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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 53-56

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


Department of General Surgery and Physical Medicine and Rehabilitation, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana, India

Date of Submission31-Oct-2020
Date of Decision05-Nov-2020
Date of Acceptance06-Nov-2020
Date of Web Publication25-Nov-2020

Correspondence Address:
Dr. B Ravindra Prasad
Department of General Surgery and Physical Medicine and Rehabilitation, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjhs.mjhs_23_20

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  Abstract 


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.

Keywords: Hollow viscus perforation, Portsmouth modification of possum, mortality, morbidity


How to cite this article:
Reddy V S, Prasad B R, Tejaswini MM, Mohan C R, Raju PS. 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. MRIMS J Health Sci 2020;8:53-6

How to cite this URL:
Reddy V S, Prasad B R, Tejaswini MM, Mohan C R, Raju PS. 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. MRIMS J Health Sci [serial online] 2020 [cited 2021 Jan 17];8:53-6. Available from: http://www.mrimsjournal.com/text.asp?2020/8/3/53/301482




  Introduction Top


The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is widely used to predict morbidity and mortality in a variety of surgical settings and provides a tool for risk adjustment and comparison.[1] In contrast to Acute Physiological and Chronic Health Evaluation II, it takes the operative findings into consideration. Risk scoring seeks to quantify a patient's risk of adverse outcome based on the severity of illness derived from the data available at an early stage of the hospital stay. The possible outcome of a surgical operation must be determined for the evolution of more effective treatment regimens.[2]

The POSSUM has been proposed as a risk adjusted scoring system to allow for direct comparison between the observed and expected adverse outcome rates. It has been called as a surgeon-based scoring system. POSSUM was first described by Copeland et al. in 1991 as a method for normalizing patient data so that direct comparisons of patient outcome could be made despite differing patterns of referral and population. The approach was then modified using the standard methods to obtain a logistic regression model that fitted well with the observed mortality.[3]

The purpose of the present study was to assess the predicting morbidity and mortality in hollow viscus perforation by applying POSSUM and Portsmouth modification of POSSUM (P-POSSUM) scores.


  Material and Methods Top


Study design

This study was a prospective, clinical study conducted at Department of 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 the surgical wards with the clinical diagnosis of hollow viscus perforation (gastric/duodenal/ileal perforation).

Samplings

A total of 33 patients were included in this study.

Inclusion criteria

  • All patients aged above 18 years with radiological features of hollow viscus perforation
  • With follow-up period of at least 6 months were included in the study.


Exclusion criteria

  • Patients aged below 15 years, tuberculosis, cardiac failure, and patients who could not come for follow-up.


The samples for laboratory investigation would be drawn at the time of arrival of patient in casualty and sent to CAIMS laboratory latest by 30 min. The average time taken for reporting shall be 45 min were excluded from the study.

Physiological and operative severity score for the enumeration of mortality and morbidity equation [Table 1] & [Table 2]
Table 1: Clustering of the cases based on physiological score

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Table 2: Operating score of patients

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  • Risk of morbidity: (0.16 × physiological score) + (0.19 × operative score) − 5.91
  • Risk of mortality: (0.13 × physiological score) + (0.16 × operative score) − 7.04.


Portsmouth modification of physiological and operative severity score for the enumeration of mortality and morbidity equation

  • Risk of mortality: (0.1692 × physiological score) + (0.155 × operative score) − 9.065.


Ethical approval

This study was reviewed and approved by the Institutional Ethics Committee, CAIMS, Karimnagar.

Statistical analysis

The data was entered in the Microsoft Excel worksheet and analyzed using proportions


  Results Top


During the present study period, a total of 136 patients were operated on the small bowel, and of these, 33 cases fulfilled all the criteria and were selected for this study. The sex distribution of hollow viscus perforation is 29 males (87.87% of cases) and 4 females (12.13% of the cases).

The overall mortality in this study was 6 (18.18% of the study), while the morbidity was noted in 17 cases (51% of study). [Table 3] shows postoperative complications arising following surgery for hollow viscus perforation. In nine cases of duodenal surgery, three cases developed respiratory infection, four wound infection, one Inter-peritoneal abscess and one Wound dehiscence. Out of two cases of gastric etiology, one case had respiratory infection while one case had wound infection. Out of six cases of ileal etiology, two had wound infection, one inter-peritoneal abscess, two with fecal fistula, and one with wound dehiscence.
Table 3: Postoperative complications arising following surgery for hollow viscus perforation

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[Table 4] shows that it was found to correlate with the zones of increasing morbidity rate derived from the logistic regression analysis. The O:E ratio was 1.67, and there was no significant difference between the observed and predicted values (χ2 = 2.31, 9 df, P = 0.3149).
Table 4: Predicted versus observed morbidity rates

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[Table 5] shows that 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). We found the difference between expected and observed mortality rates using exponential analysis. On applying P-POSSUM, using linear analysis, the expected number of deaths for our study group is 7 (O:E = 1), which is similar to the observed number of deaths, i.e., 6.
Table 5: Physiological and operative severity scoring system for the enumeration of morbidity and mortality predicted morbidity in each cases

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  Discussion Top


The aim of any surgical procedure is to cause reduction in morbidity and mortality. The outcome of surgical intervention, whether death or an uncomplicated survival, complications or long-term morbidity is not solely dependent on the abilities of a surgeon in isolation but on a multitude of patient factors.

POSSUM was developed as an auxiliary tool to evaluate the quality of the surgery service. The present study showed a mortality rate which is considered high when compared with other studies. It could be attributed to the fact that only patient's submitted to large surgeries and needing postoperative ICU cares were included in the study.[3]

In this study, in this group of patients, we found that P-POSSUM and POSSUM scoring models made good to excellent discrimination between survivors and nonsurvivors in a range of surgical specialties treated on a level 1 care ward postoperatively, but with poor calibration across risk bands and less mortality at all deciles of risk than predicted by both models.

Overall observed to expect mortality ratios were significantly lower than predicted for POSSUM and P-POSSUM, with O:E mortality 0.25 (0.20–0.32 confidence interval [CI]) for POSSUM and 0.54 (0.47–0.62 CI) for P-POSSUM.

These mortality rates are not only better than standardized mortality ratios observed for general surgical patients treated in a variety of postoperative environments, but are also comparable to the limited literature documenting POSSUM calculated O:E mortality in level 2 and 3 care areas for our patient population. In our study, we assessed the validity of POSSUM and P-POSSUM in 33 major general surgical procedures by comparing the observed morbidity rate with expected morbidity rate and observed mortality rate with expected mortality rate.

Treharne et al.' study showed that 104 consecutive open surgery cases and 49 endovascular surgery patients were included in the study. P-POSSUM scoring system was used to match the two diverse groups of patients to achieve comparability among the cohorts.[4] Even though the indications for the type of surgery depended upon the patient's physiological status, using P-POSSUM, they were able to match the two groups. The O:E ratios of 0.75 and 0.86 for open and endovascular groups served to validate P-POSSUM scoring system for predicting the mortality rate, allowing the authors to conclude that endovascular method is better than conventional method.

Tekkis et al.'s[5] study showed that 1017 patients undergoing colorectal surgery. The observed mortality rate was 7.5%, while the predicted rates by POSSUM and P-POSSUM were 8.2% and 7.1%, respectively. They found an over prediction in the young patients (P < 0.001) and under prediction in emergency cases and elderly patients (P < 0.05).[6],[7]

POSSUM scoring system to randomize two groups of patients undergoing major colonic resection in a randomized controlled trial to evaluate multimodal optimization of surgical care. Hence, POSSUM over predicted the adverse outcome following major surgery in our study using exponential analysis but able to predict the adverse outcome using linear analysis.


  Conclusion Top


In conclusion, on applying POSSUM using 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. This study is conducted on a limited number of 33 cases only. However, larger series may reveal more authentication of application of POSSUM scoring system for morbidity and P-POSSUM scoring system for mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Copeland GP, Jones D, Wilcox A, Harris PL. Comparative vascular audit using the POSSUM scoring system. Ann R Coll Surg Engl 1993;75:175-7.  Back to cited text no. 1
    
2.
Jones HJ, De Cossart L. Risk scoring in surgical patients. Br J Surg 1998;86:147-59.  Back to cited text no. 2
    
3.
Copeland GP, Sagar P, Brennan J, Roberts G, Ward J, Cornford P, et al. Risk adjusted analysis of surgeon performance: A 1-year study. Br J Surg 1995;82:408-11.  Back to cited text no. 3
    
4.
Treharne GD, Thompson MM, Whiteley MS, Bell PRF. Physiological comparison of open and endovascular aneurysm repair. Br J Surg 1999;86:760-4.  Back to cited text no. 4
    
5.
Tekkis PP, Kessaris N, Kocher HM, Poloniecki JD, Lyttle J, Windsor AC. Evaluation of POSSUM and P-POSSUM scoring systems in patients undergoing colorectal surgery. Br J Surg 2003;90:340-5.  Back to cited text no. 5
    
6.
Wijesinghe LD, Mahmood T, Scott DJA, Berridge DC, Kent PJ, Kester RC. Comparison of POSSUM and the Portsmouth predictor equation for predicting death following vascular surgery. Br J Surg 1998;83:209-12.  Back to cited text no. 6
    
7.
Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and operative Severity Score for the enUmeration of mortality and morbidity. Br J Surg 1998;85:1217-20.  Back to cited text no. 7
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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Abstract
Introduction
Material and Methods
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