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Background/aim: With the increase in the elderly population, the elderly proportion needing emergency surgery is also increasing. Despite medical advances in surgery and anesthesia, negative postoperative outcomes and high mortality rates are still present in elderly patients undergoing emergency surgery. Comorbidities are described as the main determining factors in poor outcomes. In this metaanalysis, it was aimed to investigate the effect of comorbidity on mortality in elderly patients undergoing emergency abdominal surgery., Materials and Methods: The studies published between 2010-2019 were scanned from databases of Google Scholar, Cinahl, Pub Med, Medline and Web of Science. Quality criteria proposed by Polit and Beck were used in the evaluation of the included studies. Interrater agreement was calculated by using the Kappa statistic, effect size by using the odds ratio, and heterogeneity among studies by using the Cochran’s Q statistics. Kendall’s Tau-b coefficient and funnel plot were used to determine publication bias., Results: A total of 9 studies were included in the research. There was a total of 1330 cases in the studies. The total mortality rate was 21% (n = 279), the total rate of having a comorbid factor was 83.6% (n = 1112), and the rate of having a comorbid factor in mortality was 89.2% (n = 249). According to the fixed effects model, the total effect size of comorbid factors on causing mortality was not statistically significant with a value of 1.296 (C.I; 0.84-1.97; P > 0.05)., Conclusion: Our study revealed that comorbidity had no significant effect on causing mortality in geriatric patients undergoing emergency abdominal surgery. There are controversial results in the literature, and in order to reach more precise results, studies involving wider groups of patients and further studies examining the specific effect of certain comorbid conditions are needed., Competing Interests: We openly declare that there are no conflicts of interest., (This work is licensed under a Creative Commons Attribution 4.0 International License.)

The elderly patient presenting with an acute surgical abdomen or bowel obstruction has become a common and challenging situation. These patients bring comorbidity and frailty that necessitate appropriate risk assessment and comprehensive perioperative management. Robust communication is required between patients, families and health professions. The Australia and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) study is based on the United Kingdom's National Emergency Laparotomy Audit (NELA) and will gather large scale data, providing hospital-level information to enable clinicians to reduce variation in management. Successful management of the elderly laparotomy patient requires close coordination between surgeons, anaesthetists and physicians. The ANZELA-QI study will help establish the role of collaborative models of care and the need for perioperative care teams.

Background: The number of surgical procedures performed in elderly and frail patients has greatly increased in the last decades. However, there is little research in the elderly emergency general surgery patient. The aim of this study was to assess the prevalence of frailty in the emergency general surgery population in Belgium. Secondly, we examined the length of hospital stay, readmission rate and mortality at 30 and 90 days., Methods: We conducted a prospective observational study at Ghent University Hospital. All patients older than 65 admitted to a general surgery ward from the emergency department were eligible for inclusion. Primary endpoint was mortality at 30 days. Secondary outcomes were mortality at 90 days, readmissions and length of stay. Cross-sectional observations were performed using the Fisher exact test, Mann-Whitney U-test, or one-way ANOVA. We performed a COX multivariable analysis to identify independent variables associated with mortality at 30 and 90 days as well as the readmission risk., Results: Data were collected from 98 patients in a four-month period. 23.5% of patients were deemed frail. 79% of all patients underwent abdominal surgery. Univariate analyses showed that polypharmacy, multimorbidity, a history of falls, hearing impairment and urinary incontinence were statistically significantly different between the non-frail and the group. Frail patients showed a higher incidence for mortality within 30 days (9% versus 1.3% (p = .053)). There were no differences between the two groups for mortality at 90 days, readmission, length of stay and operation. Frailty was a predictor for mortality at 90 days (p= .025) (hazard ratio (HR) 10.83 (95%CI 1.34-87.4)). Operation (p= .084) (HR 0.16 (95%CI 0.16-1.29)) and the presence of chronic cardiac failure (p= .049) (HR 0.38 (95%CI 0.14-0.99)) were protective for mortality at 90 days., Conclusion: Frailty is a significant predictor for mortality for elderly patients undergoing emergency abdominal/general surgery., Level of Evidence: Level II therapeutic study.

Background: In a previous study, we found that Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) overpredicts morbidity risk in emergency gastrointestinal surgery. Our aim was to find a POSSUM equation adjustment., Methods: A prospective observational study was performed on 2,361 patients presenting with a community-acquired gastrointestinal surgical emergency. The first 1,000 surgeries constituted the development cohort, the second 1,000 events were the first validation intramural cohort, and the remaining 361 cases belonged to a second validation extramural cohort., Results: (1) A modified POSSUM equation was obtained. (2) Logistic regression was used to yield a statistically significant equation that included age, hemoglobin, white cell count, sodium and operative severity. (3) A chi-square automatic interaction detector decision tree analysis yielded a statistically significant equation with 4 variables, namely cardiac failure, sodium, operative severity, and peritoneal soiling., Conclusions: A modified POSSUM equation and a simplified scoring system (aLicante sUrgical Community Emergencies New Tool for the enUmeration of Morbidities [LUCENTUM]) are described. Both tools significantly improve prediction of surgical morbidity in community-acquired gastrointestinal surgical emergencies., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Patients with paraplegia or quadriplegia presenting with abdominal surgical emergencies pose major clinical challenges. Difficulties in prompt diagnosis and treatment may influence patient outcomes., Methods: This is an American College of Surgeons National Surgical Quality Improvement Program study of patients undergoing an emergent abdominal operation. Patients were stratified into paraplegic (PARA), quadriplegic (QUAD), and control (CONT). PARA and QUAD groups were matched with controls by 1:2 ratio. Regression models were used to analyze the effect of paraplegia and quadriplegia on outcome., Results: A total of 76,766 patients underwent emergent abdominal operations: 274 PARA, 132 QUAD, and 76,356 CONT patients. Lower gastrointestinal operations were the most common procedures in PARA and QUAD groups; appendectomy was the most common in the CONT group. After cohort matching, patients with cord paralysis were significantly more likely to present with severe sepsis, have "infected" wounds at operation, and have increased rates of postoperative sepsis and need for reoperation., Conclusion: Patients with paraplegia or quadriplegia with acute abdominal surgical emergencies are more likely to present late and have a significantly higher incidence of postoperative septic complications and longer hospital stay. Early surgical consultation and aggressive evaluation and postoperative management are warranted in these populations., Level of Evidence: Epidemiologic study, level III; therapeutic study, level IV.

Owing the experience of 16 101 miniinvasive operations by acute diseases of the abdominal cavity, the authors pose that the introduction of polytechnological methods has certain perspectives. The combination of different methods with the use of modern technologies lead to better results.

Background: The aims of this study have been elaborated below: (1) to enumerate the common causes of acute abdominal emergencies by ultrasonography in paediatric patients; (2) to establish the diagnostic efficacy of ultrasonography in evaluation of acute abdominal conditions in children and to illustrate the associated ultrasonographic findings; (3) and, to discuss the role of ultrasonography in guiding the mode of intervention in these cases., Patients and Methods: This prospective study of ultrasonographic examination in 146 paediatric patients presenting with acute onset abdominal pain at the emergency/paediatric outpatient department section of Jawaharlal Nehru Medical College & Hospital, Aligarh, between June 2006 and December 2007, using 3.75 MHz and 8 MHz transducers of the ADARA (Siemens) machine., Results: Common causes of acute abdominal emergencies in pediatric patients as noted on ultrasonography included nonspecific pain (28%), abdominal abscess (21%), acute appendicitis (7%) and intussusception (7%). Ultrasonography was diagnostic in 45.2% cases and supportive in 12.3% of the cases. As for as the final outcome, ultrasonography prevented surgery in almost 20% cases and laparotomy was avoided in 7% of the patients as ultrasound guided interventions in the form of abscess aspiration were carried out., Conclusion: Ultrasonography evaluation of children with acute abdominal pain, helps in making significant changes in the management plan of the patients, and also reveals various clinically unsuspected diseases.

Background: The Modified Early Warning Score (MEWS) was proposed for early identification of patients deterioration. The purpose of this study was to determine if MEWS calculation can help the anaesthesist select the correct level of care to avoid inappropriate admission to the ICU and to enhance the use of the High Dependency Unit (HDU) after emergency surgical procedures., Methods: Emergency surgical patients admitted before MEWS application (Jan 2008-Mar 2009) were included in the control group, whereas emergency surgical patients after MEWS introduction constituted the intervention group (Apr 2009-Jan 2010). Admission diagnosis was included into three groups for data analysis: acute abdomen (intestinal occlusion, bowel perforation, intestinal ischemia), non-complicated surgery (hernia recurrence, cholecystitis, appendicitis), and blunt abdominal trauma. In intervention group, MEWS was calculated by the anaesthesists on duty before and after surgical procedure. Patients with a MEWS of 3 or 4 were transferred to the HDU, whereas a MEWS score of 5 or more was considered criteria for ICU admission., Results: A total of 1082 patients were enrolled in this study. The control group was made up of 604 patients, whereas the MEWS group included 478 patients. Baseline and clinical status were comparable between groups. After MEWS introduction, HDU admissions significantly increased from 14% to 21% (P=0.0008), with a significant decrease of ICU admissions (from 11% to 5%; P=0.0010). Mortality rate analysis did not differ between groups., Conclusion: This study suggests that the use of a simple and reproducible score system may help in reducing ICU admissions after emergency surgery.

An investigation of system-forming indices of severity of the state and intoxication in 276 patients with urgent surgical pathology depending on using immunotropic medicines has revealed differences in the significance of factors of system-forming indices and functional load on the inflammation mechanisms depending on the inclusion of immunotropic medicines in the complex treatment.

The authors summarized the experience of the emergency surgical treatment of 965 patients with combined gynecological and general surgical diseases. Patients were aged 15-80 years. 410 (42.5%) of women were fertile. The laparotomic access was chosen individually, though the majority (965-97.2%) had the middle or oblique-transverse laparotomy. The volume and risk level of the operation were assessed using the score method. The most frequent diseases were: the acute appendicitis, the incarcerated ventral hernia, the intestinal tumor obstruction and the acute calculous cholecystitis. The high medical and economical efficacy of the simultaneous operations allow to recommend them , considering the proper high level of surgical help.

With an incidence of 950,000 pregnancies per year in France, the likelihood of seeing one or more surgical abdominal diseases during pregnancy is high. The goal of this update was to describe the management of four different settings in the pregnant woman: colorectal cancer, laparoscopic surgery, gastrointestinal emergency surgery, and bariatric surgery., (Copyright © 2010. Published by Elsevier Masson SAS.)

Background: Laparoscopy has been widely accepted among surgeons for the diagnosis and management of acute abdominal conditions. In this study, we aim to evaluate and summarize the experience in laparoscopic procedures, both diagnostic and interventional, for emergency nontraumatic abdominal conditions, in a tertiary academic center., Methods: From June 2005 to June 2009, a total of 1414 patients were subjected to a variety of emergency procedures at the university hospital of Patras and 540 of these patients were managed laparoscopically (38.2%). Indications for operations in the laparoscopic group were abdominal pain mimicking appendicitis in 229 patients (42.4%), acute cholecystitis in 248 patients (45.9%), gastroduodenal perforated ulcer in 14 patients (2.6%), small bowel obstruction in 24 patients (4.4%), and nonspecific abdominal pain in 25 patients (4.6%)., Results: Diagnosis was established in 530 patients (98.2%) and definitive laparoscopic treatment was offered to 514 patients (95.2%). The conversion rate was 2.2%. Total mortality was 1.1% and total morbidity was 7.9%., Conclusions: Laparoscopic approach to abdominal emergency provides high diagnostic accuracy and therapeutic options. Surgical experience, optimal procedural timing, and appropriate patient selection criteria diminish perioperative mortality and morbidity, and are associated with nominal conversion.

Background: Acute abdominal conditions are a common reason for emergency admission of children. Little is available in the literature about such conditions in our subregion, especially Ghana., Objective: The aim of this study was to investigate the range of emergency abdominal surgical conditions amongst children in the subregion, with particular reference to Komfo Anokye Teaching Hospital, Kumasi, Ghana. A prospective survey of all children older than 1 year undergoing an emergency abdominal surgery was carried out., Methods: Details of all children (except infants) operated for an acute surgical abdominal condition over a 5-year period were entered into a specially designed form, capturing patient characteristics, surgical causes of the emergency, operative procedure, complications, morbidity and mortality rates., Results: Nine hundred fifty-five children aged > 1 year but < 15 years were enrolled in the study. The mean age was 8.8 +/- 3.2 years. The leading causes of surgical abdominal emergencies were typhoid perforation (TP) of the gastrointestinal tract (GIT), 68%; acute appendicitis, 16%; abdominal trauma and intestinal obstruction (including intussusception), 4.7% each; irreducible external hernias, 2.5%; primary peritonitis, 1.0%; gallbladder disease and gastric perforation, 0.8% each. Many children died from the TP group; case fatality for TP alone was 12.6%. The overall mortality was 9.7%. Morbidity was influenced by the presence of major peritoneal contamination, continuing peritonitis and surgical site infections (SSIs), which led to long hospital stay., Conclusions: In our hospital, TP of the GIT, acute appendicitis, intestinal obstruction, irreducible external hernias and primary peritonitis were the most common abdominal emergencies encountered in children after infancy. The high morbidity and mortality in TP is attributable to ignorance, poor sanitation and delay in reporting to hospital for treatment.

Background: Currently, emergency laparoscopic surgery for acute abdominal conditions has become the favored surgical approach; therefore, we investigated the diagnostic accuracy and therapeutic efficacy of laparoscopy in acute abdominal pain in Saudi Arabian patients., Patients and Methods: In this prospective study, 176 patients with acute abdominal pain (113 patients with pain localized to the right iliac region [group A] and 63 patients with generalized abdominal pain [group B] underwent emergency laparoscopy between January 2002 and December 2006. We evaluated the initial clinical diagnosis, the laparoscopic diagnosis, and the outcome in these two groups of patients., Results: In group A, a definitive diagnosis was established at laparoscopy in 89% of patients, and it was therapeutic in 81.4% of the patients, and in 9 patients (8%) a conversion to laparotomy was necessary a to manage their condition. In group B, the diagnosis was accurate in 87% of patients, and it was therapeutic in 79.4% of the patients, and in 5 patients (8%) a conversion to laparotomy was necessary. There was no mortality., Conclusions: The emergency laparoscopy is a diagnostic and therapeutic option in the majority of acute abdominal pain conditions.

Background: A higher number of elderly are seeking surgical care in the last years for different affections. The aim of the study was to analyze the characteristics of surgical emergency pathology in elderly and to establish several prognostic factors., Materials and Methods: We did a retrospective study on 22.803 patients admitted in the First and the Third Clinic of Surgery from Targu-Mures between 1999 and 2006. The data were statistically processed., Results: The elderly (> or =70 years) represented 15.10% of all cases and 20.70% of all emergencies. Almost half of them (47.80%) were admitted in emergency conditions, compared to only a third (32.53%) of the younger group. The malignancies represented 16.72%, meanwhile in the younger group only 6.98 %. Abdominal emergencies represented 83.59%, mostly due to intestinal occlusion and digestive hemorrhages. The operability ratio was 68%, close to the younger group (72%). The global mortality rate was 3.95%., Conclusions: Surgical emergencies affect elderly in a higher percentage than the younger group. The emergency condition, the elder age and neoplasia are the most important factors of negative prognosis, and more important when they cumulate, increasing the mortality rate up to fivefold compared to the elderly admitted in elective condition.

The acute abdomen is a call for prompt diagnosis and a decision for surgical or conservative therapeutic measures. The classification into clinical severity and surgical categories facilitates differentiation of the cases and determines the time frame in which the further diagnosis and treatment must proceed. The emergency doctor called in to a nonhospital setting decides whether hospital admission is necessary and which pain therapy is to be immediately initiated. According to more recent studies, the latter does not cause a delay in the ability to make a diagnosis. Laparoscopy as a diagnostic emergency intervention leads to surgical treatment in 62% of the cases.

In a case of acute abdomen, the presence of a life-threatening condition that requires immediate surgery must be precluded as quickly as possible. Generally speaking, the faster the pain develops, the more likely that it is a life-threatening emergency situation. If no urgent indication for surgery is found, the possibility of an internal disease should be considered, even pancreatitis for example.

Although patients who present for emergency medical care have a broad spectrum of symptoms, such events can generally be categorized as internal medicine, surgical, and pediatric emergency cases. Indications for emergency surgery are estimated to be infrequent compared with the overall number of patients admitted for emergency care. This study investigated the indications for emergency surgery in patients (612 of 8422 patients who sought emergency care) admitted to the surgical division of the emergency department at Konya City Hospital between January and July of 2002. This retrospective study, which investigated reasons for surgical procedures and relevant branch distribution, comprised 405 men (65%) and 207 women (35%). Ages of enrolled patients ranged from 6 months to 70 years. Most of the patients (n=280, 46%) who underwent surgery at the emergency clinic were treated for acute abdomen. Emergency indications for neurosurgery (n=71, 12%) were the second most common reason for emergency procedures. Epidural hematoma and depressed fracture were the most apparent indications for neurosurgery. Surgery of the thorax was the third most common emergency surgery performed (n=44, 7%). Patients who had emergency surgery indications and who underwent surgery account for approximately 7% of the total number of patients who presented for emergency care. Acute abdomen and trauma were the most frequently reported precipitating events.

One hundred and ninety-two urgent laparoscopic operations in 179 infants (including 31 newborn infants) were performed. Indications for surgery were intestinal obstruction (108 children), acute diseases of abdominal organs (61), and gynecological diseases (10). The rate of conversion in 3 groups was 10.9, 4.6% and 0, respectively. In all the cases conversion was performed due to technical difficulties, there were no intrasurgical complications, diagnostic value of the method reached 100%. Combined laparoscopic surgeries were performed in 25.1% cases. Intestinal invagination was the most frequent cause of laparoscopy. Comparative analysis of open (28) and laparoscopic (85) desinvagination demonstrated the advantages of the latter one both during and after surgery. Laparoscopy is the useful method for diagnosis and treatment of acute abdominal disease requiring urgent surgery in infants.

A six year old afebrile girl was referred to the emergency department with abdominal pain in the right lower region. A retrouterine partially cystic lesion with an inhomogene echogenity was demonstrated by transabdominal ultrasound. Pelvic MR showed an enlarged right-sided ovary and a thickened vascular pedicle as well as few adjacent free fluid. Diagnosis of ovarian torsion was confirmed intraoperatively. Conservative ovary-sparing treatment was not possible, so right-sided adnexectomy followed. Histopathologically a haemorrhagic infarction of the ovary and the tube was seen. No signs of malignancy and no tumor could be detected.

Body packing is a well recognized method of drug trafficking by smuggling drug containers in the gastrointestinal tract. Medical professionals might get involved with body packers after presentation by law enforcement or in case of medical emergencies such as drug overdose or mechanical intestinal obstruction due to the containers within the gastrointestinal tract. Besides the medical aspects in treating these patients, physicians must be aware of all the different legal specifics in dealing with body packers. In case of medical emergencies, drug traffickers have the legal status of regular patients with respect to professional medical discretion. The question remains of what physicians should do with the drugs after surgical removal? Even though the body packer remains the legal owner of the drugs, physicians may not return the drugs, since that constitutes the criminal offence of dealing in narcotics. Returning the drugs to law enforcement authorities is also prohibited because of professional medical discretion. The only way out of this predicament is for physicians to destroy the drugs under the observation of witnesses.

Objective: To present an analysis of our experience with 22 consecutive cases of acute abdominal gynecologic emergencies managed with a laparoscopic approach., Methods: From March 1997 to October 1998, 22 patients with a diagnosis of acute abdominal gynecologic emergencies underwent laparoscopic intervention. A transvaginal ultrasound was performed on all patients preoperatively to supplement the diagnostic workup. Surgical time, complications, and length of hospital stay were evaluated, and the laparoscopic diagnosis was compared with the preoperative diagnosis., Results: The laparoscopic diagnosis was different from the preoperative diagnosis in 31.8% of patients. Of the 22 patients, laparoscopic therapeutic procedures were performed in 18 (81.8%), all satisfactorily, and with no need for conversion to open surgery. No morbidity or mortality occurred., Conclusion: Laparoscopy is a safe and effective method for diagnosing and treating gynecologic emergencies.

Acute mesenteric ischemia represents an intensive medical emergency which, when untreated, leads to sepsis and multiorgan failure. Predictive factors for survival are the time duration between onset of symptoms and therapy, etiology,patient age, and immediate therapy with anticoagulants in case of acute mesenteric thrombosis. Pathologically raised laboratory parameters (lactate, acidosis, leukocytosis) are signs of advanced mesenteric ischemia. Therapy aims at reinstating arterial perfusion of ischemic and potentially life-threatening intestinal regions and at avoiding further ischemias or infarctions. Immediate vessel reconstruction (embolectomy, thrombectomy,TEA,bypass) can prevent mesenteric infarction and is therefore preferable to intestinal resection alone, as long as irreversible ischemia or sepsis are not present. If the degree of reperfusion is in question, the indication for "second-look laparotomy" is to be used generously.

The Authors report a rare case of duodenal neoplasia in a 17 year old boy. The patient was admitted in an emergency setting for hemorrhagic shock and duodenal perforation. Laparotomy was performed and a huge perforated neoplasia of the duodenum was found. Conservative approach was preferred, since the intraoperative histology was unuseful in choosing the better procedure: thus just a tumorectomy and closure of the duodenum were performed. Pathology examination demonstrated a neuroendocrine primitive duodenal tumors not well differentiated and with high grade of malignancy. The Authors discuss the role of the elements, clinical features and pathology, as well as emergency and postoperative management.

The development of video-laparoscopic techniques and surgical experience in this field have led to a resurgence of laparoscopy diagnostic purposes and have made it often the first action of surgical therapy with totally mini-invasive procedure. The purpose of this paper is to underline the clinical pictures of non traumatic acute abdomen that can profit from laparoscopy diagnostic ally and in related problems. The authors, in their initial experience of management of the urgency with laparoscopic approach, hold that laparoscopy can be not only the key to clarify a preoperative diagnostic doubt, but can reveal especially in some situations, such as pelvic pathologies in women of childbearing age the most correct surgical approach.

The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for patients with non-traumatic abdominal pain. Between August 1998 and April 1999, 536 consecutive patients with non-traumatic abdominal pain were entered into our study. Using a computer order entry system, physicians were asked to identify: (a) their most likely diagnosis; (b) their level of certainty in their diagnosis; (c) if they thought CT would be normal or abnormal; (d) their treatment plan (prior to knowledge of the CT results); and (e) their role in deciding to order CT. This information was correlated with each patient's post-CT diagnosis and subsequent management. Pre- and post-CT diagnoses were concordant in 200 of 536 (37%) patients. The physicians' certainty in the accuracy of their pre-CT diagnosis was less than high in 88% of patients. Prior to CT, the management plan included hospital admission for 402 patients. Following CT, only 312 patients were actually admitted; thus, the net impact of performing CT was to obviate the need for hospital admission in 90 of 536 (17%) of patients with abdominal pain. Prior to CT, 67 of 536 (13%) of all patients would have undergone immediate surgery; however, following CT only 25 (5%) actually required immediate surgery. Among patients with the four most common pre-CT diagnoses (appendicitis, abscess, diverticulitis, and urinary tract stones) CT had the greatest impact on hospital admission and surgical management for patients with suspected appendicitis. For patients with suspected appendicitis, CT reduced the hospital admission rate in 28% (26 of 91) of patients and changed the surgical management in 40% (39 of 91) of patients. Our study demonstrates the advantage of performing abdominal CT in the ED for patients with non-traumatic abdominal pain.

Background: The authors report the gynaecological pathology of surgical interest occurring in an Emergency Department in the first half of 2000 and occasionally found during an operation in women who presented a pelvic mass or abdominal pain., Methods: Six women, average age of 50 years, reached the Emergency Department: five of them were operated with an emergency procedure., Results: Of the 6 cases, 1 patient was affected by uterine mass, 1 by uterine-ovarian mass and 3 by ovarian mass; in one patient, affected by ovarian tumour, another intervention was necessary for intestinal metastasis., Conclusions: The authors have considered the clinical aspect of the abdominal masses, the age of the patients, the diagnostic laboratory and instrumental implications, the surgical approach and the histological result, referring to literature. Their contribution is related to the need for an appropriate surgical approach in emergency where it may, sometimes, solve or, at least, stabilize an uncertain clinical case, thanks to the implicit basic knowledge of multidisciplinary surgical technique.

In the large majority of cases, acute appendicitis can be diagnosed on the basis of the medical history and the patient's symptoms. Urine should be drawn from every patient for urinstix and bacteriological testing, as well as blood for a blood count, electrolytes and coagulation parameters. A US should be performed, in particular to exclude possible other diagnoses. Women should be examined by a gynecologist. Once the diagnosis has been established, the patient must be sent for surgery without delay. Should there be reason for doubt, further diagnostic measures (in particular CT) should be carried out as permitted by the urgency of the case. In life-threatening situations, laparoscopy should be done immediately, and preparations made for laparotomy should this be necessary. If the symptoms are such that a wait-and-see attitude is justified, continued observation and follow-up examinations are recommended. The diagnosis of acute appendicitis can be difficult, and every patient who rouses relevant suspicion, should be seen by a surgeon.

The most common causes for small-bowel obstructions with subsequent strangulation are intra-abdominal adhesions and external hernias. We report an unusual case of strangulated small-bowel hernia through a congenital window in the falciform ligament. The diagnosis and surgical treatment are discussed.

The case of a female patient aged 34 suffering from abdominal actinomycosis is reported. She underwent emergency surgery for an abscess-forming tumour infiltrating the lateral abdominal wall and giving rise to the clinical picture of acute abdomen. The casuistry is complemented by two further case histories of actinomyces infections in patients with fistulas of the anal region and pilonidal sinus respectively. Abdominal actinomycosis presents itself as a rare chronic bacterial inflammation, usually located in the right lower abdomen, with local abscess or fistula formation as well as tumour-like infiltration of the surrounding tissues. Exceptionally, the diagnosis is ascertained prior to surgery. Postoperative antibiotic therapy with penicillin for several months ist essential.

There are many potential reasons for an acute abdomen. Very rare is a rupture of a cystadenoma of the pancreas. We describe such a case of an 85-year old woman, who was treated with an internal drainage of the cyst with a Roux-Y-loop, as at the time of the emergency operation the histological diagnosis was not known. As for the age of the patient and her general condition a secondary procedure with total resection of the mucinous cyst was not carried out. The post-operative course was uneventful up to three months, when the patient died in a geriatric home due to a antibiotic-resistant urosepsis. Literature is reviewed and our case is discussed in respect to recent publications.

From January 1987 to December 1990 46 patients underwent laparotomy for mechanical ileus by adhesive bands at the Bürgerspital Solothurn. Supine and upright X-ray films of the abdomen had been taken in all cases. 31 patients presented typical radiographic signs. In 15 patients (32.8%) no air-fluid levels and no distention of small bowel loops were visible initially. Despite negative X-ray signs 7 of these patients underwent surgery within a median of 2 hours after hospital admission. Six times the indication was based on clinical findings alone and once on further examinations. On average symptoms had been present for 9 hours. The rate of resection was 14%. Eight cases underwent primary clinical observation. This resulted in a median delay to operation of 23 hours and a rate of resection of 50%. The 31 cases with initially positive radiologic findings had a lower rate of resection (25%) despite of a significantly (p = 0.011) longer duration of symptoms (46 hours) before admission. Diagnostic problems arise especially when X-ray signs are negative. Our cases confirm, that negative radiographs can not exclude the presence of an ileus. Quite to the contrary this group accumulates a significantly higher (p = 0.004) number of strangulation ileus. The accentuated pain leads to a significantly (p = 0.011) earlier hospital admission at a time when X-ray signs are not yet visible. Because of the real danger of intestinal necrosis the typical clinical symptoms and signs should lead to surgery without waiting for the later appearance of air-fluid levels.(ABSTRACT TRUNCATED AT 250 WORDS)

The sonography is very important diagnostic method for the abdominal emergency cases. This diagnostic screening method should be available in the surgical emergency station. Liquid, abscesses, organ ruptures and also many inflammations can be diagnosed with this not invasive method. It is our opinion that a training program in sonography should be available for young surgeons for the judgement of the abdominal emergency cases.

Emergency operations due to acute colonic disease between 1. 1. 1984 and 31. 12. 1991 were retrospectively analyzed with regard to causality, surgical procedure, complications and mortality. 55 of 1105 colonic operations were emergency cases requiring immediate surgical intervention. Primary continuity preserving resections were carried out whenever possible, attending not only to the acute situation but also to the primary disease. The mean age of the 26 females and 29 males was 69 [1, 9] years. 29 patients had a colonic ileus, 21 a diffuse peritonitis and 5 patients had an uncontrolled haemorrhage. Colorectal carcinomas were initially diagnosed in 20 of the 50 patients; 14 of these patients (70%) could be operated for potential cure and primary continuity preserving resections were also possible for 14 patients (70%). Continuity preserving resections were possible for 18 of 21 patients with peritonitis and 3 colonic perforations were oversutured. In the 5 patients with acute haemorrhage, 4 resections and one transanal intervention were performed. Postoperative complications were observed in 19 patients (35%). Postoperative mortality was 16% (9/55), 5% for operations due to peritonitis, 24% for operations due to colonic ileus and 20% for operations due to haemorrhage. Primary continuity preserving resections were possible for 39 of 55 patients (71%).

During a 19-month period 549 patients (278 women, 271 men) suffering from abdominal pain unrelated to trauma (mean age 48.2 years) entered the emergency room of the Department of Surgery of the University Hospital Zürich. 43% presented during business hours, whereas 57% were admitted during nighttime and/or weekends. Clinical examination, abdominal roentgenograms (upright and supine) as well as sonography were the most commonly used diagnostic tools. 40% suffered from abdominal pain of unknown cause. The most common diagnosis on admission was appendicitis. Only half of these cases really proved to be an appendicitis. In 36% the diagnosis on admission corresponds both to the initial diagnosis made by a member of staff during his first visit, as well as to the final diagnosis. The initial diagnosis agrees in 57% with the final diagnosis. In 10% of the patients the cause of pain was not elucidated despite extensive diagnostic procedures. High technology and sophisticated diagnostics are less important than the clinical evaluation. The decision between operative or nonoperative treatment was mainly based on clinical findings.

Survey of 304 cases of surgical, abdominal emergencies (peritonitis and bowel occlusions). We deplored 42 post-operative deaths (14%). When patients are operated within 12 hours after the beginning of the pain, out of a group of 56 patients, two died (4%). After the 48th hour, of 114 patients operated, 26 died (23%) despite a stay in an intensive care unit. 174 patients, under 60 years old, we operated; 4 died (2.3%). This is mainly due to a stay in an intensive care unit (50 were operated after the 48th hour). Out of a group of 60 eighty years old patients, 18 were operated before the 24th hour; one death, that of a 94 years old patient, was deplored. Out of the 42 patients operated after the 24th hour, 19 died (45%). On the 304 patients, 56 (18%) were operated before the 12th hour, and 18 only, before the 6th hour (6%). the delay in operating, does not increases mortality only, but increase the duration of hospitalisation; this in itself increase expenses and sufferings. The causes of these delays are analyzed. A wiser use of clinical examination would decrease them.

Eight patients required emergency laparotomy in the immediate postoperative period after coronary artery bypass (CAB). Cardiac complications were few and minor. Sepsis was the major cause of mortality. In the two patients who died, delay in operative management contributed to their deaths. The lack of cardiac causes of morbidity and mortality in our series and others suggests that a stable postoperative coronary bypass patient represents a better surgical risk than the same patient preoperatively. Therefore, aggressive management, including early laparotomy, for suspected intra-abdominal pathology after CAB is recommended to avoid uncontrollable sepsis and death.

During a 5-year period, 21 patients with metastatic cancer receiving chemotherapy for periods ranging from 2 months to 5 years have required emergency abdominal operations. Symptoms in 15 indicated perforated viscus, whereas six developed massive, unremitting hemorrhage. All were operated upon with the sole intent of correcting the life-threatening problem, and every attempt was made to maintain or normalize physiologic parameters postoperatively. Despite this, 51 major complications occurred in 19 patients, and 17 died in the immediate postoperative period, 11 following multiple systems failure. Two died within 1 month of transfer to another hospital nearer home. A single patient lived 5 months at a nursing facility. The only survivor is living in a complete state of remission 9 months after discharge. No distinguishing features that might preoperatively predict which patient might survive emergency operation were found. The monetary cost of returning the sole survivor to society was over $500,000, discounting the emotional expenditure required of patients, families, and hospital staff. The dilemma the surgeon faces in making therapeutic decisions regarding such patients requires careful weighing of realities and the willingness to assume responsibility for the best possible choice in order to free the patient and family from agonizing deliberations.

The results of 375 emergency abdominal operations in elderly patients over the age of 75 years are presented and discussed in detail. There has been a fourfold increase in the population over the age of 75 years in England and Wales during the 60-year period from 1911 to 1971. The overall mortality of these patients of 31-7 per cent is unrelated to the age of the patient, but appears to be directly related to the severity of the surgical condition and to cardiorespiratory complications. Our approach to these problems is presented and discussed.