High risk of short-term mortality and postoperative complications in patients with generalized peritonitis undergoing major emergency abdominal surgery - a cohort study

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The aim of this study was to investigate the association between secondary generalized peritonitis and short-term mortality and postoperative complications in patients undergoing major abdominal emergency surgery. Methods The study included patients with the age ≥ 18 years undergoing major emergency abdominal surgery in a University Hospital from 2017 to 2019 after the introduction of a perioperative bundle care program. The primary outcome measures were short-term mortality, defined as death within 30 and 90 days after surgery and postoperative complications within 30 days after surgery. Uni- and multivariable logistic regression analyses were performed to evaluate risk factors for 30- and 90-days mortality and 30-days postoperative complications. Results A total of 591 patients were included, of whom 21% (124/591) had generalized peritonitis. The overall 30 day-mortality rate was 12.5% (74/591). Patients with generalized peritonitis had a significantly higher 30-day mortality rate than patients with non-generalized peritonitis 18.5% (23/124) vs. 10.9% (51/467), P < 0.033. Generalized peritonitis was an independent risk factor for 30-day mortality. There was a significantly higher rate of admission to ICU for patients with generalized peritonitis 39.5% (49/124) vs. 12.6% (59/467), P < 0.001. Patients with generalized peritonitis were significantly more prone to get both a surgical and non-surgical complication compared to patients with non-generalized peritonitis 87.1% (108/124) vs. 65.7% (307/467), P < 0.001. Conclusion In a population undergoing major emergency abdominal surgery treated in a perioperative optimization protocol, generalized peritonitis was an independent risk factor for both 30- and 90-days mortality and postoperative complications. secondary peritonitis perforation acute care surgery emergency surgery abdominal surgery laparotomy Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Secondary peritonitis is the inflammation of the abdominal peritoneal lining caused by disruption of the integrity of the gastrointestinal tract and is a potential life-threatening condition [1]. Large-scale studies show that secondary peritonitis is the second leading cause of sepsis worldwide and in the worst cases with multiquadrant peritonitis, the mortality rate is reported as high as 20% [2–4]. Based on experiences in elective surgery an increasing number of studies have shown that multidisciplinary perioperative care bundles can reduce the high mortality and morbidity within the population of patients requiring acute high-risk abdominal surgery [5–9]. Some studies have shown great results reducing mortality from 15.6–9.6% [10] and 21.8–15.5% [9] within the whole group of patients with both intestinal obstruction, gastrointestinal perforation, and intestinal ischemia. Despite optimized perioperative patient care, there remains big differences in patient outcomes after emergency surgery depending on the abdominal pathology, intraoperative strategy, and patient characteristics [11–13]. Studies have shown that hollow viscus perforation in the gastrointestinal tract has one of the highest mortality rates [12] with even increased risk of mortality and complications, sepsis and ICU admission [4,14]. Hence, there is still a need to identify the patients with the need of a more tailored treatment course and to identify whether new treatment approaches can modulate outcomes through e.g. alternative routes of antibiotic administration and stress modification through perioperative treatment with inflammatory modulators. We hypothesized that the group of patients with generalized peritonitis undergoing surgery in an enhanced perioperative multimodal protocol has the highest risk of mortality and complications in the first 90 days after surgery as opposed to patients with non-generalized peritonitis. We therefore aimed to report short term outcomes in patients undergoing surgery for generalized secondary peritonitis, within a well-established perioperative care bundle, and to investigate independent risk factors for both outcomes. METHODS Study design and setting The study was a retrospective observational cohort study including data from a prospective quality assurance project implementing a local high quality multidisciplinary standardized protocol for major emergency abdominal surgical patients at the Department of Surgery, Zealand University Hospital, in a two-year period from March 2017 to February 2019 [5]. The study was approved by the Head of the Department of Surgery and by the Danish Data Protection agency (no. REG-080-2022) and did not qualify for ethics approval by Danish law. The study followed the standards of reporting of observational studies in epidemiology (STROBE) statements [15]. Study population The study included patients with the age ≥ 18 years undergoing major emergency abdominal surgery. Major emergency abdominal surgery was performed within 72 hours of admission to the Department of Surgery for conditions such as bowel obstruction, ischaemia and necrosis, gastrointestinal perforation, non-traumatic intraabdominal bleeding or abscess, washout/evacuation of intraperitoneal abscess or haematoma, fascial dehiscence, or other diagnosis requiring emergency laparoscopy or laparotomy. Additionally, patients with malignancy requiring palliative laparoscopy or laparotomy were also included. Patients involved in trauma, primary laparoscopic appendectomy and cholecystectomy, hernia without bowel obstruction, or any elective surgery were not included in the study. However, if reoperated due to complication from a non-emergency surgery and meeting the above criteria they were included. All patients received the same high quality standardized protocol with a care bundle covering surgical, emergency, anaesthesiologic, radiological, physiotherapy, and nutritional support. It contains 15 items of pre-, intra-, and postoperative interventions including rapid diagnosis, resuscitation, surgical treatment, and optimizing care postoperatively. All patients were handled by attending or consultant physicians in all the departments. The full item list is described in detail elsewhere [5]. Patients were categorized into two groups according to the perioperative peritonitis status assessed during the surgical procedure. The non-generalized group included no peritonitis findings, serous peritonitis, or local abscess, and the generalized peritonitis included findings of blood, purulent, or faecal contamination of ≥ 2 intraabdominal quadrants. All patients from March 2017 who met the above-mentioned criteria received the same standardized treatment as part of the quality assurance project. The patients included in the study had no missing data on peritonitis, mortality, or postoperative complication assessments. Outcomes The primary outcome measures were short-term mortality, defined as death within 30 and 90 days after surgery and postoperative complications within 30 days after surgery. All patients were followed up until one year after surgery to evaluate vital status. Death of all citizens is registered in the Danish Civil Registration System with a 100% follow-up and is automatically linked with the electronic patient record. Thirty days postoperative complications were evaluated by the investigators and classified according to the Clavien-Dindo Classification system and defined as Clavien-Dindo score ≥ 3b [16]. Secondary outcome measures were in hospital mortality, 180 days mortality, length of stay (LOS), readmission within 6 month of discharge, intensive care unit (ICU) admission and length of ICU stay, reoperation, and postoperative complications. Data collection All data were obtained from the electronic patient records prospectively and stored in an electronic case report form. The following demographics and preoperative variables included: sex, age, body mass index (BMI) kg/m 2 , smoking status, alcohol consumption above recommendation (84 g/week for women and 168 g/week for men), non-steroidal anti-inflammatory drugs (NSAID) and glucocorticoids (systemic) usage, American Association of Anaesthesiologists classification (ASA) [17], WHO performance score [18], and comorbidities. Investigators calculated Charlson Comorbidity Index (CCI)[19] and quick Sequential Organ Failure Assessment (qSOFA) [20]. Intraoperative variables included: length of surgical procedure, operative findings (obstruction, perforation, intraabdominal bleeding, ischemia or necrosis, anastomotic leakage, other findings, and no pathology), perioperative malignancy (yes or no), type of surgery (laparoscopy, laparoscopy converted to open, and laparotomy), surgical procedure (procedures without resection, upper GI procedure, small bowel procedure, small- and bowel procedure, large bowel and rectal procedure, and other procedure), reoperation after non-emergency surgery (yes or no), blood transfusion (yes or no). Statistics Categorical data were presented as number of cases and frequency in percentages and group comparisons were analysed with a chi-squared test or a Fisher’s exact test. The data were presented as mean with standard deviation or median and interquartile range (IQR) for numerical data. Variables, age, BMI, length of surgical procedure, length of ICU stay, and length of hospital stay, were analysed with unpaired t-test or Mann-Whitney’s test according to data distribution for group comparisons. The association between pre- and intraoperative variables and the risk of 30- and 90-days mortality and 30-days postoperative complications were analysed with uni- and multivariable logistic regression analyses. Variables included were sex, age > 70 years, active smoking, ASA ≥ 3, laparotomy, generalized peritonitis, perioperative malignancy, and reoperation after non-emergency surgery. The variables with P-values ≤ 0.2 were included in the multivariable analysis. Results were expressed as unadjusted and adjusted odds ratios (OR) with a 95% confidence interval (95% CI). P-value < 0.05 was considered statistically significant. All statistics were performed in R Studio version 4.2.2 (R Foundation for Statistical Computing, Vienna, Austria). RESULTS In a two-year study period, 632 eligible patients underwent major emergency abdominal surgery. Forty-one patients were not included in the current study, as patients did not meet the diagnosis and surgical procedure criteria of major emergency abdominal surgery protocol, leaving a total of 591 included patients (Fig. 1 ). Patient demographics are presented in Table 1 . A total of 21% (124/591) had an intraoperative finding of generalized peritonitis. Patients with generalized peritonitis were more frequently active smokers, had an alcohol consumption above recommendation, and had a q-SOFA score ≥ 1 at admission compared to patients without generalized peritonitis (Table 1 ). Table 1 Demographics and clinical characteristics of patients undergoing major emergency abdominal surgery Non-generalized peritonitis n = 467 Generalized peritonitis n = 124 P value Male sex, n (%) 252 (52.6) 53 (40.8) 0.058 Age, median [IQR] 69 [57, 78] 71 [61, 78] 0.179 BMI, median [IQR] 24.60 [22.00, 29.20] 24.75 [21.42, 28.22] 0.480 Active smoking, n (%) 102 (22.4) 45 (37.2) 0.001 Alcohol above recommendation, n (%) 40 (8.7) 24 (19.7) 0.001 ASA, n (%) 0.809 1 67 (14.3) 15 (12.1) 2 197 (42.2) 50 (40.3) 3 175 (37.5) 52 (41.9) ≥ 4 28 (6.0) 7 (5.6) WHO PS, n (%) 0.186 0 230 (49.3) 52 (41.9) 1 140 (30.0) 41 (33.1) 2 58 (12.7) 24 (19.4) 3 28 (6.0) 6 (4.8) ≥ 4 11 (2.4) 1 (0.8) Charlson Comorbidity Index, n (%) 0.235 0 49 (10.5) 13 (10.5) 1 54 (11.6) 8 (6.5) 2 68 (14.6) 14 (11.3) ≥ 3 296 (63.4) 89 (71.8) Cardiovascular diseases, n (%) 228 (48.8) 64 (51.6) 0.652 Diabetes mellitus, n (%) 57 (12.2) 15 (12.1) 1.000 Pulmonary diseases, n (%) 70 (15.0) 17 (13.7) 0.830 Chronic kidney disease, n (%) 30 (6.4) 6 (4.8) 0.656 Gastrointestinal diseases, n (%) 53 (11.3) 9 (7.3) 0.247 Malignancy, n (%) 0.089 None 325 (69.6) 87 (70.2) Active 67 (14.3) 25 (20.2) Previous 75 (16.1) 12 (11.7) Glucocorticoids, n (%) 30 (6.4) 7 (5.6) 0.913 NSAIDs, n (%) 38 (7.9) 14 (11.3) 0.314 qSOFA, n (%) 0.006 0 349 (83.9) 76 (69.7) 1 61 (14.7) 28 (25.6) 2 4 (1.0) 3 (2.8) 3 2 (0.5) 2 (1.8) BMI, body mass index. ASA, American Society of Anesthesiologists. PS, performance status. NSAID, non-steroidal anti-inflammatory drugs. qSOFA, quick Sequential Organ Failure Assessment score. Patients with generalized peritonitis were significantly more likely to have operative findings such as perforation 74.2% (92/124) vs. 10.3% (48/467) P < 0.001 and intraabdominal bleeding 4.8% (6/124) vs. 1.1% (5/467) P = 0.017, compared to the non-peritonitis group (Table 2 ). There was no significant difference in perioperative malignancy between the groups (P = 1.000). Table 2 Perioperative findings of patients undergoing major emergency abdominal surgery Non-generalized peritonitis, n = 467 Generalized peritonitis, n = 124 P value Duration of surgery, median [IQR] 139.00 [95.00, 194.50] 150.00 [110.00, 204.00] 0.111 Operative findings, n (%) Obstruction 343 (73.4) 13 (10.5) < 0.001 Perforation 48 (10.3) 92 (74.2) < 0.001 Intraabdominal bleeding 5 (1.1) 6 (4.8) 0.017 Leakage 6 (1.3) 3 (2.4) 0.614 Bowel ischemia 24 (5.1) 8 (6.5) 0.726 Other 30 (6.4) 2 (1.6) 0.060 No pathology 11 (2.4) 0 (0.0) 0.177 Perioperative malignancy, n (%) 52 (11.1) 14 (11.3) 1.000 Type of surgery, n (%) Laparoscopy 48 (10.3) 19 (15.3) 0.157 Laparoscopy converted to open 66 (14.1) 40 (32.3) < 0.001 Laparotomy 353 (75.6) 65 (52.4) < 0.001 Surgical procedure, n (%) Procedures without resection 281 (60.2) 22 (17.7) < 0.001 Upper GI 17 (3.6) 34 (27.4) < 0.001 Small bowel resection 77 (16.5) 20 (16.1) 1.000 Small and large bowel resection 40 (8.6) 11 (8.9) 1.000 Large bowel resection 39 (8.4) 36 (29.0) < 0.001 Other procedures 13 (2.8) 1 (0.8) 0.340 Reoperation after non-emergency surgery, n (%) 26 (5.6) 14 (11.3) 0.041 Perioperative transfusion, n (%) 51 (10.9) 29 (23.4) 0.001 GI, gastrointestinal. Patients with generalized peritonitis had a significantly higher rate of conversion to open approach 32.3% (40/124) compared to patients with non-generalized 14.1% (66/467) P < 0.001. However, there was no difference in the length of surgery in the two groups (P = 0.111). Furthermore, there was a significant difference in the specific surgical procedure between the generalized peritonitis group and non-generalized peritonitis group (P < 0.001). Patients with generalized peritonitis were significantly more likely to have a procedure performed on the upper GI tract 27.4% (34/124) vs. 3.6% (17/467) P < 0.001, or large bowel resection 29% (36/124) vs. 8.4% (39/467) P < 0.001. Patients with non-generalized peritonitis had a significant higher rate of procedures not requiring bowel resection 60.2% (281/467) vs. 17.7% (22/124) P < 0.001. When looking at surgery due to complication from a primary non-emergency procedure, this was more common in the generalized peritonitis group 11.3% (14/124) vs. 5.6% (26/467) P = 0.041. Moreover, blood transfusion perioperatively were likewise significantly more common in the generalized peritonitis group 23.4% (29/124) vs. 10.9% (51/467) P = 0.001 (Table 2 ). Looking postoperatively, patients with generalized peritonitis had a significant longer length of hospital stay with a median of 9.7 days versus 6.5 days (P < 0.001). There were no significant differences on readmissions within 6 months in patients with and without generalized peritonitis (45.5% vs. 47.9%, P = 0.707). There was a significantly higher rate of admission to ICU for patients with generalized peritonitis 39.5% (49/124) vs. 12.6% (59/467), P < 0.001, but there were no differences in the length of ICU admission (P = 0.202). When looking at postoperative complications of any kind, patients with generalized peritonitis were significantly more prone to get both a surgical and non-surgical complication compared to patients with non-generalized peritonitis (Table 3 ). The overall 30 day-mortality rate was 12.5% (74/591). Patients with generalized peritonitis had a significantly higher mortality rate in both overall mortality, in-hospital mortality, 30-days mortality, 90-days mortality, and 180-days mortality (Table 3 ). Table 3 Postoperative outcomes of patients undergoing major emergency abdominal surgery Non-generalized peritonitis, n = 467 Generalized peritonitis, n = 124 P value Length of admission, median [IQR] 6.49 [3.89, 11.79] 9.70 [5.16, 15.69] < 0.001 Readmission after discharge, n (%) 222 (47.9) 56 (45.5) 0.707 Admission to ICU, n (%) 59 (12.6) 49 (39.5) < 0.001 Length of ICU admission, median [IQR] 3.44 [1.46, 5.79] 3.39 [1.99, 8.35] 0.202 Any postoperative complications, n (%) 307 (65.7) 108 (87.1) < 0.001 Clavien Dindo Classification, n (%) 0.003 CD 1 13 (4.2) 3 (2.8) CD 2 77 (25.1) 19 (17.6) CD 3a 85 (27.7) 20 (18.5) CD 3b 48 (15.6) 16 (14.8) CD 4a 23 (7.5) 14 (13.0) CD 4b 10 (3.3) 13 (12.0) CD 5 51 (16.6) 23 (21.3) Reoperation, n (%) 112 (24.0) 48 (38.7) 0.002 Surgical complications, n (%) 119 (25.5) 56 (45.2) < 0.001 Cardiovascular complications, n (%) 110 (23.6) 53 (42.7) < 0.001 Pulmonary complications, n (%) 137 (29.3) 57 (46.0) 0.001 Acute kidney injury, n (%) 9 (1.9) 8 (6.5) 0.017 Mortality Inhospital, n (%) 39 (8.4) 23 (18.5) 0.002 30-days mortality, n (%) 51 (10.9) 23 (18.5) 0.033 90-days mortality, n (%) 74 (15.8) 34 (27.4) 0.005 180-days mortality, n (%) 85 (18.2) 39 (31.5) 0.002 ICU, intensive care unit. Univariable logistic regression analysis showed that, age > 70, ASA ≥ 3, generalized peritonitis, and perioperative malignancy were significantly associated with the risk of 30-days mortality. In the multivariable analysis, age > 70, ASA ≥ 3, generalized peritonitis, and perioperative malignancy were independently associated with risk of 30-days mortality (Fig. 2 ). The logistic regression analysis including the same covariates on 90 days-mortality showed that, age > 70, ASA ≥ 3, generalized peritonitis, and perioperative malignancy were significantly associated with the risk of 90-days mortality. Similar to 30-days mortality, 90-days mortality showed the same independent risk pattern in the multivariate analysis (Fig. 3 ). Univariable logistic regression on 30-days postoperative complications Clavien-Dindo ≥ 3b showed that age > 70, active smoking, ASA ≥ 3, laparotomy, generalized peritonitis, perioperative malignancy, and reoperation after non-emergency surgery were significantly associated with 30-days Clavien Dindo ≥ 3. In the multivariable analysis, all the above-mentioned factors were independently associated with risk of postoperative complications (Fig. 4 ). DISCUSSION In this retrospective cohort study, we investigated 591 patients undergoing major emergency abdominal surgery in a well-established Enhanced Recovery After Surgery (ERAS) setting. One fifth of the patients had generalized peritonitis, and they were significantly more prone to get admitted to ICU, undergo a surgical reintervention, have a longer admission, and in higher risk of getting a postoperative medical or surgical complication. About one fifth of the patients with generalized peritonitis died within 30 days, which was almost twice as many as the patients with non-generalized peritonitis. ERAS principles are well known from elective surgery, but in the last decades, the ERAS principles have been applied to major emergency abdominal surgery to reduce the mortality and morbidity [7–10,21,22]. In the current study, a well-established bundle of care including ERAS principles were applied to all included patients, and the overall 30-days mortality rate was 12.5%. This is slightly higher than in other studies which might be due to the exclusion of procedures like cholecystectomies, appendectomies, and traumas. Moreover, reporting of an overall 30-days mortality rate for patients undergoing major emergency abdominal surgery may not show the whole picture of this population. Our study shows that by categorizing patients into generalized peritonitis and non-generalized peritonitis, the mortality rate for patients with generalized peritonitis was significantly higher at both 30-, 90-, and 180-days. Furthermore, generalized peritonitis was an independent risk factor for both 30- and 90-days mortality and 30-days postoperative complications in multivariable analyses suggesting that these patients represent a subpopulation that should be targeted for optimization of innovations in perioperative care. Similar results were found in a multicentre study looking at community-acquired intraabdominal infections also including appendicitis and biliary tract diseases, concluding that generalized peritonitis was an independent risk factor for mortality HR 2.41 (1.27–4.61) [23]. A study on patients in the ICU with intraabdominal infections showed that perforation of intraabdominal organ with diffuse peritonitis was an independent risk factor for 28-days mortality OR 1.77 (1.35–2.32) [24]. On the contrary, another study on patients in the ICU with secondary peritonitis did not show diffuse peritonitis to be a risk factor of ICU mortality within 30 days [25]. A similar Danish cohort study demonstrated that implementation of an ERAS-like setting reduced both 30 days and one year mortality, in addition, they found generalized peritonitis to be an independent risk factor for one year mortality OR 3.39 (1.07–11.4) [21]. It seems that the literature cannot make a definite conclusion on weather generalized peritonitis is a risk factor or not. This demonstrates that the population of emergency abdominal surgery is very heterogenic, and studies vary in their inclusion criteria by some only including laparotomies and not laparoscopic procedures, which now is proven to be a valid method in the surgical approach [26]. In our study, surgical approach, laparoscopic or open, was not a predictor of either 30- or 90-days mortality, OR 2.28 (0.81–8.41) and OR 1.83 (0.77–5.05) respectively. A large study from the NELA cohort looked at the association of in-hospital mortality and surgical approach and demonstrated a 50% decline in mortality when a laparoscopic approach was used compared to open [27]. Similar results were found in a study looking at surgical approaches and intraoperative strategy and mortality, showing almost a 6 times higher 30 days mortality rate in patients undergoing laparotomy compared to laparoscopy [13]. One possible reason for not showing the same trend may be due to the method of pooling laparoscopic converted to open and primary laparotomy together in the risk model. However, our study shows that patients with generalized peritonitis are characterized by mostly gastrointestinal perforations and are more prone to laparoscopy and attempted laparoscopy, which is similar to a study from NELA, showing an increase adoption to laparoscopic approach and a decrease in the conversion rate [28]. Hence, despite a more severe disease pattern, patients with gastrointestinal tract perforations may be successfully managed by laparoscopy, resulting in lower mortality rate, faster recovery, short length of stay, reduced postoperative pain, and surgical site infections [28–31]. Apart from generalized peritonitis, age above 70 years, ASA above 2, and perioperative malignancy were strong predictors of both 30- and 90-days mortality. A study from the NELA population reported the same characteristics being a predictor of 30 days mortality with an OR 1.079 (1.060–1.078), 3.096 (2.650–3.616), and 1.212 (1.071–1.371) respectively [32]. This is also seen in a Danish study including 4336 patients undergoing emergency abdominal surgery [12]. Other studies found age down to 60 years was an independent risk factor of 30-days mortality [12,24]. Not surprisingly, it seems that these factors are strong predictors of short-term mortality followed by the presence of generalized peritonitis. Additionally, we found active smoking, ASA ≥ 3, laparotomy, and reoperation after non-emergency surgery as strong predictors for 30-days postoperative complications. The window for optimization is short in emergency surgery and the cornerstone in treatment of secondary peritonitis is rapid antibiotics, resuscitation, and surgical source control [4,33]. Little has changed in this modality over the years, although minimal invasive surgery, pain management, and the use of steroids have had some effects in reducing the surgical stress response and thereby mortality and morbidity [34–36]. However, this study indicates the need to rethink possible new interventions, to reduce mortality and morbidity in patients with generalized secondary peritonitis. We have identified four risk factors which both accounts for short term mortality and postoperative complications; Age above 70 years, ASA score above 2, and perioperative malignancy which we cannot alter prior to surgery and generalized peritonitis that has the potential to be modulated by alternative routes of antibiotic administration, and stress modification through perioperative treatment with inflammatory modulators. A study done on complicated appendicitis investigated treatment with granulocyte-macrophage colony-stimulating factor (GM CSF) administrated intraperitoneally and showed promising results in reducing length of stay and postoperative complications [37]. This study represents real-world conditions and practices, which enhance the external validity making them more applicable to the general population. On the contrary, the study is a single-centre retrospective study done in a highly optimized protocol for emergency abdominal surgery limiting generalizability. There is a potential for selection bias, as the cohort is determined by those who underwent surgery and may not represent all emergency abdominal cases, however all patients undergoing surgery received the same treatment and only few was excluded after surgery as they did not meet the inclusion criteria. Conclusions In conclusion, this study found that generalized peritonitis was an independent risk factor for both 30- and 90-days mortality and postoperative complications within a population undergoing major emergency abdominal surgery. Additional factors associated with mortality were age, ASA score above or equal to three, and perioperative malignancy. Moreover, the study showed the same risk profile between 30- and 90-days mortality, though generalized peritonitis was a stronger predictor for 90 days mortality. Patients with generalized peritonitis may be in need of further optimization potentially gaining effect of an add-on treatment regime. Declarations Funding No fundings were received for this study. Availability of data and material According to Danish law about data protection entire data material cannot be shared. However, if there are individual data material in relation to specific calculations the editors or reviewers request, we will try our best to share that in a responsible and safe data protection manner. Conflict of interest All authors declare no conflicts of interest or competing interests. Ethics approval The study was approved by the Danish Data Protection agency (no: REG-080-2022). The study did not qualify for ethics approval by Danish law as no intervention was carried out. Consent to participate Not applicable. Consent for publication Not applicable. References Clements TW, Tolonen M, Ball CG, et al. Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies. Scandinavian Journal of Surgery. 2021;110:139–49. https://doi.org/10.1177/1457496920984078 Murray CJL, Vos T, Lozano R, et al. 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JAMA. 2016;315:801–10. https://doi.org/10.1001/JAMA.2016.0287 Trangbæk RM, Burcharth J, Gögenur I. Implementing Bundle Care in Major Abdominal Emergency Surgery: Long-Term Mortality and Comprehensive Complication Index. World J Surg. 2023;47:106. https://doi.org/10.1007/S00268-022-06763-Y Jordan LC, Cook TM, Cook SC, et al. Sustaining better care for patients undergoing emergency laparotomy. Anaesthesia. 2020;75:1321–30. https://doi.org/10.1111/ANAE.15088 Roger C, Garrigue D, Bouhours G, et al. Time to source control and outcome in community-acquired intra-abdominal infections: The multicentre observational PERICOM study. Eur J Anaesthesiology. 2022;39:540–8. https://doi.org/10.1097/EJA.0000000000001683 Arvaniti K, Dimopoulos G, Antonelli M, et al. Epidemiology and Age-Related Mortality in Critically Ill Patients With Intra-Abdominal Infection or Sepsis: An International Cohort Study. Anaesthesia. 2023;78:1262–71. https://doi.org/doi:10.1111/anae.16096 De Pascale G, Antonelli M, Deschepper M, et al. Poor timing and failure of source control are risk factors for mortality in critically ill patients with secondary peritonitis. Intensive Care. 2022;48:1593–606. https://doi.org/10.1007/s00134-022-06883-y Trangbæk RM, Wahlstrøm K, Gögenur I, et al. Associations Between Care Bundles and Postoperative Outcomes After Major Emergency Abdominal Surgery: A Systematic Review and Meta-Analysis. Journal of Surgical Research. 2022;283:469–78. https://doi.org/10.1016/j.jss.2022.10.064 Pucher PH, Mackenzie H, Tucker V, et al. A national propensity score-matched analysis of emergency laparoscopic versus open abdominal surgery. British Journal of Surgery. 2021;108:934–40. https://doi.org/10.1093/bjs/znab048 Coe PO, Lee MJ, Boyd-Carson H, et al. Open Versus Laparoscopic Repair of Perforated Peptic Ulcer Disease: A Propensity-matched Study of the National Emergency Laparotomy Audit. Ann Surg. 2022;275:928–32. https://doi.org/10.1097/SLA.0000000000004332 Tartaglia D, Strambi S, Coccolini F, et al. Laparoscopic versus open repair of perforated peptic ulcers: analysis of outcomes and identification of predictive factors of conversion. Updates Surg. 2023;75:649–57. https://doi.org/10.1007/S13304-022-01391-6/TABLES/4 Kim CW, Kim JW, Yoon SN, et al. Laparoscopic repair of perforated peptic ulcer: a multicenter, propensity score matching analysis. BMC Surg. 2022;22:1-8. https://doi.org/10.1186/S12893-022-01681-1 Vakayil V, Bauman B, Joppru K, et al. Surgical repair of perforated peptic ulcers: laparoscopic versus open approach. Surg Endosc. 2019;33:281–92. https://doi.org/10.1007/S00464-018-6366-Y Eugene N, Kuryba A, Martin P, et al. Development and validation of a prognostic model for death 30 days after adult emergency laparotomy. Anaesthesia. 2023;78:1262–71. https://doi.org/10.1111/anae.16096 Scott MJ, Aggarwal G, Aitken RJ, et al. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations Part 2-Emergency Laparotomy: Intra-and Postoperative Care. World J Surg. 2023;47(8):1850-1880. https://doi.org/10.1007/s00268-023-07020-6 Manou-Stathopoulou V, Arta Korbonits M, Ackland GL. Redefining the perioperative stress response: a narrative review. Br J Anaesth 2019;123:570–83. https://doi.org/10.1016/j.bja.2019.08.011 Desborough JP. The stress response to trauma and surgery. Br J Anaesth. 2000;85:109–17. https://doi.org/10.1093/BJA/85.1.109 Scott MJ, Baldini G, Fearon KCH, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand. 2015;59:1212–31. https://doi.org/10.1111/AAS.12601 Fonnes S, Roepstorff S, Holzknecht BJ, et al. Shorter Total Length of Stay After Intraperitoneal Fosfomycin, Metronidazole, and Molgramostim for Complicated Appendicitis: A Pivotal Quasi-Randomized Controlled Trial. Front Surg. 2020;7. https://doi.org/10.3389/fsurg.2020.00025 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2025 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 17 Nov, 2024 Reviews received at journal 15 Nov, 2024 Reviewers agreed at journal 14 Nov, 2024 Reviews received at journal 11 Nov, 2024 Reviewers agreed at journal 11 Nov, 2024 Reviews received at journal 10 Nov, 2024 Reviewers agreed at journal 09 Nov, 2024 Reviewers agreed at journal 09 Nov, 2024 Reviewers agreed at journal 09 Nov, 2024 Reviewers invited by journal 09 Nov, 2024 Editor assigned by journal 06 Nov, 2024 Submission checks completed at journal 06 Nov, 2024 First submitted to journal 01 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5374962","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":376719723,"identity":"20dbd1a4-6807-49e2-82fa-1a22e3f692e1","order_by":0,"name":"Maria Olausson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1klEQVRIiWNgGAWjYFAC5gYIzd4Dpnj4CGthhGrhOcPAcABIsRGvRSIHrIWBoBbd9sbGzzx/6uTMJd8efPwxx06GjYH54aMbeLSYnTnYLM3bdtjYcnZessHBbclAh7EZG+fg03IjsUGat+FA4obbOWYSB7cxA7XwsEkT0NL8G+iwxA03z4C01BOlpU2ah405ccMNHpCWw0RoOXOwzXIu0C8GZ3KMDc5uOw7UTsgvx5sP33gDDDGD42cMH1Ruq7bnZ29++BifFiyAmTTlo2AUjIJRMAqwAABQbkl/KR2rtwAAAABJRU5ErkJggg==","orcid":"","institution":"Zealand University Hospital Køge","correspondingAuthor":true,"prefix":"","firstName":"Maria","middleName":"","lastName":"Olausson","suffix":""},{"id":376719724,"identity":"8a644d0e-cee5-4e35-96f5-e3a0234f903a","order_by":1,"name":"Mette A Tolver","email":"","orcid":"","institution":"Zealand University Hospital Køge","correspondingAuthor":false,"prefix":"","firstName":"Mette","middleName":"A","lastName":"Tolver","suffix":""},{"id":376719725,"identity":"54f3d82f-b3e7-4364-bf5c-ac9755985e75","order_by":2,"name":"Ismail Gögenur","email":"","orcid":"","institution":"Zealand University Hospital Køge","correspondingAuthor":false,"prefix":"","firstName":"Ismail","middleName":"","lastName":"Gögenur","suffix":""}],"badges":[],"createdAt":"2024-11-01 17:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5374962/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5374962/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-025-03637-4","type":"published","date":"2025-02-11T15:57:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68886908,"identity":"4307bb74-1700-4448-a768-7af142ba6881","added_by":"auto","created_at":"2024-11-13 06:45:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":115548,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of included patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Peritonitisfigur1flowchart.png","url":"https://assets-eu.researchsquare.com/files/rs-5374962/v1/2ac9d72b2d6e5c6aa527202b.png"},{"id":68885392,"identity":"6f10b946-53b9-41d4-9dfd-9e9fcaaa9742","added_by":"auto","created_at":"2024-11-13 06:37:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":36093,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot of multivariate logistic regression analysis of risk factors associated with 30 days mortality\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5374962/v1/ec97edc4da016f25734f46b7.png"},{"id":68885394,"identity":"eb8ad9ae-0d7e-41ee-b7e1-fccbac25910a","added_by":"auto","created_at":"2024-11-13 06:37:48","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":120644,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot of multivariable logistic regression analysis of risk factors associated with 90 days mortality\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Peritonitisfigur3plot.png","url":"https://assets-eu.researchsquare.com/files/rs-5374962/v1/40527a129b4e31597dceafc0.png"},{"id":68885396,"identity":"38124834-c079-444b-bd7c-7d2522f15350","added_by":"auto","created_at":"2024-11-13 06:37:48","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":142318,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eForest plot of multivariable logistic regression analysis of risk factors associated with 30 days postoperative complications, Clavien Dindo ≥ 3b\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Peritonitisfigur4plot.png","url":"https://assets-eu.researchsquare.com/files/rs-5374962/v1/e26c300544d94c3b143964da.png"},{"id":76487559,"identity":"1edadcf4-dee8-458a-873b-b476333ea533","added_by":"auto","created_at":"2025-02-17 16:09:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1426272,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5374962/v1/28c56061-d3aa-47a6-94b0-c73c674abf01.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"High risk of short-term mortality and postoperative complications in patients with generalized peritonitis undergoing major emergency abdominal surgery - a cohort study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSecondary peritonitis is the inflammation of the abdominal peritoneal lining caused by disruption of the integrity of the gastrointestinal tract and is a potential life-threatening condition [1]. Large-scale studies show that secondary peritonitis is the second leading cause of sepsis worldwide and in the worst cases with multiquadrant peritonitis, the mortality rate is reported as high as 20% [2\u0026ndash;4].\u003c/p\u003e \u003cp\u003eBased on experiences in elective surgery an increasing number of studies have shown that multidisciplinary perioperative care bundles can reduce the high mortality and morbidity within the population of patients requiring acute high-risk abdominal surgery [5\u0026ndash;9]. Some studies have shown great results reducing mortality from 15.6\u0026ndash;9.6% [10] and 21.8\u0026ndash;15.5% [9] within the whole group of patients with both intestinal obstruction, gastrointestinal perforation, and intestinal ischemia.\u003c/p\u003e \u003cp\u003eDespite optimized perioperative patient care, there remains big differences in patient outcomes after emergency surgery depending on the abdominal pathology, intraoperative strategy, and patient characteristics [11\u0026ndash;13]. Studies have shown that hollow viscus perforation in the gastrointestinal tract has one of the highest mortality rates [12] with even increased risk of mortality and complications, sepsis and ICU admission [4,14]. Hence, there is still a need to identify the patients with the need of a more tailored treatment course and to identify whether new treatment approaches can modulate outcomes through e.g. alternative routes of antibiotic administration and stress modification through perioperative treatment with inflammatory modulators.\u003c/p\u003e \u003cp\u003eWe hypothesized that the group of patients with generalized peritonitis undergoing surgery in an enhanced perioperative multimodal protocol has the highest risk of mortality and complications in the first 90 days after surgery as opposed to patients with non-generalized peritonitis. We therefore aimed to report short term outcomes in patients undergoing surgery for generalized secondary peritonitis, within a well-established perioperative care bundle, and to investigate independent risk factors for both outcomes.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003e The study was a retrospective observational cohort study including data from a prospective quality assurance project implementing a local high quality multidisciplinary standardized protocol for major emergency abdominal surgical patients at the Department of Surgery, Zealand University Hospital, in a two-year period from March 2017 to February 2019 [5]. The study was approved by the Head of the Department of Surgery and by the Danish Data Protection agency (no. REG-080-2022) and did not qualify for ethics approval by Danish law. The study followed the standards of reporting of observational studies in epidemiology (STROBE) statements [15].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study included patients with the age\u0026thinsp;\u0026ge;\u0026thinsp;18 years undergoing major emergency abdominal surgery. Major emergency abdominal surgery was performed within 72 hours of admission to the Department of Surgery for conditions such as bowel obstruction, ischaemia and necrosis, gastrointestinal perforation, non-traumatic intraabdominal bleeding or abscess, washout/evacuation of intraperitoneal abscess or haematoma, fascial dehiscence, or other diagnosis requiring emergency laparoscopy or laparotomy. Additionally, patients with malignancy requiring palliative laparoscopy or laparotomy were also included. Patients involved in trauma, primary laparoscopic appendectomy and cholecystectomy, hernia without bowel obstruction, or any elective surgery were not included in the study. However, if reoperated due to complication from a non-emergency surgery and meeting the above criteria they were included.\u003c/p\u003e \u003cp\u003eAll patients received the same high quality standardized protocol with a care bundle covering surgical, emergency, anaesthesiologic, radiological, physiotherapy, and nutritional support. It contains 15 items of pre-, intra-, and postoperative interventions including rapid diagnosis, resuscitation, surgical treatment, and optimizing care postoperatively. All patients were handled by attending or consultant physicians in all the departments. The full item list is described in detail elsewhere [5].\u003c/p\u003e \u003cp\u003ePatients were categorized into two groups according to the perioperative peritonitis status assessed during the surgical procedure. The non-generalized group included no peritonitis findings, serous peritonitis, or local abscess, and the generalized peritonitis included findings of blood, purulent, or faecal contamination of \u0026ge;\u0026thinsp;2 intraabdominal quadrants.\u003c/p\u003e \u003cp\u003eAll patients from March 2017 who met the above-mentioned criteria received the same standardized treatment as part of the quality assurance project. The patients included in the study had no missing data on peritonitis, mortality, or postoperative complication assessments.\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcome measures were short-term mortality, defined as death within 30 and 90 days after surgery and postoperative complications within 30 days after surgery. All patients were followed up until one year after surgery to evaluate vital status. Death of all citizens is registered in the Danish Civil Registration System with a 100% follow-up and is automatically linked with the electronic patient record. Thirty days postoperative complications were evaluated by the investigators and classified according to the Clavien-Dindo Classification system and defined as Clavien-Dindo score\u0026thinsp;\u0026ge;\u0026thinsp;3b [16].\u003c/p\u003e \u003cp\u003eSecondary outcome measures were in hospital mortality, 180 days mortality, length of stay (LOS), readmission within 6 month of discharge, intensive care unit (ICU) admission and length of ICU stay, reoperation, and postoperative complications.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eAll data were obtained from the electronic patient records prospectively and stored in an electronic case report form. The following demographics and preoperative variables included: sex, age, body mass index (BMI) kg/m\u003csup\u003e2\u003c/sup\u003e, smoking status, alcohol consumption above recommendation (84 g/week for women and 168 g/week for men), non-steroidal anti-inflammatory drugs (NSAID) and glucocorticoids (systemic) usage, American Association of Anaesthesiologists classification (ASA) [17], WHO performance score [18], and comorbidities. Investigators calculated Charlson Comorbidity Index (CCI)[19] and quick Sequential Organ Failure Assessment (qSOFA) [20]. Intraoperative variables included: length of surgical procedure, operative findings (obstruction, perforation, intraabdominal bleeding, ischemia or necrosis, anastomotic leakage, other findings, and no pathology), perioperative malignancy (yes or no), type of surgery (laparoscopy, laparoscopy converted to open, and laparotomy), surgical procedure (procedures without resection, upper GI procedure, small bowel procedure, small- and bowel procedure, large bowel and rectal procedure, and other procedure), reoperation after non-emergency surgery (yes or no), blood transfusion (yes or no).\u003c/p\u003e\n\u003ch3\u003eStatistics\u003c/h3\u003e\n\u003cp\u003eCategorical data were presented as number of cases and frequency in percentages and group comparisons were analysed with a chi-squared test or a Fisher\u0026rsquo;s exact test. The data were presented as mean with standard deviation or median and interquartile range (IQR) for numerical data. Variables, age, BMI, length of surgical procedure, length of ICU stay, and length of hospital stay, were analysed with unpaired t-test or Mann-Whitney\u0026rsquo;s test according to data distribution for group comparisons. The association between pre- and intraoperative variables and the risk of 30- and 90-days mortality and 30-days postoperative complications were analysed with uni- and multivariable logistic regression analyses. Variables included were sex, age\u0026thinsp;\u0026gt;\u0026thinsp;70 years, active smoking, ASA\u0026thinsp;\u0026ge;\u0026thinsp;3, laparotomy, generalized peritonitis, perioperative malignancy, and reoperation after non-emergency surgery. The variables with P-values\u0026thinsp;\u0026le;\u0026thinsp;0.2 were included in the multivariable analysis. Results were expressed as unadjusted and adjusted odds ratios (OR) with a 95% confidence interval (95% CI).\u003c/p\u003e \u003cp\u003eP-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All statistics were performed in R Studio version 4.2.2 (R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eIn a two-year study period, 632 eligible patients underwent major emergency abdominal surgery. Forty-one patients were not included in the current study, as patients did not meet the diagnosis and surgical procedure criteria of major emergency abdominal surgery protocol, leaving a total of 591 included patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatient demographics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 21% (124/591) had an intraoperative finding of generalized peritonitis. Patients with generalized peritonitis were more frequently active smokers, had an alcohol consumption above recommendation, and had a q-SOFA score\u0026thinsp;\u0026ge;\u0026thinsp;1 at admission compared to patients without generalized peritonitis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eDemographics and clinical characteristics of patients undergoing major emergency abdominal surgery\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-generalized peritonitis\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;467\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralized peritonitis\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;124\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale sex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e252 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (40.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 [57, 78]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 [61, 78]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.60 [22.00, 29.20]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.75 [21.42, 28.22]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.480\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive smoking, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 (22.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol above recommendation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (19.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.809\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e197 (42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (40.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (41.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ge;\u0026thinsp;4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWHO PS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e230 (49.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (41.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (33.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ge;\u0026thinsp;4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharlson Comorbidity Index, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026ge;\u0026thinsp;3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e296 (63.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (71.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular diseases, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e228 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.652\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary diseases, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.830\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney disease, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.656\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastrointestinal diseases, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignancy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e325 (69.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (70.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eActive\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (20.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePrevious\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (11.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlucocorticoids, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.913\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNSAIDs, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eqSOFA, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e349 (83.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (69.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e3\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eBMI, body mass index. ASA, American Society of Anesthesiologists. PS, performance status. NSAID, non-steroidal anti-inflammatory drugs. qSOFA, quick Sequential Organ Failure Assessment score.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatients with generalized peritonitis were significantly more likely to have operative findings such as perforation 74.2% (92/124) vs. 10.3% (48/467) P\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and intraabdominal bleeding 4.8% (6/124) vs. 1.1% (5/467) P\u0026thinsp;=\u0026thinsp;0.017, compared to the non-peritonitis group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was no significant difference in perioperative malignancy between the groups (P\u0026thinsp;=\u0026thinsp;1.000).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative findings of patients undergoing major emergency abdominal surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-generalized peritonitis,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;467\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralized peritonitis,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;124\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of surgery, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e139.00 [95.00, 194.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150.00 [110.00, 204.00]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative findings, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eObstruction\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e343 (73.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePerforation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48 (10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92 (74.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIntraabdominal bleeding\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLeakage\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBowel ischemia\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOther\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNo pathology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.177\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerioperative malignancy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of surgery, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLaparoscopy\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48 (10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLaparoscopy converted to open\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66 (14.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (32.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLaparotomy\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e353 (75.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65 (52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical procedure, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eProcedures without resection\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e281 (60.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eUpper GI\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSmall bowel resection\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSmall and large bowel resection\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLarge bowel resection\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36 (29.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOther procedures\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation after non-emergency surgery, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.041\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerioperative transfusion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eGI, gastrointestinal.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatients with generalized peritonitis had a significantly higher rate of conversion to open approach 32.3% (40/124) compared to patients with non-generalized 14.1% (66/467) P\u0026thinsp;\u0026lt;\u0026thinsp;0.001. However, there was no difference in the length of surgery in the two groups (P\u0026thinsp;=\u0026thinsp;0.111). Furthermore, there was a significant difference in the specific surgical procedure between the generalized peritonitis group and non-generalized peritonitis group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients with generalized peritonitis were significantly more likely to have a procedure performed on the upper GI tract 27.4% (34/124) vs. 3.6% (17/467) P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, or large bowel resection 29% (36/124) vs. 8.4% (39/467) P\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Patients with non-generalized peritonitis had a significant higher rate of procedures not requiring bowel resection 60.2% (281/467) vs. 17.7% (22/124) P\u0026thinsp;\u0026lt;\u0026thinsp;0.001. When looking at surgery due to complication from a primary non-emergency procedure, this was more common in the generalized peritonitis group 11.3% (14/124) vs. 5.6% (26/467) P\u0026thinsp;=\u0026thinsp;0.041. Moreover, blood transfusion perioperatively were likewise significantly more common in the generalized peritonitis group 23.4% (29/124) vs. 10.9% (51/467) P\u0026thinsp;=\u0026thinsp;0.001 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLooking postoperatively, patients with generalized peritonitis had a significant longer length of hospital stay with a median of 9.7 days versus 6.5 days (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There were no significant differences on readmissions within 6 months in patients with and without generalized peritonitis (45.5% vs. 47.9%, P\u0026thinsp;=\u0026thinsp;0.707). There was a significantly higher rate of admission to ICU for patients with generalized peritonitis 39.5% (49/124) vs. 12.6% (59/467), P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, but there were no differences in the length of ICU admission (P\u0026thinsp;=\u0026thinsp;0.202). When looking at postoperative complications of any kind, patients with generalized peritonitis were significantly more prone to get both a surgical and non-surgical complication compared to patients with non-generalized peritonitis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The overall 30 day-mortality rate was 12.5% (74/591). Patients with generalized peritonitis had a significantly higher mortality rate in both overall mortality, in-hospital mortality, 30-days mortality, 90-days mortality, and 180-days mortality (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative outcomes of patients undergoing major emergency abdominal surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-generalized peritonitis,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;467\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralized peritonitis,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;124\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of admission, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.49 [3.89, 11.79]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.70 [5.16, 15.69]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReadmission after discharge, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e222 (47.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.707\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmission to ICU, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e59 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49 (39.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of ICU admission, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.44 [1.46, 5.79]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.39 [1.99, 8.35]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny postoperative complications, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e307 (65.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e108 (87.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien Dindo Classification, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCD 1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCD 2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77 (25.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCD 3a\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85 (27.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCD 3b\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCD 4a\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCD 4b\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCD 5\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (16.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReoperation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e112 (24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48 (38.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical complications, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e119 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (45.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular complications, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e110 (23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53 (42.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary complications, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e137 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (46.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute kidney injury, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInhospital, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (8.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-days mortality, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.033\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e90-days mortality, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e180-days mortality, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (31.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eICU, intensive care unit.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUnivariable logistic regression analysis showed that, age\u0026thinsp;\u0026gt;\u0026thinsp;70, ASA\u0026thinsp;\u0026ge;\u0026thinsp;3, generalized peritonitis, and perioperative malignancy were significantly associated with the risk of 30-days mortality. In the multivariable analysis, age\u0026thinsp;\u0026gt;\u0026thinsp;70, ASA\u0026thinsp;\u0026ge;\u0026thinsp;3, generalized peritonitis, and perioperative malignancy were independently associated with risk of 30-days mortality (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe logistic regression analysis including the same covariates on 90 days-mortality showed that, age\u0026thinsp;\u0026gt;\u0026thinsp;70, ASA\u0026thinsp;\u0026ge;\u0026thinsp;3, generalized peritonitis, and perioperative malignancy were significantly associated with the risk of 90-days mortality. Similar to 30-days mortality, 90-days mortality showed the same independent risk pattern in the multivariate analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUnivariable logistic regression on 30-days postoperative complications Clavien-Dindo\u0026thinsp;\u0026ge;\u0026thinsp;3b showed that age\u0026thinsp;\u0026gt;\u0026thinsp;70, active smoking, ASA\u0026thinsp;\u0026ge;\u0026thinsp;3, laparotomy, generalized peritonitis, perioperative malignancy, and reoperation after non-emergency surgery were significantly associated with 30-days Clavien Dindo\u0026thinsp;\u0026ge;\u0026thinsp;3. In the multivariable analysis, all the above-mentioned factors were independently associated with risk of postoperative complications (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this retrospective cohort study, we investigated 591 patients undergoing major emergency abdominal surgery in a well-established Enhanced Recovery After Surgery (ERAS) setting. One fifth of the patients had generalized peritonitis, and they were significantly more prone to get admitted to ICU, undergo a surgical reintervention, have a longer admission, and in higher risk of getting a postoperative medical or surgical complication. About one fifth of the patients with generalized peritonitis died within 30 days, which was almost twice as many as the patients with non-generalized peritonitis.\u003c/p\u003e \u003cp\u003eERAS principles are well known from elective surgery, but in the last decades, the ERAS principles have been applied to major emergency abdominal surgery to reduce the mortality and morbidity [7\u0026ndash;10,21,22]. In the current study, a well-established bundle of care including ERAS principles were applied to all included patients, and the overall 30-days mortality rate was 12.5%. This is slightly higher than in other studies which might be due to the exclusion of procedures like cholecystectomies, appendectomies, and traumas. Moreover, reporting of an overall 30-days mortality rate for patients undergoing major emergency abdominal surgery may not show the whole picture of this population. Our study shows that by categorizing patients into generalized peritonitis and non-generalized peritonitis, the mortality rate for patients with generalized peritonitis was significantly higher at both 30-, 90-, and 180-days. Furthermore, generalized peritonitis was an independent risk factor for both 30- and 90-days mortality and 30-days postoperative complications in multivariable analyses suggesting that these patients represent a subpopulation that should be targeted for optimization of innovations in perioperative care. Similar results were found in a multicentre study looking at community-acquired intraabdominal infections also including appendicitis and biliary tract diseases, concluding that generalized peritonitis was an independent risk factor for mortality HR 2.41 (1.27\u0026ndash;4.61) [23]. A study on patients in the ICU with intraabdominal infections showed that perforation of intraabdominal organ with diffuse peritonitis was an independent risk factor for 28-days mortality OR 1.77 (1.35\u0026ndash;2.32) [24]. On the contrary, another study on patients in the ICU with secondary peritonitis did not show diffuse peritonitis to be a risk factor of ICU mortality within 30 days [25]. A similar Danish cohort study demonstrated that implementation of an ERAS-like setting reduced both 30 days and one year mortality, in addition, they found generalized peritonitis to be an independent risk factor for one year mortality OR 3.39 (1.07\u0026ndash;11.4) [21]. It seems that the literature cannot make a definite conclusion on weather generalized peritonitis is a risk factor or not. This demonstrates that the population of emergency abdominal surgery is very heterogenic, and studies vary in their inclusion criteria by some only including laparotomies and not laparoscopic procedures, which now is proven to be a valid method in the surgical approach [26].\u003c/p\u003e \u003cp\u003eIn our study, surgical approach, laparoscopic or open, was not a predictor of either 30- or 90-days mortality, OR 2.28 (0.81\u0026ndash;8.41) and OR 1.83 (0.77\u0026ndash;5.05) respectively. A large study from the NELA cohort looked at the association of in-hospital mortality and surgical approach and demonstrated a 50% decline in mortality when a laparoscopic approach was used compared to open [27]. Similar results were found in a study looking at surgical approaches and intraoperative strategy and mortality, showing almost a 6 times higher 30 days mortality rate in patients undergoing laparotomy compared to laparoscopy [13]. One possible reason for not showing the same trend may be due to the method of pooling laparoscopic converted to open and primary laparotomy together in the risk model. However, our study shows that patients with generalized peritonitis are characterized by mostly gastrointestinal perforations and are more prone to laparoscopy and attempted laparoscopy, which is similar to a study from NELA, showing an increase adoption to laparoscopic approach and a decrease in the conversion rate [28]. Hence, despite a more severe disease pattern, patients with gastrointestinal tract perforations may be successfully managed by laparoscopy, resulting in lower mortality rate, faster recovery, short length of stay, reduced postoperative pain, and surgical site infections [28\u0026ndash;31].\u003c/p\u003e \u003cp\u003eApart from generalized peritonitis, age above 70 years, ASA above 2, and perioperative malignancy were strong predictors of both 30- and 90-days mortality. A study from the NELA population reported the same characteristics being a predictor of 30 days mortality with an OR 1.079 (1.060\u0026ndash;1.078), 3.096 (2.650\u0026ndash;3.616), and 1.212 (1.071\u0026ndash;1.371) respectively [32]. This is also seen in a Danish study including 4336 patients undergoing emergency abdominal surgery [12]. Other studies found age down to 60 years was an independent risk factor of 30-days mortality [12,24]. Not surprisingly, it seems that these factors are strong predictors of short-term mortality followed by the presence of generalized peritonitis. Additionally, we found active smoking, ASA\u0026thinsp;\u0026ge;\u0026thinsp;3, laparotomy, and reoperation after non-emergency surgery as strong predictors for 30-days postoperative complications.\u003c/p\u003e \u003cp\u003eThe window for optimization is short in emergency surgery and the cornerstone in treatment of secondary peritonitis is rapid antibiotics, resuscitation, and surgical source control [4,33]. Little has changed in this modality over the years, although minimal invasive surgery, pain management, and the use of steroids have had some effects in reducing the surgical stress response and thereby mortality and morbidity [34\u0026ndash;36]. However, this study indicates the need to rethink possible new interventions, to reduce mortality and morbidity in patients with generalized secondary peritonitis. We have identified four risk factors which both accounts for short term mortality and postoperative complications; Age above 70 years, ASA score above 2, and perioperative malignancy which we cannot alter prior to surgery and generalized peritonitis that has the potential to be modulated by alternative routes of antibiotic administration, and stress modification through perioperative treatment with inflammatory modulators. A study done on complicated appendicitis investigated treatment with granulocyte-macrophage colony-stimulating factor (GM CSF) administrated intraperitoneally and showed promising results in reducing length of stay and postoperative complications [37].\u003c/p\u003e \u003cp\u003eThis study represents real-world conditions and practices, which enhance the external validity making them more applicable to the general population. On the contrary, the study is a single-centre retrospective study done in a highly optimized protocol for emergency abdominal surgery limiting generalizability. There is a potential for selection bias, as the cohort is determined by those who underwent surgery and may not represent all emergency abdominal cases, however all patients undergoing surgery received the same treatment and only few was excluded after surgery as they did not meet the inclusion criteria.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, this study found that generalized peritonitis was an independent risk factor for both 30- and 90-days mortality and postoperative complications within a population undergoing major emergency abdominal surgery. Additional factors associated with mortality were age, ASA score above or equal to three, and perioperative malignancy. Moreover, the study showed the same risk profile between 30- and 90-days mortality, though generalized peritonitis was a stronger predictor for 90 days mortality. Patients with generalized peritonitis may be in need of further optimization potentially gaining effect of an add-on treatment regime.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo fundings were received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to Danish law about data protection entire data material cannot be shared. However, if there are individual data material in relation to specific calculations the editors or reviewers request, we will try our best to share that in a responsible and safe data protection manner.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no conflicts of interest or competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Danish Data Protection agency (no: REG-080-2022). The study did not qualify for ethics approval by Danish law as no intervention was carried out.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eClements TW, Tolonen M, Ball CG, et al. Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies. Scandinavian Journal of Surgery. 2021;110:139\u0026ndash;49. https://doi.org/10.1177/1457496920984078 \u003c/li\u003e\n\u003cli\u003eMurray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197\u0026ndash;223. https://doi.org/10.1016/S0140-6736(12)61689-4 \u003c/li\u003e\n\u003cli\u003eStewart B, Khanduri P, Mccord C, et al. Global disease burden of conditions requiring emergency surgery. British Journal of Surgery. 2013;101:9\u0026ndash;22. https://doi.org/10.1002/bjs.9329 \u003c/li\u003e\n\u003cli\u003eRoss JT, Matthay MA, Harris HW. Secondary peritonitis: principles of diagnosis and intervention. BMJ. 2018;361:k1407. https://doi.org/10.1136/bmj.k1407 \u003c/li\u003e\n\u003cli\u003eBurcharth J, Abdulhady L, Danker J, et al. Implementation of a multidisciplinary perioperative protocol in major emergency abdominal surgery. European Journal of Trauma and Emergency Surgery. 2021;47:467\u0026ndash;77. https://doi.org/10.1007/s00068-019-01238-7 \u003c/li\u003e\n\u003cli\u003eQuiney N, Aggarwal G, Scott M, et al. Survival after Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes? World J Surg. 2016;40:1283\u0026ndash;7. https://doi.org/10.1007/S00268-016-3418-0 \u003c/li\u003e\n\u003cli\u003eAggarwal G, Peden CJ, Mohammed MA, et al. Evaluation of the Collaborative Use of an Evidence-Based Care Bundle in Emergency Laparotomy. JAMA Surg. 2019;154(5):1-9. https://doi.org/10.1001/JAMASURG.2019.0145 \u003c/li\u003e\n\u003cli\u003eM\u0026oslash;ller MH, Adamsen S, Thomsen RW, et al. Multicentre trial of a perioperative protocol to reduce mortality in patients with peptic ulcer perforation. British Journal of Surgery. 2011;98:802\u0026ndash;10. https://doi.org/10.1002/BJS.7429 \u003c/li\u003e\n\u003cli\u003eTengberg LT, Bay-Nielsen M, Bisgaard T, et al. Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery. British Journal of Surgery. 2017;104:463\u0026ndash;71. https://doi.org/10.1002/BJS.10427 \u003c/li\u003e\n\u003cli\u003eHuddart S, Peden CJ, Swart M, et al. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. British Journal of Surgery; 2015;102:57-66. https://doi.org/10.1002/BJS.9658 \u003c/li\u003e\n\u003cli\u003eGreen G, Shaikh I, Fernandes R, et al. Emergency laparotomy in octogenarians: A 5-year study of morbidity and mortality. World J Gastrointest Surg. 2013;5:216-221. https://doi.org/10.4240/wjgs.v5.i7.216 \u003c/li\u003e\n\u003cli\u003eTolstrup MB, Watt SK, G\u0026ouml;genur I. Morbidity and mortality rates after emergency abdominal surgery: an analysis of 4346 patients scheduled for emergency laparotomy or laparoscopy. Langenbeck\u0026rsquo;s Archives of Surgery. 2016;402:615\u0026ndash;23. https://doi.org/10.1007/S00423-016-1493-1 \u003c/li\u003e\n\u003cli\u003eTolstrup MB, Jensen TK, G\u0026ouml;genur I. Intraoperative Surgical Strategy in Abdominal Emergency Surgery. World J Surg. 2023;47:162\u0026ndash;70. https://doi.org/10.1007/s00268-022-06782-9 \u003c/li\u003e\n\u003cli\u003eMarshall JC, Innes M. Intensive care unit management of intra-abdominal infection. Crit Care Med. 2003;31:2228\u0026ndash;37. https://doi.org/10.1097/01.CCM.0000087326.59341.51 \u003c/li\u003e\n\u003cli\u003evon Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453\u0026ndash;7. https://doi.org/10.1016/S0140-6736(07)61602-X \u003c/li\u003e\n\u003cli\u003eClavien PA, Barkun J, De Oliveira ML, et al. The clavien-dindo classification of surgical complications: Five-year experience. Ann Surg. 2009;250:187\u0026ndash;96. https://doi.org/10.1097/SLA.0b013e3181b13ca2 \u003c/li\u003e\n\u003cli\u003eDaabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth. 2011;55:111-115. https://doi.org/10.4103/0019-5049.79879 \u003c/li\u003e\n\u003cli\u003eYoung J, Badgery-Parker T, Dobbins T, et al. Comparison of ECOG/WHO performance status and ASA score as a measure of functional status. Journal of Pain and Symptom Management. 2015;49:258\u0026ndash;64. https://doi.org/10.1016/J.JPAINSYMMAN.2014.06.006 \u003c/li\u003e\n\u003cli\u003eCharlson M, Szatrowski TP, Peterson J, et al. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47:1245\u0026ndash;51. https://doi.org/10.1016/0895-4356(94)90129-5 \u003c/li\u003e\n\u003cli\u003eSinger M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801\u0026ndash;10. https://doi.org/10.1001/JAMA.2016.0287 \u003c/li\u003e\n\u003cli\u003eTrangb\u0026aelig;k RM, Burcharth J, G\u0026ouml;genur I. Implementing Bundle Care in Major Abdominal Emergency Surgery: Long-Term Mortality and Comprehensive Complication Index. World J Surg. 2023;47:106. https://doi.org/10.1007/S00268-022-06763-Y \u003c/li\u003e\n\u003cli\u003eJordan LC, Cook TM, Cook SC, et al. Sustaining better care for patients undergoing emergency laparotomy. Anaesthesia. 2020;75:1321\u0026ndash;30. https://doi.org/10.1111/ANAE.15088 \u003c/li\u003e\n\u003cli\u003eRoger C, Garrigue D, Bouhours G, et al. Time to source control and outcome in community-acquired intra-abdominal infections: The multicentre observational PERICOM study. Eur J Anaesthesiology. 2022;39:540\u0026ndash;8. https://doi.org/10.1097/EJA.0000000000001683 \u003c/li\u003e\n\u003cli\u003eArvaniti K, Dimopoulos G, Antonelli M, et al. Epidemiology and Age-Related Mortality in Critically Ill Patients With Intra-Abdominal Infection or Sepsis: An International Cohort Study. Anaesthesia. 2023;78:1262\u0026ndash;71. https://doi.org/doi:10.1111/anae.16096 \u003c/li\u003e\n\u003cli\u003eDe Pascale G, Antonelli M, Deschepper M, et al. Poor timing and failure of source control are risk factors for mortality in critically ill patients with secondary peritonitis. Intensive Care. 2022;48:1593\u0026ndash;606. https://doi.org/10.1007/s00134-022-06883-y \u003c/li\u003e\n\u003cli\u003eTrangb\u0026aelig;k RM, Wahlstr\u0026oslash;m K, G\u0026ouml;genur I, et al. Associations Between Care Bundles and Postoperative Outcomes After Major Emergency Abdominal Surgery: A Systematic Review and Meta-Analysis. Journal of Surgical Research. 2022;283:469\u0026ndash;78. https://doi.org/10.1016/j.jss.2022.10.064 \u003c/li\u003e\n\u003cli\u003ePucher PH, Mackenzie H, Tucker V, et al. A national propensity score-matched analysis of emergency laparoscopic versus open abdominal surgery. British Journal of Surgery. 2021;108:934\u0026ndash;40. https://doi.org/10.1093/bjs/znab048 \u003c/li\u003e\n\u003cli\u003eCoe PO, Lee MJ, Boyd-Carson H, et al. Open Versus Laparoscopic Repair of Perforated Peptic Ulcer Disease: A Propensity-matched Study of the National Emergency Laparotomy Audit. Ann Surg. 2022;275:928\u0026ndash;32. https://doi.org/10.1097/SLA.0000000000004332 \u003c/li\u003e\n\u003cli\u003eTartaglia D, Strambi S, Coccolini F, et al. Laparoscopic versus open repair of perforated peptic ulcers: analysis of outcomes and identification of predictive factors of conversion. Updates Surg. 2023;75:649\u0026ndash;57. https://doi.org/10.1007/S13304-022-01391-6/TABLES/4 \u003c/li\u003e\n\u003cli\u003eKim CW, Kim JW, Yoon SN, et al. Laparoscopic repair of perforated peptic ulcer: a multicenter, propensity score matching analysis. BMC Surg. 2022;22:1-8. https://doi.org/10.1186/S12893-022-01681-1 \u003c/li\u003e\n\u003cli\u003eVakayil V, Bauman B, Joppru K, et al. Surgical repair of perforated peptic ulcers: laparoscopic versus open approach. Surg Endosc. 2019;33:281\u0026ndash;92. https://doi.org/10.1007/S00464-018-6366-Y \u003c/li\u003e\n\u003cli\u003eEugene N, Kuryba A, Martin P, et al. Development and validation of a prognostic model for death 30 days after adult emergency laparotomy. Anaesthesia. 2023;78:1262\u0026ndash;71. https://doi.org/10.1111/anae.16096 \u003c/li\u003e\n\u003cli\u003eScott MJ, Aggarwal G, Aitken RJ, et al. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations Part 2-Emergency Laparotomy: Intra-and Postoperative Care. World J Surg. 2023;47(8):1850-1880. https://doi.org/10.1007/s00268-023-07020-6 \u003c/li\u003e\n\u003cli\u003eManou-Stathopoulou V, Arta Korbonits M, Ackland GL. Redefining the perioperative stress response: a narrative review. Br J Anaesth 2019;123:570\u0026ndash;83. https://doi.org/10.1016/j.bja.2019.08.011 \u003c/li\u003e\n\u003cli\u003eDesborough JP. The stress response to trauma and surgery. Br J Anaesth. 2000;85:109\u0026ndash;17. https://doi.org/10.1093/BJA/85.1.109 \u003c/li\u003e\n\u003cli\u003eScott MJ, Baldini G, Fearon KCH, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand. 2015;59:1212\u0026ndash;31. https://doi.org/10.1111/AAS.12601 \u003c/li\u003e\n\u003cli\u003eFonnes S, Roepstorff S, Holzknecht BJ, et al. Shorter Total Length of Stay After Intraperitoneal Fosfomycin, Metronidazole, and Molgramostim for Complicated Appendicitis: A Pivotal Quasi-Randomized Controlled Trial. Front Surg. 2020;7. https://doi.org/10.3389/fsurg.2020.00025 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"secondary peritonitis, perforation, acute care surgery, emergency surgery, abdominal surgery, laparotomy","lastPublishedDoi":"10.21203/rs.3.rs-5374962/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5374962/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSecondary generalized peritonitis is a potentially life-threatening condition. The aim of this study was to investigate the association between secondary generalized peritonitis and short-term mortality and postoperative complications in patients undergoing major abdominal emergency surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e The study included patients with the age\u0026thinsp;\u0026ge;\u0026thinsp;18 years undergoing major emergency abdominal surgery in a University Hospital from 2017 to 2019 after the introduction of a perioperative bundle care program. The primary outcome measures were short-term mortality, defined as death within 30 and 90 days after surgery and postoperative complications within 30 days after surgery. Uni- and multivariable logistic regression analyses were performed to evaluate risk factors for 30- and 90-days mortality and 30-days postoperative complications.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 591 patients were included, of whom 21% (124/591) had generalized peritonitis. The overall 30 day-mortality rate was 12.5% (74/591). Patients with generalized peritonitis had a significantly higher 30-day mortality rate than patients with non-generalized peritonitis 18.5% (23/124) vs. 10.9% (51/467), P\u0026thinsp;\u0026lt;\u0026thinsp;0.033. Generalized peritonitis was an independent risk factor for 30-day mortality. There was a significantly higher rate of admission to ICU for patients with generalized peritonitis 39.5% (49/124) vs. 12.6% (59/467), P\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Patients with generalized peritonitis were significantly more prone to get both a surgical and non-surgical complication compared to patients with non-generalized peritonitis 87.1% (108/124) vs. 65.7% (307/467), P\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn a population undergoing major emergency abdominal surgery treated in a perioperative optimization protocol, generalized peritonitis was an independent risk factor for both 30- and 90-days mortality and postoperative complications.\u003c/p\u003e","manuscriptTitle":"High risk of short-term mortality and postoperative complications in patients with generalized peritonitis undergoing major emergency abdominal surgery - a cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-13 06:37:43","doi":"10.21203/rs.3.rs-5374962/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-17T20:28:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-15T14:18:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"303213507511509543236765161733353838540","date":"2024-11-14T14:04:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-11T09:03:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48246867192860390762454589682225511935","date":"2024-11-11T08:48:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-10T22:26:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108088064992007301674850671341693404047","date":"2024-11-09T17:21:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309169257497800515461957274218455091185","date":"2024-11-09T15:38:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143585052383980835533212577941046552119","date":"2024-11-09T13:54:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-09T13:48:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-07T04:13:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-06T16:11:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2024-11-01T17:39:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"48be43ea-0dd2-4d8f-afc4-c9d3dcfffdc1","owner":[],"postedDate":"November 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:02:05+00:00","versionOfRecord":{"articleIdentity":"rs-5374962","link":"https://doi.org/10.1007/s00423-025-03637-4","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2025-02-11 15:57:34","publishedOnDateReadable":"February 11th, 2025"},"versionCreatedAt":"2024-11-13 06:37:43","video":"","vorDoi":"10.1007/s00423-025-03637-4","vorDoiUrl":"https://doi.org/10.1007/s00423-025-03637-4","workflowStages":[]},"version":"v1","identity":"rs-5374962","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5374962","identity":"rs-5374962","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}