Causes of death after emergency general surgical admission: population cohort study of mortality.

BACKGROUND: A substantial number of patients treated in emergency general surgery (EGS) services die within a year of discharge. The aim of this study was to analyse causes of death and their relationship to discharge diagnoses, in patients who died within 1 year of discharge from an EGS service in Scotland. METHODS: This was a population cohort study of all patients with an EGS admission in Scotland, UK, in the year before death. Patients admitted to EGS services between January 2008 and December 2017 were included. Data regarding patient admissions were obtained from the Information Services Division in Scotland, and cross-referenced to death certificate data, obtained from the National Records of Scotland. RESULTS: Of 507 308 patients admitted to EGS services, 7917 died while in hospital, and 52 094 within 1 year of discharge. For the latter, the median survival time was 67 (i.q.r. 21-168) days after EGS discharge. Malignancy accounted for 48 per cent of deaths and was the predominant cause of death in patients aged over 35 years. The cause of death was directly related to the discharge diagnosis in 56.5 per cent of patients. Symptom-based discharge diagnoses were often associated with a malignancy not diagnosed on admission. CONCLUSION: When analysed by subsequent cause of death, EGS is a cancer-based specialty. Adequate follow-up and close links with oncology and palliative care services merit development.

Safety and efficacy of duodenal stent insertion for gastric outlet obstruction: characterisation of a regional district general hospital service.

INTRODUCTION: Placement of a duodenal or pyloric stent is a recognised palliative procedure for symptomatic relief of malignant gastric outlet obstruction. This procedure can be associated with significant complications, reinterventions and poor long-term relief of obstructive symptoms. However, there may be a faster return to diet and shorter hospital stay in comparison to other palliative procedures (eg gastrojejunostomy). The aim of this study was to determine the safety and efficacy of duodenal stenting in our regional district general hospital in comparison to that of larger tertiary centres. MATERIALS AND METHODS: All patients with gastric outlet obstruction who had duodenal stent placement attempted in our region between 1 August 2013 and 31 July 2018 were identified by retrospective analysis of prospectively maintained coding databases and medical notes. Patient demographics, safety outcomes and efficacy outcomes were then extracted. Results were interpreted with respect to data from best available published evidence from larger tertiary centres. RESULTS: Of 43 duodenal stent insertion attempts, 84% had a successful return to diet, 18% underwent reintervention, 18% suffered adverse events, mean length of stay post-intervention was 8.6 days and mean survival post-intervention was 132 days. CONCLUSIONS: Patients with malignant gastric outlet obstruction in whom duodenal stent placement was attempted had similar outcomes to published data from larger tertiary centres. Duodenal stent placement remains an acceptable treatment option for these patients in our region.

Twenty-year study of in-hospital and postdischarge mortality following emergency general surgical admission.

Background: Emergency general surgery (EGS) patients have a higher mortality than those having elective surgery. Few studies have investigated changes in EGS-associated mortality over time or explored mortality rates after discharge. The aim of this study was to conduct a comprehensive, population-based analysis of mortality in EGS patients over a 20-year time frame. Methods: This was a cross-sectional study of all adult EGS admissions in Scotland between 1996 and 2015. Data were obtained from national records. Co-morbidities were defined by Charlson Co-morbidity Index, and operations were coded by OPCS-4 classifications. Linear and multivariable logistic regression models were used to evaluate changes over time. Results: Among 1 450 296 patients, the overall inpatient, 30-day, 90-day and 1-year mortality rates were 1·8, 3·8, 6·4 and 12·5 per cent respectively. Mortality was influenced by age at admission, co-morbidity, operation performed and date of admission (all P < 0·001), and improved with time on subgroup analysis by age, co-morbidity and operation status. Medium-term mortality was high: the 1-year mortality rate in patients aged over 75 years was 35·6 per cent. The 1-year mortality rate in highly co-morbid patients decreased from 75·1 to 57·1 per cent over the time frame of the study (P < 0·001). Conclusion: Mortality after EGS in Scotland has reduced significantly over the past 20 years. This analysis of medium-term mortality after EGS admission demonstrates strikingly high rates, and postdischarge death rates are higher than is currently appreciated.

Antecedentes: Los pacientes sometidos a cirugía general urgente (emergency general surgery, EGS) presentan una mortalidad más elevada que los pacientes sometidos a cirugía electiva. Pocos estudios han investigado los cambios en la mortalidad asociada a la EGS a lo largo del tiempo o han analizado las tasas de mortalidad tras el alta hospitalaria. El objetivo de este estudio fue llevar a cabo un análisis exhaustivo de base poblacional de la mortalidad en pacientes en EGS durante un horizonte temporal de 20 años. Métodos: Se trata de un estudio transversal de todos los ingresos de adultos por EGS en Escocia entre 1996 y 2015. Los datos se obtuvieron de los registros nacionales. Las comorbilidades se definieron según el índice de comorbilidad de Charlson y las operaciones se codificaron con las clasificaciones OPCS4. Se utilizaron modelos de regresión logística lineal y multivariante para evaluar cambios a los largo del tiempo. Resultados: En un total de 1.450.296 pacientes, las tasas globales de mortalidad hospitalaria, a los 30 días, 90 días y un año fueron de 1,8%, 3,8%, 6,4% y 12,5%, respectivamente. La mortalidad estaba influida por la edad en el momento del ingreso, comorbilidad, la intervención quirúrgica realizada y la fecha de ingreso (todas las variables P < 0,001) y mejoró con el tiempo en el análisis por subgrupos de edad, comorbilidad e intervenciones quirúrgicas. La mortalidad a medio plazo fue elevada: la tasa de mortalidad a un año en pacientes mayores de 75 años fue de 35,6%. La mortalidad a un año en pacientes con elevada morbilidad disminuyó de un 75% a un 57% a lo largo del periodo del estudio (P < 0,001). Conclusión: La mortalidad tras EGS en Escocia ha disminuido significativamente a lo largo de los últimos 20 años. No obstante, el análisis de la mortalidad a medio plazo después de un ingreso por EGS demuestra unas tasas sorprendentemente elevadas y, por ello, actualmente hay que tener en cuenta la mortalidad tras el alta de forma especial.

Magnetic resonance imaging investigation of radio-lunate relations: use in assessing distal radial fracture reduction.

Reformatted magnetic resonance imaging scans of 27 normal wrists were examined in incremental degrees of rotation around the central axis of the radial shaft to 30° in both directions from true lateral. A line was superimposed on the outer border of the radial dorsal cortex and continued distally to the carpal region. Measurements were made from the superior pole of the lunate to this line. This distance did not change significantly with rotation. This allows a quick and accurate way of assessing distal radial fracture reduction from poorly taken lateral radiographs. In addition, the relevant landmarks are not obscured by implants or casts. LEVEL OF EVIDENCE: III, diagnostic study.