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Mortality following major emergency abdominal surgery is high. Surgical delay is regarded as an important modifiable prognostic factor. Current care-bundles aim at reducing surgical delay, most often using a six-hour cut-off. We aimed to investigate the evidence supporting the in-hospital delay cutoffs currently used. MEDLINE, EMBASE and the Cochrane Library were searched. We included studies assessing in-hospital surgical delay in major emergency abdominal surgery patients. Studies were only included if they performed adjusted analysis. Surgical delay beyond six hours was the primary cutfrom interest. The primary outcome was mortality at longest follow-up. Meta-analyses were conducted if possible. Eleven observational studies were included with 16,772 participants. Two studies evaluated delay in unselected major emergency abdominal surgery patients. Three studies applied a six-hour cutoff, but only a study on acute mesenteric ischemia showed an association between delay and mortality. Meta-analysis showed no association with mortality at this cutoff. An association was seen between hourly delay and mortality risk estimate, 1.02 (95% confidence interval [CI], 1.00 − 1.03), and on subgroup analysis of hourly delay in perforated peptic ulcer patients, risk estimate, 1.02 (95% CI, 1.0 − 1.03). All risk estimates had a very low Grading of Recommendations Assessment, Development, and Evaluation score. Little evidence supports a six-hour cutoff in unselected major emergency abdominal surgical patients. We found an association between hourly delay and increased mortality; however, evidence supporting this was primarily in patients undergoing surgery for perforated peptic ulcer. This review is limited by the quality of the individual studies. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing emergency abdominal surgery are at high risk of morbidity and mortality. Accurate identification of high-risk patients is important. The Acute Physiology and Chronic Health Evaluation (APACHE) II score needs to be validated in a larger heterogeneous population before implementation. We aimed to assess the predictive value of the APACHE II score in emergency abdominal surgical patients. Furthermore, we compared the APACHE II score with the American Society of Anesthesiologists (ASA) physical status score and the Charlson Comorbidity Index (CCI).Methods: We included adult patients undergoing emergency abdominal surgery screened for enrolment in the InCare trial from October 2010 to November 2012. The APACHE II score was evaluated with area under the receiver operating characteristics curve (AUROC) statistics. The primary outcome was 30-day mortality. Secondary outcomes included 90-day mortality and admission to the intensive care unit.Results: We included a total of 885 patients. All-cause 30-day mortality was 5.0%, 90-day mortality was 8.9%, and a total of 7.9% of the patients were admitted to the intensive care unit. The AUROC (95% confidence interval) of the APACHE II score was 0.72 (0.65-0.80) for 30-day mortality, 0.70 (0.64-0.76) for 90-day mortality and 0.65 (0.59-0.71) for admission to the intensive care unit. The CCI performed better in prediction of 90-day mortality (P = .04). All other results for the ASA score and CCI were comparable with the APACHE II score.Conclusion: The APACHE II score predicted mortality moderately and admission to intensive care unit poorly in emergency abdominal surgical patients. [ABSTRACT FROM AUTHOR]

Abstract Background Emergency abdominal surgery carries a 15% to 20% short-term mortality rate. Postoperative medical complications are strongly associated with increased mortality. Recent research suggests that timely recognition and effective management of complications may reduce mortality. The aim of the present trial is to evaluate the effect of postoperative intermediate care following emergency major abdominal surgery in high-risk patients. Methods and design The InCare trial is a randomised, parallel-group, non-blinded clinical trial with 1:1 allocation. Patients undergoing emergency laparotomy or laparoscopic surgery with a perioperative Acute Physiology and Chronic Health Evaluation II score of 10 or above, who are ready to be transferred to the surgical ward within 24 h of surgery are allocated to either intermediate care for 48 h, or surgical ward care. The primary outcome measure is all-cause 30-day mortality. We aim to enrol 400 patients in seven Danish hospitals. The sample size allows us to detect or refute a 34% relative risk reduction of mortality with 80% power. Discussion This trial evaluates the benefits and possible harm of intermediate care. The results may potentially influence the survival of many high-risk surgical patients. As a pioneer trial in the area, it will provide important data on the feasibility of future large-scale randomised clinical trials evaluating different levels of postoperative care. Trial registration Clinicaltrials.gov identifier: NCT01209663

Background: Emergency abdominal surgery carries a considerable risk of mortality and post-operative complications, including pulmonary complications. In major elective surgery, epidural analgesia reduces mortality and pulmonary complications. We aimed to evaluate the association between epidural analgesia and mortality in emergency abdominal surgery.Methods: In this population-based cohort study with prospective data collection, we included adults undergoing emergency abdominal laparotomy or laparoscopy between 1 January 2009 and 31 December 2010 at 13 Danish hospitals. Appendectomies were excluded. The primary outcome was 90-day mortality. Secondary outcomes included 30-day mortality and serious adverse events. We used binary logistic regression analyses (odds ratios (ORs) with 95% confidence intervals (CIs)).Results: We included 4920 patients, of whom 1134 (23.0%) died within 90 days. Overall, 27.9% of the patients were treated with epidural analgesia perioperatively. This increased to 34.0% among patients undergoing major laparotomy. The crude and adjusted association between epidural analgesia and 90-day mortality was OR 0.99 (95%CI: 0.86-1.15, P = .94) and OR 0.80 (95%CI: 0.67-0.94; P = .01), respectively. For 30-day mortality the corresponding estimates were OR 0.90 (95% CI: 0.76-1.06, P = .21) and OR 0.75 (95% CI: 0.62-0.90, P < .01), respectively. No serious adverse events were reported.Conclusion: In this population-based cohort study of adult patients undergoing emergency abdominal surgery, we found that the use of epidural analgesia perioperatively was associated with a decreased risk of mortality in the adjusted analysis. [ABSTRACT FROM AUTHOR]

Objective: Emergency major abdominal surgery carries a high mortality rate. The aim of this present study was to characterize a population of deceased abdominal surgical patients, to examine how many died unexpectedly and how many were subject to treatment limitations. Materials and methods: We included adult emergency abdominal surgical patients who died within 30 days postoperatively. We collected data from January 1, 2013, to December 31, 2014, in a Danish tertiary care hospital (Herlev). Results: A total of 138 patients were included which corresponded to a crude mortality rate of 16.5% in the population. Four percent (5 of 138) of the patients died unexpectedly without any prior signs of deterioration and 46% (65 of 138) experienced a complicated treatment course, 67% of which was treated in the intensive care unit (ICU). The remaining 50% (68 of 138) had treatment limitations, applied pre- or postoperatively, of which 4% were treated in the ICU ward. Conclusions: In the present study, we found a high number of patients with treatment limitations, offering one explanation to why so relatively few high-risk surgical patients are admitted to the ICU ward. Whether intermediary wards could serve as a viable alternative for these patients, securing a sufficient level of treatment without taking up scarce beds in the intensive care unit, remains an important question for future studies. Furthermore, five patients died unexpectedly, without any clear cause of death, proving that continual strides toward improving the overall process of postoperative care are still demanded. [ABSTRACT FROM AUTHOR]

Objective.In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing emergency abdominal surgery in general.Material and methods.All in-patients aged ≥18 years having emergency abdominal laparotomy or laparoscopy performed within 48 h of admission between 1 January 2009 and 31 December 2010 in 13 Danish hospitals were included. Baseline and clinical data, including surgical delay and 90-day mortality were collected. The crude and adjusted association between surgical delay by hour and 90-day mortality was assessed by binary logistic regression.Results.A total of 2803 patients were included. Median age (interquartile range [IQR]) was 66 (51–78) years, and 515 patients (18.4%) died within 90 days of surgery. Over the first 24 h after hospital admission, each hour of surgical delay beyond hospital admission was associated with a median (IQR) decrease in 90-day survival of 2.2% (1.9–3.3%). No statistically significant association between surgical delay by hour and 90-day mortality was shown; crude and adjusted odds ratio with 95% confidence interval 1.016 (1.004–1.027) and 1.003 (0.989–1.017), respectively. Sensitivity analyses confirmed the primary finding.Conclusions.In the present population-based cohort study of high-risk patients undergoing emergency abdominal surgery, no statistically significant adjusted association between mortality and surgical delay was found. Additional research in diagnosis-specific subgroups of high-risk patients undergoing emergency abdominal surgery is warranted. [ABSTRACT FROM AUTHOR]

Objective. Morbidity and mortality following perforated peptic ulcer (PPU) remain substantial. In the recently published PULP trial, 30-day mortality in patients surgically treated for PPU decreased from 27% to 17% following the implementation of a perioperative care protocol based on The Surviving Sepsis Guidelines. The objective of the present study was to evaluate long-term mortality in the PULP trial intervention and control cohort. Material and methods. Design: nationwide follow-up study of a multicenter, non-randomized, clinical trial with external controls. Setting: Danish patients surgically treated for PPU between 1 January 2008 and 31 December 2009. Patients: 117 patients in the intervention group and 512 in the control group. Intervention: a perioperative care protocol based on The Surviving Sepsis Guidelines. Outcome measures: 60-day, 90-day, 180-day, 1-year, and 2-year mortality rates. Statistical analysis: survival statistics. Results. Baseline characteristics, clinical, and perioperative data were in general, similar in the intervention and control group. Sixty days postoperatively, the originally observed difference in 30-day mortality had diminished (25% vs. 30%, p = 0.268). After 180 days, the mortality difference was reduced additionally (31% vs. 33%, p = 0.645), and one year postoperatively, a mortality difference was no longer present (36% in both groups, p = 0.993). Two years postoperatively, the mortality rate in the intervention group was 44%, as compared to 40% in the control group ( p = 0.472). Conclusions. The survival benefit associated with a perioperative care protocol in patients treated for PPU decreases progressively after 30 days and is no longer present after one year. Registration number: NCT00624169 (). [ABSTRACT FROM AUTHOR]

Objective. The aim of the present study was to compare the ability of four clinical prediction rules to predict adverse outcome in perforated peptic ulcer (PPU): the Boey score, the American Society of Anesthesiologists (ASA) score, the Acute Physiology and Chronic Health Evaluation (APACHE) II score, and the sepsis score. Material and methods. Design: an observational multicenter study. Participants and settings: a total of 117 patients surgically treated for PPU between 1 January 2008 and 31 December 2009 in seven gastrointestinal departments in Denmark were included. Pregnant and breastfeeding women, non-surgically treated patients, patients with malignant ulcers, and patients with perforation of other organs were excluded. Primary outcome measure: 30-day mortality rate. Statistical analysis: the ability of four clinical prediction rules to distinguish survivors from non-survivors (discrimination ability) was evaluated by the area under the receiver operating characteristic curve (AUC), positive predictive values (PPVs), negative predictive values (NPVs), and adjusted relative risks. Results. Median age (range) was 70 years (25-92 years), 51% of the patients were females, and 73% of the patients had at least one co-existing disease. The 30-day mortality proportion was 17% (20/117). The AUCs: the Boey score, 0.63; the sepsis score, 0.69; the ASA score, 0.73; and the APACHE II score, 0.76. Overall, the PPVs of all four prediction rules were low and the NPVs high. Conclusions. The Boey score, the ASA score, the APACHE II score, and the sepsis score predict mortality poorly in patients with PPU. [ABSTRACT FROM AUTHOR]

Aims: Describe and compare incidences across age groups of rehospitalization, repeated aortic surgery, and death in patients who survived surgery and hospitalization for type A aortic dissection. Methods and results: From Danish nationwide registries, we identified patients hospitalized with Stanford type A aortic dissections (2006-2018). Survivors of hospitalization and surgery on the ascending aorta and/or aortic arch comprised the study population (n = 606, 36 (38.9%) <60 years old (group I), 194 (32.0%) 60-69 years old (group II), and 176 (29.1%) >69 years old (group III)). During the first year, 62.5% were re-hospitalized and 1.4% underwent repeated aortic surgery with no significant differences across age groups (P = 0.68 and P = 0.39, respectively). Further, 5.9% died (group I: 3.0%, group II: 8.3%, group III: 7.4%, P = 0.04). After 10 years, 8.0% had undergone repeated aortic surgery (group I: 11.5%, group II: 8.5%, group III: 1.6%, P = 0.04) and 10.2% (group I), 17.0% (group II), and 22.2% (group III) had died (P = 0.01). Using multivariable Cox regression analysis, we described long-term outcomes comparing age groups. No age differences were found in one-year outcomes, while age > 69 years compared with age < 60 years was associated with a lower rate of repeated aortic surgery [hazard ratio 0.17, 95% confidence interval (CI) 0.04-0.78] and a higher rate of all-cause mortality (hazard ratio 2.44, 95% CI 1.37-4.34) in the 10-year analyses. Conclusion: Rehospitalisations in the first year after discharge were common in all age groups, but survival was high. Repeated aortic surgery was significantly more common among younger than older patients. [ABSTRACT FROM AUTHOR]

The article presents a study on the use of low APACHE II and American Society of Anesthesiologists (ASA) score for the prediction of survival in patients with perforated peptic ulcer (PPU). The study showed that the 30-day mortality proportion was 17 %, the sepsis score, was 69 %, the APACHE II score was 76%. Moreover, the study concluded that all clinical scores predict mortality poorly in patients with PPU.