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Í Soylu L, Hansen JB, Kvist M, Burcharth J, Kokotovic D. Health-related quality of life is a predictor of readmission following emergency laparotomy. World J Surg 2024. [PMID: 38898564 DOI: 10.1002/wjs.12260] [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: 01/19/2024] [Accepted: 06/02/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Health-related quality of life (HRQoL) is a multidimensional concept used to examine the impact of patient-perceived health status on quality of life. Patients' perception of illness affects outcomes in both medical and elective surgical patients; however, not much is known about how HRQoL effects outcomes in the emergency surgical setting. This study aimed to examine if patient-reported HRQoL was a predictor of unplanned readmission after emergency laparotomy. METHODS This study included 215 patients who underwent emergency laparotomy at the Copenhagen University Hospital, Herlev, between August 1, 2021, and July 31, 2022. Patient-reported HRQoL was assessed with the EuroQol group EQ5D index (EQ5D5L descriptive system and EQ-VAS). The population was followed from 0 to 180 days after discharge, and readmissions and days alive and out of hospital were registered. A Cox proportional hazard model was used to examine HRQoL and the risk of readmission within 30 and 180 days. RESULTS Within 30 days, 28.4% of patients were readmitted; within 180 days, the number accumulated to 45.1%. Low self-evaluated HRQoL predicted 180-day readmission and was significantly associated with fewer days out of hospital within both 90 and 180 days. Low HRQoL and discharge with rehabilitation were independent risk factors for short- (30-day) and long-term (180-day) emergency readmission. CONCLUSION Patient-perceived quality of life is an independent predictor of 180-day readmission, and the number of days out of hospital was correlated to self-reported HRQoL.
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Affiliation(s)
- Lív Í Soylu
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Jannick Brander Hansen
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Madeline Kvist
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Jakob Burcharth
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
| | - Dunja Kokotovic
- Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
- Emergency Surgery Research Group Copenhagen (EMERGE Cph), Copenhagen University Hospital-Herlev and Gentofte, Herlev, Denmark
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Í Soylu L, Kokotovic D, Gögenur I, Ekeloef S, Burcharth J. Short and long-term readmission after major emergency abdominal surgery: a prospective Danish study. Eur J Trauma Emerg Surg 2024; 50:295-304. [PMID: 37646801 PMCID: PMC10923996 DOI: 10.1007/s00068-023-02352-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Major emergency abdominal surgery is associated with severe in-hospital complications and loss of performance. After discharge, a substantial fraction of patients are readmitted emergently; however, limited knowledge exists of the long-term consequences. The aim of this study was to examine the risks and causes of short-term (30-day) and long-term (180-day) readmission among patients undergoing major emergency abdominal surgery. METHODS This study included 504 patients who underwent major emergency abdominal surgery at the Zealand University Hospital between March 1, 2017, and February 28, 2019. The population was followed from 0 to 180 days after discharge, and detailed readmission information was registered. A Cox proportional hazards model was used to examine the independent risk factors for readmission within 30 and 180 days. RESULTS From 0 to 30 days after discharge, 161 (31.9%) patients were readmitted emergently, accumulating to 241 (47.8%) patients within 180 days after discharge. The main reasons for short-term readmission were related to the gastrointestinal tract and surgical wounds, whereas long-term readmissions were due to infections, cardiovascular complications, and abdominal pain. Stomal placement was an independent risk factor for short-term readmission, whereas an ASA score of 3 was a risk factor for both short-term and long-term readmission. CONCLUSION Close to 50% of all patients who underwent major emergency abdominal surgery had one or more emergency readmission within 180 days of discharge, and these data points towards the risk factors involved.
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Affiliation(s)
- Lív Í Soylu
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark.
| | - Dunja Kokotovic
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Sarah Ekeloef
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Jakob Burcharth
- Department of Gastrointestinal and Hepatic Diseases, Emergency Surgical Research Group (EMERGE), Copenhagen University Hospitals - Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
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Mathis G, Lapergola A, Alexandre F, Philouze G, Mutter D, D'Urso A. Risk factors for in-hospital mortality after emergency colorectal surgery in octogenarians: results of a cohort study from a referral center. Int J Colorectal Dis 2023; 38:270. [PMID: 37987854 PMCID: PMC10663211 DOI: 10.1007/s00384-023-04565-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE The objective of this study was to investigate predictive factors of mortality in emergency colorectal surgery in octogenarian patients. METHODS It is a retrospective cohort study conducted at a single-institution tertiary referral center. Consecutive patients who underwent emergency colorectal surgery between January 2015 and January 2020 were identified. The primary endpoint was 30-day mortality. Univariate and multivariate analyses were performed using a logistic regression model. RESULTS A total of 111 patients were identified (43 men, 68 women). Mean age was 85.7 ± 3.7 years (80-96). Main diagnoses included complicated sigmoiditis in 38 patients (34.3%), cancer in 35 patients (31.5%), and ischemic colitis in 31 patients (27.9%). An ASA score of 3 or higher was observed in 88.3% of patients. The mean Charlson score was 5.9. The Possum score was 35.9% for mortality and 79.3% for morbidity. The 30-day mortality rate was 25.2%. Univariate analysis of preoperative risk factors for mortality shows that the history of valvular heart disease (p = 0.008), intensive care unit provenance (p = 0.003), preoperative sepsis (p < 0.001), diagnosis of ischemic colitis (p = 0.012), creatinine (p = 0.006) and lactate levels (p = 0.01) were significantly associated with 30-day mortality, and patients coming from home had a lower 30-day mortality rate (p = 0.018). Intraoperative variables associated with 30-day mortality included ileostomy creation (p = 0.022) and temporary laparostomy (p = 0.004). At multivariate analysis, only lactate (p = 0.032) and creatinine levels (p = 0.027) were found to be independent predictors of 30-day mortality, home provenance was an independent protective factor (p = 0.004). Mean follow-up was 3.4 years. Survival at 1 and 3 years was 57.6 and 47.7%. CONCLUSION Emergency colorectal surgery is challenging. However, age should not be a contraindication. The 30-day mortality rate (25.2%) is one of the lowest in the literature. Hyperlactatemia (> 2mmol/L) and creatinine levels appear to be independent predictors of mortality.
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Affiliation(s)
- Guillaume Mathis
- Visceral and Digestive Surgery Department, University Hospital, Strasbourg, France
| | - Alfonso Lapergola
- Visceral and Digestive Surgery Department, University Hospital, Strasbourg, France
| | - Florent Alexandre
- Visceral and Digestive Surgery Department, University Hospital, Strasbourg, France
| | - Guillaume Philouze
- Visceral and Digestive Surgery Department, University Hospital, Strasbourg, France
| | - Didier Mutter
- Visceral and Digestive Surgery Department, University Hospital, Strasbourg, France
- IRCAD (Research Institute against Digestive Cancer), Strasbourg, France
- IHU (Institut Hospitalo-Universitaire/University Hospital Institute), Strasbourg, France
| | - Antonio D'Urso
- IRCAD (Research Institute against Digestive Cancer), Strasbourg, France.
- Department of Surgery, Sapienza University Hospital, Rome, Italy.
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Kim HS, Kim HI, Yoon YJ, Yeom JH, Kim MG. Analysis of prognostic factors for postoperative complications and mortality in elderly patients undergoing emergency surgery for intestinal perforation or irreversible intestinal ischemia. Ann Surg Treat Res 2023; 105:198-206. [PMID: 37908381 PMCID: PMC10613825 DOI: 10.4174/astr.2023.105.4.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 11/02/2023] Open
Abstract
Purpose Because the global geriatric population continues to increase, the assessment of emergency surgical outcomes in elderly patients with acute peritonitis will become more important. Methods A retrospective review was conducted on the data of 174 elderly patients who underwent emergency surgery for intestinal perforation or intestinal infarction between June 2010 and November 2022. We conducted an analysis of the risk factors associated with postoperative complications and mortality by evaluating the characteristics of patients and their surgical outcomes. Results In our study, most patients (94.3%) had preexisting comorbidities, and many patients (84.5%) required transfer to the intensive care unit following emergency surgery. Postoperative complications were observed in 84 individuals (48.3%), with postoperative mortality occurring in 29 (16.7%). Multivariate analysis revealed preoperative acute renal injury, hypoalbuminemia, and postoperative ventilator support as significant predictors of postoperative mortality. Conclusion When elderly patients undergo emergency surgery for intestinal perforation or infarction, it is important to recognize that those with preoperative acute renal injury, hypoalbuminemia, and a need for postoperative ventilator support have a poor prognosis. Therefore, these patients require intensive care from the early stages of treatment.
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Affiliation(s)
- Hyung Suk Kim
- Department of Surgery, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
| | - Hyun Il Kim
- Department of Surgery, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
| | - Young Joon Yoon
- Department of Anesthesiology, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
| | - Jong Hoon Yeom
- Department of Anesthesiology, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
| | - Min Gyu Kim
- Department of Surgery, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
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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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Pigeon CA, Frigault J, Drolet S, Roy ÈM, Bujold-Pitre K, Courval V. Emergency Colon Resection in the Geriatric Population: the Modified Frailty Index as a Risk Factor of Early Mortality. J Gastrointest Surg 2023; 27:1677-1684. [PMID: 37407902 DOI: 10.1007/s11605-023-05720-x] [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: 03/19/2023] [Accepted: 05/20/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Surgical interventions in the elderly are becoming more frequent given the aging of the population. Due to their increased vulnerability in an emergent context, we aimed to evaluate various risk factors associated with an early mortality and an unfavorable postoperative trajectory. METHODS We performed a retrospective, single-center cohort study including patients over the age of 75 who underwent emergency colon resection between January 2016 and December 2020. RESULTS Among 299 patients included, the type of resection most frequently encountered was right hemicolectomy (34%). Large bowel obstruction was the surgical indication for 61% of patients (n = 182). The mortality rate within 30 days of primary surgery was 14% (n = 42). The main factors having a significant impact on early mortality were the modified Frailty Index (mFI) (26% vs 4%; p < 0.001), Charlson comorbidity index (CCI) (20 vs 0%; p = 0.03) and surgical indication (36% vs 11%; p = 0.03). No statistically significant difference was observed according to the age of the patients. Patients with a higher mFI ([Formula: see text] 3) had an increased risk of early mortality with an odds ratio (OR) of 11.94 (95%CI: 2.38-59.88; p < 0.001) in multivariate analysis. This association was also observed for the secondary outcomes, as patients with a higher mFI were less likely to return home (59% vs 32%; p = 0.009) and have their stoma closured at the end of the follow-up period (94% vs 33%; p < 0.001). CONCLUSION In the geriatric population, the use of mFI is a good predictor of early mortality following an emergency colon resection. This accessible tool could be used to guide the surgical decision-making.
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Affiliation(s)
| | - Jonathan Frigault
- Surgery Department, CHU de Quebec - Laval University, Quebec, Canada
| | - Sébastien Drolet
- Surgery Department, CHU de Quebec - Laval University, Quebec, Canada
| | - Ève-Marie Roy
- Surgery Department, CHU de Quebec - Laval University, Quebec, Canada
| | | | - Valérie Courval
- Surgery Department, CHU de Quebec - Laval University, Quebec, Canada
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George M, Mukherjee R. Prognostic Serum Biomarkers of Inflammaging in Patients Undergoing Emergency Laparotomy. J Pers Med 2023; 13:jpm13050769. [PMID: 37240939 DOI: 10.3390/jpm13050769] [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: 03/31/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023] Open
Abstract
Surgeons are increasingly faced with an ageing and frail patient population. There is a significant absence of biomarkers capable of risk stratifying patients undergoing emergency laparotomy. Inflammaging describes a state of chronic inflammation associated with ageing and frailty that may predict worse outcomes after surgery. This retrospective observational study evaluated pre-morbid inflammatory markers in the prognostication of older adult patients undergoing emergency laparotomy. Patients aged ≥65 years undergoing surgery between 1 April 2017 and 1 April 2022 were identified. Pre-admission and acute C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), total white cell count (WCC), neutrophil count (NC) and lymphocyte count (LC) datapoints were captured. Pre-operative risk stratification scores and post-operative outcomes were recorded using the National Emergency Laparotomy Audit (NELA) database. A cohort of 196 patients was included: 57.7% were female, median age 74.5 years. High risk (NELA risk of mortality ≥ 5%) and frail (clinical frailty scale ≥ 4) patients experienced a significantly longer hospital and critical care stay (p < 0.05). Pre-admission ESR ≥ 16 and LC ≥ 4.1 were significantly associated with a longer critical care stay (p < 0.05); no statistical significance was observed with CRP, WCC and NC in predicting adverse outcomes. We found that an elevated pre-morbid ESR and LC identifies a potential inflammaging cohort that demonstrates worse outcomes following emergency laparotomy. The prognostication of older adult surgical patients remains a challenge and represents an area of research deserving of future attention.
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Affiliation(s)
- Michael George
- Liverpool EmerGenT Academy, Department of Emergency General and Major Trauma Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool L9 7AL, UK
- Institute of Systems, Molecular & Integrative Biology, University of Liverpool, Biosciences Building, Crown Street, Liverpool L69 7BE, UK
| | - Rajarshi Mukherjee
- Liverpool EmerGenT Academy, Department of Emergency General and Major Trauma Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Lower Lane, Liverpool L9 7AL, UK
- Institute of Systems, Molecular & Integrative Biology, University of Liverpool, Biosciences Building, Crown Street, Liverpool L69 7BE, UK
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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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Lasithiotakis K, Kritsotakis EI, Kokkinakis S, Petra G, Paterakis K, Karali GA, Malikides V, Anastasiadis CS, Zoras O, Drakos N, Kehagias I, Kehagias D, Gouvas N, Kokkinos G, Pozotou I, Papatheodorou P, Frantzeskou K, Schizas D, Syllaios A, Palios IM, Nastos K, Perdikaris M, Michalopoulos NV, Margaris I, Lolis E, Dimopoulou G, Panagiotou D, Nikolaou V, Glantzounis GK, Pappas-Gogos G, Tepelenis K, Zacharioudakis G, Tsaramanidis S, Patsarikas I, Stylianidis G, Giannos G, Karanikas M, Kofina K, Markou M, Chrysos E. The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece. World J Surg 2023; 47:130-139. [PMID: 36109368 PMCID: PMC9483423 DOI: 10.1007/s00268-022-06723-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). METHODS This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. RESULTS There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). CONCLUSION In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.
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Affiliation(s)
- Konstantinos Lasithiotakis
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece. .,Department of General Surgery, University Hospital of Crete, 71110, Heraklion, Greece.
| | | | - Stamatios Kokkinakis
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Georgia Petra
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Konstantinos Paterakis
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Garyfallia-Apostolia Karali
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Vironas Malikides
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Charalampos S. Anastasiadis
- Department of Surgical Oncology, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Odysseas Zoras
- Department of Surgical Oncology, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Nikolas Drakos
- Department of Surgery, School of Medicine, University General Hospital of Patras, University of Patras, Patras, Greece
| | - Ioannis Kehagias
- Department of Surgery, School of Medicine, University General Hospital of Patras, University of Patras, Patras, Greece
| | - Dimitrios Kehagias
- Department of Surgery, School of Medicine, University General Hospital of Patras, University of Patras, Patras, Greece
| | - Nikolaos Gouvas
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Georgios Kokkinos
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Ioanna Pozotou
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Panayiotis Papatheodorou
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Kyriakos Frantzeskou
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Syllaios
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ifaistion M. Palios
- Second Propaedeutic Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Nastos
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Markos Perdikaris
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Nikolaos V. Michalopoulos
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Ioannis Margaris
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Evangelos Lolis
- Department of Surgery, General Hospital of Volos, Volos, Greece
| | | | | | | | | | | | - Kostas Tepelenis
- Department of Surgery, University Hospital of Ioannina, Ioannina, Greece
| | - Georgios Zacharioudakis
- Department of Surgery, School of Medicine, Ippokrateio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Savvas Tsaramanidis
- Department of Surgery, School of Medicine, Ippokrateio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Patsarikas
- Department of Surgery, School of Medicine, Ippokrateio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Georgios Giannos
- 2nd Department of Surgery, Evangelismos General Hospital, Athens, Greece
| | - Michael Karanikas
- Department of Surgery, School of Medicine, University General Hospital of Alexandroupolis, University of Thrace, Alexandroupolis, Greece
| | - Konstantinia Kofina
- Department of Surgery, School of Medicine, University General Hospital of Alexandroupolis, University of Thrace, Alexandroupolis, Greece
| | - Markos Markou
- Department of Surgery, School of Medicine, University General Hospital of Alexandroupolis, University of Thrace, Alexandroupolis, Greece
| | - Emmanuel Chrysos
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
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Implementing Bundle Care in Major Abdominal Emergency Surgery: Long-Term Mortality and Comprehensive Complication Index. World J Surg 2023; 47:106-118. [PMID: 36171351 PMCID: PMC9726819 DOI: 10.1007/s00268-022-06763-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Major abdominal emergency surgery (MAES) has a high risk of postoperative mortality and a high complication rate. The aim of this study was to evaluate whether the implementation of a perioperative care bundle reduced long-term mortality and the Comprehensive Complication Index (CCI) after MAES. METHODS This study was a single-centre retrospective cohort study. Data in the intervention group were collected prospectively and compared with a historical cohort from the same centre. It includes adult patients undergoing MAES. We implemented a care bundle under the name Abdominal Surgery Acute Protocol (ASAP). We initiated fast-track initiatives and standardised optimised care in before, during and after surgery. Data were analysed using survival analysis and multiple regression. RESULTS We included 120 patients in the intervention cohort and 258 in the historical cohort. The one-year mortality rate was 21.7% in the intervention cohort compared to 28.3% in the standard care cohort. Adjusted odds ratio of one-year mortality 0.81 (CI95% 0.41-1.56). The 30-day mortality was lowered from 19.0 to 6.7% (p = 0.003). The CCI in the intervention cohort was 8.7 (IQR 0-34) compared to 21 (IQR 0-36) in the control cohort (p = 0.932) The length of stay increased by two days (p = 0.021). Most cases had 71-80% protocol compliance. CONCLUSION Implementing bundle care in major abdominal emergency surgery lowered the 30-day postoperative mortality. The difference in mortality was preserved over time although not significant after one year. The changes in the Comprehensive Complication Index were not statistically significant.
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Song J, Cheng C, Sheng K, Jiang LL, Li Y, Xia XQ, Hu XW. Association between the reactivity of local cerebral oxygen saturation after hypo-to-hypercapnic tests and delirium after abdominal surgery in older adults: A prospective study. Front Psychiatry 2022; 13:907870. [PMID: 36405895 PMCID: PMC9672925 DOI: 10.3389/fpsyt.2022.907870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the correlation between changes in regional cerebral oxygen saturation (rSO2) and postoperative delirium in older adults undergoing major abdominal surgery. MATERIALS AND METHODS This prospective study enrolled older adults scheduled for elective major abdominal surgery at the Second Affiliated Hospital of Anhui Medical University from August 2021 to January 2022. The change in rSO2 from baseline was determined using the hypo-to-hypercapnic test. The main study outcome was the occurrence of postoperative delirium. RESULTS A total of 101 participants were included for analysis, of whom 16 (15.8%) developed postoperative delirium. Compared with non-delirium participants, the mean arterial pressure and heart rate were not significantly different in the postoperative delirium group at T0, T1, T2, T3, T4, and T6 (all Pinteraction > 0.05), but the delirium group had lower pH, lower PaO2, and higher lactate levels at T4, T5, and T6 (all Pinteraction < 0.05). rSO2 at T0, T1, T2, T3, T4, and T6 was 69.0 (63.2-75.2), 70.7 ± 7.3, 68.2 ± 7.5, 72.1 ± 8.0, 69.9 ± 7.8, 67.4 ± 7.2, and 71.7 ± 8.1, respectively. The postoperative change in rSO2 during the hypercapnia test (TΔrSO2%) was 6.62 (5.31-9.36). Multivariable analysis showed that the Cumulative Illness Rating Scale (odd ratio, OR = 1.89, 95% confidence interval, CI: 1.10-3.25, P = 0.021), preoperative albumin levels (OR = 0.67, 95% CI: 0.48-0.94, P = 0.022), rSO2 at T4 (OR = 0.61, 95% CI: 0.41-0.89, P = 0.010), and postoperative TΔrSO2% (OR = 0.80, 95% CI: 0.66-0.98, P = 0.028) were independently associated with postoperative delirium in older adults undergoing elective abdominal surgery. CONCLUSION The rSO2 measured at T4 and postoperative TΔrSO2% were independently associated with postoperative delirium in older adults undergoing elective abdominal surgery.
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Affiliation(s)
- Jie Song
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chen Cheng
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Kui Sheng
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ling-Ling Jiang
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yun Li
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Xiao-Qiong Xia
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China.,Department of Anaesthesiology, The Chaohu Affliated Hospital of Anhui Medical University, Hefei, China
| | - Xian-Wen Hu
- Department of Anaesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
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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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One-Year Outcomes Following Emergency Laparotomy: A Systematic Review. World J Surg 2021; 46:512-523. [PMID: 34837122 DOI: 10.1007/s00268-021-06385-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Emergency laparotomies (EL) are associated with significant morbidity and mortality. To date, 30-day mortality has been predominately reported, and been the focus of various national emergency laparotomy audits. Only a few studies have reported on the long-term mortality associated with EL. The aim of this study was to review the one-year mortality following EL. METHOD A systematic review was conducted using PRISMA guidelines to identify studies published in the last 10 years reporting on long-term mortality associated with EL. The data abstracted included: patient demographics, pathology or type of operation performed for EL, post-operative mortality at 7-day, 30-day, 90-day, 1-year, beyond 1-year and inpatient, functional outcomes and risk factors associated with mortality. A quality assessment of included studies was performed. RESULTS Fifteen studies reporting long-term outcomes associated with EL were identified, including the results of 48,023 patients. The indications and/or pathologies for ELs varied. The 30-day mortality after EL ranged from 5.3% to 21.8%, and the one-year mortality ranged from 15.1 to 47%. The mortality in the six studies focusing on elderly patients ranged from 30 to 47%. CONCLUSION The long-term mortality rate associated with EL is substantial. Further study is required to understand the 1-year mortality described in the studies and translate these findings for meaningful application into the clinical care of these patients.
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The risk and predictors of mortality in octogenarians undergoing emergency laparotomy: a multicentre retrospective cohort study. Langenbecks Arch Surg 2021; 406:2037-2044. [PMID: 33825046 DOI: 10.1007/s00423-021-02168-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study aims to evaluate the risk of postoperative mortality in octogenarians undergoing emergency laparotomy. METHODS In compliance with STROCSS guideline for observational studies, we conducted a multicentre retrospective cohort study. All consecutive patients aged over 80 with acute abdominal pathology requiring emergency laparotomy between April 2014 and August 2019 were considered eligible for inclusion. The primary outcome measure was 30-day postoperative mortality, and the secondary outcome measures were in-hospital mortality and 1-year mortality. Statistical analyses included simple descriptive statistics, binary logistic regression analyses, and Kaplan-Meier survival statistics. RESULTS A total of 523 octogenarians were eligible for inclusion. Emergency laparotomy in octogenarians was associated with 21.8% (95% CI 18.3-25.6%) 30-day postoperative mortality, 22.6% (95% CI 19.0-26.4%) in-hospital mortality, and 40.2% (95% CI 35.9-44.5%) 1-year mortality. Binary logistic regression analysis identified ASA status (OR, 2.49; 95% CI 1.82-3.38, P < 0.0001) and peritoneal contamination (OR, 2.00; 95% CI 1.30-3.08, P = 0.002) as predictors of 30-day postoperative mortality. The ASA status (OR, 1.92; 95% CI 1.50-2.46, P < 0.0001), peritoneal contamination (OR, 1.57; 95% CI 1.07-2.48, P = 0.020), and presence of malignancy (OR, 2.06; 95% CI 1.36-3.10, P = 0.001) were predictors of 1-year mortality. Log-rank test showed significant difference in postoperative survival rates among patients with different ASA status (P < 0.0001) and between patients with and without peritoneal contamination (P = 0.0011). CONCLUSIONS Emergency laparotomies in patients older than 80 years with ASA status more than 3 in the presence of peritoneal contamination carry a high risk of immediate postoperative and 1-year mortality. This should be taken into account in communications with patients and their relatives, consent process, and multidisciplinary decision-making process for operative or non-operative management of such patients.
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Hajibandeh S, Hajibandeh S, Antoniou GA, Antoniou SA. Meta-analysis of mortality risk in octogenarians undergoing emergency general surgery operations. Surgery 2021; 169:1407-1416. [PMID: 33413918 DOI: 10.1016/j.surg.2020.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 10/31/2020] [Accepted: 11/16/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study aimed to quantify the risk of perioperative mortality in octogenarians undergoing emergency general surgical operations and to compare such risk between octogenarians and nonoctogenarians. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards to identify studies reporting the mortality risk in patients aged over 80 years undergoing emergency general surgery operations. The primary outcome measure was 30-day mortality, which was stratified based on American Society of Anesthesiologists (ASA) status and procedure type. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Random-effects models were applied to calculate pooled outcome data. RESULTS Analysis of 66,701 octogenarians from 22 studies showed that the risk of 30-day mortality was 26% (95% confidence interval 18%-34%) for all operations: 29% (95% confidence interval 25%-33%) for emergency laparotomy; 9% (95% confidence interval 1%-23%) for nonlaparotomy emergency operations; 21% (95% confidence interval 13%-30%) for colon resection; 17% (95% confidence interval 11%-25%) for small bowel resection; 9% (95% confidence interval 7%-11%) for adhesiolysis; 6% (95% confidence interval 5.9%-6.8%) for perforated ulcer repair; 3% (95% confidence interval 2.6%-4%) for appendicectomy; 3% (95% confidence interval 2.8%-3.3%) for cholecystectomy; and 5% (95% confidence interval 0.2%-14%) for hernia repair. When stratified based on the patient's ASA status, the risk was 11% (95% confidence interval 4%-20%) for ASA 2 status, 22% (95% confidence interval 10%-36%) for ASA 3 status, 39% (95% confidence interval 29%-48%) for ASA 4 status, and 94% (95% confidence interval 77%-100%) for ASA 5 status. The risk was higher in octogenarians compared with nonoctogenarians (odds ratio: 4.07, 95% confidence interval 2.40-6.89), patients aged 70 to 79 (odds ratio: 1.21, 95% confidence interval 1.13-1.31), and patients aged 50 to 79 (odds ratio: 2.03, 95% confidence interval 1.68-2.45). CONCLUSION The risk of perioperative mortality in octogenarians undergoing emergency general surgical operations is high. The risk of perioperative death in this group is higher than in younger patients. Laparotomy, bowel resection, and ASA status above 3 carry the highest risk.
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Affiliation(s)
- Shahab Hajibandeh
- Department of General Surgery, Glan Clwyd Hospital, the Betsi Cadwaladr University Health Board, Rhyl, United Kingdom.
| | - Shahin Hajibandeh
- Department of General Surgery, Hereford County Hospital, Wye Valley NHS Trust, United Kingdom
| | - George A Antoniou
- Department of Vascular & Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Northern Care Alliance NHS Group, Manchester, United Kingdom; Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, United Kingdom
| | - Stavros A Antoniou
- Surgical Service, Mediterranean Hospital of Cyprus, Limassol, Cyprus; Medical School, European University Cyprus, Nicosia, Cyprus
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Patients' perceptions of barriers to enhanced recovery after emergency abdominal surgery. Langenbecks Arch Surg 2020; 406:405-412. [PMID: 33215245 DOI: 10.1007/s00423-020-02032-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 11/15/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE The patient-perceived barriers towards an optimized short-term recovery after major emergency abdominal surgery are unknown. The purpose was to investigate which patient-perceived barriers dominated concerning nutrition, mobilization, and early discharge after major emergency abdominal surgery. METHODS An explorative study, which focused on patient-perceived barriers for early discharge, mobilization, and nutrition, was performed within an enhanced recovery perioperative setting in major emergency abdominal surgery. Patients were asked daily from postoperative day (POD) 1 to POD 7 of their self-perceived barriers towards getting fully mobilization and resuming normal oral intake. From POD 3 to POD 7, patients were asked regarding self-perceived barriers towards early discharge. RESULTS A total of 101 patients that underwent major emergency abdominal surgery were included for final analysis from March 2017 to August 2017. The main patient self-perceived barrier towards sufficient nutrition was dominated by food aversion (including loss of appetite). The main patient self-perceived barrier towards sufficient mobilization throughout the study period was fatigue. The patient self-perceived barriers towards early discharge were more diffuse and lacked a dominant variable throughout the study period; however, fatigue was the most pronounced barrier throughout the study period. The leading initial variables were postoperative ileus, insufficient nutrition, and epidural catheter. The leading later variables besides fatigue included awaiting normalization of biochemistry values, pain, and the perception of insufficient oral intake. CONCLUSIONS The major patient-perceived factors that limited postoperative recovery after major emergency abdominal surgery included food aversion regarding normalization of oral intake and fatigue regarding mobilization and early discharge.
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Emergency laparotomy in the older patient: factors predictive of 12-month mortality-Salford-POPS-GS. An observational study. Aging Clin Exp Res 2020; 32:2367-2373. [PMID: 32449105 PMCID: PMC7591437 DOI: 10.1007/s40520-020-01578-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/25/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Although high rates of in-hospital mortality have been described in older patients undergoing emergency laparotomy (EL), less is known about longer-term outcomes in this population. We describe factors present at the time of hospital admission that influence 12-month survival in older patients. METHODS Observational study of patients aged 75 years and over, who underwent EL at our hospital between 8th September 2014 and 30th March 2017. RESULTS 113 patients were included. Average age was 81.9 ± 4.7 years, female predominance (60/113), 3 (2.6%) lived in a care home, 103 (91.2%) and 79 (69.1%) were independent of personal and instrumental activities of daily living (ADLs) and 8 (7.1%) had cognitive impairment. Median length of stay was 16 days ± 29.9 (0-269); in-hospital mortality 22.1% (25/113), post-operative 30-day, 90-day and 12-month mortality rates 19.5% (22), 24.8% (28) and 38.9% (44). 30-day and 12-month readmission rates 5.7% (5/88) and 40.9% (36). 12-month readmission was higher in frail patients, using the Clinical Frailty Scale (CFS) score (64% 5-8 vs 31.7% 1-4, p = 0.006). Dependency for personal ADLs (6/10 (60%) dependent vs. 38/103 (36.8%) independent, p = 0.119) and cognitive impairment (5/8 (62.5%) impaired vs. 39/105 (37.1%) no impairment, p = 0.116) showed a trend towards higher 12-month mortality. On multivariate analysis, 12-month mortality was strongly associated with CFS 5-9 (HR 5.0403 (95% CI 1.719-16.982) and ASA classes III-V (HR 2.704 95% CI 1.032-7.081). CONCLUSION Frailty and high ASA class predict increased mortality at 12 months after emergency laparotomy. We advocate early engagement of multi-professional teams experienced in perioperative care of older patients.
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Aakre EK, Ulvik A, Hufthammer KO, Jammer I. Mortality and complications after emergency laparotomy in patients above 80 years. Acta Anaesthesiol Scand 2020; 64:913-919. [PMID: 32270490 DOI: 10.1111/aas.13594] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/17/2020] [Accepted: 03/21/2020] [Indexed: 12/22/2022]
Abstract
Emergency laparotomy (EL) is a high-risk procedure. However, available evidence regarding outcome after emergency surgery in very old patients is limited. The aim of this observational study was to investigate outcome following EL in patients ≥80 years of age. METHODS This single-center retrospective study was undertaken at Haukeland University Hospital, Norway. Demographic data, pre-operative risk assessment, surgical procedures, intrahospital logistics, complications, mortality, and discharge data were collected from the medical records. Primary outcome was 30-day mortality. Secondary outcomes were 90-day mortality, 1-year mortality, post-operative complications, and level of care at discharge. RESULTS One hundred and six patients aged 80-96 years underwent EL between 2015 and 2016. Of these, 58% had cardiopulmonary disease, and 16% lived in a nursing home before surgery. Resection of colon was performed in 26 cases, adhesiolysis was performed in 24, and resection of small intestine in 18. Within 30 days, 28 patients died (26%), 15 during the first post-operative week. For 82% of the patients, at least one complication occurred, and medical complications were far more frequent than surgical. Post-operatively, pulmonary morbidity was found in 51 patients (48%) and delirium in 42 (40%). The number of intrahospital deaths was 25 (24%). Among the 81survivors, 53 were discharged to a nursing home (65%). One-year mortality was 47% (50/106). CONCLUSIONS Mortality after EL in octo- and nonagenarians is very high. Medical complications are more common than surgical, and functional decline is frequent. Future studies should focus on the effect of a care bundle including geriatric intervention in these patients.
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Affiliation(s)
- Elin K. Aakre
- Department of Anaesthesia and Surgical Services Haukeland University Hospital Bergen Norway
| | - Atle Ulvik
- Department of Anaesthesia and Surgical Services Haukeland University Hospital Bergen Norway
| | - Karl O. Hufthammer
- Centre for Clinical Research Haukeland University Hospital Bergen Norway
| | - Ib Jammer
- Department of Anaesthesia and Surgical Services Haukeland University Hospital Bergen Norway
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Costa G, Fransvea P, Podda M, Pisanu A, Carrano FM, Iossa A, Balducci G, Agresta F. The use of emergency laparoscopy for acute abdomen in the elderly: the FRAILESEL Italian Multicenter Prospective Cohort Study. Updates Surg 2020; 72:513-525. [PMID: 32088854 DOI: 10.1007/s13304-020-00726-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 02/13/2020] [Indexed: 02/07/2023]
Abstract
As the world population is aging rapidly, emergency abdominal surgery for acute abdomen in the elderly represents a global issue, both in developed and developing countries. Data regarding all the elderly patients who underwent emergency abdominal surgery from January 2017 to December 2017 at 36 Italian surgical departments were analyzed with the aim to appraise the contemporary reality regarding the use of emergency laparoscopy for acute abdomen in the elderly. 1993 patients were enrolled. 1369 (68.7%) patients were operated with an open technique; whereas, 624 (31.3%) underwent a laparoscopic operation. The postoperative morbidity rate was 32.6%, with a statically significant difference between the open and the laparoscopic groups (36.2% versus 22.1%, p < 0.001). The reported mortality rate was 8.8%, with a statistically significant difference between the open and the laparoscopic groups (11.2% versus 2.2%, p < 0.001). Our results demonstrated that patients in the ASA II (58.1%), ASA III (68.7%) and ASA IV (88.5%) groups were operated with the traditional open technique in most of the cases. Only a small percentage of patients underwent laparoscopy for perforated gastro-duodenal ulcer repair (18.9%), adhesiolyses with/without small bowel resection (12.2%), and large bowel resection (10.7%). Conversion to open technique was associated with a higher mortality rate (11.1% versus 2.2%, p < 0.001) and overall morbidity (38.9% versus 22.1%, p = 0.001) compared with patients who did not undergo conversion. High creatinine (p < 0.001) and glycaemia (p = 0.006) levels, low hemoglobin levels (p < 0.001), oral anticoagulation therapy (p = 0.001), acute respiratory failure (p < 0.001), presence of malignancy (p = 0.001), SIRS (p < 0.001) and open surgical approach (p < 0.001) were associated with an increased risk of postoperative morbidity. Regardless of technical progress, elderly patients undergoing emergency surgery are at very high risk for in-hospital complications. A detailed analysis of complications and mortality in the present study showed that almost 9% of elderly patients died after surgery for acute abdomen, and over 32% developed complications.
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Affiliation(s)
- Gianluca Costa
- Emergency Surgery Unit, Sant'Andrea Teaching Hospital, "La Sapienza" University of Rome, Rome, Italy
| | - Pietro Fransvea
- Emergency Surgery Unit, Sant'Andrea Teaching Hospital, "La Sapienza" University of Rome, Rome, Italy
| | - Mauro Podda
- Department of General, Emergency and Minimally Invasive Surgery, Cagliari University Hospital "D. Casula", University of Cagliari, SS 554, Km 4,500, Monserrato, 09042, Cagliari, Italy.
| | - Adolfo Pisanu
- Department of General, Emergency and Minimally Invasive Surgery, Cagliari University Hospital "D. Casula", University of Cagliari, SS 554, Km 4,500, Monserrato, 09042, Cagliari, Italy
| | - Francesco Maria Carrano
- Department of General, Emergency and Transplant Surgery, Ospedale di Circolo e "Fondazione Macchi", ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Angelo Iossa
- Department of Medicine and Surgical Sciences and Biotechnologies, "La Sapienza" University of Rome, Polo Pontino, Latina, Italy
| | - Genoveffa Balducci
- Emergency Surgery Unit, Sant'Andrea Teaching Hospital, "La Sapienza" University of Rome, Rome, Italy
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McCann A, Sorensen J, Nally D, Kavanagh D, McNamara DA. Discharge outcomes among elderly patients undergoing emergency abdominal surgery: registry study of discharge data from Irish public hospitals. BMC Geriatr 2020; 20:72. [PMID: 32075577 PMCID: PMC7031938 DOI: 10.1186/s12877-020-1469-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intra-abdominal emergency surgery is associated with high mortality risk and long length of hospital stay. The objective of this study was to explore variations in surgery rates, the relationship between admission source and discharge destination, and whether the postoperative length of stay was related to nursing home capacity in Irish counties. METHODS Data on emergency hospital episodes for 2014-18 for patients aged over 65 years with a primary abdominal procedure code were obtained from the National Quality Assurance Improvement System. Data on population and nursing home capacity were obtained from the Central Statistics Office and the Health Information and Quality Authority. Episode rates per 100,000 were estimated for sex and age groups and compared between 26 Irish counties. The association between admission source and discharge destination was explored in terms episode numbers, length of stay and mortality. A negative binomial regression model estimated casemix adjusted excess post-operative length of stay. The correlation between excess post-operative length of stay and nursing home capacity was explored by linear regression. RESULTS Overall, 4951 hospital episodes were included. The annual surgery rate ranged from 100 episodes per 100,000 65-69 years old to 250 per 100,000 85-89 year old men. 90% of the episodes were admitted from patients' home. Four in five of these patients returned to their home while 12.7% died at hospital. The proportion of episodes where patients returned to their home reduced to two in five for those aged 85-89 years. The post-operative length of stay was 13.6 days longer (p < 0.01) for episodes admitted from home and discharged to nursing home in comparison with episodes discharged home. A negative association (p = 0.08) was found between excess post-operative length of stay and county-level nursing home capacity. CONCLUSIONS This study provides relevant information to support informed consent to surgery for patients and clinicians and to improve the provision of care to older patients presenting with intra-abdominal emergencies.
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Affiliation(s)
- Aisling McCann
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland, 2 Proud’s Lane, Dublin, Ireland
| | - Jan Sorensen
- Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland, Beaux Lane House, Mercer Street Lower, Dublin, Ireland
| | - Deirdre Nally
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, 121 St. Stephen’s Green, Dublin, Ireland
| | - Dara Kavanagh
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, 121 St. Stephen’s Green, Dublin, Ireland
| | - Deborah A. McNamara
- National Clinical Programme in Surgery, Royal College of Surgeons in Ireland, 2 Proud’s Lane, Dublin, Ireland
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Emergency General Surgery in Older Patients: Where Are We Now? CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00352-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Implementation of a multidisciplinary perioperative protocol in major emergency abdominal surgery. Eur J Trauma Emerg Surg 2019; 47:467-477. [DOI: 10.1007/s00068-019-01238-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
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Katz M, Silverstein N, Coll P, Sullivan G, Mortensen EM, Sachs A, Gross JB, Girard E, Liang J, Ristau BT, Stevenson C, Smith PP, Shames BD, Millea R, Ali I, Poulos CM, Ramaraj AB, Otukoya AO, Nolan J, Wahla Z, Hardy C, Al-Naggar I, Bliss LA, McFadden DW. Surgical care of the geriatric patient. Curr Probl Surg 2019; 56:260-329. [DOI: 10.1067/j.cpsurg.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 03/13/2019] [Indexed: 12/15/2022]
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Gebremedhn EG, Agegnehu AF, Anderson BB. Outcome assessment of emergency laparotomies and associated factors in low resource setting. A case series. Ann Med Surg (Lond) 2018; 36:178-184. [PMID: 30505437 PMCID: PMC6249396 DOI: 10.1016/j.amsu.2018.09.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 06/27/2018] [Accepted: 09/21/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Emergency laparotomy is a high risk procedure which is demonstrated by high morbidity and mortality. However, the problem is tremendous in resource limited settings and there is limited data on patient outcome. We aimed to assess postoperative patient outcome after emergency laparotomy and associated factors. METHODS An observational study was conducted in our hospital from March 11- June 30, 2015 using emergency laparotomy network tool. All consecutive surgical patients who underwent emergency laparotomy were included. Binary and multiple logistic regressions were employed using adjusted odds ratios and 95% CI, and P-value < 0.05 was considered to be statistically significant. RESULT A total of 260 patients were included in the study. The majority of patients had late presentation (>6hrs) to the hospital after the onset of symptoms of the diseases and surgical intervention after hospital admission. The incidences of postoperative morbidity and mortality were 39.2% and 3.5% respectively. Factors associated with postoperative morbidity were preoperative co-morbidity (AOR = 0.383, CI = 0.156-0.939) and bowel resection (AOR = 0.232, CI = 0.091-0.591). Factors associated with postoperative mortality were anesthetists' preoperative opinion on postoperative patient outcome (AOR = 0.067, CI = 0.008-0.564), level of consciousness during recovery from anaesthesia (AOR = 0.114, CI = 0.021-10.628) and any re-intervention within 30 days after primary operation (AOR = 0.083, CI = 0.009-0.750). CONCLUSION AND RECOMMENDATION The incidence of postoperative morbidity and mortality after emergency laparotomy were high. We recommend preoperative optimization, early surgical intervention, and involvement of senior professionals during operation in these risky surgical patients. Also, we recommend the use of WHO or equivalent Surgical Safety Checklist and establishment of perioperative patient care bundle including surgical ICU and radiology investigation modalities such as CT scan.
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Affiliation(s)
- Endale Gebreegziabher Gebremedhn
- Department of Anaesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, The University of Gondar, Gondar, Ethiopia
| | - Abatneh Feleke Agegnehu
- Department of Anaesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, The University of Gondar, Gondar, Ethiopia
| | - Bernard Bradley Anderson
- Department of Surgery, School of Medicine, Gondar College of Medicine and Health Sciences, The University of Gondar, Gondar, Ethiopia
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Eugene N, Oliver C, Bassett M, Poulton T, Kuryba A, Johnston C, Anderson I, Moonesinghe S, Grocott M, Murray D, Cromwell D, Walker K, Cripps M, Cripps P, Davies E, Drake S, Galsworthy M, Goodwin J, Salih T, Lourtie J, Papadimitriou D, Peden C. Development and internal validation of a novel risk adjustment model for adult patients undergoing emergency laparotomy surgery: the National Emergency Laparotomy Audit risk model. Br J Anaesth 2018; 121:739-748. [PMID: 30236236 DOI: 10.1016/j.bja.2018.06.026] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/01/2018] [Accepted: 06/20/2018] [Indexed: 01/03/2023] Open
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Chong SE, Mohamad Zaini RH, Fadzlina W, Sulaiman AJ, Gunasekaran V. Sugammadex Rescue in Avoiding Intensive Care Unit Admission in an Octogenarian Undergoing Emergency Laparotomy. J Perianesth Nurs 2018; 33:727-731. [PMID: 30236580 DOI: 10.1016/j.jopan.2017.06.001] [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: 04/09/2017] [Revised: 05/31/2017] [Accepted: 06/04/2017] [Indexed: 11/30/2022]
Abstract
Postlaparotomy management for elderly patients with underlying comorbidities is always a challenge because of poor cardiorespiratory reserves and prolonged effect of anesthetic drugs. For these reasons, such patients usually require intensive care unit (ICU) admission in the postoperative period. We report a case of an 85-year-old chronic smoker with controlled diabetes mellitus who needed an emergency laparotomy for a perforated gastric ulcer. Unfortunately, there was a shortage of ICU backup. With the successful conduct of an early surgery using combined general and regional anesthesia, the use of sugammadex (Bridion, Merck Sharp & Dohme Corp, Oss, the Netherlands) as a reversal agent, a skilled surgeon, and good postanesthesia care, the patient did not require ICU admission. He recovered fast and was discharged home 4 days after surgery. This case study aims to contribute to the literature on experience of a successful conduct of anesthesia in a high-risk geriatric patient when ICU facilities are limited.
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Bolger JC, Zaidi A, Fuentes-Bonachera A, Kelly ME, Abbas A, Rogers A, McCormack T, Waldron B, Murray KP. Emergency surgery in octogenarians: Outcomes and factors affecting mortality in the general hospital setting. Geriatr Gerontol Int 2018; 18:1211-1214. [PMID: 29897164 DOI: 10.1111/ggi.13456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 03/28/2018] [Accepted: 04/16/2018] [Indexed: 11/26/2022]
Abstract
AIM The Western world has an expanding older population, who are living longer with increasing numbers of comorbidities. In addition, expectations of patients and relatives are increasing. As a general hospital operating in a rural setting, our University Hospital Kerry, Tralee, Ireland, deals with a significant number of emergency presentations to the acute surgical service. The aim of the present study was to examine outcomes for patients in the extremes of age who present requiring emergency surgical procedures. METHODS A retrospective review of theater and admission logs was carried out to identify all emergency surgeries from January 2008 to December 2015. All patients aged >80 years at the time of surgery were identified. Details of surgery were recorded, in addition to biochemical and hematological data, use of intensive care unit, length of stay and mortality. RESULTS In total, 128 octogenarians underwent an emergency surgery. The average patient age was 84.3 years (range 80-94 years). The commonest procedures were laparotomy (65%, n = 84), repair of strangulated/incarcerated hernia (18%, n = 23) and laparoscopic procedures (16%, n = 21). The 30-day all-cause mortality was 22.6%. On multivariate analysis, American Society of Anesthesia status and intensive care unit utilization predicted mortality (P = 0.04 and 0.05, respectively). A total of 82 patients required intensive care unit admission, with an average length of stay of 4.8 days, using 484 bed days in total. CONCLUSIONS Emergency surgery in octogenarians is a significant part of the workload of general surgeons. Poor baseline status is associated with an increased risk of mortality. Emergency surgery in older adults only utilizes a fraction of available intensive care unit resources. Geriatr Gerontol Int 2018; 18: 1211-1214.
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Affiliation(s)
- Jarlath C Bolger
- Department of Surgery, University Hospital Kerry, Tralee, Ireland
| | - Akif Zaidi
- Department of Surgery, University Hospital Kerry, Tralee, Ireland
| | | | - Michael E Kelly
- Department of Surgery, University Hospital Kerry, Tralee, Ireland
| | - Aqeel Abbas
- Department of Surgery, University Hospital Kerry, Tralee, Ireland
| | - Ailin Rogers
- Department of Surgery, University Hospital Kerry, Tralee, Ireland
| | - Tom McCormack
- Department of Surgery, University Hospital Kerry, Tralee, Ireland
| | - Brian Waldron
- Department of Surgery, University Hospital Kerry, Tralee, Ireland
| | - Kevin P Murray
- Department of Surgery, University Hospital Kerry, Tralee, Ireland
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Ruscelli P, Popivanov G, Tabola R, Polistena A, Sanguinetti A, Avenia N, Renzi C, Cirocchi R, Ursi P, Fingerhut A. Modified Paul-Mikulicz jejunostomy in frail geriatric patients undergoing emergency small bowel resection. MINERVA CHIR 2018; 74:121-125. [PMID: 29795063 DOI: 10.23736/s0026-4733.18.07714-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Proximal or extended bowel resections are sometimes necessary during emergency surgery of the small bowel and call for creating a high small bowel stomy as a part of damage control surgery. Secondary restoration of intestinal continuity in the frail geriatric patient, further weakened by subsequent severe malabsorption may be prohibitive. METHODS Six patients underwent emergency small bowel resection for proximal jejunal disease (83.3% high-grade adhesive SBO and 16.7% jejunal diverticulitis complicated with perforation). With the intention to avoid end jejunostomy and the need for repeat laparotomy for bowel continuity restoration we modified the classic Paul-Mikulicz jejunostomy. RESULTS The postoperative course was uneventful in four patients whose general condition improved considerably. At six-month follow-up, neither patients required parenteral nutrition. CONCLUSIONS This modified stoma can have the advantage of allowing a partial passage of the enteric contents, reducing the degree of malabsorption, and rendering jejunostomy reversal easy to perform later.
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Affiliation(s)
- Paolo Ruscelli
- Unit of Emergency Surgery, Torrette Hospital, Faculty of Medicine and Surgery, Polytechnic University of Marche, Ancona, Italy
| | - Georgi Popivanov
- Military Medical Academy-Sofia, Clinic of Endoscopic, Endocrine Surgery and Coloproctology, Sofia, Bulgaria
| | - Renata Tabola
- Department and Clinic of Gastrointestinal and General Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Andrea Polistena
- Unit of General Surgery and Surgical Specialties, University of Perugia, Terni, Italy
| | | | - Nicola Avenia
- Unit of General Surgery and Surgical Specialties, University of Perugia, Terni, Italy
| | - Claudio Renzi
- Department of Surgery and Biochemical Sciences, University of Perugia, Terni, Italy
| | - Roberto Cirocchi
- Department of Surgery and Biochemical Sciences, University of Perugia, Terni, Italy -
| | - Pietro Ursi
- Department of General Surgery and Surgical Specialties, Sapienza University, Rome, Italy
| | - Abe Fingerhut
- Section for Surgical Research, Medical University of Graz, Graz, Austria
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Risk Factors for Mortality and Morbidity in Elderly Patients Presenting with Digestive Surgical Emergencies. World J Surg 2017; 42:1988-1996. [DOI: 10.1007/s00268-017-4419-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Simpson G, Saunders R, Wilson J, Magee C. The role of the neutrophil:lymphocyte ratio (NLR) and the CRP:albumin ratio (CAR) in predicting mortality following emergency laparotomy in the over 80 age group. Eur J Trauma Emerg Surg 2017; 44:877-882. [PMID: 29134253 DOI: 10.1007/s00068-017-0869-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Emergency laparotomy in the elderly is an increasingly common procedure which carries high morbidity and mortality. Risk prediction tools, although imperfect, can help guide management decisions. Novel markers of surgical outcomes may contribute to these scoring systems. The neutrophil:lymphocyte ratio (NLR) and CRP:albumin ratio (CAR) have been associated with outcomes in malignancy and sepsis. We assessed the use of ratio NLR and CAR as prognostic indicators in patients over the age of 80 undergoing emergency laparotomy. METHODS A retrospective analysis of all patients over the age of 80 who underwent emergency laparotomy during a 3 year period was conducted. Pre and post-operative NLR and CAR were assessed in relation to outcome measures including inpatient, 30-day and 90-day mortality. Statistical analysis was conducted with Mann-Whitney U, receiver operating characteristics, Spearmans rank correlation coefficient and chi-squared tests. RESULTS One hundred and thirty-six patients over the age of 80 underwent emergency laparotomy. Median age was 84 years (range 80-96 years). Overall inpatient mortality was 19.2%. Pre-operative and post-operative NLR and CAR were significantly raised in patients with sepsis v no sepsis (p < 0.05). Pre-operative NLR was significantly associated with inpatient (p = 0.046), 30-day (p = 0.02) and 90-day mortality (p = 0.01) in patients with visceral perforation. A pre-operative NLR value of greater than 8 was associated with significantly increased mortality (p = 0.016, AUC:0.78). CAR was not associated with mortality. CONCLUSION Pre-operative NLR is associated with mortality in patients with visceral perforation undergoing emergency laparotomy. NLR > 8 is associated with a poorer outcome in this group of patients. CAR was not associated with mortality in over-80s undergoing emergency laparotomy.
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Affiliation(s)
- G Simpson
- Division of GI Surgery, Wirral University Teaching Hospitals, Wirral, UK
| | - R Saunders
- University of Liverpool Division of Oncology and Surgery, Liverpool, UK
| | - J Wilson
- Division of GI Surgery, Wirral University Teaching Hospitals, Wirral, UK
| | - C Magee
- Division of GI Surgery, Wirral University Teaching Hospitals, Wirral, UK.
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Hussain A, Mahmood F, Teng C, Jafferbhoy S, Luke D, Tsiamis A. Patient outcome of emergency laparotomy improved with increasing "number of surgeons on-call" in a university hospital: Audit loop. Ann Med Surg (Lond) 2017; 23:21-24. [PMID: 29021897 PMCID: PMC5633340 DOI: 10.1016/j.amsu.2017.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 09/13/2017] [Accepted: 09/17/2017] [Indexed: 12/27/2022] Open
Abstract
AIM Emergency laparotomy is a commonly performed high-mortality surgical procedure. The National Emergency Laparotomy Network (NELA) published an average mortality rate of 11.1% and a median length of stay equivalent to 16.3 days in patients undergoing emergency laparotomy. This study presents a completed audit loop after implementing the change of increasing the number of on-call surgeons in the general surgery rota of a university hospital. The aim of this study was to evaluate the outcomes of emergency laparotomy in a single UK tertiary centre after addition of one more consultant in the daily on-call rota. METHODS This is a retrospective study involving patients who underwent emergency laparotomy between March to May 2013 (first audit) and June to August 2015 (second audit). The study parameters stayed the same. The adult patients undergoing emergency laparotomy under the general surgical take were included. Appendicectomy, cholecystectomy and simple inguinal hernia repair patients were excluded. Data was collected on patient demographics, ASA, morbidity, 30-day mortality and length of hospital stay. Statistical analysis including logistic regression was performed using SPSS. RESULTS During the second 3-month period, 123 patients underwent laparotomy compared to 84 in the first audit. Median age was 65(23-93) years. 56.01% cases were ASA III or above in the re-audit compared to 41.9% in the initial audit. 38% patients had bowel anastomosis compared to 35.7% in the re-audit with 4.2% leak rate in the re-audit compared to 16.6% in the first audit. 30-day mortality was 10.50% in the re-audit compared to 21% and median length of hospital stay 11 days in the re-audit compared to 16 days. The lower ASA grade was significantly associated with increased likelihood of being alive, as was being female, younger age and not requiring ITU admission post-operatively. However, having a second on-call consultant was 2.231 times more likely to increase the chances of patients not dying (p = 0.031). CONCLUSION Our audit-loop suggests that adding a second consultant to the daily on-call rota significantly reduces postoperative mortality and morbidity. Age, ASA and ITU admission are other independent factors affecting patient outcomes. We suggest this change be applied to other high volume centres across the country to improve the outcomes after emergency laparotomy.
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Affiliation(s)
- Anwar Hussain
- SpR Colorectal Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Fahad Mahmood
- Core Trainee General Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Chui Teng
- FY1 General Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Sadaf Jafferbhoy
- SpR General Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - David Luke
- Consultant colorectal Surgeon, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Achilleas Tsiamis
- Consultant colorectal Surgeon, Department of Colorectal Surgery, University Hospital of North Midlands, UK
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Abstract
A look at what is being done to reduce morbidity and mortality in 29 hospitals in England.
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Affiliation(s)
- G Aggarwal
- Royal Surrey County Hospital NHS Foundation Trust
| | - N Quiney
- Royal Surrey County Hospital NHS Foundation Trust
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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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Prediction of Outcome After Emergency High-Risk Intra-abdominal Surgery Using the Surgical Apgar Score. Anesth Analg 2016; 123:1516-1521. [DOI: 10.1213/ane.0000000000001501] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Tengberg LT, Cihoric M, Foss NB, Bay-Nielsen M, Gögenur I, Henriksen R, Jensen TK, Tolstrup MB, Nielsen LBJ. Complications after emergency laparotomy beyond the immediate postoperative period - a retrospective, observational cohort study of 1139 patients. Anaesthesia 2016; 72:309-316. [PMID: 27809332 DOI: 10.1111/anae.13721] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 12/25/2022]
Abstract
Mortality and morbidity occur commonly following emergency laparotomy, and incur a considerable clinical and financial healthcare burden. Limited data have been published describing the postoperative course and temporal pattern of complications after emergency laparotomy. We undertook a retrospective, observational, multicentre study of complications in 1139 patients after emergency laparotomy. A major complication occurred in 537/1139 (47%) of all patients within 30 days of surgery. Unadjusted 30-day mortality was 20.2% and 1-year mortality was 34%. One hundred and thirty-seven of 230 (60%) deaths occurred between 72 h and 30 days after surgery; all of these patients had complications, indicating that there is a prolonged period with a high frequency of complications and mortality after emergency laparotomy. We conclude that peri-operative, enhanced recovery care bundles for preventing complications should extend their focus on continuous complication detection and rescue beyond the first few postoperative days.
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Affiliation(s)
- L T Tengberg
- Copenhagen University Hospital, Hvidovre, Denmark
| | - M Cihoric
- Copenhagen University Hospital, Hvidovre, Denmark
| | - N B Foss
- Copenhagen University Hospital, Hvidovre, Denmark
| | | | - I Gögenur
- Copenhagen University Hospital, Køge, Denmark
| | - R Henriksen
- Copenhagen University Hospital, Hillerød, Denmark
| | - T K Jensen
- Copenhagen University Hospital, Herlev, Denmark
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Mzoughi Z, Bayar R, Djebbi A, Talbi G, Romdhane H, Aloui W, Lassaad G, Khalfallah MT. [The POSSUM: a good scoring system for predicting mortality in elderly patients undergoing emergency surgery?]. Pan Afr Med J 2016; 24:166. [PMID: 27795763 PMCID: PMC5072875 DOI: 10.11604/pamj.2016.24.166.9528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 05/23/2016] [Indexed: 11/12/2022] Open
Abstract
Introduction Le POSSUM (Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity) est un score prédictif de mortalité qui est largement utilisé en chirurgie aortique élective et abdominale. Le but de notre étude est une validation du POSSUM chez le sujet âgé (>70 ans) opéré pour une urgence digestive. Nous nous proposons d'étudier les meilleurs seuils du POSSUM, composé d'un score physiologique et d'un score opératoire, pour prédire la mortalité dans cette population. Méthodes Il s'agit d'une étude rétrospective analytique de type cas témoin à partir d'une série de 291 patients d'âge ≥ 70 ans opérés pour une urgence digestive. Ces patients étaient répartis en deux groupes comportant 50 patients chacun. Le groupe "DC": patients décédés en post opératoire immédiat et le Groupe témoin "SURV" choisis par tirage au sort. Nous avons analysé la fiabilité du POSSUM pour prédire la mortalité et la morbidité. Par la suite, nous avons établi des courbes de ROC pour définir les seuils qui donnent le meilleur couple sensibilité/spécificité. Résultats Le score physiologique, le score opératoire et les taux de morbidité et mortalité prédits par POSSUM et la mortalité prédit par P-POSSUM représentaient des facteurs prédictifs de mortalité (P <0,0001). Les valeurs seuils du score physiologique et du score opératoire qui donnent le meilleur couple sensibilité/spécificité, étaient respectivement de 23 et 15. Conclusion Prédire la mortalité permet de cibler la prise en charge et d'informer le patient et sa famille des risques encourus.
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Affiliation(s)
- Zeineb Mzoughi
- Université de Tunis El Manar, Faculté de Médecine de Tunis, 1007, Tunis, Tunisie; Service de Chirurgie Viscérale CHU Mongi Slim, Sidi Daoued La Marsa, Tunisie
| | - Rached Bayar
- Université de Tunis El Manar, Faculté de Médecine de Tunis, 1007, Tunis, Tunisie; Service de Chirurgie Viscérale CHU Mongi Slim, Sidi Daoued La Marsa, Tunisie
| | - Achref Djebbi
- Université de Tunis El Manar, Faculté de Médecine de Tunis, 1007, Tunis, Tunisie; Service de Chirurgie Viscérale CHU Mongi Slim, Sidi Daoued La Marsa, Tunisie
| | - Ghofrane Talbi
- Université de Tunis El Manar, Faculté de Médecine de Tunis, 1007, Tunis, Tunisie; Service de Chirurgie Viscérale CHU Mongi Slim, Sidi Daoued La Marsa, Tunisie
| | - Hayfa Romdhane
- Université de Tunis El Manar, Faculté de Médecine de Tunis, 1007, Tunis, Tunisie; Service de Gastroentérologie CHU Mongi Slim, Sidi Daoued La Marsa, Tunisie
| | - Wafa Aloui
- Université de Tunis El Manar, Faculté de Médecine de Tunis, 1007, Tunis, Tunisie; Service de Gastroentérologie CHU Mongi Slim, Sidi Daoued La Marsa, Tunisie
| | - Gharbi Lassaad
- Université de Tunis El Manar, Faculté de Médecine de Tunis, 1007, Tunis, Tunisie; Service de Chirurgie Viscérale CHU Mongi Slim, Sidi Daoued La Marsa, Tunisie
| | - Mohamed Taher Khalfallah
- Université de Tunis El Manar, Faculté de Médecine de Tunis, 1007, Tunis, Tunisie; Service de Chirurgie Viscérale CHU Mongi Slim, Sidi Daoued La Marsa, Tunisie
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Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. ACTA ACUST UNITED AC 2016; 40:2877-82. [PMID: 25862547 DOI: 10.1007/s00261-015-0419-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of the study was to document the clinical impact of CT in elderly patients presenting to the emergency department (ED) with abdominal pain. METHODS This retrospective IRB-approved study from 2006 to 2013 evaluated 464 patients ≥80 years (mean 89 years, range 80-100: M150, W314), who presented to the ED with acute abdominal symptoms and underwent CT. CTs were divided into those negative and positive for actionable findings, defined as potentially requiring a change in surgical or medical management. Physician diagnosis, treatment plan, and disposition before and after CT were reviewed in the electronic medical record to assess CT influence on management and disposition. CT diagnosis was confirmed with final clinical diagnosis, surgical intervention, pathology, and follow-up. Descriptive statistics were used. RESULTS CTs were positive in 55%. The most common diagnoses were SBO (18%), diverticulitis (9%), non-ischemic vascular-related emergency (6%), bowel ischemia (4%), appendicitis (3%), and colonic obstruction (2%). These diagnoses were clinically unsuspected prior to CT in 43% (p < 0.05), with significant difficultly in diagnosing SBO (p < 0.05), diverticulitis (p < 0.01), and colonic obstruction (p < 0.01). Positive CT results influenced treatment plans in 65%, surgical in 48%, and medical in 52%. Disposition from the ED was significantly affected by CT (p < 0.001), 65% of admissions with positive CT (p < 0.001) and 63% of discharges with negative CT (p < 0.001). CONCLUSION Utilization of abdominopelvic CT in geriatric patients presenting to the ED with acute abdominal symptoms strongly influences clinical management and significantly affects disposition. As the US population ages, the clinical impact of emergent CT in the elderly will intensify.
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Abstract
The main problem in management of elderly patients who present to the emergency department with abdominal pain is related to difficulties in establishing a diagnosis, because of frequently impaired communication as well as to unusual clinical and laboratory presentations, resulting in delayed management. Early use of pertinent imaging may reduce this delay. Surgical procedures in the elderly do not differ from those in younger patients, but their associated morbidity is different. Assessing co-morbidities and patient frailty, as well as taking into consideration the diagnosis, patients' wishes and status should help in decision-making. Therapeutic decisions should involve surgeons, anesthesiologists and geriatricians alike, both pre- and postoperatively, with the goal of optimizing patients' rehabilitation and offering good and appropriate care while ensuring the humane, social and financial aspects.
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Successful conservative treatment of CT-diagnosed acute mesenteric ischemia in an extreme elderly female. Eur Geriatr Med 2015. [DOI: 10.1016/j.eurger.2014.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Raats J, Steunenberg S, Crolla R, Wijsman J, te Slaa A, van der Laan L. Postoperative delirium in elderly after elective and acute colorectal surgery: A prospective cohort study. Int J Surg 2015; 18:216-9. [DOI: 10.1016/j.ijsu.2015.04.080] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/10/2015] [Accepted: 04/23/2015] [Indexed: 12/12/2022]
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Park SY, Chung JS, Kim SH, Kim YW, Ryu H, Kim DH. The safety and prognostic factors for mortality in extremely elderly patients undergoing an emergency operation. Surg Today 2015; 46:241-7. [PMID: 25788220 DOI: 10.1007/s00595-015-1147-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 01/20/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE As the number of elderly people has increased, the number of elderly patients who need emergency operations has also increased. Although there are many models to evaluate the risk of surgery in elderly patients, they all are associated with limitations. We herein evaluated the prognostic factors for surgical mortality in elderly patients more than 80 years old who needed emergency operations. METHODS A total of 171 patients more than 80 years old underwent emergency operations from January 2001 to December 2012. Among them, 79 patients with acute cholecystitis, panperitonitis and intestinal obstruction with strangulation, which included mortality cases, were included. We retrospectively reviewed the medical records of the patients and analyzed the prognostic factors for surgical mortality. RESULTS Forty-eight patients had a co-morbidity. Thirty-one patients initially had systemic inflammatory response syndrome. There were 27 surgical mortality cases. A univariate analysis revealed that panperitonitis, a positive blood culture and the level of albumin were significant prognostic factors predicting a worse prognosis. However, a multivariate analysis revealed that a serum albumin level more than 3.5 g/dL was the only significant prognostic factor (p = 0.037). CONCLUSION Surgeons cannot fully evaluate the risk of emergency operation cases. However, our data indicate that if patients do not show hypoalbuminemia, the surgeon may be able to perform an emergency operation without a high risk of surgical mortality.
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Affiliation(s)
- Seon-Young Park
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, 162, Ilsan-dong, Wonju, Gangwon-Do, 220-701, Korea
| | - Jae Sik Chung
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, 162, Ilsan-dong, Wonju, Gangwon-Do, 220-701, Korea
| | - Sung Hoon Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, 162, Ilsan-dong, Wonju, Gangwon-Do, 220-701, Korea.
| | - Young Wan Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, 162, Ilsan-dong, Wonju, Gangwon-Do, 220-701, Korea
| | - Hoon Ryu
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, 162, Ilsan-dong, Wonju, Gangwon-Do, 220-701, Korea
| | - Dong Hyun Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, 162, Ilsan-dong, Wonju, Gangwon-Do, 220-701, Korea
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Søreide K, Desserud KF. Emergency surgery in the elderly: the balance between function, frailty, fatality and futility. Scand J Trauma Resusc Emerg Med 2015; 23:10. [PMID: 25645443 PMCID: PMC4320594 DOI: 10.1186/s13049-015-0099-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/21/2015] [Indexed: 12/15/2022] Open
Abstract
Becoming old is considered a privilege and results from the socioeconomic progress and improvements in health care systems worldwide. However, morbidity and mortality increases with age, and even more so in acute onset disease. With the current prospects of longevity, a considerable number of elderly patients will continue to live with good function and excellent quality of life after emergency surgical care. However, mortality in emergency surgery may be reported at 15-30%, doubled if associated with complications, and notably higher in patients over 75 years. A number of risks associated with death are reported, and a number of scores proposed for prediction of risk. Frailty, a decline in the physiological reserves that may make the person vulnerable to even the most minor of stressful event, appears to be a valid indicator and predictor of risk and poor outcome, but how to best address and measure frailty in the emergency setting is not clear. Futility may sometimes be clearly defined, but most often becomes a borderline decision between ethics, clinical predictions and patient communication for which no solid evidence currently exists. The number and severity of other underlying condition(s), as well as the treatment alternatives and their consequences, is a complex picture to interpret. Add in the onset of the acute surgical disease as a further potential detrimental factor on function and quality of life – and you have a perfect storm to handle. In this brief review, some of the challenging aspects related to emergency surgery in the elderly will be discussed. More research, including registries and trials, are needed for improved knowledge to a growing health care challenge.
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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.
| | - Kari F Desserud
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
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Acosta S. Surgical management of peritonitis secondary to acute superior mesenteric artery occlusion. World J Gastroenterol 2014; 20:9936-9941. [PMID: 25110423 PMCID: PMC4123374 DOI: 10.3748/wjg.v20.i29.9936] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 12/28/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Diagnosis of acute arterial mesenteric ischemia in the early stages is now possible using modern computed tomography with intravenous contrast enhancement and imaging in the arterial and/or portal phase. Most patients have acute superior mesenteric artery (SMA) occlusion, and a large proportion of these patients will develop peritonitis prior to mesenteric revascularization, and explorative laparotomy will therefore be necessary to evaluate the extent and severity of intestinal ischemia, and to perform bowel resections. The establishment of a hybrid operating room in vascular units in hospitals is most important to be able to perform successful intestinal revascularization. This review outlines current frontline surgical strategies to improve survival and minimize bowel morbidity in patients with peritonitis secondary to acute SMA occlusion. Explorative laparotomy needs to be performed first. Curative treatment is based upon intestinal revascularization followed by bowel resection. If no vascular imaging has been carried out, SMA angiography is performed. In case of embolic occlusion of the SMA, open embolectomy is performed followed by angiography. In case of thrombotic occlusion, the occlusive lesion can be recanalized retrograde from an exposed SMA, the guidewire snared from either the femoral or brachial artery, and stented with standard devices from these access sites. Bowel resections and sometimes gall bladder removal due to transmural infarctions are performed at initial laparotomy, leaving definitive bowel reconstructions to a planned second look laparotomy, according to the principles of damage control surgery. Patients with peritonitis secondary to acute SMA occlusion should be managed by both the general and vascular surgeon, and a hybrid revascularization approach is of utmost importance to improve outcomes.
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Ugolini G, Ghignone F, Zattoni D, Veronese G, Montroni I. Personalized surgical management of colorectal cancer in elderly population. World J Gastroenterol 2014; 20:3762-3777. [PMID: 24833841 PMCID: PMC3983435 DOI: 10.3748/wjg.v20.i14.3762] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 12/09/2013] [Accepted: 01/05/2014] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population. In this phase of the life cycle, treatment is frequently suboptimal. Despite the fact that, nowadays, older people tend to be healthier than in previous generations, surgical undertreatment is frequently encountered. On the other hand, surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability. Unfortunately, due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors (heterogeneity, frailty, etc.), there is a dearth of evidence-based clinical guidelines for the management of these patients. The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly. More than in any other patient group, both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC. Although cure and sphincter preservation are the primary goals, many other variables need to be taken into account, such as maintenance of cognitive status, independence, life expectancy and quality of life.
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