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

BACKGROUND: Major emergency abdominal surgery is associated with severe postoperative complications and high short- and long-term mortality. Despite recent advancements in standardizing multidisciplinary care bundles, a subgroup of patients continues to face a heightened risk of short-term mortality. This study aimed to identify and describe the high-risk surgical patients and risk factors for short-term postoperative mortality. METHODS: In this study, we included all patients undergoing major emergency abdominal surgery over 2 years and collected data on demographics, intraoperative variables, and short-term outcomes. The primary outcome measure was short-term mortality and secondary outcome measures were pre, intra, and postoperative risk factors for premature death. Multivariable binary regression analysis was performed to determine possible risk factors for short-term mortality. RESULTS: Short-term mortality within 14 days of surgery in this cohort of 754 consecutive patients was 8%. Multivariable analysis identified various independent risk factors for short-term mortality throughout different phases of patient care. These factors included advanced age, preoperative history of myocardial infarction or ischemic heart disease, chronic obstructive pulmonary disease, liver cirrhosis, chronic kidney disease, and vascular bowel ischemia or perforation of the stomach or duodenum during the primary surgery. CONCLUSION: Patients at high risk of early mortality following major emergency abdominal surgery exhibited distinct perioperative risk factors. This study underscores the importance of clinicians identifying and managing these factors in high-risk patients to ensure optimal care.

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

BACKGROUND: Health-related quality of life (HRQoL) is a multidimensional concept used to examine the impact of patient-perceived health status on quality of life. Patients' perception of illness affects outcomes in both medical and elective surgical patients; however, not much is known about how HRQoL effects outcomes in the emergency surgical setting. This study aimed to examine if patient-reported HRQoL was a predictor of unplanned readmission after emergency laparotomy. METHODS: This study included 215 patients who underwent emergency laparotomy at the Copenhagen University Hospital, Herlev, between August 1, 2021, and July 31, 2022. Patient-reported HRQoL was assessed with the EuroQol group EQ5D index (EQ5D5L descriptive system and EQ-VAS). The population was followed from 0 to 180 days after discharge, and readmissions and days alive and out of hospital were registered. A Cox proportional hazard model was used to examine HRQoL and the risk of readmission within 30 and 180 days. RESULTS: Within 30 days, 28.4% of patients were readmitted; within 180 days, the number accumulated to 45.1%. Low self-evaluated HRQoL predicted 180-day readmission and was significantly associated with fewer days out of hospital within both 90 and 180 days. Low HRQoL and discharge with rehabilitation were independent risk factors for short- (30-day) and long-term (180-day) emergency readmission. CONCLUSION: Patient-perceived quality of life is an independent predictor of 180-day readmission, and the number of days out of hospital was correlated to self-reported HRQoL.

Risk prediction models in emergency surgery: Protocol for a scoping review.

BACKGROUND: Risk prediction models are used for many purposes in emergency surgery, including critical care triage and benchmarking. Several risk prediction models have been developed, and some are used for purposes other than those for which they were developed. We aim to provide an overview of the existing literature on risk prediction models used in emergency surgery and highlight knowledge gaps. METHODS: We will conduct a scoping review on risk prediction models used for patients undergoing emergency surgery in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We will search Medline, EMBASE, and the Cochrane Library and include all study designs. We aim to answer the following questions: (1) What risk prediction models are used in emergency surgery? (2) Which variables are used in these models? (3) Which surgical specialties are the models used for? (4) Have the models been externally validated? (5) Where have the models been externally validated? (6) What purposes were the models developed for? (7) What are the strengths and limitations of the included models? We will summarize the results descriptively. The certainty of evidence will be evaluated using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. CONCLUSION: The outlined scoping review will summarize the existing literature on risk prediction models used in emergency surgery and highlight knowledge gaps.

Associations Between Care Bundles and Postoperative Outcomes After Major Emergency Abdominal Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION: Care bundles were found to improve postoperative outcomes in elective surgery. However, in major emergency general surgery studies show a divergent impact on mortality and length of stay. This meta-analysis aimed to evaluate associations between care bundles and mortality, complications, and length of stay when applied in major emergency general surgery. METHODS: A systematic literature search in PubMed and Embase was performed on the May 1, 2021. Only comparative studies on care bundles in major emergency general surgery were included. Meta-analysis and trial sequential analysis were performed on 30-d mortality. We undertook a narrative approach of long-term mortality, complications, and length of stay. RESULTS: Meta-analysis of 13 studies with 35,771 patients demonstrated that care bundles in emergency surgery were not associated with a significant reduction in odds of 30-d mortality (odds ratio = 0.8, 95% confidence interval 0.62-1.03). Trial sequential analysis confirmed that the meta-analysis was underpowered with a minimum of 78,901 patients required for firm conclusions. Seven studies reported complication rates whereof six reported lower complication rates using care bundles. CONCLUSIONS: Care bundles were reported to decrease postoperative complications in five out of seven studies and seven out of 11 studies reported a shortening in length of stay.

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

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.

Glycemic profile and quality of recovery after emergency abdominal surgery-A prospective explorative cohort study.

Associations between degrees of postoperative hyperglycemia and morbidity has previously been established. There may be an association between the glycemic profile and patient-reported recovery, and this may be a target for perioperative quality improvements. We aimed to investigate the association between metrics of the 30-day glycemic profile and patient-reported recovery in nondiabetic patients after major abdominal surgery. In a prospective, explorative cohort study, nondiabetic adult patients undergoing acute, major abdominal surgery were included within 24 h after surgery. Interstitial fluid glucose concentration was measured for 30 consecutive days with a continuous glucose measurement device. The validated questionnaire 'Quality of Recovery-15' was used to assess patient-reported quality of recovery on postoperative days 10, 20, and 30. Follow-up time was divided into five-day postoperative intervals using days 26-30 as a reference. Linear mixed models were applied to investigate temporal changes in mean p-glucose, coefficient of variation, time within 70-140 mg/dl, and time above 200 mg/dl in relation to patient-reported recovery. Twenty-seven patients completed the study per protocol. A hyperglycemic event (>200 mg/dl) occurred in 18 of 27 patients (67%) within the first three postoperative days. Compared to the reference period, the coefficient of variation was significantly increased during all time intervals, indicating prolonged postoperative insulin resistance. During 30 days of follow-up, patient-reported recovery was associated with the coefficient of variation measured for 3 and 5 days before the corresponding recovery score assessment (recovery score estimate -1.52 [p < .001] and -0.92 [p = .006], respectively). We did not find an association between the remaining metrics and patient-reported recovery. Alterations in the glycemic profile are frequent and prolonged during the first postoperative month after major surgery probably due to peripheral insulin resistance. Our findings indicate that high-glycemic variation is associated with poorer patient-reported recovery and might represent a proxy for care improvements in the postoperative period.

Validation of the NELA risk prediction model in emergency abdominal surgery.

Risk prediction models are frequently used to identify high-risk patients undergoing emergency laparotomy. The National Emergency Laparotomy Audit (NELA) developed a risk prediction model specifically for emergency laparotomy patients, which was recently updated. In this study, we validated the updated NELA model in an external population. Furthermore, we compared it with three other risk prediction models: the original NELA model, the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) model, and the American Society of Anesthesiologists Physical Status (ASA-PS). We included adult patients undergoing emergency laparotomy at Zealand University Hospital, from March 2017 to January 2019, and Herlev Hospital, from November 2017 to January 2020. Variables included in the risk prediction models were collected retrospectively from the electronic patient records. Discrimination of the risk prediction models was evaluated with area under the curve (AUC) statistics, and calibration was assessed with Cox calibration regression. The primary outcome was 30-day mortality. Out of 1226 included patients, 146 patients (11.9%) died within 30 days. AUC (95% confidence interval) for 30-day mortality was 0.85 (0.82-0.88) for the updated NELA model, 0.84 (0.81-0.87) for the original NELA model, 0.81 (0.77-0.84) for the P-POSSUM model, and 0.76 (0.72-0.79) for the ASA-PS model. Calibration showed underestimation of mortality risk for both the updated NELA, original NELA and P-POSSUM models. The updated NELA risk prediction model performs well in this external validation study and may be used in similar settings. However, the model should only be used to discriminate between low- and high-risk patients, and not for prediction of individual risk due to underestimation of mortality.

Abdominal subcutaneous obesity and the risk of burst abdomen: a matched case-control study.

PURPOSE: The causes of burst abdomen after midline laparotomy remain uncertain. Obesity is a suspected risk factor. The purpose of this study was to investigate the association between abdominal subcutaneous obesity (ASO) and burst abdomen in patients undergoing emergency midline laparotomy. METHODS: We conducted a single-centre, retrospective, matched case-control study of patients undergoing emergency midline laparotomy from May 2016 to August 2021. Patients suffering from burst abdomen were matched 1:4 with controls based on age and sex. Abdominal wall closure was standardized in the study period with the small bites, small stitches technique. ASO was defined as the highest sex-specific quartile (≥ 75%) of subcutaneous fat layer evaluated on CT. The primary outcome was the association between ASO and burst abdomen, stratified between cases and controls. Secondary outcomes included 30- and 90-day mortality, length of stay, and suspected risk factors of burst abdomen, assessed by multivariate analysis across cases and controls. RESULTS: A total of 475 patients were included in this study, with 95 cases matched to 380 controls. Liver cirrhosis, active smoking, and high alcohol consumption were more common among cases in an unadjusted analysis. Liver cirrhosis (odds ratio (OR) 3.32, p = 0.045) and active smoking (OR 1.98, p = 0.009) remained significant in a multivariate analysis and were associated with burst abdomen. One hundred twenty-four patients had ASO. ASO was not significantly associated with burst abdomen (OR 1.11, p = 0.731). CONCLUSION: ASO was not found to be associated with an increased risk of burst abdomen after emergency midline laparotomy.

Acute kidney injury following major emergency abdominal surgery - a retrospective cohort study based on medical records data.

BACKGROUND: Acute Kidney Injury (AKI) is a frequent and serious postoperative complication in trauma or critically ill patients in the intensive care unit. We aimed to estimate the risk of AKI following major emergency abdominal surgery and the association between AKI and 90-day postoperative mortality. METHODS: In this retrospective cohort study, we included patients undergoing major emergency abdominal surgery at the Department of Surgery, Zealand University Hospital, Denmark, from 2010 to 2016. The primary outcome was the occurrence of AKI within postoperative day seven (POD7). AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO)-criteria. The risk of AKI was analysed with a multivariable logistic regression. The association between AKI and 90-day mortality was analysed with a multivariable survival analysis. RESULTS: In the cohort, 122 out of 703 (17.4%) surgical patients had AKI within POD7. Of these, 82 (67.2%) had AKI stage 1, 26 (21.3%) had AKI stage 2, and 14 (11.5%) had AKI stage 3. Fifty-eight percent of the patients who developed postoperative AKI did so within the first 24 h of surgery. Ninety-day mortality was significantly higher in patients with AKI compared with patients without AKI (41/122 (33.6%) versus 40/581 (6.9%), adjusted hazard ratio 4.45 (95% confidence interval 2.69-7.39, P < 0.0001)), and rose with increasing KDIGO stage. Pre-existing hypertension and intraoperative peritoneal contamination were independently associated with the risk of AKI. CONCLUSIONS: The risk of AKI is high after major emergency abdominal surgery and is independently associated with the risk of death within 90 days of surgery.

Prevalence and Risk Factors for Chronic Abdominal Pain After Roux-en-Y Gastric Bypass Surgery: A Cohort Study.

OBJECTIVE: To investigate the prevalence and risk factors for chronic abdominal pain after Roux-en-Y gastric bypass (RYGB) surgery. SUMMARY BACKGROUND DATA: Abdominal pain is a frequent postoperative complication after RYGB surgery. Even if there have been defined several long-term complications, the literature regarding patients with unexplained chronic abdominal pain is sparse. METHODS: A single-center register-based cohort study with inclusion of all patients who underwent RYGB surgery between 2010 and 2015. Data from multiple registries, medical records, and a questionnaire were used. Patients with chronic abdominal pain were defined as those using strong analgesics, diagnosed with chronic pain, or referred to a specialized pain clinic. Patients with severe self-reported abdominal pain were defined as those reporting abdominal pain more than 2 times weekly within the last month. RESULTS: A total of 787 patients were followed for a median of 63 months. The prevalence of postoperative chronic abdominal pain was 11% and the prevalence of severe self-reported abdominal pain was 21%. Preoperative use of strong analgesics was a risk factor for chronic abdominal pain (OR, 2.26; 95% CI, 1.59-3.23) and severe self-reported abdominal pain (OR 2.82, 95% CI 1.64-4.84). Further risk factors for severe self-reported pain were unemployment or retirement (OR 1.80, 95% CI 1.09-2.93), postoperative complications (OR 2.75, 95% CI 1.44-5.22), and smoking (OR 1.80, 95% CI 1.09-2.96). CONCLUSIONS: One in 10 patients undergoing RYGB surgery developed chronic abdominal pain requiring strong analgesics, and one in five suffered from severe abdominal pain. Risk factors were preoperative use of strong analgesics, unemployment, postoperative complications, and smoking.

Patient perceptive focus on recovery: An exploratory study on follow-up after major emergency abdominal surgery.

BACKGROUND: Optimal recovery can be defined as the adequate in-hospital length of stay with minimal postoperative complications and readmissions. The quality of recovery beyond the immediate postoperative period after major emergency abdominal surgery is yet to be fully described. We hypothesized that long-term measures of overall recovery were affected after surgery. The study aimed to investigate patient-focused recovery-related parameters 1 year after major emergency abdominal surgery. METHOD: This is a prospective study including patients undergoing major emergency abdominal surgery at a Danish secondary referral center. Three questionnaires were answered regarding the recovery following the procedure; Activities Assessment Scale (AAS); Quality of Recovery-15 (QoR-15), and Self-complete Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS). All questionnaires were answered at postoperative days (PODs) 14, 30, 90, and 365. RESULTS: Eighty-two patients were included, and 68 were available for follow-up until 1 year after surgery. The response rates differed between the follow-up time points, with a response rate of 85% (n = 59) at POD30 and 50% (n = 36) at POD365. A decrease in the level of physical function following surgery was observed in 60% of the patients at POD14, which improved to 36% at POD365. Twenty-four patients (48%) reported postoperative pain at POD14, which declined to 9 (26%) at POD365. The maximum overall recovery was reached at POD30, which remained stable throughout the study period. CONCLUSION: One in three patients reported physical functional impairment, and one in four patients reported pain 1 year after their surgical procedure.

Patients' perceptions of barriers to enhanced recovery after emergency abdominal surgery.

PURPOSE: The patient-perceived barriers towards an optimized short-term recovery after major emergency abdominal surgery are unknown. The purpose was to investigate which patient-perceived barriers dominated concerning nutrition, mobilization, and early discharge after major emergency abdominal surgery. METHODS: An explorative study, which focused on patient-perceived barriers for early discharge, mobilization, and nutrition, was performed within an enhanced recovery perioperative setting in major emergency abdominal surgery. Patients were asked daily from postoperative day (POD) 1 to POD 7 of their self-perceived barriers towards getting fully mobilization and resuming normal oral intake. From POD 3 to POD 7, patients were asked regarding self-perceived barriers towards early discharge. RESULTS: A total of 101 patients that underwent major emergency abdominal surgery were included for final analysis from March 2017 to August 2017. The main patient self-perceived barrier towards sufficient nutrition was dominated by food aversion (including loss of appetite). The main patient self-perceived barrier towards sufficient mobilization throughout the study period was fatigue. The patient self-perceived barriers towards early discharge were more diffuse and lacked a dominant variable throughout the study period; however, fatigue was the most pronounced barrier throughout the study period. The leading initial variables were postoperative ileus, insufficient nutrition, and epidural catheter. The leading later variables besides fatigue included awaiting normalization of biochemistry values, pain, and the perception of insufficient oral intake. CONCLUSIONS: The major patient-perceived factors that limited postoperative recovery after major emergency abdominal surgery included food aversion regarding normalization of oral intake and fatigue regarding mobilization and early discharge.

Incidence of Venous Thromboembolism Following Major Emergency Abdominal Surgery.

BACKGROUND: In a retrospective cohort study, we looked at the incidence and risk factors of developing in-hospital venous thromboembolism (VTE) after major emergency abdominal surgery and the risk factors for developing a venous thrombosis. METHODS: Data were extracted through medical records from all patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 until 2016. The primary outcome was the incidence of venous thrombosis developed in the time from surgery until discharge from hospital. The secondary outcomes were 30-day mortality and postoperative complications. Multivariate logistic analyses were used for confounder control. RESULTS: In total, 1179 patients who underwent major emergency abdominal surgery during 2010-2016 were included. Thirteen patients developed a postoperative venous thromboembolism (1.1%) while hospitalized. Eight patients developed a pulmonary embolism all verified by CT scan and five patients developed a deep venous thrombosis verified by ultrasound scan. Patients diagnosed with a VTE were significantly longer in hospital with a length of stay of 34 versus 14 days, P < 0.001, and they suffered significantly more surgical complications (69.2% vs. 30.4%, P = 0.007). Thirty-day mortality was equal in patients with and without a venous thrombosis. In a multivariate analysis adjusting for gender, ASA group, BMI, type of surgery, dalteparin dose and treatment with anticoagulants, we found that a dalteparin dose ≥5000 IU was associated with the risk of postoperative surgical complications (odds ratio 1.55, 95% CI 1.11-2.16, P = 0.009). CONCLUSION: In this study, we found a low incidence of venous thrombosis among patients undergoing major emergency abdominal surgery, comparable to the incidence after elective surgery.

The risk of post-operative myocardial injury after major emergency abdominal surgery: A retrospective cohort study.

BACKGROUND: The aim was to examine the risk of post-operative myocardial injury after major emergency abdominal surgery and identify pre- and intra-operative risk factors of post-operative myocardial injury. Moreover, the study aimed to examine the association between post-operative myocardial injury and clinical outcomes. METHODS: This was a retrospective cohort study including patients undergoing major emergency abdominal surgery from February 2017 to January 2019. Troponin I was assessed on post-operative days 1-3. Post-operative myocardial injury was defined as a cardiac troponin I ≥ 45 ng per litre. Post-operative clinical outcomes included in-hospital myocardial infarction, in-hospital major adverse cardiovascular events, reoperation, admission to the intensive care unit, lengths of stay, 30- and 90-day all-cause mortality. RESULTS: 98 out of 401 patients (24.4%) sustained a post-operative myocardial injury within the third post-operative day. Increasing age was an independent risk factor of post-operative myocardial injury (age per 10 years adjusted odds ratio 2.2 [95% CI 1.7-2.9], P < .0001). Patients with post-operative myocardial injury had an increased risk of major adverse cardiovascular events, a higher admission rate to the intensive care unit, a longer median post-operative length of stay and a higher 30- and 90-day all-cause mortality compared with patients without myocardial injury. CONCLUSION: One in four patients suffered a post-operative myocardial injury within the third post-operative day. Post-operative myocardial injury was a risk factor of adverse cardiac and non-cardiac clinical outcomes. Troponin monitoring could potentially improve the post-operative risk stratification in this cohort of high-risk surgical patients.

Endothelial dysfunction and myocardial injury after major emergency abdominal surgery: a prospective cohort study.

BACKGROUND: Preoperative endothelial dysfunction is a predictor of myocardial injury and major adverse cardiac events. Non-cardiac surgery is known to induce acute endothelial changes. The aim of this explorative cohort study was to assess the extent of systemic endothelial dysfunction after major emergency abdominal surgery and the potential association with postoperative myocardial injury. METHODS: Patients undergoing major emergency abdominal surgery were included in this prospective cohort study. The primary outcome was the change in endothelial function expressed as the reactive hyperemia index from 4-24 h after surgery until postoperative day 3-5. The reactive hyperemia index was assessed by non-invasive digital pulse tonometry. Secondary outcomes included changes in biomarkers of nitric oxide metabolism and bioavailability. All assessments were performed at the two separate time points in the postoperative period. Clinical outcomes included myocardial injury within the third postoperative day and major adverse cardiovascular events within 30 days of surgery. RESULTS: Between October 2016 and June 2017, 83 patients were included. The first assessment of the endothelial function, 4-24 h, was performed 15.8 (SD 6.9) hours after surgery and the second assessment, postoperative day 3-5, was performed 83.7 (SD 19.8) hours after surgery. The reactive hyperemia index was suppressed early after surgery and did not increase significantly; 1.64 (95% CI 1.52-177) at 4-24 h after surgery vs. 1.75 (95% CI 1.63-1.89) at postoperative day 3-5, p = 0.34. The L-arginine/ADMA ratio, expressing the nitric oxide production, was reduced in the perioperative period and correlated significantly with the reactive hyperemia index. A total of 16 patients (19.3%) had a major adverse cardiovascular event, of which 11 patients (13.3%) had myocardial injury. The L-arginine/ADMA ratio was significantly decreased at 4-24 h after surgery in patients suffering myocardial injury. CONCLUSION: This explorative pathophysiological study showed that acute systemic endothelial dysfunction was present early after major emergency abdominal surgery and remained unchanged until day 3-5 after the procedure. Early postoperative disturbances in the nitric oxide bioavailability might add to the pathogenesis of myocardial injury. This pathophysiological link should be confirmed in larger studies. TRIAL REGISTRATION: clinicaltrials.gov no. NCT03010969.

Postoperative atrial fibrillation following emergency noncardiothoracic surgery: A systematic review.

BACKGROUND: Postoperative atrial fibrillation (POAF) occurs frequently following cardiothoracic surgery and is associated with a higher mortality and a longer hospital stay. The condition is less studied following noncardiothoracic surgery as well as emergency surgery. OBJECTIVE: The aim of this systematic review was to investigate the occurrence of atrial fibrillation following emergency noncardiothoracic surgery and associated risk factors and mortality. DESIGN: We conducted a systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Observational studies and randomised controlled trials were assessed for risk of bias using the Downs and Black checklist and Cochrane Handbook for Systematic reviews of intervention. DATA SOURCES: A systematic literature search of PubMed, EMBASE and Scopus was carried out in August 2019. No publication date- or source restrictions were imposed. ELIGIBILITY CRITERIA: Observational and randomised controlled trials were included if data on POAF occurring after an emergency, noncardiothoracic, surgical intervention on adult patients could be extracted. RESULTS: We identified 15 studies eligible for inclusion covering orthopaedic-, abdominal-, vascular-, neuro- and miscellaneous noncardiothoracic surgery. The occurrence of POAF after emergency noncardiothoracic surgery ranged from 1.5 to 12.2% depending on type of surgery and intensity of cardiac monitoring. Studies that investigated risk factors and associated mortality found emergency surgery and increasing age to be associated with risk of POAF. Moreover, POAF was generally associated with an increase in long-term and short-term mortality. CONCLUSION: In this study, atrial fibrillation occurred frequently, especially following emergency orthopaedic, vascular and neurosurgery. Emergency surgery and age were independent risk factors for developing atrial fibrillation. POAF seems to be related to a higher risk of postoperative complications and mortality, though further studies with long-term follow-up are needed. TRIAL REGISTRATION: CRD42019112090.

The impact of blood type on transfusion after major emergency abdominal surgery.

BACKGROUND: ABO dependent variation in von Willebrand factor (vWF) and factor VIII have an impact on hemostasis. Several contradictory studies have investigated the influence of ABO blood type in surgical hemorrhage. Emergency surgery is associated with an increased risk of perioperative hemorrhage leading to inferior clinical outcomes. The aim of this study was to investigate if patients with blood type O received more transfusions with blood components compared with non-O patients after major emergency abdominal surgery. STUDY DESIGN AND METHODS: This retrospective observational study combined perioperative data including hemoglobin with transfusion data in patients undergoing emergency surgery at a university hospital between January 2010 and October 2016. The primary outcome was postoperative transfusion stratified into early transfusion, within 24 hours after surgery, and late transfusion from 24 hours to 7 days (POD7) after surgery. RESULTS: A total of 869 patients were included, 363 patients with blood type O (42.0%) and 501 (58.0%) with blood type non-O. We found no difference in the need for transfusion with 42 (11.6%) patients with blood type O and 66 (13.2%) patients with blood type non-O receiving early transfusion and 39 (13.4%) and 48 (11.9%) of O and non-O patients, respectively, receiving late transfusion. Multivariate logistic regression analysis showed an adjusted OR of 0.915 (95% CI 0.569-1.471) for early transfusion and an adjusted OR of 1.307 (95% CI 0.788-2.169) for late transfusion in patients with blood type O. Likewise, no difference was seen with respect to the change in hemoglobin levels before and after surgery as well as transfused volume. CONCLUSION: We did not find an association between transfusion or perioperative changes in hemoglobin with respect to blood type ABO.

The Effect of Perioperative Iron Therapy in Acute Major Non-cardiac Surgery on Allogenic Blood Transfusion and Postoperative Haemoglobin Levels: A Systematic Review and Meta-analysis.

BACKGROUND: Perioperative anaemia in relation to surgery is associated with adverse clinical outcomes. In an elective surgical setting, it is possible to optimize patients prior to surgery, often by iron supplementation with correction of anaemia. Possibilities for optimization prior to and during acute surgical procedures are limited. This review investigates whether iron treatment initiated perioperatively improves outcomes in patients undergoing major acute non-cardiac surgery. METHOD: This systematic review was performed using PubMed, EMBASE (Ovid) and Scopus to identify current evidence on iron supplementation in acute surgery. Primary outcomes were allogenic blood transfusion (ABT) rate and changes in haemoglobin. Secondary outcomes were postoperative mortality, length of stay (LOS), and postoperative complications. Iron was administered at latest within 24 h after end of surgery. RESULTS: Of the 5413 studies screened, four randomized controlled trials and nine observational cohort studies were included. Ten studies included patients with hip fractures. A meta-analysis of seven studies showed a risk reduction of transfusion (OR = 0.35 CI 95% (0.20-0.63), p = 0.0004, I2 = 66%). No influence on plasma haemoglobin was found. Postoperative mortality was reduced in the iron therapy group in a meta-analysis of four observational studies (OR 0.50 (CI 95% 0.26-0.96) p = 0.04). No effect was found on LOS, but a reduction in postoperative infection was seen in four studies. CONCLUSIONS: This review examined perioperative iron therapy in acute major non-cardiac surgery. IV iron showed a lower 30-day mortality, a reduction in postoperative infections and a reduction in ABT largely due to the observational studies. The review primarily consisted of small observational studies and does not have the power to formally recommend this practice.

Long-term mortality and recurrence in patients treated for colonic diverticulitis with abscess formation: a nationwide register-based cohort study.

PURPOSE: The study aimed to investigate long-term mortality, recurrence, and death related to recurrence for patients admitted with acute diverticulitis with abscess formation (Hinchey stage Ib-II). METHODS: The cohort was identified by linking administrative registers for all Danish citizens in years 2000-2012. Patients were identified from ICD-10 discharge codes and stratified according to treatment (antibiotics, percutaneous abscess drainage, or surgery). RESULTS: From 6,641,672 persons, 3148 patients were identified with acute diverticulitis with abscess formation. Survival was comparable between treatment groups with a 1-year survival of 81-83% and a 5-year survival of 66-67% (p = 0.66). Glucocorticoid usage prior to admission increased risk of mortality with hazard ratio 1.64 (95%CI 1.39-1.93), 1.77 (1.20-2.63), and 1.92 (1.07-3.44) for the antibiotics, drainage, and operative treatment group, respectively. Drainage treatment increased risk of recurrence with sub-distribution hazard (SDH) of 1.52 (1.19-1.95) and operative treatment decreased risk with a SDH of 0.55 (0.32-0.93), both compared with antibiotic treatment (p = 0.0001). Recurrence occurred in 23.6% (18.5-30.1%) of patients in the drainage group, 15.5% (13.9-17.3%) in the antibiotics group, and 9.1% (5.1-16.1%) in the operative group. Recurrence-related mortality was 2.0% (0.9-4.4%) for the drainage group, 1.1% (0.7-1.8%) for the antibiotics group, and 0.6% (0.1-4.3%) for the operative group (p = 0.24). Most recurrences and recurrence-related mortality occurred within the first year after primary admission. CONCLUSIONS: This study with complete national data revealed a high mortality and recurrence rate after diverticular abscesses. Survival was comparable between treatment groups, but patients treated with drainage had significantly higher risk of recurrence.