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Background: Major emergency abdominal surgery is associated with high morbidity with outcomes worse than for similar elective surgery, including complicated physical recovery, increased need for rehabilitation, and prolonged hospitalisation., Purpose: To investigate whether low physical performance test scores were associated with an increased risk of postoperative complications, and, furthermore, to investigate the feasibility of postoperative performance tests in patients undergoing major emergency abdominal surgery. We hypothesize that patients with low performance test scores suffer more postoperative complications., Methods: The study is a prospective observational cohort study including all patients who underwent major abdominal surgery at the Department of Surgery at Zealand University Hospital between 1st March 2017 and 31st January 2019. Patients were evaluated with De Morton Mobility Index (DEMMI) score, hand grip strength, and 30-s chair-stand test., Results: The study included 488 patients (median age 69, 50.6% male). Physiotherapeutic evaluation including physical performance tests with DEMMI and hand grip strength in the immediate postoperative period were feasible in up to 68% of patients undergoing major emergency abdominal surgery. The 30-s chair-stand test was less viable in this population; only 21% of the patients could complete the 30-s chair-stand test during the postoperative period. In logistic regression models low DEMMI score (< 40) and ASA classification and low hand grip strength (< 20 kg for women, < 30 kg for men were independent risk factors for the development of postoperative severe complications Clavien-Dindo (CD) grade ≥ 3., Conclusions: In patients undergoing major emergency surgery low performance test scores (DEMMI and hand grip strength), were independently associated with the development of significant postoperative complications CD ≥ 3., (© 2024. The Author(s).)

Purpose: Postoperative pulmonary complications (PPCs) occur in up to 30% of patients undergoing surgery and are a significant contributor to the overall risk of surgery. A preoperative risk prediction tool for postoperative pulmonary complications could succour clinical identification of patients at increased risk and support clinical decision making. This original study aimed to externally validate a risk model for predicting postoperative pulmonary complications (ARISCAT) in a cohort of patients undergoing major emergency abdominal surgery at a Danish University Hospital., Methods: ARISCAT was validated prospectively in a cohort of patients undergoing major emergency abdominal surgery between March 2017 and January 2019. Predicted PPCs by ARISCAT were compared with observed PPCs. ARISCAT was validated with calibration, discrimination and accuracy and in adherence to the TRIPOD statement., Results: The study included a total of 585 patients with a median age of 70 years. The majority of patients underwent emergency laparotomy without bowel resection. The predicted PPC frequency by ARISCAT was 24.9%, while the observed frequency of PPCs in the cohort was 36.1%. The slope of the calibration plot was 0.9546, the y axis interception was 0.1269 and the plot was well fitted to a linear slope. The Hosmer Lemeshow goodness-of-fit analysis showed good calibration (p > 0.25). ARISCAT showed good discrimination with AUC 0.83 (95% CI 0.79-0.86) on a receiver-operating characteristics curve and the accuracy was also good with a Brier score of 0.19., Conclusions: ARISCAT was a promising tool to predict PPCs in a high-risk surgical population undergoing major emergency abdominal surgery., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Major emergency abdominal surgery is associated with excess mortality. Transfusion is known to be associated with increased morbidity and emergency surgery is an independent risk factor for perioperative transfusion. The primary objectives of this study were to identify risk factors for transfusion, and secondarily to investigate the influence of transfusion on clinical outcomes after major emergency abdominal surgery., Study Design and Methods: This study combined retrospective observational data including intraoperative, postoperative, and transfusion data in patients undergoing major emergency abdominal surgery from January 2010 to October 2016 at a Danish university hospital. The primary outcome was a transfusion of any kind from initiation of surgery to postoperative day 7. Secondary outcomes included 7-, 30-, 90-day and long-term mortality (median follow-up = 34.6 months, IQR = 13.0-58.3), lengths of stay, and surgical complication rate (Clavien-Dindo score ≥ 3a)., Results: A total of 1288 patients were included and 391 (30%) received a transfusion of any kind. Multivariate logistic regression identified age, hepatic comorbidity, cardiac comorbidity, post-surgical anemia, ADP-receptor inhibitors, acetylsalicylic acid, anticoagulants, and operation type as risk factors for postoperative transfusion. 60.1% of the transfused patients experienced a serious surgical complication within 30 days of surgery compared with 28.1% of the non-transfused patients (p < 0.001). Among patients receiving a postoperative transfusion, unadjusted long-term mortality was increased with a hazard ratio of 3.8 (95% CI 2.9-5.0), p < 0.01. Transfused patients had significantly higher mortality at 7-, 30-, 90- and long-term, as well as a longer hospital stay but in the multivariate analyses, transfusion was not associated with mortality., Conclusion: Peri- and postoperative transfusion in relation to major emergency abdominal surgery was associated with an increased risk of postoperative complications. The potential benefits and harms of blood transfusion and clinical significance of pre- and postoperative anemia after major emergency abdominal surgery should be further studied in clinical prospective studies., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Optimal recovery can be defined as the adequate in-hospital length of stay with minimal postoperative complications and readmissions. The quality of recovery beyond the immediate postoperative period after major emergency abdominal surgery is yet to be fully described. We hypothesized that long-term measures of overall recovery were affected after surgery. The study aimed to investigate patient-focused recovery-related parameters 1 year after major emergency abdominal surgery., Method: This is a prospective study including patients undergoing major emergency abdominal surgery at a Danish secondary referral center. Three questionnaires were answered regarding the recovery following the procedure; Activities Assessment Scale (AAS); Quality of Recovery-15 (QoR-15), and Self-complete Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS). All questionnaires were answered at postoperative days (PODs) 14, 30, 90, and 365., Results: Eighty-two patients were included, and 68 were available for follow-up until 1 year after surgery. The response rates differed between the follow-up time points, with a response rate of 85% (n = 59) at POD30 and 50% (n = 36) at POD365. A decrease in the level of physical function following surgery was observed in 60% of the patients at POD14, which improved to 36% at POD365. Twenty-four patients (48%) reported postoperative pain at POD14, which declined to 9 (26%) at POD365. The maximum overall recovery was reached at POD30, which remained stable throughout the study period., Conclusion: One in three patients reported physical functional impairment, and one in four patients reported pain 1 year after their surgical procedure., (© 2021 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: Up to 30% of patients undergoing abdominal surgery suffer from postoperative pulmonary complications. The purpose of this systematic review and meta-analyses was to investigate whether postoperative respiratory interventions and mobilization interventions compared with usual care can prevent postoperative complications following abdominal surgery., Methods: The review was conducted in line with PRISMA and GRADE guidelines. MEDLINE, Embase, and PEDRO were searched for randomized controlled trials and observational studies comparing postoperative respiratory interventions and mobilization interventions with usual care in patients undergoing abdominal surgery. Meta-analyses with trial sequential analysis on the outcome pulmonary complications were performed. Review registration: PROSPERO (identifier: CRD42019133629) RESULTS: Pulmonary complications were addressed in 25 studies containing 2068 patients. Twenty-three studies were included in the meta-analyses. Patients predominantly underwent open elective upper abdominal surgery. Postoperative respiratory interventions consisted of expiratory resistance modalities (CPAP, EPAP, BiPAP, NIV), assisted inspiratory flow modalities (IPPB, IPAP), patient-operated ventilation modalities (spirometry, PEP), and structured breathing exercises. Meta-analyses found that ventilation with high expiratory resistance (CPAP, EPAP, BiPAP, NIV) reduced the risk of pulmonary complications with OR 0.42 (95% CI 0.18-0.97, p = 0.04, I 2 = 0%) compared with usual care, however, the trial sequential analysis revealed that the required information size was not met. Neither postoperative assisted inspiratory flow therapy, patient-operated ventilation modalities, nor breathing exercises reduced the risk of pulmonary complications., Conclusion: The use of postoperative expiratory resistance modalities (CPAP, EPAP, BiPAP, NIV) after abdominal surgery might prevent pulmonary complications and it seems the preventive abilities were largely driven by postoperative treatment with CPAP., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Enhanced recovery after surgery programs is widely implemented in elective settings, however, until recently, rarely in emergency surgery. The purpose of this study was to present detailed contents and data on implementation of an emergency abdominal perioperative protocol on the basis of compliance., Methods: A multidisciplinary perioperative bundle for major emergency abdominal surgery was developed and implemented in March 2017 covering surgical, emergency, anesthesiological, radiological, physiotherapy, and nutritional support. The bundle consisted of preoperative-, intraoperative-, and postoperative initiatives. Fifteen core protocol items were identified for audit and compliance rates for each protocol item and overall compliance rates were evaluated and quarterly stratified throughout the first year of implementation., Results: A total of 227 consecutive patients underwent major emergency abdominal surgery from March 2017 throughout February 2018. The specific protocol items showed high individual compliance rates throughout all quarters of the first year. Time to suspicion of diagnosis at the emergency department, rate of perioperative thoracic epidural, and postoperative referral to physiotherapy showed the lowest compliance rates. The overall compliance rate of all 15 protocol items was 83% (min-max 71.4-100%)., Conclusion: We found it possible to implement a comprehensive detailed perioperative protocol in emergency abdominal surgery across multiple specialties with an overall good compliance of protocol items.

Background: Early oral or enteral nutrition (EEN) has been proven safe, tolerable, and beneficial in elective surgery. In emergency abdominal surgery no consensus exists regarding postoperative nutrition standard regimens. This review aimed to assess the safety and clinical outcomes of EEN compared to standard care after emergency abdominal surgery., Methods: The review protocol was performed according to the Cochrane Handbook and reported according to PRISMA. Clinical outcomes included mortality, specific complication rates, length of stay, and serious adverse events. Risk of bias was assessed by Cochrane risk of bias tool and Downs and Black. GRADE assessment of each outcome was performed, and Trial Sequential Analysis was completed to obtain the Required Information Size (RIS) of each outcome., Results: From a total of 4741 records screened, a total of five randomized controlled trials and two non-randomized controlled trials were included covering 1309 patients. The included studies reported no safety issues regarding the use of EEN. A significant reduction in the mortality rate of EEN compared with standard care was seen (OR 0.59 (CI 95% 0.34-1.00), I 2  = 0%). Meta-analyses on sepsis and postoperative pulmonary complications showed non-significant tendencies in favor of EEN compared with standard care. GRADE assessment of all outcomes was evaluated 'low' or 'very low'. Trial Sequential Analysis revealed that all outcomes had insufficient RIS to confirm the effects of EEN., Conclusion: EEN after major emergency surgery is correlated with reduced mortality, however, more high-quality data regarding the optimal timing and composition of nutrition are needed before final conclusions regarding the effects of EEN can be made., Competing Interests: Conflicts of interest No conflicts of interest exist for any of the authors., (Copyright © 2021 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Purpose: The patient-perceived barriers towards an optimized short-term recovery after major emergency abdominal surgery are unknown. The purpose was to investigate which patient-perceived barriers dominated concerning nutrition, mobilization, and early discharge after major emergency abdominal surgery., Methods: An explorative study, which focused on patient-perceived barriers for early discharge, mobilization, and nutrition, was performed within an enhanced recovery perioperative setting in major emergency abdominal surgery. Patients were asked daily from postoperative day (POD) 1 to POD 7 of their self-perceived barriers towards getting fully mobilization and resuming normal oral intake. From POD 3 to POD 7, patients were asked regarding self-perceived barriers towards early discharge., Results: A total of 101 patients that underwent major emergency abdominal surgery were included for final analysis from March 2017 to August 2017. The main patient self-perceived barrier towards sufficient nutrition was dominated by food aversion (including loss of appetite). The main patient self-perceived barrier towards sufficient mobilization throughout the study period was fatigue. The patient self-perceived barriers towards early discharge were more diffuse and lacked a dominant variable throughout the study period; however, fatigue was the most pronounced barrier throughout the study period. The leading initial variables were postoperative ileus, insufficient nutrition, and epidural catheter. The leading later variables besides fatigue included awaiting normalization of biochemistry values, pain, and the perception of insufficient oral intake., Conclusions: The major patient-perceived factors that limited postoperative recovery after major emergency abdominal surgery included food aversion regarding normalization of oral intake and fatigue regarding mobilization and early discharge.

Background: The aim was to examine the risk of post-operative myocardial injury after major emergency abdominal surgery and identify pre- and intra-operative risk factors of post-operative myocardial injury. Moreover, the study aimed to examine the association between post-operative myocardial injury and clinical outcomes., Methods: This was a retrospective cohort study including patients undergoing major emergency abdominal surgery from February 2017 to January 2019. Troponin I was assessed on post-operative days 1-3. Post-operative myocardial injury was defined as a cardiac troponin I ≥ 45 ng per litre. Post-operative clinical outcomes included in-hospital myocardial infarction, in-hospital major adverse cardiovascular events, reoperation, admission to the intensive care unit, lengths of stay, 30- and 90-day all-cause mortality., Results: 98 out of 401 patients (24.4%) sustained a post-operative myocardial injury within the third post-operative day. Increasing age was an independent risk factor of post-operative myocardial injury (age per 10 years adjusted odds ratio 2.2 [95% CI 1.7-2.9], P < .0001). Patients with post-operative myocardial injury had an increased risk of major adverse cardiovascular events, a higher admission rate to the intensive care unit, a longer median post-operative length of stay and a higher 30- and 90-day all-cause mortality compared with patients without myocardial injury., Conclusion: One in four patients suffered a post-operative myocardial injury within the third post-operative day. Post-operative myocardial injury was a risk factor of adverse cardiac and non-cardiac clinical outcomes. Troponin monitoring could potentially improve the post-operative risk stratification in this cohort of high-risk surgical patients., (© 2020 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Major emergency abdominal surgery results in high morbidity and mortality. We aimed to describe patient-reported quality of recovery after major emergency abdominal surgery., Methods: A prospective observational cohort study of patients undergoing major emergency abdominal surgery at a University Hospital was conducted in the period between November 2016 and February 2017. Patients were interviewed using the 15-item questionnaire Quality of Recovery (QoR-15) six times over the first 30 postoperative days. Patients' maximum score of QoR-15 ranging from 0-150 were divided into four groups depending on recovery status going from poor (score of 0-89), moderate (score of 90-121), good (score of 122-135) to excellent (score of 136-150) recovery., Results: A total of 37 patients were included in the trial. At postoperative day (POD) 1 the recovery status of the patients was mainly poor to moderate (poor N.=8 [22%], moderate N.=23 [62%], good N.=4 [11%] and excellent N.=2 [5%]). Sixteen (55%) of the patients reported a poor or moderate recovery within the first 7 days after surgery, which advanced to good or excellent recovery (N.=19 [68%]) from POD 14. The patients were not fully recovered at POD 30 (N.=18 [62%] had an excellent recovery)., Conclusions: Recovery measured by QoR-15 is substantially affected after major emergency abdominal surgery even after 14- and 30 days postoperatively. The patients were poor or only moderately recovered within the first seven postoperative days and only 62% of the patients were fully recovered at postoperative day 30.

Background: Preoperative endothelial dysfunction is a predictor of myocardial injury and major adverse cardiac events. Non-cardiac surgery is known to induce acute endothelial changes. The aim of this explorative cohort study was to assess the extent of systemic endothelial dysfunction after major emergency abdominal surgery and the potential association with postoperative myocardial injury., Methods: Patients undergoing major emergency abdominal surgery were included in this prospective cohort study. The primary outcome was the change in endothelial function expressed as the reactive hyperemia index from 4-24 h after surgery until postoperative day 3-5. The reactive hyperemia index was assessed by non-invasive digital pulse tonometry. Secondary outcomes included changes in biomarkers of nitric oxide metabolism and bioavailability. All assessments were performed at the two separate time points in the postoperative period. Clinical outcomes included myocardial injury within the third postoperative day and major adverse cardiovascular events within 30 days of surgery., Results: Between October 2016 and June 2017, 83 patients were included. The first assessment of the endothelial function, 4-24 h, was performed 15.8 (SD 6.9) hours after surgery and the second assessment, postoperative day 3-5, was performed 83.7 (SD 19.8) hours after surgery. The reactive hyperemia index was suppressed early after surgery and did not increase significantly; 1.64 (95% CI 1.52-177) at 4-24 h after surgery vs. 1.75 (95% CI 1.63-1.89) at postoperative day 3-5, p = 0.34. The L-arginine/ADMA ratio, expressing the nitric oxide production, was reduced in the perioperative period and correlated significantly with the reactive hyperemia index. A total of 16 patients (19.3%) had a major adverse cardiovascular event, of which 11 patients (13.3%) had myocardial injury. The L-arginine/ADMA ratio was significantly decreased at 4-24 h after surgery in patients suffering myocardial injury., Conclusion: This explorative pathophysiological study showed that acute systemic endothelial dysfunction was present early after major emergency abdominal surgery and remained unchanged until day 3-5 after the procedure. Early postoperative disturbances in the nitric oxide bioavailability might add to the pathogenesis of myocardial injury. This pathophysiological link should be confirmed in larger studies., Trial Registration: clinicaltrials.gov no. NCT03010969.

Background: In a retrospective cohort study, we looked at the incidence and risk factors of developing in-hospital venous thromboembolism (VTE) after major emergency abdominal surgery and the risk factors for developing a venous thrombosis., Methods: Data were extracted through medical records from all patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 until 2016. The primary outcome was the incidence of venous thrombosis developed in the time from surgery until discharge from hospital. The secondary outcomes were 30-day mortality and postoperative complications. Multivariate logistic analyses were used for confounder control., Results: In total, 1179 patients who underwent major emergency abdominal surgery during 2010-2016 were included. Thirteen patients developed a postoperative venous thromboembolism (1.1%) while hospitalized. Eight patients developed a pulmonary embolism all verified by CT scan and five patients developed a deep venous thrombosis verified by ultrasound scan. Patients diagnosed with a VTE were significantly longer in hospital with a length of stay of 34 versus 14 days, P < 0.001, and they suffered significantly more surgical complications (69.2% vs. 30.4%, P = 0.007). Thirty-day mortality was equal in patients with and without a venous thrombosis. In a multivariate analysis adjusting for gender, ASA group, BMI, type of surgery, dalteparin dose and treatment with anticoagulants, we found that a dalteparin dose ≥5000 IU was associated with the risk of postoperative surgical complications (odds ratio 1.55, 95% CI 1.11-2.16, P = 0.009)., Conclusion: In this study, we found a low incidence of venous thrombosis among patients undergoing major emergency abdominal surgery, comparable to the incidence after elective surgery.

Background: Myocardial injury after noncardiac surgery is common and associated with major adverse cardiac events. Surgery induces acute endothelial dysfunction, which might be central in the pathophysiology of myocardial injury; however, the relationship between surgical stress and endothelial function remains incompletely understood., Objectives: This study aimed to assess the acute peri-operative changes in endothelial function after minor elective abdominal surgery., Design: A prospective, observational, single-centre study., Setting: A university hospital from February 2016 to January 2017., Patients: Sixty patients undergoing elective minor abdominal surgery., Main Outcome Measures: The change in endothelial function, expressed as the reactive hyperaemia index (RHI), was assessed by non-invasive digital pulse tonometry. RHI, biomarkers of nitric oxide bioavailability and oxidative stress were assessed prior to and 4 h after surgery., Results: RHI decreased significantly from 1.93 [95% confidence interval (95% CI 1.78 to 2.09)] before surgery to 1.76 (95% CI 1.64 to 1.90), P = 0.03, after surgery. The nitric oxide production, L-arginine/asymmetric dimethylarginine, decreased significantly from a ratio of 213.39 (95% CI 188.76 to 241.2) to a ratio of 193.3 (95% CI 171.82 to 217.54), P = 0.03. Plasma biopterins increased significantly after surgery, while the ratio between tetrahydrobiopterin and dihydrobiopterin was unchanged. Total ascorbic acid decreased significantly after surgery (P < 0.001), while its oxidation ratio was unchanged., Conclusion: Elective minor abdominal surgery impaired systemic endothelial function early after surgery., Trial Registration: Clinicaltrials.gov identifier: NCT02690233.