Emergency laparotomy outcomes before and after the introduction of an acute surgical unit

Abstract

Introduction: Emergency laparotomy is associated with significant morbidity and mortality. This study compared emergency laparotomy outcomes in a traditional service to those after the introduction of an Acute Surgical Unit (ASU). Methods: A retrospective cohort study was performed by reviewing the medical records of all individuals that had an emergency laparotomy in twelve-month periods before and after the introduction of an ASU. Outcomes included time to surgical review, operation duration, length of stay, complications and mortality. Morbidity and mortality were compared to that predicted by P-Possum scores. Results: In the pre-ASU group there were 58 participants (26 males, 32 females) with a median age of 60 years (range 15–87) and median P-Possum predicted morbidity and mortality of 68% (18–98%) and 6% (1–66%) respectively. In the post-ASU group there were 109 participants (58 males, 53 females) with a median age of 63 years (range 11–100), and median P-Possum predicted morbidity and mortality of 82% (18–100%) and 12% (1–99%). Operating time decreased post-ASU (median 1 hr 31 min pre vs 1 hr 15 min post p = 0.030) and there was a reduction in the incidence of post-operative fistula formation (5% vs 0% p = 0.017). There were no other significant differences in morbidity or mortality. Conclusions: The post-ASU cohort had shorter operative duration and reduced incidence of complicating fistulas but no other significant difference in outcomes. Further studies may define the impact of an ASU on clinical decision making, service delivery, morbidity and mortality in patients that undergo emergency laparotomy. Highlights:

Predictors of 30-Day In-Hospital Mortality in Patients Undergoing Urgent Abdominal Surgery Due to Acute Peritonitis Complicated with Sepsis

“…Urgent laparotomy is associated with significant increased risk of mortality and is reported to be approximately 15% [13,14]. However, this number might vary and depends on the indications, specific patient characteristics, and health system factors [13,22]. Acute peritonitis remains an important cause of morbidity and mortality in emergency abdominal surgery [23].…”

“…Mortality in intra-abdominal sepsis ranges from 28% to 47% [22,24,25]. Sepsis is a life-threatening complication [13,21] of peritonitis. Our study confirmed a worldwide problem of undiagnosed sepsis, which is common in all departments.…”

“…Perioperative risk assessment has a significant influence on patient outcomes by improving multi-disciplinary decision-making, allocation of critical care resources, and communication with patients [12]. However, it is important to note that urgent laparotomy is associated with increased risk of mortality, which is approximately 15% [13,14] in combination with sepsis mortality rate increases [15].…”

“…6334 Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS]ASA physical status and APACHE II score Twenty-eight patients (42%) were ASA physical status III, 29 patients (43%) were ASA IV and 10 patients (15%) were physical status V. There were 3 non-survivors (11%) who were (APACHE II) score was13 points (5-32 points). For survivors APACHE II score was 10 points (7-28 points) compared to nonsurvivors 18 points (7-30 points) (P<0.001).…”

Acute Care Surgery Models Worldwide: A Systematic Review

“…None of the included articles reported on-site night-time attending coverage of an ASU. Six of the ASU's described were a separate (sub)unit from other surgical services [36][37][38][41][42][43]. Six articles described coverage of the ED by the ASU team or resident during working hours [37,38,43,46,48,49] [38,[47][48][49].…”