Operative Severity Score For enUmeration Research Articles

Prediction of mortality in secondary peritonitis: a prospective study comparing p-POSSUM, Mannheim Peritonitis Index, and Jabalpur Peritonitis Index

BackgroundRisk scoring systems are required to allow accurate prognostication, compare outcomes of surgery, and allow patients to make informed decisions about their health. This prospective study compares the p-POSSUM (Portsmouth Modification to Physiological and Operative Severity Score for Enumeration of Mortality), Mannheim Peritonitis Index, and Jabalpur Peritonitis Index for their utility in predicting mortality in patients with peritonitis.MethodsPerioperative data was collected from 235 patients with secondary peritonitis and used to calculate p-POSSUM, MPI, and JPI scores. The accuracy of the 3 scores was compared using receiver operator characteristic curves.Resultsp-POSSUM and Mannheim Peritonitis Index were similar in their accuracy with area under the curve (AUC) values of 0.756 and 0.757. Jabalpur Peritonitis Index had an AUC of 0.665.Conclusionp-POSSUM and Mannheim Peritonitis Index can be used to predict mortality in patients with secondary peritonitis. Jabalpur Peritonitis Index is not suited for this purpose. Further studies are required to improve the diagnostic performance of p-POSSUM and MPI in patients with secondary peritonitis.

Abstract No.: ABS3159: Utility of prognostic scores in prediction of mortality after emergency surgery in COVID-19 patients – A prospective observational cohort study

Background and Aims:Pre-operative prognostic scoring in emergency surgeries is important for informed consent and optimum resource allocation. The accuracy of pre-operative prognostic scores in patients with coronavirus disease (COVID-19) has not been studied. This study aimed to evaluate prognostic scoring tools in COVID-19 patients.Methods:A prospective, observational cohort study was conducted in adults with confirmed COVID-19 infection within 7 weeks before or 1 week after emergency surgery. (1) Demographic data, prognostic risk scores [American Association of Anaesthesiologists Physical Classification (ASA), sequential organ failure assessment (SOFA), quick SOFA (qSOFA), Physiologic and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM), and Portsmouth POSSUM (P-POSSUM) scores], and surgical and anaesthetic factors were noted along with morbidity and 30-day mortality. The correlation of prognostic scores and mortality was evaluated using univariate Cox proportional hazards regression, receiver operating characteristic curves (ROCs), Youden’s index, and the Hosmer–Lemeshow goodness-of-fit model.Results:Sixty-seven COVID-19 patients underwent emergency surgery during the study period. The overall mortality was 19%, with the highest in gastro-intestinal/general surgery and sinus surgery. Positive qSOFA and ASA 3E/4E were associated with 9.03 and 12.7 times higher mortality risk, respectively. Each unit increase of SOFA-, POSSUM-, and P-POSSUM-predicted mortality scores led to 50%, 7%, and 6% higher mortality. SOFA, POSSUM, and P-POSSUM area under the curve–ROC curves showed good discrimination between survivors and non-survivors (AUC 0.8829, 0.85, and 0.86, respectively).Conclusion:The overall mortality was comparable to the published literature. (2) SOFA, POSSUM, and P-POSSUM models are good prognostictools for predicting the post-operative 30-day mortality in COVID-19 patients. qSOFA, a simple, clinical, objective tool, also has an aprognostic value.

Damage-control surgery in patients with nontraumatic abdominal emergencies: A systematic review and meta-analysis.

After the successful implementation in trauma, damage-control surgery (DCS) is being increasingly used in patients with nontraumatic emergencies. However, the role of DCS in the nontrauma setting is not well defined. The aim of this study was to investigate the effect of DCS on mortality in patients with nontraumatic abdominal emergencies. Systematic literature search was done using PubMed. Original articles addressing nontrauma DCS were included. Two meta-analyses were performed, comparing (1) mortality in patients undergoing nontrauma DCS versus conventional surgery (CS) and (2) the observed versus expected mortality rate in the DCS group. Expected mortality was derived from Acute Physiology And Chronic Health Evaluation, Simplified Acute Physiology Score, and Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity scores. A total of five nonrandomized prospective and 16 retrospective studies were included. Nontrauma DCS was performed in 1,238 and nontrauma CS in 936 patients. Frequent indications for surgery in the DCS group were (weighted proportions) hollow viscus perforation (28.5%), mesenteric ischemia (26.5%), anastomotic leak and postoperative peritonitis (19.6%), nontraumatic hemorrhage (18.4%), abdominal compartment syndrome (17.8%), bowel obstruction (15.5%), and pancreatitis (12.9%). In meta-analysis 1, including eight studies, mortality was not significantly different between the nontrauma DCS and CS group (risk difference, 0.09; 95% confidence interval, -0.06 to 0.24). Meta-analysis 2, including 14 studies, revealed a significantly lower observed than expected mortality rate in patients undergoing nontrauma DCS (risk difference, -0.18; 95% confidence interval, -0.29 to -0.06). This meta-analysis revealed no significantly different mortality in patients undergoing nontrauma DCS versus CS. However, observed mortality was significantly lower than the expected mortality rate in the DCS group, suggesting a benefit of the DCS approach. Based on these two findings, the effect of DCS on mortality in patients with nontraumatic abdominal emergencies remains unclear. Further prospective investigation into this topic is warranted. Systematic review and meta-analysis, level III.

Comparing predicted and observed morbidity and mortality between emergency laparotomies conducted during the day and overnight at adistrict general hospital.

BackgroundIt is generally expected that emergency laparotomies performed at night confer a higher risk and thus outcomes are worse. This study hopes to determine whether there is a difference in risk of cases presenting at night, and overall outcome.MethodsData were retrospectively obtained using local notes archival software to obtain predicted and observed mortality, ASA (American Society of Anesthesiologists) grade and length of stay of emergency laparotomies conducted between August 2019 and March 2020. Day cases were defined as knife to skin time (KTS) between 08:00 and 19:59, whilst night cases were defined as KTS between 20:00 and 07:59.ResultsIn all, 81 emergency laparotomies were performed during day-time hours over the 8‑month period; 32 were performed overnight. Median ASA grade was 3 for both. Median length of stay was similar: 11 day, 12 overnight. Median P-POSSUM (Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity) morbidity score of day cases was 52% compared to 53.2% at night. Median mortality score of day cases was 5.6%, whilst at night was 2.7% (p = 0.27). Observed mortality after day cases was 13.5%, and overnight was 9.3%. Observed morbidity was 46.9% after day cases and 50% overnight.ConclusionThere was no statistically significant difference between predicted or observed morbidity and mortality between emergency laparotomies conducted during the day and those conducted overnight.

Long-Term Impact of Vascular Surgery Stress on Frail Older Patients

Frailty is a syndrome where the ability to cope with acute physiological stress is compromised, although it is unclear what impact this stress has on long-term outcomes. Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity is a validated method for calculating levels of stress associated with vascular procedures. We designed this study to evaluate the long-term impact of different levels of surgical stress among frail older patients undergoing vascular surgery procedures. We identified all independently living patients who underwent prospective frailty assessment followed by an elective vascular surgery procedure captured in the Vascular Quality Initiative registry (endovascular abdominal aortic aneurysm [AAA] repair, thoracic endovascular aortic repair, suprainguinal and infrainguinal bypass, peripheral vascular intervention, carotid endarterectomy, and open AAA) at an academic institution between January 2016 and July 2018. Patient- and procedure-level data were obtained from our institutional data warehouse and Vascular Quality Initiative database, and used to calculate Vascular-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity scores. The association between frailty and composite outcome of any major complications (surgical site infection; graft thrombectomy; major amputation; adverse cardiac, pulmonary, or neurologic event; acute renal insufficiency; and/or reoperation related to the index procedure), nonhome living status, or death within 1year after low-, medium-, and high-stress vascular procedures was evaluated using bivariate and logistic regression models. A total of 163 patients were identified (70% male, mean age 67.8years) who underwent open AAA repair (6%), endovascular AAA repair (21%), thoracic endovascular aortic repair (7%), suprainguinal bypass (5%), infrainguinal bypass (18%), carotid endarterectomy (18%), or peripheral vascular interventions (25%), which included 44 (27%) patients diagnosed with frailty before surgery. Overall, frail patients had significantly higher rates of the 1-year composite outcome (48% frail versus 27% nonfrail; P=0.012) when compared with nonfrail patients, with a significant dose-dependent effect as the level of stress increased. In comparison, increasing levels of surgical stress had a negligible effect on long-term outcomes among nonfrail patients. The interaction between frailty and high surgical stress was found in adjusted regression models to be a significant predictor of adverse outcomes within 1year after vascular surgery (odds ratio, 3.3; 95% confidence interval, 1.3-8.6; P<0.01). Frail patients who undergo high-stress vascular procedures have a significantly higher rate of complications leading to loss of functional independence and mortality within the year after their surgery. These data suggest that estimates of surgical stress should be incorporated into clinical decision making for frail older patients before and after surgery.

Evaluation of Predictive Value of P-POSSUM Score in Patients Operated for Acute Abdomen and Comparison of Scoring at Admission and Pre-operatively

Physiological and operative severity score for enumeration of mortality and morbidity (POSSUM), as reported by Copeland et al. (Br J Surg 78: 355–60, 1991) [1] and its Portsmouth modification (P-POSSUM) [2], as reported by Whiteley et al. (Br J Surg 83:812–15, 1996), remain one of the most widely accepted risk assessment scoring system in surgical patients and helps in apprising both the surgeon and the relatives with the involved risk. They have been extensively studied since their development for various surgical procedures, and though most aspects of the scoring are standardized, the timing of physiological scoring is variable (admission vs. pre-operatively) in most of the studies. Hence, we aim to evaluate the predictive value of the score in the defined patients in our setup and also to evaluate which timing of scoring is more accurate, whether at the time of admission or pre-operatively after initial resuscitation. One hundred patients, who underwent surgery for acute abdomen from November 2016 to March 2018 at our institute, were studied. Mortality and morbidity risk were calculated for each P-POSSUM score with physiological scoring done twice, i.e., at admission and pre-operatively. The ratio of observed to predicted death and morbidity (O:E) were calculated and compared for both scores using chi-square test. Area under the curve (AUC) analysis was used to compare the efficacy of both the scores. An observed to expected (O:E) ratio of 0.88 and 1.00 was obtained for mortality with physiological scoring at admission and pre-operatively. Similarly, the O:E values for morbidity were 0.85 and 0.87 respectively. P-POSSUM was found to give an accurate prediction of both mortality and morbidity in patients operated for acute abdomen. Moreover, physiological scoring done with pre-operative variables is superior in comparison to scoring at the time of admission and is a better predictor of outcome.

Perioperative considerations in nonagenarians

ObjectiveThe nation's aging population presents novel perioperative challenges. Potential benefits of operative interventions must be scrutinized in relation to recoverable quality of life. The purpose of this study is to evaluate common risk calculators used for medical decision making in a nonagenarian patient population. MethodsRetrospective medical record review was performed on patients 90 years or older who underwent operative interventions requiring anesthesia at a large academic medical center between January 1, 2013, and December 31, 2017. GraphPad 8.2.1 was used for statistical analysis. ResultsSignificant differences were found when data were stratified by age for elective versus emergent cases (P value < .0001), ability to return to baseline function (P value = .0062), and mortality (P value < .0001). Significant differences were found in emergent and elective cases, ability to return to baseline function, readmissions, and mortality (all P values < .0001) when stratified by American Society of Anesthesiologists score. Ability of patients to return to baseline functionality after intervention was influenced by their preintervention level of functionality (P value = .0008). American College of Surgeons and Portsmouth Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity risk calculators underestimated the need for rehabilitation and overestimated mortality for this population (all P values < .0001). ConclusionPerioperative cares of the extreme geriatric population are complex and should be approached collaboratively. Rehabilitation and postoperative assistance resources should be assessed and used fully. Input from palliative care teams should be sought appropriately. End-of-life and escalation-of-care discussions should ideally be organized prior to emergent interventions. Frailty and risk calculators should be used and considered for formal implementation into the preoperative workflow.

Evaluation of Nottingham Hip Fracture Score, Age-Adjusted Charlson Comorbidity Index and the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity as predictors of mortality in elderly neck of femur fracture patients

Background:This study evaluated the use of several risk prediction models in estimating short- and long-term mortality following hip fracture in an Australian population.Methods:Data from 195 patients were retrospectively analysed and applied to three models of interest: the Nottingham Hip Fracture Score, the Age-Adjusted Charlson Comorbidity Index and the Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity. The performance of these models was assessed with receiver operating characteristic curve as well as logistic regression modelling.Results:The median age of participants was 83 years and 69% were women. Ten percent of patients were deceased by 30 days, 25% at 6 months and 31% at 12 months post-operatively. While there was no statistically significant difference between the models, the Age-Adjusted Charlson Comorbidity Index had the largest area under the receiver operating characteristic curve for within 30 day and 12 month mortality, while the Nottingham Hip Fracture Score was largest for 6-month mortality. There was no evidence to suggest that the models were selecting a specific subgroup of our population, therefore, no indication was present to suggest that using multiple models would improve mortality prediction.Conclusions:While there was no statistically significant difference in mortality prediction, the Nottingham Hip Fracture Score is perhaps the best suited clinically, due to its ease of implementation. Larger prospective data collection across a variety of sites and its role in guiding clinical management remains an area of interest.

Evaluation of physiological and operative severity score for enumeration of mortality and morbidity and Portsmouth modification of possum scores in patients with hollow viscus perforation

Background: The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is widely used to predict the morbidity and mortality in a variety of surgical settings and provides a tool for risk adjustment and comparison. The aim of this study was to assess the predicting morbidity and mortality in hollow viscus perforation by applying POSSUM and Portsmouth modification of POSSUM scores. Methods: This study was a prospective study conducted on 33 patients admitted in the Department of General Surgery, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, from September 2016 to August 2017, and present detailed records of the parameters under evaluation of patients admitted to surgical wards with the clinical diagnosis of hollow viscus perforation (gastric/duodenal/ileal perforation). Results: During the present study period, a total of 136 patients were operated on small bowel, and of these 33 cases fulfilled all the criteria and were selected for this study. The overall mortality in this study was 6 (18.18% of the study), while the morbidity was noted in 17 cases (51% of study). Mortality rates differed with POSSUM scores over predicting the mortality. On applying POSSUM, using exponential analysis, we found that the expected number of deaths for our study group is 10 (O:E = 1.66). Conclusion: On applying POSSUM using the exponential analysis, we found that the expected number of deaths for our study group is 10 (O:E = 1.66). We found the difference between expected and observed mortality rates using the exponential analysis.

Risk Factors of Postoperative Complications in Laparoscopic Cholecystectomy for Acute Cholecystitis.

Introduction:There are often cases with postoperative complications after laparoscopic cholecystectomy (LC), resulting in severe consequences. This study aimed to identify potential risk factors of postoperative complications in cases of LC for acute cholecystitis.Materials and Methods:A total of 423 patients with cholecystitis underwent LC. We divided the patients into two groups: group without postoperative complications (Group A) and group with postoperative complications (Group B). Pre-operative findings, surgical findings, and the methods for evaluating the risk of peri-operative complications were compared between the two groups with a univariate analysis. Independent risk factors of postoperative complications were then evaluated in a multivariate analysis with the factors shown to be statistically significant in the univariate analysis.Results:A Physiological and Operative severity Score for enUmeration of Mortality and morbidity (POSSUM) of ≥ 48.3 and moderate or severe cholecystitis were independent risk factors of postoperative complications in LC.Conclusions:This study indicated that POSSUM morbidity and moderate or severe cholecystitis were potential risk factors of postoperative complications. The pre-operative management of the general condition and cholecystitis using antibiotics, infusion, percutaneous transhepatic gallbladder drainage, and other approaches may be significant for the prevention of postoperative complications. Once the POSSUM morbidity reaches the threshold after LC, postoperative management becomes difficult, so strict control of the general condition should be performed.

V-Possum Score as a Predictor of 30-Day Post-Mortality of Endovascular Aortic Aneurysm Repair – Thoracic Endovascular Aneurysm Repair Procedure in Cipto Mangunkusumo Hospital

Introduction: This study aims to know the performance of the Vascular – Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (V-POSSUM) score as a predictor of 30-day mortality after the Endovascular Aortic Aneurysm Repair (EVAR) – Thoracic Endovascular Aortic Repair (TEVAR) procedure in Abdominal Aortic Aneurysms (AAA) and Thoracic Aortic Aneurysms (TAA) patients in Cipto Mangunkusumo Hospital. Method: This was a retrospective cohort study using data from medical records. Data were taken according to the variables contained in the V-POSSUM scoring system in the patient who undergone EVAR – TEVAR procedure, on the period of 2013 to July 2018. Results: The study involved 85 patients who met the study requirements. It was known that physiological scores, morbidity risk, and mortality risk could be used as a model to predict mortality outcomes because they had good accuracy and discrimination performance, while the severity of the operation score cannot. The result of the goodness of fit model’s physiological score, morbidity risk, and mortality risk was significant (p &lt;0.001), while the severity score of the operation was 0.18 (p &gt;0.05). The Area Under the Curve (AUC) was 94%, 93%, 93%, with the cut points at 31, 68.8, and 10.6 for the physiological score, morbidity risk, and mortality risk, respectively. Conclusion: The V-POSSUM score had good accuracy and discrimination for the physiological score, morbidity risk, and mortality risk. Keywords: abdominal aortic aneurysm, thoracic aortic aneurysm, EVAR, TEVAR, V-POSSUM score, validation

An Analysis of the Decision-Making Process After "Decision not to Operate" in Acutely Unwell, High-Risk General Surgery Patients.

The purpose of this study was to analyze the decision-making process in emergency general surgery in an attempt to ascertain whether surgeons make the correct decision when decisions not to operate in high-risk acutely unwell surgical patients are taken. A decision not to operate is sometimes associated with a certain degree of uncertainty as to the accuracy of the decision. Difficulty lies with the fact that the decisions are made on assumptions, and the tools available are not fool proof. We retrospectively evaluated "decisions not to operate" over a period of 32 months from April 2013 to August 2015 in a district general hospital in United Kingdom and compared with consecutive similar number of patients who had an operation as recorded in the National Emergency Laparotomy Audit (NELA) database (from January 2014 to August 2015). We looked at the demographics, American Society of Anesthesiologists grade, Portsmouth-Physiological and Operative Severity Score for enumeration of Mortality and Morbidity (P-POSSUM) score, functional status, and 30-day mortality. Two groups (operated [n = 43] and conservative [n = 42]) had similar characteristics. Patients for conservative management had a higher P-POSSUM score (P < .001) and a poorer functional status (P < .001) at the time of decision-making compared to those who had surgery. Mortality at 30 days was significantly higher for patients decided for conservative management when compared with those who had surgery (76.2% and 18.6%, respectively). Elderly patients with poorer functional status and predicted risks more often drive multidisciplinary discussions on whether to operate. Within the limitations of not knowing the outcome otherwise, it appears surgeons take a reasonable approach when deciding not to operate.

Evaluation of the Use of POSSUM and P-POSSUM Score as a Tool for Prediction of Surgical Outcome

Background: There are many scoring systems that predict the risk of mortality with varyingdegrees of accuracy. The ideal scoring system for surgical outcome should be quick andeasy to use and should be applicable to all general surgical procedures. POSSUM(Physiological and Operative Severity Score for enumeration of Mortality and Morbidity) andP-POSSUM (Portsmouth POSSUM) are the most appropriate scoring systems currentlyavailable in general surgery to predict thirty days mortality and morbidity.&#x0D; Objective: The study was done to assess the value of POSSUM in predicting the morbidityrate and the value of P-POSSUM in predicting the mortality rate in general surgical patientsof our country.&#x0D; Methods: Aprospective study was performed in 120 general surgical patient. The risks ofmorbidity and mortality were calculated by using the POSSUM equation for morbidity andthe P-POSSUM equation for mortality in each patient. The predicted risks were comparedwith the observed risks of morbidity and mortality for 30 days after surgery and statisticallyanalysed.&#x0D; Results: The difference in p value of predicted risk of morbidity by POSSUM equation andobserved morbidity; calculated by chi square test(x2 =1.36, d.f=4,p=0.24,0/P ratio was1.18); which was not statistically significant. The predicted mortality by P-POSSUM equationand observed mortality; calculated by Fisher's exact test(p=1) was not found statisticallysignificant. The Pearson correlation has shown significant correlation at the 0.01 level (2tailed) for the observed and predicted mortality and morbidity(r=O. 701).ROC analysesshowed both POSSUM and P-POSSUM scores to be good predictors of 30-day morbidity andmortality with area under the curve values (AUC) of 0.887 and 0.991 respectively.&#x0D; ConclusionPOSSUM and P-POSSUM can be used as a valid tool for using risk prediction of morbidityand mortality in our set up.&#x0D; Journal of Surgical Sciences (2017) Vol. 21 (1) :11-14

Performance of the Surgical Outcomes Monitoring and Improvement Program in comparison to Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity and National Surgery Quality Improvement Program calculators in predicting mortality for emergency colectomy: A retrospective case series study

AimThe National Surgery Quality Improvement Program (NSQIP) and Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (P‐POSSUM) are well‐established risk calculators employed by surgeons worldwide to calculate predicted surgical mortality and morbidity. Since 2008, the Hospital Authority has implemented the Surgical Outcomes Monitoring and Improvement Program (SOMIP) for auditing of 30‐day mortality in emergency surgery. In the present study, we aimed to compare the performance of this locally‐developed risk calculator with NSQIP and P‐POSSUM for 30‐day mortality predictions in patients undergoing emergency colectomy.Patients and MethodsThe present study was a retrospective study of 119 patients who underwent emergency colectomy between January and December 2014 at the Department of Surgery, Queen Elizabeth Hospital, Hong Kong. The predicted mortality rate was calculated by SOMIP, NSQIP and P‐POSSUM. Data were analysed by the area under the receiver–operator characteristic curve (AUROC).ResultsThe overall mortality rate was 12.6 per cent (15/119). The AUROC for SOMIP was 0.908 [95 per cent confidence interval (CI): 0.845–0.970, P &lt; 0.05), whereas the the AUROC for NSQIP and P‐POSSUM were 0.903 (95 per cent CI: 0.815–0.990, P &lt; 0.05) and 0.842 (95 per cent CI: 0.743–0.942, P &lt; 0.05), respectively. The SOMIP calculator provided the highest AUROC and was comparable to the other two well‐established international risk calculators.ConclusionsAll three risk calculators (SOMIP, NSQIP and P‐POSSUM) showed considerable accuracy in predicting the 30‐day mortality rate. The SOMIP risk calculator was comparable to the well‐established international risk calculators NSQIP and P‐POSSUM.

Early Postoperative Morbidity After Chronic Subdural Hematoma: Predictive Usefulness of the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity, American College of Surgeons National Surgical Quality Improvement Program, and American Society of Anesthesiologists Grade in a Prospective Cohort

Although chronic subdural hematoma (CSDH) is generally benign, long-term survival (LTS) after CSDH is poor in a significant subgroup. This dichotomy has been compared to fractured neck of femur. However, although early postoperative mortality (within 30 days of CSDH) is well recorded with CSDH and similar to fractured neck of femur (4%-8%), scant accurate data exist regarding early postoperative morbidity (POMB). POMB, which prolongs length of stay (LOS) after major nonneurosurgery, is associated with decreased LTS. One recent CSDH study suggested a POMB standard of 10% i.e., notably less than with fractured neck of femur (45%). POMB was recorded in a novel prospective single-center cohort after CSDH. The POSSUM (Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity), American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) score, and American Society of Anesthesiologists (ASA) grade were assessed as tools for potentially predicting POMB. Receiver operating characteristic (ROC) curves were calculated. Early postoperative mortality (within 30 days of CSDH) occurred in 3 of 114 patients (3%). Seventy-one POMB events occurred in 54 of 114 patients (47%), with 27 of 54 (50%) having a Clavien-Dindo grade ≥2. Most POMB was neurologic (n= 47/71, 66%). Age (P= 0.01), Glasgow Coma Scale (GCS) score (P= 0.001), Markwalder grade (P= 0.01), hypertension (P= 0.047), and/or ≥1 preexistent comorbidity (P= 0.041) were predictive. LOS (P= 0.01) and discharge modified Rankin Scale score (P < 0.001) were significantly associated. Predicted and observed POMB with POSSUM were significantly disparate (χ2= 15.23; P= 0.001): POSSUM area under ROC (AUROC= 0.611) was also nondiscriminatory. ACS-NSQIP (χ2= 18.51; P < 0.001; AUROC= 0.629) and ASA grades (P= 0.25) were also nonpredictive. POMB was frequently disabling, mostly neurologic, and as frequent and diverse as with fractured neck of femur. POMB was significantly correlated with LOS and discharge modified Rankin Scale score. Surprisingly, POSSUM, ACS-NSQIP, and ASA grades were not predictive and would not aid consent. Simple parameters (age, Glasgow Coma Scale, Markwalder grade, hypertension, and/or ≥1 other comorbidity) were instead predictive. Longitudinal follow-up will determine whether POMB affects LTS. CSDH, like fractured neck of femur, is distinct.

Evaluation criteria and risk prediction of postoperative complications after radical gastrectomy for gastric cancer

The data of evidence-based medicine clinical trials and large databases showed that anastomotic leakage, pancreatic leakage and abdominal abscess were the most common complications after gastrectomy, and the complication rate was about 20% and mortality rate was about 1%. Postoperative complications criteria of gastric surgery is mainly used Clavien-Dindo classification of surgical complications, Common Terminology Criteria for Adverse Events (CTCAE v4.0) and Japanese Clinical Oncology Group (JCOG) as evaluative standard. The performance status, American Society of Anesthesiologists score, physiological operative severity score for enumeration of mortality and morbidity (POSSUM), E-PASS scoring system, acute physiology and chroaic health evaluation (APACHEⅡ), Charlson comorbidity index and frailty score were used in predicting postoperative mortality and morbidity in gastric cancer patients. Authors can objectively evaluate risk of surgery and reasonably use these scoring systems for perioperative management. Key words: Gastric surgery; Complications; Risk factors; Prognosis; Perioperative management

Quality of Life and Mortality after Endovascular, Surgical, or Conservative Treatment of Elderly Patients Suffering from Critical Limb Ischemia

Revascularization to relieve ischemic pain and prevent limb loss is the cornerstone of critical limb ischemia (CLI) treatment; however, not all elderly patients are deemed fit for revascularization. Patient-related outcome measurements are important in these patients. Quality of life (QoL) results regarding the effect of endovascular, surgical, and conservative treatment on the QoL in the elderly are scarce in the current literature. The goal of this study was to explore the outcomes of the different treatment modalities in elderly patients suffering from CLI, with a specific focus on QoL. A total of 195 CLI patients ≥70years were prospectively included between January 2012 and February 2016 and divided into 6 groups (endovascular revascularization, surgical revascularization, and conservative treatment). Two age groups (70-79 and >80years) were analyzed. Follow-up was performed at 5-7days, 6 weeks, and 6 months. World Health Organization Quality of Life-BREF questionnaire was used to determine QoL. The Vascular-Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity score was noted. QoL was used as the primary end point, with mortality and limb salvage as the secondary end points. Six-month mortality was significantly lower in surgically treated patients aged 70-79years (4%) as compared with endovascular (24%, P=0.001) or conservative treatment (25%, P=0.02). There was no significant difference in 6-month mortality in patients >80years among endovascularly (38%), surgically (15%), and conservatively treated patients (27%). QoL significantly increased at all follow-up moments in surgically treated patients between 70 and 79years and at 6 months in endovascularly treated patients. Conservatively treated patients did not improve their QoL in this age group. All patients aged >80years, including conservatively treated patients, showed significantly improved QoL results at 6 months. Elderly patients judged fit for surgery may benefit the most from surgical revascularization, reporting low mortality rates, low adverse events and significantly gained QoL in multiple domains. However, all 3 treatment modalities have significantly increased physical health at 6 months. Conservative therapy seems to be an acceptable treatment option in patients unfit for revascularization with gained physical health at 6months.

Associations of fluid amount, type, and balance and acute kidney injury in patients undergoing major surgery.

Fluid administration has been reported to be associated with an increased risk of acute kidney injury (AKI). We assessed whether, after correction for fluid balance, amount and chloride content of fluids administered have an independent association with AKI. We performed an observational study in patients after major surgery assessing the independent association of AKI with volume, chloride content and fluid balance, after adjustment for Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) score, age, elective versus emergency surgery, and duration of surgery. We studied 542 consecutive patients undergoing major surgery. Of these, 476 patients had renal function tested as part of routine clinical care and 53 patients (11.1%) developed postoperative AKI. After adjustments, a 100 ml greater mean daily fluid balance was artificially associated with a 5% decrease in the instantaneous hazard of AKI: adjusted Hazard Ratio (aHR) 0.951, 95% confidence intervals (CI) 0.935 to 0.967, <i>P</i> <0.001. However, after adjustment for the proportion of chloride-restrictive fluids, mean daily fluid amounts and balances, POSSUM morbidity, age, duration and emergency status of surgery, and the confounding effect of fluid balance, every 5% increase in the proportion of chloride-liberal fluid administered was associated with an 8% increase in the instantaneous hazard of AKI (aHR 1.079, 95% CI 1.032 to 1.128, <i>P</i>=0.001), and a 100 ml increase in mean daily fluid amount given was associated with a 6% increase in the instantaneous hazard of AKI (aHR 1.061, 95% CI 1.047 to 1.075, <i>P</i> <0.001). After adjusting for key risk factors and for the confounding effect of fluid balance, greater fluid administration and greater administration of chloride-rich fluid were associated with greater risk of AKI.

Outcome of intraoperative goal-directed therapy using Vigileo/FloTrac in high-risk patients scheduled for major abdominal surgeries: A prospective randomized trial

BackgroundThis study evaluated impact of intraoperative goal-directed therapy (GDT) judged by changes of stroke volume variation (SVV) and cardiac index (CI) using the Vigileo/FloTrac system on postoperative (PO) morbidities and mortality rates in high risk patients scheduled for major abdominal surgeries in comparison to conventional fluid therapy (CT).Methods86 patients were randomly allocated into one of two equal groups: CT group = 43 patients received crystalloid solution and on demand bolus of 250 ml colloids with possible addition of vasopressor or inotrope to target MAP at 60–90 mmHg, CVP at 8–12 mmHg and urine output at >0.5 ml/kg/hr and GDT group = 43 patients received crystalloid fluid therapy (FT) and colloids (3 ml/kg) with possible addition of vasopressor or inotrope according to predefined protocol with a target CI 2.5 L/min/m2, SVV < 12% with MAP > 65 mmHg. Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) was used to predict morbidity and mortality rates. Study outcomes included ICU and total hospital morbidity and mortality rates and length of stay (LOS).ResultsIntraoperative GDT reduced ICU morbidity rate (16.3%) than the POSSUM predicted rate (39.78%) and significantly (p = 0.039) than CT group (37.2%), while in CT group ICU morbidity rate coincided with POSSUM predicted rate (42.86%). ICU and total hospital LOS were significantly shorter with GDT group than with CT group. However, mortality rates weren’t significantly lower with GDT group than CT group (7% vs. 11.6%). The applied protocol for intraoperative GDT reduced significantly crystalloid infusion and despite of significantly higher amount of received colloids, the total amount of FT was significantly less than CT group.ConclusionThe applied protocol for intraoperative GDT provided significant reduction of PO morbidities, ICU and hospital LOS but couldn‘t significantly reduce mortality rates in high risk patients scheduled for major abdominal surgeries.

Possum Scoring In Hollow Viscus Perforation.

INTRODUCTION: Mortality and morbidity is an important and objective measure of outcome of a surgery. The outcome of surgical intervention is not solely dependent on the abilities of surgeon in isolation. The patients physiological status, disease that requires surgical corrections, severity of the diseases, the nature of the operation and the preoperative and postoperative support services have a major effect on the ultimate outcome. This POSSUM scoring (physiological and operative severity score for enumeration of mortality and morbidity) uses of the physiological and surgical variables which is a quick, noninvasive, easy to use and can be applied both in emergency and elective surgery and accurately in predicting the outcome. AIM: Aim is to predict the risk of mortality and morbidity in patients with peritonitis due to hollow viscous perforation. Assessment of surgical risk in these patients is to help in choosing the modality of post operative management in a particular patient. PERIOD OF STUDY: Nov 2014 - June 2015 MATERIALS AND METHODS: 50 patients with hollow viscous perforation admitted in Government Royapettah Hospital, Kilpauk Medical College Hospital from November 2014 to June 2015 were included in the study. Necessary date to be collected: POSSUM SCORE were to be calculated for each patient and analysis to be done. CONCLUSION: Based on my study, POSSUM can be used as a good stratification tool for predicting morbidity and mortality within 30 days from the operative day. One of the limitation in POSSUM is that it over predicts mortality in some low risk patients but prediction of morbidity is better. POSSUM scoring system is well validated for its use in risk adjusted auditing in general surgery.