METHODS This study included 504 patients who underwent major emergency abdominal surgery at the Zealand University Hospital between March 1, 2017, and February 28, 2019. The population was followed from 0 to 180 days after discharge, and detailed readmission information was registered. A Cox proportional hazards model was used to examine the independent risk factors for readmission within 30 and 180 days. RESULTS From 0 to 30 days after discharge, 161 (31.9%) patients were readmitted emergently, accumulating to 241 (47.8%) patients within 180 days after discharge. The main reasons for short-term readmission were related to the gastrointestinal tract and surgical wounds, whereas long-term readmissions were due to infections, cardiovascular complications, and abdominal pain. Stomal placement was an independent risk factor for short-term readmission, whereas an ASA score of 3 was a risk factor for both short-term and long-term readmission. CONCLUSION Close to 50% of all patients who underwent major emergency abdominal surgery had one or more emergency readmission within 180 days of discharge, and these data points towards the risk factors involved.
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Affiliation(s)
- Lív Í Soylu
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
| | - Dunja Kokotovic
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Sarah Ekeloef
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Jakob Burcharth
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
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9
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Guest JF, Fuller GW, Griffiths B. Cohort study to characterise surgical site infections after open surgery in the UK's National Health Service. BMJ Open 2023; 13:e076735. [PMID: 38110388 DOI: 10.1136/bmjopen-2023-076735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVE To characterise surgical site infections (SSIs) after open surgery in the UK's National Health Service. DESIGN Retrospective cohort analysis of electronic records of patients from Clinical Practice Research Datalink, linked with Hospital Episode Statistics' secondary care datasets. SETTING Clinical practice in the community and secondary care. PARTICIPANTS Cohort of 50 000 adult patients who underwent open surgery between 2017 and 2022. OUTCOME MEASURES Incidence of SSI, clinical outcomes, patterns of care and costs of wound management. RESULTS 11% (5281/50 000) of patients developed an SSI a mean of 18.4±14.7 days after their surgical procedure, of which 15% (806/5281) were inpatients and 85% (4475/5281) were in the community after hospital discharge. The incidence of SSI varied according to anatomical site of surgery. The incidence also varied according to a patient's risk and whether they underwent an emergency procedure. SSI onset reduced the 6 months healing rate by a mean of 3 percentage points and increased time to wound healing by a mean of 15 days per wound. SSIs were predominantly managed in the community by practice and district nurses and 16% (850/5281) of all patients were readmitted into hospital. The total health service cost of surgical wound management following SSI onset was a mean of £3537 per wound ranging from £2542 for a low-risk patient who underwent an elective procedure to £4855 for a high-risk patient who underwent an emergency procedure. CONCLUSIONS This study provides important insights into several aspects of SSI management in clinical practice in the UK that have been difficult to ascertain from surveillance data. Surgeons are unlikely to be fully aware of the true incidence of SSI and how they are managed once patients are discharged from hospital. Current SSI surveillance services appear to be under-reporting the actual incidence.
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Affiliation(s)
| | | | - Ben Griffiths
- Manchester University NHS Foundation Trust, Manchester, UK
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10
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Pinto MY, Frois AO, Weber D. A Retrospective Cohort Study on One-Year Mortality Following Emergency Laparotomy: A Tertiary Centre Experience From Western Australia. Cureus 2023; 15:e50718. [PMID: 38234926 PMCID: PMC10792340 DOI: 10.7759/cureus.50718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/19/2024] Open
Abstract
Background Emergency laparotomy is a common general surgical procedure associated with a high mortality and morbidity profile. While short-term outcomes following emergency laparotomy have been increasingly described, there remains a paucity of literature on long-term outcomes in Australia. We report our one-year mortality following emergency laparotomy at Royal Perth Hospital, Australia. Methodology A retrospective observational series of emergency laparotomies performed during 2019 and 2020 at Royal Perth Hospital was collected. The primary endpoint is the one-year mortality, and the secondary endpoints are patient demography, COVID-19 status, ASA classification, surgical category, operative indication, primary surgical pathology, procedure and surgical duration, ICU stay, post-operative destination, length of stay, 30-day mortality, and 90-day mortality. Subgroup analysis was performed for years 2019 and 2020. Results A total of 272 emergency laparotomies were performed during the two-year study period. The average age was 61 years (range 18- 98, SD ± 18.32). The majority of patients were in the ASA classification III (n= 134, 49.26%). The average length of patients' stay was 14.17 days (median 10, IQR 11). Moreover, 31.98% of patients were admitted directly to the ICU following emergency laparotomy. One year mortality was 16.6%. However, a significant difference in the long-term mortality rates was observed between the two calendar years, 24.6% in 2019 and 8.66% in 2020. The one-month mortality rate was 7.33%, and the three-month mortality rate was 10.85%. Conclusion The one-year mortality rate observed is high and considerable and similar to experiences published elsewhere. The significant reduction in mortality during the study period warrants further investigation and may reflect improved planning and attitudes around these high-risk surgeries.
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Affiliation(s)
| | - Ashley O Frois
- Department of General Surgery, Royal Perth Hospital, Perth, AUS
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, AUS
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Elamin A, Walker E, Sugrue M, Khalid SY, Stephens I, Lloyd A. Enhancing operative documentation of emergency laparotomy: a systematic review and development of a synoptic reporting template. World J Emerg Surg 2023; 18:53. [PMID: 38037125 PMCID: PMC10688081 DOI: 10.1186/s13017-023-00523-6] [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: 10/09/2023] [Accepted: 11/03/2023] [Indexed: 12/02/2023] Open
Abstract
INTRODUCTION Currently, operative reports are narrative and often handwritten, making interpretation difficult and potentially omitting key steps of the procedure. This study undertook a systematic review to determine the current availability of synoptic operative reporting and develop a synoptic operative record template for emergency laparotomy (EL). METHODS A PROSPERO registered study from January 1st, 2012, to December 31st, 2022, was conducted using PubMed, Scopus, and Web of Science databases in February 2023. KEYWORDS emergency laparotomy AND operation notes OR operative notes OR documentation OR report OR pro forma OR narrative OR synoptic OR digital OR audio-visual. Studies on paediatric or pregnant patients, systematic reviews, meta-analyses, case reports, editorial comments, and letters were excluded. A synoptic operative record was designed to include key standards in the documentation, as suggested by the Colleges of Surgeons. RESULTS The literature search yielded 4687 articles, and no relevant published articles were found. A detailed synoptic template was developed, which included 111 fields related to patient demographics, operative findings, interventions, and documentation of key variables associated with patient outcomes. 11 were text boxes, two were related to digital audio-visual uploads, and three facilitated the digital scoring/grading of findings. CONCLUSION This systematic review identified a limited number of publications reporting synoptic operative reporting, and none related to emergency laparotomy. This novel operative template provides a platform for clear documentation of the surgery performed during emergency laparotomy, potentially facilitating data analysis, resident training, and research, in turn leading to a better understanding of patient outcomes.
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Affiliation(s)
- Aiman Elamin
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Emma Walker
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland.
| | - Syed Yousaf Khalid
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Ian Stephens
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Angus Lloyd
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
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Alizai Q, Anand T, Bhogadi SK, Nelson A, Hosseinpour H, Stewart C, Spencer AL, Colosimo C, Ditillo M, Joseph B. From surveillance to surgery: The delayed implications of non-operative and operative management of pancreatic injuries. Am J Surg 2023; 226:682-687. [PMID: 37543483 DOI: 10.1016/j.amjsurg.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Our study compares the delayed outcomes of operative versus nonoperative management of pancreatic injuries. METHODS We analyzed the 2017 Nationwide Readmissions Database on adult (≥18 years) trauma patients with pancreatic injuries. Patients who died on index admission were excluded. Patients were stratified into operative (OP) and non-operative (NOP) groups and compared for outcomes within 90 days of discharge. Multivariable regression analyses were performed. RESULTS We identified 1553 patients (NOP = 1092; OP = 461). The Mean (SD) age was 39 (17.0) years, 31% of patients were female, and 77% had blunt injuries. Median ISS was 17 [9-25] and 74% had concomitant non-pancreatic intraabdominal injuries. On multivariable analysis, operative management was independently associated with increased odds of 90-day readmissions (aOR = 1.47; p = 0.03), intraabdominal abscesses (aOR = 2.7; p < 0.01), pancreatic pseudocyst (aOR = 2.4; p = 0.04), and need for percutaneous or endoscopic management (aOR = 5.8; p < 0.001). CONCLUSION Operative management of pancreatic injuries is associated with higher rates of delayed complications compared to non-operative management. Surgically treated pancreatic trauma patients may need close surveillance even after discharge.
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Affiliation(s)
- Qaidar Alizai
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Collin Stewart
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
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Skovsen AP, Burcharth J, Gögenur I, Tolstrup MB. Small bowel anastomosis in peritonitis compared to enterostomy formation: a systematic review. Eur J Trauma Emerg Surg 2023; 49:2047-2055. [PMID: 36526812 DOI: 10.1007/s00068-022-02192-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Anastomotic leakage after small bowel resection in emergency laparotomy is a severe complication. A consensus on the risk factors for anastomotic leakage has not been established, and it is still unclear if peritonitis is a risk factor. This systematic review aimed to evaluate if an entero-entero/entero-colonic anastomosis is safe in patients with peritonitis undergoing abdominal acute care surgery. METHODS A systematic literature review based on PRISMA guidelines was performed, searching the databases Pubmed/MEDLINE, Cochrane Library, and Science Direct for studies of anastomosis in peritonitis. Patients with an anastomosis after non-planned small bowel resection (ischemia, perforation, or strangulation), including secondary peritonitis, were included. Elective laparotomies and colo-colonic anastomoses were excluded. Due to the etiology, traumatic perforation, in-vitro, and animal studies were excluded. RESULTS This review identified 26 studies of small-bowel anastomosis in peritonitis with a total of 2807 patients. This population included a total of 889 small-bowel/right colonic resections with anastomoses, and 242 enterostomies. All studies, except two, were retrospective reviews or case series. The overall mortality rates were 0-20% and anastomotic leakage rates 0-36%. After performing a risk of bias evaluation there was no basis for conducting a meta-analysis. The quality of evidence was rated as low. CONCLUSION There was no evidence to refute performing a primary small-bowel anastomosis in acute laparotomy with peritonitis. There is currently insufficient evidence to label peritonitis as a risk factor for anastomotic leakage in acute care laparotomy with small-bowel resection. TRIAL REGISTRATION The review was registered with the PROSPERO register of systematic reviews on 14/07/2020 with the ID: CRD42020168670.
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Affiliation(s)
- Anders Peter Skovsen
- Surgical Department, Hillerød Hospital, University of Copenhagen, Hillerød, Denmark.
| | - Jakob Burcharth
- Surgical Department, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Ismail Gögenur
- Surgical Department, Zealand University Hospital, University of Copenhagen, Køge, Denmark
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Mai-Britt Tolstrup
- Surgical Department, Hillerød Hospital, University of Copenhagen, Hillerød, Denmark
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Kokkinakis S, Kritsotakis EI, Paterakis K, Karali GA, Malikides V, Kyprianou A, Papalexandraki M, Anastasiadis CS, Zoras O, Drakos N, Kehagias I, Kehagias D, Gouvas N, Kokkinos G, Pozotou I, Papatheodorou P, Frantzeskou K, Schizas D, Syllaios A, Palios IM, Nastos K, Perdikaris M, Michalopoulos NV, Margaris I, Lolis E, Dimopoulou G, Panagiotou D, Nikolaou V, Glantzounis GK, Pappas-Gogos G, Tepelenis K, Zacharioudakis G, Tsaramanidis S, Patsarikas I, Stylianidis G, Giannos G, Karanikas M, Kofina K, Markou M, Chrysos E, Lasithiotakis K. Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy. J Trauma Acute Care Surg 2023; 94:847-856. [PMID: 36726191 DOI: 10.1097/ta.0000000000003904] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Accurate preoperative risk assessment in emergency laparotomy (EL) is valuable for informed decision making and rational use of resources. Available risk prediction tools have not been validated adequately across diverse health care settings. Herein, we report a comparative external validation of four widely cited prognostic models. METHODS A multicenter cohort was prospectively composed of consecutive patients undergoing EL in 11 Greek hospitals from January 2020 to May 2021 using the National Emergency Laparotomy Audit (NELA) inclusion criteria. Thirty-day mortality risk predictions were calculated using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), NELA, Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM), and Predictive Optimal Trees in Emergency Surgery Risk tools. Surgeons' assessment of postoperative mortality using predefined cutoffs was recorded, and a surgeon-adjusted ACS-NSQIP prediction was calculated when the original model's prediction was relatively low. Predictive performances were compared using scaled Brier scores, discrimination and calibration measures and plots, and decision curve analysis. Heterogeneity across hospitals was assessed by random-effects meta-analysis. RESULTS A total of 631 patients were included, and 30-day mortality was 16.3%. The ACS-NSQIP and its surgeon-adjusted version had the highest scaled Brier scores. All models presented high discriminative ability, with concordance statistics ranging from 0.79 for P-POSSUM to 0.85 for NELA. However, except the surgeon-adjusted ACS-NSQIP (Hosmer-Lemeshow test, p = 0.742), all other models were poorly calibrated ( p < 0.001). Decision curve analysis revealed superior clinical utility of the ACS-NSQIP. Following recalibrations, predictive accuracy improved for all models, but ACS-NSQIP retained the lead. Between-hospital heterogeneity was minimum for the ACS-NSQIP model and maximum for P-POSSUM. CONCLUSION The ACS-NSQIP tool was most accurate for mortality predictions after EL in a broad external validation cohort, demonstrating utility for facilitating preoperative risk management in the Greek health care system. Subjective surgeon assessments of patient prognosis may optimize ACS-NSQIP predictions. LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level II.
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Affiliation(s)
- Stamatios Kokkinakis
- From the Department of General Surgery (S.K., K.P., G.-A.K., V.M., A.K., M.P., E.C., K.L.), University Hospital of Heraklion, University of Crete, School of Medicine; Laboratory of Biostatistics, University of Crete, School of Medicine (E.I.K.); Department of Surgical Oncology, University Hospital of Heraklion, University of Crete, School of Medicine (C.S.A., O.Z.), Heraklion; Department of Surgery, University General Hospital of Patras, School of Medicine (N.D., I.K., D.K.), University of Patras, Patras, Greece; Department of Surgery, General Hospital of Nicosia, School of Medicine (N.G., G.K., I.P., P.P., K.F.), University of Cyprus, Nicosia, Cyprus; First Department of Surgery (D.S., A.S.) and Second Propaedeutic Department of Surgery (I.M.P.), Laikon General Hospital, National and Kapodistrian University of Athens; Department of Surgery, University General Hospital Attikon, School of Medicine (K.N., M.P., N.V.M., I.M.), University of Athens, Athens; Department of Surgery (E.L., G.D.), General Hospital of Volos, Volos, Greece; Department of Surgery (D.P., V.N.), General Hospital of Trikala, Trikala; Department of Surgery (G.K.G., G.P.-G., K.T.), University Hospital of Ioannina, Ioannina, Greece; Department of Surgery, Ippokrateion General Hospital of Thessaloniki, School of Medicine (G.Z., S.T., I.P.), Aristotle University of Thessaloniki, Thessaloniki; Second Department of Surgery (G.S., G.G.), Evangelismos General Hospital, Athens; and Department of Surgery, University General Hospital of Alexandroupolis, School of Medicine (M.K., K.K., M.M.), University of Thrace, Alexandroupolis, Greece
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Park S, Ye JC, Lee ES, Cho G, Yoon JW, Choi JH, Joo I, Lee YJ. Deep Learning-Enabled Detection of Pneumoperitoneum in Supine and Erect Abdominal Radiography: Modeling Using Transfer Learning and Semi-Supervised Learning. Korean J Radiol 2023; 24:541-552. [PMID: 37271208 DOI: 10.3348/kjr.2022.1032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 06/06/2023] Open
Abstract
OBJECTIVE Detection of pneumoperitoneum using abdominal radiography, particularly in the supine position, is often challenging. This study aimed to develop and externally validate a deep learning model for the detection of pneumoperitoneum using supine and erect abdominal radiography. MATERIALS AND METHODS A model that can utilize "pneumoperitoneum" and "non-pneumoperitoneum" classes was developed through knowledge distillation. To train the proposed model with limited training data and weak labels, it was trained using a recently proposed semi-supervised learning method called distillation for self-supervised and self-train learning (DISTL), which leverages the Vision Transformer. The proposed model was first pre-trained with chest radiographs to utilize common knowledge between modalities, fine-tuned, and self-trained on labeled and unlabeled abdominal radiographs. The proposed model was trained using data from supine and erect abdominal radiographs. In total, 191212 chest radiographs (CheXpert data) were used for pre-training, and 5518 labeled and 16671 unlabeled abdominal radiographs were used for fine-tuning and self-supervised learning, respectively. The proposed model was internally validated on 389 abdominal radiographs and externally validated on 475 and 798 abdominal radiographs from the two institutions. We evaluated the performance in diagnosing pneumoperitoneum using the area under the receiver operating characteristic curve (AUC) and compared it with that of radiologists. RESULTS In the internal validation, the proposed model had an AUC, sensitivity, and specificity of 0.881, 85.4%, and 73.3% and 0.968, 91.1, and 95.0 for supine and erect positions, respectively. In the external validation at the two institutions, the AUCs were 0.835 and 0.852 for the supine position and 0.909 and 0.944 for the erect position. In the reader study, the readers' performances improved with the assistance of the proposed model. CONCLUSION The proposed model trained with the DISTL method can accurately detect pneumoperitoneum on abdominal radiography in both the supine and erect positions.
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Affiliation(s)
- Sangjoon Park
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Jong Chul Ye
- Kim Jaechul Graduate School of AI, Korea Advanced Institute of Science and Technology, Daejeon, Korea.
| | - Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
- Biomedical Research Institute, Chung-Ang University Hospital, Seoul, Korea.
| | - Gyeongme Cho
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jin Woo Yoon
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Joo Hyeok Choi
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ijin Joo
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Yoon Jin Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
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Chok AY, Zhao Y, Chen HLR, Tan IEH, Chew DHW, Zhao Y, Au MKH, Tan EJKW. Elderly patients over 80 years undergoing colorectal cancer resection: Development and validation of a predictive nomogram for survival. World J Gastrointest Surg 2023; 15:892-905. [PMID: 37342856 PMCID: PMC10277950 DOI: 10.4240/wjgs.v15.i5.892] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Surgery remains the primary treatment for localized colorectal cancer (CRC). Improving surgical decision-making for elderly CRC patients necessitates an accurate predictive tool.
AIM To build a nomogram to predict the overall survival of elderly patients over 80 years undergoing CRC resection.
METHODS Two hundred and ninety-five elderly CRC patients over 80 years undergoing surgery at Singapore General Hospital between 2018 and 2021 were identified from the American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) database. Prognostic variables were selected using univariate Cox regression, and clinical feature selection was performed by the least absolute shrinkage and selection operator regression. A nomogram for 1- and 3-year overall survival was constructed based on 60% of the study cohort and tested on the remaining 40%. The performance of the nomogram was evaluated using the concordance index (C-index), area under the receiver operating characteristic curve (AUC), and calibration plots. Risk groups were stratified using the total risk points derived from the nomogram and the optimal cut-off point. Survival curves were compared between the high- and low-risk groups.
RESULTS Eight predictors: Age, Charlson comorbidity index, body mass index, serum albumin level, distant metastasis, emergency surgery, postoperative pneumonia, and postoperative myocardial infarction, were included in the nomogram. The AUC values for the 1-year survival were 0.843 and 0.826 for the training and validation cohorts, respectively. The AUC values for the 3-year survival were 0.788 and 0.750 for the training and validation cohorts, respectively. C-index values of the training cohort (0.845) and validation cohort (0.793) suggested the excellent discriminative ability of the nomogram. Calibration curves demonstrated a good consistency between the predictions and actual observations of overall survival in both training and validation cohorts. A significant difference in overall survival was seen between elderly patients stratified into low- and high-risk groups (P < 0.001).
CONCLUSION We constructed and validated a nomogram predicting 1- and 3-year survival probability in elderly patients over 80 years undergoing CRC resection, thereby facilitating holistic and informed decision-making among these patients.
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Affiliation(s)
- Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
- Group Finance Analytics, Singapore Health Services, Singapore 168582, Singapore
| | | | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore 168582, Singapore
| | | | - Yue Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Singapore 169608, Singapore
| | - Marianne Kit Har Au
- Group Finance, Singapore Health Services, Singapore 168582, Singapore
- Singhealth Community Hospitals, Singapore 168582, Singapore
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Soltanizadeh S, Jensen KK, Nordklint AK, Jørgensen HL, Jørgensen LN. Even minor alteration of plasma creatinine after open abdominal surgery is associated with 30-day mortality: A single-centre cohort study. J Visc Surg 2023; 160:19-26. [PMID: 34802949 DOI: 10.1016/j.jviscsurg.2021.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Postoperative acute kidney injury is common and associated with increased length of hospital stay, costs and mortality. The impact from postoperative subclinical changes in plasma concentration of creatinine (p-creatinine) on postoperative mortality has received less attention. In this study, the association between the postoperative change of p-creatinine and all-cause mortality was investigated. METHODS A single-centre register-based, retrospective study was conducted including patients ≥60 years undergoing open abdominal surgery from 2000 to 2013. Postoperative p-creatinine change was analysed for association with 30-day mortality following adjustment for age, gender, surgical setting and surgical procedure. Main findings A total of 3,460 patients were included in the study of whom 67.6% underwent emergency surgery. The 30-day mortality rate was 18.3%, and a given 10μmol/L daily postoperative increase in p-creatinine was associated with an increased mortality risk with an odds ratio (OR) of 2.67 (95% CI; 2.28-3.14, P<0.001). In patients undergoing emergency surgery, a daily 10μmol/L increase in p-creatinine increased the risk for a fatal outcome a 2.39 OR (CI 95%; 2.05-2.78), P<0.001). In patients undergoing elective surgery, a similar increase in p-creatinine increased risk of postoperative death with a 28.85 OR (CI 95%; 10.25-81.19). CONCLUSION Even a minor postoperative p-creatinine increase following open abdominal surgery below the criteria for acute kidney injury was associated with increased 30-day mortality in patients aged 60 years or above.
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Affiliation(s)
- S Soltanizadeh
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2300 Copenhagen NV, Denmark.
| | - K K Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2300 Copenhagen NV, Denmark
| | - A K Nordklint
- Department of Clinical Biochemistry, Hvidovre Hospital, University of Copenhagen, 2650 Hvidovre, Denmark
| | - H L Jørgensen
- Department of Clinical Biochemistry, Hvidovre Hospital, University of Copenhagen, 2650 Hvidovre, Denmark
| | - L N Jørgensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2300 Copenhagen NV, Denmark
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Intraoperative Surgical Strategy in Abdominal Emergency Surgery. World J Surg 2023; 47:162-170. [PMID: 36221004 DOI: 10.1007/s00268-022-06782-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emergency abdominal surgery is associated with a high rate of postoperative complications and death. Pre- and immediate postoperative bundle-care strategies have improved outcome, but so far, no standardized intraoperative strategies have been proposed. We introduced a quality improvement model of specific intra- and postoperative strategies for the heterogenous group of patients undergoing emergency abdominal surgery. The objective was to evaluate a quality improvement strategy, using an intraoperative, multidisciplinary time-out model in emergency abdominal surgery to apply one of three surgical strategies; definitive-palliative-or damage control surgery. METHODS All patients scheduled for any gastrointestinal emergency procedure were stratified dynamically according to standardized criteria for performing definitive-palliative-or damage control surgery. Pre- intra- and postoperative data were collected according to the intraoperative strategy applied. Postoperative complications were displayed according to the Clavien-Dindo-score and the CCI (Comprehensive Complication Index). 30-90-day- and 1-year mortality was presented. RESULTS We included 436 consecutive patients undergoing emergency laparotomy or laparoscopy in 2019. Intraoperative strategy was definitive in 326(75%)-palliative in 90(21%) and damage control approach in 20(4%) patients. CCI was 21(0,45), 30(17,54) and 78(54,100) in the definitive-, the palliative-, and the damage control group, respectively. 30-day mortality was; 11.7%, 26.7% and 30%, and the 1-year mortality was 16.9%, 56.7% and 40% in the definitive- the palliative- and the damage control group, respectively. CONCLUSIONS We present a multidisciplinary, intraoperative decision-making standard as a potential quality improvement tool of ensuring individualized intra- and postoperative treatment for every emergency surgical patient and for future research-protocols.
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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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Applying calculations to clinical medicine requires nuance: response to Uy. J Clin Epidemiol 2022; 152:327-328. [PMID: 36096341 DOI: 10.1016/j.jclinepi.2022.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/18/2022] [Indexed: 01/25/2023]
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Blundell JD, Gandy RC, Close J, Harvey L. Cholecystectomy for people aged 50 years or more with mild gallstone pancreatitis: predictors and outcomes of index and interval procedures. Med J Aust 2022; 217:246-252. [PMID: 35452133 PMCID: PMC9545298 DOI: 10.5694/mja2.51492] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/25/2022] [Indexed: 12/13/2022]
Abstract
Objectives To estimate the proportions of people aged 50 years or more with mild gallstone pancreatitis who undergo index cholecystectomy (during their initial hospital admission) or interval cholecystectomy (during a subsequent admission); to compare outcomes following index and interval cholecystectomy; and to identify factors associated with undergoing interval cholecystectomy. Design, setting, participants Analysis of linked hospitalisation and deaths data for all people aged 50 years or more with mild gallstone pancreatitis who underwent cholecystectomy in New South Wales within twelve months of their index admission, 1 July 2008 ‒ 30 June 2018. Main outcome measures Cholecystectomy classification (index or interval). Secondary outcomes: all‐cause mortality (30‒365 days), emergency re‐admissions with gallstone‐related disease (within 28 or 180 days of discharge); hospital lengths of stay (index admission, and all admissions with gallstone‐related disease over six months). Results A total of 1836 patients underwent index cholecystectomy (37.9%) and 3003 interval cholecystectomy (62.1%). Mortality to twelve months was similar in the two groups. Larger proportions of people who underwent interval cholecystectomy were re‐admitted within 28 days (246, 8.2% v 23, 1.3%) or 180 days (527, 17.6% v 59, 3.2%), or required open cholecystectomy (238, 7.9% v 69, 3.8%). Mean index admission length of stay was longer for index than interval cholecystectomy (7.7 [SD, 4.7] days v 5.3 [SD, 3.9] days), but six‐month total length of stay was similar (8.2 [SD, 5.6] days v 7.9 [SD, 5.8] days). Interval cholecystectomy was more likely for patients with three or more comorbid conditions (adjusted odds ratio [aOR], 1.29; 95% CI, 1.08‒1.55) or private health insurance (aOR, 1.31; 95% CI, 1.13‒1.51), and for those admitted to low surgical volume hospitals (aOR, 1.84; 95% CI, 1.03‒3.31). Conclusions Most NSW people over 50 with mild gallstone pancreatitis did not undergo index cholecystectomy, despite recommendations in international guidelines. Delayed cholecystectomy was associated with more frequent open cholecystectomy procedures and gallstone disease‐related emergency re‐admissions, as well as with low or medium hospital surgical volume, comorbidity, and having private insurance.
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Affiliation(s)
- Jian D Blundell
- Prince of Wales Hospital and Community Health Services Sydney NSW
- Falls, Balance and Injury Research Centre Neuroscience Research Australia Sydney NSW
| | - Robert C Gandy
- Prince of Wales Hospital and Community Health Services Sydney NSW
- Prince of Wales Clinical School University of New South Wales Sydney NSW
| | - Jacqueline Close
- Falls, Balance and Injury Research Centre Neuroscience Research Australia Sydney NSW
- Prince of Wales Clinical School University of New South Wales Sydney NSW
| | - Lara Harvey
- Falls, Balance and Injury Research Centre Neuroscience Research Australia Sydney NSW
- University of New South Wales Sydney NSW
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22
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Mathiszig-Lee JF, Catling FJR, Moonesinghe SR, Brett SJ. Highlighting uncertainty in clinical risk prediction using a model of emergency laparotomy mortality risk. NPJ Digit Med 2022; 5:70. [PMID: 35676451 PMCID: PMC9177766 DOI: 10.1038/s41746-022-00616-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
Clinical prediction models typically make point estimates of risk. However, values of key variables are often missing during model development or at prediction time, meaning that the point estimates mask significant uncertainty and can lead to over-confident decision making. We present a model of mortality risk in emergency laparotomy which instead presents a distribution of predicted risks, highlighting the uncertainty over the risk of death with an intuitive visualisation. We developed and validated our model using data from 127134 emergency laparotomies from patients in England and Wales during 2013-2019. We captured the uncertainty arising from missing data using multiple imputation, allowing prospective, patient-specific imputation for variables that were frequently missing. Prospective imputation allows early prognostication in patients where these variables are not yet measured, accounting for the additional uncertainty this induces. Our model showed good discrimination and calibration (95% confidence intervals: Brier score 0.071-0.078, C statistic 0.859-0.873, calibration error 0.031-0.059) on unseen data from 37 hospitals, consistently improving upon the current gold-standard model. The dispersion of the predicted risks varied significantly between patients and increased where prospective imputation occurred. We present a case study that illustrates the potential impact of uncertainty quantification on clinical decision making. Our model improves mortality risk prediction in emergency laparotomy and has the potential to inform decision-makers and assist discussions with patients and their families. Our analysis code was robustly developed and is publicly available for easy replication of our study and adaptation to predicting other outcomes.
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Affiliation(s)
- Jakob F Mathiszig-Lee
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Anaesthesia and Perioperative Medicine, Royal Marsden Hospital, London, UK
- Imperial College London, The Commonwealth Building, The Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK
| | - Finneas J R Catling
- Department of Surgery and Cancer, Imperial College London, London, UK.
- Imperial College London, St. Mary's Campus, Norfolk Place, London, W2 1PG, UK.
| | - S Ramani Moonesinghe
- Surgical Outcomes Research Centre, Centre for Perioperative Medicine, Department for Targeted Intervention, University College London, London, UK
- University College London Hospitals National Institute for Health Research Biomedical Research Centre, London, UK
- University College London, Charles Bell House, 43-47 Foley Street, London, W1W 7TS, UK
| | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
- ICU West, The Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
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23
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Elkbuli A, Newsome K, Fanfan D, Sutherland M, Bilski T, Liu H, Ang D. Laparoscopic Versus Laparotomy Surgical Interventions for Trauma Patients with Single Upper Left Quadrant Penetrating Injuries: Analysis of the American College of Surgeons Trauma Quality Improvement Program Dataset. Am Surg 2022; 88:2182-2193. [PMID: 35592893 DOI: 10.1177/00031348221101510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We aim to identify patient cohorts where laparoscopy can be safely utilized with comparable or better outcomes to laparotomy among patients with single penetrating LUQ injuries with a hypothesis that compared to laparotomy, laparoscopy may be associated with equal or improved outcomes of low injury severity patients. METHODS Retrospective review of the ACS-TQP-Participant Use File 2016-2019 dataset. Patients with single LUQ penetrating injuries were included. Primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included: risk-adjusted complication rates, hospital length-of-stay (H-LOS), and ICU-LOS. Descriptive statistics and multivariable regression with reliability adjustments to account for variations in practice were performed. RESULTS Of 4149 patients analyzed, 3571 (86.1%) underwent laparotomy, 489 (11.8%) underwent laparoscopy, and 89 (2.1%) underwent laparoscopy-to-laparotomy conversion. Adjusted mortality rates were not significantly different among all study cohorts (P > .05). Compared to laparoscopy, adjusted odds of complications were 4.3-fold higher for all patients who underwent laparotomy and 4-fold higher for laparoscopy-to-laparotomy (LtL) patients (P < .05). Diaphragmatic injuries were associated with significantly increased odds of undergoing LtL, whereas sustaining a colonic injury, gastric injury, hepatic injury, or requiring PRBC transfusions were associated with significantly increased odds of undergoing laparotomy (P < .05). H-LOS (days) was significantly longer for patients who underwent laparotomy compared to laparoscopy (3.9 ± 4.0 vs. 10.8 ± 13.4, P < .0001). CONCLUSIONS Laparoscopy may be considered a viable alternative to laparotomy for hemodynamically stable adult patients with single penetrating LUQ injuries of low injury burden validating our hypothesis. Laparoscopy may be less safe for patients with associated diaphragmatic, colonic, or hepatic injuries.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Division of Medical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Kevin Newsome
- 5450Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Dino Fanfan
- 5450Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Mason Sutherland
- 2814NSU NOVA Southeastern University, Dr. Kiran.C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Tracy Bilski
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Division of Medical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Huazhi Liu
- Department of Surgery, Division of Trauma and Surgical Critical Care, 23703Ocala Regional Medical Center, Ocala, FL, USA
| | - Darwin Ang
- Department of Surgery, Division of Trauma and Surgical Critical Care, 23703Ocala Regional Medical Center, Ocala, FL, USA
- University of South Florida, Tampa, FL, USA
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24
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Hajibandeh S, Hajibandeh S, Waterman J, Miller B, Johnson B, Higgi A, Hale J, Pearce D, Evans L, Satyadas T, Mansour M, Havard T, Maw A. Hajibandeh Index versus NELA score in predicting mortality following emergency laparotomy: A retrospective Cohort Study. Int J Surg 2022; 102:106645. [DOI: 10.1016/j.ijsu.2022.106645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/30/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
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25
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Martin SJ, Stephen VS. Pitfalls in medicine: pain out of proportion to examination findings. Br J Hosp Med (Lond) 2022; 83:1-8. [DOI: 10.12968/hmed.2021.0599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Most life-threatening conditions form a coherent clinical picture, with examination findings confirming the patient's history. However, pain out of proportion to examination findings can also signify an emergency – acute compartment syndrome, bowel ischaemia, necrotising fasciitis and acute aortic dissection may all present in this way. A lack of situational awareness leads doctors to erroneously rely on examination findings to flag impending catastrophe, but in such cases misdiagnosis or delayed treatment can have dire consequences. Patients with unexplained pain risk significant morbidity and mortality, and doctors are vulnerable to litigation and reputational damage. This article addresses this danger, exploring the causes and pathology of pain that is out of proportion, and presenting an approach to mitigate risk and prevent catastrophe.
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Affiliation(s)
- Stephen-John Martin
- School of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK
| | - Victoria S Stephen
- Division of Emergency Medicine, Far East Rand Hospital, University of the Witwatersrand, South Africa
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26
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Jensen TK, Nielsen YW, Gögenur I, Tolstrup MB. "Sarcopenia is associated with increased risk of burst abdomen after emergency midline laparotomy: a matched case-control study". Eur J Trauma Emerg Surg 2022; 48:4189-4196. [PMID: 35353215 DOI: 10.1007/s00068-022-01958-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 03/13/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Burst abdomen is a serious complication commonly observed after emergency midline laparotomy. Sarcopenia has been associated with increased morbidity and mortality after abdominal surgery. This single-center, retrospective, matched case-control study aimed to investigate the association between sarcopenia and burst abdomen in patients undergoing emergency midline laparotomy. METHODS Patients who had burst abdomen after emergency midline laparotomy were matched 1:4 with controls based on age and sex. Abdominal wall closure was standardized in the study period with the small bites, small stitches technique. CT assessed psoas cross-sectional area was used as a surrogate measure of sarcopenia. Sarcopenia was defined as the sex-specific lowest quartile of psoas cross-sectional area adjusted for body surface area. The primary outcome was the incidence rate of sarcopenia amongst cases and controls. Secondary outcomes were risk factors for burst abdomen and death that were identified using multivariate logistic regression analysis. RESULTS 67 cases were matched to 268 controls during May 2016-December 2019. BMI > 30 kg/m2, liver cirrhosis, smoking, high ASA score and peritonitis were more frequently observed among cases. Multivariate analysis revealed that sarcopenia (odds ratio (OR) 2.3, p = 0.01), active smoking (OR 2.3, p = 0.006) and liver cirrhosis (OR 3.7, p = 0.042) were significantly associated with burst abdomen. ASA score ≥ 3 (OR 5.5, p = 0.001) and ongoing malignant disease (OR 3.2, p = 0.001) were significantly associated with increased 90-day mortality. CONCLUSION Sarcopenia is associated with increased risk of burst abdomen after midline laparotomy. Prospective trials are needed.
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Affiliation(s)
- Thomas Korgaard Jensen
- Surgical Section, Department of Gastrointestinal- and Hepatic Diseases, Copenhagen University Hospital Herlev, 2730, Herlev, Denmark.
| | | | - Ismail Gögenur
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Copenhagen University Hospital, 4600, Koege, Denmark
| | - Mai-Britt Tolstrup
- Department of Surgery, North-Zealand University Hospital, 3400, Hilleroed, Denmark
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27
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Artificial Intelligence Based Detection of Pneumoperitoneum on CT Scans in Patients Presenting with Acute Abdominal Pain: a Clinical Diagnostic Test Accuracy Study. Eur J Radiol 2022; 150:110216. [DOI: 10.1016/j.ejrad.2022.110216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/30/2022] [Accepted: 02/11/2022] [Indexed: 11/20/2022]
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28
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Gormsen J, Brunchmann A, Henriksen NA, Jensen TK, Laugesen KB, Motavaf E, Possfelt-Møller EM, Poulsen KA, Skovsen AP, Svenningsen P, Tengberg LT, Burcharth J. Perioperative clinical management in relation to emergency surgery for perforated peptic ulcer: A nationwide questionnaire survey. Clin Nutr ESPEN 2022; 47:299-305. [DOI: 10.1016/j.clnesp.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/26/2022]
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29
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Albendary M, Mohamedahmed AYY, Alamin A, Rout S, George A, Zaman S. Efficacy and safety of mesh closure in preventing wound failure following emergency laparotomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2022; 407:1333-1344. [PMID: 35020082 DOI: 10.1007/s00423-021-02421-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate comparative outcomes of emergency laparotomy closure with and without prophylactic mesh. METHODS A systematic review was performed via literature databases: PubMed, Cochrane Library, Science Direct, and Google Scholar. Studies were examined for eligibility and included if they compared prophylactic mesh closure to the conventional laparotomy closure following emergency abdominal surgery. Both acute wound failure and incisional hernia (IH) occurence were our primary outcomes. Secondary outcomes included surgical site infection (SSI), seroma/hematoma formation, Clavien-Dindo complications (score ≥ 3), total operative time, and length of hospital stay (LOS). RESULTS Two randomised controlled trials (RCTs) and four comparative studies with a total of 817 patients met the inclusion criteria. Overall acute wound failure and incisional hernia rate was significantly lower in the mesh group compared to non-mesh group (odd ratio (OR) 0.23, p = 0.002) and (OR 0.21, p = 0.00001), respectively. There was no significant difference between the two groups regarding the following outcomes: total operative time (mean difference (MD) 21.44, p = 0.15), SSI (OR 1.47, p = 0.06), seroma/haematoma formation (OR 2.74, p = 0.07), grade ≥ 3 Clavien-Dindo complications (OR 2.39, p = 0.28), and LOS (MD 0.26, p = 0.84). CONCLUSION The current evidence for the use of prophylactic mesh in emergency laparotomy is diverse and obscure. Although the data trends towards a reduction in the incidence of IH, a reliable conclusion requires further high-quality RCTs to fully assess the efficacy and safety of mesh use in an emergency setting.
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Affiliation(s)
- Mohamed Albendary
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ali Yasen Y Mohamedahmed
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK.
| | | | - Shantanu Rout
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Anil George
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West, Birmingham Hospitals NHS Trust, Birmingham, UK
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30
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Ylimartimo AT, Lahtinen S, Nurkkala J, Koskela M, Kaakinen T, Vakkala M, Hietanen S, Liisanantti J. Long-term Outcomes After Emergency Laparotomy: a Retrospective Study. J Gastrointest Surg 2022; 26:1942-1950. [PMID: 35697895 PMCID: PMC9489577 DOI: 10.1007/s11605-022-05372-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/27/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergency laparotomy (EL) is a common surgical operation with poor outcomes. Patients undergoing EL are often frail and have chronic comorbidities, but studies focused on the long-term outcomes after EL are lacking. The aim of the present study was to examine the long-term mortality after EL. METHODS We conducted a retrospective single-center cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The follow-up lasted until September 2020. The primary outcome was 2-year mortality after surgery. The secondary outcome was factors associated with mortality during follow-up. RESULTS A total of 554 (82%) patients survived > 90 days after EL and were included in the analysis. Of these patients, 120 (18%) died during the follow-up. The survivors were younger than the non-survivors (median [IQR] 64 [49-74] vs. 71 [63-80] years, p < 0.001). In a Cox regression model, death during follow-up was associated with longer duration of operation (OR 2.21 [95% CI 1.27-3.83]), higher ASA classification (OR 2.37 [1.15-4.88]), higher CCI score (OR 4.74 [3.15-7.14]), and postoperative medical complications (OR 1.61 [1.05-2.47]). CONCLUSIONS Patient-related factors, such as higher ASA classification and CCI score, were the most remarkable factors associated with poor long-term outcome and mortality 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, Finland ,Department of Surgery, Oulu University Hospital, P.O.BOX 21, 90029 OYS Oulu, Finland
| | - Sanna Lahtinen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Juho Nurkkala
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Marjo Koskela
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O.BOX 21, 90029 OYS Oulu, Finland
| | - Timo Kaakinen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Merja Vakkala
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Siiri Hietanen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland
| | - Janne Liisanantti
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
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31
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Using Machine Learning to Establish Predictors of Mortality in Patients Undergoing Laparotomy for Emergency General Surgical Conditions. World J Surg 2021; 46:339-346. [PMID: 34704147 DOI: 10.1007/s00268-021-06360-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Patients undergoing laparotomy for emergency general surgery (EGS) conditions, constitute a high-risk group with poor outcomes. These patients have a high prevalence of comorbidities. This study aims to identify patient factors, physiological and time-related factors, which place patients into a group at increased risk of mortality. METHODOLOGY In a retrospective analysis of all patients undergoing an emergency laparotomy at Greys Hospital from December 2012 to 2018, we used decision tree discrimination to identify high-risk groups. RESULTS Our cohort included 1461 patients undergoing a laparotomy for an EGS condition. The mortality rate was 12.4% (181). Nine hundred and ten patients (62.3%) had at least one known comorbidity on admission. There was a higher rate of comorbidities among those that died (154; 85.1%). Patient factors found to be associated with mortality were the age of 46 years or greater (p < 0.001), current tuberculosis (p < 0.001), hypertension (p = 0.014), at least one comorbidity (0.006), and malignancy (0.033). Significant physiological risk factors for mortality were base excess less than -6.8 mmol/L (p < 0.001), serum urea greater than 7.0 mmol/L (p < 0.001) and waiting time from admission to operation (p = 0.014). In patients with an enteric breach, those younger than 46 years and a Shock Index of more than 1.0 were high-risk. Patients without an enteric breach were high-risk if operative duration exceeded 90 min (p = 0.004) and serum urea exceeding 7 mmol/dl (p = 0.016). CONCLUSION In EGS patients, patient factors as well as physiological factors place patients into a high-risk group. Identifying a high-risk group should prompt consideration for an adjusted approach that ameliorates outcomes.
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Tvarnø CD, Lohse N, Møller MH, Møller AM, Vester‐Andersen M. Ischaemic vascular disease and long-term mortality in emergency abdominal surgical patients: A population-based cohort study. Acta Anaesthesiol Scand 2021; 65:1213-1220. [PMID: 33964017 DOI: 10.1111/aas.13846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Emergency abdominal surgery carries a high mortality, as patients are often frail with significant comorbidity. We aimed to evaluate the association between co-existing ischaemic vascular disease (IVD) and long-term mortality in patients undergoing emergency abdominal surgery. METHODS We included adult emergency abdominal surgical patients operated on 13 Danish hospitals between 1 January 2009 and 31 December 2010. Appendectomies were excluded. Data were retrieved from the National Patient Registry (NPR) and the Danish Anaesthesia Database. Preoperative IVD status was retrieved from NPR. We used crude and adjusted Cox regression analysis. The primary outcome was mortality within eight years. The secondary outcome was mortality within 30 days. RESULTS We included 4864 patients, of which 2584 (53.7%) died within 8 years. Some 20.9% (1019/4864) had preoperative IVD. The adjusted association between preoperative IVD and mortality within 8 years was hazard ratio (HR) 1.10 (95% confidence interval [CI], 1.00-1.20; P = .045). At 30 days, this association was HR 0.97 (95% CI, 0.84-1.13). CONCLUSION In adult major emergency abdominal surgical patients, preoperative IVD was prevalent and associated with a 10% relative increase in long-term mortality, but not in short-term mortality.
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Affiliation(s)
- Casper D. Tvarnø
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES) Department of Anaesthesiology Copenhagen University Hospital Herlev‐Gentofte Herlev Denmark
| | - Nicolai Lohse
- Department of Emergency Medicine Copenhagen University Hospital Nordsjælland Hillerød Denmark
- Department of Clinical Medicine Copenhagen University Copenhagen Denmark
| | - Morten H. Møller
- Department of Intensive Care 4131 Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Ann M. Møller
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES) Department of Anaesthesiology Copenhagen University Hospital Herlev‐Gentofte Herlev Denmark
| | - Morten Vester‐Andersen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES) Department of Anaesthesiology Copenhagen University Hospital Herlev‐Gentofte Herlev Denmark
- Department of Clinical Medicine Copenhagen University Copenhagen Denmark
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33
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Jansson Timan T, Hagberg G, Sernert N, Karlsson O, Prytz M. Mortality following emergency laparotomy: a Swedish cohort study. BMC Surg 2021; 21:322. [PMID: 34380437 PMCID: PMC8356422 DOI: 10.1186/s12893-021-01319-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/04/2021] [Indexed: 01/05/2023] Open
Abstract
Background Emergency laparotomy (EL) is a central, high-risk procedure in emergency surgery. Patients in need of an EL present an acute pathology in the abdomen that must be operated on in order to save their lives. Usually, the underlying condition produces an affected physiology. The perioperative management of this critically ill patient group in need of high-risk surgery and anaesthesia is challenging and related to high mortality worldwide. However, outcomes in Sweden have yet to be studied. This retrospective cohort study explores the perioperative management and outcome after 710 ELs by investigating mortality, overall length of stay (LOS) in hospital, need for care at the intensive care unit (ICU), surgical complications and a general review of perioperative management. Methods Medical records after laparotomy was retrospectively analysed for a period of 38 months (2014–2017), the emergency cases were included. Children (< 18 years), aortic surgery, second look and other expected reoperations were excluded. Demographic, management and outcome data were collected after an extensive analysis of the cohort. Results A total of 710 consecutive operations, representing 663 patients, were included in the cohort (mean age 65.6 years). Mortality (30 days/1 year) after all operations was 14.2% and 26.6% respectively. The mean LOS in hospital was 12 days, while LOS in the ICU was five days. Of all operations, 23.8% patients were admitted at any time to the ICU postoperatively and the 30-day mortality seen among ICU patients was 37.9%. Mortality was strongly correlated to existing comorbidity, high ASA classification, ICU care and faecal peritonitis. The mean/median time from notification to operate until the first incision was 3:46/3:02 h and 87% of patients had their first incision within 6 h of notification. Conclusions In this present Swedish study, high mortality and morbidity were observed after emergency laparotomy, which is in agreement with other recent studies. Trial registration: The study has been registered with ClinicalTrials.gov (NCT03549624, registered 8 June 2018).
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Affiliation(s)
- Terje Jansson Timan
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Department of Research and Development, NU-Hospital Group, Trollhättan, Sweden. .,Department of Anesthesiology and Intensive Care Unit, NU-Hospital Group, Trollhättan, Sweden.
| | - Gustav Hagberg
- Department of Surgery, NU-Hospital Group, Trollhättan, Sweden
| | - Ninni Sernert
- Department of Research and Development, NU-Hospital Group, Trollhättan, Sweden.,Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ove Karlsson
- Department of Anesthesiology and Intensive Care Unit, NU-Hospital Group, Trollhättan, Sweden.,Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Prytz
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Research and Development, NU-Hospital Group, Trollhättan, Sweden.,Department of Surgery, NU-Hospital Group, Trollhättan, Sweden
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Saunders DI, Sinclair RCF, Griffiths B, Pugh E, Harji D, Salas B, Reed H, Scott C. Emergency Laparotomy Follow-Up Study (ELFUS): prospective feasibility investigation into postoperative complications and quality of life using patient-reported outcome measures up to a year after emergency laparotomy. Perioper Med (Lond) 2021; 10:22. [PMID: 34304730 PMCID: PMC8311937 DOI: 10.1186/s13741-021-00193-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 04/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency laparotomy carries a significant risk profile around the time of surgery. This research aimed to establish the feasibility of recruitment to a study using validated scoring tools to assess complications after surgery; and patient-reported outcome measures (PROMs) to assess quality of life and quality of recovery up to a year following emergency laparotomy (EL). METHODS We used our local National Emergency Laparotomy Audit (NELA) register to identify potential participants at a single NHS centre in England. Complications were assessed at 5, 10 and 30 days after EL. Patient-reported outcome measures were collected at 1, 3, 6 and 12 months after surgery using EQ5D and WHODAS 2.0 questionnaires. RESULTS Seventy of 129 consecutive patients (54%) agreed to take part in the study. Post-operative morbidity survey data was recorded from 63 and 37 patients at postoperative day 5 and day 10. Accordion Complication Severity Grading data was obtained from 70 patients. Patient-reported outcome measures were obtained from patients at baseline and 1, 3, 6 and 12 months after surgery from 70, 59, 51, 48, to 42 patients (100%, 87%, 77%, 75% and 69% of survivors), respectively. CONCLUSIONS This study affirms the feasibility of collecting PROMs and morbidity data successfully at various time points following emergency laparotomy, and is the first longitudinal study to describe quality of life up to a year after surgery. This finding is important in the design of a larger observational study into quality of life and recovery after EL.
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Affiliation(s)
- D I Saunders
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, NHS FT, NE1 4LP, UK.
| | - R C F Sinclair
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, NHS FT, NE1 4LP, UK
| | - B Griffiths
- Department of Colorectal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, NHS FT, NE1 4LP, UK
| | - E Pugh
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, NHS FT, NE1 4LP, UK
| | - D Harji
- Department of Colorectal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, NHS FT, NE1 4LP, UK
| | - B Salas
- Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - H Reed
- Research Nurse, Department of Research and Development, Royal Victoria Infirmary, Newcastle upon Tyne, NHS FT, NE1 4LP, UK
| | - C Scott
- Research Nurse, Department of Research and Development, Royal Victoria Infirmary, Newcastle upon Tyne, NHS FT, NE1 4LP, UK
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Taghavifar S, Joyce P, Salehi S, Khosa F, Shin H, Gholamrezanezhad A, Shah S. Computed Tomography in Emergency Diagnosis and Management Considerations of Small Bowel Obstruction for Surgical vs. Non-surgical Approach. Curr Med Imaging 2021; 18:275-284. [PMID: 34182911 DOI: 10.2174/1573405617666210628154218] [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: 11/21/2020] [Revised: 03/15/2021] [Accepted: 03/30/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Small bowel obstruction (SBO) accounts for 15% of abdominal pain complaints referred to emergency departments and imposes significant financial burdens on the healthcare system. The absence of passage of flatus or stool and abdominal distention are reported as the most common symptom and a sign of SBO, respectively. Patients who do not demonstrate severe clinical or imaging findings are typically treated with conservative approaches. Patients with clinical signs of sepsis or physical findings of peritonitis are often instantly transferred to the operating room without supplementary imaging assessment. However, in cases where symptoms are non-specific, or the physical examination is challenging, such as in cases with loss of consciousness, the diagnosis can be complicated. This paper discusses the key findings detectable on Computed tomography (CT), which are vital for the emergent triage, proper treatment, and decision making in patients with speculated SBO. METHOD Narrative review of the literature. RESULTS AND CONCLUSION CT plays a key role in emergent triage, proper treatment, and decision making. It provides high sensitivity, specificity, and accuracy in the detection of early-stage obstruction and acute intestinal vascular compromise. It can also differentiate between various etiologies of this entity which is considered an important criterion in the triage of patients into surgical vs. non-surgical treatment. There are multiple CT findings, such as mesenteric edema, lack of the small-bowel feces, bowel wall thickening, fat stranding in the mesentery, and intraperitoneal fluid, which are predictive of urgent surgical exploration.
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Affiliation(s)
- Saeed Taghavifar
- Department of General Surgery, Orjhans Street, Resalat Blvd, Urmia, Iran
| | - Peter Joyce
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1500 San Pablo Street, Los Angeles, California 90033. United States
| | - Sana Salehi
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1500 San Pablo Street, Los Angeles, California 90033. United States
| | - Faisal Khosa
- Department of Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, BC. Canada
| | - Heeseop Shin
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1500 San Pablo Street, Los Angeles, California 90033. United States
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1500 San Pablo Street, Los Angeles, California 90033. United States
| | - Samad Shah
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1500 San Pablo Street, Los Angeles, California 90033. United States
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Cheong Chung JN, Ali O, Hawthornthwaite E, Watkinson T, Blyth U, McKigney N, Harji DP, Griffiths B. Closed incision negative pressure wound therapy is associated with reduced surgical site infection after emergency laparotomy: A propensity matched-cohort analysis. Surgery 2021; 170:1568-1573. [PMID: 34052025 DOI: 10.1016/j.surg.2021.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/07/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Surgical site infection contributes to a significant proportion of postoperative morbidity in patients undergoing emergency laparotomy. Surgical site infections cause significant patient burden, increase duration of stay, and have economic implications. Closed incision negative pressure therapy has been shown to reduce surgical site infection rates in patients undergoing elective laparotomy; however, there is limited evidence for their use in the emergency setting. This study aims to compare rates of surgical site infection between patients receiving closed incision negative pressure therapy and standard surgical dressing after emergency laparotomy through a propensity matched analysis. METHODS A registry-based, prospective cohort study was undertaken using data from the National Emergency Laparotomy Audit database at our center. The primary outcome measure was surgical site infection as defined by the Centers for Disease Control criteria. Secondary outcomes included 30-day postoperative morbidity and grade, duration of stay, 30-day mortality, and readmission rates. A propensity-score matching was performed in a 1:1 ratio to mitigate for selection bias. RESULTS A total of 1,484 patients were identified from the National Emergency Laparotomy Audit data set, and propensity-score matching resulted in 2 equally matched cohorts with 237 patients in each arm. The rate of surgical site infection was significantly lower in the closed incision negative pressure therapy cohort (16.9% vs 33.8%, P < .001). There were no overall differences in 30-day morbidity, Clavien-Dindo grade, Comprehensive Complication Index severity, length of hospital stay, reoperation rates, and 30-day mortality between the 2 groups. CONCLUSIONS Prophylactic closed incision negative pressure therapy in emergency laparotomy patients is associated with a reduction in surgical site infection rates.
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Affiliation(s)
| | - Omar Ali
- Newcastle University Medical School, Newcastle upon Tyne, United Kingdom
| | | | - Thomas Watkinson
- Health Education North East, Newcastle upon Tyne, United Kingdom
| | - Ursula Blyth
- Health Education North East, Newcastle upon Tyne, United Kingdom
| | - Niamh McKigney
- Health Education North East, Newcastle upon Tyne, United Kingdom
| | - Deena P Harji
- Health Education North East, Newcastle upon Tyne, United Kingdom.
| | - Ben Griffiths
- Department of Colorectal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
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Bravo-Salva A, Argudo-Aguirre N, González-Castillo AM, Membrilla-Fernandez E, Sancho-Insenser JJ, Grande-Posa L, Pera-Román M, Pereira-Rodríguez JA. Long-term follow-up of prophylactic mesh reinforcement after emergency laparotomy. A retrospective controlled study. BMC Surg 2021; 21:243. [PMID: 34006282 PMCID: PMC8130379 DOI: 10.1186/s12893-021-01243-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prevention of incisional hernias with a prophylactic mesh in emergency surgery is controversial. The present study aimed to analyze the long-term results of prophylactic mesh used for preventing incisional hernia after emergency midline laparotomies. METHODS This study was a registered (NCT04578561) retrospective analysis of patients who underwent an emergency midline laparotomy between January 2009 and July 2010 with a follow-up period of longer than 2 years. Long-term outcomes and risk factors for the development of incisional hernias between patients who received a prophylactic reinforcement mesh (Group M) and suture (Group S) were compared. RESULTS From an initial 266 emergency midline laparotomies, 187 patients were included. The median follow-up time was 64.4 months (SD 35). Both groups had similar characteristics, except for a higher rate of previous operations (62 vs. 43.2%; P = 0.01) and operation due to a revision laparotomy (32.5 vs.13%; P = 0.02) in the M group. During follow-up, 29.9% of patients developed an incisional hernia (Group S 36.6% vs. Group M 14.3%; P = 0.002). Chronic mesh infections were diagnosed in 2 patients, but no mesh explants were needed, and no patient in the M group developed chronic pain. Long-term risk factors for incisional hernia were as follows: smoking (HR = 2.47; 95% CI 1.318-4.624; P = 0.05), contaminated surgery (HR = 2.98; 95% CI 1.142-7.8; P = 0.02), surgical site infection (SSI; HR = 3.83; 95% CI 1.86-7.86; P = 0.001), and no use of prophylactic mesh (HR = 5.09; 95% CI 2.1-12.2; P = 0.001). CONCLUSION Incidence of incisional hernias after emergency midline laparotomies is high and increases with time. High-risk patients, contaminated surgery, and surgical site infection (SSI) benefit from mesh reinforcement. Prophylactic mesh use is safe and feasible in emergencies with a low long-term complication rate. TRIAL REGISTRATION NCT04578561. www.clinicaltrials.gov.
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Affiliation(s)
- A Bravo-Salva
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Ciències, Experimentals I de La Salut, Universitat Pompeu Fabra, Dr. Aiguader 88, 08003, Barcelona, Spain
| | - N Argudo-Aguirre
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Ciències, Experimentals I de La Salut, Universitat Pompeu Fabra, Dr. Aiguader 88, 08003, Barcelona, Spain
| | - A M González-Castillo
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Ciències Morfològiques, Universitat Autónoma de Barcelona, Campus Bellaterra, 08193, Cerdanyola del Vallès - Barcelona, Spain
| | - E Membrilla-Fernandez
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - J J Sancho-Insenser
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - L Grande-Posa
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - M Pera-Román
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain.,Departament de Cirurgia, Vall d'Hebrón, Unitat Departamental Parc de Salut Mar, Universitat Autónoma de Barcelona, Passeig Vall d'Hebrón 119-129, 08035, Barcelona, Spain
| | - J A Pereira-Rodríguez
- Servicio de Cirugía General Y del Aparato Digestivo, Parc de Salut Mar, Hospital del Mar, P. Marítim 23-25, 08003, Barcelona, Spain. .,Departament de Ciències, Experimentals I de La Salut, Universitat Pompeu Fabra, Dr. Aiguader 88, 08003, Barcelona, Spain.
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Vogelsang RP, Søby JH, Tolstrup MB, Burcharth J, Ekeløf S, Gögenur I. Associations between malignancy and cardiovascular complications following emergency laparotomy - A retrospective cohort study. Surg Oncol 2021; 38:101591. [PMID: 33991941 DOI: 10.1016/j.suronc.2021.101591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Systemic inflammation in patients with malignant disease has been associated with increased risk of cardiovascular events. The pro-inflammatory perturbations following surgical trauma may further promote adverse perioperative cardiovascular events and increase the risk of patients with cancer undergoing major surgery. Our objective was to estimate the association between malignant disease and postoperative cardiovascular complications. Secondarily, we aimed to identify risk factors for postoperative cardiovascular complications. METHODS We conducted a retrospective cohort study of all patients ≥18 years undergoing emergency laparotomy between 2010 and 2016 at Department of Surgery, Zealand University Hospital, Denmark. Complications were graded according to Clavien-Dindo classification of surgical complications. Multivariate logistic regression analysis was performed to estimate association between malignant disease and cardiovascular complications within 30 days of emergency laparotomy and to identify other risk factors for postoperative cardiovascular complications after emergency laparotomy. RESULTS We identified 1188 patients ≥18 years undergoing emergency laparotomy between 2010 and 2016, in which 254 (21%) had malignant disease. Within 30 days of emergency laparotomy, 89 (9.5%) of patients without malignancy died, as compared with 45 (18%) of patients with malignancy (p < 0.001). Cardiovascular death occurred in 17 (1.8%) and 5 (2.0%) patients in the non-malignant and malignant group, respectively. Severe cardiovascular complication graded CD 3-5 occurred in 93 (8%) of all patients within 30 days of emergency laparotomy. We found no association between malignancy and postoperative cardiovascular complications in patients undergoing emergency surgery (OR 0.8, 95% CI; 0.4, 1.5). Increasing age and ASA physical status classification system (ASA) score ≥ III were the only independent risk factors of cardiovascular complications graded CD 3-5. CONCLUSIONS Malignancy was not associated with postoperative cardiovascular complications after emergency laparotomy. Risk factors for major cardiovascular complications after emergency abdominal surgery were age and ASA score ≥ III.
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Affiliation(s)
- Rasmus Peuliche Vogelsang
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Denmark. https://twitter.com/RasmusVogelsang
| | - Jacob Hartmann Søby
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Denmark
| | - Mai-Britt Tolstrup
- Department of Abdominal, Bowel, and Liver Diseases, Herlev University Hospital, Denmark
| | - Jakob Burcharth
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Denmark
| | - Sarah Ekeløf
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
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Non-operative Management of Small Bowel Obstruction in Patients with No Previous Abdominal Surgery: A Systematic Review and Meta-analysis. World J Surg 2021; 45:2092-2099. [PMID: 33755752 DOI: 10.1007/s00268-021-06061-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2021] [Indexed: 01/30/2023]
Abstract
While the contemporary management of adhesive small bowel obstruction (SBO) often includes a trial of non-operative management (NOM), surgical dogma dictates urgent operative exploration in patients without previous abdominal surgery. This dogma has been challenged by recent evidence suggesting most obstructions in this population are adhesive in nature. The objectives of this review were to evaluate the feasibility of NOM in patients with SBO and no history of previous abdominal surgery, to examine the etiologies of SBO in this population, and to explore the rate of adverse events seen following NOM. Embase, Medline, Cochrane, and Google Scholar were searched from inception to September 24, 2019. Articles reporting on NOM for SBO in patients without previous abdominal surgery and without clinical or radiographic features necessitating an emergent operation were included. Data were combined to obtain a pooled proportion of patients discharged without operation following a trial of NOM. 6 studies reporting on a total of 272 patients were included. The pooled proportion of patients discharged following NOM was 49.5% (95% CI 23.7-75.3%). Adhesions were found to be the predominant cause of obstruction. NOM did not appear to increase short-term complications. Most SBOs in patients without previous abdominal surgery are adhesive in nature and many patients can be discharged from hospital without surgery. While the short-term outcomes of NOM are acceptable, future studies are needed to address the long-term outcomes and safety of NOM as a treatment strategy for SBO in patients without previous abdominal surgery.
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Abstract
BACKGROUND The term 'emergency open abdominal surgery' covers a range of common procedures with high complication and mortality risks; however, previous studies have not included descriptive analyses of the patients undergoing the procedures. The aim of this study is to present a nationwide description of all patients who undergo an emergency bowel resection, ostomy placement or drainage involving laparotomy at Danish hospitals and to report the 30- and 365-day mortality risks. METHOD We identified all of the patients in the Danish National Patient Register aged 18 + who underwent emergency open abdominal surgery in the form of a laparotomy during the period 2003-14. Using Poisson and logistic regression models, we analyzed incidence rates and mortality risk. RESULT The sample consisted of 15,680 patients, with an overall open abdominal surgery incidence rate of 30.4 cases per 100,000 person-years. The 30-day mortality risk was 19.3% for both sexes, and increased with age (at 80-89, mortality risk was 39.4% for males and 34.5% for females). The 30-day mortality risk fell by 5.4% during the study period, from 22.2% to 16.7%. CONCLUSION Open abdominal surgery is a common, high-risk procedure with a high incidence rate and mortality risk, especially for elderly patients. The incidence rate and mortality risk fell during the period studied. In Denmark, there is no standard post-discharge care program for patients who undergo emergency laparotomies. Our results support the need to investigate standardized post-operative follow-up and rehabilitation plans to reduce mortality.
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Petring Hasselager R, Foss NB, Andersen O, Cihoric M, Bay‐Nielsen M, Nielsen HJ, Camilla Andresen L, Toft Tengberg L. Mortality and major complications after emergency laparotomy: A pilot study of risk prediction model development by preoperative blood-based immune parameters. Acta Anaesthesiol Scand 2021; 65:151-161. [PMID: 33108695 DOI: 10.1111/aas.13722] [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: 06/28/2020] [Revised: 09/04/2020] [Accepted: 09/28/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Emergency laparotomy is associated with high risk of postoperative complications and mortality. Preoperative identification of patients at high risk of adverse outcome is important. The immune response to conditions requiring emergency laparotomy is not understood in detail. The present study describes preoperative blood-based immune profiles and their potential value in surgical risk assessment. METHOD Patients (N = 100) referred for emergency laparotomy at Hvidovre Hospital were consecutively included from 3 June 2013-11 April 2014. All patients had blood samples collected before surgery and the immune parameters c-reactive protein (CRP), Interleukin-6 (IL-6), Interleukin-10 (IL-10), interferon-γ induced protein 10 kDa (IP-10), tumor necrosis factor α (TNF-α) and soluble urokinase plasminogen receptor activator (suPAR) were determined. Patients were stratified according to major postoperative complications (including death), 30- and 180-day mortality. Using logistic regression models and receiver operating characteristics curves the predictive ability of the immune parameters were estimated. RESULTS Major complications were recorded in 45 (45.0%) of the patients, whereas 30-day and 180-day mortalities were 17 (17.0%) and 25 (25.0%), respectively. Concentrations of suPAR and TNF-α were associated with major complications while CRP, IL-6, suPAR and TNF-α were associated with mortality. Adding the combined immune parameters to a regression model including age, sex, American Society of Anesthesiologists physical status and Eastern Cooperative Oncology Group Performance Status significantly improved the predictive ability for major complications, 30-day mortality and 180-day mortality. CONCLUSION In emergency laparotomy, preoperative blood-based immune parameters added predictive power to regression models and could be considered in risk prediction model development.
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Affiliation(s)
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital Hvidovre Denmark
| | - Ove Andersen
- Department of Clinical Research and the Emergency Department Hvidovre Hospital Hvidovre Denmark
| | - Mirjana Cihoric
- Department of Anesthesiology and Intensive Care Hvidovre Hospital Hvidovre Denmark
| | - Morten Bay‐Nielsen
- Department of Surgery Bispebjerg and Frederiksberg Hospital Copenhagen Denmark
| | - Hans J. Nielsen
- Department of Surgical Gastroenterology 360 Hvidovre Hospital Hvidovre Denmark
| | - Linda Camilla Andresen
- Department of Clinical Research and the Emergency Department Hvidovre Hospital Hvidovre Denmark
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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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Preoperative risk factors including serum levels of potassium, sodium, and creatinine for early mortality after open abdominal surgery: a retrospective cohort study. BMC Surg 2021; 21:62. [PMID: 33499844 PMCID: PMC7836189 DOI: 10.1186/s12893-021-01070-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 01/17/2021] [Indexed: 12/22/2022] Open
Abstract
Background In hospitalized patients, abnormal plasma electrolyte concentrations are frequent and have been linked to poor outcomes following acute surgery. The aim of this study was to assess whether preoperative plasma levels of potassium, sodium, and creatinine at the time of admission were associated with 30-day mortality in patients following open abdominal surgery. Methods This was a single-center register-based retrospective study. By means of electronic search in a maintained surgery database, all patients (n = 4177) aged ≥ 60 years old undergoing open surgery in our department from January 2000 to May 2013 were identified. Plasma was assessed within 30 days prior to surgery. The primary endpoint was 30-day postoperative mortality. The association between mortality and plasma levels of potassium, sodium, and creatinine were examined using Cox proportional hazard models. Results A total of 3690 patients were included in the study cohort. The rates of abnormal preoperative plasma levels were 36, 41, and 38% for potassium, sodium, and creatinine, respectively. The overall 30 day mortality was 20%. A predictive algorithm for 30 day mortality following abdominal surgery was constructed by means of logistic regression showing excellent distinction between patients with and without a fatal postoperative outcome. Conclusion Apart from demographic factors (age, sex, and emergency surgery), preoperative imbalance in potassium, sodium and creatinine levels were significant independent predictors of early mortality following open abdominal surgery.
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44
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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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Butensky SD, Gazzara E, Sugiyama G, Coppa GF, Alfonso A, Chung PJ. Facility of Origin Predicts Mortality After Colonic Perforation. Am Surg 2020; 87:1327-1333. [PMID: 33345561 DOI: 10.1177/0003134820971623] [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] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Colonic perforation often requires emergent intervention and carries high morbidity and mortality. The objective of this study was to determine whether nonclinical factors, such as transition of care from outpatient facilities to inpatient settings, are associated with increased risk of mortality in patients who underwent emergent surgical intervention for colonic perforation. MATERIALS AND METHODS Using the 2006-2015 ACS National Surgical Quality Improvement Program database, we identified adult patients who underwent emergent partial colectomy with primary anastomosis ± protecting ostomy or partial colectomy with ostomy with intraoperative finding of wound class III or IV for a diagnosis of perforated viscus. The outcome of interest was 30-day postoperative mortality. Univariate and multivariate analyses using logistic regression were performed. RESULTS 4705 patients met criteria, of which 841 (17.9%) died. Univariate analysis showed that patients who died after emergent surgery for perforated viscus were more likely to present from a chronic care facility (13.4% vs. 4.4%, P < .0001) and had longer time from admission to undergoing surgery (mean 4.1 vs. 2.0 days, P < .0001. Logistic regression demonstrated that septic shock vs. none (OR 3.60, P < .0001), sepsis vs. none (OR 1.57, P = .00045), transfer from chronic care facility vs. home (OR 1.87, P < .0001), and increased time from admission vs. operation (OR 1.01, P = .0055) were independently associated with increased risk of death. DISCUSSION Transfer from a chronic care facility was independently associated with increased mortality in patients undergoing emergent surgery for perforated viscus.
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Affiliation(s)
- Samuel D Butensky
- 232890Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Emma Gazzara
- 232890Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Division of General Surgery, Long Island Jewish Medical Center, 5799Northwell Health, Queens, NY, USA
| | - Gainosuke Sugiyama
- 232890Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Division of General Surgery, Long Island Jewish Medical Center, 5799Northwell Health, Queens, NY, USA
| | - Gene F Coppa
- 232890Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Division of General Surgery, Long Island Jewish Medical Center, 5799Northwell Health, Queens, NY, USA
| | - Antonio Alfonso
- 232890Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Division of General Surgery, Long Island Jewish Medical Center, 5799Northwell Health, Queens, NY, USA
| | - Paul J Chung
- 232890Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Division of General Surgery, Long Island Jewish Medical Center, 5799Northwell Health, Queens, NY, USA
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Kakodkar P, Neo WX, Khan MHT, Baig MN, Khan T. An Incidental Discovery of Amyand's Hernia: A Case Study and Literature Review on Its Intraoperative Management. Cureus 2020; 12:e11858. [PMID: 33409092 PMCID: PMC7781570 DOI: 10.7759/cureus.11858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2020] [Indexed: 11/05/2022] Open
Abstract
Amyand's hernia (AH) is a rare form of an inguinal hernia where the vermiform appendix is found within the hernia sac. Diagnosis is usually based on incidental finding intraoperatively. The AH makes up a small proportion of all inguinal hernia cases, and concurrent acute ischemic complication makes up an even smaller subset. We present an 85-year-old male who was referred to general surgery services for a growing mass on his right lower quadrant in the inguinal region. This was non-tender on palpation, and therefore there was no suspicion of ischaemic complications. An open hernioplasty was performed with resection of the appendix. The AH in this patient would be conventionally classified as type 1 AH, which would be managed with hernial reduction and mesh repair. The anatomical variance in our patient's AH increased the risk for hernial incarceration; hence an appendectomy was also performed despite the absence of acute appendicitis. This approach was also deemed necessary to avoid the recurrence of hernia due to its large size and adhesions within the hernial sac. This study reports a novel management approach for an incidentally discovered type 1 AH. It highlights that there is a lack of management guidance for the AH anatomical variants. The classification and management for AH under the conventional Losanoff and Basson's AH classification model have limitations that can be amended by incorporating the physical dimensions of the AH. This approach will enable surgeons to recognize and manage more variations of AH while mitigating downstream complications.
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Affiliation(s)
- Pramath Kakodkar
- School of Medicine, National University of Ireland Galway, Galway, IRL
| | - Wee Xuan Neo
- School of Medicine, National University of Ireland Galway, Galway, IRL
| | | | - M N Baig
- Orthopaedics, University Hospital Galway, Galway, IRL
| | - Tahir Khan
- Department of Vascular Surgery, Mater Private Hospital, Cork, IRL
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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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Ekeloef S, Bjerrum E, Kristiansen P, Wahlstrøm K, Burcharth J, Gögenur I. The risk of post-operative myocardial injury after major emergency abdominal surgery: A retrospective cohort study. Acta Anaesthesiol Scand 2020; 64:1073-1081. [PMID: 32407553 DOI: 10.1111/aas.13622] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim was to examine the risk of post-operative myocardial injury after major emergency abdominal surgery and identify pre- and intra-operative risk factors of post-operative myocardial injury. Moreover, the study aimed to examine the association between post-operative myocardial injury and clinical outcomes. METHODS This was a retrospective cohort study including patients undergoing major emergency abdominal surgery from February 2017 to January 2019. Troponin I was assessed on post-operative days 1-3. Post-operative myocardial injury was defined as a cardiac troponin I ≥ 45 ng per litre. Post-operative clinical outcomes included in-hospital myocardial infarction, in-hospital major adverse cardiovascular events, reoperation, admission to the intensive care unit, lengths of stay, 30- and 90-day all-cause mortality. RESULTS 98 out of 401 patients (24.4%) sustained a post-operative myocardial injury within the third post-operative day. Increasing age was an independent risk factor of post-operative myocardial injury (age per 10 years adjusted odds ratio 2.2 [95% CI 1.7-2.9], P < .0001). Patients with post-operative myocardial injury had an increased risk of major adverse cardiovascular events, a higher admission rate to the intensive care unit, a longer median post-operative length of stay and a higher 30- and 90-day all-cause mortality compared with patients without myocardial injury. CONCLUSION One in four patients suffered a post-operative myocardial injury within the third post-operative day. Post-operative myocardial injury was a risk factor of adverse cardiac and non-cardiac clinical outcomes. Troponin monitoring could potentially improve the post-operative risk stratification in this cohort of high-risk surgical patients.
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Affiliation(s)
- Sarah Ekeloef
- Department of Surgery Center for Surgical Science Zealand University Hospital Koege Denmark
| | - Ellen Bjerrum
- Department of Surgery Center for Surgical Science Zealand University Hospital Koege Denmark
| | - Puk Kristiansen
- Department of Surgery Center for Surgical Science Zealand University Hospital Koege Denmark
| | - Kirsten Wahlstrøm
- Department of Surgery Center for Surgical Science Zealand University Hospital Koege Denmark
| | - Jakob Burcharth
- Department of Surgery Center for Surgical Science Zealand University Hospital Koege Denmark
| | - Ismail Gögenur
- Department of Surgery Center for Surgical Science Zealand University Hospital Koege Denmark
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Rajaretnam NS, Meyer-Rochow GY. Surgical Management of Primary Small Bowel NET Presenting Acutely with Obstruction or Perforation. World J Surg 2020; 45:203-207. [PMID: 32696097 DOI: 10.1007/s00268-020-05689-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2020] [Indexed: 11/30/2022]
Abstract
Up to 35% of small bowel neuroendocrine tumors (SBNETs) may present with an acute intra-abdominal complication including obstruction, perforation, bleeding or ischemia and may require emergency surgical treatment in centers not normally accustomed to managing patients with neuroendocrine tumors. These patients may have a known diagnosis of SBNET, be suspected as suffering from SBNET or have SBNET diagnosed as an incidental finding on presenting radiology or postoperative pathology. Perioperative priorities include obtaining both clinical and radiological staging with cross-sectional imaging and clinical examination, screening for the presence of carcinoid syndrome and right-sided cardiac disease and assessment of prognosis. Intraoperatively careful attention should be paid to noting the presence and location of multifocal primary and metastatic disease. Ideally, surgical resection with mesenteric lymph node dissection is the treatment of choice for obstructing and perforating lesions. Extended lymphadenectomy along the SMA, SMV and behind the pancreas should be primarily considered an elective procedure. In unwell patients with advanced disease surgical bypass (jejuno or ileocolic) or proximal defunctioning should be undertaken but, given the excellent long-term survivals in patients with stage IV disease, could be considered bridging procedures to elective resection following formal staging and multidisciplinary review.
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Affiliation(s)
- N S Rajaretnam
- Department of Surgery, Waikato Hospital, Private Bag 3200, Hamilton, 3204, New Zealand
| | - G Y Meyer-Rochow
- Department of Surgery, Waikato Hospital, Private Bag 3200, Hamilton, 3204, New Zealand.
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Harji DP, Marshall H, Gordon K, Twiddy M, Pullan A, Meads D, Croft J, Burke D, Griffiths B, Verjee A, Sagar P, Stocken D, Brown J. Laparoscopic versus open colorectal surgery in the acute setting (LaCeS trial): a multicentre randomized feasibility trial. Br J Surg 2020; 107:1595-1604. [PMID: 32573782 DOI: 10.1002/bjs.11703] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/11/2020] [Accepted: 04/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately 30 000 people undergo major emergency abdominal gastrointestinal surgery annually, and 36 per cent of these procedures (around 10 800) are carried out for emergency colorectal pathology. Some 14 per cent of all patients requiring emergency surgery have a laparoscopic procedure. The aims of the LaCeS (laparoscopic versus open colorectal surgery in the acute setting) feasibility trial were to assess the feasibility, safety and acceptability of performing a large-scale definitive phase III RCT, with a comparison of emergency laparoscopic versus open surgery for acute colorectal pathology. METHODS LaCeS was designed as a prospective, multicentre, single-blind, parallel-group, pragmatic feasibility RCT with an integrated qualitative study. Randomization was undertaken centrally, with patients randomized on a 1 : 1 basis between laparoscopic or open surgery. RESULTS A total of 64 patients were recruited across five centres. The overall mean steady-state recruitment rate was 1·2 patients per month per site. Baseline compliance for clinical and health-related quality-of-life data was 99·8 and 93·8 per cent respectively. The conversion rate from laparoscopic to open surgery was 39 (95 per cent c.i. 23 to 58) per cent. The 30-day postoperative complication rate was 27 (13 to 46) per cent in the laparoscopic arm and 42 (25 to 61) per cent in the open arm. CONCLUSION Laparoscopic emergency colorectal surgery may have an acceptable safety profile. Registration number: ISRCTN15681041 ( http://www.controlled-trials.com).
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Affiliation(s)
- D P Harji
- Department of Colorectal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - H Marshall
- Clinical Trials Research Unit, Leeds, UK
| | - K Gordon
- Clinical Trials Research Unit, Leeds, UK
| | - M Twiddy
- Institute of Clinical and Applied Health Research, University of Hull, Hull, UK
| | - A Pullan
- Clinical Trials Research Unit, Leeds, UK
| | - D Meads
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - J Croft
- Clinical Trials Research Unit, Leeds, UK
| | - D Burke
- Department of Colorectal Surgery, St James's University Hospital, Leeds, UK
| | - B Griffiths
- Department of Colorectal Surgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - A Verjee
- Patient and Public Involvement Representative for LaCeS Trial, UK
| | - P Sagar
- Department of Colorectal Surgery, St James's University Hospital, Leeds, UK
| | - D Stocken
- Clinical Trials Research Unit, Leeds, UK
| | - J Brown
- Clinical Trials Research Unit, Leeds, UK
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