Perioperative risk prediction in the era of enhanced recovery: a comparison of POSSUM, ACPGBI, and E-PASS scoring systems in major surgical procedures of the colorectal surgeon

Abstract

PurposeThis study aims to determine whether traditional risk models can accurately predict morbidity and mortality in patients undergoing major surgery by colorectal surgeons within an enhanced recovery program.MethodsOne thousand three hundred eighty patients undergoing surgery performed by colorectal surgeons in a single UK hospital (2008–2013) were included. Six risk models were evaluated: (1) Physiology and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM), (2) Portsmouth POSSUM (P-POSSUM), (3) ColoRectal (CR-POSSUM), (4) Elderly POSSUM (E-POSSUM), (5) the Association of Great Britain and Ireland (ACPGBI) score, and (6) modified Estimation of Physiologic Ability and Surgical Stress Score (E-PASS). Model accuracy was assessed by observed to expected (O:E) ratios and area under Receiver Operating Characteristic curve (AUC).ResultsEleven patients (0.8%) died and 143 patients (10.4%) had a major complication within 30 days of surgery. All models overpredicted mortality and had poor discrimination: POSSUM 8.5% (O:E 0.09, AUC 0.56), P-POSSUM 2.2% (O:E 0.37, AUC 0.56), CR-POSSUM 7.1% (O:E 0.11, AUC 0.61), and E-PASS 3.0% (O:E 0.27, AUC 0.46). ACPGBI overestimated mortality in patients undergoing surgery for cancer 4.4% (O:E = 0.28, AUC = 0.41). Predicted morbidity was also overestimated by POSSUM 32.7% (O:E = 0.32, AUC = 0.51). E-POSSUM overestimated mortality (3.25%, O:E 0.57 AUC = 0.54) and morbidity (37.4%, O:E 0.30 AUC = 0.53) in patients aged ≥ 70 years and over.ConclusionAll models overestimated mortality and morbidity. New models are required to accurately predict the risk of adverse outcome in patients undergoing major abdominal surgery taking into account the reduced physiological and operative insult of laparoscopic surgery and enhanced recovery care.Electronic supplementary materialThe online version of this article (10.1007/s00384-018-3141-4) contains supplementary material, which is available to authorized users.

<p>Application of POSSUM and P-POSSUM in Surgical Risk Assessment of Elderly Patients Undergoing Hepatobiliary and Pancreatic Surgery</p>

“…This study proves that POSSUM can accurately predict the incidence of postoperative complications in elderly patients subjected to hepatobiliary and pancreatic surgery, but it overestimates the mortality rate of patients. These results are consistent with those of Bagnall et al 14 Furthermore, this study proves that P-POSSUM can accurately predict the postoperative mortality rate. These results are consistent with the research of Nag et al 15 and Carvalho-E-Carvalho et al, 16 who indicated that P-POSSUM can be used as a tool to predict postoperative mortality rate.…”

Impact of age on feasibility and short-term outcomes of ERAS after laparoscopic colorectal resection

“…Therefore, data on specific scores evaluating patients at risk for surgery as ColoRectal Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (CR-POSSUM) score, were not included in data collection. Although colorectal CR-POSSUM and other frailty indexes[11] have proved to identify patients at risk for possible failure of ERPs[24,35], these scores tend to overestimate morbidity and mortality, since firstly elaborated for open surgery[36]. Considering this drawback and the limited use in clinical practice, such information was not considered in data collection.…”

A Multivariable Prediction Model to Select Colorectal Surgical Patients for Co-Management

“…Existing prediction models using preoperative and intraoperative variables identify patients at higher risk of death. 29,30 Most of these models are either complex, using many variables and rendering them unpractical for bedside use; or are old and do not consider the advances in minimally invasive techniques and more recent enhanced post-operative recovery programs.…”