Emergency Surgery Score (ESS) In Predicting Post- Operative Course In Patients Undergoing Emergency Laparotomy – An Indian Tertiary center experience

Emergency Surgery Score (ESS) In Predicting Post- Operative Course In Patients Undergoing Emergency Laparotomy – An Indian Tertiary center experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Emergency Surgery Score (ESS) In Predicting Post- Operative Course In Patients Undergoing Emergency Laparotomy – An Indian Tertiary center experience Srishti Bhowmik, Chandra Bhushan Singh, Sushanto Neogi, Deepak Ghuliani, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3988895/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aims And Objectives - To determine the predictive value of Emergency Surgery Score (ESS) with regards to mortality and morbidity rates of patients undergoing emergency laparotomy. Method - The ESS, ranging from 0 to 29 is an extensive risk calculator based on 22 variables including important parameters like demographics, pre-operative treatment, comorbidities, and laboratory values. Twenty patients who underwent emergency laparotomy were preoperatively assessed and ESS was calculated for each. After establishment of diagnosis and resuscitation, the patient was taken up for emergency laparotomy. Postoperatively, patients were monitored clinically as well as with laboratory and radiological investigations as per case needed till discharge and further followed up physically in OPD/ ward or interviewed telephonically for 30 days on a weekly basis. Incidence of mortality and morbidity in terms of postoperative complications, ICU admission, reoperation and readmission among the cases occurring within 30 days of procedure were recorded. Results - ESS correlated well with the outcome in the current study, 10 out of 14 patients with score less than 8 were discharged without any complications. Mean ESS was higher among non survivors. Ability of ESS to predict postoperative mortality, morbidity and ICU stay was proven statistically with c-statistics of 0.853, 0.84, 0.879 respectively. ESS was found to be good predictor for development of postoperative LRTI (c-statistic = 0.828), sepsis (c-statistic = 0.867), DIC (c-statistic = 0.805), AKI (c-statistic = 0.804). ESS showed poor correlation with reoperation and readmission rates. Conclusion - It can be concluded from the study that risk stratification should be done for patients undergoing emergency laparotomy by using ESS. Thereby it can predict necessary needs for resuscitation and patient stabilization before surgery. Using ESS, patients unsuitable for operation can be identified and optimized beforehand; well informed decisions can be taken regarding targeted treatment, operation, and post-operative care. This study is a registered study under Clinical Trials Registry - India (CTRI) with registration number CTRI/2021/07/034504 and was registered on 01/07/2021. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Patients requiring emergency general surgery procedures represent a discrete, high-risk population with frequent poor outcomes. Out of all emergency admissions to surgical units, 7.1% patients require emergency general surgery, chiefly laparotomy [ 1 ]. In low- and middle-income countries (LMICs), at least 60% of the surgical operations performed are for emergencies [ 2 ]. Multiple recent studies have shown that emergency surgeries are associated with considerably higher morbidity and mortality compared to elective surgeries, even when they are operated after physiological optimization of their altered hemodynamic and maximum stabilization. Patients undergoing Emergency General Surgery (EGS) are approximately 2.5 times more likely to experience a significant complication and have a 6-fold increase in mortality as compared to non-EGS patients. Emergency general surgery cases comprise 11% of all general surgery operations, yet account for 47% of mortalities and 28% of complications [ 3 ]. The Emergency Surgery Score (ESS) has been recently devised by Sangji et al. as the EGS equivalent of the Trauma Injury Severity Score due to an increasing need for a risk assessment tool specific for emergency laparotomy [ 4 ]. The ESS, ranging from 0 to 29 is an extensive risk calculator based on 22 variables including important parameters like demographics namely, age > 60 years, white race, pre-operative treatment; co-morbidities like ascites, BMI 10% in the preceding 6 months; and laboratory values including Serum Albumin, ALP(Alkaline Phosphate), BUN(Blood Urea Nitrogen), Creatinine, PT-INR(Prothrombin Time - international normalized ratio), TLC(Total Leucocyte Count). Currently, ESS is the only existing risk estimation tool for emergency surgical patients that has been shown to predict accurately the probability of postoperative mortality, morbidity and complications including infections [ 5 – 7 ]. Using ESS, patients unsuitable for operation can be identified and optimized beforehand; well informed decisions can be taken regarding treatment, operation, and post-operative care. Targeted care can minimize the risk of post-operative complications - avoiding mortality, morbidity and saving money. Realizing the utility of Emergency scoring system in mortality prediction in surgical patients, the current study was undertaken to evaluate the surgical outcome in form of mortality and postoperative morbidities like duration of hospital stay, ICU stay, wound infection, wound dehiscence, chest infection anastomotic leak, requirements of revision surgery and thereby finding its general and widespread applicability in our hospital setup. This will help us in propagating its use across the institutions and help us in assessing the state of health with which our patients present to emergency surgical units. Materials & Methods A prospective observational study was conducted in the Department of Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi over a period of twelve months. The study was approved by the Institutional Ethics Committee and a written informed consent was taken from all the patients. A total of 32 patients who presented to Lok Nayak hospital and underwent Emergency General Surgery for acute abdominal diseases in the surgical emergency department were screened for the study. All patients aged 18 years or above who underwent emergency laparotomy were included in the study. Patients of trauma requiring laparotomy and pregnant ladies were excluded from the study. Out of the 32, 4 patients were excluded from the study as they did not meet the inclusion criteria. From the remaining 28 patients who met the inclusion criteria of the study, 8 were excluded based on exclusion criteria. The primary end point of the study was to assess the correlation of ESS in predicting mortality among the cases occurring within 30 days of procedure. Secondary end points were ESS correlation with incidence of ICU(Intensive Care Unit) admission, postoperative complications, reoperation and readmission within 30 days of operation. All patients enrolled in the study underwent routine preoperative work up and optimization for emergency laparotomy. Patient work up included complete history and examination, blood tests (Complete blood count, Kidney Function Test with electrolytes, PT-INR, Liver Function Test with ALP, Serum Albumin) for patient management and ESS calculation before starting fluid resuscitation. Radiological investigations (Chest X Ray, Abdominal X Ray, Contrast Enhanced Computed Tomography of Abdomen as and when needed) were done. ESS was calculated pre-operatively. After complete workup, establishment of diagnosis and resuscitation, the patient was taken up for emergency laparotomy. Intraoperative findings were noted. Postoperatively, patient was monitored clinically as well as with laboratory and radiological investigations as r case needed till discharge and further followed up physically in Outpatient/ ward or interviewed telephonically for 30 days on a weekly basis. Note was made for every case undergoing emergency laparotomy with mortality, post-operative ICU requirement, re-operation and readmission within 30 days of emergency laparotomy. One or more of the postoperative complications including Post-operative surgical site infection (Superficial, deep incisional, or organ space), Wound disruption/ dehiscence, Pneumonia, Sepsis as defined by ≥ 2 SIRS(Systemic Inflammatory Response Syndrome) criteria with suspected infection, Septic shock as defined by sepsis with SBP(Systolic Blood Pressure) < 90 mmHg or MAP(Mean Arterial Pressure) < 70 mmHg not responsive to Intravenous fluids, Urinary tract infection, Pulmonary embolism, Acute kidney injury as shown by progression of baseline renal insufficiency with creatinine level of greater than 2 mg/dL or requiring dialysis, Cerebrovascular accident with neurological deficits, Coma lasting more than 24 hours, Cardiac arrest requiring cardiopulmonary resuscitation, Myocardial infarction, Internal hemorrhage requiring transfusion, Deep venous thrombosis, Gastrointestinal leak within 30 days of operation The sample size was calculated using the formula for prevalence study, using post-operative mortality as the primary endpoint. On searching the published literature, mortality was seen in 13% of patients undergoing emergency laparotomy in India according to a study by Gejoe et al. in 2017 [ 7 ]. Taking the confidence interval as 95% and precision of study as 5%, the total sample size was calculated as 173. However, due to constraints of time and ongoing pandemic situation, sample size was taken to be 20. Data were entered in MS-Excel (Microsoft corporation Redmond, Washington, USA) and analyzed using SPSS 25 (IBM Corp, SPSS Statistics for windows, version 25.0 Armonk, New York, USA). Demographic, clinical, preoperative, and /or postoperative complications on each patient were entered into a standard Performa. Each patient's postoperative outcome/ mortality was compared to determine the significance of illness on postoperative complications and mortality. Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean ± SD and median. A p value of < 0.05 was considered statistically significant. Results Acute abdomen was common in the age group of 21–30 years and 41–50 years with mean age of 40.6 years and lower mean age (37 year) of survivors than of non survivors (47 year). Perforation peritonitis was the most common cause for acute abdomen among the study population (60%) while Tuberculosis was the commonest underlying disease (8/20) and other diagnosis as shown in Fig. 1 . Minimum ESS was 1 and maximum was 12 with mean of 6.15. Maximum patients (14 patients out of 20) were in low ESS (0–7) as shown in Fig. 2 below. For survivors, mean ESS was 5.06 whereas for non survivors it was 9.4. Emergency Surgery Score correlated well with the outcome in the current study, 10 out of 14 patients with score less than 8 were discharged without any complications. As seen in the below Fig. 3 , ROC (Receiver Operator Characteristics) curve of Emergency Surgery Score for predicting mortality shows ESS to be a good predictor for mortality with Area Under Cover AUC = 0.853. Mortality was equal among females and males. A cut-off value of 7 shows a Sensitivity of 80% and a Specificity of 87% in predicting mortality for patients undergoing emergency laparotomy with a p-value of 0.013 (statistically significant). Functional dependence, weight loss > 10% in preceding 6 months and serum ALP levels > 125U/L were found to have significant effect on postoperative mortality. LRTI (Lower Respiratory Tract Infection), wound dehiscence, sepsis, AKI (Acute Kidney Injury), thrombocytopenia, DIC (Disseminated Intravascular Coagulation) and ICU stay in postoperative period were found to be significantly associated with mortality. ROC - Receiver Operator Characteristics Ability of ESS to predict postoperative morbidity and ICU stay was proven statistically with c-statistics of 0.84, 0.879 respectively as shown in Figs. 4 and 5 . Surgical site infection was the most common postoperative complication developed in 50% patients followed by lower respiratory tract infection in 45%. Wound dehiscence and sepsis developed in 25% cases each. A cut off of 7 was found which could accurately predict postoperative morbidity (p-value = 0.04) and ICU stay (p-value = 0.00018) both statistically significant. ESS was found to be good predictor for development of postoperative LRTI (c-statistic = 0.828), sepsis (c-statistic = 0.867), DIC (c-statistic = 0.805), AKI (c-statistic = 0.804). ESS showed poor correlation with reoperation and readmission rates. Discussion The severity assessment of a disease condition is useful for early priority treatment, and it reduces morbidity and mortality. High severity scores are usually associated with high morbidity and mortality, therefore these patients may require more intensive treatment than those with low scores. This was an observational study to categorize the patients undergoing exploratory laparotomy for emergency surgical conditions by calculating their Emergency Surgery Score (ESS) and assess its predictive value. The surgeon was blinded for the Emergency Surgery Score which was calculated for each patient at the admission. The decision regarding the particular operative procedure done was a subjective decision based on the resources available at the operation theater, general condition of the patient, condition of the bowel, and purulent contamination. The outcome of the patient was studied and correlated with the ESS calculated at admission to achieve the predictive value of the score regarding the outcome. In our study, 20 patients who underwent emergency laparotomy were included with age ranging from 18–72 years. The median age of the study population was 40 years. Sex distribution was unequal with a male to female ratio of 2:3. Study excludes patients requiring emergency laparotomy for traumatic causes and pregnancies. The commonest cause for perforation in this study was tubercular perforation (50%) followed by duodenal and gastric (33.33%) followed by large bowel and appendix (16.67%). This contrasts with study conducted by Agarwal et al and various other studies by Afridi SP et al in 2008, Jhobta RS et al in 2006, Dorairajan et al. In all these studies the most common cause of perforation peritonitis was acid peptic disease with incidence of 39%.32%,44.9% and 21.6% respectively [ 8 , 9 ]. A study from Pakistan had 43% causes due to tuberculosis and typhoid, it highlights the role of infectious pathology as a leading cause of perforation peritonitis in the developing world [ 10 ]. This result was quite similar to our study result. Age as determinant of outcome:- In our study the mean age of patients was 40.60 years. Maximum cases were of 3rd and 5th decade (25% each). Maximum mortality was observed in the fifth decade (40%). John Bohenen M.A studied the effect of age as a risk factor for mortality (in case of abdominal sepsis) and got the result that the patients of less than 50 year age had 17% mortality whereas those over 50 years had a 45% death rate [ 11 ]. In our study less than 40 year old had a mortality of 10%, while more than 40 years had a mortality of 40% which was corroborative with the previous results. Pointing et al, Frank B. Cerra et al studied the effects of sepsis and got the result that mean age for non survivors was higher than survivors [ 11 ]. Our studies gave similar results with lower mean age (37 year) of survivors than of non survivors (47 year) . ESS and Mortality:- We observed maximum cases in our study that had an ESS score at admission 3–5. In this group we observed 25% (1 out of 4 patients) mortality. Maximum mortality was observed in ESS score greater than 7 with 66.67% mortality. Mean ESS score was 6.15. For survivors it was 5.06 whereas for non survivors it was 9.4. There was no death in patients who scored 0–6. Figure 6 below shows the correlation between ESS with postoperative complications. Sangji et al derived and validated the ESS scoring system for the first time in 2012. 19,552 cases undergoing emergency laparotomy were studied. Mortality rate increased from 0–36% in patients who scored 0 to 11 and finally 100% at 22 with a c-statistic of 0.86 [ 4 ]. Peponis et al also worked on ESS and reported that ESS correlated well with mortality (c-statistic = 0.84); 0.4%, 39%, and 100% mortality at scores of 1, 11, and 22 respectively [ 12 ]. Kaafarani et al. recently demonstrated the efficacy of ESS in a prospective multi centric study in predicting 30-day mortality. The 30-day mortality was 14.8%. Emergency Surgery Score gradually and accurately predicted 30-day mortality; 3.5%, 50.0%, and 85.7% of patients with ESS of 3, 12, and 17 died after surgery, respectively, with a c-statistic of 0.84. It concluded ESS can be useful for perioperative patient and family counseling, triaging patients to the intensive care unit, and benchmarking the quality of emergency general surgery care [ 13 ]. ESS and Morbidity:- Postoperative complications as shown in below Fig. 7 in the form of surgical site infection, lower respiratory tract infection, and more were seen in 65% of the patients enrolled. Majority postoperative complication in our study was surgical site infection, seen in 50% of the patients followed by lower respiratory tract infection in 45% of the patients. Sepsis and wound dehiscence were seen in 25% of the patients each. 15% of the patients developed acute kidney injury postoperatively while 10% of the patients showed anastomotic leak, disseminated intravascular coagulation and thrombocytopenia each. With increasing ESS, postoperative complication rate also increased (c-statistic = 0.820). Peponis et al. extrapolated ESS to predict 30-day morbidity in patients undergoing emergency laparotomy. This study demonstrated ESS correlated well with morbidity (c-statistic = 0.74); morbidity rates steadily increased from 13% at score 0 to 58% at score 7 and 79% at score 11 after which the complication rates plateaued [ 12 ]. Nandan et al. in 2017 also validated the efficacy of ESS in predicting post-operative complications in patients undergoing emergency general surgery. It reported out of 37,999 cases enrolled, 14,446 (38%) resulted in at least one complication within a period of 30 days. The observed 30-day complication rates consistently increased from 7–53% to 91% at scores of 0, 7, and 15, respectively, after which it plateaued at a mean of 92% for ESS > 15, with a c-statistic of 0.78. On multivariable analyses, each of the 22 ESS components independently predicted the occurrence of postoperative complications. Out of the complications reported, most common was surgical site infection (12.9%) followed by pneumonia (7.3%) [ 5 ]. Our study reported a similar trend. Han et al. reported a total of 90,412 patients out of which 22% developed one or more post-operative infections, most common of which was sepsis/septic shock (12.2%), followed by surgical site infection (9%), and pneumonia (5.7%). The ESS accurately predicted infectious complications; post-operative infections developed in 7% of patients with ESS = 1, in 24% of patients with ESS = 5, and in 49% of patients with an ESS = 10. The c-statistics for overall postoperative infection was 0.73, postoperative sepsis/septic shock was 0.75, and pneumonia was 0.80. It recommended the use of ESS in estimating risk of infections in patients undergoing emergency laparotomy within a period of 30 days [ 6 ]. Kaafarani et al. also demonstrated efficacy of ESS in predicting 30-day postoperative morbidity in a study enrolling 1,649 patients. The 30-day complication rate was 53.3%. Emergency Surgery Score gradually and accurately predicted complications; 21.0%, 57.1%, and 88.9% of patients with ESS of 1, 6, and 13 developed postoperative complications, with a c-statistic of 0.74 [ 13 ]. ESS and ICU Admission:- In our study, 35% of the patients enrolled were admitted into ICU postoperatively. In a 2015 study by Banerjee et al. 70% of the patients undergoing emergency laparotomy required a high dependency unit bed or critical care [ 14 ]. Emergency Laparotomy Collaborative (ELC) and the Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) bundle project suggests that all patients should be admitted in ICU after emergency laparotomy. However due to the paucity of available ICU beds at our institution, the recommendation could not be followed. Kaafarani et al. in his study demonstrated the applicability of ESS in predicting post-operative ICU admission. 57.0% of patients required ICU admission post-operatively. Emergency Surgery Score accurately predicted which patients required intensive care unit admission (c-statistic, 0.80) with high ESS requiring critical care [ 13 ]. Our study also showed a similar trend with c-statistic of 0.87. ESS and Reoperation, Readmission:- In our study, 3 (15%) of the patients underwent reoperation. ESS score showed poor correlation with requirement of reoperation within 30 days of emergency laparotomy (c-statistic = 0.667). In a recent study by Kassahun et al 35.9% patients required subsequent reoperation after emergency laparotomy, and 547 (64.1%) did not. The incidence of postoperative complications was higher in reoperated patients (100%) than in non-reoperated patients (58.9%). There were 305 deaths, with an overall in-hospital mortality rate of 35.7%; 175 (57%) occurred in the re-operated group, and 130 (23.8%) occurred in the non-re-operated group [ 15 ]. However, in our study no significant correlation was found between reoperation requirement and mortality (p-value = 0.30) 2 (10%) of the patients had to be readmitted within 30 days of emergency laparotomy in our study. ESS had no significant correlation with Readmission rates (c-statistic = 0.55). According to Kongkaew Paisan et al out of 1,347 patients included, 234 (17.4%) had an unplanned readmission within 30 day post-operative period of emergency laparotomy [ 16 ]. The predictors for unplanned readmission included patient factors (eg, disseminated cancer [odds ratio: 2.22, P = 0.002], weight loss > 10% in the past 6 months [odds ratio: 1.65, P = 0.023], dyspnea at baseline [odds ratio: 1.62, P = 0.026], wound complications [odds ratio: 2.23, P < .001], and discharge to nursing homes [odds ratio: 1.68, P = 0.044] similar to those included in calculating ESS. Readmission however was not a significant predictor of mortality according to our study. Limitations:- Limitations in our study are small sample size, procedures performed in emergency were not included in the study, neither was the indication of reoperation or readmission recorded. White race included as one of the parameters in calculating ESS could not be used in our study. The study was carried out among the Indian population without correlation of race. Infrastructural limitations in the form of lack of ICU beds, delayed availability of operation theaters may have a corroborative effect on mortality and morbidity. Conclusions From our study we conclude that ESS is useful to predict postoperative mortality, morbidity and ICU stay was proven statistically. ESS was found to be good predictor for development of postoperative LRTI, sepsis, DIC, AKI. LRTI, wound dehiscence, sepsis, AKI, thrombocytopenia, DIC and ICU stay in postoperative period were found to be significantly associated with mortality. Thus, it can be concluded from the study that risk stratification should be done for patients undergoing emergency laparotomy by using Emergency Surgery Score. Thereby it can predict necessary needs for resuscitation and patient stabilization before surgery. Declarations Author Contribution S.B. and C.B.S. conducted the primary research.S.N. and D.G. are responsible for statistical analysis.S.B. drafted the original manuscript.S.R. edited the manuscript.All authors reviewed the manuscript. References Shafi S, Aboutanos MB, Agarwal S, et al.: Emergency general surgery: definition and estimated burden of disease. J Trauma Acute Care Surg. 2013, 74:1092-7. 10.1097/TA.0b013e31827e1bc7 Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors: Essential Surgery: Disease Control Priorities, Third Edition (Volume 1). Washington (DC): The World Bank; 2015; April 2; chapter 4. 61-76; 10.1596/978-1-4648-0346-8. 61-76. 10.1596/978-1-4648-0346-8 Stewart B, Khanduri P, McCord C, et al.: Global disease burden of conditions requiring emergency surgery. Br J Surg. 2014, 101:9-22. 10.1002/bjs.9329 Sangji NF, Bohnen JD, Ramly EP, et al.: Derivation and validation of a novel Emergency Surgery Acuity Score (ESAS). 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Jaskani S, Mehmood N, Khan NM: Surgical management of acute presentation and outcome of patients with complicated abdominal tuberculosis. J Rawalpindi Med Coll :108-12. Kalra D, Gupta S, Yadav BL, et al.: Association of clinical outcome and APACHE II score in secondary peritonitis (a study of 50 cases). Int J Health Sci Res. 2016, 6:107-113. Peponis T, Bohnen JD, Sangji NF, et al.: Does the emergency surgery score accurately predict outcomes in emergent laparotomies?. Surgery. 2017, 162:445-52. 10.1016/j.surg.2017.03.016 Kaafarani HMA: Kongkaewpaisan N, Aicher BO et al. Prospective validation of the Emergency Surgery Score in emergency general surgery: An Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg. 2020, 89:118-24. 10.1097/TA.0000000000002658 Banerjee, T., Templeton, M. & Gore, C: Emergency laparotomy clinical outcome according to patient characteristics, level of postoperative care and time of surgery. Crit Care 19. 546: Kassahun WT, Mehdorn M, Wagner TC: The effects of reoperation on surgical outcomes following surgery for major abdominal emergencies. A retrospective cohort study. Int J Surg. 2019, 72:235-240. 10.1016/j.ijsu.2019.11.024 Kongkaewpaisan N, El Hechi MW, Naar L, et al.: Unplanned readmission after emergency laparotomy: A post hoc analysis of an EAST multicenter study. Surgery. 2021, 169:1434-1440. 10.1016/j.surg.2020.11.047 Additional Declarations No competing interests reported. Supplementary Files Appendices.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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College","correspondingAuthor":false,"prefix":"","firstName":"Sarmista","middleName":"","lastName":"Roy","suffix":""}],"badges":[],"createdAt":"2024-02-25 20:00:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3988895/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3988895/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51775507,"identity":"7db80fed-cbe6-4e3d-a267-58f74a4fc353","added_by":"auto","created_at":"2024-02-28 20:43:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":157281,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of diagnosis in the study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-3988895/v1/d9abe5672a6fb26fb0b32817.png"},{"id":51775505,"identity":"b1227479-f886-467a-b256-43d87143a758","added_by":"auto","created_at":"2024-02-28 20:43:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":104277,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of ESS in the study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-3988895/v1/16352727217e6caad27fec8e.png"},{"id":51775511,"identity":"3876a3be-d9f2-4b04-b3b4-9d80fc02f9d4","added_by":"auto","created_at":"2024-02-28 20:43:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":211311,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC curve for Emergency Surgery Score calculation in mortality prediction\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-3988895/v1/dbb2f8c28a27d05a54c977b3.png"},{"id":51775510,"identity":"979bbb0f-dfec-4cd5-b592-e98479491492","added_by":"auto","created_at":"2024-02-28 20:43:18","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":42668,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC curve for Emergency Surgery Score calculation in morbidity prediction\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-3988895/v1/0e95ddac18444b5b67acbb36.png"},{"id":51775513,"identity":"8d49246e-930e-45d0-8750-5fe85c8a6cb9","added_by":"auto","created_at":"2024-02-28 20:43:18","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":85577,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eROC curve analysis for Emergency Surgery Score calculation in prediction of ICU stay\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-3988895/v1/37cf53facbe75167208bd259.png"},{"id":51775509,"identity":"ea472cc9-701f-4dd8-a175-9416b0f2ff5b","added_by":"auto","created_at":"2024-02-28 20:43:18","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":42142,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePostoperative Complication rate on y- axis with ESS on x- axis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image6.png","url":"https://assets-eu.researchsquare.com/files/rs-3988895/v1/b12f762d5b7ec8ed261f91d8.png"},{"id":51775512,"identity":"fe2df19a-deef-4b7b-8fb7-2f789ea2bc6c","added_by":"auto","created_at":"2024-02-28 20:43:18","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":45391,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePostoperative Morbidity rate on y-axis with ESS on x-axis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image7.png","url":"https://assets-eu.researchsquare.com/files/rs-3988895/v1/483260af4eae20f07f2021af.png"},{"id":52380572,"identity":"b18c4a79-ff54-4b79-bf30-46be920e697c","added_by":"auto","created_at":"2024-03-10 16:30:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":981378,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3988895/v1/7e3b8bcc-0815-476c-8eab-bcd085ab3b0b.pdf"},{"id":51775506,"identity":"f5a8bdd7-1542-428d-99f9-223e5c305cf2","added_by":"auto","created_at":"2024-02-28 20:43:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14785,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-3988895/v1/0ce3f94d33c3adf758813092.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Emergency Surgery Score (ESS) In Predicting Post- Operative Course In Patients Undergoing Emergency Laparotomy – An Indian Tertiary center experience","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePatients requiring emergency general surgery procedures represent a discrete, high-risk population with frequent poor outcomes. Out of all emergency admissions to surgical units, 7.1% patients require emergency general surgery, chiefly laparotomy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In low- and middle-income countries (LMICs), at least 60% of the surgical operations performed are for emergencies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMultiple recent studies have shown that emergency surgeries are associated with considerably higher morbidity and mortality compared to elective surgeries, even when they are operated after physiological optimization of their altered hemodynamic and maximum stabilization. Patients undergoing Emergency General Surgery (EGS) are approximately 2.5 times more likely to experience a significant complication and have a 6-fold increase in mortality as compared to non-EGS patients. Emergency general surgery cases comprise 11% of all general surgery operations, yet account for 47% of mortalities and 28% of complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Emergency Surgery Score (ESS) has been recently devised by Sangji et al. as the EGS equivalent of the Trauma Injury Severity Score due to an increasing need for a risk assessment tool specific for emergency laparotomy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe ESS, ranging from 0 to 29 is an extensive risk calculator based on 22 variables including important parameters like demographics namely, age \u0026gt; 60 years, white race, pre-operative treatment; co-morbidities like ascites, BMI \u0026lt; 20 kg/m2, COPD, Hypertension, Steroid use, Weight loss \u0026gt; 10% in the preceding 6 months; and laboratory values including Serum Albumin, ALP(Alkaline Phosphate), BUN(Blood Urea Nitrogen), Creatinine, PT-INR(Prothrombin Time - international normalized ratio), TLC(Total Leucocyte Count). Currently, ESS is the only existing risk estimation tool for emergency surgical patients that has been shown to predict accurately the probability of postoperative mortality, morbidity and complications including infections [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUsing ESS, patients unsuitable for operation can be identified and optimized beforehand; well informed decisions can be taken regarding treatment, operation, and post-operative care. Targeted care can minimize the risk of post-operative complications - avoiding mortality, morbidity and saving money.\u003c/p\u003e \u003cp\u003eRealizing the utility of Emergency scoring system in mortality prediction in surgical patients, the current study was undertaken to evaluate the surgical outcome in form of mortality and postoperative morbidities like duration of hospital stay, ICU stay, wound infection, wound dehiscence, chest infection anastomotic leak, requirements of revision surgery and thereby finding its general and widespread applicability in our hospital setup. This will help us in propagating its use across the institutions and help us in assessing the state of health with which our patients present to emergency surgical units.\u003c/p\u003e "},{"header":"Materials \u0026 Methods","content":"\u003cp\u003eA prospective observational study was conducted in the Department of Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi over a period of twelve months. The study was approved by the Institutional Ethics Committee and a written informed consent was taken from all the patients.\u003c/p\u003e\u003cp\u003eA total of 32 patients who presented to Lok Nayak hospital and underwent Emergency General Surgery for acute abdominal diseases in the surgical emergency department were screened for the study. All patients aged 18 years or above who underwent emergency laparotomy were included in the study. Patients of trauma requiring laparotomy and pregnant ladies were excluded from the study. Out of the 32, 4 patients were excluded from the study as they did not meet the inclusion criteria. From the remaining 28 patients who met the inclusion criteria of the study, 8 were excluded based on exclusion criteria.\u003c/p\u003e\u003cp\u003eThe primary end point of the study was to assess the correlation of ESS in predicting mortality among the cases occurring within 30 days of procedure. Secondary end points were ESS correlation with incidence of ICU(Intensive Care Unit) admission, postoperative complications, reoperation and readmission within 30 days of operation.\u003c/p\u003e\u003cp\u003eAll patients enrolled in the study underwent routine preoperative work up and optimization for emergency laparotomy. Patient work up included complete history and examination, blood tests (Complete blood count, Kidney Function Test with electrolytes, PT-INR, Liver Function Test with ALP, Serum Albumin) for patient management and ESS calculation before starting fluid resuscitation. Radiological investigations (Chest X Ray, Abdominal X Ray, Contrast Enhanced Computed Tomography of Abdomen as and when needed) were done. ESS was calculated pre-operatively.\u003c/p\u003e\u003cp\u003eAfter complete workup, establishment of diagnosis and resuscitation, the patient was taken up for emergency laparotomy. Intraoperative findings were noted.\u003c/p\u003e\u003cp\u003ePostoperatively, patient was monitored clinically as well as with laboratory and radiological investigations as r case needed till discharge and further followed up physically in Outpatient/ ward or interviewed telephonically for 30 days on a weekly basis.\u003c/p\u003e\u003cp\u003eNote was made for every case undergoing emergency laparotomy with mortality, post-operative ICU requirement, re-operation and readmission within 30 days of emergency laparotomy.\u003c/p\u003e\u003cp\u003eOne or more of the postoperative complications including Post-operative surgical site infection (Superficial, deep incisional, or organ space), Wound disruption/ dehiscence, Pneumonia, Sepsis as defined by ≥ 2 SIRS(Systemic Inflammatory Response Syndrome) criteria with suspected infection, Septic shock as defined by sepsis with SBP(Systolic Blood Pressure) \u0026lt; 90 mmHg or MAP(Mean Arterial Pressure) \u0026lt; 70 mmHg not responsive to Intravenous fluids, Urinary tract infection, Pulmonary embolism, Acute kidney injury as shown by progression of baseline renal insufficiency with creatinine level of greater than 2 mg/dL or requiring dialysis, Cerebrovascular accident with neurological deficits, Coma lasting more than 24 hours, Cardiac arrest requiring cardiopulmonary resuscitation, Myocardial infarction, Internal hemorrhage requiring transfusion, Deep venous thrombosis, Gastrointestinal leak within 30 days of operation\u003c/p\u003e\u003cp\u003eThe sample size was calculated using the formula for prevalence study, using post-operative mortality as the primary endpoint. On searching the published literature, mortality was seen in 13% of patients undergoing emergency laparotomy in India according to a study by Gejoe et al. in 2017 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Taking the confidence interval as 95% and precision of study as 5%, the total sample size was calculated as 173. However, due to constraints of time and ongoing pandemic situation, sample size was taken to be 20.\u003c/p\u003e\u003cp\u003eData were entered in MS-Excel (Microsoft corporation Redmond, Washington, USA) and analyzed using SPSS 25 (IBM Corp, SPSS Statistics for windows, version 25.0 Armonk, New York, USA). Demographic, clinical, preoperative, and /or postoperative complications on each patient were entered into a standard Performa. Each patient's postoperative outcome/ mortality was compared to determine the significance of illness on postoperative complications and mortality. Categorical variables were presented in number and percentage (%) and continuous variables were presented as mean ± SD and median. A p value of \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAcute abdomen was common in the age group of 21\u0026ndash;30 years and 41\u0026ndash;50 years with mean age of 40.6 years and lower mean age (37 year) of survivors than of non survivors (47 year). Perforation peritonitis was the most common cause for acute abdomen among the study population (60%) while Tuberculosis was the commonest underlying disease (8/20) and other diagnosis as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMinimum ESS was 1 and maximum was 12 with mean of 6.15. Maximum patients (14 patients out of 20) were in low ESS (0\u0026ndash;7) as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below. For survivors, mean ESS was 5.06 whereas for non survivors it was 9.4. Emergency Surgery Score correlated well with the outcome in the current study, 10 out of 14 patients with score less than 8 were discharged without any complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAs seen in the below Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, ROC (Receiver Operator Characteristics) curve of Emergency Surgery Score for predicting mortality shows ESS to be a good predictor for mortality with Area Under Cover AUC\u0026thinsp;=\u0026thinsp;0.853. Mortality was equal among females and males. A cut-off value of 7 shows a Sensitivity of 80% and a Specificity of 87% in predicting mortality for patients undergoing emergency laparotomy with a p-value of 0.013 (statistically significant). Functional dependence, weight loss\u0026thinsp;\u0026gt;\u0026thinsp;10% in preceding 6 months and serum ALP levels\u0026thinsp;\u0026gt;\u0026thinsp;125U/L were found to have significant effect on postoperative mortality. LRTI (Lower Respiratory Tract Infection), wound dehiscence, sepsis, AKI (Acute Kidney Injury), thrombocytopenia, DIC (Disseminated Intravascular Coagulation) and ICU stay in postoperative period were found to be significantly associated with mortality.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eROC - Receiver Operator Characteristics\u003c/p\u003e \u003cp\u003eAbility of ESS to predict postoperative morbidity and ICU stay was proven statistically with c-statistics of 0.84, 0.879 respectively as shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Surgical site infection was the most common postoperative complication developed in 50% patients followed by lower respiratory tract infection in 45%. Wound dehiscence and sepsis developed in 25% cases each. A cut off of 7 was found which could accurately predict postoperative morbidity (p-value\u0026thinsp;=\u0026thinsp;0.04) and ICU stay (p-value\u0026thinsp;=\u0026thinsp;0.00018) both statistically significant.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eESS was found to be good predictor for development of postoperative LRTI (c-statistic\u0026thinsp;=\u0026thinsp;0.828), sepsis (c-statistic\u0026thinsp;=\u0026thinsp;0.867), DIC (c-statistic\u0026thinsp;=\u0026thinsp;0.805), AKI (c-statistic\u0026thinsp;=\u0026thinsp;0.804). ESS showed poor correlation with reoperation and readmission rates.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe severity assessment of a disease condition is useful for early priority treatment, and it reduces morbidity and mortality. High severity scores are usually associated with high morbidity and mortality, therefore these patients may require more intensive treatment than those with low scores.\u003c/p\u003e \u003cp\u003eThis was an observational study to categorize the patients undergoing exploratory laparotomy for emergency surgical conditions by calculating their Emergency Surgery Score (ESS) and assess its predictive value. The surgeon was blinded for the Emergency Surgery Score which was calculated for each patient at the admission.\u003c/p\u003e \u003cp\u003eThe decision regarding the particular operative procedure done was a subjective decision based on the resources available at the operation theater, general condition of the patient, condition of the bowel, and purulent contamination. The outcome of the patient was studied and correlated with the ESS calculated at admission to achieve the predictive value of the score regarding the outcome.\u003c/p\u003e \u003cp\u003eIn our study, 20 patients who underwent emergency laparotomy were included with age ranging from 18\u0026ndash;72 years. The median age of the study population was 40 years. Sex distribution was unequal with a male to female ratio of 2:3.\u003c/p\u003e \u003cp\u003eStudy excludes patients requiring emergency laparotomy for traumatic causes and pregnancies.\u003c/p\u003e \u003cp\u003eThe commonest cause for perforation in this study was tubercular perforation (50%) followed by duodenal and gastric (33.33%) followed by large bowel and appendix (16.67%). This contrasts with study conducted by Agarwal et al and various other studies by Afridi SP et al in 2008, Jhobta RS et al in 2006, Dorairajan et al. In all these studies the most common cause of perforation peritonitis was acid peptic disease with incidence of 39%.32%,44.9% and 21.6% respectively [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A study from Pakistan had 43% causes due to tuberculosis and typhoid, it highlights the role of infectious pathology as a leading cause of perforation peritonitis in the developing world [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This result was quite similar to our study result.\u003c/p\u003e\n\u003ch3\u003eAge as determinant of outcome:-\u003c/h3\u003e\n\u003cp\u003eIn our study the mean age of patients was 40.60 years. Maximum cases were of 3rd and 5th decade (25% each). Maximum mortality was observed in the fifth decade (40%).\u003c/p\u003e \u003cp\u003eJohn Bohenen M.A studied the effect of age as a risk factor for mortality (in case of abdominal sepsis) and got the result that the patients of less than 50 year age had 17% mortality whereas those over 50 years had a 45% death rate [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In our study less than 40 year old had a mortality of 10%, while more than 40 years had a mortality of 40% which was corroborative with the previous results.\u003c/p\u003e \u003cp\u003ePointing et al, Frank B. Cerra et al studied the effects of sepsis and got the result that mean age for non survivors was higher than survivors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Our studies gave similar results with lower mean age (37 year) of survivors than of non survivors (47 year) .\u003c/p\u003e\n\u003ch3\u003eESS and Mortality:-\u003c/h3\u003e\n\u003cp\u003eWe observed maximum cases in our study that had an ESS score at admission 3\u0026ndash;5. In this group we observed 25% (1 out of 4 patients) mortality. Maximum mortality was observed in ESS score greater than 7 with 66.67% mortality. Mean ESS score was 6.15. For survivors it was 5.06 whereas for non survivors it was 9.4. There was no death in patients who scored 0\u0026ndash;6. Figure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e below shows the correlation between ESS with postoperative complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSangji et al derived and validated the ESS scoring system for the first time in 2012. 19,552 cases undergoing emergency laparotomy were studied. Mortality rate increased from 0\u0026ndash;36% in patients who scored 0 to 11 and finally 100% at 22 with a c-statistic of 0.86 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePeponis et al also worked on ESS and reported that ESS correlated well with mortality (c-statistic\u0026thinsp;=\u0026thinsp;0.84); 0.4%, 39%, and 100% mortality at scores of 1, 11, and 22 respectively [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKaafarani et al. recently demonstrated the efficacy of ESS in a prospective multi centric study in predicting 30-day mortality. The 30-day mortality was 14.8%. Emergency Surgery Score gradually and accurately predicted 30-day mortality; 3.5%, 50.0%, and 85.7% of patients with ESS of 3, 12, and 17 died after surgery, respectively, with a c-statistic of 0.84. It concluded ESS can be useful for perioperative patient and family counseling, triaging patients to the intensive care unit, and benchmarking the quality of emergency general surgery care [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eESS and Morbidity:-\u003c/h3\u003e\n\u003cp\u003ePostoperative complications as shown in below Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e in the form of surgical site infection, lower respiratory tract infection, and more were seen in 65% of the patients enrolled. Majority postoperative complication in our study was surgical site infection, seen in 50% of the patients followed by lower respiratory tract infection in 45% of the patients. Sepsis and wound dehiscence were seen in 25% of the patients each. 15% of the patients developed acute kidney injury postoperatively while 10% of the patients showed anastomotic leak, disseminated intravascular coagulation and thrombocytopenia each. With increasing ESS, postoperative complication rate also increased (c-statistic\u0026thinsp;=\u0026thinsp;0.820).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePeponis et al. extrapolated ESS to predict 30-day morbidity in patients undergoing emergency laparotomy. This study demonstrated ESS correlated well with morbidity (c-statistic\u0026thinsp;=\u0026thinsp;0.74); morbidity rates steadily increased from 13% at score 0 to 58% at score 7 and 79% at score 11 after which the complication rates plateaued [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNandan et al. in 2017 also validated the efficacy of ESS in predicting post-operative complications in patients undergoing emergency general surgery. It reported out of 37,999 cases enrolled, 14,446 (38%) resulted in at least one complication within a period of 30 days. The observed 30-day complication rates consistently increased from 7\u0026ndash;53% to 91% at scores of 0, 7, and 15, respectively, after which it plateaued at a mean of 92% for ESS\u0026thinsp;\u0026gt;\u0026thinsp;15, with a c-statistic of 0.78. On multivariable analyses, each of the 22 ESS components independently predicted the occurrence of postoperative complications. Out of the complications reported, most common was surgical site infection (12.9%) followed by pneumonia (7.3%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Our study reported a similar trend.\u003c/p\u003e \u003cp\u003eHan et al. reported a total of 90,412 patients out of which 22% developed one or more post-operative infections, most common of which was sepsis/septic shock (12.2%), followed by surgical site infection (9%), and pneumonia (5.7%). The ESS accurately predicted infectious complications; post-operative infections developed in 7% of patients with ESS\u0026thinsp;=\u0026thinsp;1, in 24% of patients with ESS\u0026thinsp;=\u0026thinsp;5, and in 49% of patients with an ESS\u0026thinsp;=\u0026thinsp;10. The c-statistics for overall postoperative infection was 0.73, postoperative sepsis/septic shock was 0.75, and pneumonia was 0.80. It recommended the use of ESS in estimating risk of infections in patients undergoing emergency laparotomy within a period of 30 days [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKaafarani et al. also demonstrated efficacy of ESS in predicting 30-day postoperative morbidity in a study enrolling 1,649 patients. The 30-day complication rate was 53.3%. Emergency Surgery Score gradually and accurately predicted complications; 21.0%, 57.1%, and 88.9% of patients with ESS of 1, 6, and 13 developed postoperative complications, with a c-statistic of 0.74 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eESS and ICU Admission:-\u003c/h2\u003e \u003cp\u003eIn our study, 35% of the patients enrolled were admitted into ICU postoperatively. In a 2015 study by Banerjee et al. 70% of the patients undergoing emergency laparotomy required a high dependency unit bed or critical care [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Emergency Laparotomy Collaborative (ELC) and the Emergency Laparotomy Pathway Quality Improvement Care (ELPQuiC) bundle project suggests that all patients should be admitted in ICU after emergency laparotomy. However due to the paucity of available ICU beds at our institution, the recommendation could not be followed. Kaafarani et al. in his study demonstrated the applicability of ESS in predicting post-operative ICU admission. 57.0% of patients required ICU admission post-operatively. Emergency Surgery Score accurately predicted which patients required intensive care unit admission (c-statistic, 0.80) with high ESS requiring critical care [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Our study also showed a similar trend with c-statistic of 0.87.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eESS and Reoperation, Readmission:-\u003c/h2\u003e \u003cp\u003eIn our study, 3 (15%) of the patients underwent reoperation. ESS score showed poor correlation with requirement of reoperation within 30 days of emergency laparotomy (c-statistic\u0026thinsp;=\u0026thinsp;0.667). In a recent study by Kassahun et al 35.9% patients required subsequent reoperation after emergency laparotomy, and 547 (64.1%) did not. The incidence of postoperative complications was higher in reoperated patients (100%) than in non-reoperated patients (58.9%). There were 305 deaths, with an overall in-hospital mortality rate of 35.7%; 175 (57%) occurred in the re-operated group, and 130 (23.8%) occurred in the non-re-operated group [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, in our study no significant correlation was found between reoperation requirement and mortality (p-value\u0026thinsp;=\u0026thinsp;0.30)\u003c/p\u003e \u003cp\u003e2 (10%) of the patients had to be readmitted within 30 days of emergency laparotomy in our study. ESS had no significant correlation with Readmission rates (c-statistic\u0026thinsp;=\u0026thinsp;0.55). According to Kongkaew Paisan et al out of 1,347 patients included, 234 (17.4%) had an unplanned readmission within 30 day post-operative period of emergency laparotomy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The predictors for unplanned readmission included patient factors (eg, disseminated cancer [odds ratio: 2.22, P\u0026thinsp;=\u0026thinsp;0.002], weight loss\u0026thinsp;\u0026gt;\u0026thinsp;10% in the past 6 months [odds ratio: 1.65, P\u0026thinsp;=\u0026thinsp;0.023], dyspnea at baseline [odds ratio: 1.62, P\u0026thinsp;=\u0026thinsp;0.026], wound complications [odds ratio: 2.23, P\u0026thinsp;\u0026lt;\u0026thinsp;.001], and discharge to nursing homes [odds ratio: 1.68, P\u0026thinsp;=\u0026thinsp;0.044] similar to those included in calculating ESS. Readmission however was not a significant predictor of mortality according to our study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:-\u003c/h2\u003e \u003cp\u003eLimitations in our study are small sample size, procedures performed in emergency were not included in the study, neither was the indication of reoperation or readmission recorded. White race included as one of the parameters in calculating ESS could not be used in our study. The study was carried out among the Indian population without correlation of race. Infrastructural limitations in the form of lack of ICU beds, delayed availability of operation theaters may have a corroborative effect on mortality and morbidity.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFrom our study we conclude that ESS is useful to predict postoperative mortality, morbidity and ICU stay was proven statistically. ESS was found to be good predictor for development of postoperative LRTI, sepsis, DIC, AKI. LRTI, wound dehiscence, sepsis, AKI, thrombocytopenia, DIC and ICU stay in postoperative period were found to be significantly associated with mortality. Thus, it can be concluded from the study that risk stratification should be done for patients undergoing emergency laparotomy by using Emergency Surgery Score. Thereby it can predict necessary needs for resuscitation and patient stabilization before surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.B. and C.B.S. conducted the primary research.S.N. and D.G. are responsible for statistical analysis.S.B. drafted the original manuscript.S.R. edited the manuscript.All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShafi S, Aboutanos MB, Agarwal S, et al.: Emergency general surgery: definition and estimated burden of disease. J Trauma Acute Care Surg. 2013, 74:1092-7. 10.1097/TA.0b013e31827e1bc7\u003c/li\u003e\n\u003cli\u003eDebas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, editors: Essential Surgery: Disease Control Priorities, Third Edition (Volume 1). Washington (DC): The World Bank; 2015; April 2; chapter 4. 61-76; 10.1596/978-1-4648-0346-8. 61-76. 10.1596/978-1-4648-0346-8\u003c/li\u003e\n\u003cli\u003eStewart B, Khanduri P, McCord C, et al.: Global disease burden of conditions requiring emergency surgery. Br J Surg. 2014, 101:9-22. 10.1002/bjs.9329\u003c/li\u003e\n\u003cli\u003eSangji NF, Bohnen JD, Ramly EP, et al.: Derivation and validation of a novel Emergency Surgery Acuity Score (ESAS). J Trauma Acute Care Surg. 2016, 81:213-20. 10.1097/TA.0000000000001059\u003c/li\u003e\n\u003cli\u003eNandan AR, Bohnen JD, Sangji NF, et al.: The Emergency Surgery Score (ESS) accurately predicts the occurrence of postoperative complications in emergency surgery patients. J Trauma Acute Care Surg. 2017, 83:84-9. 10.1097/TA.0000000000001500\u003c/li\u003e\n\u003cli\u003eHan K, Lee JM, Achanta A, et al.: Emergency Surgery Score Accurately Predicts the Risk of Post-Operative Infection in Emergency General Surgery. Surg Infect 4-9. 10.1089/sur.2018.101\u003c/li\u003e\n\u003cli\u003eGejoe G, Yadev I, Rahul M. : Emergency Laparotomies at a Tertiary Care Center-a Hospital-Based Cross-Sectional Study. Indian J Surg. 2017, 79:206-11. 10.1007/s12262-016-1446-5\u003c/li\u003e\n\u003cli\u003eBali RS, Jain R, Zahoor Y, et al.: Abdominal tuberculosis: a surgical emergency. Int J Res Med Sci. 2017, 5:3847-50.\u003c/li\u003e\n\u003cli\u003eCharokar K, Garg N, Jain AK: Surgical management of abdominal tuberculosis: a retrospective study from Central India. Int Surg. 2016:23-31.\u003c/li\u003e\n\u003cli\u003eJaskani S, Mehmood N, Khan NM: Surgical management of acute presentation and outcome of patients with complicated abdominal tuberculosis. J Rawalpindi Med Coll :108-12.\u003c/li\u003e\n\u003cli\u003eKalra D, Gupta S, Yadav BL, et al.: Association of clinical outcome and APACHE II score in secondary peritonitis (a study of 50 cases). Int J Health Sci Res. 2016, 6:107-113.\u003c/li\u003e\n\u003cli\u003ePeponis T, Bohnen JD, Sangji NF, et al.: Does the emergency surgery score accurately predict outcomes in emergent laparotomies?. Surgery. 2017, 162:445-52. 10.1016/j.surg.2017.03.016\u003c/li\u003e\n\u003cli\u003eKaafarani HMA: Kongkaewpaisan N, Aicher BO et al. Prospective validation of the Emergency Surgery Score in emergency general surgery: An Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg. 2020, 89:118-24. 10.1097/TA.0000000000002658\u003c/li\u003e\n\u003cli\u003eBanerjee, T., Templeton, M. \u0026amp; Gore, C: Emergency laparotomy clinical outcome according to patient characteristics, level of postoperative care and time of surgery. Crit Care 19. 546:\u003c/li\u003e\n\u003cli\u003eKassahun WT, Mehdorn M, Wagner TC: The effects of reoperation on surgical outcomes following surgery for major abdominal emergencies. A retrospective cohort study. Int J Surg. 2019, 72:235-240. 10.1016/j.ijsu.2019.11.024\u003c/li\u003e\n\u003cli\u003eKongkaewpaisan N, El Hechi MW, Naar L, et al.: Unplanned readmission after emergency laparotomy: A post hoc analysis of an EAST multicenter study. Surgery. 2021, 169:1434-1440. 10.1016/j.surg.2020.11.047\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3988895/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3988895/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAims And Objectives - To determine the predictive value of Emergency Surgery Score (ESS) with regards to mortality and morbidity rates of patients undergoing emergency laparotomy.\u003c/p\u003e \u003cp\u003eMethod - The ESS, ranging from 0 to 29 is an extensive risk calculator based on 22 variables including important parameters like demographics, pre-operative treatment, comorbidities, and laboratory values. Twenty patients who underwent emergency laparotomy were preoperatively assessed and ESS was calculated for each. After establishment of diagnosis and resuscitation, the patient was taken up for emergency laparotomy. Postoperatively, patients were monitored clinically as well as with laboratory and radiological investigations as per case needed till discharge and further followed up physically in OPD/ ward or interviewed telephonically for 30 days on a weekly basis. Incidence of mortality and morbidity in terms of postoperative complications, ICU admission, reoperation and readmission among the cases occurring within 30 days of procedure were recorded.\u003c/p\u003e \u003cp\u003eResults - ESS correlated well with the outcome in the current study, 10 out of 14 patients with score less than 8 were discharged without any complications. Mean ESS was higher among non survivors. Ability of ESS to predict postoperative mortality, morbidity and ICU stay was proven statistically with c-statistics of 0.853, 0.84, 0.879 respectively. ESS was found to be good predictor for development of postoperative LRTI (c-statistic\u0026thinsp;=\u0026thinsp;0.828), sepsis (c-statistic\u0026thinsp;=\u0026thinsp;0.867), DIC (c-statistic\u0026thinsp;=\u0026thinsp;0.805), AKI (c-statistic\u0026thinsp;=\u0026thinsp;0.804). ESS showed poor correlation with reoperation and readmission rates.\u003c/p\u003e \u003cp\u003eConclusion - It can be concluded from the study that risk stratification should be done for patients undergoing emergency laparotomy by using ESS. Thereby it can predict necessary needs for resuscitation and patient stabilization before surgery. Using ESS, patients unsuitable for operation can be identified and optimized beforehand; well informed decisions can be taken regarding targeted treatment, operation, and post-operative care.\u003c/p\u003e \u003cp\u003eThis study is a registered study under Clinical Trials Registry - India (CTRI) with registration number CTRI/2021/07/034504 and was registered on 01/07/2021.\u003c/p\u003e","manuscriptTitle":"Emergency Surgery Score (ESS) In Predicting Post- Operative Course In Patients Undergoing Emergency Laparotomy – An Indian Tertiary center experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-28 20:43:13","doi":"10.21203/rs.3.rs-3988895/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1b75eace-6708-44cb-af8d-5a98aacb83c0","owner":[],"postedDate":"February 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-10T16:22:52+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-28 20:43:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3988895","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3988895","identity":"rs-3988895","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}