Spurling, Leigh-James Edward; (2025) Perioperative care and outcome measurement in emergency laparotomy surgery. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Emergency laparotomy surgery is one of the most common reasons for urgent and out of hours general surgical intervention in hospital. Patients present with severe physiological and biochemical derangement and significant underlying pathology and comorbidities. As such, they are at high risk of deterioration and mortality, presenting a challenge to clinicians responsible for their care. The high risk nature is evidenced by historically high mortality rates, reported as averaging 14% several years ago, with rates quoted up to 40%. It was in this context that the National Emergency Laparotomy Audit was commissioned, with the mandate to improve patient care through influencing hospital systems, guided by the best available evidence and quality improvement methodology. This thesis examines postoperative critical care and the barriers to this. It answers a series of research questions seeking to identify barriers to admission, how these can be mitigated and what form alternative care models might take for such a population. Consideration of postoperative care naturally aims to improve patient outcomes. The next major theme of this thesis identifies patient important outcome measures, other than mortality, for use in emergency laparotomy. Finally, risk adjustment of this outcome is undertaken to enhance utility. This thesis identified the influence of national policy on clinical practice. Here, on postoperative critical care admission. There appears to be no difference in critical care admission rates in hospitals with higher emergency laparotomy caseloads. This suggests that centralisation of services for these frequently encountered patients would carry no advantage for this measure. Barriers to admission appear to be associated with seasonal variability. We have demonstrated that a potential opportunity exists for some patients to be cared for in an alternative enhanced care setting. This work identified a population that might be suitable for such an environment. They had only a short duration of low level organ support and lower than predicted mean mortality risk. The core outcome measure of mortality fails to address overall patient recovery. We have validated the Days Alive and Out of Hospital (DAOH30) outcome measure at 30-days in an emergency laparotomy cohort. It carries concept and predictive validity in this population. It is straightforward to measure at scale using data linkage. This thesis also provides a well performing model for risk adjustment of DAOH30, with AUC=0.81 (95% CI 0.81, 0.81). We also demonstrate possible methods for further model refinements utilising longitudinal data. The findings presented in this thesis have the potential to influence clinical practice, lending evidence towards appropriate use of enhanced care units as a bridge between ward and critical care unit. It adds to quality improvement programmes and understanding of trajectories of recovery from emergency laparotomy, through application of the DAOH30 outcome measure. There is scope for incorporating parts of this work at national policy level, driven by the National Emergency Laparotomy Audit team.

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