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Hatewar A, Mahakalkar C, Kshirsagar S, Dixit S, Reddy S. Navigating Life Post-emergency Laparotomy: A Narrative Review on Quality-of-Life Outcomes. Cureus 2024; 16:e60583. [PMID: 38894770 PMCID: PMC11184536 DOI: 10.7759/cureus.60583] [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] [Received: 05/09/2024] [Accepted: 05/18/2024] [Indexed: 06/21/2024] Open
Abstract
An emergency laparotomy is a life-saving surgical procedure performed to address acute abdominal conditions. While crucial for immediate survival, this procedure can have significant long-term implications for patients' quality of life. This comprehensive review examines the physical, psychological, and social outcomes following emergency laparotomy, highlighting the importance of addressing quality-of-life concerns in this patient population. Key findings reveal that patients may experience complications, psychological distress, and challenges in social functioning post-procedure. Age, gender, and access to support networks influence outcomes. Recommendations for clinical practice include routine assessment of quality of life, multidisciplinary care, and patient education. Further research is needed to understand predictors of poor outcomes and evaluate interventions to improve quality of life post-emergency laparotomy. Healthcare providers can enhance patient care and outcomes in this vulnerable population by addressing these issues.
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Affiliation(s)
- Akansha Hatewar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Chanrashekhar Mahakalkar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shivani Kshirsagar
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sparsh Dixit
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Srinivasa Reddy
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Hajibandeh S, Hajibandeh S, Hughes I, Mitra K, Puthiyakunnel Saji A, Clayton A, Alessandri G, Duncan T, Cornish J, Morris C, O'Reilly D, Kumar N. Development and Validation of HAS (Hajibandeh Index, ASA Status, Sarcopenia) - A Novel Model for Predicting Mortality After Emergency Laparotomy. Ann Surg 2024; 279:501-509. [PMID: 37139796 DOI: 10.1097/sla.0000000000005897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVES To develop and validate a predictive model to predict the risk of postoperative mortality after emergency laparotomy taking into account the following variables: age, age ≥ 80, ASA status, clinical frailty score, sarcopenia, Hajibandeh Index (HI), bowel resection, and intraperitoneal contamination. SUMMARY BACKGROUND DATA The discriminative powers of the currently available predictive tools range between adequate and strong; none has demonstrated excellent discrimination yet. METHODS The TRIPOD and STROCSS statement standards were followed to protocol and conduct a retrospective cohort study of adult patients who underwent emergency laparotomy due to non-traumatic acute abdominal pathology between 2017 and 2022. Multivariable binary logistic regression analysis was used to develop and validate the model via two protocols (Protocol A and B). The model performance was evaluated in terms of discrimination (ROC curve analysis), calibration (calibration diagram and Hosmer-Lemeshow test), and classification (classification table). RESULTS One thousand forty-three patients were included (statistical power = 94%). Multivariable analysis kept HI (Protocol-A: P =0.0004; Protocol-B: P =0.0017), ASA status (Protocol-A: P =0.0068; Protocol-B: P =0.0007), and sarcopenia (Protocol-A: P <0.0001; Protocol-B: P <0.0001) as final predictors of 30-day postoperative mortality in both protocols; hence the model was called HAS (HI, ASA status, sarcopenia). The HAS demonstrated excellent discrimination (AUC: 0.96, P <0.0001), excellent calibration ( P <0.0001), and excellent classification (95%) via both protocols. CONCLUSIONS The HAS is the first model demonstrating excellent discrimination, calibration, and classification in predicting the risk of 30-day mortality following emergency laparotomy. The HAS model seems promising and is worth attention for external validation using the calculator provided. HAS mortality risk calculator https://app.airrange.io/#/element/xr3b_E6yLor9R2c8KXViSAeOSK .
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Affiliation(s)
- Shahab Hajibandeh
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Shahin Hajibandeh
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Ioan Hughes
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Kalyan Mitra
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | | | - Amy Clayton
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - Giorgio Alessandri
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Trish Duncan
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Julie Cornish
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Chris Morris
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - David O'Reilly
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Nagappan Kumar
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
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Pinto MY, Frois AO, Weber D. A Retrospective Cohort Study on One-Year Mortality Following Emergency Laparotomy: A Tertiary Centre Experience From Western Australia. Cureus 2023; 15:e50718. [PMID: 38234926 PMCID: PMC10792340 DOI: 10.7759/cureus.50718] [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: 12/17/2023] [Indexed: 01/19/2024] Open
Abstract
Background Emergency laparotomy is a common general surgical procedure associated with a high mortality and morbidity profile. While short-term outcomes following emergency laparotomy have been increasingly described, there remains a paucity of literature on long-term outcomes in Australia. We report our one-year mortality following emergency laparotomy at Royal Perth Hospital, Australia. Methodology A retrospective observational series of emergency laparotomies performed during 2019 and 2020 at Royal Perth Hospital was collected. The primary endpoint is the one-year mortality, and the secondary endpoints are patient demography, COVID-19 status, ASA classification, surgical category, operative indication, primary surgical pathology, procedure and surgical duration, ICU stay, post-operative destination, length of stay, 30-day mortality, and 90-day mortality. Subgroup analysis was performed for years 2019 and 2020. Results A total of 272 emergency laparotomies were performed during the two-year study period. The average age was 61 years (range 18- 98, SD ± 18.32). The majority of patients were in the ASA classification III (n= 134, 49.26%). The average length of patients' stay was 14.17 days (median 10, IQR 11). Moreover, 31.98% of patients were admitted directly to the ICU following emergency laparotomy. One year mortality was 16.6%. However, a significant difference in the long-term mortality rates was observed between the two calendar years, 24.6% in 2019 and 8.66% in 2020. The one-month mortality rate was 7.33%, and the three-month mortality rate was 10.85%. Conclusion The one-year mortality rate observed is high and considerable and similar to experiences published elsewhere. The significant reduction in mortality during the study period warrants further investigation and may reflect improved planning and attitudes around these high-risk surgeries.
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Affiliation(s)
| | - Ashley O Frois
- Department of General Surgery, Royal Perth Hospital, Perth, AUS
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, AUS
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Kokotovic D, Jensen TK. Acute abdominal pain and emergency laparotomy: bundles of care to improve patient outcomes. Br J Surg 2023; 110:1594-1596. [PMID: 37449877 DOI: 10.1093/bjs/znad224] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Dunja Kokotovic
- Department of Gastrointestinal Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Thomas Korgaard Jensen
- Department of Gastrointestinal Surgery, Copenhagen University Hospital Herlev, Herlev, Denmark
- Emergency Research Group (EMERGE) Copenhagen, Copenhagen University Hospital Herlev, Herlev, Denmark
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Isand KG, Hussain S, Sadiqi M, Kirsimägi Ü, Bond-Smith G, Kolk H, Saar S, Lepner U, Talving P. Frailty Assessment Can Enhance Current Risk Prediction Tools in Emergency Laparotomy: A Retrospective Cohort Study. World J Surg 2023; 47:2688-2697. [PMID: 37589793 DOI: 10.1007/s00268-023-07140-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE We set out to assess the performance of the P-POSSUM and NELA risk prediction tool (NELA RPT), and hypothesized that combining them with the Clinical Frailty Scale (CFS) would significantly improve their performance. Emergency laparotomy (EL) is a high-risk surgical intervention, particularly for elderly patients with marked comorbidities and frailty. Accurate risk prediction is crucial for appropriate resource allocation, clinical decision making, and informed consent. Although patient frailty is a significant risk factor, the current risk prediction tools fail to take frailty into account. METHODS In this retrospective single-center cohort study, we analyzed all cases entered into the NELA database from the Oxford University Hospitals between 01.01.2018 and 15.06.2021. We analyzed the performance of the P-POSSUM and NELA RPT. Both tools were modified by adding the CFS to the model. RESULTS The discrimination of both the P-POSSUM and NELA RPT was good, with a slightly worse performance in the elderly. Adding CFS into the P-POSSUM and NELA RPT models improved both tools in the elderly [AUC from 0.775 to 0.846 (p < 0.05) from 0.814 to 0.864 (p < 0.05), respectively]. The improvement of the NELA RPT across all age groups did not reach statistical significance. The CFS grade was associated with 30-day mortality in patients aged > 65 years. However, in younger patients, this effect was less marked than in the elderly. CONCLUSION Our analysis demonstrated a significant improvement in the P-POSSUM and NELA risk models when combined with the CFS. Frailty also increases the 30-day mortality after EL in younger individuals.
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Affiliation(s)
- Karl G Isand
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia.
| | - Shoaib Hussain
- Oxford University Hospitals NHS Trust Surgical Emergency Unit, Oxford, UK
| | - Maseh Sadiqi
- Oxford University Hospitals NHS Trust Surgical Emergency Unit, Oxford, UK
| | - Ülle Kirsimägi
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Giles Bond-Smith
- Oxford University Hospitals NHS Trust Surgical Emergency Unit, Oxford, UK
| | - Helgi Kolk
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Sten Saar
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Urmas Lepner
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
| | - Peep Talving
- Faculty of Medicine, Tartu University, Sütiste Tee 19, 13419, Tallinn, Tartu, Estonia
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Dunlop RAN, Van Zundert A. A systematic review of predictive accuracy via c-statistic of preoperative frailty tests for extended length of stay, post-operative complications, and mortality. Saudi J Anaesth 2023; 17:575-580. [PMID: 37779562 PMCID: PMC10540983 DOI: 10.4103/sja.sja_358_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 10/03/2023] Open
Abstract
Frailty, as an age-related syndrome of reduced physiological reserve, contributes significantly to post-operative outcomes. With the aging population, frailty poses a significant threat to patients and health systems. Since 2012, preoperative frailty assessment has been recommended, yet its implementation has been inhibited by the vast number of frailty tests and lack of consensus. Since the anesthesiologist is the best placed for perioperative care, an anesthesia-tailored preoperative frailty test must be simple, quick, universally applicable to all surgeries, accurate, and ideally available in an app or online form. This systematic review attempted to rank frailty tests by predictive accuracy using the c-statistic in the outcomes of extended length of stay, 3-month post-operative complications, and 3-month mortality, as well as feasibility outcomes including time to completion, equipment and training requirements, cost, and database compatibility. Presenting findings of all frailty tests as a future reference for anesthesiologists, Clinical Frailty Scale was found to have the best combination of accuracy and feasibility for mortality with speed of completion and phone app availability; Edmonton Frailty Scale had the best accuracy for post-operative complications with opportunity for self-reporting. Finally, extended length of stay had too little data for recommendation of a frailty test. This review also demonstrated the need for changing research emphasis from odds ratios to metrics that measure the accuracy of a test itself, such as the c-statistic.
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Affiliation(s)
- Richard A. N. Dunlop
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital and The University of Queensland, Brisbane, QLD, Australia
| | - André Van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital and The University of Queensland, Brisbane, QLD, Australia
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Hansted AK, Storm N, Burcharth J, Diasso PDK, Ninh M, Møller MH, Vester-Andersen M. Validation of the NELA risk prediction model in emergency abdominal surgery. Acta Anaesthesiol Scand 2023; 67:1194-1201. [PMID: 37353882 DOI: 10.1111/aas.14294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 05/25/2023] [Accepted: 05/28/2023] [Indexed: 06/25/2023]
Abstract
Risk prediction models are frequently used to identify high-risk patients undergoing emergency laparotomy. The National Emergency Laparotomy Audit (NELA) developed a risk prediction model specifically for emergency laparotomy patients, which was recently updated. In this study, we validated the updated NELA model in an external population. Furthermore, we compared it with three other risk prediction models: the original NELA model, the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) model, and the American Society of Anesthesiologists Physical Status (ASA-PS). We included adult patients undergoing emergency laparotomy at Zealand University Hospital, from March 2017 to January 2019, and Herlev Hospital, from November 2017 to January 2020. Variables included in the risk prediction models were collected retrospectively from the electronic patient records. Discrimination of the risk prediction models was evaluated with area under the curve (AUC) statistics, and calibration was assessed with Cox calibration regression. The primary outcome was 30-day mortality. Out of 1226 included patients, 146 patients (11.9%) died within 30 days. AUC (95% confidence interval) for 30-day mortality was 0.85 (0.82-0.88) for the updated NELA model, 0.84 (0.81-0.87) for the original NELA model, 0.81 (0.77-0.84) for the P-POSSUM model, and 0.76 (0.72-0.79) for the ASA-PS model. Calibration showed underestimation of mortality risk for both the updated NELA, original NELA and P-POSSUM models. The updated NELA risk prediction model performs well in this external validation study and may be used in similar settings. However, the model should only be used to discriminate between low- and high-risk patients, and not for prediction of individual risk due to underestimation of mortality.
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Affiliation(s)
- Anna K Hansted
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital-Herlev Hospital, Copenhagen, Denmark
| | - Nicolas Storm
- Department of Surgery, Copenhagen University Hospital-Herlev Hospital, Copenhagen, Denmark
| | - Jakob Burcharth
- Department of Surgery, Copenhagen University Hospital-Herlev Hospital, Copenhagen, Denmark
- Department of Surgery, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Pernille D K Diasso
- Department of Surgery, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mian Ninh
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital-Herlev Hospital, Copenhagen, Denmark
| | - Morten H Møller
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital-Herlev Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott MJ. Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient. World J Surg 2023; 47:1881-1898. [PMID: 37277506 PMCID: PMC10241556 DOI: 10.1007/s00268-023-07039-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
- Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Research Department of Targeted Intervention, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, S 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anaesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Kaiser Permanente Research, Department of Research & Evaluation, 100 South Los Robles Ave, 2nd Floor, Pasadena, CA 91101 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Queen’s Medical Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, Queen’s Medical Centre, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, School of Medical Sciences, Orebro University Hospital, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine, and Department of Anesthesiology, Weill-Cornell Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
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Kyaruzi VM, Chamshama DE, Khamisi RH, Akoko LO. Surgical Apgar Score can accurately predict the severity of post-operative complications following emergency laparotomy. BMC Surg 2023; 23:194. [PMID: 37415104 DOI: 10.1186/s12893-023-02088-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND The Surgical Apgar Score (SAS) describes a feasible and objective tool for predicting surgical outcomes. However, the accuracy of the score and its correlation with the complication severity has not been well established in many grounds of low resource settings. OBJECTIVE To determine the accuracy of Surgical Apgar Score in predicting the severity of post-operative complications among patients undergoing emergency laparotomy at Muhimbili National Hospital. METHODS A prospective cohort study was conducted for a period of 12 months; patients were followed for 30 days, the risk of complication was classified using the Surgical Apgar Score (SAS), severity of complication was estimated using the Clavien Dindo Classification (CDC) grading scheme and Comprehensive Complication Index (CCI). Spearman correlation and simple linear regression statistic models were applied to establish the relationship between Surgical Apgar Score (SAS) and Comprehensive Complication Index (CCI). The Accuracy of SAS was evaluated by determining its discriminatory capacity on Receiver Operating Characteristics (ROC) curve, data normality was tested by Shapiro-Wilk statistic 0.929 (p < 0.001).Analysis was done using International Business Machine Statistical Product and Service Solution (IBM SPSS) version 27. RESULTS Out of the 111 patients who underwent emergency laparotomy, 71 (64%) were Male and the median age (IQR) was 49 (36, 59).The mean SAS was 4.86 (± 1.29) and the median CCI (IQR) was 36.20 (26.2, 42.40). Patients in the high-risk SAS group (0-4) were more likely to experience severe and life-threatening complications, with a mean CCI of 53.3 (95% CI: 47.2-63.4), compared to the low-risk SAS group (7-10) with a mean CCI of 21.0 (95% CI: 5.3-36.2). A negative correlation was observed between SAS and CCI, with a Spearman r of -0.575 (p < 0.001) and a regression coefficient b of -11.5 (p < 0.001). The SAS demonstrated good accuracy in predicting post-operative complications, with an area under the curve of 0.712 (95% CI: 0.523-0.902, p < 0.001) on the ROC. CONCLUSION This study has demonstrated that SAS can accurately predict the occurrence of complications following emergency laparotomy at Muhimbili National Hospital.
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Affiliation(s)
- Victor Meza Kyaruzi
- Department of General Surgery, Muhimbili University of Health and Allied Science, Dar Es Salaam, Tanzania.
| | - Douglas E Chamshama
- Department of General Surgery, Muhimbili National Hospital, Dar Es Salaam, Tanzania
| | - Ramadhani H Khamisi
- Department of General Surgery, Muhimbili University of Health and Allied Science, Dar Es Salaam, Tanzania
| | - Larry O Akoko
- Department of General Surgery, Muhimbili University of Health and Allied Science, Dar Es Salaam, Tanzania
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Kokkinakis S, Kritsotakis EI, Paterakis K, Karali GA, Malikides V, Kyprianou A, Papalexandraki M, Anastasiadis CS, Zoras O, Drakos N, Kehagias I, Kehagias D, Gouvas N, Kokkinos G, Pozotou I, Papatheodorou P, Frantzeskou K, Schizas D, Syllaios A, Palios IM, Nastos K, Perdikaris M, Michalopoulos NV, Margaris I, Lolis E, Dimopoulou G, Panagiotou D, Nikolaou V, Glantzounis GK, Pappas-Gogos G, Tepelenis K, Zacharioudakis G, Tsaramanidis S, Patsarikas I, Stylianidis G, Giannos G, Karanikas M, Kofina K, Markou M, Chrysos E, Lasithiotakis K. Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy. J Trauma Acute Care Surg 2023; 94:847-856. [PMID: 36726191 DOI: 10.1097/ta.0000000000003904] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Accurate preoperative risk assessment in emergency laparotomy (EL) is valuable for informed decision making and rational use of resources. Available risk prediction tools have not been validated adequately across diverse health care settings. Herein, we report a comparative external validation of four widely cited prognostic models. METHODS A multicenter cohort was prospectively composed of consecutive patients undergoing EL in 11 Greek hospitals from January 2020 to May 2021 using the National Emergency Laparotomy Audit (NELA) inclusion criteria. Thirty-day mortality risk predictions were calculated using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), NELA, Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM), and Predictive Optimal Trees in Emergency Surgery Risk tools. Surgeons' assessment of postoperative mortality using predefined cutoffs was recorded, and a surgeon-adjusted ACS-NSQIP prediction was calculated when the original model's prediction was relatively low. Predictive performances were compared using scaled Brier scores, discrimination and calibration measures and plots, and decision curve analysis. Heterogeneity across hospitals was assessed by random-effects meta-analysis. RESULTS A total of 631 patients were included, and 30-day mortality was 16.3%. The ACS-NSQIP and its surgeon-adjusted version had the highest scaled Brier scores. All models presented high discriminative ability, with concordance statistics ranging from 0.79 for P-POSSUM to 0.85 for NELA. However, except the surgeon-adjusted ACS-NSQIP (Hosmer-Lemeshow test, p = 0.742), all other models were poorly calibrated ( p < 0.001). Decision curve analysis revealed superior clinical utility of the ACS-NSQIP. Following recalibrations, predictive accuracy improved for all models, but ACS-NSQIP retained the lead. Between-hospital heterogeneity was minimum for the ACS-NSQIP model and maximum for P-POSSUM. CONCLUSION The ACS-NSQIP tool was most accurate for mortality predictions after EL in a broad external validation cohort, demonstrating utility for facilitating preoperative risk management in the Greek health care system. Subjective surgeon assessments of patient prognosis may optimize ACS-NSQIP predictions. LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level II.
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Affiliation(s)
- Stamatios Kokkinakis
- From the Department of General Surgery (S.K., K.P., G.-A.K., V.M., A.K., M.P., E.C., K.L.), University Hospital of Heraklion, University of Crete, School of Medicine; Laboratory of Biostatistics, University of Crete, School of Medicine (E.I.K.); Department of Surgical Oncology, University Hospital of Heraklion, University of Crete, School of Medicine (C.S.A., O.Z.), Heraklion; Department of Surgery, University General Hospital of Patras, School of Medicine (N.D., I.K., D.K.), University of Patras, Patras, Greece; Department of Surgery, General Hospital of Nicosia, School of Medicine (N.G., G.K., I.P., P.P., K.F.), University of Cyprus, Nicosia, Cyprus; First Department of Surgery (D.S., A.S.) and Second Propaedeutic Department of Surgery (I.M.P.), Laikon General Hospital, National and Kapodistrian University of Athens; Department of Surgery, University General Hospital Attikon, School of Medicine (K.N., M.P., N.V.M., I.M.), University of Athens, Athens; Department of Surgery (E.L., G.D.), General Hospital of Volos, Volos, Greece; Department of Surgery (D.P., V.N.), General Hospital of Trikala, Trikala; Department of Surgery (G.K.G., G.P.-G., K.T.), University Hospital of Ioannina, Ioannina, Greece; Department of Surgery, Ippokrateion General Hospital of Thessaloniki, School of Medicine (G.Z., S.T., I.P.), Aristotle University of Thessaloniki, Thessaloniki; Second Department of Surgery (G.S., G.G.), Evangelismos General Hospital, Athens; and Department of Surgery, University General Hospital of Alexandroupolis, School of Medicine (M.K., K.K., M.M.), University of Thrace, Alexandroupolis, Greece
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O’Connor T, MacKenzie L, Clarke RW, Bradburn M, Wilson TR, Lee MJ. Screening for malnutrition in emergency laparotomy patients: a comparison of three tools. Ann R Coll Surg Engl 2023; 105:413-421. [PMID: 36541125 PMCID: PMC10149256 DOI: 10.1308/rcsann.2022.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 05/02/2023] Open
Abstract
INTRODUCTION Malnourished patients undergoing emergency laparotomy are at risk of significant morbidity. The optimum screening tool to identify such patients in practice and research is yet to be determined. This study aims to compare the performance of three nutrition risk tools in predicting time without enteral nutrition in this population. METHODS A prospective cohort study (NCT04696367) was conducted across two sites, recruiting patients undergoing National Emergency Laparotomy Audit eligible procedures. Data collected included demographics, diagnosis, procedure and outcomes. Nutrition risk was assessed using three tools: Malnutrition Universal Screening Tool (MUST) score, Nutritional Risk Index (NRI) and Nutritional Risk Score 2002 (NRS-2002). Complications were assessed with the Comprehensive Complication Index. Quality of life was measured at baseline and 5 days postsurgery using EQ-5D-5L. RESULTS A total of 59 patients were recruited. Median age was 69 years. Of the 59 participants, 23 were judged high risk using MUST score, 13 using NRS and 8 using NRI. Median time to restart enteral intake was 7 days (interquartile range 7-14). Time without intake was correlated with increasing score using MUST (r=0.463, p<0.001) and NRS-2002 (r=0.296, p=0.03) but not NRI (r=-0.121, p=0.38). High-risk nutritional groups also had increased length of hospital stay, but not complication scores. CONCLUSIONS Patients undergoing emergency laparotomy spend a prolonged time without enteral nutrition. Although all nutritional tools demonstrated some propensity to identify patients at higher risk of needing nutritional support, their performance was variable. Nevertheless, some may be useful in future clinical studies.
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Affiliation(s)
- T O’Connor
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | - L MacKenzie
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
| | - RW Clarke
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, UK
| | - M Bradburn
- Clinical Trials Research Unit, University of Sheffield, UK
| | - TR Wilson
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, UK
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12
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Darbyshire AR, Kostakis I, Meredith P, Toh SKC, Prytherch D, Briggs J. Novel predictors of mortality in emergency bowel surgery: a single-centre cohort study. Anaesthesia 2023; 78:561-570. [PMID: 36723442 DOI: 10.1111/anae.15966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 02/02/2023]
Abstract
Pre-operative risk stratification is a key part of the care pathway for emergency bowel surgery, as it facilitates the identification of high-risk patients. Several novel risk scores have recently been published that are designed to identify patients who are frail or significantly unwell. They can also be calculated pre-operatively from routinely collected clinical data. This study aimed to investigate the ability of these scores to predict 30-day mortality after emergency bowel surgery. A single centre cohort study was performed using our local data from the National Emergency Laparotomy Audit database. Further data were extracted from electronic hospital records (n = 1508). The National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score were then calculated. The most abnormal National or Laboratory Decision Tree Early Warning Score in the 24 or 72 h before surgery was used in analysis. Individual scores were reasonable predictors of mortality (c-statistic 0.699-0.740) but all were poorly calibrated. A National Early Warning Score ≥ 4 was associated with a high overall mortality rate (> 10%). A logistic regression model was developed using age, National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score as predictor variables, and its performance compared with other established risk models. The model demonstrated good discrimination and calibration (c-statistic 0.827) but was marginally outperformed by the National Emergency Laparotomy Audit score (c-statistic 0.861). All other models compared performed less well (c-statistics 0.734-0.808). Pre-operative patient vital signs, blood tests and markers of frailty can be used to accurately predict the risk of 30-day mortality after emergency bowel surgery.
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Affiliation(s)
- A R Darbyshire
- Department of General Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - I Kostakis
- Research Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - P Meredith
- Research Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - S K C Toh
- Department of General Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - D Prytherch
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, UK
| | - J Briggs
- Centre for Healthcare Modelling and Informatics, University of Portsmouth, UK
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Connell L. NELA Risk Calculator Significantly Underestimates Mortality Risk of Laparotomy for Mesenteric and Colonic Ischaemia in Older Adult Surgical Patients. OPEN ACCESS SURGERY 2023. [DOI: 10.2147/oas.s401635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
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Mathiszig-Lee JF, Catling FJR, Moonesinghe SR, Brett SJ. Highlighting uncertainty in clinical risk prediction using a model of emergency laparotomy mortality risk. NPJ Digit Med 2022; 5:70. [PMID: 35676451 PMCID: PMC9177766 DOI: 10.1038/s41746-022-00616-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractClinical prediction models typically make point estimates of risk. However, values of key variables are often missing during model development or at prediction time, meaning that the point estimates mask significant uncertainty and can lead to over-confident decision making. We present a model of mortality risk in emergency laparotomy which instead presents a distribution of predicted risks, highlighting the uncertainty over the risk of death with an intuitive visualisation. We developed and validated our model using data from 127134 emergency laparotomies from patients in England and Wales during 2013–2019. We captured the uncertainty arising from missing data using multiple imputation, allowing prospective, patient-specific imputation for variables that were frequently missing. Prospective imputation allows early prognostication in patients where these variables are not yet measured, accounting for the additional uncertainty this induces. Our model showed good discrimination and calibration (95% confidence intervals: Brier score 0.071–0.078, C statistic 0.859–0.873, calibration error 0.031–0.059) on unseen data from 37 hospitals, consistently improving upon the current gold-standard model. The dispersion of the predicted risks varied significantly between patients and increased where prospective imputation occurred. We present a case study that illustrates the potential impact of uncertainty quantification on clinical decision making. Our model improves mortality risk prediction in emergency laparotomy and has the potential to inform decision-makers and assist discussions with patients and their families. Our analysis code was robustly developed and is publicly available for easy replication of our study and adaptation to predicting other outcomes.
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Wu XL, Shen J, Danzeng CD, Xu XS, Cao ZX, Jiang W. CT psoas calculations on the prognosis prediction of emergency laparotomy: a single-center, retrospective cohort study in eastern Asian population. World J Emerg Surg 2022; 17:31. [PMID: 35655215 PMCID: PMC9164461 DOI: 10.1186/s13017-022-00435-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/25/2022] [Indexed: 12/01/2022] Open
Abstract
Background Emergency laparotomy (EL) has a high mortality rate. Clinically, frail patients have a poor tolerance for EL. In recent years, sarcopenia has been used as an important indicator of frailty and has received much attention. There have been five different calculation methods of psoas for computed tomography (CT) to measure sarcopenia, but lack of assessment of these calculation methods in Eastern Asian EL patients. Methods We conducted a 2-year retrospective cohort study of patients over 18 years of age who underwent EL in our institution. Five CT measurement values (PMI: psoas muscle index, PML3: psoas muscle to L3 vertebral body ratio, PMD: psoas muscle density, TPG: total psoas gauge, PBSA: psoas muscle to body face area ratio) were calculated to define sarcopenia. Patients with sarcopenia defined by the sex-specific lowest quartile of each measurement were compared with the rest of the cohort. The primary outcome was "ideal outcome", defined as: (1) No postoperative complications of Clavien-Dindo Grade ≥ 4; (2) No mortality within 30 days; (3) When discharged, no need for fluid resuscitation and assisted ventilation, semi-liquid diet tolerated, and able to mobilize independently. The second outcome was mortality at 30-days. Multivariate logistic regression and receiver operating characteristic (ROC) analysis were used. Results Two hundred and twenty-eight patients underwent EL met the inclusion criteria, 192 (84.2%) patients had an ideal outcome after surgery; 32 (14%) patients died within 30 days. Multivariate analysis showed that, except PMD, each calculation method of psoas was independently related to clinical outcome (ideal outcome: PML3, P < 0.001; PMI, P = 0.001; PMD, P = 0.157; TPG, P = 0.006; PBSA, P < 0.001; mortality at 30-days: PML3, P < 0.001; PMI, P = 0.002; PMD, P = 0.088; TPG, P = 0.002; PBSA, P = 0.001). In ROC analysis, the prediction model containing PML3 had the largest area under the curve (AUC) value (AUC value = 0.922 and 0.920, respectively). Conclusion The sarcopenia determined by CT psoas measurements is significantly related to the clinical outcome of EL. The calculation of CT psoas measurement is suitable for application in outcome prediction of EL. In the future, it is necessary to develop a scoring tool that includes sarcopenia to evaluate the risk of EL better. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00435-x.
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Affiliation(s)
- Xiao-Lin Wu
- Department of Gastrointestinal Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Av., Wuhan, 430030, Hubei, People's Republic of China
| | - Jie Shen
- Department of Gastrointestinal Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Av., Wuhan, 430030, Hubei, People's Republic of China
| | - Ci-Dian Danzeng
- Department of Gastrointestinal Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Av., Wuhan, 430030, Hubei, People's Republic of China
| | - Xiang-Shang Xu
- Department of Gastrointestinal Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Av., Wuhan, 430030, Hubei, People's Republic of China
| | - Zhi-Xin Cao
- Department of Gastrointestinal Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Av., Wuhan, 430030, Hubei, People's Republic of China
| | - Wei Jiang
- Department of Gastrointestinal Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Av., Wuhan, 430030, Hubei, People's Republic of China.
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Mercer SJ, Body S, Carter NC, Van Boxel GI, Knight BC. Outcomes of emergency laparoscopy in the elderly. Ann R Coll Surg Engl 2022; 104:356-360. [PMID: 34981994 PMCID: PMC10335205 DOI: 10.1308/rcsann.2021.0205] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 04/20/2024] Open
Abstract
INTRODUCTION This paper assessed the association between operative approach and postoperative in-hospital mortality in elderly patients undergoing emergency abdominal surgery. Patients undergoing emergency laparotomy have high morbidity and mortality rates. One-third of patients requiring emergency surgery are over 75 years old, and their in-hospital mortality rate exceeds 17%. Fewer than 20% of emergency abdominal operations in the UK are attempted laparoscopically, and only 10% are completed laparoscopically. Little is known about how laparoscopic emergency surgery in the elderly might affect outcomes. METHODS An observational UK study was performed using the prospectively maintained National Emergency Laparotomy Audit (NELA) database. Operative approach, NELA risk-prediction score and in-hospital mortality were recorded. The effect of operative approach on in-hospital mortality was analysed, both on a national basis and in a high-volume laparoscopic centre. RESULTS A total of 47,667 patients were included in the study, of whom 15,068 were over 75 years of age. Nationally, surgery was completed by the laparoscopic approach in 7.8% of patients aged over 75; both crude mortality (9.2%) and risk-adjusted mortality (7.1%) were significantly reduced (p<0.0001). In our unit, surgery was completed laparoscopically in 48.4% of patients aged over 75; both crude mortality (6.6%) and risk-adjusted mortality (3.3%) were significantly reduced (p<0.0001). CONCLUSION Laparoscopy in emergency surgery has been shown in this study to significantly reduce in-hospital mortality in elderly patients and should be embraced in every centre dealing with emergency abdominal surgery.
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Affiliation(s)
- SJ Mercer
- Portsmouth Hospitals University NHS Trust, UK
| | - S Body
- Portsmouth Hospitals University NHS Trust, UK
| | - NC Carter
- Portsmouth Hospitals University NHS Trust, UK
| | | | - BC Knight
- Portsmouth Hospitals University NHS Trust, UK
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17
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Short- and long-term impact of sarcopenia on outcomes after emergency laparotomy: A systematic review and meta-analysis. Surgery 2022; 172:436-445. [DOI: 10.1016/j.surg.2022.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/15/2022] [Accepted: 02/22/2022] [Indexed: 12/29/2022]
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Barazanchi A, Bhat S, Wells CI, Taneja A, MacCormick AD, Hill AG. Short and long-term impact of sarcopenia on outcomes from emergency laparotomy. Eur J Trauma Emerg Surg 2022; 48:3869-3878. [PMID: 34999902 DOI: 10.1007/s00068-021-01833-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Emergency laparotomy (EL) carries a high risk of morbidity and mortality, that is greater among older patients. Sarcopenia refers to an age- or pathology-associated muscle loss and has been demonstrated to correlate with poorer outcomes in several surgical conditions. This study assessed the impact of sarcopenia on morbidity and mortality in elderly patients undergoing EL. METHODS Patients aged ≥ 65 years-old undergoing EL between May 2012-June 2017 with a pre-operative abdominal computerised tomography (CT) scan at Middlemore Hospital (New Zealand) were included. Psoas and Skeletal Muscle Index (PMI and SMI) were calculated from abdominal CT measurements after standardisation based on height. Validated cut-offs for sarcopenia were used. Frailty was estimated using the 11-point modified frailty index (mFI). The primary outcome was 30-day, 1-year, and 4-year post-operative mortality. Secondary outcomes included correlations between mFI and sarcopenic measures, unplanned readmissions, and post-operative complications. RESULTS A total of 167 patients (84 sarcopenic; 83 non-sarcopenic) were included. Sarcopenic and non-sarcopenic patients had similar 30-day (14.2 vs. 12.0%; p = 0.84), 1-year (23.8 vs. 25.3%; p = 0.96), and 4-year (39.3 vs. 47.0%; p = 0.40) mortality rates following an EL. Survivors had a higher mean PMI at 1-year (p = 0.0078) and 4-year (p = 0.013) but not 30-day (p = 0.40) follow-up. Sarcopenia performed poorly in discriminating between 30-day (AUC 0.51) and 1-year (AUC 0.53) mortality. The mFI did not correlate with PMI (p = 0.85) nor SMI (p = 0.18). Rates of readmissions and post-operative complications did not differ between sarcopenic and non-sarcopenic cohorts. CONCLUSION Sarcopenia does not provide useful short-term prognostic information in elderly EL patients.
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Affiliation(s)
- Ahmed Barazanchi
- Department of Surgery, University of Auckland, Auckland, New Zealand.
- General Surgery Department, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia.
| | - Sameer Bhat
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Cameron Iain Wells
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Ashish Taneja
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Andrew Donald MacCormick
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Surgery, Counties Manukau Health, Auckland, New Zealand
| | - Andrew Graham Hill
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Surgery, Counties Manukau Health, Auckland, New Zealand
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Madrazo Z, Osorio J, Videla S, Sainz B, Rodríguez-González A, Campos A, Santamaría M, Pelegrina A, González-Serrano C, Aldeano A, Sarriugarte A, Gómez-Díaz CJ, Ruiz-Luna D, García-Ruiz-de-Gordejuela A, Gómez-Gavara C, Gil-Barrionuevo M, Vila M, Clavell A, Campillo B, Millán L, Olona C, Sánchez-Cordero S, Medrano R, López-Arévalo CA, Pérez-Romero N, Artigau E, Calle M, Echenagusia V, Otero A, Tebé C, Pallarès N, Biondo S. P-POSSUM as mortality predictor in COVID-19-infected patients submitted to emergency digestive surgery. A retrospective cohort study. Int J Surg 2021; 96:106171. [PMID: 34774727 PMCID: PMC8580568 DOI: 10.1016/j.ijsu.2021.106171] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND COVID-19 infection is associated with a higher mortality rate in surgical patients, but surgical risk scores have not been validated in the emergency setting. We aimed to study the capacity for postoperative mortality prediction of the P-POSSUM score in COVID-19-positive patients submitted to emergency general and digestive surgery. MATERIAL AND METHODS Consecutive patients undergoing emergency general and digestive surgery from March to June 2020, and from March to June 2019 in 25 Spanish hospitals were included in a retrospective cohort study. MAIN OUTCOME 30-day mortality. P-POSSUM discrimination was quantified by the area under the curve (AUC) of ROC curves; calibration was assessed by linear regression slope (β estimator); and sensitivity and specificity were expressed as percentage and 95% confidence interval (CI). RESULTS 4988 patients were included: 177 COVID-19-positive; 2011 intra-pandemic COVID-19-negative; and 2800 pre-pandemic. COVID-19-positive patients were older, with higher surgical risk, more advanced pathologies, and higher P-POSSUM values (1.79% vs. 1.09%, p < 0.001, in both the COVID-19-negative and control cohort). 30-day mortality in the COVID-19-positive, intra-pandemic COVID-19-negative and pre-pandemic cohorts were: 12.9%, 4.6%, and 3.2%. The P-POSSUM predictive values in the three cohorts were, respectively: AUC 0.88 (95% CI 0.81-0.95), 0.89 (95% CI 0.87-0.92), and 0.91 (95% CI 0.88-0.93); β value 0.97 (95% CI 0.74-1.2), 0.99 (95% CI 0.82-1.16), and 0.78 (95% CI 0.74-0.82); sensitivity 83% (95% CI 61-95), 91% (95% CI 84-96), and 89% (95% CI 80-94); and specificity 81% (95% CI 74-87), 76% (95% CI 74-78), and 80% (95% CI 79-82). CONCLUSION The P-POSSUM score showed a good predictive capacity for postoperative mortality in COVID-19-positive patients submitted to emergency general and digestive surgery.
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Affiliation(s)
- Zoilo Madrazo
- Department of Surgery, Hospital Universitari de Bellvitge, L'Hospitalet del Llobregat, Barcelona, Spain Clinical Research Support Unit (HUB-IDIBELL), Clinical Pharmacology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain Department of Surgery, Complejo Hospitalario de Navarra, Pamplona, Spain Department of Surgery, Donostia University Hospital, San Sebastian, Spain Department of Surgery, Parc Taulí Health Corporation, Sabadell Hospital, Sabadell, Spain Department of Surgery, Arnau de Vilanova University Hospital, Lleida, Spain Department of Surgery, Hospital del Mar University Hospital, Barcelona, Spain Department of Surgery. Basurto University Hospital, Bilbao, Spain Department of Surgery, Granollers General Hospital, Granollers, Spain Department of Surgery, Cruces University Hospital, Bilbao, Spain Department of Surgery, Althaia Foundation, Manresa, Spain Department of Surgery, Terrassa Health Consortium, Terrassa Hospital, Terrassa, Spain General Surgery Department, Vall d'Hebrón University Hospital, Barcelona, Spain Hepatobiliopancreatic Surgery and Transplantation Department, Vall d'Hebrón University Hospital, Barcelona, Spain Department of Surgery, Viladecans Hospital, Viladecans, Spain Department of Surgery, Mataró Hospital, Maresme Health Consortium, Mataró, Spain Department of Surgery, Germans Trias i Pujol University Hospital, Badalona, Spain Department of Surgery, Sant Joan de Deu Hospital Foundation, Martorell, Spain Department of Surgery, Dr. José Molina Orosa Hospital, Lanzarote, Spain Department of Surgery, Joan XXIII University Hospital, Tarragona, Spain Department of Surgery, Igualada University Hospital, Anoia Health Consortium, Igualada, Spain Department of Surgery, Sant Pau University Hospital, Barcelona, Spain Department of Surgery. Moisès Broggi Hospital, Sant Joan Despí, Spain Department of Surgery, Mútua de Terrassa University Hospital, Terrassa, Spain Department of Surgery, Girona Dr.Josep Trueta University Hospital, Girona, Spain Department of Surgery, Alto Deba Hospital, Mondragon, San Sebastián, Spain Department of Surgery, Araba University Hospital, Txagorritxu Hospital, Vitoria, Spain Clinical Research Support Unit, Bellvitge University Hospital/Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet del Llobregat, Barcelona, Spain Biostatistics Unit of the Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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One-Year Outcomes Following Emergency Laparotomy: A Systematic Review. World J Surg 2021; 46:512-523. [PMID: 34837122 DOI: 10.1007/s00268-021-06385-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Emergency laparotomies (EL) are associated with significant morbidity and mortality. To date, 30-day mortality has been predominately reported, and been the focus of various national emergency laparotomy audits. Only a few studies have reported on the long-term mortality associated with EL. The aim of this study was to review the one-year mortality following EL. METHOD A systematic review was conducted using PRISMA guidelines to identify studies published in the last 10 years reporting on long-term mortality associated with EL. The data abstracted included: patient demographics, pathology or type of operation performed for EL, post-operative mortality at 7-day, 30-day, 90-day, 1-year, beyond 1-year and inpatient, functional outcomes and risk factors associated with mortality. A quality assessment of included studies was performed. RESULTS Fifteen studies reporting long-term outcomes associated with EL were identified, including the results of 48,023 patients. The indications and/or pathologies for ELs varied. The 30-day mortality after EL ranged from 5.3% to 21.8%, and the one-year mortality ranged from 15.1 to 47%. The mortality in the six studies focusing on elderly patients ranged from 30 to 47%. CONCLUSION The long-term mortality rate associated with EL is substantial. Further study is required to understand the 1-year mortality described in the studies and translate these findings for meaningful application into the clinical care of these patients.
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Choong JX, McIlveen E, Quasim T, Moug SJ. Decision making in emergency laparotomy: the role of predicted life expectancy. BJS Open 2021; 5:6388194. [PMID: 34633437 PMCID: PMC8504444 DOI: 10.1093/bjsopen/zrab090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/16/2021] [Indexed: 11/14/2022] Open
Abstract
Introduction Increasing numbers of older patients are undergoing emergency laparotomy (EL). They are at increased risk of adverse outcomes, making the shared decision on whether to operate challenging. This retrospective cohort study aimed to assess the role of age and life-expectancy predictions on short- and long-term survival in patients undergoing EL. Methods All patients who underwent EL at one hospital in the West of Scotland between March 2014 to December 2016 were included. Clinical parameters were collected, and patients were followed up to allow reporting of 30-, 60- and 90-day and 1-year mortality rates. Period life expectancy was used to stratify patients into below life expectancy (bLEP) and at-or-above life expectancy (aLEP) groups at presentation. Remaining life expectancy was used to calculate the net years of life gained (NYLG). Results Some 462 patients underwent EL: 20 per cent in the aLEP group. These patients were older (P < 0.001), had more co-morbidities (P < 0.001) and were high risk on P-POSSUM scoring (P = 0.008). The 30-, 60- and 90-day and 1-year mortality rates were 11, 14, 16 and 23 per cent respectively. Advanced age (P = 0.011) and high ASA score (P = 0.004) and P-POSSUM score (P < 0.001) were independent predictors of death at 1 year on multivariable analysis. The cohort NYLG were 19.2 years. Comparing patients aged less than 70 with those aged 70 years or older, the NYLG were 25.9 versus 5.5 years. Comparing bLEP and aLEP, the NYLG were 22.2 versus 4.4 years. In patients aged 70 years and older, NYLG decreased by more than half in patients with co-morbidities (ASA score 3,4,5) (9.3 versus 4.3 years). Conclusion Discussions around long-term outcomes after emergency surgery remain difficult. Although age is an influencing factor, predicted life expectancy alone does not provide additional value to shared decision making.
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Affiliation(s)
- J X Choong
- Department of Undergraduate Medicine, School of Medicine, University of Glasgow, University Avenue, Glasgow, UK
| | - E McIlveen
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK
| | - T Quasim
- Department of Anaesthesia, Critical Care and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - S J Moug
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK.,School of Medicine, Dentistry and Nursing, University of Glasgow, Royal Alexandra Hospital, Paisley, UK
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Risk factors of surgical mortality in patients with Clostridium difficile colitis. A novel scoring system. Eur J Trauma Emerg Surg 2021; 48:2013-2022. [PMID: 34480588 DOI: 10.1007/s00068-021-01769-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 08/09/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The purpose of the study is to identify the risk factors of mortality and develop a risk scoring system in patients who underwent colectomy due to Clostridium difficile colitis (CD-C). METHODS Patient information was extracted using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from 2012 to 2016. All adult patients who underwent colectomy for CD-C were included in the study. The data were split into training and testing data sets. A multiple logistic regression model was developed by backward deletion methods for risk assessment. To test the performance of the prediction model for 30-day mortality, a receiver operating characteristic (ROC) curve was generated and an area under the curve (AUC) was created. RESULTS The training data set consisted of 434 (80%) patients, and the testing data set consisted of 91 (20%) patients. The overall mortality was 35%. No significant differences were found between the training and testing data sets for patient characteristics, comorbidities and mortality. The final model of the logistic regression model revealed a highly significant 30-day mortality for an age of ≥ 75 years old, ventilator dependency, Septic shock prior to surgery and a history of steroid use. The AUC value was 0.745 (95% CI 0.660-0.826). The risk of mortality scores range from 0 to 37. The highest score of 37 was related to an 83.9% predicted mortality. CONCLUSION Older age, septic shock, ventilator dependency requiring supportive care and a history of chronic steroid use were highly associated with mortality. A nomogram showing the scores and their relationship to mortality may provide guidance to point of care physicians for deciding the goal of care. LEVEL OF EVIDENCE Level of evidence: IV.
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What is the Accuracy of the ACS-NSQIP Surgical Risk Calculator in Emergency Abdominal Surgery? A Meta-Analysis. J Surg Res 2021; 268:300-307. [PMID: 34392184 DOI: 10.1016/j.jss.2021.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/12/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator provides an estimation of 30-d post-operative complications including mortality. This tool has the potential to both aid in decision-making for patients and their families and also in optimizing the clinical management of high-risk patients. However, it's utility in patients requiring emergency abdominal surgery has shown to be inconsistent outside of NSQIP participating institutions. This study undertook a meta-analysis to assess the calculator's accuracy in predicting mortality in these patients. METHODS A literature search of PubMed, Medline and Cochrane databases was conducted between October 2019 to April 2020. The PubMed, Medline and Cochrane Databases were searched for relevant studies. The search strategy included studies from January 2013 to April 2020. Studies including elective surgery were excluded. A random effects model was used and fitted using restricted maximum likelihood estimation. The O:E ratio was used to validate the calculator's accuracy in predicting mortality. RESULTS Six studies were included in the meta-analysis, with a total of 1835 patients undergoing emergency intra-abdominal surgery. The summary estimate of the O:E ratio of the ACS-NSQIP surgical risk calculator in predicting 30-d post-operative mortality was 1.06 (95% CI 0.74-1.51). There was significant heterogeneity between studies with a Cochrane Q of 11.96 (P = 0.04) and I2 = 57.5%. CONCLUSIONS The ACS-NSQIP surgical risk calculator is a reliable predictor of mortality in this external cohort and has potential to be utilised in the multi-disciplinary care of patients undergoing emergency abdominal surgery.
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Bang Foss N, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott M. Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization. World J Surg 2021; 45:1272-1290. [PMID: 33677649 PMCID: PMC8026421 DOI: 10.1007/s00268-021-05994-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology and Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620, Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Huddinge Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Department of Surgery and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jeniffer S. Kim
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital & School of Medical Sciences, Örebro University, 701 85 Örebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital / Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054 USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 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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Fagan G, Barazanchi A, Coulter G, Leeman M, Hill AG, Eglinton TW. New Zealand and Australia emergency laparotomy mortality rates compare favourably to international outcomes: a systematic review. ANZ J Surg 2021; 91:2583-2591. [PMID: 33506977 DOI: 10.1111/ans.16563] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 12/16/2020] [Accepted: 12/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Almost 20 000 people undergo an emergency laparotomy each year in New Zealand and Australia. Common indications include small and large bowel obstruction, and intestinal perforation. Considered a high-risk procedure, emergency laparotomy is associated with significantly high morbidity and mortality. The aim of this review was to identify and compare 30-day, 90-day and 1-year mortality rates following emergency laparotomy in New Zealand and Australia. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Electronic searches were performed in Medline, Embase, PubMed and Scopus in April 2020. RESULTS Thirty-three papers met the inclusion criteria. Studies ranged in size from 58 to 75 280 patients. Weighted mean 30-day mortality was 8.40% (8.39-8.41). Mortality rates increased with longer postoperative follow up with 90-day weighted mortality rate of 14.14% (14.13-14.15) and the weighted mortality rate at 1 year of 24.60% (24.56-24.66). There was significant variability in mortality rates between countries. CONCLUSION There is a wide variability of 30-day, 90-day and 1-year mortality rates internationally. Lowering postoperative mortality rates following emergency laparotomy through quality improvement initiatives could result in up to 120 lives in New Zealand and over 250 lives in Australia being saved each year. The continued work of the Australian and New Zealand Emergency Laparotomy Audit - Quality Improvement is crucial to improving emergency laparotomy mortality rates further in New Zealand and Australia.
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Affiliation(s)
- Georgina Fagan
- Department of Surgery, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Ahmed Barazanchi
- Department of Surgery, University of Auckland, Middlemore Hospital, Auckland, New Zealand
| | - Grant Coulter
- Department of Surgery, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Matthew Leeman
- Department of Surgery, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Andrew G Hill
- Department of Surgery, University of Auckland, Middlemore Hospital, Auckland, New Zealand
| | - Tim W Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Christchurch, New Zealand
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