EP.FRI.9Meta-analysis of mortality risk in octogenarians undergoing emergency General Surgery operations

Abstract Aims To quantify the risk of perioperative mortality in octogenarians undergoing emergency general surgical operations and to compare such risk between octogenarians and non-octogenarians. Methods A systematic review was performed in accordance with the PRISMA statement standards to identify studies reporting the mortality risk in patients aged over 80 years undergoing emergency general surgery operations. The certainty of evidence was assessed using the GRADE system. Random-effects models were applied to calculate pooled outcome data. Results Analysis of 66701 octogenarians from 22 studies showed that the risk of 30-day mortality was 26% (95% CI 18-34%) for all operations;29% (95% CI 25-33%) for emergency laparotomy,9% (95% CI 1-23%) for non-laparotomy emergency operations;21% (95% CI 13-30%) for colon resection;17% (95% CI 11-25%) for small bowel resection;9% (95% CI 7-11%) for adhesiolysis;6% (95% CI 5.9-6.8%) for perforated ulcer repair;3% (95% CI 2.6-4%) for appendicectomy;3% (95% CI 2.8-3.3%) for cholecystectomy;5% (95% CI 0.2-14%) for hernia repair. When stratified based on ASA status, the risk was 11% (95% CI 4-20%) for ASA 2, 22% (95% CI 10-36%) for ASA 3, 39% (95% CI 29-48%) for ASA 4, and 94% (95% CI 77-100%) for ASA 5. The risk was higher in octogenarians compared with non-octogenarians (OR:4.07,95% CI 2.40-6.89), patients aged 70-79 (OR:1.21,95% CI 1.13-1.31), and patients aged 50-79 (OR:2.03,95% CI 1.68-2.45). Conclusions The risk of perioperative death in octogenarians undergoing emergency general surgical operations is higher than the risk in younger patients. Laparotomy, bowel resection, and ASA status above 3 carry the highest risk.

Download Full-text

Hospital Volume of Emergency General Surgery and its Impact on Inpatient Mortality for Geriatric Patients: Analysis From 3994 Hospitals

The American Surgeon ◽

10.1177/00031348211049251 ◽

2021 ◽

pp. 000313482110492

Author(s):

Darwin Ang ◽

Jonathan Sugimoto ◽

Winston Richards ◽

Huazhi Liu ◽

Kyle Kinslow ◽

...

Keyword(s):

Small Bowel ◽

General Surgery ◽

Hospital Volume ◽

Geriatric Patients ◽

Bowel Resection ◽

High Volume ◽

Small Bowel Resection ◽

Inpatient Mortality ◽

Emergency General Surgery ◽

Partial Colectomy

Background Previous investigations have shown a positive association between hospital volume of operations and clinical outcomes. However, it is unclear whether such relationships also apply to emergency surgery. We sought to examine the association between hospital case volume and inpatient mortality for 7 common emergency general surgery (EGS) operations among geriatric patients. Methods This is a population based retrospective cohort study using the Centers of Medicare and Medicaid Services (CMS) Limited Dataset Files (LDS) from 2011 to 2013. The 7 most common emergency surgeries included (1) partial colectomy, (2) small-bowel resection (SBR), (3) cholecystectomy, (4) appendectomy, (5) lysis of adhesions (LOA), (6) operative management of peptic ulcer disease (PUD), and (7) laparotomy with the primary outcome being inpatient mortality. Risk-adjusted inpatient mortality was plotted against operative volume. Subsequently an operative volume threshold was calculated using a best fit regression method. Based on these estimates, high- and low-volume hospitals were compared to examine significance of outcomes. Significance was defined as P-value < .05. Results The final cohort comprised of 414 779 patients from 3994 hospitals. The standardized mortality ratio (SMR) for high-volume centers were lower in 6 out of 8 surgeries examined. Small-bowel resection and partial colectomy operations had a significant decrease in mortality based on a volume threshold. Conclusion We observed decreased mortality with higher surgical volume for small-bowel resection and partial colectomy operations. Such differences may be related to practice patterns during the perioperative period, as complications related to the perioperative care were significantly lower for high-volume centers.

Download Full-text

892 Emergency General Surgical Practice at a District General Hospital during COVID-19 Pandemic: Implementing Royal College of Surgeons Guidance

British Journal of Surgery ◽

10.1093/bjs/znab134.502 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

K Hashmi ◽

S Khalid ◽

K Raja ◽

A Zaka ◽

J Easterbrook

Keyword(s):

Informed Consent ◽

Royal College ◽

Mortality Risk ◽

General Surgery ◽

Surgical Care ◽

District General Hospital ◽

Emergency General Surgery ◽

Surgical Practice ◽

Full Compliance ◽

Type Of Surgery

Abstract Introduction COVID-19 pandemic had a significant impact on surgical practice across NHS. RCS released guidance on altering surgical practise during the pandemic to deliver safe surgical care in March, 2020. We present an audit conducted at a DGH comparing practice of emergency general surgery (EGS) with RCS guidance at the peak of COVID-19 pandemic. Method Consecutive patients undergoing EGS from 1st April to 15th May,2020. Data of demographics, ASA grade, comorbidities, type of surgery, hospital stay, informed COVID-19 pneumonia consent, complications and 30-day mortality were collected. Pre- and post-operative COVID-19 status was determined. Results Forty-four (n = 44) patients, mean age 47.5 and IQR (26-69). Male (55.8%) and females (44.2%). Preoperative COVID19 status was confirmed in around 79.1% patients. All (100%) patients who underwent CT imaging preoperatively had CT chest performed. Informed consent for COVID19 pneumonia was taken in 4.7% patients. 30-day mortality risk was 7% and complications risk was 4.7%. RR of 30-day mortality in preoperative COVID19 status positive patients was RR = 0.92 (CI 0.85-1.01) and for complications was RR = 0.95 (CI 0.88-1.02). Conclusions RCS guidance on managing and altering practice in EGS during COVID-19 pandemic is reliable, implementable, and measurable in a DGH setting. Simple improvements in consent process can achieve full compliance with RCS guidelines.

Download Full-text

Cocaine-induced mesenteric ischaemia requiring small bowel resection

BMJ Case Reports ◽

10.1136/bcr-2020-238593 ◽

2021 ◽

Vol 14 (1) ◽

pp. e238593

Author(s):

Asya Veloso Costa ◽

Asiya Zhunus ◽

Rehana Hafeez ◽

Arsh Gupta

Keyword(s):

Small Bowel ◽

Social History ◽

Bowel Resection ◽

Early Recognition ◽

Small Bowel Resection ◽

Emergency Laparotomy ◽

Mesenteric Ischaemia ◽

Bowel Ischaemia ◽

Systemic Complications ◽

Gastrointestinal Complications

Cocaine use causes profound vasoconstriction leading to various systemic complications. Gastrointestinal complications such as mesenteric ischaemia are difficult to recognise and may result in serious consequences if not treated promptly. We report on the case of a 47-year-old man presenting with mesenteric ischaemia on a background of acute on chronic cocaine consumption, where diagnosis was not evident until second presentation. He underwent an emergency laparotomy with small bowel resection and jejunostomy formation and made a good recovery with eventual reversal surgery. The literature on cocaine-induced bowel ischaemia shows significant variability in presentation and outcome. Laboratory investigations are non-specific, and early recognition is vital. Given the increasing recreational use of cocaine in the UK, it is imperative to have a high clinical index of suspicion for mesenteric ischaemia in patients presenting with non-specific abdominal pain, and to ensure a detailed social history covering recreational drug use is not forgotten.

Download Full-text

Impact of frailty on clinical outcomes and resource use following emergency general surgery in the United States

PLoS ONE ◽

10.1371/journal.pone.0255122 ◽

2021 ◽

Vol 16 (7) ◽

pp. e0255122

Author(s):

Joseph Hadaya ◽

Yas Sanaiha ◽

Catherine Juillard ◽

Peyman Benharash

Keyword(s):

Clinical Outcomes ◽

General Surgery ◽

Resource Use ◽

Large Bowel ◽

Bowel Resection ◽

Emergency General Surgery ◽

Frail Patients ◽

Home Discharge ◽

Kaplan Meier ◽

Large Bowel Resection

Background Frailty has been recognized as an independent risk factor for inferior outcomes, but its effect on emergency general surgery (EGS) is understudied. Objective The purpose of the present study was to define the impact of frailty on risk-adjusted mortality, non-home discharge, and readmission following EGS operations. Methods Adults undergoing appendectomy, cholecystectomy, small bowel resection, large bowel resection, repair of perforated ulcer, or laparotomy within two days of an urgent admission were identified in the 2016–2017 Nationwide Readmissions Database. Frailty was defined using diagnosis codes corresponding to the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable regression was used to study in-hospital mortality and non-home discharge by operation, and Kaplan Meier analysis to study freedom from unplanned readmission at up to 90-days follow-up. Results Among 655,817 patients, 11.9% were considered frail. Frail patients most commonly underwent large bowel resection (37.3%) and cholecystectomy (29.2%). After adjustment, frail patients had higher mortality rates for all operations compared to nonfrail, including those most commonly performed (11.9% [95% CI 11.4–12.5%] vs 6.0% [95% CI 5.8–6.3%] for large bowel resection; 2.3% [95% CI 2.0–2.6%] vs 0.2% [95% CI 0.2–0.2%] for cholecystectomy). Adjusted non-home discharge rates were higher for frail compared to nonfrail patients following all operations, including large bowel resection (68.1% [95% CI 67.1–69.0%] vs 25.9% [95% CI 25.2–26.5%]) and cholecystectomy (33.7% [95% CI 32.7–34.7%] vs 2.9% [95% CI 2.8–3.0%]). Adjusted hospitalization costs were nearly twice as high for frail patients. On Kaplan-Meier analysis, frail patients had greater unplanned readmissions (log rank P<0.001), with 1 in 4 rehospitalized within 90 days. Conclusions Frail patients have inferior clinical outcomes and greater resource use following EGS, with the greatest absolute differences following complex operations. Simple frailty assessments may inform expectations, identify patients at risk of poor outcomes, and guide the need for more intensive postoperative care.

Download Full-text

Does declared surgeon specialist interest influence the outcome of emergency laparotomy?

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2020.0098 ◽

2020 ◽

Vol 102 (6) ◽

pp. 437-441

Author(s):

S Hallam ◽

M Bickley ◽

L Phelan ◽

M Dilworth ◽

DM Bowley

Keyword(s):

Length Of Stay ◽

General Surgery ◽

Special Interest ◽

Operative Procedure ◽

Emergency Laparotomy ◽

Emergency General Surgery ◽

Call Structure ◽

Increased Risk ◽

The Uk ◽

National Emergency

Introduction In the UK, general surgeons must demonstrate competency in emergency general surgery before obtaining a certificate of completion of training. Subsequently, many consultants develop focused elective specialist interests which may not mirror the breadth of procedures encountered during emergency practice. Recent National Emergency Laparotomy Audit analysis found that declared surgeon special interest impacted emergency laparotomy outcomes, which has implications for emergency general surgery service configuration. We sought to establish whether local declared surgeon special interest impacts emergency laparotomy outcomes. Methods Adult patients having emergency laparotomy were identified from our prospective National Emergency Laparotomy Audit database from May 2016 to May 2019 and categorised as colorectal or oesophagogastric according to operative procedure. Outcomes included 30-day mortality, return to theatre and length of stay. Binomial logistic regression was used to identify any association between declared consultant specialist interest and outcomes. Results Of 600 laparotomies, 358 (58.6%) were classifiable as specialist procedures: 287 (80%) colorectal and 71 (20%) oesophagogastric. Discordance between declared specialty and operation undertaken occurred in 25% of procedures. For colorectal emergency laparotomy, there was an increased risk of 30-day mortality when performed by a non-colorectal consultant (unadjusted odds ratio 2.34; 95% confidence interval 1.10–5.00; p = 0.003); however, when adjusted for confounders within multivariate analysis declared surgeon specialty had no impact on mortality, return to theatre or length of stay. Conclusion Surgeon-declared specialty does not impact emergency laparotomy outcomes in this cohort of undifferentiated emergency laparotomies. This may reflect the on-call structure at Birmingham Heartlands Hospital, where a colorectal and oesophagogastric consultant are paired on call and provide cross-cover when needed.

Download Full-text

TP9.2.21Laparoscopy in Emergency General Surgery (The LEGS Study): NELA Database Analysis -Comparison of Outcomes in Laparoscopic versus Open Surgery

British Journal of Surgery ◽

10.1093/bjs/znab362.121 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Kat Parmar ◽

Ellena Badrick ◽

Lee Malcomson ◽

Andrew Renehan ◽

Abhi Sharma ◽

...

Keyword(s):

Hospital Admission ◽

General Surgery ◽

Open Surgery ◽

Laparoscopic Approach ◽

Laparoscopic Group ◽

Time Of Day ◽

Emergency Laparotomy ◽

Emergency General Surgery ◽

Icu Stay ◽

Secondary Outcomes

Abstract Introduction Guidelines suggest the laparoscopic approach may be safe and feasible in emergency general surgery. Despite this, the UK National Emergency Laparotomy Audit (NELA) rate of laparoscopic surgery remains low. Our earlier analysis of the NELA database identified factors associated with use of laparoscopy, then recommended further analysis to compare outcomes between laparoscopic and open surgery. Methods We obtained information from the NELA database (2013 - 2017) and performed logistic regression on all first operations during the hospital admission. Outcomes were compared between open and laparoscopic approach (fully laparoscopic, laparoscopic assisted and laparoscopic converted). The primary outcome was death during hospital admission; secondary outcomes were admission to intensive care unit (ICU), length of ICU stay and return to theatre. Results The cohort comprised 68,928 open (52% men, mean age 65) and 12,144 laparoscopic (51% men, mean age 58). In a model adjusted for all factors influencing primary or secondary outcomes (age, gender, p-possum, weekday versus weekend, operative time of day, malignancy, peritoneal soiling, CEPOD urgency, surgical grade and anaesthetist grade), death rates were significantly lower in the laparoscopic group (OR 0.65, 95% CI 0.59 – 0.71). Post-operative admission to ICU and ICU stay > 3 days were both significantly lower in the laparoscopic group (OR 0.59, 95% CI 0.56 – 0.62; OR 0.82, CI 0.75 – 0.89). There was no difference in return to theatre. Conclusions Outcomes for laparoscopy in emergency general surgery appear superior to open surgery, although there may be residual unmeasured confounding factors. Further analysis will compare outcomes between pathologies.

Download Full-text

Clinical study of relaparotomy after emergency general surgery in a tertiary center of central India: a retrospective study

International Surgery Journal ◽

10.18203/2349-2902.isj20203228 ◽

2020 ◽

Vol 7 (8) ◽

pp. 2490

Author(s):

Archana Shukla ◽

Ramashankar Gupta ◽

Prateek Malpani

Keyword(s):

General Surgery ◽

Rare Complication ◽

Morbidity And Mortality ◽

Emergency Laparotomy ◽

Anastomotic Site ◽

Emergency General Surgery ◽

Case Record ◽

Mortality And Morbidity ◽

Initial Surgery ◽

Tertiary Center

Background: Relaparotomy after emergency surgery is a catastrophic situation associated with significant morbidity and mortality. Incidence is highly variable depending not only on hospital set up but also on the patient’s characteristics as well as on the initial surgery and postoperative care given. This study was thus, planned to identify the indications, procedure, risk factors and outcomes of relaparotomy so that timely intervention can lower incidence and morbidity.Methods: This was a retrospective cohort study conducted in department of general surgery, Gandhi Medical College and associated Hamidia Hospital from January 2018 to December 2019. All patients irrespective of age and sex, who have undergone emergency re-exploration of the abdomen during the period of hospitalization after the first operation and discharge of patients. Data were recorded in pre-validated case record form.Results: 32 cases of relaparotomy were identified. All patients had emergency laparotomy as primary surgery. Majority of patients required relaparotomy for anastomotic site leak in 16 cases (50%) followed by intestinal obstruction in 10 cases (31%), hemorrhage in 4 cases (16%) while the least cause being intra-abdominal sepsis in 2 cases (6.2%). Relaparotomy was associated with increased mortality and morbidity. Out of 32 patients, 4 (12.5%) patients died.Conclusions: Relaparotomy is a rare complication and a lifesaving procedure for patients. Calculative experience guided decision on relaparotomy can decrease the incidence of morbidity and mortality associated with the procedure.

Download Full-text

The influence of gastrointestinal resection on sunitinib exposure in GIST patients.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.15_suppl.10547 ◽

2013 ◽

Vol 31 (15_suppl) ◽

pp. 10547-10547

Author(s):

Djoeke de Wit ◽

Nielka P van Erp ◽

Reza Khosravan ◽

Robin Wiltshire ◽

Randy U. Allred ◽

...

Keyword(s):

Small Bowel ◽

Bowel Resection ◽

Geometric Mean ◽

Partial Gastrectomy ◽

Small Bowel Resection ◽

Colon Resection ◽

Palliative Surgery ◽

Analysis Of Covariance ◽

Pharmacokinetic Data ◽

And Control

10547 Background: GIST patients often have an altered anatomy of the GI tract due to either primary resection of the tumor or palliative surgery. It is unknown whether such GI resections affect the exposure to sunitinib and its active metabolite SU12662. Previous studies showed that the exposure to imatinib and nilotinib was decreased in GIST patients with prior major gastrectomy. Therefore, we postulated that GI resections might similarly affect sunitinib exposure. Methods: A retrospective analysis was performed to assess the effect of GI resections on sunitinib exposure. Pharmacokinetic data from 305 GIST patients included in 4 phase I-II trials were analyzed. Patients were subdivided into 6 groups according to prior GI surgery: 1)Major gastrectomy: 2)Partial gastrectomy: 3)Small bowel resection: 4)Combination of gastrectomy and small bowel resection: 5)Colon resection and 6)Controls with no prior GI surgery. Patients with uncertain GI resections were excluded. Dose normalized exposure (AUC0-24hr) of sunitinib and SU12662 was estimated with a population PK approach using NONMEM. Analysis of covariance was performed to test for significant differences in AUC between each of the subgroups and controls. Results: The geometric mean of total exposure to sunitinib and SU12662 was decreased by 21% and 28% in subgroup 4, (n=8; sunitinib: 931 ng*hr/mL (95%CI;676-1283) and SU12662: 354 ng*hr/mL (95%CI;174-720)) compared to controls (n=63; sunitinib: 1177 ng*hr/mL (95%CI;1097-1263) and SU12662: 491 ng*hr/mL (95%CI;435-555)), with the differences being significant (p<0.05) on the log scale. However, no significant differences in total exposures were observed between each of the other subgroups and control. Conclusions: In patients with a combined gastrectomy and small bowel resection, sunitinib and SU12662 exposure is significantly decreased as compared to subjects with no prior GI surgery. Contrary to previous results for imatinib, gastrectomy alone does not appear to influence sunitinib exposure. This should be taken into consideration for the treatment of GIST patients who had a gastrectomy. In theory, such patients might have better outcomes if treated with sunitinib, given the risk of subtherapeutic exposure to imatininb.

Download Full-text

Meta-analysis of mortality risk in octogenarians undergoing emergency general surgery operations

Surgery ◽

10.1016/j.surg.2020.11.027 ◽

2021 ◽

Author(s):

Shahab Hajibandeh ◽

Shahin Hajibandeh ◽

George A. Antoniou ◽

Stavros A. Antoniou

Keyword(s):

Mortality Risk ◽

General Surgery ◽

Meta Analysis ◽

Emergency General Surgery

Download Full-text

The front-line general surgery consultant as a new model of emergency care

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2017.0081 ◽

2017 ◽

Vol 99 (7) ◽

pp. 550-554 ◽

Cited By ~ 9

Author(s):

AP Navarro ◽

EJO Hardy ◽

B Oakley ◽

E Mohamed ◽

NT Welch ◽

...

Keyword(s):

Patient Satisfaction ◽

Patient Experience ◽

General Surgery ◽

Waiting Times ◽

Emergency Laparotomy ◽

Service Improvement ◽

Emergency General Surgery ◽

Resource Requirement ◽

New Model ◽

Significant Difference

Introduction Emergency general surgery services in England are undergoing rapid structural change with the aim of improving care. In our centre, the key issues identified were high numbers of admissions, inappropriate referrals, prolonged waiting times, delayed senior input and poor patient satisfaction. A new model was launched in January 2015 to address these issues: the surgical triage unit (STU). This study assesses the success of the new service. Methods All emergency general surgical admissions during a five-month period before introduction of the STU were compared with those of a comparable five-month period after its introduction. Process, clinical and patient experience outcomes were assessed to identify improvement. Results Attendance fell from 3,304 patients in the 2014 cohort to 2,830 in the 2015 cohort. During the 2015 study period, 279 more patients were discharged on the same day. Resource requirement fell by 2,635 bed days (23%). The number of true surgical emergencies remained consistent. Rates for reattendance (7.8% for 2014 vs 8.1% for 2015) and readmission (5.7% for 2014 vs 5.7% for 2015) showed no significant difference. Patient experience data demonstrated a significant improvement in both net promoter score (64.1 vs 82.2) and number of complaints (34 vs 5). Clinical outcomes for low risk procedures remained similar. Emergency laparotomy in-hospital mortality fell (11.4% vs 10.3%) despite preoperative risk stratification suggesting a risk burden that was significantly higher than the national average. Conclusions This novel model of emergency general surgery provision has improved clinical efficiency, patient satisfaction and outcomes. We encourage other units to consider similar programmes of service improvement.

Download Full-text