Complete transection of the descending colon following blunt abdominal trauma.

We present the case of a man in his 30s who was crushed between two vehicles sustaining blunt trauma to his lower limbs and torso. The patient was in shock on arrival to the emergency department, and immediate resuscitation was given with massive transfusion protocol activation. Once the patient's haemodynamic status was stabilised, a CT scan revealed a complete colon transection. The patient was taken to the operating theatre where a midline laparotomy was performed, and the transected descending colon was managed with a segmental resection and handsewn anastomosis. The patient followed an unremarkable postoperative course, with bowels opening on day 8 postoperatively. Colon injuries are rare following blunt abdominal trauma, and a delay in diagnosis may lead to increased morbidity and mortality. As such, a low threshold for surgical intervention is recommended.

Evaluation of a modified emergency surgical acuity score in predicting operative and non-operative mortality and morbidity in an acute surgical unit.

BACKGROUND: Emergency general surgery (EGS) patients have an increased risk of mortality and morbidity compared to other surgical patients. Limited risk assessment tools exist for use in both operative and non-operative EGS patients. We assessed the accuracy of a modified Emergency Surgical Acuity Score (mESAS) in EGS patients at our institution. METHODS: A retrospective cohort study from an acute surgical unit at a tertiary referral hospital was performed. Primary endpoints assessed included death before discharge, length of stay (LOS) >5 days and unplanned readmission within 28 days. Operative and non-operative patients were analysed separately. Validation was performed using the area under the receiver operating characteristic (AUROC), Brier score and Hosmer-Lemeshow test. RESULTS: A total of 1763 admissions between March 2018 and June 2021 were included for analysis. The mESAS was an accurate predictor of both death before discharge (AUROC 0.979, Brier score 0.007, Hosmer-Lemeshow P = 0.981) and LOS >5 days (0.787, 0.104, and 0.253, respectively). The mESAS was less accurate in predicting readmission within 28 days (0.639, 0.040, and 0.887, respectively). The mESAS retained its predictive ability for death before discharge and LOS >5 days in the split cohort analysis. CONCLUSION: This study is the first to validate a modified ESAS in a non-operatively managed EGS population internationally and the first to validate the mESAS in Australia. The mESAS accurately predicts death before discharge and prolonged LOS for all EGS patients, providing a highly useful tool for surgeons and EGS units worldwide.

What is the Accuracy of the ACS-NSQIP Surgical Risk Calculator in Emergency Abdominal Surgery? A Meta-Analysis.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator provides an estimation of 30-d post-operative complications including mortality. This tool has the potential to both aid in decision-making for patients and their families and also in optimizing the clinical management of high-risk patients. However, it's utility in patients requiring emergency abdominal surgery has shown to be inconsistent outside of NSQIP participating institutions. This study undertook a meta-analysis to assess the calculator's accuracy in predicting mortality in these patients. METHODS: A literature search of PubMed, Medline and Cochrane databases was conducted between October 2019 to April 2020. The PubMed, Medline and Cochrane Databases were searched for relevant studies. The search strategy included studies from January 2013 to April 2020. Studies including elective surgery were excluded. A random effects model was used and fitted using restricted maximum likelihood estimation. The O:E ratio was used to validate the calculator's accuracy in predicting mortality. RESULTS: Six studies were included in the meta-analysis, with a total of 1835 patients undergoing emergency intra-abdominal surgery. The summary estimate of the O:E ratio of the ACS-NSQIP surgical risk calculator in predicting 30-d post-operative mortality was 1.06 (95% CI 0.74-1.51). There was significant heterogeneity between studies with a Cochrane Q of 11.96 (P = 0.04) and I2 = 57.5%. CONCLUSIONS: The ACS-NSQIP surgical risk calculator is a reliable predictor of mortality in this external cohort and has potential to be utilised in the multi-disciplinary care of patients undergoing emergency abdominal surgery.

Utility of the American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator in predicting mortality in an Australian acute surgical unit.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator provides an estimate preoperatively of operative risks including mortality; however, its utility is not known in Australian emergency general surgical patients. This study sought to determine accuracy of the calculator in predicting outcome of high-risk patients in an Australian acute surgical unit to establish if this calculator could be a useful tool to identify high-risk patients in an Australian setting. METHODS: Retrospective analysis of patients admitted to the acute surgical unit at a tertiary referral centre between 2018 and 2019 was conducted. High-risk patients were defined as those who underwent an emergency operation with an ACS-NSQIP surgical mortality score ≥5%. Post-operative outcomes assessed included mortality and return to operating theatre, readmission and discharge to nursing home. External validation of the calculator was performed using discrimination and calibration statistics. RESULTS: Over a 14-month period, 58 patients were high risk, with an average age of 75 years, 93% were classified as functionally independent/partially dependent and 91.4% underwent a laparotomy. Overall 30-day mortality rate was 20.7%. The ACS-NSQIP calculator was a reliable predictor of mortality, with c-statistic of 0.835 (0.654-0.977), Brier score of 0.125 (0.081-0.176) and Hosmer-Lemeshow statistic of 0.389. The calculator was less accurate in its prediction of other outcomes assessed. CONCLUSION: The ACS-NSQIP calculator accurately approximated mortality in high-risk Australian patients requiring emergency surgery. This study has demonstrated that in this patient population, the calculator could reliably be applied in the multidisciplinary care of emergency surgical patients.