Use of Surgical APGAR Score as a Prognostic Indicator for Emergency Laparotomy Adverse Outcomes: A Multi-Center Cohort Study. The Surgical Apgar Score (SAS) is a simple intraoperative tool designed to predict postoperative complications following major surgery. Although validated in certain highincome settings, evidence regarding its accuracy and correlation with complication severity remains limited in low-resource settings, where the burden of postoperative complications remains high. Method This was a prospective observational study that recruited 146 adult patients for emergency laparotomy in three (3) hospitals. Intraoperative data, including the lowest heart rate, lowest MAP, and estimated blood loss postoperatively, were calcula (Preprint)

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BACKGROUND Post-operative complications following emergency laparotomy remain a major global health challenge, with mortality rates ranging from 8% to 18% worldwide and up to 25% within two years of surgery. 1,2. In low- and middle-income countries (LMICs), the burden is particularly high, with reported complication rates of 28%–40.8% and mortality rates between 7.9% and 18% in Kenya and Rwanda, respectively. 3,4 Given the high risks associated with these procedures, including infections, organ failure, and mortality, it is essential to use effective prognostic tools that can guide early interventions. The Surgical Apgar Score (SAS), first proposed by Gawande et al., has shown promise in predicting complications across various surgical disciplines. 3 However, its utility in the specific context of emergency laparotomies, especially within diverse clinical environments, has not been extensively studied. 5 This multi-centre study in Uganda seeks to address this gap by assessing the effectiveness of SAS across different healthcare settings, thereby determining its potential as a universal prognostic tool in predicting post-operative outcomes. The premise of this study rests on the belief that early perioperative indicators can serve as reliable predictors of a patient’s risk for severe complications or mortality. The SAS incorporates three critical intraoperative parameters—estimated blood loss, the lowest heart rate, and the lowest mean arterial pressure. 6 This may provide vital insight into the likelihood of adverse outcomes. 7 Early recognition of high-risk patients through SAS could enable clinicians to implement timely interventions, ultimately improving survival and recovery rates. 8 In Uganda, data from Mulago Regional Referral Hospital reported an in-hospital mortality rate of 10.6% among both emergency and elective surgical patients, aligning with the 5.5% to 22.4% range observed in other resource-limited settings. 9 Despite demonstrating fair discriminatory ability of the Surgical Apgar Score (SAS), most local studies, including the Onen et al. single-center study, faced several limitations; complications after laparotomy were reported as either present or absent, focusing only on major events. This limits the measure of the true burden of postoperative morbidity; blood loss estimation relied on subjective visual methods, potentially misclassifying SAS scores. The absence of preoperative data limited contextual risk adjustment, and outcomes were restricted to in-hospital events, possibly underestimating true complication and mortality rates. These constraints, coupled with early discharge, underscore the need for multicenter validation and integration of SAS into broader perioperative risk models tailored for low-resource settings. OBJECTIVE To predict emergency laparotomy adverse outcomes using the Surgical APGAR Score based stratification system. METHODS This was a multicenter hospital-based prospective observational cohort study in which we evaluated the predictive value of SAS in patients undergoing emergency laparotomy. The study was conducted in three tertiary health facilities. All patients who underwent emergency laparotomy were informed about the research and asked to participate. Those who accepted participation and satisfied all the inclusion criteria were given an informed consent document to sign, and a questionnaire was completed to obtain their social demographic and clinical characteristics. This work has been reported in line with the STROCSS Criteria, and the study was conducted from April to July 2025. 10 Inclusion criteria All adults aged >18 years, patients who presented to the study centers during the study period for an emergency laparotomy, and consented to participate in the study. Exclusion criteria Patients who presented to the hospital for emergency laparotomy but had polytrauma requiring any other surgery; patients with known advanced intra-abdominal malignancy or head injury; patients with known bleeding disorders; patients who had reoperation within the same admission or within 30 days. Sample size The Cochran (1977) formula was used to estimate the sample size to enable the prediction accuracy of the model at a power (1-β) of 80%, a type 1 error of less than 5%, and a 95% confidence interval. Using the Cochran formula. n = required sample size z = confidence level at 95% (standard value of 1.96) p = mortality rate, The mortality rate of laparotomy in a Ugandan study, according to Onen et al., 9 of 10.6%. was used in the calculation d = margin of error at 5% (standard value of 0.05) Substituting in the formula, This was a systematic non-probability consecutive sampling approach that was employed for all emergency laparotomy patients who met the inclusion criteria. Data was collected within 24 hours after surgery using a data collection sheet by the principal investigator and trained study assistants. Using the anesthesia data sheet, blood pressure and heart rate were monitored every fifteen minutes from induction to reversal of anesthesia. Mean arterial pressure was calculated using the below formula: [(2 x diastolic pressure) + systolic pressure /3] 9. Estimated blood loss was determined by estimating the hematocrit and hemoglobin level by getting the full complete blood count (CBC) result pre- and postoperatively. Inpatients and outpatients were followed up to determine any postoperative complications within thirty (30) days after the surgery. 11 Blood loss was calculated using the formula below: Blood loss = [EBV X (Hi – Hf)/ (HCTi + HCTf)/2] + (500 x Tu)12 Where EBV = estimated blood loss is assumed to be 70 cm³/kg, Hi = pre-operative hemoglobin, Hf = post-operative hemoglobin, HCTi = pre-operative packed cells, HCTf = post-operative packed cells, Tu = sum of whole blood, packed cells, and cell unit transfused13 The Apgar score was calculated using the following data from the participants: age, sex, weight, diagnosis, duration of the operation (in minutes), preoperative CBC and postoperative CBC, SAS taken from estimated blood loss, lowest recorded mean arterial pressure, lowest recorded pulse rate, the occurrence of major complications, and mortality within 30 days postoperatively.3 For risk stratification, patients were grouped into three categories based on the Surgical Apgar score (Table 1). Data analysis Descriptive Statistics: mean ± standard deviation (SD), frequencies, and percentages were used. Chi-square test (or Fisher’s exact test where appropriate) for association between SAS groups & CDC grade. Kruskal-Wallis was used to compare CCI scores across SAS groups. A 0.05 p-value or less will statistically be considered significant. Spearman’s rank correlation between SAS and CDC/CCI score. Ordinal and linear logistic regression with SAS as a predictor of CDC for complication severity, and SAS as a predictor of continuous CCI score were used. ROC Curves were used to assess accuracy; curves were plotted for SAS predicting major complications (CDC ≥ 3) and mortality (CDC grade 5). An AUC with 95% CI was calculated, and the Youden’s Index was used for SAS cut-off values. Sensitivity, specificity, and false positive rates were reported. Statistical Significance: p-value < 0.05 = statistically significant; tables and graphs were used to display results. RESULTS Patient Demographics and Clinical Characteristics In this study, a total of 146 patients who underwent emergency laparotomy were included. The largest age group was 40–60 years, comprising 43.2% of patients. Males predominated, accounting for 71.9% (n=105). The average patient weight was 72.9 ± 6.8 kg. The most common diagnoses were small bowel obstruction (36.3%), blunt abdominal trauma (19.2%), and large bowel obstruction (15.1%). Most patients were classified as ASA II (81.5%). Surgery duration was ≥120 minutes in 54.1% of cases, and 22.6% (n=33) received intraoperative blood transfusions. The majority (85.5%) had Surgical Apgar Scores (SAS) be

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