Emergency Surgery

Background: Identification of variation in practice is a key step towards standardization of service and
determination of reliable quality markers. This study aimed to investigate variation in provision and
outcome of emergency appendicectomy.
Methods: A multicentre, trainee-led, protocol-driven, prospective observational cohort study was
performed duringMay and June 2012. The main outcome of interest was the normal histopathology rate;
secondary outcomes were laparoscopy and 30-day adverse event rates. Analysis included funnel plots and
binary logistic regression models to identify patient- and hospital-related predictors of outcome.
Results: A total of 3326 patients from 95 centres were included. An initial laparoscopic approach was
performed in 66·3 per cent of patients (range in centres performing more than 25 appendicectomies
over the study period: 8·7–100 per cent). A histologically normal appendix was removed in 20·6 per
cent of patients (range in centres performing more than 25 procedures: 3·3–36·8 per cent). Funnel
plot analysis revealed that 22 centres fell below three standard deviations of the mean for laparoscopy
rates. Higher centre volume, consultant presence in theatre and daytime surgery were independently
associated with an increased use of laparoscopy, which in turn was associated with a reduction in 30-day
morbidity (adjusted for disease severity). Daytime surgery further reduced normal appendicectomy rates.
Increasing volume came at the cost of higher negative rates, and low negative rates came at the cost of
higher perforation rates.
Conclusion: This study reveals the extremely wide variation in practice patterns and outcomes among
hospitals. Organizational factors leading to this variation have been identified and should be addressed
to improve performance.

Background: Appendicectomy for acute appendicitis in children may be performed in specialist centres
by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in
children may differ between such units.
Methods: This multicentre observational study included all children (aged less than 16 years) who had
an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome
was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of
ultrasound imaging and laparoscopy, and consultant involvement in procedures.
Results: Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general
surgery units (461 children) were included. Children treated in paediatric surgery units were younger
and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant
present at the procedure, and histologically advanced appendicitis than children treated in general
surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio
(OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P <0·001), and the difference persisted after
adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P <0·001).
Female sex and preoperative ultrasonography, but not age, were significantly associated with normal
appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The
unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units
(OR 1·90, 1·18 to 3·06; P =0·011). When adjusted for case mix and consultant presence at surgery, no
statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1·59,
0·93 to 2·73; P =0·091).
Conclusion: The NAR in general surgery units was over twice that in paediatric surgery units. Despite a
more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery
units. Service provision differs between paediatric and general surgery units.

Background
Child health is a key priority on the global health agenda, yet the provision of essential and emergency surgery in children is patchy in resource-poor regions. This study was aimed to determine the mortality risk for emergency abdominal paediatric surgery in low-income countries globally.

Methods
Multicentre, international, prospective, cohort study. Self-selected surgical units performing emergency abdominal surgery submitted prespecified data for consecutive children aged <16 years during a 2-week period between July and December 2014. The United Nation's Human Development Index (HDI) was used to stratify countries. The main outcome measure was 30-day postoperative mortality, analysed by multilevel logistic regression.

Results
This study included 1409 patients from 253 centres in 43 countries; 282 children were under 2 years of age. Among them, 265 (18.8%) were from low-HDI, 450 (31.9%) from middle-HDI and 694 (49.3%) from high-HDI countries. The most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed.

Conclusions
Adjusted mortality in children following emergency abdominal surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. Effective provision of emergency essential surgery should be a key priority for global child health agendas.

Abstract
Aims
Emergency surgery is associated with poorer out- comes and higher mortality with recent studies suggesting the 30-day mortality to be 14–15 %. The aim of this study was to analyse the 30-day mortality, age-related 30-day mortality and 1-year mortality following emergency lapa- rotomy. We hope this will encourage prospective data collection, improvement of care and initiate strategies to establish best practice in this area.
Methods
This was a retrospective study of patients who underwent emergency laparotomy from June 2010 to May 2012. The primary end point of the study was 30-day mortality, age-related 30-day mortality and 1-year all- cause mortality.
Results
477 laparotomies were performed in 446 patients. 57 % were aged \70 and 43 % aged [70 years. 30-day mortality was 12, 4 % in those aged\70 years and 22 % in those [70 years (p \ 0.001). 1-year mortality was 25, 15 % in those aged under 70 years and 38 % in those aged [70 years (p \ 0.001).
Conclusions
Emergency laparotomy carries a high rate of mortality, especially in those over the age of 70 years, and more needs to be done to improve outcomes, particularly in this group. This could involve increasing acute surgical care manpower, early recognition of patients requiring emergency surgery, development of clear management protocols for such patients or perhaps even considering centralisation of emergency surgical services to specialist centres with multidisciplinary teams involving emergency surgeons and care of the elderly physicians in hospital and related community outreach services for post-discharge care.

INTRODUCTION: Appendiceal diverticulitis is a rare pathology that mimics acute appendicitis. Appendiceal diverticula are classified into congenital and acquired with difference in incidence and pathogenesis. Appendiceal diverticulitis is often overlooked because of mildness of symptomatology with increasing risk of complications, such as perforation. Appendiceal diverticula are often associated to higher risk of neoplasm especially carcinoid tumors and mucinous adenomas. PRESENTATION OF CASE: A 40-year-old caucasic male presented into Emergency Room with right lower quadrant pain associated with vomit, abdominal tenderness, fever and moderate leukocytosis (11.93 × 10; neutrophils 78.5%). Acute appendicitis was suspected and a surgical approach was chosen with a McBurney access. The removed specimen (Figs. 1 and 2) was 11 cm long with multiple hyper-aemic and oedematous diverticular protrusions. The postoperative course was regular. Discharging was on 4th postoperative day in optimal clinical conditions. The histological examination (Fig. 3) showed acute inflammation of appendiceal pseudodiverticula with acute peridiverticulitis and abscess. DISCUSSION: Currently, appendiceal diverticulitis is often overlooked with high risk of complications, above all perforation. Attention should be kept during the surgical procedure and the patholological examination in order to identify any associated neoplasm. CONCLUSION: Appendiceal diverticulitis should be considered in adult male patients with right lower quadrant pain or tenderness. Accurate appendectomy should be performed in order to permit an appropriate pathological examination and possible associate neoplasm should always be searched through. Prophylactic appendectomy should be performed in case of incidental finding of appendiceal diverticula in asymptomatic patients in order to avoid the high perforation risk.

Background There is evidence to suggest that
patients undergoing treatment at weekends may
be subject to different care processes and
outcomes compared with weekdays. This study
aimed to determine whether clinical outcomes
from weekend appendicectomy are different
from those performed on weekdays.
Method Multicentre cohort study during May–
June 2012 from 95 centres (89 within the UK).
The primary outcome was the 30-day adverse
event rate. Multilevel modelling was used to
account for clustering within hospitals while
adjusting for case mix to produce adjusted ORs
and 95% CIs.
Results When compared with Monday, there
were no significant differences for other days of
the week considering 30-day adverse events in
adjusted models. On Sunday, rates of simple
appendicitis were highest, and rates of normal
(OR 0.62, 95% CI 0.42 to 0.90) and complex
appendicitis (OR 0.65, 95% CI 0.46 to 0.93)
lowest. This was accompanied by a 43% lower
likelihood in use of laparoscopy on Sunday (OR
0.47, 95% CI 0.32 to 0.69), accompanied by the
lowest level of consultant presence for the week.
When pooling weekends and weekdays,
laparoscopy use remained less likely at the
weekend (OR 0.68, 95% CI 0.55 to 0.83), with
no significant difference for 30-day adverse event
rate (OR 1.01, 95% CI 0.80 to 1.29).
Conclusions This study found that weekend
appendicectomy was not associated with
increased 30-day adverse events. It cannot rule
out smaller increases that may be shown by larger
studies. It further illustrated that patients operated
on at weekends were subject to different care
processes, which may expose them to risk.

SUMMARY: Colonic stent placement as a bridge to surgery in patients with left-sided malignant large bowel obstruction. An observational study. S. OCCHIONORELLI, D. TARTARINI, L. CAPPELLARI, R. STANO, G. VASQUEZ Background. Acute left-sided malignant colonic obstruction is common in elderly patients, in which emergency surgery is related with high morbidity and mortality rates, and often necessitates a two-step resection. Although the use of self-expanding metallic stents (SEMS) in elderly patients has not been adequately described yet, there are almost two international important trials which are still in progress, the stenting technique is established to be, by the international literature, an useful treatment with low morbidity and mortality. It’s also a bridge to surgery, since the insertion of a SEMS can decompress the obstruction, making bowel and patient preparation possible and facilitating singlestage surgical resection. Palliative stenting can improve quality of life when c...

Intestinal obstruction is one of the most important cause of acute abdomen. An internal herniation is an uncommon yet relevant clinical entity causing an acute intestinal obstruction that can occur after major bowel surgery. Here, we describe a case of acute intestinal obstruction caused by internal herniation in a patient with muscle-invasive urinary bladder carcinoma who underwent robot-assisted radical cystectomy with an ileal conduit. We also discuss the management of adjuvant chemotherapy-induced leukopenia.

Background/Aims: To decrease surgical trauma and scar formation we present intracorporeal twoport procedure in selected patients. Methodology: Supraumbilical 5mm port is used for the laparoscope. Suprapubic 12mm port is in the midline or left paramedian position below the underpants line. Pretied loop suture is tied around the base, 1-2 cm
distally from the origin of the appendix, or below the macroscopically changed appendix. Endoclose is introduced 1-2 cm cranially from the location of appendiceal base and the endoloop is exteriorized and the appendix elevated. Harmonic scalpel is used for dissection and skeletonization and the appendix is divided with 45 mm linear cutting stapler. Results: Two-port appendectomy was attempted in 11
consecutive patients. In 3 patients operation was converted to open procedure and in 2 patients the third port was needed. Finally 6 (54%) patients were operated with the similar operating time (36-51 min) as standard three-port technique with the same postoperative pain and bowel function recovery. The postoperative stay ranged 2 - 4 days. There was one wound infection of 12-mm port. Conclusions:
This intracorporeal two-port appendectomy in selected patients does not prolong operation time and further improves the minimal invasiveness and contributes to excellent cosmetic results.

Transomental hernia is the rarest form of internal hernias. Clinical expression of this pathology is ambiguous and diagnosis is often made at complication phase, after irreversible strangulation of the herniated loop. Radiological diagnosis is still difficult and intraoperative exploration usually allows discovering this pathology when patient is operated for acute intestinal obstruction. Treatment is surgical and aims to treat intestinal obstruction and prevent recurrence. We describe the case of a 65 years old male operated for a preoperatively suspected internal hernia; surgical exploration found a transomental hernia trough the greater omentum.

Stercoral perforation (SP) is a rare cause of peritonitis. It is caused by pressure necrosis of the colonic wall by fecaloma. SP is a lethal condition that is associated with high morbidity and mortality, therefore early diagnosis and treatment are of paramount importance. Herein, we describe a case of SP in a systemic lupus erythematosus (SLE) patient. A 44-year-old female, known case of SLE, presented with severe abdominal pain, fever, and hypotension. CT scan showed features of perforated sigmoid. The patient underwent exploratory laparotomy which revealed perforation of sigmoid, fecalomas in the peritoneal cavity, and colon loaded with fecal matter. The patient underwent Hartmann&#39;s operation with successful control of her intra-abdominal sepsis. Her postoperative course was complicated by SLE flare and wound dehiscence which was probably due to long term steroid use. Even though SP is rare, it carries a worse prognosis especially if the patients are immunocompromised. The ke...

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by the firm «Lintex» (St. Petersburg) after intraperitonea
administration to animals in experiments was shown to reliabl;
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tion of adhesions in the abdominal cavity. The use of «Mezogeb
for intraperitoneal administration after dissection of adhesion
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quality of life of the patients.

“Acute abdomen” is a clinical diagnosis which defines the emergent nature of the condition, rather than the condition itself, and the true diagnosis is often only made after laparotomy or laparoscopy. On occasion, the final diagnosis is drastically different from what was clinically suspected. Diseases such as diverticulosis can have multiple possible pathological outcomes as a consequence of their inflammatory nature, such as stricture formation, adhesions, acute diverticulitis, diverticular abscess, perforation and even malignant transformation. Usually one of these complications will be the presenting factor with rarely another complication discovered during management, which may or may not have been symptomatic. Extremely rarely, will multiple pathological outcomes of a condition be present together. Here we report the case of a male patient who underwent laparotomy for a suspected hollow viscus perforation, with the resulting findings a bewildering surprise.

A 48-year-old male patient presented to the emergency department with the complaints of epigastric pain and melena for the past 3 days. The pain was started suddenly and has progressed and after a while, he passed melena stool. He also mentioned some episodes of vomiting that was not bloody. The pain score was about 8/10 (based on verbal quantitative scale) and slightly radiated to back. He loosed his appetite and the pain aggravated by meal. He did not use any drug regularly and had no positive medical history for specific disease or prior hospital admission. The patient was slightly pale and sweaty. His pulse rate was 80/minute and blood pressure was elevated as 180/100 mm Hg. Routine blood tests such as liver enzyme and serum amylase levels were normal. Complete blood cell count showed mild anemia (Haemoglobin =10 g/dl) and leucocytosis (16600/mm3). On physical examination, there were not any positive findings except mild epigastric tenderness without rebound or guarding. Electrocardiography revealed normal sinus rhythm without any pathologic findings. The patient was admitted in surgical ward and plain abdominal computed tomography (CT) scan and abdominal CT angiogram was done. The findings of CT are shown in figures 1A-D.

In this clinical study hyperbaric ropivacaine in spinal anaesthesia for lower limb and hip surgery was evaluated and results obtained were compared with those using hyperbaric bupivacaine. Methodology: Two hundred patients scheduled for lower limb and hip surgery were randomly divided into two groups of 100 patients each. These patients received a spinal injection of either 3ml (15mg) of 0.5% hyperbaric ropivacaine or 3ml (15mg) of 0.5% hyperbaric bupivacaine using 25G Quincke type spinal needle. The parameters studied were -onset and total duration of sensory block, onset and total duration of motor block, quality of intraoperative anaesthesia, hemodynamic alterations, and any intraoperative and postoperative complications. Results: The mean onset of sensory block (6±1.3min vs. 3±1.1min; p value<0.05) and motor block (13±1.6min vs. 9±1.3min; p value< 0.05) was significantly slower in ropivacaine group as compared to bupivacaine group. The total duration of sensory block was significantly shorter in ropivacaine group (160±12.9min) than in bupivacaine group (260±16.1min; p value <0.05). The mean duration of motor block was also shorter in ropivacaine group compared to bupivacaine group (126±9.2min vs. 174±12.6min; p value<0.05). Conclusion: The quality of anaesthesia was excellent in both the groups. In conclusion, a solution of ropivacaine (hyperbaric) can be used for spinal anaesthesia and is comparable with hyperbaric bupivacaine in terms of quality of block, but has shorter recovery profile.