POLSKI

PRZEGLD CHIRURGICZNY
2012, 84, 10, 488494

10.2478/v10035-012-0083-3

Patients subject to surgery due to acute abdominal

disorders during the period between 2001-2004
Katarzyna Paduszyska, Agnieszka Celnik, Lech Pomorski
ZKliniki Chirurgii Oglnej iOnkologicznej Uniwersytetu Medycznego wodzi
(Department of General and Oncological Surgery, Medical University in d)
Kierownik: prof. dr hab. L. Pomorski (do 15.04.2008 r. lek. P. Lewandowski)
The aim of the study was to evaluate the clinical spectrum of emergency surgery for acute abdominal disorders and their outcome.
Material and methods. The study group comprised 1426 patients, aged between 10 and 92 years
subject to emergency surgery, due to an acute abdomen during the period 2001-2004. Analysis comprised age, sex, concomitant diseases, ASA scale classification, postoperative diagnosis, type of surgery,
complications, mortality and duration of hospitalization. Patients were divided into two age groups:
<60 and 60 years.
Results. Appendicitis was the most common diagnosis (52.9%) in patients under 60 years, while
cholecystitis (32.5%) and ileus (30.9%) in patients over 60 years. Complications were observed in 14.8%
patients, the most common being related with wound healing (5.6%). The mortality rate amounted to
5.7%. Mortality was most often associated with bowel obstruction (29.2%), surgery for acute bowel
ischemia (25.5%), and bowel perforation (20.7%). The mean duration of hospitalization was 7.9 days.
Conclusions. 1. In comparison to elective surgery, emergency abdominal operations, particularly in
elderly patients are related with ahigher mortality rate. 2. In elderly patients, the high mortality rate
and substantial number of complications is associated with the advanced primary disease and severe
coexisting comorbidities, which significantly reduce the overall health condition.
Key words: acute abdomen, mortality rate, elderly patients

Patients subject to emergency surgery, due

to acute abdominal disorders constitute a significant percentage of patients treated in surgical departments (1, 2, 3). In recent years, not
many reports were published concerning the
spectrum of emergency surgery, as well as
their treatment results (4). Published reports
only concerned a selected patient age group,
specific diseases, or patients with specific complaints (5-9). Based on medical data one may
evaluate the frequency of occurrence of abdominal cavity disorders resulting in emergency surgery over a period of several decades.
However, there was lack of evaluation of treatment results in the above-mentioned case (1).
The aim of the study was to evaluate the
clinical spectrum of emergency surgery, due
to acute abdominal disorders, and their treatment results.

MATERIAL AND METHODS

The study group comprised 1426 patients
subject to emergency surgery, due to acute
abdominal disorders, at the Department of
General Surgery, Regional Hospital in Zgierz
during the period between January 1, 2001
and December 31, 2004. Exclusion study criteria included emergency surgery, due to
trauma or postoperative complications after
elective operations. Emergency surgery was
considered in case the operation was performed
during the initial 24 hours since admission to
the hospital.
The following features were analysed: patient age and gender, concomitant diseases,
qualification according to the ASA scale (I-V),
postoperative diagnosis, type of surgery, complications, mortality rate, and duration of

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489

Patients subject to surgery due to acute abdominal disorders during the period between 2001-2004

Patient age ranged between 10 and 92 years

(mean age: 46.6 years 23.6 years). The study
group comprised 636 (44.6%) male and 790
(56.4%) female patients. Most patients were
allocated to the following age groups: 10-19
years 290 (20.3%) and 70-79 years 240
(16.8%) patients (fig. 1).
498 (34.9%) patients were diagnosed with
at least one concomitant disease (fig. 2).
Considering the incidence of coexisting
diseases, their prevalence was as follows:
coronary artery disease 249 (17.4%), arterial hypertension 198 (13.9%), heart failure
153 (10.7%), diabetes mellitus -80 (5.6%),
chronic pulmonary diseases 47 (3.3%), and
kidney failure 16 (1.1%) patients. The incidence of coexisting diseases simultaneously
increased with patient age. Additionally, with
age, one observed increased severity of these
diseases, which resulted in the qualification of
patients to a higher ASA scale group (fig. 2).
Acute appendicitis was the most common
cause of surgery 542 (38%) cases. There were
however, differences in the frequency of their
occurrence, as well as that of other disorders,
depending on patient age (tab. 1).
Table 2 presented the factors responsible
for intestinal obstruction.
The most commonly performed operations
were as follows: appendectomy 663 (46.5%)

number of patients

RESULTS

patients, cholecystectomy 273 (19.1%), surgery associated with an incarcerated hernia

and other causes of intestinal obstruction 195
(13.7%), as well as closure of a perforated peptic ulcer 103 (7.2%) cases.
Complications in case of neoplastic disease
were the cause of surgery in 90 (6.3%) patients.
Sixty patients were diagnosed with colon can-

age (years)

Fig. 1. Patient age

occurrencea

hospitalization. Obtained data was subject to

statistical analysis using the MS Excel 2003
program.

age (years)

Fig. 2. Occurrence of coexisting comorbidities,

depending on patient age

Table 1. Postoperative diagnosis in all patients and in both age groups: <60 years and 60 years
Postoperative diagnosis
Appendicitis
Cholecystitis
Intestinal obstruction
Peptic ulcer perforation
Intestinal perforation
Mesenteric lymphadenitis
Non-characteristic abdominal pain
Reproductive system diseases
Vascular bowel necrosis
Gastrointestinal bleeding
Other

Total 1426
patients
n
%
542
38
273
19,3
212
14,7
107
7,5
48
3,4
48
3,4
44
3,1
32
2,2
29
2
28
1,9
63
4,5

<60 years
(922)
n
%
488
52,9
110
11,9
55
6
74
8
10
1,1
48
5,2
40
4,3
31
3,4
7
0,8
19
2,1
40
4,3

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60 years
(504)
n
%
54
10,7
163
32,5
157
30,8
33
6,5
38
7,7
0
0
4
0,8
1
0,2
22
4,4
9
1,8
23
4,6

p
<0,001
<0,001
<0,001
n.s.
<0,001
<0,001
<0,001
<0,001
<0,001
n.s.
n.s.

490

K. Paduszyska et al.

ileus, 4 evisceration, 4 intraabdominal

abscess, 1 leakage of the sutured perforation,
1 leakage of the anastomosis (sigmoid resection, due to occlusion associated with tumor
presence), 1 bleeding from the anastomosis
(stomach resection by means of Billroth II
method), 1 biliary peritonitis due to bile
outflow after Kehrs drain removal. Two patients operated because of vascular intestinal
necrosis, due to controlled intestinal vascularization required reoperation. In both cases the
extent of the operation was expanded.
Eighty-two (5.7%) patients died of which 43
(52.4%) during the initial 3 days of hospitalization. Table 4 presented the mortality rate,
depending on the diagnosis.
Hospitalization ranged between 1 and 128
days (mean 7.9 days 6.4) and increased with
age. The hospitalization period of patients under 40 years was significantly shorter, as compared to elderly patients (p<0.001) (fig. 4).
DISCUSSION
The largest group consisted of patients operated between the age of 10-19 years (20.3%)
and 70-79 years (16.8%). Considering the first
group acute appendicitis was the most common
diagnosis (72.3%), while in the latter groupacute cholecystitis (39.4%) and ileus (23%) (fig.
1). However, other publications reported patients aged between 60-79 years subject to
surgical intervention, due to intestinal obstruction (2, 11). Considering our study material
the greater number of patients operated for
acute cholecystitis might be associated with
the less conservative approach to cholelithiasis
treatment.

Days

(%)

cer (41 cases-occlusion, 19 intestinal perforation), three with gastric cancer, one with inoperable gall-bladder cancer, one with small
bowel cancer, and 25 with disseminated cancer
of different etiology.
Due to acute cholecystitis 273 (19.3%) patients were subject to surgical intervention.
Female patients 209 (76.5%) were operated
more often, as compared to male patients 64
(23.5%) (p<0.001). In case of patients operated
because of peptic ulcer perforation, men predominated 77 (71.9%) vs 30 female (28.1%)
patients (p<0.001). In case of other disorders
there were no gender-related differences.
Colon resections were performed in 55
(3.8%) patients and 37 (2.6%) were subject to
intestinal exteriorization. In case of 17 (1.2%)
patients subject to surgical intervention, due
to neoplastic dissemination, or extensive intestinal necrosis caused by acute ischemia, the
diagnosed intraoperative lesions rendered
impossible curative or palliative treatment.
The clinical diagnosis of acute appendicitis was
not confirmed intraoperatively in 123 (18.5%)
patients. In the above-mentioned cases symptoms were most often associated with mesenteric lympadenitis 48 (39%) patients, reproductive system diseases 31 (25.2%) patients,
especially ruptured ovarian cyst. In case of 44
(35.8%) patients we were unable to determine
the cause of symptoms.
Table 3 presented the complications which
were observed during treatment.
The incidence of complications increased
with patient age (fig. 3).
Twenty (1.4%) patients required reoperation, due to the following: 6 postoperative

patients age (years)

complications
mortality

Age (years)

Fig. 3. Occurrence of complications and mortality rate

depending on ten year intervals

Fig. 4. Mean hospitalization period depending on

patient age

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Patients subject to surgery due to acute abdominal disorders during the period between 2001-2004

Acute appendicitis was the most common

condition requiring surgical intervention,
comprising 38% of all patients. However, one
observed statistically significant differences
considering the incidence of the above-mentioned disease entity, depending on patient age
(tab. 1).
Under the age of 60 years the most common
cause of surgery was as follows: acute appendicitis (52.9%), acute cholecystitis (11.9%), and
peptic ulcer perforation (8%).
The most common cause of surgery in patients 60 years was as follows: acute cholecystitis (32.5%), intestinal obstruction (30.8%),
acute appendicitis (10.7%), and intestinal perforation (7.7%). With age, one observed an
increasing frequency of surgery, due to intestinal necrosis caused by acute ischemia. These
differences were statistically significant. This
finding confirms the observations of other authors of the change of the spectrum of acute
abdominal diseases in elderly patients towards
a higher prevalence of diseases burdened with
a potentially higher operative risk (2, 9, 10,
11). Considering all the diagnoses, only in case
of peptic ulcer perforation and gastrointestinal
bleeding, there was no statistically significant
difference between both patient age groups.
Intestinal obstruction was the third most
common cause of surgery. Similarly to other
Polish publications the above-mentioned was
caused by hernial incarceration (35.8%) and
intraperitoneal adhesions (25.7%) (1,7). Colon
cancer was responsible for approximately 20%
of cases of intestinal obstruction, although
more often in case of elderly patients (tab. 2).
The percentage of negative appendectomies
amounted to 18.5%, being comparable to data

Table 2. Cause of intestinal obstruction

Cause of obstruction
Incarcerated hernia
Intraperitoneal adhesions
Colon cancer
Neoplastic dissemination
Intestinal torsion
Crohns disease
Diverticular disease complications
Biliary stone closure
Meckels diverticulum
Small bowel tumor
Total

Number of
patients (%)
78 (36,7)
54 (25,6)
41 (19,3)
25 (11,8)
5 (2,5)
3 (1,5)
2 (0,9)
2 (0,9)
1 (0,4)
1 (0,4)
212 (100)

491

obtained by other authors, ranging between

11.2% and 25% (2, 12, 13, 14). The highest
number of preliminary erroneous diagnoses
was observed in female patients, aged between
20-29 years (30.4%), despite the fact that only
25% were diagnosed with gynecological disorders responsible for the above-mentioned
symptoms. Laparoscopy is being increasingly
used in the diagnosis and treatment of acute
appendicitis. Its use might significantly improve diagnostic results enabling to avoid unnessesary and more extensive surgical procedures (15). During our study period the abovementioned method was not used during diagnostics and therapy of acute appendicitis. Diagnosis was based on clinical symptoms, laboratory results, the ultrasound examination,
and gynecological consultations.
The mortality rate in our material (5.7%)
was within limits presented by other authors
(fig. 2 and tab. 4). The mortality rate after
acute abdominal operations ranged between
4.4% and 10.2% (2, 3, 4, 11, 14). As in other
studies the mortality rate differed significantly, depending on the cause of surgery and
increased with patient age. Of the 82 deceased
patients, 24 (29.3%) underwent surgery because
of intestinal obstruction, 21 (25.6%) because of
intestinal necrosis, due to mesenteric vascular
thrombosis or embolism, 17 (20.7%) because
of intestinal perforation, and 9 (10,9%) due to
peptic ulcer perforation (tab. 5).
The highest mortality rate (72.4%) was
observed in case of surgery, due to vascular

Table 3. Postoperative complications

Type of complication
Total:
pulmonary complications
cardiac complications
sepsis
urinary tract infection
cerebral stroke
gastrointestinal bleeding
Other
local:
wound suppuration
intestinal obstruction
intraabdominal abscess
eventration
other

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Number of patients
(%)
54 (3,8)
32 (2,2)
19 (1,3)
13 (0,9)
3 (0,6)
2 (0,1)
7 (0,7)
80 (5,6)
13 (0,9)
6 (0,4)
4 (0,3)
7 (0,7)

492

K. Paduszyska et al.
Table 4. Number of deaths and mortality depending on diagnosis

Postoperative diagnosis
Intestinal obstruction
Vascular bowel necrosis
Intestinal perforation
Peptic ulcer perforation
Acute cholecystitis
Gastrointestinal bleeding
Acute appendicitis
Other
Total

Number of patients/ number of deaths (mortality)

<60 lat
60 lat
ogem/zgony
(922)
(504)
(1426)
212 /24 (11,3%)
55/4 (7,3%)
157/20 (12,7%)
29/ 21 (72,4%)
9/4 (44,4%)
20/17 (85%)
49 /17 (34,6%)
10/2 (20%)
38/14 (36,8%)
107 / 9 (8,4%)
74/2 (2,7%)
33/7 (21,2%)
273 / 3 (1,4%)
110/0 (0%)
163/3 (1,8%)
28/ 3 (10,7%)
19 /2 (10,5%)
9/1 (11,1%)
542/ 0 (0%)
488/0 (0%)
54/0 (0%)
185/ 5 (2,2%)
157/3 (1,9%)
30/2 (6,7%)
1425/82 (5,7%)
922/18 (1,9%)
504/64 (12,8%)

intestinal necrosis. The above-mentioned was

the cause of one in four deaths, despite the fact
that only 2% of patients were operated. The
described mortality rate after surgery, due to
intestinal necrosis or mesenteric vessel thrombosis or embolism ranged between 60% and
75% (2, 8, 9). Such poor treatment results are
associated with advanced patient age and
delayed treatment, due to unspecific symptoms. Some authors deny the impact of the
extent of the resection on patient survival (9).
In our material the extent of the necrotic area
proved to be a significant prognostic factor,
although none of the deaths were associated
with short bowel syndrome disturbances.
Intestinal perforation is burdened with a
32.6% mortality rate. The described mortality
during the course of intestinal perforation
ranged between 24% and 56%, especially in
elderly patients (2, 4, 5, 6, 11, 16, 21). Most of
the deaths in our study concerned patients over
the age of 70 years, subject to surgical intervention, due to extensive fecal peritonitis, as
a consequence of colon diverticulum or tumor
perforation. Peritonitis, hypovolemic shock,
and other complications could not be controlled, despite emergency surgery and intensive postoperative treatment. The cause of
death in most of these cases was as follows:
septic shock and sepsis, or circulatory and
respiratory complications, which were previously diagnosed in these patients.
Colon obstruction was burdened with a
14.1% mortality rate. As in case of perforation,
death was associated with delayed presentation for treatment or exacerbation of coexisting
diseases. In many cases of obstruction caused
by tumor presence (Dukes C or D), intestinal
exteriorization was only possible.

The mortality rate of patients subject to

surgical treatment of a perforated peptic ulcer
amounted to 8.4%, and was comparable to
results obtained by other authors (ranging
between 7 and 13%). However, the 23% mortality rate was also observed (2, 3, 12, 17, 20). As
reported by other authors, the duration of
symptoms exceeding 24 hours, and patient
age>70 years were considered as risk factors.
Most perforations in our study concerned the
duodenum and pyloric canal, where simple
suturing of the perforation and proton pump
inhibitors render good early results, and in
conjuction with eradication, good distant results. In one case, we observed lack of tightness
at the site of the perforation during the postoperative period, which in consequence lead
towards sepsis and multiorgan failure, responsible for patient death.
The mortality rate in patients following
cholecystectomy amounted to 1.3%. Such a
death rate, especially combined with the fact
that most of the operations for acute cholecystitis concerned subjects over the age of 60 years,
often burdened with concomitant diseases,
many days of symptoms and generalized features of inflammation, confirmed the view observed in literature data that early cholecystectomy is the operation of choice in patients diagnosed with acute cholecystitis, even in the
elderly (18). Postoperative complications were
observed, either isolated or complex. Considering our patients at least one complication was
observed in 14.8% of patients, the result being
comparable with other publications (6, 7, 8).
Similarly to data obtained by other authors the
most common local complication was wound
suppuration, observed in 5.6% of patients. In
our study cardiovascular and respiratory sys-

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Patients subject to surgery due to acute abdominal disorders during the period between 2001-2004

tem symptoms predominated. Amongst general complications respiratory system symptoms were most common: pneumonia (2.1%) and
respiratory failure requiring prolonged mechanical ventilation (1.7%). Postoperative cardiovascular complications were observed in
2.6% of patients most often associated with the
intensification of heart failure symptoms.
Most authors agree that patient age is not
an independent surgical risk factor (6, 10, 14).
However, considering all available studies one
observed an increased mortality rate and occurrence of complications with the increasing
age of patients. Amongst our patients the
mortality rate increased progressively since
the age of 40 years. Fifty-nine (71.9%) deceased
patients were over the age of 70 years. The
mortality rate in patients aged between 40-49
years was 4.2%, while between 50-59 years4.3%. The mortality rate in the following age
groups was as follows: 60-69 years- 5.9%, 70-79
years 14.1%, and >80 years 26%. The factor
most responsible for the higher mortality rate
in elderly patients is the higher incidence of
significant concomitant diseases (5,6,13). In
our study, poor treatment results were observed in patients aged over 80 years. The
mortality rate in the above-mentioned group
amounted to 26% with complications diagnosed in almost half of the patients. However,
more than 80% of these patients were diagnosed with at least one concomitant disease,
and the average ASA value was 3.3. One
should also mention the fact that patients >60
years accounted for 35.3% of all subjects, even
though they constitute 17.1% of the Polish

493

population (19). This points to the need for

more frequent emergency surgical treatment,
as compared to younger patients. Over the past
60 years one observed an increased average
age of operated patients, due to acute abdominal diseases by a few to several years, depending on the disease (1). It is estimated that
further prolongation of the average life expectancy will result in the fact that by 2030 the
proportion of elderly patients will almost
double (18). This in turn will further increase
problems associated with postoperative care
and the growing number of elderly patients.
Average hospitalization amounted to 7.8
days. Hospitalization in case of patients over
40 years was significantly longer, as compared
to younger subjects. The large number of elderly patients is responsible for prolonged
hospitalization. These patients require a
greater number of examinations, intensive
treatment, and longer antibiotics therapy.
Thus, increased therapeutic costs.
CONCLUSIONS
1. Emergency surgery due to acute abdominal
disorders, especially true in case of elderly
patients, are burdened with a higher mortality rate, as compared to elective operations.
2. The high mortality rate and substantial
number of complications in elderly patients
is associated with the advanced primary
disease and severe concomitant comorbidities, which significantly reduce the overall
health condition.

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Received:19.08.2012r.
Adress correspondence: 95-100 Zgierz, ul. Parzczewska 35

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