The edition · General Surgery
A physiology-only score separated the emergency laparotomies likely to die
PESAS discriminated 30-day mortality well in an external cohort of 1086 emergency laparotomies; single-stage rendezvous cleared the duct in 95% of anticipated-difficult stones; and robotic surgery in older adults showed fewer conversions but no clear recovery benefit.
The edition in brief
An external validation of the Physiological Emergency Surgery Acuity Score (PESAS) in 1086 adults undergoing non-trauma emergency laparotomy found strong discrimination for 30-day mortality (AUROC 0.86), with mortality above 10% at a score of 5 and above 50% at 10; in an exploratory subset it also predicted anastomotic leak. A prospective Egyptian cohort of 80 patients with gallbladder and duct stones, pre-selected by CT as likely difficult cannulations, found laparoendoscopic rendezvous achieved technical success in 92.5% and duct clearance in 95% in one anaesthetic, with mild pancreatitis in 3.8%; a large periampullary diverticulum and a narrow choledochoduodenal angle predicted failure. A meta-analysis of 41 observational studies of robotic vs laparoscopic surgery in older adults found fewer colorectal conversions with robotics (OR 0.36) but inconclusive morbidity and no randomised evidence. A 37-centre US cohort of 41 737 older adults with ground-level falls found GCS 8 or less was the dominant predictor of needing urgent trauma-team intervention; in a modelled, untested strategy, restricting full activation to that threshold roughly halved over-triage without significantly raising under-triage. Today's pearl covers recognising a leak after an anastomosis.
One-stage rendezvous cleared difficult duct stones in 95% of patients
Where theatre and endoscopy can be combined, rendezvous clears most difficult duct stones in one anaesthetic; use existing CT anatomy to plan and consent.
In older adults, robotic surgery was linked to fewer colorectal conversions but not clearly to better recovery
In older colorectal patients, robotic access may reduce conversion, but there is no reliable evidence it improves recovery; counsel accordingly.
For older adults after a fall from standing, GCS 8 or less was the predictor that mattered
In older adults after a fall from standing, GCS 8 or less was the dominant predictor of needing the full trauma team; a GCS-centred activation rule looks promising but is untested.
An anastomotic leak often announces itself as tachycardia
After a bowel anastomosis, unexplained tachycardia, new AF or a rising CRP should prompt early imaging for leak.
A physiology-only score predicted death after emergency laparotomy
Score every emergency laparotomy before theatre; a PESAS of 5 or more matched observed mortality above 10% here, so use it alongside NELA or P-POSSUM, which may flag high risk at a lower level, when planning senior presence and critical care.
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