Emergency Laparotomy

Rapid Recognition and Management of the Underlying Pathophysiology of Patients Presenting for Emergency Laparotomy

Symons and colleagues published data of over 367,000 patients presenting to emergency surgical teams in the UK over a period of 10 years in 2013. The data showed that patients fell into six main categories with a seventh that covered miscellaneous problems. It showed that by the time of presentation the patient had already had a significant physiologic insult as a result of the primary intraabdominal problem. Derangements included perfusion issues because of hypovolemia resulting from fluid shifts and dehydration and/or blood loss. The hypovolemia resulted in hypotension exacerbated by vasoplegia if sepsis was also present. These patients had an inflammatory response, gut dysfunction, and insulin resistance all occurring before surgery. The underlying pathophysiologic problems and associated common underlying conditions are summarized in Table 23.1 .

Increasing amounts of data show the significant impact of sepsis on the outcomes of these patients. The presence of hypotension secondary to sepsis is particularly detrimental to survival with one large study of peptic ulcer perforation showing a 6% increased odds of 90-day mortality per hour of delay to surgery. Therefore a focus for improving outcomes for patients requiring emergency laparotomy must include proactive recognition and management of underlying pathophysiology and sepsis.

Addressing the Impact of Age, Frailty, Comorbidity, and Cognitive Dysfunction

Emergency laparotomy for a nontrauma cause largely affects older patients. As age increases, outcomes become poorer with a 10% survival reported in patients over 90 years of age. Although by the very nature of an emergency presentation, time is limited before surgery, there is increasing evidence and guidelines stating that patients should be screened for frailty and cognitive dysfunction as early as possible so that a proactive approach to ensure optimal geriatric management occurs. Steps include raising awareness of the patient’s risk for delirium, avoiding Beers’ criteria drugs that can increase delirium, ^, and extending time in the intensive care unit (ICU) so that these highly vulnerable patients do not succumb to complications on the surgical floor. There is growing discussion and acknowledgment in the literature that, in some cases, surgery may not be beneficial for very elderly frail patients where the likelihood of survival is extremely low. ^, This will be discussed further in the controversies section of this chapter.

System Organization

Multiple deficits have been highlighted worldwide in the care of EGS patients. ^{, ,} Studies of hospitals in the US NSQIP database showed that poor emergency performance was distinct from elective performance (i.e., hospitals that could provide high-quality elective care could fail in the provision of EGS care). In addition, major studies have shown that outcomes are related to the availability of imaging, ICU beds, and surgeon presence. ^, The developing specialty of emergency surgery may have increased availability of specialist surgeons in major US centers and improved outcomes at some. Elsewhere, progress has been made through standardization of care pathways and defining key components of care, such as seniority of surgical and anesthesia teams present during emergency laparotomy. Measurement against defined standards, such as that made publicly available in the UK through NELA, have helped improve outcomes. ^,

Outcomes

Patients who proceed to have emergency laparotomy have consistently poor outcomes compared with elective surgery for similar procedures. ^, Nevertheless, over the last decade, there has been progress in reducing morbidity and mortality. In 2012, in large US and UK cohort studies, 30-day mortality was reported to be 15% overall, rising to 25% in patients over 80 years of age. ^, With increased awareness of these poor outcomes and work to address underlying causes, mortality as reported by NELA has improved to 9% at 30 days in the UK. Strategies that may have driven these improved outcomes are discussed in the following sections.

Managing the Acute Physiologic Change

A focus on rapid recognition and management of sepsis and underlying deranged physiology was tested in a number of small studies in the UK and Denmark and found to decrease risk-adjusted mortality and improve other outcomes. Measures in the UK study called the “Emergency Laparotomy Quality Improvement Care bundle” (ELPQuIC) included screening all patients with an early warning score; screening every patient for sepsis, including by measuring blood lactate; and optimizing and responding rapidly to detected abnormalities in line with early warning score and sepsis algorithms, including rapid administration of antibiotics as appropriate. The important components of a bundle of care to manage sepsis and physiologic derangement are shown in Fig. 23.1 . When this approach was tested across a larger number of patients in a collaborative made up of 28 major hospitals, process delivery improved and mortality decreased from 9.8% to 8.3% in year two of the project, and length of stay also decreased compared with a baseline control group. Evidence from large-scale audits shows that administration of antibiotics to emergency laparotomy patients with signs of sepsis is frequently not done within recommended time frames, and this is one common area for improvement.

Managing the Older Emergency Laparotomy Patient

Age is associated with poorer outcomes for patients undergoing emergency laparotomy. Nevertheless, a number of recent studies show that it is possible to improve outcomes for older patients. A large Canadian study used an “acute care for the elderly” model for older patients undergoing EGS. The intervention consisted of a geriatric assessment team; evidence-based, elder-friendly interventions; patient-oriented rehabilitation; and proactive discharge planning; it showed a 19% reduction in mortality or major complications and a decreased length of stay by an average of 3 days with an increase in the number of patients able to directly return home. A parallel paper showed a reduction in the costs of care.

There is now strong evidence that increasing frailty is associated with increasing mortality. In a study of 1-year outcomes in older patients who had an emergency laparotomy, the strongest predictors of a poor outcome were frailty and American Society of Anesthesiologists (ASA) status. Very frail patients will have little physiologic reserve to survive surgery and any ensuing complications. These patients must be closely managed after surgery to ensure that if complications do occur, they are detected and managed early because failure to rescue is a major issue in older patients undergoing EGS.

The incidence of cognitive impairment in older patients undergoing EGS has been reported as very high, and these patients are at high risk for delirium and perioperative neurocognitive disorders (PNDs). There are a number of recent guidelines that provide mitigating actions to reduce and manage delirium and PND in at-risk patients. Although studies of implementation are lacking for EGS patients, one study that applied a modified version of the “Hospital Elder Life Program” (HELP; a program of simple measures such as early mobilization, socialization with volunteers, and white boards for orientation) showed a significant reduction in the incidence of delirium and length of stay in older patients undergoing major elective abdominal surgery.

Evidence for Improving the System of Care

Evidence shows that there is potential for improvement in optimizing the delivery of care for these emergency patients. One approach to improve management of the emergency surgical patients in the United States has been the development of acute care surgery encompassing EGS, trauma, and surgical critical care. The focus is to have the same team treating the patient across the whole pathway of the EGS patient from the moment the patient is referred to the surgical service. This involves diagnosis, decision to operate, intraoperative and postoperative critical care management, and the involvement of other specialties, such as anesthesiology and geriatric medicine. Outcomes have improved in major centers. System change requires resources. When the ELPQuIC bundle of six components was expanded across a much larger collaborative network of 28 hospitals in the “Emergency Laparotomy Collaborative” (ELC) project, the larger collaborative project used social engagement techniques to reinforce improvement work such as regular feedback of benchmarked performance, regular in-person and virtual meetings, engagement of senior leadership, and voluntary peer review. It was not until year two of the collaborative that process improvements drove reductions in mortality and length of stay. One hospital that participated in both ElPQuIC and ELC has written a review of how their improvements were lost over a relatively short time period. They then worked to improve again using communication, regular data review, and system prompts to embed the changes more securely. This work shows the importance of organizational will, executive engagement and support, and tackling change at a system level to produce impactful reduction in mortality and morbidity. A very large study, which was much more ambitious and attempted to implement change across a pathway of 37 evidence-based processes in about a year across the UK, showed improvement in process adherence but did not show a reduction in mortality. The relatively short time for hospitals to establish the program, the step-wedged cluster approach that reduced the ability for hospitals to share learning, and the number of interventions made implementation challenging. These studies suggest that when trying to implement system-level change for complex emergency laparotomy patients, focus on a small number of high-impact interventions, such as rapid optimization of deranged physiology, is likely to be most impactful, especially when resources are limited.

In the last 5 years there has been an explosion of literature and studies on this patient group. In the following sections, we aim to give a concise overview of the most up-to-date literature in the formulation of a pathway for optimal treatment.

Overview of an Evidence-Based Pathway for Emergency Laparotomy