Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
Trent Oesophago-Gastric Unit, Nottingham City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK.
BJS Open. 2021 Jan 8;5(1). doi: 10.1093/bjsopen/zraa060.
Past studies have highlighted variation in in-hospital mortality rates among hospitals performing emergency laparotomy for large bowel perforation. The aim of this study was to investigate whether failure to rescue (FTR) contributes to this variability.
Patients aged 18 years or over requiring surgery for large bowel perforation between 2013 and 2016 were extracted from the National Emergency Laparotomy Audit (NELA) database. Information on complications were identified using linked Hospital Episode Statistics data and in-hospital deaths from the Office for National Statistics. The FTR rate was defined as the proportion of patients dying in hospital with a recorded complication, and was examined in hospitals grouped as having low, medium or high overall postoperative mortality.
Overall, 6413 patients were included with 1029 (16.0 per cent) in-hospital deaths. Some 3533 patients (55.1 per cent) had at least one complication: 1023 surgical (16.0 per cent) and 3332 medical (52.0 per cent) complications. There were 22 in-hospital deaths following a surgical complication alone, 685 deaths following a medical complication alone, 150 deaths following both a surgical and medical complication, and 172 deaths with no recorded complication. The risk of in-hospital death was high among patients who suffered either type of complication (857 deaths in 3533 patients; FTR rate 24.3 per cent): 172 deaths followed a surgical complication (FTR-surgical rate 16.8 per cent) and 835 deaths followed a medical complication (FTR-medical rate of 25.1 per cent). After adjustment for patient characteristics and hospital factors, hospitals grouped as having low, medium or high overall postoperative mortality did not have different FTR rates (P = 0.770).
Among patients having emergency laparotomy for large bowel perforation, efforts to reduce the risk of in-hospital death should focus on reducing avoidable complications. There was no evidence of variation in FTR rates across National Health Service hospitals in England.
既往研究强调了行急诊剖腹手术治疗大肠穿孔的医院之间院内死亡率的差异。本研究旨在探讨失败救治（FTR）是否导致了这种变异性。
从国家急诊剖腹手术审计（NELA）数据库中提取 2013 年至 2016 年间因大肠穿孔行手术治疗且年龄≥18 岁的患者。使用链接的医院入院统计数据识别并发症信息，使用国家统计局的院内死亡数据识别院内死亡病例。FTR 率定义为记录并发症且死亡的患者比例，根据总体术后死亡率将医院分为低、中、高死亡率组进行评估。
共纳入 6413 例患者，1029 例（16.0%）院内死亡。3533 例（55.1%）患者至少发生 1 种并发症：1023 例手术（16.0%）和 3332 例非手术（52.0%）并发症。单纯手术并发症后院内死亡 22 例，单纯非手术并发症后死亡 685 例，手术和非手术并发症后均死亡 150 例，无记录并发症的死亡 172 例。发生任何类型并发症的患者院内死亡风险均较高（3533 例患者中共有 857 例死亡；FTR 率 24.3%）：单纯手术并发症后死亡 172 例（FTR-手术率 16.8%），单纯非手术并发症后死亡 835 例（FTR-非手术率 25.1%）。调整患者特征和医院因素后，总体术后死亡率分组为低、中、高的医院 FTR 率无差异（P=0.770）。
在因大肠穿孔行急诊剖腹手术的患者中，降低院内死亡风险的重点应放在减少可避免的并发症上。英格兰国民保健署医院间 FTR 率无差异。
