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

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

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

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

E-PASS系统评估结直肠癌手术风险的临床价值

目的采用生理能力与手术侵袭度评分系统(E-PASS)预测结直肠癌患者择期手术风险,探讨其在术后并发症风险预测中的临床应用价值。方法回顾性分析313例结直肠癌患者使用E-PASS评分系统评估其手术风险,比较E-PASS中的术前风险分数(PRS)、手术侵袭度分数(SSS)和综合风险分数(CRS)评分与实际手术预后的关系,并探讨E-PASS各项指标与术后风险的关系。结果纳入分析的患者中,有22例(7.0%)患者发生术后并发症。患者的年龄(P=0.003)、体重(P=0.019)、肿瘤组织学类型(P=0.033)、Dukes分期(P=0.001)、严重心脏疾病(P=0.019)、严重肺部疾病(P=0.000)、体能状态指数(P=0.000)、失血量/体重(P=0.007)、失血量(P=0.001)和手术时间(P=0.000)均与并发症的发生相关;肿瘤分化程度(P=0.503)、糖尿病(P=0.745)、ASA分级(P=0.085)和手术切口大小(P=0.726)与并发症的发生无关。有并发症组的PRS和CRS明显高于无并发症组(P<0.001),而SSS在2组间的差异无统计学意义(P=0.059)。结论 E-PASS评分系统是一个相对方便、有效和易操作的手术风险评估系统,能够较准确地预测结直肠癌患者术后短期并发症的发生。     

生理能力与手术侵袭度评分系统评估结肠癌手术风险的临床价值

目的 探讨生理能力与手术侵袭度(E-PASS)评分系统预测结肠癌患者择期手术后并发症风险的临床应用价值.方法 回顾性分析2009年8月至10月四川大学华西医院收治的符合本研究纳入标准的158例结肠癌患者的临床资料.采用E-PASS评分系统评估其手术风险,并比较E-PASS评分系统中的术前风险分数(PRS)、手术侵袭度分数(SSS)和综合风险分数(CRS)评分与实际手术预后的关系.采用多元线性回归分析E-PASS评分系统各项指标与术后风险的关系.结果 纳入分析的158例患者中,经过E-PASS评分系统预评估的术后近期并发症总体发生率为19.4%±2.0%,术后实际并发症发生率为17.1%(27/158).并发症的发生与Dukes分期、体能状态指数分级、严重心脏疾病、严重肺部疾病、手术时间有关(r=0.193,0.410,0.183,0.174,0.198,P＜0.05);且PRS、CRS和SSS均具有良好的预测作用(r=0.299,0.349,0.183,P＜0.05).结论 E-PASS评分系统是一个相对方便有效,易操作的手术风险评估系统,能够准确预测结肠癌患者的术后早期并发症发生风险.     

Less-invasive surgery for gastric cancer prolongs survival in patients over 80 years of age

This study was undertaken to determine the most appropriate form of surgery for elderly patients with gastric cancer in relation to postoperative complications and long-term survival. A total of 72 consecutive patients over 80 years of age who underwent partial or total gastrectomy were evaluated using an E-PASS scoring system. This system is comprised of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) determined by both the PRS and SSS. Patients with a CRS≥0.5 had significantly higher rates of morbidity and mortality at 45.0% and 20.0%, respectively, than those with CRS≤0.5, at 17.0% and 2.1%, respectively. A Cox regression analysis of long-term survival, including death from other causes, identified five significant prognostic factors, namely: stage, curability, SSS, CRS, and allogeneic blood transfusion. Among the patients without any apparent residual cancer, a significantly better survival was seen in those who underwent less invasive surgery (SSS<0.25), those with a CRS≤0.5, and those who had not been given a blood transfusion. These results suggest that less invasive surgery not requiring a blood transfusion is advisable for patients over 80 years of age with gastric cancer. Furthermore, gastrectomy with a CRS≥0.5 may have a poor therapeutic effect on both early and long-term outcome.     

Feasibility of E-PASS score to predict postoperative complications in laparoscopic nephrectomy

Purpose

To evaluate the usefulness of E-PASS score to predict postoperative complications after laparoscopic nephrectomy.

Methods

Between 2008 and 2020, 424 patients (179 patients: simple nephrectomy, 158 patients: radical nephrectomy, 87 patients: donor nephrectomy) who underwent laparoscopic nephrectomy in our clinic, were included in the study. Patient groups separated according to the presence of postoperative complications were compared retrospectively regarding demographic, clinical, intraoperative, and postoperative data, comorbidities, and E-PASS scores (PRS, SSS, and CRS). The relationship between postoperative complications and E-PASS scores was examined.

Results

Postoperative complications occurred in 43 (10.1%) of the patients. Age, previous abdominal/retroperitoneal surgery, radical nephrectomy rate of surgeries, operation time, amount of bleeding, need for blood transfusion, rate of conversion from laparoscopic surgery to open surgery, hospitalization time, E-PASS PRS, SSS, and CRS were statistically significantly higher in the group with postoperative complications. The cutoff value of the E-PASS CRS was ? 0.2996 to predict the development of postoperative complications (AUC?=?0.706; 95% CI 0.629–0.783; p?<?0.001). According to multivariate analysis, presence of previous abdominal/retroperitoneal surgery (OR?2.977; 95% CI?1.502–5.899; p?=?0.002), laparoscopic radical nephrectomy (OR?2.518; 95% CI?1.224–5.179; p?=?0.012), conversion from laparoscopic surgery to open surgery (OR?4.869; 95% CI?1.046–22.669; p?=?0.044) and E-PASS CRS?>?? 0.2996 (OR?2.816; 95% CI?1.321–6.004; p?=?0.007) were found to be independent risk factors predicting postoperative complications.

Conclusion

The E-PASS scoring system is an effective and convenient system for predicting postoperative complications after laparoscopic nephrectomy.

     

E-PASS (The Estimation of Physiologic Ability and Surgical Stress) scoring system helps the prediction of postoperative morbidity and mortality in thoracic surgery

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

Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate outcome after elective abdominal aortic aneurysm surgery

BACKGROUND: The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was designed on the premise that the balance between the patient's physiologic reserve capacity and the surgical stress inflicted at operation was important in the occurrence of postoperative complications. The aim of this study was to assess its value in predicting mortality and morbidity after open elective abdominal aortic aneurysm (AAA) repair. METHODS: E-PASS data items were collected prospectively in a group of 204 patients undergoing elective open AAA repair over a 6-year period. The operative morbidity and mortality rates were compared with the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of E-PASS. The group comprised 180 (88%) males and the median age was 73 (range 44 to 86) years. RESULTS: There were 13 (6%) deaths and 121 (59%) experienced a postoperative complication. As the PRS, SSS and CRS increased, the incidence of postoperative morbidity and mortality significantly increased (P < .0001). Overall mean CRS was .52 (+/-.27). Mean CRS in the groups of patients who survived and died were .49 (+/-.24) and .98 (+/-26), respectively. PRS, SSS, and CRS all had extremely good predictive power for both mortality and morbidity as demonstrated by high areas under the receiver operator curve (range .799 to .953). CRS also showed a strong statistically significant association with the severity of postoperative complication (P < .0001) and length of hospital stay (P < .0001). CONCLUSIONS: The E-PASS model appears to be a promising method of predicting death and the development of postoperative complications in patients undergoing elective open AAA surgery. It requires further validation in arterial surgery at different geographical locations.     

E-PASS量表评估新辅助化疗对结直肠癌患者术后风险发生的影响

目的以生理能力和手术应激评估(E-PASS)量表作为风险评估工具,探讨新辅助化疗是否会增加结直肠癌患者术后的风险。方法回顾性分析2009年1月至2009年12月期间在四川大学华西医院胃肠外科中心住院并由同一治疗组手术治疗的161例结直肠癌患者的临床资料,其中新辅助化疗组78例,非新辅助化疗组83例,运用E-PASS量表计算术前风险评分(PRS)、手术应激评分(SSS)和综合风险评分(CRS),比较2组各评分的差异。结果 2组患者基本情况比较差异无统计学意义(P>0.05)。新辅助化疗组术后并发症总发生率为10.26%(8/78),非新辅助化疗组术后并发症总发生率为7.23%(6/83),2组并发症总发生率比较差异无统计学意义(P>0.05)。新辅助化疗组的平均PRS、SSS及CRS分别为78.42、80.77及80.74分,非新辅助化疗组分别为83.42、81.22及81.24分,2组PRS、SSS及CRS比较差异均无统计学意义(P值分别为0.497、0.951及0.976)。E-PASS量表在新辅助化疗组和非新辅助化疗组分别准确评估了70例和78例的手术风险,2组间比较差异同样无统计学意义(P=0.325)。结论新辅助化疗不会增加结直肠癌患者的术后风险,E-PASS量表可以较为准确地评价新辅助化疗患者的手术风险。     

老年髋部骨折手术风险评估系统研究进展

老年髋部骨折患者多首选手术治疗,但此类患者常合并一种或多种基础疾病,手术风险大为增加,如何有效评估老年髋部骨折的手术风险,对于提高手术安全性、保证手术效果具有重要意义。目前用以预测骨科患者手术风险的通用评分系统多达数十种,但老年髋部骨折有其特殊性,不能完全照搬通用的评分系统。该文在介绍外科及骨科常用手术风险评分系统的基础上,重点综述用于死亡率和并发症率计算的生理学和手术严重程度评分（POSSUM）、Portsmouth改良POSSUM（P-POSSUM）、改良骨科POSSUM、生理功能与手术应激评估（EPASS）等评分系统在老年髋部骨折手术风险评估中的应用。     

Laparoscopic nephrectomy outcomes of elderly patients in the 21st century

BACKGROUND AND PURPOSE: As life expectancy continues to increase, we will be faced with the need to counsel older patients on the risks and benefits of undergoing surgery. It is clear that laparoscopic renal surgery has significant benefits over open renal surgery. However, contemporary data on whether these benefits carry over to the elderly is less robust. The objective of this study is to compare the perioperative outcomes of laparoscopic nephrectomy in patients age 70 and over to those under age 70. Outcomes from the study can be used to assist in preoperative counseling for older patients. PATIENTS AND METHODS: Between February 2000 and December 2005, 405 consecutive patients underwent laparoscopic nephrectomy for benign or malignant conditions. To decrease selection bias, kidney donors, bilateral nephrectomies, partial nephrectomies, as well as patients under the age of 17 were excluded. Laparoscopic nephrectomies included simple nephrectomies, radical nephrectomies, and nephroureterectomies. A total of 158 patients were included in the analysis. Patient demographics and perioperative data were recorded prospectively. The preoperative American Society of Anesthesiologists (ASA) score was used to reflect patient co-morbidity. Subset analysis between pure laparoscopic nephrectomy (LN) and hand-assisted laparoscopic nephrectomy (HALN) was also performed. RESULTS: Average hospital stay for patients 70 years and older was 3.6 days versus 2.6 days for their younger counterparts (p = 0.02). All other demographic and perioperative parameters were comparable between groups, including incidence of intraoperative or postoperative complications, blood transfusions, and conversions to open surgery. In a subset analysis of patients undergoing HALN, despite having similar co-morbid conditions (ASA score 2.57 vs. 2.56, p = 0.9), the elderly group had a significantly increased length of stay compared to patients younger than 70 years (3.0 vs. 4.2 days, p < 0.05). However, in the group undergoing LN, there was no statistically significant difference in hospital stay (3.1 vs. 2.4 days, p = 0.22), despite the older group having higher co-morbid conditions (ASA score 2.55 vs. 2.10, p < 0.01). CONCLUSION: Other than an increased hospital stay by one day, patients 70 years and older undergoing laparoscopic nephrectomy can expect comparable perioperative outcomes to those achieved in younger patients. Such differences in the length of hospital stay may be mitigated by pure laparoscopic nephrectomy as opposed to hand-assisted laparoscopic nephrectomy in patients 70 years or older. These data may be useful in preoperative decision-making and counseling in this growing subset of patients.     

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

Purpose  

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system, which quantifies a patient’s reserve and surgical stress, is used to predict morbidity and mortality in patients before elective gastrointestinal surgery. We conducted this study to clarify whether the E-PASS scoring system is useful for assessing the risks of emergency abdominal surgery.     

Perioperative mortality score: data collection and cost

The perioperative mortality score aims to predict mortality in elderly patients undergoing noncardiac surgery using three preoperative risk factors (age, albumin and American Society of Anesthesiologists physical status) and then modify this risk assessment if any of three postoperative complications occur (unplanned intensive care unit admission, systemic inflammation and acute renal failure). In order to determine the cost of routine perioperative mortality score calculation in future research, we audited the incidence of clinician-initiated preoperative albumin, pre- and postoperative creatinine and postoperative white cell count testing in patients aged > or = 70 years presenting for elective and emergency noncardiac surgery requiring at least overnight admission over a three-month period. We recruited 637 noncardiac surgical patients. All laboratory tests required for perioperative mortality score calculation were performed in only 47% of patients and the total cost of testing all untested patients was A$12,057 (A$18,927 per 1000 patients). Preoperative hypoalbuminaemia was present in 11% of tested patients, acute renal impairment in 24% of tested patients and high white cell count in 33% of tested patients. These results may be used to inform future research or clinical use of the score.     

Comparison of surgical outcome using the prediction scoring system of E-PASS for thoracic surgery.

OBJECTIVE: The purpose of this study was to determine if our predictive scoring system, E-PASS, can estimate the surgical outcome. METHODS: We conducted a multicenter cohort study for 3 years in four national hospitals. A consecutive series of 731 patients who underwent elective thoracic operations were analyzed. The preoperative risk score (PRS) and the comprehensive risk score (CRS) of the E-PASS were determined preoperatively and immediately after the operation, respectively. The cost of the surgical admission and the severity of the postoperative complications were recorded at the time of discharge. RESULTS: The CRS significantly correlated with the severity of the postoperative complications (rs = 0.728, P < 0.0001) and the charge (rs = 0.530, P< 0.0001). When the estimated/real morbidity ratio (MR) among the hospitals was compared, it varied from 0.16 to 0.59. A significant increase in the cost was observed according to the CRS. CONCLUSION: The E-PASS scoring system may be useful for standardizing the patient population and surgical severity to compare the surgical outcome.     

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目的探讨生理能力与手术应激评分系统(E-PASS)预测胃肿瘤择期手术风险和术后早期并发症的临床应用价值。方法前瞻性收集2011年11月至2012年2月四川大学华西医院胃肠外科中心121例胃肿瘤择期手术病人的临床资料,比较有并发症组和无并发症组的临床-手术-病理相关指标有无差异,并确定综合风险分数(CRS)预警术后并发症的切点值。结果 121例病人中术后并发症发生率为14.9%,有并发症组和无并发症组的年龄、性别、肿瘤组织学类型、糖尿病、体能状态指数、美国麻醉医师协会(ASA)分级、切口大小、失血量-体重比、体重、失血量、手术时间、术前风险分数(PRS)和手术应激分数(SSS)的差异无统计学意义;而两组之间术前合并严重心脏疾病(P=0.000)和严重肺部疾病(P=0.000)差异有统计学意义。有并发症组CRS高于无并发症组(P=0.043),但相关分析并未得出CRS值预警术后并发症的切点值(r<0.400,P>0.05)。结论 E-PASS评分系统中CRS值对预测胃肿瘤择期手术风险有一定价值,但CRS预警切点值的确定须进一步研究。     

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

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

Comparison of surgical outcome using the prediction scoring system of E-PASS for thoracic surgery

Objective

The purpose of this study was to determine if our predictive scoring system, E-PASS, can estimate the surgical outcome.

Methods

We conducted a multicenter cohort study for 3 years in four national hospitals. A consecutive series of 731 patients who underwent elective thoracic operations were analyzed. The preoperative risk score (PRS) and the comprehensive risk score (CRS) of the E-PASS were determined preoperatively and immediately after the operation, respectively. The cost of the surgical admission and the severity of the postoperative complications were recorded at the time of discharge.

Results

The CRS significantly correlated with the severity of the postoperative complications (r_s = 0.728, P < 0.0001) and the charge (r_s = 0.530, P < 0.0001). When the estimated/real morbidity ratio (MR) among the hospitals was compared, it varied from 0.16 to 0.59. A significant increase in the cost was observed according to the CRS.

Conclusion

The E-PASS scoring system may be useful for standardizing the patient population and surgical severity to compare the surgical outcome.     

Efficacy of laparoscopic resection in elderly patients with colorectal cancer

Purpose

The perioperative outcomes of laparoscopic colorectal surgery in elderly patients were compared with those of open surgery in elderly patients and those of laparoscopic surgery in nonelderly patients to evaluate the feasibility and efficacy of laparoscopic surgery in elderly patients with colorectal cancer.

Methods

The data of the patients who underwent surgical resection for colorectal cancer between January 2007 and September 2012 were retrospectively collected. The clinical backgrounds and outcomes of elderly patients (≥70 years of age) who underwent laparoscopic surgery (EL group) were compared with those of elderly patients who underwent open surgery (EO group) and those of nonelderly patients (<70 years of age) who underwent laparoscopic surgery (NL group).

Results

Compared with the EO group, the EL group showed significantly less blood loss (15 versus 100 ml), fewer postoperative complications (10.7 versus 36.7 %), earlier resumption of an oral diet (4 versus 5 days) and shorter postoperative hospital stays (16 versus 28 days). A case-matched analysis showed similar results. All perioperative outcomes were equivalent between the EL and NL groups.

Conclusions

Laparoscopic colorectal surgery in elderly patients with cancer was not only superior to open surgery in elderly patients, but also equivalent to laparoscopic surgery in nonelderly patients in terms of the postoperative outcomes.     

Why routine intensive care unit admission after elective open infrarenal Abdominal Aortic Aneurysm repair is no longer an evidence based practice

BackgroundElective open infrarenal Abdominal Aortic Aneurysm (AAA) repair is major surgery performed on high-risk patients. Routine ICU admission postoperatively is the current accepted standard of care. Few of these patients actually require a level of care that cannot be provided just as effectively in a surgical high dependency unit (HDU). Our aim was to determine, ‘can high risk patients that will require ICU admission postoperatively be reliably identified preoperatively?’.MethodsA retrospective analysis of all elective open infrarenal AAA repairs in our institution over a 3-year period was performed. The Estimation of Physiological Ability and Surgical Stress (E-PASS) model was used as our risk stratification tool for predicting post-operative morbidity. Renal function was also considered as a predictor of outcome, independent of the E-PASS.Results80% (n = 16) were admitted to ICU. Only 30% (n = 6) of the total study population necessitated intensive care. There were 9 complications in 7 patients in our study. The E-PASS comprehensive risk score (CRS)/Surgical stress score (SSS) were found to be significantly associated with the presence of a complication (p = 0.009)/(p = 0.032) respectively. Serum creatinine (p = 0.013) was similarly significantly associated with the presence of a complication.ConclusionsThe E-PASS model possessing increasing external validity is an effective risk stratification tool in safely deciding the appropriate level of post-operative care for elective infrarenal AAA repairs.