POSSUM Scoring Research Articles

“An Analytical Study To Compare The Effectiveness Of P-Possum And Possum Scores In Predicting Mortality And Morbidity Following Emergency Laparotomy"

Background: Surgical outcomes are increasingly scrutinized as part of efforts to ensure accountability and improve the quality of care. The Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) and its modification, the Portsmouth POSSUM (P-POSSUM), are widely used tools for predicting surgical outcomes. Objective: This study aimed to assess the accuracy of POSSUM in predicting morbidity and P-POSSUM in predicting mortality for patients undergoing emergency laparotomies in a North Indian tertiary care center. Methods: A hospital-based, analytic observational study was conducted at S.M.S. Medical College and Hospital, Jaipur, involving 160 patients who underwent emergency laparotomy. Preoperative physiological and intraoperative data were collected and used to calculate POSSUM and P-POSSUM scores. Mortality predictions were compared using linear and exponential analyses, and the observed-to-expected (O:E) mortality ratio was calculated. Statistical significance was determined using the Chi-square test. Results: The mean age of the cohort was 49.65 years, with males comprising 64.37% of the population. Peptic perforation (20.6%) was the most common cause of surgery. POSSUM significantly over-predicted mortality (O:E ratio = 0.26, p=0.04), while P-POSSUM provided a more accurate prediction (O:E ratio = 0.45, p=0.81). POSSUM also overestimated morbidity (O:E ratio = 0.8, p=0.51). Conclusion: While POSSUM tends to over-predict both mortality and morbidity, P-POSSUM offers a more accurate prediction of mortality in patients undergoing emergency laparotomy. These scoring systems can serve as valuable tools for surgical audits and improving the quality of care, though careful selection of the appropriate predictive model is essential

Revisiting Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) Scores: Are They Valid in Cases of Ileal Perforation?

Introduction Ileal perforation due to typhoid is common in tropical countries, and the ensuing secondary peritonitis is treated by resuscitation and surgery. The Physiological and Operative Severity Scorefor the Enumeration of Mortality and Morbidity (POSSUM) was developed to predict postoperative outcomes to overcome systemic obstacles in any healthcare setupand is considered fairly accurate. The Portsmouth-POSSUM (P-POSSUM) score was developed as a corrective scoring system for overestimations made by the POSSUM score vis-à-vis mortality. Our study aimed to examine the validity of these two scores in the postoperative prediction of surgical outcomes in patients with ileal perforation. Materials and methods An observational study involving 40 patients diagnosed with ileal perforations was undertaken over 18 months. The postoperative outcome for each patient was calculated as per the POSSUM and P-POSSUM parameters. Statistical analysis was done using SPSS(IBM Corp., Armonk, NY) and the results were tabulated. Results We found that age, gender, respiratory dysfunction, propensity for multiple surgeries, duration of surgery, co-morbidities, underlying malignancy, and systolic blood pressure played a significant role in determining postoperative outcomes. Haemoglobin, potassium, and urea levels were also found to be significantly associated with outcome. Cardiac signs, pulse, white blood cell count, Glasgow Coma Scale score, sodium, and electrocardiography, part of the physiological score parameters, were found to be insignificant in the prediction of postoperative outcomes. Among the intraoperative parameters, peritoneal soiling was found to be insignificant. Conclusion Some parameters inherent to POSSUM and P-POSSUM calculations appear to bear no statistical significance to the final score, highlighting that these need to be revisited and perhaps modified to further simplify the calculation.The POSSUM score is an excellent predictor of postoperative morbidity and mortality in ileal perforation patients but is of questionable reliability due to its tendency to overestimate them. P-POSSUM has a better predictive power of postoperative mortality by correcting POSSUM mortality overestimation.

Predictive value of POSSUM scoring system for postoperative complications and mortality in elderly patients with colorectal cancer.

The POSSUM scoring system, widely employed in assessing surgical risks, offers a simplified and objective approach for the prediction of complications and mortality in patient. Despite its effectiveness in various surgical fields, including orthopedics and cardiovascular surgery, yet its utilization in elderly patients undergoing colorectal cancer surgery is infrequent. To analyze the predictive value of POSSUM scoring system for postoperative complications and mortality in elderly with colorectal cancer. 306 elderly colorectal cancer patients were grouped according to the complications and death within 30 days after surgery. Among them, 108 cases in complication group, 198 cases in non-complication group, 16 cases in death group and 290 cases in survival group. POSSUM scores of all subjects were obtained and its predictive value for postoperative complications and mortality of elderly was conducted by ROC curve. No apparent difference were observed in complications and mortality among patients with different disease types, operation types and operation timing (P> 0.05). The R2 in complication group was higher than non-complication group (P< 0.05). The R1 in death group were higher than survival group (P< 0.05). The AUC of R2 for predicting postoperative complications was 0.955 with a sensitivity of 88.89% and a specificity of 94.44% and the AUC of R1 for evaluating postoperative mortality of elderly with colorectal cancer was 0.783 with a sensitivity of 56.25% and a specificity of 82.93%. POSSUM score system has a certain predictive value for postoperative complications and mortality in elderly with colorectal cancer. However, the predicted mortality rate is higher than actual mortality rate.

Evaluation of Possum and P Possum Scoring Systems in Patients Undergoing Emergency Abdominal Surgeries

Evaluation of Possum and P Possum Scoring Systems in Patients Undergoing Emergency Abdominal Surgeries

Evaluation of possum score for outcome prediction in patients undergoing emergency midline laparotomy in tertiary health care center of central India: A prospective observational study

Evaluation of possum score for outcome prediction in patients undergoing emergency midline laparotomy in tertiary health care center of central India: A prospective observational study

Efficacy of Possum and P Possum Scoring System to Assess Outcomes in Emergency Gastrointestinal Surgeries

Efficacy of Possum and P Possum Scoring System to Assess Outcomes in Emergency Gastrointestinal Surgeries

More than 30 Years of POSSUM: Are Scoring Systems Still Relevant Today for Colorectal Surgery?

The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) weights the patient's individual health status and the extent of the surgical procedure to estimate the probability of postoperative complications and death of general surgery patients. The variations Portsmouth-POSSUM (P-POSSUM) and colorectal POSSUM (CR-POSSUM) were developed for estimating mortality in patients with low perioperative risk and for patients with colorectal carcinoma, respectively. The aim of the present study was to evaluate the significance of POSSUM, P-POSSUM, and CR-POSSUM in two independent colorectal cancer cohorts undergoing surgery, with an emphasis on laparoscopic procedures. For each patient, an individual physiological score (PS) and operative severity score (OS) was attributed to calculate the predicted morbidity and mortality, respectively. Logistic regression analysis was used to evaluate the possible correlation between the subscores and the probability of postoperative complications and mortality. The POSSUM equation significantly overpredicted postoperative morbidity, and all three scoring systems considerably overpredicted in-hospital mortality. However, the POSSUM score identified patients at risk of anastomotic leakage, sepsis, and the need for reoperation. Logistic regression analysis demonstrated a strong correlation between the subscores and the probability of postoperative complications and mortality, respectively. Our results suggest that the three scoring systems are too imprecise for the estimation of perioperative complications and mortality of patients undergoing colorectal surgery in the present day. Since the subscores proved valid, a revision of the scoring systems could increase their reliability in the clinical setting.

POSSUM scoring in hollow viscus perforation at National Medical College and Teaching Hospital, Nepal

Background: Peritonitis as a result of hollow viscus perforation is a common condition in developing countries like Nepal where post-operative period is unpredictable even if patient reaches hospital in time and being operated. Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) helps to identify patients at increased risk of developing deaths and complications. It is based on 12 physiological and 6 operative parameters. Methods: A total of 50 patients of hollow viscus perforation admitted and operated at National Medical College and Teaching Hospital Birgunj, Nepal from July 2020 to June 2021 were included in study. It was a prospective observational study. Results: During the study 9 patients died and the observed to expected ratio (O: E) 0.3 was obtained. Out of 41 patients who survived 28 suffered complications an observed to expected ratio (O: E) of 0.68 was obtained. Conclusions: POSSUM scoring system is reliable for predicting post-operative morbidity and mortality and helps to improve prognosis of patients operated for perforated hollow viscus.

Risk factors for in-hospital mortality after emergency colorectal surgery in octogenarians: results of a cohort study from a referral center

PurposeThe objective of this study was to investigate predictive factors of mortality in emergency colorectal surgery in octogenarian patients.MethodsIt is a retrospective cohort study conducted at a single-institution tertiary referral center. Consecutive patients who underwent emergency colorectal surgery between January 2015 and January 2020 were identified. The primary endpoint was 30-day mortality. Univariate and multivariate analyses were performed using a logistic regression model.ResultsA total of 111 patients were identified (43 men, 68 women). Mean age was 85.7 ± 3.7 years (80–96). Main diagnoses included complicated sigmoiditis in 38 patients (34.3%), cancer in 35 patients (31.5%), and ischemic colitis in 31 patients (27.9%). An ASA score of 3 or higher was observed in 88.3% of patients. The mean Charlson score was 5.9. The Possum score was 35.9% for mortality and 79.3% for morbidity. The 30-day mortality rate was 25.2%. Univariate analysis of preoperative risk factors for mortality shows that the history of valvular heart disease (p = 0.008), intensive care unit provenance (p = 0.003), preoperative sepsis (p < 0.001), diagnosis of ischemic colitis (p = 0.012), creatinine (p = 0.006) and lactate levels (p = 0.01) were significantly associated with 30-day mortality, and patients coming from home had a lower 30-day mortality rate (p = 0.018). Intraoperative variables associated with 30-day mortality included ileostomy creation (p = 0.022) and temporary laparostomy (p = 0.004). At multivariate analysis, only lactate (p = 0.032) and creatinine levels (p = 0.027) were found to be independent predictors of 30-day mortality, home provenance was an independent protective factor (p = 0.004). Mean follow-up was 3.4 years. Survival at 1 and 3 years was 57.6 and 47.7%.ConclusionEmergency colorectal surgery is challenging. However, age should not be a contraindication. The 30-day mortality rate (25.2%) is one of the lowest in the literature. Hyperlactatemia (> 2mmol/L) and creatinine levels appear to be independent predictors of mortality.

299 Predictive Performance of NELA Versus P-POSSUM Mortality Scores; Are We Underestimating the Risk of Mortality Following Emergency Laparotomy?

Abstract Aim To compare the performance of NELA and P-POSSUM mortality risk scores in predicting 30-day and 90-day mortality in patients undergoing emergency laparotomy. Method A retrospective cohort study was conducted to compare predicative performance of pre-operative NELA, post-operative NELA and P-POSSUM predicted mortality scores in patients undergoing emergency laparotomy between 2014 and 2021. The outcomes of interest included the observed 30-day and 90-day mortality. The discrimination of the mortality tools was assessed and compared by determining the Area Under the Curve (AUC) for each tool using Receiver Operating Characteristic curve analysis. Results A total of 681 patients were included. The observed risk of 30-day and 90-day mortality were 10.4% (71/681) and 14.2% (97/681), respectively. In terms of 30-day mortality, the AUC was 0.791 (0.727-0.855) for pre-operative NELA score, 0.784 (0.721-0.848) for pre-operative P-POSSUM score, and 0.761 (0.699-0.824) for post-operative NELA score. In terms of 90-day mortality, the AUC was 0.765 (0.708-0.821) for pre-operative NELA score, 0.749 (0.692-0.807) for pre-operative P-POSSUM score, and 0.745 (0.691-0.800) for post-operative NELA score. Observed/Expected ratio for 30-day and 90-day mortality were calculated as 3.25 and 4.43 for pre-operative NELA, 2.81 and 3.84 for pre-operative P-POSSUM, and 2.17 and 2.96 for post-operative NELA, respectively. Pairwise comparisons showed no statistically significant difference in discrimination among the three models. Conclusions Pre-operative NELA, post-operative NELA and P- POSSUM scores underestimated the risk of 30-day and 90-day mortality for patients undergoing emergency laparotomy. No significant difference in predictive performance was found among the three models.

Effects of surgical treatment modalities on postoperative cognitive function and delirium in elderly patients with extremely unstable hip fractures.

As the perioperative risk of elderly patients with extremely unstable hip fractures (EUHFs) is relatively high and therapeutic effect is not satisfactory, new thera-peutic strategies need to be proposed urgently to improve the efficacy and clinical outcomes of such patients. To determine the influence of two surgical treatment modalities on postoperative cognitive function (CF) and delirium in elderly patients with EUHFs. A total of 60 elderly patients consecutively diagnosed with EUHF between September 2020 and January 2022 in the Chongqing University Three Gorges Hospital were included. Of them, 30 patients received conventional treatment (control group; general consultation + fracture type-guided internal fixation), and the other 30 received novel treatment (research group; perioperative multidisciplinary treatment diagnosis and treatment + individualized surgical plan + risk prediction). Information on hip function [Harris hip score (HHS)], perioperative risk of orthopedic surgery [Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM)], CF [Montreal cognitive assessment scale (MoCA)], postoperative delirium [mini-cognitive (Mini-Cog)], adverse events (AEs; internal fixation failure, infection, nonunion, malunion, and postoperative delirium), and clinical indicators [operation time (OT), postoperative hospital length of stay (HLOS), ambulation time, and intraoperative blood loss (IBL)] were collected from both groups for comparative analyses. The HHS scores were similar between both groups. The POSSUM score at 6 mo after surgery was significantly lower in the research group compared with the control group, and MoCA and Mini-Cog scores were statistically higher. In addition, the overall postoperative complication rate was significantly lower in the research than in the control group, including reduced OT, postoperative HLOS, ambulation time, and IBL. The new treatment modality has more clinical advantages over the conventional treatment, such as less IBL, faster functional recovery, more effectively optimized perioperative quality control, improved postoperative CF, mitigated postoperative delirium, and reduced operation-related AEs.

Combined and intraoperative risk modelling for oesophagectomy: A systematic review.

Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages. However, the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration. Appropriate patient selection, counselling and resource allocation is essential. Numerous risk models have been devised to guide surgeons in making these decisions. To evaluate which multivariate risk models, using intraoperative information with or without preoperative information, best predict perioperative oesophagectomy outcomes. A systematic review of the MEDLINE, EMBASE and Cochrane databases was undertaken from 2000-2020. The search terms used were [(Oesophagectomy) AND (Model OR Predict OR Risk OR score) AND (Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)]. Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy. Articles were excluded if they only required preoperative or any post-operative data. Studies appraising univariate risk predictors such as preoperative sarcopenia, cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded. The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model. All captured risk models were appraised for clinical credibility, methodological quality, performance, validation and clinical effectiveness. Twenty published studies were identified which examined eleven multivariate risk models. Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values. Only two risk models were identified as promising in predicting mortality, namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and POSSUM scores. A further two studies, the intraoperative factors and Esophagectomy surgical Apgar score based nomograms, adequately forecasted major morbidity. The latter two models are yet to have external validation and none have been tested for clinical effectiveness. Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes, there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.

Use of POSSUM (Physiologic and Operative Severity Score for the Study of Mortality and Morbidity) and Portsmouth-POSSUM for Surgical Assessment in Patients Undergoing Emergency Abdominal Surgeries.

The POSSUM (Physiologic and Operative Severity Score for the Study of Mortality and Morbidity) and Portsmouth-POSSUM (P-POSSUM) models have been popularly recommended as appropriate for predicting postoperative mortality and morbidity in surgical practice. This study aims to evaluate the efficacy and accuracy of both scoring systems for surgical risk assessment in predicting postoperative mortality and morbidity in patients undergoing emergency abdominal surgeries. The study was conducted as a part of a post-doctoral fellowship program. A total of 150 patients, undergoing emergency abdominal surgery in a tertiary care hospital in Bhubaneswar, were evaluated using POSSUM and P-POSSUM. Physiological scoring was done prior to surgery and operative scoring was performed intra-operatively. Patients were followed up for 30 days after the operative period. The observed mortality rate was then compared with POSSUM and P-POSSUM predicted mortality rates. POSSUM predicted a morbidity rate of 116, whereas the actual morbidity rate was 92 (p < 0.05). P-POSSUM predicted a morbidity rate of 109, whereas the actual morbidity rate was 92 (p < 0.05). POSSUM predicted a mortality rate of 23, whereas the actual mortality rate was 21 (p < 0.05). P-POSSUM predicted a mortality rate of 25, whereas the actual mortality rate was 21 (p < 0.05). With a reasonably good prediction of morbidity and mortality rate, POSSUM and P-POSSUM scores are both effective scoring systems in clinical practice for use in abdominal surgery.

Impact of Introducing a PACU24 Concept on the Perioperative Outcome of Patients with Advanced Ovarian Cancer Treated with Cytoreductive Surgery.

Patients with ovarian cancer who undergo multivisceral surgery usually require intensive care monitoring postoperatively. In view of the ever-fewer numbers of high-care/intensive care beds and the introduction of fast-track treatment concepts, it is increasingly being suggested that these patients should be cared for postoperatively in 24-h Post Anesthesia Care Units (PACU24). No analyses have been carried out to date to investigate whether such a postoperative care concept might be associated with a potential increase in postoperative complications in this patient cohort. A PACU24 unit was set up in our institution in 2015 and it has become the primary postoperative care pathway for patients with ovarian cancer who have undergone cytoreductive (debulking) surgery. A structured, retrospective analysis of data from patients treated before (control group) and after (PACU group) the introduction of this care concept was carried out, with a particular focus on postoperative complications and secondary admission to an intensive care unit where necessary. The data of 42 patients were analyzed for the PACU group and 45 patients for the control group. According to the analysis, the preoperative and surgical data of both groups were comparable (age, ASA, BMI, FIGO stage, duration of surgery, blood loss). The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM score) as a measure for the risk of postoperative complications was higher in the PACU group (11.1% vs. 9.7%, p=0.001). Patients in the PACU group underwent bowel resection with anastomosis significantly more often (76.3% vs. 33.3%, p<0.001), although the extent of surgery was otherwise comparable. The total number, type and severity of postoperative complications and the duration of the overall stay in hospital did not differ between the two groups. None of the patients required secondary transfer from the PACU or normal ward to an intensive care unit (ICU). Our data support the assumption that the care concept of transferring patients to a PACU24 represents a safe and cost-saving care pathway for the postoperative care of patients even after complex gynecological-oncological procedures.

Rectal cancer surgery: does low volume imply worse outcome-a single surgeon experience.

The centralisation of rectal cancer management to high-volume oncology centres has translated to improved oncological and survival outcomes. We hypothesise that individual surgeon caseload, specialisation, and experience may be as significant in determining oncologic and postoperative outcomes in rectal cancer surgery. A prospectively maintained colorectal surgery database was reviewed for patients undergoing rectal cancer surgery between January 2004 and June 2020. Data studied included demographics, Dukes' and TNM staging, neoadjuvant treatment, preoperative risk assessment scores, postoperative complications, 30-day readmission rates, length of stay (LOS), and long-term survival. Primary outcome measures were 30-day mortality and long-term survival compared to national and international standards and best practice guidelines. In total, 87 patients were included (mean age: 66years [range: 36-88]). The mean length of stay (LOS) was 16.5days (SD 6.0). The median ICU LOS was 3days (range 2-17). Overall, 30-day readmission rate was 16.4%. Twenty-four patients (26.4%) experienced ≥ 1 postoperative complication. The 30-day operative mortality rate was 3.45%. Overall 5-year survival rate was 66.6%. A significant correlation was observed between P-POSSUM scores and postoperative complications (p = 0.041), and all four variants of POSSUM, CR-POSSUM, and P-POSSUM scores and 30-day mortality. Despite improved outcomes seen with centralisation of rectal cancer services at an institutional level, surgeon caseload, experience, and specialisation is of similar importance in obtaining optimal outcomes within institutions.

The novel derived preoperative-POSSUM score as a predictor of surgical patients’ allocation to an elective postoperative ICU ordered by anesthesiologists at Cairo University Hospital

Backgroun d Anesthesiologists depend on multiple factors to request a postoperative ICU bed after elective surgeries. This decision may be based on the risk of surgery and comorbidities. Some surgeries may be postponed, or some patients may be exposed to unnecessary ICU admission. So, this aroused the need for certain scores upon which anesthesiologist could build their request for ICU admission. Aim To evaluate the accuracy of the pre-Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) score as a predictor for the need for postoperative ICU. Patients and methods This study calculated the POSSUM score preoperatively (pre-POSSUM) for 308 patients who underwent elective general surgeries at Kasr Alainy Hospital, a leading tertiary care hospital in Cairo, Egypt. Results Our study showed the possibility of having a cutoff value of pre-POSSUM score that could predict patients who would benefit most from a postoperative ICU stay. The best cutoff value for the estimated morbidity percent was 19.545, with 100% sensitivity and 64.3% specificity. Moreover, the estimated mortality percent at a cutoff value of 3.375 showed 100% sensitivity and 62% specificity. Conclusion The pre-POSSUM could be used as a reliable tool for the allocation of patients after elective general surgeries, identify those who require intensive postoperative care, and use the cutoff values shown in a study to help to triage patients after elective surgeries.

EVALUATION AND OUTCOME OF EMERGENCY GIT SURGERIES

Background: Emergency gastrointestinal surgeries are frequently performed procedure which have mortality and morbidity much more than that of elective surgery, they carry a substantial risk of operative and postoperative complications and death. A system was developed to allow for the rst time an assessment of surgical quality that was risk adjusted for the patient's acute and chronic physiological status and for the nature of operation. The POSSUM audit system was designed to be easy and rapid to use and to have wide application across the general surgical spectrum both in the elective and emergency settings. Our study was conducted on 96 Pat Methods: ients of acute abdomen and blunt injury undergoing emergency GIT surgery and patients which develop postoperative complications admitted in department of surgery, RD Gardi Medical College,Ujjain between November 2018 to April 2020 Our study Signies that Forty-thre Results: e percent patients had morbidity in these group of patients, among which wound related complication has the predominant cause of morbidity, pulmonary complication were also common. In total eight patients died in patients undergoing emergency laparotomy four because of of MODS three due to SIRS and one due to sepsis. In our study, ve patients had cardiac risk . Respiratory signs were more prevalent seventeen patients having them, Blood loss was also higher with eleven patients having more than 1000 ml blood loss. Peritoneal soiling was also very common, with thirty seven patients having localised pus collections in forty-one, spillage of bowel contents seen in seventeen patients and hemoperitoneum in four patients Recognizing Conclusions. patients who are at high risk to develop complications and who have high risk of mortality would prompt us to take necessary and timely action and aid us in the better management of the patient. POSSUM mortality equation over predicts mortality especially in low risk groups, while predictive value improves signicantly when exponential analysis is used.Hence POSSUM scoring system has an undeniable advantage in our set up for better patient counseling, improving the surgical outcomes in emergency wards and for better management of limited resources and manpower.

PREDICTORS OF POST OPERATIVE MORTALITY AND MORBIDITY USING THE PPOSSUM SCORING SYSTEM IN GENERAL SURGICAL PATIENTS

Introduction: The risk scoring system in all elds of medicine is gaining popularity in order to assess the outcome and improve the patient care. Various scoring systems are available to predict the surgical outcome, but most of them fail to incorporate surgical factors. Portsmouth Physiological and Operative Severity Scores for the enumeration of Mortality and Morbidity (P-POSSUM) scoring system help in predicting the outcome in the surgical patients. This study was conducted to evaluate the validity of P- POSSUM in patients undergoing major surgery and to enumerate the risk factors for low outcome in our setup. Methods: A longitudinal observational study on 250 consenting patients who underwent medium, major and major + surgeries as dened by POSSUM scoring system. Data was collected as per 12 physiological and 6 operative factors to obtain P-POSSUM scores and statistical analysis was done to compare the actual and predicted mortality. Result: The predicted mortality score was statistically signicant in predicting the death (p- 0.0004). Among all the risk factors studied, 12 physiological and the 5 operative parameters had a signicant contribution towards predicting the post operative mortality. A threshold score beyond which the mortality can be predicted was also obtained by plotting the ROC curve. Conclusion: This study validates P-POSSUM scoring system accurately in predicting mortality in patients who underwent major surgical procedures in our setup and helped in identifying the factors responsible for the poor outcome.

EP-90 Bouveret Syndrome: A challenging case of impacted gallstone within the fourth part of the duodenum

Abstract Aims Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. We present a case of a 68-year-old with recurrent small bowel obstruction secondary to a large gallstone impacted in the fourth part of the duodenum and cholecysto-duodenal fistula. We describe our atypical approach to surgical retrieval. Methods The patient presented acutely with abdominal pain and vomiting, on a background of recent admission for gallstone ileus managed conservatively. Initially, due to high anaesthetic risk (P POSSUM score = 14% mortality, 60% morbidity), the patient was managed conservatively with nasogastric drainage and total parenteral nutrition. On day 6 of admission, emergency laparotomy was performed after identifying radiological signs of impending perforation and clinical deterioration. Endoscopic management was not available locally. The stone could not be milked proximally for retrieval via pyloroplasty. Subsequently, high-pressure water flushes delivered via the gastrostomy expelled the stone distally. The stone was then retrieved via a jejunotomy at the DJ flexure. Results The patient required a 2-day high dependency unit admission and she was discharged 3 weeks post-operatively at her functional baseline. She was clinically well and asymptomatic when reviewed at the four-month post-operative surgical follow-up appointment. Conclusions This is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. Enterolithotomy can be considered safe option in patients with large, impacted stone and multiple co-morbidities.

WE5.13 Improving Pre-operative Risk Score Assessment In Patients Undergoing Emergency Laparotomy

Abstract Aim This audit was conducted with the aim to assess the compliance of recording of risk (P-POSSUM) scores in patients undergoing emergency laparotomy, with the objectives being to establish how many patients required ITU/HDU admission, documentation of P-POSSUM in patients requiring post-operative critical care admission and, pre operative P-POSSUM documentation in elderly patients aged &amp;gt;70 years. Methods Data of all emergency laparotomies at a DGH were obtained from electronic theatre records. The first cycle was from 14/02/2021 to 07/03/2021. The results were presented in the Divisional Audit meeting. Following this, audit cycle was completed with data from 20/06/2021 to 15/08/2021. Patient notes and theatre booking forms were reviewed to assess if P-POSSUM score was recorded and analyzed with Microsoft Excel. Results Twenty- three emergency laparotomies were performed between 14th February 2021 and 7th March 2021. Of these, P-POSSUM scores were recorded in 21.7% (5 of 23 patients). During the second cycle, 50 patients underwent emergency laparotomy. Following the presentation of our audit the compliance to recording P-POSSUM increased to 64% (32 of 50 patients). Of those patients requiring critical care admissions, there was a significant increase in the pre-operative recording of risk scores from 13.33% (2 of 15 patients) to 51.61% (16 to 31 patients). Conclusion Our compliance with documentation of risk score pre operatively in patients undergoing emergency laparotomy has improved over time. However, there remains a room for improvement. We recommend encouragement to record P Possum Scores compulsorily as standard prior to Laparotomies and to standardize the location of recording scores.