Trainee-led emergency laparotomy operating

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

BACKGROUND

This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care.

METHODS

Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations.

RESULTS

Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process.

CONCLUSIONS

These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Outcomes After Independent Trainee Versus Consultant-led Emergency Laparotomy: Inverse Propensity Score Population Dataset Analysis

OBJECTIVE

We utilized a population dataset to compare outcomes for patients where surgery was independently performed by trainees to cases led by a consultant.

SUMMARY OF BACKGROUND DATA

Emergency laparotomy is a common, high-risk, procedure. Although trainee involvement to improve future surgeons' experience and ability in the management of such cases is crucial, some studies have suggested this is to the detriment of patient outcomes. In the UK, appropriately skilled trainees may be entrusted to perform emergency laparotomy without supervision of a consultant (attending).

METHODS

Patients who underwent emergency laparotomy between 2013 and 2018 were identified from the National Emergency Laparotomy Audit of England and Wales. To reduce selection and confounding bias, the inverse probability of treatment weighting approach was used, allowing robust comparison of trainee-led and consultant-led laparotomy cases accounting for eighteen variables, including details of patient, treatment, pathology, and preoperative mortality risk. Groups were compared for mortality and length of stay.

RESULTS

A total of 111,583 patients were included in the study. The operating surgeon was a consultant in 103,462 cases (92.7%) and atrainee in 8121 cases (7.3%). Mortality at discharge was 11.6%. Trainees were less likely to operate on high-risk and colorectal cases. After weighting, mortality (12.2% vs 11.6%, P = 0.338) was equivalent between trainee- and consultant-led cases. Median length of stay was 11 (interquartile range 7, 19) versus 11 (7, 20) days ( P = 0.004), respectively. Trainee-led operations reported fewer cases of blood loss >500mL (9.1% vs 11.1%, P < 0.001).

CONCLUSIONS

Major laparotomy maybe safely entrusted to appropriately skilled trainees without impacting patient outcomes.

Evaluating temporal trends and the impact of surgical subspecialisation on patient outcomes following adhesional small bowel obstruction: a multicentre cohort study

PURPOSE

Small bowel obstruction (SBO) is the most common indication for laparotomy in the UK. While general surgeons have become increasingly subspecialised in their elective practice, emergency admissions commonly remain undifferentiated. This study aimed to assess temporal trends in the management of adhesional SBO and explore the influence of subspecialisation on patient outcomes.

METHODS

Data was collected for patients admitted acutely with adhesional SBO across acute NHS trusts in Northern England between 01/01/02 and 31/12/16, including demographics, co-morbidities and procedures performed. Patients were excluded if a potentially non-adhesional cause was identified and were grouped by the responsible consultant's subspecialty. The primary outcome of interest was 30-day inpatient mortality.

RESULTS

Overall, 2818 patients were admitted with adhesional SBO during a 15-year period. There was a consistent female preponderance, but age and comorbidity increased significantly over time (both p < 0.001). In recent years, more patients were managed operatively with a trend away from delayed surgery also evident (2002-2006: 65.7% vs. 2012-2016: 42.7%, p < 0.001). Delayed surgery was associated with an increased mortality risk on multivariable regression analysis (OR: 2.46 (1.46-4.23, p = 0.001)). CT scanning was not associated with management strategy or timing of surgery (p = 0.369). There was an increased propensity for patients to be managed by gastrointestinal (colorectal and upper gastrointestinal) subspecialists over time. Length of stay (p < 0.001) and 30-day mortality (p < 0.001) both improved in recent years, with the best outcomes seen in colorectal (2.6%) and vascular subspecialists (2.4%). However, following adjustment for confounding variables, consultant subspecialty was not a predictor of mortality.

CONCLUSION

Outcomes for patients presenting with adhesional SBO have improved despite the increasing burden of age and co-morbidity. While gastrointestinal subspecialists are increasingly responsible for their care, mortality is not influenced by consultant subspecialty.

Declining Surgical Resident Operative Autonomy in Acute Care Surgical Cases

INTRODUCTION

Surgical resident operative autonomy has decreased markedly over time, reducing resident readiness for independent practice. We sought to examine operative resident autonomy for emergency acute care surgery (ACS) compared to elective cases and associated patient outcomes at veterans affairs hospitals.

METHODS

The Veterans Affairs Surgical Quality Improvement Program database was queried for ACS cases (emergency general, vascular, and thoracic) at veterans affairs hospitals from 2004 to 2019. Cases are coded prospectively for the level of supervision: attending primary surgeon (AP); attending scrubbed with resident surgeon (AR); resident primary (RP), attending not scrubbed. Baseline demographics, operative variables, and outcomes were compared.

RESULTS

A total of 61,275 ACS cases and 605,146 elective cases were performed during the study period. The ACS had a higher proportion of RP cases (7.2% versus 5.7%, P < 0.001). The proportion of ACS RP cases decreased from 9.9% to 4.1% (58.6%); elective RP cases decreased from 8.9% to 2.9% (67.4%). The most common ACS RP surgeries were appendectomy, amputations, and cholecystectomy. RP cases had lower American Society of Anesthesia class and lower median work relative value units than AP and AR. There was no difference between mortality rates of RP compared to AP (adjusted odds ratio [OR] 0.94 [0.80-1.09] or AR 0.94 [0.81-1.08]). While there was no difference in complications between the RP and AP (OR 1.01 [0.92-1.12]), there were significantly more complications in AR compared to RP (OR 1.20 [1.10-1.31]).

CONCLUSIONS

More autonomy is granted for ACS cases compared to elective cases. While both decreased over time, the decrease is less for ACS cases. Resident autonomy does not negatively impact outcomes, even in emergent cases.

Surgical Registrars as Primary Operators Have Acceptable Outcomes for Trauma Laparotomy

Background: The literature has suggested that acceptable outcomes in elective general surgery can be achieved with registrars operating but is less clear with trauma surgery. Methods: This was a retrospective study of all laparotomies performed for adult trauma between 2012 and 2020 at a Level 1 Trauma Centre in New Zealand to identify potential differences in clinical outcomes between primary operators. The primary operator of each operation was identified, along with the presence or absence of a consultant and the clinical outcome. Results: During the 9-year study period, a total of 204 trauma laparotomies were performed at Waikato Hospital. The groups of the primary operators were: a registrar with a consultant present (27%), a registrar without a consultant present (22%), a registrar assisting a consultant (48%), and a consultant who operated without a registrar (3%). Direct comparison was made between the three groups where registrars were involved in the laparotomy. There was no significant difference in the clinical outcomes, whether a consultant was present or not. Conclusions: Surgical registrars have acceptable outcomes for trauma laparotomy in the appropriate patients. A consultant surgeon should still operate on patients with more significant physiological derangements.

Surgical management and outcomes of adhesive small bowel obstruction: teaching versus non-teaching hospitals

BACKGROUND

The relationship between surgical management of adhesive small bowel obstruction (ASBO) and hospital teaching status is not well known. We sought to elucidate the association between hospital teaching status and clinical metrics for ASBO.

METHODS

Using the 2007-2017 California Office of Statewide Health Planning and Development database, we identified adult ASBO patients hospitalized for surgical intervention. Hospital teaching status was categorized as major teaching (MajT), minor teaching (MinT), and non-teaching (NT). Cox proportional hazards modeling was used to evaluate risk of death and other adverse outcomes.

RESULTS

Of 25,047 admissions, 15.4% were at MajT, 32.0% at MinT, and 52.6% at NT; 2.9% died. Patients at MajT had longer overall hospital stays (HLOS) than those at MinT or NT (median days 9 vs. 8 vs. 8; p = 0.005), longer post-ASBO procedure HLOS (median days 7 vs. 6 vs. 6; p = 0.0001) and higher rates of small bowel resection (27.1% vs. 21.7% vs. 21.7%; p < 0.0001). Mean time to first surgery at MajT was 3.3 days compared with 2.6 days (p = 0.004) at MinT and NT. Compared with patients at NT, those at MajT were significantly less likely to die (HR 0.62, p < 0.0001), develop pneumonia (HR 0.57, p = 0.001), or experience adverse discharge disposition (HR 0.79, p < 0.0001).

CONCLUSION

Mortality and morbidity of ASBO surgery were reduced at MajT; however, time to surgery, HLOS, and rate of small bowel resection were greater. These findings may guide improvements in the management of ASBO patients.

Independent Operating by General Surgery Residents: An ACS-NSQIP Analysis

OBJECTIVE

Surgical resident autonomy during training is paramount to independent practice. We sought to determine prevalence of general surgery resident autonomy for surgeries commonly performed on emergency general surgery services and identify trends with time.

DESIGN

We queried ACS-NSQIP for patients undergoing one of 7 emergency general surgery operations. We evaluated trends in independent operating (defined as a resident operating alone, without attending having scrubbed) over the study period. Other outcomes of interest: operative time, 30-day-mortality and complications.

SETTING

The ACS-NSQIP database.

PARTICIPANTS

Patients undergoing one of 7 emergency general surgery operations.

RESULTS

Data regarding resident involvement was only available for the years 2005-2010. 90,790 operations were performed, 922 (1%) by residents operating independently. Appendectomy accounted for 61% independent cases. Independent resident operating was associated with a longer operative time (65 versus 58 minutes, p < 0.001), but lower risk of bleeding requiring transfusion (p < 0.001) and progressive renal insufficiency (p = 0.02). Independent operating was not associated with increased risk of complications/mortality.

CONCLUSION

Independent resident operating is rare, even with increasing attention to its importance, and is not associated with increased complications or mortality. National data on this subject is old and not currently collected. There is need for a national registry on resident involvement to understand the current effect of independent operating on outcomes.

Comparison of Outcomes of Emergency Laparotomies Performed During Daytime Versus Nights and Weekends in Rwandan University Teaching Hospitals

BACKGROUND

Emergency laparotomy is a common procedure with high morbidity and mortality. The aim of this study was to assess if the time of surgery (day versus night and weekend) affects the morbidity and mortality in a low-resource setting.

METHODS

A retrospective study was conducted in 2 university teaching hospitals in Rwanda. Patient characteristics, time of laparotomy, operative details and postoperative outcomes were recorded. Chi-square and Wilcoxon rank sum tests were used to determine factors and outcomes associated with time of surgery. Logistic regression was used to determine factors associated with mortality.

RESULTS

In 309 patients, who underwent emergency laparotomy, 147 (48%) patients were operated during the daytime, 123 (40%) patients were operated during the night shift and 39 (12%) patients were operated on the weekend. Common diagnoses were intestinal obstruction (n = 141, 46%), peritonitis (n = 101, 33%) and abdominal trauma (n = 40, 13%). The overall mortality rate was 16% with 14% in patients operated during day and 17% in patients operated during night and weekends (p = 0.564). Overall, the morbidity rate was 30% with 27% in patients operated during the day compared with 32% in patients operated during night/weekends (p = 0.348). After controlling for confounding factors, there was no association between time of operation and mortality or morbidity.

CONCLUSION

Morbidity and mortality associated with emergency laparotomy are high but the time of day for emergency laparotomy did not affect outcome in Rwandan referral hospitals.

A comparison of intra-operative diagnosis to histopathological diagnosis of acute appendicitis in paediatric and adult cohorts: an analysis of over 1000 patients

BACKGROUND

Appendicitis is a common general surgical emergency. The role of removing a normal appendix is debated. However, this relies on accurate intra-operative diagnosis of a normal appendix by the operating surgeon. This study aimed to compare surgeon's intra-operative assessment to final histological result acute appendicitis in paediatric and adult patients.

METHODS

All patients who underwent appendicectomy over a 14-year period in a general surgical department were identified using the prospective Lothian Surgical Audit system and pathology reports retrieved to identify final histological diagnosis. Open appendicectomy was selected to examine, as the routine practise at our institution is to remove a normal appendix at open appendicectomy.

RESULTS

A total of 1035 open appendicectomies were performed for clinically suspected appendicitis. Sensitivity of intra-operative diagnosis of appendicitis with operating surgeon was high at 95.13% with no difference between trainee and consultant surgeon or between adult and paediatric cases. Specificity of intra-operative diagnosis was lower in the paediatric group (32.58%) than in the adult group (40.58%). Women had a higher rate of negative appendicectomy than men.

CONCLUSION

The results of this study highlight some discordance between histological evidence of acute appendicitis and intra-operative impression. Therefore other clinical variables and not just macroscopic appearance alone should be used when deciding to perform appendicectomy.