Background (aims, hypotheses, or objectives) Emergency laparotomy (EL) is a high‐risk surgical procedure associated with considerable morbidity and mortality around the world. A reliable risk‐assessment tool that is specific to patients undergoing EL allows the early identification of high‐risk patients and enables appropriate healthcare resource allocation. The objective of this study was to compare the commonly used Portsmouth‐physiologic and operative severity score for the enumeration of mortality and morbidity (P‐POSSUM) with the recently developed National Emergency Laparotomy Audit (NELA) score in terms of their accuracy for identifying patients at increased risk of 30‐day mortality in a predominantly Asian population. Methods Physiological and operative data from a prospectively collected audit of adult patients undergoing EL in 2018 and 2019 across two tertiary hospitals in Singapore were used to retrospectively calculate both the P‐POSSUM and NELA scores for each patient encounter. This was then compared to actual mortality rates to determine each model's accuracy and precision. Results 830 patients were included in the study with a 30‐day mortality of 5.66%. The area under the receiver operating characteristics curve (AUROC) was similar for both the NELA (0.86, p < 0.001, 95% CI 0.81–0.91) and the P‐POSSUM models (0.84, p < 0.001, 95% CI 0.78–0.89). While the models over‐predicted mortality, overall O:E ratios showed that the NELA model performance was superior to that of P‐POSSUM (0.58 [95% CI 0.43–0.77] compared to 0.34 [95% CI 0.26–0.46]). Conclusion The NELA risk‐prediction model accurately predicts 30‐day mortality in this large cohort of patients undergoing EL and outperforms the current P‐POSSUM model. We recommend that the NELA score should replace the P‐POSSUM score as a model to distinguish between high‐ and low‐risk patients undergoing EL.
Aim: The Emergency Surgery and Trauma (ESAT) team is a dedicated consultant-led service to streamline the emergency surgical workload in Singapore. As acute appendicitis is one of the most common acute surgical conditions, we aim to compare outcomes of patients with appendicitis in the ESAT model as compared to the traditional on-call model. Methods: A retrospective review of patients admitted to Khoo Teck Puat Hospital, Singapore, with acute appendicitis between two periods: May-October 2014 (6 months pre-ESAT) versus January-June 2017 (post-ESAT). Patient demographics, operative details, efficiency, clinical outcomes, and hospital bill savings were evaluated. Results: There were 192 patients in the pre-ESAT period and 179 patients in the post-ESAT period. Patient demographics and comorbidities were comparable (P > 0.05). Time from emergency department referral to surgical review was significantly reduced in the ESAT period: 77.8 AE 46.9 min versus 127 AE 102 in the pre-ESAT period (P = 0.002). Time from case booking to operating theatre was significantly shorter in the ESAT period: 72.4 AE 55.2 min compared to 157.3 AE 209.1 (P < 0.01). More cases were carried out in the daytime during the ESAT period, 50.2% versus 39.1% (P = 0.029). The majority underwent laparoscopic appendectomy 156/179 (87.2%) in the ESAT period, with fewer open appendectomies 3/179 (1.7%) as compared to the pre-ESAT period (P = 0.062). There were higher intraoperative consultant supervision rates during the ESAT period, 38/166 (22.9%) as compared to 12/166 (6.7%) in the pre-ESAT period (P = 0.001). There were fewer complications (Clavien-Dindo grade II and above) in the ESAT period, 1 (0.6%) as compared to 6 (3.4%) pre-ESAT (P = 0.07). Conclusion: The ESAT service is associated with better efficiency outcomes for patients with acute appendicitis.
Dear Editor, Emergency laparotomy (EL) is a common procedure in the treatment of a myriad of potentially life-threatening abdominal conditions. Unlike elective surgery, EL is associated with high morbidity and mortality. 1-3 Compared to their younger counterparts, elderly patients are at higher risk of postoperative complications and mortality that are attributed to multiple comorbidities and reduced physiological reserves. 3-5 Additionally, patients who require EL tend to be critically ill with limited time for preoperative optimisation. Studies on EL have revealed substantial variations in processes and lack of coordination of EL care. 6-8 In the United Kingdom (UK), the National Emergency Laparotomy Audit (NELA) has shown a reduction in 30-day mortality from 11.8% to 9.5% since 2013. 6 In its third report, NELA described 9 key standards that can improve efficiency in the management of EL patients. To date, there is no standard practice in EL management in our institution and postoperative EL outcomes in Singapore are not known. In this study, we described EL outcomes in an acute hospital in Singapore, determined factors associated with 30-day mortality and explored perioperative outcomes in elderly patients.
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