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Associations Between Care Bundles and Postoperative Outcomes After Major Emergency Abdominal Surgery: A Systematic Review and Meta-Analysis. J Surg Res 2023; 283:469-478. [PMID: 36436282 DOI: 10.1016/j.jss.2022.10.064] [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: 01/28/2022] [Revised: 09/05/2022] [Accepted: 10/15/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Care bundles were found to improve postoperative outcomes in elective surgery. However, in major emergency general surgery studies show a divergent impact on mortality and length of stay. This meta-analysis aimed to evaluate associations between care bundles and mortality, complications, and length of stay when applied in major emergency general surgery. METHODS A systematic literature search in PubMed and Embase was performed on the May 1, 2021. Only comparative studies on care bundles in major emergency general surgery were included. Meta-analysis and trial sequential analysis were performed on 30-d mortality. We undertook a narrative approach of long-term mortality, complications, and length of stay. RESULTS Meta-analysis of 13 studies with 35,771 patients demonstrated that care bundles in emergency surgery were not associated with a significant reduction in odds of 30-d mortality (odds ratio = 0.8, 95% confidence interval 0.62-1.03). Trial sequential analysis confirmed that the meta-analysis was underpowered with a minimum of 78,901 patients required for firm conclusions. Seven studies reported complication rates whereof six reported lower complication rates using care bundles. CONCLUSIONS Care bundles were reported to decrease postoperative complications in five out of seven studies and seven out of 11 studies reported a shortening in length of stay.
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Gormsen J, Brunchmann A, Henriksen NA, Jensen TK, Laugesen KB, Motavaf E, Possfelt-Møller EM, Poulsen KA, Skovsen AP, Svenningsen P, Tengberg LT, Burcharth J. Perioperative clinical management in relation to emergency surgery for perforated peptic ulcer: A nationwide questionnaire survey. Clin Nutr ESPEN 2022; 47:299-305. [DOI: 10.1016/j.clnesp.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/26/2022]
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Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial. Br J Anaesth 2021; 127:521-531. [PMID: 34389168 DOI: 10.1016/j.bja.2021.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/27/2021] [Accepted: 06/23/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND More than 50% of patients have a major complication after emergency gastrointestinal surgery. Intravenous (i.v.) fluid therapy is a life-saving part of treatment, but evidence to guide what i.v. fluid strategy results in the best outcome is lacking. We hypothesised that goal-directed fluid therapy during surgery (GDT group) reduces the risk of major complications or death in patients undergoing major emergency gastrointestinal surgery compared with standard i.v. fluid therapy (STD group). METHODS In a randomised, assessor-blinded, two-arm, multicentre trial, we included 312 adult patients with gastrointestinal obstruction or perforation. Patients in the GDT group received i.v. fluid to near-maximal stroke volume. Patients in the STD group received i.v. fluid following best clinical practice. Postoperative target was 0-2 L fluid balance. The primary outcome was a composite of major complications or death within 90 days. Secondary outcomes were time in intensive care, time on ventilator, time in dialysis, hospital stay, and minor complications. RESULTS In a modified intention-to-treat analysis, we found no difference in the primary outcome between groups: 45 (30%) (GDT group) vs 39 (25%) (STD group) (odds ratio=1.24; 95% confidence interval, 0.75-2.05; P=0.40). Hospital stay was longer in the GDT group: median (inter-quartile range), 7 (4-12) vs 6 days (4-8.5) (P=0.04); no other differences were found. CONCLUSION Compared with pressure-guided i.v. fluid therapy (STD group), flow-guided fluid therapy to near-maximal stroke volume (GDT group) did not improve the outcome after surgery for bowel obstruction or gastrointestinal perforation but may have prolonged hospital stay. CLINICAL TRIAL REGISTRATION EudraCT number 2015-000563-14; the Danish Scientific Ethics Committee and the Danish Data Protection Agency (REG-18-2015).
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Angeles MA, Martínez-Gómez C, Del M, Migliorelli F, Daix M, Provendier A, Picard M, Ruiz J, Chantalat E, Leray H, Martinez A, Gladieff L, Ferron G. Risk factors for gastric perforation after cytoreductive surgery in patients with peritoneal carcinomatosis: Splenectomy and increased body mass index. PLoS One 2021; 16:e0248205. [PMID: 33661999 PMCID: PMC7932550 DOI: 10.1371/journal.pone.0248205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background Gastric perforation after cytoreductive surgery (CRS) is an infrequent complication. There is lack of evidence regarding the risk factors for this postoperative complication. The aim of this study was to assess the prevalence of postoperative gastric perforation in patients undergoing CRS for peritoneal carcinomatosis (PC) and to evaluate risk factors predisposing to this complication. Methods We designed a unicentric retrospective study to identify all patients who underwent an open upfront or interval CRS after a primary diagnosis of PC of different origins between March 2007 and December 2018 at a French Comprehensive Cancer Center. The main outcome was the occurrence of postoperative gastric perforation. Results Five hundred thirty-three patients underwent a CRS for PC during the study period and 13 (2.4%) presented a postoperative gastric perforation with a mortality rate of 23% (3/13). Neoadjuvant chemotherapy was administered in 283 (53.1%) patients and 99 (18.6%) received hyperthermic intraperitoneal chemotherapy (HIPEC). In the univariate analysis, body mass index (BMI), peritoneal cancer index, splenectomy, distal pancreatectomy, and histology were significantly associated with postoperative gastric perforation. After multivariate analysis, BMI (OR [95%CI] = 1.13 [1.05–1.22], p = 0.002) and splenectomy (OR [95%CI] = 26.65 [1.39–509.67], p = 0.029) remained significantly related to the primary outcome. Conclusions Gastric perforation after CRS is a rare event with a high rate of mortality. While splenectomy and increased BMI are risk factors associated with this complication, HIPEC does not seem to be related. Gastric perforation is probably an ischemic complication due to a multifactorial process. Preventive measures such as preservation of the gastroepiploic arcade and prophylactic suture of the greater gastric curvature require further assessment.
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Affiliation(s)
- Martina Aida Angeles
- Department of Surgical Oncology, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Carlos Martínez-Gómez
- Department of Surgical Oncology, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- INSERM CRCT Team 1, Tumor Immunology and Immunotherapy, Toulouse, France
| | - Mathilde Del
- Department of Surgical Oncology, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Federico Migliorelli
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal des Vallées de l’Ariège, St Jean de Verges, France
| | - Manon Daix
- Department of Surgical Oncology, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Anaïs Provendier
- Department of Surgical Oncology, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Muriel Picard
- Intensive Care Unit, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Jean Ruiz
- Intensive Care Unit, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Elodie Chantalat
- Department of Surgical Oncology, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Hélène Leray
- Department of Surgical Oncology, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- INSERM CRCT Team 1, Tumor Immunology and Immunotherapy, Toulouse, France
| | - Laurence Gladieff
- Department of Medical Oncology, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Gwénaël Ferron
- Department of Surgical Oncology, Institut Claudius Regaud – Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- INSERM CRCT Team 19, ONCOSARC – Oncogenesis of sarcomas, Toulouse, France
- * E-mail:
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Akgunduz F, Sozutek A, Irkorucu O, Yaman A. The Adjunctive Effect of DuraSeal® vs. 2-Octyl-Cyanoacrylate on Delayed Repair of Gastric Perforation: An Experimental Study. J INVEST SURG 2021; 35:542-548. [PMID: 33645439 DOI: 10.1080/08941939.2021.1887414] [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: 10/22/2022]
Abstract
OBJECTIVE Delayed primary suture closure of gastric perforation is prone to dehiscence hence the repaired area should be buttressed to avoid re-operation. We aimed to investigate whether DuraSeal®(DS) has a potent adjunctive effect on delayed closure of gastric perforation comparing with 2-octly-cyanoacrylate(CYN) in an experimental model. METHODS Sixty rats were randomly divided into 6 groups. All subjected to gastric perforation, subsequently perforation areas were repaired by primary suturing, delayed repair was performed 12 h after surgery. According to DS or CYN application on anastomosis, the groups were classified as control(C), delayed control(CD), closure with CYN(CYN), delayed closure with CYN(D-CYN), closure with DS(DS), delayed closure with DS(D-DS).After euthanization on POD 7,anastomotic bursting pressure(ABP) were measured. Tissue samples were taken for histopathological examination and hydroxyproline(TH) assessment. RESULTS Delayed condition significantly reduced ABP and TH levels in CD group comparing with all groups(p < 0.01).Either CYN or DS application on delayed repaired area significantly raised the measure of ABP and TH up to the levels of C group(p < 0.05,comparing with CD).Microscopically,either CYN or DS application significantly improved tissue necrosis, submucosal bridging and collagen formation comparing with CD group(p < 0.012).There were no difference regarding ABP, TH and tissue healing between each CYN and DS groups. CONCLUSION DuraSeal® application on sutured gastric perforation area yielded a significant adjunctive effect both in normal and delayed conditions. However, DuraSeal® revealed no superior effect to CYN in both condition.Our results demonstrated that the clinical use of DuraSeal® can be considered for reinforcing the sutured line in patients undergoing delayed surgery for gastric perforation.
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Affiliation(s)
- Fatih Akgunduz
- General Surgery, Health Sciences University, Adana Training and Research Hospital, Adana, Turkey
| | - Alper Sozutek
- Gastroenterological Surgery, Health Sciences University, Adana Training and Research Hospital, Adana, Turkey
| | - Oktay Irkorucu
- General Surgery, Health Sciences University, Adana Training and Research Hospital, Adana, Turkey
| | - Abit Yaman
- General Surgery, Health Sciences University, Adana Training and Research Hospital, Adana, Turkey
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Swann N, LeTendre N, Cox B, Recabaren J. Evaluating the Evolving Morbidity of Omentoplasty for Perforated Peptic Ulcer Disease. Am Surg 2021; 86:1289-1295. [PMID: 33284667 DOI: 10.1177/0003134820964226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Mortality for perforated peptic ulcer (PPU) surgery ranges from 2-22% with morbidity ranging from 15-45%. Traditionally, these had been repaired with vagotomy and antrectomy or pyloroplasty with smaller perforations repaired with an omentoplasty. Laparoscopic repair has become increasingly prevalent and demonstrated to have shorter length of stay (LOS) and fewer complications. We are evaluating the surgical repair of PPU with omentoplasty to determine trends of utilization and surgical outcomes. We conducted a 13-year (2005-2017) retrospective review, utilizing the National Surgical Quality Improvement Program database. A total of 6873 patients had open or laparoscopic repair of a PPU, with 2285 patients identified as utilizing omentoplasty. Five hundred eighty-eight omentoplasty patients were further identified as having a laparoscopic technique. We compared patient demographics, comorbidities, and perioperative morbidity and mortality for surgical patients between 2005-2011 and 2012-2017. We trended the perioperative outcomes across the study intervals. Parametric and nonparametric tests were used to evaluate outcomes. Between 2005 and between 2017, laparoscopic surgical repair with omentoplasty has increased from 3.8% to 34.6%. Overall mortality for open operations declined during this interval (12.7%-9.3%) while it remained unchanged for laparoscopic operations (4.6%-4.2%), there was not a significant difference between the laparoscopic and open 30-day mortality. Both open surgery and laparoscopic surgery are being used on an increasingly healthy cohort (increased functional status decreased predicted perioperative morbidity). Relative to the 2005-2011, the laparoscopic surgery 2012-2017 cohort had increases in both serious and overall morbidity, although this was not statistically significant. Compared to the 2005-2011, the 2012-2017 open surgery cohort had increasing serious morbidity (OR 2.03) and overall morbidity (OR 1.91). There was a trend of decreasing LOS and increased return to the operating room for patients with laparoscopic surgery. Laparoscopic Graham patch repair of peptic ulcers significantly increased, although open repair still constitutes the majority of the cases. Despite Graham patch repair being utilized on a healthier patient population, morbidity and mortality for laparoscopic repair have remained unchanged. Postoperative morbidity and mortality for open surgery have increased. This indicates that laparoscopic repair is more commonly utilized for low- or medium risk patients, leaving an increasingly sick patient population selected to open repair.
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Affiliation(s)
| | | | - Brian Cox
- Huntington Hospital, Pasadena, CA, USA
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Dadfar A, Edna TH. Epidemiology of perforating peptic ulcer: A population-based retrospective study over 40 years. World J Gastroenterol 2020; 26:5302-5313. [PMID: 32994689 PMCID: PMC7504248 DOI: 10.3748/wjg.v26.i35.5302] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/23/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The incidence of peptic ulcer disease has decreased during the last few decades, but the incidence of reported peptic ulcer complications has not decreased. Perforating peptic ulcer (PPU) is a severe form of the disease.
AIM To assess trends in the incidence, presentation, and outcome of PPU over a period of 40 years.
METHODS This was a single-centre, retrospective, cohort study of all patients admitted to Levanger Hospital, Norway, with PPU from 1978 to 2017. The patients were identified in the Patient Administrative System of the hospital using International Classification of Diseases (ICD), revision 8, ICD-9, and ICD-10 codes for perforated gastric and duodenal ulcers. We reviewed the medical records of the patients to retrieve data. Vital statistics were available for all patients. The incidence of PPU was analysed using Poisson regression with perforated ulcer as the dependent variable, and sex, age, and calendar year from 1978 to 2017 as covariates. Relative survival analysis was performed to compare long-term survival over the four decades.
RESULTS Two hundred and nine patients were evaluated, including 113 (54%) men. Forty-six (22%) patients were older than 80 years. Median age increased from the first to the last decade (from 63 to 72 years). The incidence rate increased with increasing age, but we measured a decline in recent decades for both sexes. A significant increase in the use of acetylsalicylic acid, from 5% (2/38) to 18% (8/45), was observed during the study period. Comorbidity increased significantly over the 40 years of the study, with 22% (10/45) of the patients having an American Society of Anaesthesiologists (ASA) score 4-5 in the last decade, compared to 5% (2/38) in the first decade. Thirty-nine percent (81/209) of the patients had one or more postoperative complications. Both 100-day mortality and long-term survival were associated with ASA score, without significant variations between the decades.
CONCLUSION Declining incidence rates occurred in recent years, but the patients were older and had more comorbidity. The ASA score was associated with both short-term mortality and long-term survival.
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Affiliation(s)
- Aydin Dadfar
- Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger 7600, Norway
| | - Tom-Harald Edna
- Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger 7600, Norway
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim 7491, Norway
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Hansted AK, Møller MH, Møller AM, Wetterslev J, Rosenberg J, Jorgensen LN, Waldau T, Vester‐Andersen M. Long-term mortality in the Intermediate care after emergency abdominal surgery (InCare) trial-A post-hoc follow-up study. Acta Anaesthesiol Scand 2020; 64:1100-1105. [PMID: 32386082 DOI: 10.1111/aas.13613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients undergoing emergency abdominal surgery are at high risk of post-operative complications. Although post-operative treatment at an intermediate care unit may improve early outcome, there is a lack of studies on the long-term effects of such therapy. The aim of this study was to assess the long-term effect of intermediate care versus standard surgical ward care on mortality in the Intermediate Care After Emergency Abdominal Surgery (InCare) trial. METHODS We included adult patients undergoing emergency major laparoscopy or laparotomy with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 10 or more, who participated in the InCare trial from October 2010 to November 2012. In the InCare trial, patients were randomized to either post-operative intermediate care or standard surgical ward care. The primary outcome was time to death within 6 years after surgery. We assessed mortality with Coxregression analysis. RESULTS A total of 286 patients were included. The all-cause 6-year landmark mortality was 52.8% (76 of 144 patients) in the intermediate care group and 47.9% (68 of 142 patients) in the ward care group. There was no statistically significant difference in mortality risk between the two groups (hazard ratio 1.06 (95% confidence interval 0.76-1.47), P = .73). CONCLUSION We found no statistically significant difference in 6-year mortality between patients randomized to post-operative intermediate care or ward care after emergency abdominal surgery. However, we detected an absolute mortality risk reduction of 5% in favour of ward care, possibly due to random error.
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Affiliation(s)
- Anna K. Hansted
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES) Department of Anaesthesiology Herlev HospitalUniversity of Copenhagen Herlev Denmark
| | - Morten H. Møller
- Department of Intensive Care 4131 RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Ann M. Møller
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES) Department of Anaesthesiology Herlev HospitalUniversity of Copenhagen Herlev Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit Dpt. 7812 RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Jacob Rosenberg
- Department of Surgery Herlev HospitalUniversity of Copenhagen Copenhagen Denmark
| | - Lars N. Jorgensen
- Digestive Disease Center Bispebjerg HospitalUniversity of Copenhagen Copenhagen Denmark
| | - Tina Waldau
- Department of Intensive Care Herlev HospitalUniversity of Copenhagen Herlev Denmark
| | - Morten Vester‐Andersen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES) Department of Anaesthesiology Herlev HospitalUniversity of Copenhagen Herlev Denmark
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Perforated Peptic Ulcer Surgery: Decreased Length of Stay but No Difference in Mortality with Laparoscopic Repair. Surg Laparosc Endosc Percutan Tech 2019; 28:410-415. [PMID: 30312196 DOI: 10.1097/sle.0000000000000584] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Perforated peptic ulcer (PPU) surgery mortality ranges 1% to 24%. We hypothesized a decrease in length of stay (LOS) with laparoscopic surgical repair (LSR) compared with open surgical repair (OSR). METHODS Patients undergoing PPU surgery 2005 to 2015 were identified in NSQIP. LSR was compared with OSR 2005 to 2015. LSR 2005 to 2010 was compared with 2011 to 2015. OSR 2005 to 2010 was compared with 2011 to 2015. The primary outcome was LOS. Secondary outcomes were mortality and morbidity. RESULTS Between 2005 and 2015, LSR had a decreased LOS, was more likely to wean from the ventilator, but had no significant difference in mortality compared with OSR. There was no significant difference in mortality for LSR or OSR over time. CONCLUSIONS When patients are appropriately selected, LSR for PPU is a viable alternative to OSR, decreasing LOS and pulmonary complications. This demonstrates significant benefit to patients and hospital throughput.
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Thorsen K, Søreide JA, Søreide K. Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age, Comorbidity Burden and Severe Postoperative Complications. World J Surg 2017; 41:410-418. [PMID: 27734076 DOI: 10.1007/s00268-016-3747-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Perforated peptic ulcer (PPU) is a surgical emergency associated with high short-term mortality. However, studies on long-term outcomes are scarce. Our aim was to investigate long-term survival after surgery for PPU. MATERIALS AND METHODS A population-based, consecutive cohort of patients who underwent surgery for PPU between 2001 and 2014 was reviewed, and the long-term mortality was assessed. Survival was investigated by univariate analysis (log-rank test) and displayed using Kaplan-Meier survival curves. Multivariable analysis of risk factors for long-term mortality was assessed by Cox proportional hazards regression and reported as hazard ratio (HR) with 95 % confidence intervals (CI). RESULTS A total of 234 patients were available for the calculation of ninety-day, one-year and two-year mortality, and the results showed rates of 19.2 % (45/234), 22.6 % (53/234) and 24.8 % (58/234), respectively. At the end of follow-up, a total of 109 of the 234 patients (46.6 %) had died. Excluding 37 (15.2 %) patients who died within 30 days of surgery, 197 patients had long-term follow-up (median 57 months, range 1-168) of which 36 % (71/197) died during the follow-up period. In multivariable analyses, age >60 years (HR 3.95, 95 % CI 1.81-8.65), active cancer (HR 3.49, 95 % CI 1.73-7.04), hypoalbuminemia (HR 1.65, 95 % CI 0.99-2.73), pulmonary disease (HR 2.06, 95 % CI 1.14-3.71), cardiovascular disease (HR 1.67, 95 % CI 1.01-2.79) and severe postoperative complications (HR 1.76, 95 % CI 1.07-2.89) during the initial stay for PPU were all independently associated with an increased risk of long-term mortality. Cause of long-term mortality was most frequently (18 of 71; 25 %) attributed to new onset sepsis and/or multiorgan failure. CONCLUSION The long-term mortality after surgery for PPU is high. One in every three patients died during follow-up. Older age, comorbidity and severe postoperative complications were risk factors for long-term mortality.
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Affiliation(s)
- K Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway.
| | - J A Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, PO Box 8100, 4068, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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12
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Tengberg LT, Bay-Nielsen M, Bisgaard T, Cihoric M, Lauritsen ML, Foss NB, Orbæk J, Veyhe L, Jørgen Nielsen H, Lindgaard L. Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery. Br J Surg 2017; 104:463-471. [DOI: 10.1002/bjs.10427] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/30/2016] [Accepted: 10/07/2016] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Acute high-risk abdominal (AHA) surgery carries a very high risk of morbidity and mortality and represents a massive healthcare burden. The aim of the present study was to evaluate the effect of a standardized multidisciplinary perioperative protocol in patients undergoing AHA surgery.
Methods
The AHA study was a prospective single-centre controlled study in consecutive patients undergoing AHA surgery, defined as major abdominal pathology requiring emergency laparotomy or laparoscopy including reoperations after elective gastrointestinal surgery. Consecutive patients were included after initiation of the AHA protocol as standard care. The intervention cohort was compared with a predefined, consecutive historical cohort of patients from the same department. The protocol involved continuous staff education, consultant-led attention and care, early resuscitation and high-dose antibiotics, surgery within 6 h, perioperative stroke volume-guided haemodynamic optimization, intermediate level of care for the first 24 h after surgery, standardized analgesic treatment, early postoperative ambulation and early enteral nutrition. The primary outcome was 30-day mortality.
Results
Six hundred patients were included in the study and compared with 600 historical controls. The unadjusted 30-day mortality rate was 21·8 per cent in the control cohort compared with 15·5 per cent in the intervention cohort (P = 0·005). The 180-day mortality rates were 29·5 and 22·2 per cent respectively (P = 0·004).
Conclusion
The introduction of a multidisciplinary perioperative protocol was associated with a significant reduction in postoperative mortality in patients undergoing AHA surgery. NCT01899885 (http://www.clinicaltrials.gov).
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Affiliation(s)
- L T Tengberg
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M Bay-Nielsen
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - T Bisgaard
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M Cihoric
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M L Lauritsen
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark
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Hasselager RB, Lohse N, Duch P, Møller MH. Risk factors for reintervention after surgery for perforated gastroduodenal ulcer. Br J Surg 2016; 103:1676-1682. [DOI: 10.1002/bjs.10273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/11/2016] [Accepted: 06/21/2016] [Indexed: 01/04/2023]
Abstract
Abstract
Background
Perforated gastroduodenal ulcer carries a high mortality rate. Need for reintervention after surgical repair is associated with worse outcome, but knowledge on risk factors for reintervention is limited. The aim was to identify prognostic risk factors for reintervention after perforated gastroduodenal ulcer in a nationwide cohort.
Methods
All patients treated surgically for perforated gastroduodenal ulcer in Denmark between 2003 and 2014 were included using data from the Danish Clinical Register of Emergency Surgery. Potential risk factors for reintervention were assessed, and their crude and adjusted associations calculated by the competing risks subdistribution hazards approach.
Results
A total of 4086 patients underwent surgery for perforated gastroduodenal ulcer during the study interval. Median age was 71·1 (i.q.r. 59·6–81·0) years and the overall 90-day mortality rate was 30·8 per cent (1258 of 4086). Independent risk factors for reintervention were: male sex (adjusted hazard ratio (HR) 1·46, 95 per cent c.i. 1·20 to 1·78), in-hospital perforation (adjusted HR 1·36, 1·11 to 1·68), high BMI (adjusted HR 1·49, 1·10 to 2·01), high ASA physical status grade (adjusted HR 1·54, 1·23 to 1·94), shock on admission (adjusted HR 1·40, 1·13 to 1·74), surgical delay (adjusted HR 1·07, 1·02 to 1·14) and other co-morbidity (adjusted HR 1·24, 1·02 to 1·51). Preadmission use of steroids (adjusted HR 0·59, 0·41 to 0·84) and age above 70 years (adjusted HR 0·72, 0·59 to 0·89) were associated with a reduced risk of reoperation.
Conclusion
Obese men with coexisting diseases and high disease severity who have surgery for gastroduodenal perforation are at increased risk of reoperation.
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Affiliation(s)
- R B Hasselager
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, Hvidovre, Denmark
| | - N Lohse
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, Hvidovre, Denmark
- Department of Anaesthesia, Centre of Head and Orthopaedics 4231, Copenhagen, Denmark
| | - P Duch
- Department of Anaesthesiology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - M H Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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14
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Malmi H, Kautiainen H, Virta LJ, Färkkilä MA. Increased short- and long-term mortality in 8146 hospitalised peptic ulcer patients. Aliment Pharmacol Ther 2016; 44:234-45. [PMID: 27240732 DOI: 10.1111/apt.13682] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 11/09/2015] [Accepted: 05/09/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Incidence and complications of peptic ulcer disease (PUD) have declined, but mortality from peptic ulcer bleeding has remained unchanged. The few recent studies on mortality associated with both uncomplicated and complicated patients with peptic ulcer disease provide contradictory results. AIMS To evaluate short- and long-term mortality, and the main causes of death in peptic ulcer disease. METHODS In this retrospective epidemiologic cohort study, register data on 8146 adult patients hospitalised with peptic ulcer disease during 2000-2008 were collected in the capital region of Finland. All were followed in the National Cause of Death Register until the end of 2009. The data were linked with the nationwide Drug Purchase Register of the Finnish Social Insurance Institution. RESULTS Mean follow-up time was 4.9 years. Overall mortality was substantially increased, standardised mortality ratio 2.53 (95% CI: 2.44-2.63); 3.7% died within 30 days, and 11.8% within 1 year. At 6 months, the survival of patients with perforated or bleeding ulcer was lower compared to those with uncomplicated ulcer; hazard ratios were 2.06 (1.68-2.04) and 1.32 (1.11-1.58), respectively. For perforated duodenal ulcers, both the short- and long-term survival was significantly impaired in women. The main causes of mortality at 1 year were malignancies and cardiovascular diseases. Previous use of statins was associated with significant reduction in all-cause mortality. CONCLUSIONS One-year mortality in patients hospitalised with peptic ulcer disease remained high with no change. This peptic ulcer disease cohort had a clearly decreased survival rate up to 10 years, especially among women with a perforated duodenal ulcer, most likely explained by poorer survival due to underlying comorbidity.
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Affiliation(s)
- H Malmi
- Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Kautiainen
- Department of General Practice and Primary Health Care, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Eastern Finland, Kuopio, Finland
| | - L J Virta
- Research Department, The Social Insurance Institution of Finland, Turku, Finland
| | - M A Färkkilä
- Helsinki University Clinic of Gastroenterology, University of Helsinki, Helsinki, Finland
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15
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Abstract
BACKGROUND Refractory peptic ulcers are ulcers in the stomach or duodenum that do not heal after eight to 12 weeks of medical treatment or those that are associated with complications despite medical treatment. Recurrent peptic ulcers are peptic ulcers that recur after healing of the ulcer. Given the number of deaths due to peptic ulcer-related complications and the long-term complications of medical treatment (increased incidence of fracture), it is unclear whether medical or surgical intervention is the better treatment option in people with recurrent or refractory peptic ulcers. OBJECTIVES To assess the benefits and harms of medical versus surgical treatment for people with recurrent or refractory peptic ulcer. SEARCH METHODS We searched the specialised register of the Cochrane Upper GI and Pancreatic Diseases group, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers until September 2015 to identify randomised trials and non-randomised studies, using search strategies. We also searched the references of included studies to identify further studies. SELECTION CRITERIA We considered randomised controlled trials and non-randomised studies comparing medical treatment with surgical treatment in people with refractory or recurrent peptic ulcer, irrespective of language, blinding, or publication status for inclusion in the review. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and extracted data. We planned to calculate the risk ratio, mean difference, standardised mean difference, or hazard ratio with 95% confidence intervals using both fixed-effect and random-effects models with Review Manager 5 based on intention-to-treat analysis. MAIN RESULTS We included only one non-randomised study published 30 years ago in the review. This study included 77 participants who had gastric ulcer and in whom medical therapy (histamine H2 receptor blockers, antacids, and diet) had failed after an average duration of treatment of 29 months. The authors do not state whether these were recurrent or refractory ulcers. It appears that the participants did not have previous complications such as bleeding or perforation. Of the 77 included participants, 37 participants continued to have medical therapy while 40 participants received surgical therapy (antrectomy with or without vagotomy; subtotal gastrectomy with or without vagotomy; vagotomy; pyloroplasty and suture of the ulcer; suture or closure of ulcer without vagotomy or excision of the ulcer; proximal gastric or parietal cell vagotomy alone; suture or closure of the ulcer with proximal gastric or parietal cell vagotomy). Whether to use medical or surgical treatment was determined by participant's or treating physician's preference.The study authors reported that two participants in the medical treatment group (2 out of 37; 5.4%) had gastric cancer, which was identified by repeated biopsy. They did not report the proportion of participants who had gastric cancer in the surgical treatment group. They also did not report the implications of the delayed diagnosis of gastric cancer in the medical treatment group. They did not report any other outcomes of interest for this review (that is health-related quality of life (using any validated scale), adverse events and serious adverse events, peptic ulcer bleeding, peptic ulcer perforation, abdominal pain, and long-term mortality). AUTHORS' CONCLUSIONS We found no studies that provide the relative benefits and harms of medical versus surgical treatment for recurrent or refractory peptic ulcers. Studies that evaluate the natural history of recurrent and refractory peptic ulcers are urgently required to determine whether randomised controlled trials comparing medical versus surgical management in patients with recurrent or refractory peptic ulcers or both are necessary. Such studies will also provide information for the design of such randomised controlled trials. A minimum follow-up of two to three years will allow the calculation of the incidence of complications and gastric cancer (in gastric ulcers only) in recurrent and refractory peptic ulcers. In addition to complications related to treatment and disease, health-related quality of life and loss of productivity should also be measured.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Elena Pallari
- University College LondonDepartment of General Surgery4th Floor, Rockefeller Building21 University StreetLondonUKWC1E 6DE
- King's College London School of MedicineDivision of Cancer Studies, Cancer Epidemiology GroupGuy's Hospital, Great Maze PondResearch OncologyLondonUKSE1 6RT
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16
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Abstract
Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kenneth Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Ewen M Harrison
- MRC Centre for Inflammation Research, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Morten H Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Michael Ohene-Yeboah
- Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jon Arne Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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17
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Søreide K, Thorsen K, Søreide JA. Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. Br J Surg 2013; 101:e51-64. [PMID: 24338777 DOI: 10.1002/bjs.9368] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed. METHODS PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred. RESULTS Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence. CONCLUSION Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.
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Affiliation(s)
- K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, and Department of Clinical Medicine, University of Bergen, Bergen, Norway
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18
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Buck DL, Vester-Andersen M, Møller MH. Surgical delay is a critical determinant of survival in perforated peptic ulcer. Br J Surg 2013; 100:1045-9. [DOI: 10.1002/bjs.9175] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2013] [Indexed: 12/30/2022]
Abstract
Abstract
Background
Morbidity and mortality following perforated peptic ulcer (PPU) remain substantial. Surgical delay is a well established negative prognostic factor, but evidence derives from studies with a high risk of bias. The aim of the present nationwide cohort study was to evaluate the adjusted effect of hourly surgical delay on survival after PPU.
Methods
This was a cohort study including all Danish patients treated surgically for PPU between 1 February 2003 and 31 August 2009. Medically treated patients and those with a malignant ulcer were excluded. The associations between surgical delay and 30-day survival are presented as crude and adjusted relative risks (RRs) with 95 per cent confidence intervals (c.i.).
Results
A total of 2668 patients were included. Their median age was 70·9 (range 16·2–104·2) years and 55·4 per cent (1478 of 2668) were female. Some 67·5 per cent of the patients (1800 of 2668) had at least one of six co-morbid diseases and 45·6 per cent had an American Society of Anesthesiologists fitness grade of III or more. A total of 708 patients (26·5 per cent) died within 30 days of surgery. Every hour of delay from admission to surgery was associated with an adjusted 2·4 per cent decreased probability of survival compared with the previous hour (adjusted RR 1·024, 95 per cent c.i. 1·011 to 1·037).
Conclusion
Limiting surgical delay in patients with PPU seems of paramount importance.
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Affiliation(s)
- D L Buck
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - M Vester-Andersen
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - M H Møller
- Department of Intensive Care, 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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