This report of a large number of patients undergoing emergency laparotomy in the UK confirms a remarkably high mortality by modern standards across the range. Very few pathologies or procedures can be considered anything other than high risk. The need for routine consultant involvement and critical care is evident, and the case distribution helps define the surgical skill set needed for a modern emergency laparotomy service. Preliminary data relating outcomes from emergency colonic surgery to surgical subspecialty require urgent further study.

on behalf of the UK Emergency Laparotomy Network ABStRAct INTRODUCTION Emergency laparotomy is a common procedure, with 30,000-50,000 performed annually in the UK. This large scale study reports the current spectrum of emergency laparotomies, and the influence of the surgical procedure, underlying pathology and subspecialty of the operating surgeon on mortality. METHODS Anonymised data on consecutive patients undergoing an emergency laparotomy were submitted for a three-month period. The primary outcome measure was unadjusted 30-day mortality. Appendicectomy and cholecystectomy were among the procedures excluded. RESULTS Data from 1,708 patients from 35 National Health Service hospitals were analysed. The overall 30-day mortality rate was 14.8%. 'True' emergency laparotomies (ie those classified by the National Confidential Enquiry into Patient Outcome and Death as immediate or urgent) comprised 86.5% of cases. The mortality rate rose from 8.0% among expedited cases to 14.3% among urgent cases and to 25.7% among laparotomies termed immediate. Among the most common index procedures, small bowel resection exhibited the highest 30-day mortality rate of 21.1%. The presence of abdominal sepsis was associated with raised 30-day mortality (17.5% in the presence of sepsis vs 12.6%, p=0.027). Colorectal procedures comprised 44.3% and within this group, data suggest that mortality from laparotomy may be influenced by surgical subspecialisation. CONCLUSIONS This report of a large number of patients undergoing emergency laparotomy in the UK confirms a remarkably high mortality by modern standards across the range. Very few pathologies or procedures can be considered anything other than high risk. The need for routine consultant involvement and critical care is evident, and the case distribution helps define the surgical skill set needed for a modern emergency laparotomy service. Preliminary data relating outcomes from emergency colonic surgery to surgical subspecialty require urgent further study.

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fibrinogen levels slightly above generally accepted reference ranges. However, no patients with sepsis, thromboembolism, or clinical signs of a hypercoagulable state were included in our study. We indeed investigated a rather large study population of 92 patients, and only one reagent type per patient was performed. To eliminate an inter-device imprecision, the same thromboelastography device was used for analysis of both the point-of-care (POC) and the PTS sample. To further increase precision, the analyses of both the POC and the PTS sample were performed in duplicate simultaneously. As this approach required all four measurement channels simultaneously, only one reagent type per patient was run. A total of 92 patients were included in the study, thus 368 (!) measurements were performed. Thank you for drawing our attention to two recently published investigations on rotational thromboelastography and PTS. 1 2 We were unable to discuss these results in our publication, 3 since both studies were published during the peer review process of our submitted manuscript. Concerning a potential pre-activation by PTS, it is interesting to see that the analyses of Lance and colleagues did not demonstrate a pre-activation as a result of PTS measured by the thrombin generation assay. 1 We agree with Lance and colleagues and strongly support their suggestion to validate and investigate the pre-analytical effects of PTS on coagulation tests in every hospital. However, this is a major task, especially in smaller hospitals. We further emphasize the importance to investigate pre-analytical effects of PTS on samples of patients with impaired haemostasis.