Medical versus surgical causes of death following colorectal resection: a Queensland Audit of Surgical Mortality (QASM) study.

BACKGROUND: The causes of death following colorectal resection remain poorly explored. Few studies have addressed whether early post-operative mortality is predominantly caused by a patient's medical co-morbidities, or from factors pertaining to the presenting surgical disease process itself. This study analyses data from the Queensland audit of surgical mortality (QASM) to report the causes of in-hospital death following colorectal resection, identifies whether these were due to either medical or surgical factors, and determines the patient characteristics associated with a medical cause of death. METHODS: Through analysis of QASM Surgical Case Forms, the causes of in-hospital death were determined in 750 patients who died in Queensland following colorectal resection between January 2010 and December 2020. Deaths were attributed to a specific medical or surgical cause, with multivariate analysis used to identify independent risk factors associated with a medical cause of death. RESULTS: In total, 395 patients (52.7%) died due to surgical causes and 355 (47.3%) died due to medical causes. Respiratory co-morbidities (OR 1.832, 95% CI: 1.267-2.650), advanced malignancy (OR 1.814, 95% CI: 1.262-2.607), neurological co-morbidities (OR 1.794, 95% CI: 1.168-2.757) and advanced age (OR 1.430, 95% CI: 1.013-2.017) were independent risk factors associated with increased risk of a medical cause of death. CONCLUSION: Even in the absence of complicating surgical factors, a significant number of patients died in hospital following colorectal resection due to their underlying co-morbidities. Multi-disciplinary models of care which allow for the early recognition and treatment of medical complications may reduce post-operative mortality in these patients.

Perioperative outcomes of emergency and elective colorectal surgery: a bi-institutional study.

BACKGROUND: Emergency colorectal surgery tends to be associated with poorer outcomes compared to elective colorectal surgery. This study assessed the morbidity and mortality in patients undergoing emergency and elective colorectal resection in two metropolitan hospitals. METHODS: Patients were identified retrospectively from two institutions between April 2018 and July 2020. Baseline, operative and postoperative parameters were collected for comparative analysis between emergency and elective surgery groups. A binary logistic regression was performed to identify independent predictors of postoperative complications. RESULTS: During the study period, 454 patients underwent colorectal resection, 135 were emergency cases (29.74%) and 319 were elective cases (70.26%). Compared with elective resections, patients undergoing emergency resections were observed to have a higher American Society of Anesthesiologists (ASA) score of III to IV (53.33% vs. 38.56%) (P = 0.004). The mortality rate was similar between the emergency and elective group (1.48% vs. 0.63%, P = 0.369). The overall complication rate was higher in patients undergoing emergency resections (64.44% vs. 36.68%, P < 0.001), but the major complication rate was similar between groups (12.59% vs. 10.34%, P = 0.484). Independent predictors for postoperative complications included emergency surgery (Odds Ratio (OR) 2.77, 95% Confidence Interval (CI): 1.66 to 4.61) and an ASA Score of III to IV (OR 2.87, 95% CI: 1.84 to 4.47). CONCLUSION: The overall complication rate was higher in patients undergoing emergency colorectal resection, however, rates of major complications and mortality were similar between groups. Higher complication rates reflect advanced disease pathology in patients who are more comorbid.

Critical Analysis of the Causes of In-Hospital Mortality following Colorectal Resection: A Queensland Audit of Surgical Mortality (QASM) Registry Study.

BACKGROUND: Colorectal resection is a major gastrointestinal operation. Improvements in peri-operative care has led to improved outcomes; however, mortalities still occur. Using data from the Queensland Audit of Surgical Mortality (QASM), this study examines the demographic and clinical characteristics of patients who died in hospital following colorectal resection, and also reports the primary cause of death in this population. METHODS: Patients who died in hospital following colorectal resection in Queensland between January 2010 and December 2020 were identified from the QASM database. RESULTS: There were 755 patients who died in the 10 year study period. Pre-operatively, the risk of death as subjectively determined by operating surgeons was 'considerable' in 397 cases (53.0%) and 'expected' in 90 cases (12.0%). The patients had a mean of 2.7 (±1.5) co-morbidities, and a mean American Society of Anaesthesiologists (ASA) score of 3.6 (±0.8). Operations were categorised as emergency in 579 patients (77.2%), with 637 patients (85.0%) requiring post-operative Intensive Care Unit (ICU) support. The primary cause of death was related to a surgical cause in 395 patients (52.7%) and to a medical cause in 355 patients (47.3%). The primary causes of death were advanced surgical pathology (n=292, 38.9%), complications from surgery (n=103, 13.7%), complications arising from pre-existing medical co-morbidity (n=282, 37.6%) or new medical complications unrelated to pre-existing conditions (n=73, 9.7%). CONCLUSIONS: Patients who died had significant co-morbidities and often presented emergently with an advanced surgical pathology. Surgical and medical causes of death both contributed equally to the mortality burden.

The impact of obesity on outcomes in patients undergoing emergency cholecystectomy for acute cholecystitis.

BACKGROUND: Obesity is a perceived risk factor for poorer surgical outcomes, including increased complication rates and mortality. As obesity rates rise annually, evaluating surgical outcomes in the obese population has become increasingly important. This study examines the impact of obesity on outcomes following emergency laparoscopic cholecystectomy (LC) for acute cholecystitis. METHODS: A retrospective review of patients who underwent emergency LC for acute cholecystitis between March 2018 and March 2021 was performed. A total of 326 patients were included and stratified by body mass index (BMI) into two groups: obese (BMI ≥30 kg/m2 , n = 156) and non-obese (BMI <30 kg/m2 , n = 170). Primary outcomes included length of stay, time to definitive surgery, and postoperative complications. Secondary outcomes included total operative time and intraoperative findings. RESULTS: Obese patients were younger than non-obese patients (median, 45 [34.3-56.8] and 48.5 [34.0-66.3] years; p < 0.001) and had a higher prevalence of diabetes (13.5% versus 6.5%; p = 0.034). Higher American Society of Anesthesiologists (ASA) classification (p < 0.001) and operative grading scores were observed in the obese group (76.3% versus 40.6%, p < 0.001), who were more likely to have a distended gallbladder (19.9% versus 11.2%, p = 0.030) and gallstone impaction (23.1% versus 11.8%, p = 0.007) in comparison to the non-obese group. Length of hospital stay, time to definitive surgery, and postoperative complication rates were similar between groups. CONCLUSION: Although obesity is associated with greater technical difficulty during surgery than non-obese patients, similar postoperative outcomes were achieved. Obesity should not be a contraindication for LC and can be safely performed in the emergency setting.

Comparative Analysis of Models of Care and Its Impact on Emergency Cholecystectomy Outcomes.

Background: The implementation of the acute surgical unit (ASU) model has been demonstrated to improve care outcomes for the emergency general surgery patient in comparison to the traditional "on call" model. Currently, only few studies have evaluated surgical outcomes of the ASU model in patients with acute biliary pathologies. This is the first comparative study of two different emergency surgery structures in the acute management of patients with acute cholecystitis and biliary colic. Methods: A retrospective review of patients who underwent emergency cholecystectomy for acute cholecystitis and biliary colic at two tertiary hospitals between April 2018 and March 2019 was conducted. Primary outcomes included length of hospital stay, time from admission to definitive surgery, and postoperative complications. Secondary outcomes include proportion of cases performed during daylight hours, length of operating time, rate of conversion to open cholecystectomy, and consultant surgeon involvement. Results: A total of 339 patients presented with acute biliary symptoms and were managed operatively. Univariate analysis identified a shorter mean time to surgery in the traditional group compared to the ASU group (29.2 hours versus 43.1 hours; P < .001). There was no difference in mean length of stay, operation duration between models, and postoperative complication rates between groups, with the majority of surgeries performed during daylight hours. The ASU group had a greater proportion of consultant-led cases (48.2% versus 2.5%, P < .001) compared to the traditional group. Conclusion: Patients with acute biliary pathology requiring laparoscopic cholecystectomy achieve equivalent surgical outcomes irrespective of the model of acute surgical care.

Comparative analysis of emergency general surgery on-call structure and its impact on emergency appendicectomy outcomes.

BACKGROUND: In Australia, there has been a shift from the traditional 'on-call' surgical model to the 'acute surgical unit' (ASU) model to improve outcomes in acute general surgery. Using emergency appendicectomy as a standardized procedure, we aimed to identify the different patterns of care between these on-call structures by comparing two metropolitan district hospitals; one that employs a traditional on-call model and the other, which employ the ASU model. METHODS: Data on consecutive patients undergoing emergency appendectomies at the two hospitals (traditional and ASU model) between July 2018 and December 2018 were retrieved for retrospective review. Patient factors, preoperative factors, operative factors and post-operative outcomes were collected and tabulated for comparative analysis between the traditional versus ASU model of care. RESULTS: Univariate analysis demonstrated that there were a greater proportion of consultant-led cases (P < 0.001), a shorter time to theatre (P = 0.047) and a greater number of out-of-hours operations (P < 0.001) in the ASU model compared to the traditional model. A larger proportion of patients from the traditional model underwent a computed tomography scan as part of their diagnostic workup compared to the ASU model (P < 0.001). There was no difference in negative appendicectomy rates, intraoperative conversion rates, post-operative complication rates or mean lengths of hospital stay between the two on-call models. CONCLUSION: The ASU and traditional on-call model appears to achieve equivalent care outcomes for patients with acute appendicitis.