Emergency General Surgery: Time for Anesthesiology and Surgery to Work Together to Drive Improvement in Outcomes

It was in the early 5th century BC that the Greek physician Hippocrates was the first to describe the ominous signs of the acute abdomen, which the Greeks described as “ileus” or “iliac passion.” He wrote: In ileus the belly becomes hard, there are no motions, the whole abdomen is painful, there are fever and thirst and sometimes the patient is so tormented that he vomits bile. Medicines are not retained and enemas do not penetrate. It is an acute and dangerous disease.1 Through the following centuries, the etiology of the acute abdomen was poorly understood except in penetrating trauma in warfare, when it was recognized that when abdominal wounds spilt the bowel, the wounds were usually fatal, although there have been case reports of survival of injuries with fecal fistulas. In the United States, emergency general surgery (EGS) is around 11% of surgical admissions, yet it accounts for over 50% of surgical mortality.2 The cost burden of EGS currently exceeds that for managing diabetes, cancer, and myocardial infarction.3 A recent article by Ogola et al4 estimated that the annual financial burden of EGS in the United States could reach $40 billion by 2060. Yet, it is only as recently as 2013 that the American Association for the Surgery of Trauma formulated a definition of EGS and primary EGS diagnostic codes.5 Using these definitions, Gale et al3 calculated that from 2001 to 2010, there were 27,668,807 EGS admissions comprising 7.1% of all hospital admissions. The annual case rate (1290 of 100,000) is higher than the sum of all new cancer diagnoses. Over the past 50 years, increasing subspecialization in elective surgery has led to improved surgical outcomes, the patient undergoing emergency surgery appears to have not benefited in the same way. Those patients who proceed to emergency laparotomy fare particularly poorly, with mortality in the United States and the United Kingdom around 15%, rising to around 25% in patients over 80 years of age.6,7 Unfortunately, there have been significant challenges to improving outcomes in emergency surgery in many health care systems. The development of the specialty of acute care surgery in the United States encompassing EGS, trauma, and surgical critical care is a move to address this. In the October 2017 issue of Anesthesia & Analgesia, Aggarwal et al8 examine recent studies done to improve outcomes in EGS patients who proceed to emergency laparotomy. These improvements have all focused on standardizing the process of care of patients undergoing emergency laparotomy, focusing on the pathway rather than the surgical technique itself. This parallels the impact that enhanced recovery after surgery (ERAS) pathways have had on improving modern surgical outcomes in colorectal surgery with minimal changes in surgical technique. Given that emergency surgery is associated with a 1 in 8 chance of dying within 30 days, individuals of all ages should be concerned about potential risk. The chance of a complicated recovery requiring intensive care is much higher in this emergency surgery group, particularly when there is fecal peritonitis. In 2006, Khuri et al’s9 article examining the long-term determinants of outcomes after different types of major surgery in the Veterans Affairs Medical System identified that major complications were the key predictor of long-term survival over 10 years, not preoperative risk. A more recent study by Moonesinghe et al10 has shown that those patients identified as having a prolonged complication classified by the postoperative morbidity score had an increased relative hazard for death for up to 3 years after surgery, returning to baseline thereafter. Although our understanding of the pathophysiology of severe illness and its long-term effects is limited, there is clearly a prolonged cellular effect with a survival impact well beyond the traditional 30-day mortality marker. Therefore, it is our duty as clinicians to identify these causes and reduce this impact for our patients. A recent analysis by McCoy et al11 of the National Surgical Quality Improvement Project of 7 index EGS operations showed that these operations accounted for only 14% of the emergency operations, but resulted in 56% of the complications. The link between mortality rates and complications have been directly linked to individual hospital practices and more distinctly to the “failure to rescue” of the patient with complications.12,13 The extension of the definition of acute care surgery in the United States to now include rescue surgery has been recently advocated by the Pittsburgh group.14 More important, the defining role of the acute care surgeon in the United States as intensivist and rescue surgeon has been greatly amplified by the formation of a multidisciplinary team of critical care specialists, along the entire pathway of the EGS patient, from the moment of encounter in the emergency room, to the early decision for simultaneous source control and critical resuscitation, in preoperative, intraoperative, and subsequent postoperative critical care management. The delivery of surgical critical care, through multidisciplinary specialists, to include surgery, anesthesia, and emergency medicine, all following a common protocolized pathway for resuscitation and rescue, becomes vital for optimization of outcomes in emergency surgery. The 3 articles discussed by Aggarwal8 show common themes to improve outcomes in this EGS laparotomy patient population: Early diagnosis (using scoring systems, tests such as abdominal computed tomography scan and experienced surgical assessment), immediate broad-spectrum antibiotic therapy, rapid fluid resuscitation, and use of a noninvasive hemodynamic monitoring device to guide perioperative fluid therapy, urgent availability of an operating room, experienced surgical, anesthetic, and critical care input, and high-level monitoring on intensive care postoperatively to maintain homeostasis until appropriate deescalation of care is possible. The result is a pathway that reduces cellular stress and injury and treats sepsis promptly: “Surviving Sepsis” meets ERAS. Just like ERAS pathways, where it is no individual element that makes a major difference, it is the sum of the parts of the EGS pathway and the expediency with which they are delivered that appear to be important.15 The patient effectively has a complication before arriving to hospital, and the sooner the pathology is corrected and the homeostasis restored, the better the outcome.16 It is clear that to improve outcomes, rapid diagnosis and referral to a surgeon need to occur, whether in the community, by the primary care physician, the emergency department, or the intern on the hospital floor. Patients may not present with peritonitis or abdominal findings all the time, and the variable nature of the pathology means there can be a multitude of presenting clinical features. However, the presence of hypotension, tachypnea, and altered mental state are warning signs of rapid decline. Features of sepsis are present in up to 25% of cases requiring laparotomy. The early use of antibiotics is critical in patients for whom the risk of sepsis is high. The use of antibiotics does not just show benefit in the frankly septic patient or those with peritonitis, but for any patient for whom the integrity of the gut mucosa is at risk, such as ischemia, obstruction, or colitis, and the risk of bacteremia is high. There is a continued need to develop a rapid high-sensitivity real-time polymerase chain reaction point of care test to identify patients who are at risk for further decompensation to prompt physicians to act.17 For example, arterial lactate remains a useful indicator of severity of presenting illness, but may be a late indicator and limited to those in the hospital. Fluid therapy and hemodynamic monitoring setting goals to restore intravascular volume and allow the judicious use of vasopressor and inotropes have been a feature of all 3 papers. However, just like in studies of sepsis, there is still a lack of cohesive strategies to target fluid therapy end points. This patient group is at risk of the effects of hypovolemia, which can lead to organ damage and gut hypoperfusion but also the dangers of hypervolemia due to indiscriminant fluid resuscitation and damage of the intravascular glycocalyx with the risk of capillary leak and resultant tissue edema. A variety of technologies are available for fluid optimization, but the advantages of each technology depend on many factors and whether the patient is being mechanically ventilated or not. Further work evaluating different technologies is necessary to understand the importance of when and when not to give patients a fluid bolus. The use of transthoracic echocardiography, combined with noninvasive hemodynamic monitoring, has yet to be studied but offers the benefit that venous capacitance can be estimated as well as hemodynamic response to a fluid bolus. This combination may allow the appropriate use of vasopressors such as norepinephrine and avoid the risks of using vasopressors in the presence of hypovolemia. Mortality is higher in the elderly and has long-term implications. The high morbidity in patients >80 years of age can lead to a marked change in health status that can lead to patients not returning to their home and needing long-term care. In patients >90 years of age, the message is also clear: 90% die by 30 days. This raises the ethical question of whether surgery is an appropriate intervention in this group or whether this meets the criteria of futile care such that palliation may be the most appropriate pathway. Like all areas of medicine, there will always be exceptions in which patients make miraculous recoveries, but in this age group, even survival may mean a significant reduction in postoperative function. In times in which not treating seems a difficult task, we need to develop a mandate for a consistent approach: perhaps to treat those who may benefit from surgery and then deescalate care to palliation if there is no improvement at 48–72 hours to avoid prolonged inappropriate care and suffering. It is increasingly important in the current health care environment that anesthesiologists contribute to the improvement of patient care and provide added value beyond that of just giving anesthesia. The experience that anesthesiologists have as a specialty of understanding of the pathophysiology and restoration of physiological parameters to try and normalize body homeostasis in very sick patients should not be underestimated. This is the similar pathway that trauma surgeons in the United States took in reevaluating their identity and their role in the expedient and critical care of a patient presenting to the emergency department in need of emergent surgery for both trauma and nontrauma causes, and formally expanded their identity, training, and skills to first include surgical critical care, and later, emergency surgery.18 A similar pathway can be seen for anesthesia. In all 3 of the articles showing improved outcomes a senior anesthesiologist had significant involvement in the delivery of care in the majority of cases. It is often not doing something especially clever that makes a difference to our patients, but not going wrong, and clinical experience is a key factor to deliver optimum care in situations of extreme physiological insult. Anesthesiologists have spearheaded the EGS quality improvement in Europe, given the experience of managing complex patients in critical care, and understand the complex pathophysiology of intra-abdominal catastrophe and sepsis. Nial Quiney and Carol Peden, both experts in quality improvement, have been champions for many years in trying to improve the care of emergency laparotomy patients. Despite the challenges in performing research on emergency patients, the use of quality improvement methodology has led to several significant quality improvement projects to improve the evidence base.19 Therefore, it is clear that in the United States, we must embrace a similar approach to improving the care for EGS patients while understanding the pivotal role of the acute care surgeon in this process, as well as the need for a collaborative multidisciplinary approach. This must start with the definition of which patients to study, which pathway elements we wish to include in the quality improvement bundle (risk scoring, fluid strategy, etc), and how best to measure both mortality and the function of patients who survive. The recent Agency for Healthcare Research and Quality grant for Enhanced Recovery After Surgery awarded to the Armstrong Institute at Johns Hopkins in collaboration with the American College of Surgeons aims to incorporate EGS pathways into the implementation process. This could be an opportunity for the whole of the United States to engage in a common goal to improve care for our EGS patients. It is now the time for anesthesiologists to take joint accountability with their surgical colleagues to finally improve the outcomes of patients with an “ileus in the belly.” DISCLOSURES Name: Michael J. Scott, MBChB, FRCP, FRCA, FFICM. Contribution: This author helped write the manuscript and approve the final version. Conflicts of Interest: M. J. Scott joined the Advisory Board for Merck, Baxter. This author is on the Executive Committee for the Enhanced Recovery after Surgery (ERAS) Society. Name: Michel B. Aboutanos, MD, MPH, FACS. Contribution: This author helped write the manuscript and approve the final version. Conflicts of Interest: None. Name: Lee Fleisher, MD, FACC, FAHA. Contribution: This author helped write the manuscript and approve the final version. Conflicts of Interest: None. This manuscript was handled by: Maxime Cannesson, MD, PhD.