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Implementing Bundle Care in Major Abdominal Emergency Surgery: Long-Term Mortality and Comprehensive Complication Index. World J Surg 2023; 47:106-118. [PMID: 36171351 PMCID: PMC9726819 DOI: 10.1007/s00268-022-06763-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Major abdominal emergency surgery (MAES) has a high risk of postoperative mortality and a high complication rate. The aim of this study was to evaluate whether the implementation of a perioperative care bundle reduced long-term mortality and the Comprehensive Complication Index (CCI) after MAES. METHODS This study was a single-centre retrospective cohort study. Data in the intervention group were collected prospectively and compared with a historical cohort from the same centre. It includes adult patients undergoing MAES. We implemented a care bundle under the name Abdominal Surgery Acute Protocol (ASAP). We initiated fast-track initiatives and standardised optimised care in before, during and after surgery. Data were analysed using survival analysis and multiple regression. RESULTS We included 120 patients in the intervention cohort and 258 in the historical cohort. The one-year mortality rate was 21.7% in the intervention cohort compared to 28.3% in the standard care cohort. Adjusted odds ratio of one-year mortality 0.81 (CI95% 0.41-1.56). The 30-day mortality was lowered from 19.0 to 6.7% (p = 0.003). The CCI in the intervention cohort was 8.7 (IQR 0-34) compared to 21 (IQR 0-36) in the control cohort (p = 0.932) The length of stay increased by two days (p = 0.021). Most cases had 71-80% protocol compliance. CONCLUSION Implementing bundle care in major abdominal emergency surgery lowered the 30-day postoperative mortality. The difference in mortality was preserved over time although not significant after one year. The changes in the Comprehensive Complication Index were not statistically significant.
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Voldby AW, Boolsen AW, Aaen AA, Burcharth J, Ekeløf S, Loprete R, Jønck S, Eskandarani HA, Thygesen LC, Møller AM, Brandstrup B. Complications and Their Association with Mortality Following Emergency Gastrointestinal Surgery-an Observational Study. J Gastrointest Surg 2022; 26:1930-1941. [PMID: 35606601 DOI: 10.1007/s11605-021-05240-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/29/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE Emergency gastrointestinal surgery is followed by a high risk of major complications and death. This study aimed to investigate which complications showed the strongest association with death following emergency surgery for gastrointestinal obstruction or perforation. METHODS We retrospectively included adults who had undergone emergency gastrointestinal surgery for radiologically verified obstruction or perforation at three Danish hospitals between 2014 and 2015. The exposure variables comprised 16 predefined Clavien-Dindo-graded complications. Cox regression with delayed entry was used to analyze the association of these complications with 90-day mortality. We adjusted for hospital, age, American Society of Anesthesiologists classification, pre-operative Sepsis-2 score, cardiac comorbidity, renal comorbidity, hypertension, active cancer, bowel obstruction or perforation, and the surgical procedure. Subgroup analyses were done for patients with gastrointestinal obstruction or perforation. RESULTS Of the 349 included patients, 281 (80.5%) experienced at least one complication. The risk of death was 20.6% (14) for patients with no complications and varied between 21 and 57% for patients with complications. Renal impairment (hazard ratio (HR): 6.8 (95%CI: 3.7-12.4)), arterial thromboembolic events (HR 4.8 (2.3-9.9)), and atrial fibrillation (HR 4.4 (2.8-6.8)) showed the strongest association with 90-day mortality. Atrial fibrillation was the only complication significantly associated with death in patients with gastrointestinal obstruction as well as perforation. CONCLUSION This study of patients undergoing emergency gastrointestinal surgery revealed that renal impairment, arterial thromboembolic events, and atrial fibrillation had the strongest association with death. Atrial fibrillation may serve as an in-situ marker of patients needing escalation of care.
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Affiliation(s)
- Anders Winther Voldby
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark.
| | - Anders Watt Boolsen
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
| | - Anne Albers Aaen
- Department of Anesthesiology and Intensive Care Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Jakob Burcharth
- Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Sarah Ekeløf
- Department of Surgery, Zealand University Hospital, Roskilde, Denmark
| | | | - Simon Jønck
- Department of Emergency Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Hassan Ali Eskandarani
- Department of Anesthesiology and Intensive Care Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Lau Caspar Thygesen
- Department of Population Health and Morbidity, University of Southern Denmark, Odense, Denmark
| | - Ann Merete Møller
- Department of Anesthesiology and Intensive Care Medicine, Herlev Hospital, Herlev, Denmark
| | - Birgitte Brandstrup
- Department of Surgery, Holbæk Hospital, Part of Copenhagen University Hospitals, Smedelundsgade 60, 4300, Holbaek, Denmark
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Shaker A, Hasanin A, Nagy M, Mostafa M, Fouad AZ, Mohamed H, Abdallah AS, Elsayad M. The Use of Lactate-Capillary Refill Time Product as Novel Index for Tissue Perfusion in Patients with Abdominal Sepsis: A Prospective Observational Study. Int J Gen Med 2022; 15:7443-7448. [PMID: 36172088 PMCID: PMC9512536 DOI: 10.2147/ijgm.s380195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/19/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ahmed Shaker
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
- Correspondence: Ahmed Hasanin, Department of anesthesia and critical care medicine, Faculty of Medicine, 01 elsarayah Street, Elmanyal, Cairo, Egypt, Tel +201000365115, Fax +20224168736, Email
| | - Mostafa Nagy
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Z Fouad
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Hassan Mohamed
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | | | - Mohamed Elsayad
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Shahait AD, Dolman H, Mostafa G. Postoperative Outcomes After Emergency Laparotomy in Nontrauma Settings: A Single-Center Experience. Cureus 2022; 14:e23426. [PMID: 35481305 PMCID: PMC9033638 DOI: 10.7759/cureus.23426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction: Emergency laparotomy (EL) is a common operation that deals with a wide range of pathologies. Preoperative optimization is often lacking due to the urgent nature of the disease process with a reported mortality rate of up to 44%. This study examines the mortality of EL at an academic acute care surgery medical center. Methods: A retrospective analysis of nontrauma EL from January 2008 to December 2013 was conducted. Data included demographics, clinical features, preoperative laboratory studies, comorbidities, time to surgery, ICU admission, and 30-day mortality. Results: A total of 234 patients (123 males, 52.6%) were included in the study. EL was performed within four hours (immediate) of presentation in 93 (39.7%) patients, within 4-12 hours (early) in 53 (25.4%) patients, and within 12-24 hours (late) in 63 (30.1%) patients. Overall mortality was 16 (6.8%) at 30 days. Mortality was significantly higher with chronic obstructive pulmonary disease (p = 0.014), blood transfusion (p < 0.001), ICU admission (p < 0.001), ventilator days > four (p = 0.013), hyperlipidemia (p = 0.014), heart rate > 90 beats/minute (p = 0.003), temperature > 38°C or < 35°C (p = 0.013), and systolic blood pressure < 90 mmHg (p < 0.001). Conclusion: EL can be performed with lower mortality than previously reported. Specific predictors of mortality are identified and can be used for risk assessment.
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Kassahun WT, Babel J, Mehdorn M. Assessing differences in surgical outcomes following emergency abdominal exploration for complications of elective surgery and high-risk primary emergencies. Sci Rep 2022; 12:1349. [PMID: 35079087 PMCID: PMC8789789 DOI: 10.1038/s41598-022-05326-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/06/2022] [Indexed: 11/09/2022] Open
Abstract
Irrespective of its etiology, emergency surgical abdominal exploration (EAE) is considered a high-risk procedure with mortality rates exceeding 20%. The aim of this study was to evaluate differences in outcomes in patients who required EAE due to complications of complex elective abdominal procedures and those who required EAE due to high-risk primary abdominal emergencies. Patients undergoing EAE for acute surgical complications of complex abdominal elective surgical procedures (N = 293; Elective group) and patients undergoing EAE for high-risk primary abdominal emergencies (N = 776; Emergency group) from 2012 to 2019 at our institution were retrospectively assessed for morbidity and mortality. Postoperative complications occurred in 196 patients (66.94%) in the elective group and 585 patients (75.4%) in the emergency group. The relatively low complication burden in the elective group was also evidenced by a significantly lower comprehensive complication index score (54.00 ± 37.36 vs. 59.25 ± 37.08, p = 0.040). The in-hospital mortality rates were 31% (91 of 293) and 38% (295 of 776) in the elective and emergency groups, respectively. This difference between the two groups was statistically significant (p = 0.035). In multivariate analysis, age, peripheral artery disease, pneumonia, thromboembolic events, ICU stay, ventilator dependence, acute kidney failure and liver failure were independent predictors of mortality. Our data show that patients undergoing EAE due to acute complications of major elective surgery tolerate the procedure relatively well compared with patients undergoing EAE due to primary high-risk abdominal emergencies.
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Affiliation(s)
- Woubet Tefera Kassahun
- Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebig Strasse 20, 04103, Leipzig, Germany.
| | - Jonas Babel
- Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebig Strasse 20, 04103, Leipzig, Germany
| | - Matthias Mehdorn
- Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebig Strasse 20, 04103, Leipzig, Germany
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6
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Smith MTD, Clarke DL. Staged laparotomy for acute non-traumatic intra-abdominal emergencies in a tertiary South African unit. ANZ J Surg 2021; 91:2637-2643. [PMID: 34636467 DOI: 10.1111/ans.17270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Patients undergoing laparotomy for emergency general surgery (EGS) have poor outcomes. Attempts have been made to improve these outcomes by adopting damage control principles known to benefit polytraumatized patients. Studies describing the use of staged laparotomy (SL) in EGS have been modest in size and heterogenous. The aim of this study was to describe our experience with SL at a tertiary hospital in KwaZulu-Natal, South Africa. METHODS The Hybrid Electronic Medical Registry (HEMR) at Greys Hospital was interrogated for all consecutive admissions undergoing staged EGS laparotomy. Descriptive and inferential statistics were performed. RESULTS From 2012 to 2018, 242 patients (16.5% of all EGS laparotomies) underwent SL for an EGS condition. The median patient age was 38 years old (IQR 27-56 years). Physiological indications were present in 125 patients (51.7%) and non-physiological indications (NPI) in 117 (48.3%). Haemodynamic instability was the most common physiological indication (51; 21.1%) and gross contamination was the most non-physiological indication (91; 37.6%). Adverse event and mortality rates were 84.8% and 26.9%, respectively. Independent predictors of mortality were enteric breach (OR3.9; 95% CI (2.1-7.8)), physiological indication (OR 2.1; 95% CI (1.1-3.7)) and anastomosis (OR 2.0; 1.05-3.73). "Clip and drop" did not contribute to mortality (P = 0.43; OR1.34 (0.64-2.7)). Mortality was higher in the group without repeat laparotomy. Mortality rate was not associated with increasing number of relaparotomies. CONCLUSION Patients undergoing EGS laparotomy form a high-risk group. "Clip and drop" approach and number of relaparotomies were not associated with mortality. Indications and components of this approach need to be standardized.
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Affiliation(s)
- Michelle T D Smith
- Department of Surgery, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Damian L Clarke
- Department of Surgery, University of KwaZulu-Natal, Pietermaritzburg, South Africa
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Twahirwa I, Niyonshuti N, Uwase C, Rickard J. Comparison of Outcomes of Emergency Laparotomies Performed During Daytime Versus Nights and Weekends in Rwandan University Teaching Hospitals. World J Surg 2021; 46:61-68. [PMID: 34581844 DOI: 10.1007/s00268-021-06327-6] [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: 08/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency laparotomy is a common procedure with high morbidity and mortality. The aim of this study was to assess if the time of surgery (day versus night and weekend) affects the morbidity and mortality in a low-resource setting. METHODS A retrospective study was conducted in 2 university teaching hospitals in Rwanda. Patient characteristics, time of laparotomy, operative details and postoperative outcomes were recorded. Chi-square and Wilcoxon rank sum tests were used to determine factors and outcomes associated with time of surgery. Logistic regression was used to determine factors associated with mortality. RESULTS In 309 patients, who underwent emergency laparotomy, 147 (48%) patients were operated during the daytime, 123 (40%) patients were operated during the night shift and 39 (12%) patients were operated on the weekend. Common diagnoses were intestinal obstruction (n = 141, 46%), peritonitis (n = 101, 33%) and abdominal trauma (n = 40, 13%). The overall mortality rate was 16% with 14% in patients operated during day and 17% in patients operated during night and weekends (p = 0.564). Overall, the morbidity rate was 30% with 27% in patients operated during the day compared with 32% in patients operated during night/weekends (p = 0.348). After controlling for confounding factors, there was no association between time of operation and mortality or morbidity. CONCLUSION Morbidity and mortality associated with emergency laparotomy are high but the time of day for emergency laparotomy did not affect outcome in Rwandan referral hospitals.
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Affiliation(s)
- Isaie Twahirwa
- University of Rwanda, Kigali, Rwanda
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Norbert Niyonshuti
- University of Rwanda, Kigali, Rwanda
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Clement Uwase
- University of Rwanda, Kigali, Rwanda
- University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jennifer Rickard
- University of Rwanda, Kigali, Rwanda.
- University Teaching Hospital of Kigali, Kigali, Rwanda.
- University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA.
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Batt JP, Vincent RC. Are we selecting appropriate admissions for intensive care following major abdominal surgery: A retrospective cohort study on outcomes of 1059 patients. Int J Crit Illn Inj Sci 2021; 11:14-17. [PMID: 34159131 PMCID: PMC8183373 DOI: 10.4103/ijciis.ijciis_9_20] [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: 02/06/2020] [Revised: 03/26/2020] [Accepted: 05/05/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Like any other medical treatment, The intensive care unit (ICU) is a limited resource that needs to be utilized appropriately. This study aimed to identify the outcomes of patients admitted to the ICU based on patient demographic and severity score parameters. Methods: An observational retrospective cohort study of 1059 patients undergoing laparotomy who were admitted to the ICU was performed. Cases were sub-classified by the mode of admission and risk prediction scores and analyzed outcomes of mortality, ICU length of stay (LOS), and hospital LOS. Results: The mean age of patients who did not survive was older than those who survived, and higher Acute Physiology and Chronic Health Evaluation (APACHE) II and Intensive Care National Audit and Research Centre Physiology Score (ICNARC) observed in patients who died. Emergency admission was also an indicator of increased mortality. Survivors APACHE II scores were the same if they were elective or emergency admissions, although Survivors ICNARC scores were higher in emergency than in elective admissions. Patients who did not survive had a longer ICU LOS stay than those who survived, whereas elective survivors had shorter ICU LOS than the emergency survivors. Regardless of this hospital LOS was the same for both elective and emergency survivors. Conclusion: The most unwell patients had the highest risk prediction scores, were more often admitted in the emergency setting, required longer stays in ICU, and had less favorable outcomes. However, ICU did appear to expedite the hospital discharges of emergency patients to match their elective counterparts. Decisions around when and to which patients ICU is an appropriate intervention remains a difficult decision and one that cannot be made without full consideration of all aspects of patient factors.
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Affiliation(s)
- Jeremy P Batt
- Department of General Surgery, Royal United Hospitals, Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, England
| | - Rosie C Vincent
- Department of General Surgery, Royal United Hospitals, Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, England
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9
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The importance of discussing mortality risk prior to emergency laparotomy. Updates Surg 2020; 72:859-865. [DOI: 10.1007/s13304-020-00756-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/23/2020] [Indexed: 11/25/2022]
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10
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Tukanova K, Markar SR, Jamel S, Vidal-Diez A, Hanna GB. An international comparison of the utilisation of and outcomes from minimal access surgery for the treatment of common abdominal surgical emergencies. Surg Endosc 2020; 34:2012-2018. [PMID: 31428852 PMCID: PMC7113203 DOI: 10.1007/s00464-019-06980-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/22/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Minimal access surgery (MAS) has suggested improvements in clinical outcomes compared to open surgery in several abdominal elective and emergency surgeries. The aims of this study were to compare England with the United States in the utilisation of MAS and mortality from four common abdominal surgical emergencies. METHODS Between 2006 and 2012, the rate of MAS and in-hospital mortality for appendicitis, incarcerated or strangulated abdominal hernia, small or large bowel and peptic ulcer perforation were compared between England and the United States. Univariate and multivariate analyses were performed to adjust for differences in baseline patient demographics. RESULTS 132,364 admissions in England were compared to an estimated 1,811,136 admissions in the United States. Minimal access surgery was used less commonly in England for appendicitis (odds ratio (OR) 0.27, 95% CI 0.267-0.278), abdominal hernia (OR 0.16, 95% CI 0.15-0.17), small or large bowel perforation (OR 0.33, 95% CI 0.32-0.35) and peptic ulcer perforation (OR 0.93, 95% CI 0.87-0.99). In-hospital mortality was increased in England compared to the United States for all four conditions: appendicitis (OR 2.11, 95% CI 1.66-2.68), abdominal hernia (OR 3.25, 95% CI 3.10-3.40), small or large bowel perforation (OR 3.88, 95% CI 3.76-3.99) and peptic ulcer perforation (OR 3.09, 95% CI 2.94-3.25). In England, after adjustment for patient demographics, open surgery was associated with increased in-hospital mortality for abdominal hernia (OR 1.80, 95% CI 1.26-2.71), small or large bowel perforation (OR 1.59, 95% CI 1.37-1.87) and peptic ulcer perforation (OR 2.31, 95% CI 1.91-2.82). CONCLUSIONS Minimal access surgery was performed less commonly and in-hospital mortality was increased in England compared to the United States for common abdominal surgical conditions. Therefore, strategies to enhance adoption of MAS in emergency conditions in England need to be optimised and include appropriate patient selection and improved surgeon MAS training.
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Affiliation(s)
- Karina Tukanova
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sheraz R. Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sara Jamel
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - George B. Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
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Mačiulienė A, Maleckas A, Kriščiukaitis A, Mačiulis V, Vencius J, Macas A. Predictors of 30-Day In-Hospital Mortality in Patients Undergoing Urgent Abdominal Surgery Due to Acute Peritonitis Complicated with Sepsis. Med Sci Monit 2019; 25:6331-6340. [PMID: 31441459 PMCID: PMC6717438 DOI: 10.12659/msm.915435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is a life-threatening condition with high morbidity and mortality rate. Identifying early prediction factors of critical situations in intra-abdominal sepsis patients can help reduce mortality rates. This prospective study was carried out to evaluate the association of technically available factors with 30-day in-hospital mortality. Material/Methods There were 67 intra-abdominal sepsis patients included in the study; patients were observed for 30 days postoperatively. The data was processed using SPSS24.0 statistical analysis package. All tests that had a significance level of 0.05 were selected. Results Septic shock in association with increase in age per year showed increase the odds of mortality and prognosed 30-days in hospital mortality correctly in 79% of cases. The observed OR was 12.24 (P<0.001). Multiple logistic regression model 2 for the 30-day mortality identified a combination of septic shock, age (≥70 years), time from peritonitis symptoms to surgery prognose mortality with accuracy of 82%. The most accurate model to prognose 30-day in-hospital mortality included the presents of septic shock, age, time from peritonitis symptoms to surgery, drop of MAP <65 mmHg) post-induction, the odds of mortality 8.86 (P=0.001). Severe hypotension post-induction was more frequent in patients who were not diagnosed with sepsis (P=0.035). Conclusions The present study revealed a simple indicator for the risk for death under diffuse peritonitis patients complicated with sepsis. Septic shock, increase in age per year, peritonitis symptoms lasting more than 30 hours, and severe hypotension post-induction had a negative prognostic value for mortality in patients with intra-abdominal sepsis, and might be a high risk for 30-day mortality.
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Affiliation(s)
- Asta Mačiulienė
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Almantas Maleckas
- Department of General Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Algimantas Kriščiukaitis
- Department of Physics, Mathematics and Biophysics, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vytautas Mačiulis
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Justinas Vencius
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Andrius Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Baldock TE, Brown LR, McLean RC. Perforated diverticulitis in the North of England: trends in patient outcomes, management approach and the influence of subspecialisation. Ann R Coll Surg Engl 2019; 101:563-570. [PMID: 31155922 DOI: 10.1308/rcsann.2019.0076] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION In recent years, several management options have been used in the management of perforated diverticulitis, ranging from conservative treatment to laparotomy. General surgery has also become increasingly specialised over time. This retrospective cohort study investigated changes in patient outcomes following perforated diverticulitis, management approach and the influence of consultant subspecialisation over time. MATERIALS AND METHODS Data was collected on patients admitted with perforated diverticulitis in the North of England between 2002 and 2016. Subspecialisation was categorised as colorectal or other general subspecialties. The primary outcome of interest was overall 30-day mortality; secondary outcomes included surgical approach, stoma and anastomosis rate. RESULTS A total of 3394 cases of perforated diverticulitis were analysed (colorectal, n = 1290 and other subspecialists, n = 2104) with a 30-day mortality of 11.6%. There was a significant reduction in mortality over time (2002-2006: 18.6% to 2012-2016: 6.8, P < 0.001).There was a significant reduction in open surgery (60% to 25.3%, P < 0.001) with increased conservative management (37.4% to 63.5%, P < 0.001), laparoscopic resection (0.1% to 4.9%, P < 0.001) and laparoscopic washout (0.1% to 5.7%, P < 0.001).Patients admitted under colorectal surgeons had lower mortality than other subspecialists (9.9% vs 12.4%, P = 0.027), which remained significant following multivariate adjustment (hazard ratio 1.44, P = 0.039). These patients had fewer stomas (13.9% vs. 21.0%, P = 0.001) and higher anastomosis rates (22.1% vs 15.8%, P = 0.004). CONCLUSION This study demonstrated considerable improvements in the management of perforated diverticulitis alongside the positive impact of subspecialisation on patient outcomes.
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Affiliation(s)
- T E Baldock
- County Durham and Darlington NHS Foundation Trust, Darlington Memorial Hospital, Darlington, UK
| | - L R Brown
- Health Education England North East, Newcastle Upon Tyne, UK
| | - R C McLean
- Health Education England North East, Newcastle Upon Tyne, UK
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13
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Gebremedhn EG, Agegnehu AF, Anderson BB. Outcome assessment of emergency laparotomies and associated factors in low resource setting. A case series. Ann Med Surg (Lond) 2018; 36:178-184. [PMID: 30505437 PMCID: PMC6249396 DOI: 10.1016/j.amsu.2018.09.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 06/27/2018] [Accepted: 09/21/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Emergency laparotomy is a high risk procedure which is demonstrated by high morbidity and mortality. However, the problem is tremendous in resource limited settings and there is limited data on patient outcome. We aimed to assess postoperative patient outcome after emergency laparotomy and associated factors. METHODS An observational study was conducted in our hospital from March 11- June 30, 2015 using emergency laparotomy network tool. All consecutive surgical patients who underwent emergency laparotomy were included. Binary and multiple logistic regressions were employed using adjusted odds ratios and 95% CI, and P-value < 0.05 was considered to be statistically significant. RESULT A total of 260 patients were included in the study. The majority of patients had late presentation (>6hrs) to the hospital after the onset of symptoms of the diseases and surgical intervention after hospital admission. The incidences of postoperative morbidity and mortality were 39.2% and 3.5% respectively. Factors associated with postoperative morbidity were preoperative co-morbidity (AOR = 0.383, CI = 0.156-0.939) and bowel resection (AOR = 0.232, CI = 0.091-0.591). Factors associated with postoperative mortality were anesthetists' preoperative opinion on postoperative patient outcome (AOR = 0.067, CI = 0.008-0.564), level of consciousness during recovery from anaesthesia (AOR = 0.114, CI = 0.021-10.628) and any re-intervention within 30 days after primary operation (AOR = 0.083, CI = 0.009-0.750). CONCLUSION AND RECOMMENDATION The incidence of postoperative morbidity and mortality after emergency laparotomy were high. We recommend preoperative optimization, early surgical intervention, and involvement of senior professionals during operation in these risky surgical patients. Also, we recommend the use of WHO or equivalent Surgical Safety Checklist and establishment of perioperative patient care bundle including surgical ICU and radiology investigation modalities such as CT scan.
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Affiliation(s)
- Endale Gebreegziabher Gebremedhn
- Department of Anaesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, The University of Gondar, Gondar, Ethiopia
| | - Abatneh Feleke Agegnehu
- Department of Anaesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, The University of Gondar, Gondar, Ethiopia
| | - Bernard Bradley Anderson
- Department of Surgery, School of Medicine, Gondar College of Medicine and Health Sciences, The University of Gondar, Gondar, Ethiopia
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Tocaciu S, Thiagarajan J, Maddern GJ, Wichmann MW. Mortality after emergency abdominal surgery in a non‐metropolitan Australian centre. Aust J Rural Health 2018; 26:408-415. [DOI: 10.1111/ajr.12428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Shreya Tocaciu
- Department of General Surgery Mount Gambier General Hospital Mount Gambier South Australia Australia
| | - Jayaraman Thiagarajan
- Department of Anaesthesia Mount Gambier General Hospital Mount GambierSouth Australia Australia
| | - Guy J. Maddern
- Department of General Surgery Mount Gambier General Hospital Mount Gambier South Australia Australia
- Discipline of Surgery The Queen Elizabeth Hospital University of Adelaide Adelaide South Australia Australia
| | - Matthias W. Wichmann
- Department of General Surgery Mount Gambier General Hospital Mount Gambier South Australia Australia
- Discipline of Surgery The Queen Elizabeth Hospital University of Adelaide Adelaide South Australia Australia
- Flinders University Rural Medical School Flinders University Adelaide South Australia Australia
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Voldby AW, Aaen AA, Møller AM, Brandstrup B. Goal-directed fluid therapy in urgent GAstrointestinal Surgery-study protocol for A Randomised multicentre Trial: The GAS-ART trial. BMJ Open 2018; 8:e022651. [PMID: 30429144 PMCID: PMC6252645 DOI: 10.1136/bmjopen-2018-022651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/05/2018] [Accepted: 09/12/2018] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Intravenous fluid therapy during gastrointestinal surgery is a life-saving part of the perioperative care. Too little fluid may lead to hypovolaemia, decreased organ perfusion and circulatory shock. Excessive fluid administration increases postoperative complications, worsens pulmonary and cardiac function as well as the healing of surgical wounds. Intraoperative individualised goal-directed fluid therapy (GDT) and zero-balance therapy (weight adjusted) has shown to reduce postoperative complications in elective surgery, but studies in urgent gastrointestinal surgery are sparse. The aim of the trial is to test whether zero-balance GDT reduces postoperative mortality and major complications following urgent surgery for obstructive bowel disease or perforation of the gastrointestinal tract compared with a protocolled standard of care. METHODS/ANALYSIS This study is a multicentre, randomised controlled trial with planned inclusion of 310 patients. The randomisation procedure is stratified by hospital and by obstructive bowel disease and perforation of the gastrointestinal tract. Patients are allocated into either 'the standard group' or 'the zero-balance GDT group'. The latter receive intraoperative GDT (guided by a stroke volume algorithm) and postoperative zero-balance fluid therapy based on body weight and fluid charts. The protocolled treatment continues until free oral intake or the seventh postoperative day.The primary composite outcome is death, unplanned reoperations, life-threatening thromboembolic and bleeding complications, a need for mechanical ventilation or dialysis. Secondary outcomes are additional complications, length of hospital stay, length of stay in the intensive care unit, length of mechanical ventilation, readmissions and time to death. Follow-up is 90 days.We plan intention-to-treat analysis of the primary outcome. ETHICS AND DISSEMINATION The Danish Scientific Ethics Committee approved the GAS-ART trial before patient enrolment (J: SJ-436). Enrolment of patients began in August 2015 and is proceeding. We expect to publish the GAS-ART results in Summer 2019. TRIAL REGISTRATION NUMBER EudraCT 2015-000563-14.
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Affiliation(s)
| | - Anne Albers Aaen
- Department of Anaesthesiology, Holbaek University Hospital, Holbaek, Denmark
| | - Ann Merete Møller
- Department of Anaesthesiology and Intensive Care Medicine, Herlev University Hospital, Holbaek, Denmark
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Ebm C, Aggarwal G, Huddart S, Cecconi M, Quiney N. Cost-effectiveness of a quality improvement bundle for emergency laparotomy. BJS Open 2018; 2:262-269. [PMID: 30079396 PMCID: PMC6069361 DOI: 10.1002/bjs5.62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 02/22/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The recent Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) study showed that the use of a specific care bundle reduced mortality in patients undergoing emergency laparotomy. However, the costs of implementation of the ELPQuiC bundle remain unknown. The aim of this study was to assess the in-hospital and societal costs of implementing the ELPQuiC bundle. METHODS The ELPQuiC study employed a before-after approach using quality improvement methodology. To assess the costs and cost-effectiveness of the bundle, two models were constructed: a short-term model to assess in-hospital costs and a long-term model (societal decision tree) to evaluate the patient's lifetime costs (in euros). RESULTS Using health economic modelling and data collected from the ELPQuiC study, estimated costs for initial implementation of the ELPQuiC bundle were €30 026·11 (range 1794·64-40 784·06) per hospital. In-hospital costs per patient were estimated at €14 817·24 for standard (non-care bundle) treatment versus €15 971·24 for the ELPQuiC bundle treatment. Taking a societal perspective, lifetime costs of the patient in the standard group were €23 058·87, compared with €19 102·37 for patients receiving the ELPQuiC bundle. The increased life expectancy of 4 months for patients treated with the ELPQuiC bundle was associated with cost savings of €11 410·38 per quality-adjusted life-year saved. CONCLUSION Implementation of the ELPQuiC bundle is associated with lower mortality and higher in-hospital costs but reduced societal costs.
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Affiliation(s)
- C. Ebm
- Department of Anaesthesia and General ManagementWiener Privatklinik (WPK) ViennaViennaAustria
| | - G. Aggarwal
- Department of AnaesthesiaRoyal Surrey County HospitalGuildfordUK
| | - S. Huddart
- Department of AnaesthesiaRoyal Surrey County HospitalGuildfordUK
| | - M. Cecconi
- Department of Intensive Care MedicineSt George's Healthcare Trust and St George's University of LondonLondonUK
| | - N. Quiney
- Department of AnaesthesiaRoyal Surrey County HospitalGuildfordUK
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Gokani SA, Elmqvist KO, El-Koubani O, Ash J, Biswas SK, Rigaudy M. A cost-utility analysis of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service. Clinicoecon Outcomes Res 2018; 10:105-117. [PMID: 29497321 PMCID: PMC5822843 DOI: 10.2147/ceor.s150176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose This study aimed to perform an economic evaluation of small bite sutures versus large bite sutures in the closure of midline laparotomies in the United Kingdom National Health Service (NHS). Methods A cost-utility analysis was conducted using data from a systematic literature review. Large bite sutures placed 10 mm from the wound edge were compared to small bite sutures 3–6 mm from the wound edge. The analysis used a 3-year time horizon in order to take into account complications including incisional hernias and surgical site infections (SSIs). Cost and benefit data were considered from the perspective of the NHS. A two-way sensitivity analysis was conducted to assess the impact of a variation in the clinical effectiveness of small bite sutures. Results The incremental cost-effectiveness ratio was calculated to be −£482.61 per quality-adjusted life year (QALY) using the proposed small bite suture technique, indicating a cost saving to the NHS. Sensitivity analysis demonstrated that small bites are a cost-neutral technique provided that the cost of using small bites is less than £98 per patient. Small bites cost less than £20,000/QALY when they reduce either the rate of SSIs by more than 15% or the rate of hernias by more than 3.4%. Conclusion This study proposes that small bite sutures should become the mainstay suturing technique in the closure of midline laparotomies, replacing large bite sutures, which dominate current practice. The financial savings accompanied by the decrease in SSI rates and herniation warrant the use of this new technique. The sensitivity analysis demonstrates that findings hold true for a wide range of levels of clinical effectiveness for small bites.
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Affiliation(s)
| | | | | | - Javier Ash
- Faculty of Medicine, Imperial College London, London, UK
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Jønsson LR, Ingelsrud LH, Tengberg LT, Bandholm T, Foss NB, Kristensen MT. Physical performance following acute high-risk abdominal surgery: a prospective cohort study. Can J Surg 2018; 61:42-49. [PMID: 29368676 PMCID: PMC5785288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Acute high-risk abdominal (AHA) surgery is associated with high mortality, multiple postoperative complications and prolonged hospital stay. Further development of strategies for enhanced recovery programs following AHA surgery is needed. The aim of this study was to describe physical performance and barriers to independent mobilization among patients who received AHA surgery (postoperative days [POD] 1-7). METHODS Patients undergoing AHA surgery were consecutively enrolled from a university hospital in Denmark. In the first postoperative week, all patients were evaluated daily with regards to physical performance, using the Cumulated Ambulation Score (CAS; 0-6 points) to assess basic mobility and the activPAL monitor to assess the 24-hour physical activity level. We recorded barriers to independent mobilization. RESULTS Fifty patients undergoing AHA surgery (mean age 61.4 ± 17.2 years) were included. Seven patients died within the first postoperative week, and 15 of 43 (35%) patients were still not independently mobilized (CAS < 6) on POD-7, which was associated with pulmonary complications developing (53% v. 14% in those with CAS = 6, p = 0.012). The patients lay or sat for a median of 23.4 hours daily during the first week after AHA surgery, and the main barriers to independent mobilization were fatigue and abdominal pain. CONCLUSION Patients who receive AHA surgery have very limited physical performance in the first postoperative week. Barriers to independent mobilization are primarily fatigue and abdominal pain. Further studies investigating strategies for early mobilization and barriers to mobilization in the immediate postoperative period after AHA surgery are needed.
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Affiliation(s)
- Line Rokkedal Jønsson
- From the Physical Medicine & Rehabilitation Research — Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
| | - Lina Holm Ingelsrud
- From the Physical Medicine & Rehabilitation Research — Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
| | - Line Toft Tengberg
- From the Physical Medicine & Rehabilitation Research — Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
| | - Thomas Bandholm
- From the Physical Medicine & Rehabilitation Research — Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
| | - Nicolai Bang Foss
- From the Physical Medicine & Rehabilitation Research — Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
| | - Morten Tange Kristensen
- From the Physical Medicine & Rehabilitation Research — Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
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Jønsson LR, Ingelsrud LH, Tengberg LT, Bandholm T, Foss NB, Kristensen MT. Physical performance following acute high-risk abdominal surgery: a prospective cohort study. Can J Surg 2017. [PMID: 29368676 DOI: 10.1503/cjs.012616] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Acute high-risk abdominal (AHA) surgery is associated with high mortality, multiple postoperative complications and prolonged hospital stay. Further development of strategies for enhanced recovery programs following AHA surgery is needed. The aim of this study was to describe physical performance and barriers to independent mobilization among patients who received AHA surgery (postoperative days [POD] 1-7). METHODS Patients undergoing AHA surgery were consecutively enrolled from a university hospital in Denmark. In the first postoperative week, all patients were evaluated daily with regards to physical performance, using the Cumulated Ambulation Score (CAS; 0-6 points) to assess basic mobility and the activPAL monitor to assess the 24-hour physical activity level. We recorded barriers to independent mobilization. RESULTS Fifty patients undergoing AHA surgery (mean age 61.4 ± 17.2 years) were included. Seven patients died within the first postoperative week, and 15 of 43 (35%) patients were still not independently mobilized (CAS < 6) on POD-7, which was associated with pulmonary complications developing (53% v. 14% in those with CAS = 6, p = 0.012). The patients lay or sat for a median of 23.4 hours daily during the first week after AHA surgery, and the main barriers to independent mobilization were fatigue and abdominal pain. CONCLUSION Patients who receive AHA surgery have very limited physical performance in the first postoperative week. Barriers to independent mobilization are primarily fatigue and abdominal pain. Further studies investigating strategies for early mobilization and barriers to mobilization in the immediate postoperative period after AHA surgery are needed.
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Affiliation(s)
- Line Rokkedal Jønsson
- From the Physical Medicine & Rehabilitation Research -Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
| | - Lina Holm Ingelsrud
- From the Physical Medicine & Rehabilitation Research -Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
| | - Line Toft Tengberg
- From the Physical Medicine & Rehabilitation Research -Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
| | - Thomas Bandholm
- From the Physical Medicine & Rehabilitation Research -Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
| | - Nicolai Bang Foss
- From the Physical Medicine & Rehabilitation Research -Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
| | - Morten Tange Kristensen
- From the Physical Medicine & Rehabilitation Research -Copenhagen (PMR-C), Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Hvidovre, Denmark (Jønsson, Bandholm, Kristensen); the Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark (Ingelsrud, Tange Kristensen); the Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark, and the Department of Surgery, Zealand University Hospital, Køge, Denmark (Tengberg); the Clinical Research Centre, Copenhagen University Hospital, Hvidovre, Denmark (Bandholm); and the Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark (Foss)
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Hussain A, Mahmood F, Teng C, Jafferbhoy S, Luke D, Tsiamis A. Patient outcome of emergency laparotomy improved with increasing "number of surgeons on-call" in a university hospital: Audit loop. Ann Med Surg (Lond) 2017; 23:21-24. [PMID: 29021897 PMCID: PMC5633340 DOI: 10.1016/j.amsu.2017.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 09/13/2017] [Accepted: 09/17/2017] [Indexed: 12/27/2022] Open
Abstract
AIM Emergency laparotomy is a commonly performed high-mortality surgical procedure. The National Emergency Laparotomy Network (NELA) published an average mortality rate of 11.1% and a median length of stay equivalent to 16.3 days in patients undergoing emergency laparotomy. This study presents a completed audit loop after implementing the change of increasing the number of on-call surgeons in the general surgery rota of a university hospital. The aim of this study was to evaluate the outcomes of emergency laparotomy in a single UK tertiary centre after addition of one more consultant in the daily on-call rota. METHODS This is a retrospective study involving patients who underwent emergency laparotomy between March to May 2013 (first audit) and June to August 2015 (second audit). The study parameters stayed the same. The adult patients undergoing emergency laparotomy under the general surgical take were included. Appendicectomy, cholecystectomy and simple inguinal hernia repair patients were excluded. Data was collected on patient demographics, ASA, morbidity, 30-day mortality and length of hospital stay. Statistical analysis including logistic regression was performed using SPSS. RESULTS During the second 3-month period, 123 patients underwent laparotomy compared to 84 in the first audit. Median age was 65(23-93) years. 56.01% cases were ASA III or above in the re-audit compared to 41.9% in the initial audit. 38% patients had bowel anastomosis compared to 35.7% in the re-audit with 4.2% leak rate in the re-audit compared to 16.6% in the first audit. 30-day mortality was 10.50% in the re-audit compared to 21% and median length of hospital stay 11 days in the re-audit compared to 16 days. The lower ASA grade was significantly associated with increased likelihood of being alive, as was being female, younger age and not requiring ITU admission post-operatively. However, having a second on-call consultant was 2.231 times more likely to increase the chances of patients not dying (p = 0.031). CONCLUSION Our audit-loop suggests that adding a second consultant to the daily on-call rota significantly reduces postoperative mortality and morbidity. Age, ASA and ITU admission are other independent factors affecting patient outcomes. We suggest this change be applied to other high volume centres across the country to improve the outcomes after emergency laparotomy.
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Affiliation(s)
- Anwar Hussain
- SpR Colorectal Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Fahad Mahmood
- Core Trainee General Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Chui Teng
- FY1 General Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Sadaf Jafferbhoy
- SpR General Surgery, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - David Luke
- Consultant colorectal Surgeon, Department of Colorectal Surgery, University Hospital of North Midlands, UK
| | - Achilleas Tsiamis
- Consultant colorectal Surgeon, Department of Colorectal Surgery, University Hospital of North Midlands, UK
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Egan RJ, Abdelrahman T, Tate S, Ansell J, Harries R, Davies L, Clark G, Lewis WG. Modular emergency general surgery training: A pilot study of a novel programme. Ann R Coll Surg Engl 2016; 98:475-8. [PMID: 27269241 PMCID: PMC5210010 DOI: 10.1308/rcsann.2016.0187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2016] [Indexed: 11/22/2022] Open
Abstract
Introduction Pan-speciality consensus guidance advocates mandatory emergency general surgery (EGS) training modules for specialist registrars (StRs). This pilot study evaluated the impact of EGS modules aimed at StRs over 1 year. Methods Eleven StRs were allocated a focused 4-week EGS module, in addition to the standard 1:12 on-call duty rota, in a tertiary surgical centre. Primary outcome measures included the number of indicative emergency operations and validated Procedure Based Assessments (PBAs) performed, both during the EGS module and over the training year. Results StRs performed a median of 11 (range 5-15) laparotomies during the EGS module versus 31 (range 9-49) over the whole training year. StRs attended 43.7% of available laparotomies during the module (range 24.1-63.7%). EGS modules provided more than one-third of the total emergency laparotomy experience, and a quarter of the emergency colectomy, appendicectomy and Hartmann's procedure experience. There were no differences in EGS module-related outcomes between junior and senior StRs. Significantly more PBAs related to laparotomy and segmental colectomy were completed during EGS modules than the on-call duty rota, at 32% versus 14% (p<0.001) and 48% versus 22% (p=0.019), respectively. Performance levels were maintained following module completion. Conclusions These findings provide an important baseline when considering future modular EGS training.
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Affiliation(s)
- R J Egan
- Wales Deanery, Neuadd Meirionnydd , Cardiff , UK
| | | | - S Tate
- Wales Deanery, Neuadd Meirionnydd , Cardiff , UK
| | - J Ansell
- Wales Deanery, Neuadd Meirionnydd , Cardiff , UK
| | | | - L Davies
- University Hospital of Wales , Cardiff , UK
| | - Gwb Clark
- University Hospital of Wales , Cardiff , UK
| | - W G Lewis
- University Hospital of Wales , Cardiff , UK
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Pearce L, Smith SR, Parkin E, Hall C, Kennedy J, Macdonald A. Emergency General Surgery: evolution of a subspecialty by stealth. World J Emerg Surg 2016; 11:2. [PMID: 26733342 PMCID: PMC4700620 DOI: 10.1186/s13017-015-0058-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 12/31/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency surgical patients account for around half of all NHS surgical workload and 80 % of surgical deaths. Few trainees opt to CCT in General Surgery, and there is no recognised subspecialty training program in Emergency General Surgery (EGS). Despite this lack of training and relevant assessment by examination, there appears to be an increasing number of EGS posts advertised. This study aims to provide information about potential future employment opportunities for surgical trainees. METHODS All consultant surgeon posts, advertised in the British Medical Journal between January 2009 and December 2014 were included. Data collected included specialty, region and institute of advertised post. For the purposes of statistical analysis, data was divided into two separate year bands: 2009-2011 and 2012-2014. Statistical analysis was by Chi-squared test; p <0.01 was considered statistically significant. An online tool was also used to determine experience and attitudes towards EGS amongst Consultant members of the ASGBI and all UK trainees in national training number (NTN) posts. RESULTS Over the six-year study period, there were 1240 consultant job adverts in a general surgical specialty. Nine hundred and 75 were substantive posts; the region with the most jobs was London and the South East (n = 278). There were 55 jobs advertised in EGS, either with (20) or without (35) another subspecialty. The number of EGS adverts increased significantly in 2012-14 compared to 2009-11 (p = 0.008). 229 (28 %) Consultants and 309 (22 %) trainees responded to the survey. 16 % of consultants work in NHS institutions with Emergency General Surgeons. Only 21 % of trainees believe EGS will be delivered by EGS consultants in the future whilst 8.2 % of trainees stated EGS as their career plan. Less than half of all UK consultant surgeons see EGS as a subspecialty. CONCLUSIONS This data demonstrates increasing societal need for EGS consultants over the last six years and the emergence of Emergency Surgery as a new subspecialty. In order to meet the EGS needs of the NHS, general surgical training and the examination system need to be revised.
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Affiliation(s)
- L Pearce
- Clinical Research Fellow, Department of General Surgery, Central Manchester University Hospitals Foundation Trust, Oxford Road, Manchester, M13 9WL UK
| | - S R Smith
- Clinical Research Fellow, Department of General Surgery, Central Manchester University Hospitals Foundation Trust, Oxford Road, Manchester, M13 9WL UK
| | - E Parkin
- Clinical Research Fellow, Department of General Surgery, Central Manchester University Hospitals Foundation Trust, Oxford Road, Manchester, M13 9WL UK
| | - C Hall
- Clinical Research Fellow, Department of General Surgery, Central Manchester University Hospitals Foundation Trust, Oxford Road, Manchester, M13 9WL UK
| | - J Kennedy
- Clinical Research Fellow, Department of General Surgery, Central Manchester University Hospitals Foundation Trust, Oxford Road, Manchester, M13 9WL UK
| | - A Macdonald
- Clinical Research Fellow, Department of General Surgery, Central Manchester University Hospitals Foundation Trust, Oxford Road, Manchester, M13 9WL UK
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Sharrock AE, Gokani VJ, Harries RL, Pearce L, Smith SR, Ali O, Chu H, Dubois A, Ferguson H, Humm G, Marsden M, Nepogodiev D, Venn M, Singh S, Swain C, Kirkby-Bott J. Defining our destiny: trainee working group consensus statement on the future of emergency surgery training in the United Kingdom. World J Emerg Surg 2015; 10:26. [PMID: 26161133 PMCID: PMC4496942 DOI: 10.1186/s13017-015-0019-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/22/2015] [Indexed: 11/16/2022] Open
Abstract
The United Kingdom National Health Service treats both elective and emergency patients and seeks to provide high quality care, free at the point of delivery. Equal numbers of emergency and elective general surgical procedures are performed, yet surgical training prioritisation and organisation of NHS institutions is predicated upon elective care. The increasing ratio of emergency general surgery consultant posts compared to traditional sub-specialities has yet to be addressed. How should the capability gap be bridged to equip motivated, skilled surgeons of the future to deliver a high standard of emergency surgical care? The aim was to address both training requirements for the acquisition of necessary emergency general surgery skills, and the formation of job plans for trainee and consultant posts to meet the current and future requirements of the NHS. Twenty nine trainees and a consultant emergency general surgeon convened as a Working Group at The Association of Surgeons in Training Conference, 2015, to generate a united consensus statement to the training requirement and delivery of emergency general surgery provision by future general surgeons. Unscheduled general surgical care provision, emergency general surgery, trauma competence, training to meet NHS requirements, consultant job planning and future training challenges arose as key themes. Recommendations have been made from these themes in light of published evidence. Careful workforce planning, education, training and fellowship opportunities will provide well-trained enthusiastic individuals to meet public and societal need.
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Affiliation(s)
- A. E. Sharrock
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
- />Department of Emergency Surgery, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD UK
| | - V. J. Gokani
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - R. L. Harries
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - L. Pearce
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - S. R. Smith
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - O. Ali
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - H. Chu
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - A. Dubois
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - H. Ferguson
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - G. Humm
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - M. Marsden
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - D. Nepogodiev
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - M. Venn
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - S. Singh
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - C. Swain
- />Association of Surgeons in Training (ASiT), Royal College of Surgeons England, 35 – 43 Lincoln’s Inn Fields, London, WC2A 3P3 UK
| | - J. Kirkby-Bott
- />Department of Emergency Surgery, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD UK
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Ng HJ, Yule M, Twoon M, Binnie NR, Aly EH. Current outcomes of emergency large bowel surgery. Ann R Coll Surg Engl 2015; 97:151-6. [PMID: 25723694 PMCID: PMC4473394 DOI: 10.1308/003588414x14055925059679] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2014] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Emergency large bowel surgery (ELBS) is known to carry an increased risk of morbidity and mortality. Previous studies have reported morbidity and mortality rates up to 14.3%. However, there has not been a recent study to document the outcomes of ELBS following several major changes in surgical training and provision of emergency surgery. The aim of this study was therefore to explore the current outcomes of ELBS. METHODS A retrospective review was performed of a prospectively maintained database of the clinical records of all patients who had ELBS between 2006 and 2013. Data pertaining to patient demographics, ASA (American Society of Anesthesiologists) grade, diagnosis, surgical procedure performed, grade of operating surgeon and assistant, length of hospital stay, postoperative complications and in-hospital mortality were analysed. RESULTS A total of 202 patients underwent ELBS during the study period. The mean patient age was 62 years and the most common cause was colonic carcinoma (n=67, 33%). There were 32 patients (15.8%) who presented with obstruction and 64 (31.7%) had bowel perforation. The overall in-hospital mortality rate was 14.8% (n=30). A consultant surgeon was involved in 187 cases (92.6%) as either first operator, assistant or available in theatre. CONCLUSIONS ELBS continues to carry a high risk despite several major changes in the provision of emergency surgery. Further developments are needed to improve postoperative outcomes in these patients.
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Affiliation(s)
| | - M Yule
- University of Aberdeen, UK
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25
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Stoneham M, Murray D, Foss N. Emergency surgery: the big three - abdominal aortic aneurysm, laparotomy and hip fracture. Anaesthesia 2013; 69 Suppl 1:70-80. [DOI: 10.1111/anae.12492] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2013] [Indexed: 01/23/2023]
Affiliation(s)
- M. Stoneham
- Nuffield Division of Anaesthetics; Oxford University Hospitals NHS Trust; Oxford UK
| | - D. Murray
- James Cook University Hospital; Middlesbrough UK
| | - N. Foss
- Department of Anaesthesia; Hvidovre University Hospital; Copenhagen Denmark
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