Estimation Of Physiologic Ability And Surgical Stress Scoring Research Articles

Management of Large Ovarian Tumors in Elderly Patients Using the Aron Alpha Method and Principles of Enhanced Recovery after Surgery

Abstract Objectives: We performed preoperative evaluations of giant ovarian tumors in older adult patients using the comprehensive geriatric assessment (CGA) and estimation of physiologic ability and surgical stress (E-PASS) scoring systems. We report a case in which the Aron Alpha method was performed, and perioperative management was performed using enhanced recovery after surgery (ERAS). Materials and Methods: We performed preoperative evaluations using the E-PASS scoring system and CGA on older adult patients with giant ovarian tumors, followed by the minimally invasive Aron Alpha method and perioperative management using ERAS. Results: The mean patient age was 75.8 ± 8.8 years; comorbidities included hypertension in three patients, hyperlipidemia in two, angina pectoris in one, cholecystitis in one, and lower extremity varicose veins in one. The mean tumor size was 21.0 ± 5.4 cm. The E-PASS scoring system showed a preoperative risk score of 0.7 ± 0.4, a surgical stress score of 0, and a comprehensive risk score of 0.3 ± 0.3. CGA showed that two patients had problems with activities of daily living and cognitive function. The mean duration of surgery was 89.0 ± 16.6 min, and the mean blood loss was 56.0 ± 65.4 mL. No surgery-associated complications were observed. No patients had prolonged hospitalization or a decline in activities of daily living. Conclusion: We showed the usefulness of performing detailed preoperative evaluations using CGA and the E-PASS system, followed by the minimally invasive Aron Alpha surgical method and perioperative management using ERAS in improving surgical outcomes in older adult patients with giant ovarian tumors.

Efficiency of the estimation of physiologic ability and surgical stress (E-PASS) score in predicting postoperative complications after robot-assisted radical prostatectomy.

Robot-Assisted Radical Prostatectomy (RARP) is increasingly becoming the standard surgical treatment for prostate cancer. While some risk factors for postoperative complications of RARP have been identified, no scoring model that incorporates both preoperative physical status of the patient and intraoperative risk factors has been developed. The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was initially described to predict postoperative complications after gastrointestinal surgical procedures. This study aims to assess the effectiveness of the E-PASS score in predicting postoperative complications of RARP. A retrospective evaluation was conducted on 204 patients who underwent RARP between 2019 and 2022. Demographic data, parameters indicating patients' preoperative physical condition, and intraoperative risk factors were analyzed. The E-PASS score and subscores were calculated for each patient. Of the patients, 164 (80.4%) were discharged without any postoperative complications (Group 1), and 40 (19.6%) experienced various degrees of complications (Group 2). Patients in Group 2 had higher rates of previous abdominal surgery, elevated Eastern Cooperative Oncology Group (ECOG) performance scores, longer surgical durations, and higher E-PASS scores. To assess the effectiveness of the Comprehensive Risk Score (CRS) as a predictive factor for postoperative complications, a receiver operating characteristic (ROC) curve was constructed with a 95% confidence interval (CI), and a cut-off value was established. The cut-off value for CRS was determined to be -0.0345 (area under the curve [AUC]=0.783, CI: 0.713-0.853; p<0.001). Patients with a CRS higher than the cut-off value had a 16.4 times higher rate of postoperative complications after RARP (95% CI: 5.58-48.5). The E-PASS scoring model successfully predicts postoperative complications in patients undergoing RARP by using preoperative data about the physical status of the patient and surgical risk factors. The E-PASS score and its subscores could be utilized as objective criteria to determine the risk of postoperative complications before and immediately after surgery.

E-PASS Scoring System May Be Useful for Prediction of Postoperative Complications in Super Elderly Colorectal Cancer Surgery Patients.

Objectives: Japan is facing an aging society. Elderly individuals are generally more prone to comorbidities and have weaker immune defenses, with ominous prognostic implications if postoperative complications arise. The aim of this study was to explore scoring systems for predicting postoperative morbidity risk in super elderly patients (≥85 years old) after colorectal surgery for cancer. Methods: A population of elderly patients (n = 145) surgically treated for primary colorectal cancer within our department between April 2007 and December 2018 was examined retrospectively, assessing the capacities of various indices, such as Estimation of Physiologic Ability and Surgical Stress (E-PASS), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), prognostic nutritional index (PNI), and modified Glasgow Prognostic Score (mGPS), to predict postoperative complications. Results: NLR, PLR, and mGPS did not differ significantly in the presence or absence of complications, whereas PNI tended to be lower if complications developed. The E-PASS system showed no group-wise differences in preoperative risk score (PRS), but the surgical stress score (SSS) and the comprehensive risk score (CRS; a composite of PRS and SSS) was significantly higher in patients with complications. Based on the cutoff value calculated from the Receiver operating curve (ROC) for the E-PASS CRS (−0.0580), patients were stratified into low-scoring and high-scoring (HSG) groups. Although not significantly different, the overall survival in the HSG tended to be lower by comparison. Conclusions: The E-PASS scoring system may be a useful predictor of postoperative complications in super elderly patients requiring colorectal cancer surgery.

The use of the E-PASS scoring system in determining complication development in patients with isolated acetabular fractures

The decision to treat acetabular fractures is occasionally deferred or foregone in patients perceived to be unfit for surgery. The previously validated estimation of physiologic ability and surgical stress (E-PASS) score has been shown to predict outcome in a variety of fractures, and consists of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS). To correlate E-PASS and its components with postoperative complication to quantify risk for individual surgical and patient factors in acetabular fracture management. A retrospective review of patient records was performed for all patients with acetabular fractures surgically treated between January 2013 and June 2018 in a level 1 Trauma Centre. Patients with multiple injuries and/or malignancies were excluded. E-PASS scores were determined with standard demographic data and subscores were correlated with complication development. Of the included 106 patients (mean age 61years, range 17-93), complications were reported in 37 (34.9%) patients and 3 (2.8%) died. Hospital postoperative morbidity and mortality rates increased significantly with the PRS and CRS. The SSS did not correlate significantly with frequency of complications. Age was found to be the only significant independent risk factor (p value=0.031, OR=1.03 per year of age). Latent patient factors have a clear influence on adverse outcomes in contrast to controllable factors such as surgical stress indicating an important role for perioperative care in reducing postoperative complications. Integrated orthogeriatric care with assessment of comorbidities, prevention or early recognition, and treatment of perioperative complications is essential.

Three preoperative scoring systems to predict 30-day mortality in elderly patients undergoing hip fracture surgery

Objective To compare 3 kinds of preoperative scoring systems used to predict 30-day mortality in a hip fracture population, Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM), Portsmouth modified POSSUM (P-POSSUM) and Estimation of Physiologic Ability and Surgical Stress (E-PASS). Methods A retrospective study was conducted to analyze the aged 654 patients who had undergone surgery for femoral intertrochanteric fracture or femoral neck fracture from January 2010 through June 2014 at our hospital. They were 225 men and 429 women, 60 to 103 years of age (average, 71.7 years). There were 363 femoral intertrochanteric fractures and 291 femoral neck fractures. Closed reduction and intramedullary nailing was performed in 363 cases, artificial dipolar replacement in 242 cases, and total hip replacement in 49 cases. POSSUM, P-POSSUM and E-PASS scoring systems were used to predict the 30-day mortality. The discrepancy between the predictive risk and the actual observation was analyzed. Results Of the 654 patients, 25 died within 30 days after operation. According to POSSUM scoring system, the predictability (observed deaths/POSSUM deaths) was 0.30, showing a significant difference between the predictive deaths and the actual deaths (χ2=34.840,P=0.009). According to P-POSSUM and E-PASS scoring systems, the predictability was respectively 0.83 and 1.04, demonstrating no significant differences between the predictive deaths and the actual deaths (P>0.05). Conclusion P-POSSUM and E-PASS scoring systems may predict 30-day mortality more accurately than POSSUM scoring system in elderly patients undergoing hip fracture surgery. Key words: Hip fractures; Mortality; Score system; Aged

Evaluation of the utility of the Estimation of Physiologic Ability and Surgical Stress score for predicting post-operative morbidity after orthopaedic surgery.

The purpose of this study was to investigate the utility of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system for predicting post-operative morbidity. We included 1,883 patients (mean age, 52.1 years) who underwent orthopaedic surgery. The post-operative complications were classified as surgical site and non-surgical site complications, and the relationship between the E-PASS scores and post-operative morbidity was investigated. The incidence of post-operative complications (n = 274) significantly increased with an increase in E-PASS scores (p < 0.001). The areas under the curve for the comprehensive risk score of the E-PASS scoring system for overall and non-surgical site complications were 0.777 and 0.794, respectively. The E-PASS scoring system showed some utility in predicting post-operative morbidity after general orthopaedic surgery. However, creating a new risk score that is more suitable for orthopaedic surgery will be challenging.

Estimation of Physiologic Ability and Surgical Stress Scoring System Appraises Laparoscopy-Assisted and Open Distal Gastrectomy in Treatment of Early Gastric Cancer

Laparoscopy-assisted distal gastrectomy (LADG) has been widely used to treat early gastric cancer (EGC). The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system predicts the risk of fatal postoperative complications by quantifying the patient’s reserve and degree of surgical stress, but there have been a few reports of use of the E-PASS scoring system to assess the risk of mortality following special types of surgical procedures such as LADG. In this study we assessed the feasibility of LADG versus open distal gastrectomy (ODG) by the E-PASS scoring system. The subjects of this study consisted of 69 stage IA gastric cancer patients who underwent LADG (LADG group) and 69 stage IA gastric cancer patients who underwent ODG (ODG group). The mean age of the patients in the LADG group was 68.6 years, which was significantly higher than the mean age of 63.4 years in the ODG group. There were no statistically significant differences between the groups in operation time or preoperative risk score, but there were statistically significant differences in blood loss, surgical stress score, comprehensive risk score, and duration of postoperative hospital stay. We conclude that using the E-PASS scoring system, LADG appreciates a more beneficial procedure for the treatment of EGC than ODG.

Estimation of Physiologic Ability and Surgical Stress Scoring System Appraises Laparoscopy-Assisted and Open Distal Gastrectomy in Treatment of Early Gastric Cancer

Laparoscopy-assisted distal gastrectomy (LADG) has been widely used to treat early gastric cancer (EGC). The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system predicts the risk of fatal postoperative complications by quantifying the patient’s reserve and degree of surgical stress, but there have been a few reports of use of the E-PASS scoring system to assess the risk of mortality following special types of surgical procedures such as LADG. In this study we assessed the feasibility of LADG versus open distal gastrectomy (ODG) by the E-PASS scoring system. The subjects of this study consisted of 69 stage IA gastric cancer patients who underwent LADG (LADG group) and 69 stage IA gastric cancer patients who underwent ODG (ODG group). The mean age of the patients in the LADG group was 68.6 years, which was significantly higher than the mean age of 63.4 years in the ODG group. There were no statistically significant differences between the groups in operation time or preoperative risk score, but there were statistically significant differences in blood loss, surgical stress score, comprehensive risk score, and duration of postoperative hospital stay. We conclude that using the E-PASS scoring system, LADG appreciates a more beneficial procedure for the treatment of EGC than ODG.

Using the E-PASS scoring system to estimate the risk of emergency abdominal surgery in patients with acute gastrointestinal disease

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system, which quantifies a patient's reserve and surgical stress, is used to predict morbidity and mortality in patients before elective gastrointestinal surgery. We conducted this study to clarify whether the E-PASS scoring system is useful for assessing the risks of emergency abdominal surgery. The subjects of this retrospective study were 51 patients who underwent emergency gastrointestinal surgery at a public general hospital. The main outcomes were the E-PASS scores and the postoperative course, defined by mortality and morbidity. Postoperative complications developed in 15 of the 51 patients (29.4%). The E-PASS score was significantly higher in the patients with postoperative complications than in those without (0.61 ± 0.31 vs 0.20 ± 0.35, respectively; n = 36). The morbidity rates were significantly lower in the patients with a value less than 0.5 than in those with a value more than 0.5 (17.1% and 56.3%, respectively; P < 0.01). There were 7 operative deaths among the 16 patients with a high score, versus none among the 9 patients with a low score (P < 0.01). Three patients underwent laparoscopic-assisted bowel resection with a good postoperative course, with scores of less than 0.5. The E-PASS scoring system is useful for surgical decision making and evaluating whether patients will tolerate emergency gastrointestinal surgery. Minimally invasive therapy would assist in lowering the risk of complications.

Can the physiologic ability and surgical stress (E-PASS) scoring system predict operative morbidity after distal pancreatectomy?

Mortality rates after pancreatic resection are now lower than 5% in high-volume centers; however, morbidity remains high. This stresses the importance of identifying accurate predictors of operative morbidity after pancreatic resection. The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system was developed for a comparative audit of general surgical patients. Our previous study confirmed its usefulness for predicting morbidity after pancreaticoduodenectomy. In the present study, we evaluated whether the E-PASS scoring system can predict the occurrence of complications after distal pancreatectomy (DP). The subjects were 46 patients who underwent DP for pancreatic disease. We studied correlations between the incidence of postoperative complications and the preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) of the E-PASS scoring system. A collective total of 20 postoperative complications developed in 13 (28.3%) of the 46 patients. All E-PASS scores, particularly PRS and CRS, were significantly higher in the patients with postoperative complications than in those without complications. The complication rate increased with increasing PRS, SSS, and CRS scores. The E-PASS scoring system is useful for predicting morbidity after DP.

Reply to Letter to the Editor: New Equations for Predicting Postoperative Risk in Patients with Hip Fracture

I appreciate Dr. Moppett's comments regarding the article by Hirose et al. [2]. In response to his concerns, first, this study was performed to establish and evaluate equations for estimating morbidity and mortality rates in candidates for hip fracture surgery using the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system, and to compare the predictive quality of the E-PASS and POSSUM systems. To accomplish these purposes, all patients with and without complications were studied to develop and evaluate the equations and to compare the predictive quality of inhospital mortality between the E-PASS and P-POSSUM systems. I limited the subjects only in the calculations of predicted 30-day morbidity and mortality rates to compare the predictive quality of the E-PASS and O-POSSUM because O-POSSUM assesses 30-day morbidity and mortality [4]. The E-PASS scoring system can be used preoperatively to predict the occurrence of postoperative morbidity or mortality, and retrospective findings concerning complications are necessary to evaluate the quality of E-PASS. Regarding the second question regarding the statistical assessment of goodness of fit, I used the Hosmer-Lemeshow test for the equations of E-PASS and POSSUM systems. The E-PASS scores showed good concordance with inhospital morbidity (chi square test, p = 0.65), inhospital mortality (p = 0.40), 30-day morbidity (p = 0.35), and 30-day mortality (p = 0.48). The POSSUM scores also were meaningful but showed less concordance with inhospital mortality (p = 0.30), 30-day morbidity (p = 0.11), and 30-day mortality (p = 0.24). Regarding the third point about the rationale for the comparisons with E-PASS and POSSUM, I recognize the POSSUM scoring for predicting 30-day mortality was not particularly useful in the population for hip fracture surgery [5]. However, the POSSUM systems are useful in hip fracture surgery for predicting inhospital morbidity [1] and 30-day morbidity and mortality [6]. Furthermore, the POSSUM and E-PASS systems need not only preoperative evaluation but also surgical factors for calculating their scores. Therefore, I compared these two scoring systems despite the narrow ranges of their surgical stress scores in a population with hip fractures. I agree that the preoperative scoring system, the Nottingham Hip Fracture Score (NHFS) described by Maxwell et al. [3], reasonably predicts 30-day mortality. In contrast, the equations using the E-PASS score developed by Hirose et al. [2] are focused mainly on predicting inhospital risk. Additional studies to evaluate and compare these established risk scoring systems may provide better predictive tools for this population, depending on purpose.

Letter to the Editor: New Equations for Predicting Postoperative Risk in Patients with Hip Fracture

To the Editor: We read with interest the recent article “New Equations for Predicting Postoperative Risk in Patients with Hip Fracture” by Hirose et al. [4] and their previous relevant reports [5, 6]. In their series of studies, they reportedly validated the effectiveness of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system to predict postoperative risk in patients with hip fracture based on significant correlations between E-PASS scores and hospitalization outcomes. However, we consider the correlation coefficients in their studies [4–6] low (the majority of which were less than 0.2). The degree of the correlation of two variables is determined by the absolute value of either Pearson’s correlation coefficient r or ranked Spearman correlation coefficient ρ. Commonly, |r| > 0.7 or |ρ| > 0.7 indicates a strong correlation, |r| or |ρ| between 0.3 and 0.7 indicates a moderate correlation, and |r| < 0.3 or |ρ| < 0.3 indicates a weak correlation [2]. Thus, although statistically significant, most correlations in their studies were weak. We wonder if one variable can be effective for predicting the other when they are weakly related. In addition, the square of Pearson’s correlation coefficient (r2) may provide an easier interpretation, which represents the proportion of the variation of one variable “explained” by the other [2]; for example, the strongest correlation in one [5] of the articles: surgical stress score (SSS) and costs of postoperative hospitalization (r = 0.44), which correlated significantly (p < 0.0001). However, only approximately 19% (r2 = 0.44 × 0.44%) of the variation of costs can be “explained” by SSS. Considering the even smaller parts of variation of costs “explained” by preoperative risk score and comprehensive risk score (1.4% = 0.12 × 0.12%, 5.3% = 0.23 × 0.23%, respectively), the conclusion that E-PASS was useful for estimating costs should be interpreted with caution. The E-PASS scoring system originally was established to predict adverse postoperative effects in patients undergoing elective gastrointestinal surgery [3]. Although it has been verified to be effective in other types of surgery, such as elective repair of abdominal aortic aneurysms [7] and thoracic surgery [8], it was a poor predictor of complications in patients requiring liver resection [1], and the authors recommended a new modified logistic regression to better predict the postoperative outcome. Therefore, the E-PASS scoring system is not applicable to every surgery without adjustment. Because the majority of the correlations between each E-PASS score and hospitalization outcomes were weak in the serial studies of Hirose et al., we suggest this system may not be a useful predictor for patients with hip fractures, and the E-PASS system might need to be modified for better evaluation.

Reply to Letter to the Editor: New Equations for Predicting Postoperative Risk in Patients with Hip Fracture

I appreciate the interest and comments from Drs. Zhou ZhiJie and Fan ShunWu regarding the article, New Equations for Predicting Postoperative Risk in Patients with Hip Fracture [7] and two previous studies [8, 9]. In several studies, the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system correlated with the incidence of postoperative morbidity and mortality and the severity of potential postoperative complications [8, 9]. It also correlated with the length and cost of hospitalization [9]. However, the correlation coefficients in the studies were low. I recognize the correlation coefficient less than 0.2 means weak correlation. Moreover, the E-PASS score is a poor predictor of complications in patients requiring liver resection although the mortality is effectively predicted [1]. Therefore, the predictive ability of the E-PASS scores was confirmed [7]. First, equations were established to predict the morbidity and mortality rates in candidates for hip fracture surgery using the E-PASS system, and then the equations were compared with the Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) systems. POSSUM systems are the best available for assessing outcomes by risk adjustment analysis in various types of surgery [4, 6, 10], and their usefulness for hip fracture surgery also has been reported [2, 3]. Hirose et al. [7] showed the E-PASS more correctly predicted the actual morbidity and mortality rates than the POSSUM system. The observed to estimated ratios for morbidity and mortality as a risk-adjusted quality measure were 1.06 and 0.71 calculated by the developed equations, respectively. The predicted rates for inhospital and 30-day morbidity and mortality calculated by POSSUM systems were overestimated by 2.6-fold to 6.7-fold compared with those by E-PASS. Based on these results, it was concluded that the E-PASS score was effective and reproducible as an audit tool to predict the postoperative course of patients considered for hip fracture surgery. The E-PASS scoring system is comprised of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) that is determined by the PRS and SSS. In hip fracture surgery, the E-PASS scores have some inconsequential parameters such as the extent of the skin incision, which means a laparotomy and/or thoracotomy for calculating the SSS, because this scoring system was developed originally for gastrointestinal surgery [5]. Therefore, additional studies are being done to modify the E-PASS scores to evaluate more accurately the postoperative course for hip fracture. As few scoring systems are still practical to predict postoperative risk in patients with hip fractures, I recommend the E-PASS system and presume their predictive values will be evaluated in many institutions.

New Equations for Predicting Postoperative Risk in Patients with Hip Fracture

Predicting the postoperative course of patients with hip fractures would be helpful for surgical planning and risk management. We therefore established equations to predict the morbidity and mortality rates in candidates for hip fracture surgery using the Estimation of Physiologic Ability and Surgical Stress (E-PASS) risk-scoring system. First we evaluated the correlation between the E-PASS scores and postoperative morbidity and mortality rates in all 722 patients surgically treated for hip fractures during the study period (Group A). Next we established equations to predict morbidity and mortality rates. We then applied these equations to all 633 patients with hip fractures treated at seven other hospitals (Group B) and compared the predicted and actual morbidity and mortality rates to assess the predictive ability of the E-PASS and Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) systems. The ratio of actual to predicted morbidity and mortality rates was closer to 1.0 with the E-PASS than the POSSUM system. Our data suggest the E-PASS scoring system is useful for defining postoperative risk and its underlying algorithm accurately predicts morbidity and mortality rates in patients with hip fractures before surgery. This information then can be used to manage their condition and potentially improve treatment outcomes. Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Is an estimation of physiologic ability and surgical stress able to predict operative morbidity after pancreaticoduodenectomy?

Mortality rates after pancreaticoduodenectomy (PD) are below 4% in high volume centers, although morbidity rates still remain high. Therefore, it is important to clarify a predictor associated with operative morbidity after PD. The estimation of physiologic ability and surgical stress (E-PASS) score has been developed for comparative audit in general surgical patients. To evaluate whether E-PASS scoring system could predict the occurrence of complications after PD. We performed retrospective analysis of 69 patients (42.0% pancreatic cancer, 31.9% bile duct cancer, and others) who underwent PD using the E-PASS as a predictor of morbidity. Correlations between the incidence rates of postoperative complications and the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of the E-PASS scoring system were evaluated. Of the 69 patients 30 (43.5%) experienced a total of 54 postoperative complications. All E-PASS scores, especially PRS and CRS were significantly higher in the patients with postoperative complications than in the patients without complication. The complication rate gradually increased as the PRS, SSS and CRS score increased. Under receiver operating characteristic analysis, if a cut-off point of CRS was 0.75, sensitivity and specificity for the prediction of operative morbidity after PD was 80.0 and 79.5%, respectively. Neoadjuvant chemotherapy and intraoperative radiation therapy (IORT) did not influenced on operative morbidity after PD. E-PASS scoring system is useful to evaluate for morbidity after PD. Neoadjuvant chemotherapy and IORT could be adapted without significant extra risk for surgical complication.

Estimation of Physiologic Ability and Surgical Stress (E-PASS system) in patients with esophageal squamous cell carcinoma undergoing resection

Background The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system was designed on the hypothesis that the balance between the patient’s physiological reverse capacity and the surgical stress of operation was important in the development of postoperative complications. The aim of this study was to evaluate whether the E-PASS scoring system could predict the occurrence of complications after elective esophagectomy for esophageal cancer, including salvage esophagectomy.

Evaluation of estimation of physiologic ability and surgical stress (E-PASS) to predict the postoperative risk for hip fracture in elder patients

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system is comprised of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) determined by both the PRS and SSS. E-PASS predicts the postoperative risk by quantifying the patient's reserve and surgical stress in general surgery. This study aims to evaluate the usefulness of this scoring system for the hospitalization outcomes in hip fracture. A consecutive series of 419 elderly patients who underwent surgery with osteosynthesis or arthroplasty for hip fracture were prospectively assessed for the E-PASS scoring system, which was compared with their postoperative course. The postoperative morbidity and mortality rates in hospital increased linearly as the PRS and CRS increased, with significant correlation (rho = 0.2, P < 0.01) in both operations. The cost of hospital stay also related significantly to the SSS (r = 0.6, P < 0.0001) and CRS (r = 0.4, P < 0.0001). These results suggest that E-PASS may be useful for predicting postoperative risk and estimating medical expense for surgical cases with hip fracture.

Usefulness of an Estimation of Physiologic Ability and Surgical Stress (E‐PASS) Scoring System to Predict the Incidence of Postoperative Complications in Gastrointestinal Surgery

Surgical intervention induces various host responses to maintain homeostasis. When postoperative inflammation is intense and persists for a long time, postoperative complications may occur, sometimes developing into multiple organ failure. Therefore, it is very important to assess surgical stress and predict the risk of morbidity and mortality. Using a new scoring system, an estimation of physiologic ability and surgical stress (E-PASS) scoring system, surgical stress following gastrointestinal surgery was evaluated to assess the feasibility of this scoring system. This system comprises a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) that is calculated from both the PRS and the SSS. The relationship of the E-PASS score to the incidence of morbidity and mortality was examined. The relationship between the E-PASS score and a sequential organ failure (SOFA) score was also evaluated. The CRS had a significant positive correlation between not only the incidence but also the grade of postoperative complications. Total maximum SOFA score in patients with a CRS of more than 1 was significantly higher than that in patients with a CRS of less than 1. In conclusion, the E-PASS scoring system will be useful for predicting and recognizing the risk of postoperative complications. This scoring system is brief, simple, and reproducible and can be useful in all types of hospitals.

E-PASS (The Estimation of Physiologic Ability and Surgical Stress) Scoring System Helps the Prediction of Postoperative Morbidity and Mortality in Thoracic Surgery

Objective: When a new scoring system, ‘E-PASS’, standing for the Estimation of Physiologic Ability and Surgical Stress that predicts the postoperative surgical risk by quantification of the patient’s reserve and surgical stress applied to a population of general thoracic surgery patients, it should be investigated if this system could help us or not. Methods: The comprehensive risk score (CRS) of the E-PASS and the clinical course were evaluated retrospectively in 282 consecutive patients with primary lung cancer (group A), and in 458 patients who underwent elective thoracic operations (group B). Results: The morbidity and mortality rates in both group A and group B increased as the CRS increased. The CRS correlated significantly with the morbidity score, length of stay and cost of hospitalization. Conclusions: E-PASS scoring system may be useful in surgical decision-making and evaluating quality of care in patients who are tolerable for lung resection.

Estimation of physiologic ability and surgical stress (E-PASS) for a surgical audit in elective digestive surgery

Background This study was undertaken to establish an equation to estimate mortality with the use of the prediction scoring system designated as the Estimation of Physiologic Ability and Surgical Stress (E-PASS), and to evaluate the system's usefulness in defining quality of care by comparing it with the Physiologic and Operative Severity Score for the enUmeration for Mortality and morbidity (POSSUM) and Portsmouth-possum (P-POSSUM) scoring systems previously generated for surgical audit. Methods Patients (n = 5212; group A) who underwent elective gastrointestinal surgery were analyzed to establish equations for estimated 30-day and in-hospital mortality rates. The usefulness of E-PASS was evaluated in another series of 1934 patients (group B) who underwent elective digestive surgery in 6 national hospitals. The ratio of observed to estimated mortality rates (OE ratio) of each hospital was defined as a measure of quality. Results In group A, 30-day and in-hospital mortality rates increased as the Comprehensive Risk Score (CRS) increased, providing equations for estimated mortality rates. There was an excellent correlation between the estimated and observed mortality rates in individual diseases: R = 0.958, N = 6, P = .0027 for in-hospital mortality; R = 0.937, N = 6, P = .0059 for 30-day mortality. In all patients of group B, the E-PASS system estimated the 30-day mortality rates by 0.63-fold (linear analysis), whereas the POSSUM score was 11.0-fold (exponential analysis). The E-PASS system estimated the in-hospital mortality rates by 1.2-fold (linear analysis), whereas the P-POSSUM score was 4.5-fold (linear analysis). The OE ratios for 30-day mortality among the 6 hospitals defined by E-PASS correlated well with those defined by POSSUM: R = 0.996, N = 6, P<.0001. Similarly, the OE ratios for in-hospital mortality defined by E-PASS were also highly correlated with those defined by P-POSSUM:( R = 0.929, N = 6, P = .0075. Conclusions The E-PASS scoring system may be useful in defining surgical quality and may be more accurate than existing systems in evaluating elective digestive surgery.