Development and internal validation of a clinical prediction model for serious complications after emergency laparotomy.

PURPOSE: Emergency laparotomy (EL) is a common operation with high risk for postoperative complications, thereby requiring accurate risk stratification to manage vulnerable patients optimally. We developed and internally validated a predictive model of serious complications after EL. METHODS: Data for eleven carefully selected candidate predictors of 30-day postoperative complications (Clavien-Dindo grade > = 3) were extracted from the HELAS cohort of EL patients in 11 centres in Greece and Cyprus. Logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) was applied for model development. Discrimination and calibration measures were estimated and clinical utility was explored with decision curve analysis (DCA). Reproducibility and heterogeneity were examined with Bootstrap-based internal validation and Internal-External Cross-Validation. The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) model was applied to the same cohort to establish a benchmark for the new model. RESULTS: From data on 633 eligible patients (175 complication events), the SErious complications After Laparotomy (SEAL) model was developed with 6 predictors (preoperative albumin, blood urea nitrogen, American Society of Anaesthesiology score, sepsis or septic shock, dependent functional status, and ascites). SEAL had good discriminative ability (optimism-corrected c-statistic: 0.80, 95% confidence interval [CI] 0.79-0.81), calibration (optimism-corrected calibration slope: 1.01, 95% CI 0.99-1.03) and overall fit (scaled Brier score: 25.1%, 95% CI 24.1-26.1%). SEAL compared favourably with ACS-NSQIP in all metrics, including DCA across multiple risk thresholds. CONCLUSION: SEAL is a simple and promising model for individualized risk predictions of serious complications after EL. Future external validations should appraise SEAL's transportability across diverse settings.

Floret Biofortification of Broccoli Using Amino Acids Coupled with Selenium under Different Surfactants: A Case Study of Cultivating Functional Foods.

Broccoli serves as a functional food because it can accumulate selenium (Se), well-known bioactive amino-acid-derived secondary metabolites, and polyphenols. The chemical and physical properties of Se are very similar to those of sulfur (S), and competition between sulfate and selenate for uptake and assimilation has been demonstrated. Towards an efficient agronomic fortification of broccoli florets, the working questions were whether we could overcome this competition by exogenously applying the S-containing amino acids cysteine (Cys) or/and methionine (Met), or/and the precursors of Glucosinolate (GSL) types along with Se application. Broccoli plants were cultivated in a greenhouse and at the beginning of floret growth, we exogenously applied sodium selenate in the concentration gradient of 0, 0.2, 1.5, and 3.0 mM to study the impact of increased Se concentration on the organic S (Sorg) content of the floret. The Se concentration of 0.2 mM (Se0.2) was coupled with the application of Cys, Met, their combination, or a mixture of phenylalanine, tryptophane, and Met. The application took place through fertigation or foliar application (FA) by adding isodecyl alcohol ethoxylate (IAE) or a silicon ethoxylate (SiE) surfactant. Fresh biomass, dry mass, and Se accumulation in florets were evaluated, along with their contents of Sorg, chlorophylls (Chl), carotenoids (Car), glucoraphanin (GlRa), glucobrassicin (GlBra), glucoiberin (GlIb), and polyphenols (PPs), for the biofortification efficiency of the three application modes. From the studied selenium concentration gradient, the foliar application of 0.2 mM Se using silicon ethoxylate (SiE) as a surfactant provided the lowest commercially acceptable Se content in florets (239 µg or 0.3 µmol g-1 DM); it reduced Sorg (-45%), GlIb (-31%), and GlBr (-27%); and it increased Car (21%) and GlRa (27%). Coupled with amino acids, 0.2 mM Se provided commercially acceptable Se contents per floret only via foliar application. From the studied combinations, that of Met,Se0.2/FA,IAE provided the lowest Se content per floret (183 µg or 0.2 µmol g-1 DM) and increased Sorg (35%), Car (45%), and total Chl (27%), with no effect on PPs or GSLs. Cys,Met,Se0.2/FA,IAE and amino acid mix,Se0.2/FA,IAE increased Sorg content, too, by 36% and 16%, respectively. Thus, the foliar application with the IAE surfactant was able to increase Sorg, and methionine was the amino acid in common in these treatments, with varying positive effects on carotenoids and chlorophylls. Only the Cys,Met,Se0.2 combination presented positive effects on GSLs, especially GlRa, but it reduced the fresh mass of the floret. The foliar application with SiE as a surfactant failed to positively affect the organic S content. However, in all studied combinations of Se 0.2 mM with amino acids, the Se content per floret was commercially acceptable, the yield was not affected, the content of GSLs was increased (especially that of GlRa and GlIb), and PPs were not affected. The content of GlBr decreased except for the treatment with methionine (Met,Se0.2/FA,SiE) where GlBr remained unaffected. Hence, the combination of Se with the used amino acids and surfactants can provide enhanced biofortification efficiency in broccoli by providing florets as functional foods with enhanced functional properties.

A Rare Case of Synchronous Primary Gallbladder and Sigmoid Colon Neoplasms.

Colorectal cancer is considered the third most common cancer worldwide. On the other hand, gallbladder cancer is rare. Synchronous tumors in both the colon and the gallbladder are extremely infrequent. Herein, we report the case of a female patient with sigmoid colon cancer and incidental detection of synchronous gallbladder cancer on histopathological examination of the surgical specimen. As synchronous gallbladder and colonic carcinomas are rare, physicians should be aware of these so that an optimal course of treatment can be chosen.

Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy.

BACKGROUND: Accurate preoperative risk assessment in emergency laparotomy (EL) is valuable for informed decision making and rational use of resources. Available risk prediction tools have not been validated adequately across diverse health care settings. Herein, we report a comparative external validation of four widely cited prognostic models. METHODS: A multicenter cohort was prospectively composed of consecutive patients undergoing EL in 11 Greek hospitals from January 2020 to May 2021 using the National Emergency Laparotomy Audit (NELA) inclusion criteria. Thirty-day mortality risk predictions were calculated using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), NELA, Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM), and Predictive Optimal Trees in Emergency Surgery Risk tools. Surgeons' assessment of postoperative mortality using predefined cutoffs was recorded, and a surgeon-adjusted ACS-NSQIP prediction was calculated when the original model's prediction was relatively low. Predictive performances were compared using scaled Brier scores, discrimination and calibration measures and plots, and decision curve analysis. Heterogeneity across hospitals was assessed by random-effects meta-analysis. RESULTS: A total of 631 patients were included, and 30-day mortality was 16.3%. The ACS-NSQIP and its surgeon-adjusted version had the highest scaled Brier scores. All models presented high discriminative ability, with concordance statistics ranging from 0.79 for P-POSSUM to 0.85 for NELA. However, except the surgeon-adjusted ACS-NSQIP (Hosmer-Lemeshow test, p = 0.742), all other models were poorly calibrated ( p < 0.001). Decision curve analysis revealed superior clinical utility of the ACS-NSQIP. Following recalibrations, predictive accuracy improved for all models, but ACS-NSQIP retained the lead. Between-hospital heterogeneity was minimum for the ACS-NSQIP model and maximum for P-POSSUM. CONCLUSION: The ACS-NSQIP tool was most accurate for mortality predictions after EL in a broad external validation cohort, demonstrating utility for facilitating preoperative risk management in the Greek health care system. Subjective surgeon assessments of patient prognosis may optimize ACS-NSQIP predictions. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level II.

The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece.

BACKGROUND: Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). METHODS: This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. RESULTS: There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). CONCLUSION: In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.

An Extremely Rare Case of a Primary Pancreatic Yolk Sac Tumor.

Yolk sac tumor (YST) is a rare malignant type of germ cell tumor (GCT). Extragonadal yolk sac tumor is a very rare entity. We report the case of a 33-year-old male with a pancreatic mass, which proved to be a primary yolk sac tumor, arising in the pancreas.

Colouterine and Jejunouterine Fistula Secondary to Chronic Diverticulitis.

Fistulae between the colon or the small intestine and the uterus are extremely rare as the uterus is a thick, muscular organ. Here, we present the case of a 74-year-old female presenting to our surgical department because of fecal vaginal discharge for the past few months, which proved to be caused by a combined colouterine and jejunouterine fistula due to chronic diverticulitis. Total abdominal hysterectomy with bilateral oophorectomy with en bloc resection of part of the jejunum and the sigmoid colon and primary anastomoses were performed. This case represents an unusual type of diverticulitis complication and aims to point out the diagnostic and therapeutic issues of such a rare medical condition.

Mortality after groin hernia surgery.

OBJECTIVE: To analyze mortality following groin hernia operations. SUMMARY BACKGROUND DATA: It is well known that the incidence of groin hernia in men exceeds the incidence in women by a factor of 10. However, gender differences in mortality following groin hernia surgery have not been explored in detail. METHODS: The study comprises all patients 15 years or older who underwent groin hernia repair between January 1, 1992 and December 31, 2005 at units participating in the Swedish Hernia Register (SHR). Postoperative mortality was defined as standardized mortality ratio (SMR) within 30 days, ie, observed deaths of operated patients over expected deaths considering age and gender of the population in Sweden. RESULTS: A total of 107,838 groin hernia repairs (103,710 operations), were recorded prospectively. Of 104,911 inguinal hernias, 5280 (5.1%) were treated emergently, as compared with 1068 (36.5%) of 2927 femoral hernias. Femoral hernia operations comprised 1.1% of groin hernia operations on men and 22.4% of operations on women. After femoral hernia operation, the mortality risk was increased 7-fold for both men and women. Mortality risk was not raised above that of the background population for elective groin hernia repair, but it was increased 7-fold after emergency operations and 20-fold if bowel resection was undertaken. Overall SMR was 1.4 (95% confidence interval, 1.2-1.6) for men and 4.2 (95% confidence interval, 3.2-5.4) for women, in accordance with a greater proportion of emergency operations among women compared with men, 17.0%, versus 5.1%. CONCLUSIONS: Mortality risk following elective hernia repair is low, even at high age. An emergency operation for groin hernia carries a substantial mortality risk. After groin hernia repair, women have a higher mortality risk than men due to a greater risk for emergency procedure irrespective of hernia anatomy and a greater proportion of femoral hernia.