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1.
Ann R Coll Surg Engl ; 104(3): 202-209, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34519559

RESUMO

INTRODUCTION: We investigated all-cause mortality following emergency laparotomy at 1 and 5 years. We aimed to establish a basis from which to advise patients and relatives on long-term mortality. METHODS: Local data from a historical audit of emergency laparotomies from 2010 to 2012 were combined with National Emergency Laparotomy Audit (NELA) data from 2017 to 2020. Covariates collected included deprivation status, preoperative blood work, baseline renal function, age, American Society of Anesthesiologists (ASA) grade, operative time, anaesthetic time and gender. Associations between covariates and survival were determined using multivariate logistic regression and Kaplan-Meier analysis. We used patients undergoing laparoscopic cholecystectomy between 2015 and 2020 as controls. RESULTS: ASA grade was the best discriminator of long-term outcome following laparotomy (n=894) but was not a predictor of survival following cholecystectomy (n=1,834), with mortality being significantly greater in the laparotomy group. Following cholecystectomy, 95% confidence intervals for survival at 5 years were 98-99%. Following laparotomy these intervals were: ASA grade 1, 79-96%; ASA grade 2, 69-82%; ASA grade 3, 44-58%; ASA grade 4, 33-48%; and ASA grade 5, 4-51%. The majority of deaths occurred after 30 days. CONCLUSIONS: Emergency laparotomy is associated with a significantly increased risk of death in the following 5 years. The risk is strongly correlated to ASA grade. Thirty-day mortality estimation is not a good basis on which to advise patients and carers on long-term outcomes. ASA grade can be used to predict long-term outcomes and to guide patient counsel.


Assuntos
Laparotomia/mortalidade , Idoso , Idoso de 80 Anos ou mais , Serviços Médicos de Emergência , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia
2.
J Surg Res ; 262: 65-70, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33548675

RESUMO

BACKGROUND: Nontraumatic surgical emergencies constitute a significant portion of total surgical workload and are associated with a significant mortality rate. The spectrum and outcome of surgical emergencies in a low-middle-income country may differ from that in high-income countries. This study aims to describe the spectrum and outcome of emergency laparotomy for nontrauma surgical emergencies at a single-tertiary center in South Africa. METHODS: A retrospective interrogation of a hybrid electronic record system of consecutive patients undergoing emergency laparotomy for nontraumatic surgical emergencies presenting to Greys Hospital from December 2012 to December 2018. RESULTS: One thousand four hundred sixty four patients were included with a median age of 34 y (IQR 23-52) and male predominance (861; 59%). The mortality rate was 12.5% (183). The most common comorbidity was human immunodeficiency virus (353; 24.1%) which did not influence mortality. At least one comorbidity increased the odds of mortality by 4 times (95% CI 2.7-6.2). Mortality was associated with longer waiting times to operation (12.8 versus 8.4 h; P < 0.001) and longer operating times (105 min versus 80 min respectively; P < 0.001). Temporary abdominal closure was used in 245 (16.7%) patients. Planned repeat laparotomy was performed in 193 (13.2%) patients. Acute appendicitis (594, 40.6%) was the most common pathology of which 61.4% had the American Association for the Surgery of Trauma grade of 4 or more (high grade). This was followed by perforated peptic ulcer disease (10.5%). The adverse event rate was 51.5% (754). Postoperative pulmonary complications and acute kidney injury were the most common. The strongest predictors of mortality were abdominal compartment syndrome (OR 26.5, 95% CI 9.36-94.13) and postoperative hemodynamic instability 17.43 (OR 17.4, 95% CI 11.80-25.98). CONCLUSIONS: Our spectrum of disease differs to that found in high-income countries. The morbidity and mortality rates are significant, and attention must be focused on attempts to reduce this. Various comorbidities and adverse events are associated with increased mortality.


Assuntos
Serviço Hospitalar de Emergência , Laparotomia/efeitos adversos , Adulto , Idoso , Comorbidade , Feminino , Humanos , Laparotomia/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária , Adulto Jovem
3.
Am J Surg ; 222(3): 625-630, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33509544

RESUMO

BACKGROUND: Emergency general surgery (EGS) lacks mechanisms to compare performance between institutions. Focusing on higher-risk procedures may efficiently identify outliers. METHODS: EGS patients were identified from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Risk-adjusted mortality was calculated as an O:E ratio, generating expected mortality from a model including demographic and procedural factors. Outliers were centers whose 90% confidence intervals excluded 1. This was repeated in several subsets, to determine if these yielded outliers similar to the overall dataset. RESULTS: We identified 45,430 EGS patients. Overall, 3 high performing centers and 5 low performing centers were identified. Exclusion of appendectomies and cholecystectomies resulted in a remaining data set of 13,569 patients (29.9% of the overall data set), with 2 high performers and 5 low performers. One low performer in the limited data set was not identified in the overall set. CONCLUSION: Evaluation of 5 procedures, making up less than a third of EGS, identifies most outliers. A streamlined monitoring procedure may facilitate maintenance of an EGS registry.


Assuntos
Tratamento de Emergência/mortalidade , Cirurgia Geral , Hospitais/normas , Sistema de Registros , Procedimentos Cirúrgicos Operatórios/mortalidade , Apendicectomia/mortalidade , Benchmarking , Colecistectomia/mortalidade , Intervalos de Confiança , Bases de Dados Factuais , Emergências , Florida , Mortalidade Hospitalar , Humanos , Kentucky , Laparotomia/mortalidade , New York , Razão de Chances , Discrepância de GDH , Resultado do Tratamento
4.
Surg Today ; 51(8): 1285-1291, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33420826

RESUMO

PURPOSE: Open abdominal management (OAM) is being adopted increasingly frequently in nontrauma patients. This study assessed the effectiveness of OAM in nontrauma older adults. METHODS: We retrospectively reviewed all adults who underwent nontrauma emergency laparotomy requiring postoperative intensive care unit (ICU) management between September 2012 and August 2017 at our hospital. Patients ≥ 80 years old, who underwent OAM, were compared with those < 80 years old. The primary outcome was the 90-day mortality. Secondary outcomes were the 30-day mortality, unplanned relaparotomy, and the ICU length of stay (LOS). RESULTS: The OAM group comprised 58 patients, including 27 who were ≥ 80 years old. The patients ≥ 80 years old in the OAM group had a significantly higher 90-day mortality rate (33% vs. 10%; p = 0.027) than those < 80 years old. There were no significant differences in the 30-day mortality rate, patients' unplanned relaparotomy rate, or ICU LOS between the patients ≥ 80 years old and those < 80 in the OAM group. CONCLUSIONS: Older adults who underwent OAM had a significantly higher mortality rate than younger patients. However, the OAM strategy for older nontrauma patients may still be useful and reasonable considering the severe condition of these patients.


Assuntos
Abdome/cirurgia , Serviços Médicos de Emergência , Laparotomia/mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Emergências , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Cuidados Pós-Operatórios , Reoperação , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo
5.
J Vasc Surg ; 73(5): 1603-1610, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33080323

RESUMO

OBJECTIVE: Although the transabdominal approach (TAA) and lateral approach (LA) to open abdominal aortic aneurysm repair (OAR) are both acceptable and widely used, a paucity of data evaluating subsequent postoperative laparotomy-associated complications (LCs) is available. The aim of the present study was to establish the incidence of LCs after OAR and determine which approach was associated with an increase in long-term LCs. METHODS: An institutional database for OAR (2010-2019) was queried, excluding urgent and emergent cases. The primary endpoint was long-term LCs, defined as any complication related to entry into the abdomen. The LA included retroperitoneal and thoracoabdominal approaches and the TAA included all patients with midline incisions. A Kaplan-Meier analysis was used to estimate the freedom from LCs, and the Fine-Gray method was used to determine the predictors of LCs, with death as a competing risk. RESULTS: A total of 241 patients (mean age, 70.0 ± 9.1 years; 71.7% men) had undergone OAR, 91 via a TAA and 150 via a LA. The patients in the TAA group were significantly younger (age, 66.7 ± 8.9 vs 72.1 ± 8.7 years; P < .001), more likely to be male (83.5% vs 64.7%; P = .002), and more likely to have a history of small bowel obstruction (SBO; 3.3% vs 0%; P = .025). Patients in the LA group were more likely to have required a supraceliac clamp (20.7% vs 1.1%; P < .001). No difference was found in the incidence of perioperative complications or long-term mortality. The most common LCs were hernia (TAA, 26.4%; LA, 11.3%; P = .003), SBO (TAA, 8.8%, LA, 1.3%; P = .005), and other (TAA, 13.2%; LA, 2.0%; P = .001), which included evisceration, bowel ischemia, splenic injuries requiring reintervention, enterocutaneous fistula, internal hernia, and retrograde ejaculation. Operative LCs were more common in the TAA group (17.6% vs 2.7%; P < .001). The unadjusted 1-, 3-, and 5-year freedom from LCs was 77.7% (95% confidence interval [CI], 66.0%-85.8%), 60.5% (95% CI, 46.5%-71.9%), and 54.0% (95% CI, 38.8%-67.0%) for TAA and 94.8% (95% CI, 88.8%-97.7%), 82.2% (95% CI, 72.2%-88.9%), and 79.1% (95% CI, 68.4%-86.5%) for LA, respectively (log-rank P < .001). The predictors for LCs were a history of SBO (P = .001), increasing body mass index (P = .005), and the use of the TAA (P < .001). CONCLUSIONS: Use of the TAA was an independent predictor of long-term LCs after OAR, along with an increasing body mass index and a history of SBO. In patients with amenable anatomy, the LA is favorable for preventing long-term LCs, especially in high-risk patients.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Laparotomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Laparotomia/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/mortalidade
6.
Am J Surg ; 221(5): 1069-1075, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32917366

RESUMO

INTRODUCTION: We sought to evaluate whether the Emergency Surgery Score (ESS) can accurately predict outcomes in elderly patients undergoing emergent laparotomy (EL). METHODS: This is a post-hoc analysis of an EAST multicenter study. Between April 2018 and June 2019, all adult patients undergoing EL in 19 participating hospitals were prospectively enrolled, and ESS was calculated for each patient. Using the c-statistic, the correlation between ESS and mortality, morbidity, and need for ICU admission was assessed in three patient age cohorts (65-74, 75-84, ≥85 years old). RESULTS: 715 patients were included, of which 52% were 65-74, 34% were 75-84, and 14% were ≥85 years old; 51% were female, and 77% were white. ESS strongly correlated with postoperative mortality (c-statistic:0.81). Mortality gradually increased from 0% to 20%-60% at ESS of 2, 10 and 16 points, respectively. ESS predicted mortality, morbidity, and need for ICU best in patients 65-74 years old (c-statistic:0.81, 0.75, 0.83 respectively), but its performance significantly decreased in patients ≥85 years (c-statistic:0.72, 0.64, 0.67 respectively). CONCLUSION: ESS is an accurate predictor of outcome in the elderly EL patient 65-85 years old, but its performance decreases for patients ≥85. Consideration should be given to modify ESS to better predict outcomes in the very elderly patient population.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/mortalidade , Feminino , Humanos , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Masculino , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos
7.
J Trauma Acute Care Surg ; 90(1): 11-20, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-32925573

RESUMO

INTRODUCTION: The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers' injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center's injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients. METHODS: We performed a (2017) analysis of the Trauma Quality Improvement Program database. We included adult (age, ≥18 years) blunt and penetrating trauma patients who required emergent laparotomies for hemorrhage control. Trauma centers were stratified based on their blunt and penetrating laparotomy volumes: high volume (HV), ≥25 cases per year; medium volume (MV), 13 to 24 cases per year; and low volume (LV), ≤12 cases per year. Multivariate regression analysis was performed to explore predictors of in-hospital mortality. RESULTS: A total of 8,588 patients underwent emergent laparotomy for either blunt (4,936; 57.5%) or penetrating injuries (3,652; 42.5%). Overall, mean ± SD age was 40 ± 17 years, abdomen Abbreviated Injury Scale was 3 (2-4), and Injury Severity Score was 26 (17-35). For American College of Surgeons (ACS) level I centers, 50% were HV; 29%, MV; and 21%, LV. For ACS level II centers, 7% were HV; 23%, MV; and 70%, LV. For ACS level III centers, 100% were LV. On multivariate regression analysis, admission of blunt and penetrating trauma patients to HV blunt and HV penetrating centers, respectively, was independently associated with improved in-hospital mortality. High-volume blunt centers had a significantly lower time to laparotomy (72 [41-144] minutes) versus MV (81 [49-145] minutes) and LV (94 [56-158] minutes) centers (p < 0.001). The same trend was observed for HV penetrating trauma centers (35 [24-52] minutes) versus MV (46 [33-63] minutes) and LV (51 [38-69] minutes) centers (p < 0.001). CONCLUSION: Blunt and penetrating injury patients requiring emergent laparotomy had higher survival when admitted to trauma centers with HV operative experience for their particular mechanism of injury. The regionalization of trauma care should be based on a thorough evaluation of trauma centers' injury-specific operative experience. LEVEL OF EVIDENCE: Prognostic, Level III; Therapeutic/Care management, Level IV.


Assuntos
Laparotomia/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Escala Resumida de Ferimentos , Adolescente , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Laparotomia/mortalidade , Masculino , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Centros de Traumatologia/normas , Resultado do Tratamento , Ferimentos não Penetrantes/epidemiologia , Ferimentos não Penetrantes/mortalidade , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/epidemiologia , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia , Adulto Jovem
8.
J Surg Res ; 260: 428-435, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33272596

RESUMO

BACKGROUND: Despite increases in surgical capacity in Malawi, minimal data exist on postoperative complications. Identifying surgical management gaps and targeting quality improvement requires detailed, longitudinal complications, and outcome data that assess surgical safety and efficacy. METHODS: We conducted a 6-mo prospective, observational study of patients >12 y after laparotomy at a tertiary hospital in Lilongwe, Malawi. Outcomes included postoperative complications and mortality. The seniormost rounding physician determined complication diagnoses. Bivariate and Poisson regression analyses identified predictors of mortality. RESULTS: Only patients undergoing emergent laparotomy (77.8%) died before discharge, so analysis excluded elective cases. Of 189 patients included, the median age was 33.5 y (IQR 22-50.5), 22 (12.2%) had prior abdominal surgery, and 11 (12.1%) were human immunodeficiency virus-positive. Gastrointestinal perforation was the most common diagnosis (35.5%). The most common procedures were primary gastrointestinal repair (24.9%), diverting ostomy (21.2%), and bowel resection with anastomosis (16.4%). Overall postoperative mortality was 14.8%. Intra-abdominal complication occurred in 17 (9.0%) patients, of whom 8 (47.1%) died. Older age (RR 1.05, 95% CI 1.02-1.08, P < 0.001) and intra-abdominal complication (RR 2.88, 95% CI 1.28-6.46, P = 0.01) increased the relative risk of mortality. Preoperative diagnosis, surgical intervention type, and symptom-to-surgery time did not increase the relative risk of mortality. CONCLUSIONS: The incidence of complications and mortality after laparotomy at a large referral hospital in Malawi is high. Older age and intra-abdominal complications increase the risk of death. Strategies to improve operative mortality in Malawi should prioritize postoperative surveillance and management and continued outcomes reporting.


Assuntos
Países em Desenvolvimento , Laparotomia/mortalidade , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Incidência , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Segurança do Paciente , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Centros de Atenção Terciária , Adulto Jovem
9.
JAMA Surg ; 156(1): 68-74, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33237323

RESUMO

Importance: In this aging society, older patients are more commonly undergoing emergency general surgery (EGS). Although frailty has been associated with worse outcomes in this population, EGS encompasses a heterogeneous mix of procedures. Objective: To determine if the association of frailty with morbidity and mortality in EGS patients varies based on the level of procedural risk. Design, Setting, and Participants: This cross-sectional study analyzed Medicare inpatient claims file (January 2007-December 2015) and included all inpatients who underwent 1 of 7 previously described EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally. Analysis took place from September 2019 to January 2020. Exposures: The primary exposure of interest was risk procedural level. EGS procedures were stratified as high risk (excision of small intestine, excision of large intestine, peptic ulcer repair, lysis of peritoneal adhesions, and laparotomy) and low risk (appendectomy and cholecystectomy). Main Outcomes and Measures: The primary outcome was overall 30-day mortality after discharge. Frailty was assessed using a claims-based frailty index. Multivariate logistic regression analysis was used and was stratified by risk level. Results: A total of 882 929 EGS patients were included in this study (mean [SD] age, 77.9 [7.5] years; 483 637 [54%] were female). Overall mortality was 4.5% (n = 40 304). The frailty index classified 12.6% (n = 111 513) of patients as frail, and mortality within this group was 9.9% (n = 11 307). High-risk procedures represented 53% (n = 468 098) of the caseload, and mortality was 6.8% (n = 31 979). For low-risk procedures, mortality was 2% (n = 8325). Frailty was significantly associated with mortality (odds ratio, 1.64; 95% CI, 1.60-1.68). After stratified analysis, this association remained significant for high-risk (odds ratio, 1.53; 95% CI, 1.49-1.58) and low-risk (odds ratio, 2.05; 95% CI, 1.94-2.17) procedures. Conclusions and Relevance: Frailty was significantly associated with mortality in patients undergoing EGS, with an even greater association in low-risk procedures. Preoperative frailty assessment is imperative even in low-risk procedures.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Fragilidade/complicações , Fragilidade/mortalidade , Cirurgia Geral/estatística & dados numéricos , Laparotomia/mortalidade , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Feminino , Idoso Fragilizado , Mortalidade Hospitalar , Humanos , Laparotomia/efeitos adversos , Modelos Logísticos , Masculino , Razão de Chances , Medição de Risco , Fatores de Risco
10.
Cancer Med ; 9(24): 9236-9245, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33236825

RESUMO

OBJECTIVE: To compare the long-term oncologic outcomes of minimally invasive surgery (MIS) vs laparotomy for patients with stage IB (2018 FIGO) cervical cancer. METHODS: A matched retrospective study of cervical cancer patients who underwent MIS or laparotomy at Sun Yat-sen University Cancer Center from January 2012 to December 2015 was carried out. Patients were restaged according to the 2018 FIGO staging system for cervical cancer, 700 cases with stage IB cervical cancer were enrolled. Propensity score matching (PSM) was performed by software SPSS version 22.0, and a total of 426 patients were enrolled and analyzed. Oncologic outcomes were compared between patients undergoing MIS vs laparotomy. RESULTS: After PSM, there were no statistical differences in other baseline characteristics between MIS and laparotomy, except for age (p = 0.008). In all stage IB patients, MIS group had significantly lower disease-free survival (DFS) rate and overall survival (OS) rate compared with laparotomy group (5-year DFS rate, 87.5% vs 94.1%, hazard ratio for disease recurrence, 2.403; 95% CI, 1.216-4.744; 5-year OS rate, 92.3% vs 98.1%, hazard ratio for death, 3.719; 95% CI, 1.370-10.093). In stage IB1 patients population, MIS was still associated with worse DFS and OS compared to laparotomy (5-year DFS rate: 89.5% vs 100%, p = 0.012; 5-year OS rate: 93.4% vs 100%, p = 0.043). Even in stage IB1 patients without lymph vascular space invasion, worse oncologic outcome could be observed in MIS group (DFS: p = 0.021; OS: p = 0.076). CONCLUSION: Our study suggested that laparotomy resulted in better OS and DFS compared with MIS among patients with stage IB cervical cancer. Even in stage IB1 patients without lymph vascular space invasion (2018 FIGO), laparotomy might be still an oncologically safer approach.


Assuntos
Laparotomia/mortalidade , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Recidiva Local de Neoplasia/cirurgia , Procedimentos Cirúrgicos Robóticos/mortalidade , Neoplasias do Colo do Útero/cirurgia , Feminino , Humanos , Laparotomia/métodos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Pontuação de Propensão , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Taxa de Sobrevida , Neoplasias do Colo do Útero/patologia
11.
Sci Rep ; 10(1): 16999, 2020 10 12.
Artigo em Inglês | MEDLINE | ID: mdl-33046829

RESUMO

Emergency Laparotomy (EL) is associated with significant morbidity and mortality. Variation in practice and patient outcomes for patients undergoing emergency laparotomy has been identified through the UK National Emergency Laparotomy Audit (NELA), with 30-day mortality ranging from 11 to 15%. A correlation between preoperative haemodynamic parameters and increased postoperative mortality has been demonstrated by both NELA and other observational studies. The association between intraoperative haemodynamic parameters and overall postoperative morbidity has not been evaluated in EL patients. The aims of our study were to investigate the association between perioperative haemodynamic and logistic parameters and postoperative morbidity in a tertiary referral university hospital; and to compare our outcomes to that of the NELA data. A retrospective analysis correlating a range of perioperative parameters with Comprehensive Complication Index (CCI) among 86 patients who underwent EL during 2018 was conducted. Mean age was 64 years (SD 16). Median CCI was 27 [9-45], and 30-day mortality was 11.7%. Several intraoperative parameters correlated with CCI on univariate analysis. On multivariate analysis, ASA status (P = 0.005) and unplanned escalation to postoperative intensive care (P = 0.03) were independently associated with CCI. Our study shows a correlation between ASA status and unplanned escalation to ITU with increased postoperative morbidity in patients undergoing emergency laparotomy. We did not demonstrate an independent correlation between intraoperative parameters and postoperative morbidity. These findings warrant confirmation in a larger scale observational study. Outcomes in our institution are comparable to those seen in the NELA.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Laparotomia/mortalidade , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Período Perioperatório , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Medição de Risco
12.
World J Surg ; 44(12): 3993-3998, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32737559

RESUMO

BACKGROUND: Comprehensive analysis of trauma care between high-, middle-, and low-income countries (HIC/MIC/LIC) is needed to improve global health. Comparison of HIC and MIC outcomes after damage control laparotomy (DCL) for patients is unknown. We evaluated DCL utilization among patients treated at high-volume trauma centers in the USA and South Africa, an MIC, hypothesizing similar mortality outcomes despite differences in resources and setting. METHODS: Post hoc analysis of prospectively collected trauma databases from participating centers was performed. Injury severity, physiologic, operative data and post-operative outcomes were abstracted. Univariate and multivariable analyses were performed to assess differences between HIC/MIC for the primary outcome of mortality. RESULTS: There were 967 HIC and 602 MIC patients who underwent laparotomy. DCL occurred in 144 MIC patients (25%) and 241 HIC (24%) patients. Most sustained (58%) penetrating trauma with higher rates in the MIC compared to the HIC (71 vs. 32%, p = 0.001). Between groups, no differences were found for admission physiology, coagulopathy, or markers of shock except for increased presence of hypotension among patients in the HIC. Crystalloid infusion volumes were greater among MIC patients, and MIC patients received fewer blood products than those in the HIC. Overall mortality was 30% with similar rates between groups (29 in HIC vs. 33% in MIC, p = 0.4). On regression, base excess and penetrating injury were independent predictors of mortality but not patient residential status. CONCLUSION: Use and survival of DCL for patients with severe abdominal trauma was similar between trauma centers in HIC and MIC settings despite increased penetrating trauma and less transfusion in the MIC center. While the results overall suggest no gap in care for patients requiring DCL in this MIC, it highlights improvements that can be made in damage control resuscitation.


Assuntos
Traumatismos Abdominais/cirurgia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Laparotomia/efeitos adversos , Laparotomia/estatística & dados numéricos , Traumatismos Abdominais/mortalidade , Adulto , Feminino , Humanos , Laparotomia/mortalidade , Masculino , Estudos Retrospectivos , África do Sul/epidemiologia , Centros de Traumatologia , Resultado do Tratamento
13.
Cancer Med ; 9(16): 5908-5921, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32628356

RESUMO

OBJECTIVE: To compare survival outcomes of minimally invasive surgery (MIS) and laparotomy in early-stage cervical cancer (CC) patients. METHODS: A multicenter retrospective cohort study was conducted with International Federation of Gynecology and Obstetrics (FIGO, 2009) stage IA1 (lymphovascular invasion)-IIA1 CC patients undergoing MIS or laparotomy at four tertiary hospitals from 2006 to 2017. Propensity score matching and weighting and multivariate Cox regression analyses were performed. Survival was compared in various matched cohorts and subgroups. RESULTS: Three thousand two hundred and fifty-two patients (2439 MIS and 813 laparotomy) were included after matching. (1) The 2- and 5-year recurrence-free survival (RFS) (2-year, hazard ratio [HR], 1.81;95% confidence interval [CI], 1.09-3.0; 5-year, HR, 2.17; 95% CI, 1.21-3.89) or overall survival (OS) (2-year, HR, 1.87; 95% CI, 1.03-3.40; 5-year, HR, 2.57; 95% CI, 1.29-5.10) were significantly worse for MIS in patients with stage I B1, but not the cohort overall (2-year RFS, HR, 1.04; 95% CI, 0.76-1.42; 2-year OS, HR, 0.99; 95% CI, 0.70-1.41; 5-year RFS, HR, 1.12; 95% CI, 0.76-1.65; 5-year OS, HR, 1.20; 95% CI, 0.79-1.83) or other stages (2) In a subgroup analysis, MIS exhibited poorer survival in many population subsets, even in patients with less risk factors, such as patients with squamous cell carcinoma, negative for parametrial involvement, with negative surgical margins, negative for lymph node metastasis, and deep stromal invasion < 2/3. (3) In the cohort treated with (2172, 54%) or without adjuvant treatment (1814, 46%), MIS showed worse RFS than laparotomy in patients treated without adjuvant treatment, whereas no differences in RFS and OS were observed in adjuvant-treatment cohort. (4) Inadequate surgeon proficiency strongly correlated with poor RFS and OS in patients receiving MIS compared with laparotomy. CONCLUSIONS: MIS exhibited poorer survival outcomes than laparotomy group in many population subsets, even in low-risk subgroups. Therefore, laparotomy should be the recommended approach for CC patients.


Assuntos
Histerectomia/mortalidade , Neoplasias do Colo do Útero/mortalidade , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , China , Competência Clínica , Intervalos de Confiança , Intervalo Livre de Doença , Feminino , Humanos , Histerectomia/métodos , Laparotomia/mortalidade , Laparotomia/estatística & dados numéricos , Metástase Linfática , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Pontuação de Propensão , Análise de Regressão , Estudos Retrospectivos , Cirurgiões/normas , Neoplasias do Colo do Útero/patologia , Neoplasias do Colo do Útero/cirurgia
14.
Ann Surg ; 272(2): 253-265, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675538

RESUMO

OBJECTIVE: To perform an individual participant data meta-analysis using randomized trials and propensity-score matched (PSM) studies which compared laparoscopic versus open hepatectomy for patients with colorectal liver metastases (CLM). BACKGROUND: Randomized trials and PSM studies constitute the highest level of evidence in addressing the long-term oncologic efficacy of laparoscopic versus open resection for CLM. However, individual studies are limited by the reporting of overall survival in ways not amenable to traditional methods of meta-analysis, and violation of the proportional hazards assumption. METHODS: Survival information of individual patients was reconstructed from the published Kaplan-Meier curves with the aid of a computer vision program. Frequentist and Bayesian survival models (taking into account random-effects and nonproportional hazards) were fitted to compare overall survival of patients who underwent laparoscopic versus open surgery. To handle long plateaus in the tails of survival curves, we also exploited "cure models" to estimate the fraction of patients effectively "cured" of disease. RESULTS: Individual patient data from 2 randomized trials and 13 PSM studies involving 3148 participants were reconstructed. Laparoscopic resection was associated with a lower hazard rate of death (stratified hazard ratio = 0.853, 95% confidence interval: 0.754-0.965, P = 0.0114), and there was evidence of time-varying effects (P = 0.0324) in which the magnitude of hazard ratios increased over time. The fractions of long-term cancer survivors were estimated to be 47.4% and 18.0% in the laparoscopy and open surgery groups, respectively. At 10-year follow-up, the restricted mean survival time was 8.6 months (or 12.1%) longer in the laparoscopy arm (P < 0.0001). In a subgroup analysis, elderly patients (≥65 years old) treated with laparoscopy experienced longer 3-year average life expectancy (+6.2%, P = 0.018), and those who live past the 5-year milestone (46.1%) seem to be cured of disease. CONCLUSIONS: This patient-level meta-analysis of high-quality studies demonstrated an unexpected survival benefit in favor of laparoscopic over open resection for CLM in the long-term. From a conservative viewpoint, these results can be interpreted to indicate that laparoscopy is at least not inferior to the standard open approach.


Assuntos
Neoplasias Colorretais/patologia , Laparoscopia/mortalidade , Laparotomia/mortalidade , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/secundário , Idoso , Teorema de Bayes , Intervalo Livre de Doença , Feminino , Hepatectomia/métodos , Humanos , Estimativa de Kaplan-Meier , Laparoscopia/métodos , Laparotomia/métodos , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Prognóstico , Pontuação de Propensão , Modelos de Riscos Proporcionais , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise de Sobrevida
15.
ANZ J Surg ; 90(10): 1895-1902, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32580245

RESUMO

BACKGROUND: Emergency laparotomy (EL) is a common procedure with high mortality leading to several efforts to record and reduce mortality. Risk scores currently used by quality improvement programmes either require intraoperative data or are not specific to EL. To be of utility to clinicians/patients, estimation of preoperative risk of mortality is important. We aimed to explore individual preoperative risk factors that might be of use in developing a preoperative mortality risk score. METHODS: Two independent reviewers identified relevant articles from searches of MEDLINE, EMBASE and Cochrane databases from January 1980 to January 2018. We selected studies that evaluated only preoperative predictive factors for mortality in EL patients. RESULTS: The search yielded 6648 articles screened, with 22 studies included examining 157 728 patients. The combined post-operative 30-day mortality was 13%. All, but one small study, were at low risk of bias. A meta-analysis of results was not possible due to the heterogeneity of populations and outcomes. Age, American Society of Anesthesiologists, preoperative sepsis, dependency status, current cancer and comorbidities were associated with increased mortality. Acute physiological derangements seen in renal, albumin and complete blood count assays were strongly associated with mortality. Delay to surgery and diabetes did not influence mortality. Higher body mass index was protective. CONCLUSION: Preoperatively, risk factors identified can be used to develop and update risk scores specific for EL mortality. This scoping review focused on the preoperative setting which helps tailor treatment decisions. It highlights the need for further research to test the relevance of newer risk factors such as frailty and nutrition.


Assuntos
Serviço Hospitalar de Emergência , Laparotomia , Humanos , Laparotomia/mortalidade , Estado Nutricional , Melhoria de Qualidade , Fatores de Risco
16.
World J Surg ; 44(10): 3299-3309, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32488666

RESUMO

BACKGROUND: All-cause perioperative mortality rate (POMR) is a commonly reported metric to assess surgical quality. Benchmarking POMR remains difficult due to differences in surgical volume and case mix combined with the burden of reporting and leveraging this complex and high-volume data. We seek to determine whether the pooled and individual procedure POMR of each bellwether (cesarean section, laparotomy, management of open fracture) correlate with state-level all-cause POMR in the interest of identifying benchmark procedures that can be used to make standardized regional comparisons of surgical quality. METHODS: The Brazilian National Healthcare Database (DATASUS) was queried to identify unadjusted all-cause POMR for all patient admissions among public hospitals in Brazil in 2018. Bellwether procedures were identified as any procedure involving laparotomy, cesarean section, or treatment of open long bone fracture and then classified as emergent or elective. The pooled POMR of all bellwether procedures as well as for each individual bellwether procedure was compared with the all-cause POMR in each of the 26 states, and one federal district and correlations were calculated. Funnel plots were used to compare surgical volume to perioperative mortality for each bellwether procedure. RESULTS: 4,756,642 surgical procedures were reported to DATASUS in 2018: 237,727 emergent procedures requiring laparotomy, 852,821 emergent cesarean sections, and 210,657 open, long bone fracture repairs. Pooled perioperative mortality for all of the bellwether procedures was correlated with all-procedure POMR among states (r = 0.77, p < 0.001). POMR for emergency procedures (2.4%) correlated with the all-procedure (emergent and elective) POMR (1.6%, r = 0.93, p < .001), while POMR for elective procedures (0.4%) did not (p = .247). POMR for emergency laparotomy (4.4%) correlated with all-procedure POMR (1.6%, r = 0.52, p = .005), as did the POMR for open, long bone fractures (0.8%, r = 0.61, p < .001). POMR for emergency cesarean section (0.05%) did not correlate with all-procedure POMR (p = 0.400). There was a correlation between surgical volume and emergency laparotomy POMR (r = - 0.53, p = .004), but not for emergency cesarean section or open, long bone fractures POMR. CONCLUSION: Procedure-specific POMR for laparotomy and open long bone fracture correlates modestly with all-procedure POMR among Brazilian states which is primarily driven by emergency procedure POMR. Selective reporting of emergency laparotomy and open fracture POMR may be a useful surrogate to guide subnational surgical policy decisions.


Assuntos
Cesárea/mortalidade , Fraturas Expostas/cirurgia , Laparotomia/mortalidade , Período Perioperatório/mortalidade , Causas de Morte , Emergências , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Gravidez
17.
Updates Surg ; 72(3): 859-865, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32385794

RESUMO

Emergency laparotomies are often required for life-threatening conditions and consequently are associated with high mortality. This risk should be discussed with patients and ideally their next of kin (NOK). Failure to do so denies patients and their relatives the opportunity to prepare, breaches consent guidance, and may result in complaints and negligent claims. Patients who underwent an emergency laparotomy over 6 months were retrospectively studied. Mortality risk discussion with patients and their NOK as evidenced by documentation on consent forms or clinical notes was recorded. Factors influencing these discussions included patient's age, American Society of Anaesthesiologists' score, pre-operative diagnosis, Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM); seniority of consenting surgeon was also investigated. Seventy-six consecutive patients underwent an emergency laparotomy. Sixty-nine had capacity to give consent. Mortality risk was discussed with 24 (34.8%). These patients were older (median age 77.5 v 65.5 years; P < 0.05) and had a higher median P-POSSUM score (11.5% v 7%; P = 0.313) compared to patient with whom mortality risk was not discussed. Mortality risk was discussed with 14 (18.4%) NOK. This was not influenced by any factor studied. For patients requiring an emergency laparotomy, mortality risk was infrequently discussed with both patients and their NOK. These patients have a higher mortality risk than any other and this "failure to inform" has the potential for serious ramifications.


Assuntos
Consentimento Livre e Esclarecido/estatística & dados numéricos , Laparotomia/mortalidade , Fatores Etários , Idoso , Emergências , Feminino , Humanos , Masculino , Cuidados Pré-Operatórios , Estudos Retrospectivos , Risco , Índice de Gravidade de Doença , Fatores de Tempo
18.
Anaesthesia ; 75(10): 1321-1330, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32395823

RESUMO

Emergency laparotomy is associated with high mortality. Implementation of an evidence-based care bundle has been shown to improve patient outcomes. A quality improvement project to implement a six-component care bundle was undertaken between July 2015 and May 2018. As part of this project, we worked with 27 hospitals in the Emergency Laparotomy Collaborative. Previous pilot implementation of the same bundle in our hospital between December 2012 and July 2013 had shown marked improvement, maintained until April 2014, but then deterioration. Understanding the reasons for this deterioration informed our work to re-implement the bundle and sustain improvement. A cohort of 930 consecutive patients requiring emergency laparotomy between October 2014 and April 2019 were included. Baseline data were collected between October 2014 and June 2015, and the bundle was re-implemented in July 2015. Thirty-day mortality decreased from 11% in the baseline group to 7.3% after bundle implementation. Hospital length of stay decreased from 19.5 to 17.9 days. Full bundle compliance improved from < 60% to > 80% for all patients, with improvement in application of all individual bundle components. This study provides further evidence that outcomes for high-risk surgical patients can be improved with an evidence-based care bundle, but attention must be paid to maintaining bundle compliance. Issues around sustaining improvement must be considered from project initiation.


Assuntos
Serviços Médicos de Emergência/normas , Laparotomia/normas , Assistência ao Paciente/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Medicina Baseada em Evidências , Feminino , Fidelidade a Diretrizes , Humanos , Laparotomia/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pacotes de Assistência ao Paciente , Melhoria de Qualidade , Risco , Resultado do Tratamento
19.
Minerva Chir ; 75(6): 419-425, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32456399

RESUMO

BACKGROUND: The open abdomen or laparostomy is a great advance of surgery based on the concept of damage control surgery. Aim of the study is to review the laparostomy outcomes of non-trauma emergency surgery patients in a district general hospital and identify parameters affecting early definite primary fascial closure. METHODS: The records of all non-trauma emergency surgical patients who underwent laparostomy in a three-year period in a single institute were studied retrospectively. Outcomes included length of stay, morbidity, mortality, readmission rates, number of re-look operations, rate of definite primary fascial closure and time to closure. RESULTS: Thirty-two patients were included. Morbidity was 84.4% and mortality rates were 21.9% (in-hospital), 18.8% (30-day) and 46.9% (overall). Median length of hospital stay was 22 days. Rate of primary fascial closure was 87.5% and median time to closure was two days. The number of relook operations was the only independent prognostic factor of definite early primary fascial closure, with higher rates of closure in patients with 1-2 relooks. CONCLUSIONS: Although the open abdomen has been demonstrated to improve survival, the precise role in abdominal sepsis has not been elucidated. Current consensus does not support use of open abdomen routinely, however in selected situations it becomes unavoidable. Laparostomy is a valid option in non-trauma emergency surgery and can be managed safely in a district hospital. High closure rates can be achieved if one or two re-look operations are performed with an early attempt for closure.


Assuntos
Fasciotomia , Técnicas de Abdome Aberto , Adulto , Idoso , Idoso de 80 Anos ou mais , Emergências , Fáscia , Fasciotomia/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Hospitais de Distrito , Hospitais Gerais , Humanos , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Técnicas de Abdome Aberto/mortalidade , Técnicas de Abdome Aberto/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Cirurgia de Second-Look/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
20.
World J Surg ; 44(9): 2976-2981, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32430741

RESUMO

BACKGROUND: The term 'emergency open abdominal surgery' covers a range of common procedures with high complication and mortality risks; however, previous studies have not included descriptive analyses of the patients undergoing the procedures. The aim of this study is to present a nationwide description of all patients who undergo an emergency bowel resection, ostomy placement or drainage involving laparotomy at Danish hospitals and to report the 30- and 365-day mortality risks. METHOD: We identified all of the patients in the Danish National Patient Register aged 18 + who underwent emergency open abdominal surgery in the form of a laparotomy during the period 2003-14. Using Poisson and logistic regression models, we analyzed incidence rates and mortality risk. RESULT: The sample consisted of 15,680 patients, with an overall open abdominal surgery incidence rate of 30.4 cases per 100,000 person-years. The 30-day mortality risk was 19.3% for both sexes, and increased with age (at 80-89, mortality risk was 39.4% for males and 34.5% for females). The 30-day mortality risk fell by 5.4% during the study period, from 22.2% to 16.7%. CONCLUSION: Open abdominal surgery is a common, high-risk procedure with a high incidence rate and mortality risk, especially for elderly patients. The incidence rate and mortality risk fell during the period studied. In Denmark, there is no standard post-discharge care program for patients who undergo emergency laparotomies. Our results support the need to investigate standardized post-operative follow-up and rehabilitation plans to reduce mortality.


Assuntos
Abdome/cirurgia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Adolescente , Adulto , Assistência ao Convalescente , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Laparotomia/mortalidade , Laparotomia/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
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