The National Emergency Laparotomy Audit: impact for general surgical training and service provision

Boyd-Carson, Hannah (2020) The National Emergency Laparotomy Audit: impact for general surgical training and service provision. PhD thesis, University of Nottingham.

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Abstract

Emergency Laparotomies (Em Lap) are one of the most commonly performed emergency general surgical procedures worldwide. They are invasive abdominal operations performed to treat conditions such as intestinal obstruction or perforation. Mortality rates are high compared to planned general surgical procedures and the post-operative sequelae may represent significant burdens to patients, families, and healthcare systems. Prior to 2012, repeated observations were made regarding the deficiencies and variability of care received by the patients who required an Em Lap. Following this The National Emergency Laparotomy Audit (NELA) began in 2013.This collects detailed data about patients who have Em Lap and the care they receive within England and Wales, and hopes to improve outcomes for these patients.

The aim of this thesis was to use data from NELA to address issues specifically relating to general surgical service provision and training

The first study (Chapter 3) explored the relationship between time to theatre and mortality in patients with intra-abdominal sepsis. The NELA annual reports have highlighted that the identification and management of patients with intra-abdominal sepsis is lacking. Patients with perforated peptic ulcer disease were used to model time to theatre as a continuous variable and investigate if a longer time to theatre led to increased mortality. Multivariate regression analysis demonstrated a cumulative increased risk of death by 90 days of 4% (Odds ratio (OR) 1.04, 95% Confidence Interval (CI)1.02-1.07) which increased to 6% (OR 1.06, 95% Cl 1.01-1.11) in patients with physiological derangements.

The second study (Chapter 4) addressed the impact of consultant surgeon elective special interest on post-operative outcomes. Procedures performed at Em Lap can be due to pathology from either end of the gastrointestinal tract and can be managed by general surgeons with an elective special interest at odds to the pathology.

This study found an increased post-operative mortality if Em Lap was performed by consultant surgeon with a special interest not in the area of pathology (Colorectal procedures OR 1.23, 95%CI1.13-1.33and Upper Gastrointestinal procedures OR 1.02, 95% Cl 1.05-1.20). Return to theatre was increased in the colorectal operative group.

The next two studies (Chapter 5 and 6)focused on training opportunities for general surgical trainees who are required to gain experience in Em Lap operating by recording at least 100 Em Laps in their training log books. Trainees complete their training in one geographical area (deanery) and Chapter 5 analysed, by deanery, the numbers of Em Laps and core emergency procedures occurring that are required for completion of training. This identified inter deanery variation in numbers of Em Lap. This raises questions relating to the number of training opportunities for trainees working in these areas.

The final chapter aimed to describe trends in trainee led operating by deanery, hospital size and time of day. The association between trainee led operating and mortality was also investigated. The analysis demonstrated trainees were most likely to operate independently in the Health Education Yorkshire and Humber deanery, in high volume centres and at night. No increased risk of death was observed if a trainee was the most senior surgeon in theatre across all Em Lap and emergency procedural groups (P<= 0.001).

This thesis has provided data to inform and improve health care policy for patients who require high risk emergency surgery. It has also provided data to help shape, improve and inform the future generation of general surgeons.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Lund, J.N.
Tierney, G.M.
Keywords: Laparotomies; Abdominal surgical procedures; Surgeons; Training
Subjects: W Medicine and related subjects (NLM Classification) > WI Digestive system
Faculties/Schools: UK Campuses > Faculty of Medicine and Health Sciences > School of Graduate Entry Medicine and Health
Item ID: 63815
Depositing User: Boyd-Carson, Hannah
Date Deposited: 07 Jan 2021 15:21
Last Modified: 07 Jan 2021 15:30
URI: http://eprints.nottingham.ac.uk/id/eprint/63815

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