Enhancing operative documentation of emergency laparotomy: a systematic review and development of a synoptic reporting template

INTRODUCTION

Currently, operative reports are narrative and often handwritten, making interpretation difficult and potentially omitting key steps of the procedure. This study undertook a systematic review to determine the current availability of synoptic operative reporting and develop a synoptic operative record template for emergency laparotomy (EL).

METHODS

A PROSPERO registered study from January 1st, 2012, to December 31st, 2022, was conducted using PubMed, Scopus, and Web of Science databases in February 2023.

KEYWORDS

emergency laparotomy AND operation notes OR operative notes OR documentation OR report OR pro forma OR narrative OR synoptic OR digital OR audio-visual. Studies on paediatric or pregnant patients, systematic reviews, meta-analyses, case reports, editorial comments, and letters were excluded. A synoptic operative record was designed to include key standards in the documentation, as suggested by the Colleges of Surgeons.

RESULTS

The literature search yielded 4687 articles, and no relevant published articles were found. A detailed synoptic template was developed, which included 111 fields related to patient demographics, operative findings, interventions, and documentation of key variables associated with patient outcomes. 11 were text boxes, two were related to digital audio-visual uploads, and three facilitated the digital scoring/grading of findings.

CONCLUSION

This systematic review identified a limited number of publications reporting synoptic operative reporting, and none related to emergency laparotomy. This novel operative template provides a platform for clear documentation of the surgery performed during emergency laparotomy, potentially facilitating data analysis, resident training, and research, in turn leading to a better understanding of patient outcomes.

Prophylactic onlay mesh placement techniques for optimal abdominal wall closure: randomized controlled trial in an ex vivo biomechanical model

BACKGROUND

Incisional hernias occur after up to 40 per cent of laparotomies. Recent RCTs have demonstrated the role of prophylactic mesh placement in reducing the risk of developing an incisional hernia. An onlay approach is relatively straightforward; however, a variety of techniques have been described for mesh fixation. The biomechanical properties have not been interrogated extensively to date.

METHODS

This ex vivo randomized controlled trial using porcine abdominal wall investigated the biomechanical properties of three techniques for prophylactic onlay mesh placement at laparotomy closure. A classical onlay, anchoring onlay, and novel bifid onlay approach were compared with small-bite primary closure. A biomechanical abdominal wall model and ball burst test were used to assess transverse stretch, bursting force, and loading characteristics.

RESULTS

Mesh placement took an additional 7-15 min compared with standard primary closure. All techniques performed similarly, with no clearly superior approach. The minimum burst force was 493 N, and the maximum 1053 N. The classical approach had the highest mean burst force (mean(s.d.) 853(152) N). Failure patterns fell into either suture-line or tissue failures. Classical and anchoring techniques provided a second line of defence in the event of primary suture failure, whereas the bifid method demonstrated a more compliant loading curve. All mesh approaches held up at extreme quasistatic loads.

CONCLUSION

Subtle differences in biomechanical properties highlight the strengths of each closure type and suggest possible uses. The failure mechanisms seen here support the known hypotheses for early fascial dehiscence. The influence of dynamic loading needs to be investigated further in future studies.

Prophylactic onlay mesh at emergency laparotomy: promising early outcomes with long-acting synthetic resorbable mesh

Background

Careful surgical strategy is paramount in balancing the prevention of fascial dehiscence, incisional hernia (IH) and fear of additional mesh‐related wound complications post‐laparotomy. This study aims to review early outcomes of patients undergoing an emergency laparotomy with prophylactic TIGR® mesh, used to reduce early fascial dehiscence and potential subsequent IH.

Method

A retrospective, ethically approved review of 24 consecutive patients undergoing prophylactic TIGR® mesh placement during emergency laparotomies by a single surgeon between January 2017 and June 2021 at a University Hospital. A standardized approach included onlay positioning of the mesh, small‐bite fascial closure, and a wound bundle. We recorded patient demographics, operative indications, findings, degree of peritonitis, postoperative complications, and mortality.

Result

The study included 24 patients; 16/24 (66.6%) were female and median age was 72.5 (range 31–86); 14/24 patients were ASA grade III or greater; 4/24 patients (16.6%) developed six complications and 3/6 occurred in a single patient. Complications included subphrenic abscess, seroma, intrabdominal hematoma, enterocutaneous fistula leading to deep wound infection and small bowel perforation. Five (20.8%) patients died in hospital; central venous catheter sepsis (n = 1), fungal septicaemia (n = 1) and multiorgan failure (n = 3). Surgical site infection and seroma rates were low, occurring in 2/24 patients (4% each).

Conclusion

This study has identified that prophylactic onlay mesh in patients undergoing an emergency laparotomy is not associated with significant wound infection or seroma when used with an active wound bundle. The wider use of TIGR® to prevent fascial dehiscence and potential long‐term IH prevention should be considered.

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.

A comparison of oncological outcomes after abdominoperineal excision before and after the implementation of a selective perineal flap closure program

BACKGROUND AND OBJECTIVES

Abdominoperineal excision (APE) is the operation chosen when a patient has low rectal cancer unamenable to sphincter preserving surgery. Perineal flap reconstruction is associated with less wound morbidity but little is known about oncological outcomes. The objective was to compare outcomes in patients undergoing APE before and after the introduction of a program that utilized flap reconstruction of the perineum.

METHODS

A retrospective review of a prospectively maintained database was performed. Patients who underwent APE followed by primary closure or flap reconstruction between 1998 and 2018 were selected. The cohorts were divided according to the implementation of the flap reconstruction program in July 2009. Clinicopathological data, recurrence and survival were compared between the cohorts.

RESULTS

One hundred and forty nine patients underwent APE for rectal adenocarcinoma between 1998 and 2018. There were 57 patients in the pre-flap era and 92 in the post-flap era. Forty-six patients underwent flap reconstruction in the latter cohort (50%). More patients in the post-flap era underwent neoadjuvant chemoradiotherapy (85.9% vs. 63.2%; p < .01). Margin positivity rates decreased from 21.1% in the pre-flap era to 10.9% in the post-flap era (p = .10) and there was an associated improvement in incidence and time to local recurrence (p = .03).

CONCLUSION

The use of perineal flap reconstruction is associated with a longer median time to local recurrence. Perineal flap reconstruction may contribute to reduced margin positivity.

Negative Pressure Wound Therapy for Closed Laparotomy Incisions in General and Colorectal Surgery: A Systematic Review and Meta-analysis

Importance

Surgical site infections (SSIs) are common after laparotomy wounds and are associated with a significant economic burden. The use of negative pressure wound therapy (NPWT) has recently been broadened to closed surgical incisions.

Objective

To evaluate the association of prophylactic NPWT with SSI rates in closed laparotomy incisions performed for general and colorectal surgery in elective and emergency settings.

Data Sources

The PubMed, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar databases were searched without language restrictions for relevant articles from inception until December 2017. The latest search was performed on December 31, 2017. The bibliographies of retrieved studies were further screened for potential additional studies.

Study Selection

Randomized clinical trials and nonrandomized studies were included. Unpublished reports were excluded, as were studies that examined NPWT (or standard nonpressure) dressings only without a comparator group. Studies that evaluated the use of NPWT in open abdominal incisions were also excluded. Disagreement was resolved by discussion, and if the question remained unsettled, the opinion of the senior author was sought. A total of 198 citations were identified, and 189 were excluded.

Data Extraction and Synthesis

This meta-analysis was conducted according to PRISMA guidelines. Data were independently extracted by 2 authors. A random-effects model was used for statistical analysis.

Main Outcomes and Measures

The primary outcome measure was SSI, and secondary outcomes included seroma and wound dehiscence rates. These outcomes were chosen before data collection.

Results

Nine unique studies (3 randomized trials and 2 prospective and 4 retrospective studies) capturing 1266 unique patients were included. Of these, 1187 patients with 1189 incisions were included in the final analysis (52.3% male among 7 studies reporting data on sex; mean [SD] age, 52 [15] years among 8 studies reporting data on age). Significant clinical and methodologic heterogeneity existed among studies. On random-effects analysis, NPWT was associated with a significantly lower rate of SSI compared with standard dressings (pooled odds ratio [OR], 0.25; 95% CI, 0.12-0.52; P < .001). However, no difference in rates of seroma (pooled OR, 0.38; 95% CI, 0.12-1.23; P = .11) or wound dehiscence (pooled OR, 2.03; 95% CI, 0.61-6.78; P = .25) was found. On sensitivity analysis, focusing solely on colorectal procedures, NPWT significantly reduced SSI rates (pooled OR, 0.16; 95% CI, 0.07-0.36; P < .001).

Conclusions and Relevance

Application of NPWT on closed laparotomy wounds in general and colorectal surgery is associated with reduced SSI rates but similar rates of seroma and wound dehiscence compared with conventional nonpressure dressings.

TGF-β mimic proteins form an extended gene family in the murine parasite Heligmosomoides polygyrus

We recently reported the discovery of a new parasite-derived protein that functionally mimics the immunosuppressive cytokine transforming growth factor (TGF)-β. The Heligmosomoides polygyrus TGF-β Mimic (Hp-TGM) shares no homology to any TGF-β family member, however it binds the mammalian TGF-β receptor and induces expression of Foxp3, the canonical transcription factor of both mouse and human regulatory T cells. Hp-TGM consists of five atypical Complement Control Protein (CCP, Pfam 00084) domains, each lacking certain conserved residues and 12-15 amino acids longer than the 60-70 amino acids consensus domain, but with a recognizable 3-cysteine, tryptophan, cysteine motif. We now report on the identification of a family of nine related Hp-TGM homologues represented in the secreted proteome and transcriptome of H. polygyrus. Recombinant proteins from five of the nine new TGM members were tested for TGF-β activity, but only two were functionally active in an MFB-F11 reporter assay, and by the induction of T cell Foxp3 expression. Sequence comparisons reveal that proteins with functional activity are similar or identical to Hp-TGM across the first three CCP domains, but more variable in domains 4 and 5. Inactive proteins diverged in all domains, or lacked some domains entirely. Testing truncated versions of Hp-TGM confirmed that domains 1-3 are essential for full activity in vitro, while domains 4 and 5 are not required. Further studies will elucidate whether these latter domains fulfill other functions in promoting host immune regulation during infection and if the more divergent family members play other roles in immunomodulation.

The isolation and identification of cis-diamminedichloroplatinum (ii)-DNA adducts by anion-exchange HPLC and inductively coupled plasma mass-spectrometry

The adducts produced by the reaction of cis-diamminedichloroplatinum(II) with DNA have previously been isolated and characterised. These adducts may be measured at the cellular level by immunochemical detection but the accuracy of this assay is dependent on the number of adducts per nucleotide. We have developed a novel assay for cisplatin-DNA adducts, utilising an established method in which platinated DNA is digested to form a mixture of nucleotides and adducts; these are then separated by anion exchange HPLC. The number of cisplatin-DNA adducts is determined by measurement of the platinum content of the HPLC fractions by inductively coupled plasma mass spectrometry. The assay has been validated by cochromatography of purified drug-DNA adducts whose identity has been confirmed by NMR. We describe an application of the assay, namely the measurement of in vitro removal of cisplatin-DNA adducts from calf thymus DNA by cell free extracts derived from tumour cell lines. Adduct removal is dependent on both the amount of extract protein and the duration of the reaction. Almost 70% of adducts are removed from 5mug of DNA (drug:nucleotide ratio 0.08) by 80mug of extract. Other potential applications of the assay are discussed.

Weekend hospitalization and additional risk of death: an analysis of inpatient data

OBJECTIVE

To assess whether weekend admissions to hospital and/or already being an inpatient on weekend days were associated with any additional mortality risk.

DESIGN

Retrospective observational survivorship study. We analysed all admissions to the English National Health Service (NHS) during the financial year 2009/10, following up all patients for 30 days after admission and accounting for risk of death associated with diagnosis, co-morbidities, admission history, age, sex, ethnicity, deprivation, seasonality, day of admission and hospital trust, including day of death as a time dependent covariate. The principal analysis was based on time to in-hospital death.

PARTICIPANTS

National Health Service Hospitals in England.

MAIN OUTCOME MEASURES

30 day mortality (in or out of hospital).

RESULTS

There were 14,217,640 admissions included in the principal analysis, with 187,337 in-hospital deaths reported within 30 days of admission. Admission on weekend days was associated with a considerable increase in risk of subsequent death compared with admission on weekdays, hazard ratio for Sunday versus Wednesday 1.16 (95% CI 1.14 to 1.18; P < .0001), and for Saturday versus Wednesday 1.11 (95% CI 1.09 to 1.13; P < .0001). Hospital stays on weekend days were associated with a lower risk of death than midweek days, hazard ratio for being in hospital on Sunday versus Wednesday 0.92 (95% CI 0.91 to 0.94; P < .0001), and for Saturday versus Wednesday 0.95 (95% CI 0.93 to 0.96; P < .0001). Similar findings were observed on a smaller US data set.

CONCLUSIONS

Admission at the weekend is associated with increased risk of subsequent death within 30 days of admission. The likelihood of death actually occurring is less on a weekend day than on a mid-week day.

Safety and immunogenicity of live attenuated quadrivalent human-bovine (UK) reassortant rotavirus vaccine administered with childhood vaccines to infants

The safety and immunogenicity of an orally administered, live rotavirus vaccine comprised of four strains, each with a titer of 10(5.3) or 10(5.8) pfu, and each having 10 genes from the UK bovine strain and the VP7 gene from human rotavirus serotype 1, 2, 3, or 4, were evaluated in adults, young children and infants in randomized, double-blind phase 1 trials. Three doses of rotavirus vaccine or placebo given with childhood immunizations to infants at 2, 4, and 6 months of age were well tolerated and did not inhibit antibody responses to childhood vaccines which included DTP, Hib, hepatitis B and OPV. Serum rotavirus antibody responses were detected in 12 of 20 infants after 1 dose, and in 19/19 of the vaccinees after three doses. Neutralizing antibody responses were detected more often against the bovine rotavirus UK strain (95%) than to human rotavirus VP7 serotypes 1 (37%), 2 (32%), 3 (32%) or 4 (32%). The efficacy of this quadrivalent rotavirus vaccine needs to be evaluated further.

Erythrocyte Fy antigen phenotyping helps differentiate so-called benign tertian malarias

Isolated cases of malaria are increasing in frequency in nonendemic countries. Blood film examination remains a mainstay of diagnosis of these sporadic cases because immunologic and molecular methods are unavailable, expensive, and problematic. Two tertian malarial species, Plasmodium vivax and Plasmodium ovale, may appear to be similar morphologically. Plasmodium ovale infection is infrequent, and misdiagnosis of this species is common. Plasmodium vivax infection can be ruled out, however, if a patient's erythrocytes phenotype as Fy(a-b-), because these cells completely resist entry by the latter species.

Community case management for mental illness

These case vignettes clearly illustrate the complexity which is modern psychiatric case management. In the case of Mr D, one of the salient facets of case management was medication monitoring in the context of the introduction of a new depot injection. This was a function in which nursing knowledge of medications and their side effects was undoubtedly advantageous. Any adverse experience with medication is likely to have negative ramifications regarding future compliance. Therefore, a nurse case manager is ideally suited to provide the appropriate information on psychotropic medications and to confidently answer most questions about these medications, and promptly identify any possible emerging side effects. In the case of Mr X, the management began with a practical and crisis focus involving suicide prevention. This developed into supportive psychotherapy, which required sensitive but proactive intervention and, ultimately, significant counselling skills. Mr L's case management had a different focus again, characterised by the development of a new and comprehensive case formulation and a creative nurturing of an individual's identified strength in music. The vignettes not only serve to highlight the well-established heterogeneity of mental illness, but they also importantly illuminate the heterogeneity of case management, a reality obscured in the descriptions of case management models which perhaps misleadingly have given the impression of the process as being merely a number of clearly defined tasks or functions. In actual fact, though the coordination of care appears to represent a common feature, the case management relationship remains an ever changing one, with adaptability, refined clinical skills and practical problem solving skills being the essential requisites of an effective case manager. Therefore, attempts to present this important activity in terms of any one model seem to miss the point. For the consumers of psychiatric services, the experience of case management is unique, and for case managers too the experience with each 'case managed' individual is unique. This uniqueness, together with the diverse skills involved in case management needs to be acknowledged. One way of acknowledging this is, as demonstrated, in the presentation of case vignettes and comprehensive case studies. As psychiatric nursing moves toward the new millennium, case management offers psychiatric nurses (as the clinician most often cast in the role of case manager), the exciting opportunity to extend their role and responsibilities. More importantly, it offers mental health care workers the opportunity to be more actively involved in the liberation of psychiatric patients from a situation of custodial care to a new life in the community.

Hepatitis B vaccination of premature infants: a reassessment of current recommendations for delayed immunization

OBJECTIVE

Current American Academy of Pediatrics and United States Public Health Service Immunization Practices Advisory Committee recommendations for hepatitis B immunization in premature infants weighing <2 kg at birth born to hepatitis B surface antigen (HBSAg)-negative mothers are to delay the initiation of vaccination until such infants reach 2 kg or until 2 months of age. This proposal to delay vaccination at birth in these low-risk infants was based on limited studies not conducted in the United States. We sought to reassess current recommendations to delay administration of hepatitis B vaccine in low-risk premature infants by determining the immunogenicity of early hepatitis B vaccination in a US population and identifying variables associated with poor immunogenicity.

METHODS

A total of 148 infants <37 weeks' gestation born to mothers negative for HBSAg were recruited at birth and stratified to three birth weight groups: <1000 g, 1000 to 1500 g, and >1500 g. Recombinant hepatitis B vaccine was administered within the first week of life, at 1 to 2 months of age, and at 6 to 7 months of age. Serum obtained at birth and after the second and third doses of vaccine was tested for antibody to HBSAg. Variables associated with poor response were sought prospectively by collecting demographic and clinical data.

RESULTS

A total of 118 subjects (83%) completed the study. Postsecond dose sera were available for 117 infants and postthird dose sera were available for 112 infants. The seroprotection rate (attaining >/=10 mIU/mL HBS antibody) after two doses was low (25%) regardless of birth weight; infants weighing <1000 g at birth had the poorest response (11%). The seroprotection response rate after three doses of vaccine increased with birth weight; infants weighing </=1500 g at birth (groups 1 and 2) had lower rates of response (52% and 68%, respectively) than did infants weighing >1500 g at birth (group 3; 84% response rate). The seroprotection response rate of group 3 infants after three doses of vaccine, although low, could not be differentiated from the response rates reported for full-term infants using 95% confidence intervals. Of all infants who did not achieve protective levels of antibody after three doses of vaccine, 96% (26/27) weighed <1700 g at birth. The geometric mean HBS antibody levels in responders were 88 and 386 mIU/mL after two and three doses, respectively. Of 36 children with a birth weight >1500 g, 33 (91%) achieved levels of HBS antibody >100 mIU/mL after three doses of vaccine, compared with 25/35 (71%) of infants with birth weight <1500 g. Using logistic regression analysis, nonresponders were more likely than were responders to have been treated with steroids (26% vs 9%) and to have had a low birth weight (1037 g vs 1455 g). In addition, the seroresponse rate of black infants was more likely than that of white infants to be associated with poor weight gain (falling off 2 percentile ranks in weight) in the first 6 months of life: 22% of black and 60% of white children who failed to gain weight adequately responded to vaccination, compared with 92% of black and 70% of white children who were growing adequately. Of interest, the only infant with a birth weight of >1700 g who did not make protective levels of specific antibody after three doses of vaccine was 2300 g at birth, but had inadequate weight gain in the first 6 months of life.

CONCLUSIONS

This study supports current recommendations of the American Academy of Pediatrics and the Centers for Disease Control and Prevention for delaying the initiation of hepatitis B immunization beyond the first week of life for premature infants at low risk for hepatitis B infection, particularly in newborns weighing <1700 g at birth. In addition, we have identified variables other than birth weight that were associated with an inadequate immune response to early hepatitis B vaccination in premature infants, such as poor weight gain in the first 6 months of life

Single step selection of cis-diamminedichloroplatinum(II) resistant mutants from a human ovarian carcinoma cell line

We have shown that cis diamminedichloroplatinum-(II) (DDP) resistant mutants can be isolated from the human ovarian carcinoma cell line A2780 using a single-step selection protocol with DDP. DDP resistant colonies were calculated to be present at a frequency of 1.7 x 10(-6)/viable cell using a fluctuation analysis. The mutational origin of these surviving colonies is inferred by the fact that their frequency is increased by treatment of the A2780 cells with the chemical mutagen ethyl methane-sulfonate, with a maximum frequency observed after a 3-day expression time. Independently isolated clones maintain, in the absence of selection, a DDP resistant phenotype up to 7-fold more resistant than the parental A2780 cells. The resistance modifiers aphidicolin and buthionine sulfoximine have no effect on the frequency of DDP resistant mutants. Therefore neither of these drugs appears to have an effect on increasing the sensitivity of DDP resistant mutants existing in a cell population prior to DDP exposure.