Failure to rescue patients after emergency laparotomy for large bowel perforation: analysis of the National Emergency Laparotomy Audit (NELA)

Abstract

Background Past studies have highlighted variation in in-hospital mortality rates among hospitals performing emergency laparotomy for large bowel perforation. The aim of this study was to investigate whether failure to rescue (FTR) contributes to this variability. Methods Patients aged 18 years or over requiring surgery for large bowel perforation between 2013 and 2016 were extracted from the National Emergency Laparotomy Audit (NELA) database. Information on complications were identified using linked Hospital Episode Statistics data and in-hospital deaths from the Office for National Statistics. The FTR rate was defined as the proportion of patients dying in hospital with a recorded complication, and was examined in hospitals grouped as having low, medium or high overall postoperative mortality. Results Overall, 6413 patients were included with 1029 (16.0 per cent) in-hospital deaths. Some 3533 patients (55.1 per cent) had at least one complication: 1023 surgical (16.0 per cent) and 3332 medical (52.0 per cent) complications. There were 22 in-hospital deaths following a surgical complication alone, 685 deaths following a medical complication alone, 150 deaths following both a surgical and medical complication, and 172 deaths with no recorded complication. The risk of in-hospital death was high among patients who suffered either type of complication (857 deaths in 3533 patients; FTR rate 24.3 per cent): 172 deaths followed a surgical complication (FTR-surgical rate 16.8 per cent) and 835 deaths followed a medical complication (FTR-medical rate of 25.1 per cent). After adjustment for patient characteristics and hospital factors, hospitals grouped as having low, medium or high overall postoperative mortality did not have different FTR rates (P = 0.770). Conclusion Among patients having emergency laparotomy for large bowel perforation, efforts to reduce the risk of in-hospital death should focus on reducing avoidable complications. There was no evidence of variation in FTR rates across National Health Service hospitals in England.

Impact of Preoperative Stoma Site Marking on Morbidity and Mortality in Patients with Colorectal Perforation: A Nationwide Retrospective Cohort Study

“…The 30-day mortality rate for colorectal perforation in this study was 4.7%, which was lower than the 10-20% reported in previous studies [1][2][3][4][5][6]. The reason for this discrepancy is unclear; however, one possible reason may be that 86% of the hospitals included in this study were academic hospitals.…”

“…As colorectal perforation is a serious condition with high morbidity and mortality [1][2][3][4][5][6], the decision of whether to perform stoma site marking before emergency surgery is important for patients, surgeons, and nurses. In this study, stoma site marking was performed in 3.2% patients with colorectal perforation who underwent emergency surgery, which was consistent with the reported rate (0-15%) in previous studies [9,15].…”

“…Third, it was impossible to distinguish between right or left hemisphere resections because of the lack of relevant data in the database. However, a previous study reported that the site of colonic perforation was not associated with worse short‐term outcomes [6].…”

“…Colorectal perforation is a serious medical condition with a high operative morbidity rate of approximately 50% and a mortality rate of approximately 10-20% [1][2][3][4][5][6]. Hartmann's procedure is a suitable emergency surgical strategy for patients with colorectal perforation; the associated mortality rates and prevalence of reoperation are lower than those associated with primary anastomosis without a diverting stoma [5,7,8].…”

Failure to Rescue in Major Abdominal Surgery: A Regional Australian Experience

“…Our study only included Clavien–Dindo 3–5 patients, thus who require some intervention, and who have by definition an increased risk of RTT and mortality. Peacock et al [42] in their study of FTR after emergency laparotomy for large bowel perforation reported a FTR‐surgical rate of 16.8% ( n = 172) [42], while ours was similar at 16.7% ( n = 47) for all colorectal emergencies. The significant association between comorbidities and FTR is similar to what was observed by Pandit et al [43] in a retrospective study of 49, 000 patients undergoing colectomies.…”