The virtual uncertainty of futility in emergency surgery

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Impact of mechanical bowel preparation in elective colorectal surgery: a meta-analysis

AIM: To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery. METHODS: Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. RESULTS: A total of 36 studies (23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates (OR = 0.90, 95%CI: 0.74 to 1.10, p = 0.32), surgical site infection (OR = 0.99, 95%CI: 0.80 to 1.24, p = 0.96), intraabdominal collection (OR = 0.86, 95%CI: 0.63 to 1.17, p = 0.34), mortality (OR = 0.85, 95%CI: 0.57 to 1.27, p = 0.43), reoperation (OR = 0.91, 95%CI: 0.75 to 1.12, p = 0.38) or hospital length of stay (overall mean difference 0.11 d, 95%CI: -0.51 to 0.73, p = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlled trials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. CONCLUSION: In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery

The role of oral antibiotic preparation in elective colorectal surgery: a meta-analysis

© 2018 The Author(s). Published by Wolters Kluwer Health, Inc. Objectives:To compare the impact of the use of oral antibiotics (OAB) with or without mechanical bowel preparation (MBP) on outcome in elective colorectal surgery.Summary Background Data:Meta-analyses have demonstrated that MBP does not impact upon postoperative morbidity or mortality, and as such it should not be prescribed routinely. However, recent evidence from large retrospective cohort and database studies has suggested that there may be a role for combined OAB and MBP, or OAB alone in the prevention of surgical site infection (SSI).Methods:A meta-analysis of randomized controlled trials and cohort studies including adult patients undergoing elective colorectal surgery, receiving OAB with or without MBP was performed. The outcome measures examined were SSI, anastomotic leak, 30-day mortality, overall morbidity, development of ileus, reoperation and Clostridium difficile infection.Results:A total of 40 studies with 69,517 patients (28 randomized controlled trials, n = 6437 and 12 cohort studies, n = 63,080) were included. The combination of MBP+OAB versus MBP alone was associated with a significant reduction in SSI [risk ratio (RR) 0.51, 95% confidence interval (CI) 0.46-0.56, P < 0.00001, I2 = 13%], anastomotic leak (RR 0.62, 95% CI 0.55-0.70, P < 0.00001, I2 = 0%), 30-day mortality (RR 0.58, 95% CI 0.44-0.76, P < 0.0001, I2 = 0%), overall morbidity (RR 0.67, 95% CI 0.63-0.71, P < 0.00001, I2 = 0%), and development of ileus (RR 0.72, 95% CI 0.52-0.98, P = 0.04, I2 = 36%), with no difference in Clostridium difficile infection rates. When a combination of MBP+OAB was compared with OAB alone, no significant difference was seen in SSI or anastomotic leak rates, but there was a significant reduction in 30-day mortality, and incidence of postoperative ileus with the combination. There is minimal literature available on the comparison between combined MBP+OAB versus no preparation, OAB alone versus no preparation, and OAB versus MBP.Conclusions:Current evidence suggests a potentially significant role for OAB preparation, either in combination with MBP or alone, in the prevention of postoperative complications in elective colorectal surgery. Further high-quality evidence is required to differentiate between the benefits of combined MBP+OAB or OAB alone

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

Abstract Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions. </jats:sec

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

An exploration of futility and extreme risk in emergency laparotomy

An emergency laparotomy is an invasive abdominal surgical procedure used to treat conditions such as intestinal perforation or obstruction. It is one of the most common emergency surgeries worldwide, but is associated with significant mortality and morbidity. The National Emergency Laparotomy Audit (NELA) was established in 2012 to improve outcomes for emergency laparotomy patients in England and Wales. Prior to NELA’s establishment the national outcomes of these patients were completely unknown. NELA’s work identified groups of patients that had worse outcomes than their peers or were undefined and understudied; in particular older patients, very high-risk patients and those that died in the early post-operative period. The aim of the thesis was to address these areas of research paucity. Chapter 4 was a scoping literature review exploring surgical futility in emergency laparotomy literature. Futility in medicine has been defined through seven guiding principles, which in the context of emergency surgery, have been relatively unexplored. This review identified just three papers exploring futility in emergency laparotomy, which all used a quantitative definition of futility, using the binary of post-operative mortality within 48-72 hours of their procedure as their measure of futile surgery. Chapter 5 builds on the previous chapter, by applying this definition of futile surgery to the NELA database and assessing for predictors of early post-operative mortality. Key factors that are not currently included in commonly used risk prediction models were found to be significantly predictive of mortality within three days of surgery. Examples included bowel ischaemia (OR 2.67; 95% CI 2.50-2.85), intestinal perforation (OR 1.55; 95% CI 1.47-1.65), frailty (OR 1.38; 95% CI 1.22-1.55) and a high blood lactate (arterial lactate 4-6, OR 5.27; 95% CI 3.93-7.07). Another example of futile surgery is intra-operative mortality. The next study (Chapter 6) aimed to characterise the group of patients that die during an emergency laparotomy and assess this group for predictors of on-table mortality. This study found that the incidence of on-table mortality during emergency laparotomy is 1 in 400 (450/180,985, 0.2%). These patients had a good functional baseline, but were critically unwell at presentation. Acute mesenteric ischaemia was highly associated with peri-operative mortality (OR 2.97; 95% CI 2.35-3.75), with implications for emergency department assessment pathways and for shared-decision making discussions about proceeding with high-risk surgery for this indication. High-risk surgery in emergency laparotomy has been defined as a predicted 30-day mortality risk of ≥5%. Although there is a large difference between a risk of death of 5% and a risk of death of 50%, outcomes for all high-risk patients are usually expressed as a single group. What defines an extreme level of risk has not yet been studied. The final study (Chapter 7) examined the outcomes of ‘extreme-risk’ patients, which we defined as those with a predicted 30-day mortality of ≥50%. Compared to their high-risk counterparts, extreme-risk patients had 40% higher rates of unplanned returns to theatre for complications, protracted critical care stays and more than double the length of hospital stay. This thesis has examined understudied populations within emergency laparotomy patients in order to provide data that can inform shared decision-making discussions with patients and their relatives. It has provided more nuanced quantitative outcomes that can be used in a qualitative way, addressing areas that were previously gaps in our knowledge regarding the emergency laparotomy patient journey

An exploration of futility and extreme risk in emergency laparotomy

An emergency laparotomy is an invasive abdominal surgical procedure used to treat conditions such as intestinal perforation or obstruction. It is one of the most common emergency surgeries worldwide, but is associated with significant mortality and morbidity. The National Emergency Laparotomy Audit (NELA) was established in 2012 to improve outcomes for emergency laparotomy patients in England and Wales. Prior to NELA’s establishment the national outcomes of these patients were completely unknown. NELA’s work identified groups of patients that had worse outcomes than their peers or were undefined and understudied; in particular older patients, very high-risk patients and those that died in the early post-operative period. The aim of the thesis was to address these areas of research paucity. Chapter 4 was a scoping literature review exploring surgical futility in emergency laparotomy literature. Futility in medicine has been defined through seven guiding principles, which in the context of emergency surgery, have been relatively unexplored. This review identified just three papers exploring futility in emergency laparotomy, which all used a quantitative definition of futility, using the binary of post-operative mortality within 48-72 hours of their procedure as their measure of futile surgery. Chapter 5 builds on the previous chapter, by applying this definition of futile surgery to the NELA database and assessing for predictors of early post-operative mortality. Key factors that are not currently included in commonly used risk prediction models were found to be significantly predictive of mortality within three days of surgery. Examples included bowel ischaemia (OR 2.67; 95% CI 2.50-2.85), intestinal perforation (OR 1.55; 95% CI 1.47-1.65), frailty (OR 1.38; 95% CI 1.22-1.55) and a high blood lactate (arterial lactate 4-6, OR 5.27; 95% CI 3.93-7.07). Another example of futile surgery is intra-operative mortality. The next study (Chapter 6) aimed to characterise the group of patients that die during an emergency laparotomy and assess this group for predictors of on-table mortality. This study found that the incidence of on-table mortality during emergency laparotomy is 1 in 400 (450/180,985, 0.2%). These patients had a good functional baseline, but were critically unwell at presentation. Acute mesenteric ischaemia was highly associated with peri-operative mortality (OR 2.97; 95% CI 2.35-3.75), with implications for emergency department assessment pathways and for shared-decision making discussions about proceeding with high-risk surgery for this indication. High-risk surgery in emergency laparotomy has been defined as a predicted 30-day mortality risk of ≥5%. Although there is a large difference between a risk of death of 5% and a risk of death of 50%, outcomes for all high-risk patients are usually expressed as a single group. What defines an extreme level of risk has not yet been studied. The final study (Chapter 7) examined the outcomes of ‘extreme-risk’ patients, which we defined as those with a predicted 30-day mortality of ≥50%. Compared to their high-risk counterparts, extreme-risk patients had 40% higher rates of unplanned returns to theatre for complications, protracted critical care stays and more than double the length of hospital stay. This thesis has examined understudied populations within emergency laparotomy patients in order to provide data that can inform shared decision-making discussions with patients and their relatives. It has provided more nuanced quantitative outcomes that can be used in a qualitative way, addressing areas that were previously gaps in our knowledge regarding the emergency laparotomy patient journey

Appendectomy versus antibiotic treatment for acute appendicitis.

Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.Background: Acute appendicitis is one of the most common emergency general surgical conditions worldwide. Uncomplicated/simple appendicitis can be treated with appendectomy or antibiotics. Some studies have suggested possible benefits with antibiotics with reduced complications, length of hospital stay, and the number of days off work. However, surgery may improve success of treatment as antibiotic treatment is associated with recurrence and future need for surgery. Objectives: To assess the effects of antibiotic treatment for uncomplicated/simple acute appendicitis compared with appendectomy for resolution of symptoms and complications. Search methods: We searched CENTRAL, MEDLINE, Embase, and two trial registers (World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov) on 19 July 2022. We also searched for unpublished studies in conference proceedings together with reference checking and citation search. There were no restrictions on date, publication status, or language of publication. Selection criteria: We included parallel-group randomised controlled trials (RCTs) only. We included studies where most participants were adults with uncomplicated/simple appendicitis. Interventions included antibiotics (by any route) compared with appendectomy (open or laparoscopic). Data collection and analysis: We used standard methodology expected by Cochrane. We used GRADE to assess the certainty of evidence for each outcome. Primary outcomes included mortality and success of treatment, and secondary outcomes included number of participants requiring appendectomy in the antibiotic group, complications, pain, length of hospital stay, sick leave, malignancy in the antibiotic group, negative appendectomy rate, and quality of life. Success of treatment definitions were heterogeneous although mainly based on resolution of symptoms rather than incorporation of long-term recurrence or need for surgery in the antibiotic group. Main results: We included 13 studies in the review covering 1675 participants randomised to antibiotics and 1683 participants randomised to appendectomy. One study was unpublished. All were conducted in secondary care and two studies received pharmaceutical funding. All studies used broad-spectrum antibiotic regimens expected to cover gastrointestinal bacteria. Most studies used predominantly laparoscopic surgery, but some included mainly open procedures. Six studies included adults and children. Almost all studies aimed to exclude participants with complicated appendicitis prior to randomisation, although one study included 12% with perforation. The diagnostic technique was clinical assessment and imaging in most studies. Only one study limited inclusion by sex (male only). Follow-up ranged from hospital admission only to seven years. Certainty of evidence was mainly affected by risk of bias (due to lack of blinding and loss to follow-up) and imprecision. Primary outcomes It is uncertain whether there was any difference in mortality due to the very low-certainty evidence (Peto odds ratio (OR) 0.51, 95% confidence interval (CI) 0.05 to 4.95; 1 study, 492 participants). There may be 76 more people per 1000 having unsuccessful treatment in the antibiotic group compared with surgery, which did not reach our predefined level for clinical significance (risk ratio (RR) 0.91, 95% CI 0.87 to 0.96; I2 = 69%; 7 studies, 2471 participants; low-certainty evidence). Secondary outcomes At one year, 30.7% (95% CI 24.0 to 37.8; I2 = 80%; 9 studies, 1396 participants) of participants in the antibiotic group required appendectomy or, alternatively, more than two-thirds of antibiotic-treated participants avoided surgery in the first year, but the evidence is very uncertain. Regarding complications, it is uncertain whether there is any difference in episodes of Clostridium difficile diarrhoea due to very low-certainty evidence (Peto OR 0.97, 95% CI 0.24 to 3.89; 1 study, 1332 participants). There may be a clinically significant reduction in wound infections with antibiotics (RR 0.25, 95% CI 0.09 to 0.68; I2 = 16%; 9 studies, 2606 participants; low-certainty evidence). It is uncertain whether antibiotics affect the incidence of intra-abdominal abscess or collection (RR 1.58, 95% CI 0.61 to 4.07; I2 = 19%; 6 studies, 1831 participants), or reoperation (Peto OR 0.13, 95% CI 0.01 to 2.16; 1 study, 492 participants) due to very low-certainty evidence, mainly due to rare events causing imprecision and risk of bias. It is uncertain if antibiotics prolonged length of hospital stay by half a day due to the very low-certainty evidence (MD 0.54, 95% CI 0.06 to 1.01; I2 = 97%; 11 studies, 3192 participants). The incidence of malignancy was 0.3% (95% CI 0 to 1.5; 5 studies, 403 participants) in the antibiotic group although follow-up was variable. Antibiotics probably increased the number of negative appendectomies at surgery (RR 3.16, 95% CI 1.54 to 6.49; I2 = 17%; 5 studies, 707 participants; moderate-certainty evidence). Authors' conclusions: Antibiotics may be associated with higher rates of unsuccessful treatment for 76 per 1000 people, although differences may not be clinically significant. It is uncertain if antibiotics increase length of hospital stay by half a day. Antibiotics may reduce wound infections. A third of the participants initially treated with antibiotics required subsequent appendectomy or two-thirds avoided surgery within one year, but the evidence is very uncertain. There were too few data from the included studies to comment on major complications

The management of adult appendicitis during the COVID-19 pandemic : an interim analysis of a UK cohort study

Background: Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). Methods: Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. Results: The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p Conclusion: COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.</div

Characterisation of older patients that require, but do not undergo, emergency laparotomy:a multicentre cohort study

BackgroundOlder adults (≥65 yr) account for the majority of emergency laparotomies in the UK and are well characterised with reported outcomes. In contrast, there is limited knowledge on those patients that require emergency laparotomy but do not undergo surgery (NoLaps).MethodsA multicentre cohort study (n=64 UK surgical centres) recruited 750 consecutive NoLap patients (February 15th - November 15th 2021, inclusive of a 90-day follow up period). Each patient was admitted to hospital with a surgical condition treatable by an emergency laparotomy (defined by The National Emergency Laparotomy Audit (NELA) criteria), but a decision was made not to undergo surgery (NoLap).ResultsNoLap patients were predominately female (452 patients, 60%), of advanced age (median age 83.0 yr, interquartile range 77.0–88.8), frail (523 patients, 70%), and had severe comorbidity (750 patients, 100%); 99% underwent CT scanning. The commonest diagnoses were perforation (26%), small bowel obstruction (17%), and ischaemic bowel (13%). The 90-day mortality was 79% and influencing factors were &gt;80 yr, underweight BMI, elevated serum lactate or creatinine concentration. The majority of patients died in hospital (77%), with those with ischaemic bowel dying early. For the 21% of NoLap patients that survived to 90 days, 77% returned home with increased care requirements.ConclusionsThis study reports that the NoLap patient population present significant medical challenges because of their extreme levels of comorbidity, frailty, and physiology. Despite these complexities a fifth remained alive at 90 days. Further work is underway to explore this high-risk decision-making process