Postoperative morbidity survey, mortality and length of stay following emergency laparotomy

Sustained improved emergency laparotomy outcomes over 3 years after a transdisciplinary perioperative care pathway-A 1:1 propensity score matched study

BACKGROUND

Emergency laparotomy is associated with high morbidity and significant global health burden. This study aims to compare postoperative outcomes of patients who underwent emergency laparotomy before and after implementation of a emergency laparotomy pathway.

METHODS

This is a single-center study of all patients who presented with an acute abdomen and/or conditions requiring emergency laparotomy during pre-emergency laparotomy pathway (retrospective cohort from January 2016 to December 2018) and after the emergency laparotomy pathway (prospective cohort from January 2019 to December 2021). Patients who underwent emergency laparotomy for trauma or vascular surgery were excluded. A 1:1 propensity score matching was performed to address for confounding factors.

RESULTS

There were 888 patients (emergency laparotomy pathway, n = 428, and pre-emergency laparotomy pathway, n = 460) in the unmatched cohort. The mean age was 63.0 ± 15.4 years, and 43.8% had predicted mortality >10% using Portsmouth-Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity. The most common indication for emergency laparotomy was intestinal obstruction (30.5%). Overall incidence rates of major morbidity and 30-day mortality were 16.2% and 3.5%, respectively. There were 736 patients (n = 368 patients per arm) after propensity score matching. Demographic characteristics were comparable after propensity score matching. The emergency laparotomy pathway was associated with more patients assessed by geriatric medicine (odds ratio = 15.22; P < .001), reduced major morbidity (odds ratio = 0.63; P = .024), reduced intra-abdominal collection (odds ratio = 0.39; P = .006), and need for unplanned radiological and/or surgical intervention after index emergency laparotomy (odds ratio = 0.63; P = .024). Length of stay and 30-day mortality were comparable between the emergency laparotomy pathway and pre-emergency laparotomy pathway in both the unmatched and propensity score matched cohort.

CONCLUSION

Sustained improved postoperative outcomes were achieved 3 years postimplementation of the emergency laparotomy pathway .

Association between reduced physical performance measures and short-term consequences after major emergency abdominal surgery: a prospective cohort study

BACKGROUND

Major emergency abdominal surgery is associated with high morbidity with outcomes worse than for similar elective surgery, including complicated physical recovery, increased need for rehabilitation, and prolonged hospitalisation.

PURPOSE

To investigate whether low physical performance test scores were associated with an increased risk of postoperative complications, and, furthermore, to investigate the feasibility of postoperative performance tests in patients undergoing major emergency abdominal surgery. We hypothesize that patients with low performance test scores suffer more postoperative complications.

METHODS

The study is a prospective observational cohort study including all patients who underwent major abdominal surgery at the Department of Surgery at Zealand University Hospital between 1st March 2017 and 31st January 2019. Patients were evaluated with De Morton Mobility Index (DEMMI) score, hand grip strength, and 30-s chair-stand test.

RESULTS

The study included 488 patients (median age 69, 50.6% male). Physiotherapeutic evaluation including physical performance tests with DEMMI and hand grip strength in the immediate postoperative period were feasible in up to 68% of patients undergoing major emergency abdominal surgery. The 30-s chair-stand test was less viable in this population; only 21% of the patients could complete the 30-s chair-stand test during the postoperative period. In logistic regression models low DEMMI score (< 40) and ASA classification and low hand grip strength (< 20 kg for women, < 30 kg for men were independent risk factors for the development of postoperative severe complications Clavien-Dindo (CD) grade ≥ 3.

CONCLUSIONS

In patients undergoing major emergency surgery low performance test scores (DEMMI and hand grip strength), were independently associated with the development of significant postoperative complications CD ≥ 3.

Palliative Emergency General Surgery

Acute care surgeons encounter patients experiencing surgical emergencies related to advanced malignancy, catastrophic vascular events, or associated with multisystem organ failure. The acute nature is a factor in establishing a relationship between surgeon, patient, and family. Surgeons must use effective communication skills, empathy, and a knowledge of legal and ethical foundations. Training in palliative care principles is limited in many medical school and residency curricula. We offer examples of clinical situations facing acute care surgeons and discuss evidence-based recommendations to facilitate successful treatment and outcomes.

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.

Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit

BACKGROUND

Quantitative futility is an appraisal of the risk of failure of a treatment. For those who do not survive, a laparotomy has provided negligible therapeutic benefit and may represent a missed opportunity for palliation. The aim of this study was to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the National Emergency Laparotomy Audit (NELA) database.

METHODS

A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013-December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Baseline characteristics of this group were compared to all others. Multilevel logistic regression was carried out with potentially clinically important predictors defined a priori.

RESULTS

Quantitative futility occurred in 4% of patients (7442/180,987). Median age was 74 years (range 65-81 years). Median NELA risk score was 32.4% vs. 3.8% in the surviving cohort (p < 0.001). Early mortality patients more frequently presented with sepsis (p < 0.001). Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality (95% CI 1.22-1.55). Surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery (OR 2.67; 95% CI 2.50-2.85).

CONCLUSIONS

Quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively. These findings should be incorporated qualitatively by the multidisciplinary team into shared decision-making discussions with extremely high-risk patients.

Incidence of Post-laparotomy Acute Kidney Injury Among Abdominal Trauma Patients and Its Associated Risk Factors at King Abdulaziz Medical City, Riyadh

Background This research study investigates the prevalence of acute kidney injury (AKI) in trauma patients undergoing emergency laparotomies. AKI is a common complication in major surgeries and is associated with various adverse effects. The study aims to explore the relationship between AKI and other comorbidities in this specific context. Methodology This is a retrospective cohort study. All patients who had laparotomy after abdominal trauma at King Abdulaziz Medical City (KAMC) and met the inclusion criteria were included in the study. Nonprobability consecutive sampling was used. Data were collected by chart review using the Best-Care system at KAMC. Descriptive statistics were used to summarize and describe the characteristics of the study participants. Frequencies and percentages were calculated for categorical variables, such as comorbidities. For continuous variables, mean and standard deviations were calculated and tabulated. All statistical calculations were performed using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY, USA). Results This research study included 152 patients who underwent laparotomy, and the majority of patients (146, 96%) did not experience AKI. Several comorbidities were observed, with hypertension and diabetes being the most prevalent at 37 (24.3%) and 35 (23%), respectively. Intraoperative hypotension was experienced by 23 (15.1%) patients, while 129 (84.9%) did not have this issue. Norepinephrine was the most common vasopressor used (25.7%), followed by ephedrine and a combination of norepinephrine and epinephrine. Gender and age groups did not show significant associations with AKI, comorbidities like diabetes, heart failure, and chronic kidney disease (CKD) demonstrated significant relationships with AKI. There was no significant difference in eGFR and serum creatinine baseline levels between patients meeting AKI criteria and those who did not. Conclusions The low overall incidence of AKI in this patient population is encouraging. However, healthcare professionals must be aware of the significant impact of comorbidities such as diabetes, heart failure, and CKD on AKI development. Vigilant monitoring of postoperative kidney function, particularly serum creatinine levels within the first 48 hours, is essential for early detection and timely intervention. By understanding and addressing these risk factors, healthcare providers can take proactive steps to prevent and manage AKI in patients undergoing laparotomy, ultimately leading to improved patient outcomes and reduced healthcare costs.

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

BACKGROUND

This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care.

METHODS

Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations.

RESULTS

Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process.

CONCLUSIONS

These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Transanal endoscopic microsurgery technique: an acceptable approach for retrorectal tumors

INTRODUCTION

Retrorectal lesions (RRLs) are rare lesions that originate from the tissue present in the retrorectal space. The gold standard of care is complete resection regardless of pathology. The traditional approaches (anterior, posterior, and combined) are relatively well described. Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique offered as an alternative approach for RRLs.

AIM

To evaluate the outcomes of patients diagnosed with RRL and treated by the TEM approach, especially postoperative complications, and the recurrence rate.

METHODS

Patients with RRLs treated with the TEM technique in one medical center between 2000 and 2020 were identified. Their postoperative outcomes were compared with historical controls.

RESULTS

Thirty-nine patients diagnosed with RRL were operated on using the TEM platform. Thirty-seven RRLs were benign, and two were malignant. Their median size (IQR) was 20 mm (15, 32.5). The median distance (IQR) from the anal verge was 50 mm (50, 72.5). The median operative time (IQR) was 48.5 min (41.75, 60). All, except one lesion, were completely resected. The median length of stay (IQR) was one day (1, 1 day). Postoperative complications were diagnosed in three patients, two of which resolved following a second operation.

CONCLUSIONS

The implementation of TEM for the resection of RRLs demonstrated excellent overall results with acceptable complication and recurrence rate and represented a viable alternative surgical approach.

Emergency laparotomy at St Olav's Hospital, Trondheim

BACKGROUND

Emergency laparotomies are associated with higher mortality and longer hospital stays than elective laparotomies. The purpose of this study was to survey patient characteristics, hospital care pathways, and mortality for patients undergoing emergency laparotomy at St Olav's Hospital, Trondheim.

MATERIAL AND METHODS

This is a retrospective cohort study of all patients over 18 years of age who underwent emergency laparotomy at St Olav's Hospital, Trondheim, between 1 January 2015 and 1 April 2020. Patients were selected based on National Emergency Laparotomy Audit inclusion and exclusion criteria. Surgeries due to trauma or appendicitis were excluded, as were those for gynaecological or vascular aetiology. Patient and surgery characteristics, as well as date of death, were retrieved from electronic medical records.

RESULTS

A total of 939 patients with a median (interquartile range) age of 68 years (54-76) were included. Intestinal obstruction was the primary indication for surgery in 488 (52.0 %) patients, followed by perforation in 220 (23.4 %) and ischaemia in 85 (9.1 %). In all, 788 (83.9 %) patients underwent emergency surgery within the timeframe scheduled. The median postoperative hospital stay was 10 days (6-18) and 30-day mortality was 8.2 %.

INTERPRETATION

Although caution should be exercised when comparing findings between studies, our results suggest that the quality of treatment at St Olav's Hospital, Trondheim, is on a par with that at similar institutions. At the same time, the study provides an opportunity to identify areas for improvement in the provision of emergency surgery.

Understanding Outcomes After Major Surgery

The global volume of surgery is increasing. Adverse outcomes after surgery have resource implications and long-term impact on quality of life and consequently represent a significant and underappreciated public health issue. Standardization of outcome reporting is essential for evidence synthesis, risk stratification, perioperative care planning, and to inform shared decision-making. The association between short- and long-term outcomes, which persists when corrected for base-line risk, has significant implications for patients and providers and warrants further investigation. Candidate mechanisms include sustained inflammation and reduced physician activity, which may, in the future, be mitigated by targeted interventions.

Spectrum, Management, and Outcomes of Abdominal Surgical Emergencies at a Referral Hospital in North West Cameroon

Purpose: Abdominal surgical emergencies are a major health burden in low- and middle-income countries where management is often very challenging, and associated with high morbidity and mortality. The spectrum, management, and outcomes of abdominal surgical emergencies needs to be updated.Methods: This was a hospital-based retrospective cross-sectional study carried out in Bamenda, Cameroon over a 2-year period. Records of patients who met the inclusion criteria were reviewed, with pre-, intra- and postoperative data collected and analyzed.Results: There were 207 patients included in this retrospective review (male to female ratio of 1.4:1. The mean age was 47.4 (± 19.4) years. Intestinal obstruction (34.8%) and perforated peptic ulcers (15.5%) were the most common abdominal surgical emergencies. The median delay and interquartile range to presentation and in-hospital delay were 6 (4) days and 8 (12) hours, respectively. The mean length of hospital stay post-surgery was 11days. There were 48.3% of patients who developed a complication; 34.78% were major, 17.9% had an unplanned reoperation, and 15 (7.2%) were readmitted after discharge. The 30-day in hospital mortality was 19.8%. Mortality was independently associated with a high American Society of Anesthesiologists (ASA) score; ASA score > 3, age > 60 years, and referral from other health facilities.Conclusion: Intestinal obstructions from intraperitoneal neoplasm is the most common cause of abdominal surgical emergency in North West Cameroon. Abdominal emergencies here are associated with a very high morbidity and mortality in males > 60 years with an ASA score > 3 and with more than one comorbidity.

Postoperative Outcomes After Emergency Laparotomy in Nontrauma Settings: A Single-Center Experience

Introduction: Emergency laparotomy (EL) is a common operation that deals with a wide range of pathologies. Preoperative optimization is often lacking due to the urgent nature of the disease process with a reported mortality rate of up to 44%. This study examines the mortality of EL at an academic acute care surgery medical center.

Methods: A retrospective analysis of nontrauma EL from January 2008 to December 2013 was conducted. Data included demographics, clinical features, preoperative laboratory studies, comorbidities, time to surgery, ICU admission, and 30-day mortality.

Results: A total of 234 patients (123 males, 52.6%) were included in the study. EL was performed within four hours (immediate) of presentation in 93 (39.7%) patients, within 4-12 hours (early) in 53 (25.4%) patients, and within 12-24 hours (late) in 63 (30.1%) patients. Overall mortality was 16 (6.8%) at 30 days. Mortality was significantly higher with chronic obstructive pulmonary disease (p = 0.014), blood transfusion (p < 0.001), ICU admission (p < 0.001), ventilator days > four (p = 0.013), hyperlipidemia (p = 0.014), heart rate > 90 beats/minute (p = 0.003), temperature > 38°C or < 35°C (p = 0.013), and systolic blood pressure < 90 mmHg (p < 0.001).

Conclusion: EL can be performed with lower mortality than previously reported. Specific predictors of mortality are identified and can be used for risk assessment.

Analgesic effects of ultrasound-guided four-quadrant transabdominal plane block in patients with cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective, randomized, controlled study

Background

Postoperative pain occurring after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is difficult to control because of extensive surgical injuries and long incisions. We assessed whether the addition of a four-quadrant transabdominal plane (4Q-TAP) block could help in analgesic control.

Methods

Seventy-two patients scheduled to undergo elective CRS with HIPEC and intravenous patient-controlled analgesia (IV PCA) were enrolled. The patients received 4Q-TAP blocks in a 10 ml mixture of 2% lidocaine and 0.75% ropivacaine per site (4Q-TAP group, n = 36) or normal saline (control group, n = 33). Oxycodone in the post-anesthesia care unit (PACU) and pethidine or tramadol in the ward were used as rescue analgesics. The primary outcome was less than 3 times of rescue analgesic administration (%) in the ward for 5 postoperative days. Secondary endpoints included oxycodone requirement in PACU, fentanyl doses of IV PCA, morphine milligram equivalent (MME) of total opioid use, hospital stay, and postoperative complications.

Results

During 5 postoperative days, there was no difference in pain scores and total rescue analgesic administration between two groups. However, the use of oxycodone in PACU (P = 0.011), fentanyl requirement in IV PCA (P = 0.029), and MME/kg of total opioid use (median, 2.35 vs. 3.21 mg/kg, P = 0.009) were significantly smaller in the 4Q-TAP group. Hospital stay and incidence of postoperative morbidity were similar in both groups.

Conclusions

The 4Q-TAP block enhanced multimodal analgesia and decreased opioid requirements in patients with CRS with HIPEC, but did not change postoperative recovery outcomes.

Perioperative Outcome in Dogs Undergoing Emergency Abdominal Surgery: A Retrospective Study on 82 Cases (2018-2020)

Emergency abdominal surgery carries high morbidity and mortality rates in human medicine; however, there is less evidence characterising the outcome of these surgeries as a single group in dogs. The aim of the study was to characterise the clinical course, associated complications and outcome of dogs undergoing emergency abdominal surgery. A retrospective study was conducted. Dogs undergoing emergency laparotomy were included in the study. Logistic regression analysis was performed to identify variables correlated with death and complications. Eighty-two dogs were included in the study. The most common reason for surgery was a gastrointestinal foreign body. Overall, the 15-day mortality rate was 20.7% (17/82). The median (range) length of hospitalisation was 3 (0.5-15) days. Of the 82 patients, 24 (29.3%) developed major complications and 66 (80.5%) developed minor complications. Perioperative factors significantly associated with death included tachycardia (p < 0.001), hypothermia (p < 0.001), lactate acidosis (p < 0.001), shock index > 1 (p < 0.001), leukopenia (p < 0.001) and thrombocytopenia (p < 0.001) at admission, as well as intraoperative hypotension (p < 0.001) and perioperative use of blood products (p < 0.001). The results of this study suggest that mortality and morbidity rates after emergency abdominal surgery in dogs are high.

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

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.

New Zealand and Australia emergency laparotomy mortality rates compare favourably to international outcomes: a systematic review

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.

Meta-analysis of mortality risk in octogenarians undergoing emergency general surgery operations

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.

Situational analysis on the recovery of patients who have undergone major abdominal surgery

Aim

To analyse the recovery situation of patients who underwent abdominal surgery.

Design

A descriptive study.

Method

This study was conducted among 50 participants: 15 postoperative patients, 16 caregivers, 2 surgeons and 17 nurses in a tertiary hospital in Thailand. The state of patients' recovery after undergoing major abdominal surgery was analysed using Donabedian's approach.

Results

The findings showed that hospitals and some organizations do not have a clear policy about clinical care to help patients recover after undergoing major surgery or to prevent the risk of complications following major abdominal surgery. In addition, there were no clinical practice guidelines in use in each ward. Each ward should have a set of guidelines and procedures for assisting with patient recovery. The procedures should be based on nursing care. It is necessary to have a coordinated multidisciplinary care guideline to use with other health professionals to promote the recovery of patients.

Patients' perceptions of barriers to enhanced recovery after emergency abdominal surgery

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.

Operative management of colonic diverticular disease in the setting of immunosuppression: A systematic review and meta-analysis

BACKGROUND

Immunosuppressed patients with diverticular disease are at higher risk of postoperative complications, however reported rates have varied. The aim of this study is to compare postoperative outcomes in immunosuppressed and immunocompetent patients undergoing surgery for diverticular disease.

METHODS

Medline, EMBASE, and CENTRAL were searched. Articles were included if they compared immunosuppressed and immunocompetent patients undergoing surgery for diverticular disease.

RESULTS

From 204 citations, 11 studies with 2,977 immunosuppressed patients and 780,630 immunocompetent patients were included. Mortality was greater in immunosuppressed patients compared to immunocompetent patients for emergent surgery (RR 1.91, 95%CI 1.24-2.95, p < 0.01), but not elective surgery (RR 1.70, 95%CI 0.14-20.47, p = 0.68). Morbidity was greater in immunosuppressed patients compared to immunocompetent patients for elective surgery (RR 2.18, 95%CI 1.02-4.65, p = 0.04), but not emergent surgery (RR 1.40, 95%CI 0.68-2.90, p = 0.37).

CONCLUSIONS

Increased consideration for elective operation may preclude the need for emergent surgery and the associated increase in postoperative mortality.

Risk factors for mortality after emergency laparotomy: scoping systematic review

BACKGROUND

Emergency laparotomy (EL) is a common procedure with high mortality leading to several efforts to record and reduce mortality. Risk scores currently used by quality improvement programmes either require intraoperative data or are not specific to EL. To be of utility to clinicians/patients, estimation of preoperative risk of mortality is important. We aimed to explore individual preoperative risk factors that might be of use in developing a preoperative mortality risk score.

METHODS

Two independent reviewers identified relevant articles from searches of MEDLINE, EMBASE and Cochrane databases from January 1980 to January 2018. We selected studies that evaluated only preoperative predictive factors for mortality in EL patients.

RESULTS

The search yielded 6648 articles screened, with 22 studies included examining 157 728 patients. The combined post-operative 30-day mortality was 13%. All, but one small study, were at low risk of bias. A meta-analysis of results was not possible due to the heterogeneity of populations and outcomes. Age, American Society of Anesthesiologists, preoperative sepsis, dependency status, current cancer and comorbidities were associated with increased mortality. Acute physiological derangements seen in renal, albumin and complete blood count assays were strongly associated with mortality. Delay to surgery and diabetes did not influence mortality. Higher body mass index was protective.

CONCLUSION

Preoperatively, risk factors identified can be used to develop and update risk scores specific for EL mortality. This scoping review focused on the preoperative setting which helps tailor treatment decisions. It highlights the need for further research to test the relevance of newer risk factors such as frailty and nutrition.

Early Postoperative Death in Patients Undergoing Emergency High-Risk Surgery: Towards a Better Understanding of Patients for Whom Surgery May Not Be Beneficial

The timing, causes, and quality of care for patients who die after emergency laparotomy have not been extensively reported. A large database of 13,953 patients undergoing emergency laparotomy, between July 2014 and March 2017, from 28 hospitals in England was studied. Anonymized data was extracted on day of death, patient demographics, operative details, compliance with standards of care, and 30-day and in-patient mortality. Thirty-day mortality was 8.9%, and overall inpatient mortality was 9.8%. Almost 40% of postoperative deaths occurred within three days of surgery, and 70% of these early deaths occurred on the day of surgery or the first postoperative day. Such early deaths could be considered nonbeneficial surgery. Patients who died within three days of surgery had a significantly higher preoperative lactate, American Society of Anesthesiologists Physical Status (ASA-PS) grade, and Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM). Compliance with perioperative standards of care based on the Emergency Laparotomy Collaborative care bundle was high overall and better for those patients who died within three days of surgery. Multidisciplinary team involvement from intensive care, care of the elderly physicians, and palliative care may help both the communication and the burden of responsibility in deciding on the risk–benefit of operative versus nonoperative approaches to care.

Incidence and Cost of Deep Vein Thrombosis in Emergency General Surgery Over 15 Years

BACKGROUND

Deep vein thromboses (DVTs) are a significant sequela of surgery and are associated with significant of morbidity and mortality in the United States. Operative emergency general surgery (EGS) cases have been demonstrated to have a greater burden of DVT than other types of surgery.

MATERIALS AND METHODS

DVT in EGS cases were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2015 Q3 based on ICD-9 code specification. National incidence of DVT in EGS was calculated using the National Inpatient Sample-Healthcare Cost and Utilization Project sampling methodology, and propensity score matching was used to assess costs associated with DVT.

RESULTS

Among 15,148,352 sample-weighted hospitalizations, 0.623% (94,392) experienced DVT. Incidence of DVT was greatest in GI ulcer surgery (1.705%) and lowest in appendectomy (0.095%). Patients with a perioperative DVT incurred $22,301 more in hospital-related costs than their counterparts who did not have a DVT. Although rates of DVT remained stable over the period analyzed, DVT-associated costs increased at a 2.09% annual rate in excess of inflation during the period analyzed. This increase in costs was most significant for laparotomy, which increased at a rate of 8.09% annually.

CONCLUSIONS

DVT continues to be a significant burden on resources in EGS in spite of efforts with DVT prophylaxis. Considering the increase in costs and little change in incidence, further research on cost-effective management of DVT in EGS is warranted.

Early Postoperative Outcomes of Normal Pressure Hydrocephalus: Results of a Service Evaluation

BACKGROUND

Patients with normal pressure hydrocephalus (NPH) are often elderly, frail and affected by multimorbidity. Treatment is surgical with cerebrospinal diversion shunts. The selection of patients that are of an acceptable level of risk to be treated surgically has been a matter of debate for years and has deprived some patients of life-changing surgery. The aim of this service evaluation was to investigate the preoperative risk factors and early postoperative morbidity of patients with NPH using a standardized postoperative survey.

MATERIALS AND METHODS

Consecutive NPH patients admitted for neurosurgical management of NPH between May 2017 and May 2018 were included in this prospective service evaluation. In addition to the collection of traditional outcome measures, the cardiac version of the Postoperative Morbidity Survey (C-POMS) was conducted on postoperative days 4, 7, and 10 to identify postoperative morbidity.

RESULTS

Eighty-eight patients (63 males, age mean±SD, 75±7 y) underwent 106 surgical procedures (61 lumbar drains, 45 ventriculoperitoneal shunts). There was no 30-day mortality and no unexpected return to the operating room or admission to intensive care unit. There was 1 conservatively managed surgical complication. On postoperative day 4, the C-POMS identified no postoperative morbidity in 72% of the patients, and mild morbidity (postoperative nausea and mobility issues) in 28%. There was a delay in discharge in 50% of the patients with no postoperative morbidity on day 4, highlighting areas of our service requiring improvement.

CONCLUSIONS

Early postoperative outcomes of NPH patients are good after both ventriculoperitoneal shunt insertion and lumbar drainage. This evaluation provides initial evidence on the utility of the C-POMS as a service evaluation tool in the standardized assessment postoperative outcomes in neurosurgery patients.

Mortality after abdominal emergency surgery in nonagenarians

PURPOSE

To search the pattern of diagnoses in nonagenarians undergoing emergency abdominal surgery between January 2009 and December 2013 in two hospitals. To test the hypothesis that pre-hospital functional status is an effective criterion for predicting postoperative mortality in nonagenarians after emergency abdominal surgery.

METHODS

The study is an observational study on 157 patients. Patients were identified from the operation database and perioperative data were extracted as prospectively information supplied by retrospective data from patient electronic files. The primary endpoints were short, middle and long-term mortality and the secondary endpoint was to identify preoperative factors associated with postoperative mortality.

RESULTS

The most frequent reason for operation was intestinal obstruction. Overall mortality in the cohort was 34% (n = 54) after 30 days and 54% (n = 84) after 1 year. Amongst patients developing a serious complication (classified as Clavien Dindo class III or greater) after surgery (n = 45) the mortality was 80% (n = 36) after 30 days and 89% (n = 40) after 1 year. In multivariate analysis, a high American Association of Anesthesiologists class (ASA) and a high Performance Status (PS) class (low performance) were significant predictors of post-operative mortality.

CONCLUSION

Our data support pre-admission functional status for predicting postoperative mortality after emergency abdominal surgery in nonagenarians.

Does the Implementation of a Quality Improvement Care Bundle Reduce the Incidence of Acute Kidney Injury in Patients Undergoing Emergency Laparotomy?

PURPOSE

Previous work has demonstrated a survival improvement following the introduction of an enhanced recovery protocol in patients undergoing emergency laparotomy (the emergency laparotomy pathway quality improvement care (ELPQuiC) bundle). Implementation of this bundle increased the use of intra-operative goal directed fluid therapy and ICU admission, both evidence-based strategies recommended to improve kidney outcomes. The aim of this study was to determine if the observed mortality benefit could be explained by a difference in the incidence of AKI pre- and post-implementation of the protocol.

METHOD

The primary outcome was the incidence of AKI in the pre- and post-ELPQuiC bundle patient population in four acute trusts in the United Kingdom. Secondary outcomes included the KDIGO stage specific incidence of AKI. Serum creatinine values were obtained retrospectively at baseline, in the post-operative period and the maximum recorded creatinine between day 1 and day 30 were obtained.

RESULTS

A total of 303 patients pre-ELPQuiC bundle and 426 patients post-ELPQuiC bundle implementation were identified across the four centres. The overall AKI incidence was 18.4% in the pre-bundle group versus 19.8% in the post bundle group p = 0.653. No significant differences were observed between the groups.

CONCLUSIONS

Despite this multi-centre cohort study demonstrating an overall survival benefit, implementation of the quality improvement care bundle did not affect the incidence of AKI.

Central venous oxygen saturation/lactate ratio: a novel predictor of outcome following emergency open laparotomy

INTRODUCTION

Emergency laparotomy is associated with high rates of morbidity and mortality. The need for highly sensitive readily prognostic biomarkers is necessary to improve the outcome. We investigated the usefulness of post-operative arterial lactate and ScvO₂/lactate ratio as predictors of outcome after post-operative emergency open laparotomy. To the best of our knowledge, the novel ScvO₂/lactate ratio was not investigated before in emergency open laparotomy patients.

METHODS

It is a prospective observational cohort study. We investigated the usefulness of post-operative arterial lactate and ScvO₂/lactate ratio as predictors of early mortality in 40 patients following emergency open laparotomy admitted to the ICU.

RESULTS

Admission and 24 h lactate levels were predictor of mortality with cut-off point > 3.95 mmol/L, sensitivity 100%, and specificity 93.3%, and cut-off > 3.5 mmol/L, sensitivity 100%, and specificity 96.7%, respectively. In this study, ScvO₂/lactate ratio on admission was predictor of at day 7 with cut-off point < 13.95, sensitivity 100%, and specificity 96.7% p < 0.0001. Lactate at 12 and 24 h was also predictor of survival p < 0.0001. Serial arterial lactate was highly correlated to ICU length of stay; admission APACHE II and day 1; and 2 MODS and SOFA scores (p < 0.001).

CONCLUSION

Serial blood lactate as well as the novel ScvO₂/lactate ratio can be useful for early predictors of mortality at 7 days. Serial lactate levels correlate to admission ICU scores APACHE II; MODS and SOFA in post-operative emergency open laparotomy patients.

Short-term morbidity factors associated with length of hospital stay (LOS): Development and validation of a Hip Fracture specific postoperative morbidity survey (HF-POMS)

BACKGROUND

We aimed to describe and quantify postoperative complications in the older hip fracture population, develop and validate a hip fracture postoperative morbidity survey tool (HF-POMS).

METHODS

A prospective clinical observation study of patients (≥ 70 years) admitted for emergency hip fracture surgery, was conducted across three English National Health Service hospitals. Outcome data items were developed from the Postoperative Morbidity Survey (POMS), Cardiac-POMS, hip fracture postoperative literature and orthogeriatric clinical team input. Postoperative outcome data were collected on days 1, 3, 5, 8 and 15; 341 patients participated.

RESULTS

A 12-domain HF-POMS tool was developed with acceptable construct validity on all HF-POMS days. Patients with high perioperative risk scores as measured by the NHFS and ASA grade were more prone to develop HF-POMS defined morbidities. High morbidity rates occurred in the following domains; renal, ambulation assistance, pain and infectious. Presence of any morbidity on postoperative days 8 and 15 was associated with subsequent length of stay of 3.08 days (95% CI 0.90-5.26, p = 0.005) and 15.81 days (95% CI 13.35-18.27, p = 0.001) respectively. Observed average length of stay was 16.9 days. HF-POMS is a reliable and valid tool for measuring early postoperative complications in hip fracture patients. Additional domains are necessary to account for all morbidity aspects in this patient population compared to the original POMS.

CONCLUSION

Many patients remained in hospital for non-medical reasons. HF-POMS may be a useful tool to assist in discharge planning and randomised control trial outcome definitions.

Physiological and operative severity score for the enumeration of mortality and morbidity, frailty, and perioperative quality of life in the elderly

Background:

Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) is a validated instrument used to predict morbidity. The aim of our study was to evaluate the performance of the POSSUM score system on predicting perioperative frailty and quality of life (QOL) in elderly surgical patients.

Patients and Methods:

An observational prospective study was conducted during 3 months. POSSUM was used to determine operative morbidity risk. Patients with a POSSUM score ≥26 were considered as having a high POSSUM (PHP). WHODAS 2.0, EuroQOL-5 dimensions (EQ-5D), Charlson score, and the Clinical Frailty Scale were used to assess the QOL and frailty. Chi-square, Fisher's exact, or Mann–Whitney tests were used for comparisons.

Results:

Two hundred and thirty-five patients were included. Median age was 69 years; 58% were ASA I/II and 42% ASA III/IV. Frailty was present in 53 patients (23%). Median POSSUM score was 26. Patients PHP were older (median age 71 vs. 68, P = 0.008), more frequently ASA III/IV (P = 0.001), had higher median Charlson scores (7 vs. 5, P = 0.006) and were more frail (49% vs. 26%, P < 0.001). PHP presented more problems in EQ-5D dimensions preoperatively (mobility: 59% vs 41%, P = 0.008; care: 41% vs. 25%, P = 0.013; activity: 52% vs. 32%, P = 0.002; pain: 59% vs. 45%, P = 0.041) but not anxiety (P = 0.137). Three months after surgery, PHP patients presented more problems in mobility: 63% vs. 38%, P < 0.001; care: 48% vs. 31%, P = 0.009; activity: 58% vs. 44%, P = 0.036; pain 59% vs. 37%, P = 0.001 and anxiety: 54% vs. 50%, P = 0.025.

Conclusions:

Patients PHP were frailer and had worse perioperative QOL.

Outcome assessment of emergency laparotomies and associated factors in low resource setting. A case series

BACKGROUND

Emergency laparotomy is a high risk procedure which is demonstrated by high morbidity and mortality. However, the problem is tremendous in resource limited settings and there is limited data on patient outcome. We aimed to assess postoperative patient outcome after emergency laparotomy and associated factors.

METHODS

An observational study was conducted in our hospital from March 11- June 30, 2015 using emergency laparotomy network tool. All consecutive surgical patients who underwent emergency laparotomy were included. Binary and multiple logistic regressions were employed using adjusted odds ratios and 95% CI, and P-value < 0.05 was considered to be statistically significant.

RESULT

A total of 260 patients were included in the study. The majority of patients had late presentation (>6hrs) to the hospital after the onset of symptoms of the diseases and surgical intervention after hospital admission. The incidences of postoperative morbidity and mortality were 39.2% and 3.5% respectively. Factors associated with postoperative morbidity were preoperative co-morbidity (AOR = 0.383, CI = 0.156-0.939) and bowel resection (AOR = 0.232, CI = 0.091-0.591). Factors associated with postoperative mortality were anesthetists' preoperative opinion on postoperative patient outcome (AOR = 0.067, CI = 0.008-0.564), level of consciousness during recovery from anaesthesia (AOR = 0.114, CI = 0.021-10.628) and any re-intervention within 30 days after primary operation (AOR = 0.083, CI = 0.009-0.750).

CONCLUSION AND RECOMMENDATION

The incidence of postoperative morbidity and mortality after emergency laparotomy were high. We recommend preoperative optimization, early surgical intervention, and involvement of senior professionals during operation in these risky surgical patients. Also, we recommend the use of WHO or equivalent Surgical Safety Checklist and establishment of perioperative patient care bundle including surgical ICU and radiology investigation modalities such as CT scan.

Prognostic Significance of Acute Kidney Injury Following Emergency Laparotomy: A Prospective Observational Cohort Study

AIMS

Post-operative acute kidney injury (AKI) is a common and independent mortality risk factor carrying high clinical and economic cost. This study aimed to establish the incidence of AKI in patients undergoing emergency laparotomy (EL), to determine patients' risk profile and consequent mortality.

METHODS

Consecutive 239 patients of median age 68 (IQR 51-76) years, undergoing EL in a UK tertiary hospital, were studied. Primary outcome measure was AKI and in-hospital operative mortality.

RESULTS

Ninety-five patients (39.7%) developed AKI, which was associated with in-hospital mortality in 32 patients (33.7%) compared with 7 patients (4.9%) without AKI. AKI occurred in 81.1% of all mortalities, but none occurred when AKI resolved within 48 h of EL. AKI was associated with chronic kidney disease, age, serum lactate, white cell count, pre-EL systolic blood pressure and tachycardia (p < 0.010). Median length of hospital stay in AKI survivors was 15 days compared with 11 days in the absence of AKI (p < 0.001). On multivariable analysis, only AKI at 48 h post-EL was significantly and independently associated with mortality [HR 10.895, 95% CI 3.152-37.659, p < 0.001].

CONCLUSION

Peri-operative AKI after EL was common and associated with a more than sixfold significant greater mortality. Pre-operative risk profile assessment and prompt protocol-driven intervention should minimise AKI and reduce EL mortality.

Femoral Nerve Block Intervention in Neck of Femur Fracture (FINOF): a randomised controlled trial

OBJECTIVE

Fractured neck of femur is a severely painful condition with significant mortality and morbidity. We investigated whether early and continuous use of femoral nerve block can improve pain on movement and mobility after surgery in older participants with fragility neck of femur fracture.

DESIGN

Prospective single-centre, randomised controlled pragmatic trial.

SETTING

Secondary care, acute National Health Service Trust, UK.

PARTICIPANTS

Participants admitted with a history and examination suggesting fractured neck of femur.

INTERVENTION

Immediate continuous femoral nerve block via catheter or standard analgesia.

OUTCOME MEASURES

Primary outcome measures were Cumulative Dynamic Pain score and Cumulated Ambulation Score from surgery until day 3 postoperatively. Secondary outcome measures included pain scores at rest, cumulative side effects (nausea and constipation), quality of life (measured by EuroQOL 5 D instrument (EQ-5D) score) at day 3 and day 30, and rehabilitation outcome (measured by mobility score).

RESULTS

141 participants were recruited, with 23 excluded. No significant difference was detected between Cumulative Dynamic Pain Score (standard care (n=56) vs intervention (n=55) 20 (IQR 15-24) vs 20 (15-23), p=0.51) or Cumulated Ambulation Score (standard care vs intervention 6 (5-9) vs 7 (5-10), p=0.76). There were no statistically different differences in secondary outcomes except cumulative pain at rest: 5 (0.5-6.5) in the standard care group and 2 (0-5) in the intervention group (p=0.043).

CONCLUSIONS

Early application of continuous femoral nerve block compared with standard systemic analgesia did not result in improved dynamic pain score or superior postoperative ambulation. This technique may provide superior pain relief at rest. Continuous femoral nerve block did not delay initial control of pain or mobilisation after surgery.

TRIAL REGISTRATION NUMBER

ISRCTN92946117; Pre-results.

A systematic review and overview of health economic evaluations of emergency laparotomy

Background

Little is known about the economic impact of emergency laparotomy (EL) surgery in healthcare systems around the world. The aim of this systematic review is to describe the primary resource utilisation, healthcare economic and societal costs of EL in adults in different countries.

Methods

MEDLINE, EMBASE, ISI Web of Knowledge, Cochrane Central Register Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were searched for full and partial economic analyses of EL published between 1 January 1991 and 31 December 2015. Quality of studies was assessed using the Consensus on Health Economic Criteria (CHEC) checklist.

Results

Sixteen studies were included from a range of countries. One study was a full economic analysis. Fifteen studies were partial economic evaluations. These studies revealed that emergency abdominal surgery is expensive compared to similar elective surgery when comparing primary resource utilisation costs, with an important societal impact. Most contemporaneous studies indicate that in-hospital costs for EL are in excess of US$10,000 per patient episode, rising substantially when societal costs are considered.

Discussion

EL is a high-risk and costly procedure with a disproportionate financial burden for healthcare providers, relative to national funding provisions and wider societal cost impact. There is substantial heterogeneity in the methodologies and quality of published economic evaluations of EL; therefore, the true economic costs of EL are yet to be fully defined. Future research should focus on developing strategies to embed health economic evaluations within national programmes aiming to improve EL care, including developing the required measures and infrastructure.

Conclusions

Emergency laparotomy is expensive, with a significant cost burden to healthcare and systems and society worldwide. Novel strategies for reducing this econmic burden should urgently be explored if greater access to this type of surgery is to be pursued as a global health target.

Trial registration

PROSPERO registration no. 42015027210.

Predicting Postoperative Complications for Acute Care Surgery Patients Using the ACS NSQIP Surgical Risk Calculator

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator has been used to assist surgeons in predicting the risk of postoperative complications. This study aims to determine if the risk calculator accurately predicts complications in acute care surgical patients undergoing laparotomy. A retrospective review was performed on all patients on the acute care surgery service at a tertiary hospital who underwent laparotomy between 2011 and 2012. The preoperative risk factors were used to calculate the estimated risks of postoperative complications in both the original ACS NSQIP calculator and updated calculator (June 2016). The predicted rate of complications was then compared with the actual rate of complications. Ninety-five patients were included. Both risk calculators accurately predicted the risk of pneumonia, cardiac complications, urinary tract infections, venous thromboembolism, renal failure, unplanned returns to operating room, discharge to nursing facility, and mortality. Both calculators underestimated serious complications (26% vs 39%), overall complications (32.4% vs 45.3%), surgical site infections (9.3% vs 20%), and length of stay (9.7 days versus 13.1 days). When patients with prolonged hospitalization were excluded, the updated calculator accurately predicted length of stay. The ACS NSQIP risk calculator underestimates the overall risk of complications, surgical infections, and length of stay. The updated calculator accurately predicts length of stay for patients <30 days. The acute care surgical population represents a high-risk population with an increased rate of complications. This should be taken into account when using the risk calculator to predict postoperative risk in this population.

Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery

Background

Acute high-risk abdominal (AHA) surgery carries a very high risk of morbidity and mortality and represents a massive healthcare burden. The aim of the present study was to evaluate the effect of a standardized multidisciplinary perioperative protocol in patients undergoing AHA surgery.

Methods

The AHA study was a prospective single-centre controlled study in consecutive patients undergoing AHA surgery, defined as major abdominal pathology requiring emergency laparotomy or laparoscopy including reoperations after elective gastrointestinal surgery. Consecutive patients were included after initiation of the AHA protocol as standard care. The intervention cohort was compared with a predefined, consecutive historical cohort of patients from the same department. The protocol involved continuous staff education, consultant-led attention and care, early resuscitation and high-dose antibiotics, surgery within 6 h, perioperative stroke volume-guided haemodynamic optimization, intermediate level of care for the first 24 h after surgery, standardized analgesic treatment, early postoperative ambulation and early enteral nutrition. The primary outcome was 30-day mortality.

Results

Six hundred patients were included in the study and compared with 600 historical controls. The unadjusted 30-day mortality rate was 21·8 per cent in the control cohort compared with 15·5 per cent in the intervention cohort (P = 0·005). The 180-day mortality rates were 29·5 and 22·2 per cent respectively (P = 0·004).

Conclusion

The introduction of a multidisciplinary perioperative protocol was associated with a significant reduction in postoperative mortality in patients undergoing AHA surgery. NCT01899885 (http://www.clinicaltrials.gov).

Complications after emergency laparotomy beyond the immediate postoperative period - a retrospective, observational cohort study of 1139 patients

Mortality and morbidity occur commonly following emergency laparotomy, and incur a considerable clinical and financial healthcare burden. Limited data have been published describing the postoperative course and temporal pattern of complications after emergency laparotomy. We undertook a retrospective, observational, multicentre study of complications in 1139 patients after emergency laparotomy. A major complication occurred in 537/1139 (47%) of all patients within 30 days of surgery. Unadjusted 30-day mortality was 20.2% and 1-year mortality was 34%. One hundred and thirty-seven of 230 (60%) deaths occurred between 72 h and 30 days after surgery; all of these patients had complications, indicating that there is a prolonged period with a high frequency of complications and mortality after emergency laparotomy. We conclude that peri-operative, enhanced recovery care bundles for preventing complications should extend their focus on continuous complication detection and rescue beyond the first few postoperative days.

Estimated costs before, during and after the introduction of the emergency laparotomy pathway quality improvement care (ELPQuIC) bundle

Implementation of a quality improvement bundle for peri-operative management of emergency laparotomy (ELPQuIC) improved mortality in a previous study. We used data from one site that participated in that study to examine whether it was associated with the cost of care. We collected data from 396 patients: 144 before, 144 during and 108 after implementation of the bundle. We estimated costs incurred using previously published methodology based on the time the patient spent in hospital, in the operating theatre and in critical care. Duration of stay in hospital and critical care did not differ between time periods, p = 0.14 and p = 0.28, respectively. The costs per patient and per survivor did not differ between the time periods, p = 0.87 and p = 0.17, respectively. Costs were similar for patients aged < 80 years vs. ≥ 80 years. Implementation of a quality improvement bundle for emergency laparotomy has the capacity to save lives without increasing hospital costs.