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Background: Emergency laparotomies (EL) are associated with significant morbidity and mortality. To date, 30-day mortality has been predominately reported, and been the focus of various national emergency laparotomy audits. Only a few studies have reported on the long-term mortality associated with EL. The aim of this study was to review the one-year mortality following EL. Method: A systematic review was conducted using PRISMA guidelines to identify studies published in the last 10 years reporting on long-term mortality associated with EL. The data abstracted included: patient demographics, pathology or type of operation performed for EL, post-operative mortality at 7-day, 30-day, 90-day, 1-year, beyond 1-year and inpatient, functional outcomes and risk factors associated with mortality. A quality assessment of included studies was performed. Results: Fifteen studies reporting long-term outcomes associated with EL were identified, including the results of 48,023 patients. The indications and/or pathologies for ELs varied. The 30-day mortality after EL ranged from 5.3% to 21.8%, and the one-year mortality ranged from 15.1 to 47%. The mortality in the six studies focusing on elderly patients ranged from 30 to 47%. Conclusion: The long-term mortality rate associated with EL is substantial. Further study is required to understand the 1-year mortality described in the studies and translate these findings for meaningful application into the clinical care of these patients. [ABSTRACT FROM AUTHOR]

Since the discovery of the Cope rearrangement in the 1940s, no asymmetric variant of the rearrangement of achiral 1,5-dienes has emerged, despite the successes that have been achieved with its heteroatom variants (Claisen, aza-Cope, and so on). This article reports the first example of an enantioselective Cope reaction that starts from an achiral diene. The new gold(I) catalyst derived from double Cl?-abstraction of ((S)-3,5-xylyl-PHANEPHOS(AuCl)2), has been developed for the sigmatropic rearrangement of alkenyl-methylenecyclopropanes. The reaction proceeds at low temperature and the synthetically useful vinylcyclopropane products are obtained in high yield and enantioselectivity. Density functional theory calculations predict that: (1) the reaction proceeds via a cyclic carbenium ion intermediate, (2) the relief of strain in the methylenecyclopropane moiety provides the thermodynamic driving force for the rearrangement and (3) metal complexation of the transition-state structure lowers the rearrangement barriers. [ABSTRACT FROM AUTHOR]

Background: Classical medical teaching has made a clear distinction between signs and symptoms, and diagnosis. However, at the time of ward admission, a diagnosis may remain unclear. We propose administrative pressures during the admission process may have reduced the ability for pathological diagnosis. This may result in increased hospitalisation for investigation of signs and symptoms, rather than for treatment of clear diagnoses. We sought to further clarify this hypothesis and investigate changes in the nature of admissions during the last two decades in an adult emergency general surgery service. Methods: A retrospective analysis of emergency general surgical admissions during four six-month time periods, between 2000 and 2018, was conducted. The six-month periods were spaced evenly during the 18-year study. Demographic information, emergency department length of stay, incidence of a pathological diagnosis on ward admission and accuracy of admission diagnosis were analysed. Results: 2763 patients were admitted in the four six-month time periods. A significant reduction in number of patients admitted with a pathological diagnosis was noted between the 2012 and 2018 study periods (p < 0.05), with 21.2% of patients admitted in 2018 for investigation of signs and symptoms. The incidence of an accurate admission diagnosis (as assessed by the discharge diagnosis) ranged from 62.3 to 63.6% and did not differ significantly by year. Conclusion: Between 2012 and 2018, there was a significant increase in the number of emergency general surgical patients admitted for investigation of signs and symptoms. However, accuracy of admission diagnosis was unchanged during the study period. [ABSTRACT FROM AUTHOR]

Introduction: Modern management of severe acute complicated diverticulitis continues to evolve towards more conservative and minimally invasive strategies. Although open sigmoid colectomy with end colostomy remains the most commonly used procedure for the treatment of perforated diverticulitis with purulent/faeculent peritonitis, recent major advances challenged this traditional approach, including the increasing attitude towards primary anastomosis as an alternative to end colostomy and use of laparoscopic approach for urgent colectomy.Technique: Provided an accurate patients selection, having the necessary haemodynamic stability, pneumoperitoneum is established with open Hasson technique and diagnostic laparoscopy is performed. If faeculent peritonitis (Hinchey IV perforated diverticulitis) is found, laparoscopy can be continued and a further three working ports are placed using bladeless trocars, as in traditional laparoscopic sigmoidectomy, with the addition of fourth trocar in left flank. The feacal matter is aspirated either with large-size suction devices or, in case of free solid stools, these can be removed with novel application of tight sealing endobags, which can be used for scooping the feacal content out and for its protected retrieval. After decontamination, a sigmoid colectomy is performed in the traditional laparoscopic fashion. The sigmoid is fully mobilised from the retroperitoneum, and mesocolon is divided up to the origin of left colic vessels. Whenever mesentery has extremely inflamed and thickened oedematous tissues, an endostapler with vascular load can be used to avoid vascular selective ligatures. Splenic flexure should be appropriately mobilised. The specimen is extracted through mini-Pfannenstiel incision with muscle splitting technique. Transanal colo-rectal anastomosis is fashioned. Air-leak test must be performed and drains placed where appropriate.Results: The video shows operative technique for a single-stage, entirely laparoscopic, washout and sigmoid colectomy with primary colorectal anastomosis in a 35-year-old male patient with severe and diffuse free faeculent diverticular peritonitis (Hinchey IV). The patient was managed post-operatively according to enhanced recovery protocol and discharged home after 9 days, following an uneventful recovery.Conclusions: This case documents the technical feasibility of a minimally invasive single-stage procedure in a patient with Hinchey IV perforated diverticulitis with diffuse feacal peritonitis. The laparoscopic approach facilitated an effective decontamination of the peritoneal cavity, with a combination of large suction devices and aid of protected retrieval by closed endobags for effectively and completely laparoscopic removal of the solid feacal matter, offering clear advantages and excellent results even in such challenging cases. With necessary expertise, the sigmoid resection can be thereafter safely and entirely performed laparoscopically, the specimen extracted through mini-Pfannenstiel incision, and a laparoscopic intracorporeal transanal circular primary anastomosis performed. [ABSTRACT FROM AUTHOR]

Background: Traumatic abdominal wall hernias (TAWH) have been recognized for more than a century since they were first reported by Selby (JAMA 47:1485-1486, 1906). They continue to be a rare diagnosis, encountered in approximately 1 % blunt trauma admissions. The present study is a 10-year retrospective review of patients presenting with TAWH to a State Major Trauma Unit in Western Australia. We hypothesized that the timing of the repair of TAWH was dependent on the severity of the abdominal wall injury, as well as associated injuries, and in turn, this may affect patient outcomes. Materials and methods: The Trauma Registry at Royal Perth Hospital (the only Level I Trauma Centre for adults in Western Australia) was scrutinized for TAWH, between 2003 and 2013. The injuries were graded by the classification system of Dennis et al. (Am J Surg 197:413-417, 2009) .Patients with TAWH following penetrating trauma were excluded. Results: During the study period, 44 patients were diagnosed to have TAWH accounting for 0.08 % of admissions. Thirty (68 %) of the patients were male and the median age was 36 years (IQR 24-54). The median BMI was between 25 and 30. The majority of the patients sustained trauma secondary to motor vehicle crashes and the commonest associated injury was a pelvic fracture. Grades 3 and 4 injuries were found to have an association with a pelvic fracture ( p < 0.001). No association was seen in the present study between seat belt use and the development of TAWH or between the location of TAWH and seat belt pattern. The median time of diagnosis of TAWH following arrival to hospital was 18 hours while the median time of surgery from diagnosis was 15.5 hours. Forty-one (93 %) of the patients underwent surgery. Of these, 8 (20 %) were emergent due to a simultaneous bowel perforation and another five had primary mesh repairs. Three of the patients suffered superficial complications (7.5 %) and there were 3 (7 %) recurrences at a mean time of 7.25 months from the first repair. The follow-up period ranged from 1 to 51 months with an average time of 16 months. Conclusion: This series is the largest single institution study conducted on TAWH to date. Despite its retrospective nature and small numbers, it has generated some important questions. A larger prospective study with a longer follow-up period is required to generate reliable treatment algorithms as well as to standardize the management of TAWH. [ABSTRACT FROM AUTHOR]