1. Do we need an NHS network for emergency laparotomy in the elderly? Dave Murray James Cook University Hospital Middlesbrough Dave.murray@stees.nhs.uk

2. 10 years ago….. Over 90 years old –30 day mortality –93% non-elective surgery Hemiarthroplasty 24% Hip Screw 23% Laparotomy 13% Amputation 4%

3. Jin, BJA 2001,87,608-14

4. Jin, BJA 2001,87,608-14 NCEPOD

5. Prevalence of comorbidity NICE

6. NCEPODNICE Prevalence of comorbidity

7. 10 years on, have we got any better? Fluid management The seniority of clinicians Delays in surgery Anaesthetic management Acute Pain Management Post Operative Cognitive Dysfunction Use of Critical Care Nutrition Comorbidites Medications Thromboembolism prophylaxis Consent Peri-operative Hypothermia Elective and Emergency Surgery in the Elderly

8. 10 years on, have we got any better? NCEPODJCUH Surgeon57%78% Anaesthetist50%54% Antibiotics52%83% Temperature73% Imaging95% HDU /ICU10%67%

9. 10 years on, have we got any better? NCEPODJCUH Surgeon57%78% Anaesthetist50%54% Antibiotics52%83% Temperature73% Imaging95% HDU /ICU10%67% EWTD MRSA NICE

10. Age 30 day mortality 1 year survival 3 year survival JCUH Emergency laparotomy >7527%43% NCEPOD>9020% Ca bowel elective >65 4%55% Ca bowel emergency 13%32% Hip# VA >6510%33%

11. 3-year survival following laparotomy for bowel cancer NORCAG 7 th annual report

12. What would a network achieve? Collaboration Data collection Sharing of good practice and EBM Benchmarking Improved coordination of care

13. Evidence PubMed citations Hip # 14500 Emergency laparotomy 1390 AAA presentations –2009 –20085/7 hip#, –2007…..

14. emergency+laparotomy+elderly

15. Since 1999 Increasing elderly population means more evidence available The elderly are no longer constitute a one off admission to ITU Sepsis care bundles CO monitoring Stenting for colonic tumours Need for collaboration and dissemination of EBM

16. What would a network achieve? Collaboration Data collection Sharing of good practice and EBM Benchmarking Improved coordination of care

17. Benefits of benchmarking Hip # in NSF Business plan approved for orthogeriatrician Increased trauma theatre provision Weekend consultant trauma sessions

18. Hip #s Single diagnosis Presenting complaint obvious –get to correct speciality Diagnostic imaging straightforward By definition, all require surgery –or palliation Easy to define timescales

19. Common themes Lack of theatres Lack of pre-op investigation Lack of adequate resus Comorbidity Time pressures –Hip #, late surgery associated with worse outcome –Laparotomy, disease process

20. Laparotomy Multiple pathologies Multiple presentations Multiple investigations Multiple treatment options Multiple specialities

21. Multiple pathologies Cancer Diverticular disease Inflammatory bowel disease Perforated DU/PU Adhesions Volvulus Strangulated hernias

22. Multiple presentations 30% admitted with non-GI symptoms Obstruction Sepsis GI bleed Toxic megacolon Gas under diaphragm Pneumonia  coughing  hernia  strangulates  dead bowel  sepsis  laparotomy

23. Multiple investigations CXR USS CT Ba enema Biopsy Endoscopy

24. Multiple treatment options 15% need surgery Drip and suck Stent –Palliation –Bridge to surgery Surgery Endoscopy (Diagnostic laparotomy)

25. Multiple specialities Medicine Surgery Endoscopy Radiology Anaesthesia ITU

26. Emergency laparotomy More complicated……

27. Emergency laparotomy More complicated.….. ……or too complicated? Hip # network, ~5% are non-anaesthetists

28. 10 years on, have we got any better? Still cant say Lack of denominator figures: network might allow that EESE may provide some answers, catalyst rather than driving force Network may be the way forward Do you want to be involved?