A calculator for mortality following emergency general surgery based on the American College of Surgeons National Surgical Quality Improvement Program database

Extent of resection and underlying liver disease influence the accuracy of the preoperative risk assessment with the American College of Surgeons Risk Calculator

BACKGROUND

Liver surgery is associated with a significant risk of postoperative complications, depending on the extent of liver resection and the underlying liver disease. Therefore, adequate patient selection is crucial. This study aimed to assess the accuracy of the American College of Surgeons Risk Calculator (ACS-RC) by considering liver parenchyma quality and the type of liver resection.

METHODS

Patients who underwent open or minimally invasive liver resection for benign or malignant indications between January 2019 and March 2023 at the University Hospital Basel were included. Brier score and feature importance analysis were performed to investigate the accuracy of the ACS-RC.

RESULTS

A total of 376 patients were included in the study, 214 (57%) who underwent partial hepatectomy, 89 (24%) who underwent hemihepatectomy, and 73 (19%) who underwent trisegmentectomy. Most patients had underlying liver diseases, with 143 (38%) patients having fibrosis, 75 patients (20%) having steatosis, and 61 patients (16%) having cirrhosis. The ACS-RC adequately predicted surgical site infection (Brier score of 0.035), urinary tract infection (Brier score of 0.038), and death (Brier score of 0.046), and moderate accuracy was achieved for serious complications (Brier score of 0.216) and overall complications (Brier score of 0.180). Compared with the overall cohort, the prediction was limited in patients with cirrhosis, fibrosis, and steatosis and in those who underwent hemihepatectomy and trisegmentectomy. The inclusion of liver parenchyma quality improved the prediction accuracy.

CONCLUSION

The ACS-RC is a reliable tool for estimating 30-day postoperative morbidity, particularly for patients with healthy liver parenchyma undergoing partial liver resection. However, accurate perioperative risk prediction should be adjusted for underlying liver disease and extended liver resections.

Comparison of Acute Physiology and Chronic Health Evaluation (APACHE) II and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) scoring system in predicting postoperative mortality in patients undergoing emergency laparotomy: A retrospective study

Background and Aims

There is paucity of studies on preoperative risk assessment tools in patients undergoing emergency surgery. The present study evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and American Society of Anesthesiologists (ASA) physical status (PS) classification system in patients undergoing emergency exploratory laparotomy.

Methods

This retrospective study included 60 adult patients who underwent emergency exploratory laparotomy for perforation peritonitis. The clinical details, ASA PS classification, laboratory investigations and postoperative course of patients were retrieved from their medical records. Based on these details, APACHE II and ACS-NSQIP were calculated for the patients. The study's primary outcome was the accuracy of the preoperative APACHE II, ACS-NSQIP risk calculator and ASA PS class in predicting the postoperative 30-day mortality of patients.

Results

The area under the curve (AUC) of APACHE II, ACS-NSQIP score, and ASA PS classification for mortality 30 days after surgery was 0.737, 0.694 and 0.601, respectively. The P value for the Hosmer-Lemeshow (H-L) test of scoring systems was 0.05, 0.25 and 0.05, respectively. AUC for postoperative complications was 0.799 for APACHE II, 0.683 for ACS-NSQIP and 0.601 for ASA PS classification. H-L test of these scoring systems for complications after surgery revealed P values of 0.62, 0.36 and 0.53, respectively.

Conclusion

Compared to the ACS-NSQIP and ASA PS classification system, the APACHE II score has a better discriminative ability for postoperative complications and mortality in adult patients undergoing emergency exploratory laparotomy.

EGS plus: Predicting futility in LVAD patients with emergency surgical disease

BACKGROUND

While emergent, non-cardiac surgery can be safely performed in LVAD patients, the inherent perioperative challenges of these rare procedures and the perception that these patients may be poor surgical candidates can contribute to reluctance to perform necessary emergency general surgery (EGS) procedures. We, therefore, sought to identify predictors of inpatient mortality to assist perioperative decision-making.

METHODS

The Nationwide Inpatient Sample (2010-2015Q3) was used to identify patients with previously placed LVADs with a subsequent EGS admission diagnosis. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day mortality, and a risk-adjusted probability of death was calculated for significant patient subgroups across age. Additional demographic variables were included in the regression due to clinical relevance.

RESULTS

There were 1805 (weighted) LVAD-EGS patients with an overall mortality rate of 11%. Independent predictors of mortality were intestinal ischemia and sepsis present on admission. Patients older than 70 with sepsis had an 80% probability of in-hospital mortality (10.6 OR, 1.70-65.5 95% CI) while those over 70 presenting with intestinal ischemia had a 38% probability of death (3.6 OR, 1.50-8.78 95% CI). Mortality risk for younger patients with sepsis was still approximately 50%.

CONCLUSION

Older LVAD patients presenting with either sepsis or intestinal ischemia have a substantial mortality risk while younger patients have a modest risk. These results can be used to guide treatment discussions when emergency surgery is being considered in LVAD patients.

A novel machine learning approach to identify social risk factors associated with textbook outcomes after surgery

BACKGROUND

Identifying social determinants of health has become a priority for many researchers, health care providers, and payers. The vast amount of patient and population-level data available on social determinants creates, however, both an opportunity and a challenge as these data can be difficult to synthesize and analyze.

METHODS

Medicare beneficiaries who underwent 1 of 4 common operations between 2013 and 2017 were identified. Using a machine learning algorithm, the primary independent variable, surgery social determinants of health index, was derived from 15 common, publicly available social determents of health measures. After development of a surgery social determinants of health index, multivariable logistic regression was used to estimate the association of this index with textbook outcomes, as well as the component metrics of textbook outcomes.

RESULTS

A novel surgery social determinants of health index was developed with factor component weights that varied relative to their impact on postoperative outcomes. Factors with the highest weight in the algorithm relative to postoperative outcomes were the proportion of noninstitutionalized civilians with a disability and persons without high school diploma, while components with the lowest weights were the proportion of households with more people than rooms and persons below poverty. Overall, an increase in surgery social determinants of health index was associated with 6% decreased odds (95% confidence interval: 0.93-0.94) of achieving a textbook outcome. In addition, an increase in surgery social determinants of health index was associated with increased odds of each of the individual components of textbook outcome; ranging from 3% increased odds (95% confidence interval: 1.03-1.04) for 90-day readmission to 10% increased odds (95% confidence interval: 1.09-1.11) for 90-day mortality. Further, there was 6% increased odds (95% confidence interval: 1.05-1.07) of experiencing a complication and 7% increased odds (95% confidence interval: 1.06-1.07) of having an extended length of stay. Minority patients from a high surgery social determinants of health index had 38% lower odds (95% confidence interval: 0.60-0.65) of achieving a textbook outcome compared with White/non-Hispanic patients from a low surgery social determinants of health index area.

CONCLUSION

Using a machine learning approach, we developed a novel social determents of health index to predict the probability of achieving a textbook outcome after surgery.

Outcomes in patients requiring intensive care unit (ICU) admission after emergency laparotomy - a retrospective study

Purpose

Outcomes after emergency laparotomy (EL) are poor. These patients are often admitted to an intensive care unit (ICU). This study explored outcomes in patients who were admitted to an ICU within 48 h after EL.

Materials and Methods

This retrospective single‐center registry study included all patients over 16 years of age that underwent an EL and were admitted to an ICU within 48 h after surgery in Oulu University Hospital, Finland between January 2005 and May 2015. Survival was followed until the end of 2019.

Results

We included 525 patients. Hospital mortality was 13.3%, 30‐day mortality was 17.3%, 90‐day mortality was 24.2%, 1‐year mortality was 33.0%, and 5‐year mortality was 59.4%. Survivors were younger (57 [45–70] years) than the non‐survivors (73 [62–80] years; p < .001). According to the Cox regression model, death during the follow‐up was associated with age, APACHE II‐score, lower postoperative CRP levels and platelet count of the first postoperative day, and the admission from the post‐anesthesia care unit (PACU) to the ICU instead of direct ICU admission.

Conclusion

Age, high APACHE II‐score, low CRP and platelet count, and admission from the PACU to the ICU associated with mortality after EL in patients admitted to an ICU within 48 h after EL.

Validation of the Emergency Surgery Score (ESS) in a Greek patient population: a prospective bi-institutional cohort study

PURPOSE

The Emergency Surgery Score (ESS) is a reliable point-based score that predicts mortality and morbidity in emergency surgery patients. However, it has been validated only in the U.S.

PATIENTS

We aimed to prospectively validate ESS in a Greek patient population.

METHODS

All patients who underwent an emergent laparotomy were prospectively included over a 15-month period. A systematic chart review was performed to collect relevant preoperative, intraoperative, and postoperative variables based on which the ESS was calculated for each patient. The relationship between ESS and 30-day mortality, morbidity (i.e., the occurrence of at least one complication), and the need for intensive care unit (ICU) admission was evaluated and compared between the Greek and U.S. patients using the c-statistics methodology. The study was registered on "Research Registry" with the unique identifying number 5901.

RESULTS

A total of 214 patients (102 Greek) were included. The mean age was 64 years, 44% were female, and the median ESS was 7. The most common indication for surgery was hollow viscus perforation (25%). The ESS reliably and incrementally predicted mortality (c-statistics = 0.79 [95% CI 0.67-0.90] and 0.83 [95% CI 0.74-0.92]), morbidity (c-statistics = 0.83 [95% CI 0.76-0.91] and 0.79 [95% CI 0.69-0.88]), and ICU admission (c-statistics = 0.88 [95% CI 0.81-0.96] and 0.84 [95% CI 0.77-0.91]) in both Greek and U.S.

CONCLUSION

The correlation between the ESS and the surgical outcomes was statistically significant in both Greek and U.S. patients undergoing emergency laparotomy. ESS could prove globally useful for preoperative patient counseling and quality-of-care benchmarking.

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization

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.

An International Comparison of the Management of Gastrointestinal Surgical Emergencies in Octogenarians-England Versus United States: A National Population-based Cohort Study

OBJECTIVE

To compare the United States and England for the utilization of surgical intervention and in-hospital mortality from 5 gastrointestinal emergencies in octogenarians.

BACKGROUND

The proportion of older adults is growing and will represent a substantial challenge to clinicians in the next decade.

METHODS

Between 2006 and 2012, the rate of surgical intervention and in-hospital mortality for 5 index conditions for octogenarians were compared between the United States and England: appendicitis, incarcerated/strangulated abdominal hernia, perforation of esophagus, small or large bowel, and peptic ulcer. Univariate and multivariate analyses were performed to adjust for underlying differences in patient demographics.

RESULTS

Thirty-two thousand one hundred fifty-one admissions of octogenarians in England for 5 index surgical emergencies were compared with 162,142 admissions in the USA.Surgical intervention was significantly more common in the USA than in England for all 5 conditions: appendicitis [odds ratio (OR) 4.63, 95% confidence interval (95% CI) 4.21-5.09], abdominal hernia (OR 2.06, 95% CI 1.97-2.15), perforated esophagus (OR 1.71, 95% CI 1.31-2.24), small and large bowel perforation (OR 4.33, 95% CI 4.12-4.56), and peptic ulcer perforation (OR 4.63, 95% CI 4.27-5.02). In-hospital mortality was significantly more common in England than in the USA for all 5 conditions: appendicitis (OR 3.22, 95% CI 2.73-3.78), abdominal hernia (OR 3.49, 95% CI 3.29-3.70), perforated esophagus (OR 4.06, 95% CI 3.03-5.44), small and large bowel perforation (OR 6.97, 95% CI 6.60-7.37), and peptic ulcer perforation (OR 3.67, 95% CI 3.40-3.96).

CONCLUSION

Surgery is used less commonly in England for emergency gastrointestinal conditions in octogenarians, which may be associated with a high rate of in-hospital mortality from these conditions compared with the USA.

Preoperative risk factors including serum levels of potassium, sodium, and creatinine for early mortality after open abdominal surgery: a retrospective cohort study

Background

In hospitalized patients, abnormal plasma electrolyte concentrations are frequent and have been linked to poor outcomes following acute surgery. The aim of this study was to assess whether preoperative plasma levels of potassium, sodium, and creatinine at the time of admission were associated with 30-day mortality in patients following open abdominal surgery.

Methods

This was a single-center register-based retrospective study. By means of electronic search in a maintained surgery database, all patients (n = 4177) aged ≥ 60 years old undergoing open surgery in our department from January 2000 to May 2013 were identified. Plasma was assessed within 30 days prior to surgery. The primary endpoint was 30-day postoperative mortality. The association between mortality and plasma levels of potassium, sodium, and creatinine were examined using Cox proportional hazard models.

Results

A total of 3690 patients were included in the study cohort. The rates of abnormal preoperative plasma levels were 36, 41, and 38% for potassium, sodium, and creatinine, respectively. The overall 30 day mortality was 20%. A predictive algorithm for 30 day mortality following abdominal surgery was constructed by means of logistic regression showing excellent distinction between patients with and without a fatal postoperative outcome.

Conclusion

Apart from demographic factors (age, sex, and emergency surgery), preoperative imbalance in potassium, sodium and creatinine levels were significant independent predictors of early mortality following open abdominal surgery.

Developing a toolbox for identifying when to engage senior surgeons in emergency general surgery: A multicenter cohort study

BACKGROUND

Having a senior surgeon present for high-risk patients is an important safety measure in emergency surgery, but 24-h consultant cover is not efficient. We aimed to develop a user-friendly toolbox (risk identification, outcome prediction and patient stratification) to support when to involve a senior surgeon.

MATERIALS AND METHODS

We included 11,901 general surgery patients (10.0% emergencies) in a multicenter prospective cohort in China (2015-2016). Patient information and surgeons' seniority were compared between emergency and elective surgery with the same procedure codes. Risk indicators common in these two surgical timings and specific to emergency surgery were identified, and their clinical importance was evaluated by a working group of 48 experienced surgeons. Predictive models for mortality and morbidity were built using logistic regression models. Stratification rules were created to balance patients' risk and surgeons' caseload with an Acute Call Team (ACT) model.

RESULTS

Emergency patients had significantly higher risks of mortality (3.6% vs 0.6%) and morbidity (7.8% vs 4.3%) than elective patients, but disproportionally fewer senior surgeons (59.9% vs 91.4%) were present. Using three risk indicators (American Society of Anesthesiologists score, age, blood urea nitrogen), C-statistic (95% CI) for prediction of emergency mortality was high [0.90 (0.84-0.96)]. It was less complex but equally accurate as two existing and validated models (0.86 [0.79-0.93] and 0.86 [0.77-0.95]). Using five indicators, C-statistic (95% CI) was moderate for prediction of overall morbidity [0.77 (0.72-0.83)], but high for severe morbidity [0.92 (0.88-0.97)]. Based on stratification rules of the ACT model, patient mortality and morbidity were 0.5% and 5.3% in the low-risk stratum (composing 64.6% of emergency caseload), and 15.9% and 29.0% in the very high-risk stratum (6.9% of caseload).

CONCLUSION

These findings show the practical feasibility of using a risk assessment tool to direct senior surgeons' involvement in emergency general surgery.

Risk factors for mortality after emergency laparotomy: scoping systematic review

BACKGROUND

Emergency laparotomy (EL) is a common procedure with high mortality leading to several efforts to record and reduce mortality. Risk scores currently used by quality improvement programmes either require intraoperative data or are not specific to EL. To be of utility to clinicians/patients, estimation of preoperative risk of mortality is important. We aimed to explore individual preoperative risk factors that might be of use in developing a preoperative mortality risk score.

METHODS

Two independent reviewers identified relevant articles from searches of MEDLINE, EMBASE and Cochrane databases from January 1980 to January 2018. We selected studies that evaluated only preoperative predictive factors for mortality in EL patients.

RESULTS

The search yielded 6648 articles screened, with 22 studies included examining 157 728 patients. The combined post-operative 30-day mortality was 13%. All, but one small study, were at low risk of bias. A meta-analysis of results was not possible due to the heterogeneity of populations and outcomes. Age, American Society of Anesthesiologists, preoperative sepsis, dependency status, current cancer and comorbidities were associated with increased mortality. Acute physiological derangements seen in renal, albumin and complete blood count assays were strongly associated with mortality. Delay to surgery and diabetes did not influence mortality. Higher body mass index was protective.

CONCLUSION

Preoperatively, risk factors identified can be used to develop and update risk scores specific for EL mortality. This scoping review focused on the preoperative setting which helps tailor treatment decisions. It highlights the need for further research to test the relevance of newer risk factors such as frailty and nutrition.

Development and validation of a real-time mortality risk calculator before, during and after hepatectomy: an analysis of the ACS NSQIP database

BACKGROUND

Although most conventional risk prediction models have been based on preoperative information, intra- and post-operative events may be more relevant to mortality after surgery. We sought to develop a mortality risk calculator based on real time characteristics associated with hepatectomy.

METHODS

Patients who underwent hepatectomy between 2014 and 2017 were identified in the ACS-NSQIP dataset. Three prediction models (pre-, intra-, post-operative) were developed and validated using perioperative data.

RESULTS

Among 14,720 patients, 197 (1.3%) experienced 30-day mortality. The predictive ability of the real-time mortality risk calculator was very good based on only preoperative factors (AUC; training cohort: 0.813, validation cohort: 0.731). Incorporating intra-operative variables into the model increased the AUC (training: 0.838, validation: 0.777), while the post-operative model achieved an AUC of 0.922 in the training and 0.885 in the validation cohorts, respectively. While patients with low preoperative risk had only very small fluctuations in the estimated 30-day mortality risk during the intraoperative (Δ0.4%) and postoperative (Δ0.6%) phases, patients who were already deemed high risk preoperatively had additional increased mortality risk based on factors that occurred in the intraoperative (Δ5.4%) and postoperative (Δ9.3%) periods.

CONCLUSION

A real-time mortality risk calculator may better help clinicians identify patients at risk of death at the different stages of the surgical episode.

Evaluation of the Performance of ACS NSQIP Surgical Risk Calculator in Emergency General Surgery Patients

The ACS NSQIP Surgical Risk Calculator is designed to estimate the chance of an unfavorable outcome after surgery. Our goal was to evaluate the accuracy of the calculator in our emergency general surgery population. Surgical outcomes were compared to predicted risk. The risk was calculated with surgeon adjustment scores (SASs) of 1 (no adjustment), 2 (risk somewhat higher), and 3 (risk significantly higher than estimate). Two hundred and twenty-seven patients met the inclusion criteria. An SAS of 1 or 2 accurately predicted risk of mortality (5.7% and 8.5% predicted versus 7.9% actual), whereas a risk adjustment of 3 indicated significant overestimation of mortality rate (14.8% predicted). There was good overall prediction performance for most variables with no clear preference for SAS 1, 2, or 3. Poor correlation was seen with SSI, urinary tract infection, and length of stay variables. The ACS NSQIP Surgical Risk Calculator yields valid predictions in the emergency general surgery population, and the data support its use to inform conversations about outcome expectations.

Evidence-Based Management of Calculous Biliary Disease for the Acute Care Surgeon

Background: Gallstones and cholecystitis are common clinical problems. There is a wide spectrum of disease severity, from rare symptoms of biliary colic to severe cholecystitis with marked gallbladder infection and inflammation that can cause life-threatening sepsis. The care of such patients is similarly varied and multi-disciplinary. Despite the prevalence of cholecystitis, there remain questions about how to manage patients appropriately. Methods: A multi-disciplinary team created institutional cholecystitis guidelines, and supporting evidence was compiled for review. Results: Even in "routine" cholecystitis, patient triage and work-up can be variable, resulting in unnecessary tests and delay to cholecystectomy. Beyond this, there are new treatment options available that may serve special populations particularly well, although the appropriate pattern of emerging endoscopic and percutaneous treatment modalities is not well defined. Conclusions: This review outlines evidence-based management of cholecystitis from diagnosis to treatment with a focused discussion of special populations and emerging therapies.

Predisposed to failure? The challenge of rescue in the medical intensive care unit

BACKGROUND

Medical intensive care unit (MICU) patients develop acute surgical processes that require operative intervention. There are limited data addressing outcomes of emergency general surgery (EGS) in this population. The aim of our study was to characterize the breadth of surgical consults from the MICU and assess mortality after abdominal EGS cases.

METHODS

All MICU patients with an EGS consult in an academic medical center between January 2010 and 2016 were identified from an electronic medical record-based registry. Charts were reviewed to determine reason for consult, procedures performed, and to obtain additional clinical data. A multivariate logistic regression was used to determine patient factors associated with patient mortality.

RESULTS

Of 911 MICU patients seen by our service, 411(45%) required operative intervention, with 186 patients undergoing an abdominal operation. The postoperative mortality rate after abdominal operations was 37% (69/186), significantly higher than the mortality of 16% (1833/11192) for all patients admitted to the MICU over the same period (p < 0.05). Damage-control procedures were performed in 64 (34%) patients, with 46% mortality in this group. The most common procedures were bowel resections, with mortality of 42% (28/66) and procedures for severe clostridium difficile, mortality of 38% (9/24). Twenty-seven patients met our definition of surgical rescue, requiring intervention for complications of prior procedures, with mortality of 48%. Need for surgical rescue was associated with increased admission mortality (odds ratio, 13.07; 95% confidence interval, 2.86-59.77). Twenty-six patients had pathology amenable to surgical intervention but did not undergo operation, with 100% mortality. In patients with abdominal pathology at the time of operation, in-hospital delay was associated with increased mortality (odds ratio, 5.13; 95% confidence interval, 1.11-23.77).

CONCLUSION

Twenty percent of EGS consults from the MICU had an abdominal process requiring an operative intervention. While the MICU population as a whole has a high baseline mortality, patients requiring abdominal surgical intervention are an even higher risk.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Number and Type of Complications Associated With Failure to Rescue in Trauma Patients

BACKGROUND

Failure to rescue (FTR) is becoming a ubiquitous metric of quality care. The aim of our study is to determine the type and number of complications associated with FTR after trauma.

METHODS

We reviewed the Trauma Quality Improvement Program including patients who developed complications after admission. Patients were divided as the following: "FTR" if the patient died or "rescued" if the patient did not die. Logistic regression was used to ascertain the effect of the type and number of complications on FTR.

RESULTS

A total of 25,754 patients were included with 972 identified as FTR. Logistic regression identified sepsis (odds ratio [OR] = 6.61 [4.72-9.27]), pneumonia (OR = 2.79 [2.15-3.64]), acute respiratory distress syndrome (OR = 4.6 [3.17-6.69]), and cardiovascular complications (OR = 24.22 [19.39-30.26]) as predictors of FTR. The odds ratio of FTR increased by 8.8 for every single increase in the number of complications.

CONCLUSIONS

Specific types of complications increase the odds of FTR. The overall complication burden will also increase the odds of FTR linearly.

LEVEL OF EVIDENCE

Level III Prognostic.

Rethinking our definition of operative success: predicting early mortality after emergency general surgery colon resection

Background

The postoperative outcomes of emergency general surgery patients can be fraught with uncertainty. Although surgical risk calculators exist to predict 30-day mortality, they are often of limited utility in preparing patients and families for immediate perioperative complications. Examination of trends in mortality after emergent colectomy may help inform complex perioperative decision-making. We hypothesized that risk factors could be identified to predict early mortality (before postoperative day 5) to inform operative decisions.

Methods

This analysis was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database (2012-2014). Patients were stratified into three groups: early death (postoperative day 0-4), late death (postoperative day 5-30), and those who survived. Multivariable logistic regression was used to explore characteristics associated with early death. Kaplan-Meier models and Cox regression were used to further characterize their impact.

Results

A total of 18 803 patients were analyzed. Overall 30-day mortality was 12.5% (3316); of these, 37.1% (899) were early deaths. The preoperative factors most predictive of early death were septic shock (OR 3.62, p<0.001), ventilator dependence (OR 2.81, p<0.001), and ascites (OR 1.63, p<0.001). Postoperative complications associated with early death included pulmonary embolism (OR 5.78, p<0.001), presence of new-onset or ongoing postoperative septic shock (OR 4.45, p<0.001) and new-onset renal failure (OR 1.89, p<0.001). Patients with both preoperative and postoperative shock had an overall mortality rate of 47% with over half of all deaths occurring in the early period.

Conclusions

Nearly 40% of patients who die after emergent colon resection do so before postoperative day 5. Early mortality is heavily influenced by the presence of both preoperative and new or persistent postoperative septic shock. These results demonstrate important temporal trends of mortality, which may inform perioperative patient and family discussions and complex management decisions.

Level of evidence

Level III. Study type: Prognostic.

Predicting Postoperative Complications after Acute Care Surgery: How Accurate is the ACS NSQIP Surgical Risk Calculator?

The ACS NSQIP Surgical Risk Calculator (SRC) is an evidence-based clinical tool commonly used for evaluating postoperative risk. The goal of this study was to validate SRC-predicted complications by comparing them with observed outcomes in the acute care surgical setting. In this study, pre- and postoperative data from 1693 acute care surgeries (hernia repair, enterolysis, intestinal incision/excision and enterectomy, gastrectomy, debridement, colectomy, appendectomy, cholecystectomy, gastrorrhaphy, and incision and drainage of soft tissue, breast abscesses, and removal of foreign bodies) performed at a Level I trauma center over a five-year time period were abstracted. Predictions for any and serious complications were based on SRC were compared with observed outcomes using various measures of diagnostic. When evaluated as one group, the SRC had good discriminative power for predicting any and serious complications after acute care surgeries (Area Under the Curve (AUC) 0.79, 0.81). In addition, the SRC met Brier score requirements for an informative model overall. However, the predictive accuracy of the SRC varied for various procedures within the acute care patient population. For serious complications, the diagnostic measures ranged from an AUC of 0.61 and negative likelihood ratio of 0.716 for incision & drainage soft tissue to AUC of 0.91 and negative likelihood ratio of 0.064 for gastrorrhaphy. Length of stay was significantly underestimated by the SRC overall (8.56 days, P < 0.01) and for individual procedures. The SRC performs well at predicting complications after acute care surgeries overall; however, there is great variability in performance between procedure types. Further refinements in risk stratification may improve SRC predictions.

Emergency Surgery Score Accurately Predicts the Risk of Post-Operative Infection in Emergency General Surgery

BACKGROUND

The Emergency Surgery Score (ESS) was validated recently as an accurate and user-friendly post-operative mortality risk calculator specific for Emergency General Surgery (EGS). ESS is calculated by adding one to three integer points for each of 22 pre-operative variables (demographics, co-morbidities, and pre-operative laboratory values); increasing scores accurately and gradually predict higher mortality rates. We sought to evaluate whether ESS can predict the occurrence of post-operative infectious complications in EGS patients.

PATIENTS AND METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2007-2015, all EGS patients were identified by using the "emergent" ACS-NSQIP variable and a concomitant surgery Current Procedural Terminology code for "digestive system." Patients with any missing ESS variables or those who died within 72 hours from the surgical procedure were excluded. A composite variable, post-operative infection, was created and defined as the post-operative occurrence of one or more of the following: superficial, deep incisional or organ/space surgical site infection, surgical site disruption, pneumonia, sepsis, septic shock, or urinary tract infection. ESS was calculated for all included patients, and the correlation between ESS and post-operative infection was examined using c-statistics.

RESULTS

Of a total of 4,456,809 patients, 90,412 patients were included. The mean age of the population was 56 years, 51% were female, and 70% were white; 22% developed one or more post-operative infections, most commonly sepsis/septic shock (12.2%), surgical site infection (9%), and pneumonia (5.7%). The ESS gradually and consistently predicted infectious complications; post-operative infections developed in 7%, 24%, and 49% of patients with an ESS of 1, 5, and 10, respectively. The c-statistics for overall post-operative infection, post-operative sepsis/septic shock, and pneumonia were 0.73, 0.75, and 0.80, respectively.

CONCLUSION

The ESS accurately predicts the occurrence of post-operative infectious complications in EGS patients and could be used for pre-operative clinical decision-making as well as quality benchmarking of infection rates in EGS.

Surgical Transfer Decision Making: How Regional Resources are Allocated in a Regional Transfer Network

BACKGROUND

Tertiary care centers often operate above capacity, limiting access to emergency surgical care for patients at nontertiary facilities. For nontraumatic surgical emergencies there are no guidelines to inform patient selection for transfer to another facility. Such decisions may be particularly difficult for gravely ill patients when the benefits of transfer are uncertain.

METHODS

To characterize surgeons' decision-making strategies for transfer, a qualitative analysis of semistructured interviews was conducted with 16 general surgeons who refer and accept patients within a regional transfer network. Interviews included case-based vignettes about surgical patients with high comorbidity, multisystem organ failure, and terminal conditions. An inductive coding strategy was used, followed by performance of a higher-level analysis to characterize important themes and trends.

RESULTS

Surgeons at outlying hospitals seek transfer when the resources to care for patients' surgical needs or comorbid conditions are unavailable locally. In contrast, surgeons at the tertiary center accept all patients regardless of outcome or resource considerations. Bed availability at the tertiary care center restricts transfer capacity, harming patients who cannot be transferred. Surgeons sometimes transfer dying patients in order to exhaust all treatment options or appease families, but they are conflicted about the value of transfer, which displaces patients from their local communities and limits access to tertiary care for others.

CONCLUSION

Decisions to transfer surgical patients are complex and require comprehensive understanding of local capacity and regional resources. Current decision-making strategies fail to optimize patient selection for transfer and can inappropriately allocate scarce tertiary care beds.