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Evaluating and improving current risk prediction tools in emergency laparotomy.

Ahmed Barazanchi1, Sameer Bhat, Kate Palmer-Neels

  • 1From the Middlemore Hospital, University of Auckland (A.B., S.B., K.P.-N., W.S.M., W.X., A.T., A.D.M., A.G.H.); Middlemore Hospital (I.Z.); and Department of Surgery (A.D.M., A.G.H.), Middlemore Hospital, Auckland, New Zealand.

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Summary

The National Emergency Laparotomy Audit (NELA) tool accurately predicts mortality after emergency laparotomy (EL). Adding frailty and nutrition data further improves its predictive accuracy for better surgical decision-making.

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Area of Science:

  • Surgery
  • Critical Care Medicine
  • Health Services Research

Background:

  • Emergency laparotomy (EL) is a high-risk procedure with challenging preoperative risk assessment due to patient heterogeneity.
  • The UK National Emergency Laparotomy Audit (NELA) developed a risk prediction tool for EL, requiring external validation.
  • Accurate risk stratification is crucial for informed operative decision-making in EL patients.

Purpose of the Study:

  • To externally validate the NELA risk prediction tool for 30-day mortality after EL.
  • To assess and compare the performance of other risk prediction tools, including P-POSSUM, APACHE-II, and ACS-NSQIP.
  • To investigate the potential improvement of risk prediction by incorporating the modified frailty index (mFI) and nutritional status.

Main Methods:

  • Retrospective review of 758 EL patients' records from May 2012 to June 2017 at Middlemore Hospital, New Zealand.
  • External validation of NELA, P-POSSUM, APACHE-II, and ACS-NSQIP tools for 30-day mortality prediction.
  • Assessment of calibration using the Hosmer-Lemeshow test and discrimination using the c statistic; addition of mFI and nutrition to models.

Main Results:

  • The observed 30-day mortality rate was 7.9%.
  • The NELA tool demonstrated good calibration (predicted 7.4% mortality, p=0.22) and the highest c statistic (0.83).
  • Combining NELA with mFI and nutritional status improved the c statistic to 0.88, outperforming other validated tools.

Conclusions:

  • The NELA tool is the most accurate predictor of mortality following emergency laparotomy.
  • Incorporating the modified frailty index and nutritional status enhances the predictive accuracy of the NELA tool.
  • The validated NELA tool, potentially augmented with frailty and nutrition data, can significantly aid preoperative risk assessment and surgical decision-making in EL.