Follow-up after emergency laparotomy suggests high one- and five-year mortality with risk stratified by ASA

Q: What are the key findings of this study?

Emergency laparotomy is associated with a high 5-year mortality that strongly correlates with ASA grade (OR 2.65, p<0.001), with actual survivorship at 5 years for ASA grade 3 or 4 approximating 50%.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Emergency laparotomy (n=2787). Intervention: Emergency laparotomy vs. Laparoscopic cholecystectomy. Primary outcome: All-cause mortality at 5 years (predictor: ASA grade) (OR 2.65 per ASA grade increase, p=<0.001).

Q: What question did this study set out to answer?

To investigate 1-year and 5-year all-cause mortality following emergency laparotomy and evaluate American Society of Anesthesiologists (ASA) physical status grades to guide long-term patient counselling.

Kenneth Nicoll; James Lucocq; Thanaa M. Khalil; Mohammed Rohi Khalil; Helena Watson; Pradeep Patil

doi:10.1308/rcsann.2021.0156

September 14, 2021Annals of The Royal College of Surgeons of EnglandOpen Access

Follow-up after emergency laparotomy suggests high one- and five-year mortality with risk stratified by ASA

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Key result

Higher ASA grade linked to ~2.6-fold higher 5-year mortality after emergency laparotomy.

OR 2.65 per ASA grade increase
P<0.001
n=2,787

Why the study?

All-cause mortality at 1 and 5 years following emergency laparotomy was investigated to establish a basis to advise patients and relatives on long-term mortality.

What is the long-term (1- and 5-year) all-cause mortality following emergency laparotomy, and how does it compare to a laparoscopic cholecystectomy control group stratified by ASA grade?

Key Points

To investigate 1-year and 5-year all-cause mortality following emergency laparotomy and evaluate American Society of Anesthesiologists (ASA) physical status grades to guide long-term patient counselling.
Combined historical audit data (2010–2012) with National Emergency Laparotomy Audit data (2017–2020) for 953 laparotomy patients (894 with ASA grades), using 1,834 laparoscopic cholecystectomy patients (2015–2020) as controls.
Tracked survival over a median follow-up of 495 days (IQR 143–2,788 days) for laparotomy and 1,042 days (IQR 627–1,495 days) for cholecystectomy.
Assessed associations between clinical covariates and mortality using multivariate logistic regression and Kaplan-Meier survival analysis.
Five-year survival after emergency laparotomy dropped progressively by ASA grade (95% CI: ASA 1, 79–96%; ASA 2, 69–82%; ASA 3, 44–58%; ASA 4, 33–48%; ASA 5, 4–51%) compared with 98–99% following laparoscopic cholecystectomy.
The majority of deaths occurred after 30 postoperative days, with 30-day mortality showing no significant change between 2010–2012 (11.9%) and 2017–2020 (10.9%, p=0.62).
Multivariate logistic regression identified ASA grade as the dominant predictor of 5-year mortality (OR 2.65, p<0.001), alongside age per year above 16 (OR 1.03, p<0.001), generating an AUC of 77.8%.

Study Design

Type

Cohort (n=2,787)

Multicenter

Yes

Structured PICO

What is the long-term (1- and 5-year) all-cause mortality following emergency laparotomy, and how does it compare to a laparoscopic cholecystectomy control group stratified by ASA grade?

P

Population

2,787 adult patients (953 undergoing emergency laparotomy and 1,834 undergoing laparoscopic cholecystectomy as controls) followed for up to 5 years to evaluate long-term mortality.

E

Exposure

Emergency laparotomy

C

Comparator

Laparoscopic cholecystectomy

O

Outcome

All-cause mortality at 1 and 5 yearshard clinical

Main Result

Odds Ratio: 2.65

p-value: p=<0.001

Long-term mortality following emergency laparotomy is remarkably high and strongly predicted by ASA grade, demonstrating that 30-day mortality estimates are insufficient for robust preoperative patient counseling.

Limitations

Lack of detailed information on the final pathology for all patients
Missing preoperative blood values for some patients
No detailed information on the final pathology for all patients
Retrospective inclusion of historical audit data

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

High 5-year mortality after emergency laparotomy, especially ASA 3-4, warrants cautious long-term risk discussion; leaves open prospective validation of modifiable predictors.

Abstract

INTRODUCTION: We investigated all-cause mortality following emergency laparotomy at 1 and 5 years. We aimed to establish a basis from which to advise patients and relatives on long-term mortality. METHODS: Local data from a historical audit of emergency laparotomies from 2010 to 2012 were combined with National Emergency Laparotomy Audit (NELA) data from 2017 to 2020. Covariates collected included deprivation status, preoperative blood work, baseline renal function, age, American Society of Anesthesiologists (ASA) grade, operative time, anaesthetic time and gender. Associations between covariates and survival were determined using multivariate logistic regression and Kaplan-Meier analysis. We used patients undergoing laparoscopic cholecystectomy between 2015 and 2020 as controls. RESULTS: =1,834), with mortality being significantly greater in the laparotomy group. Following cholecystectomy, 95% confidence intervals for survival at 5 years were 98-99%. Following laparotomy these intervals were: ASA grade 1, 79-96%; ASA grade 2, 69-82%; ASA grade 3, 44-58%; ASA grade 4, 33-48%; and ASA grade 5, 4-51%. The majority of deaths occurred after 30 days. CONCLUSIONS: Emergency laparotomy is associated with a significantly increased risk of death in the following 5 years. The risk is strongly correlated to ASA grade. Thirty-day mortality estimation is not a good basis on which to advise patients and carers on long-term outcomes. ASA grade can be used to predict long-term outcomes and to guide patient counsel.

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Cite This Study

Nicoll et al. (2021) conducted a cohort in Emergency laparotomy (n=2,787). Emergency laparotomy vs. Laparoscopic cholecystectomy was evaluated on All-cause mortality at 5 years (predictor: ASA grade) (OR 2.65 per ASA grade increase, p=<0.001). Emergency laparotomy is associated with a high 5-year mortality that strongly correlates with ASA grade (OR 2.65, p<0.001), with actual survivorship at 5 years for ASA grade 3 or 4 approximating 50%.

synapsesocial.com/papers/6a5039fda1cf396479ce9e3b https://doi.org/10.1308/rcsann.2021.0156

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Follow-up after emergency laparotomy suggests high one- and five-year mortality with risk stratified by ASA

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Follow-up after emergency laparotomy suggests high one- and five-year mortality with risk stratified by ASA

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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