Evaluating outcomes following emergency laparotomy in the North of England and the impact of the National Emergency Laparotomy Audit - A retrospective cohort study

A Retrospective Cohort Study on One-Year Mortality Following Emergency Laparotomy: A Tertiary Centre Experience From Western Australia

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.

Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy

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.

Ileal Tubulo-Villous Adenoma Causing Small Bowel Obstruction in a Virgin Abdomen

Small bowel obstructions (SBO) are a common surgical problem accounting for up half of all emergency laparotomies in the United States. SBO in the virgin abdomen (SBO-VA) presents surgeons with a unique predicament as historical teaching has mandated operative exploration in these situations due to their association with more sinister etiologies. More recent research has demonstrated that this may not be the case, with adhesive disease comprising the majority of SBO-VA. Small bowel neoplasms however comprise a considerable portion of SBO-VA. Small bowel tumors comprise around 0.5%-2% of all gastrointestinal tumors, with adenomas being the most common type of benign small bowel tumor. These lesions are most commonly encountered in the duodenum, typically involving the peri-ampullary region, Their incidence decreases with descent down the gastrointestinal tract, and are least commonly found in the ileum. Ileal adenomas have been increasingly described in the literature with the rise of advanced imaging and endoscopic capabilities. The vast majority of these lesions remain asymptomatic; however, they have been reported to undergo malignant transformation resulting in obstruction and intussusception. Small bowel obstruction due to ileal adenomas in the absence of malignancy is exceedingly rare, with only one previously reported case in the literature. We describe a case of an SBO-VA secondary to ileal stricture caused by a tubulo-villous adenoma. We then discuss the topics of SBO and SBO-VA, specifically regarding their etiology and historical and modern management, with a particular focus on the diagnosis and management of small bowel neoplasms, specifically small bowel adenomas.