We recommend basic analgesic techniques: paracetamol + NSAID or cyclooxygenase-2 specific inhibitor + surgical site local anaesthetic infiltration. Paracetamol and NSAID should be started before or during operation with dexamethasone (GRADE A). Opioid should be reserved for rescue analgesia only (GRADE B). Gabapentanoids, intraperitoneal local anaesthetic, and transversus abdominis plane blocks are not recommended (GRADE D) unless basic analgesia is not possible. Surgically, we recommend low-pressure pneumoperitoneum, postprocedure saline lavage, and aspiration of pneumoperitoneum (GRADE A). Single-port incision techniques are not recommended to reduce pain (GRADE A).

PURPOSE Emergency laparotomy (EL) encompasses a high-risk group of operations, which are increasingly performed on a heterogeneous population of patients, making preoperative risk assessment potentially difficult. The UK National Emergency Laparotomy Audit (NELA) recently produced a risk predictive tool for EL that has not yet been externally validated. We aimed to externally validate and potentially improve the NELA tool for mortality prediction after EL. METHODOLOGY We reviewed computer and paper records of EL patients from May 2012 to June 2017 at Middlemore Hospital (New Zealand). The inclusion criteria mirrored the UK NELA. We examined the NELA, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Acute Physiology and Chronic Health Evaluation II (APACHE-II), and American College of Surgeons National Surgical Quality Improvement Programs risk predictive tools for 30-day mortality. The Hosmer-Lemeshow test was used to assess calibration, and the c statistic, to evaluate discrimination (accuracy) of the tools. We added the modified frailty index (mFI) and nutrition to improve the accuracy of risk predictive tools. RESULTS A total of 758 patients met the inclusion criteria, with an observed 30-day mortality of 7.9%. The NELA was the only well calibrated tool, with predicted 30-day mortality of 7.4% (p = 0.22). When combined with mFI and nutritional status, the c statistic for NELA improved from 0.83 to 0.88. American College of Surgeons National Surgical Quality Improvement Programs, APACHE-II, and P-POSSUM had lower c statistics, albeit also showing an improvement (0.84, 0.81, and 0.74, respectively). CONCLUSION We have demonstrated the NELA tool to be most predictive of mortality after EL. The NELA tool would therefore facilitate preoperative risk assessment and operative decision making most precisely in EL. Future research should consider adding mFI and nutritional status to the NELA tool. LEVEL OF EVIDENCE Level IV; Retrospective observational cohort study.

There are 12 CPRs available for diagnosis of appendicitis in adults. The AIR score appeared to be the best performer and most pragmatic CPR.

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IVL has shown limited benefit towards reducing early pain and morphine consumption when compared with placebo in colorectal surgery. However, IVL did not show any significant reduction in pain or opioid consumption when compared with epidural. Further research investigating IVL combined with intraperitoneal local anaesthetic is warranted.

Background: Anastomotic leakage (AL) is a dreaded complication following colorectal surgery. Procalcitonin is one of many biomarkers studied and research has suggested that it has improved accuracy for the diagnosis of AL compared with other inflammatory biomarkers such as C-reactive protein. This meta-analysis was conducted to evaluate the accuracy of procalcitonin in the early diagnosis of AL following colorectal surgery. Methods: MEDLINE, Embase and PubMed were searched for studies evaluating procalcitonin in the context of AL following colorectal surgery in the elective setting. The literature was reviewed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. Quality of the studies was assessed using the Quality Assessment Diagnostic Accuracy Studies (QUADAS)-2 tool. Meta analyses were conducted using area under the receiver operating characteristic curves for day 3, 4 and 5 post-surgery as a diagnostic test to detect AL. Results: A total of eight studies were analysed. Results showed that the highest diagnostic accuracy for procalcitonin is on day 5 post surgery. The reported optimal cut-off values ranged from 0.25 to 680 ng/mL from postoperative day 3 to 5, with reported negative predictive values ranging from 95% to 100%, and positive predictive values of up to 34%. The highest area under the receiver operating characteristic curve was 0.88 on postoperative day 5. Conclusion: Procalcitonin is a useful negative test for AL following elective colorectal surgery. However, as an isolated test, it is not useful in detecting AL.© 2019 Royal Australasian College of Surgeons ANZ J Surg 90 (2020) 675-680ANZJSurg.com

Background: Emergency laparotomy (EL) is a common procedure with high mortality leading to several efforts to record and reduce mortality. Risk scores currently used by quality improvement programmes either require intraoperative data or are not specific to EL. To be of utility to clinicians/patients, estimation of preoperative risk of mortality is important. We aimed to explore individual preoperative risk factors that might be of use in developing a preoperative mortality risk score. Methods: Two independent reviewers identified relevant articles from searches of MEDLINE, EMBASE and Cochrane databases from January 1980 to January 2018. We selected studies that evaluated only preoperative predictive factors for mortality in EL patients. Results: The search yielded 6648 articles screened, with 22 studies included examining 157 728 patients. The combined post-operative 30-day mortality was 13%. All, but one small study, were at low risk of bias. A meta-analysis of results was not possible due to the heterogeneity of populations and outcomes. Age, American Society of Anesthesiologists, preoperative sepsis, dependency status, current cancer and comorbidities were associated with increased mortality. Acute physiological derangements seen in renal, albumin and complete blood count assays were strongly associated with mortality. Delay to surgery and diabetes did not influence mortality. Higher body mass index was protective. Conclusion: Preoperatively, risk factors identified can be used to develop and update risk scores specific for EL mortality. This scoping review focused on the preoperative setting which helps tailor treatment decisions. It highlights the need for further research to test the relevance of newer risk factors such as frailty and nutrition.

From the analysis of these studies, intraperitoneal local anaesthetic had an analgesic benefit over intravenous lignocaine with regard to decreased opioid consumption for abdominal surgery. Further research investigating IVL combined with intraperitoneal local anaesthetic is warranted.