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Abstract Background Surgical site infection (SSI) is a very common complication of emergency laparotomy and causes significant morbidity. The PICO◊ device delivers negative pressure wound therapy (NPWT) to closed incisions, with some studies suggesting a role for prevention of SSI in heterogenous surgical populations. We aimed to compare SSI rates between patients receiving PICO◊ versus conventional dressing post-emergency laparotomy. Secondary objectives were to observe seroma and dehiscence rates, length of stay, days on dressing and patients’ wound experience. Methods This double blinded randomized controlled trial was conducted in University Malaya Medical Centre between October 2019 and March 2022. Patients undergoing emergency laparotomy requiring incisions less than 35 cm were included. Statistical analysis was performed using χ2 test for categorical variables, independent T-test or Mann–Whitney U were used for parametric or non-parametric data respectively besides logistic regression. P values of

Background: Emergency laparotomies are high-risk surgical procedures often complicated by various postoperative outcomes. Diabetic patients are known to have higher morbidity and mortality rates due to their compromised immune status and delayed wound healing. This study aims to compare postoperative complications and mortality between diabetic and non-diabetic patients undergoing emergency laparotomies. Materials and Methods: This observational study was conducted over six months in the Department of General Surgery at Narayan Medical College and Hospital, Jamuhar. 200 patients, aged 18 years and above, who underwent emergency laparotomies were included. Patients were divided into two groups: diabetic (n=20) and non-diabetic (n=180). Immunocompromised patients (excluding diabetics), patients with malignancies, gynecological and urological emergencies, and pediatric patients were excluded. Data were collected through detailed history, general and systemic examinations, and relevant laboratory and radiological investigations. Preoperative prophylactic antibiotics were administered. Statistical analysis was performed using appropriate tests, with a p-value of less than 0.05 considered significant. Results: Postoperative complications were observed in 70% of diabetic patients and 40% of non-diabetic patients. The most common complications included wound infection (50% in diabetics vs. 20% in non-diabetics), sepsis (20% in diabetics vs. 10% in non-diabetics), and prolonged hospital stay (30% in diabetics vs. 10% in non-diabetics). Mortality rates were higher in diabetic patients (20%) compared to non-diabetic patients (10%). Conclusion: Diabetic patients undergoing emergency laparotomies exhibit a higher incidence of postoperative complications and mortality compared to non-diabetic patients. This underscores the need for meticulous perioperative management and targeted interventions to improve surgical outcomes in diabetic patients. [ABSTRACT FROM AUTHOR]

Background: Preoperative assessment of risk for emergency laparotomy may enhance decision making with regards to urgency or perioperative critical care admission and promote a more informed consent process for patients. Accordingly, we aimed to assess the performance of risk assessment tools in predicting mortality after emergency laparotomy. Methods: PubMed, Embase, the Cochrane Library and CINAHL were searched to 12 February 2022 for observational studies reporting expected mortality based on a preoperative risk assessment and actual mortality after emergency laparotomy. Study screening, data extraction, and risk of bias using the Downs and Black checklist were performed in duplicate. Data on setting, operation undertaken, expected and actual mortality rates were extracted. Meta-analysis was planned but not possible due to heterogeneity. This study is registered with PROSPERO, CRD42022299227. Results: From 10,168 records, 82 observational studies were included. 17 risk assessment tools were described, the most common of which were P-POSSUM (42 studies), POSSUM (13 studies), NELA (12 studies) and MPI (11 studies). Articles were published between 1990 and 2022 with the most common country of origin being the UK (33 studies) followed by India (11 studies). Meta-analysis was not possible. Observed mortality and expected mortality based on risk assessment is reported for each study and generally shows most studies show accurate risk prediction. Conclusions: This review synthesises available literature to characterise the performance of various risk assessment tools in predicting mortality after emergency laparotomy. Findings from this study may benefit those undertaking emergency laparotomy and future research in risk prediction.

Abstract Background The high rate of stoma placement during emergency laparotomy for secondary peritonitis is a paradigm in need of change in the current fast-track surgical setting. Despite growing evidence for the feasibility of primary bowel reconstruction in a peritonitic environment, little data substantiate a surgeons’ choice between a stoma and an anastomosis. The aim of this retrospective analysis is to identify pre- and intraoperative parameters that predict the leakage risk for enteric sutures placed during source control surgery (SCS) for secondary peritonitis. Methods Between January 2014 and December 2020, 497 patients underwent SCS for secondary peritonitis, of whom 187 received a primary reconstruction of the lower gastro-intestinal tract without a diverting stoma. In 47 (25.1%) patients postoperative leakage of the enteric sutures was directly confirmed during revision surgery or by computed tomography. Quantifiable predictors of intestinal suture outcome were detected by multivariate analysis. Results Length of intensive care, in-hospital mortality and failure of release to the initial home environment were significantly higher in patients with enteric suture leakage following SCS compared to patients with intact anastomoses (p

We aimed to study the relationship between mortality following emergency laparotomy (EL) in elderly patients and admission to a hospital facility, hypothesizing that patients initially admitted to a general surgery service have a better outcome. A retrospective review of the medical records of all the elderly patients (≥65 years) who underwent EL over three years was conducted in a single tertiary medical center. The outcomes evaluated include postoperative morbidity, mortality, discharge destination, and readmission. A total of 200 patients were eligible for this study; 106 (53%) were male, with a mean age of 77 ± 8.3 years. The mortality rate was 29.5% (59 patients), and 55% of all patients were discharged home after initial admission. Bowel obstruction was the most common indication for surgery (91, 45.5%). Patients undergoing an operation from non-general surgical services had higher readmission, unfavorable discharge and mortality rates, a greater incidence of stoma formation, and required a tracheostomy or were TPN-dependent (all p < 0.001). The mortality rate is higher in elderly patients needing an EL when initially admitted through a non-general surgery service. A correct and rapid initial diagnosis and decision are crucial when treating elderly individuals; initial admission to a general surgery service increases the probability of discharge home. [ABSTRACT FROM AUTHOR]

Abstract Background Emergency laparotomy is a commonly performed surgical procedure that has higher post-operative morbidity and mortality than elective surgery. Previous research has identified that patients valued postoperative quality of life (QoL) more than the risk of mortality when deciding to undergo emergency surgery. Current pre-operative scoring and risk stratification systems for emergency laparotomy do not account for or provide prediction tools for post-operative QoL. This study aims to systematically review previous literature to determine post-operative QoL in patients who undergo emergency laparotomy. Methods A literature search was undertaken in Medline, EMBASE and the Cochrane Library to identify studies measuring post-operative QoL in patients who have had emergency laparotomy up to 29th April 2023. Mean QoL scores from the studies included were combined to calculate the average effect of emergency laparotomy on QoL. The primary outcome of the review was postoperative QoL after emergency laparotomy when compared with a comparator group. Secondary outcomes included the quality of included studies. Results Ten studies in the literature assessing the QoL of patients after emergency laparotomy were identified. Three studies showed that patients had improved QoL and seven showed worse QoL following emergency laparotomy. Length of time for QoL to return to baseline varied ranged from 3 to 12 months post-operatively. Length of hospital stay was identified as an independent risk factor for poorer QoL post-surgery. Conclusions Outcome reporting for patients who undergo emergency laparotomy should be expanded further to include QoL. Further work is required to investigate this and elicit factors that can improve QoL post-operatively.

Introduction: Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by antiphospholipid antibodies (aPL), leading to a hypercoagulable state and an increased risk of thrombotic events. While abdominal complications have been reported as the initial presentation of APS in some cases, these instances are predominantly observed in female patients. Here, we present a case of a 49-year-old male patient who presented with complaints and a CT scan mimicking intestinal ileus. However, no mechanical or other evident cause of ileus could be found on the explorative laparotomy. After an uneventful postoperative hospitalization and being discharged in good condition, the patient was readmitted within two weeks, and this time, an extensive small bowel resection due to ischemia was done. After going home in a good and stable condition, he presents again, but this time with cerebral ischemia. Further investigations led to the APS diagnosis. With this case, we want to emphasize the importance of being aware of and considering the diagnosis of APS, especially in cases with repeated, unexplained abdominal pain and non-typical complaints, even in male patients. An early diagnosis could prevent a more complex disease complication. Conclusion: This case underscores the importance of considering APS in the differential diagnosis of unexplained abdominal pain, particularly in male patients with a history of thrombotic events or elevated aPL levels. Heightened awareness of APS in the emergency setting can facilitate timely diagnosis and appropriate management, ultimately optimizing patient care and outcomes.

Objective: To instantly stop life threatening abdominal bleeding (e.g., a ruptured abdominal aneurysm), every surgeon should be familiar with the principles of emergency laparotomy (EL) and aortic clamping. Simulation training in a safe environment can be used to rehearse these situations like other medical emergencies. Owing to the lack of a suitable commercial simulator, a homemade task trainer was constructed. This study aimed to evaluate the feasibility of an EL simulation training course among surgical residents using this low cost task trainer. Methods: To enable simulation training for massive abdominal bleeding with subsequent EL and aortic clamping, a multiprofessional team developed an EL task trainer. A structured evaluation of the trainer and its applicability was performed by external consultants, who tested the trainer themselves. Instructions for constructing the trainer were created and costs were calculated. During the EL simulation course targeted for surgical trainees early in their careers, 34 participants familiarised themselves with EL. Their experiences of the feasibility of the course and increase in self assessed clinical competence in managing the situation were studied using a questionnaire. In a subgroup of trainees, the simulation was compared with a real life EL subsequent to the course. Results: Participants found that the trainer was fit for its purpose (mean score, 4.7 out of 5). Their self assessed clinical competence increased in several domains: EL as a procedure (p < 0.01), handling of intra-abdominal tissues and organs during EL (p = 0.008), and emergency procedures in intra-abdominal haemorrhage (p < 0.001). The cost for the body of the trainer was €108 and there was an additional €42 for the disposables for one training scenario. Conclusion: A low cost task trainer with pulsatile flow enabling surgical residents to rehearse EL with aortic clamping can be constructed from commonly available materials. Preliminary experience of its feasibility and effects on learning in a simulation training course have been positive.

Abstract Introduction Currently, operative reports are narrative and often handwritten, making interpretation difficult and potentially omitting key steps of the procedure. This study undertook a systematic review to determine the current availability of synoptic operative reporting and develop a synoptic operative record template for emergency laparotomy (EL). Methods A PROSPERO registered study from January 1st, 2012, to December 31st, 2022, was conducted using PubMed, Scopus, and Web of Science databases in February 2023. Keywords: emergency laparotomy AND operation notes OR operative notes OR documentation OR report OR pro forma OR narrative OR synoptic OR digital OR audio-visual. Studies on paediatric or pregnant patients, systematic reviews, meta-analyses, case reports, editorial comments, and letters were excluded. A synoptic operative record was designed to include key standards in the documentation, as suggested by the Colleges of Surgeons. Results The literature search yielded 4687 articles, and no relevant published articles were found. A detailed synoptic template was developed, which included 111 fields related to patient demographics, operative findings, interventions, and documentation of key variables associated with patient outcomes. 11 were text boxes, two were related to digital audio-visual uploads, and three facilitated the digital scoring/grading of findings. Conclusion This systematic review identified a limited number of publications reporting synoptic operative reporting, and none related to emergency laparotomy. This novel operative template provides a platform for clear documentation of the surgery performed during emergency laparotomy, potentially facilitating data analysis, resident training, and research, in turn leading to a better understanding of patient outcomes.

Abstract Background and aims The Portsmouth-Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) is one of the scores that is used most frequently for determining the likelihood of mortality in patients undergoing emergency laparotomy. National Emergency Laparotomy Audit (NELA) presents a novel and validated score. Therefore, we aimed to compare the performance of the NELA and P-POSSUM mortality risk scores in predicting 30-day and 90-day mortality in patients undergoing emergency laparotomy. Methods Between August 2020 and October 2022, this cohort study was undertaken at Menoufia University Hospital. We compared the P-POSSUM, preoperative NELA, and postoperative NELA scores in patients undergoing emergency laparotomy. All variables needed to calculate the used scores were collected. The outcomes included the death rates at 30 and 90 days. By calculating the area under the curve (AUC) for every mortality instrument, the discrimination of the various methods was evaluated and compared. Results Data from 670 patients were included. The observed risk of 30-day and 90-day mortality was 10.3% (69/670) and 13.13% (88/670), respectively. Concerning 30-day mortality, the AUC was 0.774 for the preoperative NELA score, 0.763 for the preoperative P-POSSUM score, and 0.780 for the postoperative NELA score. Regarding 90-day mortality, the AUCs for the preoperative NELA score, preoperative P-POSSUM score, and postoperative NELA score were 0.649 (0.581–0.717), 0.782 (0.737–0.828), and 0.663 (0.608–0.718), respectively. There was noticeable difference in the three models' capacity for discrimination, according to pairwise comparisons. Conclusions The probability of 30-day and 90-day death across the entire population was underestimated by the NELA and P-POSSUM scores. There was discernible difference in predictive performance between the two scores.

Abstract Background Emergency laparotomy (EmLAP) is one of the commonest emergency operations performed in the United Kingdom (approximately 30, 000 laparotomies annually). These potentially high-risk procedures can be life changing with frail patients and/ or older adults (≥ 65 years) having the poorest outcomes, including mortality. There is no gold standard of frailty assessment and no clinical chemical biomarkers existing in practice. Early detection of subclinical changes or deficits at the molecular level are essential in improving our understanding of the biology of frailty and ultimately improving patient outcomes. This study aims primarily to compare preoperative frailty markers, including a blood-based biomarker panel, in their ability to predict 30 and 90-day mortality post-EmLAP. The secondary aim is to analyse the influence of perioperative frailty on morbidity and quality of life post-EmLAP. Methods A prospective single centred observational study will be conducted on 150 patients ≥ 40 years of age that undergo EmLAP. Patients will be included according to the established NELA (National Emergency Laparotomy Audit) criteria. The variables collected include demographics, co-morbidities, polypharmacy, place of residence, indication and type of surgery (as per NELA criteria) and prognostic NELA score. Frailty will be assessed using: a blood sample for ultra-high performance liquid chromatography mass spectrometry analysis; preoperative CT abdomen pelvis (sarcopenia) and Rockwood Clinical Frailty Scale (CFS). Patients will be followed up for 90 days. Variables collected include blood samples (at post operative day 1, 7, 30 and 90), place of residence on discharge, morbidity, mortality and quality of life (EQ-5D-5 L). The frailty markers will be compared between groups of frail (CFS ≥ 4) and non-frail using statistical methods such as regression model and adjusted for appropriate confounding factors. Discussion This study hypothesises that frailty level changes following EmLAP in frail and non- frail patients, irrespective of age. We propose that non- frail patients will have better survival rates and report better quality of life compared to the frail. By studying the changes in metabolites/ biomarkers in these patients and correlate them to frailty status pre-surgery, this highly novel approach will develop new knowledge of frailty and define a new area of clinical biomolecular research. Trial registration ClinicalTrials.gov: NCT05416047. Registered on 13/06/2022 (retrospectively registered).

Background: Emergency laparotomy (EL) is associated with high mortality rates and is performed on a heterogenous patient population. Pre-operative risk assessment is one tool which can assist with EL patient care. We aimed to characterise rates of pre-operative risk assessment for EL patients in South Australia. Methods: A retrospective audit of all patients undergoing EL over one year in six participating hospitals in South Australia was undertaken. Patient demographics, operation details, risk assessments (e.g. NELA, POSSUM, ACS-NSQIP) and outcomes were recorded. Results: 422 ELs were audited. Preoperative risk assessments were recorded for 42 (10 %) operations. The 30-day mortality rate was 9 %. There was no difference in mortality rates for patients with or without a risk assessment documented. Hospital participation in the Australia and New Zealand Emergency Laparotomy Audit (ANZELA) was associated with increased rates of risk assessment. Increasing patient age and then presence of certain comorbidities were also associated with increased rates of risk assessment. Conclusions: This audit shows poor uptake of recommendations for preoperative risk assessment in EL patients in South Australia. Comparable mortality rates to previously published Australian and international data are demonstrated. Factors associated with increased risk assessment rates are identified and are relevant to future quality improvement activities.

Background: Quantitative futility is an appraisal of the risk of failure of a treatment. For those who do not survive, a laparotomy has provided negligible therapeutic benefit and may represent a missed opportunity for palliation. The aim of this study was to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the National Emergency Laparotomy Audit (NELA) database. Methods: A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013–December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Baseline characteristics of this group were compared to all others. Multilevel logistic regression was carried out with potentially clinically important predictors defined a priori. Results: Quantitative futility occurred in 4% of patients (7442/180,987). Median age was 74 years (range 65–81 years). Median NELA risk score was 32.4% vs. 3.8% in the surviving cohort (p < 0.001). Early mortality patients more frequently presented with sepsis (p < 0.001). Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality (95% CI 1.22–1.55). Surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery (OR 2.67; 95% CI 2.50–2.85). Conclusions: Quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively. These findings should be incorporated qualitatively by the multidisciplinary team into shared decision-making discussions with extremely high-risk patients. [ABSTRACT FROM AUTHOR]

Abstract Background The number of older patients with multiple comorbidities in the emergency service is increasingly frequent, which implies the risk of incurring in futile surgical interventions. Some interventions generate false expectations of survival or quality of life in patients and families and represent a negligible therapeutic benefit in patients whose chances of survival are minimal. In order to address this dilemma, we describe mortality in a cohort of patients undergoing emergency laparotomy with a risk ≥ 75% per the ACS NSQIP Surgical Risk Calculator. Methods A retrospective observational study was designed to analyze postoperative mortality and factors associated with postoperative mortality in a cohort of patients undergoing emergency laparotomy between January 2018 and December 2021 in a high-complexity hospital who had a mortality risk ≥ 75% per the ACS NSQIP Surgical Risk Calculator. Results A total of 890 emergency laparotomies were performed during the study period, and 50 patients were included for the analysis. Patient median age was 82.5 (IQR: 18.25) years old and 33 (66.00%) were male. The most frequent diagnoses were mesenteric ischemia 21 (42%) and secondary peritonitis 18 (36%). Mortality in the series was 92%. Twenty-four (54.34%) died within the first 24 h of the postoperative period; 11 (23.91%) within 72 h and 10 (21.73%) within 30 days. APACHE II and SOFA scores were statistically significantly higher in patients who died. Conclusions All available tools should be used to make decisions, with the most reliable and objective information possible, and be particularly vigilant in patients at extreme risk (mortality risk greater than 75% according to ACS NSQIP Surgical Risk Calculator) to avoid futility and its consequences. The available information should be shared with the patient, the family, or their guardians through an assertive and empathetic communication strategy. It is necessary to insist on a culture of surgical ethics based on reflection and continuous improvement in patient care and to know how to accompany them in order to have a proper death.

Background: Non-traumatic emergency abdominal surgeries are common in most healthcare settings. To a significant extent, the outcomes of treatment are determined by the promptness of surgical interventions. However, the in-hospital waiting time which reflects perioperative promptness remains largely unexplored in developing countries. Objective: To describe the preoperative waiting time, identify the causes of delays, and determine subsequent outcomes for non-traumatic emergency abdominal surgeries. Methods: A cross-sectional study was conducted at a consultant zonal hospital in northern Tanzania from September 2012 to March 2013. Patients admitted and surgically treated for non-traumatic acute abdominal conditions were consecutively sampled. Sociodemographic and clinical data were obtained from medical records. Delays in surgical interventions were assessed based on observations at the Emergency Department and record analysis. Descriptive statistics and regression analysis were used to summarize the data and assess for factors influencing post-operative outcomes, respectively. Results: The study included 111 participants with a median age of 29 years (IQR=18-53). The median in-hospital preoperative waiting was 10.5 hours (IQR=6.6-14.7), with a substantial majority (78.4%) experiencing delays beyond 6 hours. The frequent reasons for delayed surgery included personnel shortage (37.8%), unavailable theater space (31.5%), and investigation-related factors (28.8%). Delayed hospital presentation (symptoms ≥24 hours) (OR=3.9, 95% CI=1.0-14.9) and prolonged waiting time (>6 hours) (OR=2.7, 95% CI=1.0-7.2) were significantly associated (P

Burst abdomen is a grave complication of laparotomy. X-suturing has been developed as a new method for reducing risk of burst abdomen. Five randomised controlled trials were conducted comparing X-suture with continuous suture in patients undergoing emergency laparotomy. The analysis of pooled data is presented. Data from five randomised controlled trials were collated. Data on individual patients were obtained from each centre on an Excel database format. A total of 1005 patients undergoing emergency laparotomy were studied. Of these 494 patients were randomised to X-suture arm and 511 to the continuous suture arm. The occurrence of burst abdomen was the main outcome of interest and the suture technique the main predictor of burst. The continuous suture group was considered the reference category. Risk ratio, risk difference, attributable proportion in exposed and prevented fraction in the exposed were calculated. Burst abdomen occurred in 9.31% patients in the X-suture group and in 20.35% patients in the continuous suture group. The risk difference (11%) and relative risk = 0.45 were highly significant (p = 0.0001) with a prevented fraction = 54%. Presence of diabetes, intraperitoneal sepsis, uraemia, and raised serum bilirubin were associated with increased risk of burst abdomen. The risk of burst abdomen can be substantially reduced with the use of X-suture in patients undergoing emergency laparotomy. [ABSTRACT FROM AUTHOR]

Abstract Background Emergency laparotomy (EL) has a high mortality rate. Clinically, frail patients have a poor tolerance for EL. In recent years, sarcopenia has been used as an important indicator of frailty and has received much attention. There have been five different calculation methods of psoas for computed tomography (CT) to measure sarcopenia, but lack of assessment of these calculation methods in Eastern Asian EL patients. Methods We conducted a 2-year retrospective cohort study of patients over 18 years of age who underwent EL in our institution. Five CT measurement values (PMI: psoas muscle index, PML3: psoas muscle to L3 vertebral body ratio, PMD: psoas muscle density, TPG: total psoas gauge, PBSA: psoas muscle to body face area ratio) were calculated to define sarcopenia. Patients with sarcopenia defined by the sex-specific lowest quartile of each measurement were compared with the rest of the cohort. The primary outcome was "ideal outcome", defined as: (1) No postoperative complications of Clavien-Dindo Grade ≥ 4; (2) No mortality within 30 days; (3) When discharged, no need for fluid resuscitation and assisted ventilation, semi-liquid diet tolerated, and able to mobilize independently. The second outcome was mortality at 30-days. Multivariate logistic regression and receiver operating characteristic (ROC) analysis were used. Results Two hundred and twenty-eight patients underwent EL met the inclusion criteria, 192 (84.2%) patients had an ideal outcome after surgery; 32 (14%) patients died within 30 days. Multivariate analysis showed that, except PMD, each calculation method of psoas was independently related to clinical outcome (ideal outcome: PML3, P

Abstract Background While emergency laparotomy has been associated with high rates of postoperative mortality and adverse events, preoperative systematic evaluation of patients may improve perioperative outcomes. However, due to the critical condition of the patient and the limited operation time, it is challenging to conduct a comprehensive evaluation. In recent years, sarcopenia is considered a health problem associated with an increased incidence of poor prognosis. This study aimed to investigate the effect of sarcopenia on 30-day mortality and postoperative adverse events in patients undergoing emergency laparotomy. Methods We systematically searched databases including PubMed, Embase, and Cochrane for all studies comparing emergency laparotomy in patients with and without sarcopenia up to March 1, 2022. The primary outcome was of 30-day postoperative mortality. Secondary outcomes were the length of hospital stay, the incidence of adverse events, number of postoperative intensive care unit (ICU) admissions, and ICU length of stay. Study and outcome-specific risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) tool. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE). Result A total of 11 eligible studies were included in this study. The results showed that patients with sarcopenia had a higher risk of death 30 days after surgery (OR = 2.42, 95% CI = 1.93–3.05, P

Background: Emergency laparotomy cases account for a significant proportion of the surgical caseload requiring postoperative intensive care. However, access to Intensive Care Unit (ICU) services has been limited by the scarcity of resources, lack of guidelines, and paucity of triaging tools. Objective: This study aimed at developing a feasible Post-emergency laparotomy ICU admission Predictive (PIP) scoring tool. Methodology: A case-control study utilizing the records of 108 patients who underwent emergency laparotomy was conducted. The primary outcome was the postoperative disposition status. Cases were defined as emergency laparotomy patients admitted to the ICU. The control group constituted patients admitted to the general ward. Logistic regression analysis was performed to identify the perioperative predictors of outcome. The PIP score was developed as a composite of each statistically significant variable remaining in the final logistic regression model. Results: The significant positive predictors of ICU admission included a worsening American Society of Anesthesiologists - Physical Status, decreasing preoperative baseline axillary temperature, increasing preoperative baseline pulse rate, and intraoperative blood-product transfusion. The scoring system incorporating the identified predictors was presented as a numeric scale ranging from zero to four. Two levels of prediction were defined with reference to the optimum cut-off value; a score of

This article discusses the value of frailty assessments in older surgical patients undergoing emergency laparotomies in Singapore. The study highlights the high mortality rates associated with emergency laparotomy and the increased vulnerability of older patients. Frailty is defined as a gradual loss of physiological reserves, and evidence suggests that frailty is a better predictor of postoperative morbidity and mortality than chronological age alone. The Clinical Frailty Scale (CFS) is recommended as a validated tool for screening frailty. Implementing standardized frailty assessments in Singapore would improve benchmarking of surgical outcomes and allow for targeted interventions and individualized care plans for frail older patients. [Extracted from the article]

Abstract Background Emergency laparotomy (EL) is a central, high-risk procedure in emergency surgery. Patients in need of an EL present an acute pathology in the abdomen that must be operated on in order to save their lives. Usually, the underlying condition produces an affected physiology. The perioperative management of this critically ill patient group in need of high-risk surgery and anaesthesia is challenging and related to high mortality worldwide. However, outcomes in Sweden have yet to be studied. This retrospective cohort study explores the perioperative management and outcome after 710 ELs by investigating mortality, overall length of stay (LOS) in hospital, need for care at the intensive care unit (ICU), surgical complications and a general review of perioperative management. Methods Medical records after laparotomy was retrospectively analysed for a period of 38 months (2014–2017), the emergency cases were included. Children (

Abstract Background Emergency laparotomy carries a significant risk profile around the time of surgery. This research aimed to establish the feasibility of recruitment to a study using validated scoring tools to assess complications after surgery; and patient-reported outcome measures (PROMs) to assess quality of life and quality of recovery up to a year following emergency laparotomy (EL). Methods We used our local National Emergency Laparotomy Audit (NELA) register to identify potential participants at a single NHS centre in England. Complications were assessed at 5, 10 and 30 days after EL. Patient-reported outcome measures were collected at 1, 3, 6 and 12 months after surgery using EQ5D and WHODAS 2.0 questionnaires. Results Seventy of 129 consecutive patients (54%) agreed to take part in the study. Post-operative morbidity survey data was recorded from 63 and 37 patients at postoperative day 5 and day 10. Accordion Complication Severity Grading data was obtained from 70 patients. Patient-reported outcome measures were obtained from patients at baseline and 1, 3, 6 and 12 months after surgery from 70, 59, 51, 48, to 42 patients (100%, 87%, 77%, 75% and 69% of survivors), respectively. Conclusions This study affirms the feasibility of collecting PROMs and morbidity data successfully at various time points following emergency laparotomy, and is the first longitudinal study to describe quality of life up to a year after surgery. This finding is important in the design of a larger observational study into quality of life and recovery after EL.

Aim: There is evolving evidence that preoperative frailty predicts outcomes of older adults undergoing emergency laparotomy (EmLap). We assessed frailty scoring in an emergency surgical population that included patients of all ages and then compared this to an established perioperative prognostic score. Method: Data from the prospective Emergency Laparoscopic and Laparotomy Scottish Audit (ELLSA; November 2017–October 2018) was used. All adults over 18 were included. Frailty was measured using 7‐point clinical frailty score (CFS). Outcome measures: 30‐day mortality, hospital length of stay (LOS), 30‐day readmission. Areas under the receiver‐operating characteristic (ROC) curves were calculated for CFS (1–7) and compared to the National Emergency Laparotomy Audit (NELA) score with Forest plots used to compare 30‐day mortality across CFS and NELA categories. Results: A total of 2246 patients (median age 65 years [IQR 51–75]; female 51%) underwent EmLap (60% for colorectal pathology). A total of 10.6% were frail preoperatively (≥CFS 5). As CFS increased so did 30‐day mortality (2.1% CFS1 to 25.3% CFS6 and 7; ꭓ278.2, p < 0.001) and median LOS (10 days CFS1 to 20 days CFS6 and 7; p < 0.001). Readmission rates did not differ significantly across CFS. ROC (95% CI) for mortality was 0.71 (0.65–0.77) for CFS and 0.84 (0.78–0.89) for NELA. Addition of CFS to NELA did not increase ROC value. Conclusion: This study supports the prognostic role of frailty in the emergency surgical setting, finding increasing frailty to be associated with increased mortality and longer LOS in adults of all ages. Although NELA performed better, CFS remained predictive and has the advantage of being calculated preoperatively to aid decision‐making and treatment planning. [ABSTRACT FROM AUTHOR]

Introduction: Emergency laparotomy is a considerable component of a colorectal surgeon's workload and conveys substantial morbidity and mortality, particularly in older patients. Frailty is associated with poorer surgical outcomes. Frailty and sarcopenia assessment using Computed Tomography (CT) calculation of psoas major area predicts outcomes in elective and emergency surgery. Current risk predictors do not incorporate frailty metrics. We investigated whether sarcopenia measurement enhanced mortality prediction in over-65 s who underwent emergency laparotomy and emergency colorectal resection. Methods: An analysis of data collected prospectively during the National Emergency Laparotomy Audit (NELA) was conducted. Psoas major (PM) cross-sectional area was measured at the L3 level and a ratio of PM to L3 vertebral body area (PML3) was calculated. Outcome measures included inpatient, 30-day and 90-day mortality. Statistical analysis was conducted using Mann–Whitney, Chi-squared and receiver operating characteristics (ROC). Logistic regression was conducted using P-POSSUM variables with and without the addition of PML3. Results: Nine-hundred and forty-four over-65 s underwent emergency laparotomy from three United Kingdom hospitals were included. Median age was 76 years (IQR 70–82 years). Inpatient mortality was 21.9%, 30-day mortality was 16.3% and 90-day mortality was 20.7%. PML3 less than 0.39 for males and 0.31 for females indicated significantly worse outcomes (inpatient mortality 68% vs 5.6%, 30-day mortality 50.6% vs 4.0%,90-day mortality 64% vs 5.2%, p < 0.0001). PML3 was independently associated with mortality in multivariate analysis (p < 0.0001). Addition of PML3 to P-POSSUM variables improved area under the curve (AUC) on ROC analysis for inpatient mortality (P-POSSUM:0.78 vs P-POSSUM + PML3:0.917), 30-day mortality(P-POSSUM:0.802 vs P-POSSUM + PML3: 0.91) and 90-day mortality (P-POSSUM:0.79 vs P-POSSUM + PML3: 0.91). Conclusion: PML3 is an accurate predictor of mortality in over-65 s undergoing emergency laparotomy. Addition of PML3 to POSSUM appears to improve mortality risk prediction. [ABSTRACT FROM AUTHOR]

Abstract Background Abdominal cocoon syndrome is a rare cause of intestinal obstruction in which loops of small bowel get entrapped inside a fibro-collagenous membrane. Condition is also known in the literature as sclerosing peritonitis and in the majority of cases, it has no known cause. Although the majority of patients exhibit long-standing signs and symptoms of partial bowel obstruction in an out-patient clinic, its acute presentation in the emergency room with features of sepsis is extremely rare. This case report aims to describe the emergency presentation of cocoon abdomen with septic peritonitis. Case presentation A 35-year-old male with no known co-morbidity and no prior history of prior laparotomy presented in emergency room first time with a 1-day history of generalized abdomen pain, vomiting, and absolute constipation. He was in grade III shock and had metabolic acidosis. The clinical impression was of the perforated appendix, but initial contrast-enhanced computed tomography (CECT) was suggestive of strangulated internal herniation of small bowel. Emergency laparotomy after resuscitation revealed hypoperfused, but viable loops of small bowel entrapped in the sclerosing membrane. Extensive adhesiolysis and removal of the membrane were performed and the entire bowel was straightened. Postoperatively he remained well and discharged as planned. Histopathology report confirms features of sclerosing peritonitis. Discussion Cocoon abdomen is a very rare cause of acute small bowel obstruction presenting in an emergency with features of septic peritonitis. Condition is mostly chronic and generally mimics abdominal TB in endemic areas like India and Pakistan. A high index of suspicion is required in an emergency setting and exploratory laparotomy is diagnostic and therapeutic as well and the condition mimics internal herniation in acute cases. Conclusion Cocoon abdomen as a cause of septic peritonitis is extremely rare and might be an unexpected finding at laparotomy. Removal of membrane and estimation of the viability of entrapped bowel loops is the treatment of choice, which may require resection in the extreme case of gangrene.

Background: Days alive and out of hospital (DAOH) is a composite, patient-centred outcome measure describing a patient's postoperative recovery, encompassing hospitalisation and mortality. DAOH is the number of days not in hospital over a defined postoperative period; patients who die have DAOH of zero. The Standardising Endpoints in Perioperative Medicine (StEP) group recommended DAOH as a perioperative outcome. However, DAOH has never been validated in patients undergoing emergency laparotomy. Here, we validate DAOH after emergency laparotomy and establish the optimal duration of observation.Methods: Prospectively collected data of patients having emergency laparotomy in England (December 1, 2013-November 30, 2017) were linked to national hospital admission and mortality records for the year after surgery. We evaluated construct validity by assessing DAOH variation with known perioperative risk factors and predictive validity for 1 yr mortality using a multivariate Bayesian mixed-effects logistic regression. The optimal postoperative DAOH period (30 or 90 days) was judged on distributional and pragmatic properties.Results: We analysed 78 921 records. The median 30-day DAOH (DAOH30) was 16 (inter-quartile range [IQR], 0-22) days and the median DAOH90 was 75 (46-82) days. DAOH was shorter in the presence of known perioperative risk factors. For patients surviving the first 30 postoperative days, shorter DAOH30 was associated with higher 1-yr mortality (odds ratio=0.94; 95% credible interval, 0.94-0.94).Conclusion: DAOH is a valid, patient-centred outcome after emergency laparotomy. We recommend its use in clinical trials, quality assurance, and quality improvement, measured at 30 days as mortality heavily skews DAOH measured at 90 days and beyond. [ABSTRACT FROM AUTHOR]

Abstract Background Despite the importance of predicting adverse postoperative outcomes, functional performance status as a proxy for frailty has not been systematically evaluated in emergency abdominal surgery. Our aim was to evaluate if the Eastern Cooperative Oncology Group (ECOG) performance score was independently associated with mortality following high-risk emergency abdominal surgery, in a multicentre, retrospective, observational study of a consecutive cohort. Methods All patients aged 18 or above undergoing high-risk emergency laparotomy or laparoscopy from four emergency surgical centres in the Capitol Region of Denmark, from January 1 to December 31, 2012, were included. Demographics, preoperative status, ECOG performance score, mortality, and surgical characteristics were registered. The association of frailty with postoperative mortality was evaluated using multiple regression models. Likelihood ratio test was applied for goodness of fit. Results In total, 1084 patients were included in the cohort; unadjusted 30-day mortality was 20.2%. ECOG performance score was independently associated with 30-day mortality. Odds ratio for mortality was 1.70 (95% CI (1.0, 2.9)) in patients with ECOG performance score of 1, compared with 5.90 (95% CI (1.8, 19.0)) in patients with ECOG performance score of 4 (p < 0.01). Likelihood ratio test suggests improvement in fit of logistic regression modelling of 30-day postoperative mortality when including ECOG performance score as an explanatory variable. Conclusions This study found ECOG performance score to be independently associated with the postoperative 30-day mortality among patients undergoing high-risk emergency laparotomy. The utility of including functional performance in a preoperative risk assessment model of emergency laparotomy should be evaluated.

Abstract Background Uterine leiomyomas are common benign tumours found in women of reproductive age that are rarely associated with intra-abdominal haemorrhage. The aetiology behind this relationship is poorly understood and the aforementioned association poorly recognized from a patient’s clinical presentation. Available information in the literature is limited to case reports. The aim of this systematic review is to document and highlight the occurrence of intra-abdominal haemorrhage from uterine fibroids, and determine associated morbidity and mortality. Methods A systematic review of Medline, EMBASE, Web of Science, Scopus, and The Cochrane Library – CENTRAL was performed from the databases inception through to December 2018 for case report and series of patients who experienced intra-abdominal haemorrhage from uterine fibroids. Findings were presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Results We identified 115 publications reporting on 125 original case reports. The documented intra-abdominal haemorrhage were commonly due to the rupture of superficial blood vessels over the surface of a fibroid, followed by rupture and avulsion of the fibroid involved. A clinical picture of sudden and profound hypovolemic shock with severe abdominal pain was often the presenting complaint, with a correct pre-operative diagnosis only made in 7 cases on computed tomography imaging. Hysterectomy and myomectomy were the most common surgery performed. Mortality was reported in 4 cases which were directly related to complications of uterine fibroids. Conclusion Intra-abdominal haemorrhage secondary to uterine fibroids remained a rare phenomenon which is poorly recognized among clinicians. While this association is not representative of the population of interest, it highlights the pathophysiological spectrum of uterine fibroids and its relevance to emergency physicians, surgeons and gynaecologists during clinical practice.

IntroductionCystic adenomyosis is a rare type of adenomyosis that often occurs in adolescents or women of childbearing age. Due to the few reports of this case, its clinical characteristics have not been clearly established.Case PresentationWe treated a 32-year-old married patient with cystic adenomyosis that reported persistent abdominal pain and massive vaginal bleeding, so an emergency laparotomy was performed. The intraoperative findings and post-operative pathology proved that the diagnosis was correct. The prognosis of the patient is good, and there is no recurrence within 3 months after surgery.ResultsSurgery is the most effective way to treat cystic adenomyosis. Ultrasound and magnetic resonance are the most effective auxiliary examinations for diagnosing the disease.ConclusionCystic adenomyosis is a sporadic disease. This article summarizes this condition's clinical manifestations, pathological features, diagnosis, treatment, and prognosis by reviewing the existing literature and the case presented in this report. It is noteworthy that early diagnosis and individualized treatment strategies can improve patients' quality of life.

Introduction There is established evidence on the role of enhanced recovery after surgery (ERAS) protocols in elective surgeries but its effectiveness in emergency surgeries has been nominally studied. We aimed at studying the feasibility and effectiveness of ERAS protocols in patients undergoing emergency abdominal surgery for intestinal perforation and small bowel obstruction and compare their surgical outcomes with conventional care. Materials and methods This prospective randomized study was performed for a period of 16 months. A total of 100 patients presenting either with intestinal perforation or acute small bowel obstruction were recruited; 50 each in the ERAS and the conventional care groups. The primary outcomes studied were the postoperative length of stay and 30-day morbidity and mortality. Results It was seen that the median (interquartile range) of the duration of hospital stay in the ERAS group was 4 (1) days while it was 7 (3) days in the conventional care group, which was statistically significant (W = 323.000, p ≤ 0.001). Similarly, postoperative morbidities like a chest infection and surgical site infections) were significant in the conventional care group. Conclusion The ERAS protocols are safe and effective in emergency surgeries and result in a better postoperative outcome.

The impact of synchronous diseases or conditions on operative management of Trauma patients is not well established. In trauma patients, secondary diagnoses may complicate the treatment strategy and lead to changes in management and potentially outcomes. We present 5 unusual trauma cases and we discuss the difficulties and the outcomes we experienced in managing these patients.

Introduction: Although high rates of in-hospital mortality have been described in older patients undergoing emergency laparotomy (EL), less is known about longer-term outcomes in this population. We describe factors present at the time of hospital admission that influence 12-month survival in older patients. Methods: Observational study of patients aged 75 years and over, who underwent EL at our hospital between 8th September 2014 and 30th March 2017. Results: 113 patients were included. Average age was 81.9 ± 4.7 years, female predominance (60/113), 3 (2.6%) lived in a care home, 103 (91.2%) and 79 (69.1%) were independent of personal and instrumental activities of daily living (ADLs) and 8 (7.1%) had cognitive impairment. Median length of stay was 16 days ± 29.9 (0–269); in-hospital mortality 22.1% (25/113), post-operative 30-day, 90-day and 12-month mortality rates 19.5% (22), 24.8% (28) and 38.9% (44). 30-day and 12-month readmission rates 5.7% (5/88) and 40.9% (36). 12-month readmission was higher in frail patients, using the Clinical Frailty Scale (CFS) score (64% 5–8 vs 31.7% 1–4, p = 0.006). Dependency for personal ADLs (6/10 (60%) dependent vs. 38/103 (36.8%) independent, p = 0.119) and cognitive impairment (5/8 (62.5%) impaired vs. 39/105 (37.1%) no impairment, p = 0.116) showed a trend towards higher 12-month mortality. On multivariate analysis, 12-month mortality was strongly associated with CFS 5–9 (HR 5.0403 (95% CI 1.719–16.982) and ASA classes III–V (HR 2.704 95% CI 1.032–7.081). Conclusion: Frailty and high ASA class predict increased mortality at 12 months after emergency laparotomy. We advocate early engagement of multi-professional teams experienced in perioperative care of older patients. [ABSTRACT FROM AUTHOR]

Abstract Background Little is known about the economic impact of emergency laparotomy (EL) surgery in healthcare systems around the world. The aim of this systematic review is to describe the primary resource utilisation, healthcare economic and societal costs of EL in adults in different countries. Methods MEDLINE, EMBASE, ISI Web of Knowledge, Cochrane Central Register Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were searched for full and partial economic analyses of EL published between 1 January 1991 and 31 December 2015. Quality of studies was assessed using the Consensus on Health Economic Criteria (CHEC) checklist. Results Sixteen studies were included from a range of countries. One study was a full economic analysis. Fifteen studies were partial economic evaluations. These studies revealed that emergency abdominal surgery is expensive compared to similar elective surgery when comparing primary resource utilisation costs, with an important societal impact. Most contemporaneous studies indicate that in-hospital costs for EL are in excess of US$10,000 per patient episode, rising substantially when societal costs are considered. Discussion EL is a high-risk and costly procedure with a disproportionate financial burden for healthcare providers, relative to national funding provisions and wider societal cost impact. There is substantial heterogeneity in the methodologies and quality of published economic evaluations of EL; therefore, the true economic costs of EL are yet to be fully defined. Future research should focus on developing strategies to embed health economic evaluations within national programmes aiming to improve EL care, including developing the required measures and infrastructure. Conclusions Emergency laparotomy is expensive, with a significant cost burden to healthcare and systems and society worldwide. Novel strategies for reducing this econmic burden should urgently be explored if greater access to this type of surgery is to be pursued as a global health target. Trial registration PROSPERO registration no. 42015027210 .

Background: Studies across healthcare systems have demonstrated between-hospital variation in survival after an emergency laparotomy. We postulate that this variation can be explained by differences in perioperative process delivery, underpinning organisational structures, and associated hospital characteristics.Methods: We performed this nationwide, registry-based, prospective cohort study using data from the National Emergency Laparotomy Audit organisational and patient audit data sets. Outcome measures were all-cause 30- and 90-day postoperative mortality. We estimated adjusted odds ratios (ORs) for perioperative processes and organisational structures and characteristics by fitting multilevel logistic regression models.Results: The cohort comprised 39 903 patients undergoing surgery at 185 hospitals. Controlling for case mix and clustering, a substantial proportion of between-hospital mortality variation was explained by differences in processes, infrastructure, and hospital characteristics. Perioperative care pathways [OR: 0.86; 95% confidence interval (CI): 0.76-0.96; and OR: 0.89; 95% CI: 0.81-0.99] and emergency surgical units (OR: 0.89; 95% CI: 0.80-0.99; and OR: 0.89; 95% CI: 0.81-0.98) were associated with reduced 30- and 90-day mortality, respectively. In contrast, infrequent consultant-delivered intraoperative care was associated with increased 30- and 90-day mortality (OR: 1.61; 95% CI: 1.01-2.56; and OR: 1.61; 95% CI: 1.08-2.39, respectively). Postoperative geriatric medicine review was associated with substantially lower mortality in older (≥70 yr) patients (OR: 0.35; 95% CI: 0.29-0.42; and OR: 0.64; 95% CI: 0.55-0.73, respectively).Conclusions: This multicentre study identified low-technology, readily implementable structures and processes that are associated with improved survival after an emergency laparotomy. Key components of pathways, perioperative medicine input, and specialist units require further investigation. [ABSTRACT FROM AUTHOR]

Background: International studies reporting outcomes following emergency laparotomies have consistently demonstrated wide inter‐hospital variation and a 30‐day mortality in excess of 10%. The UK then prioritized the funding of the National Emergency Laparotomy Audit. In a prospective Western Australian audit there was minimal inter‐hospital variation and a 6.6% 30‐day mortality. In the absence of any multi‐hospital Australian data the aim of the present study was to compare national administrative data with that previously reported. Methods: Data on emergency laparotomies performed in Australian public hospitals during 2013/2014 and 2014/2015 were extracted from admitted patient activity and costing data sets collated by the Independent Hospital Pricing Authority. The data sets, containing episode‐level data relating to admitted acute and sub‐acute care patients, included administrative, demographic and clinical information such as patient age, cost, length of stay, in‐hospital mortality, diagnosis and surgical procedure details. Results: Ninety‐nine public hospitals undertaking at least 50 emergency laparotomies performed 20 388 procedures over the 2 years. The overall in‐hospital mortality was 5.2%. There was a wide interstate and inter‐hospital variation in risk‐adjusted in‐hospital mortality (4.8–6.6% and 0–9.3%, respectively), length of stay (12.5–16.8 days and 5.8–18.9 days, respectively) and intensive care unit admissions (24.5–40.2% and 0–75.7%, respectively). Conclusion: This data suggest the wide variation in outcomes and care process observed overseas exist in Australia. However, administrative data has considerable limitations and is not a substitute for high quality prospective data. Minimizing variations through prospective quality improvement processes will improve patient outcomes. [ABSTRACT FROM AUTHOR]

High risk general surgical patients are over-represented in mortality rates following an emergency laparotomy. Nine studies were identified in order to identify prognostic factors affecting mortality in these high-risk patients with the conclusion that these patients need early recognition and consultant-led care to reduce mortality rates. [ABSTRACT FROM AUTHOR]

Background; Nowadays penetrating trauma is increasing because of the growth of violence in our society. The penetrating injury (PI) constitute about 6% of the hospitalized cases and 10% of visits to the emergency department (ED), they are calculated to the second as the leading cause of death after motor vehicle accident (MVA) and occupied 20% of deaths related to injuries in the USA.[1] Objective: The purpose of this study was to evaluate the management results of patients with penetrating abdominal injuries. Patients and methods; We have used a standardized data collection instrument, case records of all patients with penetrating trauma (PT) diagnosed between January 2015 and August 2017. All patients who had performed or not emergency laparotomy (EL) after sustaining Blast injuries (BI), Gunshot wounds (GSW), stab wounds (SW), Sharp tools wounds (STW) were included in our study. Results; We have recorded 102 patients (Pt)[93(91%) male & 9(9%) female] with PAT in this study. Of 102 Pt, 47 (46%) were coming from Tirana, and 55 (54%) from another hospital. The mean age was 34.6 (10-80) years. The distribution of data based on mechanism of injury was; 2 (2%) of Pt was after BI, 34(33%) of Pt was after GSW, 55 (54%) of Pt was after SW, 11(11%) of Pt was after STW, were included in our study. Conclusions; Management of PAT remains a serious issue in ED. The outcome of treatment is dependent on the mechanism of injury, age, presence of shock in admission, number of injuries organ, associations with extra-abdominal injuries…

Emergency laparotomy is a common general surgical emergency procedure carried out worldwide. It carries with it a very high morbidity and mortality, second only to surgery for ruptured aortic artery aneurysm. There has been considerable work done to improve the outcomes following emergency laparotomy worldwide. In the United Kingdom, the National Emergency Laparotomy Audit (NELA) was established in 2014. It aims to improve the quality of care for emergency laparotomy patients by providing high quality comparative data collected nationally. It also highlights key standards in the provision of care. The focus of NELA and other quality improvement projects related to emergency laparotomy is improving every step in the patient pathway. This includes access to diagnostic investigations, consultant care, risk stratification and post-operative care in an appropriate destination. Every small improvement in each step would aggregate to provide a considerable reduction in patient mortality and morbidity, as well as reduction in the healthcare burden to the system. The aim of this review is to discuss some of the significant steps in improving the quality of emergency laparotomy care and the accompanying evidence. [ABSTRACT FROM AUTHOR]

Objectives: In 2011, the Royal College of Surgeons published Emergency Surgery: Standards for Unscheduled Care in response to variable clinical outcomes for emergency surgery. The purpose of this study was to examine whether different treatment modalities would alter survival.Methods: All patients who underwent emergency laparotomy between April 2011 and December 2012 at Warwick Hospital (Warwick, UK) were included retrospectively. Information relating to their demographics; preoperative score; primary pathology; timing of surgery; intraoperative details; and postoperative outcome, including 30-day mortality, were collated for statistical analysis.Results: In total, 91 patients underwent 97 operations. The median age was 64 years (range 50-90, male:female 1:2). Sixty-five percent of cases were obstruction and perforation, and 66% of all operations were performed during office hours. The unadjusted 30-day mortality was 15.4%. Compared with nonsurvivors, survivors had a significantly higher Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity score (P < 0.001), prolonged duration of hypotension and use of inotropes (P = 0.013), higher volume of colloid use (P = 0.04), and lower core body temperature (P < 0.05). Grades of surgeons did not influence mortality.Conclusions: The 30-day mortality rate is comparable to the national standard. Further studies are warranted to determine whether trauma management modalities may be adopted to target high-risk patients who exhibit the lethal triad of hypotension, coagulopathy, and hypothermia. [ABSTRACT FROM AUTHOR]

Jejunal diverticula with perforation is very rare. Incidence of Jejunal diverticula on enteroclysis is 2.0–2.3% and on autopsy it is 0.06–4.6%. Incidence of perforation in Jejunal diverticula is 2.3-6.4%. Pathologically it is pulsion type of pseudo diverticula occuring along the mesenteric border of the intestine, where the blood vessels pierce the muscularis layer causing weak areas to develop. These out-pouchings contain mucosa and submucosa only hence perforates easily. 74 year old male patient presents with pain in abdomen since 1 day. Patient was toxic and per abdomen examination shows diffuse tenderness+, guarding+, rigidity+, abdomen distention +, Bowel sounds absent. Erect X-ray abdomen showed air under the diaphragm. Emergency Laparotomy performed and multiple Jejunal diverticula with a perforation in mesenteric border of Jejunum was noted. Segmental Resection and end to end anastamosis was done. Postoperative period was uneventful. Jejunal diverticula with perforation is very rare and mostly an incidental finding during Laparotomy. Segmental Resection and anastamosis is the treatment of choice.

Background: Intra-abdominal hypertension (IAH) is defined as a sustained elevation in intra-abdominal pressure (IAP) greater than or equal to 12 mmHg. IAH has been shown to cause organ derangements and dysfunction in the body. Objective screening of IAH is neither done early enough nor at all thus leading to significant morbidity and mortality among surgical patients. The epidemiology and outcome of IAH among surgical patients has not been documented in Uganda. The aim of this study was to determine the prevalence, incidence and outcome of intra-abdominal hypertension among patients undergoing emergency laparotomy. Methodology: Prospective observational study, conducted from January to April 2015 among patients undergoing emergency laparotomy. Inclusion criteria was; age >7 yrs, scheduled for emergency laparotomy, able to lie supine. Exclusion Criteria: pregnant, failed urethral catheterization, known cardiac, renal and respiratory disorders. Consecutive sampling was used. IAP, blood pressure, heart rate, respiratory rate, Sp02, Serum creatinine, Serum urea, and Urine output were measured preoperatively and postoperatively at 0, 6, 24 and 48 h. IAH was defined as IAP > 12 mmHg on three consecutive readings 3 min apart. Results: In total 192 patients were enrolled. Mean age ± SD was 14.25 (±3.16) yrs in the paediatrics and 34.4(±13.72) yrs in the adults with male preponderance 65 and 80.7 % respectively. The prevalence of IAH was 25 % paediatrics and 17.4 % adults and the cumulative incidence after surgery was 20 % paediatrics and 21 % adults. In paediatrics, IAH was associated with mortality at 0 h postoperatively, RRR = 1:24, 95 % CI (1.371-560.178), p-value 0.048. In adults, the statistically significant outcomes associated with IAH were respiratory system dysfunction RRR1:2.783, p-value 0.023, 95 % CI (1.148-6.744) preoperatively and mortality RRR 1:2.933, p-value 0.034, 95 % CI (1.017-8.464) at 6 h, RRR 1:3.769, p-value 0.033, 95 % CI (1.113-12.760) at 24 h postoperatively. Conclusion: The prevalence and incidence of IAH in the paediatrics and adults group in our study population were high. IAH was associated with mortality in both adult and paediatrics groups and respiratory system dysfunction in adult group. This calls for objective monitoring of intraabdominal pressure in patients undergoing emergency laparotomy with the aim of reducing associated mortality. [ABSTRACT FROM AUTHOR]

Monitoring of surgical outcome is increasingly important part of governance of surgical activity. The aim of the study. POSSUM scoring system was applied prospectively to determine how it performed in predicting morbidity and mortality in patients undergoing emergency laparotomy in our hospital, a group known to be at high risk of complications and death. Material and methods. A total of 100 cases of emergency laparotomies were studied in patients admitted in general surgery department during the period of May 2008 to August 2010. The study group consisted of the following cases. Duodenal perforation (37 cases), intestinal obstruction (27 cases), gastric perforation (8 cases), ileal perforation (8 cases), appendicular perforation (7 cases), blunt trauma (4 cases) and others (9 cases). They were scored using POSSUM scoring system. Physiological scoring was done at the time of admission and operative scoring was done intraoperatively. They were followed up for the first 30 day post operative period for any complications and the outcome was noted. The observed morbidity and mortality rates were compared with the POSSUM predicted morbidity and mortality rates. Results. 15 patients died (mortality rate of 15%). The POSSUM predicted mortality was 20 deaths. O:E ratio of 0.71 was obtained. There was no statistically significant difference between the observed and predicted mortality rates (χ2=1.72, p=0.974). 71 patients experienced complications. The POSSUM predicted morbidity was 61 patients. O:E ratio of 1.19 was obtained. There was no statistically significant difference between the observed and predicted morbidity rates (χ2=1.594, p=0.991). Conclusions. POSSUM scoring is an accurate predictor of mortality and morbidity following emergency laparotomy and is a valid means of assessing adequacy of care provided to the patient. POSSUM can be used for surgical audit to assess and improve the quality of surgical care and helps in better outcome to the patient [ABSTRACT FROM AUTHOR]