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Amati AL, Ebert R, Maier L, Panah AK, Schwandner T, Sander M, Reichert M, Grau V, Petzoldt S, Hecker A. Reduced preoperative serum choline esterase levels and fecal peritoneal contamination as potential predictors for the leakage of intestinal sutures after source control in secondary peritonitis. World J Emerg Surg 2024; 19:21. [PMID: 38840189 PMCID: PMC11151556 DOI: 10.1186/s13017-024-00550-x] [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: 04/25/2024] [Accepted: 05/29/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND The high rate of stoma placement during emergency laparotomy for secondary peritonitis is a paradigm in need of change in the current fast-track surgical setting. Despite growing evidence for the feasibility of primary bowel reconstruction in a peritonitic environment, little data substantiate a surgeons' choice between a stoma and an anastomosis. The aim of this retrospective analysis is to identify pre- and intraoperative parameters that predict the leakage risk for enteric sutures placed during source control surgery (SCS) for secondary peritonitis. METHODS Between January 2014 and December 2020, 497 patients underwent SCS for secondary peritonitis, of whom 187 received a primary reconstruction of the lower gastro-intestinal tract without a diverting stoma. In 47 (25.1%) patients postoperative leakage of the enteric sutures was directly confirmed during revision surgery or by computed tomography. Quantifiable predictors of intestinal suture outcome were detected by multivariate analysis. RESULTS Length of intensive care, in-hospital mortality and failure of release to the initial home environment were significantly higher in patients with enteric suture leakage following SCS compared to patients with intact anastomoses (p < 0.0001, p = 0.0026 and p =0.0009, respectively). Reduced serum choline esterase (sCHE) levels and a high extent of peritonitis were identified as independent risk factors for insufficiency of enteric sutures placed during emergency laparotomy. CONCLUSIONS A preoperative sCHE < 4.5 kU/L and generalized fecal peritonitis associate with a significantly higher incidence of enteric suture insufficiency after primary reconstruction of the lower gastro-intestinal tract in a peritonitic abdomen. These parameters may guide surgeons when choosing the optimal surgical procedure in the emergency setting.
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Affiliation(s)
- A L Amati
- Department of General, Visceral, Thoracic and Transplant Surgery, University Hospital of Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany.
| | - R Ebert
- Department of General, Visceral, Thoracic and Transplant Surgery, University Hospital of Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - L Maier
- Department of General, Visceral, Thoracic and Transplant Surgery, University Hospital of Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - A K Panah
- Department of General, Visceral and Transplant Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - T Schwandner
- Department of General and Visceral Surgery, Asklepios Clinic Lich, Goethestrasse 4, 35423, Lich, Germany
| | - M Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - M Reichert
- Department of General, Visceral, Thoracic and Transplant Surgery, University Hospital of Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - V Grau
- Department of General, Visceral, Thoracic and Transplant Surgery, University Hospital of Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - S Petzoldt
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
| | - A Hecker
- Department of General, Visceral, Thoracic and Transplant Surgery, University Hospital of Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany
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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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3
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Cheng DT, Miyata N, Asomah F. An 8-year retrospective review of emergency laparotomy outcomes in a Queensland rural hospital. Aust J Rural Health 2023; 31:991-998. [PMID: 37635294 DOI: 10.1111/ajr.13034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023] Open
Abstract
OBJECTIVE Emergency laparotomy (EL) is a major operation performed in critically unwell patients. The National Emergency Laparotomy Audit (NELA), undertaken in the UK since 2013 has shown progressive improvement in clinical outcomes, specifically reduced mortality, and length of stay (LOS) through the implementation of perioperative key performance indicators (KPIs) (ANZ J Surg. 2021;91:2575, Br J Surg. 2015;102:57, Br J Surg. 2017;104:463, JAMA Surg. 2019;154:e190145). The objective is to generate a rural hospital EL audit (MELA) to evaluate local outcomes and clinical standards of practice with regional, national, and international benchmarks. METHODS A review of medical records between January 2014 and December 2021 of patients who undergo an EL. Data collected include patient demographics, clinical information, compliance to KPIs and the primary outcomes of 30-day mortality and LOS. DESIGN This is a descriptive quantitative study. The inclusion and exclusion criteria were similar to those defined in NELA and ANZELA-QI. SETTING AND PARTICIPANTS The general surgeons at the rural hospital provide emergency surgery services for the North-West Queensland community. MAIN OUTCOME MEASURES To review local clinical outcomes of 30-day mortality, LOS, and adherence to perioperative KPIs. RESULTS Overall, 84 patients met inclusion criteria. The median age (IQR) was 61 (48.8-70.3) years. The 30-day mortality was 3.6% and mean LOS was 12.8 (±13.4) days which was secondary to the low-risk patients within the data set. Compliance to KPIs (≥80%) was achieved in five of eight standards assessed. CONCLUSION Local outcomes appear to be comparable to national and international benchmarks and a similar rural setting. The audited cohort outperformed the national standard in adherence to perioperative KPIs.
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Affiliation(s)
- Dong Tony Cheng
- Department of General Surgery, Mount Isa Base Hospital, Mount Isa, Queensland, Australia
| | - Nariyoshi Miyata
- Department of General Surgery, Mount Isa Base Hospital, Mount Isa, Queensland, Australia
- Mount Isa Base Hospital, Mount Isa, Queensland, Australia
| | - Francis Asomah
- Mount Isa Base Hospital, Mount Isa, Queensland, Australia
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4
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Holmes M, Rugendyke A, Ming YJ, Howley P, Gani J, Pockney P. Getting back 'home' after emergency laparotomy: how many never make it? ANZ J Surg 2023; 93:2433-2438. [PMID: 37675923 DOI: 10.1111/ans.18685] [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: 05/18/2023] [Revised: 07/19/2023] [Accepted: 08/27/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Emergency laparotomy (EL) is performed on about 15 500 patients in Australia each year. Aside from mortality there is significant concern about the possibility that previously independent patients discharged after EL will become reliant on long-term dependent care. This study aimed to establish the proportion of patients not returning to their pre-admission residence, a proxy for dependent care, following EL. METHODS Data were collected on all adult patients who underwent EL across four Australian hospitals over 2 years. A total of 113 data points were collected including pre-hospital residence, discharge destination, mortality and place of residence at 90 and 365 days. RESULTS A total of 782 patients underwent EL, the mean age was 64 years. Pre-admission, 95.5% of patients were living in their own home. Inpatient mortality was 7.0% and at discharge 72.4% of patients returned directly back to their pre-hospital residence. At 90 days, mortality was 10.5%, and 87% of patients had returned to their pre-hospital residence, including all patients under 70 years of age. By 365 days, overall mortality was 16.8%, and only 1.5% of patients (all aged >70 years) had not returned to their pre-hospital residence. CONCLUSION Patients who survive 90 and 365 days following EL nearly all return to their pre-hospital residence, with only a very small proportion of previously independent patients entering dependent care. This should help inform shared decision-making regarding emergency laparotomy in the acute setting.
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Affiliation(s)
- Merran Holmes
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Anya Rugendyke
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Yan Joyce Ming
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter Howley
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Jon Gani
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Peter Pockney
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
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5
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Pule LM, Kopunic H, Aitken RJ. Low mortality rate after emergency laparotomy in Australia is a reflection of its national surgical mortality audit influencing futile surgery. Br J Surg 2023; 110:1367-1373. [PMID: 37409943 DOI: 10.1093/bjs/znad200] [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: 02/23/2023] [Revised: 04/06/2023] [Accepted: 06/13/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Australia's unique national surgical mortality audit has had a long-term focus on the avoidance of futile surgery. The 30-day mortality rate after emergency laparotomy in Australia is lower than in other countries. Early death (within 72 h) after emergency laparotomy may reflect futile surgery. This paper considers whether Australia's national mortality audit is the reason for its lower mortality rate after emergency laparotomy. METHODS Data were extracted from the Australia and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) from 2018 to 2022. The time elapsed from emergency laparotomy to death was determined for each patient. The cumulative daily mortality rate was calculated for the first 30 days and expressed as a proportion of all emergency laparotomies, and 30-day and in-hospital mortality. Mortality data were compared with those in the only three similar overseas studies. The mortality rate after emergency laparotomy for patients who required but did not undergo surgery was calculated for each hospital. The proportion of patients with high-risk characteristics was compared with that in the National Emergency Laparotomy Audit (NELA). RESULTS Compared with overseas studies, there was a lower early (within 72 h) mortality rate in ANZELA-QI. Although the lower mortality rate in ANZELA-QI persisted to 30 days, there was a relative increase after 14 days that likely reflected known poor compliance with care standards. Australian patients had fewer high-risk characteristics than those in NELA. CONCLUSION The present findings support the hypothesis that the lower mortality rate after emergency laparotomy in Australia is likely a consequence of its national mortality audit and the avoidance of futile surgery.
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Affiliation(s)
- Lettie M Pule
- Royal Australasian College of Surgeons, Morbidity Audits, Research, Audit & Academic Surgery, Adelaide, South Australia, Australia
| | - Helena Kopunic
- Royal Australasian College of Surgeons, Morbidity Audits, Research, Audit & Academic Surgery, Adelaide, South Australia, Australia
| | - R James Aitken
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
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6
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Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023; 47:1850-1880. [PMID: 37277507 PMCID: PMC10241558 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA 9110 USA
| | - Nicholas P. Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104 USA
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7
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Green L, Stienstra R, Brown LR, McLean RC, Wilson MSJ, Crumley ABC, Hendry PO. Evaluating temporal trends and the impact of surgical subspecialisation on patient outcomes following adhesional small bowel obstruction: a multicentre cohort study. Eur J Trauma Emerg Surg 2023; 49:1343-1353. [PMID: 36653530 DOI: 10.1007/s00068-023-02224-w] [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: 09/22/2022] [Accepted: 01/07/2023] [Indexed: 01/20/2023]
Abstract
PURPOSE Small bowel obstruction (SBO) is the most common indication for laparotomy in the UK. While general surgeons have become increasingly subspecialised in their elective practice, emergency admissions commonly remain undifferentiated. This study aimed to assess temporal trends in the management of adhesional SBO and explore the influence of subspecialisation on patient outcomes. METHODS Data was collected for patients admitted acutely with adhesional SBO across acute NHS trusts in Northern England between 01/01/02 and 31/12/16, including demographics, co-morbidities and procedures performed. Patients were excluded if a potentially non-adhesional cause was identified and were grouped by the responsible consultant's subspecialty. The primary outcome of interest was 30-day inpatient mortality. RESULTS Overall, 2818 patients were admitted with adhesional SBO during a 15-year period. There was a consistent female preponderance, but age and comorbidity increased significantly over time (both p < 0.001). In recent years, more patients were managed operatively with a trend away from delayed surgery also evident (2002-2006: 65.7% vs. 2012-2016: 42.7%, p < 0.001). Delayed surgery was associated with an increased mortality risk on multivariable regression analysis (OR: 2.46 (1.46-4.23, p = 0.001)). CT scanning was not associated with management strategy or timing of surgery (p = 0.369). There was an increased propensity for patients to be managed by gastrointestinal (colorectal and upper gastrointestinal) subspecialists over time. Length of stay (p < 0.001) and 30-day mortality (p < 0.001) both improved in recent years, with the best outcomes seen in colorectal (2.6%) and vascular subspecialists (2.4%). However, following adjustment for confounding variables, consultant subspecialty was not a predictor of mortality. CONCLUSION Outcomes for patients presenting with adhesional SBO have improved despite the increasing burden of age and co-morbidity. While gastrointestinal subspecialists are increasingly responsible for their care, mortality is not influenced by consultant subspecialty.
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Affiliation(s)
- Lewis Green
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, Scotland
| | - Roxane Stienstra
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, Scotland
| | - Leo R Brown
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, Scotland. .,Clinical Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, Scotland.
| | - Ross C McLean
- Department of General Surgery, Queen Elizabeth Hospital, Gateshead, England
| | - Michael S J Wilson
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, Scotland
| | - Andrew B C Crumley
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, Scotland
| | - Paul O Hendry
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, Scotland
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8
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Tran ET, Ho KM. Utility of the National Emergency Laparotomy Audit prognostic model in predicting outcomes in an Australian health system. Anaesth Intensive Care 2023; 51:51-58. [PMID: 36475889 DOI: 10.1177/0310057x221105291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Royal College of Anaesthetists was commissioned by the United Kingdom Health Quality Partnership to conduct the National Emergency Laparotomy Audit of England and Wales (NELA), to compare outcomes of patients undergoing emergency laparotomy in order to promote quality improvement. Prior to 2016 there were minimal data for emergency laparotomy patients in Australia. The aim of this cohort study was to assess the utility and applicability of the NELA model in a tertiary centre in Western Australia. NELA-related data of patients who underwent emergency laparotomy, between June 2018 and May 2020, were merged with other administrative databases and clinical records. The discriminative ability and calibration of the model were assessed by the area under the receiver operating characteristic (AUROC) curve and calibration plot, respectively. Cox proportional hazards regression was used to assess whether the NELA-predicted risks were an independent predictor of hospital mortality. Of the 502 patients included, 168 (33.5%) patients had a NELA-predicted risk >10%, and of these, 93 (55.4%) were admitted to a critical care unit in a planned fashion immediately after surgery. The NELA model had a good ability to discriminate between survivors and non-survivors (AUROC 0.892, 95% confidence intervals 0.854 to 0.93, P <0.001). However, the model was not perfectly calibrated, with the predicted risks tending to overestimate the observed risks of mortality, especially when the predicted risks were >50%. A high NELA-predicted risk remained significantly associated with mortality after adjusting for other covariates, including sepsis and plasma lactate concentration, suggesting that it is a reliable screening tool for identifying high-risk patients requiring emergency laparotomy.
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Affiliation(s)
- Elizabeth T Tran
- Department of Intensive Care Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Australia.,School of Veterinary & Life Sciences, Murdoch University, Perth, Western Australia, Australia
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9
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Ming YJ, Howley P, Holmes M, Gani J, Pockney P. Sarcopenia 'made simple' and outcomes from emergency laparotomy. ANZ J Surg 2022; 92:3198-3203. [PMID: 35578776 PMCID: PMC10084216 DOI: 10.1111/ans.17759] [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: 12/02/2021] [Revised: 04/16/2022] [Accepted: 04/20/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Emergency Laparotomy (EL) is recognized as high-risk surgery with high mortality. Established surgical risk assessment tools (NELA Risk Prediction Calculator, P-POSSUM, ACS-NSQIP) are accurate predictors of morbidity and mortality. However, their multicomponent complexity limits their use in practice. Sarcopenia is associated with poorer surgical outcomes. This study tests for an association between a simple measure of radiological sarcopenia and mortality in EL patients in an Australian cohort. METHODS A retrospective analysis was conducted of 500 patients admitted to four Australian hospitals who underwent EL during 2016-2017. All patients had a contemporaneous abdomino-pelvic CT scan. Radiological sarcopenia was measured as the ratio of total psoas muscle area (PM) to L3 vertebral body cross sectional area (PM:L3). Patients were followed up to 12 months. Primary outcomes were 30-, 90- and 365-day mortality. RESULTS The mean 30-day mortality predictions for NELA, P-POSSUM and ACS-NSQIP were 11.36%, 17.28% and 11.30% respectively. PM:L3 ratio was associated with 30-, 90- and 365-day mortality (P < 0.001) and sex (P < 0.001) and negatively correlated with age (r = -0.4612; P < 0.001). Radiological sarcopenia had a weak negative correlation with NELA (r = -0.2737; P < 0.001), P-POSSUM (r = -0.1880; P < 0.001) and ACS-NSQIP (r = -0.2351; P < 0.001). The latter three metrics were significantly correlated (r > 0.5696; P < 0.001). CONCLUSION Radiological sarcopenia (CT-assessed PM:L3) is a significant predictor of mortality in EL patients in Australia. The results of this study suggest that radiological sarcopenia is equivalent to established risk assessment tools. The more timely and easily accessible CT-assessed PM:L3 metric is potentially automatable and may have significant utility in clinical practice.
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Affiliation(s)
- Yan Joyce Ming
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter Howley
- School of Information and Physical Sciences/Statistics, University of Newcastle, Newcastle, New South Wales, Australia
| | - Merran Holmes
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Jon Gani
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Peter Pockney
- Medical School, University of Western Australia, Crawley, WA, Australia.,Department of Surgery, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
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10
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Outcomes and associated factors among patients undergone emergency laparotomy: A retrospective study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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11
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Aitken RJ, Griffiths B, Van Acker J, O'Loughlin E, Fletcher D, Treacy JP, Watters D, Babidge WJ. Two-year outcomes from the Australian and New Zealand Emergency Laparotomy Audit-Quality Improvement pilot study. ANZ J Surg 2021; 91:2575-2582. [PMID: 34184372 DOI: 10.1111/ans.17037] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/28/2021] [Accepted: 06/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of the Australian and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) pilot study was to determine (i) the outcomes of emergency laparotomy (EL) and (ii) the feasibility of a national, multi-disciplinary quality improvement (QI) project based on a bundle of evidence-based care standards. METHODS An online database was created using the Research Electronic Data Capture (REDCap) programme. National ethics approval with waiver of consent was obtained. Data were entered directly onto REDCap and extracted monthly for eight care standards (preoperative consultant radiologist reporting of computed tomography scans, preoperative mortality risk score, consultant presence in theatre, timely access to theatre and critical care commensurate with risk and involvement of aged care). Monthly QI run charts using 'traffic' light graphics (green ≥80%, amber ≥50% to <80% and red <50%) reported compliance with the standards. RESULTS Sixty hospitals indicated interest, but difficulties with site-specific ethics approval resulted in only 24 hospitals participating (2886 EL in 2755 patients). The overall in-hospital mortality was 7.1% (2.3%-13.3%) and average length of stay 15.5 (8.6-22.7) days. Both significantly declined. Preoperative risk assessment (overall 45%) improved almost three-fold during the study. Only 60% had timely access to theatre and only 70% with a predicted mortality risk of >10% were admitted to critical care. CONCLUSION Overall mortality compared favourably with similar international studies and declined in association with participation in the audit. Compliance with some care standards shows considerable scope to improve EL care using QI methodology.
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Affiliation(s)
| | - R James Aitken
- Department of General Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Ben Griffiths
- Department of Anaesthetics, Auckland Hospital, Auckland, New Zealand
| | - Jill Van Acker
- Department of Anaesthetics, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Edmond O'Loughlin
- Department of General Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - David Fletcher
- Department of General Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - John P Treacy
- Department of General Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - David Watters
- Department of General Surgery, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
| | - Wendy J Babidge
- Research, Audit and Academic Surgery, Royal Australian College of Surgeons, Adelaide, South Australia, Australia.,Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
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12
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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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13
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McLean RC, Brown LR, Baldock TE, O'Loughlin P, McCallum IJ. Evaluating outcomes following emergency laparotomy in the North of England and the impact of the National Emergency Laparotomy Audit - A retrospective cohort study. Int J Surg 2020; 77:154-162. [PMID: 32234579 DOI: 10.1016/j.ijsu.2020.03.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency laparotomy is associated with high morbidity and mortality. Current trends suggest improvements have been made in recent years, with increased survival and shorter lengths of stay in hospital. The National Emergency Laparotomy Audit (NELA) has evaluated participating hospitals in England and Wales and their individual outcomes since 2013. This study aims to establish temporal trends for patients undergoing emergency laparotomy and evaluate the influence of NELA. METHODS Data for emergency laparotomies admitted to NHS hospitals in the Northern Deanery between 2001 and 2016 were collected, including demographics, co-morbidities, diagnoses, operations undertaken and outcomes. The primary outcome of interest was in-hospital death within 30 days of admission. Cox-regression analysis was undertaken with adjustment for covariates. RESULTS There were 2828 in-hospital deaths from 24,291 laparotomies within 30 days of admission (11.6%). Overall 30-day mortality significantly reduced during the 15-year period studied from 16.3% (2001-04), to 8.1% during 2013-16 (p < 0.001). After multivariate adjustment, laparotomies undertaken in more recent years were associated with a lower mortality risk compared to earlier years (2013-16: HR 0.73, p < 0.001). There was a significant improvement in 30-day postoperative mortality year-on-year during the NELA period (from 9.1 to 7.1%, p = 0.039). However, there was no difference in postoperative mortality for patients who underwent laparotomy during NELA (2013-16) compared with the preceding three years (both 8.1%, p = 0.526). DISCUSSION 30 day postoperative mortality for emergency laparotomy has improved over the past 15-years, with significantly reduced mortality risk in recent years. However, it is unclear if NELA has yet had a measurable effect on 30-day post-operative mortality.
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Affiliation(s)
- Ross C McLean
- Department of General Surgery, Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead, NE9 6SX, UK.
| | - Leo R Brown
- Health Education England North East, Waterfront 4, Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, UK
| | - Thomas E Baldock
- County Durham and Darlington NHS Foundation Trust, Darlington Memorial Hospital, Hollyhurst Road, Darlington, County Durham, DL3 6HX, UK
| | - Paul O'Loughlin
- Department of General Surgery, Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Avenue, Gateshead, NE9 6SX, UK
| | - Iain Jd McCallum
- Department of Colorectal Surgery, Northumbria Health NHS Foundation Trust, North Tyneside Hospital, Rake Lane, North Shields, NE29 8NH, UK
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14
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Asare EA, Davis CH, Chiang YJ, Sabir S, Rajkot NF, Phillips PR, Roland CL, Torres KE, Hunt KK, Feig BW. Management and outcomes of ruptured, perforated or fistulized tumors of mesenchymal origin. J Surg Oncol 2020; 121:474-479. [PMID: 31846095 DOI: 10.1002/jso.25807] [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: 09/12/2019] [Accepted: 12/02/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients with ruptured, perforated or fistulized (RPF) sarcomas commonly have issues such as sepsis and malnutrition and are usually unsuitable for oncologic resection in the emergency setting. We present our approach for managing a series of patients and the outcomes which were achieved with multidisciplinary care. METHODS We reviewed records of patients referred to the section of sarcoma surgical oncology. Clinicopathologic factors, preoperative and operative interventions as well as short-term oncologic outcomes were assessed. RESULTS Sixteen patients were identified between 1 January 1998 to 31 December 2018. Median age was 42.8 years. Histologies were; Gastrointestinal stromal tumors (7), desmoid (4), spindle cell tumor (2), dedifferentiated liposarcoma (2), and nonseminomatous germ cell tumor (1). Five patients had preoperative sepsis, 8 received antimicrobials, and 50% required hospitalization with a median stay of 21 days. Total parenteral nutrition was administered to 5 (31.3%) patients. Median tumor size and estimated blood loss were 13.1 cm and 350 mL respectively. No perioperative mortality occurred. Two patients have expired at a median follow-up of 16.1 months. CONCLUSION Preoperative optimization, including the use of percutaneous drains, and antibiotics to control sepsis, where necessary, can lead to eventual oncologic resection with acceptable morbidity and no short-term mortality for patients with RPF sarcomas.
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Affiliation(s)
- Elliot A Asare
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas.,Department of Surgery, University of Utah and Huntsman Cancer Institute, Salt Lake City, Utah
| | | | - Yi-Ju Chiang
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Sharjeel Sabir
- Department of Interventional Radiology, Scripps Mercy Hospital, San Diego, California
| | - Nikita F Rajkot
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Paula R Phillips
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Christina L Roland
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Keilla E Torres
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Kelly K Hunt
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
| | - Barry W Feig
- Department of Surgical Oncology, University of Texas, M. D. Anderson Cancer Center, Houston, Texas
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15
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Guetta O, Brotfain E, Shaked G, Sebbag G, Klein M, Czeiger D. Intra-abdominal pressure may be elevated in patients with open abdomen after emergent laparotomy. Langenbecks Arch Surg 2020; 405:91-96. [PMID: 31955259 DOI: 10.1007/s00423-020-01854-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/09/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE To estimate the change in intra-abdominal pressure (IAP) among critically ill patient who were left with open abdomen and temporary abdominal closure after laparotomy, during the first 48 h after admission. METHODS A cohort study in a single ICU in a tertiary care hospital. All adult patients admitted to the ICU after emergent laparotomy for acute abdomen or trauma, who were left with temporary abdominal closure (TAC), were included. Patients were followed up to 48 h. IAP was routinely measured at 0, 6, 12, 24, and 48 h after admission to ICU. RESULTS Thirty-nine patients were included, 34 were operated due to acute abdomen and 5 due to abdominal trauma. Seventeen patients were treated with skin closure, 13 with Bogota bag, and 9 with negative pressure wound therapy (NPWT). Eleven patients (28.2%) had IAP of 15 mmHg or above at time 0, (mean pressure 19.0 ± 3.0 mmHg), and it dropped to 12 ± 4 mmHg within 48 h (p < 0.01). Reduction in lactate level (2.4 ± 1.0 to 1.2 ± 0.2 mmol/L, p < 0.01) and increase in PaO2/FiO2 ratio (163 ± 34 to 231 ± 83, p = 0.03) were observed as well after 48 h. CONCLUSIONS This is the first large report of IAP in open abdomen. Elevated IAP may be measured in open abdomen and may subsequently relieve after 48 h.
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Affiliation(s)
- Ohad Guetta
- Department General Surgery B, Soroka University Medical Center, Ben-Gurion University of the Negev, POB 151, Be'er Sheva, Israel.
| | - Evgeni Brotfain
- Department of Anesthesiology and Critical Care, Soroka University Medical Center, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Gad Shaked
- Head of Trauma Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Gilbert Sebbag
- Department General Surgery B, Soroka University Medical Center, Ben-Gurion University of the Negev, POB 151, Be'er Sheva, Israel
| | - Moti Klein
- Head of Critical Care Department, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - David Czeiger
- Department General Surgery B, Soroka University Medical Center, Ben-Gurion University of the Negev, POB 151, Be'er Sheva, Israel
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16
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Watson MM, Maddern GJ, Mudalige VPK, Pradhan CP, Wichmann MW. Rural Emergency Laparotomy Audit. ANZ J Surg 2019; 89:666-671. [DOI: 10.1111/ans.15167] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/02/2019] [Accepted: 03/03/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew M. Watson
- Department of General SurgeryMount Gambier and Districts Health Service Mount Gambier South Australia Australia
- Discipline of Surgery, Queen Elizabeth HospitalThe University of Adelaide Adelaide South Australia Australia
- Rural Clinical SchoolThe University of Adelaide Adelaide South Australia Australia
- Flinders Rural Health South AustraliaFlinders University Adelaide South Australia Australia
| | - Guy J. Maddern
- Discipline of Surgery, Queen Elizabeth HospitalThe University of Adelaide Adelaide South Australia Australia
| | - V. Priyantha K. Mudalige
- Discipline of Surgery, Queen Elizabeth HospitalThe University of Adelaide Adelaide South Australia Australia
- Rural Clinical SchoolThe University of Adelaide Adelaide South Australia Australia
- Department of General SurgeryWhyalla Hospital Whyalla South Australia Australia
| | - Chetan P. Pradhan
- Flinders Rural Health South AustraliaFlinders University Adelaide South Australia Australia
- Department of General SurgeryRiverland General Hospital Berri South Australia Australia
| | - Matthias W. Wichmann
- Department of General SurgeryMount Gambier and Districts Health Service Mount Gambier South Australia Australia
- Discipline of Surgery, Queen Elizabeth HospitalThe University of Adelaide Adelaide South Australia Australia
- Rural Clinical SchoolThe University of Adelaide Adelaide South Australia Australia
- Flinders Rural Health South AustraliaFlinders University Adelaide South Australia Australia
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