P-POSSUM and the NELA Score Overpredict Mortality for Laparoscopic Emergency Bowel Surgery: An Analysis of the NELA Database.
Journal
World journal of surgery
ISSN: 1432-2323
Titre abrégé: World J Surg
Pays: United States
ID NLM: 7704052
Informations de publication
Date de publication:
03 2022
03 2022
Historique:
accepted:
20
11
2021
pubmed:
11
1
2022
medline:
19
2
2022
entrez:
10
1
2022
Statut:
ppublish
Résumé
Risk stratification has become a key part of the care processes for patients having emergency bowel surgery. This study aimed to determine if operative approach influences risk-model performance, and risk-adjusted mortality rates in the United Kingdom. A prospectively planned analysis was conducted using National Emergency Laparotomy Audit (NELA) data from December 2013 to November 2018. The risk-models investigated were P-POSSUM and the NELA Score, with model performance assessed in terms of discrimination and calibration. Risk-adjusted mortality was assessed using Standardised Mortality Ratios (SMR). Analysis was performed for the total cohort, and cases performed open, laparoscopically and converted to open. Sub-analysis was performed for cases with ≤ 20% predicted mortality. Data were available for 116 396 patients with P-POSSUM predicted mortality, and 46 935 patients with the NELA score. Both models displayed excellent discrimination with little variation between operative approaches (c-statistic: P-POSSUM 0.801-0.836; NELA Score 0.811-0.862). The NELA score was well calibrated across all deciles of risk, but P-POSSUM over-predicted risk beyond 20% mortality. Calibration plots for operative approach demonstrated that both models increasingly over-predicted mortality for laparoscopy, relative to open and converted to open surgery. SMRs calculated using both models consistently demonstrated that risk-adjusted mortality with laparoscopy was a third lower than open surgery. Risk-adjusted mortality for emergency bowel surgery is lower for laparoscopy than open surgery, with P-POSSUM and NELA score both over-predicting mortality for laparoscopy. Operative approach should be considered in the development of future risk-models that rely on operative data.
Sections du résumé
BACKGROUND
Risk stratification has become a key part of the care processes for patients having emergency bowel surgery. This study aimed to determine if operative approach influences risk-model performance, and risk-adjusted mortality rates in the United Kingdom.
METHODS
A prospectively planned analysis was conducted using National Emergency Laparotomy Audit (NELA) data from December 2013 to November 2018. The risk-models investigated were P-POSSUM and the NELA Score, with model performance assessed in terms of discrimination and calibration. Risk-adjusted mortality was assessed using Standardised Mortality Ratios (SMR). Analysis was performed for the total cohort, and cases performed open, laparoscopically and converted to open. Sub-analysis was performed for cases with ≤ 20% predicted mortality.
RESULTS
Data were available for 116 396 patients with P-POSSUM predicted mortality, and 46 935 patients with the NELA score. Both models displayed excellent discrimination with little variation between operative approaches (c-statistic: P-POSSUM 0.801-0.836; NELA Score 0.811-0.862). The NELA score was well calibrated across all deciles of risk, but P-POSSUM over-predicted risk beyond 20% mortality. Calibration plots for operative approach demonstrated that both models increasingly over-predicted mortality for laparoscopy, relative to open and converted to open surgery. SMRs calculated using both models consistently demonstrated that risk-adjusted mortality with laparoscopy was a third lower than open surgery.
CONCLUSION
Risk-adjusted mortality for emergency bowel surgery is lower for laparoscopy than open surgery, with P-POSSUM and NELA score both over-predicting mortality for laparoscopy. Operative approach should be considered in the development of future risk-models that rely on operative data.
Identifiants
pubmed: 35001139
doi: 10.1007/s00268-021-06404-w
pii: 10.1007/s00268-021-06404-w
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
552-560Informations de copyright
© 2021. The Author(s) under exclusive licence to Société Internationale de Chirurgie.
Références
The NELA Project Team (2020) Sixth Patient Report of the National Emergency Laparotomy Audit. 1–51 https://www.nela.org.uk/reports
Oliver CM et al (2018) Organisational factors and mortality after an emergency laparotomy: multilevel analysis of 39 903 national emergency laparotomy audit patients. BJA 121:1346–1356
doi: 10.1016/j.bja.2018.07.040
Aggarwal G et al (2019) Evaluation of the collaborative use of an evidence-based care bundle in emergency laparotomy. JAMA Surg 154:e190145–e190210
doi: 10.1001/jamasurg.2019.0145
Prytherch DR et al (1998) POSSUM and Portsmouth POSSUM for predicting mortality. Br J Surg 85:1217–1220
doi: 10.1046/j.1365-2168.1998.00840.x
Eugene N et al (2018) Development and internal validation of a novel risk adjustment model for adult patients undergoing emergency laparotomy surgery: the national emergency laparotomy audit risk model. Br J Anaesth 121:739–748
doi: 10.1016/j.bja.2018.06.026
Moonesinghe SR, Mythen MG, Das P, Rowan KM, Grocott MPW (2013) Risk stratification tools for predicting morbidity and mortality in adult patients undergoing major surgery. Anesthesiology 119:959–981
doi: 10.1097/ALN.0b013e3182a4e94d
Oliver CM, Walker E, Giannaris S, Grocott MPW, Moonesinghe SR (2015) Risk assessment tools validated for patients undergoing emergency laparotomy: a systematic review. BJA 115:849–860
doi: 10.1093/bja/aev350
Boyd-Carson H et al (2020) The association of pre-operative anaemia with morbidity and mortality after emergency laparotomy. Anaesthesia 75:904–912
doi: 10.1111/anae.15021
Jarman B et al (1999) Explaining differences in English hospital death rates using routinely collected data. BMJ 318:1515–1520
doi: 10.1136/bmj.318.7197.1515
Iezzoni LI (1997) The risks of risk adjustment. JAMA 278:1600–1607
doi: 10.1001/jama.278.19.1600
Guillou PJ et al (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet (London, England) 365:1718–1726
doi: 10.1016/S0140-6736(05)66545-2
Jayne DG et al (2010) Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg 97:1638–1645
doi: 10.1002/bjs.7160
Biere SSAY et al (2012) Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet (London, England) 379:1887–1892
doi: 10.1016/S0140-6736(12)60516-9
van der Pas MH et al (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218
doi: 10.1016/S1470-2045(13)70016-0
Bonjer HJ et al (2015) A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 372:1324–1332
doi: 10.1056/NEJMoa1414882
Mariette C et al (2019) Hybrid minimally invasive Esophagectomy for Esophageal cancer. N Engl J Med 380:152–162
doi: 10.1056/NEJMoa1805101
Calster BV et al (2019) Calibration: the Achilles heel of predictive analytics. BMC Med 17:230–237
doi: 10.1186/s12916-019-1466-7
DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845
doi: 10.2307/2531595
von Elm E et al (2008) The strengthening the reporting of observational studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61:344–349
doi: 10.1016/j.jclinepi.2007.11.008
The NELA Project Team (2017) Third patient report of the national emergency laparotomy audit (NELA). 1–190 https://www.nela.org.uk/downloads/The%20Third%20Patient%20Report%20of%20the%20National%20Emergency%20Laparotomy%20Audit%202017%20-%20Full%20Patient%20Report.pdf
Mohammed MA et al (2009) Evidence of methodological bias in hospital standardised mortality ratios: retrospective database study of English hospitals. BMJ 338:b780–b788
doi: 10.1136/bmj.b780
Heywood N et al (2021) The laparoscopy in emergency general surgery (LEGS) study: a questionnaire survey of UK practice. Ann Royal Coll Surg Engl 103:120–129
doi: 10.1308/rcsann.2020.7005
The NELA Project Team (2015) The First Patient Report of the National Emergency Laparotomy Audit. 1–151 https://www.nela.org.uk/All-Patient-Reports .
Badrick E, et al. (2020) Laparoscopy in emergency general surgery (The LEGS Study): NELA database analysis. B J Surg
Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, Cohen ME (2013) Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am College Surg 217(5):833-842.e3
doi: 10.1016/j.jamcollsurg.2013.07.385
Liu Y, Cohen ME, Hall BL, Ko CY, Bilimoria KY (2016) Evaluation and enhancement of calibration in the American college of surgeons NSQIP surgical risk calculator. J Am Coll Surg 223:231–239
doi: 10.1016/j.jamcollsurg.2016.03.040
Bertsimas D, Dunn J, Velmahos GC, Kaafarani HMA (2018) Surgical risk is not linear: derivation and validation of a novel, user-friendly, and machine-learning-based predictive optimal trees in emergency surgery risk (POTTER) calculator. Ann Surg 268:574–583
doi: 10.1097/SLA.0000000000002956
Pucher PH, Mackenzie H, Tucker V, Mercer SJ (2021) A national propensity score-matched analysis of emergency laparoscopic versus open abdominal surgery. B J Surg. https://doi.org/10.1093/bjs/znab048
doi: 10.1093/bjs/znab048
Sallinen V et al (2019) Laparoscopic versus open adhesiolysis for adhesive small bowel obstruction (LASSO): an international, multicentre, randomised, open-label trial. Lancet Gastroenterol Hepatol 4:278–286
doi: 10.1016/S2468-1253(19)30016-0
Harji DP et al (2020) Laparoscopic versus open colorectal surgery in the acute setting (LaCeS trial): a multicentre randomized feasibility trial. Br J Surg 107:1595–1604
doi: 10.1002/bjs.11703
Søreide K, Thorsen K, Søreide JA (2014) Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. Br J Surg 101:e51-64
doi: 10.1002/bjs.9368
Moghadamyeghaneh Z, Talus H, Ballantyne G, Stamos MJ, Pigazzi A (2020) Short-term outcomes of laparoscopic approach to colonic obstruction for colon cancer. Surg Endosc. https://doi.org/10.1007/s00464-020-07743-w
doi: 10.1007/s00464-020-07743-w
pubmed: 32572627
Darbyshire AR, Kostakis I, Pucher PH, Toh S, Mercer SJ (2021) The impact of laparoscopy on emergency surgery for adhesional small bowel obstruction: prospective single centre cohort study. Annals Royal College Surg England. https://doi.org/10.1308/rcsann.2020.7079
doi: 10.1308/rcsann.2020.7079
Shibata J et al (2015) Surgical stress response after colorectal resection: a comparison of robotic, laparoscopic, and open surgery. Tech Coloproctol 19:275–280
doi: 10.1007/s10151-014-1263-4
Crippa J, Mari GM, Miranda A, Costanzi ATM, Maggioni D (2018) Surgical stress response and enhanced recovery after laparoscopic surgery - a systematic review. Chirurgia 113:455–510
doi: 10.21614/chirurgia.113.4.455
Foss NB, Kehlet H (2020) Challenges in optimising recovery after emergency laparotomy. Anaesthesia 75:A4876–A4877
Martin P (2020) NELA risk adjustment model: recalibration of predictor coefficients. 1–6 https://data.nela.org.uk/getattachment/Support/NELA-Risk-Adjustment-Model/NELA-(2020)-Recalibrated-risk-model-coefficients.pdf.aspx?lang=en-GB