Background Risk stratification has become a key part of the care processes for patients having emergency bowel surgery. This study aimed to determine if operative approach influences risk‐model performance, and risk‐adjusted mortality rates in the United Kingdom. Methods A prospectively planned analysis was conducted using National Emergency Laparotomy Audit (NELA) data from December 2013 to November 2018. The risk‐models investigated were P‐POSSUM and the NELA Score, with model performance assessed in terms of discrimination and calibration. Risk‐adjusted mortality was assessed using Standardised Mortality Ratios (SMR). Analysis was performed for the total cohort, and cases performed open, laparoscopically and converted to open. Sub‐analysis was performed for cases with ≤ 20% predicted mortality. Results Data were available for 116 396 patients with P‐POSSUM predicted mortality, and 46 935 patients with the NELA score. Both models displayed excellent discrimination with little variation between operative approaches (c‐statistic: P‐POSSUM 0.801–0.836; NELA Score 0.811–0.862). The NELA score was well calibrated across all deciles of risk, but P‐POSSUM over‐predicted risk beyond 20% mortality. Calibration plots for operative approach demonstrated that both models increasingly over‐predicted mortality for laparoscopy, relative to open and converted to open surgery. SMRs calculated using both models consistently demonstrated that risk‐adjusted mortality with laparoscopy was a third lower than open surgery. Conclusion Risk‐adjusted mortality for emergency bowel surgery is lower for laparoscopy than open surgery, with P‐POSSUM and NELA score both over‐predicting mortality for laparoscopy. Operative approach should be considered in the development of future risk‐models that rely on operative data.

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Pre-operative risk stratification is a key part of the care pathway for emergency bowel surgery, as it facilitates the identification of high-risk patients. Several novel risk scores have recently been published that are designed to identify patients who are frail or significantly unwell. They can also be calculated preoperatively from routinely collected clinical data. This study aimed to investigate the ability of these scores to predict 30-day mortality after emergency bowel surgery. A single centre cohort study was performed using our local data from the National Emergency Laparotomy Audit database. Further data were extracted from electronic hospital records (n = 1508). The National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score were then calculated. The most abnormal National or Laboratory Decision Tree Early Warning Score in the 24 or 72 h before surgery was used in analysis. Individual scores were reasonable predictors of mortality (c-statistic 0.699-0.740) but all were poorly calibrated. A National Early Warning Score ≥ 4 was associated with a high overall mortality rate (> 10%). A logistic regression model was developed using age, National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score as predictor variables, and its performance compared with other established risk models. The model demonstrated good discrimination and calibration (c-statistic 0.827) but was marginally outperformed by the National Emergency Laparotomy Audit score (c-statistic 0.861). All other models compared performed less well (c-statistics 0.734-0.808). Preoperative patient vital signs, blood tests and markers of frailty can be used to accurately predict the risk of 30-day mortality after emergency bowel surgery.

Introduction Laparoscopic anti-reflux surgery is the standard surgical treatment for gastro-oesophageal reflux disease in patients for who long-term pharmacotherapy is intolerable or ineffective. Advances in anaesthesia and minimally invasive surgery have led to day case treatment being adopted by some centres. The objective of this study is to describe our day case pathway and peri- and postoperative outcomes. Materials and methods This is a single centre, retrospective case series review of a prospectively collected database from October 2014 to August 2019 performed in a tertiary centre for upper gastrointestinal surgery. Data collected included demographics, comorbidities, indications, complications, length of stay and readmission. Results A total of 362 patients underwent laparoscopic anti-reflux surgery with or without hiatus hernia repair of up to 10cm, with day case rates of 59%. Unplanned admission following day surgery was 5.1% (13/225) and 30-day readmission was 2.2% (8/362); 90.6% of patients remained in hospital for less than 24 hours. There was one intraoperative complication and one patient required revisional surgery within 30 days. The rate of all postoperative complications was 1.38% (5/362) with one postoperative mortality. Discussion The inclusion of larger hernias is unusual, as most studies limit size to 5cm or less. Our results show the safety and feasibility of the procedure even when applied to hiatus hernias up to 10cm. Success was multifactorial and based on standardisation of procedures and support from dedicated specialist nursing staff. Conclusion Laparoscopic anti-reflux surgery can be performed safely as a day case procedure even in larger hiatus hernias, with a dedicated care pathway and specialist nurse practitioners to support it.

Introduction Appendicitis continues to be a common surgical emergency in children, but its diagnosis remains challenging. Use of diagnostic imaging to confirm appendicitis has gained popularity in some countries because it is associated with lower negative appendicectomy rates. This study reports our centre’s experience of adopting routine ultrasound for the investigation of suspected appendicitis in children. Methods A single-centre retrospective cohort study was performed investigating all children aged 5–16 years admitted under surgeons with suspected appendicitis, in January–December 2019. Primary outcomes were the rate of ultrasound use, its accuracy in diagnosing/excluding appendicitis and negative appendicectomy rate. Other outcomes were treatment received, length of stay and complications. Results The majority of the 193 children with suspected appendicitis underwent a diagnostic ultrasound (87.5%). Ultrasound was highly sensitive (0.90, 95% confidence interval (CI) 0.81–0.96) and specific (1.0, 95% CI 0.96–1.0) for appendicitis in this study. Negative appendicectomy rate was extremely low (1.4%). Laparoscopic appendicectomy was the preferred management (75/86), with one case started open and no conversions to open. A minority of cases of simple appendicitis (10/86) were treated primarily with antibiotics. Rates of complex appendicitis and postoperative complications were similar to other studies. Conclusion Ultrasound can be highly sensitive and specific for appendicitis. Its routine use to confirm appendicitis prior to surgery is associated with a low negative appendicectomy rate. This is a major change in practice for a general surgical unit in the United Kingdom.

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Introduction Laparoscopic adhesiolysis is increasingly being used to treat adhesional small bowel obstruction (ASBO) as it has been associated with reduced postoperative length of stay (LOS) and faster recovery. However, concerns regarding limited working space, iatrogenic bowel injury and failure to relieve the obstruction have limited its uptake. This study reports our centre’s experience of adopting laparoscopy as the standard operative approach. Methods A single-centre prospective cohort study was performed incorporating local data from the National Emergency Laparotomy Audit Database; January 2015 to December 2019. All patients undergoing surgery for ASBO were included. Patient demographic, operative and inhospital outcomes data were compared between different surgical approaches. Linear regression analysis was performed for LOS. Results A total of 299 cases were identified. Overall, 76.3% of cases were started laparoscopically and 52.2% were completed successfully. Patients treated laparoscopically had lower Portsmouth – Physiological and Operative Severity Score for the enuMeration of Mortality and morbidity (P-POSSUM) predicted mortality (median 2.1 (interquartile range (IQR) 1.3–5.0) vs 5.7 (IQR 2.0–12.4), p=<0.001) and shorter postoperative LOS compared with open (median 4.2 days (IQR 2.5–8.2) vs 11.3 days (IQR 7.3–16.6), p=0.000). Inhospital mortality was lower in the laparoscopic group (2 vs 7 deaths, p=<0.001). In regression analysis, laparoscopic surgery was found to have the strongest association with postoperative LOS (β −8.51 (−13.87 to −3.16) p=0.002) compared with open surgery. Conclusions Laparoscopy is a safe and feasible approach for adhesiolysis in the majority of patients with ASBO. It is associated with reduced LOS with no impact on complications or mortality.

Laparoscopic fundoplication has become a standard surgical treatment for gastro-oesophageal reflux disease. Many of these patients also have a hiatus hernia that is repaired at the same time. However, suture-only repair of larger hiatus hernias has recurrence rates as high as 50%. Evidence on the effectiveness and safety of surgical mesh to reinforce hiatal repair compared with suture-only repair is currently lacking. This study aims to assess the feasibility of running a randomised controlled trial comparing the results of large hiatus hernia repair with DynaMesh-HIATUS® crural reinforcement versus standard suture repair alone. This is a single-centre, double-blind, parallel group randomised feasibility study. Forty patients with large hiatus hernia will be randomised to standard laparoscopic suture repair or suture repair with cruroplasty using the DynaMesh-HIATUS® circumferential mesh, with a 3-year follow-up period. Participants and assessors will be blinded to treatment allocation. Outcomes include trial process indicators (eligible participants, recruitment, and retention rates), surgical indicators (placement of mesh, operative complications, length of stay), adverse events, patient quality of life and symptom scores and mesh position after 1 year, and patient quality of life measures to 3 years. Feasibility will be assessed by rates of recruitment, retention, and successful surgical procedures. Clinical and patient-related outcomes for the two surgical methods will be described, and those most appropriate to include in a definitive trial identified. Correlation will be made between the position of the mesh on magnetic resonance imaging (MRI) and clinical outcomes. The DYNAMIC study will provide information to design and deliver a definitive randomised controlled trial of DynaMesh-HIATUS® cruroplasty compared with suture repair alone.