Sriwijaya Journal of Surgery

Establishing an APACHE II Cut-off Score for Predicting Mortality in Post-Thoracotomy Patients: A Single-Center Cohort Analysis

2025-09-11T04:20:51+00:00

Introduction: Thoracotomy represents a significant physiological challenge with considerable mortality risk. Early, objective risk stratification in the General Intensive Care Unit (GICU) is essential for guiding clinical management. This study sought to evaluate the utility of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score as a prognostic tool in a heterogeneous post-thoracotomy population at a tertiary referral center in Southeast Asia.

Methods: A retrospective cohort study was conducted on 33 consecutive patients admitted to the GICU following thoracotomy between January and December 2024. The APACHE II score was calculated using the most deranged physiological values within the first 24 hours of admission. The primary outcome was in-hospital mortality. Statistical analyses included non-parametric tests for group comparisons, Spearman's rank correlation, and Receiver Operating Characteristic (ROC) curve analysis. A novel aspect of this study was the post-hoc stratification of the cohort by the primary surgical indication (malignancy versus non-malignancy) to explore sources of prognostic variability.

Results: The overall mortality rate was 27.3% (9 of 33 patients). Non-survivors had a significantly higher median APACHE II score than survivors (23 vs. 8; p < 0.001). A strong, positive correlation was observed between the APACHE II score and mortality (Spearman's ρ = 0.706; p < 0.001). ROC analysis demonstrated excellent discriminatory performance for the overall cohort, with an Area Under the Curve (AUC) of 0.956 (95% CI: 0.891–1.000). A score of ≥12.5 was identified as the optimal cut-off, yielding a sensitivity of 88.9% and specificity of 87.5%. Analysis of the APACHE II components revealed that mortality was primarily driven by derangements in neurological (GCS), renal (Creatinine), and acid-base (pH) parameters.

Conclusion: In this preliminary, single-center analysis, the initial 24-hour APACHE II score demonstrated potential as a powerful prognostic marker for in-hospital mortality following thoracotomy. A candidate cut-off score of ≥12.5 successfully identified a high-risk subgroup. However, given the study's significant limitations, including a small and heterogeneous sample, these findings should be interpreted as hypothesis-generating. They underscore the need for larger, prospective studies to validate this cut-off and to develop more refined prognostic models for specific subgroups of post-thoracotomy patients.

Integrating the Colon Leakage Score (CLS) and Serum Albumin to Predict Anastomotic Leakage in Colorectal Cancer Surgery: A Diagnostic Accuracy Study in an Indonesian Cohort

2025-09-12T05:52:01+00:00

Introduction: Anastomotic leakage (AL) is a devastating complication in colorectal surgery, associated with high rates of morbidity and mortality. Accurate preoperative risk stratification is essential for guiding clinical decision-making. This study aimed to evaluate the diagnostic accuracy of a synergistic model combining the clinical Colon Leakage Score (CLS) with the biochemical marker of preoperative serum albumin for predicting AL in an Indonesian patient cohort.

Methods: A retrospective diagnostic accuracy study was conducted at a single tertiary care center. The study included 60 patients who underwent resection and primary anastomosis for colorectal cancer between January 2022 and June 2024. Patients who received a diverting stoma were excluded. A "high-risk" status was defined by a composite criterion: a CLS > 11 and a preoperative serum albumin level < 3.5 g/dL. The primary outcome was clinically significant AL. Following the identification of inconsistencies in the initial analysis, a complete data re-analysis was performed. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, and overall accuracy, with 95% confidence intervals (CI), were calculated.

Results: The incidence of AL was 21.7% (13/60 patients). A striking 71.7% of the cohort presented with preoperative hypoalbuminemia. The analysis revealed that the combined model demonstrated poor sensitivity of 46.2% (95% CI: 19.2% - 74.9%) but excellent specificity of 97.9% (95% CI: 88.7% - 99.9%). The model yielded a high PPV of 85.7% (95% CI: 42.1% - 99.6%) and a robust NPV of 86.8% (95% CI: 75.0% - 94.6%). The overall accuracy was 86.7%.

Conclusion: The combined CLS-albumin model functions as a highly specific "rule-in" test, not a general screening tool. While it fails to identify more than half of the patients who will leak, a positive result correctly identifies a small subset of patients at extremely high risk for anastomotic leakage. The findings also highlight a profound baseline burden of malnutrition in this population, which warrants further investigation and clinical attention.

The Lung Organ Failure Score (LOFS) as an Early Predictor of Mortality in Blunt Thoracic Trauma: A Preliminary Validation Study in a Southeast Asian Cohort

2025-09-17T03:53:54+00:00

Introduction: Blunt thoracic trauma is a leading cause of trauma-related mortality. Early and accurate risk stratification is essential for optimizing outcomes, yet many prognostic scores lack validation in diverse populations. This study aimed to perform a preliminary evaluation of the prognostic value of the lung organ failure score (LOFS) for predicting in-hospital mortality in patients with blunt thoracic trauma in an Indonesian tertiary trauma center.

Methods: This retrospective, single-center, exploratory cohort study included adult patients (≥18 years) admitted with blunt thoracic trauma to Dr. Mohammad Hoesin General Hospital from January 2023 to January 2025. Data on demographics, injury characteristics, initial physiological parameters, and clinical outcomes were collected. The LOFS was calculated for each patient. The primary outcome was in-hospital mortality. Statistical analyses included bivariate comparisons, Kendall's Tau correlation, and Receiver Operating Characteristic (ROC) curve analysis.

Results: A total of 32 patients were included. The overall in-hospital mortality rate was 21.9% (n=7). The non-survivor group had a significantly higher mean LOFS than the survivor group (21.00±5.29 vs. 14.16±3.92, p=0.001). LOFS demonstrated a moderate, positive correlation with mortality (Kendall's Tau r=+0.568, p=0.001). ROC analysis showed that LOFS had excellent discriminative ability for mortality, with an Area Under the Curve (AUC) of 0.840 (95% CI: 0.685–0.995, p=0.001). An optimal cut-off score of ≥18 yielded a sensitivity of 85.7% and a specificity of 80.0%.

Conclusion: In this preliminary study, LOFS was strongly associated with in-hospital mortality and demonstrated excellent discriminative performance. The findings suggest LOFS is a promising and simple tool for early risk stratification in this high-risk population. However, the study's small sample size precluded a reliable assessment of its independence from other risk factors. Further validation in larger, prospective multicenter studies is essential to confirm these findings.

External Validation of the RASH Score in Surgically Managed Acute Subdural Hematoma: A Critical Appraisal of Prognostic Accuracy and Surgical Factors in a Southeast Asian Cohort

2025-09-17T08:31:02+00:00

Introduction: Acute subdural hematoma (ASDH) is a lethal form of traumatic brain injury (TBI) with high mortality. The Richmond Acute Subdural Hematoma (RASH) score is a simple prognostic tool, but its validity in diverse populations is untested. This study aimed to perform the first external validation of the RASH score in an Indonesian cohort and critically appraise its performance alongside key surgical factors.

Methods: We conducted a retrospective, single-center, diagnostic accuracy study of 67 adult patients who underwent surgery for traumatic ASDH between January 2022 and December 2024 at a tertiary neurosurgical center in Palembang, Indonesia. The RASH score was calculated from admission data. We additionally analyzed the type of surgery (craniotomy vs. decompressive craniectomy) and time from injury to operation. The primary outcome was in-hospital mortality. Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the RASH score's predictive performance.

Results: The overall in-hospital mortality rate was 20.9% (n=14). The RASH score demonstrated excellent discrimination for mortality, with an Area Under the ROC Curve (AUC) of 0.824 (95% CI: 0.715–0.933; p<0.001). A score of 5 or greater was identified as the optimal cut-off, yielding a sensitivity of 78.6% and specificity of 77.4%. This threshold provided a high Negative Predictive Value (NPV) of 93.2% but a modest Positive Predictive Value (PPV) of 47.8%. In bivariate analysis, decompressive craniectomy and longer time to surgery were significantly associated with mortality.

Conclusion: The RASH score is a simple and robust tool for risk stratification in this selected surgical population. Its high NPV is valuable for identifying patients with a higher likelihood of survival. However, its utility must be interpreted cautiously due to the significant selection bias inherent in studying only operable patients. The score should serve as an adjunct to, not a replacement for, comprehensive clinical judgment.

Determinants of In-Hospital Mortality Following Pelvic Ring Fractures: A 4.5-Year Analysis from a Developing Country's Trauma Center

2025-09-18T08:58:36+00:00

Introduction: Pelvic ring fractures are calamitous injuries with high mortality. While clinical risk factors are well-defined in high-income countries, there is a scarcity of data from low- and middle-income countries (LMICs), where socioeconomic factors may critically influence survival. This study sought to explore the sociodemographic and clinical factors associated with in-hospital mortality following pelvic fractures at a tertiary trauma center in Indonesia.

Methods: A retrospective cohort study was performed on all patients (N=31) admitted with traumatic pelvic fractures to Dr. Mohammad Hoesin General Hospital between January 2021 and June 2025. Data on patient demographics, socioeconomic variables, injury mechanisms, and clinical management were analyzed. The primary outcome was in-hospital mortality. Given the exploratory nature of the study and the small sample size, bivariate analysis using Pearson's Chi-Square and Fisher’s Exact tests was conducted to identify potential associations.

Results: The overall in-hospital mortality rate was 9.7% (3 of 31 patients). The cohort was primarily young adults (61.3% aged 20-59 years) injured in traffic accidents (87.1%). The only variable found to have a statistically significant association with mortality was occupation. All three fatalities occurred in patients from the informal employment sector, corresponding to a 37.5% mortality rate within this subgroup (p=0.008). No significant association was found for established clinical predictors, including Young-Burgess fracture classification (p=0.736), a finding likely attributable to the study's limited statistical power.

Conclusion: This study, though limited by its sample size, identified a powerful association between informal sector employment and mortality after pelvic fracture. This finding generates the critical hypothesis that in an LMIC setting, socioeconomic vulnerability is a paramount driver of poor outcomes, likely mediated through delays in care and presentation with more severe physiological derangement. These results underscore the need for a socio-clinical approach to trauma care and highlight a crucial area for future, more definitive research.

A Preliminary Retrospective Analysis of the Blunt Abdominal Trauma Scoring System (BATSS) in a High-Prevalence Cohort: A Single-Center Indonesian Experience

2025-09-24T04:23:30+00:00

Introduction: The triage of blunt abdominal trauma (BAT) is a critical challenge, and the utility of clinical scoring systems like the blunt abdominal trauma scoring system (BATSS) requires validation in diverse clinical settings. This study aimed to provide a preliminary, critical appraisal of the BATSS's diagnostic performance and the behavior of its individual components in a unique, high-risk cohort at a tertiary Indonesian trauma center.

Methods: A retrospective analysis was conducted on 37 BAT patients who underwent definitive diagnostic evaluation (CT scan or laparotomy) between July 2021 and July 2025 in Palembang, Indonesia. The cohort was noted to have a significant selection bias, with an intra-abdominal injury (IAI) prevalence of 91.9% (34 injured, 3 uninjured). A component-level analysis of the seven BATSS variables was performed alongside a standard diagnostic accuracy assessment using an ROC curve to determine the optimal cut-off.

Results: The cohort was predominantly young males injured in traffic accidents. The ROC analysis demonstrated poor discriminatory power (AUC = 0.525). At an optimal cut-off of 8.5, BATSS showed a sensitivity of 82.4% and a statistically unstable specificity of 33.3% (95% CI: 0.8% to 90.6%). The PPV was 93.3%, while the NPV was critically low at 14.3%. Component analysis revealed that sensitivity was primarily driven by high-point variables like a positive FAST scan, while low specificity was associated with non-specific signs like abdominal tenderness.

Conclusion: In this high-prevalence, pre-selected cohort, BATSS failed to perform as a reliable triage tool. Its poor specificity and dangerously low NPV render it unsuitable and unsafe for ruling out IAI. The score's apparent sensitivity was driven by variables that already indicate a high-risk patient, suggesting the score adds little value to standard clinical assessment. This preliminary study highlights the critical need for robust, large-scale validation before clinical adoption and suggests BATSS may be inappropriate for settings with a high pre-test probability of injury.

Elevated Serum Lactate as an Indicator of Neurometabolic Derangement and its Independent Correlation with Clinical Outcomes in Traumatic Brain Injury

2025-09-29T04:15:50+00:00

Introduction: Traumatic brain injury (TBI) is a primary cause of global death and disability, where early and accurate prognostication is critical but remains a clinical challenge. Serum lactate is emerging as a biomarker of the complex neurometabolic derangement following TBI, extending beyond its traditional role as a marker of hypoxia. This study aimed to determine if serum lactate is an independent predictor of outcomes in TBI patients.

Methods: We conducted a prospective, single-center observational study of 33 TBI patients at Dr. Mohammad Hoesin General Hospital. Serial venous serum lactate levels were measured at admission, 24, and 48 hours. The primary outcome was unfavorable functional status (Glasgow Outcome Scale [GOS] 1-3) at hospital discharge. Multivariate logistic regression was used to assess lactate as an independent predictor of unfavorable outcome, controlling for age and initial Glasgow Coma Scale (GCS) score. Survival was analyzed using Kaplan-Meier curves and a Cox proportional hazards model.

Results: The cohort (N=33) was predominantly male (63.6%) with a mean age of 37.91 years. Higher admission lactate was strongly associated with worse GOS categories (p=0.002). After adjusting for age and initial GCS score, admission serum lactate remained a significant independent predictor of unfavorable outcome at discharge. For every 1 mmol/L increase in lactate, the odds of an unfavorable outcome increased by over twofold (Adjusted Odds Ratio: 2.15; 95% CI: 1.12-4.13; p=0.021). Similarly, lactate was an independent predictor of in-hospital mortality in the Cox proportional hazards model (Adjusted Hazard Ratio: 1.78; 95% CI: 1.05-3.01; p=0.032).

Conclusion: Elevated admission serum lactate is a strong, independent predictor of unfavorable in-hospital functional outcome and mortality in TBI patients. As a readily available biomarker, it reflects the severity of the underlying neurometabolic crisis and provides crucial prognostic information beyond initial clinical and demographic assessments, aiding in early risk stratification.

Dissecting the Triad of Distress: A Multivariate Analysis of Clinical, Surgical, and Sociodemographic Determinants of Quality of Life in Indonesian Breast Cancer Patients Undergoing Chemotherapy

2025-09-29T08:16:50+00:00

Introduction: The assessment of health-related quality of life (HRQoL) is a paramount outcome in breast cancer survivorship, yet the interplay of disease-specific, treatment-related, and patient-level factors is not fully understood in Southeast Asian populations. This study aimed to comprehensively model the predictors of HRQoL and fatigue by simultaneously evaluating clinical, surgical, and sociodemographic variables among Indonesian breast cancer patients.

Methods: A cross-sectional study was conducted with 102 female breast cancer patients undergoing chemotherapy at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia. Data on clinical variables (AJCC stage, chemotherapy cycles, treatment intent), surgical procedures (breast and axillary surgery type), and sociodemographic characteristics were collected. HRQoL was assessed using the validated Indonesian versions of the Functional Assessment of Cancer Therapy-General (FACT-G) and Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaires. Bivariate correlations and a hierarchical multivariate linear regression analysis were performed to identify significant independent predictors of FACIT-F scores.

Results: The cohort was characterized by advanced disease (Stage III/IV: 62.7%) and aggressive surgical management (Mastectomy: 75.5%; Axillary Lymph Node Dissection: 68.6%). In the multivariate analysis, several factors emerged as significant independent predictors of poorer HRQoL. These included advanced cancer stage (β = -0.41, p < 0.001), having undergone a mastectomy versus breast-conserving surgery (β = -0.28, p = 0.002), having had an axillary lymph node dissection versus sentinel node biopsy (β = -0.25, p = 0.005), and a higher number of chemotherapy cycles (β = -0.19, p = 0.018). The final model explained a substantial portion of the variance in HRQoL (Adjusted R² = 0.58). In contrast, sociodemographic factors including age, income, and education were not significant predictors in the final model (p > 0.05).

Conclusion: HRQoL in this cohort is not determined by a single factor but by a triad of distress: the biological burden of the disease (stage), the physical and psychological morbidity of surgical treatment, and the cumulative toxicity of chemotherapy. These treatment-related realities powerfully override the influence of sociodemographic characteristics. These findings mandate a paradigm shift towards an integrated supportive care model that proactively addresses surgical morbidity alongside systemic side effects from the point of diagnosis.

Antifibrinolytic Therapy in Neurosurgical Oncology: A Randomized, Double-Blind, Placebo-Controlled Trial on the Efficacy and Safety of Tranexamic Acid for Hypervascular Intracranial Meningiomas

2025-10-24T04:02:52+00:00

Introduction: Resection of hypervascular intracranial meningiomas is frequently complicated by significant intraoperative hemorrhage, increasing patient morbidity and transfusion requirements. Tranexamic acid (TXA), an antifibrinolytic agent, has shown promise in other surgical fields, but high-level evidence in intracranial tumor surgery is lacking. This study aimed to rigorously evaluate the efficacy and safety of perioperative TXA in reducing blood loss during craniotomy for convexity and spheno-orbital meningiomas.

Methods: This single-center, double-blind, randomized, placebo-controlled trial enrolled 30 adult female patients scheduled for elective resection of convexity or spheno-orbital meningiomas. Patients were randomized to receive either intravenous TXA (15 mg/kg bolus followed by a 1 mg/kg/hr infusion) or a matching saline placebo. The primary outcome was total intraoperative blood loss. Secondary outcomes included transfusion volume, perioperative changes in hematological and coagulation parameters, and the incidence of thromboembolic events within 30 days.

Results: The TXA group (n=15) and the placebo group (n=15) were well-matched at baseline. Mean intraoperative blood loss was significantly lower in the TXA group compared to the placebo group (765.0 ± 94.39 mL vs. 1010.0 ± 131.20 mL; mean difference, -245 mL; 95% CI, -444.2 to -45.8; p = 0.019; Cohen's d = 2.15). The TXA group exhibited a significantly smaller postoperative drop in hemoglobin (-0.97 g/dL vs. -2.36 g/dL; p = 0.041) and significantly lower D-dimer levels at 24 hours (850 ± 210 ng/mL vs. 1620 ± 450 ng/mL; p < 0.001). There was no significant difference in PRBC transfusion volume (p = 0.410). No thromboembolic events were recorded in either group.

Conclusion: In patients undergoing resection of hypervascular convexity and spheno-orbital meningiomas, perioperative TXA administration significantly reduces intraoperative blood loss and preserves postoperative hemoglobin. The agent demonstrated a favorable safety profile with no observed increase in thromboembolic risk in this cohort