The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece

2022-09-16

Our latest research was just published in the World Journal of Surgery (International Society of Surgery), 15 September 2022.

HELAS: A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece

Lasithiotakis K, Kritsotakis EI, Kokkinakis S, Petra G, Paterakis K, Karali GA, Malikides V, Anastasiadis CS, Zoras O, Drakos N, Kehagias I, Kehagias D, Gouvas N, Kokkinos G, Pozotou I, Papatheodorou P, Frantzeskou K, Schizas D, Syllaios A, Palios IM, Nastos K, Perdikaris M, Michalopoulos NV, Margaris I, Lolis E, Dimopoulou G, Panagiotou D, Nikolaou V, Glantzounis GK, Pappas-Gogos G, Tepelenis K, Zacharioudakis G, Tsaramanidis S, Patsarikas I, Stylianidis G, Giannos G, Karanikas M, Kofina K, Markou M, Chrysos E.

Independent risk factors of 30-day post-operative mortality. The forest plot depicts adjusted odds ratios (aOR) as diamonds and 95% confidence intervals (CI) as horizontal lines on a logarithmic scale. The reference category for the American Society of Anaesthesiologists (ASA) class is the I-II class. The reference category for the sepsis grades is absence of sepsis. Reported effects were estimated by multivariable mixed-effects logistic regression with hospital entered as random intercept. The final set of risk factors was selected following purposeful variable selection from 19 candidate preoperative factors.

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Abstract

Background: Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA).

Methods: This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality.

Results: There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%).

Conclusion: In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.

Keywords: Emergency laparotomy, postoperative mortality, postoperative morbidity, emergency surgery.

Smoothed locally weighted regression lines (lowess) of the associations of age and body mass index with 30-day postoperative mortality on the log-odds scale (left) and on the probability scale (right). Entering an untransformed continuous variable into a logistic regression model assumes linearity on the log-odds scale. The graphs show that a linear relationship with the log odds of 30-day mortality is a good approximation for age, but for body mass index a U-shaped relationship is evident. Therefore, age was modelled on its original continuous scale, but body mass index was modelled using restricted cubic splines (RCS) with four knots chosen at the 5th, 35th, 65th and 95th percentiles.