Implementing Bundle Care in Major Abdominal Emergency Surgery: Long-Term Mortality and Comprehensive Complication Index

Trends in Clinical Outcomes After Major Emergency Abdominal Surgery in Denmark, Data From 2002-2022

Importance

Major emergency abdominal surgery is associated with high morbidity and mortality. Understanding trends in outcomes over time can reveal critical practice-changing improvements, identify gaps in postoperative care, and establish a large-scale benchmark for future research.

Objective

To investigate trends in morbidity and mortality after major emergency abdominal surgery in Denmark.

Design, Setting, and Participants

This was a nationwide, population-based cohort study. Analyses were performed based on data from Danish nationwide administrative registries. Within the public health care system in Denmark, all adult patients undergoing major emergency abdominal surgery from 2002 to 2022 were included. Major emergency abdominal surgeries included laparotomy or laparoscopy due to intra-abdominal pathologies, including intestinal perforation, ischemia, bowel obstruction, abscess, or bleeding.

Exposure

Major emergency abdominal surgery.

Main Outcomes and Measures

The primary outcome was the trend in 30- and 90-day mortality after major emergency abdominal surgery over time.

Results

A total of 61 476 patients (mean [SD] age, 66.2 [16.3] years; 34 827 female [56.7%]) were included. The annual number of surgeries remained constant, with a mean (SD) of 3044 (165) surgeries per year. The 30- and 90-day mortality was reduced from 25% and 33%, respectively, to 13% and 18%, respectively (P < .001). Median (IQR) hospital length of stay was decreased from 10 (5-17) days to 6 (4-13) days (P < .001). The rate of 30-day postoperative complications (classified Clavien-Dindo ≥3a) was reduced from 49% to 44% (P <.001) and the 90-day rate was reduced from 53% to 48% (P <.001), however, with a tendency toward more patients undergoing earlier intervention. The 30- and 90-day readmission rate increased drastically from 9% and 13%, respectively, to 25% and 33%, respectively (P < .001).

Conclusions and Relevance

Results of this cohort study suggest notable reductions in mortality and hospital length of stay after major emergency abdominal surgery. A marked increased readmission rate and a persistently high rate of postoperative complications were found. These shifts underscore the need for enhanced postoperative monitoring and postdischarge follow-up.

Key interventions and outcomes in perioperative care pathways in emergency laparotomy: a systematic review

INTRODUCTION

Emergency laparotomy (EmLap) is a complex clinical arena, delivering time-sensitive, definitive care to a high-risk patient cohort, with significant rates of post-operative morbidity and mortality. Embedding perioperative care pathways within this complex setting has the potential to improve post-operative outcomes, however, requires an in-depth understanding of their design, delivery and outcome assessment. Delivering and implementing complex interventions such as perioperative pathways require transparent reporting with detailed and indepth description of all components during the assessment and evaluation phase. The aim of this systematic review was to identify the current design and reporting of perioperative pathways in the EmLap setting.

METHODS

The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and December 2023. All randomised and non-randomised cohort studies reporting outcomes on perioperative care pathways in adult patients (> 18 years old) undergoing major emergency abdominal surgery were included. A narrative description of all perioperative pathways included was reported to identify design and description of the pathway including the delivery and timing of component interventions. All pathways were evaluated against the Template for Intervention Description and Replication (TIDieR) checklist.

RESULTS

Eleven RCTs and 19 non-randomised studies were identified, with most studies considered to be at moderate risk of bias. Twenty-six unique pathways were identified and described, delivering a total of 400 component interventions across 44,055 patients. Component interventions were classified into 24 domains across the perioperative pathway. Twenty studies (66.6%) did not report the TIDieR framework items, with thirteen studies reporting less than 50% of all items. Two hundred and fifty individual outcomes were reported across pathways, with the most commonly reported outcomes related to morbidity, mortality and length of stay.

CONCLUSION

Current perioperative pathways in EmLap setting are underpinned by variable component interventions, with a lack of in-depth intervention reporting and evaluation. Future studies should incorporate the TIDieR checklist when reporting on perioperative pathways in the EmLap setting.

CLINICAL TRIAL NUMBER

Not applicable.

Safety and efficacy of prophylactic onlay resorbable synthetic mesh with a comprehensive wound bundle at laparotomy closure in high-risk emergency abdominal surgery: an observational study

BACKGROUND

There has been a slow uptake of wound bundles and prophylactic mesh augmentation (PMA) strategies despite evidence supporting their role in reducing burst abdomens and incisional hernias (IH). This study evaluates outcomes of resorbable synthetic prophylactic mesh augmentation in reducing these rates and assesses the complication profile in emergency abdominal surgery.

METHODS

A retrospective ethically approved observational study of all patients who underwent emergency open abdominal surgery using supplemental prophylactic onlay TIGR® Mesh at Letterkenny University Hospital between September 2017 and April 2024 was undertaken to assess safety, complication profiles and outcomes. Comprehensive wound bundles and subcutaneous space closure were used.

RESULTS

Of the 49 patients included, the mean age was 64 years (± 16.4, 31-86), 33/49 (67%) were female, and the mean body mass index (BMI) was 27 (± 7.4,17.3-45). 20% of patients had previous abdominal surgery. 19/49 (38%) patients experienced postoperative complications, of these 8 (42%) were Clavien-Dindo Grade I-II, and 11 (58%) were Grade III-IV. There were 7 in-hospital post-operative deaths (Grade V). 8 patients had open abdomens. Thirteen surgical site occurrences (SSO) were identified in 9 (18%) patients. There were no burst abdomens. Four of the superficial SSIs responded to antibiotics while one required opening and wound NPWT. Three patients (6%) developed an incisional hernia, which was detected at a mean follow-up of 353 days.

CONCLUSION

A comprehensive, evidence-based wound bundle using onlay PMA with a synthetic resorbable mesh, achieves efficacious, safe abdominal wall closure in high-risk, emergency laparotomy patients, including those who require delayed abdominal wall closure.

High risk of short-term mortality and postoperative complications in patients with generalized peritonitis undergoing major emergency abdominal surgery-a cohort study

BACKGROUND

Secondary generalized peritonitis is a potentially life-threatening condition. The aim of this study was to investigate the association between secondary generalized peritonitis and short-term mortality and postoperative complications in patients undergoing major abdominal emergency surgery.

METHODS

The study included patients with the age ≥ 18 years undergoing major emergency abdominal surgery in a University Hospital from 2017 to 2019 after the introduction of a perioperative bundle care program. The primary outcome measures were short-term mortality, defined as death within 30 and 90 days after surgery and postoperative complications within 30 days after surgery. Uni- and multivariable logistic regression analyses were performed to evaluate risk factors for 30- and 90-days mortality and 30-days postoperative complications.

RESULTS

A total of 591 patients were included, of whom 21% (124/591) had generalized peritonitis. The overall 30 day-mortality rate was 12.5% (74/591). Patients with generalized peritonitis had a significantly higher 30-day mortality rate than patients with non-generalized peritonitis 18.5% (23/124) vs. 10.9% (51/467), P = 0.033. Generalized peritonitis was an independent risk factor for 30- and 90- days mortality. There was a significantly higher rate of admission to ICU for patients with generalized peritonitis 39.5% (49/124) vs. 12.6% (59/467), P < 0.001. Patients with generalized peritonitis had significantly higher rates of surgical and non-surgical complication compared to patients with non-generalized peritonitis 87.1% (108/124) vs. 65.7% (307/467), P < 0.001. Generalized peritonitis was an independent risk factor of 30 days postoperative complications.

CONCLUSION

In a population undergoing major emergency abdominal surgery treated in a perioperative optimization protocol, generalized peritonitis was an independent risk factor for both 30- and 90-days mortality and postoperative complications.

Enhanced recovery after surgery protocols following emergency intra-abdominal surgery: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to evaluate whether Enhanced Recovery After Surgery (ERAS) protocols for patients undergoing emergency intra-abdominal surgery improve postoperative outcomes as compared to conventional care.

METHODS

MEDLINE, EMBASE, WoS, CENTRAL, and Pubmed were searched from inception to December 2022. Articles were eligible if they were randomized controlled trials (RCT) or non-randomized studies comparing ERAS protocols to conventional care for patients undergoing emergency intra-abdominal surgery. The outcomes included postoperative length of stay (LOS), postoperative morbidity, prolonged postoperative ileus (PPOI), and readmission. An inverse variance random effects meta-analysis was performed. A risk of bias was assessed with Cochrane tools. Certainty of evidence was assessed with GRADE.

RESULTS

After screening 1018 citations, 20 studies with 1615 patients in ERAS programs and 1933 patients receiving conventional care were included. There was a reduction in postoperative LOS in the ERAS group for patients undergoing upper gastrointestinal (GI) surgery (MD3.35, 95% CI 2.52-4.17, p < 0.00001) and lower GI surgery (MD2.80, 95% CI 2.62-2.99, p < 0.00001). There was a reduction in postoperative morbidity in the ERAS group for patients undergoing upper GI surgery (RR0.56, 95% CI 0.30-1.02, p = 0.06) and lower GI surgery (RR 0.66, 95%CI 0.52-0.85, p = 0.001). In the upper and lower GI subgroup, there were nonsignificant reductions in PPOI in the ERAS groups (RR0.59, 95% CI 0.30-1.17, p = 0.13; RR0.49, 95% CI 0.21-1.14, p = 0.10). There was a nonsignificant increased risk of readmission in the ERAS group (RR1.60, 95% CI 0.57-4.50, p = 0.50).

CONCLUSION

There is low-to-very-low certainty evidence supporting the use ERAS protocols for patients undergoing emergency intra-abdominal surgery. The currently available data are limited by imprecision.

The effects of troponin screening among patients undergoing acute high-risk abdominal surgery: A retrospective cohort study

BACKGROUND

Acute high-risk abdominal (AHA) surgery is associated with a high short-term mortality rate. This might be partly attributed to myocardial injury after non-cardiac surgery (MINS) defined by elevated postoperative troponin levels. The myocardial injury is often asymptomatic; thus, troponin screening seems to be the best diagnostic method. We aimed to assess whether implementing troponin screening with subsequent individualised interventions as standard care is associated with reduced mortality after AHA surgery. We also explored the treatment implications in the screening period.

METHODS

A retrospective cohort of 558 patients undergoing surgery from February 2018 to March 2021 was included. The patients undergoing surgery before March 2019 served as the historical control group, while the screening group consisted of patients undergoing surgery from March 1, 2019. Troponin I was to be measured 6-12 h postoperatively and in the morning of the succeeding 4 days. Patients with myocardial injury were assessed, and treatment was individualised after multiple disciplinary consultations. The primary outcome was the unadjusted 30-day mortality rates. Inverse probability treatment weighting was used to adjust for selection bias.

RESULTS

We included 558 patients: 382 in the screening group and 176 in the historical control group. In the screening group, 15 patients (3.9%) died before the first blood sampling, and in 31 patients (8.1%), troponin screening was omitted, leaving only 336 patients screened. Myocardial injury was diagnosed in 81 patients (24.1%) of the 336 patients. Of these, 59 (72.8%) had a cardiac consultation. No interventions or alterations in relation to myocardial injury were done in 67 patients (82.7%). The 30-day mortality was 13.8% (95% CI 8.7%-18.9%) in the control group and 11.1% (95% CI 8.0%-14.3%) in the screening group. The absolute risk difference was -2.7% (95% CI -8.7%-3.3%; p = .38), which was unchanged after adjustment. The difference remained unchanged after 90 days and 1 year.

CONCLUSION

The implementation of postoperative troponin screening was not associated with reduced mortality after AHA surgery. Research on the prevention and treatment of MINS is warranted before the implementation of standard troponin screening.

Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis

BACKGROUND

Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes.

METHODS

The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling.

RESULTS

Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001).

DISCUSSION

Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.

Association between troponin I levels and mortality among patients undergoing acute high-risk abdominal surgery-A cohort study

BACKGROUND

Myocardial injury after noncardiac surgery (MINS) is associated with 30-day mortality in heterogeneous surgical populations but is barely described after acute high-risk abdominal surgery. The impact of dynamic changes has not previously been investigated. The objectives were to determine the incidence of MINS in this population, the association between mortality and MINS, and whether plasma troponin I (TnI) dynamics have any impact on mortality.

METHODS

A prospective cohort study of 341 patients undergoing acute high-risk gastrointestinal surgery was conducted. Plasma TnI was measured at the first four postoperative days. MINS was defined as any increased TnI level >59 ng/L. TnI dynamic required either two succeeding measurements of TnI >59 ng/L with a >20% increase/fall or one measurement of TnI >59 ng/L with a succeeding measurement of TnI <59 ng/L with a >50% decrease. Adjusted mortality rates were calculated using inverse probability of treatment weighting and competing risk analyses.

RESULTS

The incidence of MINS was 23.8% and dynamic TnI changes occurred in 15.6% of the patients. The unadjusted 30-day and 1-year mortality were 19.8% and 35.9% in patients with MINS, compared with 2.7% and 11.6%, respectively, in patients without MINS (p < 0.001). After adjusting, the differences remained significant. There was no difference in mortality between patients with or without dynamic changes in TnI level.

CONCLUSION

MINS occurred frequently and was associated with increased mortality. TnI monitoring might help identify patients with increased risk of mortality and improve care. Research on preventive measures and treatments is warranted.

TRIAL REGISTRATION NUMBER AND AGENCY

ClinicalTrials.gov Identifier: NCT05933837, retrospective registered.