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Javanmard-Emamghissi, Hannah (2024) An exploration of futility and extreme risk in emergency laparotomy. PhD thesis, University of Nottingham.

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Abstract

An emergency laparotomy is an invasive abdominal surgical procedure used to treat conditions such as intestinal perforation or obstruction. It is one of the most common emergency surgeries worldwide, but is associated with significant mortality and morbidity. The National Emergency Laparotomy Audit (NELA) was established in 2012 to improve outcomes for emergency laparotomy patients in England and Wales. Prior to NELA’s establishment the national outcomes of these patients were completely unknown. NELA’s work identified groups of patients that had worse outcomes than their peers or were undefined and understudied; in particular older patients, very high-risk patients and those that died in the early post-operative period. The aim of the thesis was to address these areas of research paucity.

Chapter 4 was a scoping literature review exploring surgical futility in emergency laparotomy literature. Futility in medicine has been defined through seven guiding principles, which in the context of emergency surgery, have been relatively unexplored. This review identified just three papers exploring futility in emergency laparotomy, which all used a quantitative definition of futility, using the binary of post-operative mortality within 48-72 hours of their procedure as their measure of futile surgery.

Chapter 5 builds on the previous chapter, by applying this definition of futile surgery to the NELA database and assessing for predictors of early post-operative mortality. Key factors that are not currently included in commonly used risk prediction models were found to be significantly predictive of mortality within three days of surgery. Examples included bowel ischaemia (OR 2.67; 95% CI 2.50-2.85), intestinal perforation (OR 1.55; 95% CI 1.47-1.65), frailty (OR 1.38; 95% CI 1.22-1.55) and a high blood lactate (arterial lactate 4-6, OR 5.27; 95% CI 3.93-7.07).

Another example of futile surgery is intra-operative mortality. The next study (Chapter 6) aimed to characterise the group of patients that die during an emergency laparotomy and assess this group for predictors of on-table mortality. This study found that the incidence of on-table mortality during emergency laparotomy is 1 in 400 (450/180,985, 0.2%). These patients had a good functional baseline, but were critically unwell at presentation. Acute mesenteric ischaemia was highly associated with peri-operative mortality (OR 2.97; 95% CI 2.35-3.75), with implications for emergency department assessment pathways and for shared-decision making discussions about proceeding with high-risk surgery for this indication.

High-risk surgery in emergency laparotomy has been defined as a predicted 30-day mortality risk of ≥5%. Although there is a large difference between a risk of death of 5% and a risk of death of 50%, outcomes for all high-risk patients are usually expressed as a single group. What defines an extreme level of risk has not yet been studied. The final study (Chapter 7) examined the outcomes of ‘extreme-risk’ patients, which we defined as those with a predicted 30-day mortality of ≥50%. Compared to their high-risk counterparts, extreme-risk patients had 40% higher rates of unplanned returns to theatre for complications, protracted critical care stays and more than double the length of hospital stay.

This thesis has examined understudied populations within emergency laparotomy patients in order to provide data that can inform shared decision-making discussions with patients and their relatives. It has provided more nuanced quantitative outcomes that can be used in a qualitative way, addressing areas that were previously gaps in our knowledge regarding the emergency laparotomy patient journey.

Item Type:	Thesis (University of Nottingham only) (PhD)
Supervisors:	Tierney, Gillian M. Lund, Jon N. Moug, Susan
Keywords:	Laparotomy; Surgical futility; Morbidity; Complications
Subjects:	W Medicine and related subjects (NLM Classification) > WI Digestive system
Faculties/Schools:	UK Campuses > Faculty of Medicine and Health Sciences > School of Medicine
Item ID:	77741
Depositing User:	Javanmard-Emamghissi, Hannah
Date Deposited:	17 Jul 2024 04:40
Last Modified:	17 Jul 2024 04:40
URI:	https://eprints.nottingham.ac.uk/id/eprint/77741

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