Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes?

Enhanced recovery after surgery (ERAS) has been adopted by many centres and across whole healthcare systems. The results have shown significant reductions in length of stay and postoperative complications. However, there has been very little change in these factors and mortality in emergency surgery. Can we learn from principles of ERAS for emergency abdominal surgery?

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy.

BACKGROUND: Emergency laparotomies in the U.K., U.S.A. and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care. METHODS: The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. RESULTS: Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6.47 in the baseline interval (299 patients included) to 12.44 after implementation (427 patients included) (P < 0.001). The overall case mix-adjusted risk of death decreased from 15.6 to 9.6 per cent (risk ratio 0.614, 95 per cent c.i. 0.451 to 0.836; P = 0.002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0.197 and 0.223 before and after implementation respectively; P = 0.395). CONCLUSION: Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.

Randomized clinical trial on enhanced recovery versus standard care following open liver resection.

BACKGROUND: Enhanced recovery programmes (ERPs) have been shown to reduce length of hospital stay (LOS) and complications in colorectal surgery. Whether ERPs have the same benefits in open liver resection surgery is unclear, and randomized clinical trials are lacking. METHODS: Consecutive patients scheduled for open liver resection were randomized to an ERP group or standard care. Primary endpoints were time until medically fit for discharge (MFD) and LOS. Secondary endpoints were postoperative morbidity, pain scores, readmission rate, mortality, quality of life (QoL) and patient satisfaction. ERP elements included greater preoperative education, preoperative oral carbohydrate loading, postoperative goal-directed fluid therapy, early mobilization and physiotherapy. Both groups received standardized anaesthesia with epidural analgesia. RESULTS: The analysis included 46 patients in the ERP group and 45 in the standard care group. Median MFD time was reduced in the ERP group (3 days versus 6 days with standard care; P < 0·001), as was LOS (4 days versus 7 days; P < 0·001). The ERP significantly reduced the rate of medical complications (7 versus 27 per cent; P = 0·020), but not surgical complications (15 versus 11 per cent; P = 0·612), readmissions (4 versus 0 per cent; P = 0·153) or mortality (both 2 per cent; P = 0·987). QoL over 28 days was significantly better in the ERP group (P = 0·002). There was no difference in patient satisfaction. CONCLUSION: ERPs for open liver resection surgery are safe and effective. Patients treated in the ERP recovered faster, were discharged sooner, and had fewer medical-related complications and improved QoL. REGISTRATION NUMBER: ISRCTN03274575 (http://www.controlled-trials.com).

Liver resection for colorectal cancer metastases involving the caudate lobe.

BACKGROUND: Up to 5 per cent of liver resections for colorectal cancer metastases involve the caudate lobe, with cancer-involved resection margins of over 50 per cent being reported following caudate lobe resection. METHODS: Outcomes of consecutive liver resections for colorectal metastases involving the caudate lobe between 1996 and 2009 were reviewed retrospectively, and compared with those after liver surgery without caudate resection. RESULTS: Twenty-five patients underwent caudate and 432 non-caudate liver resection. Caudate resection was commonly performed as part of extended resection. There were no differences in operative complications (24 versus 21·1 per cent; P = 0·727) or blood loss (median 300 versus 250 ml; P = 0·234). The operating time was longer for caudate resection (median 283 versus 227 min; P = 0·024). Tumour size was larger in the caudate group (median 40 versus 27 mm; P = 0·018). Resection margins were smaller when the caudate lobe was involved by tumour, than in resections including tumour-free caudate or non-caudate resection; however, there was no difference in the proportion of completely excised tumours between caudate and non-caudate resections (96 versus 96·1 per cent; P = 0·990). One-year overall survival rates were 90 and 89·3 per cent respectively (P = 0·960), with 1-year recurrence-free survival rates of 62 and 71·2 per cent (P = 0·340). CONCLUSION: Caudate lobe surgery for colorectal cancer liver metastases does not increase the incidence of resection margin involvement, although when the caudate lobe contains metastases the margins are significantly closer than in other resections.

Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy.

Background: Acute gallstone disease is a high-volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance. Methods: Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods. Results: Of 13 sites invited to join Chole-QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole-QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8-day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals. Conclusion: A surgeon-led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.

Antecedentes: La patología biliar aguda litiásica es una de las urgencias con más volumen de casos en cirugía general, con amplias variaciones en la calidad de la atención prestada en todo el Reino Unido. En este estudio de cohortes controlado se valoró si la participación en un enfoque colaborativo de mejora de la calidad disminuía el tiempo hasta la cirugía en pacientes con patología biliar aguda litiásica a menos de 8 días desde la presentación, de acuerdo con la guía nacional. Métodos: Se identificó a los pacientes que precisaron un ingreso hospitalario por patología biliar aguda en Inglaterra y Gales, del 1 de abril de 2014 al 31 de diciembre de 2017, a partir de datos de las estadísticas de episodios hospitalarios. Se crearon series temporales de actividad trimestral para Chole­QuIC y para todos los demás hospitales de agudos del NHS (grupo control). Se utilizó un modelo de regresión binomial negativa para comparar la proporción de pacientes sometidos a cirugía dentro de los primeros 8 días en los periodos basal y de intervención. Resultados: De los 13 sitios invitados a unirse a Chole­QuIC, 12 participaron durante toda la colaboración, que se desarrolló entre octubre de 2016 y enero de 2018. De los 7.944 ingresos, en 1.160 pacientes se realizó la colecistectomía dentro de los 8 días posteriores a su ingreso, una mejora significativa (P < 0,05) en comparación con el periodo previo a la intervención. Esto representó un cambio relativo de 1,56 (i.c. del 95%: 1,38 a 1,75) en comparación con 1,08 para el grupo de control. A nivel de cada uno de los hospitales, ocho de los 12 centros Chole­QuIC presentaron una mejora significativa (P < 0,05), y en cuatro de ellos el porcentaje de cirugía en 8 días aumentó a más del 20% de todos los ingresos urgentes, muy por encima del promedio de 15,3% para hospitales de control. Conclusión: Un enfoque colaborativo de mejora de la calidad dirigido por el cirujano mejoró la atención a los pacientes que precisan una colecistectomía urgente.

Cost-effectiveness of a quality improvement bundle for emergency laparotomy.

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.

Use of a care bundle to reduce mortality following emergency laparotomy.

Emergency laparotomy is a common intra-abdominal procedure with outcomes recognized to be poor. Efforts are being made to improve these outcomes, both nationally and internationally. This article describes the methodology of a successfully implemented collaborative quality improvement project that improved outcomes following emergency laparotomy in four NHS trusts.

Resuscitation skills amongst anaesthetists.

Resuscitation skills were assessed in a group of 24 anaesthetists of varying experience using 3 pre-determined scenarios. Seventy-nine percent of participants were found to be competent at resuscitation following the guidelines suggested by the Resuscitation Council (UK) in 1989. No one grade of anaesthetist was found to be consistently poor at resuscitation. Anaesthetists by the nature of their jobs may maintain the skills and knowledge of cardiopulmonary resuscitation as well as other groups in the hospital.

The inflatable wedge: an aid to bilateral hip arthroplasty.

A reusable inflatable wedge system is described for use during bilateral hip arthroplasty. It allows rapid repositioning during the procedure, with minimal interference to the surgical field. It is robust, cheap and provides minimal compromise to surgical asepsis. It has potential for use in a variety of procedures.

Survival and recurrence after neo-adjuvant chemotherapy and liver resection for colorectal metastases: a ten year study.

BACKGROUND: Currently liver resection offers the only potential cure for colorectal liver metastases (CRLM). We prospectively audited the outcome of CRLM treated by a combination of neo-adjuvant chemotherapy and surgery. METHODS: 283 consecutive patients underwent liver resection for CRLM over 10 years with curative intent. Patients received chemotherapy preoperatively for synchronous and early (< 2 years) metachronous metastases. Univariate and multivariate analyses were used to identify mortality risk factors. RESULTS: Overall survival at 1, 3 and 5 years was 90%, 59.2% and 46.1%, respectively. Disease free survival at 1, 3 and 5 years was 68.1%, 34.8% and 27.9%, respectively. Operative mortality was 2.1% and morbidity was 23.7%. Patients with macroscopic diaphragm invasion by tumour, CEA > 100 ng/ml, tumour size > 5 cm or cancer involved resection margins (CIRM) had a significantly worse overall survival. Incidence of CIRM and re-resection was 4.9% and 4.5%, respectively. CONCLUSIONS: Neo-adjuvant chemotherapy followed by liver surgery is associated with improved survival and low CIRM and re-resection rates.