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PTU-249 Outcomes of emergency colorectal surgery in district general hospital
  1. R Mcbride,
  2. C Magee,
  3. K Mulholland
  1. General Surgery, Ulster Hospital, Dundonald, UK

Abstract

Introduction Emergencies make up greater than one third of all general surgical admissions with many of these patients being elderly with significant co-morbidities. Mortality in this group is high, varying from 15–25%. Concerns over the quality of emergency surgical care prompted the formulation from RCS: Standards for unscheduled care. Using the standards set by this guideline, the practice in a DGH was audited. Primary focus was consultant presence in cases with predicted mortality >10%.

Method Theatre Management System from 01/09/12–31/07/13 identified all emergency laparotomies. All cases were reviewed and elective, non-colorectal and re-laparotomies were excluded. Patient charts were reviewed and a predicted perioperative mortality (Portsmouth-POSSUM score) calculated. Specific outcomes included consultant presence, procedure performed, post-operative level of care and complications.

Results In total 188 laparotomies were identified with 40 emergency colorectal cases. The mean age was 74 years with a male to female ratio of 45:55. Sepsis was the indication in 58% of cases. The mean P-POSSUM was 29.85% (range 1–87) with an observed 30 day mortality of 30%. Benign pathology accounted for 65% of cases with maliganacy the remaining 35%.

Patients operated on a Saturday and Sunday had a mortality of 50–60% with the remainder of the week between 14–25%. Time of day also had an affect on mortality as, whilst only 20% of patients were operated on after midnight, mortality was 50%. In comparison 53% were operated during normal working hours (8 am–5 pm) with a morality of 24%.

A consultant surgeon was present at 80% of all cases, with 76% present at those with a P-POSSUM >10%. Consultant anaesthetist was present at 62.5% and 64% respectively. For patients who died a consultant anaesthetist was only present at 40% of these cases with surgeon at 75%. Neither surgeon nor anaesthetist was present at 25% of these cases.

Conclusion Emergency laparotomy for acute colorectal pathology carries a high morbidity and mortality. In 35% of patients this was an acute presentation of colorectal cancer. Our results are broadly comparable with national figures and consultant presence was generally good. There was a trend towards reduced mortality when present, in particular anaesthetic presence. Use of a tool, such as P-POSSUM may help to highlight cases which would benefit from consultant level anaesthetic and surgical input. A regionally agreed emergency surgery checklist may help guide critical care referral and senior review.

Disclosure of interest None Declared.

References

  1. Royal College of Surgeons: Emergency surgery, standards for unscheduled care, February 2011

  2. NELA: Organisational Report of the National Emergency Laparotomy Audit, May 2014

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