Welcome back to the second part of our look at the holy trinity of emergency surgery; a look at the three biggest operations and particularly focusing on their impact on the elderly population undergoing them. Today we turn our attention to the laparotomy, the go-to guy for all manner of intra-abdominal problems. As I mentioned in the last post, the basis for this blog post is the recent Anaesthesia supplement looking at ‘The Big Three’ of emergency surgery If you haven’t had a look at it yet check it out via the link below:
What's The Story?
First, let’s remind ourselves of the authors’ simple key point about the ‘Big Three’; they have much worse outcomes than their elective counterparts. The post operative in hospital and 30 day mortality rate for laparotomy is 15% compared with the 6% seen for elective colorectal cancer surgery. Now I know this isn’t quite as dramatic a comparison after we have just looked at the abdominal aortic aneurysm (AAA) comparison (38% compared with 5% mortality rates) but it is still over double the mortality rate, for what in surgical terms is pretty similar.
The numbers don’t look much better on closer inspection either. The pattern is similar to that seen in last post (and the one before that actually); the older you are the worse your outcome is likely to be. The UK Emergency Laparotomy Network provides a rough approximation of risk. They describe that mortality for patients in their 50’s was around 10%, with this mortality increasing by 5% per decade. The worse outcomes in the elderly aren’t just limited to mortality either, with both post-operative complications rates and the chances of being discharged home being notably worse in the emergency group (88% vs 39% for complications and 69% vs 6.5% for discharge home).
The numbers don’t look much better on closer inspection either. The pattern is similar to that seen in last post (and the one before that actually); the older you are the worse your outcome is likely to be. The UK Emergency Laparotomy Network provides a rough approximation of risk. They describe that mortality for patients in their 50’s was around 10%, with this mortality increasing by 5% per decade. The worse outcomes in the elderly aren’t just limited to mortality either, with both post-operative complications rates and the chances of being discharged home being notably worse in the emergency group (88% vs 39% for complications and 69% vs 6.5% for discharge home).
Why The Difference?
Some of the reasons are exactly the same as for those patients with a ruptured AAA. These patients have less in the way of physiological reserve, are on multiple drugs, and are less likely to get level 2 or 3 care post-op (copied directly from the last post to highlight the point). Whilst the contrast in the pathology is not quite as dramatic as a ruptured AAA compared with an intact aorta, they are still different enough for it to be understandable that there will be an increased mortality in those needing emergency surgery. Abdominal viscus perforation is less than ideal no matter what your age is, and pathology such as acute colitis, obstruction, GI haemorrhage and diverticulitis are pretty unpleasant. Yes, colorectal cancer is not a great diagnosis either but in terms of its acute effects on the body it doesn’t really compare to the emergency presentations.
The authors go on point out, with a few examples, that these may be patients in which medical therapy has been tried and failed, with surgery being postponed until further down the line when there has been more time for deterioration (e.g. failed endoscopic control of peptic ulcer disease, failed medical management of the acute colitis episode). They also return to this idea of the importance of critical care after these procedures and the tangible difference that it makes to the outcome of these patients, mainly by reducing or identifying the post-operative complications earlier. Trusts with a higher ratio of ICU beds to hospital beds have better 30-day mortality figures, and patients admitted directly to ICU having a reduced mortality compared with those going straight to the ward (30% compared with 38% in one reported study). They suggest that it might actually be these post-op complications (and there subsequent detection and management) that has the biggest impact on survival after such major surgery.
The authors go on point out, with a few examples, that these may be patients in which medical therapy has been tried and failed, with surgery being postponed until further down the line when there has been more time for deterioration (e.g. failed endoscopic control of peptic ulcer disease, failed medical management of the acute colitis episode). They also return to this idea of the importance of critical care after these procedures and the tangible difference that it makes to the outcome of these patients, mainly by reducing or identifying the post-operative complications earlier. Trusts with a higher ratio of ICU beds to hospital beds have better 30-day mortality figures, and patients admitted directly to ICU having a reduced mortality compared with those going straight to the ward (30% compared with 38% in one reported study). They suggest that it might actually be these post-op complications (and there subsequent detection and management) that has the biggest impact on survival after such major surgery.
What Should We Do?
The authors have highlighted some components of the peri-operative care that has the potential to improve the poor outcomes seen in these patients.
Pre-op:
Pre-op:
- Early antibiotics in patients with concurrent sepsis (the sooner the better)
- Early diagnosis through senior, multi-disciplinary clinician assessment and CT scanning
- Early surgery, minimising delay as much as possible
- Invasive arterial blood pressure monitoring
- Core temperature monitoring and maintenance
- Use of near patient testing (notably for acid-base balance, haemoglobin concentration, and oxygen exchange)
- Goal directed fluid administration (more controversial)
- Consideration of epidural use (a risk-benefit decision)
- Critical care admission post-op (though obvious resource limitations)
- Implementation of appropriate ‘care-bundles’
Let's Summarise
I think that is about it for a quick look at the entity that is the emergency laparotomy. Whilst I think it’s clear that the outcomes are never going to be as good as those from carefully planned, elective procedures, the authors make a good argument that there is still plenty of room to improve the outcomes of our patients, particularly our elderly patients. As with the management of the ruptured AAA, a lot of the improvements will come from areas outside our direct influence as anaesthetists or intensivists, but there are plenty of areas that do fall under our care.
The last point I wanted to cover was one that stood out for me from the authors’ analysis of assessing and preparing these patients for this major surgical procedure. Though they have gone into detail to point out how age is a major risk factor for adverse outcomes in these patients, they highlight that 70% of patients aged over 90 do survive until (at least) 30 days post surgery. One of the most common adverse events in patients with this range of pathology was looking back and feeling that the operation should have gone ahead when it didn't.
Thanks once again for reading and I have tried to put together a list of a few more interesting resources to keep you busy until the grand finale of this trilogy .
Tom Heaton
The last point I wanted to cover was one that stood out for me from the authors’ analysis of assessing and preparing these patients for this major surgical procedure. Though they have gone into detail to point out how age is a major risk factor for adverse outcomes in these patients, they highlight that 70% of patients aged over 90 do survive until (at least) 30 days post surgery. One of the most common adverse events in patients with this range of pathology was looking back and feeling that the operation should have gone ahead when it didn't.
Thanks once again for reading and I have tried to put together a list of a few more interesting resources to keep you busy until the grand finale of this trilogy .
Tom Heaton
www.patient.co.uk - A nice refresher on the acute abdomen
www.rcoa.ac.uk - A link to some of the webcasts on the RCOA website with a few nice videos on emergency laparatomy
www.nela.org.uk - A link to the home page of the NELA group.
www.rcoa.ac.uk - A link to some of the webcasts on the RCOA website with a few nice videos on emergency laparatomy
www.nela.org.uk - A link to the home page of the NELA group.
Image courtesy of Arztsamui/FreeDigitalPhotos.net
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