Competition Test Veteran Affairs Medical Centre (VAMC) Score And KIMS-14 For Predicting the Dehiscence of Abdoment Post Laparotomy Operating Wounds

Introduction. Abdominal wound dehiscence (AWD) is a complication of severe postoperative abdominal surgery, with reported death rates ranging from 10% to 45%. Significant mortality, prolonged hospitalization, increased incidence of incisional hernias and reoperations for ruptured stomachs, with costs associated with the community, emphasize the severity of these complications. The VAMC score and KIMS-14 can be used as screening in predicting surgical injury dehiscence Method.This study is a diagnostic test study to assess the sensitivity and specificity of VAMC and KIMS-14 scoring in predicting the occurrence of abdominal wound dehiscence to be performed in surgery outpatient and digestive surgery ward at the General Hospital, Dr. Mohammad Hoesin Palembang in the period March to May 2019. Results. There were 44 subjects that participated in this study. VAMC has a sensitivity value of 87.5% and specificity of 97.2 with an area under curve value of 0.958 with a cut-off of  10. KIMS 14 has a sensitivity value of 100% and a specificity of 94.4% with an area under curve value of 0.944 with a cut-off of  5. Conclusion: KIMS-14 is better in sensitivity, but VAMC is more specific to predict dehiscence licensing in patients undergoing intraabdominal surgery.


Introduction
Abdominal wound dehiscence (AWD) is a complication of severe postoperative abdominal surgery, with reported death rates ranging from 10% to 45%. AWD is defined as reopening a closed abdominal incision with a separation of the stomach lining, including fascia.
Dehiscence abdominal injuries can be partial or complete and can cause evisceration of stomach contents. Various literature says the incidence rate varies between 0.4% and 3.8% and AWD recurrence is seen in 0% to 10.9% of cases. AWD is most commonly observed on days 9 to 10 but varies between 0 and 32 days. In 90% of all cases, AWD appears on its own before the 15 th postoperative day. On the first day after surgery, the ability of the wound to close does not yet exist, but this increases with time. In the third week after closing the incision, the strength of the wound to close reaches 20% and after 6-12 weeks 70-80%. The cause of AWD in many cases is due to tearing of the sutures through the fascia. Other possible causes are infection, broken stitches, facial necrosis and loose knots. According to the literature, after recovery from AWD incisional hernias are seen in 13% to 83% of patients. [1][2][3][4][5] Several studies have been published that compare different material and suturing techniques and this in terms of complications such as the incidence of wound infections, incisional hernias and ruptured stomachs. The same is true for risk factors for a ruptured stomach, but this is very different from the limited number of studies that discuss treatments for a ruptured abdomen. In addition, there are many variations in reported mortality, recurrence and incisional hernia after dehiscence of abdominal injuries and little is known about quality of life. [1][2][3][4][5] Several studies have identified risk factors associated with this complication; However, many reports have conflicting results. Two studies, by Webster C, et al in 2003 and Gokak, et al in 2017, were reported to be a scoring system developed based on multivariable stepwise logistic regression models of preoperative, intraoperative and postoperative variables entered sequentially as independent predictors of wound dehiscence. Both risk scoring systems were validated by the authors of this study based on the population studied; they help clinical management. However, whether this scoring system can accurately predict dehiscence abdominal injuries in other populations remains unclear. 3,4,6 The first scoring system is based on data from the Veterans Affairs National Surgical Quality Improvement Program (NSQIP) used at 132 Veterans Affairs Medical Centers between October 1996 and September 2000, hereinafter referred to as VAMC risk scores. The second scoring system is based on a medical register that was developed from July 2014 to January 2017 at a KIMS Hubli hospital, India, hereinafter referred to as the KIMS-14 score. For both scoring systems, a higher score predicts a higher risk. 3,4,6 In the analysis of Jakub's research between the VAMC scoring and the dehiscence licensing event, it was found that the VAMC showed an AUC value of 0.84 (OR 1.1 CI 95% 1.1 -1.2). In the Gokak study, KIMS-14 did not show AUC values. In the Gokak study, it showed that the age variable  60 years (P = 0.013) male sex (p = 0.001), hypotension (p  0.005), duration of symptoms (p = 0.005) chronic lung disease, anemia (anemia) p = 0.005), hyperbilirubinemia (p = 0.005), albumin level, (p  0.005), uremia (p = 0.005), time of operation (p = 0.005), peritonitis perforation or contaminated wounds (p = 0.005) have a prevalence that is higher abdominal wound dehiscence licensing. However, the two scoring systems show very significant results regardless of the results of the AUC curve. 3,4,6 Jakub also got the result that VAMC would look very specific 94% with a cut-off point of 25 points / 44 points (max) with an accuracy of 83%, but not sensitive (48%). When the cutoff is reduced by 14 points (based on Webster's research in 2003), a sensitivity result of 70% is obtained, a specificity of 82% with an accuracy value of 73%. This Gokak study did not show the cut-off point value nor its sensitivity and specificity, in this study only showed that the higher the total score obtained the higher the risk of abdominal wound dehiscence licensing. 3,4,6 Significant mortality, prolonged hospitalization, increased incidence of incisional hernias and reoperations for ruptured stomachs, with costs associated with the community, emphasize the severity of these complications. This makes researchers want to examine the abdominal wound dehiscence licensing using tools / references to the occurrence of the dehiscence.
Reference in this case is risk factor score KIMS-14 and VAMC. This research has never been carried out at the Central General Hospital Dr. Mohammad Hoesin Palembang. 6

Methods
This study is a diagnostic test study to assess the sensitivity and specificity of VAMC

Subject distribution based on VAMC criteria
Subject distribution based on VAMC criteria can be seen in table 1. In the distribution of subjects based on VAMC criteria, it was found that 4.5% of subjects had a history of CVA / stroke, 9.1% of subjects had a history of COPD, 0% had a diagnosis of pneumonia, 27.3% of subjects who underwent emergency surgery, 13.6% of subjects who underwent more than 2.5 operations hours, 47.7% of subjects undergoing surgery by residents, 9.1% of subjects who had clean wound, 13.6% of subjects who had superficial wound infection, 4.5% of subjects who had deep wound infection, 0.0% with weaning failure, 9.1% of subjects with> 1 complication. ROC analysis test was performed to see the sensitivity and specificity value of VAMC criteria for the occurrence of abdomen wound dehiscence licensing, it was found that the VAMC had a sensitivity value of 87.5% and specificity of 97.2 with an area under curve value of 0.958 with a cut-off of  10.   Licensing, 94.4% of subjects had a KIMS14 score of  5 and 5.6% of subjects who had a KIMS14 score of  5 in the undiagnosed group, while there were 0.0% of subjects who had a KIMS14 score of  5 and 100.0% of subjects who had a KIMS14 score  5. In the Fisher's Exact analysis-test it was found that the KIMS14 score was significantly related to Abdomen Dehiscence Licensing.

Discussions
Abdominal wound dehiscence (AWD) is a complication of severe postoperative abdominal surgery, with reported death rates ranging from 10% to 45%. AWD is defined as reopening a closed abdominal incision with a separation of the stomach lining, including fascia.
Dehiscence abdominal injuries can be partial or complete and can cause evisceration of stomach contents. Various literature says the incidence rate varies between 0.4% and 3.8% and AWD recurrence is seen in 0% to 10.9% of cases. AWD is most commonly observed on days 9 to 10 but varies between 0 and 32 days. In 90% of all cases, AWD appears on its own before the 15 th postoperative day. In the ROC analysis test to see the sensitivity and specificity value of VAMC criteria for with an accuracy of 83%, but not sensitive (48%). When the cut-off is reduced by 14 points and VAMC as scoring that is sensitive and specific in predicting the occurrence of abdominal dehiscence licensing, this scoring system indirectly minimizes hospital costs before abdominal dehiscence license injuries occur.

Conclusion
KIMS-14 is superior in sensitivity, but VAMC is superior in specificity to predict the occurrence of dehiscence licensing in patients undergoing intraabdominal surgery at General Hospital Dr. Mohammad Hoesin Palembang. KIMS-14 has a cut-off of 5 with a sensitivity of 100.0% and a specificity of 94.4%. VAMC has a cut-off of 10 with a sensitivity of 87.5% and a specificity of 97.2%