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World Journal of Surgery

, Volume 42, Issue 5, pp 1278–1284 | Cite as

Outcomes of Emergency Laparotomy (EL) Care Protocol at Tertiary Care Center from Low–Middle-Income Country (LMIC)

  • Nitin Vashistha
  • Dinesh Singhal
  • Sandeep Budhiraja
  • Bharat Aggarwal
  • Raj Tobin
  • Kamal Fotedar
Original Scientific Report

Abstract

Background

Emergency laparotomy mortality ranges between 10 and 20% in best of Western healthcare systems and is currently a major focus for quality improvement programs. In contrast, emergency surgery scenario in LMIC is largely undefined, often neglected and complex (large burden of diseases but only limited capacity for adequate treatment). We evaluated the efficacy of ‘EL care protocol’ aimed at cost-effective optimal utilization of best available local expertise and infrastructure.

Methods

One hundred and two consecutive adult patients (≥16 years) who underwent EL from December 2012–December 2015 at a private tertiary hospital were retrospectively analyzed. The patients who underwent emergency laparoscopic procedures were excluded from the analysis. The EL care protocol included. (1) Admission to surgical intensive care unit for pre- and postoperative optimization. (2) Preferred radiologic investigation: abdominal computed tomography (CT) scan. (3) Surgery and critical care by senior surgical gastroenterologists and internists/anesthesiologists, respectively. Outcome measures were procedure-related complications (Clavien–Dindo classification), readmissions and costs.

Results

Of the 102 patients, there were 62 males and 40 females with median age of 60 (range 16–93) years. There were no complications in 22 (21.6%) patients, while Clavien–Dindo complications grade I or II occurred in 48 (47%) patients. Grade V Clavien–Dindo complications and the 30-day mortality were similar of 19 (18.6%). The readmission rate was 8 (7.8%). The expected mortality for the study group by P-POSSUM score was 31.2 (30.6%). The ratio (O/E) of observed to expected mortality was 0.61. The all inclusive median cost of treatment was INR 379,255 ($5590).

Conclusions

LMIC centers should develop their own center-specific EL care protocols to improve outcomes of EL.

References

  1. 1.
    Shapter SL, Paul MJ, White SM (2012) Incidence and estimated annual cost of emergency laparotomy in England: is there a major funding shortfall? Anaesthesia 67(5):474–478CrossRefPubMedGoogle Scholar
  2. 2.
    Editorial (2016) Changing emergency general surgery in England. Lancet 387:1592Google Scholar
  3. 3.
    Huddart S, Peden CJ, Swart M, on behalf of ELPQuiC Colloborator group et al (2015) Use of pathway quality improvement care protocol to reduce mortality after emergency laparotomy. Br J Surg 102:57–66CrossRefPubMedGoogle Scholar
  4. 4.
    Vester-Andersen M, Lundstrom LH, Moller MH et al (2014) Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population based cohort study. Br J Anaesth 112:860–872CrossRefPubMedGoogle Scholar
  5. 5.
    Scott JW, Olufajo OA, Brat GA et al (2016) Use of National burden to define operative emergency general surgery. JAMA Surg 151(6):e160480.  https://doi.org/10.1001/jamasurg.2016.0480 CrossRefPubMedGoogle Scholar
  6. 6.
    Symons NR, Moorthy K, Almoudaris AM et al (2013) Mortality in high risk emergency general surgical admissions. Br J Surg 100(10):1318–1325CrossRefPubMedGoogle Scholar
  7. 7.
    Khan OA, McGlon ER, Mercer SJ et al (2015) Outcomes following major emergency gastric surgery: the importance of specialist surgeons. Acta Chir Belg 115(2):131–135CrossRefPubMedGoogle Scholar
  8. 8.
    Leppaniemi A (2014) Organization of emergency surgery. Br J Surg 101:e7–e8.  https://doi.org/10.1002/bjs.9326 CrossRefPubMedGoogle Scholar
  9. 9.
    Sheetz KH, Waits SA, Krell RW et al (2013) Improving mortality following emergent surgery in older patients requires focus on complications rescue. Ann Surg 258(4):614–617PubMedPubMedCentralGoogle Scholar
  10. 10.
    Stewart B, Khanduri P, McCord C et al (2014) Global disease burden of conditions requiring emergency surgery. Br J Surg 101(1):e9–e22.  https://doi.org/10.1002/bjs.9329 CrossRefPubMedGoogle Scholar
  11. 11.
    Farmer PE, Kim JY (2008) Surgery and global health: a view from beyond the OR. World J Surg 32(4):533–536CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Sengupta A, Nundy S (2005) The private health sector in India. BMJ. 19;331(7526):1157-1158Google Scholar
  13. 13.
    Ozedemir BA, Sinha S, Karthikkesalingam A et al (2016) Mortality of emergency general surgical patients and associations with hospital structures and processes. Br J Anaesthesiol 116:54–62CrossRefGoogle Scholar
  14. 14.
    Eveleigh MO, Howes TE, Peden CJ et al (2016) Estimated costs before, during and after the introduction of the emergency laparotomy pathway quality improvement care (ELPQuiC) protocol. Anaesthesia 71(11):1291–1295CrossRefPubMedGoogle Scholar
  15. 15.
    Duron JJ, Duron E, Dugue T et al (2011) Risk factors for mortality in major digestive surgery in the elderly: a multicenter prospective study. Ann Surg 254(2):375–382CrossRefPubMedGoogle Scholar
  16. 16.
    Awad S, Herrod PJ, Palmer R et al (2012) One and two year outcomes and predictors of mortality following emergency laparotomy: a consecutive series from a United Kingdom teaching hospital. World J Surg 36(9):2060–2067CrossRefPubMedGoogle Scholar
  17. 17.
    Sharrock AE, McLachlan J, Chambers R (2016) Emergency abdominal surgery in elderly: can we predict mortality. World J Surg.  https://doi.org/10.1007/s00268-016-3751-3 PubMedCentralGoogle Scholar
  18. 18.
    Bali RS, Verma S, Agarwal PN et al. Perforation peritonitis and the developing world. ISRN Surg 20142014:105492Google Scholar
  19. 19.
    Souvik A, Mahammed ZH, Das A et al (2010) Etiology and outcome of acute intestinal obstruction: a review of 367 patients in Eastern India. Saudi J Gastroenterol 16:285–287CrossRefPubMedCentralGoogle Scholar
  20. 20.
    Yadav D, Garg PK (2013) Spectrum of perforation peritonitis in Delhi: 77cases experience. Indian J Surg 75:133–137CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2017

Authors and Affiliations

  • Nitin Vashistha
    • 1
  • Dinesh Singhal
    • 1
  • Sandeep Budhiraja
    • 2
  • Bharat Aggarwal
    • 3
  • Raj Tobin
    • 4
  • Kamal Fotedar
    • 4
  1. 1.Department of Surgical GastroenterologyMax Super Speciality HospitalSaketIndia
  2. 2.Department of Internal MedicineMax Super Speciality HospitalSaketIndia
  3. 3.Department of RadiologyMax Super Speciality HospitalSaketIndia
  4. 4.Department of AnesthesiologyMax Super Speciality HospitalSaketIndia

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