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Background: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. Methods: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Results: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. Conclusions: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies. [ABSTRACT FROM AUTHOR]

Background: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. Methods: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. Results: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. Conclusions: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies. [ABSTRACT FROM AUTHOR]

Background: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. Methods: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1. Results: Twelve components of preoperative care were considered. Consensus was reached after three rounds. Conclusions: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients. [ABSTRACT FROM AUTHOR]

This post hoc study aimed to determine whether major elective abdominal surgery had any acute impact on mitochondrial pyruvate dehydrogenase complex (PDC) activity and maximal mitochondrial ATP production rates (MAPR) in a large muscle group (vastus lateralis -VL) distant to the site of surgical trauma. Fifteen patients undergoing major elective open abdominal surgery were studied. Muscle biopsies were obtained after the induction of anesthesia from the VL immediately before and after surgery for the determination of PDC and maximal MAPR (utilizing a variety of energy substrates). Muscle PDC activity was reduced by >50% at the end of surgery compared with pre-surgery (p < 0.05). Muscle MAPR were comprehensively suppressed by surgery for the substrate combinations: glutamate + succinate; glutamate + malate; palmitoylcarnitine + malate; and pyruvate + malate (all p < 0.05), and could not be explained by a lower mitochondrial yield. PDC activity and mitochondrial ATP production capacity were acutely impaired in muscle distant to the site of surgical trauma. In keeping with the limited data available, we surmise these events resulted from the general anesthesia procedures employed and the surgery related trauma. These findings further the understanding of the acute dysregulation of mitochondrial function in muscle distant to the site of major surgical trauma in patients, and point to the combination of general anesthesia and trauma related inflammation as being drivers of muscle metabolic insult that warrants further investigation. Registered at (NCT01134809). [ABSTRACT FROM AUTHOR]

Summary Background & aims The aims of this study were to identify whether differences in distribution of adipose tissue and skeletal muscle in obese and non-obese individuals contribute to the magnitude of the postoperative inflammatory response and insulin resistance, with and without preoperative treatment with carbohydrate drinks. Methods Thirty-two adults (16 obese/16 non-obese) undergoing elective major open abdominal surgery participated in this 2 × 2 factorial, randomised, double-blind, placebo-controlled study. Participants received Nutricia preOp® or placebo (800 ml on the night before surgery/400 ml 2–3 h preoperatively) after stratifying for obesity. Insulin sensitivity was measured using the hyperinsulinaemic-euglycaemic clamp preoperatively and on the 1st postoperative day. Vastus lateralis, omental and subcutaneous fat biopsies were taken pre- and postoperatively and analysed after RNA extraction. The primary endpoint was within subject differences in insulin sensitivity. Results Major abdominal surgery was associated with a 42% reduction in insulin sensitivity from mean(SD) M value of 37.3(11.8) μmol kg−1 fat free mass (FFM) to 21.7(7.4) μmol kg−1 FFM, but this was not influenced by obesity or preoperative carbohydrate treatment. Activation of the triggering receptor expressed on myeloid cells (TREM1) pathway was seen in response to surgery in omental fat samples. In postoperative muscle samples, gene expression differences indicated activation of the peroxisome proliferator-activated receptor (PPAR-α)/retinoid X-receptor (RXR-α) pathway in obese but not in non-obese participants. There were no significant changes in gene expression pathways associated with carbohydrate treatment. Conclusion The reduction in insulin sensitivity associated with major abdominal surgery was confirmed but there were no differences associated with preoperative carbohydrates or obesity. [ABSTRACT FROM AUTHOR]

Summary Background & aims Postoperative hyperglycaemia is common in patients having major surgery and is associated with adverse outcomes. This study aimed to determine whether bacteraemia contributed to postoperative systemic inflammation, and whether increases in the expression of muscle mRNAs and proteins reflecting increased muscle inflammation, atrophy and impaired carbohydrate oxidation were evident at the time of surgery, and both local and distant to the site of trauma, and could be associated with impaired glucoregulation. Methods Fifteen adult patients without diabetes undergoing major abdominal surgery participated in this observational study set in a university teaching hospital. Arterialised-venous blood samples and muscle biopsies were obtained before and after major elective abdominal surgery, from sites local (rectus abdominis – RA) and remote to the site of surgery (vastus lateralis – VL). The main outcome measures included blood glucose concentrations, gut permeability and changes in expression of muscle mRNAs and proteins linked to inflammation and glucose regulation. Results Immediately postoperatively, RA demonstrated markedly increased mRNA expression levels of cathepsin-L (7.5-fold, P < 0.05), FOXO1 (10.5-fold, P < 0.05), MAFbx (11.5-fold, P < 0.01), PDK4 (7.8-fold, P < 0.05), TNF-α (16.5-fold, P < 0.05) and IL-6 (1058-fold, P < 0.001). A similar, albeit blunted, response was observed in VL. Surgery also increased expression of proteins linked to inflammation (IL-6; 6-fold, P < 0.01), protein degradation (MAFbx; 4.5-fold, P < 0.5), and blunted carbohydrate oxidation (PDK4; 4-fold, P < 0.05) in RA but not VL. Increased systemic inflammation (TNF-α, P < 0.05; IL-6, P < 0.001), and impaired postoperative glucose tolerance (P < 0.001), but not bacteraemia (although gut permeability was increased significantly, P < 0.05) or increased plasma cortisol, were noted 48 h postoperatively. Conclusions A systemic postoperative proinflammatory response was accompanied by muscle inflammation and metabolic dysregulation both local and remote to the site of surgery, and was not accompanied by bacteraemia. Clinical trial registration Registered at http://clinicaltrials.gov (NCT01134809). [ABSTRACT FROM AUTHOR]

We aimed to study outcome in patients with an open abdomen in whom the abdominal vacuum-assisted closure system (V.A.C.® Therapy™) was used to provide temporary cover and achieve wound closure. All patients in whom V.A.C. Therapy was used to manage laparotomy wounds between February 2006 and May 2007 at a University Teaching Hospital were followed up prospectively until successful completion or stoppage of V.A.C. Therapy. Of the 51 consecutive patients (33 male), V.A.C. Therapy was used to manage a laparostomy in 10 patients and abdominal wound dehiscence in 41. Median (IQR) duration of V.A.C. Therapy was 17 (7–26) days. Wound healing was achieved in 31 (61%) patients, four of whom had additional surgery to assist wound closure. The rest healed by secondary intention. Treatment was withdrawn due to therapy-related complications in nine patients and due to medical or logistical reasons in seven. Four patients died while on therapy. While most V.A.C. Therapy-related problems were minor, two patients developed enteric fistulae that necessitated surgical repair. At a median (IQR) follow-up of 8 (4–13) months, 18 patients had stable cutaneous coverage with no incisional hernia, 12 developed an incisional hernia, 9 were lost to follow-up, and 12 died. V.A.C. Therapy is a useful adjunct in the management of the open abdomen and should be considered in the treatment of this problem. Restoration of cutaneous and fascial integrity of the abdominal wall, the risk of fistulisation, and the cost-effectiveness of this therapy require further evaluation. [ABSTRACT FROM AUTHOR]

Yamazaki et al. [[1]] have presented an interesting retrospective cohort study on the safety and feasibility of the use of a hyaluronate carboxymethylcellulose (HCM)-based bioresorbable membrane to reduce adhesions at the second stage of a two-stage pancreaticoduodenectomy performed 4-8 weeks after the initial resection. While we appreciate that the use of the HCM-based membrane reduced adhesions at the second stage, it is difficult to rationalise how the presence of the HCM-based membrane would reduce adhesions on the one hand and promote good external fistulisation with granulation tissue formation on the other. [Extracted from the article]

Abstract: The term ‘acute abdomen’ encompasses a spectrum of medical and surgical conditions ranging from the trivial to the life threatening that require hospital admission, investigation and treatment. A careful, methodical approach (including history taking, clinical examination and investigation) is necessary in the management of acute abdomen. The immediate goal is to ascertain if emergency surgery is indicated. Patients must be adequately resuscitated while being investigated if immediate surgery is not required. Initial management includes assessment of the airway, breathing and circulation, and establishing respiratory and cardiovascular stability. Occasionally, resuscitation and surgical intervention may have to be undertaken simultaneously. A detailed clinical history must be obtained because it provides important clues to the differential diagnosis. The initial step in the clinical examination is to document the vital signs (including pulse rate and rhythm, blood pressure, respiratory rate, temperature, Glasgow Coma Score). A thorough general physical examination, abdominal examination and examination of other relevant systems must be performed. The signs must be interpreted in conjunction with history, general condition, age, sex and potential risk factors. Investigations must be aimed at establishing the diagnosis, determining the need for surgical intervention and assessing the fitness of the patient for intervention. The common laboratory and radiological tests used in the diagnosis of the acute abdomen are discussed in this contribution. A laparotomy or a laparoscopy may be the ultimate diagnostic investigation in the difficult patient (in addition to being therapeutic). [Copyright &y& Elsevier]

Key Clinical Message A 76-year-old man developed a hemoperitoneum after ERCP for choledocholithiasis. He underwent a laparotomy and splenectomy for a capsular tear at the splenic hilum, a rare complication of ERCP. 'Bowing' of the endoscope with torsion on the greater curvature of the stomach may lead to shear forces causing splenic injury. [ABSTRACT FROM AUTHOR]

The article accounts on a 70-years old woman with a case of recurrent pancreatitis, with increases in serum amylase, alkaline phosphatase and gamma glutamyl transferase but normal bilirubin. She has undergone laparotomy and routine cholecystectomy. However, postoperatively, the symptoms of pancreatitis recurred, which was a result of a gastric polyp, prolapsing into the duodenum diagnosed upon gastroscopy and proved to be a benign cystic leiomyoma.