Assessing the risk: Scoring systems for outcome prediction in emergency laparotomies

Deb Sanjay Nag, Deb Sanjay Nag

Abstract

Emergency laparotomy is the commonest emergency surgical procedure in most hospitals and includes over 400 diverse surgical procedures. Despite the evolution of medicine and surgical practices, the mortality in patients needing emergency laparotomy remains abnormally high. Although surgical risk assessment first started with the ASA Physical Status score in 1941, efforts to find an ideal scoring system that accurately estimates the risk of mortality, continues till today. While many scoring systems have been developed, no single scoring system has been validated across multiple centers and geographical locations. While some scoring systems can predict the risk merely based upon preoperative findings and parameters, some rely on intra-operative assessment and histopathology reports to accurately stratify the risk of mortality. Although most scoring systems can potentially be used to compare risk-adjusted mortality across hospitals and amongst surgeons, only those which are based on preoperative findings can be used for risk prognostication and identify high-risk patients before surgery for an aggressive treatment. The recognition of the fact, that in the absence of outcome data in these patients, it would be impossible to evaluate the impact of quality improvement initiatives on risk-adjusted mortality, hospital groups and surgical societies have got together and started to pool data and analyze it. Appropriate scoring systems for emergency laparotomies would help in risk prognostication, risk-adjusted audit and assess the impact of quality improvement initiative in patient care across hospitals. Large multi-centric studies across varied geographic locations and surgical practices need to assess and validate the ideal and most apt scoring system for emergency laparotomies. While APACHE-II and P-POSSUM continue to be the most commonly used scoring system in emergency laparotomies,studies need to compare them in their ability to predict mortality and explore if either has a higher sensitivity and specificity than the other.

Keywords: Emergency; Laparotomy; Mortality; Risk assessment; Scoring methods.

References

    1. Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ. UK Emergency Laparotomy Network. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. Br J Anaesth. 2012;109(3):368–75. doi: 10.1093/bja/aes165.
    1. Vester-Andersen M, Lundstrøm LH, Møller MH, Waldau T, Rosenberg J, Møller AM. Danish Anaesthesia Database. Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population-based cohort study. Br J Anaesth. 2014;112:860–70. doi: 10.1093/bja/aet487.
    1. Ahuja Ashish, Pal Ravinder. Prognostic scoring indicator in evaluation of clinical outcome in intestinal perforations. J Clin Diagn Res. 2013;7:1953–5.
    1. Mercer SJ, Guha A, Ramesh VJ. The P-POSSUM scoring systems for predicting the mortality of neurosurgical patients undergoing craniotomy: further validation of usefulness and application across healthcare systems. Indian J Anaesth. 2013;57:587–91. doi: 10.4103/0019-5049.123332.
    1. Neary WD, Heather BP, Earnshaw JJ. The Physiological and Operative Severity Score for the enumeration of Mortality and morbidity. Br J Surg. 2003;90:157–65. doi: 10.1002/bjs.4041.
    1. Knaus W, Wagner D, Draper E. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest. 1991;100:1619–36. doi: 10.1378/chest.100.6.1619.
    1. Chang R. Individual outcome prediction models for predictive care unit. Lancet. 1989;11:143–6. doi: 10.1016/S0140-6736(89)90193-1.
    1. Copeland GP, Jones D, Walters M. POSSUM: A scoring system for surgical audit. Br J Surg. 1991;78:355–60. doi: 10.1002/bjs.1800780327.
    1. Bann SD. Comparative Audit: The trouble with POSSUM. JR Soc Med. 2001;94:632–4.
    1. Rix TE, Bates T. Pre-operative risk scores for the prediction of outcome in elderly people who require emergency surgery. World J Emerg Surg. 2007;2:1–6. doi: 10.1186/1749-7922-2-16.
    1. Chieng TH, Roslan AC, Chuah JA. Risk-adjusted analysis of patients undergoing laparotomy using POSSUM and P-POSSUM score in Queen Elizabeth Hospital, Sabah. Med J Malaysia. 2010;65:286–90.
    1. Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833–42. doi: 10.1016/j.jamcollsurg.2013.07.385.
    1. Huddart S, Peden CJ, Swart M, McCormick B, Dickinson M, Mohammed MA. ELPQuiC Collaborator Group; ELPQuiC Collaborator Group. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. Br J Surg. 2015;102(1):57–66. doi: 10.1002/bjs.9658.
    1. Sankar A, Johnson SR, Beattie WS, Tait G, Wijeysundera DN. Reliability of the American Society of Anesthesiologists physical status scale in clinical practice. Br J Anaesth. 2014;113(3):424–32. doi: 10.1093/bja/aeu100.
    1. Thorsen K, Søreide JA, Søreide K. Scoring systems for outcome prediction in patients with perforated peptic ulcer. Scand J Trauma ResuscEmerg Med. 2013;21:2–5. doi: 10.1186/1757-7241-21-2.
    1. Gawande AA, Kwaan MR, Regenbogen SE, Lipsitz SA, Zinner MJ. An Apgar score for surgery. J Am Coll Surg. 2007;204(2):201–8. doi: 10.1016/j.jamcollsurg.2006.11.011.
    1. Kennedy RH, al-Mufti RA, Brewster SF, Sherry EN, Magee TR, Irvin TT. The acute surgical admission: is mortality predictable in the elderly? Ann R CollSurg Engl. 1994;76(5):342–5.
    1. Miyazaki N, Haga Y, Matsukawa H, Ishimura T, Fujita M, Ejima T. The development and validation of the Calculation of post-Operative Risk in Emergency Surgery (CORES) model. Surg Today. 2014;44(8):1443–56. doi: 10.1007/s00595-013-0707-1.
    1. Oka Y, Nishijima J, Oku K, Azuma T, Inada K, Miyazaki S. Usefulness of an estimation of physiologic ability and surgical stress (E-PASS) scoring system to predict the incidence of postoperative complications in gastrointestinal surgery. World J Surg. 2005;29:1029–33. doi: 10.1007/s00268-005-7719-y.
    1. Koushi K, Korenaga D, Kawanaka H, Okuyama T, Ikeda Y, Takenaka K. Using the E-PASS scoring system to estimate the risk of emergency abdominal surgery in patients with acute gastrointestinal disease. Surg Today. 2011;41(11):1481–5. doi: 10.1007/s00595-010-4538-z.
    1. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173(6):676–82. doi: 10.1093/aje/kwq433.
    1. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med. 1981;9:591–7. doi: 10.1097/00003246-198108000-00008.
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818–29. doi: 10.1097/00003246-198510000-00009.
    1. Vincent JL, Moreno R. Clinical review: scoring systems in the critically ill. Crit Care. 2010;14(2):207. doi: 10.1186/cc8204.
    1. Schein M, Gecelter G, Freinkel Z, Gerding H. APACHE II in emergency operations for perforated ulcers. Am J Surg. 1990;159:309–13. doi: 10.1016/S0002-9610(05)81225-5.
    1. Bosscha K, Reijnders K, Hulstaert PF, Algra A, van der Werken C. Prognostic scoring systems to predict outcome in peritonitis and intra-abdominal sepsis. Br J Surg. 1997;84:1532–4. doi: 10.1002/bjs.1800841110.
    1. Kulkarni SV, Naik AS, Subramanian N., Jr APACHE-II scoring system in perforative peritonitis. Am J Surg. 2007;194:549–52. doi: 10.1016/j.amjsurg.2007.01.031.
    1. Ding LA, Sun LQ, Chen SX, Qu LL, Xie DF. Modified physiological and operative score for the enumeration of mortality and morbidity risk assessment model in general surgery. World J Gastroenterol. 2007;13:5090–5. doi: 10.3748/wjg.v13.i38.5090.
    1. Koç M, Yoldaş O, Kiliç YA, Göçmen E, Ertan T, Dizen H. Comparison and validation of scoring systems in a cohort of patients treated for perforated peptic ulcer. Langenbecks Arch Surg. 2007;392:581–5. doi: 10.1007/s00423-007-0156-7.
    1. Malik AA, Wani KA, Dar LA, Wani MA, Wani RA, Parray FQ. Mannheim Peritonitis Index and APACHE II--prediction of outcome in patients with peritonitis. Ulus Travma Acil Cerrahi Derg. 2010;16:27–32.
    1. Berreta J, Kociak D, Balducci A, De Feo F, Laplacette MV, Bellido F. Generalized secondary peritonitis: predictors of in-hospital mortality and survival and mortality evolutive links. Acta Gastroenterol Latinoam. 2010;40:105–16.
    1. Aslar AK, Ozdemir S, Mahmoudi H, Kuzu MA. Analysis of 230 cases of emergent surgery for obstructing colon cancer--lessons learned. J Gastrointest Surg. 2011;15(1):110–9. doi: 10.1007/s11605-010-1360-2.
    1. Delibegovic S, Markovic D, Hodzic S. APACHE II scoring system is superior in the prediction of the outcome in critically ill patients with perforative peritonitis. Med Arh. 2011;65:82–5.
    1. van Ruler O, Kiewiet JJ, Boer KR, Lamme B, Gouma DJ, Boermeester MA. Failure of available scoring systems to predict ongoing infection in patients with abdominal sepsis after their initial emergency laparotomy. BMC Surg. 2011;11:3–8. doi: 10.1186/1471-2482-11-3.
    1. Viehl CT, Kraus R, Zürcher M, Ernst T, Oertli D, Kettelhack C. The Acute Physiology and Chronic Health Evaluation II score is helpful in predicting the need of relaparotomies in patients with secondary peritonitis of colorectal origin. Swiss Med Wkly 2012; 142: w13640.
    1. Thorsen K, Søreide JA, Søreide K. Scoring systems for outcome prediction in patients with perforated peptic ulcer. Scand J Trauma Resusc Emerg Med. 2013;21:2–5. doi: 10.1186/1757-7241-21-25.
    1. Das K, Ozdogan M, Karateke F, Uzun AS, Sozen S, Ozdas S. Comparison of APACHE II, P-POSSUM and SAPS II scoring systems in patients underwent planned laparotomies due to secondary peritonitis. Ann Ital Chir. 2014;85:16–21.
    1. Ausania F, Guzman Suarez S, Alvarez Garcia H, Senra Del Rio P, CasalNuñez E. Gallbladder perforation: morbidity, mortality and preoperative risk prediction. Surg Endosc. 2015;29(4):955–60. doi: 10.1007/s00464-014-3765-6.
    1. V A M, C P M, S S, Srinivasarangan M. Efficacy of Mannheim Peritonitis Index (MPI) Score in Patients with Secondary Peritonitis. J Clin Diagn Res 2014 Dec; 8(12): NC01–3. doi: 10.7860/JCDR/2014/8609.5229. Epub 2014 Dec 5.
    1. Qureshi AM, Zafar A, Saeed K, Quddus A. Predictive power of Mannheim Peritonitis Index. J Coll Physicians Surg Pak. 2005;15:693–6.
    1. Boey J, Wong J, Ong GB. A prospective study of operative risk factors in perforated duodenal ulcers. Ann Surg. 1982;195:265–9. doi: 10.1097/00000658-198203000-00004.
    1. Boey J, Choi SK, Poon A, Alagaratnam TT. Risk stratification in perforated duodenal ulcers. A prospective validation of predictive factors. Ann Surg. 1987;205:22–6. doi: 10.1097/00000658-198701000-00005.
    1. Altaca G, Sayek I, Onat D, Cakmakçi M, Kamiloğlu S. Risk factors in perforated peptic ulcer disease: comparison of a new score system with the Mannheim Peritonitis Index. Eur J Surg. 1992;158:217–21.
    1. Mishra A, Sharma D, Raina VK. A simplified prognostic scoring system for peptic ulcer perforation in developing countries. Indian J Gastroenterol. 2003;22:49–53.
    1. Møller MH, Engebjerg MC, Adamsen S, Bendix J, Thomsen RW. Acta Anaesthesiol Scand. The Peptic Ulcer Perforation (PULP) score: a predictor of mortality following peptic ulcer perforation. A cohort study. 2012;56(5):655–62.
    1. Lawrence S, Friedman MD. Surgery in the Patient with Liver Disease. Trans Am Clin Climatol Assoc. 2010;121:192–205.
    1. Teh SH, Nagorney DM, Stevens SR, Offord KP, Therneau TM, Plevak DJ. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007;132(4):1261–9. doi: 10.1053/j.gastro.2007.01.040.
    1. Alves A, Panis Y, Mantion G, Slim K, Kwiatkowski F, Vicaut E. The AFC score: validation of a 4-item predicting score of postoperative mortality after colorectal resection for cancer or diverticulitis: results of a prospective multicenter study in 1049 patients. Ann Surg. 2007;246:91–6. doi: 10.1097/SLA.0b013e3180602ff5.
    1. Fazio VW, Tekkis PP, Remzi F, Lavery IC. Assessment of operative risk in colorectal cancer surgery: the cleveland clinic foundation colorectal cancer model. Dis Colon Rectum. 2004;47:2015–24. doi: 10.1007/s10350-004-0704-y.
    1. Whiteley MS, Prytherch D, Higgins B, Weaver PC, Prout WG. An evaluation of the POSSUM surgical scoring system. Br J Surg. 1996;83:812–15. doi: 10.1002/bjs.1800830628.
    1. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and operative severity score for the enumeration of mortality and morbidity. Br J Surg. 1998;85:1217–20. doi: 10.1046/j.1365-2168.1998.00840.x.
    1. Mohamed K, Copeland GP, Boot DA, Casserley HC, Shackleford IM, Sherry PG. An assessment of the POSSUM system in orthopaedic surgery. Journal of Bone & Joint Surgery - British Volume. 2002;84:735–9. doi: 10.1302/0301-620X.84B5.12626.
    1. Kurita M, Ichioka S, Tanaka Y, Umekawa K, Oshima Y, Ohura N. Validity of the orthopedic POSSUM scoring system for the assessment of postoperative mortality in patients with pressure ulcers. Wound Repair Regen. 2009;17(3):312–7. doi: 10.1111/j.1524-475X.2009.00486.x.
    1. Mosquera D, Chiang N, Gibberd R. Evaluation of surgical performance using V-POSSUM risk-adjusted mortality rates. ANZ J Surg. 2008;78(7):535–9. doi: 10.1111/j.1445-2197.2008.04567.x.
    1. Ozkan O, Guner A, Kaya U, Kece C, Reis E, Kesici S. Evaluation of CR-POSSUM, original ACPGBI and new ACPGBI scoring systems for colorectal cancer surgery. Chirurgia (Bucur) 2014;109:800–5.
    1. Finlay IG, Edwards TJ, Lambert AW. Damage control laparotomy. Br J Surg. 2004;91:83–5. doi: 10.1002/bjs.4434.
    1. Mohil RS, Bhatnagar D, Bahadur L, Rajneesh, Dev DK, Magan M. POSSUM and P-POSSUM for risk-adjusted audit of patients undergoing emergency laparotomy. Br J Surg. 2004;91:500–3. doi: 10.1002/bjs.4465.
    1. Brooks MJ, Sutton R, Sarin S. Comparison of Surgical Risk Score, POSSUM and p-POSSUM in higher-risk surgical patients. Br J Surg. 2005;92:1288–92. doi: 10.1002/bjs.5058.
    1. Campillo-Soto A, Flores-Pastor B, Soria-Aledo V, Candel-Arenas M, Andrés-García B, Martín-Lorenzo JG. The POSSUM scoring system: an instrument for measuring quality in surgical patients. Cir Esp. 2006;80:395–9. doi: 10.1016/S0009-739X(06)70993-9.
    1. Ding LA, Sun LQ, Chen SX, Qu LL, Xie DF. Modified physiological and operative score for the enumeration of mortality and morbidity risk assessment model in general surgery. World J Gastroenterol. 2007;13:5090–5. doi: 10.3748/wjg.v13.i38.5090.
    1. Mohil RS, Singh T, Arya S, Bhatnagar D. Risk adjustment is crucial in comparing outcomes of various surgical modalities in patients with ileal perforation. Patient Saf Surg. 2008;2:31. doi: 10.1186/1754-9493-2-31.
    1. Kumar P, Rodrigues GS. Comparison of POSSUM and P-POSSUM for risk-adjusted audit of patients undergoing emergency laparotomy. Ulus Travma Acil Cerrahi Derg. 2009;15:19–22.
    1. de Castro SM, Houwert JT, Lagard SM, Busch OR, van Gulik TM, Gouma DJ. POSSUM predicts survival in patients with unresectable pancreatic cancer. Dig Surg. 2009;26:75–9. doi: 10.1159/000194982.
    1. Luna A, Rebasa P, Navarro S, Montmany S, Coroleu D, Cabrol J. An evaluation of morbidity and mortality in oncologic gastric surgery with the application of POSSUM, P-POSSUM, and O-POSSUM. World J Surg. 2009;33(9):1889–94. doi: 10.1007/s00268-009-0118-z.
    1. Garcea G, Ganga R, Neal CP, Ong SL, Dennison AR, Berry DP. Preoperative early warning scores can predict in-hospital mortality and critical care admission following emergency surgery. J Surg Res. 2010;159(2):729–34. doi: 10.1016/j.jss.2008.08.013.
    1. Yadav K, Singh M, Griwan M, Mishra Ts, Kumar N, Kumar H. Evaluation of POSSUM and P-POSSUM as a tool for prediction of surgical outcomes in the Indian population. Australas Med J. 2011;4(7):366–73. doi: 10.4066/AMJ.2011.558.
    1. Sreeharsha H, Sp R, Sreekar H, Reddy R. Efficacy of POSSUM score in predicting the outcome in patients undergoing emergency laparotomy. Pol Przegl Chir. 2014;86(4):159–65.
    1. Glance LG, Lustik SJ, Hannan EL, Osler TM, Mukamel DB, Qian F. The Surgical Mortality Probability Model: derivation and validation of a simple risk prediction rule for noncardiac surgery. Ann Surg. 2012;255(4):696–702. doi: 10.1097/SLA.0b013e31824b45af.
    1. Shapter SL, Paul MJ, White SM. Incidence and estimated annual cost of emergency laparotomy in England: is there a major funding shortfall? Anaesthesia. 2012;67(5):474–8. doi: 10.1111/j.1365-2044.2011.07046.x.
    1. Nightingale JJ, Burmeister L, Hopkins D. A national survey of the use of epidural analgesia in patients with sepsis undergoing laparotomy. Anaesthesia. 2011;66(4):311–2. doi: 10.1111/j.1365-2044.2011.06672.x.

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