Challenges of Malignant Small Bowel Obstruction – Results of a State Surgical Mortality Dataset.

Background: Small bowel obstruction is a common acute surgical pathology. Despite the substantial postoperative mortality associated with small bowel obstruction (SBO), there is limited evidence to support clinical decision-making. The purpose of this study was to identify differences in system, patient and operative features in adults who died following operative treatment of malignant versus nonmalignant small bowel obstruction. Methods: Retrospective analysis of adults with SBO who died in hospital while under the care of a surgeon. Data was collected by the Australian and New Zealand Audit of Surgical Mortality from Queensland hospitals between January 2009 and December 2014. Results: 523 patients died post-operatively following surgical treatment of small bowel obstruction over the six-year study period. The most common etiologies were adhesive (41%), malignancy (25%) and hernia (16%). Compared to those with a nonmalignant etiology, patients with malignant SBO were younger (P < 0.001) but had a longer mean pre-operative inpatient admission (P = 0.007), and were more likely to require an anastomosis at the time of operation (P < 0.001). Conclusion: Despite being younger, patients with malignant small bowel obstruction are challenging to manage. Further studies are needed to help surgeons manage patients with malignant small bowel obstruction.

Perioperative Care Related Events are Different Following Elective and Emergency Right Hemicolectomy.

Introduction: Right hemicolectomy is frequently performed for malignancy but emergency surgery is associated with double the mortality rate of elective colonic resection. The study was designed to compare perioperative clinical incidents patients who died following elective and emergency right hemicolectomy. Methods: Adult patients who died under the care of a surgeon following elective and emergency right hemicolectomy in Queensland, Australia were identified from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database. Demographic data, free text entries and surgeon reviewer conclusions were analysed. Results: The two groups had different indications for surgery but were of similar age and gender. Surgeon reviewers (first and second line) identified similar rates of untoward perioperative events in both groups however post operative events tended towards being more frequent after elective surgery while pre operative events were more frequent in the emergency group. Almost half of the incidents occurred post operatively and often related to delayed diagnosis and management of anastomotic leak. Conclusion: This analysis suggests more thorough pre operative medical work up may be required prior to right hemicolectomy and that greater attention should be focused on recognizing intra-abdominal sepsis - predominantly following emergency surgery.

Increasing Number of Comorbidities is Related to Delay to Surgical Management of a Perforated Peptic Ulcer in Patients who Died.

Introduction: The incidence of peptic ulcer disease has declined since the introduction of medical therapy, but the rate of perforated peptic ulcer and associated mortality has remained relatively constant. Delay to definitive treatment is known to adversely affect survival. Methods: The Australian and New Zealand Audit of Surgical Mortality (ANZASM) retrospectively collects data on patients who died following surgery. To determine which patient characteristics are associated with delayed (not on the day of admission) surgical treatment of a perforated peptic ulcer, all patients who died in Queensland were identified from the ANZASM database. Results: There were 39 deaths between 2007 and 2013 with a median age was 76 years. The median number of comorbidities was three and American Society of Anaesthesiologists (ASA) class was 4. Twenty nine patients had operative intervention on the day of admission and 10 underwent surgery later. Those with delayed surgery had a greater number of comorbidities (4 vs. 3; p = 0.016) but did not differ with respect to other demographics compared to those who underwent repair on the day of admission. The reviewing surgeon found no management issues in two thirds of patients. Conclusion: Queensland patients with an increasing number of comorbidities were more likely to have delayed surgical intervention for a perforated peptic ulcer. Surgical delay is a known determinant of survival in patients with a perforated peptic ulcer and surgeons must be especially vigilant in multiply comorbid patients in making the diagnosis and expediting repair.