Prospective validation of the Emergency Surgery Score in emergency general surgery: An Eastern Association for the Surgery of Trauma multicenter study

Haytham M. Kaafarani, From the Division of Trauma (H.M.A.K., N.K., G.C.V.), Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School (H.M.A.K.), Boston, Maryland; Division of Acute Care and Ambulatory Surgery (N.K.), Siriraj Hospital, Mahidol University, Bangkok, Thailand; R Adams Cowley Shock Trauma Center, Department of Surgery, (B.O.A., J.J.D.Jr., L.B.O.), University of Maryland Medical Center, Baltimore, Maryland; Department of Surgery, UCHealth Memorial Hospital Central Trauma Center (C.D., J.R., T.S.), Colorado Springs, Colorado; Dewitt Daughtry Family Department of Surgery, Ryder Trauma Center/Jackson Memorial Hospital (R.R., G.V., D.D.Y.), Miami, Florida; Loma Linda University Medical Center (U.J.S., D.T.), Department of Surgery, Loma Linda, California; Department of Surgery, Marshfield Clinic (D.C.C., C.B.E.), Marshfield, Wisconsin; Department of Surgery, University of Utah (M.L.M., N.W.), Salt Lake City, Utah; Department of Surgery, Cooper University Hospital (J.B., A.G-S), Camden, New Jersey; Department of Surgery, University of Colorado Anschutz Medical Campus (H.C., C.V.), Aurora, Colorado; Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine (R.C., J.V.S.), Baltimore, Maryland; Department of Surgery, Eastern Maine Medical Center (K.B.), Bangor, Maine; Department of Surgery, University of Texas Southwestern Medical Center and Parkland Hospital (G.B., T.S.), Dallas, Texas; Department of Surgery, Staten Island University Hospital (Z.C., V.S.), Northwell Health, Staten Island, New York; Department of Surgery, University of Florida College of Medicine-Jacksonville (F.M., D.S.), Jacksonville, Florida; Department of Surgery, Mayo Clinic (M.C., M.D.Z.), Rochester, Minnesota; Department of Surgery, Miami Valley Hospital (C.H., M.W.), Dayton, Ohio; Department of Surgery, New York University School of Medicine (M.K., S.R.), New York, New York; Papageorgiou General Hospital, Aristotle University School of Medicine (V.N.P., G.T.), Thessaloniki Greece; Department of Surgery, Hackensack University Medical Center (J.M.P.), Hackensack, New Jersey.
Napaporn Kongkaewpaisan
Brittany O. Aicher
Jose J. Diaz
Lindsay B. O'Meara
Cassandra Decker
Jennifer Rodriquez
Thomas Schroeppel
Rishi Rattan
Georgia Vasileiou
D Dante Yeh
Ursula J. Simonoski
David Turay
Daniel C. Cullinane
Cory B. Emmert
Marta L. McCrum
Natalie Wall
Jeremy Badach
Anna Goldenberg-Sandau
Heather Carmichael
Catherine Velopulos
Rachel Choron
Joseph V. Sakran
Khaldoun Bekdache
George Black
Thomas Shoultz
Zachary Chadnick
Vasiliy Sim
Firas Madbak
Daniel Steadman
Maraya Camazine
Martin D. Zielinski


BACKGROUND: The Emergency Surgery Score (ESS) was recently developed and retrospectively validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively validate ESS, specifically in the high-risk nontrauma emergency laparotomy (EL) patient. METHODS: This is an Eastern Association for the Surgery of Trauma multicenter prospective observational study. Between April 2018 and June 2019, 19 centers enrolled all adults (aged >18 years) undergoing EL. Preoperative, intraoperative, and postoperative variables were prospectively and systematically collected. Emergency Surgery Score was calculated for each patient and validated using c-statistic methodology by correlating it with three postoperative outcomes: (1) 30-day mortality, (2) 30-day complications (e.g., respiratory/renal failure, infection), and (3) postoperative intensive care unit (ICU) admission. RESULTS: A total of 1,649 patients were included. The mean age was 60.5 years, 50.3% were female, and 71.4% were white. The mean ESS was 6, and the most common indication for EL was hollow viscus perforation. The 30-day mortality and complication rates were 14.8% and 53.3%; 57.0% of patients required ICU admission. 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. Similarly, ESS 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. Emergency Surgery Score also accurately predicted which patients required intensive care unit admission (c-statistic, 0.80). CONCLUSION: This is the first prospective multicenter study to validate ESS as an accurate predictor of outcome in the EL patient. Emergency Surgery Score can prove useful for (1) perioperative patient and family counseling, (2) triaging patients to the intensive care unit, and (3) benchmarking the quality of emergency general surgery care. LEVEL OF EVIDENCE: Prognostic study, level III.