7 emergency surgeries you don't want to have to get
Just seven types of procedures account for about 80 percent of all hospital admissions, deaths, complications, and costs attributed to emergency general surgeries across the country, according to new research published in JAMA Surgery.
Each year, more than 3 million patients in the U.S. are admitted to hospitals for emergency general surgeries -- a group that includes the highest risk and most acutely ill patients.
Prior to the study, lead researcher Dr. Joaquim M. Havens, director of Emergency Surgical Services at Brigham & Women's Hospital in Boston, said he noticed that patients who were coming in with serious medical problems requiring unplanned emergency surgery were not faring as well as he thought they should.
"When you look at surgeries done emergently and surgeries done electively, the outcomes are so different," he told CBS News. "It really challenged me to look deeper into what was going on."
Havens and a team of researchers analyzed a government database of more than 420,000 patients who underwent emergency general surgery between 2008 and 2011. Heart-related procedures and surgery resulting from traumatic events like car crashes were not included in the analysis.
The researchers ranked procedures by total burden, taking into account frequency, complications, mortality rates, and financial costs. In the end, they found seven operations that collectively accounted for 80 percent of procedures, 80 percent of deaths, 79 percent of complications, and 80 percent of inpatient costs nationwide.
Click through to see which seven surgeries topped the list.
The procedure that accounted for the highest burden in the study was a partial colectomy, or removal of part of the colon. Havens said that although this is not the most commonly done procedure on the list, it has a high mortality and complication rate when performed in an emergency situation.
"I suspect this is for several reasons," he said. "The diseases that affect the colon that would require emergency surgery can be very severe, including diverticulitis or perforated cancers that can make patients very sick when they come."
When done electively, doctors often have time to prep the bowel before the surgery by cleansing the colon, he explained. But when done emergently, there is significantly less time to do this, making the surgery more risky and leading to the potential for more complications.
Small-bowel resection is a procedure that removes part of the small bowel.
Havens noted that this surgery ranked high on the list because patients who need this procedure done are also often very ill, which can lead to further complications.
"The diseases that lead to it are varied," he said. "Bowel obstructions, tumors of the small bowel, other things that make the patient very sick when they present."
Gall bladder removal
Gall bladder removal -- medically referred to as a cholecystectomy -- also ranked high on the list, but not because of its complication rate.
"Generally, this procedure is relatively safe and the complication rate is reasonably low," Haven said.
However, he pointed out that there are major differences in causes when it's done electively and when it needs to be performed in an emergency. "Often it's done electively for mild symptoms of discomfort," he said. "And when it's done emergently it's for severe infection or blockage of the gall bladder which can make you very sick."
Havens also noted that since the surgery is performed so frequently, even small numbers of deaths or complications are magnified.
Operation for peptic ulcer disease
Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach. These ulcers sometimes bleed and need to be controlled.
Surgery is not very common, as medications such as proton pump inhibitors have been developed to help prevent the disease.
"It used to be much more common 30, 40, 50 years ago," Havens said. "So now, because of that, the only patients who wind up needing surgery are the ones who have failed other therapies before so the surgeries are much more difficult than they used to be."
As a result, this surgery is one of the lowest frequencies on the list, but has one of the highest rates of complication and mortality.
Removal of abdominal adhesions
Patients who have undergone intestinal procedures can sometimes develop painful adhesions months or years later that need to be removed with surgery.
"This one is interesting because it's a disease of the first world," Havens said. "It's generally in patients who have scar tissue from prior surgery. We find in the developing world, where patients don't often have surgeries, this isn't a problem."
If not treated, abdominal adhesions can lead to serious complications, which can make treating them with emergency surgeries risky. "Patients taken to the operating room within a day of presenting with a bowel obstruction may have a dead or perforated intestine, making them really sick," Havens said.
The removal of the appendix is a very safe procedure, even when done emergently, the study showed. However, it ranked high in terms of costs and frequency.
"This one is very safe," Havens said. "The mortality rate is very low, and the complication rate is quite low, as well. But because we do so many of them, the cost times the frequency means that it costs society a lot, but not in life lost or time lost. That's how it made the list."
A laparotomy is a procedure done to open the abdomen, when no other treatment is performed. The researchers found this procedure wasn't very common but had a very high mortality and complication rate.
"Often the reason that you would open up the abdomen but not do anything therapeutic on the inside is that either you find horrible cancer or some other problem that can't be fixed, so you would expect that those patients would do terribly," Havens explained.
Another reason to perform a laparotomy is to place a feeding tube in patients who had a stroke and can't eat. "Again, those patients overall don't do well," Havens said. "So it's not the surgery itself that is so dangerous, but if you have the surgery, that means there's something else going on."
What can be done to lessen the burden
The surgeries that topped this list all involved the abdominal area. There are several reason for this, Havens said.
First, surgeries involving the abdomen are very common. "When we look at the numbers, there may be only 4,000 amputations compared to 600,000 gall bladder surgeries, he said.
Second, the complication rate is fairly high. "When you operate on the intestines, if you think about it, it's full of bacteria, which puts you at a high risk of infection," Havens said. "And if you're getting an operation on your intestine, you're likely not eating. You may not have been eating before the surgery. You won't eat for a while after the surgery. So, often nutrition is a problem."
Finally, many of these procedures are done more commonly in elderly patients, which can increase risk of complications and death.
Havens said the findings shed light on the procedures that need more attention and resources. He said future research needs to identify why these particular surgeries are so burdensome and what can be done to improve outcomes.
"I think emergency general surgery needs to be defined as a separate and unique specialty like cardiac surgery or vascular surgery," he said. "This could stimulate discussion and perhaps lead to training changes to improve the quality and make emergency general surgeries safer so patients could get through this with less burden."