Underwent Emergency Laparotomy Research Articles

299 Predictive Performance of NELA Versus P-POSSUM Mortality Scores; Are We Underestimating the Risk of Mortality Following Emergency Laparotomy?

Abstract Aim To compare the performance of NELA and P-POSSUM mortality risk scores in predicting 30-day and 90-day mortality in patients undergoing emergency laparotomy. Method A retrospective cohort study was conducted to compare predicative performance of pre-operative NELA, post-operative NELA and P-POSSUM predicted mortality scores in patients undergoing emergency laparotomy between 2014 and 2021. The outcomes of interest included the observed 30-day and 90-day mortality. The discrimination of the mortality tools was assessed and compared by determining the Area Under the Curve (AUC) for each tool using Receiver Operating Characteristic curve analysis. Results A total of 681 patients were included. The observed risk of 30-day and 90-day mortality were 10.4% (71/681) and 14.2% (97/681), respectively. In terms of 30-day mortality, the AUC was 0.791 (0.727-0.855) for pre-operative NELA score, 0.784 (0.721-0.848) for pre-operative P-POSSUM score, and 0.761 (0.699-0.824) for post-operative NELA score. In terms of 90-day mortality, the AUC was 0.765 (0.708-0.821) for pre-operative NELA score, 0.749 (0.692-0.807) for pre-operative P-POSSUM score, and 0.745 (0.691-0.800) for post-operative NELA score. Observed/Expected ratio for 30-day and 90-day mortality were calculated as 3.25 and 4.43 for pre-operative NELA, 2.81 and 3.84 for pre-operative P-POSSUM, and 2.17 and 2.96 for post-operative NELA, respectively. Pairwise comparisons showed no statistically significant difference in discrimination among the three models. Conclusions Pre-operative NELA, post-operative NELA and P- POSSUM scores underestimated the risk of 30-day and 90-day mortality for patients undergoing emergency laparotomy. No significant difference in predictive performance was found among the three models.

351 A Service Evaluation of Emergency Laparotomy and Total Parenteral Nutrition at a Single Teaching Hospital

Abstract Aim Malnourished patients undergoing emergency general surgery (EGS) have a greater risk of mortality than those not malnourished. There is often a need for nutritional support in EGS. This study investigated the risk factors for total parenteral nutrition (TPN) in patients undergoing emergency laparotomy, and whether there is an association with the NELA risk score. Method A five-year review (June 2016-2021) of the local NELA database and referrals to the Nutrition Support Team was performed. Pre-operative, operative and post-operative data for patients who received TPN and those who did not was collected. Associations between risk factors including NELA score and TPN use were examined using chi squared test and Mann Whitney U, as appropriate. Results There were 931 NELA patients, of which 22.8% (n = 173) received TPN. Intestinal obstruction was the commonest indication for surgery at 51.3% (n = 478) with no difference in age or sex. Despite patients receiving TPN being more likely to be frail (0.004), have higher ASA scores (0.001), lower albumin levels (<0.001), and worse pre- and post-operative NELA scores (both 0.002), stoma formation (0.002) and mortality (<0.001) was half that in patients without TPN. Sub-analysis reveals this was irrespective of when TPN was administered. Conclusions Two mutually exclusive explanations exist. TPN may be a predictor of disease severity and subsequent clinical intervention, or it may indeed improve the nutritional and clinical outcomes in this high risk EGS group. Further studies are needed to clarify this, in addition to the most appropriate method of identifying malnutrition in NELA-eligible patients.

Incidence of Post-laparotomy Acute Kidney Injury Among Abdominal Trauma Patients and Its Associated Risk Factors at King Abdulaziz Medical City, Riyadh.

Background This research study investigates the prevalence of acute kidney injury (AKI) in trauma patients undergoing emergency laparotomies. AKI is a common complication in major surgeries and is associated with various adverse effects. The study aims to explore the relationship between AKI and other comorbidities in this specific context. Methodology This is a retrospective cohort study. All patients who had laparotomy after abdominal trauma at King Abdulaziz Medical City (KAMC) and met the inclusion criteria were included in the study. Nonprobability consecutive sampling was used.Data were collected by chart review using the Best-Care system at KAMC. Descriptive statistics were used to summarize and describe the characteristics of the study participants. Frequencies and percentages were calculated for categorical variables, such as comorbidities. For continuous variables, mean and standard deviations were calculated and tabulated.All statistical calculations were performed using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY, USA). Results This research study included 152 patients who underwent laparotomy, and the majority of patients (146, 96%)did not experience AKI. Several comorbidities were observed, with hypertension and diabetes being the most prevalent at 37 (24.3%) and 35 (23%), respectively. Intraoperative hypotension was experienced by 23 (15.1%) patients, while 129 (84.9%) did not have this issue. Norepinephrine was the most common vasopressor used (25.7%), followed by ephedrine and a combination of norepinephrine and epinephrine. Gender and age groups did not show significant associations with AKI, comorbidities like diabetes, heart failure, and chronic kidney disease (CKD) demonstrated significant relationships with AKI. There was no significant difference in eGFR and serum creatinine baseline levels between patients meeting AKI criteria and those who did not. Conclusions The low overall incidence of AKI in this patient population is encouraging. However, healthcare professionals must be aware of the significant impact of comorbidities such as diabetes, heart failure, and CKD on AKI development. Vigilant monitoring of postoperative kidney function, particularly serum creatinine levels within the first 48 hours, is essential for early detection and timely intervention. By understanding and addressing these risk factors, healthcare providers can take proactive steps to prevent and manage AKI in patients undergoing laparotomy, ultimately leading to improved patient outcomes and reduced healthcare costs.

NELA 1 Sarcopenia versus clinical frailty scale in predicting the risk of postoperative mortality after emergency laparotomy: A retrospective cohort study

Abstract Aims To compare predictive significance of sarcopenia and clinical frailty scale in terms of postoperative mortality in patients undergoing emergency laparotomy. Methods In compliance with STROCSS statement standards a retrospective cohort study with prospective data collection approach was conducted. The study period was between January 2017 and January 2022. All adult patients with non-traumatic acute abdominal pathology who underwent emergency laparotomy in our centre were included. The primary outcome was 30-day mortality and secondary outcomes were in-hospital mortality and 90-day mortality. The predictive value of sarcopenia and clinical frailty scale were compared using the Receiver Operating Characteristic (ROC) curve analysis and multivariable binary logistic regression analysis. Results A total of 1043 eligible patients were included. The risk of 30-day mortality, in-hospital mortality, and 90-day mortality were 8%, 10%, and 11%, respectively. ROC curve analysis suggested that sarcopenia is a significantly stronger predictor of 30-day mortality (AUC: 0.87 vs 0.70, P<0.0001), in-hospital mortality (AUC: 0.79 vs 0.67, P=0.0011), and 90-day mortality (AUC: 0.79 vs 0.67, P=0.0009) compared with clinical frailty scale. Moreover, multivariable binary logistic regression analysis identified sarcopenia as an independent predictor of mortality (coefficient: 4.22119, P<0.0001) but did not identify clinical frailty score as independent predictor (coefficient: 0.066311, P=0.5544). Conclusions Sarcopenia is a stronger predictor of postoperative mortality compared with clinical frailty score in patients undergoing emergency laparotomy. It cancels out the predictive value of clinical frailty scale in multivariable analyses; hence among the two variables, sarcopenia deserves to be included in preoperative predictive tools.

WTP4.6 Assessment of the Over 75’s undergoing Emergency Laparotomy

Abstract Introduction The National Emergency Laparotomy Audit (NELA) 2019 reported 55% of patients undergoing emergency laparotomies were over 65 years old. 19% had formal frailty assessments and 37% had geriatrician input. Due to the multi-morbid nature of frailty this population carry additional surgical and post-operative risk and may require intensive rehabilitation. NELA and The Centre for Preoperative care recommend patients over 65 should have clinical frailty assessments and be reviewed by an MDT with early Care of the Elderly (COE) input. This audit reviewed use of these recommendations at a large District General Hospital (DGH). Methods We performed an audit on all patients over the age of 75 who had an emergency laparotomy between September 2020 to September 2022. We collected data from their admissions, including clinical frailty scores, AMTS and if COE reviews had occurred. Results We collected data on 57 patients. The average age was 82 (75-96), and the average length of stay was 22 (5-80) days. No patients had either clinical frailty or AMTS scores documented. 16% had a COE review. 16% (9) patients died before 30 days. Conclusion The DGH failed to meet the recommendations for frailty assessment and COE input for patients over 75 having an emergency laparotomy. Suggested improvements may include: a referral pathway to prompt elderly care reviews, or the creation of the “general surgery geriatrician” similar to that of ortho-geriatrician role may be of benefit. Documenting clinical frailty assessments could improve patient outcomes, reduce mortality/morbidity, and provide a more holistic patient approach.

SP1.2 Accuracy of NELA score in predicting the risk of mortality following emergency laparotomy in patients aged above and below 80: A cohort study

Abstract Aims To compare accuracy of National Emergency Laparotomy Audit (NELA) score in predicting the risk of mortality following emergency laparotomy in patients aged above and below 80. Methods In compliance with STROCSS statement standards, a retrospective cohort study was conducted. The study period was between January 2017 and January 2022. All adult patients with non-traumatic acute abdominal pathology who underwent emergency laparotomy in two centres were included. The Receiver Operating Characteristic (ROC) curve analysis and Hosmer & Lemeshow test were conducted to evaluate the discrimination and calibration of NELA score in predicting the risk of 30-day mortality in patients aged above and below 80 years. Results A total of 1458 eligible patients were included; 289 patients were aged above 80 with median age of 84 (IQR 81-87) and 1168 patients were aged below 80 with median age of 60 (IQR 46-71). The risk of 30-day mortality was 13.5 % in the above 80 group and 8% in the below 80 group. ROC curve analysis showed that the AUC of NELA score was 0.78 (95% CI 0.73-0.83) in the above 80 group and 0.89 (95% CI 0.87-0.91) in the below 80 group. The score was not well-calibrated for either group. Conclusions The NELA score is less accurate in predicting the risk of mortality following emergency laparotomy in patients aged above 80 compared to younger patients. This may be explained by the fact that it does not take into account the measures of age-related decline in physical status of the patients.

ThTP5.3 Outcome of weekend physiotherapy input post emergency laparotomy

Abstract Aims Early ambulatory has been shown to reduce risk of morbidity and length of stay. It is evident in elective laparotomy patients but there is limited data on emergency laparotomy patients. We aim to explore the outcome of morbidity and physiotherapy input over weekend. Methods Patients ≥18 years old underwent emergency laparotomy (EmLap) as per NELA criteria from July 2021 to Dec 2021 in a busy district hospital were reviewed. Data on demographics, physiotherapy input and morbidity (post-operative ileus and pneumonia) were analysed. P-value of <0.05 was considered significant. Results A total of 81 patients were included with 56% female and median age 69 years. Ratio of smoker: Non-smoker: Ex-smoker was 1:4:1. 74% were seen by physiotherapist over the weekend (POW) and 48% had chest physiotherapy post-operative day 1. The overall rate of post-operative ileus was 18.5% (19% no-POW vs 18.3% POW; p= 0.942) while the rate of post-operative pneumonia was 11.1% with 2/3 non-smoker (9.5% non-POW vs 11.7% POW; p= 0.855). Median post-operative length of stay was 10 days (8 days No-POW vs 11 days POW). Conclusion Physiotherapy input post EmLap over the weekend did not significantly improve morbidity. Weekend input is provided by the oncall physiotherapist and the requirement of the service could reflect the high risk status of patients. Besides physiotherapists, ward nurses play an important role in continuous encouragement of mobilisation post-operative to reduce morbidity rate.

SP1.5 Mortality rate for frail and sarcopenic patients post emergency laparotomy

Abstract Aims Frail patients and sarcopenic patients are predicted to have high morbidity and mortality after undergoing emergency laparotomy (EmLap). However frailty and sarcopenia can be present independently or mutually. We aim to explore the association between 30- day mortality, frailty and sarcopenia. Methods Analysis was performed on a prospectively collected database of EmLap patients ≥40 years in a busy district hospital. Frailty was assessed via Clinical Frailty Score with score ≥4 defined as frail. Sarcopenia was assessed via total psoas index (TPI). TPI is the total L3 psoas area on CT (cm2)/ patient’s height (m2), stratified according to gender with sarcopenia being present in the lowest quartile. Statistical analysis was performed using logistic regression and p value of <0.05 was considered significant. Results 100 patients were included with a median age of 66 years; 59% were female. The overall 30- day mortality rate was 9%. Frailty was present in 49% and within this group, mortality rate was 16.3% (OR 9.76, p= 0.012), 24% were sarcopenic and 30- day mortality was 12.5% (OR 1.57, p= 0.545). 14% of patients were both frail and sarcopenic and the 30- day mortality was 21.4% (OR 3.64, p= 0.080). Conclusion Mortality rate is high in EmLap patients and is higher when patients are both frail and sarcopenic. Frailty and sarcopenia are interlinked and can be improved, hence both should be assessed in all EmLap patients to allow early identification, improvement in shared decision making and development of targeted post-operative interventions to improve EmLap outcomes in this cohort of patients.

SP8.7 Long-term outcomes after stoma siting in emergency surgery – a retrospective multi-centre cohort study

Abstract Pre-operative stoma siting has been shown to reduce stoma-related complications in the elective setting and may improve patient quality of life (QoL). However, there is less evidence regarding the effect of stoma siting in patients undergoing Emergency Laparotomy (EmLap), when stoma siting rates may be lower due to time constraints of emergency surgery. This retrospective multi-centre cohort study aimed to compare the long-term outcomes of patients undergoing EmLap who had pre-operative stoma siting with those who didn’t. A retrospective review of a prospectively maintained database of EmLap patients from 3 hospitals across 2 years (Dec ’19-’21) was performed in Dec ’22. Patients with emergency stoma formation per NELA criteria were included and clinical notes were reviewed, including prospectively maintained follow-up from stoma practitioners. Any patients lost to follow-up within a year were excluded. n=381 patients were identified (Mean age-65years, Median follow up-21 months). n=185(48.6%) were marked for a stoma pre-operatively (89.2% by stoma nurse; 10.8% by surgeon). Those not marked pre-operatively had a higher incidence of 30-day overall morbidity (77% v 67%, p=0.0388), stoma-related skin problems (28.1%v18.9%, p=0.0357), ischaemia/necrosis (16v1%, p<0.005) and muco-cutaneous separation (12v3%, p=0.044). There was no significant difference in stoma-related complications between those marked by a stoma nurse compared with those marked by a surgeon (79.4%v66.7%, p=0.1851). Stoma siting in emergency laparotomy is associated with reduced early stoma complications. There are similar outcomes whether the patient is sited by a stoma CNS or a surgeon. Additional education and training should be aimed at surgeons in order to improve frequency of stoma siting in order to improve patient outcomes.

WTP4.3 A Service Evaluation of Emergency Laparotomy and Total Parenteral Nutrition at a Single Teaching Hospital

Abstract Aims Malnourished patients undergoing emergency general surgery (EGS) have a greater risk of mortality than those not malnourished. There is often a need for nutritional support in EGS. This study investigated the risk factors for total parenteral nutrition (TPN) in patients undergoing emergency laparotomy, and whether there is an association with the NELA risk score. Methods A five-year review (June 2016-2021) of the local NELA database and referrals to the Nutrition Support Team was performed. Pre-operative, operative and post-operative data for patients who received TPN and those who did not was collected. Associations between risk factors including NELA score and TPN use were examined using chi squared test and Mann Whitney U, as appropriate. Results There were 931 NELA patients, of which 22.8% (n=173) received TPN. Intestinal obstruction was the commonest indication for surgery at 51.3% (n=478) with no difference in age or sex. Despite patients receiving TPN being more likely to be frail (0.004), have higher ASA scores (0.001), lower albumin levels (<0.001), and worse pre- and post-operative NELA scores (both 0.002), stoma formation (0.002) and mortality (<0.001) was half that in patients without TPN. Sub-analysis reveals this was irrespective of when TPN was administered. Conclusions Two mutually exclusive explanations exist. TPN may be a predictor of disease severity and subsequent clinical intervention, or it may indeed improve the nutritional and clinical outcomes in this high risk EGS group. Further studies are needed to clarify this, in addition to the most appropriate method of identifying malnutrition in NELA-eligible patients.

SP11.1 A co-ordinated approach to trainee quality improvement projects to reduce mortality and length of stay in patients undergoing emergency laparotomy

Abstract Aim To support trainees in completing specific and achievable quality improvement projects (QIP) that are beneficial to patient care and aligned with clinical priority areas in emergency general surgery. Method A fishbone analysis of factors contributing to poor outcomes in patients undergoing emergency laparotomy was created. From this, key priorities for improvement were identified by a multidisciplinary team, enabling multiple QIP with clear aims to be developed. QIP included National Emergency Laparotomy Audit (NELA) data capture, risk scoring and documentation of mortality, identification and management of sepsis, pre-operative antibiotics, infection prevention and early radiological imaging. QIP were allocated to groups of trainees comprising of at least one foundation doctor, one core trainee and one specialty registrar. Mortality and length of stay data was collected over 6 months using the run charts for the hospital site available at data.nela.org. Results In 6 months, 9 QIP were started, with the first cycle of data collected in all projects and 3 projects completed by trainees. Initial QIP results have been presented locally for 5 projects and 2 QIP have been presented nationally, thus supporting completion of ARCP requirements and specialty job applications, as well as the sharing of outcomes. Although not statistically significant a downwards trend in length of stay and mortality has also been observed. Conclusion Having a focused and co-ordinated approach to quality improvement with clear aims and objectives can support training and improve patient outcomes. Further study is required to assess the sustainability and longevity of these results.

ThTP5.10 A clinical audit of assessment of the risk of malnutrition and the subsequent nutritional support prescribed for older emergency laparotomy patients

Abstract Aims Patients should have assessment of the risk for malnutrition on admission using a Malnutrition Universal Screening Tool (MUST) and this should trigger a response if patients are categorised as high risk (National Institute for Health Care and Excellence, 2017). This clinical audit sought to identify if older patients undergoing emergency laparotomy were identified as at risk of malnutrition with subsequent interventions to address protein and energy deficiencies. Methods Patients entered onto the National Emergency Laparotomy Audit (NELA) database who were over 65 years of age during 1/1/21 to 31/12/22 were included. The patient records were screened for the MUST score on admission and whether nutritional supplementation was prescribed, or dietetic referral made, following the recording of a high-risk MUST score. Results Three hundred patients were included in the audit with 99.3% of the patients having a MUST score recorded on admission. One hundred and fourteen patients recorded a high MUST score, with 35% of the high MUST patients not receiving a dietetic review and 24% receiving neither oral nor parenteral supplementation. Mortality at 30 days was 13.9%. The wide variety of supplementation prescribed was changed to a protein and energy-based supplement upon dietetic review. Conclusions MUST scores are available to surgical teams, but high-risk scores do not always trigger an intervention to address deficiencies in older NELA patients. A protocol to ensure consistent approaches to supplementation before dietetic review would reduce variation and education of prescribers is needed to address the importance of prescribing protein-based supplements is needed.

Poor outcomes in patients with sepsis undergoing emergency laparotomy and laparoscopy are attenuated by faster time to care measures.

Emergency laparotomy and laparoscopy (EmLap) are amongst the commonest surgical procedures, with high prevalence of sepsis and hence poorer outcomes. However, whether time taken to receive care influences outcomes in patients requiring antibiotics for suspected infection remains largely unexplored. The aim of this work was to determine whether (1) time to care contributes to outcome differences between patients with and without suspected infection and (2) its impact on outcomes only amongst those with suspected infection. Clinical information was retrospectively obtained from the 2017-2018 Emergency Laparotomy and Laparoscopic Scottish Audit (ELLSA). Time to care referred to six temporal variables describing radiological investigation, anaesthetic triage and surgical management. Outcome measures [mortality, readmission, hospital death, postoperative destination and length of stay (LoS)] were compared using adjusted and unadjusted regression analyses to determine whether the outcome differences could be explained by faster or slower time to care. Amongst 2243 EmLap patients [median age 65 years (interquartile range 51-75 years), 51.1% female], 892 (39.77%) received antibiotics for suspected infection. Although patients with suspected infection had faster time to care (all p ≤ 0.001) and worse outcomes compared with those who did not, outcome differences were not statistically significant when accounted for time (all p > 0.050). Amongst those who received antibiotics, faster time to care was also associated with decreased risk of postoperative intensive care unit (ICU) stay and shorter LoS (all p < 0.050). Worse outcomes associated with infection in EmLap patients were attenuated by faster time to care, which additionally reduced the LoS and ICU stay risk amongst those with suspected infection.

Mortality in Patients Undergoing Emergency Laparotomy and its comparison with Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity Scoring

Objective: To evaluate the role of physiological and operative severity score for the enumeration of mortality and morbidity in predicting mortality in patients undergoing emergency laparotomy. Study Design: Prospective Comparative study. Place and Duration of Study: General Surgical Ward 1 and 2, Combined Military Hospital, Rawalpindi, from Jan to Aug, 2018. Methodology: Adult patients between 12 and 60 years of age admitted from Emergency Department in Surgical ward who underwent emergency laparotomy within 48 hours of admission were enrolled in the study. Physiological and operative scores were measured for Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity and predicted mortality calculated. Patients were stratified into three groups according to the predicted mortality. Patients were then followed up 30 days post-operatively and mortality noted. Observed to predicted (O:P) mortality was calculated. Results: A total of 94 patients were enrolled out of which 85 were followed up. All patients were male with a mean age of 56.5±16 years. Most common indication for surgery was intestinal obstruction and gut perforation. Mean duration of admission was 7.97±3.5 days. Out of 85 patients 13 patients died within 30 days of surgery which equals a crude mortality rate of 15.2%. Observed to predicted mortality ratio (O:P) was 0.65. Conclusion: Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity slightly overpredicted the mortality in or study. Still it is a useful tool in risk stratification of patients according to expected outcome and...

Development and validation of a prognostic model for death 30 days after adult emergency laparotomy.

The probability of death after emergency laparotomy varies greatly between patients. Accurate pre-operative risk prediction is fundamental to planning care and improving outcomes. We aimed to develop a model limited to a few pre-operative factors that performed well irrespective of surgical indication: obstruction; sepsis; ischaemia; bleeding; and other. We derived a model with data from the National Emergency Laparotomy Audit for patients who had emergency laparotomy between December 2016 and November 2018. We tested the model on patients who underwent emergency laparotomy between December 2018 and November 2019. There were 4077/40,816 (10%) deaths 30 days after surgery in the derivation cohort. The final model had 13 pre-operative variables: surgical indication; age; blood pressure; heart rate; respiratory history; urgency; biochemical markers; anticipated malignancy; anticipated peritoneal soiling; and ASA physical status. The predicted mortality probability deciles ranged from 0.1% to 47%. There were 1888/11,187 deaths in the test cohort. The scaled Brier score, integrated calibration index and concordance for the model were 20%, 0.006 and 0.86, respectively. Model metrics were similar for the five surgical indications. In conclusion, we think that this prognostic model is suitable to support decision-making before emergency laparotomy as well as for risk adjustment for comparing organisations.

Surgical Apgar Score can accurately predict the severity of post-operative complications following emergency laparotomy

BackgroundThe 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.ObjectiveTo determine the accuracy of Surgical Apgar Score in predicting the severity of post-operative complications among patients undergoing emergency laparotomy at Muhimbili National Hospital.MethodsA 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.ResultsOut 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.ConclusionThis study has demonstrated that SAS can accurately predict the occurrence of complications following emergency laparotomy at Muhimbili National Hospital.

Weekend effect in emergency laparotomy: a propensity score-matched analysis.

The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients. A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity-score matched analysis was used to remove potential confounding patient characteristics. Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464). These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect.

Validation of the NELA risk prediction model in emergency abdominal surgery.

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.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care.

This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. Experts in aspects of management of high-risk and emergency general surgical patients 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 on each item 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 (GRADE) 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. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. 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.