Evaluation of POSSUM for patients undergoing pancreatoduodenectomy

The accuracy of pre-operative (P)-POSSUM scoring and cardiopulmonary exercise testing in predicting morbidity and mortality after pancreatic and liver surgery: A systematic review

Background

Cardiopulmonary exercise-testing (CPET) and the (Portsmouth) Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity ((P)-POSSUM) are used as pre-operative risk stratification and audit tools in general surgery, however, both have been demonstrated to have limitations in major hepatopancreatobiliary (HPB) surgery.

Materials and methods

The aim of this review is to determine if CPET and (P)-POSSUM scoring systems accurately predict morbidity and mortality. Eligible articles were identified with an electronic database search. Analysis according to surgery type and tool used was performed.

Results

Twenty-five studies were included in the final review. POSSUM predicted morbidity demonstrated weighted O/E ratios of 0.75(95%CI0.57–0.97) in hepatic surgery and 0.85(95%CI0.8–0.9) in pancreatic surgery. P-POSSUM predicted mortality in pancreatic surgery demonstrated an O/E ratio of 0.75(95%CI0.27–2.13) and 0.94(95%CI0.57–1.55) in hepatic surgery. In both pancreatic and hepatic surgery an anaerobic threshold(AT) of between 9 0.5–11.5 ml/kg/min was predictive of post-operative complications, and in pancreatic surgery ventilatory equivalence of carbon dioxide(˙VE/˙VCO2) was predictive of 30-day mortality.

Conclusion

POSSUM demonstrates an overall lack of predictive fit for morbidity, whilst CPET variables provide some predictive power for post-operative outcomes. Development of a new HPB specific risk prediction tool would be beneficial; the combination of parameters from POSSUM and CPET, alongside HPB specific markers could overcome current limitations.

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Current pre-operative scoring for pancreatic and liver surgery is inaccurate.

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In pancreatic and liver surgery anaerobic threshold scores were predictive of complications.

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In pancreatic surgery ventilatory equivalence of carbon dioxide was predictive of mortality.

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P-POSSUM is inaccurate for predicting mortality and morbidity in pancreatic surgery.

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

Purpose

To investigate the efficacy and accuracy of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scoring systems in the risk assessment of postoperative complications and death in elderly patients undergoing hepatobiliary and pancreatic surgery.

Patients and Methods

Using POSSUM and P-POSSUM, 274 elderly patients undergoing hepatobiliary and pancreatic surgery were evaluated, and the complications and deaths predicted by the systems were compared with the actual situation. The accuracy and predictive ability of POSSUM and P-POSSUM were evaluated using chi-squared and t-tests, consistency of predicted and actual complication rates (observed/expected, OE ratio), and receiver operating characteristic (ROC) curve.

Results

The complication rate predicted by POSSUM (R1) was 22.57%, while the actual postoperative complication rate was 17.88% (P>0.05). The mortality rate predicted by POSSUM (R2) was 4.61%, while the actual rate was 1.09% (P<0.05). The mortality rate predicted by P-POSSUM (R) was 1.42%, while the actual rate was 1.09% (P>0.05). Patients with complications had higher physiology scores (PS), operative severity scores (OS), and POSSUM scores than those without complications (P<0.05). Furthermore, PS, OS, and POSSUM scores were higher in the mortality group than in the survival group. However, the number of individuals in the mortality group was too small to accurately reflect the overall situation. Stratified analysis showed that consistency of the OE ratio in different subgroups was close to 1. The ROC curve showed that the area under the curve for the complication rate predicted by POSSUM was 0.76.

Conclusion

Although the postoperative mortality rate was higher than the actual value, POSSUM could accurately predict the postoperative complication rate in elderly patients undergoing hepatobiliary and pancreatic surgery. The P-POSSUM accurately predicted the postoperative mortality rate in this population. Patients with complications had higher POSSUM scores.

A simplified scoring system for the prediction of pancreatoduodenectomy's complications: An observational study

To assess the efficiency of several previous scoring systems in the prediction of postoperative complications of pancreatoduodenectomy (PCPD) and to explore a new simplified scoring system for PCPD prediction.All 183 consecutive patients scheduled for PD from 2010 to 2017 in the Second Affiliated Hospital of Chongqing Medical University were collected retrospectively. The area under the curve (AUC) for the prediction of PCPD was calculated for POSSUM, E-PASS, APACHE-II, and APACHE-III, which were used to test the efficiency of PCPD prediction. The independent risk factors included in the new scoring system were determined by univariate analysis and a logistic regression model. Next, the prediction efficiency was validated.The results of the univariate analysis showed that such variables as male sex, weight, WBC, serum sodium, arterial pH, postoperative 24 hours urine output, and operation time were influence factors for postoperative complications (P <.05). Arterial pH, serum sodium, postoperative 24 hours urine output, and WBC were independent risk factors of postoperative complications based on the logistic regression analysis (P <.05). The AUC of the novel scoring system for PCPD prediction was 85.4%.The proposed scoring system might be a more effective tool for predicting PCPD compared with previous multipurpose scoring systems.

Portsmouth physiological and operative severity score for the Enumeration of Mortality and morbidity scoring system in general surgical practice and identifying risk factors for poor outcome

Background:

Estimation of the outcome is paramount in disease stratification and subsequent management in severely ill surgical patients. Risk scoring helps us quantify the prospects of adverse outcome in a patient. Portsmouth-Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM) the world over has proved itself as a worthy scoring system and the present study was done to evaluate the feasibility of P-POSSUM as a risk scoring system as a tool in efficacious prediction of mortality and morbidity in our demographic profile.

Materials and Methods:

Validity of P-POSSUM was assessed prospectively in fifty major general surgeries performed at our hospital from May 2011 to October 2012. Data were collected to obtain P-POSSUM score, and statistical analysis was performed.

Results:

Majority (72%) of patients was male and mean age was 40.24 ± 18.6 years. Seventy-eight percentage procedures were emergency laparotomies commonly performed for perforation peritonitis. Mean physiological score was 17.56 ± 7.6, and operative score was 17.76 ± 4.5 (total score = 35.3 ± 10.4). The ratio of observed to expected mortality rate was 0.86 and morbidity rate was 0.78.

Discussion:

P-POSSUM accurately predicted both mortality and morbidity in patients who underwent major surgical procedures in our setup. Thus, it helped us in identifying patients who required preferential attention and aggressive management. Widespread application of this tool can result in better distribution of care among high-risk surgical patients.

How I Do It: Hybrid Laparoscopic and Robotic Pancreaticoduodenectomy

Minimally invasive pancreatic resections remain technically challenging. Distal pancreatectomy has been embraced at multiple centers as an acceptable minimally invasive technique in selected patients. In contrast, minimally invasive pancreaticoduodenectomy has not achieved broad acceptance, partly due to technical challenges. We detail a minimally invasive technique that utilizes both laparoscopic and robotic approaches which capitalizes on the advantages of each. Our early results have encouraged the continued development of this minimally invasive pancreatic surgery program. This hybrid technique may be an approach that is useful for surgeons striving to adopt the advantages of minimally invasive surgery for their patients.

Assessing surgical quality: comparison of general and procedure-specific morbidity estimation models for the risk adjustment of pancreaticoduodenectomy outcomes

INTRODUCTION

The use of outcomes to evaluate surgical quality implies the need for detailed risk adjustment. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a generally applicable risk adjustment model suitable for pancreatic surgery. A pancreaticoduodenectomy (PD)-specific intraoperative pancreatic risk assessment (IPRA) estimates the risk of postoperative pancreatic fistula (POPF) and associated morbidity based on factors that are not incorporated into POSSUM.

OBJECTIVE

The aim of the study was to compare the risk estimations of POSSUM and IPRA in patients undergoing PD.

METHODS

An observational single-center cohort study was conducted including 195 patients undergoing PD in 2008-2010. POSSUM and IPRA data were recorded prospectively. Incidence and severity of postoperative morbidity was recorded according to established definitions. The cohort was grouped by POSSUM and IPRA risk groups. The estimated and observed outcomes and morbidity profiles of POSSUM and IPRA were scrutinized.

RESULTS

POSSUM-estimated risk (62 %) corresponded with observed total morbidity (65 %). Severe morbidity was 17 % and in-hospital-mortality 3.1 %. Individual and grouped POSSUM risk estimates did not reveal associations with incidence (p = 0.637) or severity (p = 0.321) of total morbidity or POPF. The IPRA model identified patients with high POPF risk (p < 0.001), but was even associated with incidence (p < 0.001) and severity (p < 0.001) of total morbidity.

CONCLUSION

The risk factors defined by a PD-specific model were significantly stronger predictive indicators for the incidence and severity of postoperative morbidity than the factors incorporated in POSSUM. If available, reliable procedure-specific risk factors should be utilized in the risk adjustment of surgical outcomes. For pancreatic surgery, generally applicable tools such as POSSUM still have to prove their relevance.

Value of general surgical risk models for predicting postoperative morbidity and mortality in pancreatic resections for pancreatobiliary carcinomas

BACKGROUND

The present study evaluated the utility of general surgical risk models to predict postoperative morbidity and mortality in the specialty field of pancreatic resections for pancreatobiliary carcinomas.

METHODS

We investigated Estimation of Physiologic Ability and Surgical Stress (E-PASS), its modified version (mE-PASS), and Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in 231 patients undergoing pancreatoduodenectomy or distal pancreatectomy (Group A). We also analyzed E-PASS and mE-PASS in another cohort of the same procedures (Group B, n = 313).

RESULTS

Areas under the receiver operating characteristic curve (AUC) for detecting in-hospital mortality in Group A were moderate at 0.75 for E-PASS, 0.69 for mE-PASS, and 0.69 for P-POSSUM. The predicted mortality rates of the models significantly correlated with severity of postoperative complications (ρ = 0.17, P = 0.011 for E-PASS; ρ = 0.15, and P = 0.027 for P-POSSUM). The AUCs were also moderate in Group B at 0.68 for E-PASS and 0.69 for mE-PASS. The predicted mortality rates significantly correlated with severity of postoperative complications (ρ = 0.18, P = 0.0018 for E-PASS; ρ = 0.17, and P = 0.0022 for mE-PASS).

CONCLUSIONS

The present study suggests that the predictive powers of general risk models may be moderate in pancreatic resections. A novel model would be desirable for these procedures.

Pre-operative cardiopulmonary exercise testing predicts adverse post-operative events and non-progression to adjuvant therapy after major pancreatic surgery

BACKGROUND

Surgery followed by chemotherapy is the primary modality of cure for patients with resectable pancreatic cancer but is associated with significant morbidity. The aim of the present study was to evaluate the role of cardiopulmonary exercise testing (CPET) in predicting post-operative adverse events and fitness for chemotherapy after major pancreatic surgery.

METHODS

Patients who underwent a pancreaticoduodenectomy or total pancreatectomy for pancreatic head lesions and had undergone pre-operative CPET were included in this retrospective study. Data on patient demographics, comorbidity and results of pre-operative evaluation were collected. Post-operative adverse events, hospital stay and receipt of adjuvant therapy were outcome measures.

RESULTS

One hundred patients were included. Patients with an anaerobic threshold less than 10 ml/kg/min had a significantly greater incidence of a post-operative pancreatic fistula [International Study Group for Pancreatic Surgery (ISGPS) Grades A-C, 35.4% versus 16%, P = 0.028] and major intra-abdominal abscesses [Clavien-Dindo (CD) Grades III-V, 22.4% versus 7.8%, P = 0.042] and were less likely to receive adjuvant therapy [hazard ratio (HR) 6.30, 95% confidence interval (CI) 1.25-31.75, P = 0.026]. A low anaerobic threshold was also associated with a prolonged hospital stay (median 20 versus 14 days, P = 0.005) but not with other adverse events.

DISCUSSION

CPET predicts a post-operative pancreatic fistula, major intra-abdominal abscesses as well as length of hospital stay after major pancreatic surgery. Patients with a low anaerobic threshold are less likely to receive adjuvant therapy.

POSSUM and P-POSSUM as predictors of postoperative morbidity and mortality in patients undergoing hepato-biliary-pancreatic surgery: a meta-analysis

BACKGROUND

Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) models are used extensively to predict postoperative morbidity and mortality in general surgery. The aim was to undertake the first meta-analysis of the predictive value of these models in patients undergoing hepato-biliary-pancreatic surgery.

METHODS

Eligible articles were identified by searches of electronic databases from 1991 to 2012. All data were specific to hepato-biliary-pancreatic surgery. Predictive value of morbidity and mortality were assessed by calculating weighted observed to expected (O/E) ratios. Subanalysis was also performed.

RESULTS

Sixteen studies were included in final review. The morbidity analysis included nine studies on POSSUM with a weighted O/E ratio of 0.78 [95 % confidence interval (CI) 0.68-0.88]. The mortality analysis included seven studies on POSSUM and nine studies on P-POSSUM (Portsmouth predictor equation for mortality). Weighted O/E ratios for mortality were 0.35 (95 % CI 0.17-0.54) for POSSUM and 0.95 (95 % CI 0.65-1.25) for P-POSSUM. POSSUM had more accuracy to predict morbidity after pancreatic surgery (O/E ratio 0.82; 95 % CI 0.72-0.92) than after hepatobiliary surgery (O/E ratio 0.66; 95 % CI 0.57-0.74), in large sample size studies (O/E ratio 0.90; 95 % CI 0.85-0.96) than in small sample size studies (O/E ratio 0.69; 95 % CI 0.59-0.79).

CONCLUSIONS

POSSUM overpredicted postoperative morbidity after hepato-biliary-pancreatic surgery. Predictive value of POSSUM to morbidity was affected by the type of surgery and the sample size of studies. Compared with POSSUM, P-POSSUM was more accurate for predicting postoperative mortality. Modifications to POSSUM and P-POSSUM are needed for audit in hepato-biliary-pancreatic surgery.

A systematic review of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity and its Portsmouth modification as predictors of post-operative morbidity and mortality in patients undergoing pancreatic surgery

BACKGROUND

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model and its Portsmouth modification (P-POSSUM) are used extensively to predict postoperative mortality and morbidity in general surgery. The aim of this study was to undertake the first systematic review of the predictive value of these models in patients undergoing pancreatic surgery.

METHODS

Eligible articles were identified by searches of electronic databases for those published from 1991 to 2012. Two independent reviewers assessed each study against inclusion and exclusion criteria. All data were specific to pancreatic surgery. Predictive value of morbidity and mortality were assessed by calculating observed/expected ratios.

RESULTS

Nine studies were included in the final review. The morbidity analysis included 8 studies (1,734 patients) of POSSUM with a weighted observed/expected ratio of .85. The mortality analysis included 5 studies (936 patients) of POSSUM and 4 studies (716 patients) of P-POSSUM. Weighted observed/expected ratios for mortality were .35 for POSSUM and 1.39 for P-POSSUM.

CONCLUSIONS

POSSUM overpredicted postoperative morbidity in patients undergoing pancreatic surgery. Both POSSUM and P-POSSUM failed to offer significant predictive value for mortality in pancreatic surgery, and more data collection in large populations undergoing pancreatic surgery are needed.

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 (χ (2) = 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.

A decision model of therapy for potentially resectable pancreatic cancer

BACKGROUND

Optimal treatment for potentially resectable pancreatic cancer is controversial. Resection is considered the only curative treatment, but neoadjuvant chemoradiotherapy may offer significant advantages.

MATERIALS AND METHODS

We developed a decision model for potentially resectable pancreatic cancer. Initial therapeutic choices were surgery, neoadjuvant chemoradiotherapy, or no treatment; subsequent decisions offered a second intervention if not prohibited by complications or death. Payoffs were calculated as the median expected survival. We gathered evidence for this model through a comprehensive MEDLINE search. One-way sensitivity analyses were performed.

RESULTS

Neoadjuvant chemoradiation is favored over initial surgery, with expected values of 18.6 and 17.7 mo, respectively. The decision is sensitive to the probabilities of treatment mortality and tumor resectability. Threshold probabilities are 7.0% mortality of neoadjuvant chemoradiotherapy, 69.2% resectability on imaging after neoadjuvant therapy, and 73.7% resectability at exploration after neoadjuvant therapy, 92.2% resectability at initial resection, and 9.9% surgical mortality following chemoradiotherapy. The decision is sensitive to the utility of time spent in chemoradiotherapy, with surgery favored for utilities less than 0.3 and -0.8, for uncomplicated and complicated chemoradiotherapy, respectively.

CONCLUSIONS

The ideal treatment for potentially resectable pancreatic cancer remains controversial, but recent evidence supports a slight benefit for neoadjuvant therapy. Our model shows that the decision is sensitive to the probability of tumor resectability and chemoradiation mortality, but not to rates of other treatment complications. With minimal benefit of one treatment over another based on survival alone, patient preferences will likely play an important role in determining best treatment.

Chronic pancreatitis: early results of pancreatoduodenectomy and analysis of risk factors

OBJECTIVES

Although mortality after pancreatoduodenectomy for chronic pancreatitis has declined, the complication rate remains high. Today, there is an increasing need to base clinical decisions on the available scientific evidence to provide the best available treatment for the patients. Therefore, we retrospectively analyzed comprehensive preoperative and postoperative characteristics of patients undergoing pancreatic head resection for chronic pancreatitis and performed an outcome analysis to provide prospective selection or managing criteria that could improve the early surgical results.

METHODS

Data from 168 patients who underwent pancreatic head resection for chronic pancreatitis between October 1993 and November 2008 in our center were retrospectively analyzed. Risk factors for surgical complications were evaluated by multivariate analysis.

RESULTS

Perioperative mortality was 0.6%, and surgical morbidity was 14.3%. Multivariate analysis identified hypertension as significant independent risk factor for surgical complications with an odds ratio (OR) of 3.24. We also found protective factors, namely, preoperative exocrine insufficiency (OR, 0.33) and preoperative diabetes (OR, 0.18). Both protective factors might indicate an advanced chronic pancreatitis.

CONCLUSIONS

As patients undergoing pancreatic head resection are highly selected, the identified risk factors should only individually be considered in the decision to operate.

Outcomes in pancreatic cancer surgery

The increase in surgery for pancreatic cancer during the last 3 decades can be correlated with a gradual decline in operative mortality and postoperative complications. Although not all surgeons (nor all hospitals) can have equal outcomes, the definition and tabulation of these outcomes have been difficult. This article asks several pertinent questions: (1) what is the scientific rationale for pancreatic resection? (2) what are the best available results at this time? (3) who should be performing pancreatic resections? The article analyzes results of resection for adenocarcinoma of the exocrine pancreas, and excludes duodenal and ampullary cancers, pancreatic endocrine tumors, and tumors of less malignant potential.