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Silva L, Abbas Mohamed S, Meggy A, Ng JH, Torkington J, Moug S, Watts T, Bisson J, Cornish JA. Psychosocial outcomes following emergency laparotomy (POLO) study: a study protocol for a multicentre mixed-methods prospective cohort study assessing the psycho-social outcomes following emergency laparotomy in adults. BMJ Open 2024; 14:e081821. [PMID: 38986553 DOI: 10.1136/bmjopen-2023-081821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Morbidity from an emergency laparotomy (EmLap) is difficult to define and poorly understood. Morbidity is a holistic concept, reliant upon an interplay of bio-psychosocial outcomes that evolve long after discharge. To date, no previous study has explored the psychosocial outcomes following EmLap as a collective, nor their change over time. This study aims to describe the holistic morbidity following EmLap within the first year following surgery. METHODS AND ANALYSIS This is a multicentre, mixed-methods prospective 12-month cohort study with two participant populations: patient participants and family caregivers (FCGs). A target of 160 adult patients who undergo EmLap and can give informed consent will be included in the patient participant group. Patient participants will be asked to complete three patient surveys, incorporating validated patient-reported outcome measures (PROMs) to assess bio-psychosocial outcomes (EuroQol five-dimension five-level (EQ5D-5L), Gastrointestinal Quality Life Index-36, Patient Health Questionnaire-9, Generalised Anxiety Disorder 7, International Trauma Questionnaire, Caregiver Interaction Scale and Fatigue Severity Scale) in the 12 months following surgery. A subgroup of 15 patient participants will be asked to take part in two semistructured interviews at 6 and 12 months. A target of 15 associated family caregivers will be included in the FCG group. FCGs will be asked to take part in a semi-structured interview at 6 months to assess the EmLap impact on the wider support network. The primary outcome will be a change in quality of life (EQ5D-5L) at 12 months. Secondary outcomes will be changes in bio-psychosocial status at 3 and 12 months. Qualitative analysis will allow contextualisation of PROMS and further explore themes of EmLap morbidity. It is anticipated that the results of this study will help inform and develop standards of aftercare for future EmLap patients. ETHICS AND DISSEMINATION This study has received ethical approval (Wales REC7;12/WA/0297) and will be undertaken in accordance with the principles of Good Clinical Practice. We intend to disseminate study results in peer-reviewed journals and medical conferences, as well as a lay report to study participants. TRIAL REGISTRATION NUMBER Clinical Trials.gov NCT05281627.
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Affiliation(s)
- Louise Silva
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
- Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | | | - Alun Meggy
- Research and Development, Cardiff and Vale University Hospital, Cardiff, UK
| | | | - Jared Torkington
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | | | - Tessa Watts
- School of Health Sciences, Cardiff University, Cardiff, UK
| | - Jonathan Bisson
- Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Julie A Cornish
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
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Hatewar A, Mahakalkar C, Kshirsagar S, Dixit S, Reddy S. Navigating Life Post-emergency Laparotomy: A Narrative Review on Quality-of-Life Outcomes. Cureus 2024; 16:e60583. [PMID: 38894770 PMCID: PMC11184536 DOI: 10.7759/cureus.60583] [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] [Received: 05/09/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024] Open
Abstract
An emergency laparotomy is a life-saving surgical procedure performed to address acute abdominal conditions. While crucial for immediate survival, this procedure can have significant long-term implications for patients' quality of life. This comprehensive review examines the physical, psychological, and social outcomes following emergency laparotomy, highlighting the importance of addressing quality-of-life concerns in this patient population. Key findings reveal that patients may experience complications, psychological distress, and challenges in social functioning post-procedure. Age, gender, and access to support networks influence outcomes. Recommendations for clinical practice include routine assessment of quality of life, multidisciplinary care, and patient education. Further research is needed to understand predictors of poor outcomes and evaluate interventions to improve quality of life post-emergency laparotomy. Healthcare providers can enhance patient care and outcomes in this vulnerable population by addressing these issues.
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Affiliation(s)
- Akansha Hatewar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Chanrashekhar Mahakalkar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shivani Kshirsagar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sparsh Dixit
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Srinivasa Reddy
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Khanderia E, Aggarwal R, Bouras G, Patel V. Quality of life after emergency laparotomy: a systematic review. BMC Surg 2024; 24:73. [PMID: 38409008 PMCID: PMC10898072 DOI: 10.1186/s12893-024-02337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/30/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Emergency laparotomy is a commonly performed surgical procedure that has higher post-operative morbidity and mortality than elective surgery. Previous research has identified that patients valued postoperative quality of life (QoL) more than the risk of mortality when deciding to undergo emergency surgery. Current pre-operative scoring and risk stratification systems for emergency laparotomy do not account for or provide prediction tools for post-operative QoL. This study aims to systematically review previous literature to determine post-operative QoL in patients who undergo emergency laparotomy. METHODS A literature search was undertaken in Medline, EMBASE and the Cochrane Library to identify studies measuring post-operative QoL in patients who have had emergency laparotomy up to 29th April 2023. Mean QoL scores from the studies included were combined to calculate the average effect of emergency laparotomy on QoL. The primary outcome of the review was postoperative QoL after emergency laparotomy when compared with a comparator group. Secondary outcomes included the quality of included studies. RESULTS Ten studies in the literature assessing the QoL of patients after emergency laparotomy were identified. Three studies showed that patients had improved QoL and seven showed worse QoL following emergency laparotomy. Length of time for QoL to return to baseline varied ranged from 3 to 12 months post-operatively. Length of hospital stay was identified as an independent risk factor for poorer QoL post-surgery. CONCLUSIONS Outcome reporting for patients who undergo emergency laparotomy should be expanded further to include QoL. Further work is required to investigate this and elicit factors that can improve QoL post-operatively.
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Affiliation(s)
- Esha Khanderia
- Watford General Hospital, West Hertfordshire Teaching Hospitals NHS Trust, Watford, UK.
| | - Ravi Aggarwal
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - George Bouras
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Vanash Patel
- Watford General Hospital, West Hertfordshire Teaching Hospitals NHS Trust, Watford, UK
- Department of Surgery & Cancer, Imperial College London, London, UK
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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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Javanmard-Emamghissi H, Doleman B, Lund JN, Frisby J, Lockwood S, Hare S, Moug S, Tierney G. Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit. Tech Coloproctol 2023; 27:729-738. [PMID: 36609892 PMCID: PMC10404199 DOI: 10.1007/s10151-022-02747-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/13/2022] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- H Javanmard-Emamghissi
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK.
| | - B Doleman
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J Frisby
- Department of Palliative Care Medicine, Royal Derby Hospital, Derby, UK
| | - S Lockwood
- Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK
| | - S Hare
- Department of Anaesthesia, Medway Maritime Hospital, Kent, UK
| | - S Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
| | - G Tierney
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
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Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study. Eur J Trauma Emerg Surg 2023; 49:17-32. [PMID: 36693948 PMCID: PMC9925585 DOI: 10.1007/s00068-022-02191-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/27/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications. MATERIAL AND METHODS We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41-0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11-0.96), p = 0.045] complications could be detected when using energy devices. CONCLUSIONS Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.
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Short- and long-term impact of sarcopenia on outcomes after emergency laparotomy: A systematic review and meta-analysis. Surgery 2022; 172:436-445. [DOI: 10.1016/j.surg.2022.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/15/2022] [Accepted: 02/22/2022] [Indexed: 12/29/2022]
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Ylimartimo AT, Lahtinen S, Nurkkala J, Koskela M, Kaakinen T, Vakkala M, Hietanen S, Liisanantti J. Long-term Outcomes After Emergency Laparotomy: a Retrospective Study. J Gastrointest Surg 2022; 26:1942-1950. [PMID: 35697895 PMCID: PMC9489577 DOI: 10.1007/s11605-022-05372-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/27/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergency laparotomy (EL) is a common surgical operation with poor outcomes. Patients undergoing EL are often frail and have chronic comorbidities, but studies focused on the long-term outcomes after EL are lacking. The aim of the present study was to examine the long-term mortality after EL. METHODS We conducted a retrospective single-center cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The follow-up lasted until September 2020. The primary outcome was 2-year mortality after surgery. The secondary outcome was factors associated with mortality during follow-up. RESULTS A total of 554 (82%) patients survived > 90 days after EL and were included in the analysis. Of these patients, 120 (18%) died during the follow-up. The survivors were younger than the non-survivors (median [IQR] 64 [49-74] vs. 71 [63-80] years, p < 0.001). In a Cox regression model, death during follow-up was associated with longer duration of operation (OR 2.21 [95% CI 1.27-3.83]), higher ASA classification (OR 2.37 [1.15-4.88]), higher CCI score (OR 4.74 [3.15-7.14]), and postoperative medical complications (OR 1.61 [1.05-2.47]). CONCLUSIONS Patient-related factors, such as higher ASA classification and CCI score, were the most remarkable factors associated with poor long-term outcome and mortality after EL.
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Affiliation(s)
- Aura T. Ylimartimo
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O.BOX 21, 90029 OYS Oulu, Finland
| | - Sanna Lahtinen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Juho Nurkkala
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Marjo Koskela
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O.BOX 21, 90029 OYS Oulu, Finland
| | - Timo Kaakinen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Merja Vakkala
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Siiri Hietanen
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland
| | - Janne Liisanantti
- Medical Research Center of Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
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