Acute abdominal pain and emergency laparotomy: bundles of care to improve patient outcomes

Prevalence and Impact of Postoperative Sexual Dysfunction After Major Emergency Abdominal Surgery: A Prospective Cohort Study

INTRODUCTION

Sexual dysfunction is commonly reported after cancer surgery or pelvic surgery; however, the incidence following major emergency abdominal surgery remains unknown. This study aimed to investigate the incidence and sex differences in sexual dysfunction up to 90 days postoperatively after major emergency abdominal surgery.

METHODS

This single-center prospective cohort study included all consecutive patients undergoing major emergency abdominal surgery at Copenhagen University Hospital Herlev from March 2023 to March 2024. Follow-up was conducted at 30 and 90 days postoperatively. Sexual function was assessed using the Brief Sexual Symptom Checklist (BSSC), and patients were asked to report whether they were sexually active before and after surgery.

RESULTS

Of the 180 patients who responded at postoperative day (POD) 30, 69 patients (38.3%) reported being sexually active before surgery but only 31 patients (17.2%) remained active after surgery. At POD 90, 71 (48.3%) of 147 patients reported being sexually active before surgery, whereas 48 patients (32.7%) remained active postoperatively. A significant decrease in sexual activity was observed in both men (63.2% at POD 30 and 45.5% at POD 90) and women (45.2% at POD 30 and 21.1% at POD 90) (p < 0.001 for both time points). Out of the patients who completed the BSSC questionnaire, 32 patients (32.6%) reported dissatisfaction with their sexual function at POD 30, which slightly decreased to 22 patients (26.8%) at POD 90. No significant difference in dissatisfaction rates between men and women was found at either time point.

CONCLUSION

Sexual dysfunction was common after major emergency abdominal surgery in both men and women, with no significant sex differences observed. These findings highlight the need for proactive discussions, information, and management of sexual health in the perioperative period to improve patient outcomes and quality of life.

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.

Patients' Surgical History Profile and Its Association With Complexity in Major Emergency Abdominal Surgery

INTRODUCTION

Emergency abdominal surgery often involves patients with a surgical history. Previous abdominal surgery can complicate new procedures. The correlation between surgical history and complexity in major emergency surgery has not been assessed. The purpose of this study was to profile patients undergoing emergency abdominal surgery, regarding quantity and type of previous abdominal procedures and to assess their association with intraoperative complexity. We hypothesized that a history of abdominal surgery would be associated with increased intraoperative complexity, defined as a composite outcome of complicating factors and intraoperative events.

MATERIALS AND METHODS

We conducted an exploratory analysis of 754 consecutive patients undergoing major emergency abdominal surgery at a single institution. While multiple procedure- and patient-related variables were prospectively recorded in our local database, data on patient history and previous abdominal surgeries were collected retrospectively. Intraoperative iatrogenic lesions (unintended lesions to intra-abdominal organs), prolonged procedural time (≥3 h), or excessive intraoperative bleeding (≥1 L) were established as indicative of a complex procedure ('complexity factor'). Data were analyzed using multivariable logistic regression to identify significant preoperative risk factors for intraoperative complexity.

RESULTS

A total of 754 patients were included, with a median age of 71 y (interquartile range: 58-79), and 51% of the cohort were female. Among them, 476 patients (61%) had a history of previous abdominal surgery. In 192 (25%) of the procedures, surgeons reported at least one complexity factor. Previous colonic or rectal resection was associated with intraoperative complexity (2.34 risk ratio, confidence interval 95: 1.01-5.41, P = 0.05). Other significant factors were prior laparotomy, severe intra-abdominal adhesions, previous intra-abdominal abscess, and prior small bowel obstruction.

CONCLUSIONS

This study profiles emergency surgical patients with a history of abdominal surgery and explores the associations between previous surgery and complexity in subsequent procedures. Awareness of factors associated with increased procedural complexity is valuable to the surgical and anesthesiologic team in the planning of the procedure.

Impact of a transition of care bundle on health-related quality of life after major emergency abdominal surgery: before-and-after study

INTRODUCTION

The transition from hospital to home can be challenging. This study investigated whether a standardized transition of care bundle could enhance health-related quality of life (HRQoL), reduce readmission rates, and increase days alive and out of hospital after major emergency abdominal surgery.

METHODS

A single-centre before-and-after study including consecutive patients undergoing major emergency abdominal surgery was conducted at Copenhagen University Hospital Herlev from 1 January 2022 to 31 December 2023. A transition of care bundle including standardized discharge coordination, written material, and multidisciplinary information meetings for patients and relatives was implemented on 1 January 2023. Patients were followed up by phone interviews and hospital records. HRQoL was assessed by the EQ-5D-5L questionnaire.

RESULTS

A total of 667 patients were included (before group 333 patients (median age 70.9), after group 335 patients (median age 72.2)). The predominant surgical procedure was emergency laparotomy for bowel obstruction (before group: n = 187, 56.2%, after group: n = 171, 51.5%). HRQoL was significantly higher in the after group compared with the before group at postoperative day (POD) 30 (0.846 versus 0.750, P < 0.001), postoperative day 90 (0.925 versus 0.847, P < 0.001), and at postoperative day 180 (0.907 versus 0.875, P = 0.039). No difference in days alive and out of hospital or readmission was found between the groups. A significant reduction in patients transitioning to a rehabilitation facility at discharge was found in the after group versus before group (12.5% versus 23.3%).

CONCLUSIONS

A transition of care bundle with coordination, written material, and multidisciplinary efforts increased HRQoL up to 180 days after major emergency abdominal surgery.

Short-term outcomes in mesh versus suture-only treatment of burst abdomen: a case-series from a university hospital

PURPOSE

Surgery for a burst abdomen after midline laparotomy is associated with later incisional hernia formation. Accommodating prophylactic measures, notably mesh augmentation, are of interest. However, data regarding safety and outcomes are scarce. This study aimed to evaluate the short-term risk profile of mesh prophylaxis in the context of a burst abdomen.

METHODS

This is a single-center prospective study of patients suffering from burst abdomen from 2021 to 2023. A treatment protocol for the management of burst abdomen was introduced, including the synthetic, partially absorbable onlay mesh. Adult patients (≥ 18 years) with a life expectancy of > 1 year with no plans of future pregnancies were recommended to be treated with a prophylactic mesh. In this analysis, adult patients were included if they suffered from a burst abdomen after elective or emergency laparotomy. The study evaluates short-term outcomes, including 90-day wound complications, length of stay, and mortality.

RESULTS

Sixty-seven patients fulfilled the inclusion criteria and underwent treatment for a burst abdomen during the study period. Thirty-eight patients were treated with a suture-only technique, and 29 patients were supplemented with a mesh. 13 of 14 observed wound complications in the mesh group were of mild degree (Clavien Dindo 1-3b), while one patient (3%) needed mesh-explantation. The 90-day mortality rate was 21% and comparable between suture-only and mesh techniques.

CONCLUSION

Mesh augmentation in surgery for a burst abdomen seems safe in well-selected patients at 90 days follow-up. Long-term data on the prophylactic effect on hernia development is needed.

Long-term impact of emergency laparotomy on health-related quality of life

PURPOSE

Emergency laparotomy can result in a range of physical and neuropsychiatric postoperative complaints, potentially impacting quality of life. This study aimed to assess the effect of emergency laparotomy on health-related quality of life (HRQoL) and how HRQoL influences the risk of readmission.

METHOD

HRQoL was assessed in patients undergoing emergency laparotomy during a 1-year period. Patients who completed the baseline HRQoL evaluation underwent a reassessment on postoperative day (POD) 30, 90, and 180. HRQoL was measured with the EQ5D index, and patients were categorized in 'high' and 'low' HRQoL. A decrease from high baseline HRQoL to low HRQoL by POD 30 was classified as 'acquired low HRQoL'.

RESULTS

All 215 patients who completed the baseline HRQoL evaluation were followed. On average, patients reported a lower mean (M) HRQoL from baseline (M = 0.876, standard deviation (SD) = 0.171) to POD 30 (M = 0.735, SD = 0.260). On POD 90, HRQoL had somewhat improved (M = 0.763, SD = 0.298), and by POD 180 HRQoL had returned to normal (M = 0.853, SD = 0.235). From the full-record population (n = 73), 20.5% acquired low HRQoL of whom 33% had not recovered by POD180. For patients with acquired low HRQoL, the risk of 180-day readmission was increased, and days alive and out of hospital within 180 days was reduced.

CONCLUSION

For most patients, HRQoL has returned to normal within 180 days after emergency laparotomy. However, patients who acquired low HRQoL after the procedure had an increased risk of long-term readmission.

The cumulative risk and severity of postoperative complications in patients with frailty undergoing major emergency abdominal surgery-A prospective cohort study

BACKGROUND

Major emergency abdominal surgery (MEAS) has high morbidity and mortality rates. With an aging and frail population, understanding the impact of frailty on postoperative complications is crucial.

METHODS

This prospective cohort study was conducted at a major university hospital in Denmark from October 1, 2020, to January 1, 2024. A total of 733 patients undergoing MEAS were assessed for frailty using the clinical frailty scale (CFS) at admission and grouped into low (CFS 1-3), moderate (CFS 4-6), and high (CFS 7-9) frailty categories. Postoperative complications were classified by the Clavien-Dindo score and comprehensive complication index (CCI) until discharge.

RESULTS

Patients with CFS one to three had 140 complications per 100 patients, CFS four to six had 267 complications per 100 patients, and CFS seven to nine had 297 complications per 100 patients (p < 0.001). Increased frailty was associated with higher severity of complications (Clavien-Dindo score). Median CCI scores were 8.7 (CFS 1-3), 29.6 (CFS 4-6), and 38.2 (CFS 7-9) (p < 0.001). The cumulative risk of complications was higher in patients with CFS four to six and seven to nine.

CONCLUSION

Higher frailty scores correlate with an increased number and severity of complications as well as a greater overall burden of postoperative complications. The clinical frailty scale is effective for preoperative identification of high-risk patients.

TRIAL REGISTRATION

The study was approved by the Capital Region of Denmark (P-2020-1166 and R-21038079) and the Danish Data Protection Agency (P-2021-431).

Effects of closed- versus open-system intensive care units on mortality rates in patients with cancer requiring emergent surgical intervention for acute abdominal complications: a single-center retrospective study in Korea

BACKGROUND

In this study, we aimed to compare the in-hospital mortality of patients with cancer who experienced acute abdominal complications that required emergent surgery in open (treatment decisions made by the primary attending physician of the patient's admission department) versus closed (treatment decisions made by intensive care unit [ICU] intensivists) ICUs.

METHODS

This retrospective, single-center study enrolled patients with cancer admitted to the ICU before or after emergency surgery between November 2020 and September 2023. Univariate and logistic regression analyses were conducted to explore the associations between patient characteristics in the open and closed ICUs and in-hospital mortality.

RESULTS

Among the 100 patients (open ICU, 49; closed ICU, 51), 23 died during hospitalization. The closed ICU group had higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, vasopressor use, mechanical ventilation, and preoperative lactate levels and a shorter duration from diagnosis to ICU admission, surgery, and antibiotic administration than the open ICU group. Univariate analysis linked in-hospital mortality and APACHE II score, postoperative lactate levels, continuous renal replacement therapy (CRRT), and mechanical ventilation. Multivariate analysis revealed that in-hospital mortality rate increased with CRRT use and was lower in the closed ICU.

CONCLUSIONS

Compared to an open ICU, a closed ICU was an independent factor in reducing in-hospital mortality through prompt and appropriate treatment.

The clinical consequences of burst abdomen after emergency midline laparotomy: a prospective, observational cohort study

PURPOSE

The emergency midline laparotomy is a commonly performed procedure with a burst abdomen being a critical surgical complication requiring further emergency surgery. This study aimed to investigate the clinical outcomes of patients with burst abdomen after emergency midline laparotomy.

METHODS

A single-center, prospective, observational cohort study of patients undergoing emergency midline laparotomy during a two-year period was done. Abdominal wall closure followed a standardized technique using monofilament, slowly absorbable suture in a continuous suturing technique with a suture-to-wound ratio of at least 4:1. Treatment of burst abdomen was surgical. Data, including intra-hospital postoperative complications, were collected and registered chronologically based on journal entries. The primary outcome was to describe postoperative complications, length of stay, and the overall morbidity based on the Comprehensive Complication Index (CCI), stratified between patients who did and did not suffer from a burst abdomen during admission.

RESULTS

A total of 543 patients were included in the final cohort, including 24 patients with burst abdomen during admission. The incidence of burst abdomen after emergency midline laparotomy was 4.4%. Patients with a burst abdomen had a higher total amount of complications per patient (median of 3, IQR 1.3-5.8 vs. median of 1, IQR 0.0-3.0; p = 0.001) and a significantly higher CCI (median of 53.0, IQR 40.3-94.8 vs. median of 21.0, IQR 0.0-42.0; p =  < 0.001).

CONCLUSION

Patients with burst abdomen had an increased risk of postoperative complications during admission as well as a longer and more complicated admission with multiple non-surgical complications.

Understanding early deaths after major emergency abdominal surgery: An observational study of 754 patients

BACKGROUND

Major emergency abdominal surgery is associated with severe postoperative complications and high short- and long-term mortality. Despite recent advancements in standardizing multidisciplinary care bundles, a subgroup of patients continues to face a heightened risk of short-term mortality. This study aimed to identify and describe the high-risk surgical patients and risk factors for short-term postoperative mortality.

METHODS

In this study, we included all patients undergoing major emergency abdominal surgery over 2 years and collected data on demographics, intraoperative variables, and short-term outcomes. The primary outcome measure was short-term mortality and secondary outcome measures were pre, intra, and postoperative risk factors for premature death. Multivariable binary regression analysis was performed to determine possible risk factors for short-term mortality.

RESULTS

Short-term mortality within 14 days of surgery in this cohort of 754 consecutive patients was 8%. Multivariable analysis identified various independent risk factors for short-term mortality throughout different phases of patient care. These factors included advanced age, preoperative history of myocardial infarction or ischemic heart disease, chronic obstructive pulmonary disease, liver cirrhosis, chronic kidney disease, and vascular bowel ischemia or perforation of the stomach or duodenum during the primary surgery.

CONCLUSION

Patients at high risk of early mortality following major emergency abdominal surgery exhibited distinct perioperative risk factors. This study underscores the importance of clinicians identifying and managing these factors in high-risk patients to ensure optimal care.

Health-related quality of life is a predictor of readmission following emergency laparotomy

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.

Impact of clinical frailty on surgical and non-surgical complications after major emergency abdominal surgery

BACKGROUND

Major emergency abdominal surgery is associated with a high risk of morbidity and mortality. Given the ageing and increasingly frail population, understanding the impact of frailty on complication patterns after surgery is crucial. The aim of this study was to evaluate the association between clinical frailty and organ-specific postoperative complications after major emergency abdominal surgery.

METHODS

A prospective cohort study including all patients undergoing major emergency abdominal surgery at Copenhagen University Hospital Herlev, Denmark, from 1 October 2020 to 1 August 2022, was performed. Clinical frailty scale scores were determined for all patients upon admission and patients were then analysed according to clinical frailty scale groups (scores of 1-3, 4-6, or 7-9). Postoperative complications were registered until discharge.

RESULTS

A total of 520 patients were identified. Patients with a low clinical frailty scale score (1-3) experienced fewer total complications (120 complications per 100 patients) compared with patients with clinical frailty scale scores of 4-6 (250 complications per 100 patients) and 7-9 (277 complications per 100 patients) (P < 0.001). A high clinical frailty scale score was associated with a high risk of pneumonia (P = 0.009), delirium (P < 0.001), atrial fibrillation (P = 0.020), and infectious complications in general (P < 0.001). Patients with severe frailty (clinical frailty scale score of 7-9) suffered from more surgical complications (P = 0.001) compared with the rest of the cohort. Severe frailty was associated with a high risk of 30-day mortality (33% for patients with a clinical frailty scale score of 7-9 versus 3.6% for patients with a clinical frailty scale score of 1-3, P < 0.001). In a multivariate analysis, an increasing degree of clinical frailty was found to be significantly associated with developing at least one complication.

CONCLUSION

Patients with frailty have a significantly increased risk of postoperative complications after major emergency abdominal surgery, especially atrial fibrillation, delirium, and pneumonia. Likewise, patients with frailty have an increased risk of mortality within 90 days. Thus, frailty is a significant predictor for adverse events after major emergency abdominal surgery and should be considered in all patients undergoing major emergency abdominal surgery.