A n e s t h e s i a f o r Em e r g e n c y

Abdominal Surgery
Carol Peden, MB ChB, MD, FRCA, FFICM, MPHa,*, Michael J. Scott, MB ChB, MRCP, FRCA, FFICMb,c

KEYWORDS
 Emergency surgery  Laparotomy  Sepsis  Surviving Sepsis  Enhanced recovery
 High mortality  ELPQuIC bundle

KEY POINTS
 Emergency laparotomy is a common procedure with high mortality and morbidity.
 There is a diverse range of causes and surgical treatment, with up to 40% of patients
having sepsis at the time of presentation.
 Patients who are elderly often have multiple comorbidities and a mortality of up to 25%,
and for those undergoing emergency colorectal resection their life expectancy at 1 year
is around 50%.
 Patients presenting for surgery have deranged body homeostasis and gut dysfunction,
and a high incidence of sepsis; they are effectively experiencing a complication before
surgery.
 Little research has been done in this area; however, the introduction of standardized path-
ways of care expediting diagnosis, resuscitation, and sepsis management with urgent
surgery followed by critical care admission may improve outcomes.

INTRODUCTION

This article reviews the epidemiology and pathophysiology of patients presenting for
emergency intra-abdominal surgery (excluding vascular and trauma-related surgery),
particularly the generic operation known as emergency laparotomy. This procedure is
well known to every anesthesiologist who deals with emergency surgery; however, the
common factor of a surgeon opening an abdomen to manage an intra-abdominal
emergency can have multiple causes, and multiple different procedures are encom-
passed by the overarching term laparotomy. This article examines the organizational
issues that may challenge health care teams trying to optimize care for this group of
patients. It reviews the latest developments and evidence base for anesthesia and
perioperative care pathways to optimize outcomes.

a
Royal United Hospital, Combe Park, Bath BA1 3NG, UK; b Department of Anesthesia and Peri-
operative Medicine, Royal Surrey County Hospital NHS Foundation Trust, Surrey, Guildford GU1
7XX, UK; c Surrey Perioperative Anesthesia Critical Care Research Group (SPACeR), University of
Surrey, Surrey, Guildford GU2 7XH, UK
* Corresponding author.
E-mail address: [email protected]

Anesthesiology Clin 33 (2015) 209–221

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210 Peden & Scott

EPIDEMIOLOGY

Patients undergoing emergency general surgery (EGS) have much higher mortality
and morbidity than those patients undergoing elective or scheduled procedures. US
outcomes, using data from the American College of Surgeons (ACS) National Surgical
Quality Improvement Program (NSQIP), showed a mortality of 14% at 30 days for pa-
tients who had undergone emergency laparotomy.1 Comparison of hospital perfor-
mance in emergency versus elective general surgery, adjusted for patient-related
and operation-related risk factors, showed that emergency status was a significant
predictor for morbidity, serious morbidity, and mortality.2 Outcomes from other coun-
tries are similarly poor, with a large UK database study showing an average mortality
of 15.6%,3 and a prospective study with data from 35 hospitals showing a mortality of
14.4% overall, with mortality in patients more than 80 years of age increasing to an
average 24.4%.4 Other countries also show high average mortality, with a Danish
cohort study showing a mean mortality of 18.5% at 30 days.5 Long-term outcomes
are even worse, with only 49% of patients more than 80 years of age who had under-
gone nonelective colorectal resection alive at 1 year.6
The resource burden of emergency general surgery is high, with a 10-year analysis
of the US Nationwide Inpatient sample (2001–2010) showing that 7.1% of all hospital
admissions were related to EGS, with 29% of these patients requiring surgery; the
population-adjusted case rate of 1290 admissions per 100,000 people was higher
than the sum of all new cancer diagnoses, and has increased annually since 2001.7
Despite the volume of patient episodes, high mortality, and use of resources by this
patient group there has been, until recently, little discussion about the management of
these patients in the anesthetic or surgical literature. One of the reasons for this may
be the number and diversity of causes of EGS, ranging from an incarcerated hernia to
infarcted bowel, with an associated range of morbidity and mortality. Symons and col-
leagues3 analyzed the hospital episode statistics (HES) database of the UK National
Health Service system for EGS admissions with a greater than 5% 30-day mortality.
From a total of 367,796 patients, the investigators defined 8 groups of high-risk diag-
noses, with 30-day mortality ranging between 7.4% and 47.4%. Al-Temimi and col-
leagues1 found that the commonest indications for EGS in the NSQIP database
were intestinal obstruction (33.6%), perforation (19%), and exploratory laparotomy
with or without wound debridement or abscess drainage (10%); the strongest predic-
tors of mortality were a white blood cell count of less than 4500/mm3 or greater than
20,000 mm3, septic shock, an American Society of Anesthesiologists (ASA) class IV at
the time of surgery, age 70 years or older, and a dependent functional status. Patients
with all these risk factors present had a predicted 30-day mortality of 50%.
The studies showing poor outcomes from EGS also show significant variation be-
tween hospitals after risk adjustment, with clear high and low outlying hospitals.1–4
Hospitals with low mortality from EGS had significantly more intensive care beds
per 1000 hospital beds and made significantly greater use of computed tomography
(CT) and ultrasonography.3 Saunders and colleagues4 showed that, despite the high
mortality for patients undergoing EGS, and a Cochrane Review showing benefit for
goal-directed fluid therapy in high-risk patients,8 only 15% of patients undergoing
emergency laparotomy received intraoperative goal-directed fluid therapy. Hospital
outcomes for EGS are not consistent with performance as an elective provider (ie, a
hospital with good outcomes for elective surgery may not provide good outcomes
for EGS).2
Patient outcomes for emergency surgery are likely to be improved by prompt inves-
tigation, diagnosis, and management. The National Emergency Laparotomy Audit in
 Anesthesia for Emergency Abdominal Surgery 211

the United Kingdom collected data on organizational facilities9 from 191 English and
Welsh hospitals performing EGS and compared them with agreed standards.10,11
Most centers met key recommendations; however, there was substantial variation be-
tween hospitals in their ability to provide optimal care, with, for example, two-thirds of
hospitals unable to provide 24-hour on-site interventional radiology. The aim of col-
lecting and publishing this type of data, which is linked to a National Audit of Emer-
gency Laparotomy outcomes,12 is to identify organizational structures, processes,
and practices that need improvement or that, more positively, may be linked to
good outcomes and from which other centers may learn.
Pathophysiology of Patients Presenting for Emergency Abdominal Surgery
Symons and colleagues3 analyzed 10 years of hospital data from the United Kingdom
and categorized the types of presentation for emergency surgical patients into 6 main
categories with a seventh to include other miscellaneous causes. When the patho-
physiologic process of intra-abdominal disorder is mapped it can be seen that pa-
tients already have a significant physiologic insult, with the development of a stress
response, gut dysfunction, insulin resistance, and a systemic inflammatory response
syndrome (SIRS) response, with up to 40% of patients having a septic focus. The
presence of hypotension secondary to sepsis has a particularly poor outcome and
delay in antibiotic administration leads to increased mortality.13 The derangement in
pathophysiology in each case depends on the patient’s physiologic, metabolic, and
immune status, the type of disorder, and the duration of injury before presentation
to hospital (Table 1).
Why are Outcomes so Poor for this Group of Patients and is there any Evidence that
Improvement Could Occur?
There are several key reasons why this group of patients may have such a poor
outcome.14 First, they can present from several sources; elderly patients in particular
may present with nonspecific abdominal pain and gut disturbance and may initially be

Table 1
Potential pathophysiologic processes that develop in emergency surgical patients

30-d 28-d Surgical

No. of Mortality Length of Readmission Treatment
Diagnostic Group Patients (%) Stay (d)* (%) (%)
Liver and biliary 49,611 7.4 8 (5–14) 14.8 5.1 —
conditions
Hernias with 31,156 8.2 6 (3–12) 10.7 83.1 Fluid shifts/
obstruction Sepsis
or gangrene
Bowel obstruction 158,652 9.8 6 (3–13) 16.3 26.8 Fluid shifts
Gastrointestinal 26,050 21.5 9 (6–17) 8.5 80.9 Bleeding
ulcers
Peritonitis 28,218 27.3 9 (4–16) 18.2 25.7 Sepsis
Miscellaneous 27,843 28.0 11 (5–21) 16.3 39.9 Sepsis
diagnoses
Bowel ischemia 20,766 47.4 13 (7–23) 14.2 52.5 Sepsis/SIRS
Total 367,796 15.6 8 (4–15) 14.9 37.4 —

* Values are median (interquartile range).

Data from Symons NR, Moorthy K, Almoudaris AM, et al. Mortality in high-risk emergency gen-
eral surgical admissions. Br J Surg 2013;100:1318–25.
212 Peden & Scott

presumed to have an infective problem and be managed by physicians, delaying time

to definitive surgical management. There is some evidence that mortality increases in
this group of patients.15 Second, the patients are often elderly with comorbidities and
with additional condition-related insults of sepsis and dehydration. Ingraham and col-
leagues2 found that 42.4% of patients for EGS presented with SIRS, sepsis, and septic
shock, compared with 4.3% in elective general surgery group data, supported by
another small study showing that 46% of patients requiring emergency colorectal sur-
gery presented in septic shock.16 Third, many hospitals organize their services around
elective patients with emergency general surgical patients receiving low priority; there
is considerable data to support this.2,9
Although the specialty of EGS is developing around the world,17 it is still possible to
have a complex colorectal procedure performed on a critically ill patient at night by a
general surgeon whose main expertise is in breast surgery. There is evidence to show
that availability of acute care surgeons improves outcomes in patients requiring emer-
gent colon surgery.16 Moore and colleagues16 argue that a paradigm shift is needed
for the management of patients having emergency surgery, with early evidence-
based resuscitation using Surviving Sepsis, guidelines including volume resuscitation
and early antibiotics, surgery within 6 hours of presentation, damage control laparot-
omy, and postoperative care in the intensive care unit (ICU) (Fig. 1).
The pathophysiologic insults to patients presenting for EGS are significant, as dis-
cussed earlier. It could be argued that the nature of the insult and the limited ability to
influence preoperative optimization could explain the high levels of morbidity and mor-
tality. However, case study reviews show multiple defects in the care of these high-risk
patients. The 2011 UK National Confidential Enquiry into Patient Outcome and Death18
examined the care of patients undergoing surgery, both elective and emergency, and
found significant deficits; for example, only 26% of high-risk patients had an arterial
line placed and only 14% had a central venous catheter. A review of high mortality
in patients undergoing colorectal surgery in Veterans Affairs hospitals (63% of the
cases were emergencies)19 showed that delay in diagnosis occurred in 19% of cases,
22% had a delay to surgery, and 14% should have received less radical surgery;

Fig. 1. Changing the way clinicians think: understanding urgency and risk. MOF, multi-or-
gan failure. (Adapted from Moore LJ, Turner KL, Jones SL, et al. Availability of acute care
surgeons improves outcomes in patients requiring emergent colon surgery. Am J Surg
2011;202(6):840; with permission.)
 Anesthesia for Emergency Abdominal Surgery 213

system issues were identified in 19% and practitioner-related issues in 20% of the
cases of patients who died. These findings suggest that there is significant need for
improvement in perioperative management in high-risk emergency cases.

CONDUCT OF ANESTHESIA

Anesthetists face many challenges with this group of patients. The emergency presen-
tation means there is often minimal time to assess and optimize the patient before
operation. However, a short time spent assessing and resuscitating patients before in-
duction of anesthesia; ensuring that the patient has had broad-spectrum antibiotics, if
appropriate; and that they are resuscitated with satisfactory intravascular volume, car-
diac output, and oxygen delivery can lead to a more stable perioperative period.
Depending on the institute, this can be done in the operating room, an anesthetic
room, or on the ICU. Arterial line insertion and central venous line insertion can be per-
formed to assess the patient. Although a central venous line is not a good predictor of
fluid responsiveness, it is useful for delivering inotropes and to sample blood for
venous extraction. Minimally invasive cardiac output monitoring may also be of
benefit. Many anesthetists and intensivists are now becoming skilled at transthoracic
echocardiography assessment and this can be used to assess cardiac structure and
function, guide resuscitation, and identify perioperative issues such as valve stenosis
and regurgitation and areas of myocardial dyskinesia.
Many patients in this group have a SIRS response or are septic and need vasopres-
sors such as a noradrenaline infusion to maintain mean arterial pressure. Vasopressor
infusions should ideally be commenced once intravascular volume is replete to avoid
occult splanchnic hypovolemia and hypoperfusion; this may not be possible if the pa-
tient’s condition is critical, but the anesthesiologist should be aware that gut perfusion
may be compromised. In elective surgical patients the role of hemodynamic optimiza-
tion and targeting oxygen delivery is still unclear. However, Surviving Sepsis supports
early restoration and maintenance of intravascular volume and mean arterial pressure
with crystalloid and noradrenaline infusions and ensuring adequate oxygen delivery
using inotropes and blood transfusion as necessary.20

Induction and Maintenance of Anesthesia

Anesthetists should aim to induce anesthesia and rapidly secure the airway to avoid
the risk of pulmonary aspiration. A rapid sequence induction is classically performed
with a predetermined dose of induction agent, suxamethonium, and the addition of
cricoid pressure to reduce this risk. Experienced anesthetists often modify the induc-
tion by using opioids and titration of induction agents to maintain better hemodynamic
stability and use rocuronium to avoid the use of suxamethonium to enable rapid endo-
tracheal intubation. Intubation aids such as a gum elastic bougie and fiberoptic laryn-
goscopes should be immediately available. An awake fiberoptic intubation can be
performed if difficult intubation is predicted.
Anesthesia should be maintained using oxygen-enriched air with a short-acting anes-
thetic such as sevoflurane or desflurane. There is no evidence to support one anesthetic
agent rather than another or to use propofol target-controlled infusions in this group.
Short-acting opioids can be used, such as fentanyl of a remifentanil infusion. Muscle
relaxation guided by a peripheral nerve stimulator should be maintained through the
procedure to help the surgeon. Fluids and blood products should be warmed and
forced-air warming used to maintain normothermia as appropriate throughout the
procedure. Some patients may have sepsis or a SIRS response, and may have pyrexia,
so nasopharyngeal temperature monitoring should be used to guide warming.
214 Peden & Scott

Ventilation should be done using a low tidal volume and high respiratory rate with
optimal positive end-expiratory pressure to reduce the risk of acute lung injury.21,22
In order to reduce the risk of microaspiration around the tracheal cuff, which can pre-
dispose to postoperative pneumonia, polyurethane cuffs and correctly sized endotra-
cheal tubes should be used.

ANALGESIA

In elective midline laparotomy the use of thoracic epidural analgesia (TEA) offers many
benefits in addition to analgesia, such as reduced use of opioids, reduced pulmonary
complications, reduced thromboembolic risk, reduced incidence of ileus, and reduction
of the stress response23; however, as an emergency procedure its use is more problem-
atic. Patients can be too unstable to insert the epidural before surgery or may have con-
traindications such as sepsis or a coagulation disorder. There may be an opportunity to
insert TEA on the ICU or to use an alternative such as rectus sheath catheters, wound
catheters, and transversus abdominis plane blocks, so where possible consent should
be taken for this before anesthesia.24 Intravenous morphine is effective and efficacious
but has the disadvantage of increasing postoperative nausea and vomiting, increasing
the risk of ileus, and increasing somnolence and sleep disturbance.

SURGERY

There is evidence that, for this group of patients, the duration of surgery is critical.25
Although patients may require a simple procedure, such as oversewing of a perfora-
tion to save their life, others require complex, difficult surgery. The concept of
damage-control surgery was first developed to minimize surgical stress for patients
following major trauma; however, the concept can equally be applied to those patients
undergoing emergency surgery for nontrauma intra-abdominal disorders.26 If the pa-
tient is septic, urgent source control of the sepsis is required. For many procedures
encompassed by the term emergency laparotomy, the surgeon must consider
whether a primary anastomosis and closure of the patient’s abdomen are appropriate
at the time of the initial surgery, or whether these procedures should be delayed until
the patient’s physiologic state has improved.16,26,27

POSTOPERATIVE CARE

Although in most elective surgical cases it is the intention of the anesthetist to wake
and extubate the patient at the end of surgery, the physiologic processes in this group
of patients may require a period of postoperative ventilatory support in the ICU to opti-
mize outcome. Reasons for this include:
 Septic shock with an oxygen deficit and increased lactate level
 Hemodynamic instability or the need for large doses of vasopressors and
inotropes
 Significant acidosis
 Massive bleeding with coagulopathy
 Requirement for renal support/continuous venovenous hemodialysis
 Abdominal distension that can cause significant reduction in functional residual
capacity so that there would be respiratory compromise at extubation
Careful assessment should be made of patients before extubation. Depending on
the length and nature of the intra-abdominal surgery, reassessment of the patient’s
predicted outcome using a scoring system taking into account blood loss,
 Anesthesia for Emergency Abdominal Surgery 215

temperature, blood glucose, lactate, and surgical findings is likely to be justified.28

Depending on the results of this assessment an informed decision can be made about
whether or not the patient should be extubated, and what level of postoperative care is
needed.
Evidence suggests that postoperative management is an area in which major im-
provements in care could be made for patients having EGS.29 In an important article
examining determinants of long-term survival after major surgery, the occurrence of a
30-day postoperative complication was more important than preoperative patient risk
and intraoperative factors in determining survival after major surgery. The complica-
tions with the greatest impact, pneumonia and myocardial infarction occurring within
30 days of surgery, reduced survival up to 5 years after surgery. This article and others
from the ACS NSQIP program also show that, when attention is paid to quality and
process improvement in perioperative care, outcomes even for high-risk patients
improve. Hall and colleagues30 reported on 118 hospitals participating in the NSQIP
programme; 66% of hospitals improved risk-adjusted mortality and 82% improved
risk-adjusted complication rates. There was a correlation between initial observed/ex-
pected outcome ratios and the degree of improvement, initially worse-performing hos-
pitals had more likelihood of improvement but hospitals that originally performed well
also improved and the variation in outcome was reduced.
Preventing mortality and morbidity in patients undergoing EGS may require
improved postoperative monitoring to detect and manage complications early. Gha-
feri and colleagues31 described high-mortality and low-mortality surgical hospitals,
and these hospitals had similar rates of major complications and postoperative com-
plications overall; what determined the different rates of death between low-mortality
and high-mortality hospitals seemed to be the timely recognition and management of
complications when they occurred, which may be best achieved by admission to a
critical care bed. Although there are many scoring systems that can be used to assess
operative risk,32 there is little evidence that these are routinely used to enhance deci-
sion making about postoperative location for the emergency patient,12 and triage may
be required when bed availability is limited.33 High-risk patients undergoing EGS may
not always get optimal postoperative care and may be less likely to be admitted to crit-
ical care than patients undergoing major elective procedures with much lower mortal-
ity.34–36 Most patients undergoing emergency laparotomy are likely to need critical
care. The Emergency Laparotomy Network report found that patients who were
more than 65 years of age and/or ASA III or more had a mortality of greater than
10%; these are criteria for ICU admission by most standards, but 33% of these pa-
tients were not admitted to a monitored bed postoperatively.4 One of the suggested
reasons for the high mortality (18.5% at 30 days and 24% at 90 days) of patients in
the Danish cohort study5 was that 84% of the patients did not receive any postoper-
ative critical care.
Older patients (>65 years) are at substantially greater risk for adverse events
following EGS procedures, with evidence of substantial variation in the quality of
care delivered.37,38 When variation exists it is likely that significant improvement is
achievable through the reliable delivery of evidence-based processes, such as objec-
tive decision making about postoperative location.38

IMPROVING PERIOPERATIVE CARE

There are many options and areas to focus on to improve outcomes for high-risk
surgical patients. A work plan can be visualized through the development of a driver
diagram such as is shown in Fig. 2.
 216
Decrease:
Mortality
Complications
Cost

Service Postoperative Intraoperative Preoperative

End of Life Care
Organization Care Care Care

Team
Patient and Strategies “Damage Patient
Adequate ORs experienced Delirium Physical Pain and fluid WHO Surgical Optimal SCIP Risk Preoperative
family Palliative Care other than limitation” information/ Optimization
and ICU beds in management management therapy management checklist monitoring measures assessment assessment
involvement surgery surgery consent
of EGS

Fig. 2. Driver diagram. OR, operating room; SCIP, surgical care improvement project; WHO, World Health Organization. (Adapted from Peden CJ. Emergency
surgery in the elderly patient: a quality improvement approach. Anaesthesia 2011;66:435–45; with permission.)
 Anesthesia for Emergency Abdominal Surgery 217

This list of areas that could have improvement projects attached is not comprehen-
sive, but is a systematic approach to identifying areas on which to focus. Continued
measurement for improvement of process and outcome data in each project area to
understand how a service is performing will help to understand areas of practice to
be worked on to drive better patient care and create the energy for improvement.
Use of checklists to facilitate key components of care across surgical pathways has
been shown to improve morbidity and mortality even in low-risk groups of patients.39
Improving outcomes for this complex patient group may be best achieved by stan-
dardization of the patient pathway and adherence to delivery of key components. The
articles in this issue discuss the concept of fast track or enhanced recovery for patients
undergoing elective procedures, but there is no reason why the principle should not be
applied to emergency patients.40 Simplification through protocolization of a high-risk
hospital episode may enable delivery of essential components of care. An enhanced re-
covery programme is designed to deliver care that minimizes the patient’s physiologic
stress response to surgery with an evidence-based, patient-centered approach
combining individual interventions, which, when used together consistently by a multi-
disciplinary team, are synergistic, with a greater impact on outcome than when used
alone or in a haphazard way.41–43 Although the preoperative components of such a pro-
gramme may not be relevant to emergency patients, intraoperative management and
postoperative care can be delivered in line with the principles of enhanced recovery.
Key elements for optimizing postoperative recovery following colorectal surgery:
1. Appropriate postoperative care location: ward/high dependency unit/ICU
2. Balanced analgesia
3. Appropriate monitoring during the initial postoperative period, when increased ox-
ygen demand and fluid shifts demand individualized titration of fluids to maintain
normovolemia, but avoid crystalloid excess
4. Early enteral nutrition
5. Early and structured postoperative mobilization
6. Venous thromboembolism prophylaxis
7. Patients should be involved in the process and motivated to reach predefined goals
A structured pathway for unscheduled adult general surgery is provided in “The
Higher Risk General Surgical Patient” document from the Royal College of Surgeons
England 2011,10 which has 4 components: clinical assessment, diagnostics, intrao-
perative assessment, and postoperative care.
The principles of enhanced recovery and the pathway suggested earlier were tested
in 4 hospitals. The hospitals developed a care bundle with 5 key components to be
delivered to patients undergoing emergency laparotomy, termed the Emergency Lap-
arotomy Quality Improvement Care (ELPQuIC) bundle.
The ELPQuIC bundle consists of:
1. Early assessment and resuscitation
2. Antibiotics administered to patients who show signs of sepsis
3. Prompt diagnosis and early surgery
4. Goal-directed fluid therapy in theaters and continued to ICU
5. Postoperative intensive care for all patients
The 4 participating hospitals measured their performance on these key metrics and
several other process measures. No hospital achieved reliable delivery of all key pro-
cesses, but all teams improved in delivery of all care bundle components from their
baseline levels of performance. There was a significant reduction in risk-adjusted mor-
tality across all 4 hospitals following implementation of the care bundle.44 This study
218 Peden & Scott

showed that it is possible to improve outcomes in the diverse group of patients under-
going emergency laparotomy using a quality-improvement approach to improve deliv-
ery of evidence-based components of a standardized care pathway.
The difficulty in undertaking randomized controlled trials in the diverse, sick patients
who undergo emergency laparotomy may account for the paucity of research in this pa-
tient group to date. However, the increasing recognition that quality-improvement
studies can lead to change, and are scientifically valid, is gaining traction. The British
National Institute of Health Research has given major funding to the EPOCH (Enhanced
Perioperative Care for High-risk patients) study to use quality-improvement methodol-
ogy with the aim of reducing 90-day mortality in patients undergoing emergency mor-
tality.45 The EPOCH study draws its outcome data from participating hospitals’ own
submissions to the National Emergency Laparotomy Audit database.
Focus on the Elderly
Many of the patients presenting for EGS are elderly. Studies of older patients undergoing
elective surgery have shown that proactive identification and management of problems
such as nutrition and frailty can improve outcomes with a significant reduction in com-
plications and length of stay46; this proactive approach is the same as that advocated
by enhanced recovery programs. A small study in patients presenting for emergency
surgery suggested that proactive referral to care of the elderly physicians, even if
done at the time of surgery, may reduce length of stay.47 The British Hip Fracture Data-
base48 shows that monitored delivery of key components of care, including periopera-
tive management by orthogeriatric physicians, has led to a continued improvement in
outcomes in elderly patients undergoing urgent surgery for fractured neck of femur.
When outcomes of emergency intestinal surgery were compared with outcomes of
similar procedures performed electively, elderly patients were much less likely to be dis-
charged back to independent status, with 69% of elective patients discharged directly
home compared with 6.5% of emergency surgical patients.49 It is this type of outcome
data that patients may value most when making decisions about undergoing high-risk
EGS, but there are few data about long-term outcomes and quality of life following
EGS, particularly in the elderly50; there is evidence of underappreciation of the impact
of a hospital stay on functional performance of patients discharged to the community.51
It may be that, for some patients, the risk of surgery is so high and the quality of survival so
poor that a focus on pain relief and palliative care is in their best interests. However, more
outcomes research is needed before clinicians can have truly informed discussions with
their patients, particularly the elderly, before they undergo emergency laparotomy.52

SUMMARY AND FUTURE CONSIDERATIONS

Specific pathways of care may be needed to focus on patients having EGS who have
different needs to those of patients undergoing elective general surgery. A focus on
reliable delivery of key components of care, the early and optimal management of
sepsis, preoperative resuscitation, and prevention of postoperative complications
can lead to significantly improved outcomes for this high-risk group of surgical
patients. Further research is needed into optimizing the perioperative care pathway,
surgery, and rehabilitation after EGS.

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