Complications and outcomes of patients after emergency laparotomy

Abstract Emergency laparotomy (EL) is one of the most common emergency gastrointestinal procedures. A limited number of studies focus on the onset of postoperative complications, long-term mortality and the impact of preoperative quality of life (QoL) on the rate of postoperative complications after EL. This thesis examined the factors associated with postoperative complications after EL as well as their impact on short- and long-term outcomes. In addition, this thesis assessed whether the preoperative QoL affects the rate of postoperative complications. The thesis consists of one prospective and three retrospective studies. Overall, these studies comprised a total of 1 299 EL patients operated during 2005–2022 at Oulu University Hospital, Finland. The QoL before EL was evaluated using the RAND-36 questionnaire. Patients with postoperative complications reported lower general health in RAND-36 domains than patients without complications. Medical complications occurred mainly in the early postoperative phase while operation-related complications occurred later. Of 674 EL patients, 50% had medical complications and 30% had operation-related complications. In multivariate analysis, patient-related factors such as advanced age, high ASA and preoperative CRP and low albumin were risk factors for medical complications. Patients with medical complications had higher 30-day mortality than patients with operation-related complications (17.2% vs. 13.5%). Both short- and long-term mortality was significantly worse in EL patients with postoperative complications compared to patients without complications: 30-day mortality 15.9% vs. 5.3%, 90-day mortality 24.7% vs. 8.4%, and 2-year mortality 39.3% vs. 17.5%. In multivariate analysis, high ASA and CCI scores and longer duration of operation were associated with mortality after EL in patients surviving more than 90 days. EL patients who required ICU treatment within 48 hours of surgery had high mortality rates; the 5-year mortality was 58%. EL patients are at high risk for postoperative complications, and mortality after EL is significant. By taking into account the onset of complications and risk factors the early identification of complications can be improved and their treatment made more effective.Tiivistelmä Päivystyslaparotomia on yksi yleisimmistä yleiskirurgisista toimenpiteistä. Päivystyslaparotomian jälkeisten komplikaatioiden ilmaantuvuudesta ja leikkausta edeltävän elämänlaadun vaikutuksesta komplikaatioihin on niukasti aiempaa tutkimusta. Tässä väitöskirjatyössä tarkasteltiin päivystyslaparotomian jälkeisiä komplikaatioita ja niiden vaikutusta lyhyen- ja pitkän aikavälin ennusteeseen. Lisäksi arvioitiin, vaikuttaako leikkausta edeltävä elämänlaatu komplikaatioiden ilmaantuvuuteen. Väitöskirjatyö koostuu yhdestä prospektiivisesta ja kolmesta retrospektiivisestä tutkimuksesta. Tutkimukseen kuului 1 299 vuosina 2005–2022 Oulun yliopistollisessa sairaalassa leikattua päivystyslaparotomiapotilasta. Elämänlaatua ennen päivystyslaparatomiaa arvioitiin käyttämällä RAND-36-kyselyä. Potilaat, jotka saivat leikkauksen jälkeisen komplikaation, raportoivat heikomman yleisen terveyden RAND-36-kyselyssä kuin ilman komplikaatiota toipuneet. Ei-kirurgiset komplikaatiot ilmaantuivat pääosin varhaisvaiheessa ja kirurgiset komplikaatiot myöhäisvaiheessa. 674 päivystyslaparotomiapotilaasta 50 %:lla esiintyi ei-kirurgisia komplikaatioita ja 30 %:lla kirurgisia komplikaatioita. Monimuuttujamallissa ei-kirurgisten komplikaatioiden riskitekijöitä olivat potilaaseen liittyvät tekijät, kuten ikä, korkea ASA ja leikkausta edeltävä CRP sekä matala albumiini. Potilailla, joille ilmaantui ei-kirurgisia komplikaatioita, oli korkeampi 30 päivän kuolleisuus kuin potilailla, joilla oli kirurgisia komplikaatioita (17,2 % vs. 13,5 %). Sekä lyhyt- että pitkäaikainen kuolleisuus oli korkeampi potilailla, joille ilmaantui komplikaatioita verrattuna potilaisiin, joille ei tullut komplikaatiota: 30 päivän kuolleisuus 15,9 % vs. 5,3 % ja 90 päivän kuolleisuus 24,7 % vs. 8,4 %, ja 2 vuoden kuolleisuus 39,3 % vs. 17,5 %. Monimuuttujamallissa kuolleisuuden riskitekijöitä yli 90 päivää leikkauksen jälkeen eläneillä potilailla oli korkea ASA, korkeat CCI pisteet ja pidempi leikkauksen kesto. Tehohoitoa 48 tunnin sisällä leikkauksesta tarvinneilla päivystyslaparotomiapotilailla oli korkea kuolleisuus; 5 vuoden kuolleisuus oli 58 %. Päivystyslaparotomiapotilailla on suuri riski saada leikkauksen jälkeinen komplikaatio ja kuolleisuus päivystyslaparotomian jälkeen on merkittävä. Huomioimalla komplikaatioiden ilmaantuvuuden ja riskitekijät, voidaan parantaa komplikaatioiden varhaista tunnistamista ja tehostaa niiden hoitoa

Outcomes in patients requiring intensive care unit (ICU) admission after emergency laparotomy:a retrospective study

Abstract Purpose: Outcomes after emergency laparotomy (EL) are poor. These patients are often admitted to an intensive care unit (ICU). This study explored outcomes in patients who were admitted to an ICU within 48 h after EL. Materials and Methods: This retrospective single-center registry study included all patients over 16 years of age that underwent an EL and were admitted to an ICU within 48 h after surgery in Oulu University Hospital, Finland between January 2005 and May 2015. Survival was followed until the end of 2019. Results: We included 525 patients. Hospital mortality was 13.3%, 30-day mortality was 17.3%, 90-day mortality was 24.2%, 1-year mortality was 33.0%, and 5-year mortality was 59.4%. Survivors were younger (57 [45–70] years) than the non-survivors (73 [62–80] years; p < .001). According to the Cox regression model, death during the follow-up was associated with age, APACHE II-score, lower postoperative CRP levels and platelet count of the first postoperative day, and the admission from the post-anesthesia care unit (PACU) to the ICU instead of direct ICU admission. Conclusion: Age, high APACHE II-score, low CRP and platelet count, and admission from the PACU to the ICU associated with mortality after EL in patients admitted to an ICU within 48 h after EL

Evolution of pancreatic surgery over time and effects of centralization:a single-center retrospective cohort study

Abstract Background: Short-term outcomes of pancreatic surgery have improved globally during the last two decades. Long-term survival of resectable pancreatic ductal adenocarcinoma (PDAC) has also shown slight improvement. We describe a cohort of 566 consecutive pancreatectomies performed at a Northern Finnish tertiary center. We analyze the trends in short-term outcomes of all-cause pancreatic surgery and long-term survival of PDAC patients. Methods: All pancreatic resections performed at the Oulu University Hospital during years 2000–2020 were included. Patient data was analyzed in four time periods (2000–2005, 2006–2010, 2011–2015 and 2016–2020). Clinicopathological parameters of patients and tumors, complication data and short-term mortality were recorded for all patients and compared between time quartiles. Long-term survival and administration rates of neo-, and/or adjuvant therapy of PDAC patients were analyzed. Results: A total of 566 pancreatectomies were performed during the study period: 359 (63%) pancreatoduodenectomies (PDs), 130 (23.0%) open left pancreatectomies (LPs), 45 (8.0%) laparoscopic LPs, 26 (5.1%) total pancreatectomies (TPs), and 6 (1.1%) enucleations. Median age of patients was 63 [57–71] years, and 49% [267] of patients were men. Number of pancreatectomies per time period increased from 67 in 2000–2005 to 266 in 2016–2020. American Society of Anesthesiologists (ASA) Physical Classification III patients and T3 tumors were more frequently operated on in later time periods. Complication rates remained at constant low levels throughout the study period, but reoperation rate increased from 9.4% in 2000–2010 to 16.2% in 2011–2020. Short-term (90-day) mortality after pancreatectomy decreased from 3.1% to 0.74%, while 5-year survival improved from 14.3% in 2006–2011 to 21.4% in 2011–2015. Resection rate of diagnosed PDAC cases, as reported by the Finnish Cancer Registry (FCR) for the catchment area, increased from 3.2% to 14.9% over the study period. Conclusions: The hospital volume of pancreatectomies has increased substantially, while complications and postoperative mortality have remained at acceptable levels. Long-term survival and resection rate of PDAC patients showed notable improvement over two decades

Nutrition delivery after emergency laparotomy in surgical ward:a retrospective cohort study

Abstract Purpose: Adequate nutrition after major abdominal surgery is associated with less postoperative complications and shorter hospital length of stay (LOS) after elective procedures, but there is a lack of studies focusing on the adequacy of nutrition after emergency laparotomies (EL). The aim of the present study was to investigate nutrition adequacy after EL in surgical ward. Methods: The data from 405 adult patients who had undergone emergency laparotomy in Oulu University Hospital (OUH) between years 2015 and 2017 were analyzed retrospectively. Nutrition delivery and complications during first 10 days after the operation were evaluated. Results: There was a total of 218 (53.8%) patients who were able to reach cumulative 80% nutrition adequacy during the first 10 postoperative days. Patients with adequate nutrition (> 80% of calculated calories) met the nutritional goals by the second postoperative day, whereas patients with low nutrition delivery (< 80% of calculated calories) increased their caloric intake during the first 5 postoperative days without reaching the 80% level. In multivariate analysis, postoperative ileus [4.31 (2.15–8.62), P < 0.001], loss of appetite [3.59 (2.18–5.93), P < 0.001] and higher individual energy demand [1.004 (1.003–1.006), P = 0.001] were associated with not reaching the 80% nutrition adequacy. Conclusions: Inadequate nutrition delivery is common during the immediate postoperative period after EL. Oral nutrition is the most efficient way to commence nutrition in this patient group in surgical ward. Nutritional support should be closely monitored for those patients unable to eat

Postoperative complications and outcome after emergency laparotomy:a retrospective study

Abstract Background: Emergency laparotomy (EL) is a common urgent surgical procedure with high risk for postoperative complications. Complications impair the prognosis and prolong the hospital stay. This study explored the incidence and distribution of complications and their impact on short-term mortality after EL. Methods: This was a retrospective single-center register-based cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The primary outcome was operation-related or medical complication after EL. The secondary outcome was mortality in 90-day follow-up. Multivariate logistic regression analyses were used to identify independent risk factors for complications. Results: A total of 389 (58%) patients developed complications after EL, including 215 (32%) patients with operation-related complications and 361 (54%) patients with medical complications. Most of the complications were Clavien-Dindo classification type 4b (28%) and type 2 (22%). Operation-related complications occurred later compared to medical complications. Respiratory complications were the most common medical complications, and infections were the most common operation-related complications. The 30- and 90-day mortalities were higher in both the medical (17.2%, 26.2%) and operation-related complication groups (13.5%, 24.2%) compared to patients without complications (10.5% and 4.8%, 14.8% and 8.0%). Low albumin, high surgical urgency, excessive alcohol consumption and medical complications were associated with operation-related complications. Older age, high ASA class and operation-related complications were associated with medical complications. Conclusions: This study demonstrated that EL is associated with a high risk of complications and poor short-term outcome. Complications impair the prognosis regardless of which kind of EL is in question

Long-term outcomes after emergency laparotomy:a retrospective study

Abstract Background: Emergency laparotomy (EL) is a common surgical operation with poor outcomes. Patients undergoing EL are often frail and have chronic comorbidities, but studies focused on the long-term outcomes after EL are lacking. The aim of the present study was to examine the long-term mortality after EL. Methods: We conducted a retrospective single-center cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The follow-up lasted until September 2020. The primary outcome was 2-year mortality after surgery. The secondary outcome was factors associated with mortality during follow-up. Results: A total of 554 (82%) patients survived > 90 days after EL and were included in the analysis. Of these patients, 120 (18%) died during the follow-up. The survivors were younger than the non-survivors (median [IQR] 64 [49–74] vs. 71 [63–80] years, p < 0.001). In a Cox regression model, death during follow-up was associated with longer duration of operation (OR 2.21 [95% CI 1.27–3.83]), higher ASA classification (OR 2.37 [1.15–4.88]), higher CCI score (OR 4.74 [3.15–7.14]), and postoperative medical complications (OR 1.61 [1.05–2.47]). Conclusions: Patient-related factors, such as higher ASA classification and CCI score, were the most remarkable factors associated with poor long-term outcome and mortality after EL