C. E. Sharoky1, E. A. Bailey1, M. M. Sellers1, A. J. Sinnamon1, C. Wirtalla1, D. N. Holena1, R. R. Kelz1 1Hospital Of The University Of Pennsylvania,Center For Surgery And Health Economics, Department Of Surgery,Philadelphia, PA, USA
Introduction: Acute care surgeons are charged with caring for a heterogeneous population, including patients who become acutely ill while hospitalized. Decision-making regarding these patients is often complicated, yet the majority of emergency general surgery (EGS) research has focused on the population operated on within the first two days of hospitalization. We examined outcomes of patients who had EGS at least three days after admission in order to identify preoperative and operative factors that predict mortality and postoperative length of stay >30d (LOS30) in this high risk cohort.
Methods: Patients >18y who had one of seven most common EGS operations (appendectomy, partial colectomy, small bowel resection, operative management of peptic ulcer disease, cholecystectomy, lysis of adhesions, exploratory laparotomy) after hospital day two on an emergent basis were identified in the ACS NSQIP registry (2011-2014). Exploratory laparotomy with no secondary procedure code was presumed non-therapeutic (NTEL). Descriptive statistics were performed. Multivariable logistic regression was used to identify predictors of 30 day mortality or LOS30 in independent models.
Results: Of 10,674 EGS patients who met inclusion criteria, the median age was 66 (IQR: 53-77) years. The majority of patients were white (65.5%), functionally independent (86.6%), and admitted from home (81.6%). Sepsis was the most common surgical indication (n=4,295; 40.2%). Median postoperative LOS was 8d (IQR 4-14d), and 719 (7.5%) patients experienced LOS30. Thirteen percent (n=1,424) of patients died within 30 days of operation (median time to death: 8d IQR 2-16d). Of those who died, 742 (52.1%) had a partial colectomy, 290 (20.4%) had a small bowel resection, and 600 (42.1%) failed extubation within 48 hours. Of patients who had NTEL, 171 (41.0%) died within 30 days. Factors most significantly associated with death were ASA class, age and procedure type. NTEL was the greatest operative predictor of death (OR 6.9 p<0.001). Factors most significantly associated with LOS30 were failure to extubate, ASA class and procedure type. Compared to patients whose index operation occurred during week 1, odds of death increased for each subsequent week prior to surgery (week 6 OR 2.6; CI: 1.8-3.9). Odds of LOS30 also increased weekly (week 6 OR 5.5 CI: 3.3-8.3). NTEL after week 3 had ≥50% risk of LOS30.
Conclusion: An important subset of patients require EGS after hospitalization. Although these patients are functionally independent on admission, mortality in this cohort is even higher than currently reported in published EGS literature. Risk of death and LOS30 increase as time from hospitalization to operation increases. Those who have NTEL are at particularly high risk of death or LOS30 following surgery. Patient and societal benefit versus risk of surgery in this cohort is complex and demands more attention from the research community.