Department of Ageing and Complex Medicine, Salford Royal Hospital, Salford, UK.
Clinical Fellow, Glasgow Royal Infirmary, Glasgow, UK; University of Glasgow, Glasgow, UK.
Br J Anaesth. 2024 Nov;133(5):973-982. doi: 10.1016/j.bja.2024.07.009. Epub 2024 Oct 4.
Older adults (≥65 yr) account for the majority of emergency laparotomies in the UK and are well characterised with reported outcomes. In contrast, there is limited knowledge on those patients that require emergency laparotomy but do not undergo surgery (NoLaps).
A multicentre cohort study (n=64 UK surgical centres) recruited 750 consecutive NoLap patients (February 15th - November 15th 2021, inclusive of a 90-day follow up period). Each patient was admitted to hospital with a surgical condition treatable by an emergency laparotomy (defined by The National Emergency Laparotomy Audit (NELA) criteria), but a decision was made not to undergo surgery (NoLap).
NoLap patients were predominately female (452 patients, 60%), of advanced age (median age 83.0 yr, interquartile range 77.0-88.8), frail (523 patients, 70%), and had severe comorbidity (750 patients, 100%); 99% underwent CT scanning. The commonest diagnoses were perforation (26%), small bowel obstruction (17%), and ischaemic bowel (13%). The 90-day mortality was 79% and influencing factors were >80 yr, underweight BMI, elevated serum lactate or creatinine concentration. The majority of patients died in hospital (77%), with those with ischaemic bowel dying early. For the 21% of NoLap patients that survived to 90 days, 77% returned home with increased care requirements.
This study reports that the NoLap patient population present significant medical challenges because of their extreme levels of comorbidity, frailty, and physiology. Despite these complexities a fifth remained alive at 90 days. Further work is underway to explore this high-risk decision-making process.
ISRCTN14556210.
在英国，≥65 岁的老年人占急诊剖腹手术的大多数，并且其预后已有报道。相比之下，对于那些需要紧急剖腹手术但未接受手术的患者（NoLaps），人们知之甚少。
一项多中心队列研究（纳入了 64 家英国外科中心）纳入了 750 例连续的 NoLap 患者（2021 年 2 月 15 日-11 月 15 日，包括 90 天的随访期）。每位患者因可通过急诊剖腹手术治疗的外科疾病入院（定义为国家急诊剖腹手术审核（NELA）标准），但决定不接受手术（NoLap）。
NoLap 患者主要为女性（452 例，60%），年龄较大（中位数年龄 83.0 岁，四分位距 77.0-88.8），身体虚弱（523 例，70%），合并严重疾病（750 例，100%）；99%接受了 CT 扫描。最常见的诊断为穿孔（26%）、小肠梗阻（17%）和肠缺血（13%）。90 天死亡率为 79%，影响因素为年龄>80 岁、低体重指数、血清乳酸或肌酐浓度升高。大多数患者（77%）在医院死亡，伴有肠缺血的患者早期死亡。在存活至 90 天的 NoLap 患者中（21%），77%返回家庭，需要增加护理需求。
本研究报告称，NoLap 患者人群由于其极高水平的合并症、虚弱和生理状况，带来了重大的医疗挑战。尽管存在这些复杂性，仍有五分之一的患者在 90 天内存活。进一步的工作正在进行中，以探讨这一高风险的决策过程。
ISRCTN81633244。
