Predictive Performance of NELA Versus P-POSSUM Mortality Scores: Are We Underestimating the Risk of Mortality Following Emergency Laparotomy?

Background In this study, we aimed to compare the performance of the National Emergency Laparotomy Audit (NELA) and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) mortality risk scores in predicting 30-day and 90-day mortality in patients undergoing emergency laparotomy. Methodology A retrospective cohort study was conducted to compare the predictive performance of preoperative NELA, postoperative NELA, and P-POSSUM predicted mortality scores in patients undergoing emergency laparotomy between 2014 and 2021. The outcomes of interest included the observed 30-day and 90-day mortality. The discrimination of the mortality tools was assessed and compared by determining the area under the curve (AUC) for each tool using the receiver operating characteristic curve analysis. Results A total of 681 patients were included. The observed risk of 30-day and 90-day mortality was 10.4% (71/681) and 14.2% (97/681), respectively. Regarding 30-day mortality, the AUC was 0.791 (0.727-0.855) for the preoperative NELA score, 0.784 (0.721-0.848) for the preoperative P-POSSUM score, and 0.761 (0.699-0.824) for the postoperative NELA score. Regarding 90-day mortality, the AUC was 0.765 (0.708-0.821) for the preoperative NELA score, 0.749 (0.692-0.807) for the preoperative P-POSSUM score, and 0.745 (0.691-0.800) for the postoperative NELA score. The observed/expected ratio for 30-day and 90-day mortality was 3.25 and 4.43 for preoperative NELA, 2.81 and 3.84 for preoperative P-POSSUM, and 2.17 and 2.96 for postoperative NELA, respectively. Pairwise comparisons showed no statistically significant difference in discrimination among the three models. Conclusions Preoperative NELA, postoperative NELA, and P-POSSUM scores underestimated the risk of 30-day and 90-day mortality in patients undergoing emergency laparotomy. No significant difference in predictive performance was found among the three models.

Meta-analysis and trial sequential analysis of three-port vs four-port laparoscopic cholecystectomy (level 1 evidence).

To compare the outcomes of three-port and four-port laparoscopic cholecystectomy. In compliance with PRISMA statement standards, electronic databases were searched to identify all comparative studies investigating outcomes of three-port vs four-port laparoscopic cholecystectomy. Two techniques were compared using direct comparison meta-analysis model. The risks of type 1 or type 2 error in the meta-analysis model were assessed using trial sequential analysis model. The certainty of evidence was assessed using GRADE system. Random effects modelling was applied to calculate pooled outcome data. Analysis of 2524 patients from 17 studies showed that both techniques were comparable in terms of operative time (MD:- 0.13, P = 0.88), conversion to open operation (OR:0.80, P = 0.43), gallbladder perforation (OR: 1.43, P = 0.13), bleeding from gallbladder bed (OR:0.81, P = 0.34), bile duct injury (RD: 0.00, P = 0.97), iatrogenic visceral injury (RD: - 0.00, P = 0.81), bile or stone spillage (OR:1.67, P = 0.08), port site infection (OR: 0.90, P = 0.76), port site hernia (RD: 0.00, P = 0.89), port site haematoma (RD: - 0.01, P = 0.23), port site seroma (RD: 0.00, P = 1.00), and need for reoperation (RD: - 0.00, P = 0.94). However, the three-port technique was associated with lower VAS pain score at 12 h (MD: - 0.66, P < 0.00001) and 24 h (MD: - 0.54, P < 0.00001) postoperatively, shorter length of hospital stay (MD:-0.09, P = 0.41), and shorter time to return to normal activities (MD: - 0.79, P = 0.02). Trial sequential analysis confirmed that the meta-analysis was conclusive with no significant risks of type 1 or type 2 error. Robust evidence (level 1 with high certainty) suggests that in an elective setting with uncomplicated cholelithiasis as indication for cholecystectomy, three-port laparoscopic cholecystectomy is comparable with the four-port technique in terms of procedural and morbidity outcomes and may be associated with less postoperative pain, shorter length of hospital stay and shorter time to return to normal activities.

Validation of a Patient-Completed Caprini Risk Assessment Tool for Spanish, Arabic, and Polish Speakers.

Targeted prophylaxis for venous thromboembolism (VTE) using the Caprini risk score (CRS) is effective reducing postoperative VTE. Despite its availability as preventive strategy, risk scoring remains underutilized. Critics to the CRS contend the time it takes to complete, and its limitation to English language. Aim is to create and validate patient-completed CRS tools for Spanish, Arabic, and Polish speakers. We translated the first patient-completed CRS to Spanish, Arabic, and Polish. We conducted a pilot study followed by the validation study. Using PASS version 11, we determined that a sample size of 37 achieved a power of 80%, to detect a difference of 0.1 between the null hypothesis correlation of 0.5 and the alternative hypothesis correlation of 0.7 using a 2-sided hypothesis test, significance level of .05. We tabulated and categorized scores using SPSS version 23 to estimate κ, linear correlation, and Bland Altman test. κ value >0.8 was defined as "almost perfect agreement." From 129 recruited patients, 50 (39%) spoke Spanish, 40 (31%) spoke Arabic, and 39 (30%) spoke Polish; average age 51 (16.69) years, 58 (45%) were men, with less than college education (67%). Mean (standard deviation) CRS was 5 (3.90), the majority (63%) above moderate VTE risk. We report excellent agreement comparing physician and patient results (κ = 0.93) and high correlation 0.97 ( P < .01) for the overall score. Bland Altman did not show trend for extreme values. We created and validated the first Spanish, Arabic, and Polish versions of the patient-completed CRS, with excellent correlation and agreement when compared to CRS-trained physician-completed form. Based on these results, the physician needs to calculate the body mass index. Completing the form was not time-consuming.