30-Day and 1-year mortality in emergency general surgery laparotomies: an area of concern and need for improvement?

AIMS: Emergency surgery is associated with poorer outcomes and higher mortality with recent studies suggesting the 30-day mortality to be 14-15%. The aim of this study was to analyse the 30-day mortality, age-related 30-day mortality and 1-year mortality following emergency laparotomy. We hope this will encourage prospective data collection, improvement of care and initiate strategies to establish best practice in this area. METHODS: This was a retrospective study of patients who underwent emergency laparotomy from June 2010 to May 2012. The primary end point of the study was 30-day mortality, age-related 30-day mortality and 1-year all-cause mortality. RESULTS: 477 laparotomies were performed in 446 patients. 57% were aged <70 and 43% aged >70 years. 30-day mortality was 12, 4% in those aged <70 years and 22% in those >70 years (p < 0.001). 1-year mortality was 25, 15% in those aged under 70 years and 38% in those aged >70 years (p < 0.001). CONCLUSIONS: Emergency laparotomy carries a high rate of mortality, especially in those over the age of 70 years, and more needs to be done to improve outcomes, particularly in this group. This could involve increasing acute surgical care manpower, early recognition of patients requiring emergency surgery, development of clear management protocols for such patients or perhaps even considering centralisation of emergency surgical services to specialist centres with multidisciplinary teams involving emergency surgeons and care of the elderly physicians in hospital and related community outreach services for post-discharge care.

A national survey of attitudes to research in Scottish General Surgery Trainees.

INTRODUCTION: Given the importance placed on awareness and participation in research by Speciality and Training organisations, we sought to survey Scottish trainee attitudes to exposure to research practice during training and research in or out of programme. METHODS: An online survey was distributed to core and specialist trainees in general surgery in Scotland. RESULTS: Over a 4-month period, 108 trainees (75 ST/SPRs and 33 CTs) completed the survey. In their current post, most were aware of ongoing research projects (77%) and 55% were aware of trial recruitment. Only 47% attend regular journal clubs. Most believe that they are expected to present (89%) and publish (82%) during training. Most (59%) thought that participation in research is well supported. 57% were advised to undertake time out of programme research, mostly by consultants (48%) and training committee (36%). Of the 57 with time out of programme research experience, most did so in early training (37%) or between ST3-5 (47%). 28 out of the 36 (78%) without a national training number secured one after starting research. Most undertook research in a local academic unit (80%) funded by small grants (47%) or internally (33%). Most research (69%) was clinically orientated (13/55 clinical, 25/55 translational). 56% of those completing time out of programme research obtained an MD or PhD. About 91% thought that research was relevant to a surgical career. CONCLUSIONS: Most trainees believe that research is an important part of training. Generally, most trainees are exposed to research practices including trial recruitment. However, <50% attend regular journal clubs, a pertinent point, given the current 'exit exam' includes the assessment of critical appraisal skills.

Massive mesenteric and portal venous thrombosis secondary to hormone replacement therapy.

Hormone replacement therapy increases risk of deep venous thrombosis (DVT) mainly in the extremities and lungs. There are reports of mesenteric ischemia secondary to oral contraceptive pills but no reports on hormone replacement therapy and mesenteric thrombosis. The authors present a case of a 44-year-old obese (BMI 32) woman, on long-term hormone replacement therapy, presented with thrombosis of portal, splenic and superior mesenteric veins. She underwent surgical resection of ischemic bowel and planned re-look laparotomies with further resections and jejuno-ileal anastomosis at final laparotomy. Thorough haematological investigations were normal. The authors conclude that hormone replacement therapy in obese patients with no other risk factors can cause a catastrophic mesenteric thrombosis. Aggressive surgical resection with re-look laparotomies and further resections can be lifesaving.

Groove pancreatitis: a case series and review of the literature.

INTRODUCTION: Groove pancreatitis is a form of chronic pancreatitis affecting the space surrounded by the pancreatic head, duodenum and common bile duct. The clinical findings can conflict with pancreatic cancer causing diagnostic dilemma preoperatively. CASE SERIES: We describe two patients with a history of alcohol excess, who presented with a few months history of upper abdominal pain associated with weight loss and vomiting. Endoscopic and radiological investigations related duodenal narrowing, biliary dilatation and multiple pseudocysts around the head of the pancreas and duodenum. A Whipple's pancreaticoduodenectomy was carried out in both patients. Histopathology report demonstrated cystic areas in both medial and lateral walls of the duodenum microscopically consistent with groove pancreatitis. CONCLUSION: The diagnosis of groove pancreatitis should be considered in patients with duodenal stenosis and cystic lesions around the head of the pancreas associated with history of alcohol excess. Differentiation from pancreatic cancer is difficult preoperatively.

Mesenteric lipoma causing small bowel perforation: a case report and review of literature.

A lipoma of the small bowel mesentery is a rare pathological entity. It has been shown to rarely cause obstruction and volvulus of the small bowel. We report a case of a 72-year-old man who presented with lower abdominal pain and slightly raised inflammatory markers. Computerized tomography of the abdomen showed small bowel perforation and oedematous terminal ileum. At laparotomy the cause was found to be a mesenteric lipoma causing small bowel perforation. As far as the authors are aware, this presentation is not described in the English language literature.

Rhythmical eye-head-torso rotation alters fore-aft head stabilization during treadmill locomotion in humans.

A repetitive manoeuvre called torso rotation (TR) is known to temporarily reduce the gain of the horizontal vestibulo-ocular reflex by 10-15% in healthy humans. TR consists of a series of rhythmical rotations of the eyes, head and upper body executed continuously for 30 minutes while standing. Our aim was to investigate whether TR affects the ability to hold the head in a fixed fore-aft position relative to space while walking on a treadmill with eyes closed. Ten healthy subjects stood in a carefully standardized position on a stationary treadmill. The treadmill started unexpectedly and ran for 4 s at 29 cm/s. The test stimulus was a linear acceleration in the fore-aft direction at the moment of treadmill start-up. Linear head position (i.e., ability to stabilize the head) was measured during and following the stimulus. A mechanical system prevented head rotation. Two series of 60 trials were performed before TR (control 1 and control 2 series) and one after TR. Before TR, subjects drifted rearward at an average drift velocity +/- S.D. = 3.1 +/- 0.9 cm/s. This drift was reasonably stable over time within and between the two control series. After TR, head holding ability was further impaired, with subjects having more difficulty to stabilize their head after treadmill start-up. In the first 10 trials after the arrest of TR, the average drift velocity was significantly larger than before TR(6.1 +/- 1.5 cm/sec, p < 0.01). Recovery to control values followed a roughly exponential time course, with 67% recovery occurring in the first 3.4 minutes after TR. Our results indicate that TR impairs the ability to sense and/or respond to fore-aft linear accelerations of the head following treadmill start-up in the absence of vision.

"Torso Rotation" experiments. 4: the role of vision and the cervico-ocular reflex in compensation for a deficient VOR.

Acute, reversible changes in human vestibular function can be produced by exposure to "Torso Rotation" (TR), a method involving the overuse of certain types of simple, self-generated movements. A single session results in multiple, short-lasting aftereffects, including perceptual illusions, VOR gain reduction, gaze and postural instability, and motion sickness. With repeated exposure, motion sickness susceptibility disappears and gaze stability improves. VOR gain continues to be reduced, however. Therefore, another gaze stabilizing system must come into play. Are visual and/or neck inputs involved in this functional compensation? Six subjects participated in this 7-day experiment. Eye and head movements were measured during 2 tests: 1) voluntary "head only" shaking between 0.3 and 3.0 Hz (lights off) and 2) voluntary "head and torso" shaking, moving the upper body en bloc (neck immobilized). Measurements were obtained before and repeatedly after TR. Velocity gain (eye velocity/head velocity) was determined for each of these tests. Each day, mean velocity gain during "head only" shaking in the dark (averaged over 1.0 to 2.0 Hz) dropped significantly after TR (P < 0.01), with no long-term improvement (P > 0.9). Similar results, although more noisy, were obtained for "head and torso" shaking. As a control, EOG calibration data confirmed that gaze stability in the light did improve over the 7 days of testing. This experiment demonstrates that the reduction in gaze instability following repeated exposure to TR results from an increased use of vision. It excludes the VOR, the COR, and predictive mechanisms (including efference copy) as contributors. In addition, in the 20 minutes following TR completion, gaze stability recovered less than during previous VOR testing in the dark. These results are compatible with the motion that exposure to TR leads to a change in sensorimotor strategy involving a de-emphasis of vestibular inputs.

Pointing at memorized targets during prolonged microgravity.

BACKGROUND: Watt et al. (15) and Young et al. (17) have demonstrated that during prolonged microgravity, large errors can be made when pointing at memorized targets in the absence of vision. However, those experiments could not distinguish between errors caused by not knowing where the arm was pointed and errors caused by not knowing target location. The primary goal of this study was to determine the relative contribution of each of these potential sources of error. HYPOTHESIS: It was hypothesized that pointing errors would be greater than pre-flight controls if vision was continuously absent during testing, but not greater than pre-flight if vision was restricted only while pointing. METHODS: Five subjects on Spacelab SLS-2 (Part A) pointed at targets while keeping their eyes closed continuously; (Part B) touched various body parts and estimated the position of their arms while the eyes remained closed; and (Part C) pointed at the same targets as in A but closed their eyes only while pointing. RESULTS: On the ground, if the eyes were closed only while pointing, pointing errors averaged 4.5 degrees. After several days n space, errors averaged 7.0 degrees (p < 0.05). Again on the ground, if the eyes were closed continuously while pointing, an additional error of 4.0 degrees was measured. However, after several days in space, the additional error was 10.5 degrees (p < 0.0005). CONCLUSIONS: The results of this study suggest that the major problem encountered when pointing at memorized targets in microgravity is a lack of knowledge of target, not limb, position.

"Torso rotation" experiments; 1: Adaptation to motion sickness does not correlate with changes in VOR gain.

Following a 30-minute exposure to an unusual motor strategy called "Torso Rotation" (TR), the signs and symptoms of motion sickness appear along with perceptual illusions during movement, gaze and postural instability, and a significantly reduced vestibulo-ocular response (VOR) gain. With repeated exposure to TR, the motion sickness disappears and gaze instability seems to be reduced. Is this apparent improvement in gaze stability associated with a reduction of the transient change in VOR gain? Motion sickness (subjective questionnaire) and VOR gain (passive step rotations in darkness) were measured before and repeatedly after TR on 7 consecutive days. Despite a complete loss of symptoms in 3 to 4 days, the transient, daily change in VOR gain remained unaffected. Furthermore, there was no increase in the use of compensatory saccades. It is concluded that adaptation to TR-induced motion sickness is not the result of a change in VOR's sensitivity to TR.

"Torso rotation" experiments; 2: Gaze stability during voluntary head movements improves with adaptation to motion sickness.

Following a 30-minute exposure to an unusual motor strategy called "Torso Rotation" (TR), the signs and symptoms of motion sickness appear along with perceptual illusions during movement, gaze and postural instability, and a significantly reduced vestibulo-ocular response (VOR) gain. With repeated exposure to TR, motion sickness symptoms disappear and gaze instability seems reduced, but without any concomitant change in VOR gain. Is the reduction in gaze instability a perceptual illusion or a real, measurable phenomenon? Velocity gain (eye velocity/ head velocity) was evaluated during voluntary head shaking in the light over the frequency range 0.3 to 3.0 Hz. A significant improvement was seen after 3 days of testing (P < 0.01). Furthermore, the time course of improvement in gaze stability was correlated with the loss of motion sickness symptoms reported in the previous study (1). We suggest that adaptation to motion sickness could be related to an overall change in sensori-motor strategy, perhaps including a de-emphasis of a vestibular reference.

"Torso rotation" experiments; 3: Effects of acute changes in vestibular function on the control of voluntary head movements.

"Torso Rotation" (TR) produces an acute, reversible change in human vestibular function. Experiments were performed to determine if repeated exposure to this technique would result in long-term adaptive modifications. In one experiment, VOR gain was evaluated. Measurements were obtained before and 3 times after 30 minutes of TR, on 7 consecutive days. VOR gain dropped each day after TR, returning to normal within about 20 min. In a separate experiment with different subjects, eyes-open gaze stability was measured during voluntary head shaking between 3.0 and 0.3 Hz. The same test schedule was used. Analysis of gaze stability (limited to frequencies between 1.0 and 2.0 Hz) was complicated by an unexpected finding. Despite careful instructions, head displacement increased each day after TR, also returning to normal within about 20 min. Surprisingly, subjects were unaware of this change. Combining the 2 experiments, VOR gain and head amplitude were averaged across all 7 days, separately for the 4 daily tests. Head amplitude was plotted against VOR gain for these 4 averages. Amplitude was greater when VOR gain was reduced, with a remarkably high correlation (R2 = 0.996). These findings confirm that vestibular feedback plays an important role in the control of voluntary head movement. Furthermore, the data suggest that instability of the visual scene reported by subjects shaking their heads after TR resulted not only from a lower VOR gain, but also from the inadvertent use of higher head velocities.

The vestibulo-ocular reflex and its possible roles in space motion sickness.

Prolonged exposure to an inappropriate vestibulo-ocular reflex (VOR) will usually lead to motion sickness, and it has been predicted on theoretical grounds that VOR gain may be decreased in weightlessness. While experiments during parabolic flight in aircraft tend to confirm this prediction, experiments during orbital spaceflight have led to apparently contradictory results. It is suggested that VOR gain is reduced initially, but that rapid compensatory mechanisms restore it to normal within minutes of reaching weightlessness. However, even though this process may lead to the rapid return of functionally normal gaze stability, it may not protect against the development of motion sickness.

M.I.T./Canadian vestibular experiments on the Spacelab-1 mission: 1. Sensory adaptation to weightlessness and readaptation to one-g: an overview.

Experiments on human spatial orientation were conducted on four crewmembers of Space Shuttle Spacelab Mission 1. This introductory paper presents the conceptual background of the project, the relationship among the experiments and their relevance to a "sensory reinterpretation hypothesis". Detailed experiment procedures and results are presented in the accompanying papers in this series. The overall findings are discussed in this article as they pertain to the following aspects of hypothesized sensory reinterpretation in weightlessness: utricular otolith afferent signals are reinterpreted as indicating head translation rather than tilt, sensitivity of reflex responses to footward acceleration is reduced, and increased weighting is given to visual and tactile cues in orientation perception and posture control. Three subjects developed space motion sickness symptoms, which abated after several days. Head movements, as well as visual and tactile cues to orientation influenced symptoms in a manner consistent with the sensory-motor conflict theory of space motion sickness. Six short duration tests of motion sickness susceptibility, conducted pre-flight, failed to predict sickness intensity in weightlessness. An early otolith-spinal reflex, measured by electromyography from the gastrocnemius-soleus muscles during sudden footward acceleration, was inhibited immediately upon entering weightlessness and declined further during the flight, but was unchanged from pre-flight when measured shortly after return to earth. Dynamic visual-vestibular interaction was studied by measuring subjective roll self-motion created by looking into a spinning drum. Results suggest increased weighting of visual cues and reduced weighting of graviceptor signals in weightlessness. Following the 10 day flight, erect posture with eyes closed was disturbed for several days.(ABSTRACT TRUNCATED AT 250 WORDS)

M.I.T./Canadian vestibular experiments on the Spacelab-1 mission: 3. Effects of prolonged weightlessness on a human otolith-spinal reflex.

Reflex responses that depend on human otolith organ sensitivity were measured before, during and after a 10 day space flight. Otolith-spinal reflexes were elicited by means of sudden, unexpected falls. In weightlessness, "falls" were achieved using elastic cords running from a torso harness to the floor. Electromyographic (EMG) activity was recorded from gastrocnemius-soleus. The EMG response occurring in the first 100-120 ms of a fall, considered to be predominantly otolith-spinal in origin, decreased in amplitude immediately upon entering weightlessness, and continued to decline throughout the flight, especially during the first two mission days. The response returned to normal before the first post-flight testing session. The results suggest that information coming from the otolith organs is gradually ignored by the nervous system during prolonged space flight, although the possibility that otolith-spinal reflexes are decreased independent of other otolith output pathways cannot be ruled out.