Loss of Community-Dwelling Status Among Survivors of High-Acuity Emergency General Surgery Disease

Mortality burden from variation in provision of surgical care in emergency general surgery: a cohort study using the National Inpatient Sample

Background

The decision to undertake a surgical intervention for an emergency general surgery (EGS) condition (appendicitis, diverticulitis, cholecystitis, hernia, peptic ulcer, bowel obstruction, ischemic bowel) involves a complex consideration of factors, particularly in older adults. We hypothesized that identifying variability in the application of operative management could highlight a potential pathway to improve patient survival and outcomes.

Methods

We included adults aged 65+ years with an EGS condition from the 2016-2017 National Inpatient Sample. Operative management was determined from procedure codes. Each patient was assigned a propensity score (PS) for the likelihood of undergoing an operation, modeled from patient and hospital factors: EGS diagnosis, age, gender, race, presence of shock, comorbidities, and hospital EGS volumes. Low and high probability for surgery was defined using a PS cut-off of 0.5. We identified two model-concordant groups (no surgery-low probability, surgery-high probability) and two model-discordant groups (no surgery-high probability, surgery-low probability). Logistic regression estimated the adjusted OR (AOR) of in-hospital mortality for each group.

Results

Of 375 546 admissions, 21.2% underwent surgery. Model-discordant care occurred in 14.6%; 5.9% had no surgery despite a high PS and 8.7% received surgery with low PS. In the adjusted regression, model-discordant care was associated with significantly increased mortality: no surgery-high probability AOR 2.06 (1.86 to 2.27), surgery-low probability AOR 1.57 (1.49 to 1.65). Model-concordant care showed a protective effect against mortality (AOR 0.83, 0.74 to 0.92).

Conclusions

Nearly one in seven EGS patients received model-discordant care, which was associated with higher mortality. Our study suggests that streamlined treatment protocols can be applied in EGS patients as a means to save lives.

Level of evidence

III.

No healthcare coverage, big problem: lack of insurance for older population associated with worse emergency general surgery outcomes

Introduction

Older populations, being a unique subset of patients, have poor outcomes for emergency general surgery (EGS). In regions lacking specialized medical coverage for older patients, disparities in healthcare provision lead to poor clinical outcomes. We aimed to identify factors predicting index admission inpatient mortality from EGS among sexagenarians, septuagenarians, and octogenarians.

Methods

Data of patients aged >60 years with EGS conditions defined by the American Association for the Surgery of Trauma at primary index admission from 2010 to 2019 operated and non-operated at a large South Asian tertiary care hospital were analyzed. The primary outcome was primary index admission inpatient 30-day mortality. Parametric survival regression using Weibull distribution was performed. Factors such as patients' insurance status and surgical intervention were assessed using adjusted HR and 95% CI with a p-value of <0.05 considered statistically significant.

Results

We included 9551 primary index admissions of patients diagnosed with the nine most common primary EGS conditions. The mean patient age was 69.55±7.59 years. Overall mortality and complication rates were 3.94% and 42.29%, respectively. Primary index admission inpatient mortality was associated with complications including cardiac arrest and septic shock. Multivariable survival analysis showed that insurance status was not associated with mortality (HR 1.13; 95% CI 0.79, 1.61) after adjusting for other variables. The odds of developing complications among self-paid individuals were higher (adjusted OR 1.17; 95% CI 1.02, 1.35).

Conclusion

Lack of healthcare coverage for older adults can result in delayed presentation, leading to increased morbidity. Close attention should be paid to such patients for timely provision of treatment. There is a need to expand primary care access and proper management of comorbidities for overall patient well-being. Government initiatives for expanding insurance coverage for older population can further enhance their healthcare access, mitigating the risk of essential treatments being withheld due to financial limitations.

Level of evidence

III.

In their own words: recovery after emergency general surgery in the older patient

Objectives

Emergency general surgery (EGS) conditions, such as perforated intestines or complicated hernias, can lead to significant postoperative morbidity and mortality. We sought to understand the recovery experience of older patients at least 1 year after EGS to identify key factors for a successful long-term recovery.

Methods

We conducted semi-structured interviews to explore recovery experiences of patients and their caregivers after admission for an EGS procedure. We screened patients who were aged 65 years or older at the time of an EGS operation, admitted at least 7 days, and still alive and able to consent at least 1 year postoperatively. We interviewed the patients, their primary caregiver, or both. Interview guides were developed to explore medical decision making, patient goals and expectations surrounding recovery after EGS, and to identify barriers and facilitators of recovery. Interviews were recorded and transcribed, and we used an inductive thematic approach to analysis.

Results

We performed 15 interviews (11 patients and 4 caregivers). Patients wanted to return to their prior quality of life, or 'get back to normal.' Family was key in providing both instrumental support (eg, for daily tasks such as cooking, driving, wound care) and emotional support. Provision of temporary support was key to the recovery of many patients. Although most patients returned to their prior lifestyle, some also experienced depression, persistent abdominal effects, pain, or decreased stamina. When asked about medical decision making, patients expressed viewing the decision for having an operation not as a choice but, rather, the only rational option to treat a severe symptom or life-threating illness.

Conclusions

There is an opportunity in healthcare to provide better education for older patients and their caregivers around instrumental and emotional support to bolster successful recovery after emergency surgery.

Level of evidence

Qualitative study, level II.

What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients

INTRODUCTION

Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC).

MATERIALS AND METHODS

We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations.

RESULTS

We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations.

CONCLUSIONS

Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.

Functional Status is Key to Long-term Survival in Emergency General Surgery Conditions

INTRODUCTION

Emergency General Surgery (EGS) conditions in older patients constitutes a substantial public health burden due to high morbidity and mortality. We sought to utilize a supervised machine learning method to determine combinations of factors with the greatest influence on long-term survival in older EGS patients.

METHODS

We identified community dwelling participants admitted for EGS conditions from the Medicare Current Beneficiary Survey linked with claims (1992-2013). We categorized three binary domains of multimorbidity: chronic conditions, functional limitations, and geriatric syndromes (such as vision or hearing impairment, falls, incontinence). We also collected EGS disease type, age, and sex. We created a classification and regression tree (CART) model to identify groups of variables associated with our outcome of interest, three-year survival. We then performed Cox proportional hazards analysis to determine hazard ratios for each group with the lowest risk group as reference.

RESULTS

We identified 1960 patients (median age 79 [interquartile range [IQR]: 73, 85], 59.5% female). The CART model identified the presence of functional limitations as the primary splitting variable. The lowest risk group were patient aged ≤81 y with biliopancreatic disease and without functional limitations. The highest risk group was men aged ≥75 y with functional limitations (hazard ratio [HR] 11.09 (95% confidence interval [CI] 5.91-20.83)). Notably absent from the CART model were chronic conditions and geriatric syndromes.

CONCLUSIONS

More than the presence of chronic conditions or geriatric syndromes, functional limitations are an important predictor of long-term survival and must be included in presurgical assessment.

Impact of Comorbidities on the Cause of Death by Necrotizing Soft Tissue Infections

Background: The aim of this study was to identify the cause of death in patients with necrotizing soft tissue infections (NSTIs) stratified by patient's pre-existing comorbidities (American Society of Anesthesiologists [ASA] classification 3/4 vs. ASA 1/2). Differences in clinical presentation, mortality rate, and factors associated with mortality between those two comorbidity groups were investigated. Patients and Methods: A retrospective multicenter study of patients with NSTIs between 2010 and 2020 was conducted. The primary outcome was the cause of death within the first 30 days. Furthermore, factors associated with mortality were identified. All analysis were stratified by severity of comorbidities (ASA 1/2 or ASA 3/4). Results: Of the 187 patients, 39 patients (21%) died within 30 days. American Society of Anesthesiologists 1/2 patients (overall mortality rate, 11%) died more often as direct result of the infection compared with ASA 3/4 patients (overall mortality rate, 33%) (ASA 1/2 group: 92% vs. ASA 3/4 group: 48%; p = 0.013). American Society of Anesthesiologists 3/4 patients died more often due to withdrawal of life-sustaining therapies based on assumed poor outcome after severe critical illness (ASA 1/2 group: 52% vs. ASA 3/4 group: 8%; p = 0.013). Conclusions: Mortality rates of patients with NSTIs varied from 11% in previously healthy patients to 33% in patients with multiple or severe comorbidities. The predominant cause of mortality was overwhelming infection and associated sepsis in healthy patients whereas in patients with multiple or severe pre-existing medical disease, death most often occurred after treatment limitations based on patient's wishes and prognosis.

What if You Need More Than One? More Acute Care Surgery Procedures Are Associated with Mortality

Background: It is unknown whether having multiple acute care surgery (ACS) procedures performed in one admission confers additional risk. We hypothesized that having multiple procedures (for example, hernia repair plus bowel resection) would be associated with higher mortality. Patients and Methods: We identified all 2017 National Inpatient Sample admissions with ACS procedures including: colon, small bowel/appendix (SB), hernia, adhesiolysis, peptic ulcer procedures, gallbladder, debridement, other laparotomy, other laparoscopy. The total number of procedures for each admission and common dyad (two-procedure) and triad (three-procedure) combinations were identified. Logistic regression estimated the odds of in-hospital mortality for increasing procedure count and specific dyad and triad combinations, using patients with one procedure as the reference. Results: A total of 216,317 ACS patients (median age, 57, interquartile range [IQR], 43-70; 50.6% female) were included; 2.8% died. Patients with multiple procedures were more likely to die than patients with one procedure (7.4% vs. 1.9%). An increasing number of procedures was associated with higher odds of death (two procedures: odds ratio [OR], 3.0; 95% confidence interval [CI], 2.9-3.2] to six or more procedures, OR, 9.5; 95% CI, 4.9-18.5); having more than three procedures was associated with at least fivefold higher odds of death. Specific dyads/triads were associated with particularly high risk of mortality, including ulcer/laparotomy (OR, 15.5; 95% CI, 13.7-17.5) and laparotomy/SB (OR, 8.31; 95% CI, 5.15-13.40). Conclusions: Multiple ACS procedures in one hospitalization confer increased odds of in-hospital mortality. This knowledge enables the ACS providers to better counsel patients by giving more specific expectations regarding mortality based on the number of procedures required or anticipated during an admission.

Heath status, frailty, and multimorbidity in patients with emergency general surgery conditions

BACKGROUND

Although nearly 1 million older adults are admitted for emergency general surgery conditions yearly, the extent to which baseline health influences the development and treatment of emergency general surgery conditions is unknown. We evaluated baseline health and older patients with and without emergency general surgery conditions.

METHODS

We used the prospectively collected Medicare Current Beneficiary Survey with Medicare claims and 2 validated health frameworks: (1) Deficit Accumulation Frailty Score and (2) Complex Multimorbidity. Self-reported health and function items were used to derive pre-emergency general surgery conditions Deficit Accumulation Frailty Score and Complex Multimorbidity scores. Deficit Accumulation Frailty Score ranges from 0 (no frailty deficits) to 100 (all possible deficits present). Complex Multimorbidity is a 3-point categorical rank based on the presence of chronic conditions, functional limitations, and geriatric syndromes. Specific survey factors were also examined to determine association with development of emergency general surgery conditions or use of operative management.

RESULTS

Of 54,417 individuals, 1,960 had emergency general surgery conditions (median age 79 [interquartile range 73-84]). Patients with emergency general surgery conditions had significantly higher Deficit Accumulation Frailty Score (19 [interquartile range 11-31] vs 14 [8-24]) and were more likely to be in the most severe Complex Multimorbidity category (38% vs 29%). Emergency general surgery conditions patients had higher proportions of nearly every health category, with the most striking differences in functional limitations. Patients who were treated nonoperatively had the poorest overall baseline health.

CONCLUSION

Patients who developed emergency general surgery conditions had more severe health burden than patients who did not, particularly in functional status. Clinicians must better understand the interaction between baseline health vulnerability and emergency surgical disease to improve prognostication and ensure alignment of patient goals and treatment strategies.

Association of Complex Multimorbidity and Long-term Survival After Emergency General Surgery in Older Patients With Medicare

Importance

Although nearly 1 million older patients are admitted for emergency general surgery (EGS) conditions yearly, long-term survival after these acute diseases is not well characterized. Many older patients with EGS conditions have preexisting complex multimorbidity defined as the co-occurrence of at least 2 of 3 key domains: chronic conditions, functional limitations, and geriatric syndromes. The hypothesis was that specific multimorbidity domain combinations are associated with differential long-term mortality after patient admission with EGS conditions.

Objective

To examine multimorbidity domain combinations associated with increased long-term mortality after patient admission with EGS conditions.

Design, Setting, and Participants

This cohort study included community-dwelling participants aged 65 years and older from the Medicare Current Beneficiary Survey with linked Medicare data (January 1992 through December 2013) and admissions for diagnoses consistent with EGS conditions. Surveys on health and function from the year before EGS conditions were used to extract the 3 domains: chronic conditions, functional limitations, and geriatric syndromes. The number of domains present were summed to calculate a categorical rank: no multimorbidity (0 or 1), multimorbidity 2 (2 of the 3 domains present), and multimorbidity 3 (all 3 domains present). Whether operative treatment was provided during the admission was also identified. Data were cleaned and analyzed between January 16, 2020, and April 29, 2021.

Exposures

Mutually exclusive multimorbidity domain combinations (functional limitations and geriatric syndromes; functional limitations and chronic conditions; chronic conditions and geriatric syndromes; or functional limitations, geriatric syndromes, and chronic conditions).

Main Outcomes and Measures

Time to death (up to 3 years from EGS conditions admission) in patients with multimorbidity combinations was analyzed using a Cox proportional hazards model and compared with those without multimorbidity; hazard ratios (HRs) and 95% CIs are presented. Models were adjusted for age, sex, and operative treatment.

Results

Of 1960 patients (median [IQR] age, 79 [73-85] years; 1166 [59.5%] women), 383 (19.5%) had no multimorbidity, 829 (42.3%) had 2 multimorbidity domains, and 748 (38.2%) had all 3 domains present. A total of 376 (19.2%) were known to have died in the follow-up period, with a median (IQR) follow-up of 377 (138-621) days. Patients with chronic conditions and geriatric syndromes had a mortality risk similar to those without multimorbidity. However, all domain combinations with functional limitations were associated with significantly increased risk of death: functional limitations and chronic conditions (HR, 1.83; 95% CI, 1.03-3.23); functional limitations and geriatric syndromes (HR, 2.91; 95% CI, 1.37-6.18); and functional limitations, geriatric syndromes, and chronic conditions (HR, 2.08; 95% CI, 1.49-2.89).

Conclusions and Relevance

Findings of this study suggest that a patient's baseline complex multimorbidity level efficiently identifies risk stratification groups for long-term survival. Functional limitations are rarely considered in risk stratification paradigms for older patients with EGS conditions compared with chronic conditions and geriatric syndromes. However, functional limitations may be the most important risk factor for long-term survival.

Narrative review of palliative care in trauma and emergency general surgery

OBJECTIVE

The purpose of this article is to discuss the goals of palliative care with regards to acute care surgery patients and review the literature regarding administration and implementation of palliative programs.

BACKGROUND

For patients who experience unexpected and sometimes catastrophic life changes related to trauma or emergency general surgery, palliative care is a crucial adjunct that can help ensure the provision of optimal symptom management, communication, and goal-concordant care provided.

METHODS

Palliative care is medical specialty with a philosophy of care focused on improving the quality of life for patients with serious injury or illness and their loved ones. Palliative care provides significant benefit across the entire spectrum of illness and injury, regardless of prognosis. We will discuss palliative care topics related to trauma and emergency general surgery patients, including symptom management, goal setting, end of life care, communication strategies, addressing implicit/explicit bias, trauma-specific and emergency general surgery-specific considerations, and implementation strategies to reduce barriers for utilization of palliative care.

CONCLUSIONS

Unfortunately, palliative care is often underutilized in the trauma and emergency general surgery population. Acute care surgeons should be familiar with principles of primary palliative care, as well as understand the added benefits that be provided by consultant palliative care specialists.

Initial emergency laparotomy outcomes following a transdisciplinary perioperative care pathway in Singapore

Aim

Emergency laparotomy (EL) is a common surgery associated with high morbidity and mortality. An enhanced care pathway incorporates evidence-based care bundles with the aim of providing standardized perioperative care. Prior to 2019, EL management in our institution was not standardized. This study aims to assess whether implementation of a transdisciplinary perioperative Emergency Laparotomy (ELAP) pathway improves clinical and efficiency outcomes of EL.

Methods

A prospective single-center audit was undertaken between 1 January and 31 December, 2019 following the implementation of the ELAP pathway. Comparisons were made with retrospective data from the preimplementation period between 1 January and 31 December, 2017. Demographics and clinical and efficiency outcomes were compared for patients (age > 16 years old) requiring EL for acute abdominal conditions.

Results

There were 152 and 162 patients from preimplementation and postimplementation periods, respectively. There was a nonsignificant reduction of 30-day mortality in the intervention group receiving perioperative pathway care compared with the preintervention group (3.1% versus 5.3%, respectively; P = 0.40). There was a decrease in postoperative complications in the intervention group, in particular for Clavien-Dindo IV complications (11.2% versus 3.1%, p < 0.01). Efficiency outcomes improved postimplementation with increased consultant surgeon and anesthetist presence in operating theater and postoperative geriatric assessment for elderly patients. There was an overall reduction in cost of hospital stay from S$32,128 to $27,947 (p = 0.24).

Conclusion

Implementation of a transdisciplinary perioperative care pathway was associated with significant reduction in postoperative complications, improvement in 30-day mortality and efficiency outcomes at reduced hospital costs for patients following EL in our institution.

Necrotizing Soft Tissue Infection in the Elderly: Effect of Pre-Operative Factors on Mortality and Discharge Disposition

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressing, life-threatening diseases associated with substantial morbidity and mortality, especially in patients 65 years or older. We aimed to evaluate clinical factors associated with mortality and discharge disposition after NSTIs in elderly patients. Patients and Methods: Retrospective data were obtained from the 2007-2017 American College of Surgeons-National Surgical Quality (ACS-NSQIP) database. Patients aged 65 years or older with a post-operative diagnosis of an NSTI (defined as gas gangrene, necrotizing fasciitis, or Fournier gangrene) were included. Univariable and multivariable analyses were performed to identify independent clinical and demographic factors associated with mortality and with discharge disposition. Results: A total of 1,460 patients were included. Median age was 71 years, 43% were females. Overall, 30-day mortality was 18.5% and 30-day morbidity was 63.6%. The most important predictors of mortality included pre-operative septic shock (odds ratio [OR], 6.36; 95% confidence interval [CI], 3.61-11.18), pre-operative dialysis dependence (OR, 2.99; 95% CI, 1.77-5.05), coagulopathy (international normalized ratio [INR], >1.5, OR, 2.25; 95% CI, 1.51-3.37), hepatobiliary disease (bilirubin >1.0 mg/dL; OR, 2.05; 95% CI, 1.38-3.04) and aged 80 years or older (OR, 3.36; 95% CI, 2.08-5.44). Patients without any of these risk factors had a mortality of 7.3%. Predictors of discharge to inpatient rehabilitation or skilled care included age 80 years or older (OR, 2.49; 95% CI, 1.44-4.30), American Society of Anesthesiologists (ASA) ≥3 (OR, 2.05; 95% CI, 1.03-4.05)] and amputation as opposed to debridement (OR, 2.53; 95% CI,1.48-4.32). Conclusions: We identified several pre-operative clinical factors that were associated with increased post-operative mortality and discharge to post-acute care. The next steps should focus on determining if optimization of modifiable predictors would improve mortality.

Basic Introduction to Statistics in Medicine, Part 1: Describing Data

Background: Standardized and concise data presentation forms the base for subsequent analysis and interpretation. This article reviews types of data, data properties and distributions, and both numerical and graphical methods of data presentation. Methods: For the purposes of illustration, the National Inpatient Sample was queried to categorize patients as having either emergency general surgery or non-emergency general surgery admissions. Results: Variables are categorized as either categorical or numerical. Within the former, there are ordinal and or nominal subtypes; within the latter, there are ratio and interval subtypes. Categorical data are typically displayed as number (%). Numerical data must be assessed for normality as normally distributed data behave in certain patterns that allow for specific statistical tests to be used. Several properties exist for numerical data, including measurements of central tendency (mean, median, and mode), as well as standard deviation, range, and interquartile range. The best initial assessment of the distribution of numerical data is graphical with both histograms and box plots. Conclusion: Knowledge of the types, distribution, and properties of data is essential to move forward with hypothesis testing.

Predictors of mortality, limb loss, and discharge disposition at admission among patients with necrotizing skin and soft tissue infections

BACKGROUND

Necrotizing soft tissue infections (NSTI) represent a heterogeneous group of rapidly progressive skin and soft tissue infections associated with significant morbidity and mortality. Efforts to identify factors associated with death have produced mixed results, and little or no data is available for other adverse outcomes. We sought to determine whether admission variables were associated with mortality, limb loss, and discharge disposition in patients with NSTI.

METHODS

We analyzed prospectively collected data of adult patients with surgically confirmed NSTI from an NSTI registry maintained at a quaternary referral center. Factors independently associated with mortality, amputation, and skilled nursing facility discharge were identified using logistic regression.

RESULTS

Between 2015 and 2018, 446 patients were identified. The median age was 55 years (interquartile range, 43-62). The majority of patients were male (65%), white (77%), and transferred from another facility (90%). The perineum was most commonly involved (37%), followed by the lower extremity (34%). The median number of operative debridements was 3 (interquartile range, 2-4). Overall mortality was 15%, and 21% of extremity NSTI patients required amputation. Age greater than 60 years; creatinine greater than 2 mg/dL; white blood cell count greater than 30 x 10^ /μl, platelets less than 150 × 10/μL, and clostridial involvement were independently associated with greater odds of death; perineal involvement was associated with lower odds of death. Age greater than 60 years; sex, male; nonwhite race; diabetes; chronic wound as etiology; leg involvement; transfer status; and sodium, less than 130 mEq/L were independently associated with amputation. Age greater than 60 years; sex, female; nonwhite race; perineal involvement; and amputation were associated with skilled care facility discharge.

CONCLUSION

Necrotizing soft tissue infections are a heterogeneous group of infections involving significantly different patient populations with different outcomes; efforts to differentiate and predict adverse outcomes in NSTI should include laboratory data, comorbidities, infection site, and/or etiology to improve predictions and better account for this heterogeneity.

LEVEL OF EVIDENCE

Prognostic, Level III.

Analyzing Outcomes Among Older Adults With Necrotizing Soft-Tissue Infections in the United States

BACKGROUND

Necrotizing soft-tissue infections (NSTIs) encompass a group of severe, life-threatening diseases with high morbidity and mortality. Evidence suggests advanced age is associated with worse outcomes. To date, no large data sets exist describing outcomes in older individuals, and risk factor identification is lacking.

METHODS

Retrospective data were obtained from the 2015 Medicare 100% sample. Included in the analysis were those aged ≥65 y with a primary diagnosis of an NSTI (gas gangrene, necrotizing fasciitis, cutaneous gangrene, or Fournier's gangrene). Risk factors for in-hospital mortality and discharge disposition were examined. Continuous variables were assessed using central tendency, t-tests, and Wilcoxon rank-sum tests. Categorical variables were assessed using the chi-squared and Fisher's exact tests. Statistical significance was defined as P < 0.05.

RESULTS

1427 patient records were reviewed. 59% of patients were male, and the overall mean age was 75.4±8.6 y. 1385 (97.0%) patients required emergency surgery for their NSTI diagnosis. The overall mortality was 5.3%. Several underlying comorbidities were associated with higher rates of mortality including cancer (OR: 3.50, P = 0.0009), liver disease (OR: 2.97, P = 0.03), and kidney disease (OR: 2.15, P = 0.01). While associated with high in-hospital mortality, these diagnoses were not associated with a difference in the rate of discharge to home compared with skilled nursing or rehab. Overall, patients discharged to skilled nursing facilities or rehab had higher rates of underlying comorbidities than patients who were discharged home (3 or more comorbid illness 84.3% versus 68.6%, P < 0.0001); however, no individual comorbid illness was associated with discharge location.

CONCLUSIONS

In our Medicare data set, we identified several medical comorbidities that are associated with increased rates of in-hospital mortality. Patients with underlying cancers had the highest odds of increased mortality. The effect on outcomes of the potentially immunosuppressive cancer treatments in these patients is unknown. These data suggest that patients with underlying illnesses, especially cancer, kidney disease, or liver disease have higher mortalities and are more likely to be discharged to skilled nursing facilities or rehab. It is unclear why these illnesses were associated with these worse outcomes while others including diabetes and heart disease were not. These data suggest that these particular comorbid illnesses may have special prognostic implications, although further analysis is necessary to identify the causative factors.

Challenges in optimising recovery after emergency laparotomy

Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.