Frailty and Long-Term Mortality Following Emergency Laparotomy: A Comparison Between the 11-Item and 5-Item Modified Frailty Indices.

INTRODUCTION: Emergency laparotomy (EL) is a high-risk operation which is increasingly performed on an aging patient population. Objective frailty assessment using a validated index has the potential to improve preoperative risk stratification. This study aimed to assess the correlation between frailty and long-term mortality and morbidity outcomes for older EL patients. Secondary aims were to compare the 11-item and shortened five-item modified frailty indices (mFIs) in terms of value and predictive validity. METHODS: A prospective multicenter observational study of patients aged ≥55 y undergoing EL was conducted across five hospitals in New Zealand between 2017 and 2022. Frailty was measured using the 11-item and abbreviated five-item mFIs. Multivariable logistic regression was used to determine whether frailty was independently associated with one-year postoperative mortality and other morbidity outcomes. Correlation between the two frailty indices were assessed with the Spearman's correlation coefficient (P). RESULTS: Frailty assessments were performed in 861 participants, with the prevalence being 18.7% and 29.8% using the 11-item and five-item mFIs, respectively. Both frailty indices demonstrated similar associations with one-year mortality (two-fold increased risk), major complications, admission to intensive care unit, rehabilitation, and 30-d readmission. The 11-item mFI demonstrated a greater association with early mortality (four-fold increased risk), reoperations, and increased length of stay compared with the five-item frailty index. Spearman P was 0.6 (P < 0.001). CONCLUSIONS: Frailty, as identified by the 11-item and five-item mFIs, was associated with one-year mortality and other important morbidity outcomes for older EL patients. These forms of frailty assessment provide important information that may aid in risk assessment and patient-centered decision-making.

Association between frailty, long-term mortality and functional outcomes for older adults undergoing emergency laparotomy.

BACKGROUND: An increasing number of older patients are undergoing emergency laparotomy (EL). Frailty is thought to contribute to adverse outcomes in this group. The best method to assess frailty and impacts on long-term mortality and other important functional outcomes for older EL patients have not been fully explored. METHODS: A prospective multicenter study of older EL patients was conducted across four hospital sites in New Zealand from August 2017 to September 2022. The Clinical Frailty Scale (CFS) was used to measure frailty-defined as a CFS of ≥5. Primary outcomes were 30-day and one-year mortality. Secondary outcomes were postoperative morbidity, admission for rehabilitation, and increased care level on discharge. A multivariate logistic regression analysis was conducted, adjusting for age, sex, and ethnicity. RESULTS: A total of 629 participants were included. Frailty prevalence was 14.6%. Frail participants demonstrated higher 30-day and 1-year mortality-20.7% and 39.1%. Following adjustment, frailty was directly associated with a significantly increased risk of short- and long-term mortality (30-day aRR 2.6, 95% CI 1.5, 4.3, p = <0.001, 1-year aRR 2.0, 95% CI 1.5, 2.8, p < 0.001). Frailty was correlated with a 2-fold increased risk of admission for rehabilitation and propensity of being discharged to an increased level of care, complications, and readmission within 30 days. CONCLUSION: Frailty was associated with increased risk of postoperative mortality up to 1-year and other functional outcomes for older patients undergoing EL. Identification of frailty in older EL patients aids in patient-centered decision-making, which may lead to improvement in outcomes.

Impact of pre-existing mesh at the hiatus at revisional hiatal hernia surgery.

Recurrence after laparoscopic hiatus hernia repair (LHR) is high, with few symptomatic patients undergoing redo LHR. Morbidity is higher in redo surgery compared with the primary operation. Tens of studies have explored the safety of redoing LHR. However, the impact of existing mesh on operative risk is rarely examined. We aim to assess the impact of mesh at the hiatus on the safety of redo LHR. This was a cohort study examining redo LHR patients from a prospectively maintained database from January 2002 to December 2023. The primary outcome was intra-/postoperative complications. Follow-up was extracted from clinical records. Predictors of complications were assessed using univariable and multivariable logistic regression analyses. Redo LHR was performed in 100 patients; 22 had previous mesh. One encountered mortality with 23 complications. Five patients had absorbable mesh, with the remainder nonabsorbable. Overall complications were significantly higher with mesh at nine (40.9%) compared to no mesh redo at 14 (17.9%), P = 0.023. There was no difference in rates of visceral injury with mesh at four (18.2%) and no mesh at six (7.7%), P = 0.22. The median follow-up was 7 months; there was no difference in reflux rates (P = 0.70) but higher rates of dysphagia (P = 0.010). Higher overall complications were noted in patients with previous hiatal mesh repair at the time of LHR. However, major visceral complications were similar regardless of mesh use. Mesh at the hiatus should not be a deterrent for reoperative hiatus surgery.

Efficacy and safety of laparoscopic Roux-en-Y gastric bypass in symptomatic patients following fundoplication failure: a meta-analysis.

Revisional surgery may be required in a subset of patients who remain symptomatic despite undergoing laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD). While revisional LF (RLF) is feasible in these patients, laparoscopic Roux-en-Y gastric bypass (LRYGB) may serve as an alternative, although its efficacy and safety remains unknown. This study aimed to determine the outcomes of LRYGB in symptomatic patients following failed LF for GERD. MEDLINE, EMBASE, and PubMed databases were systematically searched for studies reporting LRYGB outcomes in symptomatic adults despite undergoing LF for GERD. Postoperative symptom resolution, recurrence of heartburn and dysphagia, proton pump inhibitor (PPI) use, and body mass index (BMI) reduction were assessed to determine LRYGB efficacy. Postoperative morbidity and mortality were used to evaluate LRYGB safety. Twenty-two studies with 1523 patients were included. Pooled rates of symptom resolution, recurrence of heartburn and dysphagia, PPI use, morbidity, and mortality were 71.6% (95% CI 59.4-86.4), 15.6% (8.9-27.3), 20.7% (12.5-34.3), 29.6% (18.8-46.5), 39.5% (29.9-52.3), and 2.2% (1.2-4.0), respectively, following LRYGB. Similar rates were observed after RLF. However, BMI reduction was significantly greater after LRYGB compared with RLF (mean difference 6.1 kg/m2, 4.8-7.4; p < 0.0001). LRYGB resulted in symptom relief in a majority of patients, and proved comparable to RLF regarding symptom recurrence and PPI use. Morbidity and mortality following LRYGB also did not differ from RLF. However, LRYGB was associated with considerably greater weight loss relative to RLF. Therefore, LRYGB is efficacious and an acceptable revisional procedure in symptomatic GERD patients who have previously undergone LF.

Intravenous Local Anesthetic Compared With Intraperitoneal Local Anesthetic in Laparoscopic Colectomy: A Double-blind Randomized Controlled Trial.

INTRODUCTION: Controlling perioperative pain is essential to improving patient experience and satisfaction following surgery. Traditionally opioids have been frequently utilized for postoperative analgesia. Although they are effective at controlling pain, they are associated with adverse effects, including postoperative nausea, vomiting, ileus, and long-term opioid dependency.Following laparoscopic colectomy, the use of intravenous or intraperitoneal infusions of lidocaine (IVL, IPL) are promising emerging analgesic options. Although both techniques are promising, there have been no direct, prospective randomized comparisons in patients undergoing laparoscopic colon resection. The purpose of this study was to compare IPL with IVL. METHODS: Double-blinded, randomized controlled trial of patients undergoing laparoscopic colonic resection. The 2 groups received equal doses of either IPL or IVL which commenced intra-operatively with a bolus followed by a continuous infusion for 3 days postoperatively. Patients were cared for through a standardized enhanced recovery after surgery program. The primary outcome was total postoperative opioid consumption over the first 3 postoperative days. Patients were followed for 60 days. RESULTS: Fifty-six patients were randomized in a 1:1 fashion to the IVL or IPL groups. Total opioid consumption over the first 3 postoperative days was significantly lower in the IPL group (70.9 mg vs 157.8 mg P < 0.05) and overall opioid consumption during the total length of stay was also significantly lower (80.3 mg vs 187.36 mg P < 0.05. Pain scores were significantly lower at 2 hours postoperatively in the IPL group, however, all other time points were not significant. There were no differences in complications between the 2 groups. CONCLUSION: Perioperative use of IPL results in a significant reduction in opioid consumption following laparoscopic colon surgery when compared to IVL. This suggests that the peritoneal cavity/compartment is a strategic target for local anesthetic administration. Future enhanced recovery after surgery recommendations should consider IPL as an important component of a multimodal pain strategy following colectomy.

Topical Versus Oral Metronidazole After Excisional Hemorrhoidectomy: A Double-Blind Randomized Controlled Trial.

BACKGROUND: Both topical and oral metronidazole have been shown to reduce pain after excisional hemorrhoidectomy. Although recent meta-analyses have demonstrated efficacy against placebo, there has been no comparison between the 2 routes. OBJECTIVE: This study aims to investigate whether topical or oral metronidazole provides the most analgesic properties after excisional hemorrhoidectomy. DESIGN: A prospective, double-blind, randomized controlled trial was performed. SETTING: This trial was conducted at 2 hospitals in New Zealand between March 2019 and February 2020. PATIENTS: Adults undergoing elective excisional hemorrhoidectomy for grade III/IV hemorrhoids were randomized. INTERVENTIONS: Participants were randomized to receive either topical metronidazole ointment and an oral placebo versus oral metronidazole with a placebo ointment for 7 days. MAIN OUTCOME MEASURES: The primary outcome was daily pain scores for 7 days, estimated using a generalized linear mixed model fitted with time and treatment arm and tested for interaction with time and treatment arm. Secondary outcomes included additional analgesia, return to normal activity, recovery scores, and adverse effects. RESULTS: A total of 120 participants were included, with 60 in each group. A unimodal peak of pain was recorded with the maximum at days 3 and 4, but there was no significant difference in resting pain scores, with a mean difference at day 3 of 0.47 (-0.48, 1.42). There were no significant differences for secondary outcomes. Fourteen (11.7%) participants were readmitted, without significant difference between groups. Fifty-nine percent of participants preferred topical analgesic compared with 31% who preferred oral and 9.7% who had no preference. LIMITATIONS: This was a pragmatic study in which we could not have stopped participants seeking other analgesics and with less than perfect complete compliance. CONCLUSION: Postoperative oral and topical metronidazole provide similar analgesia after excisional hemorrhoidectomy. The route should depend on patient preference, with topical administration potentially benefiting from improved antimicrobial stewardship and having less effect on the gut microbiome. See Video Abstract at http:/links.lww.com/DCR/B853 .METRONIDAZOL TÓPICO VERSUS ORAL DESPUÉS DE UNA HEMORROIDECTOMÍA POR ESCISIÓN: UN ENSAYO CONTROLADO ALEATORIO DOBLE CIEGO. ANTECEDENTES: Se ha demostrado que tanto el metronidazol tópico como el oral reducen el dolor después de una hemorroidectomía por escisión. Aunque los metaanálisis más recientes han demostrado eficacia frente al placebo, no ha habido comparación entre las dos vías. OBJETIVO: Este estudio tiene como objetivo investigar si el metronidazol tópico u oral proporciona las propiedades más analgésicas después de una hemorroidectomía por escisión. DISEO: Se realizó un ensayo prospectivo, controlado, aleatorio, a doble ciego. AJUSTE: Este ensayo fue realizado en dos hospitales de Nueva Zelanda entre marzo de 2019 y febrero de 2020. PACIENTES: Se asignaron al azar pacientes adultos sometidos a hemorroidectomía por escisión electiva por hemorroides de grado III / IV. INTERVENCIONES: Los participantes fueron asignados al azar para recibir un ungüento de metronidazol tópico y un placebo oral versus metronidazol oral con un ungüento de placebo durante siete días. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fueron las puntuaciones diarias de dolor durante siete días, estimadas mediante un modelo lineal mixto generalizado ajustado tanto con el tiempo y el brazo de tratamiento y probado para la interacción con el tiempo y el brazo de tratamiento. Los resultados secundarios incluyen analgesia adicional, retorno a la actividad normal, puntuaciones de recuperación y efectos adversos. RESULTADOS: Se incluyó un total de 120 participantes, 60 en cada grupo. Se registró un pico de dolor unimodal con el máximo en los días 3 y 4, pero no hubo diferencias significativas en las puntuaciones de dolor en reposo, con una diferencia media en el día 3 de 0,47 (-0,48, 1,42). No hubo diferencias significativas para los resultados secundarios. Catorce (11,7%) participantes fueron readmitidos, sin diferencias significativas entre los grupos. El cincuenta y nueve por ciento de los participantes prefirió el tópico, en comparación con el 31% por vía oral y el 9,7% sin preferencia. LIMITACIONES: Este fue un estudio pragmático en el que no pudimos haber impedido que los participantes buscaran otros analgésicos, con un cumplimiento completo menos que perfecto. CONCLUSINES: El metronidazol posoperatorio por vía oral o tópica proporciona una analgesia similar después de una hemorroidectomía por escisión. La vía debe depender de la preferencia del paciente, y la administración tópica se beneficia potencialmente por una mejor protección de los antimicrobianos y un menor efecto sobre el microbioma intestinal. Consulte Video Resumen en http://links.lww.com/DCR/B853 . (Traducción-Dr Osvaldo Gauto).

Epidemiology of haemorrhoids and publicly funded excisional haemorrhoidectomies in New Zealand (2007-2016): a population-based cross-sectional study.

AIM: Haemorrhoids are frequently encountered by the general or colorectal surgeon. Although a benign disease, those with symptomatic, advanced grades frequently require excisional haemorrhoidectomy for definitive management. Despite their widespread nature, the epidemiological burden of haemorrhoids and haemorrhoidectomies on populations is not well described. This study seeks to establish the incidence of both haemorrhoids diagnosed and haemorrhoidectomies performed in New Zealand. METHOD: This is a population-based cross-sectional study examining the incidence of all patients who were newly diagnosed with haemorrhoids in New Zealand public hospital outpatient clinics and those who received excisional haemorrhoidectomy in New Zealand public hospitals from 2007 to 2016. Data were extracted and linked using the New Zealand National Minimum Dataset and the National Non-Admitted Patient Collection. Variables collected included age group, sex, ethnicity and geographical location. RESULTS: A total of 46 095 recorded diagnoses of haemorrhoids were made, with a total of 18 739 haemorrhoidectomies in the 10-year period recorded. The incidence rate of diagnosis increased from 84.6 to 120.5 per 100 000 and the incidence rate of haemorrhoidectomies performed from 30.4 to 51.1 per 100 000, a significantly increased annual incidence. There was a unimodal peak prevalence in the fifth decade of life with women more affected. Europeans formed the largest group affected, with Asians showing the highest rate of increased incidence. CONCLUSION: There is an increasing incidence of patients with symptomatic haemorrhoids presenting to the New Zealand public healthcare system, with a preponderance in working age adults, especially women.

Patient Experiences of the Emergency Laparotomy Pathway: A Qualitative Study.

INTRODUCTION: Emergency laparotomy (EL) is a commonly performed operation with high rates of morbidity and mortality. Despite a growing body of literature on outcomes from EL, there is sparse literature on the patient experience. The aim of this study is to capture the perspective of patients on their EL experience. Qualitative methodology is used as a platform to allow patients to express their personal experiences and ideas around the EL process. MATERIALS AND METHOD: Participants were consented as a part of a large observational study, established across the three public teaching hospitals in Auckland, New Zealand. Patients who had an EL within the past 4 months were recruited. A recorded interview was conducted either face-to-face or over the telephone, using questions formulated from a previous systematic review on EL outcomes. Transcripts were transported to NVivo and thematically analysed by two reviewers. RESULTS: Fifteen participants were interviewed. The majority of participants were female, New Zealand European and 65 or older. Five important themes were identified. Overall, participants expressed satisfaction with their interactions with hospital staff. However, they wanted more information about their condition, operation and what outcomes might occur. Participants also described post-operative priorities in the acute setting, as well as long-standing physical and emotional impacts. CONCLUSION: This study provides a better understanding of what is important to patients during the EL process. This information is important when considering ways to improve care and communication with patients undergoing EL.

Intraperitoneal Tramadol in Abdominal Surgery: A Systematic Review.

BACKGROUND: Multimodal analgesic regimes are required to treat pain. Intraperitoneal (IP) agents, such as local anesthetics (LAs), have been shown to reduce pain after abdominal surgery. Other IP analgesics have been tested in several randomized control trials (RCTs), but no reviews or guidelines have evaluated their use. Tramadol is an effective oral and intravenous analgesia with recent evidence supporting the use of IP tramadol (IPT). We aimed to review the efficacy of IPT as an adjunct to intraperitoneal local anesthetics (IPLAs) for pain relief after abdominal surgery. MATERIALS AND METHODS: Relevant articles were identified by two independent reviewers from MEDLINE, EMBASE and PubMed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines up to January 2019. Only RCT comparing IPT + IPLA with IPLA alone were included. Outcomes recorded were the postoperative analgesic requirement, pain scores at 4 h and 24 h and adverse events. Data were analyzed with Review Manager, version 5.3. RESULTS: A total of five RCTs (4× laparoscopic cholecystectomy and 1× abdominal hysterectomy) were included in this review from 419 studies screened. All doses were given as a single bolus. Pain relief requirements over the first 24 h weres less in the IPT + IPLA groups when compared with those in IPLA alone. Pain scores were less for IPT + IPLA groups at 4 h and 24 h. There were no significant differences in adverse events between groups. CONCLUSIONS: In summary, IPT, in combination with IPLA, is effective in the management of acute postoperative pain and reduces the total amount of pain relief consumed in the first 24 h after surgery. Studies reporting the use of IPT + IPLA reported no toxicity or systemic adverse events. Further research into standardizing the dosing of IPT to optimize its effectiveness and further reduce the additional analgesic requirement is indicated.

Local Anaesthesia Alone Versus Regional or General Anaesthesia in Excisional Haemorrhoidectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: Excisional haemorrhoidectomy has been traditionally performed under general or regional anaesthesia. However, these modes are associated with complications such as nausea, urinary retention and motor blockade. Local anaesthesia (LA) alone has been proposed to reduce side effects as well as to expedite ambulatory surgery. This systematic review aims to assess LA versus regional or general anaesthesia for excisional haemorrhoidectomy. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, EMBASE and CENTRAL databases were searched to 13 January 2020. All randomised controlled trials comparing LA only versus regional or general anaesthesia in patients who received excisional haemorrhoidectomy were included. The main outcomes included pain, adverse effects and length of stay. RESULTS: Nine trials, consisting of six studies comparing local versus regional anaesthesia and three comparing LA versus general anaesthesia, were included. Meta-analysis showed a significantly lower relative risk for need of rescue analgesia (RR 0.32 [95% CI 0.16-0.62]), intra-operative hypotension (RR 0.17 [95% CI 0.04-0.76]), headache (RR 0.13 [0.02-0.67]) and urinary retention (RR 0.17 [95% CI 0.09-0.29]) for LA when compared with regional anaesthesia. There was mixed evidence for both regional and general anaesthesia in regard to post-operative pain. CONCLUSIONS: LA alone may be considered as an alternative to regional anaesthesia for excisional haemorrhoidectomy with reduced complications and reduction in the amount of post-operative analgesia required. The evidence for LA compared to general anaesthesia for haemorrhoidectomy is low grade and mixed.

Intravenous Local Anaesthetic Compared with Intraperitoneal Local Anaesthetic in Abdominal Surgery: A Systematic Review.

INTRODUCTION: Modern perioperative care strategies aim to optimise perioperative care by reducing the body's stress response to surgery. A major facet of optimising an abdominal surgery analgesia programme is using a multimodal opioid sparing approach. Local anaesthetics have shown promise and there has been considerable research into the most effective route for their administration. This review aims to determine if there is a difference in analgesic efficacy between intraperitoneal local anaesthetic (IPLA) and intravenous local anaesthetic (IVLA). MATERIALS AND METHODOLOGY: In concordance with the PRISMA statement, a literature search was conducted to identify randomised control trials that compared IVLA with IPLA in abdominal surgery. The primary outcomes of interest were opioid analgesia requirements and pain score assessed by visual analogue score. Data were extracted and entered into pre-designed electronic spreadsheets. RESULTS: This review has identified six papers that compared intravenous lignocaine to intraperitoneal lignocaine. This review showed significantly lower morphine consumption at 4 and 24 h in the intraperitoneal group. There was no significant difference in pain scores. CONCLUSION: 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.

Evidence-Based Management of Pain After Excisional Haemorrhoidectomy Surgery: A PROSPECT Review Update.

BACKGROUND: The aim of this systematic review was to update previous PROSPECT ( http://www.postoppain.org ) review recommendations for the management of pain after excisional haemorrhoidectomy. METHODS: Randomized studies and reviews published in the English language from July 2006 (end date of last review) to March 2016, assessing analgesic, anaesthetic, and operative interventions pertaining to excisional haemorrhoidectomy in adults, and reporting pain scores, were retrieved from the EMBASE and MEDLINE databases. RESULTS: An additional 464 studies were identified of which 74 met the inclusion criteria. There were 48 randomized controlled trials and 26 reviews. Quantitative analyses were not performed, as there were limited numbers of trials with a sufficiently homogeneous design. CONCLUSION: Pudendal nerve block, with or without general anaesthesia, is recommended for all patients undergoing haemorrhoidal surgery. Either closed haemorrhoidectomy, or open haemorrhoidectomy with electrocoagulation of the pedicle is recommended as the primary procedure. Combinations of analgesics (paracetamol, non-steroidal anti-inflammatory drugs, and opioids), topical lignocaine and glyceryl trinitrate, laxatives, and oral metronidazole are recommended post-operatively. The recommendations are largely based on single intervention, not multimodal intervention, studies.

Routine Neurectomy of Inguinal Nerves During Open Onlay Mesh Hernia Repair: A Meta-analysis of Randomized Trials.

OBJECTIVE: The aim of the study was to establish whether an inguinal neurectomy at the time of hernia repair would reduce the risk of postoperative pain for open tension-free sutured mesh repair. BACKGROUND: Inguinal hernia repair is a common operative procedure. The development of postoperative pain is uncommon, but at times debilitating. The role of inguinal neurectomy is currently unknown, with no single large study available, and previous reviews included only a few heterogeneous studies. METHODS: Relevant randomized trials were identified from searches of MEDLINE, EMBASE, and EBM Review databases until October 2014. Meta-analysis was performed based on Cochrane Methods using RevMan v5.3 software. Pain, pain scores, sensory changes, and complications over short (half to <3 months), mid (3 to <12 mo), and long term (≥12 mo) were recorded. RESULTS: All included studies performed Lichtenstein hernia repair. Eleven studies on 1031 patients showed significant reduction in pain with neurectomy for short (RR = 0.61, 0.40-0.93) and midterm (RR = 0.30, 0.20-0.46), but not for long term (RR = 0.50, 0.25-1.01). Three studies (270 patients) showed significantly reduced short-term pain (RR = 0.69, 0.52-0.90). No studies included genitofemoral neurectomy. Rates of hematoma, infection, urinary retention, and recurrence were not different between groups. CONCLUSIONS: Routine ilioinguinal neurectomy during Lichtenstein-type herniorrhaphy seems to be a safe and effective method to reduce pain in the short and midterm, but may have little long-term impact. Iliohypogastric neurectomy seems to reduce pain in at least the short term.

Frailty using the Clinical Frailty Scale to predict short- and long-term adverse outcomes following emergency laparotomy: meta-analysis.

BACKGROUND: Emergency laparotomy has high morbidity and mortality rates. Frailty assessment remains underutilized in this setting, in part due to time constraints and feasibility. The Clinical Frailty Scale has been identified as the most appropriate tool for frailty assessment in emergency laparotomy patients and is recommended for all older patients undergoing emergency laparotomy. The prognostic impact of measured frailty using the Clinical Frailty Scale on short- and long-term mortality and morbidity rates remains to be determined. METHODS: Observational cohort studies were identified by systematically searching Medline, Embase, Scopus and CENTRAL databases up to February 2024, comparing outcomes following emergency laparotomy for frail and non-frail participants defined according to the Clinical Frailty Scale. The primary outcomes were short- and long-term mortality rates. A random-effects model was created with pooling of effect estimates and a separate narrative synthesis was created. Risk of bias was assessed. RESULTS: Twelve articles comprising 5704 patients were included. Frailty prevalence was 25% in all patients and 32% in older adults (age ≥55 years). Older patients with frailty had a significantly greater risk of postoperative death (30-day mortality rate OR 3.84, 95% c.i. 2.90 to 5.09, 1-year mortality rate OR 3.03, 95% c.i. 2.17 to 4.23). Meta-regression revealed that variations in cut-off values to define frailty did not significantly affect the association with frailty and 30-day mortality rate. Frailty was associated with higher rates of major complications (OR 1.93, 95% c.i. 1.27 to 2.93) and discharge to an increased level of care. CONCLUSION: Frailty is significantly correlated with short- and long-term mortality rates following emergency laparotomy, as well as an adverse morbidity rate and functional outcomes. Identifying frailty using the Clinical Frailty Scale may aid in patient-centred decision-making and implementation of tailored care strategies for these 'high-risk' patients, with the aim of reducing adverse outcomes following emergency laparotomy.

Consensus-defined sarcopenia predicts adverse outcomes after elective abdominal surgery: meta-analysis.

BACKGROUND: Sarcopenia refers to the progressive age- or pathology-associated loss of skeletal muscle. When measured radiologically as reduced muscle mass, sarcopenia has been shown to independently predict morbidity and mortality after elective abdominal surgery. However, the European Working Group on Sarcopenia in Older People (EWGSOP) recently updated their sarcopenia definition, emphasizing both low muscle 'strength' and 'mass'. The aim of this systematic review and meta-analysis was to determine the prognostic impact of this updated consensus definition of sarcopenia after elective abdominal surgery. METHODS: MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for studies comparing prognostic outcomes between sarcopenic versus non-sarcopenic adults after elective abdominal surgery from inception to 15 June 2022. The primary outcomes were postoperative morbidity and mortality. Sensitivity analyses adjusting for confounding patient factors were also performed. Methodological quality assessment of studies was performed independently by two authors using the QUality in Prognosis Studies (QUIPS) tool. RESULTS: Twenty articles with 5421 patients (1059 sarcopenic and 4362 non-sarcopenic) were included. Sarcopenic patients were at significantly greater risk of incurring postoperative complications, despite adjusted multivariate analysis (adjusted OR 1.56, 95 per cent c.i. 1.39 to 1.76). Sarcopenic patients also had significantly higher rates of in-hospital (OR 7.62, 95 per cent c.i. 2.86 to 20.34), 30-day (OR 3.84, 95 per cent c.i. 1.27 to 11.64), and 90-day (OR 3.73, 95 per cent c.i. 1.19 to 11.70) mortality. Sarcopenia was an independent risk factor for poorer overall survival in multivariate Cox regression analysis (adjusted HR 1.28, 95 per cent c.i. 1.13 to 1.44). CONCLUSION: Consensus-defined sarcopenia provides important prognostic information after elective abdominal surgery and can be appropriately measured in the preoperative setting. Development of targeted exercise-based interventions that minimize sarcopenia may improve outcomes for patients who are undergoing elective abdominal surgery.

Weekend effect in emergency laparotomy: a propensity score-matched analysis.

BACKGROUND: The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients. METHODS: A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity-score matched analysis was used to remove potential confounding patient characteristics. RESULTS: Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464). CONCLUSIONS: These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect.

Short and long-term impact of sarcopenia on outcomes from emergency laparotomy.

PURPOSE: Emergency laparotomy (EL) carries a high risk of morbidity and mortality, that is greater among older patients. Sarcopenia refers to an age- or pathology-associated muscle loss and has been demonstrated to correlate with poorer outcomes in several surgical conditions. This study assessed the impact of sarcopenia on morbidity and mortality in elderly patients undergoing EL. METHODS: Patients aged ≥ 65 years-old undergoing EL between May 2012-June 2017 with a pre-operative abdominal computerised tomography (CT) scan at Middlemore Hospital (New Zealand) were included. Psoas and Skeletal Muscle Index (PMI and SMI) were calculated from abdominal CT measurements after standardisation based on height. Validated cut-offs for sarcopenia were used. Frailty was estimated using the 11-point modified frailty index (mFI). The primary outcome was 30-day, 1-year, and 4-year post-operative mortality. Secondary outcomes included correlations between mFI and sarcopenic measures, unplanned readmissions, and post-operative complications. RESULTS: A total of 167 patients (84 sarcopenic; 83 non-sarcopenic) were included. Sarcopenic and non-sarcopenic patients had similar 30-day (14.2 vs. 12.0%; p = 0.84), 1-year (23.8 vs. 25.3%; p = 0.96), and 4-year (39.3 vs. 47.0%; p = 0.40) mortality rates following an EL. Survivors had a higher mean PMI at 1-year (p = 0.0078) and 4-year (p = 0.013) but not 30-day (p = 0.40) follow-up. Sarcopenia performed poorly in discriminating between 30-day (AUC 0.51) and 1-year (AUC 0.53) mortality. The mFI did not correlate with PMI (p = 0.85) nor SMI (p = 0.18). Rates of readmissions and post-operative complications did not differ between sarcopenic and non-sarcopenic cohorts. CONCLUSION: Sarcopenia does not provide useful short-term prognostic information in elderly EL patients.

Outcomes following out-of-hours acute cholecystectomy: A systematic review and meta-analysis.

BACKGROUND: Cholecystectomy is one of the most commonly performed abdominal operations. Rising demands on acute operating theater availability and resource utilization in the daytime have led to acute cholecystectomy being performed out-of-hours (in the evenings, at night, or on weekends), although it remains unknown whether outcomes differ between out-of-hours and in-hours (during the daytime on weekdays) acute cholecystectomy. This systematic review and meta-analysis aimed to compare outcomes following out-of-hours versus in-hours acute cholecystectomy. METHODS: The study protocol was prospectively registered on PROSPERO (ID: CRD42021226127). MEDLINE, EMBASE, and Scopus databases were systematically searched for studies comparing outcomes following out-of-hours and in-hours acute cholecystectomy in adults with any acute benign gallbladder disease. The outcomes of interest were rates of bile leakage, bile duct injury, overall postoperative complications, conversion to open cholecystectomy, specific intraoperative and postoperative complications, length of stay, readmission, and mortality. Subgroup (evening/night-time vs. daytime, weekend vs. weekday, acute surgical unit [ASU]-only, non-ASU, and laparoscopic-only) and sensitivity analyses of adjusted multivariate regression analysis results was also performed. RESULTS: Eleven studies were included. There were no differences between out-of-hours and in-hours acute cholecystectomy for rates of bile leakage, bile duct injury, overall postoperative complications, conversion to open cholecystectomy, operative duration, readmission, mortality, and postoperative length of stay. Higher rates of postoperative sepsis (odds ratio, 1.58; 95% confidence interval, 1.04-2.41; p = 0.03) and pneumonia (odds ratio, 1.55; 95% confidence interval, 1.06-2.26; p = 0.02) were observed following out-of-hours acute cholecystectomy on univariate meta-analysis, but not after the adjusted multivariate meta-analysis. Higher conversion rates were observed when out-of-hours cholecystectomy was performed in centers without an ASU. CONCLUSION: This systematic review and meta-analysis has not shown an increased risk in overall or specific complications associated with out-of-hours compared with in-hours acute cholecystectomy. However, future studies should assess the potential impact of structural hospital factors, such as an ASU, on outcomes following out-of-hours acute cholecystectomy. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis Study, Level IV.

Short- and long-term impact of sarcopenia on outcomes after emergency laparotomy: A systematic review and meta-analysis.

BACKGROUND: Sarcopenia refers to the progressive age and pathology-associated loss of skeletal muscle, which has been shown to independently predict mortality in patients undergoing major elective surgery. Emergency laparotomy is commonly performed for a range of procedures and is associated with high rates of mortality. However, the prognostic utility of sarcopenia after emergency laparotomy remains unknown. The aim of this study was to compare short and long-term survival between patients with and without sarcopenia undergoing emergency laparotomy. METHODS: MEDLINE, EMBASE, and Scopus databases were systematically searched for articles comparing survival outcomes between adults with and without radiologically defined sarcopenia after emergency gastrointestinal surgery regardless of indication and approach (open/laparoscopic). The primary outcome was postoperative mortality. Sensitivity analysis of adjusted multivariate analyses was performed. RESULTS: Twenty articles comprising 6,737 patients were included. Sarcopenia was most commonly assessed using axial abdominal computerized tomography at L3, although cut-off thresholds were heterogeneous and rarely sex-specific. Postoperative mortality was higher among patients with sarcopenia than without in the in-hospital setting, and at 30- and 90-day follow-up on univariate but not on multivariate meta-analysis. However, mortality was significantly higher among sarcopenic cohorts in the 1-year (odds ratio 2.8, 95% confidence interval: 1.5-5.6; P = .002) follow-up period, despite adjusting for confounding preoperative and patient factors. CONCLUSION: The meta-analysis has shown sarcopenia to provide useful long-term prognostic information following emergency laparotomy. This may aid with preoperative risk assessment, patient counseling, and in perioperative decision-making for patients undergoing emergency laparotomy.

New Zealand and Australia emergency laparotomy mortality rates compare favourably to international outcomes: a systematic review.

BACKGROUND: Almost 20 000 people undergo an emergency laparotomy each year in New Zealand and Australia. Common indications include small and large bowel obstruction, and intestinal perforation. Considered a high-risk procedure, emergency laparotomy is associated with significantly high morbidity and mortality. The aim of this review was to identify and compare 30-day, 90-day and 1-year mortality rates following emergency laparotomy in New Zealand and Australia. METHODS: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Electronic searches were performed in Medline, Embase, PubMed and Scopus in April 2020. RESULTS: Thirty-three papers met the inclusion criteria. Studies ranged in size from 58 to 75 280 patients. Weighted mean 30-day mortality was 8.40% (8.39-8.41). Mortality rates increased with longer postoperative follow up with 90-day weighted mortality rate of 14.14% (14.13-14.15) and the weighted mortality rate at 1 year of 24.60% (24.56-24.66). There was significant variability in mortality rates between countries. CONCLUSION: There is a wide variability of 30-day, 90-day and 1-year mortality rates internationally. Lowering postoperative mortality rates following emergency laparotomy through quality improvement initiatives could result in up to 120 lives in New Zealand and over 250 lives in Australia being saved each year. The continued work of the Australian and New Zealand Emergency Laparotomy Audit - Quality Improvement is crucial to improving emergency laparotomy mortality rates further in New Zealand and Australia.