PURPOSE Emergency laparotomy (EL) encompasses a high-risk group of operations, which are increasingly performed on a heterogeneous population of patients, making preoperative risk assessment potentially difficult. The UK National Emergency Laparotomy Audit (NELA) recently produced a risk predictive tool for EL that has not yet been externally validated. We aimed to externally validate and potentially improve the NELA tool for mortality prediction after EL. METHODOLOGY We reviewed computer and paper records of EL patients from May 2012 to June 2017 at Middlemore Hospital (New Zealand). The inclusion criteria mirrored the UK NELA. We examined the NELA, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Acute Physiology and Chronic Health Evaluation II (APACHE-II), and American College of Surgeons National Surgical Quality Improvement Programs risk predictive tools for 30-day mortality. The Hosmer-Lemeshow test was used to assess calibration, and the c statistic, to evaluate discrimination (accuracy) of the tools. We added the modified frailty index (mFI) and nutrition to improve the accuracy of risk predictive tools. RESULTS A total of 758 patients met the inclusion criteria, with an observed 30-day mortality of 7.9%. The NELA was the only well calibrated tool, with predicted 30-day mortality of 7.4% (p = 0.22). When combined with mFI and nutritional status, the c statistic for NELA improved from 0.83 to 0.88. American College of Surgeons National Surgical Quality Improvement Programs, APACHE-II, and P-POSSUM had lower c statistics, albeit also showing an improvement (0.84, 0.81, and 0.74, respectively). CONCLUSION We have demonstrated the NELA tool to be most predictive of mortality after EL. The NELA tool would therefore facilitate preoperative risk assessment and operative decision making most precisely in EL. Future research should consider adding mFI and nutritional status to the NELA tool. LEVEL OF EVIDENCE Level IV; Retrospective observational cohort study.

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Background: Functional dyspepsia (FD) is a common gastroduodenal disorder, yet its pathophysiology remains poorly understood. Bioelectrical gastric slowwave abnormalities are thought to contribute to its multifactorial pathophysiology. Electrogastrography (EGG) has been used to record gastric electrical activity; however, the clinical associations require further evaluation.Aims: This study aimed to systematically assess the clinical associations of EGG in FD.Methods: MEDLINE, EMBASE, and CENTRAL databases were systematically searched for articles using EGG in adults with FD. Primary outcomes were percentage normal versus abnormal rhythm (bradygastria, normogastria, and tachygastria). Secondary outcomes were dominant power, dominant frequency, percentage coupling, and the meal responses.Results: 1751 FD patients and 555 controls from 47 studies were included. FD patients spent less time in normogastria while fasted (SMD −0.74; 95%CI −1.22 to −0.25) and postprandially (−0.86; 95%CI −1.35 to −0.37) compared with controls. FD patients also spent more fasted time in bradygastria (0.63; 95%CI 0.33-0.93) and tachygastria (0.45; 95%CI 0.12-0.78%). The power ratio (−0.17; 95%CI −0.83-0.48) and dominant frequency meal-response ratio (0.06; 95%CI −0.08-0.21) were not significantly different to controls. Correlations between EGG metrics and the presence and timing of FD symptoms were inconsistent. EGG methodologies were diverse and variably applied. Conclusion:Abnormal gastric slow-wave rhythms are a consistent abnormality present in FD, as defined by EGG and, therefore, likely play a role in pathophysiology. The aberrant electrophysiology identified in FD warrants further investigation, including into underlying mechanisms, associated spatial patterns, and symptom correlations.

Background High‐output double enterostomies (DESs) and enteroatmospheric fistulas (EAFs) of the small bowel account for substantial patient morbidity and mortality. Management may include parenteral nutrition (PN) and prolonged admissions, at high cost. Reinfusion of chyme into the distal bowel is a proposed therapeutic alternative when the distal DES limb is accessible; however, standardized information on this technique is required. This review aimed to critically assess the literature regarding chyme reinfusion (CR) to define its current status and future directions. Methods A systematic search of medical databases was conducted for articles investigating CR in adults. Articles reporting indications, methods, benefits, technical issues, and complications resulting from CR were reviewed. A narrative synthesis of the retrieved data was undertaken. Results In total, 24 articles reporting 481 cases of CR were identified, although articles were heterogeneous in their structure and reporting. CR was most frequently performed for remediation of high‐output DES and intestinal failure and for proximally located DES. Effluent output collection was commonly manual, with distal reinfusion more commonly automated, and with few dedicated systems. Multiple benefits attributed to CR were reported, encompassing weight gain, cessation of PN, and improvements in liver function. Technical problems included distaste, labor‐intensive methods, reflux of contents, and tube dislodgement. No serious AEs or mortality directly attributable to CR were reported. Conclusions CR appears to be a promising, safe and well‐validated intervention for small bowel DES and EAF. However, more efficient and acceptable methods are required to promote greater adoption of the practice of CR.

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