- Design
- Retrospective single-centre external validation cohort
- Population
- 1086 adults undergoing emergency non-traumatic exploratory laparotomy
- Primary outcome
- 30-day mortality (secondary: anastomotic leak requiring reoperation)
- Effect
- AUROC 0.86 (0.83–0.88) for mortality; 0.82 (0.73–0.90) for leak; mortality >10% at score 5, >50% at 10
The Physiological Emergency Surgery Acuity Score (PESAS) is built entirely from objective physiological variables, and this study was its first external validation in emergency general surgery. It applied the score retrospectively to 1086 adults having exploratory laparotomy for non-traumatic emergencies at a single centre.
Thirty-day mortality was 14.7%. PESAS discriminated well (AUROC 0.86, 95% CI 0.83 to 0.88) with acceptable calibration overall. Observed mortality rose sharply at two points: above 10% at a score of 5 and above 50% at 10. In an exploratory analysis of 414 patients with a bowel anastomosis (21 leaks), the score also predicted leak requiring reoperation (AUROC 0.82, 0.73 to 0.90).
Risk scoring before emergency laparotomy changes decisions: who goes to theatre with a consultant surgeon and anaesthetist, who is booked for intensive care, whether an anastomosis or a stoma is the safer choice, and what the family is told. A score that needs no subjective input can be calculated automatically from the observations and laboratory results already taken. It still needs calibration at patient level before it replaces established tools such as NELA or P-POSSUM.
- Calculate a documented risk score for every emergency laparotomy before the decision to operate.
- At a PESAS of 5 or more, observed mortality exceeded 10%: consultant surgeon and anaesthetist presence and a critical care bed are warranted, and NELA or P-POSSUM may call for them at lower predicted risk.
- At a PESAS of 10 or more, expect mortality above 50%: discuss goals of care with the patient and family before theatre.
- A higher score may favour a stoma, alongside usual clinical factors; the leak finding rests on 21 events and is exploratory.
- Keep using a validated tool such as NELA or P-POSSUM alongside it until PESAS is calibrated in your population.
Why it matters
An objective, automatable score makes pre-operative risk stratification possible even where no one has time to fill in a form at 3 a.m.
Don't overread it
This is a retrospective single-centre validation; the leak analysis rested on 21 events and is exploratory.
The statistics, in plain English
An AUROC of 0.86 means that if you pick one patient who died and one who survived, the score ranks the one who died higher 86% of the time. 'Calibration-in-the-large' means predicted and observed deaths matched on average across the whole cohort, not necessarily for each individual risk level.
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