Perioperative treatment of patients undergoing acute high-risk abdominal surgery .

: Critically ill acute high-risk abdominal surgery patients represent a major challenge to health care providers, with the typical patient being elderly and frail, and with severe and multiple comorbidities. The mortality rate in this population is high, and the postoperative course is characterized by complications, prolonged hospitalisation and considerable risk of permanent disability. With an ageing population, the number of elderly patients, as well as challenges concerning treatment will arise, calling for a coordinated effort both nationally and internationally to enhance treatment in this vulnerable patient group. By the time of admission, the acute high-risk abdominal surgery patients are often physiologically deranged. The burden of multiple organ system dysfunction caused by an acute abdominal catastrophe, is associated with great risk. Timely stabilisation, diagnosis, pain management and surgical treatment are essential for a good out-come. Except from a few initiatives in subpopulations, there has, up until now, been an absence of organised multidisciplinary collaboration in approaching the critically ill emergency surgery patient. We have not been able, neither nationally or internationally, to introduce a standardised approach to the perioperative treatment based on the existing evidence. By analysing data from 4 hospitals in Denmark, we were able to illustrate a protracted critical period following acute high-risk abdominal surgery, where the frequency of postoperative complications is high, and associated with an increased risk of dying. The mortality in the cohort was 34% one year after surgery. A standardised, multimodal and multidisciplinary perioperative treatment protocol was implemented at Copenhagen University Hospital, Hvidovre. This resulted in a significant and persistent reduction in mortality during a follow-up period of 6 months. Despite the standardised course, we recognised the difficulty in mobilising patients during the first postoperative week due to fatigue and pain. Traditionally, the
 success in treatment is measured by death- and complication rates, and length of hospital stay, but the literature is sparse when reporting patient outcome measures. We found a surprisingly good quality of life in a small group of elderly patients who had survived acute high risk abdominal surgery. In the future, it is essential to use patients' knowledge and experience to develop quality improvement initiatives in treatment, as well as to improve the dialogue between the patient, doctor, and closest relatives, helping them in forming realistic expectations of the postoperative outcomes. Unfortunately, as of now, we have no systematic collection of patient reported outcome measures in this critically ill and rather vulnerable population. This is a challenging group of patients with a need for extensive treatment, and specialized care, and rehabilitation. Future research should be conducted in dedicated specialized wards, where the staff is educated and motivated to see the complicated task through. The initiative from the research group behind this thesis should be considered as a clinically relevant, pragmatic introduction to a hopefully larger and necessary effort to improve the quality of care and the outcome following acute high-risk abdominal surgery.