Key result
Hourly surgical delay in major emergency abdominal surgery was associated with increased mortality (risk estimate 1.02; 95% CI 1.00-1.03), though little evidence supported a strict six-hour cutoff.
Why the study?
Mortality after major emergency abdominal surgery is high and care-bundles use a six-hour cut-off to reduce delay, but evidence supporting current in-hospital delay cutoffs needed investigation.
Does surgical delay beyond six hours increase mortality in patients undergoing major emergency abdominal surgery?
Meta-Analysis (n=16,772)
Does surgical delay beyond six hours increase mortality in patients undergoing major emergency abdominal surgery?
Relative Risk: 1.02 (95% CI 1–1.03)
There is little evidence supporting a strict six-hour cutoff for surgical delay in unselected major emergency abdominal surgery, though hourly delay is associated with a slight increase in mortality risk.
Questions routine six-hour thresholds for emergency abdominal surgery; leaves open optimal timing and need for prospective trials.
BACKGROUND: Mortality following major emergency abdominal surgery is high. Surgical delay is regarded as an important modifiable prognostic factor. Current care-bundles aim at reducing surgical delay, most often using a six-hour cut-off. We aimed to investigate the evidence supporting the in-hospital delay cutoffs currently used. METHODS: MEDLINE, EMBASE and the Cochrane Library were searched. We included studies assessing in-hospital surgical delay in major emergency abdominal surgery patients. Studies were only included if they performed adjusted analysis. Surgical delay beyond six hours was the primary cutfrom interest. The primary outcome was mortality at longest follow-up. Meta-analyses were conducted if possible. RESULTS: Eleven observational studies were included with 16,772 participants. Two studies evaluated delay in unselected major emergency abdominal surgery patients. Three studies applied a six-hour cutoff, but only a study on acute mesenteric ischemia showed an association between delay and mortality. Meta-analysis showed no association with mortality at this cutoff. An association was seen between hourly delay and mortality risk estimate, 1.02 (95% confidence interval [CI], 1.00 - 1.03), and on subgroup analysis of hourly delay in perforated peptic ulcer patients, risk estimate, 1.02 (95% CI, 1.0 - 1.03). All risk estimates had a very low Grading of Recommendations Assessment, Development, and Evaluation score. CONCLUSION: Little evidence supports a six-hour cutoff in unselected major emergency abdominal surgical patients. We found an association between hourly delay and increased mortality; however, evidence supporting this was primarily in patients undergoing surgery for perforated peptic ulcer. This review is limited by the quality of the individual studies.
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Hansen et al. (2022) conducted a meta-analysis in major emergency abdominal surgery (n=16,772). Surgical delay vs. Shorter delay was evaluated on mortality at longest follow-up (risk estimate 1.02, 95% CI 1.00 - 1.03). Hourly surgical delay in major emergency abdominal surgery was associated with increased mortality (risk estimate 1.02; 95% CI 1.00-1.03), though little evidence supported a strict six-hour cutoff.
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