Rare causes of abdominal pain: a primer for the admitting general surgeon.

The broad uptake of the acute surgical unit (ASU) model of surgical care in Australia has resulted in general surgeons becoming increasingly involved in the management of patients with acute abdominal pain (AAP), some of whom will be labelled as having non-specific abdominal pain (NSAP) (Kinnear N, Jolly S, Herath M, et al. The acute surgical unit: An updated systematic review and meta-analysis. review. Int. J. Surg. 2021;94:106109; Lehane CW, Jootun RN, Bennett M, Wong S, Truskett P. Does an acute care surgical model improve the management and outcome of acute cholecystitis? ANZ J. Surg. 2010;80:438-42). NSAP patients lack a clear diagnosis of surgical pathology based on standard clinical, laboratory and imaging work-up, although they may require ASU admission for pain control and assessment. This article provides a review of uncommon conditions, presenting as AAP, that could possibly be mis-labelled as NSAP, with a focus on aspects of the presentation that may aid diagnosis and management including specific demographic features, clinical findings, key investigations and initial treatment priorities for ASU clinicians. Ultimately, most of the conditions discussed will not require surgical intervention, however, they require a diagnosis to be made and initial treatment planning before on-referral to the appropriate specialty. For the on-call general surgeon, some knowledge of these conditions and an index of suspicion are invaluable for the prompt diagnosis and efficient management of these patients.

Use of Temporary Abdominal Closure in Non-Trauma Surgery: A Cohort Study.

BACKGROUND: Damage control surgery in trauma is widely used but the evidence for the use of laparostomy in non-trauma abdominal emergencies is limited. This study aimed to characterise outcomes in emergency abdominal surgery by comparing laparostomy to one-stage laparotomy for patients of similar illness severity. METHODS: A retrospective study of adult patients requiring emergency abdominal surgery and post-operative intensive care stay was performed between 2016 and 2020 at a major Australian metropolitan hospital. Case selection was from a prospectively maintained database, and case notes were reviewed. Patients having delayed abdominal closure were compared with those having one-stage abdominal closure. The primary outcome was odds of in-hospital mortality. The secondary outcomes included intensive care unit length of stay (LOS), overall hospital LOS, definitive stoma rate and discharge destination. Multivariable logistic regression analysis was performed to adjust for potentially confounding variables. RESULTS: Two hundred and eighteen patients met inclusion criteria (80 laparostomy and 138 non-laparostomy). The most common indications for laparostomy were bowel ischaemia (41.3%), sepsis (26.3%) and physiological instability (22.5%). There was no evidence of difference in odds of in-hospital mortality between groups (adjusted OR = 1.67, CI: 0.85-3.28; p = 0.138). Patients requiring laparostomy had a slightly longer median ICU LOS (4 vs. 3 days; p < 0.001), similar median hospital LOS (19 vs. 14 days, p = 0.245) and similar discharge destination. There was no difference in stoma rate (35.0% vs. 35.5%). CONCLUSION: Compared with standard one-stage laparotomy, laparostomy resulted in similar odds of in-hospital mortality in emergency abdominal surgery patients requiring intensive care.

An algorithm for the management of traumatic abdominal wall hernia based on a 9-year review.

BACKGROUND: Traumatic abdominal wall hernia (TAWH) is a rare consequence of blunt abdominal trauma, usually in the setting of multitrauma, with little consensus or guidelines for management. We present a case series of patients with traumatic herniae over a 9-year period and a suggested management algorithm. METHOD: Retrospective review of all patients with TAWH from 1st January 2011 to 31st December 2019 at a Level 1 adult Major Trauma Centre. Clinical presentation, surgical intervention and complications and recurrence were analysed. RESULTS: Forty-seven patients were found to have TAWH, 0.5% of all major trauma admissions. Thirty (63.8%) were repaired, 12 acutely, 11 semi-acute and 7 delayed. All but 1 (fall>3 m) were transport associated, with a median Injury Severity Score (ISS) of 29. Follow-up data for operative cases were available for all but one (97%). Seven (23.3%) cases had a recurrence, more common in the acute repair group (33.3%) compared to semi-acute (18.2%), and elective group (14.3%). CONCLUSION: TAWH is a rare but potentially serious consequence of blunt abdominal trauma. This series has favoured earlier repair for anterior TAWH, or all those undergoing a laparotomy for other reasons, and elective repair for lumbar or lateral TAWH that do not require a laparotomy for other conditions. We present our preferred algorithm for management, accepting that there are many available strategies in this heterogeneous group of injuries. Loss of follow up and recurrence are a concern, and clinicians are encouraged to develop processes to ensure that TAWH are not a 'forgotten hernia'.

Massive gastric distension due to bulimia nervosa: a hotpot emergency.

Acute massive gastric distension is a rare but potentially life-threatening surgical complication of bulimia nervosa. This results from repeated binge eating and is likely compounded by increased gastric compliance and delayed gastric emptying. We describe a case of acute massive gastric distension in a 26-year-old female with undiagnosed bulimia nervosa who underwent a laparotomy and anterior gastrotomy after failed conservative measures for gastric decompression. It highlights the importance of early recognition of a potentially life-threatening condition and that a multi-disciplinary approach is necessary to prevent the recurrence and morbidity associated with it.

Validity and Utility Testing of a Criteria-led Discharge Checklist to Determine Post-operative Recovery after Abdominal Surgery: an International Multicentre Prospective Cohort Trial.

BACKGROUND: Criteria-led discharge (CLD) has promising potential to reduce unnecessary hospital stay after abdominal surgery; however, the validity and utility of CLD is uncertain as studies are limited to small single-centre studies involving predominantly elective colorectal surgery. METHODS: This prospective international multicentre cohort study explored the relationship between a CLD checklist, post-operative recovery, and hospital length of stay using patient-level data from four clinical trials involving 1071 adults undergoing all types of emergency and elective abdominal surgery at five hospitals across Australia and New Zealand. Patients were assessed daily for 21 post-operative days using a standardised CLD checklist. Surgeons and hospital clinicians were masked to findings. Criterion, construct, and content validity of the checklist to accurately reflect discharge decisions by surgical teams, assess physiological recovery, and encompass parameters signalling physiological readiness to discharge were tested. Potential utility of CLD to minimise unnecessary hospital stay was assessed by comparing day of readiness to discharge to actual day of discharge. RESULTS: The CLD checklist had concordance with existing discharge planning practices and accurately measured a longer post-operative recovery in more complex clinical situations. The CLD checklist in its current format did not detect all legitimate medical and surgical reasons necessitating a continued stay in hospital. Day of readiness to discharge was 0.8 days (95% CI 0.7 to 0.9, p < 0.001) less than actual day of discharge. CONCLUSION: A CLD checklist has excellent criterion and construct validity in measuring physiological recovery following all types of major elective and emergency abdominal surgery. Content validity could be improved. The use of CLD has the potential to reduce unnecessary hospital stay although the safety of discharging patients according to the criteria requires investigation prior to implementation. TRIAL REGISTRATION: Trials were prospectively registered at the Australian New Zealand Clinical Trials Registry (LIPPSMAck POP 12613000664741, ICEAGE 12615000318583, PLASTIC 12619001344189, NIPPER PLUS 12617000269336).

Traumatic diaphragmatic rupture with underlying lung laceration and tension pneumoperitoneum.

Tension pneumoperitoneum is commonly caused by gastrointestinal perforation and pulmonary causes are extremely rare. We present a case of a 47-year-old male post motor vehicle accident with a suspected left-sided haemopneumothorax on initial chest x-ray. CT of the chest post chest tube insertion showed a left-sided diaphragmatic rupture and an extensive diaphragmatic hernia. While en-route to the operating theatre, the intubated patient developed tension pneumoperitoneum with positive pressure ventilation and required immediate surgical intervention and repair. A review of the literature around tension pneumoperitoneum and diaphragmatic hernia in trauma is discussed.

Compliance of antithrombotic management at a tertiary paediatric hospital with international guidelines: a 100-Day audit.

INTRODUCTION: Thromboembolic disease is a growing problem in paediatric care. American College of Chest Physicians (ACCP) guidelines for antithrombotic therapy in paediatric patients provide consensus recommendations regarding appropriate antithrombotic therapy. MATERIALS AND METHODS: This study assessed antithrombotic management practices in a tertiary paediatric centre and the level of agreement of current practice with consensus guidelines across a 100-day prospective chart audit. Details of indication for each administration of antithrombotic agent was collected and categorized as either ACCP 'recommended', 'non-listed' or 'contraindicated'. RESULTS: At least one antithrombotic medication was administered to 526 inpatients (12.8%), with a total of 5885 individual episodes of antithrombotic administration. Complete adherence to ACCP indications and dosing recommendations was observed in 2915 administrations (49.5%). A key area where there was disagreement between clinical practice and guidelines was the routine use of unfractionated heparin infusions in children with central venous lines. CONCLUSION: The level of compliance found in this study was relatively low, especially in areas where recommendations were based on 'weak' evidence. This reflects clinician confidence in the strength of evidence currently available for paediatric antithrombotic therapy. This study has identified areas where more robust research should be conducted to aid physicians in making more informed decisions for children needing antithrombotic therapy.

Clinical outcomes of management of CVAD occlusions.

Central venous access device (CVAD) occlusions are commonly treated with tissue plasminogen activator (tPA). Eighty-seven patients with 97 catheters at The Royal Children's Hospital, Melbourne were given tPA as per clinical practice guidelines. Restoration of CVAD patency and long-term CVAD survival were measured. Cumulative CVAD restoration rates for tPA treatment were 68.5% and 78.7% after one and two doses, respectively. A significantly lower rate of successful tPA treatment was found in implantable ports (46.2% compared with 81% for Hickman catheters). CVAD time of survival until non-elective removal for 3 months, 6 months and 12 months was 64%, 57% and 47%, respectively. The authors conclude that tPA is safe and effective in extending the life of occluded CVADs occlusions by months to years but is less effective in implantable ports.