Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network

Abstract

This study confirms that emergency laparotomy in the UK carries a high mortality. The variation in clinical management and outcomes indicates the need for a national quality improvement programme.

Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture

“…Cook and Day reported an in-hospital postoperative mortality among elderly emergency laparotomy patients aged~80 years of 44% in 1998 [34] and 42% in 2007 [35], similar to other recent studies in the UK (21% 30-day aged over 70 years [36]) and USA (32% for emergency colorectal surgery in octogenarians [37]). In a prospective audit of almost 1900 patients undergoing emergency laparotomy, the UK Emergency Laparotomy Network reported a direct relationship between age and 30-day mortality; for patients in their 50s, mortality was 10%, increasing by~5% per decade, such that patients in their 80 s had a 30-day mortality of 24.4% and in their 90 s, 32% [5].…”

“…Despite this, there is little evidence that outcomes have improved [5,35,37,62]. However, the National Emergency Laparotomy Audit has been recently established in the UK, with the aim of improving outcome after emergency laparotomy [63].…”

“…Given that the number of elderly patients presenting for emergency surgery is likely to rise as the population ages, this review summarises the evidence on which such guidance is based, and provides information about how anaesthetists might participate in audit and research aimed at improving local and national outcomes for these most vulnerable of patients. More recently, national audits have reported several-fold variations in the care of elderly emergency surgical patients in the UK [4][5][6], and importantly, these data are beginning to be used to drive quality improvement [11] through professional guidance [12][13][14] that advocates early, focused, multidisciplinary 70 …”

“…Over the last decade, postoperative mortality and (costly) morbidity rates have remained unacceptably high in comparison with relative improvements in outcome after similar procedures undertaken electively. For example, postoperative inhospital or 30-day mortalities are~38%,~15% and 8.2% after emergency open ruptured aortic aneurysm repair [4], laparotomy [5] and hip fracture [6] fixation, compared with~5%,~6% and 1.2% after elective open surgery for abdominal aortic aneurysm (AAA) [4], colorectal cancer [7] and primary total hip replacement (aged > 80 years) [8]. Emergency ruptured aneurysm repair, laparotomy and hip fracture fixation are high-risk procedures [9] undertaken primarily on elderly patients who have limited physiological reserve and co-morbidities, are often frail and take numerous medications.…”

“…More recently, national audits have reported several-fold variations in the care of elderly emergency surgical patients in the UK [4][5][6], and importantly, these data are beginning to be used to drive quality improvement [11] through professional guidance [12][13][14] that advocates early, focused, multidisciplinary care, and targeted research. This review summarises the evidence on which such guidance is based.…”