RESUMEN
INTRODUCTION: Increasing numbers of older patients are undergoing emergency laparotomy (EL). They are at increased risk of adverse outcomes, making the shared decision on whether to operate challenging. This retrospective cohort study aimed to assess the role of age and life-expectancy predictions on short- and long-term survival in patients undergoing EL. METHODS: All patients who underwent EL at one hospital in the West of Scotland between March 2014 to December 2016 were included. Clinical parameters were collected, and patients were followed up to allow reporting of 30-, 60- and 90-day and 1-year mortality rates. Period life expectancy was used to stratify patients into below life expectancy (bLEP) and at-or-above life expectancy (aLEP) groups at presentation. Remaining life expectancy was used to calculate the net years of life gained (NYLG). RESULTS: Some 462 patients underwent EL: 20 per cent in the aLEP group. These patients were older (P < 0.001), had more co-morbidities (P < 0.001) and were high risk on P-POSSUM scoring (P = 0.008). The 30-, 60- and 90-day and 1-year mortality rates were 11, 14, 16 and 23 per cent respectively. Advanced age (P = 0.011) and high ASA score (P = 0.004) and P-POSSUM score (P < 0.001) were independent predictors of death at 1 year on multivariable analysis. The cohort NYLG were 19.2 years. Comparing patients aged less than 70 with those aged 70 years or older, the NYLG were 25.9 versus 5.5 years. Comparing bLEP and aLEP, the NYLG were 22.2 versus 4.4 years. In patients aged 70 years and older, NYLG decreased by more than half in patients with co-morbidities (ASA score 3,4,5) (9.3 versus 4.3 years). CONCLUSION: Discussions around long-term outcomes after emergency surgery remain difficult. Although age is an influencing factor, predicted life expectancy alone does not provide additional value to shared decision making.
Asunto(s)
Laparotomía , Esperanza de Vida , Anciano , Anciano de 80 o más Años , Toma de Decisiones , Humanos , Estudios Retrospectivos , Medición de RiesgoRESUMEN
Patients eligible for emergency laparotomy who do not proceed to surgery are not as well characterised as patients who do proceed to surgery. We studied patients eligible for laparotomy, as defined by National Emergency Laparotomy Audit criteria, from August 2015 to October 2016. We analysed the association of individual variables with survival and two composite scores: P-POSSUM and a general survival model. Out of 314 patients, 214 (68%) underwent laparotomy and 100 (32%) did not. Median (IQR [range]) follow-up was 1.3 (0.1-1.8 [0.0-2.5]) years for the cohort, 1.5 (1.1-2.0 [0.0-2.6]) years after laparotomy and 0.0 (0.0-1.1 [0.0-2.2]) years without laparotomy. There were 126/314 (40%) deaths in the follow-up period, 52/214 (24%) deaths after laparotomy and 74/100 (74%) deaths without surgery. Ninety out of 126 deaths (71%) were within one month of hospital admission. Patient variables were different for the two groups, which when combined in the general survival model generated background median (IQR [range]) life expectancies of 12 (6-21 [0-49]) and 4 (2-6 [0-36]) years, respectively, p < 0.0001. 'Poor fitness' precluded laparotomy in 74/100 (74%) patients. The decision to not operate involved a consultant less often than the decision to operate: 66/100 (66%) vs. 178/214 (83%), p = 0.001. Our study supports the contention that survival beyond 30 postoperative days could be predicted reasonably accurately. Survival in patients who did not have laparotomy was shorter than expected. Emergency laparotomy might have prolonged survival in some patients.
Asunto(s)
Laparotomía/estadística & datos numéricos , Negativa del Paciente al Tratamiento/estadística & datos numéricos , Anciano , Estudios de Cohortes , Urgencias Médicas , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Análisis de Supervivencia , Reino UnidoRESUMEN
INTRODUCTION: Acute renal transplant emboli can be disastrous and result in loss of the renal transplant. This case was successfully treated with thrombolysis. CASE PRESENTATION: A 66-year-old female underwent a right-sided deceased heart-beating donor renal transplant. She had excellent transplant function but presented acutely three years later with pain in the transplanted kidney, an acute rise in serum creatinine and new onset atrial fibrillation. Bedside ultrasound scan demonstrated absent transplant perfusion. Emergency angiogram confirmed acute emboli in the transplant renal artery with some kidney perfusion. Thrombolysis with alteplase and anticoagulation with heparin was commenced. Serial imaging at 24 and 36 h demonstrated significant improvement in transplant perfusion. Following a period of supportive therapy, her transplant function recovered, although not to pre-morbid baseline levels. CONCLUSION: Consider acute embolus in a renal transplant patient with acute kidney injury, transplant tenderness and cardiac arrhythmia. Early thrombolysis may salvage renal transplants and good transplant function may be regained.
Asunto(s)
Cateterismo Periférico/métodos , Embolia/diagnóstico por imagen , Embolia/cirugía , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/cirugía , Terapia Trombolítica/métodos , Anciano , Anticoagulantes/administración & dosificación , Femenino , Fibrinolíticos/administración & dosificación , Heparina/administración & dosificación , Humanos , Trasplante de Riñón , Activador de Tejido Plasminógeno/administración & dosificaciónRESUMEN
AIM: In addition to TNM stage there are adverse tumour and host factors, such as venous invasion and the presence of an elevated systemic inflammatory response (SIR), that influence the outcome in colorectal cancer. The present study aimed to examine how these factors varied in screen-detected (SD) and nonscreen-detected (NSD) tumours. METHOD: Prospectively maintained databases of the prevalence round of a biennial population faecal occult blood test screening programme and a regional cancer audit database were analysed. Interval cancers (INT) were defined as cancers identified within 2 years of a negative screening test. RESULTS: Of the 395 097 people invited, 204 535 (52%) responded, 6159 (3%) tested positive and 421 (9%) had cancer detected. A further 708 NSD patients were identified [468 (65%) nonresponders, 182 (25%) INT cancers and 58 (10%) who did not attend or did not have cancer diagnosed at colonoscopy]. Comparing SD and NSD patients, SD patients were more likely to be male, and have a tumour with a lower TNM stage (both P < 0.05). On stage-by-stage analysis, SD patients had less evidence of an elevated SIR (P < 0.05). Both the presence of venous invasion (P = 0.761) and an elevated SIR (P = 0.059) were similar in those with INT cancers and in those that arose in nonresponders. CONCLUSION: Independent of TNM stage, SD tumours have more favourable host prognostic factors than NSD tumours. There is no evidence that INT cancers are biologically more aggressive than those that develop in the rest of the population and are hence likely to be due to limitations of screening in its current format.