Mortality rate prediction by Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM), Portsmouth POSSUM and Colorectal POSSUM and the development of new scoring systems in Chinese colorectal cancer patients

Background

The aim of this study was to compare the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM), Portsmouth POSSUM (P-POSSUM), and Colorectal POSSUM (Cr-POSSUM) for predicting surgical mortality in Chinese colorectal cancer patients and to create new scoring systems to achieve better prediction.

Methods

Data from 903 patients undergoing surgery for colon and rectal cancers from 1992 to 2005 at Peking University Third Hospital were included in this study. POSSUM, P-POSSUM, and Cr-POSSUM were used to predict mortality. Stepwise logistic regression was used to develop the modified P-POSSUM and Cr-POSSUM. Their performances were tested by receiver operating characteristic curve, Hosmer-Lemeshow statistic, and observed:expected ratio.

Results

The actual inpatient mortality was 1.0% (9 of 903). The predicted mortality of POSSUM, P-POSSUM, and Cr-POSSUM were 5.6%, 2.8%, and 4.8%, respectively, which were significantly higher than the actual mortality in our cohort. The predicted mortality of the modified P-POSSUM and Cr-POSSUM was very close to the observed mortality. Both the modified models offered better accuracy than P-POSSUM.

Conclusions

The predicted mortality of POSSUM, P-POSSUM, and Cr-POSSUM were significantly higher than the observed mortality in our patients. The modified P-POSSUM and Cr-POSSUM models provided an accurate prediction of inpatient mortality rate in colorectal cancer patients in China.     

Analysis of POSSUM score and postoperative morbidity in patients with rectal cancer undergoing surgery

Background  The Physiological and Operative Severity Score for the enUmeration of Mortality andmorbidity (POSSUM) and later modifications (P-POSSUM y CR-POSSUM) have been used to predictmorbidity and mortality rates among patients with rectal cancer undergoing surgery. These calculations needsome adjustment, however. The aim of this study was to assess the applicability of POSSUM to a group ofpatients with rectal cancer undergoing surgery, analysing surgical morbidity by means of several variables. Methods   between January 1995 and December 2004, 273 consecutive patients underwent surgery forrectal cancer. Information was gathered about the patients, tumour and therapy. To assess the predictioncapacity of POSSUM, subgroups for analysis were created according to variables related to operativemorbidity and mortality. Results  The global morbidity rate was 23.6% (31.2% predicted by POSSUM). The mortality rate was 0.7%(6.64, 1.95 and 2.08 predicted by POSSUM, P-POSSUM and CR-POSSUM respectively). POSSUMpredictions may be more accurate for patients younger than 51 years, older than 70 years, with low anaesthetic risk (ASA I/II), DUKES stage C and D, surgery duration of less than 180 minutes and for thosereceiving neoadjuvant therapy. Conclusion  POSSUM is a good instrument to make results between different institutions and publicationcomparable. We found prediction errors for some variables related to morbidity. Modifications of surgicalvariables and specifications for neoadjuvant therapy as well as physiological variables including life stylemay improve future prediction of surgical risk. More research is needed to identify further potential riskfactors for surgical complications.     

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM)

BACKGROUND AND METHODS: The development of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is described and its methods of analysis and value in a modern surgical practice are reviewed. A computerized search of all published data in Medline, the Cochrane Library and Embase was made for the last 12 years. Relevant articles were then searched manually for further papers on risk analysis, case-mix comparison and POSSUM methodology. RESULTS AND CONCLUSION: POSSUM has been evaluated extensively in both general and specialist surgery. While there are problems with both data collection and analysis, when used correctly POSSUM can usefully compare outcomes between surgeons and between hospitals. In specialist surgery, individual regression equations may be needed for each index procedure.     

Factors influencing changing bowel habits in patients undergoing sphincter-saving surgery for rectal cancer

A research survey research was conducted to identify factors affecting changes in bowel habits of rectal cancer patients undergoing sphincter-saving surgery and to provide basic information useful in nursing interventions supporting treatment for rectal cancer patients. The subjects were rectal cancer patients who had undergone sphincter-saving surgery over 2 years ago. The final analysis included 107 patients who had made outpatient visits to the colorectal surgery from 12th to 31st May, 2014. Collected data were processed with SPSS Version 21.0. Changes in bowel habits in the subjects were observed: frequent bowel movement in 74 patients (69.2%) and faecal incontinence in 48 (44.9%). Most of the patients used self-care to improve their bowel function including dietary modification (78.5%), regular exercise (72.0%) and pelvic floor exercise (34.6%). Frequent defecation was associated with adjuvant chemoradiation therapy (P < 0.001) and faecal incontinence was associated with age of ≥65 years (P = 0.019) and a group who underwent adjuvant radiation therapy (P < 0.001). It is necessary to give sufficient information about possible postoperative changes in bowel habits to patients with the risk factors before surgery.     

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目的比较直肠癌前切除术采用加速康复外科治疗与传统围手术期处理方法的安全性及有效性。方法2006年11月至2007年6月在南京军区南京总医院对20例直肠癌行根治性前切除手术病人采用加速康复外科治疗(加速康复组),和同期22例按传统方法进行围手术期处理的直肠癌病人(传统方法组)作对照。比较两组病人术后住院时间、恢复肠排气时间、停止静脉输液的时间、营养状态的变化,和治疗费用以及两组术后并发症的发生情况。结果加速康复外科组与传统方法组相比,前组术后住院时间缩短,治疗费用降低,术后首次肠道排气时间提前,停止静脉输液时间提前,手术后体重下降减轻。两组术后并发症的发生率差异无显著性意义。结论直肠癌经腹前切除术行加速康复外科治疗是安全、有效的方法,既有利病人术后器官功能的康复,又可以减少住院时间与治疗费用。     

应用APACHEⅡ和POSSUM评分指导胰腺癌患者外科治疗的临床分析

目的 探讨POSSUM和APACHEⅡ评分系统对胰腺癌患者外科治疗影响的临床价值。方法 应用POSSUM和APACHEⅡ评分系统对84例胰腺癌患者围手术期进行回顾分析。结果 本组患者中,青年组（n=36)的病死率和并发症分别为5.5%和19.4%,老年组（n=48)病死率和并发症分别为6.2%和20.8%略低于APACHEⅡ和POSSUM评分预测的老年组病死率（12.5%)和并发症（25.5%),中青年组病死率（11.1%)和并发症（25%）。结论 PSSSUM和APACHEⅡ能反映胰腺癌患者的病情,并且可影响选择最适宜的手术方式,POSSUM评分系统更适宜于指导胰腺癌手术的围手术期处理。     

Comparison of the possum, P-POSSUM and Cr-POSSUM scoring systems as predictors of postoperative mortality in patients undergoing major colorectal surgery

BACKGROUND: Physiologic and operative severity score for the enumeration of mortality and morbidity (POSSUM), 'Portsmouth'-physiologic and operative severity score for the enumeration of mortality and morbidity (P-POSSUM) and 'Colorectal'-physiologic and operative severity score for the enumeration of mortality and morbidity (Cr-POSSUM) are three related scoring systems, which uses individual patient parameters to predict postoperative mortality. POSSUM overpredicts mortality in low-risk patients and underpredicts mortality in elderly and emergency patients. P-POSSUM was developed to compensate for these weaknesses. Cr-POSSUM was developed specifically for colorectal surgery. We aim to establish which of these scoring systems would be most useful in an Australasian context. METHODS: Data were collected for 308 patients and predicted mortality risk values were generated using each of the three systems. The Mann-Whitney U-test was then carried out on the scores for each system. Receiver-operator characteristic curves were designed to determine the relative accuracy of each approach at discriminating between death and survival. RESULTS: All three POSSUM scoring systems showed a statistically significant ability to predict postoperative mortality. Additionally, in each system there was a significant difference in the raw physiologic and operative severity scores between survivors and those who died. A risk-stratification model was applied to each set of data, showing a correlation between an increase in risk and an increase in mortality rate. Finally, the receiver-operator characteristic curves generated showed that in this study group POSSUM, P-POSSUM and Cr-POSSUM were all satisfactory predictive tools although the latter tended to be relatively less accurate. CONCLUSION: Physiologic and operative severity score for the enumeration of mortality and morbidity, P-POSSUM and Cr-POSSUM are all reliable predictors of postoperative mortality in the Australasian context; although there was a trend towards POSSUM and P-POSSUM being better predictors than Cr-POSSUM. However, Cr-POSSUM requires fewer individual patient parameters to be calculated and is thus easier to generate. An ideal preoperative scoring system remains to be developed for predicting mortality in patients undergoing colorectal surgery.     

Current state of laparoscopic rectal cancer surgery in Australasia

Background: To establish the current surgical approach to rectal cancer in a group of colorectal surgeons in Australasia and the current opinion regarding laparoscopic rectal cancer surgery. Methods: An online survey was distributed to the Colorectal Surgical Society of Australia and New Zealand members. Results: 123/177 surgeons responded. During the last year, 94.3% had performed a laparoscopic colorectal case, 77.2% a laparoscopic rectal case and 65% a laparoscopic rectal cancer case. The most common approach to high anterior resection was pure laparoscopic (52.8%). Low anterior resections were most commonly performed with a laparoscopic component (25.2% pure laparoscopic, 33.3% hybrid). Most surgeons (>50%) performed ultra‐low anterior resections or abdomino‐perineal resections via an open technique. In addition, 64.2% intended to perform laparoscopic total mesorectal excision (TME) within 2 years. Most surgeons believe that the quality of laparoscopic TME and oncological outcomes are similar, and surgical access and short‐term outcomes are superior when compared to the open procedure. The major concerns were in performing a low rectal transection, controlling haemorrhage and resource utilization/cost. Conclusion: Laparoscopic rectal surgery is now widely practiced by Australasian colorectal surgeons and projected to increase in the near future. However, only 10% of surgeons are routinely performing total laparoscopic ultra‐low anterior resections which may have implications for the generalizability of clinical trials in laparoscopic TME and the ability to credential surgeons in this technically challenging field. Quality of TME and oncological outcomes were rated similar to the open operation. Areas of concern included low rectal transection, haemorrhage control and resource utilization/cost.     

Evaluation of a Modified POSSUM Scoring System for Predicting the Morbidity in Patients Undergoing Lumbar Surgery

For most spine surgeons, operative intervention is common for the treatment of lumbar disc herniation, lumbar stenosis, lumbar fracture or lumbar spondylolisthesis. However, with the increase in lumbar surgery, the complication rate increases accordingly. Whereas the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) scoring system has been widely used to predict morbidity in various surgical fields, the application of this system in lumbar surgery has not been reported. From January 2008 to January 2010, we recruited 158 patients (85 males and 73 females) with operation for lumbar disc herniation, lumbar stenosis, lumbar fracture, or lumbar spondylolisthesis. All patients were analyzed to compare the morbidity by a modified POSSUM scoring system. According to the modified POSSUM, the expected morbidity was 51 cases (32.3 %), whereas the observed mortality was 42 cases (26.6 %). The overall observed-to-expected ratio was 0.82, and the chi-squared test indicated no statistically significant difference between the expected and observed morbidities (χ² = 1.23, P = 0.27), suggesting that the modified POSSUM can accurately estimate the outcome. The modified POSSUM scoring system we developed is a useful tool for predicting and evaluating morbidity in lumbar surgery. Further studies are required to investigate whether this scoring system can predict mortality.     

Risk-adjusted surgical audit with the POSSUM scoring system in a developing country. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity

BACKGROUND: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is an objective and appropriate scoring system for risk-adjusted comparative general surgical audit. This score was devised in the UK and has been used widely, but application of POSSUM to centres outside the UK has been limited, especially in developing countries. This prospective study validated its application in a surgical practice with a different population and level of resources. METHODS: All general surgical patients who were operated on under regional or general anaesthesia as inpatients over a 4-month period at Sarawak General Hospital in 1999 were entered into the study. All data (12 physiological and six operative factors) were analysed for mortality only with the POSSUM equation and the modified Portsmouth POSSUM (P-POSSUM) equation. Comparisons were made between predicted and observed mortality rates according to four groups of risk: 0-4, 5-14, 15-49 and 50 per cent or more using the 'linear' method of analysis. RESULTS: There were 605 patients who satisfied the criteria for the study. Some 56.7 per cent of patients were in the lowest risk group. The POSSUM predictor equation significantly overestimated the mortality in this group, by a factor of 9.3. The overall observed mortality rate was 6.1 per cent and, again, the POSSUM predictor equation overestimated it at 10.5 per cent (P < 0.01). In contrast, the observed and predicted mortality rates for all risk groups, including the predicted overall mortality rate of 4.8 per cent, were comparable when the P-POSSUM predictor equation was used. CONCLUSION: The POSSUM scoring system with the modified P-POSSUM predictor equation for mortality was applicable in Malaysia, a developing country, for risk-adjusted surgical audit. This scoring system may serve as a useful comparative audit tool for surgical practice in many geographical locations.     

The use of laser in rectal surgery

Ten patients with rectal tumors were treated by surgical excision of the tumor using a CO2 laser Sharplan 733 CO2 laser, Laser Industries Ltd., Israel. The laser permitted sharp excision, evaporization, or fulguration of tissue. Good hemostasis was achieved. Anesthesia was unnecessary in cooperative, calm patients. There was no mortality or morbidity related to the procedure. In five patients with villous adenoma the tumor was resected with one recurrence as yet (followup 4-16 months). Five patients with inoperable carcinoma were treated for palliation with good results. Our preliminary results indicate that the CO2 laser can be a useful asset in rectal tumor surgery, especially in elderly, moribund patients and in the definite treatment of benign tumors of the rectum.     

系统化护理干预模式在低位直肠癌行腹腔镜手术患者中的应用

目的探讨系统化护理干预模式在低位直肠癌行腹腔镜手术患者中的应用效果。方法采用历史对照研究,将2013-01后实行系统护理干预的62例低位直肠癌患者作为干预组,2012-01—2012-12间常规护理59例低位直肠癌患者作为对照组,比较2组患者术后镇痛药物使用率、术后恢复情况、并发症发生率。出院后患者均接受1~3个月随访,采用SF-36量表评价患者生活质量。结果 2组患者均保肛成功,干预组肠功能恢复时间、平均住院时间明显短于对照组,止痛药物使用率为11.26%,并发症发生率3.23%,均低于对照组,2组比较差异有统计学意义(P<0.05)。患者出院后均随访1~3个月,干预组患者在总体评分及生理机能等8个维度评分均高于对照组,2组比较,差异有统计学意义(P<0.05)。结论系统护理干预为患者提供多角度、全方位指导,不仅有利于治疗方案的顺利实施,对术后的康复及生活质量的提高至关重要。     

Laparoscopic surgery for rectal cancer: oncological results and clinical outcome of 225 patients

Introduction  The efficacy and feasibility of laparoscopic resection for rectal cancer has been proved, but the results of prospective, randomized studies are not yet available. Here we present a prospective observational study evaluating oncological and clinical outcome after laparoscopic surgery in patients with rectal cancer. Patients and Methods  Between January 1998 and March 2005, 225 patients with rectal adenocarcinoma underwent laparoscopic surgery at the University of Regensburg Medical Center. Clinical and oncological outcome of these patients including perioperative and long-term complications was evaluated. Survival curves were calculated according to the Kaplan–Meier method. Minimum follow-up was 24 months. Results  The distribution of the International Union against Cancer (UICC) stages was: 37.7% stage I, 20.5% stage II, 24.9% stage III, and 16.9% stage IV. Local recurrence was diagnosed in 5.8% and distant metastases in 8.1% of cases after mean follow-up of 36.4 months. The 5-year overall survival rate was 75.7% after curative and 40.7% after palliative surgery (p < 0.05). The stage-related survival rates were 86.7% for UICC stage I, 61.7% for stage II, 68.1% for stage III, and 40.1% for stage IV. Conclusions  Our results demonstrate the efficacy and technical feasibility of laparoscopic surgery for rectal cancer regarding the perioperative morbidity and the oncological outcome. Ayman Agha, Alois Fürst—both authors contributed equally.