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Background: Acute appendicitis is the most common cause of abdominal pain requiring surgery, usually managed with laparoscopic appendectomy. In Denmark, the standard postoperative treatment for complicated cases involves intravenous antibiotics. This study compares peroral versus intravenous antibiotics in the context of fast-track surgery and Enhanced Recovery After Surgery (ERAS) protocols. Our objective is to evaluate the impact of peroral versus intravenous antibiotics on patient-reported outcomes following laparoscopic appendectomy for complicated appendicitis. Methods: This was a sub-study within a broader Danish cluster-randomized non-inferiority trial conducted at Zealand University Hospital, focusing on adult patients undergoing laparoscopic appendectomy for complicated appendicitis. Participants were randomized into two groups: one receiving a three-day course of peroral antibiotics and the other intravenous antibiotics after surgery. Recovery quality was assessed on the third postoperative day using the Quality of Recovery-15 (QoR-15) questionnaire. Results: The study included 54 patients, 23 in the peroral and 31 in the intravenous groups. The peroral group reported significantly better recovery outcomes, with higher QoR-15 scores (mean difference of 12 points, p < 0.001). They also experienced shorter hospital stays, averaging 47 h less than the intravenous group (p < 0.001). No significant differences between the groups were observed in readmissions or severe postoperative complications. Conclusions: Peroral antibiotic administration after laparoscopic appendectomy for complicated appendicitis significantly improves patient recovery and reduces hospital stay compared to intravenous antibiotics. These results advocate a potential shift towards peroral antibiotic use in postoperative care, aligning with ERAS principles. Trial Registration Number: ClinicalTrials.gov NCT04803422. [ABSTRACT FROM AUTHOR]

Abstract Background Trauma is one of the leading causes of morbidity and mortality worldwide. Morbidity and mortality review of selected patient cases is used to improve the quality of trauma care by identifying opportunities for improvement (OFI). The aim of this study was to assess how patient and process factors are associated with OFI in trauma care. Methods We conducted a registry-based study using all patients between 2017 and 2021 from the Karolinska University Hospital who had been reviewed regarding the presence of OFI as defined by a morbidity and mortality conference. We used bi- and multivariable logistic regression to assess the associations between the following patient and process factors and OFI: age, sex, respiratory rate, systolic blood pressure, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), survival at 30 days, highest hospital care level, arrival on working hours, arrival on weekends, intubation status and time to first computed tomography (CT). Results OFI was identified in 300 (5.8%) out of 5182 patients. Age, missing Glasgow Coma Scale, time to first CT, highest hospital care level and ISS were statistically significantly associated with OFI. Conclusion Several patient and process factors were found to be associated with OFI, indicating that patients with moderate to severe trauma and those with delays to first CT are at the highest odds of OFI.

Background: Trauma is one of the leading causes of morbidity and mortality worldwide. Morbidity and mortality review of selected patient cases is used to improve the quality of trauma care by identifying opportunities for improvement (OFI). The aim of this study was to assess how patient and process factors are associated with OFI in trauma care. Methods: We conducted a registry-based study using all patients between 2017 and 2021 from the Karolinska University Hospital who had been reviewed regarding the presence of OFI as defined by a morbidity and mortality conference. We used bi- and multivariable logistic regression to assess the associations between the following patient and process factors and OFI: age, sex, respiratory rate, systolic blood pressure, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), survival at 30 days, highest hospital care level, arrival on working hours, arrival on weekends, intubation status and time to first computed tomography (CT). Results: OFI was identified in 300 (5.8%) out of 5182 patients. Age, missing Glasgow Coma Scale, time to first CT, highest hospital care level and ISS were statistically significantly associated with OFI. Conclusion: Several patient and process factors were found to be associated with OFI, indicating that patients with moderate to severe trauma and those with delays to first CT are at the highest odds of OFI. [ABSTRACT FROM AUTHOR]

Summary: Background: The COVID-19 pandemic caused an important reduction in surgical activities during the first wave. Aim of this retrospective time-trend analysis was to examine whether also during the second wave in fall and winter 2020/2021 surgical interventions decreased. Methods: Absolut numbers and types of surgeries in a tertiary university hospital during the second COVID-19 wave in fall/winter 2020/2021 were collected from the surgical planning software and compared with the same time frame over the last 5 years. In a second step, the reduction of surgical interventions during the second wave was compared with the reduction of surgical procedures during the first wave in spring 2020 at the same hospital. Results: Despite a higher 7‑day incidence of COVID-19 infection and a higher number of patients needing ICU treatment during the second wave, the reduction of surgical interventions was 3.22% compared to 65.29% during the first wave (p < 0.0001). Elective surgical interventions decreased by 88.63% during the first wave compared to 1.79% during the second wave (p < 0.0001). Emergency and oncological interventions decreased by 35.17% during the first wave compared to 5.15% during the second wave (p : 0.0007) and 47.59% compared to 3.89% (p < 0.0001), respectively. Surgical activity reduction in our institution was less pronounced despite higher occupancy of ICU beds during the second COVID-19 wave in fall/winter 2020/2021. Conclusion: Better understanding of the disease, adequate supply of disposables and improved interdisciplinary day by day management of surgical and ICU resources may have contributed to this improvement. [ABSTRACT FROM AUTHOR]

Introduction The literature converges regarding the use of C-reactive protein (CRP) tests between postoperative days (PODs) 3 and 5 of elective procedures. In this period, they have great sensitivity and negative predictive value (NPV) for severe and anastomotic complications about two days before the first clinical sign. The few studies on colorectal urgency suggest that, despite the different initial values according to the surgical indication, following POD 3, the level of CRP is similar to that of elective procedures. However, given the heterogeneity of the studies, there is no consensus on the cutoff values for this use. Objective To validate the use and propose a PO CRP cut-off value in urgent colorectal procedures as an exclusion criterion for complications of anastomosis or the abdominal cavity. Method Retrospective analysis of the medical records of 308 patients who underwent urgent colorectal surgical procedures between January 2017 and December 2019. The following data were considered: age, gender, surgical indication, type of procedure performed, complications, CRP levels preoperatively and from POD 1 to 4, and the severity of the complications. We compared the CRP levels and the percentage variations between the preoperative period and PODs 1 to 4 as markers of severe complications using the receiver operating characteristic (ROC) curve. Results The levels of CRP on POD4, and their percentage drops between PODs 2 to 4 and PODs 3 to 4, were better to predict severe complications. A cutoff of 7.45 mg/dL on POD 4 had 91.7% of sensitivity and NPV. A 50% drop between PODs 3 and 4 had 100% of sensitivity and NPV. Conclusion Determining the level of CRP is useful to exclude severe complications, and it could be a criterion for hospital discharge in POD 4 of emergency colorectal surgery.

Introduction: Management of deep facial burns is a serious challenge for many reasons: a considerable anatomic and functional diversity is concentrated in a small space, a uniform treatment does not exist, late sequelae are frequent and may be severe, and the literature on the subject is ambiguous.Aim: To analyse management of deep facial burns.Patients and methods: A retrospective medical chart review was conducted for 569 patients with deep facial burns hospitalized between January 2005 and January 2015. Demographic data, type, depth and size of burns, chronology and type of surgical treatment, length of hospital stay, and type and incidence of late sequelae were analysed and compared.Results: Over 10 years, 596 patients with deep facial burns, 216 (36.24%) females and 380 (63.76%) males, aged from 5 months to 95 years (mean 39.5±26 years) were treated. The most common burn agents were hot liquids and flames. The mean total body surface area (TBSA) burned was 17±13.3%. Concomitant eye injury was detected in 63 (10.6%) patients. Priority was given to the early, meticulous, staged surgical approach aimed at sparing the survived tissues and rapid wound closure. Follow-up ranged from 3 months to 5 years. Late functional sequelae were documented for 50 (8.38%) patients and ocular sequelae - for 33 (5.54%) of them. There was no incidence of secondary corneal perforation or definitive loss of vision.Conclusions: Adequate and up-to-date acute management of deep facial burns based on early, judicious, surgical approach could limit initial damage and reduce late sequelae.

The purpose of this study was to evaluate changes to acute pediatric surgical needs during the early phase of the SARS-Cov2 (COVID-19) pandemic. We performed a retrospective cohort study of all in-hospital pediatric surgery consultations placed through the consult paging system at a single institution. We compared both median and absolute differences for emergency department (ED), operative, and hospital outcomes between March, April, and May of 2019 versus 2020. There were 225 in-hospital pediatric surgery consults in 2019 and 123 in 2020. Overall, mean age was 8.4-y (standard deviation = 6.4) and 60% were male. Initial vitals were similar between years and a similar proportion of patients underwent laboratory and imaging tests. In 2020, children spent a median of 1.1-h fewer in the ED (95% confidence interval = −2.2, −0.1) and 0.9-h fewer in the ED before surgical consultation (95% confidence interval = −1.5, −0.3) compared to 2019. Patients required significantly more procedures in the ED in 2020 (n = 16, 14.3%) than 2019 (n = 13, 6.2%) (P = 0.02), most commonly laceration repairs. In 2019, 46 children (20.4% of all consults in 2019) presented with appendicitis and 27 children (22.0% of all consults in 2020) in 2020. Complicated appendicitis was more common in 2020 (n = 12, 44.4%) than 2019 (n = 9, 19.6%) (P = 0.02). Two children (7.4%) were managed nonoperatively with a drain in 2020 compared to none in 2019 (P = 0.13). Median time from surgical consultation to surgery, median operative time, and median time to discharge was similar for children with appendicitis in both years. The early phase of the pandemic was associated with more efficient triaging in the ED, but more ED procedures and more complex surgical pathology. [ABSTRACT FROM AUTHOR]

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 (

PURPOSE OF THE STUDY The study analyses a cohort of patients with surgically treated ankle fractures who developed complete distal tibiofibular synostoses. It focuses on their occurrence and association with the extent of tibiotalar dislocation of the ankle joint on the trauma X-ray and its relation to the choice of surgery. MATERIAL AND METHODS The cohort of a total of 824 patients with type B and C fractures according to Weber classification was followed up for 9 years. The cohort consisted of 403 (48.9%) men and 421 (51.1%) women. The exclusion criteria included associated talus fractures, calcaneus fractures and fractures of the other bones of the foot. The studied data were obtained retrospectively from medical documentation and by evaluation of trauma X-rays and X-rays obtained during the postoperative checks. The ankle fractures were classified based on the Weber classification and the basic epidemiologic data (age and gender), type of fracture and extent of tibiotalar dislocation of ankle fractures on the trauma X-ray were evaluated. Posttraumatic ankle dislocation was divided into tibiotalar dislocation > 10 mm, tibiotalar dislocation < 10 mm and the group with regular ankle joint. When evaluating the treatment method, the cohort was divided into three groups: Group 1 with one-stage osteosynthesis, Group 2 with temporary K-wire transfixation or external fixation and subsequent secondary conversion to internal osteosynthesis, and Group 3 with definitive transfixation or external fixation of the ankle. The results were statistically evaluated using the Pearson s chi-square test, or the Fisher s exact test for low frequencies. A multivariant logistic regression model was created to identify statistically significant factors contributing to the development of synostosis. The results with the p-value < 0.05 were considered statistically significant. RESULTS In the whole cohort, the synostosis of distal tibiofibular joint was observed in a total of 131 (15.9%) patients. In men it was in 85 (21.1%) cases and in women in 46 (10.9%) cases, which was statistically significant (p < 0.0001). There was a statistically significant difference (p = 0.0020) between the mean age in the group of patients with synostosis (54.4 years) and the mean age in the group of patients without synostosis (49.1 years). Complete distal tibiofibular synostoses were found in 78 (12.7%) fractures classified as type B according to the Weber classification and in 53 (25.5%) type C fractures. When taking into account the gender, synostoses occurred more frequently in men in both types of fractures classified based on the Weber classification, only in type C fractures no statistical significance was established (p = 0.3026). Various size of posttraumatic tibiotalar dislocation was present in both types of fractures. The group with less severe type B ankle fractures showed a statistically significant dominance of synostosis development in cases with large tibiotalar dislocation of more than 10 mm (p<0.0001). In the group with type C fractures different results were obtained. The highest frequency of cases with synostosis was reported in the group with dislocation smaller than 10 mm (p = 0.0698). In the entire cohort, 615 (74.6%) one-stage osteosyntheses were performed and synostoses developed in 77 (12.5%) cases. In 165 (20.0%) patients, transfixation with K-wires or external fixation with subsequent conversion to secondary osteosynthesis were used and synostoses were identified in 50 (30.3%) cases (p < 0.0001). The open fractures showed an insignificantly smaller number of synostoses than the closed fractures (p = 0.5902). DISCUSSION Posttraumatic distal tibiofibular synostoses have varied morphology. A number of studies confirmed that they do not affect much the functional status of the ankle, even despite their extensive finding in the area of syndesmosis is evident on the Xray. Etiologically, a certain role in their development is reported to be played by posttraumatic hematoma in case of damage to deep soft and bony structures of the ankle. CONCLUSIONS A higher occurrence of synostoses was observed in male population, older age patients and also in type C fractures according to the Weber classification. Larger tibiotalar dislocation showed statistical significance in the development of synostoses in type B fractures according to the Weber classification, whereas in type C fractures it was not the main factor contributing to the development of synostosis. In cases where one-staged osteosynthesis was performed, the occurrence of synostoses was statistically significantly lower than in secondary osteosynthesis after temporary stabilisation. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objectives: The PREDICT study aimed to determine how the COVID-19 pandemic affected surgical services and surgical patients and to identify predictors of outcomes in this cohort. Background: High mortality rates were reported for surgical patients with COVID-19 in the early stages of the pandemic. However, the indirect impact of the pandemic on this cohort is not understood, and risk predictors are yet to be identified. Methods: PREDICT is an international longitudinal cohort study comprising surgical patients presenting to hospital between March and August 2020, conducted alongside a survey of staff redeployment and departmental restructuring. A subgroup analysis of 3176 adult emergency patients, recruited by 55 teams across 18 countries is presented. Results: Among adult emergency surgical patients, all-cause in-hospital mortality (IHM) was 3.6%, compared to 15.5% for those with COVID-19. However, only 14.1% received a COVID-19 test on admission in March, increasing to 76.5% by July. Higher Clinical Frailty Scale scores (CFS >7 aOR 18.87), ASA grade above 2 (aOR 4.29), and COVID-19 infection (aOR 5.12) were independently associated with significantly increased IHM. The peak months of the first wave were independently associated with significantly higher IHM (March aOR 4.34; April aOR 4.25; May aOR 3.97), compared to non-peak months. During the study, UK operating theatre capacity decreased by a mean of 63.6% with a concomitant 27.3% reduction in surgical staffing. Conclusion: The first wave of the COVID-19 pandemic significantly impacted surgical patients, both directly through co-morbid infection and indirectly as shown by increasing mortality in peak months, irrespective of COVID-19 status. Higher CFS scores and ASA grades strongly predict outcomes in surgical patients and are an important risk assessment tool during the pandemic. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to develop and validate a model to predict 90-day mortality after acute colorectal cancer surgery. Methods: The model was developed in all patients undergoing acute colorectal cancer surgery in 2014–2016 and validated in a patient group operated in 2017 in Denmark. The outcome was 90-day mortality. Tested predictor variables were age, sex, performance status, BMI, smoking, alcohol, education level, cohabitation status, tumour localization and primary surgical procedure. Variables were selected according to the smallest Akaike information criterion. The model was shrunken by bootstrapping. Discrimination was evaluated with a receiver operated characteristic curve, calibration with a calibration slope and the accuracy with a Brier score. Results: A total of 1450 patients were included for development of the model and 451 patients for validation. The 90-day mortality rate was 19% and 20%, respectively. Age, performance status, alcohol, smoking and primary surgical procedure were the final variables included in the model. Discrimination (AUC = 0.79), calibration (slope = 1.04, intercept = 0.04) and accuracy (brier score = 0.13) were good in the developed model. In the temporal validation, discrimination (AUC = 0.80) and accuracy (brier score = 0.13) were good, and calibration was acceptable (slope = 1.19, intercept = 0.52). Conclusion: We developed prediction model for 90-day mortality after acute colorectal cancer surgery that may be a promising tool for surgeons to identify patients at risk of postoperative mortality. [ABSTRACT FROM AUTHOR]

Innsbruck Medical University Hospital, Austria, provides the highest level of care for a region of approximately 1.8 million people. During the early COVID-19 outbreak in spring 2020 surgical activity was drastically reduced with the prime goal of preserving hospital capacities, especially intensive care beds. We conducted a retrospective analysis of surgical activities performed at Innsbruck Medical University Hospital during the lockdown period from March 15 to April 14, 2020 and compared these activities to the same period during the previous 5 years. Total surgical activity was reduced by 65.4% compared to the same period during the previous 5 years (p < 0.001); elective surgeries were reduced by 88.7%, acute surgeries by 35.3% and oncological surgeries by 47.8% compared to the previous 5 years (all p < 0.001). This dramatic decrease in acute and oncological surgeries can most likely be ascribed to the fact that many patients avoided health care facilities because of the strict stay-at-home policy and/or the fear of contracting SARS-CoV-2 in the hospital. In view of future waves, the population should be encouraged to seek medical help for acute symptoms and to attend cancer screening programs.

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 (< 18 years), aortic surgery, second look and other expected reoperations were excluded. Demographic, management and outcome data were collected after an extensive analysis of the cohort.Results: A total of 710 consecutive operations, representing 663 patients, were included in the cohort (mean age 65.6 years). Mortality (30 days/1 year) after all operations was 14.2% and 26.6% respectively. The mean LOS in hospital was 12 days, while LOS in the ICU was five days. Of all operations, 23.8% patients were admitted at any time to the ICU postoperatively and the 30-day mortality seen among ICU patients was 37.9%. Mortality was strongly correlated to existing comorbidity, high ASA classification, ICU care and faecal peritonitis. The mean/median time from notification to operate until the first incision was 3:46/3:02 h and 87% of patients had their first incision within 6 h of notification.Conclusions: In this present Swedish study, high mortality and morbidity were observed after emergency laparotomy, which is in agreement with other recent studies.Trial Registration: The study has been registered with ClinicalTrials.gov (NCT03549624, registered 8 June 2018). [ABSTRACT FROM AUTHOR]

Background: Older patients undergoing emergency surgery experience higher mortality and morbidity. ‘Care of Older People in Surgery’ (COPS) is a comprehensive geriatric care model developed for acute surgical units (ASU) to improve clinical outcomes in older general surgical patients. This study aimed to evaluate the impact of COPS on clinical and health service outcomes in an Australian hospital. Methods: The before-and-after study was conducted in the ASU, at Nepean Hospital. Data from patients ≥75 years admitted for >24 h into the ASU during the intervention period between April 2017 and March 2018 were compared to patients admitted in the previous year (April 2016 to March 2017) prior to the COPS intervention (n = 212). Health service outcomes measured include the average stay length, medical emergency team response, unplanned intensive care unit admission and 28-day readmission rates. Results: The COPS group (n = 214) suffered significantly fewer medical complications, including less acute kidney injuries, arrhythmias and urinary tract infections compared to the pre-intervention cohort (n = 212). Medical emergency team activation was significantly reduced after COPS model implementation and the average length of stay decreased. However, the incidence of postoperative delirium and acute coronary syndrome were higher in COPS cohort. Conclusion: Our study demonstrated that comprehensive geriatric assessment and care delivered through a shared model of care in older general surgical patients improved clinical outcome and patient safety measures. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive esophagectomy and gastrectomy are increasingly performed and might be superior to their open equivalents in an elective setting. The aim of this study was to evaluate whether minimally invasive approaches can be safely applied in the acute setting as well. Methods: All patients who underwent an acute surgical intervention for primary esophageal or gastric cancer between 2011 and 2017 were identified from the nationwide database of the Dutch Upper GI Cancer Audit (DUCA). Conversion rates, postoperative complications, re-interventions, postoperative mortality, hospital stay and oncological outcomes (radical resection rates and median lymph node yield) were evaluated. Results: Between 2011 and 2017, surgery for esophagogastric cancer was performed in an acute setting in 2% (190/8861) in The Netherlands. A total of 14 acute resections for esophageal cancer were performed, which included 7 minimally invasive esophagectomies and 7 open esophagectomies. As these numbers were very low, no comparison between minimally invasive and open esophagectomies was made. A total of 122 acute resections for gastric cancer were performed, which included 39 minimally invasive gastrectomies and 83 open gastrectomies. Conversion occurred in 9 patients (23%). Minimally invasive gastrectomy was at least comparable to open gastrectomy regarding postoperative complications (36% versus 51%), median hospital stay (9 days [IQR: 7–16 days] versus 11 days [IQR: 7–17 days]), readmissions (8% versus 11%) and oncological outcomes (radical resection rate: 87% versus 66%, median lymph node yield: 21 [IQR: 15–32 days] versus 16 [IQR: 11–24 days]). Conclusions: Minimally invasive surgery for gastric cancer is safe and feasible in the acute setting, with at least comparable postoperative clinical and short-term oncological outcomes compared to open surgery but a relatively high conversion rate. [ABSTRACT FROM AUTHOR]

At the time of writing, coronavirus disease-2019 (COVID-19) has affected 6.42 million people globally and over 380,000 deaths, with the United Kingdom now having the highest death rate in Europe. The plastic surgery department at Leeds Teaching Hospitals put necessary steps in place to maintain an excellent urgent elective and acute service whilst also managing COVID-positive medical patients in the ward. We describe the structures and pathways implemented together with complex decision-making, which has allowed us to respond early and effectively. We hope these lessons will prove a useful tool as we look to open conversations around the recovery of normal activity. [ABSTRACT FROM AUTHOR]

Abstract Background Acutely admitted medical patients are often fragile and in risk of future surgery. The biomarker soluble urokinase plasminogen activator receptor (suPAR) is a predictor of readmission and mortality in the acute care setting. We aimed to investigate if suPAR also predicts acute surgery, which is associated with higher mortality than elective surgery, and if it predicts post-operative mortality. Methods A retrospective registry-based cohort study of 17,312 patients admitted to an acute medical unit in Denmark, from 18 November 2013 until 30 September 2015. The first admission with available suPAR was defined as the index admission, and patients were followed via national registries until 1 January 2016. The risk of acute surgery during the entire follow-up period as well as the 90-day post-operative mortality risk was modeled by Cox regression analyses adjusted for sex, age, C-reactive protein, and Charlson Comorbidity Index (Charlson Score). Results Acute surgery was carried out on 2404 patients (13.9%) after a median of 45 days (interquartile range 5–186) following the index admission. Patients receiving acute surgery had higher baseline suPAR compared with patients receiving elective- or no surgery (p

The devastating effects of the opioid epidemic are well documented. We implemented a surgeon/pharmacist opioid reduction initiative at an academic medical center that incorporated multimodal pain therapy in an attempt to reduce total inpatient opioids prescribed. We hypothesized that less opioids would be used postoperatively without affecting pain scores or length of stay. This single-center observational cohort analysis included patients admitted to the acute general surgical service and had one of 10 emergent general surgical (nontrauma) procedures. Patients who underwent surgery before the opioid reduction initiative were compared with patients who underwent surgery postinitiative. The primary objective was to evaluate differences in daily oral morphine equivalents and average pain scores in patients before and after implementation of the surgeon/pharmacist initiative. Eighty-three patients in the preopioid reduction initiative group and 92 patients in the postopioid reduction initiative group met inclusion criteria. Oral morphine equivalents were significantly different at 24 h before discharge when comparing across both year (P = 0.032) and number of procedures (P = 0.013). Our results showed decreased opioid utilization in the postopioid reduction initiative group on all observed postoperative days with unaffected pain scores. An opioid reduction initiative showed promise in lowering the number of opioids used during inpatient admission without affecting pain scores in emergent general surgical procedures. This initiative can be easily reproduced at other institutions to help combat the opioid epidemic. [ABSTRACT FROM AUTHOR]

Introduction of laparoscopic colectomy, initially as a hand-assisted procedure and finally performed completely laparoscopically, in the 1990s met with the serious concerns of surgeons of that period regarding the safe performance of these major procedures in a minimally invasive manner and, especially for colon cancer patients, the oncologic outcome. Impressively, due to the very frequent problem of port metastases (up to 21%!), laparoscopic colectomies were allowed to be performed only in clinical protocols. However, initial concerns were elucidated and outcomes were widely accepted. This was achieved due to well organized training courses of surgeons and the conclusion that, beyond the well known advantages of laparoscopic surgery, the surgical outcomes of patients treated for benign and more importantly malignant diseases were as good as them in open surgery. In this brief report, an analysis of this evolution historically and from the point of evidence-based surgery is carried out.

Background: Acute abdomen is a time‐critical condition, which requires prompt diagnosis, initiation of first‐line preoperative therapy and expedient surgical intervention. The earliest opportunity to intervene occurs at presentation to the emergency department triage. The aim of this audit was to evaluate the relationship between emergency triage and time performance measures in the preoperative management of abdominal emergencies. Methods: Retrospective audit of time performance measures of key clinical events from emergency triage. Patient characteristics, elapsed time from triage to commencement of fluid resuscitation, intravenous antibiotics and emergency surgery and post‐operative outcomes were obtained from review of operative medical records data over a 1‐year duration. Results: There was variability in triage allocation of patients with acute abdomen requiring urgent surgery. Category 3 was the most commonly assigned triage category (65.6%). The majority of patients (94.8%) had initial clinical assessment within the National Emergency Access Target '4‐hour' rule, and 41.7% seen within 1‐h from triage. Despite this, in cases of intra‐abdominal sepsis, there was nearly a fourfold elapsed time for first dose intravenous antibiotics, beyond the 1‐h recommendation in the Sepsis Kills pathway. There was non‐significant trend in faster overall time performances with successive higher triage category allocation. Conclusion: This study highlights an opportunity to consider alternative triage methods or fast‐track of patients with acute abdomen to promote early surgical assessment, resuscitation, antibiotic therapy and definitive intervention. [ABSTRACT FROM AUTHOR]

In the last decade, emergency general surgery (EGS) in Australia and New Zealand has seen a transition from the traditional on‐call system to the acute surgical unit (ASU) model. The importance and growing demand for EGS has resulted in the implementation of the General Surgeons Australia's 12‐point plan for emergency surgery. Since its release, the 12‐point plan has been used as a benchmark of a well‐functioning ASU, both locally and abroad. This study aims to provide a descriptive review on the relevance of the 12‐point plan to the ASU model and review the current evidence to support this framework. The review concludes that the establishment of the ASU model has met the aims set out by the Royal Australasian College of Surgeons for EGS. The 12‐point plan is relevant and has good evidence to support its framework. [ABSTRACT FROM AUTHOR]

Purpose: Image-based measurement of sarcopenia is an established predictor of a decreased outcome for a large variety of surgical procedures. Sarcopenia in elderly patients undergoing emergency abdominal surgery has not been well studied. This study aims to investigate the association between the total psoas area (TPA) and postoperative mortality after 90 days in a group of elderly emergency laparotomy patients.Methods: We retrospectively reviewed the emergency CT-scans of 150 elderly patients from a consecutive cohort undergoing emergency abdominal surgery at our surgical center. TPA was measured manually at the level of L3 and indexed to patient height. Sarcopenia was defined as having a TPA index below the first quartile for gender in the cohort. Other collected variables were age, vital status/date of death, ASA-score, surgical procedure, and WHO performance score.Results: Overall 90-day mortality was 42.7%. Sarcopenic patients had a higher 90-day mortality (60.5%) than non-sarcopenic patients (36.6%), corresponding to an odds ratio of 2.66 (95% confidence interval 1.2-5.7, p = 0.01). Sarcopenic patients had an increased mortality compared with non-sarcopenic patients (p = 0.0009, Log-rank test), with a clear separation of the two groups within 30 days postoperatively. In a multivariate logistic regression model, with age, ASA-score, and WHO performance score as covariates, sarcopenia was independently associated with 90-day mortality.Conclusion: Manual measurement of TPA on an abdominal CT-scan is a relevant risk factor for postoperative mortality in elderly patients undergoing high-risk emergency abdominal surgery. Incorporation of sarcopenia in postoperative risk-prediction models in emergency abdominal surgery should be considered. [ABSTRACT FROM AUTHOR]

Objectives. With a steadily growing number of patients with non-valvular atrial fibrillation, anticoagulation use increases. Anticoagulation therapy is associated with increased risk of serious bleeding and an increased complexity in management of patients in need for urgent surgery. We wanted to assess the magnitude of this challenge as well as review current and potential future clinical management strategies. Design. A review of the literature on the magnitude of patients using antigoaculants in potential need for acute restoration of hemostasis was conducted, as well as current status of reversal agents for non-vitamin K antagonist oral anticoagulants (NOACs). Additionally, a case illustration of its use is presented. Results. Two main groups of patients may need acute restoration of hemostasis, those in need of acute surgery or acute invasive procedures, ∼ 2% of patients annually, and those with serious and critical hemorrhage, ∼1.5% annually. One specific reversal agent is available on the market (idarucizumab) and two (andexanet alfa, ciraparantag) are in clinical development. Idarucizumab is a specific antidote for the thrombin inhibitor dabigatran while andexanet alfa is factor Xa inhibitor class-specific currently in late-stage development. Ciraparantag is a universal reversal agent in early-phase development. These agents can facilitate effective management of bleeding or bleeding risk, as illustrated in a patient on dabigatran in urgent need for a pacemaker. Conclusions. Amongst patients using anticoagulants, around 3.5%, could be in need of immediate restoration of hemostasis annually. The availability and use of specific reversal agents for NOACs could be crucial for the clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Acutely admitted medical patients are often fragile and in risk of future surgery. The biomarker soluble urokinase plasminogen activator receptor (suPAR) is a predictor of readmission and mortality in the acute care setting. We aimed to investigate if suPAR also predicts acute surgery, which is associated with higher mortality than elective surgery, and if it predicts post-operative mortality. Methods: A retrospective registry-based cohort study of 17,312 patients admitted to an acutemedical unit in Denmark, from 18 November 2013 until 30 September 2015. The first admission with available suPAR was defined as the index admission, and patients were followed via national registries until 1 January 2016. The risk of acute surgery during the entire follow-up period as well as the 90-day post-operative mortality risk was modeled by Cox regression analyses adjusted for sex, age, C-reactive protein, and Charlson Comorbidity Index (Charlson Score). Results: Acute surgery was carried out on 2404 patients (13.9%) after a median of 45 days (interquartile range 5-186) following the index admission. Patients receiving acute surgery had higher baseline suPAR compared with patients receiving elective- or no surgery (p < 0.0001). The hazard ratio (HR) for acute surgery was 1.50 (95% confidence interval (CI): 1.42-1.59) for every doubling of the suPAR level in the adjusted Cox regression analysis. Death within 90 days occurred in 439 (18.3%) patients receiving acute surgery, and the adjusted HR for post-operative mortality was 1.73 (95% CI: 1.52-1.95). Discussion: Elevated levels of suPAR in acutely admitted medical patients were independently associated with increased risk of future acute surgery as well as with 90-day post-operative mortality. [ABSTRACT FROM AUTHOR]

Background This study provides data supporting the supposition that more elderly patients are requiring surgical care and illustrates the risks associated with acute surgical illness in elderly patients. Methods The clinical records database was accessed to identify all patients discharged from general surgery and acute surgical unit ( ASU) during 2013 and 2014. These groups were stratified by age (over 80 years). Data were collected on number of patients discharged per year, length of stay, number of intensive care unit admissions and number of procedures and mortality rates. Results There is an increasing number of patients aged over 80 years who were discharged from ASU; 7.02% ( n = 296) in 2013 and 8.20% ( n = 344) in 2014. Patients aged over 80 years were spending 1.88 days ( P-value < 0.001) longer in hospital than those under 80 years in 2014. Mortality rates in 2013 were 3.716 deaths per 100 admissions and 5.814 per 100 admissions in 2014. In 2013, the risk ratio of death in hospital for patients over 80 years was 36.4 ( P-value < 0.001) times higher than patients under 80 years. Conclusion The mean length of stay and mortality rates are higher for patients over 80 years. Mortality rates are higher in acute admissions compared with elective admissions. This identifies a need for increased care for elderly patients admitted for acute surgical care. We suggest a trial of attaching a specialist geriatrician to the ASU who will provide a service for at risk patients. [ABSTRACT FROM AUTHOR]

Introduction of laparoscopic colectomy, initially as a hand-assisted procedure and finally performed completely laparoscopically, in the 1990s met with the serious concerns of surgeons of that period regarding the safe performance of these major procedures in a minimally invasive manner and, especially for colon cancer patients, the oncologic outcome. Impressively, due to the very frequent problem of port metastases (up to 21%!), laparoscopic colectomies were allowed to be performed only in clinical protocols. However, initial concerns were elucidated and outcomes were widely accepted. This was achieved due to well organized training courses of surgeons and the conclusion that, beyond the well known advantages of laparoscopic surgery, the surgical outcomes of patients treated for benign and more importantly malignant diseases were as good as them in open surgery. In this brief report, an analysis of this evolution historically and from the point of evidence-based surgery is carried out. [ABSTRACT FROM AUTHOR]

Background Information about predictors for the duration of convalescence and the overall general wellbeing after laparoscopic surgery for suspected appendicitis is missing in the scientific literature. We aimed to describe and identify predictors for the duration of convalescence and the quality of recovery for patients undergoing laparoscopic surgery for suspected appendicitis. Methods A prospective cohort of adult patients undergoing laparoscopic surgery for suspected appendicitis was performed between July 2014 and December 2014. Patients completed a QoR-15 questionnaire six times during the 30-d postoperative period. Time until resumption of recreational and occupational activities was recorded. Potential predictors for the duration of convalescence and the quality of recovery measured by the QoR-15 score were identified. Results A total of 108 patients were included, and 95 patients were eligible for analysis. The median duration of convalescence was 13 d. Disease, depressive mood, level of recreational activities, age, and pain at rest on the first postoperative day were significant predictors of the duration of convalescence. Gender, postoperative complications, disease, and anxiety were significant predictors of the quality of recovery during the 30-d postoperative period. A 10% increase in the QoR-15 score increased the hazard ratio of 1.24 (95% confidence interval, 1.08-1.43, P = 0.002) for ending the period of convalescence. Conclusions Duration of convalescence after laparoscopic surgery for appendicitis seems long. Psychological factors, demographical factors, and perioperative outcomes were important predictors for the quality of recovery and the duration of convalescence. Increased quality of recovery is associated with a shorter period of convalescence. [ABSTRACT FROM AUTHOR]

Objective To assess the frailty and the incidence of delirium in elderly patients undergoing elective and acute colorectal surgery in correlation with morbidity and mortality. Methods Patients aged 65 years and older having elective and acute colorectal surgery, between April 2013 and December 2013 were included in a prospective database. Patients diagnosed with a colorectal carcinoma or diverticulitis who were operated on were included. Factors that characterize frailty of patients were noted. The incidence rates of delirium after elective and acute surgery were recorded. Delirium was diagnosed using the Delirium Observation Screening Scale (DOSS). Preoperative evaluation, surgical outcome including morbidity, hospital stay and mortality were analyzed. Results Patients ≥65 years were included, 83 (75%) received elective and 28 (25%) acute surgery. The overall incidence of delirium was 21%, 18% for elective and 29% for patients having urgent surgery ( p = 0.24). Patients with delirium were older than the non-delirious patients (median 82 years vs. 74 years; p < 0.001). Delirious patients showed higher incidence of adverse events. Hospital stay, mortality and discharge to a nursing home were significant higher in the delirious compared to the non-delirious group ( p = 0.01; 0.01; 0.02 respectively). Conclusion High incidence of delirium was found in both acute and elective colorectal surgery. Delirium was associated with adverse outcomes. [ABSTRACT FROM AUTHOR]