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Hansen D, Itotoh F, Helena K, Aitken RJ. Observations from Australia's National Surgical Mortality Audit. World J Surg 2023; 47:3140-3148. [PMID: 37882828 DOI: 10.1007/s00268-023-07205-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Australia is the only country with a national surgical mortality audit. Every Australian surgical mortality is independently and externally reviewed by another surgeon. Extensive educational feedback to surgeons and hospitals is provided through individual patient reviews, state and national symposia and reports, and the distribution of deidentified informative cases. This study reports a longitudinal analysis of the Australian surgical morality audit. METHODS The standardised mortality ratio (SMR) was calculated for each state and territory, nine surgical specialties and nationally. The index year used was 2016, or every 5 years for those states with earlier data. Overall data were analysed in three groups-all deaths, postoperative deaths and non-operative deaths. Overall specialty data were analysed nationally. RESULTS There was a consistent progressive fall, usually in excess of 20%, in the SMR in each state and territory and by specialty when compared to the index year. This was statistically significant nationally (p = 0.044). The same change was observed in earlier years in states with longer-term data. CONCLUSION The period of this observational study has been associated with a nationwide fall in surgical mortality. As other improvements in care will have occurred during this period, the contribution that Australia's national mortality audit made towards the lower surgical mortality cannot be stated with certainty.
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Affiliation(s)
- Dylan Hansen
- Royal Australasian College of Surgeons (RACS), Melbourne, Australia
| | - Franca Itotoh
- Royal Australasian College of Surgeons (RACS), Melbourne, Australia
| | - Kopunic Helena
- Royal Australasian College of Surgeons (RACS), Melbourne, Australia
| | - R James Aitken
- Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia.
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2
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Keane E, Charlesworth M. Data-driven decision-making for extreme-risk emergency laparotomy: a national success story? Anaesthesia 2023; 78:1431-1434. [PMID: 37772614 DOI: 10.1111/anae.16136] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 09/30/2023]
Affiliation(s)
- E Keane
- Department of Anaesthesia and Critical Care, University Hospital Limerick, Limerick, Ireland
| | - M Charlesworth
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
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3
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Javanmard-Emamghissi H, Doleman B, Lund JN, Lockwood S, Hare S, Pearce L, Moug S, Tierney GM. Beyond high-risk: analysis of the outcomes of extreme-risk patients in the National Emergency Laparotomy Audit. Anaesthesia 2023; 78:1376-1385. [PMID: 37772642 DOI: 10.1111/anae.16130] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 09/30/2023]
Abstract
Patients who require emergency laparotomy are defined as high risk if their 30-day predicted risk of mortality is ≥ 5%. Despite a large difference in the characteristics of patients with a mortality risk score of between 5% and 50%, these outcomes are aggregated by the National Emergency Laparotomy Audit (NELA). Our aim was to describe the outcomes of the cohort of patients at extreme risk of death, which we defined as having a NELA-predicted 30-day mortality of ≥ 50%. All patients enrolled in the NELA database between December 2012 and 2020 were included. We compared patient characteristics; length of hospital stay; rates of unplanned return to the operating theatre; and 90-day survival in extreme-risk groups (predicted ≥ 50%) and high-risk patients (predicted 5-49%). Of 161,337 patients, 5193 (3.2%) had a predicted mortality of ≥ 50%. When patients were further subdivided, 2437 (47%) had predicted mortality of 50-59% (group 50-59); 1484 (29%) predicted mortality of 60-69% (group 60-69); 840 (16%) predicted mortality of 70-79% (group 70-79); and 423 (8%) predicted mortality of ≥ 80% (group 80+). Extreme-risk patients were significantly more likely to have been admitted electively than high-risk patients (p < 0.001). Length of stay increased from a median (IQR [range]) of 26 (16-43 [0-271]) days in group 50-59 to 35 (21-56 [0-368]) days in group 80+, compared with 17 (10-30 [0-1136]) days for high-risk patients. Rates of unplanned return to the operating theatre were higher in extreme-risk groups compared with high-risk patients (11% vs. 8%). The 90-day survival was 43% in group 50-59, 34% in group 60-69, 27% in group 70-79 and 17% in group 80+. These data underscore the need for a differentiated approach when discussing risk with patients at extreme risk of mortality following an emergency laparotomy. Clinicians should focus on patient priorities on quantity and quality of life during informed consent discussions before surgery. Future work should extend beyond the immediate postoperative period to encompass the longer-term outcomes (survival and function) of patients who have emergency laparotomies.
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Affiliation(s)
- H Javanmard-Emamghissi
- Department of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - B Doleman
- Department of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Department of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - S Lockwood
- Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK
| | - S Hare
- Department of Anaesthesia, William Harvey Hospital, East Kent University Hospitals, Ashford, UK
| | - L Pearce
- Department of Colorectal Surgery, Salford Royal Hospital, Salford, UK
| | - S Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
| | - G M Tierney
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
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4
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Pule LM, Kopunic H, Aitken RJ. Low mortality rate after emergency laparotomy in Australia is a reflection of its national surgical mortality audit influencing futile surgery. Br J Surg 2023; 110:1367-1373. [PMID: 37409943 DOI: 10.1093/bjs/znad200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/06/2023] [Accepted: 06/13/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Australia's unique national surgical mortality audit has had a long-term focus on the avoidance of futile surgery. The 30-day mortality rate after emergency laparotomy in Australia is lower than in other countries. Early death (within 72 h) after emergency laparotomy may reflect futile surgery. This paper considers whether Australia's national mortality audit is the reason for its lower mortality rate after emergency laparotomy. METHODS Data were extracted from the Australia and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) from 2018 to 2022. The time elapsed from emergency laparotomy to death was determined for each patient. The cumulative daily mortality rate was calculated for the first 30 days and expressed as a proportion of all emergency laparotomies, and 30-day and in-hospital mortality. Mortality data were compared with those in the only three similar overseas studies. The mortality rate after emergency laparotomy for patients who required but did not undergo surgery was calculated for each hospital. The proportion of patients with high-risk characteristics was compared with that in the National Emergency Laparotomy Audit (NELA). RESULTS Compared with overseas studies, there was a lower early (within 72 h) mortality rate in ANZELA-QI. Although the lower mortality rate in ANZELA-QI persisted to 30 days, there was a relative increase after 14 days that likely reflected known poor compliance with care standards. Australian patients had fewer high-risk characteristics than those in NELA. CONCLUSION The present findings support the hypothesis that the lower mortality rate after emergency laparotomy in Australia is likely a consequence of its national mortality audit and the avoidance of futile surgery.
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Affiliation(s)
- Lettie M Pule
- Royal Australasian College of Surgeons, Morbidity Audits, Research, Audit & Academic Surgery, Adelaide, South Australia, Australia
| | - Helena Kopunic
- Royal Australasian College of Surgeons, Morbidity Audits, Research, Audit & Academic Surgery, Adelaide, South Australia, Australia
| | - R James Aitken
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
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5
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Fowler AJ, Wahedally MAH, Abbott TEF, Prowle JR, Cromwell DA, Pearse RM. Long-term disease interactions amongst surgical patients: a population cohort study. Br J Anaesth 2023:S0007-0912(23)00237-4. [PMID: 37400340 PMCID: PMC10375505 DOI: 10.1016/j.bja.2023.04.041] [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: 05/06/2022] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND The average age of the surgical population continues to increase, as does prevalence of long-term diseases. However, outcomes amongst multi-morbid surgical patients are not well described. METHODS We included adults undergoing non-obstetric surgical procedures in the English National Health Service between January 2010 and December 2015. Patients could be included multiple times in sequential 90-day procedure spells. Multi-morbidity was defined as presence of two or more long-term diseases identified using a modified Charlson comorbidity index. The primary outcome was 90-day postoperative death. Secondary outcomes included emergency hospital readmission within 90 days. We calculated age- and sex-adjusted odds ratios (OR) with 95% confidence intervals (CI) using logistic regression. We compared the outcomes associated with different disease combinations. RESULTS We identified 20 193 659 procedure spells among 13 062 715 individuals aged 57 (standard deviation 19) yr. Multi-morbidity was present among 2 577 049 (12.8%) spells with 195 965 deaths (7.6%), compared with 17 616 610 (88.2%) spells without multi-morbidity with 163 529 deaths (0.9%). Multi-morbidity was present in 1 902 859/16 946 808 (11.2%) elective spells, with 57 663 deaths (2.7%, OR 4.9 [95% CI: 4.9-4.9]), and 674 190/3 246 851 (20.7%) non-elective spells, with 138 302 deaths (20.5%, OR 3.0 [95% CI: 3.0-3.1]). Emergency readmission followed 547 399 (22.0%) spells with multi-morbidity compared with 1 255 526 (7.2%) without. Multi-morbid patients accounted for 57 663/114 783 (50.2%) deaths after elective spells, and 138 302/244 711 (56.5%) after non-elective spells. The rate of death varied five-fold from lowest to highest risk disease pairs. CONCLUSION One in eight patients undergoing surgery have multi-morbidity, accounting for more than half of all postoperative deaths. Disease interactions amongst multi-morbid patients is an important determinant of patient outcome.
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Affiliation(s)
- Alexander J Fowler
- School of Medicine and Dentistry, Queen Mary University of London, London, UK; Royal College of Surgeons of England, London, UK.
| | | | - Tom E F Abbott
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - John R Prowle
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - David A Cromwell
- Royal College of Surgeons of England, London, UK; London School of Hygiene and Tropical Medicine, London, UK
| | - Rupert M Pearse
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
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6
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott MJ. 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. World J Surg 2023:10.1007/s00268-023-07039-9. [PMID: 37277506 DOI: 10.1007/s00268-023-07039-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Carol J Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA, 90033, USA.
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX, UK
| | - Robert J Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia
| | - Iain D Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD, UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU, Scotland
| | | | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
- Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Jugdeep K Dhesi
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Research Department of Targeted Intervention, Division of Surgery & Interventional Science, University College London, London, UK
| | - W Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA, 23298, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, UK
| | - Joaquim M Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Daniel N Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anaesthesia, St George's Hospital, Tooting, London, UK
| | - Jeniffer S Kim
- Kaiser Permanente Research, Department of Research & Evaluation, 100 South Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - Nicholas P Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD, UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Queen's Medical Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, NG7 2UH, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, Queen's Medical Centre, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, School of Medical Sciences, Orebro University Hospital, Orebro University, 701 85, Orebro, Sweden
| | - Carlos A Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cl 5 No. 36-08, 760032, Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX, UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10th Ave, Columbus, OH, 43210, USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA, 94143, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Medicine, and Department of Anesthesiology, Weill-Cornell Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Michael J Scott
- Department of Anesthesiology and Critical Care Medicine, and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA
- University College London, London, UK
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Darbyshire AR, Kostakis I, Meredith P, Toh SKC, Prytherch D, Briggs J. Novel predictors of mortality in emergency bowel surgery: a single-centre cohort study. Anaesthesia 2023; 78:561-570. [PMID: 36723442 DOI: 10.1111/anae.15966] [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] [Accepted: 12/15/2022] [Indexed: 02/02/2023]
Abstract
Pre-operative risk stratification is a key part of the care pathway for emergency bowel surgery, as it facilitates the identification of high-risk patients. Several novel risk scores have recently been published that are designed to identify patients who are frail or significantly unwell. They can also be calculated pre-operatively from routinely collected clinical data. This study aimed to investigate the ability of these scores to predict 30-day mortality after emergency bowel surgery. A single centre cohort study was performed using our local data from the National Emergency Laparotomy Audit database. Further data were extracted from electronic hospital records (n = 1508). The National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score were then calculated. The most abnormal National or Laboratory Decision Tree Early Warning Score in the 24 or 72 h before surgery was used in analysis. Individual scores were reasonable predictors of mortality (c-statistic 0.699-0.740) but all were poorly calibrated. A National Early Warning Score ≥ 4 was associated with a high overall mortality rate (> 10%). A logistic regression model was developed using age, National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score as predictor variables, and its performance compared with other established risk models. The model demonstrated good discrimination and calibration (c-statistic 0.827) but was marginally outperformed by the National Emergency Laparotomy Audit score (c-statistic 0.861). All other models compared performed less well (c-statistics 0.734-0.808). Pre-operative patient vital signs, blood tests and markers of frailty can be used to accurately predict the risk of 30-day mortality after emergency bowel surgery.
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Affiliation(s)
- A R Darbyshire
- Department of General Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - I Kostakis
- Research Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - P Meredith
- Research Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - S K C Toh
- Department of General Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - D Prytherch
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, UK
| | - J Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, UK
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Carlisle JB. To operate or not? Uncertainty, regret and the art of conversation. Anaesthesia 2023; 78:155-158. [PMID: 36196780 DOI: 10.1111/anae.15875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 01/11/2023]
Affiliation(s)
- J B Carlisle
- Department of Peri-operative Medicine, Anaesthesia and Intensive Care, Torbay Hospital, Torquay, Devon, UK
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9
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Ylimartimo AT, Nurkkala J, Koskela M, Lahtinen S, Kaakinen T, Vakkala M, Hietanen S, Liisanantti J. Postoperative Complications and Outcome After Emergency Laparotomy: A Retrospective Study. World J Surg 2023; 47:119-129. [PMID: 36245004 PMCID: PMC9726776 DOI: 10.1007/s00268-022-06783-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency laparotomy (EL) is a common urgent surgical procedure with high risk for postoperative complications. Complications impair the prognosis and prolong the hospital stay. This study explored the incidence and distribution of complications and their impact on short-term mortality after EL. METHODS This was a retrospective single-center register-based cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The primary outcome was operation-related or medical complication after EL. The secondary outcome was mortality in 90-day follow-up. Multivariate logistic regression analyses were used to identify independent risk factors for complications. RESULTS A total of 389 (58%) patients developed complications after EL, including 215 (32%) patients with operation-related complications and 361 (54%) patients with medical complications. Most of the complications were Clavien-Dindo classification type 4b (28%) and type 2 (22%). Operation-related complications occurred later compared to medical complications. Respiratory complications were the most common medical complications, and infections were the most common operation-related complications. The 30- and 90-day mortalities were higher in both the medical (17.2%, 26.2%) and operation-related complication groups (13.5%, 24.2%) compared to patients without complications (10.5% and 4.8%, 14.8% and 8.0%). Low albumin, high surgical urgency, excessive alcohol consumption and medical complications were associated with operation-related complications. Older age, high ASA class and operation-related complications were associated with medical complications. CONCLUSIONS This study demonstrated that EL is associated with a high risk of complications and poor short-term outcome. Complications impair the prognosis regardless of which kind of EL is in question.
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Affiliation(s)
- Aura T. Ylimartimo
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O. Box 21, 90029 OYS Oulu, Finland
| | - Juho Nurkkala
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Marjo Koskela
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Surgery, Oulu University Hospital, P.O. Box 21, 90029 OYS Oulu, Finland
| | - Sanna Lahtinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Timo Kaakinen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Merja Vakkala
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - Siiri Hietanen
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland
| | - Janne Liisanantti
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine, Medical Research Center of Oulu, Oulu, Finland ,Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
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10
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Ebrahim M, Lauritsen ML, Cihoric M, Hilsted KL, Foss NB. Triage and outcomes for a whole cohort of patients presenting for major emergency abdominal surgery including the No-LAP population: a prospective single-center observational study. Eur J Trauma Emerg Surg 2023; 49:253-260. [PMID: 35838771 PMCID: PMC9284504 DOI: 10.1007/s00068-022-02052-4] [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: 03/07/2022] [Accepted: 06/30/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE This study aimed to characterize 252 consecutive patients with an indication for major emergency abdominal surgery including patients not proceeding to surgery (No-Lap). Patients who do not proceed to major emergency abdominal surgery and their clinical outcomes are not well characterized in the existing literature. Triage criteria may vary between centers, potentially impacting reported outcomes. METHODS A single-center prospective observational study in a high-volume Danish surgical center including 252 patients presenting with an indication for major emergent abdominal surgery was conducted from the 15th of October 2020 to the 15th of August 2021. The primary outcome was to estimate the prevalence of No-Lap patients. RESULTS Overall, 21 patients (8.3%) of our total study cohort did not proceed to surgery. These patients were significantly older, more comorbid with higher ASA scores, poorer performance status, and were more likely to have bowel ischemia. Poor functional performance and surgeons' consideration of futile intervention were the main reasons for deferring surgery in all 21 patients. Overall, 30-day mortality was 95% for the No-LAP cohort, 9% for the LAP cohort, and 16% for the whole cohort, respectively. CONCLUSIONS The No-LAP group selection process could be one of the main determinants of reported postoperative outcomes. Prospective international multi-center studies to characterize the entire cohort of patients eligible for emergency laparotomy including the No-LAP population are needed, as large variations in triage criteria and culture seem to exist. Trial registration Retrospectively registered.
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Affiliation(s)
- Mohamed Ebrahim
- Department of Gastrointestinal Surgery, Hvidovre Hospital, University of Copenhagen, 2650, Hvidovre, Copenhagen, Denmark.
| | - Morten Laksáfoss Lauritsen
- grid.411905.80000 0004 0646 8202Department of Gastrointestinal Surgery, Hvidovre Hospital, University of Copenhagen, 2650 Hvidovre, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mirjana Cihoric
- grid.411905.80000 0004 0646 8202Department of Anesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Hvidovre, Denmark
| | - Karen Lisa Hilsted
- grid.411905.80000 0004 0646 8202Department of Gastrointestinal Surgery, Hvidovre Hospital, University of Copenhagen, 2650 Hvidovre, Copenhagen, Denmark
| | - Nicolai Bang Foss
- grid.5254.60000 0001 0674 042XDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark ,grid.411905.80000 0004 0646 8202Department of Anesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Hvidovre, Denmark
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Javanmard-Emamghissi H, Moug SJ. The virtual uncertainty of futility in emergency surgery. Br J Surg 2022; 109:1184-1185. [PMID: 36066240 PMCID: PMC10364746 DOI: 10.1093/bjs/znac313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 12/31/2022]
Abstract
Futility is a controversial topic within surgery. This editorial defines the concept, explains the differing types of surgical futility, and discusses the ethical issues around the subject.
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Affiliation(s)
- Hannah Javanmard-Emamghissi
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - Susan J Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley and Golden Jubilee National Hospital, Clydebank, UK.,College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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12
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Rodriguez S, Shen TS, Lebrun DG, Della Valle AG, Ast MP, Rodriguez JA. Ambulatory total hip arthroplasty: Causes for failure to launch and associated risk factors. Bone Jt Open 2022; 3:684-691. [PMID: 36047458 PMCID: PMC9533240 DOI: 10.1302/2633-1462.39.bjo-2022-0106.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aims The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m2 (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. Conclusion SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology. Cite this article: Bone Jt Open 2022;3(9):684–691.
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Affiliation(s)
- Samuel Rodriguez
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Tony S. Shen
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Drake G. Lebrun
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Alejandro G. Della Valle
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Michael P. Ast
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
| | - Jose A. Rodriguez
- Department of Orthopedic Surgery Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, New York, USA
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13
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Wainwright TW, Jakobsen DH, Kehlet H. The current and future role of nurses within enhanced recovery after surgery pathways. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:656-659. [PMID: 35736850 DOI: 10.12968/bjon.2022.31.12.656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been proven to expedite recovery after many procedures and reduce lengths of stay in hospital and surgical complications. However, improvements are still needed, especially in postoperative ERAS components delivered by nurses such as early mobilisation and oral feeding. This article summarises the current and possible future role of nurses within ERAS, and recommends areas for future research. DISCUSSION Nurses are the professionals who spend the most time with patients throughout the perioperative pathway and are known to play a vital role in delivering many components of an ERAS pathway. They frequently co-ordinate care across disciplines and ensure continuity of care. However, there is a paucity of ERAS research specific to nurses compared to other professional groups. Continual training on ERAS will be required to ensure nurses are highly educated and for the best possible ERAS implementation. In certain types of surgery, nurses may fulfil extended roles in the postoperative period, such as taking over responsibility and leadership for co-ordinating pain management, mobilisation and discharge. However, this requires a well-defined care programme, a clear definition of nursing responsibilities from surgeons, agreed discharge criteria and highly qualified nurses, along with the collection and analysis of data to test safety and efficacy. CONCLUSION Increasing nurse involvement in ERAS research is vital to drive improvements in care and to develop nursing roles. Nurses should have a major role in the preoperative clinic, the early postoperative phase and the follow-up post-discharge period, where the benefits of ERAS need to be further documented.
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Affiliation(s)
- Thomas W Wainwright
- Professor in Orthopaedics. Orthopaedic Research Institute, Bournemouth University, and Physiotherapy Department, University Hospitals Dorset, Bournemouth
| | - Dorthe Hjort Jakobsen
- Head Clinical Nurse, Department of Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Denmark
| | - Henrik Kehlet
- Professor, Department of Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Denmark, and Chair, Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
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14
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Mathiszig-Lee JF, Catling FJR, Moonesinghe SR, Brett SJ. Highlighting uncertainty in clinical risk prediction using a model of emergency laparotomy mortality risk. NPJ Digit Med 2022; 5:70. [PMID: 35676451 PMCID: PMC9177766 DOI: 10.1038/s41746-022-00616-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractClinical prediction models typically make point estimates of risk. However, values of key variables are often missing during model development or at prediction time, meaning that the point estimates mask significant uncertainty and can lead to over-confident decision making. We present a model of mortality risk in emergency laparotomy which instead presents a distribution of predicted risks, highlighting the uncertainty over the risk of death with an intuitive visualisation. We developed and validated our model using data from 127134 emergency laparotomies from patients in England and Wales during 2013–2019. We captured the uncertainty arising from missing data using multiple imputation, allowing prospective, patient-specific imputation for variables that were frequently missing. Prospective imputation allows early prognostication in patients where these variables are not yet measured, accounting for the additional uncertainty this induces. Our model showed good discrimination and calibration (95% confidence intervals: Brier score 0.071–0.078, C statistic 0.859–0.873, calibration error 0.031–0.059) on unseen data from 37 hospitals, consistently improving upon the current gold-standard model. The dispersion of the predicted risks varied significantly between patients and increased where prospective imputation occurred. We present a case study that illustrates the potential impact of uncertainty quantification on clinical decision making. Our model improves mortality risk prediction in emergency laparotomy and has the potential to inform decision-makers and assist discussions with patients and their families. Our analysis code was robustly developed and is publicly available for easy replication of our study and adaptation to predicting other outcomes.
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15
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Berry M, Gosling JL, Bartlett RE, Brett SJ. Exploring red cell distribution width as a potential risk factor in emergency bowel surgery—A retrospective cohort study. PLoS One 2022; 17:e0266041. [PMID: 35511937 PMCID: PMC9071152 DOI: 10.1371/journal.pone.0266041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/12/2022] [Indexed: 11/18/2022] Open
Abstract
Increased preoperative red cell distribution width (RDW) is associated with higher mortality following non-cardiac surgery in patients older than 65 years. Little is known if this association holds for all adult emergency laparotomy patients and whether it affects 30-day or long-term mortality. Thus, we examined the relationship between increased RDW and postoperative mortality. Furthermore, we investigated the prognostic worth of anisocytosis and explored a possible association between increased RDW and frailty in this cohort. We conducted a retrospective, single centre National Emergency Laparotomy Audit (NELA) database study at St Mary’s Hospital Imperial NHS Trust between January 2014 and April 2018. A total of 356 patients were included. Survival models were developed using Cox regression analysis, whereas RDW and frailty were analysed using multivariable logistic regression. Underlying model assumptions were checked, including discrimination and calibration. We internally validated our models using bootstrap resampling. There were 33 (9.3%) deaths within 30-days and 72 (20.2%) overall. Median RDW values for 30-day mortality were 13.8% (IQR 13.1%-15%) in survivors and 14.9% (IQR 13.7%-16.1%) in non-survivors, p = 0.007. Similarly, median RDW values were lower in overall survivors (13.7% (IQR 13%-14.7%) versus 14.9% (IQR 13.9%-15.9%) (p<0.001)). Mortality increased across quartiles of RDW, as did the proportion of frail patients. Anisocytosis was not associated with 30-day mortality but demonstrated a link with overall death rates. Increasing RDW was associated with a higher probability of frailty for 30-day (Odds ratio (OR) 4.3, 95% CI 1.22–14.43, (p = 0.01)) and overall mortality (OR 4.9, 95% CI 1.68–14.09, (p = 0.001)). We were able to show that preoperative anisocytosis is associated with greater long-term mortality after emergency laparotomy. Increasing RDW demonstrates a relationship with frailty. Given that RDW is readily available at no additional cost, future studies should prospectively validate the role of RDW in the NELA cohort nationally.
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Affiliation(s)
- Michael Berry
- King’s Critical Care, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Rachel Elizabeth Bartlett
- St. Mary’s Hospital Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Stephen James Brett
- Hammersmith Hospital Department of Intensive Care, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- * E-mail:
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16
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Association of Serum Creatinine Level with Prognosis of Laparotomy for Acute Mesenteric Ischemia after Cardiovascular Surgery. Surg Res Pract 2022; 2022:1737161. [PMID: 35386950 PMCID: PMC8979745 DOI: 10.1155/2022/1737161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/14/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Acute mesenteric ischemia is a life-threatening complication after cardiovascular surgery with a mortality rate of 52.9–81.3%. However, few studies have evaluated the predictors of clinical outcome after treatment for acute mesenteric ischemia following cardiovascular surgery. Therefore, this study aimed to elucidate prognostic factors in patients who underwent laparotomy for acute mesenteric ischemia after cardiovascular surgery. Methods We retrospectively analyzed 29 patients (20 men and 9 women; median age, 71.0 years) who underwent laparotomy for acute mesenteric ischemia after cardiovascular surgery between January 2010 and August 2020. These patients were classified into the survivor group (comprising patients who were discharged or referred to another hospital, n = 16) and the nonsurvivor group (comprising those who experienced in-hospital mortality, n = 13). We compared clinical parameters between the groups to identify the predictors of outcomes. Results More patients in the nonsurvivor group underwent emergency cardiovascular surgery (62.5% vs. 100%, p = 0.017) and received hemodialysis (12.5% vs. 61.5%, p = 0.008) at the onset of acute mesenteric ischemia than those in the survivor group. The prelaparotomy serum creatinine level was higher in the nonsurvivor group than in the survivor group (1.27 vs. 2.33 mg/dL, p = 0.004). Logistic regression analysis revealed an association between preoperative serum creatinine level and in-hospital mortality (odds ratio 5.047, p = 0.046), and Cox regression analysis demonstrated a relationship between serum creatinine level and in-hospital mortality (hazard ratio 1.610, p = 0.009). The area under the curve (receiver operating characteristic analysis) for the serum creatinine level was 0.813. Furthermore, the optimal cutoff value of the serum creatinine level was 1.59 mg/dL with a sensitivity and specificity of 0.846 and 0.687, respectively, in predicting in-hospital mortality. Conclusions The elevated serum creatinine level was associated with a poor clinical outcome after surgery for acute mesenteric ischemia following cardiovascular surgery.
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17
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Javanmard-Emamghissi H, Lockwood S, Hare S, Lund JN, Tierney GM, Moug SJ. The false dichotomy of surgical futility in the emergency laparotomy setting: scoping review. BJS Open 2022; 6:zrac023. [PMID: 35389427 PMCID: PMC8988868 DOI: 10.1093/bjsopen/zrac023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Futile is defined as 'the fact of having no effect or of achieving nothing'. Futility in medicine has been defined through seven guiding principles, which in the context of emergency surgery, have been relatively unexplored. This scoping review aimed to identify key concepts around surgical futility as it relates to emergency laparotomy. METHODS Using the Arksey and O'Malley framework, a scoping review was conducted. A search of the Cochrane Library, Google Scholar, MEDLINE, and Embase was performed up until 1 November 2021 to identify literature relevant to the topic of futility in emergency laparotomy. RESULTS Three cohort studies were included in the analysis. A total of 105 157 patients were included, with 1114 patients reported as futile. All studies were recent (2019 to 2020) and focused on the principle of quantitative futility (assessment of the probability of death after surgery) within a timeline after surgery: two defining futility as death within 48 hours of surgery and one as death within 72 hours. In all cases this was derived from a survival histogram. Predictors of defined futile procedures included age, level of independence prior to admission, surgical pathology, serum creatinine, arterial lactate, and pH. CONCLUSION There remains a paucity of research defining, exploring, and analysing futile surgery in patients undergoing emergency laparotomy. With limited published work focusing on quantitative futility and the binary outcome of death, research is urgently needed to explore all principles of futility, including the wishes of patients and their families.
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Affiliation(s)
- Hannah Javanmard-Emamghissi
- Faculty of Medicine, Division of Health Sciences and Graduate Entry Medicine, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - Sonia Lockwood
- Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK
| | - Sarah Hare
- Department of Anaesthesia, Medway Maritime Hospital, Kent, UK
| | - Jon N. Lund
- Faculty of Medicine, Division of Health Sciences and Graduate Entry Medicine, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | | | - Susan J. Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
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18
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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: 0] [Impact Index Per Article: 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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19
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Improving Outcomes for Elderly Patients Following Emergency Surgery: a Cutting-edge Review. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00500-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
The aim of this review is to explore the consequence of emergency general surgery in the elderly, and to summarise recent developments in the pre-, peri- and postoperative management of these patients, in order to improve outcomes.
Recent Findings
Preoperatively, accurate risk assessment is vital to ensure the right patients undergo emergency surgery. Perioperatively, there are multiple interventions specific to elderly patients that have been shown to improve outcomes. Postoperatively, elderly patients must be cared more in an appropriate setting in order to avoid failure to rescue and promote return to function.
Summary
This review of contemporary evidence identifies multiple pre-, peri- and postoperative interventions that can improve outcomes for elderly patients after emergency general surgery. These evidence-based recommendations should help direct care of elderly patients undergoing emergency surgery and foster further quality improvement measures and research investigations.
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20
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Remote diagnosis of surgical-site infection using a mobile digital intervention: a randomised controlled trial in emergency surgery patients. NPJ Digit Med 2021; 4:160. [PMID: 34795398 PMCID: PMC8602321 DOI: 10.1038/s41746-021-00526-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/27/2021] [Indexed: 02/03/2023] Open
Abstract
Surgical site infections (SSI) cause substantial morbidity and pose a burden to acute healthcare services after surgery. We aimed to investigate whether a smartphone-delivered wound assessment tool can expedite diagnosis and treatment of SSI after emergency abdominal surgery. This single-blinded randomised control trial (NCT02704897) enroled adult emergency abdominal surgery patients in two tertiary care hospitals. Patients were randomised (1:1) to routine postoperative care or additional access to a smartphone-delivered wound assessment tool for 30-days postoperatively. Patient-reported SSI symptoms and wound photographs were requested on postoperative days 3, 7, and 15. The primary outcome was time-to-diagnosis of SSI (Centers for Disease Control definition). 492 patients were randomised (smartphone intervention: 223; routine care: 269). There was no significant difference in the 30-day SSI rate between trial arms: 21 (9.4%) in smartphone vs 20 (7.4%, p = 0.513) in routine care. Among the smartphone group, 32.3% (n = 72) did not utilise the tool. There was no significant difference in time-to-diagnosis of SSI for patients receiving the intervention (-2.5 days, 95% CI: -6.6-1.6, p = 0.225). However, patients in the smartphone group had 3.7-times higher odds of diagnosis within 7 postoperative days (95% CI: 1.02-13.51, p = 0.043). The smartphone group had significantly reduced community care attendance (OR: 0.57, 95% CI: 0.34-0.94, p = 0.030), similar hospital attendance (OR: 0.76, 95% CI: 0.28-1.96, p = 0.577), and significantly better experiences in accessing care (OR: 2.02, 95% CI: 1.17-3.53, p = 0.013). Smartphone-delivered wound follow-up is feasible following emergency abdominal surgery. This can facilitate triage to the appropriate level of assessment required, allowing earlier postoperative diagnosis of SSI.
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21
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Choong JX, McIlveen E, Quasim T, Moug SJ. Decision making in emergency laparotomy: the role of predicted life expectancy. BJS Open 2021; 5:6388194. [PMID: 34633437 PMCID: PMC8504444 DOI: 10.1093/bjsopen/zrab090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/16/2021] [Indexed: 11/14/2022] Open
Abstract
Introduction Increasing numbers of older patients are undergoing emergency laparotomy (EL). They are at increased risk of adverse outcomes, making the shared decision on whether to operate challenging. This retrospective cohort study aimed to assess the role of age and life-expectancy predictions on short- and long-term survival in patients undergoing EL. Methods All patients who underwent EL at one hospital in the West of Scotland between March 2014 to December 2016 were included. Clinical parameters were collected, and patients were followed up to allow reporting of 30-, 60- and 90-day and 1-year mortality rates. Period life expectancy was used to stratify patients into below life expectancy (bLEP) and at-or-above life expectancy (aLEP) groups at presentation. Remaining life expectancy was used to calculate the net years of life gained (NYLG). Results Some 462 patients underwent EL: 20 per cent in the aLEP group. These patients were older (P < 0.001), had more co-morbidities (P < 0.001) and were high risk on P-POSSUM scoring (P = 0.008). The 30-, 60- and 90-day and 1-year mortality rates were 11, 14, 16 and 23 per cent respectively. Advanced age (P = 0.011) and high ASA score (P = 0.004) and P-POSSUM score (P < 0.001) were independent predictors of death at 1 year on multivariable analysis. The cohort NYLG were 19.2 years. Comparing patients aged less than 70 with those aged 70 years or older, the NYLG were 25.9 versus 5.5 years. Comparing bLEP and aLEP, the NYLG were 22.2 versus 4.4 years. In patients aged 70 years and older, NYLG decreased by more than half in patients with co-morbidities (ASA score 3,4,5) (9.3 versus 4.3 years). Conclusion Discussions around long-term outcomes after emergency surgery remain difficult. Although age is an influencing factor, predicted life expectancy alone does not provide additional value to shared decision making.
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Affiliation(s)
- J X Choong
- Department of Undergraduate Medicine, School of Medicine, University of Glasgow, University Avenue, Glasgow, UK
| | - E McIlveen
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK
| | - T Quasim
- Department of Anaesthesia, Critical Care and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - S J Moug
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK.,School of Medicine, Dentistry and Nursing, University of Glasgow, Royal Alexandra Hospital, Paisley, UK
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22
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Li ZE, Lu SB, Kong C, Sun WZ, Wang P, Zhang ST. Comparative short-term outcomes of enhanced recovery after surgery (ERAS) program and non-ERAS traditional care in elderly patients undergoing lumbar arthrodesis: a retrospective study. BMC Musculoskelet Disord 2021; 22:283. [PMID: 33731057 PMCID: PMC7968191 DOI: 10.1186/s12891-021-04166-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) program is an evidence-based improvement over non-ERAS traditional care. The aim of the present study was to analyze the safety, feasibility, and efficacy of an ERAS program in patients over 70 years undergoing lumbar arthrodesis by comparison with non-ERAS traditional care. Methods During January 2018 to December 2018, patients enrolled received non-ERAS traditional care, while the ERAS program was implemented from January to December 2019. Demographic characteristics, comorbidities, surgical data and postoperative recovery parameters were collected from all patients. Postoperative pain scores were evaluated by visual analog scales (VAS). The clinical outcomes were length of stay (LOS), postoperative complications and postoperative pain scores. Compliance results were also collected. Result A total of 127 patients were enrolled, including 67 patients in the non-ERAS traditional care group and 60 patients in the ERAS group. The demographic characteristics and comorbidities of the two groups showed no significant differences. The LOS of patients treated with ERAS program (13.6 ± 4.0 days) was significantly less than that of patients treated with non-ERAS traditional care (15.6 ± 3.9 days) (p = 0.034). Complication rate was 8.3% in the ERAS group versus 20.9% in the non-ERAS traditional care group (p = 0.048). VAS (back) in the ERAS group was significantly lower on postoperative day (POD) 1 and POD2. Postoperative recovery parameters were improved in the ERAS group. The overall compliance with the ERAS program was 94%. Conclusions Based on our results, ERAS program is safer and more effective for elderly patients over 70 undergoing lumbar arthrodesis than non-ERAS traditional care.
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Affiliation(s)
- Zhong-En Li
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Shi-Bao Lu
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China. .,National Clinical Research Center for Geriatric Diseases, Beijing, China.
| | - Chao Kong
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Wen-Zhi Sun
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Peng Wang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China.,Capital Medical University, Beijing, China
| | - Si-Tao Zhang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, Beijing, China.,National Clinical Research Center for Geriatric Diseases, Beijing, China
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Petring Hasselager R, Foss NB, Andersen O, Cihoric M, Bay‐Nielsen M, Nielsen HJ, Camilla Andresen L, Toft Tengberg L. Mortality and major complications after emergency laparotomy: A pilot study of risk prediction model development by preoperative blood-based immune parameters. Acta Anaesthesiol Scand 2021; 65:151-161. [PMID: 33108695 DOI: 10.1111/aas.13722] [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: 06/28/2020] [Revised: 09/04/2020] [Accepted: 09/28/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Emergency laparotomy is associated with high risk of postoperative complications and mortality. Preoperative identification of patients at high risk of adverse outcome is important. The immune response to conditions requiring emergency laparotomy is not understood in detail. The present study describes preoperative blood-based immune profiles and their potential value in surgical risk assessment. METHOD Patients (N = 100) referred for emergency laparotomy at Hvidovre Hospital were consecutively included from 3 June 2013-11 April 2014. All patients had blood samples collected before surgery and the immune parameters c-reactive protein (CRP), Interleukin-6 (IL-6), Interleukin-10 (IL-10), interferon-γ induced protein 10 kDa (IP-10), tumor necrosis factor α (TNF-α) and soluble urokinase plasminogen receptor activator (suPAR) were determined. Patients were stratified according to major postoperative complications (including death), 30- and 180-day mortality. Using logistic regression models and receiver operating characteristics curves the predictive ability of the immune parameters were estimated. RESULTS Major complications were recorded in 45 (45.0%) of the patients, whereas 30-day and 180-day mortalities were 17 (17.0%) and 25 (25.0%), respectively. Concentrations of suPAR and TNF-α were associated with major complications while CRP, IL-6, suPAR and TNF-α were associated with mortality. Adding the combined immune parameters to a regression model including age, sex, American Society of Anesthesiologists physical status and Eastern Cooperative Oncology Group Performance Status significantly improved the predictive ability for major complications, 30-day mortality and 180-day mortality. CONCLUSION In emergency laparotomy, preoperative blood-based immune parameters added predictive power to regression models and could be considered in risk prediction model development.
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Affiliation(s)
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital Hvidovre Denmark
| | - Ove Andersen
- Department of Clinical Research and the Emergency Department Hvidovre Hospital Hvidovre Denmark
| | - Mirjana Cihoric
- Department of Anesthesiology and Intensive Care Hvidovre Hospital Hvidovre Denmark
| | - Morten Bay‐Nielsen
- Department of Surgery Bispebjerg and Frederiksberg Hospital Copenhagen Denmark
| | - Hans J. Nielsen
- Department of Surgical Gastroenterology 360 Hvidovre Hospital Hvidovre Denmark
| | - Linda Camilla Andresen
- Department of Clinical Research and the Emergency Department Hvidovre Hospital Hvidovre Denmark
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Improvement in fast-track hip and knee arthroplasty: a prospective multicentre study of 36,935 procedures from 2010 to 2017. Sci Rep 2020; 10:21233. [PMID: 33277508 PMCID: PMC7718264 DOI: 10.1038/s41598-020-77127-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/03/2020] [Indexed: 12/18/2022] Open
Abstract
“Fast-track” protocols has improved surgical care with a reduction in length of hospital stay (LOS) in total hip (THA) and knee arthroplasty (TKA). However, the effects of continuous refinement of perioperative care lack detailed assessment. We studied time-related changes in LOS and morbidity after THA and TKA within a collaboration with continuous scientific refinement of perioperative care. Prospective multicentre consecutive cohort study between 2010 and 2017 from nine high-volume orthopaedic centres with established fast-track THA and TKA protocols. Prospective collection of comorbidities and complete 90-day follow-up from the Danish National Patient Registry and medical records. Of 36,935 procedures median age was 69 [62 to 75] years and 58% women. LOS declined from three [two to three] days in 2010 to one [one to two] day in 2017. LOS > 4 days due to “medical” or “surgical” complications, and “with no recorded morbidity” declined from 4.4 to 2.7%, 1.5 to 0.6%, and 3.8 to 1.3%, respectively. 90-days readmission rate declined from 8.6 to 7.7%. Our multicentre study in a socialized healthcare setting was associated with a continuous reduction in LOS and morbidity after THA and TKA.
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Law J, Welch C, Javanmard-Emamghissi H, Clark M, Bisset CN, O'Neil P, Moug SJ. Decision-making for older patients undergoing emergency laparotomy: defining patient and clinician values and priorities. Colorectal Dis 2020; 22:1694-1703. [PMID: 32464712 DOI: 10.1111/codi.15165] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/07/2020] [Indexed: 01/05/2023]
Abstract
AIM There remains limited knowledge on what patients value and prioritize in their decision to undergo emergency laparotomy (ELap) and during their subsequent recovery. The aim of this study was to explore factors in decision-making and to reach a consensus amongst patients on the 10 most important priorities in decision-making in ELap. METHODS Patients aged over 65 years who had required an ELap decision within the preceding 12 months (regardless of management) were identified and invited to attend a modified Delphi process focus group. RESULTS A total of 20 participants attended: eight patients, four relatives and eight perioperative specialists. The perioperative specialists group defined 12 important factors for perioperative decision-making. The patient group agreed that only six (50%) of these factors were important: independence, postoperative complications, readmission to hospital, requirement for stoma formation, delirium (including long-term cognition) and presence of an advocate (such as a friend or family member). Open discussion refined multiple themes. Agreement was reached by patients and relatives about 10 factors that they valued as most important in their ELap patient journey: return to independence, realistic expectations, postoperative complications, what to expect postoperatively, readmission to hospital, nutrition, postoperative communication, stoma, follow-up and delirium. CONCLUSION Patients and clinicians have different values and priorities when discussing the risks and implications of undergoing ELap. Patients value quality of life outcomes, in particular, the formation of a stoma, returning to their own home and remaining independent. This work is the first to combine both perspectives to guide future ELap research outcomes.
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Affiliation(s)
- J Law
- Blackpool Victoria Hospital, North West Deanery, UK
| | - C Welch
- Geriatric Medicine, University of Birmingham,, Birmingham, UK
| | | | - M Clark
- Royal Alexandra Hospital, Paisley, UK
| | | | - P O'Neil
- Royal Alexandra Hospital, Paisley, UK
| | - S J Moug
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK
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Jensen BT, Lauridsen SV, Jensen JB. Optimal Delivery of Follow-Up Care After Radical Cystectomy for Bladder Cancer. Res Rep Urol 2020; 12:471-486. [PMID: 33117747 PMCID: PMC7569073 DOI: 10.2147/rru.s270240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/24/2020] [Indexed: 01/10/2023] Open
Abstract
Purpose of Review To identify components representing optimal delivery of follow-up care after radical cystectomy because of bladder cancer and report the current level of evidence. Methods We conducted a systematic literature search of the following databases: Cochrane, MEDLINE, Embase, CINAHL, Web of Science, Physiotherapy Evidence Database and ClinicalTrials.gov. The search results were managed in Covidence Reference Manager and abstracts were screened by title. Articles relevant to the subject of interest were included and the results are reported narratively. Results Several studies have evaluated the positive impact of enhanced recovery after surgery (ERAS) on length of stay, albeit not on the further impact on 90-day postoperative complication rate, functional recovery, or mortality. Minimally invasive surgery may result in a slighter shorter length of stay compared to open surgery. Physical training combined with nutritional intervention can improve functional recovery up to one year after surgery. Nutritional supplements can preserve muscle and bone mass, and potentially improve recovery. Patient education in stoma care and prevention of infection can significantly improve self-efficacy and avoid symptoms of infection postoperatively. Moreover, specific devices like applications (apps) can support these efforts. Continued smoking increases the risk of developing postoperative complications while no evidence was found on the impact of continued alcohol drinking. Currently, there is no evidence on psychological well-being, sexual health, or shared decision making interventions with an impact on rehabilitation after radical cystectomy. Conclusion Data are scarce but indicate that peri- and postoperative multi-professional interventions can reduce prevalence of sarcopenia, and improve functional recovery, physical capacity, nutritional status, and self-efficacy in stoma care (level 1 evidence). Continued smoking increases the risk of complications, but the effects of a smoking and alcohol intervention remain unclear (level 3 evidence). The results of this review provide guidance for future directions in research and further attempts to develop and test an evidence-based program for follow-up care after radical cystectomy.
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Affiliation(s)
| | - Susanne Vahr Lauridsen
- Department of Urology, Copenhagen University Hospital, Denmark and WHO-CC, Clinical Health Promotion Centre, The Parker Institute Bispebjerg & Frederiksberg University Hospital, Copenhagen, Denmark
| | - Jørgen Bjerggaard Jensen
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Hu ZW, Xin RQ, Xia YJ, Jia GP, Chen XX, Wang S. Application of POSSUM and P-POSSUM in Surgical Risk Assessment of Elderly Patients Undergoing Hepatobiliary and Pancreatic Surgery. Clin Interv Aging 2020; 15:1121-1128. [PMID: 32764899 PMCID: PMC7367927 DOI: 10.2147/cia.s258659] [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: 05/07/2020] [Accepted: 06/26/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the efficacy and accuracy of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scoring systems in the risk assessment of postoperative complications and death in elderly patients undergoing hepatobiliary and pancreatic surgery. Patients and Methods Using POSSUM and P-POSSUM, 274 elderly patients undergoing hepatobiliary and pancreatic surgery were evaluated, and the complications and deaths predicted by the systems were compared with the actual situation. The accuracy and predictive ability of POSSUM and P-POSSUM were evaluated using chi-squared and t-tests, consistency of predicted and actual complication rates (observed/expected, OE ratio), and receiver operating characteristic (ROC) curve. Results The complication rate predicted by POSSUM (R1) was 22.57%, while the actual postoperative complication rate was 17.88% (P>0.05). The mortality rate predicted by POSSUM (R2) was 4.61%, while the actual rate was 1.09% (P<0.05). The mortality rate predicted by P-POSSUM (R) was 1.42%, while the actual rate was 1.09% (P>0.05). Patients with complications had higher physiology scores (PS), operative severity scores (OS), and POSSUM scores than those without complications (P<0.05). Furthermore, PS, OS, and POSSUM scores were higher in the mortality group than in the survival group. However, the number of individuals in the mortality group was too small to accurately reflect the overall situation. Stratified analysis showed that consistency of the OE ratio in different subgroups was close to 1. The ROC curve showed that the area under the curve for the complication rate predicted by POSSUM was 0.76. Conclusion Although the postoperative mortality rate was higher than the actual value, POSSUM could accurately predict the postoperative complication rate in elderly patients undergoing hepatobiliary and pancreatic surgery. The P-POSSUM accurately predicted the postoperative mortality rate in this population. Patients with complications had higher POSSUM scores.
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Affiliation(s)
- Zhi-Wei Hu
- Department of Hepatobiliary and Pancreatic Surgery, Inner Mongolia People's Hospital, Hohhot, Inner Mongolia Autonomous Region, People's Republic of China
| | - Rui-Qiang Xin
- Department of Hepatobiliary and Pancreatic Surgery, Inner Mongolia People's Hospital, Hohhot, Inner Mongolia Autonomous Region, People's Republic of China
| | - Yi-Jun Xia
- Department of Hepatobiliary and Pancreatic Surgery, Inner Mongolia People's Hospital, Hohhot, Inner Mongolia Autonomous Region, People's Republic of China
| | - Guang-Peng Jia
- Department of Hepatobiliary and Pancreatic Surgery, Inner Mongolia People's Hospital, Hohhot, Inner Mongolia Autonomous Region, People's Republic of China
| | - Xiao-Xu Chen
- Department of Hepatobiliary and Pancreatic Surgery, Inner Mongolia People's Hospital, Hohhot, Inner Mongolia Autonomous Region, People's Republic of China
| | - Shi Wang
- Department of Hepatobiliary and Pancreatic Surgery, Inner Mongolia People's Hospital, Hohhot, Inner Mongolia Autonomous Region, People's Republic of China
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Foss NB. Emergency laparotomy success - optimisation or triage? Anaesthesia 2020; 75:1289-1292. [PMID: 32472947 DOI: 10.1111/anae.15114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 12/26/2022]
Affiliation(s)
- N B Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
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Cihoric M, Tengberg LT, Foss NB, Gögenur I, Tolstrup MB, Bay-Nielsen M. Functional performance and 30-day postoperative mortality after emergency laparotomy-a retrospective, multicenter, observational cohort study of 1084 patients. Perioper Med (Lond) 2020; 9:13. [PMID: 32391145 PMCID: PMC7199328 DOI: 10.1186/s13741-020-00143-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 03/24/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite the importance of predicting adverse postoperative outcomes, functional performance status as a proxy for frailty has not been systematically evaluated in emergency abdominal surgery. Our aim was to evaluate if the Eastern Cooperative Oncology Group (ECOG) performance score was independently associated with mortality following high-risk emergency abdominal surgery, in a multicentre, retrospective, observational study of a consecutive cohort. METHODS All patients aged 18 or above undergoing high-risk emergency laparotomy or laparoscopy from four emergency surgical centres in the Capitol Region of Denmark, from January 1 to December 31, 2012, were included. Demographics, preoperative status, ECOG performance score, mortality, and surgical characteristics were registered. The association of frailty with postoperative mortality was evaluated using multiple regression models. Likelihood ratio test was applied for goodness of fit. RESULTS In total, 1084 patients were included in the cohort; unadjusted 30-day mortality was 20.2%. ECOG performance score was independently associated with 30-day mortality. Odds ratio for mortality was 1.70 (95% CI (1.0, 2.9)) in patients with ECOG performance score of 1, compared with 5.90 (95% CI (1.8, 19.0)) in patients with ECOG performance score of 4 (p < 0.01). Likelihood ratio test suggests improvement in fit of logistic regression modelling of 30-day postoperative mortality when including ECOG performance score as an explanatory variable. CONCLUSIONS This study found ECOG performance score to be independently associated with the postoperative 30-day mortality among patients undergoing high-risk emergency laparotomy. The utility of including functional performance in a preoperative risk assessment model of emergency laparotomy should be evaluated.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Hvidovre, Kettegaard allé 30, 2650 Hvidovre, Copenhagen, Denmark
| | - Line Toft Tengberg
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Koege, Denmark
| | - Nicolai Bang Foss
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Hvidovre, Kettegaard allé 30, 2650 Hvidovre, Copenhagen, Denmark
| | - Ismail Gögenur
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Koege, Denmark
| | - Mai-Britt Tolstrup
- Department of Gastrointestinal Surgery, Copenhagen University Hospital, Herlev, Copenhagen, Denmark
| | - Morten Bay-Nielsen
- Department of Gastrointestinal Surgery, Hvidovre University Hospital, Copenhagen, Denmark
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Early Postoperative Death in Patients Undergoing Emergency High-Risk Surgery: Towards a Better Understanding of Patients for Whom Surgery May Not Be Beneficial. J Clin Med 2020; 9:jcm9051288. [PMID: 32365617 PMCID: PMC7288295 DOI: 10.3390/jcm9051288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/25/2020] [Accepted: 04/28/2020] [Indexed: 12/24/2022] Open
Abstract
The timing, causes, and quality of care for patients who die after emergency laparotomy have not been extensively reported. A large database of 13,953 patients undergoing emergency laparotomy, between July 2014 and March 2017, from 28 hospitals in England was studied. Anonymized data was extracted on day of death, patient demographics, operative details, compliance with standards of care, and 30-day and in-patient mortality. Thirty-day mortality was 8.9%, and overall inpatient mortality was 9.8%. Almost 40% of postoperative deaths occurred within three days of surgery, and 70% of these early deaths occurred on the day of surgery or the first postoperative day. Such early deaths could be considered nonbeneficial surgery. Patients who died within three days of surgery had a significantly higher preoperative lactate, American Society of Anesthesiologists Physical Status (ASA-PS) grade, and Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM). Compliance with perioperative standards of care based on the Emergency Laparotomy Collaborative care bundle was high overall and better for those patients who died within three days of surgery. Multidisciplinary team involvement from intensive care, care of the elderly physicians, and palliative care may help both the communication and the burden of responsibility in deciding on the risk–benefit of operative versus nonoperative approaches to care.
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Foss NB, Kehlet H. Challenges in optimising recovery after emergency laparotomy. Anaesthesia 2020; 75 Suppl 1:e83-e89. [PMID: 31903571 DOI: 10.1111/anae.14902] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2019] [Indexed: 12/19/2022]
Abstract
Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.
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Affiliation(s)
- N B Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - H Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Abstract
Emergency laparotomies have remained a challenging entity since many decades. Only during the past 10 years, serious efforts have been made to improve their outcome by conducting audits and designing care pathways. Indications for emergency laparotomies can be broadly classified into trauma and non-trauma surgeries, which are either done for control of hemorrhage or/and done for control of sepsis and organ dysfunction. Goal-directed resuscitation for septic/hemorrhagic shock, consultant-led multidisciplinary teams, and timely transfer to intensive care units form core principles of management for these patients. Global inequity in access to standard and affordable emergency surgeries is an area of concern requiring integrated efforts at international level. How to cite this article: Ahmed A, Azim A. Emergency Laparotomies: Causes, Pathophysiology, and Outcomes. Indian J Crit Care Med 2020;24(Suppl 4):S183–S189.
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Affiliation(s)
- Armin Ahmed
- Department of Critical Care Medicine, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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