INTRODUCTION: Emergency laparotomy (EL) is associated with high morbidity and mortality, often exceeding 10%. This study evaluated the impact of the EMergency Laparotomy Audit (EMLA) interdisciplinary perioperative pathway on patient outcomes, hospital costs and length of stay (LOS) within a single centre. METHOD: A prospective cohort study was conducted from August 2020 to July 2023. The intervention team included specialist clinicians, hospital administrators and an in-hospital quality improvement team. Patients who underwent EL were divided into a pre-intervention control group (n=136) and a post-intervention group (n=293), and an 8-item bundle was implemented. Propensity scoring with a 1:1 matching method was utilised to reduce confounding and selection bias. The primary outcomes examined were LOS, hospitalis-ation costs and surgical morbidity, while secondary outcomes included 30-day mortality and adherence to the intervention protocol. RESULTS: The utilisation of the EMLA perioperative care bundle led to a significant reduction in surgical complications (34.8% to 20.6%, P<0.01), a decrease in LOS by 3.3 days (15.4 to 12.1 days, P=0.03) and lower hospitalisation costs (SGD 40,160 to 30,948, P=0.04). Compliance with key interventions also showed improvement. However, there was no difference in 30-day mortality. CONCLUSION This study offers insights on how surgical units can implement systemic perioperative changes to improve outcomes for patients undergoing emergency laparotomy.
Humans ; Laparotomy/methods* ; Propensity Score ; Female ; Male ; Prospective Studies ; Length of Stay/statistics & numerical data* ; Middle Aged ; Hospital Costs/statistics & numerical data* ; Postoperative Complications/epidemiology* ; Aged ; Emergencies ; Perioperative Care/methods* ; Critical Pathways ; Singapore ; Adult

Objective: To examine the safety and effectiveness of laparoscopic individualized surgical treatment for chronic traumatic diaphragmatic hernia (CTDH). Methods: The clinical data and follow-up data of 29 CTDH cases admitted to the Qilu Hospital of Shandong University or the First Affiliated Hospital of Shandong First Medical University from June 2015 to January 2023 were retrospectively analyzed. There were 21 males and 8 females, aged (49.4±17.8) years (range: 19 to 79 years). The main clinical manifestations were symptoms of the digestive system and respiratory system, and only 4 cases were asymptomatic. All patients received laparoscopic treatment (conversion to open surgery was not excluded). Intraoperative exploration (location of the hernia, contents of the hernia, diameter of the hernia ring), surgical conditions (surgical repair plan, operation time, blood loss, postoperative complications) and postoperative follow-up were analyzed and discussed. Results: Laparoscopic repair was successfully completed in 27 cases, including simple suture in 6 cases, suture and patch repair in 17 cases, the anterior abdominal wall muscle flap reversal suture and patch repair of in 3 cases, and patch bridge repair in 1 case. The operation time was (112.8±44.7) minutes (range: 60 to 200 minutes). The amount of bleeding (M(IQR)) was 35 (58) ml (range: 10 to 300 ml). The other 2 patients were converted to laparotomy. Except for one patient with transverse colon strangulation necrosis who died of aggravated pulmonary infection after surgery, the remaining 28 patients were discharged successfully. The follow-up time was 36 (24) months (range: 1 to 60 months). During the follow-up period, only two patients had occasional left upper abdominal discomfort. Twenty-seven patients with left diaphragmatic hernia had no recurrence, and the symptoms of 1 patient with right diaphragmatic hernia were relieved. Conclusion: Customized laparoscopic surgical repair for CTDH according to the location and size of the diaphragmatic defect can achieve good surgical results.
Male ; Female ; Humans ; Hernia, Diaphragmatic, Traumatic/surgery* ; Retrospective Studies ; Laparoscopy/methods* ; Postoperative Complications ; Laparotomy ; Surgical Mesh

Adrenal gland trauma is a rare phenomenon, due to the small size and retroperitoneal location of the organ. The majority of adrenal gland trauma is due to blunt force injury and is only rarely encountered due to the penetrating mechanisms. A 20-year-old male sustained a gunshot wound to the left abdomen. Upon exploration, he was found to have a through and through injury to the left adrenal gland, among other injuries. Injury to the adrenal gland due to penetrating trauma is exceptionally rare. The principles of management are to control bleeding from the gland with debridement and hemostasis rather than attempt to resect the entire organ. The management of a penetrating injury to the adrenal gland is straightforward and should not be a contributor to a patient's morbidity or mortality.
Adrenal Glands ; diagnostic imaging ; injuries ; Adult ; Debridement ; Hemorrhage ; etiology ; therapy ; Hemostasis, Surgical ; Humans ; Laparotomy ; Male ; Multiple Trauma ; therapy ; Organ Sparing Treatments ; methods ; Tomography, X-Ray Computed ; Treatment Outcome ; Wounds, Gunshot ; complications ; diagnostic imaging ; therapy ; Young Adult

A trichobezoar is a type of bezoar that is composed of hair. In most cases, it is confined to the stomach, but in rare cases, it may extend to the small intestine. This condition is referred to as Rapunzel syndrome. The therapeutic method for bezoar removal depends on its type, location, and size. Generally, the treatment for Rapunzel syndrome involves surgical laparotomy. Endoscopic removal has also been effective in some cases. On the other hand, complications, such as respiratory difficulty and esophageal impaction may be encountered during endoscopic removal. Until now, the successful endoscopic removal of trichobezoars has been limited to the stomach or duodenum. This paper reports the case of a 4-year-old female patient with Rapunzel syndrome whose trichobezoar reached the proximal jejunum. The trichobezoar was removed without complications using an electrosurgical knife and snare through a single-balloon enteroscopy. The trichobezoar can be removed successfully using enteroscopy under general anesthesia without abdominal laparotomy in young children. Therefore, this method of removal can be considered preferentially for children with Rapunzel syndrome.
Anesthesia, General ; Bezoars ; Child ; Child, Preschool ; Duodenum ; Female ; Hair ; Hand ; Humans ; Intestine, Small ; Jejunum ; Laparotomy ; Methods ; SNARE Proteins ; Stomach

A differential diagnosis of ascites is always challenging for physicians. Peritoneal tuberculosis is particularly difficult to distinguish from peritoneal carcinomatosis because of the similarities in clinical manifestations and laboratory results. Although the definitive diagnostic method for ascites is to take a biopsy of the involved tissues through laparoscopy or laparotomy, there are many limitations in performing biopsies in clinical practice. For this reason, physicians have attempted to find surrogate markers that can substitute for a biopsy as a confirmative diagnostic method for ascites. CA 125, which is known as a tumor marker for gynecological malignancies, has been reported to be a biochemical indicator for peritoneal tuberculosis. On the other hand, the sensitivity of serum CA 125 is low, and CA 125 may be elevated due to other benign or malignant conditions. This paper reports the case of a 66-year-old male who had a moderate amount of ascites and complained of dyspepsia and a febrile sensation. His abdominal CT scans revealed a conglomerated mass, diffuse omental infiltration, and peritoneal wall thickening. Initially, peritoneal tuberculosis was suspected due to the clinical symptoms, CT findings, and high serum CA 125 levels, but non-specific malignant cells were detected on cytology of the ascitic fluid. Finally, he was diagnosed with primary malignant peritoneal mesothelioma after undergoing a laparoscopic biopsy.
Aged ; Ascites ; Ascitic Fluid ; Biomarkers ; Biopsy ; CA-125 Antigen ; Carcinoma ; Diagnosis, Differential ; Dyspepsia ; Hand ; Humans ; Laparoscopy ; Laparotomy ; Male ; Mesothelioma ; Methods ; Peritoneum ; Peritonitis, Tuberculous ; Sensation ; Tomography, X-Ray Computed

OBJECTIVE: To compare the long-term survival outcomes of Siewert II adenocarcinoma of esophagogastric junction (AEG) between transthoracic (TT) approach and transabdominal (TA) approach. METHODS: The databases of Gastrointestinal Surgery Department and Thoracic Surgery Department in West China Hospital of Sichuan University from 2006 to 2014 were integrated. Patients of Siewert II AEG who underwent resection were retrospectively collected. INCLUSION CRITERIA: (1) adenocarcinoma confirmed by gastroscopy and biopsy; (2) tumor involvement in the esophagogastric junction line; (3) tumor locating from lower 5 cm to upper 5 cm of the esophagogastric junction line, and tumor center locating from upper 1 cm to lower 2 cm of esophagogastric junction line; (4)resection performed at thoracic surgery department or gastrointestinal surgery department; (5) complete follow-up data. Patients at thoracic surgery department received trans-left thoracic, trans-right thoracic, or transabdominothoracic approach; underwent lower esophagus resection plus proximal subtotal gastrectomy; selected two-field or three-field lymph node dissection; underwent digestive tract reconstruction with esophagus-remnant stomach or esophagus-tubular remnant stomach anastomosis above or below aortic arch using hand-sewn or stapler instrument to perform anastomosis. Patients at gastrointestinal surgery department received transabdominal(transhiatal approach), or transabdominothoracic approach; underwent total gastrectomy or proximal subtotal gastrectomy; selected D1, D2 or D2 lymph node dissection; underwent digestive tract reconstruction with esophagus-single tube jejunum or esophagus-jejunal pouch Roux-en-Y anastomosis, or esophagus-remnant stomach or esophagus-tubular remnant stomach anastomosis; completed all the anastomoses with stapler instruments. The follow-up ended in January 2018. The TNM stage system of the 8th edition UICC was used for esophageal cancer staging; survival table method was applied to calculate 3-year overall survival rate and 95% cofidence interval(CI); log-rank test was used to perform survival analysis; Cox regression was applied to analyze risk factors and calculate hazard ratio (HR) and 95%CI. RESULTS: A total of 443 cases of Siewert II AEG were enrolled, including 89 cases in TT group (with 3 cases of transabdominothoracic approach) and 354 cases in TA group. Median follow-up time was 50.0 months (quartiles:26.4-70.2). The baseline data in TT and TA groups were comparable, except the length of esophageal invasion [for length <3 cm, TA group had 354 cases(100%), TT group had 44 cases (49.4%), χ²=199.23,P<0.001]. The number of harvested lymph node in thoracic surgery department and gastrointestinal surgery department were 12.0(quartiles:9.0-17.0) and 24.0(quartiles:18.0-32.5) respectively with significant difference (Z=11.29,P<0.001). The 3-year overall survival rate of TA and TT groups was 69.2%(95%CI:64.1%-73.7%) and 55.8% (95%CI:44.8%-65.4%) respectively, which was not significantly different by log-rank test (P=0.059). However, the stage III subgroup analysis showed that the survival of TA group was better [the 3-year overall survival in TA group and TT group was 78.1%(95%CI:70.5-84.0) and 46.3%(95%CI:31.0-60.3) resepectively(P=0.001)]. Multivariate Cox regression analysis revealed that the TT group had poor survival outcome (HR=2.45,95%CI:1.30-4.64, P=0.006). CONCLUSION The overall survival outcomes in the TA group are better, especially in stage III patients, which may be associated with the higher metastatic rate of abdominal lymph node and the more complete lymphadenectomy via TA approach.
Adenocarcinoma ; classification ; mortality ; pathology ; surgery ; China ; Databases, Factual ; Esophageal Neoplasms ; classification ; pathology ; surgery ; Esophagectomy ; methods ; Esophagogastric Junction ; pathology ; surgery ; Gastrectomy ; methods ; Humans ; Laparotomy ; Lymph Node Excision ; methods ; Neoplasm Staging ; Retrospective Studies ; Stomach Neoplasms ; classification ; mortality ; pathology ; surgery ; Survival Analysis ; Thoracic Surgical Procedures

PURPOSE: Despite the use of different surgical methods, surgical site infection is still an important cause of mortality and morbidity in patients and imposes a considerable cost on the healthcare system. Administration of supplemental oxygen during surgery has been reported to reduce surgical site infection (SSI); however, that result is still controversial. This study was performed to evaluate the effect of hyperoxygenation during colorectal surgery on the incidence of wound infection. METHODS: This study was a prospective double-blind case-control study. The main aim of the study was to evaluate the effect of hyperoxygenation during colorectal surgery on the incidence of SSI. Also, secondary outcomes, such as atelectasis, pneumonia, respiratory failure, length of hospital stay, and required hospitalization in the intensive care unit were evaluated. RESULTS: SSI was recorded in 2 patients (2 of 40, 5%) in the hyperoxygenation group (FiO2 80%) and 6 patients (6 of 40, 15%) in the control group (FiO2 30%) (P < 0.05). Time of hospitalization was 6 ± 6.4 days in the hyperoxygenation group and 9.2 ± 2.4 days in the control group (P < 0.05). CONCLUSION: This study showed a positive effect of hyperoxygenation in reducing SSI in colorectal surgery, especially surgery in an emergency setting. When the low risk, low cost, and effectiveness of this method in patients undergoing a laparotomy are considered, it is recommended for all patients undergoing colorectal surgery.
Anesthesia ; Case-Control Studies ; Colorectal Surgery ; Delivery of Health Care ; Emergencies ; Hospitalization ; Humans ; Incidence ; Intensive Care Units ; Laparotomy ; Length of Stay ; Methods ; Mortality ; Oxygen ; Pneumonia ; Prospective Studies ; Pulmonary Atelectasis ; Respiratory Insufficiency ; Surgical Wound Infection ; Wound Infection

A trichobezoar is a type of bezoar that is composed of hair. In most cases, it is confined to the stomach, but in rare cases, it may extend to the small intestine. This condition is referred to as Rapunzel syndrome. The therapeutic method for bezoar removal depends on its type, location, and size. Generally, the treatment for Rapunzel syndrome involves surgical laparotomy. Endoscopic removal has also been effective in some cases. On the other hand, complications, such as respiratory difficulty and esophageal impaction may be encountered during endoscopic removal. Until now, the successful endoscopic removal of trichobezoars has been limited to the stomach or duodenum. This paper reports the case of a 4-year-old female patient with Rapunzel syndrome whose trichobezoar reached the proximal jejunum. The trichobezoar was removed without complications using an electrosurgical knife and snare through a single-balloon enteroscopy. The trichobezoar can be removed successfully using enteroscopy under general anesthesia without abdominal laparotomy in young children. Therefore, this method of removal can be considered preferentially for children with Rapunzel syndrome.
Anesthesia, General ; Bezoars ; Child ; Child, Preschool ; Duodenum ; Female ; Hair ; Hand ; Humans ; Intestine, Small ; Jejunum ; Laparotomy ; Methods ; SNARE Proteins ; Stomach

A differential diagnosis of ascites is always challenging for physicians. Peritoneal tuberculosis is particularly difficult to distinguish from peritoneal carcinomatosis because of the similarities in clinical manifestations and laboratory results. Although the definitive diagnostic method for ascites is to take a biopsy of the involved tissues through laparoscopy or laparotomy, there are many limitations in performing biopsies in clinical practice. For this reason, physicians have attempted to find surrogate markers that can substitute for a biopsy as a confirmative diagnostic method for ascites. CA 125, which is known as a tumor marker for gynecological malignancies, has been reported to be a biochemical indicator for peritoneal tuberculosis. On the other hand, the sensitivity of serum CA 125 is low, and CA 125 may be elevated due to other benign or malignant conditions. This paper reports the case of a 66-year-old male who had a moderate amount of ascites and complained of dyspepsia and a febrile sensation. His abdominal CT scans revealed a conglomerated mass, diffuse omental infiltration, and peritoneal wall thickening. Initially, peritoneal tuberculosis was suspected due to the clinical symptoms, CT findings, and high serum CA 125 levels, but non-specific malignant cells were detected on cytology of the ascitic fluid. Finally, he was diagnosed with primary malignant peritoneal mesothelioma after undergoing a laparoscopic biopsy.
Aged ; Ascites ; Ascitic Fluid ; Biomarkers ; Biopsy ; CA-125 Antigen ; Carcinoma ; Diagnosis, Differential ; Dyspepsia ; Hand ; Humans ; Laparoscopy ; Laparotomy ; Male ; Mesothelioma ; Methods ; Peritoneum ; Peritonitis, Tuberculous ; Sensation ; Tomography, X-Ray Computed

PURPOSE: Colostomy creation is an essential procedure for colorectal surgeons, but the preferred method of colostomy varies by surgeon. We compared the outcomes of trephine colostomy creation with open those for the (laparotomy) and laparoscopic methods and evaluated appropriate indications for a trephine colostomy and the advantages of the technique. METHODS: We retrospectively evaluated 263 patients who had undergone colostomy creation by trephine, open and laparoscopic approaches between April 2006 and March 2016. We compared the clinical features and the operative and postoperative outcomes according to the approach used for stoma creation. RESULTS: One hundred sixty-three patients (62%) underwent colostomy surgery for obstructive causes and 100 (38%) for fistulous problems. The mean operative time was significantly shorter with the trephine approach (trephine, 46.0 ± 1.9 minutes; open, 78.7 ± 3.9 minutes; laparoscopic, 63.5 ± 5.0 minutes; P < 0.001), as was the time to flatus (1.8 ± 0.1 days, 2.1 ± 0.1 days, 2.2 ± 0.3 days, P = 0.025). Postoperative complications (<30 days) were not different among the 3 approaches (trephine, 4.3%; open, 1.2%; laparoscopic, 0%; P = 0.828). In patients who underwent rectal surgery, a trephine colostomy was feasible for a diversion colostomy (P < 0.001). CONCLUSION: The trephine colostomy is safe and can be implemented quickly in various situations, and compared to other colostomy procedures, the patient's recovery is faster. Previous laparotomy history was not a contraindication for a trephine colostomy, and a trephine transverse colostomy is feasible for patients who have undergone previous rectal surgery.
Colostomy* ; Flatulence ; Humans ; Laparotomy ; Methods ; Operative Time ; Postoperative Complications ; Retrospective Studies ; Surgeons