Risk-Adjusted Analysis of Patients Undergoing Emergency Laparotomy Using POSSUM and P-POSSUM Score: A Prospective Study

Comparative evaluation of P-POSSUM and NELA scores in predicting 30-day mortality following emergency laparotomy: A prospective observational study

Objective

Emergency laparotomy carries a 10-18% mortality risk, influenced by factors such as age, medical conditions, and sarcopenia. Scoring models like the Portsmouth physiological and operative severity score (P-POSSUM) and the National Emergency Laparotomy Audit (NELA) have been developed to predict outcomes and assist decision-making. Both models are widely used, but their effectiveness in predicting outcomes, particularly in the Indian context, requires further evaluation. This study aimed to compare the P-POSSUM and NELA scores in predicting 30-day mortality for patients undergoing emergency laparotomy.

Material and Methods

This single-institution prospective observational study included 238 adult patients of age ≥18 years undergoing emergency laparotomy for acute abdominal conditions, following ethical approval. P-POSSUM and NELA scores were calculated preoperatively, and their predictive accuracy was evaluated by comparing predicted versus observed mortality using sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve.

Results

The NELA area under the curve was 0.699, while the P-POSSUM area under the curve was 0.687. NELA demonstrated higher sensitivity (73.9%) and specificity (45.6%) than P-POSSUM, which had a sensitivity of 52.2% and specificity of 27.4%. P-POSSUM and NELA scores were significantly higher in patients requiring intensive care unit admission than in those who did not.

Conclusion

Our study found that the NELA score outperforms the P-POSSUM score in predicting 30-day mortality in emergency laparotomy patients, indicating that NELA is a more reliable tool for preoperative risk stratification and clinical decision-making.

Development and validation of an EHR-based risk prediction model for geriatric patients undergoing urgent and emergency surgery

BACKGROUND

Clinical determination of patients at high risk of poor surgical outcomes is complex and may be supported by clinical tools to summarize the patient's own personalized electronic health record (EHR) history and vitals data through predictive risk models. Since prior models were not readily available for EHR-integration, our objective was to develop and validate a risk stratification tool, named the Assessment of Geriatric Emergency Surgery (AGES) score, predicting risk of 30-day major postoperative complications in geriatric patients under consideration for urgent and emergency surgery using pre-surgical existing electronic health record (EHR) data.

METHODS

Patients 65-years and older undergoing urgent or emergency non-cardiac surgery within 21 hospitals 2017-2021 were used to develop the model (randomly split: 80% training, 20% test). The primary outcome was a 30-day composite outcome including several postoperative major complications and mortality; secondary outcomes included common individual complications included in the primary composite outcome (sepsis, progressive renal insufficiency or renal failure, and mortality). Patients' EHR-based clinical history, vital signs, labs, and demographics were included in logistic regression, LASSO, decision tree, Random Forest, and XGBoost models. Area under the receiver operating characteristics curve (AUCROC) was used to compare model performance.

RESULTS

Overall, 66,262 patients (median [IQR] age 78 [(70.9-84.0], female 53.9%, White race 68.5%) received urgent or emergency non-cardiac surgery (25.7% orthopedic cases, 21.9% general surgery cases). AUCROC ranged from 0.655 (Decision Tree) - 0.804 (XGBoost) for the primary composite outcome. XGBoost AUCROC was 0.823, 0.781, and 0.839 in predicting outcomes of sepsis, progressive renal insufficiency or renal failure, and mortality, respectively.

CONCLUSIONS

We developed a model to accurately predict major postoperative complications in geriatric patients undergoing urgent or emergency surgery using the patient's own existing EHR data. EHR implementation of this model could efficiently support clinicians' surgical risk assessment and perioperative decision-making discussions in this vulnerable patient population.

Revisiting Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) Scores: Are They Valid in Cases of Ileal Perforation?

Introduction Ileal perforation due to typhoid is common in tropical countries, and the ensuing secondary peritonitis is treated by resuscitation and surgery. The Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) was developed to predict postoperative outcomes to overcome systemic obstacles in any healthcare setup and is considered fairly accurate. The Portsmouth-POSSUM (P-POSSUM) score was developed as a corrective scoring system for overestimations made by the POSSUM score vis-à-vis mortality. Our study aimed to examine the validity of these two scores in the postoperative prediction of surgical outcomes in patients with ileal perforation. Materials and methods An observational study involving 40 patients diagnosed with ileal perforations was undertaken over 18 months. The postoperative outcome for each patient was calculated as per the POSSUM and P-POSSUM parameters. Statistical analysis was done using SPSS (IBM Corp., Armonk, NY) and the results were tabulated. Results We found that age, gender, respiratory dysfunction, propensity for multiple surgeries, duration of surgery, co-morbidities, underlying malignancy, and systolic blood pressure played a significant role in determining postoperative outcomes. Haemoglobin, potassium, and urea levels were also found to be significantly associated with outcome. Cardiac signs, pulse, white blood cell count, Glasgow Coma Scale score, sodium, and electrocardiography, part of the physiological score parameters, were found to be insignificant in the prediction of postoperative outcomes. Among the intraoperative parameters, peritoneal soiling was found to be insignificant. Conclusion Some parameters inherent to POSSUM and P-POSSUM calculations appear to bear no statistical significance to the final score, highlighting that these need to be revisited and perhaps modified to further simplify the calculation. The POSSUM score is an excellent predictor of postoperative morbidity and mortality in ileal perforation patients but is of questionable reliability due to its tendency to overestimate them. P-POSSUM has a better predictive power of postoperative mortality by correcting POSSUM mortality overestimation.

Emergency hernia repair in the elderly: multivariate analysis of morbidity and mortality from an Italian registry

PURPOSE

The incidence of inguinal hernia is higher in elderly because of aging-related diseases like prostatism, bronchitis, collagen laxity. A conservative management is common in elderly to reduce surgery-related risks, however watchful waiting can expose to obstruction and strangulation. The aim of the present study was to assess the impact of emergency surgery in a large series of elderly with complicated groin hernia and to identify the independent risk factors for postoperative morbidity and mortality. The predictive performance of prognostic risk scores has been also assessed.

METHODS

This is a prospective observational study carried out between January 2017 and June 2018 in elderly patients who underwent emergency surgery for complicated hernia in 38 Italian hospitals. Pre-operative, surgical and postoperative data were recorded for each patient. ASA score, Charlson's comorbidity index, P-POSSUM and CR-POSSUM were assessed.

RESULTS

259 patients were recruited, mean age was 80 years. A direct repair without mesh was performed in 62 (23.9%) patients. Explorative laparotomy was performed in 56 (21.6%) patients and bowel resection was necessary in 44 (17%). Mortality occurred in seven (2.8%) patients. Fifty-five (21.2%) patients developed complications, 12 of whom had a major one. At univariate and multivariate analyses, Charlson's comorbidity index ≥ 6, altered mental status, and need for laparotomy were associated with major complications and mortality CONCLUSION: Emergency surgery for complicated hernia is burdened by high morbidity and mortality in elderly patients. Preoperative comorbidity played a pivotal role in predicting complications and mortality and therefore Charlson's comorbidity index could be adopted to select patients for elective operation.

Morbimortality assessment in abdominal surgery: are we predicting or overreacting?

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.

Audit of pain management following emergency laparotomies in cancer patients: A prospective observational study from an Indian tertiary care hospital

Background:

Emergency laparotomies present a challenge in pain management given sick patients, odd timings and poor outcomes. Current recommendations favour multimodal opioid-sparing analgesia following elective laparotomies. No recommendation exists for emergency surgeries.

Methodology:

After approval and registration of the trial, adult patients posted for emergency laparotomy in the hospital (tertiary centre for cancer care) starting August 2015, for 6 months, were included in this prospective study. Patients' details including indication for emergency surgery, preoperative haemodynamic parameters, baseline coagulation status were captured. Patients were followed for pain scores, satisfaction with pain management and outcome. The number of anaesthesiologists present and their experience concerning regional techniques were noted.

Results:

Intestinal obstruction was the commonest cause of emergency laparotomy. Most patients belonged to the ASA IE/IIE class (91%). Intraoperatively, opioids were the mainstay of pain management with an epidural catheter inserted in only 9% of cases even though most cases were conducted by anaesthesiologists confident/expert in thoracic epidural insertion. There was no correlation of choice of pain management technique with the time of surgery (P = 0.22), ASA grading (P = 0.28), predicted mortality by p-Possum scores (P = 0.24). Pain at movement was moderate-severe in more than 50% of patients within the first 24 h. The regional group had better satisfaction when compared to opioid and non-opioid based management. (P < 0.001).

Conclusion:

Regional techniques for pain management in emergency laparotomies are less preferred, therefore, opioids are the mainstay. Lack of experience is essentially not the primary reason for regional techniques not gaining popularity. Pain management in this group needs a thorough re-evaluation.