Objective To estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality. Design Systematic review and meta-analysis. Data sources MEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022. Eligibility criteria Studies reporting data on the incidence and outcomes of AMI in adult populations. Data extraction and synthesis Data extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms. Results From 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis. Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4). Conclusions In adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised. PROSPERO registration number CRD42021247148.

/pdf/incidence-and-outcomes-of-acute-mesenteric-ischaemia-a-2dolk1th.pdf

Incidence and outcomes of acute mesenteric ischaemia: a systematic review and meta-analysis

Key Points Question Can days alive and at home at day 90 (DAAH90)—a composite of mortality and the number of days at home at day 90 after intensive care unit (ICU) admission—be used to capture the burden of acute hospitalization and long-term functional outcomes in patients who require at least 7 days of mechanical ventilation? Findings In this cohort study of 463 patients receiving invasive ventilation across 10 medical or surgical ICUs in Canada, lower DAAH90 was associated with multiple markers of higher ICU intensity and with worse functional outcomes and higher mortality up to 1 year following ICU discharge. Meaning The findings of this study suggest that DAAH90 reflects the burden of critical illness and captures the long-term consequences of critical illness for functional status, quality of life, and survival.

/pdf/association-of-days-alive-and-at-home-at-day-90-after-2rz81o52.pdf

Association of Days Alive and at Home at Day 90 After Intensive Care Unit Admission With Long-term Survival and Functional Status Among Mechanically Ventilated Patients

Frailty in emergency general surgery: Low-risk procedures pose similar risk as high-risk procedures for frail patients.

Emergency general surgery (EGS) refers to the treatment of a subset of general surgical disease necessitating emergency evaluation and management (operative or non-operative)1. The majority of these disorders relate to the abdomen and gastrointestinal tract, with a range of severity. Operations for EGS conditions have higher rates of perioperative complications and death than comparable elective procedures, and many of these deaths are thought to be preventable2,3. There are limited population-level data regarding the impact of EGS. Existing studies4–6 suggest a trend towards decreased mortality with time. Many of these studies relied on incomplete population data that were weighted to estimate more comprehensive regional or national information5,6. Additionally, previous evaluations were largely limited to admitted patients. Emergency department (ED) overcrowding is a worsening public health problem, with potential effects on timely access to care and clinical outcomes7. Patients may be diverted to outpatient surgery, develop complications that change their admitting diagnosis, or even die. Therefore, evaluating EGS-related ED presentations and management even without admission is important. The contribution of individual EGS diagnoses to overall trends in ED presentations, admissions, and mortality is also largely unexplored, yet this information will be essential in anticipating the future needs of the EGS workforce and associated distribution of resources. The objective of this study was to determine the population-level trends in ED presentations, hospital admissions, and mortality from EGS conditions over 17 years in Ontario, Canada. 

Population-level trends in emergency general surgery presentations and mortality over time

Applying Evidence-based Principles to Guide Emergency Surgery in Older Adults.

BACKGROUND While the short-term risks of emergency general surgery (EGS) admission among older adults have been studied, little is known about long-term functional outcomes in this population. Our objective was to evaluate the relationship between EGS admission and the probability of an older adult being alive and residing in their own home 5 years later. We also examined the extent to which specific EGS diagnoses, need for surgery, and frailty modified this relationship. METHODS We performed a population-based, retrospective cohort study of community-dwelling older adults (age, ≥65 years) admitted to hospital for one of eight EGS diagnoses (appendicitis, cholecystitis, diverticulitis, strangulated hernia, bowel obstruction, peptic ulcer disease, intestinal ischemia, or perforated viscus) between 2006 and 2018 in Ontario, Canada. Cases were matched to controls from the general population. Time spent alive and at home (measured as time to nursing home admission or death) was compared between cases and controls using Kaplan-Meier analysis and Cox models. RESULTS A total of 90,245 older adults admitted with an EGS diagnosis were matched with controls. In the 5 years following an EGS admission, cases experienced significantly fewer months alive and at home compared with controls (mean time, 43 vs. 50 months; p < 0.001). Except for patients operated on for appendicitis and cholecystitis, all remaining patient subgroups experienced reduced time alive and at home compared with controls (p < 0.001). Cases remained at elevated risk of nursing home admission or death compared with controls for the entirety of the 5-year follow-up (hazard ratio, 1.17-5.11). CONCLUSION Older adults who required hospitalization for an EGS diagnosis were at higher risk for death or admission to a nursing home for at least 5 years following admission compared with controls. However, most patients (57%) remained alive and living in their own home at the end of this 5-year period. LEVEL OF EVIDENCE Epidemiological, level III.

Alive and at home: Five-year outcomes in older adults following emergency general surgery.

BACKGROUND Emergency general surgery (EGS) conditions are increasingly common among nursing home residents. While such patients have a high risk of in-hospital mortality, long-term outcomes in this group are not well described, which may have implications for goals of care discussions. In this study, we evaluate long-term survival among nursing home residents admitted for EGS conditions. METHODS We performed a population-based, retrospective cohort study of nursing home residents (65 years or older) admitted for one of eight EGS diagnoses (appendicitis, cholecystitis, strangulated hernia, bowel obstruction, diverticulitis, peptic ulcer disease, intestinal ischemia, or perforated viscus) from 2006 to 2018 in a large regional health system. The primary outcome was 1-year survival. To ascertain the effect of EGS admission independent of baseline characteristics, patients were matched to nursing home residents without an EGS admission based on demographics and baseline health. Kaplan-Meier analysis was used to evaluate survival across groups. RESULTS A total of 7,942 nursing home residents (mean age, 85 years) were admitted with an EGS diagnosis and matched to controls. One quarter of patients underwent surgery, and 18% died in hospital. At 1 year, 55% of cases were alive, compared with 72% of controls (p < 0.001). Among those undergoing surgery, 61% were alive at 1 year, compared with 72% of controls (p < 0.001). The 1-year survival probability was 57% in patients who did not require mechanical ventilation, 43% in those who required 1 to 2 days of ventilation, and 30% in those who required ≥3 days of ventilation. CONCLUSION Although their risk of in-hospital mortality is high, most nursing home residents admitted for an EGS diagnosis survive at least 1 year. While nursing home residents presenting with an EGS diagnosis should be cited realistic odds for the risk of death, long-term survival is achievable in the majority of these patients. LEVEL OF EVIDENCE Epidemiological, level III.

Long-term survival in high-risk older adults following emergency general surgery admission.

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Alive and at home: Five-year outcomes in older adults following emergency general surgery.

Long-term survival in high-risk older adults following emergency general surgery admission.