Discussion
One of the objectives of this study was to examine the mortality rate for patients undergoing emergency laparotomy at St Olav's Hospital, Trondheim. In our patient material, the observed 30-day mortality rate was 8.2 %. In comparison, a systematic review of 33 studies of emergency laparotomy and laparoscopy found that 30-day mortality ranged from 0 % to 24%; Danish hospitals were among those with the highest mortality rates, with an average of 13.9 % (10).
Comparing studies on emergency laparotomy is challenging because both the surgeries and the patients themselves are highly heterogeneous. Differences in study inclusion criteria make it difficult to compare results between hospitals or countries, or over time. In our study, we therefore used the inclusion criteria from the National Emergency Laparotomy Audit, in which 30-day mortality was reported to be 9.3 % (8, 11).
The average postoperative stay at St Olav's Hospital, Trondheim, was 14.5 days, while the corresponding figure in the 2019 Sixth Patient Report of the National Emergency Laparotomy Audit, which included 24 823 patients, was 15.4 days. The shorter length of stay in our dataset was observed despite the fact that St Olav's Hospital had a higher proportion of patients with intra-abdominal cancer (27 % vs. 19 %), more patients over 65 years of age (60 % vs. 56 %), and more patients in higher ASA classes (26 % vs. 18 % with ASA class 4 or 5) (8).
In a Danish study with almost identical inclusion criteria, patients also tended to be in lower ASA classes than the patients at St. Olav's Hospital (1). One possible explanation may be differences in the way anaesthesiologists at St Olav's Hospital assign patients to ASA classes compared to their counterparts at hospitals in England, Wales and Denmark. It may also be that patients at St Olav's Hospital have a higher disease burden than patients at hospitals in England and Wales, as indicated by the higher proportion of patients with malignant disease in the current study (8). Although caution is required in drawing conclusions based on a retrospective review, our results suggest somewhat greater survival and shorter length of hospital stay for patients at St Olav's Hospital compared with international data.
This study has also identified areas that could be targeted by the Surgical Clinic at St Olav's Hospital to further reduce postoperative mortality after acute laparotomy. Early surgery is important to increase survival rates (14, 15). Among patients who were scheduled to undergo emergency surgery within 6 hours, 85.7 % were operated on within this timeframe, thereby meeting the National Emergency Laparotomy Audit's recommended minimum standard of 85 % (8). The Surgical Clinic aims for at least 90 % of patients scheduled for surgery within 6 or 24 hours to undergo surgery within the specified timeframe. Patients undergoing emergency laparotomies are often vulnerable elderly patients with multimorbidity, a group with high mortality risk. It is therefore necessary to identify, prior to surgery, those patients with the highest risk of death. Decisions can then be made collectively regarding the most suitable treatment level and surgical strategy, and on securing early access to surgery. Sufficient access to emergency operating theatres and personnel has been identified as one of the most important factors for good emergency surgery provision (16).
Hospitals that participated in the National Emergency Laparotomy Audit reduced their 30-day mortality from 11.8 % in 2013 to 9.3 % in 2019. The greatest reduction in mortality was in patients over the age of 65. This was due to improved identification of high-risk patients through measures such as the use of risk calculators for acute laparotomy (8). Requirements have also been introduced for senior consultants in anaesthesiology and surgery to be involved in pre- and perioperative care for high-risk patients. Compliance is assessed by measuring the percentage of such patients that are managed by senior consultants. Access to planned postoperative intensive care has also been improved for high-risk patients.
Finally, geriatricians are now involved to a greater degree in assessing vulnerability in the oldest patients (8). This may have led to greater use of conservative and palliative approaches rather than attempts at curative surgery. These factors are likely to be relevant not only to St Olav's Hospital but also to other Norwegian hospitals that perform emergency surgery. An essential prerequisite for implementing measures such as these is that data on the management and outcomes of this patient population are reviewed, discussed, and form the basis for any changes.
A strength of this study is that, with few exceptions, it features complete data on a well-defined group of patients, which reduces the possibility of selection bias. A weakness of the retrospective study design is that it is based on information in medical records. This made classification of multimorbidity in particular challenging, as information on this topic in the medical records was often incomplete.