Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

Carol J Peden^{1

2}, Geeta Aggarwal³, Robert J Aitken⁴, Iain D Anderson^{5

6}, Angie Balfour⁷, Nicolai Bang Foss⁸, Zara Cooper^{9

10}, Jugdeep K Dhesi^{11

12

13}, W Brenton French¹⁴, Michael C Grant¹⁵, Folke Hammarqvist^{16

17}, Sarah P Hare¹⁸, Joaquim M Havens¹⁹, Daniel N Holena²⁰, Martin Hübner²¹, Carolyn Johnston²², Jeniffer S Kim²³, Nicholas P Lees²⁴, Olle Ljungqvist²⁵, Dileep N Lobo^{26

27}, Shahin Mohseni²⁸, Carlos A Ordoñez^{29

30}, Nial Quiney³, Catherine Sharoky³¹, Richard D Urman³², Elizabeth Wick³³, Christopher L Wu³⁴, Tonia Young-Fadok³⁵, Michael J Scott^{36

37}

Affiliations

¹ Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA, 90033, USA. carol.peden@gmail.com.
² Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA. carol.peden@gmail.com.
³ Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX, UK.
⁴ Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia.
⁵ Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD, UK.
⁶ University of Manchester, Manchester, UK.
⁷ Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU, Scotland.
⁸ Hvidovre University Hospital, Copenhagen, Denmark.
⁹ Center for Surgery and Public Health, Harvard Medical School, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
¹⁰ Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
¹¹ Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.
¹² Faculty of Life Sciences and Medicine, King's College London, London, UK.
¹³ Research Department of Targeted Intervention, Division of Surgery & Interventional Science, University College London, London, UK.
¹⁴ Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA, 23298, USA.
¹⁵ Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA.
¹⁶ Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
¹⁷ Karolinska University Hospital Huddinge, Hälsovägen 3. B85, S 141 86, Stockholm, Sweden.
¹⁸ Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, UK.
¹⁹ Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
²⁰ Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA.
²¹ Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
²² Department of Anaesthesia, St George's Hospital, Tooting, London, UK.
²³ Kaiser Permanente Research, Department of Research & Evaluation, 100 South Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA.
²⁴ Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD, UK.
²⁵ Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
²⁶ Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Queen's Medical Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, NG7 2UH, UK.
²⁷ MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, Queen's Medical Centre, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH, UK.
²⁸ Division of Trauma and Emergency Surgery, Department of Surgery, School of Medical Sciences, Orebro University Hospital, Orebro University, 701 85, Orebro, Sweden.
²⁹ Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia.
³⁰ Sección de Cirugía de Trauma y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cl 5 No. 36-08, 760032, Cali, Colombia.
³¹ Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA.
³² Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10th Ave, Columbus, OH, 43210, USA.
³³ Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA, 94143, USA.
³⁴ Department of Anesthesiology, Critical Care and Pain Medicine, and Department of Anesthesiology, Weill-Cornell Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
³⁵ Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ, 85054, USA.
³⁶ Department of Anesthesiology and Critical Care Medicine, and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
³⁷ University College London, London, UK.

PMID: 37277506
PMCID: PMC10241556
DOI: 10.1007/s00268-023-07039-9

Review

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

Carol J Peden et al. World J Surg. 2023 Aug.

. 2023 Aug;47(8):1881-1898.

doi: 10.1007/s00268-023-07039-9. Epub 2023 Jun 5.

Authors

Affiliations

¹ Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA, 90033, USA. carol.peden@gmail.com.
² Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA. carol.peden@gmail.com.
³ Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX, UK.
⁴ Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia.
⁵ Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD, UK.
⁶ University of Manchester, Manchester, UK.
⁷ Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU, Scotland.
⁸ Hvidovre University Hospital, Copenhagen, Denmark.
⁹ Center for Surgery and Public Health, Harvard Medical School, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
¹⁰ Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
¹¹ Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy's and St Thomas' NHS Foundation Trust, London, UK.
¹² Faculty of Life Sciences and Medicine, King's College London, London, UK.
¹³ Research Department of Targeted Intervention, Division of Surgery & Interventional Science, University College London, London, UK.
¹⁴ Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA, 23298, USA.
¹⁵ Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, 21287, USA.
¹⁶ Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
¹⁷ Karolinska University Hospital Huddinge, Hälsovägen 3. B85, S 141 86, Stockholm, Sweden.
¹⁸ Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, UK.
¹⁹ Division of Trauma, Burns and Surgical Critical Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
²⁰ Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA.
²¹ Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
²² Department of Anaesthesia, St George's Hospital, Tooting, London, UK.
²³ Kaiser Permanente Research, Department of Research & Evaluation, 100 South Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA.
²⁴ Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD, UK.
²⁵ Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
²⁶ Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Queen's Medical Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, NG7 2UH, UK.
²⁷ MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, Queen's Medical Centre, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH, UK.
²⁸ Division of Trauma and Emergency Surgery, Department of Surgery, School of Medical Sciences, Orebro University Hospital, Orebro University, 701 85, Orebro, Sweden.
²⁹ Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia.
³⁰ Sección de Cirugía de Trauma y Emergencias, Universidad del Valle - Hospital Universitario del Valle, Cl 5 No. 36-08, 760032, Cali, Colombia.
³¹ Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA.
³² Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10th Ave, Columbus, OH, 43210, USA.
³³ Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA, 94143, USA.
³⁴ Department of Anesthesiology, Critical Care and Pain Medicine, and Department of Anesthesiology, Weill-Cornell Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
³⁵ Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ, 85054, USA.
³⁶ Department of Anesthesiology and Critical Care Medicine, and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
³⁷ University College London, London, UK.

PMID: 37277506
PMCID: PMC10241556
DOI: 10.1007/s00268-023-07039-9

Abstract

Background: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care.

Methods: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations.

Results: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process.

Conclusions: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

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Conflict of interest statement

Dr. Scott has honoraria from and serves on advisory boards of Baxter, Edwards Lifesciences, Deltex, Trevena, and Merck. He also receives travel reimbursement from these companies and is President of ERAS® USA. Dr. Peden has received consultancy fees from the American College of Surgeons Improving Care and Surgical Recovery program, and from Medtronic for unrelated work, and is Executive Medical Director for Clinical Quality for the Blue Cross Blue Shield Association, USA. Dr. Lobo has received an unrestricted educational grant from B. Braun and speaker’s honoraria from Abbott, Corza and Nestlé for unrelated work. He is the Scientific Chair of the ERAS® Society. Dr. Wu has nothing to disclose. Dr. Hübner has nothing to disclose. Dr. Lees has nothing to disclose. Dr. Urman has received research funding or fees from Merck, Covidien/Medtronic, AcelRx and Pfizer outside the submitted work, as well as federal funding from NIH, AHRQ and NSF. Dr. Aitken has nothing to disclose. Dr. Anderson has nothing to disclose. Dr. Grant has nothing to disclose. Dr. Hammarqvist has nothing to disclose. Dr. Hare has nothing to disclose. Dr. Havens has research grant funding from Johnson and Johnson outside the submitted work. Dr Johnston has nothing to disclose, Dr Ljungqvist is the Chairman of the ERAS® Society, founded and owns stock in Encare AB, and has received honoraria for advice, lecturing including travel support from Nutricia, Fresenius-Kabi, Pharmacosmos, Encare AB, and lecturing honoraria from Medtronic and BBraun outside the related work. Dr Ljungqvist previously held a now expired patent for a preoperative carbohydrate drink. Angie Balfour—ERAS® Coach, Encare®. Co-Director of The Enhanced Recovery after Surgery Society (UK) C.I.C. (not-for-profit organization—Company No. 10932208). No relevant conflict of interest related to this work.

Dr. Ordoñez has nothing to disclose. Dr. Kim has nothing to disclose. Dr. French has nothing to disclose. Dr. Aggarwal has nothing to disclose. Dr. Quiney has nothing to disclose. Dr. Holena has nothing to disclose. Dr. Cooper has funding from the National Institute on Aging and the John A. Hartford Foundation outside of the submitted work. Dr. Wick has funding from the Agency for Healthcare Research and Quality outside the submitted work. Dr. Bang Foss has nothing to disclose. Dr. Young-Fadok has nothing to disclose. Dr. Mohseni has nothing to disclose. Dr. Dhesi has nothing to disclose. Dr. Sharoky has nothing to disclose.

Figures

**Fig. 1**
A diagrammatic representation of the whole emergency laparotomy pathway, showing specific and contiguous pre-, intra- and postoperative components. Updated and adapted from Peden CJ. Enhanced Recovery after Surgery: Emergency Laparotomy. In Enhanced Recovery After Surgery. Eds. Ljunqvist, Francis, Urman. 2020 Springer Nature, Switzerland

**Fig. 2**
An illustrative example of an Emergency Laparotomy bundle, from Aggarwal et al. [14]

See this image and copyright information in PMC

References

1. Peden CJ, Aggarwal G, Aitken RJ, et al. Guidelines for perioperative care for emergency laparotomy enhanced recovery after surgery (ERAS) society recommendations: part 1-preoperative: diagnosis, rapid assessment and optimization. World J Surg. 2021;45:1272–1290. doi: 10.1007/s00268-021-05994-9. - DOI - PMC - PubMed
1. Guyatt GH, Oxman AD, Kunz R, et al. Going from evidence to recommendations. BMJ. 2008;336:1049–1051. doi: 10.1136/bmj.39493.646875.AE. - DOI - PMC - PubMed
1. Brown BB. Delphi process: a methodology used for the elicitation of opinions of experts. Santa Monica, CA: RAND Corporation; 1968.
1. Brindle M, Nelson G, Lobo DN, et al. Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines. BJS Open. 2020;4:157–163. doi: 10.1002/bjs5.50238. - DOI - PMC - PubMed
1. NELA Project Team (2017) Audit inclusion and exclusion criteria: NELA inclusion criteria. In: National emergency laparotomy audit. https://www.nela.org.uk/Criteria. Accessed 20 Aug 2019

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Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

Affiliations

Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

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Research Materials