Emergency Laparotomy Research Articles

EP1 External validation of HAS model in predicting mortality after emergency laparotomy: A retrospective cohort study

Abstract Aims The HAS (Hajibandeh Index, American Society of Anaesthesiologists status, and sarcopenia) model has demonstrated superior predictive ability compared to the NELA (National Emergency Laparotomy Audit) score for mortality after emergency laparotomy. However, external validation of this model is lacking. This study aimed to validate the HAS model's performance in predicting mortality after emergency laparotomy and compare its predictive accuracy with the NELA score. Methods This retrospective cohort study included all adult patients (>17 years) who underwent emergency laparotomy between January 2022 and June 2023 at an urban district general hospital. Receiver operating characteristic curve analysis was used to compare the HAS model and NELA score in predicting 30-day mortality. Subgroup analysis was conducted for age groups: ≥50, ≥60, ≥70, and ≥80. Results A total of 117 patients were included. The area under the curve (AUC) for the HAS model in predicting 30-day mortality was 0.90 (95% CI 0.83-0.95). There was no statistically significant difference in AUC between the HAS and NELA scores for all patients (0.90 vs 0.80, p = 0.097). However, the AUC of the HAS model was significantly superior to that of the NELA score in patients aged ≥50 (0.89 vs 0.75, p = 0.040), ≥60 (0.87 vs 0.69, p = 0.020), ≥70 (0.85 vs 0.67, p = 0.030), and ≥80 (0.90 vs 0.66, p < 0.001). Conclusions This study provides external validation of the HAS model for predicting 30-day mortality after emergency laparotomy. Prospective studies with larger sample sizes are warranted to confirm these findings.

EP109 Assesment of factors contributing to delay of emergency laparotomies and potential solutions to optimize patient flow at a high volume centre. A Quality Improvement Project

Abstract Aim To identify factors resulting in delay of emergency laparotomies and offer potential solutions. Methods This was a retrospective study spanning 7 months including all laparotomies and major laparoscopic procedures excluding appendicectomies and cholecystectomeis. Data from the trust IT system was used to populate the various times of each procedure. Results 265 patients were studied in total including 76 category 1 laparotomies. Transport time defined as the duration between completion of the briefing to patient arrival at the operating theatre was found to be inaccurately documented in 66 cases. Median time was 20 min with 15 patients needing more than 45 min for transport. Median anaesthetic time defined as time from patient arrival to initiation of surgery was 50 min. Median procedure duration was 113 min. Median post operative time defined as the duration between surgery completion and exiting the operating theatre was 17 min. Median post op recovery time was 137 min with 15 patients requiring more than 12 hours in recovery. Post changes of informal education the median transport time reduced to 17 min. Conclusions Factors that can be optimized to reduce delays are ensuring ward prepardeness before transferring to theatres, appropriate documentation of transport times so staff are aware they maybe audited and satisfactory communication between teams (including site/bed managers) to ensure adequate prepardeness and a smooth flow of patients to the ward and prevent a hold up in recovery.

Synergistic effect of sarcopenia and ASA status in predicting mortality after emergency laparotomy: a systematic review and meta-analysis with meta-regression.

The aim of this study was to investigate the relationship between sarcopenia and American Society of Anesthesiologists (ASA) status in predicting post-operative mortality after emergency laparotomy. A PRISMA-compliant systematic review and meta-analysis (using random effects modelling) was performed searching for studies reporting 30-day mortality risk in patients with sarcopenia undergoing emergency laparotomy. The ASA status of sarcopenic and non-sarcopenic patients was determined, and the effect of difference in ASA status on 30-day mortality in sarcopenic and non-sarcopenic patients was determined via a meta-regression model. The risk of bias and certainty was assessed using the QUIPS tool and the GRADE system, respectively. Seven studies comprising 2663 patients were included. Thirty-day mortality risk was 22.9% (95% CI 11.6-40.0%) in sarcopenic patients and 6.2% (95% CI 2.9-13.0%) in non-sarcopenic patients; the risk was significantly higher in sarcopenic patients (OR: 4.452, p = 0.016). In sarcopenic patients, ASA status IV-V increased the risk of mortality (Coefficient: 0.07612, p < 0.0001), while ASA status I-II (Coefficient: - 0.09039, p < 0.0001) or ASA status III (Coefficient: 0.01300, p = 0.344) did not. In non-sarcopenic patients, ASA status III (Coefficient: 0.06830, p < 0.0001) and ASA status IV-V (Coefficient: 0.17809, p < 0.0001) increased the risk of mortality, while ASA status I-II (Coefficient: - 0.05841, p < 0.0001) did not. The GRADE certainty was moderate. Sarcopenia and ASA status are two independent predictors of mortality after emergency laparotomy with no significant collinearity. Sarcopenia and ASA status synergistically increase the risk of mortality after emergency laparotomy. ASA status IV and ASA status III are critical thresholds for increased risk of mortality in sarcopenic and non-sarcopenic patients, respectively.

Effect of isotonic sodium bicarbonate infusion on perioperative acid-base status among patients undergoing emergency laparotomy for perforation peritonitis (ISABEL trial): a randomized controlled trial.

Perioperative metabolic acidosis negatively affects patient outcomes. Perioperative fluid therapy has a clinically significant effect on acid-base balance. This study was conducted to evaluate the effects of isotonic sodium bicarbonate infusion (ISB) versus balanced crystalloid solution (BCS) on perioperative acid-base balance, in terms of postoperative base excess, among patients undergoing emergency laparotomy for perforation peritonitis. This prospective, randomized, single-center, double-blinded study was conducted in a tertiary hospital from October 2021 to November 2022. A total of 90 patients undergoing emergency laparotomy for perforation peritonitis were randomly assigned to receive either isotonic sodium bicarbonate (ISB) or Ringer's Lactate as a balanced crystalloid solution (BCS) for perioperative maintenance fluid therapy. The primary outcome was to compare the base excess (BE) at the end of surgery. The secondary outcomes were to compare the postoperative clinical outcomes, including the requirement of vasopressors, duration of mechanical ventilation, HDU/ICU stay, the incidence of AKI within seven days, the incidence of re-exploration, and in-hospital mortality. Additionally, pH, PaCO2, HCO3, BE, and lactates intraoperatively and up to 24h postoperatively were also compared. The median base excess (BE) values at the end of surgery were significantly better in the ISB group -4.80 [-6.80, -4.10] as compared to the BCS group -7.30 [-8.50, -6.30]. The ISB group had a lower incidence of postoperative AKI (9% ISB versus 24% BCS) and requirement of vasopressors (18% ISB versus 44% BCS). However, there was no major difference between the incidence of re-exploration, length of ICU/HDU stay, and in-hospital mortality. Infusing isotonic sodium bicarbonate (ISB) for intraoperative maintenance fluid therapy in patients undergoing emergency laparotomy for perforation peritonitis significantly improves perioperative acid-base balance with better postoperative clinical outcomes compared to a balanced crystalloid solution (BCS).

Socioeconomic Deprivation and Risk of Operative Mortality After Emergency Laparotomy: A Systematic Review and Meta-Analysis.

The aim was to determine the effect of socioeconomic deprivation on operative mortality after emergency laparotomy. A PRISMA-compliant systematic review and meta-analysis (random-effects modeling) was performed searching for studies comparing operative mortality between the least and the most socioeconomically deprived patients undergoing emergency laparotomy. Both unadjusted and adjusted odds ratio (OR) were calculated as summary measure. Risk of bias was assessed using the Quality In Prognosis Studies tool, and certainty of evidence was assessed using the GRADE system. Four studies comprising 87,690 patients were included. There was no difference in the risk of operative mortality between the most and least deprived groups (unadjusted OR: 1.57, 95% CI .92, 2.68, P = .100) and when adjusted for other predictors (adjusted OR: 1.11, 95% CI .93, 1.32, P = .230). Subgroup analysis showed consistency of the findings in the United Kingdom (unadjusted OR: 1.36, 95% CI .92, 2.01, P = .130; adjusted OR: 1.15, 95% CI .92, 1.43, P = .230) and in the United States (unadjusted OR: 1.75, 95% CI .75, 4.06, P = .190; adjusted OR: 1.01, 95% CI .79, 1.29, P = .940). Sensitivity analyses showed inconsistency in favor of higher mortality risk in the most deprived patients. The GRADE certainty was moderate. Socioeconomic deprivation may have minor effect on operative mortality after emergency laparotomy; however, such effect fades away once adjusted for other predictors of mortality. Although independent research is required, it may be reasonable to predict that incorporation of socioeconomic deprivation into preoperative risk assessment tools may not improve their predictive performance.

Prediction of In-Hospital Mortality after Emergency Laparotomy Using Glasgow Coma Scale, ASA Physical Status Classification, and P-POSSUM Score.

To determine the importance of the Glasgow Coma scale (GCS), ASA physical status classification system, and P-POSSUM score in predicting mortality among patients undergoing emergency laparotomies. An analytical study. Place and Duration of the Study: Department of General Surgery, Sheikh Khalifa Bin Zayed Al-Nahyan Hospital Muzaffarabad, Pakistan, from October 2020 to January 2022. All emergency laparotomies performed during the above-mentioned period were included consecutively, excluding trauma laparotomies, re-do laparotomies after elective surgery, appendectomies, cholecystectomies, pancreatectomies, organ transplantation surgeries, and laparotomies due to gynaecological or vascular causes such as ruptured abdominal aortic aneurysm. The GCS scores were broken down into mild (14-15), moderate (9-13), and severe (3-8) categories. The ASA scoring was classified into five classes, i.e., Classes I to V. The P-POSSUM scores were assessed for each of the following five groups: (≤10, 11-20, 21-30, 31-40, and ≥41). Out of 50 patients (mean age: 47 ± 19 years), there were 39 (78%) males and 11 (22%) females. The median values for GCS and P-POSSUM scores were 15 and 11.1, respectively. According to the ASA, most patients (21, 42%) fit into Class II. Twelve (24%) patients died, while 38 (76%) survived. The mortality rate increased with an increasing P-POSSUM score, a lowering GCS score, and a higher class of ASA (all p <0.001). The ROC curve analysis showed that P-POSSUM had the best performance at 0.987, followed by ASA (0.951) and GCS (0.411). The ASA Physical Status Classification System and P-POSSUM scoring were significantly predictive of mortality after an emergency laparotomy. ASA Physical Status Classification System, Emergency laparotomy, Glasgow coma scale, Mortality, Outcome, P-POSSUM.

EP112 "Beyond Age: Unveiling the Real Drivers of Complications in Emergency Laparotomy"

eP112 "Beyond Age: Unveiling the Real Drivers of Complications in Emergency Laparotomy"

EP31 Safety of bowel anastomosis in emergency laparotomy

eP31 Safety of bowel anastomosis in emergency laparotomy

O3 Estimating the effect of frailty on longer-term survival following emergency laparotomy an observational study using National Emergency Laparotomy Audit data

O3 Estimating the effect of frailty on longer-term survival following emergency laparotomy an observational study using National Emergency Laparotomy Audit data

EP10 Decision Making For and Against Emergency Laparotomy in High Risk Patients: A Prospective Trust-Wide Study

eP10 Decision Making For and Against Emergency Laparotomy in High Risk Patients: A Prospective Trust-Wide Study

EP41 CORES model scoring system for predicting post-operative mortality in patients undergoing Emergency Laparotomy and its comparison with APACHE II: An observational study

eP41 CORES model scoring system for predicting post-operative mortality in patients undergoing Emergency Laparotomy and its comparison with APACHE II: An observational study

EP71 Audit of Emergency Laparotomy Workload in a District General Hospital: Are We Compliant with NELA Data Entry?

eP71 Audit of Emergency Laparotomy Workload in a District General Hospital: Are We Compliant with NELA Data Entry?

EP75 The effect of time of intra-abdominal drain insertion on surgical outcomes in patients undergoing emergency laparotomy

eP75 The effect of time of intra-abdominal drain insertion on surgical outcomes in patients undergoing emergency laparotomy

EP92 Impact of a ‘Peri-operative Care of Older People undergoing Surgery (POPS)’ service on length of hospital stay in older patients undergoing emergency laparotomy

eP92 Impact of a ‘Peri-operative Care of Older People undergoing Surgery (POPS)’ service on length of hospital stay in older patients undergoing emergency laparotomy

EP84 The good, the bad, and the ugly - use of a care bundle reduces surgical site infection after all grades of contaminated emergency laparotomy

eP84 The good, the bad, and the ugly - use of a care bundle reduces surgical site infection after all grades of contaminated emergency laparotomy

O2 Are elderly patients undergoing emergency laparotomy receiving appropriate geriatrician input: a closed loop audit as looking at NELA standards

O2 Are elderly patients undergoing emergency laparotomy receiving appropriate geriatrician input: a closed loop audit as looking at NELA standards

Intestinal Invagination Secondary to Vanek Tumor, A Rare Cause of Intestinal Obstruction in Adults: Case Report

Introduction: Mechanical intestinal obstruction is a common surgical condition with a wide range of causes, including intrinsic intestinal problems such as intestinal invagination. This condition is extremely rare in the adult population and is mostly caused by neoplasms. The clinical presentation, although varied, is typically gradual and nonspecific. Among intestinal neoplasms, inflammatory fibroid polyps (IFPs) are very rare, constituting less than 0.1% of gastrointestinal tract polyps. Case Presentation: We present a 48-year-old female patient who presented with abdominal pain lasting for 1 month, with a 4-month history of constipation. A CT scan showed findings suggestive of pseudo-obstruction secondary to intestinal invagination. After an emergency laparotomy, histopathological analysis reported a Vanek tumor in the terminal ileum. Discussion: Intestinal intussusception in adults is a rare condition, often caused by benign tumors that act as lead points. Inflammatory fibroid polyps (IFP), commonly located in the ileum, are such tumors. The symptoms are typically nonspecific, making early diagnosis challenging. In the presented case, a laparotomy was performed to address the obstruction and resect the tumor, which was histologically confirmed as an IFP. This case highlights the importance of considering these tumors in the differential diagnosis of adult intussusception and the need for timely surgical intervention. Conclusion: IFPs should be considered in the differential diagnosis of adult intussusception, especially in cases of chronic, non-specific symptoms and intestinal obstruction.

Perioperative emergency laparotomy pathway for patients undergoing emergency laparotomy: A propensity score matched study

Perioperative emergency laparotomy pathway for patients undergoing emergency laparotomy: A propensity score matched study

A Case Series of Delayed Laparoscopic Drainage of Haemoperitoneum in Blunt Liver Trauma

Background: Liver trauma is a leading cause of mortality in blunt abdomen trauma. Laparoscopy in blunt abdomen trauma has been described in the acute setting, however delayed laparoscopy as a tool of reevaluation of non operative management and drainage of haemoperitoneum in those with signs of inflammation, has not been widely evaluated. Materials and Methods: In this article, we retrospectively explore a series of 5 cases of blunt liver trauma presenting to our emergency department at CIVIL Hospital Ahmendabad, where delayed laparoscopic drainage was done. Results and Conclusions: Average of 1200 +/- 274 ml of haemoperitoneum was drained. Two out of 5 cases had bile staining of the drained collection. Mean operative duration was 40.8 +/- 7.6 mins. Post operative recovery was uneventful and all patients were doing well on review after two weeks. This throws light on delayed laparoscopic drainage being a safe and effective adjunct to non operative management of blunt liver trauma and avoids the trauma of emergency laparotomy. Keywords: blunt liver trauma, laparoscopy, haemoperitoneum

Inflamed Mesenteric Pseudocyst Associated with Meckel’s Diverticulitis: Cause or Consequence

Introduction: Mesenteric pseudocyst describes an abdominal mass that appears on small bowel mesentery or mesocolon, or at any part of the abdomen and retroperitoneum. This paper aims to emphasize the non-specific clinical appearance and highlight Meckel’s diverticulitis as a potential cause of the development of pseudocyst. Case Report: A 26-year-old male with a palpable mass in the right upper abdominal quadrant and an increased body temperature of 38.3∘C was admitted for further medical investigation. Computed tomography (CT) presented a cystic mass with a diameter of 5.5 cm, and emergency laparotomy was performed. Wedge resection of pathologic findings of small bowel, its mesenterium, and the cyst mass associated with nearby Meckel’s diverticulum was performed. Discussion: Meckel’s diverticulum can be considered as a risk for developing mesenteric pseudocyst, because of its frequent exacerbation of chronic inflammation. This report adds to the limited literature on the association between Meckel’s diverticulum and mesenteric pseudocysts, providing valuable insights that can guide future clinical evaluations and surgical interventions. Early and accurate diagnosis, aided by imaging techniques such as CT and magnetic resonance imaging (MRI), is essential for effective management. This case highlights the potential link between chronic inflammation in Meckel’s diverticulum and the formation of mesenteric pseudocysts. Conclusion: This case highlights the need to consider Meckel’s diverticulitis in patients with mesenteric pseudocysts, suggesting a possible pathophysiological link between them. Surgical resection is recommended for effective management.