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Study of the Incidence of Post Operative Mortality after Emergency Laparotomy in a Tertiary Care Centre in Vindhya Region of Madhya Pradesh

Background: Emergency laparotomy is a common intra-abdominal procedure. Outcomes are generally recognized to be poor. Emergency laparotomy is associated with significant morbidity and mortality. Multiple factors are associated with post operative morbidity and mortality following emergency laparotomy. Early identification and aggressive treatment goes a long way to tide over the progress to a life threatening state Materials and Methods: 271 patients who got admitted through SOPD, casualty or transferred from other departments and underwent emergency laparotomy during the period of study were included in the study irrespective of the age and sex. Post operatively patients were regularly monitored and treated accordingly. Post operative morbidity and mortality was recorded and incidence was calculated. Results: The mean age of the patients in our study was 36.1 and standard deviation of 15. Out of 271 patients, 219 were males 52 were females. Most common etiology of peritonitis was Peptic perforation (35.4%) followed by ileal perforation (23.6%). Incidence of mortality was 13.20% in post operative period. Conclusions: Post operative morbidity and mortality continues to be significant following emergency laparotomies. This study confirms that emergency laparotomy in India carries a high mortality. The variation in clinical management and outcomes indicates the need for a national quality improvement programme.


Introduction
The term 'emergency laparotomy' describes an exploratory procedure for which the clinical presentation, underlying pathology, anatomical site of surgery, and perioperative management vary considerably. The total number of surgical procedures that can be coded within this emergency laparotomy population exceeds 400, www.jmscr.igmpublication.org Impact Factor 5.84 Index Copernicus Value: 71.58 ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: https://dx.doi.org/10.18535/jmscr/v6i1.42 reflecting the diverse nature of this surgical cohort. 1 . The variation in surgical pathology, coupled with the limited time period in which to optimize co-morbidities, is likely to contribute significantly to postoperative morbidity and mortality. Although patients requiring emergency laparotomy are frequently elderly, with significant co-morbidity and additional high-risk insults such as sepsis 2 , evidence suggests that intervention can improve outcomes. Khuri and colleagues found that most of the strongest predictors of mortality following major surgery were postoperative complications 3 , and that the occurrence of any complication was a more important predictor than any pre-or intra-operative factor. Effectiveness of rescue in the event of complications is also known to be an important factor in survival 4 . Despite such evidence, the literature quantifying complications following emergency laparotomy is sparse and heterogeneous. To make advances in care, there is a Need first for a robust understanding of the nature, type and incidence of postoperative complications in this high-risk patient group.

Methods
The present study was carried out in 271 patients in the Department of Surgery, Shyam Shah Medical College and associated G.M. and S.G.M. Hospitals, Rewa (M.P.) during the period of 1 st August 2015 to 31 st July 2016. Patients were admitted in surgical wards through OPD, casualty or admitted in other wards and then transferred to surgery. Patients were interrogated in detail regarding their particulars, presenting complaints, past history, treatment received, any previous surgery done etc. Patients were resuscitated by IV fluid, antibiotic and supportive treatments. Diagnostic investigations like X-ray abdomen, USG abdomen were done; other essential investigations like hemoglobin, TLC, DLC, blood sugar, LFT, blood urea, sr. creatinine etc were done.
Patients were given antibiotic and supportive treatment. Patients who were fit for surgery, exploratory laparotomy was done. Patients were regularly monitored and Post complications were recorded based on investigative and clinical findings. Patients were treated accordingly. Mortality was recorded and incidence was calculated.

Results
The mean age of the patients in our study was 36.1 and standard deviation of 15. Out of 271 patients, 219 were males 52 were females. Most common etiology of peritonitis was Peptic perforation (35.4%) followed by ileal perforation (23.6%).Overall incidence of post operative complications was 41.6% and mortality was 13.20% in postoperative period. (         Overall mortality observed in our study was 13.2% which is comparable to 14.9% observed by the UK Emergency Laparotomy Network (ELN). For the elderly (≥70 years), 30-day mortality was 33.3% (24.4% in the ELN), confirming the findings of previous studies that these patients 'peri-operative mortality risk is amongst the highest of any surgical group [5,6,7] Clarke A et al 8 (2011) reported that Mortality after emergency laparotomy was high, and very high in patients more than 80 years of age.  9 reported that there appeared to be a direct relationship between increasing age of the patient and 30 day mortality; from a mortality of just under 10% for a patient in their 50s, mortality increased by ∼4% for each additional 10 yr of age. For patients aged 80 and over, the mortality was 24.4%. Vivekanand K.H, Mohankumar K 10 (2015) reported as the patients age increases mortality increases. In our study highest incidence (27.2%) was in 8 th decade, followed by 7 th decade (20%); and lowest incidence in 6th decade (6.89%). Vivekanand K.H, Mohankumar K 10 (2015) reported that females has higher rate of mortality (35%) as compared to males (15%). In our study, 27 out of 219 males succumbed (12.32%). While, 9 out 52 females died post operatively (17.3%). Study by various authors on post operative mortality (11,12,13)

Conclusion
The successful outcome of a laparotomy depends of patients factors, pre operative biochemical parameters, delay between onset of symptom and surgery, diagnosis, duration of surgery, technique etc. Some factors are potentially modifiable; prompt intervention and correction of those factors can significantly reduce complications following laparotomy.