TPTh4

Background

Gastro-intestinal conditions requiring emergency laparotomy are common, but it has been increasingly recognised that many patients never undergo surgery.  This study used electronic health care records to provide an insight into the number of patients admitted with gastro-intestinal emergencies.  In this paper we present condition specific outcomes for nine common diagnoses which may require emergency laparotomy.  

Methods

A single centre retrospective cohort study was conducted at a tertiary public hospital (01/12/2013-31/01/2020). Patients were identified using diagnosis codes for gastro-intestinal emergencies, based on the inclusion criteria for the National Emergency Laparotomy Audit.  Relevant data was extracted from electronic health care records.  

Results

Approximately half of the 2,274 patients included received non-operative management, and its use was notably high for intestinal ischaemia (72.3%) and complex diverticulitis (60.5%).  Perforated peptic-ulcers (92.9%), volvulus (70.4%) and adhesional small bowel obstruction (61.9%) were most likely to require surgery.  Emergency laparoscopy rates were high (56.4%) and rate of conversion relatively low (29.5%).  Median length of stay was shorter for non-operative management than surgery (5.8 days vs 10 to 16 days).  30-day mortality for non-operative management was much higher than surgery (24.7% vs 12.5%).  Patients classified as clinically-unstable using vital signs/routine blood tests, had a much higher 30-day mortality rate than those who were stable (38.7% vs 5.8%), notably in the non-operative group (46.6% vs 6.4%).  

Conclusion

A higher-proportion of gastro-intestinal emergencies are treated with non-operative management than might be expected.  However, mortality rates for non-operative management were higher than surgery, particularly in clinically unstable patients.  

Aims

This audit aimed to assess the necessity of routine preoperative blood grouping and saving (G&S) tests for patients undergoing laparoscopic appendicectomy. Specifically, we evaluated the frequency of perioperative blood transfusions and conducted a cost analysis of G&S samples. The secondary aim was to determine if routine G&S testing could be optimized to reduce unnecessary resource use.

Methods

The audit was conducted in two cycles: the first (October–December 2024) included 150 patients, and the second (January–May 2025) included 100 patients. Retrospective analysis of case notes was performed, collecting data on demographics, ASA (American Society of Anesthesiologists) grades, number of G&S samples, and blood transfusion requirements. Inclusion criteria were laparoscopic appendicectomy patients, excluding high-risk individuals, those on anticoagulants, or with preoperative anemia.

Results

In the first cycle, no patients required blood transfusions. Of 150 patients, 75% had two G&S samples, and 21% had one. A similar pattern was observed in the second cycle, with no transfusions required. Demographics, including ASA grades, were consistent across both cycles, with 53% of patients being ASA Grade 1 in cycle one and 80% in cycle two.

Conclusions

Routine preoperative G&S testing for laparoscopic appendicectomy is unnecessary, as no transfusions were required in either cycle. We recommend a more selective approach to G&S testing, based on patient risk factors such as comorbidities, anticoagulant use, and anemia, improving cost-efficiency without compromising safety.

Aim:

To assess adherence to World Society of Emergency Surgery (WSES) 2020 guidelines in the management of acute appendicitis, focusing on post-operative antibiotic prescribing and intra-operative documentation, and to evaluate the impact of targeted educational and system-level interventions

Methods:

A closed-loop audit was conducted across two cycles. The first cycle included patients undergoing laparoscopic appendicectomy over a six-month period. Compliance with WSES-recommendations regarding post-operative antibiotic use and duration, intra-operative documentation of disease severity and contamination, and microbiological sampling was assessed. Findings were presented locally and informed consultant-led education and the development of a revised electronic laparoscopic appendicectomy theatre note designed to embed guideline-based prompts within the documentation workflow. A second audit cycle evaluated early changes in prescribing behaviour and documentation practices following these interventions, prior to full system-wide implementation.

Results:

Eighty-one patients were included in cycle one and 31 in cycle two. The re-audit demonstrated early changes in antibiotic prescribing, with reduced duration in complicated appendicitis (9.2 to 8.4 days). Ongoing variation in prescribing for uncomplicated appendicitis was identified. Selective fluid culture sampling in high-risk cases yielded positive microbiology in all samples. Improved data capture supported refinement of discharge planning and antimicrobial stewardship. Negative appendicectomy rates remained low-6.5%

Conclusions:

This audit demonstrates that combining education with early system development can support improved antimicrobial stewardship in acute appendicitis. The development of an electronic documentation tool embedding guideline-based prompts represents a sustainable strategy to reduce practice variation. Ongoing evaluation will assess the impact of full implementation on guideline adherence and patient outcomes.

Aims

This audit evaluated baseline compliance with the standards set out in the best-practice guidance for laparoscopic appendicectomy Getting It Right First Time (GIRFT) and assessed whether an AI-assisted operative note template and targeted education could improve documentation quality.

Methods

A retrospective audit reviewed 70 laparoscopic appendicectomy operative notes against GIRFT best-practice standards. Each note was scored out of 16 based on inclusion of the core elements. A structured operative note template was then created with  a Large Language Model (LLM). The LLM draft was reviewed and edited by the lead author to address inaccuracies. The final template was distributed to the surgical department on the same day that initial audit results were presented at departmental teaching. A subsequent re-audit of operative notes was then conducted.

Results

 In the initial audit, typed operative notes achieved a mean score of 9.8/16, while handwritten notes scored significantly lower at 7.0/16.

Particularly weak areas included:

 Indication (44%)

 Grade of the main surgeon (14%)

 Haemostasis (45%)

Following template introduction and education, re-audit showed modest overall improvement:

 Typed notes: mean score improved to 10.4/16

 Handwritten notes: mean score improved to 7.7/16

Weak areas demonstrated variable gains:

 Indication: largely unchanged at 43%

 Grade of main surgeon: improved to 41%

 Haemostasis: increased to 70.3%

Conclusion

The introduction of an AI-assisted, GIRFT-aligned operative note template, combined with targeted education, resulted in modestly improved compliance with aforementioned guidance. This quality improvement project demonstrates that Large Language Models can serve as valuable adjunct in improving standardisation of surgical documentation.

Background:

Acute lower gastrointestinal bleeding (LGIB) is a common emergency presentation requiring rapid assessment and timely investigation. British Society of Gastroenterology (BSG) guidelines recommend CT angiography (CTA) as a first-line investigation in selected high-risk patients; however, optimal patient selection remains crucial to balance diagnostic yield, intervention rates, and resource utilization.

Methods:

We performed a retrospective review of 345 patients presenting with acute LGIB at our institution. Patients were stratified by haemodynamic status using the Shock Index (SI) and transfusion requirements. CTA utilization, diagnostic yield, and subsequent management outcomes were analysed across low-risk (SI < 1) and high-risk (SI > 1) cohorts in line with BSG guidance.  

Results:

CTA was performed in 53 patients (15%). Overall positive yield was 20% (11/53; 95% CI 10–34%). In the low-risk group (n=326), 49 patients underwent CTA, with a positive yield of 18% (9/49), of whom 22% required intervention. In the high-risk group (shock index >1, n=19), CTA was performed in 4 patients, with 50% demonstrating active extravasation. All CTA-positive high-risk patients had clinically confirmed active bleeding. CTA positivity was higher in high-risk compared with low-risk patients (relative risk approximately 2.8). Most CTA-positive cases were managed conservatively (72%), with interventional radiology embolisation required in 18% and surgery in 9%.

Conclusion:

CTA demonstrates the highest diagnostic value in haemodynamically unstable patients with ongoing active bleeding. Selective use guided by objective criteria such as Shock Index and transfusion requirements optimizes diagnostic accuracy while reducing unnecessary imaging. 

Aim

Acute biliary disease accounts for a third of emergency General Surgery presentations. Early laparoscopic cholecystectomy (LC) is now recommended for symptomatic gallstone disease with the establishment of ‘hot gallbladder’ pathways in acute centres. Predicting the operative difficulty of cholecystectomy is of major benefit for pre-operative planning and the identification of high-risk cases. This study aims to evaluate whether artificial intelligence and machine learning (ML) can accurately predict the level of operative difficulty based on patient demographics, clinical observations, and blood results.

Methods

A retrospective cohort of patients admitted between 2020 and 2022 with acute abdominal pain at a busy university teaching hospital who underwent LC were identified and included in the study. Operation notes were reviewed and scored according to the Surgical Cholecystectomy Score (SCS) and categorised into ‘Easy’ (score<2), and ‘Difficult’ (Grade >=2) cases. ML models were trained using R and a Random Forest Classifier. Inputs included patient demographics, clinical observations and laboratory blood results were extracted, and SCS categories as outputs. 

Results

There were 417 patients included in the final cohort (33.6% males), which was split into training (70%) and test (30%) sets. The model achieved an accuracy of 0.67, sensitivity of 0.96, and specificity of 0.11.

Conclusion

ML models show promise for early prediction of difficult LC. However, this study highlights the poor specificity of ML when training only using patient demographics, clinical observations and blood results. Additional data such as imaging data should be used in future work to improve model accuracy. 

Aims
Conservative management of acute appendicitis is being increasingly adopted with advances in imaging, antibiotic therapy and evolving pressures on emergency services. Aim was to determine safety of conservative management in appropriately selected patients.

Methods
A retrospective cohort study included 461 adults with acute appendicitis at a District General Hospital between 2020-2024. Patients were managed operatively(OP) or conservatively(CP) based on clinical and radiological factors. Outcomes included early failure(≤30 days), complications, recurrence, length of stay and incidental malignancy. Minimum follow-up was 6 months and all patients underwent interval imaging.

Results
75%(347/461) had surgery and rest were conservative. Imaging confirmed the diagnosis in 92.6%(427/461) overall and all CP patients. CP was successful in 93.8%(107/114). 25 patients were managed as outpatients with favourable outcomes. Early failure occurred in 1.75%(2/114), both proceeding to uncomplicated surgery. Early complications were lower in CP(1.7, 2/114) than OP(.2, 18/347), with no perforation or abscess in CP during the index admission. Recurrence occurred in 23%(27/114), predominantly uncomplicated, with median time to recurrence 7 months. Of recurrences, 56%(15/27) underwent appendicectomy and 44%(12/27) were managed with repeat CP, all with uneventful outcomes. Incidental malignancy occurred in 2%(7/347) of OP patients; 86%(6/7) were suggested on pre-operative imaging. Median length of stay was 3 days(CP) vs 2 days(OP). Cost of CP admissions was two-thirds of OP admissions. No mortality occurred.

Conclusions
Conservative management when supported by interval imaging and appropriate patient selection does not compromise patient safety.

Background:
Distal intestinal obstruction syndrome (DIOS) is a recognised complication of cystic fibrosis (CF). It can mimic surgical emergencies such as appendicitis or bowel obstruction, yet conservative management often succeeds if diagnosis is prompt.

Case Presentation:
A 41-year-old man with CF, bronchiectasis, gout, and chronic kidney disease presented with severe abdominal pain and vomiting. CT imaging showed small bowel obstruction at the ileocecal valve with colonic wall thickening, consistent with DIOS. He was treated conservatively with intravenous fluids, nasogastric decompression, and oral Gastrografin. His symptoms resolved without need for surgery.

Discussion:
DIOS involves inspissated intestinal contents obstructing the distal ileum and caecum. In adults with CF who present with acute abdominal pain or suspicion of obstruction, DIOS should be considered. Differentiating DIOS from constipation or appendicitis is key to avoid unnecessary laparotomy.

Conclusion:
In adults with cystic fibrosis presenting with acute abdominal pain, DIOS should be considered early to avoid unnecessary surgical intervention. Conservative management with Gastrografin is often effective, and collaboration with CF specialists is essential to prevent recurrence

Aims:
This audit assessed adherence to guidelines for post-operative antibiotic use following appendectomy, focusing on duration and route of administration in uncomplicated and complicated appendicitis

Methods:
A retrospective audit was conducted on patients who underwent appendectomy between March 2025 and 30 September 2025. Appendicitis was classified as uncomplicated or complicated based on intra-operative findings. Data collected included post-operative antibiotic prescription, route of administration, total duration of intravenous and oral therapy, and length of hospital stay. Antibiotic use was assessed against BMJ Best Practice guidelines.

Results:
A total of 154 patients were identified. 19 patients were excluded due to unavailable operation records, and 2 were excluded because of appendiceal malignancy, leaving 133 patients for analysis. 67 patients had uncomplicated appendicitis, of whom 52 (77.6%) received post-operative antibiotics. 25 patients were discharged with more than 5 days of oral antibiotics. In 29 cases, the operation documented no further antibiotics; this instruction was followed in only 14 cases (48%). Where a duration or route of antibiotic therapy was specified, compliance was 27.78%. In complicated appendicitis, the combined duration of intravenous and oral antibiotics frequently exceeded 8 days. 47 patients received a further 5 days of oral antibiotics after approximately 3 days of intravenous antibiotics , exceeding the recommended total duration of 5 days.

Conclusions:

This audit demonstrates poor compliance with post-operative antibiotic guidelines following appendectomy. Recommendations were implemented, and targeted teaching sessions for junior doctors were initiated. A second audit cycle will be undertaken to assess the impact of these interventions.

Aims

International guidelines posit that non-operative management (NOM) of uncomplicated acute appendicitis (UAA) with antibiotics is a safe alternative to appendicectomy. Whilst patients may avoid surgery and its complications, NOM comes with a risk of failure and a 39% chance of recurrence within 5 years. The GMC advise patients have a right to be involved in treatment decision-making and must be provided the information and support required to give informed consent. We reviewed the management of UAA at a 500-bed hospital and documentation of counselling regarding treatment options.

Methods

A closed-loop audit was performed. The first cycle included admissions with UAA from April-June 2025. Scanned notes were retrospectively reviewed for demographics, clinical details and counselling regarding treatment options. Results were presented at a local clinical governance meeting and a second prospective cycle performed between December 2025 and January 2026.

Results

Cycle 1 included 40 patients (22F, 18M, median age 44) whilst cycle 2 had 10 patients (5F, 5M, median age 36). Documentation of counselling regarding operative versus NOM was found in 63% (n=25) in cycle A and 70% (n=7) in cycle B indicating a slight improvement in practice following cycle 1.

Conclusions

Though some progress was made in counselling patients on NOM between cycles, there is room for improvement. 30% of cycle 2 cases still had no documentation of a patient-surgeon discussion regarding treatment options. This is important from a medico-legal perspective, ensuring patients are fully involved in their care and are able to adequately consent to their decided treatment.

Introduction

An appendicolith is a hardened stone of compacted faeces, within the appendix. Appendicoliths are present in 30% of patients presenting with acute appendicitis. At the time of emergency laparoscopic appendicectomy it is possible for appendicoliths to be expelled from the appendix. They may also be expelled prior to this in the event of a ruptured appendix. Retained appendicoliths are associated with complication which may require re-intervention. 

Methods

A search was performed of the PubMed database using the terms ‘retained faecolith’ and ‘retained appendicolith.’ 38 case studies returned, with a total number of 48 patients included.

Results

The most common complication was intra-abdominal abscess, recorded for 17 patients. Also common was perihepatic abscess (8 patients) and pelvic abscess (4 patients). Wound infections and fistulae were recorded in 3 cases, and recurring stump appendicitis twice. 

Other serious complications included empyema, small bowel obstruction, and tubo-ovarian abscess. The furthest migrating appendicolith was found in a gluteal abscess. 

Surgical management was recorded in 31 of these patients. 7 had percutaneous drainage, and 1 utilised endoscopic retrograde appendicitis therapy. 

2 of the patients underwent further iatrogenic harm when their symptoms were incorrectly attributed to malignancy and IBD.

The time frame between initial appendicectomy and diagnosis of retained appendicolith ranged from 1 week to 10 years, where recorded. 

Conclusion

Retained appendicoliths can cause significant morbidity. Management usually involves another surgery, thus increasing the risk to the patient. Care should be taken to ensure appendicoliths are not left behind at initial laparoscopic appendicectomy. 

Background: 

The World Society of Emergency Surgery (WSES) and Get It Right First Time (GIRFT) guidelines recommend risk scoring all suspected appendicitis to guide imaging. We aimed to audit compliance with guidelines for risk scoring and imaging of patients with suspected appendicitis.  

Methods:

Data was collected retrospectively on all patients who underwent appendicectomy between October 2025 and December 2025 in a district general hospital. Children were defined as aged under 16 and were compared to the GIRFT guidelines and adults compared to the WSES guidelines. Risk scores were retrospectively calculated for all patients using the Paediatric Appendicitis Score (PAS) for children and Alvarado score for adults.

Results:

85 patients were included, 62 adults and 23 children. No adult patients had a risk score documented on admission. 46 adult patients (74%) underwent imaging, 9/46 (20%) were in the low-risk group (Alvarado < 5) where imaging is not recommended. 34/46 (74%) patients underwent computerised tomography (CT) as first line imaging, going against the recommendation of CT only being used when ultrasound was equivocal. A risk score was documented for 2 (9%) paediatric patients on admission. 13 children (57%) had an ultrasound, 6/13 (46%) were males in the high-risk group (PAS > 6) recommended to proceed to diagnostic laparoscopy without imaging. 

Conclusion:

There is minimal routine use of risk scores for adult and paediatric patients presenting with suspected appendicitis and increased reliance on imaging in patient groups where it is not recommended. There is a need for standardisation of appendicitis diagnostic pathways. 

Background:

With an increasingly frail emergency surgery demographic, the decision around when not to operate for conditions otherwise treated with an emergency laparotomy (NoLap) has become a key area of interest. A comprehensive social history is an important factor in complex decision making around non-operative management and National Emergency Laparotomy Audit (NELA) guidelines recommend patients aged over 65 undergo a formal frailty assessment. We aimed to audit compliance with the NELA standard of frailty assessment in NoLap patients.

Methods:
All patients recorded as NoLaps between April 2024 and December 2025 in a district general hospital were included. Data was retrospectively collected on social history documentation including frailty assessment, mobility, cognition and place of residence. 

Results:
We identified 47 patients, with a median age of 80. 34 patients (72%) had a social history recorded, in 30 patients (88%) this was done by the surgical team. No patients had a clinical frailty score recorded. 33 patients (70%) had no documentation on cognitive status. Baseline mobility was not recorded in 21 (45%) of patients and exercise tolerance was not recorded in 39 patients (83%). 15 patients (32%) did not have documentation about package of care and 12 (26%) did not have their place of residence recorded.

Conclusion:
There is large variability in social history documentation in NoLap patients, with a particular deficiency in initial frailty assessment of patients. There is a need for standardisation of social history assessment in emergency surgical patients to facilitate decision making around suitability for operative management. 

Aims

Acute appendicitis is one of the most common emergency general surgical presentations, with timely appendicectomy considered one of the indicators of patient safety. Delays to surgery allow for disease progression, thereby increasing the risk of perforation, sepsis and postoperative complications. This study aims to describe these delays to surgery and its relationship with postoperative complications and complicated appendicitis.

Methods

This is a retrospective observational study at a large district general hospital over 10-weeks including patients undergoing appendicectomy. Time taken from hospital admission to surgery and time from symptom onset to surgery were both recorded. Subsequently, outcomes including postoperative complications and complicated appendicitis (evidenced by intra-operative, post-operative or radiological findings), were noted. 

Results

In total, 108 patients undergoing appendicectomy were included. Most patients underwent surgery within 24 hours of admission with postoperative complications occurring in 12.0%. However, a higher complication rate was observed with increasing admission to surgery time, rising from 10.9% in patients operated within 16 hours to 16.7% after 36 hours. Patients that underwent appendectomy 24 hours after admission had higher complication rates than those managed earlier. Additionally, delays prior to hospital presentation were common, with many patients symptomatic for several days before hospital admission.

Conclusions

There is an evident positive trend in postoperative complications with longer in-hospital time to appendicectomy. These highlight patient safety implications and although formal statistical analysis is required to determine the significance of this finding, the results suggest that delays to emergency surgery may represent a modifiable factor influencing outcomes in acute appendicitis.

Background:

Acute appendicitis (AA) is a common surgical emergency, usually managed by laparoscopic appendicectomy. Negative appendicectomy rate (NAR) is defined as the removal of a histologically normal appendix in suspected appendicitis. The main clinical feature of appendicitis, right iliac fossa pain, has a broad differential diagnosis which can contribute to increased NAR. Therefore, in our trust, pre-operative imaging is required.

The UK NAR was reported as 20% in the Right Iliac Fossa Pain Treatment (RIFT) study in 2020. Furthermore, a systematic review estimated a global NAR of 13% in 2023. An audit in 2021 in our Trust demonstrated a NAR of 3.05%, improving to 2.04% on re-audit. 

The aim is to evaluate our Trust’s current NAR comparing it with national, global and previous Trust data.

Methods:

A retrospective review of histopathology reports was conducted for all emergency appendicectomies performed over a six-month period. Patients aged ≥16 years who underwent an appendicectomy with pre-operative diagnosis of AA were included. The NAR was calculated as a proportion of appendicectomies with normal histopathology.

Results: 

150 patients (77 male, 73 female) underwent emergency appendicectomy. 7 patients (6 female, 1 male) had normal histopathology, resulting in a NAR of 4.67%, all had pre-operative imaging. Compared with our previous audit, the overall NAR increased (p=0.21). In patients aged 16-25, NAR increased to 11.54% but remained below the reported national rate.

Conclusion: 

Our Trust continues to demonstrate a lower NAR than national standards, though an increase from previous audits. This highlights the importance of ongoing clinical education.

Aims 

The National Emergency Laparotomy Audit (NELA) recommends a Peri-operative Care of Older People undergoing Surgery (POPS) review for patients undergoing emergency laparotomy aged ≥80 years (≥65 years if frail). We aimed to investigate patient characteristics, POPS review and outcomes between two acute hospitals within an NHS Trust, one with peri-operative geriatrics services and one without. 

Methods 

A retrospective observational study investigated patients aged ≥65 years undergoing emergency laparotomy over 6 months at a large NHS Trust. Age, Clinical Frailty Scale (CFS), co-morbidities, indication for surgery, length of stay (LOS), mortality and documentation of peri-operative decision-making were analysed. 

Results 

There were 90 patients with median age 78 (IQR 71–83) years (n=50 POPS site and n=40 non-POPS site). Bowel obstruction was the most common indication. POPS reviews were recorded for 64% (32/50) at the POPS site and 0/40 at the non-POPS site; p<0.001. Median LOS was higher at the POPS site (25 (IQR 12–40) vs. 11 (7–20) days; p<0.001), and a higher proportion required admission to the Intensive Care Unit (38/50 vs. 13/40 respectively; p<0.001). In-hospital mortality was 24% (12/50) vs. 30% (12/40) respectively; p=0.633). Documentation regarding operative decision-making was more complete at the POPS site, with earlier involvement of pre-operative optimisation. 

Conclusions 

There were comparable mortality outcomes between sites despite a more unwell POPS cohort, who were more often reviewed in the perioperative period by POPS. These data generate the hypothesis that peri-operative geriatrics involvement (as recommended by NELA) support safer emergency laparotomy care.