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Rosario BH, Kwok KM, Sim SKR. The value of frailty assessments in older surgical patients undergoing emergency laparotomies in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2024; 53:340-341. [PMID: 38979989 DOI: 10.47102/annals-acadmedsg.2024193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Mortality in emergency laparotomy (EL) far exceeds that of elective bowel surgery, and standards for the National Emergency Laparotomy Audit (NELA) in the UK were introduced due to the high mortality within 1 month of EL.1 In Singapore, 30-day mortality varies between 5.4% and 14.7% after EL.2,3 However, 30-day mortality in older patients has been reported to be as high as 31.5%.3
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Affiliation(s)
| | - Kah Meng Kwok
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore
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2
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Shekar N, Debata PK, Debata I, Nair P, Rao LS, Shekar P. Use of POSSUM (Physiologic and Operative Severity Score for the Study of Mortality and Morbidity) and Portsmouth-POSSUM for Surgical Assessment in Patients Undergoing Emergency Abdominal Surgeries. Cureus 2023; 15:e40850. [PMID: 37489217 PMCID: PMC10363332 DOI: 10.7759/cureus.40850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/26/2023] Open
Abstract
INTRODUCTION The POSSUM (Physiologic and Operative Severity Score for the Study of Mortality and Morbidity) and Portsmouth-POSSUM (P-POSSUM) models have been popularly recommended as appropriate for predicting postoperative mortality and morbidity in surgical practice. This study aims to evaluate the efficacy and accuracy of both scoring systems for surgical risk assessment in predicting postoperative mortality and morbidity in patients undergoing emergency abdominal surgeries. METHODOLOGY The study was conducted as a part of a post-doctoral fellowship program. A total of 150 patients, undergoing emergency abdominal surgery in a tertiary care hospital in Bhubaneswar, were evaluated using POSSUM and P-POSSUM. Physiological scoring was done prior to surgery and operative scoring was performed intra-operatively. Patients were followed up for 30 days after the operative period. The observed mortality rate was then compared with POSSUM and P-POSSUM predicted mortality rates. RESULTS POSSUM predicted a morbidity rate of 116, whereas the actual morbidity rate was 92 (p < 0.05). P-POSSUM predicted a morbidity rate of 109, whereas the actual morbidity rate was 92 (p < 0.05). POSSUM predicted a mortality rate of 23, whereas the actual mortality rate was 21 (p < 0.05). P-POSSUM predicted a mortality rate of 25, whereas the actual mortality rate was 21 (p < 0.05). CONCLUSIONS With a reasonably good prediction of morbidity and mortality rate, POSSUM and P-POSSUM scores are both effective scoring systems in clinical practice for use in abdominal surgery.
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Affiliation(s)
- Nithya Shekar
- General Surgery, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, IND
| | - P K Debata
- General Surgery, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Ipsita Debata
- Community and Family Medicine, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Pallavi Nair
- General Surgery, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Lakshmi S Rao
- General Surgery, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | - Prithvi Shekar
- General Surgery, Vydehi Institute of Medical Sciences and Research Center, Bengaluru, IND
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Wanjiang F, Xiaobo Z, Xin W, Ye M, Lihua H, Jianlong W. Application of POSSUM and P-POSSUM scores in the risk assessment of elderly hip fracture surgery: systematic review and meta-analysis. J Orthop Surg Res 2022; 17:255. [PMID: 35526015 PMCID: PMC9077349 DOI: 10.1186/s13018-022-03134-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/13/2022] [Indexed: 11/26/2022] Open
Abstract
Background Since Mohamed et al. analyzed 2326 orthopedic cases in 2002 and believed that the POSSUM formula can be directly used to predict postoperative morbidity and mortality in orthopedic patients, applications of POSSUM and P-POSSUM scores in the hip fracture surgery have been mostly reported in the field of orthopedics, but there are still some inconsistencies in the related reports. Methods The electronic library was searched for all literature that met the purpose from its inception to 2021. Relative risk (RR) was selected to evaluate whether the model could be used to assess the risk of surgery in patients with elderly hip fractures. Finally, sensitivity analyses and subgroup analyses were performed. Results Thirteen studies were finally included, including 9 retrospective and 4 prospective studies.The morbidity analysis includes 11 studies, and the result was RR = 1.07 (95% CI 0.93–1.24), The mortality analysis includes 11 studies on POSSUM and 5 studies on P-POSSUM. The results of mortality by POSSUM and by P-POSSUM were RR = 1.93 (95% CI 1.21–3.08) and RR = 1.15 (95% CI 0.89–1.50), respectively. POSSUM had more accuracy to predict mortality for sample < 200 subgroup(RR = 2.45; 95% CI 0.71–8.42) than sample > 200 subgroup(RR = 1.59; 95% CI 1.06–2.40), and in the subgroup of hip fractures that did not distinguish between specific fracture types(RR = 1.69, 95% CI 0.87–3.32) than intertrochanteric neck fracture subgroup(RR = 5.04, 95% CI 1.07–23.75) and femoral femoral fracture subgroup(RR = 1.43,95% CI 1.10–1.84). Conclusion POSSUM can be used to predict morbidity in elderly hip fractures. The P-POSSUM was more accurate in predicting mortality in elderly hip fracture patients compared to the POSSUM, whose predictive value for mortality was influenced by the sample size and type of fracture studied. In addition, we believe that appropriate improvements to the POSSUM system are needed to address the characteristics of orthopedic surgery.
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Affiliation(s)
- Feng Wanjiang
- Department of Orthopedics, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zhang Xiaobo
- Department of Orthopedics, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Wu Xin
- Department of Orthopedics, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Meng Ye
- Department of Orthopedics, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Huang Lihua
- Center for Experimental Medicine, Third Xiangya Hospital of Central South University, No.138 Tongzipo Road, Changsha, 410013, Hunan, China.
| | - Wang Jianlong
- Department of Orthopedics, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China.
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Yin Y, Jiang L, Xue L. Which Frailty Evaluation Method Can Better Improve the Predictive Ability of the SASA for Postoperative Complications of Patients Undergoing Elective Abdominal Surgery? Ther Clin Risk Manag 2022; 18:541-550. [PMID: 35548665 PMCID: PMC9084513 DOI: 10.2147/tcrm.s357285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine which frailty method can better improve the predictive ability of the Surgical Apgar Score combined with American Society of Anesthesiologists physical status classification (SASA). Patients and Methods A prospective cohort study was conducted. A total of 194 elderly patients undergoing elective abdominal surgery were included. Preoperative frailty using FRAIL questionnaire, frailty index (FI), Clinical Frailty Scale (CFS) and SASA scores was assessed. Primary outcome was in-hospital Clavien-Dindo ≥grade II complications. Multiple logistic regression was used to examine the association between frailty and complications. Receiver operating characteristic curves were used to explore the predictive ability of frailty. Results According to the FRAIL, FI and CFS criteria, the prevalence of frailty in the study population was 43.8%, 32.5%, and 36.6%, respectively. After adjusting for all covariates, frailty was significantly associated with postoperative complications in hospital by FRAIL [odds ratio: 5.11, 95% CI: 1.41–18.44, P = 0.013], by FI [OR: 4.25, 95% CI: 1.21–14.90, P = 0.024] and by CFS [OR: 5.10, 95% CI: 1.52–17.17, P = 0.008]. The area under the curve (AUC) for SASA was 0.768 (95% CI: 0.702–0.826). Addition of frailty assessment (FRAIL, FI and CFS) increased the AUC to 0.787 (95% CI: 0.722–0.842), 0.798 (95% CI: 0.734–0.852), and 0.815 (95% CI: 0.753–0.867), respectively. Compared to SASA, only addition of CFS had a significant difference (P = 0.0478). Conclusion Frailty is an effective predictor of postoperative complications in elderly Chinese patients undergoing elective abdominal surgery. Frailty assessment of CFS can better improve the predictive ability of SASA.
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Affiliation(s)
- Yanyan Yin
- Department of Neurological Rehabilitation, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, 100144, People’s Republic of China
| | - Li Jiang
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, 100053, People’s Republic of China
- Correspondence: Li Jiang, Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, People’s Republic of China, Tel +8613601366055, Email
| | - Lixin Xue
- Department of General Surgery, Fuxing Hospital, Capital Medical University, Beijing, 100038, People’s Republic of China
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Valenzuela S, Niño L, Conde D, Girón F, Rodríguez L, Venegas D, Rey C, Nassar R, Vanegas M, Jiménez D. Morbimortality assessment in abdominal surgery: are we predicting or overreacting? BMC Surg 2022; 22:19. [PMID: 35042495 PMCID: PMC8764813 DOI: 10.1186/s12893-021-01455-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High-risk surgical procedures represent a fundamental part of general surgery practice due to its significant rates of morbidity and mortality. Different predictive tools have been created in order to quantify perioperative morbidity and mortality risk. POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity) is one of the most widely validated predictive scores considering physiological and operative variables to precisely define morbimortality risk. Nevertheless, seeking greater accuracy in predictions P-POSSUM was proposed. We aimed to compare POSSUM and P-POSSUM for patients undergoing abdominal surgery. METHODS A retrospective observational study with a prospective database was conducted. Patients over 18 years old who complied with inclusion criteria between 2015 and 2016 were included. Variables included in the POSSUM and P-POSSUM Scores were analyzed. Descriptive statistics of all study parameters were provided. The analysis included socio-demographic data, laboratory values , and imaging. Bivariate analysis was performed. RESULTS 350 Patients were included in the analysis, 55.1% were female. The mean age was 55.9 ± 20.4 years old. POSSUM revealed a moderated index score in 61.7% of the patients, mean score of 12.85 points ± 5.61. 89.1% of patients had no neoplastic diagnosis associated. Overall morbidity and mortality rate was 14.2% and 7.1%. P-POSSUM could predict more precisely mortality (p < 0.00). CONCLUSIONS The POSSUM score is likely to overestimate the risk of morbidity and mortality in patients with high/moderate risk, while the P-POSSUM score seems to be a more accurate predictor of mortality risk. Further studies are needed to confirm our results.
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Affiliation(s)
- Sebastian Valenzuela
- Department of Surgery, Hospital Universitario Mederi, Calle 103a 21-93, 110111, Bogotá, D.C, Colombia
| | - Laura Niño
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Danny Conde
- Department of Surgery, Hospital Universitario Mederi, Calle 103a 21-93, 110111, Bogotá, D.C, Colombia.
- School of Medicine, Universidad del Rosario, Bogotá, Colombia.
| | - Felipe Girón
- Department of Surgery, Hospital Universitario Mederi, Calle 103a 21-93, 110111, Bogotá, D.C, Colombia
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
- School of Medicine, Universidad de los Andes, 111711, Bogotá, Colombia
| | - Lina Rodríguez
- School of Medicine, Universidad de los Andes, 111711, Bogotá, Colombia
| | - David Venegas
- Department of Surgery, Hospital Universitario Mederi, Calle 103a 21-93, 110111, Bogotá, D.C, Colombia
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Carlos Rey
- Department of Surgery, Hospital Universitario Mederi, Calle 103a 21-93, 110111, Bogotá, D.C, Colombia
| | - Ricardo Nassar
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
- School of Medicine, Universidad de los Andes, 111711, Bogotá, Colombia
| | - Marco Vanegas
- Department of Surgery, Hospital Universitario Mederi, Calle 103a 21-93, 110111, Bogotá, D.C, Colombia
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Daniel Jiménez
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
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AlSowaiegh R, Naar L, El Moheb M, Parks JJ, Fawley J, Mendoza AE, Saillant NN, Velmahos GC, Kaafarani HMA. The Emergency Surgery Score is a powerful predictor of outcomes across multiple surgical specialties: Results of a retrospective nationwide analysis. Surgery 2021; 170:1501-1507. [PMID: 34176601 DOI: 10.1016/j.surg.2021.05.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/11/2021] [Accepted: 05/20/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The Emergency Surgery Score was recently validated in a prospective multicenter study as an accurate predictor of mortality in emergency general surgery patients. The Emergency Surgery Score is easily calculated using multiple demographic, comorbidity, laboratory, and acuity of disease variables. We aimed to investigate whether the Emergency Surgery Score can predict 30-day postoperative mortality across patients undergoing emergency surgery in multiple surgical specialties. METHODS Our study is a retrospective cohort study using data from the national American College of Surgeons National Surgical Quality Improvement Program database (2007-2017). We included patients that underwent emergency gynecologic, urologic, thoracic, neurosurgical, orthopedic, vascular, cardiac, and general surgical procedures. The Emergency Surgery Score was calculated for each patient, and the correlation between the Emergency Surgery Score and 30-day mortality was assessed for each specialty using the c-statistics methodology. RESULTS Of 6,485,915 patients, 173,890 patients were included. The mean age was 60 years, 50.6% were female patients, and the overall mortality was 9.7%. The Emergency Surgery Score predicted mortality best in emergency gynecologic, general, and urologic surgery (c-statistics: 0.97, 0.87, 0.81, respectively). The Emergency Surgery Score predicted mortality moderately well in emergency thoracic, neurosurgical, orthopedic, and vascular surgery (c-statistics 0.73-0.79). For example, the mortality of gynecology patients with an Emergency Surgery Score of 5, 9, and 13 was 2%, 27%, and 50%, respectively. The Emergency Surgery Score performed poorly in cardiac surgery. CONCLUSION The Emergency Surgery Score accurately predicts mortality across patients undergoing emergency surgery in multiple surgical specialties, especially general, gynecologic, and urologic surgery. The Emergency Surgery Score can prove useful for perioperative patient counseling and for benchmarking the quality of surgical care.
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Affiliation(s)
- Reem AlSowaiegh
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA.
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Christou CD, Naar L, Kongkaewpaisan N, Tsolakidis A, Smyrnis P, Tooulias A, Tsoulfas G, Papadopoulos VN, Velmahos GC, Kaafarani HMA. Validation of the Emergency Surgery Score (ESS) in a Greek patient population: a prospective bi-institutional cohort study. Eur J Trauma Emerg Surg 2021; 48:1197-1204. [PMID: 34296323 PMCID: PMC8297717 DOI: 10.1007/s00068-021-01734-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 06/19/2021] [Indexed: 02/05/2023]
Abstract
Purpose The Emergency Surgery Score (ESS) is a reliable point-based score that predicts mortality and morbidity in emergency surgery patients. However, it has been validated only in the U.S. patients. We aimed to prospectively validate ESS in a Greek patient population. Methods All patients who underwent an emergent laparotomy were prospectively included over a 15-month period. A systematic chart review was performed to collect relevant preoperative, intraoperative, and postoperative variables based on which the ESS was calculated for each patient. The relationship between ESS and 30-day mortality, morbidity (i.e., the occurrence of at least one complication), and the need for intensive care unit (ICU) admission was evaluated and compared between the Greek and U.S. patients using the c-statistics methodology. The study was registered on "Research Registry" with the unique identifying number 5901. Results A total of 214 patients (102 Greek) were included. The mean age was 64 years, 44% were female, and the median ESS was 7. The most common indication for surgery was hollow viscus perforation (25%). The ESS reliably and incrementally predicted mortality (c-statistics = 0.79 [95% CI 0.67–0.90] and 0.83 [95% CI 0.74–0.92]), morbidity (c-statistics = 0.83 [95% CI 0.76–0.91] and 0.79 [95% CI 0.69–0.88]), and ICU admission (c-statistics = 0.88 [95% CI 0.81–0.96] and 0.84 [95% CI 0.77–0.91]) in both Greek and U.S. patients. Conclusion The correlation between the ESS and the surgical outcomes was statistically significant in both Greek and U.S. patients undergoing emergency laparotomy. ESS could prove globally useful for preoperative patient counseling and quality-of-care benchmarking.
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Affiliation(s)
- Chrysanthos Dimitris Christou
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Leon Naar
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Alexandros Tsolakidis
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Smyrnis
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andreas Tooulias
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Tsoulfas
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios Nikolaos Papadopoulos
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Constantinos Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Haytham Mohamed Ali Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
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A Comparison of the P-POSSUM and NELA Risk Score for Patients Undergoing Emergency Laparotomy in Singapore. World J Surg 2021; 45:2439-2446. [PMID: 33903953 DOI: 10.1007/s00268-021-06120-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND (AIMS, HYPOTHESES, OR OBJECTIVES) Emergency laparotomy (EL) is a high-risk surgical procedure associated with considerable morbidity and mortality around the world. A reliable risk-assessment tool that is specific to patients undergoing EL allows the early identification of high-risk patients and enables appropriate healthcare resource allocation. The objective of this study was to compare the commonly used Portsmouth-physiologic and operative severity score for the enumeration of mortality and morbidity (P-POSSUM) with the recently developed National Emergency Laparotomy Audit (NELA) score in terms of their accuracy for identifying patients at increased risk of 30-day mortality in a predominantly Asian population. METHODS Physiological and operative data from a prospectively collected audit of adult patients undergoing EL in 2018 and 2019 across two tertiary hospitals in Singapore were used to retrospectively calculate both the P-POSSUM and NELA scores for each patient encounter. This was then compared to actual mortality rates to determine each model's accuracy and precision. RESULTS 830 patients were included in the study with a 30-day mortality of 5.66%. The area under the receiver operating characteristics curve (AUROC) was similar for both the NELA (0.86, p < 0.001, 95% CI 0.81-0.91) and the P-POSSUM models (0.84, p < 0.001, 95% CI 0.78-0.89). While the models over-predicted mortality, overall O:E ratios showed that the NELA model performance was superior to that of P-POSSUM (0.58 [95% CI 0.43-0.77] compared to 0.34 [95% CI 0.26-0.46]). CONCLUSION The NELA risk-prediction model accurately predicts 30-day mortality in this large cohort of patients undergoing EL and outperforms the current P-POSSUM model. We recommend that the NELA score should replace the P-POSSUM score as a model to distinguish between high- and low-risk patients undergoing EL.
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Naar L, El Hechi M, Kokoroskos N, Parks J, Fawley J, Mendoza AE, Saillant N, Velmahos GC, Kaafarani HMA. Can the Emergency Surgery Score (ESS) predict outcomes in emergency general surgery patients with missing data elements? A nationwide analysis. Am J Surg 2020; 220:1613-1622. [PMID: 32102760 DOI: 10.1016/j.amjsurg.2020.02.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/09/2020] [Accepted: 02/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Emergency Surgery Score (ESS) is an accurate mortality risk calculator for emergency general surgery (EGS). We sought to assess whether ESS can accurately predict 30-day morbidity, mortality, and requirement for postoperative Intensive Care Unit (ICU) care in patients with missing data variables. METHODS All EGS patients with one or more missing ESS variables in the 2007-2015 ACS-NSQIP database were included. ESS was calculated assuming that a missing variable is normal (i.e. no additional ESS points). The correlation between ESS and morbidity, mortality, and postoperative ICU level of care was assessed using the c-statistics methodology. RESULTS Out of a total of 4,456,809 patients, 359,849 were EGS, and of those 256,278 (71.2%) patients had at least one ESS variable missing. ESS correlated extremely well with mortality (c-statistic = 0.94) and postoperative requirement of ICU care (c-statistic = 0.91) and well with morbidity (c-statistic = 0.77). CONCLUSION ESS performs well in predicting outcomes in EGS patients even when one or more data elements are missing and remains a useful bedside tool for counseling EGS patients and for benchmarking the quality of EGS care.
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Affiliation(s)
- Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Nikolaos Kokoroskos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Parks
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Selwood A, Blakely B, Senthuran S, Lane P, North J, Clay-Williams R. Variability in clinicians' understanding and reported methods of identifying high-risk surgical patients: a qualitative study. BMC Health Serv Res 2020; 20:427. [PMID: 32414412 PMCID: PMC7227052 DOI: 10.1186/s12913-020-05316-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 05/11/2020] [Indexed: 12/13/2022] Open
Abstract
Background High-risk patients presenting for surgery require complex decision-making and perioperative management. However, given there is no gold standard for identifying high-risk patients, doing so may be challenging for clinicians in practice. Before a gold standard can be established, the state of current practice must be determined. This study aimed to understand how working clinicians define and identify high-risk surgical patients. Methods Clinicians involved in the care of high-risk surgical patients at a public hospital in regional Australia were interviewed as part of an ongoing study evaluating a new shared decision-making process for high-risk patients. The new process, Patient-Centred Advanced Care Planning (PC-ACP) engages patients, families, and clinicians from all relevant specialties in shared decision-making in line with the patient’s goals and values. The semi-structured interviews were conducted before the implementation of the new process and were coded using a modified form of the ‘constant comparative method’ to reveal key themes. Themes concerning patient risk, clinician’s understanding of high risk, and methods for identifying high-risk surgical patients were extricated for close examination. Results Thirteen staff involved in high-risk surgery at the hospital at which PC-ACP was to be implemented were interviewed. Analysis revealed six sub-themes within the major theme of factors related to patient risk: (1) increase in high-risk patients, (2) recognising frailty, (3) risk-benefit balance, (4) suitability and readiness for surgery, (5) avoiding negative outcomes, and (6) methods in use for identifying high-risk patients. There was considerable variability in clinicians’ methods of identifying high-risk patients and regarding their definition of high risk. This variability occurred even among clinicians within the same disciplines and specialties. Conclusions Although clinicians were confident in their own ability to identify high-risk patients, they acknowledged limitations in recognising frail, high-risk patients and predicting and articulating possible outcomes when consenting these patients. Importantly, little consistency in clinicians’ reported methods for identifying high-risk patients was found. Consensus regarding the definition of high-risk surgical patients is necessary to ensure rigorous decision-making.
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Affiliation(s)
- Amanda Selwood
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie Park, NSW, 2109, Australia.
| | - Brette Blakely
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie Park, NSW, 2109, Australia
| | - Siva Senthuran
- Townsville Hospital and Health Service, 100 Angus Smith Drive, Douglas, QLD, 4814, Australia.,College of Medicine & Dentistry, James Cook University, Townsville, QLD, 4811, Australia
| | - Paul Lane
- Townsville Hospital and Health Service, 100 Angus Smith Drive, Douglas, QLD, 4814, Australia
| | - John North
- Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia
| | - Robyn Clay-Williams
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie Park, NSW, 2109, Australia
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11
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Thahir A, Pinto-Lopes R, Madenlidou S, Daby L, Halahakoon C. Mortality risk scoring in emergency general surgery: Are we using the best tool? J Perioper Pract 2020; 31:153-158. [PMID: 32368947 DOI: 10.1177/1750458920920133] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND It is imperative that an accurate assessment of risk of death is undertaken preoperatively on all patients undergoing an emergency laparotomy. Portsmouth-Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) is one of the most widely used scores. National Emergency Laparotomy Audit (NELA) presents a novel, validated score, but no direct comparison with P-POSSUM exists. We aimed to determine which would be the best predictor of mortality. METHODS We analysed all the entries on the online NELA database over a four-and-a-half-year period. The Hosmer-Lemeshow goodness of fit test was performed to assess model calibration. For the outcome of death and for each scoring system, a non-parametric receiver operator characteristic analysis was done. The sensitivity, specificity, area under receiver operator characteristic curve and their standard errors were calculated. RESULTS Data pertaining to 650 patients were included. There were 59 deaths, giving an overall observed mortality rate of 9.1%. Predicted mortality rate for the P-POSSUM score and NELA score were 15.2% and 7.8%, respectively. The discriminative power for mortality was highest for the NELA score (C-index = 0.818, CI: 0.769-0.867, p < 0.001), when compared to P-POSSUM (C-index = 0.769, CI: 0.712-0.827, p < 0.001). CONCLUSIONS The NELA score showed good discrimination in predicting mortality in the entire cohort. The P-POSSUM over-predicted observed mortality and the NELA score under-predicted observed mortality.
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Affiliation(s)
- Azeem Thahir
- Department of General Surgery of 2592Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Rui Pinto-Lopes
- Department of General Surgery of 2592Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Stavroula Madenlidou
- Department of General Surgery of 2592Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Laura Daby
- Department of General Surgery of 2592Colchester Hospital University NHS Foundation Trust, Colchester, UK
| | - Chandima Halahakoon
- Department of General Surgery of 2592Colchester Hospital University NHS Foundation Trust, Colchester, UK
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12
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Mačiulienė A, Maleckas A, Kriščiukaitis A, Mačiulis V, Vencius J, Macas A. Predictors of 30-Day In-Hospital Mortality in Patients Undergoing Urgent Abdominal Surgery Due to Acute Peritonitis Complicated with Sepsis. Med Sci Monit 2019; 25:6331-6340. [PMID: 31441459 PMCID: PMC6717438 DOI: 10.12659/msm.915435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is a life-threatening condition with high morbidity and mortality rate. Identifying early prediction factors of critical situations in intra-abdominal sepsis patients can help reduce mortality rates. This prospective study was carried out to evaluate the association of technically available factors with 30-day in-hospital mortality. Material/Methods There were 67 intra-abdominal sepsis patients included in the study; patients were observed for 30 days postoperatively. The data was processed using SPSS24.0 statistical analysis package. All tests that had a significance level of 0.05 were selected. Results Septic shock in association with increase in age per year showed increase the odds of mortality and prognosed 30-days in hospital mortality correctly in 79% of cases. The observed OR was 12.24 (P<0.001). Multiple logistic regression model 2 for the 30-day mortality identified a combination of septic shock, age (≥70 years), time from peritonitis symptoms to surgery prognose mortality with accuracy of 82%. The most accurate model to prognose 30-day in-hospital mortality included the presents of septic shock, age, time from peritonitis symptoms to surgery, drop of MAP <65 mmHg) post-induction, the odds of mortality 8.86 (P=0.001). Severe hypotension post-induction was more frequent in patients who were not diagnosed with sepsis (P=0.035). Conclusions The present study revealed a simple indicator for the risk for death under diffuse peritonitis patients complicated with sepsis. Septic shock, increase in age per year, peritonitis symptoms lasting more than 30 hours, and severe hypotension post-induction had a negative prognostic value for mortality in patients with intra-abdominal sepsis, and might be a high risk for 30-day mortality.
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Affiliation(s)
- Asta Mačiulienė
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Almantas Maleckas
- Department of General Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Algimantas Kriščiukaitis
- Department of Physics, Mathematics and Biophysics, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vytautas Mačiulis
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Justinas Vencius
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Andrius Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
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13
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Han B, Li Q, Chen X. Frailty and postoperative complications in older Chinese adults undergoing major thoracic and abdominal surgery. Clin Interv Aging 2019; 14:947-957. [PMID: 31190780 PMCID: PMC6535429 DOI: 10.2147/cia.s201062] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/25/2019] [Indexed: 01/01/2023] Open
Abstract
Purpose: To determine the association between frailty and postoperative complications in elderly Chinese patients and to determine whether addition of frailty assessment improves the predictive ability of the American Society of Anesthesiologists (ASA) score, Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM), and Estimation of Physiologic Ability and Surgical Stress (E-PASS) score. Patients and methods: A prospective cohort study was conducted in a tertiary hospital. Elderly patients undergoing major thoracic or abdominal surgery were included. Frailty phenotype and ASA, POSSUM, and E-PASS scores were assessed. Demographic, preoperative, and surgical variables were extracted from medical records. Primary outcome measure was in-hospital Clavien-Dindo ≥ grade II complications. Multiple logistic regression was used to examine the association between frailty and complications. Receiver operating characteristic curves were used to explore the predictive ability of frailty. Results: Prevalence of frailty was 26.12%. Significant differences were observed between the frail and non-frail groups with respect to age, Activities of Daily Living, Charlson Comorbidity Index, respiratory function, presence of malignancy, serum albumin, prealbumin, and hemoglobin levels (P<0.05). ASA, POSSUM, and E-PASS scores were higher in the frail group. After adjusting for all covariates, frailty was significantly associated with postoperative complications in hospital [odds ratio: 16.59, 95% CI: 4.56–60.40, P<0.001]. The area under the curve (AUC) for frailty was 0.762 (95% CI: 0.703–0.814). The AUC for ASA, POSSUM, and E-PASS for prediction of complications was 0.751 (95% CI: 0.692–0.804), 0.762 (95% CI: 0.704–0.814), and 0.824 (95% CI: 0.771–0.870), respectively. Addition of frailty assessment increased the AUC to 0.858 (95% CI: 0.808–0.899), 0.842 (95% CI: 0.790–0.885), and 0.854 (95% CI: 0.803–0.896), respectively. Conclusion: Frailty is an effective predictor of postoperative complications in elderly Chinese patients undergoing major thoracic and abdominal surgery. Frailty assessment can improve the predictive ability of current surgical risk assessment tools. Frailty phenotype should be considered perioperatively. Frailty assessment could also expand the scope for nurses to evaluate patients for safety management.
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Affiliation(s)
- Binru Han
- Department of Nursing, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Qiuping Li
- Department of Nursing, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xi Chen
- Department of Nursing, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China
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14
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Lima MJM, Cristelo DFM, Mourão JB. Physiological and operative severity score for the enumeration of mortality and morbidity, frailty, and perioperative quality of life in the elderly. Saudi J Anaesth 2019; 13:3-8. [PMID: 30692881 PMCID: PMC6329238 DOI: 10.4103/sja.sja_275_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) is a validated instrument used to predict morbidity. The aim of our study was to evaluate the performance of the POSSUM score system on predicting perioperative frailty and quality of life (QOL) in elderly surgical patients. Patients and Methods: An observational prospective study was conducted during 3 months. POSSUM was used to determine operative morbidity risk. Patients with a POSSUM score ≥26 were considered as having a high POSSUM (PHP). WHODAS 2.0, EuroQOL-5 dimensions (EQ-5D), Charlson score, and the Clinical Frailty Scale were used to assess the QOL and frailty. Chi-square, Fisher's exact, or Mann–Whitney tests were used for comparisons. Results: Two hundred and thirty-five patients were included. Median age was 69 years; 58% were ASA I/II and 42% ASA III/IV. Frailty was present in 53 patients (23%). Median POSSUM score was 26. Patients PHP were older (median age 71 vs. 68, P = 0.008), more frequently ASA III/IV (P = 0.001), had higher median Charlson scores (7 vs. 5, P = 0.006) and were more frail (49% vs. 26%, P < 0.001). PHP presented more problems in EQ-5D dimensions preoperatively (mobility: 59% vs 41%, P = 0.008; care: 41% vs. 25%, P = 0.013; activity: 52% vs. 32%, P = 0.002; pain: 59% vs. 45%, P = 0.041) but not anxiety (P = 0.137). Three months after surgery, PHP patients presented more problems in mobility: 63% vs. 38%, P < 0.001; care: 48% vs. 31%, P = 0.009; activity: 58% vs. 44%, P = 0.036; pain 59% vs. 37%, P = 0.001 and anxiety: 54% vs. 50%, P = 0.025. Conclusions: Patients PHP were frailer and had worse perioperative QOL.
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Affiliation(s)
| | | | - Joana B Mourão
- Faculty of Medicine, Porto University, Porto, Portugal.,Department of Anaesthesiology, Centro Hospitalar São João, Porto, Portugal
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