The introduction of a multidisciplinary perioperative protocol was associated with a significant reduction in postoperative mortality in patients undergoing AHA surgery. NCT01899885 (http://www.clinicaltrials.gov).

Mortality and morbidity occur commonly following emergency laparotomy, and incur a considerable clinical and financial healthcare burden. Limited data have been published describing the postoperative course and temporal pattern of complications after emergency laparotomy. We undertook a retrospective, observational, multicentre study of complications in 1139 patients after emergency laparotomy. A major complication occurred in 537/1139 (47%) of all patients within 30 days of surgery. Unadjusted 30-day mortality was 20.2% and 1-year mortality was 34%. One hundred and thirty-seven of 230 (60%) deaths occurred between 72 h and 30 days after surgery; all of these patients had complications, indicating that there is a prolonged period with a high frequency of complications and mortality after emergency laparotomy. We conclude that peri-operative, enhanced recovery care bundles for preventing complications should extend their focus on continuous complication detection and rescue beyond the first few postoperative days.

We have demonstrated the SAS to be significantly predictive but weakly discriminative for major complications and death among adults undergoing emergency high-risk abdominal surgery. Despite its predictive value, the SAS cannot in its current version be recommended as a standalone prognostic tool in an emergency setting.

Background: Despite the importance of predicting adverse postoperative outcomes, functional performance status as a proxy for frailty has not been systematically evaluated in emergency abdominal surgery. Our aim was to evaluate if the Eastern Cooperative Oncology Group (ECOG) performance score was independently associated with mortality following high-risk emergency abdominal surgery, in a multicentre, retrospective, observational study of a consecutive cohort. Methods: All patients aged 18 or above undergoing high-risk emergency laparotomy or laparoscopy from four emergency surgical centres in the Capitol Region of Denmark, from January 1 to December 31, 2012, were included. Demographics, preoperative status, ECOG performance score, mortality, and surgical characteristics were registered. The association of frailty with postoperative mortality was evaluated using multiple regression models. Likelihood ratio test was applied for goodness of fit. Results: In total, 1084 patients were included in the cohort; unadjusted 30-day mortality was 20.2%. ECOG performance score was independently associated with 30-day mortality. Odds ratio for mortality was 1.70 (95% CI (1.0, 2.9)) in patients with ECOG performance score of 1, compared with 5.90 (95% CI (1.8, 19.0)) in patients with ECOG performance score of 4 (p < 0.01). Likelihood ratio test suggests improvement in fit of logistic regression modelling of 30-day postoperative mortality when including ECOG performance score as an explanatory variable. Conclusions: This study found ECOG performance score to be independently associated with the postoperative 30-day mortality among patients undergoing high-risk emergency laparotomy. The utility of including functional performance in a preoperative risk assessment model of emergency laparotomy should be evaluated.

Background The main disease etiologies requiring emergency high‐risk abdominal surgery are intestinal obstruction and perforated viscus and the differences in immune response to these pathologies are largely unexplored. In search of improvement of patient assessment in the perioperative phase, we examined the inflammatory response in this setting, focusing on potential difference in pathophysiology. Methods The electronic medical records of 487 patients who underwent emergency abdominal surgery from year 2013‐2015 for intestinal obstruction and perforated viscus were reviewed. We evaluated the relationship between pre‐ and postoperative C‐reactive protein (CRP) trajectory, fluid balance, and perioperative morbidity and mortality according to type of surgery, intervention, and surgical pathology. Results A total of 418 patients were included. Pre‐ and postoperative absolute CRP values were significantly higher in patients with perforated viscus (n = 203) than in intestinal obstruction (n = 215) (P < .0001). Relative changes at hour 6 and POD 1 were non‐significant (P = .716 and P = .816 respectively). There was significant association between both pre‐ (quartile 1 vs 4, OR 5.11; P < .01) and postoperative (quartile 1 vs 4, OR 4.10; P < .001) CRP and adverse outcome, along with fluid balance and adverse outcome in patients with obstruction but not in those with perforation. Fluid balance and CRP had statistically significant positive correlation in patients with obstruction. Conclusions In this explorative study, a high pre‐ and postoperative CRP and a high positive fluid balance were associated with worse outcome in patients with intestinal obstruction, but not in patients with perforated viscus. Future studies should address the different inflammatory and fluid trajectories in these specific pathologies.

Purpose This study aimed to characterize 252 consecutive patients with an indication for major emergency abdominal surgery including patients not proceeding to surgery (No-Lap). Patients who do not proceed to major emergency abdominal surgery and their clinical outcomes are not well characterized in the existing literature. Triage criteria may vary between centers, potentially impacting reported outcomes. Methods A single-center prospective observational study in a high-volume Danish surgical center including 252 patients presenting with an indication for major emergent abdominal surgery was conducted from the 15th of October 2020 to the 15th of August 2021. The primary outcome was to estimate the prevalence of No-Lap patients. Results Overall, 21 patients (8.3%) of our total study cohort did not proceed to surgery. These patients were significantly older, more comorbid with higher ASA scores, poorer performance status, and were more likely to have bowel ischemia. Poor functional performance and surgeons' consideration of futile intervention were the main reasons for deferring surgery in all 21 patients. Overall, 30-day mortality was 95% for the No-LAP cohort, 9% for the LAP cohort, and 16% for the whole cohort, respectively. Conclusions The No-LAP group selection process could be one of the main determinants of reported postoperative outcomes. Prospective international multi-center studies to characterize the entire cohort of patients eligible for emergency laparotomy including the No-LAP population are needed, as large variations in triage criteria and culture seem to exist. Trial registration Retrospectively registered.

Background: Emergency laparotomy is associated with high risk of postoperative complications and mortality. Preoperative identification of patients at high risk of adverse outcome is important. The immune response to conditions requiring emergency laparotomy is not understood in detail. The present study describes preoperative blood-based immune profiles and their potential value in surgical risk assessment. Method: Patients (N = 100) referred for emergency laparotomy at Hvidovre Hospital were consecutively included from 3 June 2013-11 April 2014. All patients had blood samples collected before surgery and the immune parameters c-reactive protein (CRP), Interleukin-6 (IL-6), Interleukin-10 (IL-10), interferon-γ induced protein 10 kDa (IP-10), tumor necrosis factor α (TNF-α) and soluble urokinase plasminogen receptor activator (suPAR) were determined. Patients were stratified according to major postoperative complications (including death), 30-and 180-day mortality. Using logistic regression models and receiver operating characteristics curves the predictive ability of the immune parameters were estimated. Results: Major complications were recorded in 45 (45.0%) of the patients, whereas 30-day and 180-day mortalities were 17 (17.0%) and 25 (25.0%), respectively. Concentrations of suPAR and TNF-α were associated with major complications while CRP, IL-6, suPAR and TNF-α were associated with mortality. Adding the combined immune parameters to a regression model including age, sex, American Society of Anesthesiologists physical status and Eastern Cooperative Oncology Group Performance Status significantly improved the predictive ability for major complications, 30-day mortality and 180-day mortality. Conclusion:In emergency laparotomy, preoperative blood-based immune parameters added predictive power to regression models and could be considered in risk prediction model development.

BACKGROUNDPatients undergoing emergency high-risk abdominal surgery potentially suffer from both systemic dehydration and hypovolaemia. Data on the prevalence and clinical impact of electrolyte disturbances in this patient group, speci cally the potential differences in patients with intestinal obstruction (IO) versus perforated viscus (PV) is lacking. METHODSIn this retrospective single center cohort study, adult patients undergoing emergency high-risk abdominal surgery in a standardized perioperative pathway were included. Electrolyte and arterial blood gas analysis were measured prior to and just after surgery. Prevalence and clinical impact of electrolyte disturbances were assessed. RESULTSA total of 354 patients were included in the study. Acid-base and electrolyte disturbances had a high incidence in both groups with preoperative alkalemia dominating preoperatively, signi cantly more prevalent in IO (45 vs.32%, p<.001), and acidosis being most pronounced postoperatively in PV (49 vs. 28%, p<.0001). Preoperative hypochloraemia and hypokalemia were more prevalent in the IO group (34 vs 20 % and 37 vs 25 % respectively).Hyponatremia was highly prevalent in both IO and PV.Of the electrolyte and acid-base disturbances pre-and postoperative hypochloremia were the only ones independently associated with day-30 postoperative major complications and/or death in patients with IO, OR 2.87 (1.35, 6.23) p= 0.006 and OR 6.86 (1.71, 32.2) p= 0.009 respectively. Hypochloremic patients presented with reduced long-term survival as compared with the normo-and hyperchloremic patients, with postoperative hypochloremia having the most pronounced association (p<0.05).Neither plasma sodium nor potassium showed association with outcome. CONCLUSIONThese observations suggest that both acute high risk abdominal patient have frequent preoperative alkalosis shifting to postoperative acidosis, and that both pre-and postoperative hypochloremia are independently associated with both impaired short-and long-term outcome in patients with intestinal obstruction, which potential implications for the choice of resuscitations uids. Research on pathophysiology and treatment strategies for electrolyte disturbances are needed in patients undergoing emergency high-risk abdominal surgery. BackgroundIntravenous uid therapy is one of the most frequent interventions in critically ill patients(1). All high-risk surgical patients are given intravenous uid therapy(2) and abnormalities in acid-based homeostasis and electrolytes are common but insu ciently described.Patients undergoing emergency high-risk abdominal surgery due to e.g. intestinal obstruction (IO) or perforated viscus (PV) potentially suffer from systemic dehydration due to inadequate uid intake, vomiting ,pathological