The impact of urgency and timing in emergency abdominal surgery for inflammatory bowel disease
Publication Date
October 12, 2025
Creator
Abstract
There have been significant improvements in the quality of care of patients having emergency abdominal surgery over the last decade. This is partly due to processes like the National Emergency Laparotomy Audit (NELA) and the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD). NELA and NCEPOD publications have recommended changes to improve patient care, both clinically and at organisational levels.
There has never been a particular focus on patients with inflammatory bowel disease (IBD) in NELA and, as a result, there is a lack of high quality, data driven, evidence-based guidance regarding their care in the emergency surgery setting.
This thesis aims to summarise the published evidence on outcomes in emergency abdominal surgery for IBD and use data from NELA and NCEPOD to investigate how clinical urgency may be used to guide patient care.
The first study chapter is a scoping review of the factors which affect the outcomes of patients having emergency abdominal surgery for IBD. After abstract and full paper screening, 17 articles were included in the study. Allowing for significant heterogeneity within the reported cohorts, it is likely that increasing age, increasing ASA grade, comorbidity and organ dysfunction contribute to adverse outcomes in this cohort. The more significant finding of this study was that only six authors defined what was considered an emergency operation. This study highlights the importance of accurate and detailed reporting of cohort studies, especially in IBD patients who can vary significantly in their presentations.
Chapter four investigates the significance of clinical urgency with regards to patient characteristics, presentation, and outcomes. In published literature, post-operative mortality after emergency surgery for Crohn’s disease or Ulcerative Colitis is cited at four to five percent. This study found that post-operative mortality is better represented as a range from one to fifteen percent depending on clinical urgency and that patients having emergency surgery for IBD should not be considered one single cohort.
Chapter five focusses on risk stratification whilst adjusting for clinical urgency. It asks the question whether the elective specialist interest of the operating surgeon has an impact on the clinical outcomes in the different urgency categories. This study found that in the lowest urgency category, there was significantly reduced mortality and post-operative length of stay in patients with IBD having emergency abdominal surgery when operated on by a colorectal surgeon, mortality OR 2.99 (CI 1.2 – 7.8) P=0.025 and length of stay IRR 1.18 (CI 1.02 – 1.4) P=-0.025.
The final study chapter, six, investigates timeliness in emergency abdominal surgery for Crohn’s disease and reports on the factors associated with delays in making the decision to operate. This study uses data from both NELA and the 2023 NECPOD report ‘Making the Cut’. There is a significant delay in the decision to operate in patients admitted under the care of a gastroenterologist in comparison to a general surgeon, IRR 5.05 (CI 2.37-10.77) p=<0.001. This study also highlights delays in surgery for patients presenting with sepsis as a complication of Crohn’s disease, waiting on average 30.1 hours for the decision to operate.
This thesis has provided evidence that we should not consider patients having emergency abdominal surgery for IBD a single cohort, but their reporting in cohort studies, and risk stratification should be according to clinical urgency. It provides data to help shape the discussion regarding timeliness and emergency surgery for patients with IBD which may ultimately improve outcomes for these patients.
Item Type
ethesis
Thesis Type
PhD
Supervisors
Subjects (LC)
Associated Schools / Departments
School of Medicine
eprints ID
82797
UoN Repository URI
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Thesis for submission.pdf
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Full-text
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Examined. Resubmission after minor corrections.
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