A newly devised scoring system for prediction of mortality in patients with colorectal cancer: a prospective study

More than 30 Years of POSSUM: Are Scoring Systems Still Relevant Today for Colorectal Surgery?

BACKGROUND

The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) weights the patient's individual health status and the extent of the surgical procedure to estimate the probability of postoperative complications and death of general surgery patients. The variations Portsmouth-POSSUM (P-POSSUM) and colorectal POSSUM (CR-POSSUM) were developed for estimating mortality in patients with low perioperative risk and for patients with colorectal carcinoma, respectively. The aim of the present study was to evaluate the significance of POSSUM, P-POSSUM, and CR-POSSUM in two independent colorectal cancer cohorts undergoing surgery, with an emphasis on laparoscopic procedures.

METHODS

For each patient, an individual physiological score (PS) and operative severity score (OS) was attributed to calculate the predicted morbidity and mortality, respectively. Logistic regression analysis was used to evaluate the possible correlation between the subscores and the probability of postoperative complications and mortality.

RESULTS

The POSSUM equation significantly overpredicted postoperative morbidity, and all three scoring systems considerably overpredicted in-hospital mortality. However, the POSSUM score identified patients at risk of anastomotic leakage, sepsis, and the need for reoperation. Logistic regression analysis demonstrated a strong correlation between the subscores and the probability of postoperative complications and mortality, respectively.

CONCLUSION

Our results suggest that the three scoring systems are too imprecise for the estimation of perioperative complications and mortality of patients undergoing colorectal surgery in the present day. Since the subscores proved valid, a revision of the scoring systems could increase their reliability in the clinical setting.

Prediction of Postoperative Survival in Young Colorectal Cancer Patients: A Cohort Study Based on the SEER Database

Objective

Our aim is to make accurate and robust predictions of the risk of postoperative death in young colorectal cancer patients (18-44 years old) by combining tumor characteristics with medical and demographic information about the patient.

Materials and Methods

We used the SEER database to retrieve young patients diagnosed with colorectal cancer who had undergone surgery between 2010 and 2015 as the study cohort. After excluding cases with missing information, the study cohort was divided in a 7 : 3 ratio into a training dataset and a validation dataset. To assess the predictive ability of each predictor on the prognosis of colorectal cancer patients, we used two steps of Cox univariate analysis and Cox stepwise regression to screen variables, and the screened variables were included in a multifactorial Cox proportional risk regression model for modeling. The performance of the model was tested using calibration curves, decision curves, and area under the curve (AUC) for receiver operating characteristic (ROC).

Results

After excluding cases with missing information (n = 23,606), a total of 11,803 patients were included in the study with a median follow-up time of 45 months (1-119). In the training set, we determined that ethnicity, marital status, insurance status, median annual household income, degree of tumor differentiation, type of pathology, degree of infiltration, and tumor location had independent effects on prognosis. In the training dataset, taking 1 year, 3 years, and 5 years as the time nodes, the areas under the working characteristic curve of subjects are 0.825, 0.851, and 0.839, respectively, and in the validation dataset, they are 0.834, 0.837, and 0.829, respectively.

Conclusion

We trained and validated a model using a large multicenter cohort of young colorectal cancer patients with stable and excellent performance in both training and validation datasets.

Critical Analysis of the Causes of In-Hospital Mortality following Colorectal Resection: A Queensland Audit of Surgical Mortality (QASM) Registry Study

Background

Colorectal resection is a major gastrointestinal operation. Improvements in peri-operative care has led to improved outcomes; however, mortalities still occur. Using data from the Queensland Audit of Surgical Mortality (QASM), this study examines the demographic and clinical characteristics of patients who died in hospital following colorectal resection, and also reports the primary cause of death in this population.

Methods

Patients who died in hospital following colorectal resection in Queensland between January 2010 and December 2020 were identified from the QASM database.

Results

There were 755 patients who died in the 10 year study period. Pre-operatively, the risk of death as subjectively determined by operating surgeons was ‘considerable’ in 397 cases (53.0%) and ‘expected’ in 90 cases (12.0%). The patients had a mean of 2.7 (±1.5) co-morbidities, and a mean American Society of Anaesthesiologists (ASA) score of 3.6 (±0.8). Operations were categorised as emergency in 579 patients (77.2%), with 637 patients (85.0%) requiring post-operative Intensive Care Unit (ICU) support. The primary cause of death was related to a surgical cause in 395 patients (52.7%) and to a medical cause in 355 patients (47.3%). The primary causes of death were advanced surgical pathology (n=292, 38.9%), complications from surgery (n=103, 13.7%), complications arising from pre-existing medical co-morbidity (n=282, 37.6%) or new medical complications unrelated to pre-existing conditions (n=73, 9.7%).

Conclusions

Patients who died had significant co-morbidities and often presented emergently with an advanced surgical pathology. Surgical and medical causes of death both contributed equally to the mortality burden.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06534-9.

Data analytics and artificial intelligence in predicting length of stay, readmission, and mortality: a population-based study of surgical management of colorectal cancer

Data analytics and artificial intelligence (AI) have been used to predict patient outcomes after colorectal cancer surgery. A prospectively maintained colorectal cancer database was used, covering 4336 patients who underwent colorectal cancer surgery between 2003 and 2019. The 47 patient parameters included demographics, peri- and post-operative outcomes, surgical approaches, complications, and mortality. Data analytics were used to compare the importance of each variable and AI prediction models were built for length of stay (LOS), readmission, and mortality. Accuracies of at least 80% have been achieved. The significant predictors of LOS were age, ASA grade, operative time, presence or absence of a stoma, robotic or laparoscopic approach to surgery, and complications. The model with support vector regression (SVR) algorithms predicted the LOS with an accuracy of 83% and mean absolute error (MAE) of 9.69 days. The significant predictors of readmission were age, laparoscopic procedure, stoma performed, preoperative nodal (N) stage, operation time, operation mode, previous surgery type, LOS, and the specific procedure. A BI-LSTM model predicted readmission with 87.5% accuracy, 84% sensitivity, and 90% specificity. The significant predictors of mortality were age, ASA grade, BMI, the formation of a stoma, preoperative TNM staging, neoadjuvant chemotherapy, curative resection, and LOS. Classification predictive modelling predicted three different colorectal cancer mortality measures (overall mortality, and 31- and 91-days mortality) with 80-96% accuracy, 84-93% sensitivity, and 75-100% specificity. A model using all variables performed only slightly better than one that used just the most significant ones.

Validation of the Surgical Outcome Risk Tool (SORT) for Predicting Postoperative Mortality in Colorectal Cancer Patients Undergoing Surgery and Subgroup Analysis

BACKGROUND

The accurate evaluation of perioperative risk is crucial to facilitate the shared decision-making process. Surgical outcome risk tool (SORT) has been developed to provide enhanced and more feasible identification of high-risk surgical patients. Nonetheless, SORT has not been validated for patients with colorectal cancer undergoing surgery. Our aim was to determine whether SORT can accurately predict mortality after surgery for colorectal cancer and to compare it with traditional risk models.

METHOD

526 patients undergoing surgery performed by a colorectal surgical team in a single Greek tertiary hospital (2011-2019) were included. Five risk models were evaluated: (1) SORT, (2) Physiology and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM), (3) Portsmouth POSSUM (P-POSSUM), (4) Colorectal POSSUM (CR-POSSUM), and (5) the Association of Great Britain and Ireland (ACPGBI) score. Model accuracy was assessed by observed to expected (O:E) ratios, and area under Receiver Operating Characteristic curve (AUC).

RESULTS

Ten patients (1.9%) died within 30 days of surgery. SORT was associated with an excellent level of discrimination [AUC:0.81 (95% CI:0.68-0.94); p = 0.001] and provided the best performing calibration of all models in the entire dataset analysis (H-L:2.82; p = 0.83). Nonetheless, SORT underestimated mortality. SORT model demonstrated excellent discrimination and calibration predicting perioperative mortality in patients undergoing (1) open surgery, (2) emergency/acute surgery, and (3) in cases with colon-located cancer.

CONCLUSION

SORT is an easily adopted risk-assessment tool, associated with enhanced accuracy, that could be implemented in the perioperative pathway of patients undergoing surgery for colorectal cancer.

Evaluating and improving current risk prediction tools in emergency laparotomy

PURPOSE

Emergency laparotomy (EL) encompasses a high-risk group of operations, which are increasingly performed on a heterogeneous population of patients, making preoperative risk assessment potentially difficult. The UK National Emergency Laparotomy Audit (NELA) recently produced a risk predictive tool for EL that has not yet been externally validated. We aimed to externally validate and potentially improve the NELA tool for mortality prediction after EL.

METHODOLOGY

We reviewed computer and paper records of EL patients from May 2012 to June 2017 at Middlemore Hospital (New Zealand). The inclusion criteria mirrored the UK NELA. We examined the NELA, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Acute Physiology and Chronic Health Evaluation II (APACHE-II), and American College of Surgeons National Surgical Quality Improvement Programs risk predictive tools for 30-day mortality. The Hosmer-Lemeshow test was used to assess calibration, and the c statistic, to evaluate discrimination (accuracy) of the tools. We added the modified frailty index (mFI) and nutrition to improve the accuracy of risk predictive tools.

RESULTS

A total of 758 patients met the inclusion criteria, with an observed 30-day mortality of 7.9%. The NELA was the only well calibrated tool, with predicted 30-day mortality of 7.4% (p = 0.22). When combined with mFI and nutritional status, the c statistic for NELA improved from 0.83 to 0.88. American College of Surgeons National Surgical Quality Improvement Programs, APACHE-II, and P-POSSUM had lower c statistics, albeit also showing an improvement (0.84, 0.81, and 0.74, respectively).

CONCLUSION

We have demonstrated the NELA tool to be most predictive of mortality after EL. The NELA tool would therefore facilitate preoperative risk assessment and operative decision making most precisely in EL. Future research should consider adding mFI and nutritional status to the NELA tool.

LEVEL OF EVIDENCE

Level IV; Retrospective observational cohort study.

Challenges of Modeling Outcomes for Surgical Infections: A Word of Caution

Background: We developed a novel analytic tool for colorectal deep organ/space surgical site infections (C-OSI) prediction utilizing both institutional and extra-institutional American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data. Methods: Elective colorectal resections (2006-2014) were included. The primary end point was C-OSI rate. A Bayesian-Probit regression model with multiple imputation (BPMI) via Dirichlet process handled missing data. The baseline model for comparison was a multivariable logistic regression model (generalized linear model; GLM) with indicator parameters for missing data and stepwise variable selection. Out-of-sample performance was evaluated with receiver operating characteristic (ROC) analysis of 10-fold cross-validated samples. Results: Among 2,376 resections, C-OSI rate was 4.6% (n = 108). The BPMI model identified (n = 57; 56% sensitivity) of these patients, when set at a threshold leading to 80% specificity (approximately a 20% false alarm rate). The BPMI model produced an area under the curve (AUC) = 0.78 via 10-fold cross- validation demonstrating high predictive accuracy. In contrast, the traditional GLM approach produced an AUC = 0.71 and a corresponding sensitivity of 0.47 at 80% specificity, both of which were statstically significant differences. In addition, when the model was built utilizing extra-institutional data via inclusion of all (non-Mayo Clinic) patients in ACS-NSQIP, C-OSI prediction was less accurate with AUC = 0.74 and sensitivity of 0.47 (i.e., a 19% relative performance decrease) when applied to patients at our institution. Conclusions: Although the statistical methodology associated with the BPMI model provides advantages over conventional handling of missing data, the tool should be built with data specific to the individual institution to optimize performance.

Australasian ACPGBI risk prediction model for 30-day mortality after colorectal cancer surgery

BACKGROUND

Postoperative mortality after colorectal cancer surgery varies across hospitals and countries. The aim of this study was to test the Association of Coloproctologists of Great Britain and Ireland (ACPGBI) models as predictors of 30-day mortality in an Australian cohort.

METHODS

Data from patients who underwent surgery in six hospitals between 1996 and 2015 (CRC data set) were reviewed to test ACPGBI models, and patients from 79 hospitals in the Bi-National Colorectal Cancer Audit between 2007 and 2016 (BCCA data set) were analysed to validate model performance. Recalibrated models based on ACPGBI risk models were developed, tested and validated on a data set of Australasian patients.

RESULTS

Of 18 752 patients observed during the study, 6727 (CRC data set) and 3814 (BCCA data set) were analysed. The 30-day mortality rate was 1·1 and 3·5 per cent in the CRC and BCCA data sets respectively. Both the original and revised ACPGBI models overestimated 30-day mortality for the CRC data set (observed to expected (O/E) ratio 0·17 and 0·21 respectively). Their ability to correctly predict mortality risk was poor (P < 0·001, Hosmer-Lemeshow test); however, the area under the curve for both models was 0·88 (95 per cent c.i. 0·85 to 0·92) showing good discriminatory power to classify 30-day mortality. The recalibrated original model performed well for calibration and discrimination, whereas the recalibrated revised model performed well for discrimination but not for calibration. Risk prediction was good for both recalibrated models. On external validation using the BCCA data set, the recalibrated models underestimated mortality risk (O/E ratio 3·06 and 2·98 respectively), whereas both original and revised ACPGBI models overestimated the risk (O/E ratio 0·48 and 0·69). All models showed similar good discrimination.

CONCLUSION

The original and revised ACPGBI models overpredicted risk of 30-day mortality. The new Australasian calibrated ACPGBI model needs to be tested further in clinical practice.

Prediction of overall survival following colorectal cancer surgery in elderly patients

BACKGROUND

With advanced age and chronic illness, the life expectancy of a patient with colorectal cancer (CRC) becomes less dependent on the malignant disease and more on their pre-morbid condition. Justifying major surgery for these elderly patients can be challenging. An accurate tool demonstrating post-operative survival probability would be useful for surgeons and their patients.

AIM

To integrate clinically significant prognostic factors relevant to elective colorectal surgery in the elderly into a validated pre-operative scoring system.

METHODS

In this retrospective cohort study, patients aged 70 and above who underwent surgery for CRC at Singapore General Hospital between 1 January 2005 and 31 December 2012 were identified from a prospectively maintained database. Patients with evidence of metastatic disease, and those who underwent emergency surgery or had surgery for benign colorectal conditions were excluded from the analysis. The primary outcome was overall 3-year overall survival (OS) following surgery. A multivariate model predicting survival was derived and validated against an equivalent external surgical cohort from Kyungpook National University Chilgok Hospital, South Korea. Statistical analyses were performed using Stata/MP Version 15.1.

RESULTS

A total of 1267 patients were identified for analysis. The median post-operative length of stay was 8 [interquartile range (IQR) 6-12] d and median follow-up duration was 47 (IQR 19-75) mo. Median OS was 78 (IQR 65-85) mo. Following multivariate analysis, the factors significant for predicting overall mortality were serum albumin < 35 g/dL, serum carcinoembryonic antigen ≥ 20 µg/L, T stage 3 or 4, moderate tumor cell differentiation or worse, mucinous histology, rectal tumors, and pre-existing chronic obstructive lung disease. Advanced age alone was not found to be significant. The Korean cohort consisted of 910 patients. The Singapore cohort exhibited a poorer OS, likely due to a higher proportion of advanced cancers. Despite the clinicopathologic differences, there was successful validation of the model following recalibration. An interactive online calculator was designed to facilitate post-operative survival prediction, available at http://bit.ly/sgh_crc. The main limitation of the study was selection bias, as patients who had undergone surgery would have tended to be physiologically fitter.

CONCLUSION

This novel scoring system generates an individualized survival probability following colorectal resection and can assist in the decision-making process. Validation with an external population strengthens the generalizability of this model.

Total pelvic exenteration for locally advanced and locally recurrent rectal cancer in the elderly

BACKGROUND

Total pelvic exenteration (TPE) is a radical approach for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) in case of tumour invasion into the urogenitary tract. The aim of this study is to assess surgical and oncological outcomes of TPE for LARC and LRRC in elderly patients compared to younger patients.

METHODS

All patients who underwent TPE for LARC and LRRC between January 1990 and March 2017 were retrospectively analyzed. Patients aged <70 years were classified as younger and ≥70 years as elderly patients.

RESULTS

In total 126 patients underwent TPE, of whom 88 younger and 38 elderly patients. Elderly patients had a significantly higher number of ASA > II patients (p = 0.01). Indication for surgery LARC (n = 73) and LRRC (n = 53) did not differ significantly. The 30-day mortality rate was significantly higher (p = 0.01) in elderly (13%) compared to younger patients (3%). Elderly patients experienced more anastomotic leakage (p = 0.02). Median overall survival (OS) was 75 months [95%CI 37.1; 112.9] for elderly and 45 months [95%CI 22.4; 67.8] for younger patients (p = 0.77). The 5-year OS rate was 44% in both groups. Median disease specific survival (DSS) was 78 months [95%CI 69.1; 86.9] for elderly and 60 months [95%CI 36.6; 83.4] for younger patients (p = 0.34). The 5-year DSS rate was 57% and 49%, respectively.

CONCLUSION

TPE is an invasive treatment for rectal cancer with high 30-day mortality in elderly patients. Oncological outcomes are similar in elderly and younger patients. Therefore, TPE should not be withheld because of high age only, but careful patient selection is needed.

A model predicting operative mortality in the UK has only limited value in Denmark

PURPOSE

Postoperative mortality from colorectal cancer varies between surgical departments. Several models have been developed to predict the operative risk. This study aims to investigate whether the original and the revised Association of Coloproctology of Great Britain and Ireland (ACPGBI) model can predict 30-day mortality after colorectal cancer surgery in Denmark.

METHODS

Data were collected from the Danish Colorectal Cancer Group database which has > 95% completeness. All patients operated on from January 2007 to December 2013 were included. The individual estimated operative risk was calculated with the original and revised ACPGBI models. Discrimination and calibration were evaluated with a Receiver Operating Characteristic (ROC) curve analysis and a Hosmer-Lemeshow test, respectively.

RESULTS

In total, 22,807 patients underwent open or laparoscopic colorectal cancer surgery. After excluding 1437 patients because of missing data, 21,370 patients were left for the analyses. The observed 30-day mortality was 5.0%. The original and revised ACPGBI models estimated an operative risk of 7.0 and 4.0%, respectively, with a significant difference in observed and estimated mortality in both models. However, in patients with an estimated risk of at least 26%, i.e., high-risk, good calibration was found with the original ACPGBI model. Discrimination was good with an AUC of 0.83 (95% CI 0.82-0.84) in both models.

CONCLUSION

The original and revised ACPGBI models are not suitable prediction models for postoperative mortality in the Danish colorectal cancer population. However, the original model might be applicable in predicting mortality in high-risk patients.

Validity of the CR-POSSUM model in surgery for colorectal cancer in Spain (CCR-CARESS study) and comparison with other models to predict operative mortality

Background

To validate and recalibrate the CR- POSSUM model and compared its discriminatory capacity with other European models such as POSSUM, P-POSSUM, AFC or IRCS to predict operative mortality in surgery for colorectal cancer.

Methods

Prospective multicenter cohort study from 22 hospitals in Spain. We included patients undergoing planned or urgent surgery for primary invasive colorectal cancers between June 2010 and December 2012 (N = 2749). Clinical data were gathered through medical chart review. We validated and recalibrated the predictive models using logistic regression techniques. To calculate the discriminatory power of each model, we estimated the areas under the curve - AUC (95% CI). We also assessed the calibration of the models by applying the Hosmer-Lemeshow test.

Results

In-hospital mortality was 1.5% and 30-day mortality, 1.7%. In the validation process, the discriminatory power of the CR-POSSUM for predicting in-hospital mortality was 73.6%. However, in the recalibration process, the AUCs improved slightly: the CR-POSSUM reached 75.5% (95% CI: 67.3–83.7). The discriminatory power of the CR-POSSUM for predicting 30-day mortality was 74.2% (95% CI: 67.1–81.2) after recalibration; among the other models the POSSUM had the greatest discriminatory power, with an AUC of 77.0% (95% CI: 68.9–85.2). The Hosmer-Lemeshow test showed good fit for all the recalibrated models.

Conclusion

The CR-POSSUM and the other models showed moderate capacity to discriminate the risk of operative mortality in our context, where the actual operative mortality is low. Nevertheless the IRCS might better predict in-hospital mortality, with fewer variables, while the CR-POSSUM could be slightly better for predicting 30-day mortality.

Trail registration

Registered at: ClinicalTrials.gov Identifier: NCT02488161

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2839-x) contains supplementary material, which is available to authorized users.

Estimates of cancer burden in Veneto

Aims and background

In Veneto a regional cancer registry has been operating since 1987 which provides incidence and survival data for the region. It currently covers 48% of the regional population. The aim of this paper is to provide estimates of the incidence, mortality and prevalence of the major cancers for the whole Veneto region in the period 1970—2015.

Methods

The estimates were obtained by applying the MIAMOD method, a statistical back-calculation approach to derive incidence and prevalence figures starting from mortality and relative survival data. Survival was modeled on the basis of published data from the Italian cancer registries.

Results

In 2012 the most frequent cancer sites were colon-rectum, prostate and breast with 4,677, 3,760 and 3,729 new diagnosed cases, respectively. The incidence rates were estimated to increase constantly for female lung cancer, prostate cancer, colorectal cancer and melanoma, while they were decreasing for cervical cancer and stomach cancer. For male lung cancer and female breast cancer the rates increased, reaching a peak, and then decreased. In the last years of the period of analysis, mortality declined for all cancers: the highest number of deaths (2,390 in both sexes) was estimated for lung cancer in 2012. Prevalence was increasing for all the considered cancer sites with the exception of lung cancer in men, for which the prevalence was estimated to increase until 2007 and then stabilize. By contrast, the cervical cancer decreased during the whole period. In 2012 breast cancer had the highest prevalence, with about 52,000 cases.

Conclusion

This paper provides a description of the burden of the major cancers in Veneto until 2015. The estimates highlight the continuing reduction of cancer mortality. This decline can be related to the improvement of clinical treatments and to multidisciplinary treatment approaches. In order for this positive trend to continue, implementation and reinforcement of the screening programs is needed, especially for breast and colorectal cancer.

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

PURPOSE

This 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.

METHODS

One 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).

RESULTS

Eleven 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.

CONCLUSION

All 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.

Estimation of physiologic ability and surgical stress (E-PASS) scoring system could provide preoperative advice on whether to undergo laparoscopic surgery for colorectal cancer patients with a high physiological risk

Laparoscopic colorectal surgery had been widely used for colorectal cancer patient and showed a favorable outcome on the postoperative morbidity rate. We attempted to evaluate physiological status of patients by mean of Estimation of physiologic ability and surgical stress (E-PASS) system and to analyze the difference variation of postoperative morbidity rate of open and laparoscopic colorectal cancer surgery in patients with different physiological status.In total 550 colorectal cancer patients who underwent surgery treatment were included. E-PASS and some conventional scoring systems were reviewed to examine their mortality prediction ability. The preoperative risk score (PRS) in the E-PASS system was used to evaluate the physiological status of patients. The difference of postoperative morbidity rate between open and laparoscopic colorectal cancer surgeries was analyzed respectively in patients with different physiological status.E-PASS had better prediction ability than other conventional scoring systems in colorectal cancer surgeries. Postoperative morbidities were developed in 143 patients. The parameters in the E-PASS system had positive correlations with postoperative morbidity. The overall postoperative morbidity rate of laparoscopic surgeries was lower than open surgeries (19.61% and 28.46%), but the postoperative morbidity rate of laparoscopic surgeries increased more significantly than in open surgery as PRS increased. When PRS was more than 0.7, the postoperative morbidity rate of laparoscopic surgeries would exceed the postoperative morbidity rate of open surgeries.The E-PASS system was capable to evaluate the physiological and surgical risk of colorectal cancer surgery. PRS could assist preoperative decision-making on the surgical method. Colorectal cancer patients who were assessed with a low physiological risk by PRS would be safe to undergo laparoscopic surgery. On the contrary, surgeons should make decisions prudently on the operation method for patient with a high physiological risk.

Implications for determining the optimal treatment for locally advanced rectal cancer in elderly patients aged 75 years and older

Patients were excluded if they were older than 75 years of age in most clinical trials. Thus, the optimal treatment strategies in elderly patients with locally advanced rectal cancer (LARC) are still controversial. We designed our study to specifically evaluate the cancer specific survival of four subgroups of patients according to four different treatment modalities: surgery only, radiation (RT) only, neoadjuvant RT and adjuvant RT by analyzing the Surveillance, Epidemiology, and End Results (SEER)-registered database. The results showed that the 5-year cancer specific survival (CSS) was 52.1% in surgery only, 27.7% in RT only, 70.4% in neoadjuvant RT and 60.4% in adjuvant RT, which had significant difference in univariate log-rank test (P < 0.001) and multivariate Cox regression (P < 0.001). Thus, the neoadjuvant RT and surgery may be the optimal treatment pattern in elderly patients, especially for patients who are medically fit for the operation.

30-day mortality after elective colorectal surgery can reasonably be predicted

BACKGROUND

The aim of the present study was to develop a clinically relevant, accurate and usable risk assessment scoring system solely for colorectal cancer patients undergoing elective resection.

METHODS

All colorectal resections for colorectal cancer 2006-2012 were identified from the American College of Surgeons Quality Improvement Program. Independent risk factors for 30-day mortality after elective surgery were identified using univariable and multivariable logistic regression. A points-calculator based on factors most strongly associated with mortality and accurately predicting risk of mortality was developed.

RESULTS

Fifty-nine thousand nine hundred eighty-six patients underwent elective colorectal cancer surgery, and 1096 (1.8 %) died within 30 days. On multivariable analysis, the strongest risk factors for mortality were age ≥65 years [odds ratio (OR) 2.17, 95 % confidence interval (CI) 1.61-2.92], American Society of Anesthesiologists score ≥3 (OR 1.77, 95 % CI 1.29-2.42), renal failure (OR 3.15, 95 % CI 1.01-9.77), disseminated cancer (OR 2.56, 95 % CI 1.96-3.35), hypoalbuminemia (OR 2.84, 95 % CI 2.21-3.65), preoperative ascites (OR 3.17, 95 % CI 2.07-4.87), heart failure (OR 2.08, 95 % CI 1.35-3.20) and functional status (OR 2.05, 95 % CI 1.56-2.70). A model that accurately predicted risk of mortality was created using forward stepwise logistic regression and externally validated (area under the curve 0.826). This allowed for development of an eight-factor predictive score; maximum points conferred mortality of 96.1 % (p < 0.0001).

CONCLUSIONS

A simple preoperative scoring system predicting 30-day mortality with good capability may allow better preoperative risk assessment, optimization and decision-making.

The Impact of Postoperative Complications on Long-term Oncologic Outcomes After Laparoscopic Low Anterior Resection for Rectal Cancer

Laparoscopic rectal cancer surgery has technical difficulties with a higher complication rate than colon cancer. However, few studies have examined whether postoperative complications are associated with oncologic outcomes. The aim of this study is to evaluate the impact of postoperative complications on long-term oncologic outcomes after laparoscopic low anterior resection for rectal cancer.Between January 2005 and December 2012, we evaluated 686 consecutive patients who underwent laparoscopic low anterior resection for stage I-III rectal cancer. Patients were divided into complication (n = 175) and noncomplication (n = 511) groups. The median follow-up period was 38 months (range, 2-118). We compared perioperative clinicopathologic outcomes, 5-year survival, and local recurrence between groups and evaluated prognostic factors.Five-year overall survival rates were 91.4% and 89.2% (P = 0.234) and 5-year disease-free survival rates were 83.2% and 77.7% (P = 0.002) in the noncomplication and complication groups for all stages, respectively. For stage I cancer, both the 5-year overall survival and the 5-year disease-free survival rate of the complication group were lower than the noncomplication group. Local recurrence rates were 3.1% and 7.8% in the noncomplication and complication groups, respectively (P = 0.002). In multivariate analysis, the presence of postoperative complications was a significant predictor of 5-year disease-free survival (hazard ratio, 1.65; P = 0.012).Postoperative complications had a negative impact on 5-year disease-free survival after laparoscopic low anterior resection for rectal cancer. The rate of local recurrence in the complication group increased more than the noncomplication group. In particular, postoperative complications were associated with poorer oncologic outcomes for stage I cancer. Laparoscopic surgery is preferred for early-stage rectal cancer so careful attention should be paid to avoid postoperative complications.

Complications and risk prediction in treatment of elderly patients with rectal cancer

PURPOSE

The primary aim of this study was to characterise complications, identify predictors of postoperative morbidity and mortality and to evaluate existing risk prediction models in elderly rectal cancer patients.

METHODS

An observational single-centre study of 330 consecutive patients >75 years treated in 1994-2006. Analyses were performed by age group: 75-79 years, 80-85 years and >85 years.

RESULTS

Total observed in-hospital morbidity was 48.7 %. In multivariate analysis, age (OR 1.04, 95 % CI 1.01-1.08, p = 0.04), ASA grade ≥ 3 (p = 0.01), acute presentation (OR 1.67, 95 % CI 1.2-13.2, p = 0.02) and major surgery (APR OR 3.72, 95 % CI 1.37-10.15, p = 0.01, LAR OR 2.98, 95 % CI 1.14-7.79, p = 0.03, Hartmann OR 5.46, 95 % CI 1.60-19.28, p = 0.02) were independent risk factors for postoperative morbidity. The 30-day mortality was 6.3, 6.4 and 14.3 % (p = 0.146) in the three age groups, and the 100-day mortality was 8.7, 10.1 and 22.2 % (p = 0.03), respectively. ASA group 3 (OR 6.21, 95 % CI 4.39-27.69, p = 0.017), ASA group 4 (OR 32.6, 95 % CI 5.12-207.75, p < 0.001) and acute presentation (OR 6.48, 95 % CI 1.62-25.99, p = 0.008) increased the risk of 100-day mortality. The Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) observed/estimated (O/E) ratio for morbidity was 1.05. For 30-day mortality, the colorectal POSSUM (Cr-POSSUM) O/E ratio was 0.74, Surgical Risk Scale 0.61 and the Association of Coloproctology of Great Britain and Ireland (ACPGBI) mortality model 0.63, and for 100-day mortality, ratios were 1.12, 0.91 and 0.95, respectively.

CONCLUSION

In this series, age increased the risk of in-hospital morbidity and 100-day mortality. Cr-POSSUM, SRS and ACPGBI overestimated 30-day mortality but predicted 100-day mortality with a high degree of accuracy. POSSUM correctly predicted in-hospital morbidity.

Risk assessment tools validated for patients undergoing emergency laparotomy: a systematic review

Emergency laparotomies are performed commonly throughout the world, but one in six patients die within a month of surgery. Current international initiatives to reduce the considerable associated morbidity and mortality are founded upon delivering individualised perioperative care. However, while the identification of high-risk patients requires the routine assessment of individual risk, no method of doing so has been demonstrated to be practical and reliable across the commonly encountered spectrum of presentations, co-morbidities and operative procedures. A systematic review of Embase and Medline identified 20 validation studies assessing 25 risk assessment tools in patients undergoing emergency laparotomy. The most frequently studied general tools were APACHE II, ASA-PS and P-POSSUM. Comparative, quantitative analysis of tool performance was not feasible due to the heterogeneity of study design, poor reporting and infrequent within-study statistical comparison of tool performance. Reporting of calibration was notably absent in many prognostic tool validation studies. APACHE II demonstrated the most consistent discrimination of individual outcome across a variety of patient groups undergoing emergency laparotomy when used either preoperatively or postoperatively (area under the curve 0.76-0.98). While APACHE systems were designed for use in critical care, the ability of APACHE II to generate individual risk estimates from objective, exclusively preoperative data items may lead to better-informed shared decisions, triage and perioperative management of patients undergoing emergency laparotomy. Future endeavours should include the recalibration of APACHE II and P-POSSUM in contemporary cohorts, modifications to enable prediction of morbidity and assessment of the impact of adoption of these tools on clinical practice and patient outcomes.

Evaluation of the POSSUM, p-POSSUM, o-POSSUM, and APACHE II scoring systems in predicting postoperative mortality and morbidity in gastric cancer patients

BACKGROUND/OBJECTIVE

Gastric cancer is the fourth most prevalent cancer worldwide. The ability to accurately predict surgery-related morbidity and mortality is critical in deciding both the timing of surgery and choice of surgical procedure. The aim of this study is to compare the POSSUM, p-POSSUM, o-POSSUM, and APACHE II scoring systems for predicting surgical morbidity and mortality in Chinese gastric cancer patients, as well as to create new scoring systems to achieve better prediction.

METHODS

Data from 612 gastric cancer patients undergoing gastrectomy between January 2007 and December 2011 were included in this study. The predictive abilities of the four scoring systems were compared by examining observed-to-expected (O/E) ratios, the receiver operating characteristic curve, Student t test, and χ² test results.

RESULTS

The observed complication rate of 34% (n = 208) did not differ significantly from the rate of 36.6% (n = 208) predicted by the POSSUM scoring system (O/E ratio = 0.93). The observed mortality rate was 2.9% (n = 18). For predicting mortality, POSSUM had an O/E ratio of 0.34 as compared with p-POSSUM (O/E ratio = 0.91), o-POSSUM (O/E ratio = 1.26), and APACHE II (O/E ratio = 0.28).

CONCLUSION

The POSSUM scoring system performed well with respect to predicting morbidity risk following gastric cancer resection. For predicting postoperative mortality, p-POSSUM and o-POSSUM exhibited superior performance relative to POSSUM and APACHE II.

Colorectal surgical mortality and morbidity in elderly patients: comparison of POSSUM, P-POSSUM, CR-POSSUM, and CR-BHOM

PURPOSE

This study aims to compare the predictive value of POSSUM, P-POSSUM, CR-POSSUM and CR-BHOM in colorectal surgical mortality and morbidity in patients over 80 years old.

METHODS

This is a retrospective observational longitudinal study. A total of 991 patients who underwent major colorectal surgery between 2008 and 2012 in a secondary hospital in Portugal were screened, and 204 who were over 80 years old were included. Subgroup analysis was performed for malignant/benign disease and emergent/elective surgery. The main outcome measure was 30-day postoperative mortality and morbidity with Clavien-Dindo classification ≥ 2.

RESULTS

Of the 204 patients included in this study, 155 had malignant disease, and 65 underwent emergent procedures. Overall average age was 84.3 ± 3.9 years (range 80-100). Overall surgical mortality and morbidity were 18.6% (n = 38) and 52.4% (n = 87), respectively. Expected mortality followed the order P-POSSUM<CR-POSSUM<CR-BHOM (p < 0.001), and expected morbidity followed the order POSSUM<CR-BHOM (p < 0.001) in all groups. All scores were higher in the emergent surgery group compared with elective surgery (p < 0.05). All scores had sensitivity below 60%. Physiology scores were higher among patients with surgical mortality (p < 0.05), with no differences in operative scores.

CONCLUSIONS

In our population, CR-POSSUM was the best predictor of surgical mortality. POSSUM and P-POSSUM underestimated surgical mortality and morbidity, and CR-BHOM overestimated surgical mortality, being however the best predictor of morbidity. Nevertheless, none of the scores showed sufficient discriminatory power to have clinical application value. Moreover, our results suggest that, in elderly patients, it is the patient's health status and not the type of surgery that is mainly responsible for the surgical outcome.

Model for risk adjustment of postoperative mortality in patients with colorectal cancer

Background

A model was developed for risk adjustment of postoperative mortality in patients with colorectal cancer in order to make fair comparisons between healthcare providers. Previous models were derived in relatively small studies with the use of suboptimal modelling techniques.

Methods

Data from adults included in a national study of major surgery for colorectal cancer were used to develop and validate a logistic regression model for 90-day mortality. The main risk factors were identified from a review of the literature. The association with age was modelled as a curved continuous relationship. Bootstrap resampling was used to select interactions between risk factors.

Results

A model based on data from 62 314 adults was developed that was well calibrated (absolute differences between observed and predicted mortality always smaller than 0·75 per cent in deciles of predicted risk). It discriminated well between low- and high-risk patients (C-index 0·800, 95 per cent c.i. 0·793 to 0·807). An interaction between age and metastatic disease was included as metastatic disease was found to increase postoperative risk in young patients aged 50 years (odds ratio 3·53, 95 per cent c.i. 2·66 to 4·67) far more than in elderly patients aged 80 years (odds ratio 1·48, 1·32 to 1·66).

Conclusion

Use of this model, estimated in the largest number of patients with colorectal cancer to date, is recommended when comparing postoperative mortality of major colorectal cancer surgery between hospitals, clinical teams or individual surgeons.

Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon

BACKGROUND

EMR of advanced mucosal neoplasia (AMN) (ie, sessile or laterally spreading lesions of ≥20 mm) of the colon has become an increasingly popular alternative to surgical resection. However, data regarding safety and mortality of EMR in comparison to surgery are limited.

OBJECTIVE

To compare actual endoscopic with predicted surgical mortality.

DESIGN

Prospective, observational, multicenter cohort study.

SETTING

Academic, high-volume, tertiary-care referral center.

PATIENTS

Consecutive patients referred for EMR.

INTERVENTION EMR MAIN OUTCOME MEASUREMENTS

To predict hypothetical surgical mortality, the Association of Coloproctology of Great Britain and Ireland score, composed of physiological and surgical components, was calculated for each patient. Predicted surgical mortality was then compared with actual outcomes of EMR. The results were validated by an unselected subcohort by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity.

RESULTS

Among 1050 patients with AMN treated by EMR, including patients with a predicted mortality rate of greater than 5% (13.8% of cohort), no deaths occurred within 30 days after the procedure. The predicted surgical mortality rate was 3.3% with the Association of Coloproctology of Great Britain and Ireland score (P < .0001). This suggests a significant advantage of EMR over surgery. The results were validated by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity in 390 patients predicting a surgical mortality rate of 3.2% (P = .0003).

LIMITATIONS

Nonrandomized study.

CONCLUSION

In this large multicenter study of EMR for colonic AMN, the predicted surgical mortality rate was significantly higher than the actual endoscopic mortality rate. Given that endoscopic therapy is less morbid and less expensive than surgery and can be performed as an outpatient treatment, it should be considered as the first line of treatment for most patients with these lesions.

Postoperative 30-day mortality in patients undergoing surgery for colorectal cancer: development of a prognostic model using administrative claims data

PURPOSE

To develop a prognostic model to predict 30-day mortality following colorectal cancer (CRC) surgery using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked data and to assess whether race/ethnicity, neighborhood, and hospital characteristics influence model performance.

METHODS

We included patients aged 66 years and older from the linked 2000-2005 SEER-Medicare database. Outcome included 30-day mortality, both in-hospital and following discharge. Potential prognostic factors included tumor, treatment, sociodemographic, hospital, and neighborhood characteristics (census-tract-poverty rate). We performed a multilevel logistic regression analysis to account for nesting of CRC patients within hospitals. Model performance was assessed using the area under the receiver operating characteristic curve (AUC) for discrimination and the Hosmer-Lemeshow goodness-of-fit test for calibration.

RESULTS

In a model that included all prognostic factors, important predictors of 30-day mortality included age at diagnosis, cancer stage, and mode of presentation. Race/ethnicity, census-tract-poverty rate, and hospital characteristics were independently associated with 30-day mortality, but they did not influence model performance. Our SEER-Medicare model achieved moderate discrimination (AUC = 0.76), despite suboptimal calibration.

CONCLUSIONS

We developed a prognostic model that included tumor, treatment, sociodemographic, hospital, and neighborhood predictors. Race/ethnicity, neighborhood, and hospital characteristics did not improve model performance compared with previously developed models.

Predicting postoperative mortality after colorectal surgery: a novel clinical model

AIM

The aim of this study was to develop and externally validate a clinically, practical and discriminative prediction model designed to estimate in-hospital mortality of patients undergoing colorectal surgery.

METHOD

All consecutive patients who underwent elective or emergency colorectal surgery from 1990 to 2005, at the Zaandam Medical Centre, The Netherlands, were included in this study. Multivariate logistic regression analysis was performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) linking the explanatory variables to the outcome variable in-hospital mortality, and a simplified Identification of Risk in Colorectal Surgery (IRCS) score was constructed. The model was validated in a population of patients who underwent colorectal surgery from 2005 to 2011 in Barcelona, Spain. Predictive performance was estimated by calculating the area under the receiver operating characteristic curve.

RESULTS

The strongest predictors of in-hospital mortality were emergency surgery (OR = 6.7, 95% CI 4.7-9.5), tumour stage (OR = 3.2, 95% CI 2.8-4.6), age (OR = 13.1, 95% CI 6.6-26.0), pulmonary failure (OR = 4.9, 95% CI 3.3-7.1) and cardiac failure (OR = 3.7, 95% CI 2.6-5.3). These parameters were included in the prediction model and simplified scoring system. The IRCS model predicted in-hospital mortality and demonstrated a predictive performance of 0.83 (95% CI 0.79-0.87) in the validation population. In this population the predictive performance of the CR-POSSUM score was 0.76 (95% CI 0.71-0.81).

CONCLUSIONS

The results of this study have shown that the IRCS score is a good predictor of in-hospital mortality after colorectal surgery despite the relatively low number of model parameters.

Risk model for right hemicolectomy based on 19,070 Japanese patients in the National Clinical Database

BACKGROUND

Right hemicolectomy is a very common procedure throughout the world, although this procedure is known to carry substantial surgical risks. The present study aimed to develop a risk model for right hemicolectomy outcomes based on a nationwide internet-based database.

METHODS

The National Clinical Database (NCD) collected records on over 1,200,000 surgical cases from 3,500 Japanese hospitals in 2011. After data cleanup, we analyzed 19,070 records regarding right hemicolectomy performed between January 2011 and December 2011.

RESULTS

The 30-day and operative mortality rates were 1.1 and 2.3 %, respectively. The 30-day mortality rates of patients after elective and emergency surgery were 0.7 and 6.0 %, respectively (P < 0.001). The odds ratios of preoperative risk factors for 30-day mortality were: platelet <50,000/μl, 5.6; ASA grade 4 or 5, 4.0; acute renal failure, 3.2; total bilirubin over 3 mg/dl, 3.1; and AST over 35 U/l, 3.1. The odds ratios for operative mortality were: previous peripheral vascular disease, 3.1; cancer with multiple metastases, 3.1; and ASA grade 4 or 5, 2.9. Sixteen and 26 factors were selected for risk models of 30-day and operative mortality, respectively. The c-index of both models was 0.903 [95 % confidence interval (CI) 0.877-0.928; P < 0.001] and 0.891 (95 % CI 0.873-0.908; P < 0.001), respectively.

CONCLUSION

We performed the first reported risk stratification study for right hemicolectomy based on a nationwide internet-based database. The outcomes of right hemicolectomy in the nationwide population were satisfactory. The risk models developed in this study will help to improve the quality of surgical practice.

The challenge of education in colorectal cancer surgery: a comparison of early oncological results, morbidity, and mortality between residents and attending surgeons performing an open right colectomy

OBJECTIVES

Ongoing education in surgical oncology is mandatory in a modern residency program. Achieving acceptable morbidity and mortality rates, together with oncological adequacy, is mandatory. The aim of the study was to compare early surgical outcomes in 2 groups of patients, those operated on by a surgical resident supervised by an attending surgeon and those operated on by 2 attending surgeons.

DESIGN

Data from consecutive patients with right colon cancer undergoing a right hemicolectomy were collected and analyzed. The patients were divided into 2 groups according to the surgeons' credentials: residents supervised by an attending surgeon and 2 attending surgeons. To evaluate the specific case mix of the 2 groups, the Portsmouth-Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (P-POSSUM) was calculated. Observed over expected 30-day morbidity and mortality rates were compared for the 2 groups. The number of lymph nodes retrieved was chosen to determine oncological appropriateness. Duration of the procedures was also recorded.

RESULTS

From January 2008 to January 2012, 139 patients underwent an right hemicolectomy (76 resections performed by surgical residents and 63 by attending surgeons). Patient characteristics according to the P-POSSUM score and cancer stage were equivalent in the 2 groups. Observed over expected mortality and morbidity rates according to P-POSSUM were 0%/3.5% and 21.6%/40.5%, respectively, for the resident group (p = nonsignificant, p = 0.01) and 4.7%/5.8% and 25.4%/42.9%, respectively, for the attending surgeons (p = nonsignificant). The node count was 23.6 nodes for residents and 23.1 for the attending surgeons. The length of surgery was 159.9 minutes vs 159.4 minutes for residents and attending surgeons, respectively.

CONCLUSIONS

Surgical oncology training of residents by expert surgeons cannot put patient's safety at risk. Our study showed that oncological accuracy and the 30-day complication rate were equivalent to the standard of care in both groups. Duration of the procedure was not affected by the presence of a trainee.

Impact of pre-storage and bedside filtered leukocyte-depleted blood transfusions on infective morbidity after colorectal resection: a single-center analysis of 437 patients

BACKGROUND

Leukocyte-depleted blood transfusions were introduced to reduce transfusion-associated immunomodulation, but the clinical effects of different types of leukocyte depletion have been analyzed rarely. The aim of this survey was to analyze the clinical impact of pre-storage leukocyte-depleted blood transfusions (considered as pre-storage or bedside-filtered) on post-operative complications in patients undergoing elective or urgent colorectal resection.

METHODS

Data were collected retrospectively from the medical records of 437 consecutive patients who underwent colorectal resection from 2005 to 2010. All patients requiring transfusion received pre-storage or bedside-filtered leukocyte-depleted red blood cell concentrates according to availability at the blood bank. The outcomes were measured by the analysis of post-operative morbidity in patients receiving the different types of transfusions or having other potentially predictive risk factors.

RESULTS

The overall morbidity rate, infective morbidity rate, and non-infective morbidity rate were, respectively, 35.6%, 28.1%, and 21.0%. Two hundred five patients (46.9%) received peri-operative transfusions. On multivariable analysis, leukocyte-depleted transfusion (odds ratio [OR] 3.33; 95% confidence interval [CI] 2.14-5.20; p<0.001) and both pre-storage (OR 2.82; 95% CI 1.73-4.59; p<0.001) and bedside-filtered (OR 4.69; 95% CI 2.54-8.67; p<0.001) transfusions were independent factors for post-operative morbidity. Prolonged operation (p=0.035), American Society of Anesthesiologists score≥3 points (p=0.023), diagnosis of cancer rather than benign disease (p=0.022), and urgent operation (p=0.020) were other independent predictors of post-operative complications. Patients transfused with bedside-filtered blood showed significantly higher rates of infective complications (51.4% vs. 31.8%; p=0.006), but not non-infectious complications (35.7% vs. 32.6; p=0.654) than patients who received pre-storage transfusions.

CONCLUSIONS

Leukocyte-depleted blood transfusions and, in particular, bedside-filtered blood have a significant negative effect on infectious complications after colorectal resection.

Recalibration and validation of a preoperative risk prediction model for mortality in major colorectal surgery

BACKGROUND

In 2009, Barwon Health designed a risk stratification model for mortality in major colorectal surgery with the use of only preoperative risk factors. The Barwon Health 2009 model was shown to predict mortality reliably, and it was comparable to other models, such as the original, POSSUM. However, the Barwon Health 2009 model was never validated with data other than those used to develop the model.

OBJECTIVE

The aim of this study was to perform temporal and external validation of the Barwon Health 2009 model and to compare it with other published models.

DESIGN

: The temporal validation was a prospective observational study, whereas the external validation was a retrospective observational study. The discrimination and calibration of the models were assessed by using the area under receiver operator characteristic and χ test of Hosmer-Lemeshow goodness-of-fi technique.

SETTINGS

This is a multi-institutional study. Data were collected from 2008 to 2010.

RESULTS

There were 474 major colorectal cases at Geelong Hospital (temporal validation) and 389 cases at Western Hospital (external validation). The overall mortality rate was 5.10% and 1.03%. In the comparison of the 2 demographics, Geelong Hospital had a higher proportion of patients who were older and had higher ASA scores and comorbidity counts, whereas Western Hospital surgeons were operating on a higher number of urgent cases. Despite the differences, the Barwon Health 2009 model was able to discriminate mortality reliably (area under receiver operator characteristic = 0.753) but had poor model calibration (p < 0.001) on temporal validation. Hence, the model was recalibrated to predict mortality accurately(area under receiver operator characteristic = 0.772; p = 0.83), and this was successfully validated at Western Hospital (area under receiver operator characteristic = 0.788; p = 0.24).

CONCLUSIONS

We have developed a model that can accurately predict mortality after major colorectal surgery by using only data that are available preoperatively. After recalibration, the model was successfully validated in a second hospital.

Estimates of cancer burden in Trentino-Alto Adige

Aims and background

The Trentino-Alto Adige region is composed of two autonomous provinces (Trento and Bolzano), each with its own cancer registry. The registries' total coverage is 100% of the regional population. The main difference between the two provinces in terms of cancer epidemiology is related to the prostate cancer incidence and survival, with higher values in Bolzano. This paper provides an update until 2015 of the basic epidemiological indicators for seven major cancers for the entire region.

Methods

The indicators were estimated by means of the MIAMOD method, a statistical back-calculation approach to derive incidence and prevalence figures starting from mortality and relative survival data. Mortality data were provided by ISTAT for the period 1970—2002 while survival was modeled on the basis of published data from the Italian cancer registries.

Results

The estimates for 2012 show that breast cancer was the most common cancer in women and prostate cancer was most common in men. Incidence and mortality were decreasing for cervix cancer and stomach cancer in both genders during the whole study period. The lung cancer incidence and mortality were decreasing in men but increasing in women. The colorectal cancer incidence rose in both genders while the mortality was decreasing in women. The incidence of skin melanoma increased in both sexes, while the mortality remained very low. The breast cancer incidence was increasing up to 2015 while the mortality was declining since 1986. The prostate cancer incidence increased up to 2006, thereafter the rates stabilized while mortality started to decrease in the early 2000s. The highest mortality rates were estimated for lung cancer in men and breast cancer in women.

Conclusions

Lifestyle plays an important role in cancer trends, as does organized screening for early detection of cervix, breast and colorectal cancer. The provincial data on risk factor distribution and adherence to and coverage of organized screening are satisfactory and their optimization may allow additional benefits in terms of public health.

Estimates of cancer burden in Lombardy

Aims and background

Cancer registration in Lombardy covers almost half of the regional population and started in 1976 in the Varese province. The aim of this paper is to provide estimates of the incidence, mortality and prevalence of seven major cancers for the entire Lombardy region in the period 1970—2015.

Methods

The estimates were obtained by applying the MIAMOD method, a statistical back-calculation approach to derive incidence and prevalence figures starting from mortality and relative survival data. Published data from the Italian cancer registries were modeled in order to estimate the regional cancer survival.

Results

In Lombardy, about 9,000 new cases of breast cancer, 8,500 of colorectal cancer, 7,200 of prostate cancer and 6,700 of lung cancer were expected to be diagnosed in the year 2012. Incidence rates are still rising for female breast cancer, skin melanoma in both sexes, and lung cancer in women. By contrast, the rates have been declining for cervix and stomach cancer. For lung cancer in men, prostate cancer and colorectal cancer the rates increased, reaching a peak in different periods, and then decreased. Prevalence increased for all cancers considered except cervix cancer. The rise was less pronounced in stomach cancer due to the impressive reduction of its incidence and was striking for breast and prostate cancer, with 116,000 and 58,900 prevalent cases in 2012. Mortality dropped for all considered cancers with the only exception of lung cancer in women.

Conclusion

This up-to-date picture of the cancer risk and burden in Lombardy shows the increasing demand for oncology services as one of the major challenges for the region. However, primary prevention is still the only way to simultaneously reduce incidence, prevalence and mortality rates, thus saving further lives and preserving health resources.

Outcomes of intensive care unit admissions after elective cancer surgery

BACKGROUND

Postoperative care for major elective cancer surgery is frequently provided on the Intensive Care Unit (ICU).

OBJECTIVE

To analyze the characteristics and outcome of patients after ICU admission following elective surgery for different cancer diagnoses.

METHODS

We analyzed all ICU admissions following elective cancer surgery in the Netherlands collected in the National Intensive Care Evaluation registry between January 2007 and January 2012.

RESULTS

28,973 patients (9.0% of all ICU admissions; 40% female) were admitted to the ICU after elective cancer surgery. Of these admissions 77% were planned; in 23% of cases the decision for ICU admission was made during or directly after surgery. The most frequent malignancies were colorectal cancer (25.6%), lung cancer (18.5%) and tumors of the central nervous system (14.3%). Mechanical ventilation was necessary in 24.8% of all patients, most frequently after surgery for esophageal (62.5%) and head and neck cancer (50.2%); 20.7% of patients were treated with vasopressors in the acute postoperative phase, in particular after surgery for esophageal cancer (41.8%). The median length of stay on the ICU was 0.9 days (interquartile ranges [IQR] 0.8-1.5); surgery for esophageal cancer was associated with the longest ICU length of stay (median 2.0 days) with the largest variation (IQR 1.0-4.8 days). ICU mortality was 1.4%; surgery for gastrointestinal cancer was associated with the highest ICU mortality (colorectal cancer 2.2%, pancreatico-cholangiocarcinoma 2.0%).

CONCLUSION

Elective cancer surgery represents a significant part of all ICU admissions, with a short length of stay and low mortality.

Anesthesia and perioperative management of colorectal surgical patients - A clinical review (Part 1)

Colorectal surgery is commonly performed for colorectal cancer and other pathology such as diverticular and inflammatory bowel disease. Despite significant advances, such as laparoscopic techniques and multidisciplinary recovery programs, morbidity and mortality remain high and vary among surgical centers. The use of scoring systems and assessment of functional capacity may help in identifying high-risk patients and predicting complications. An understanding of perioperative factors affecting colon blood flow and oxygenation, suppression of stress response, optimal fluid therapy, and multimodal pain management are essential. These fundamental principles are more important than any specific choice of anesthetic agents. Anesthesiologists can significantly contribute to enhance recovery and improve the quality of perioperative care.

Predicting outcome following colorectal cancer surgery using a colorectal biochemical and haematological outcome model (Colorectal BHOM)

AIM

To present a new biochemistry and haematology outcome model which uses a minimum dataset to model outcome following colorectal cancer surgery, a concept previously shown to be feasible with arterial operations.

METHOD

Predictive binary logistic regression models (a mortality and morbidity model) were developed for 704 patients who underwent colorectal cancer surgery over a 6-year period in one hospital. The variables measured included 30-day mortality and morbidity. Hosmer-Lemeshow goodness of fit statistics and frequency tables compared the predicted vs the reported number of deaths. Discrimination was quantified using the c-index.

RESULTS

There were 573 elective and 131 nonelective interventional cases. The overall mean predicted risk of death was 7.79% (50 patients). The actual number of reported deaths was also 50 patients (χ(2) = 1.331, df = 4, P-value = 0.856; no evidence of lack of fit). For the mortality model, the predictive c-index was = 0.810. The morbidity model had less discriminative power but there was no evidence of lack of fit (χ(2) = 4.198, df = 4, P-value = 0.380, c-index = 0.697).

CONCLUSIONS

The Colorectal Biochemistry and Haematology Outcome mortality model suggests good discrimination (c-index > 0.8) and uses only a minimal number of variables. However, it needs to be tested on independent datasets in different geographical locations.

Evaluation of modified estimation of physiologic ability and surgical stress in colorectal carcinoma surgery

BACKGROUND

We recently modified Estimation of Physiologic Ability and Surgical Stress, our prediction scoring system.

OBJECTIVE

This study evaluated the usefulness of our modified version for colorectal carcinoma in comparison with existing models.

DESIGN

This investigation studied a multicenter cohort.

SETTINGS

The study was conducted in regional referral hospitals in Japan.

PATIENTS

Patients were included who underwent elective surgery for colorectal carcinoma.

MAIN OUTCOME MEASURES

Postoperative morbidity, mortality, and predicted mortality rates for original and modified Estimation of Physiologic Ability and Surgical Stress were investigated in 2388 patients in comparison with existing European models.

RESULTS

Among the models, the modified Estimation of Physiologic Ability and Surgical Stress demonstrated the highest discriminatory power in terms of in-hospital mortality (area under receiver operating characteristic curve: 0.84 for Estimation of Physiologic Ability and Surgical Stress, 0.87 for modified Estimation of Physiologic Ability and Surgical Stress, 0.84 for Portsmouth modification of POSSUM, 0.74 for ASA status-based model), as well as 30-day mortality (area under receiver operating characteristic curve: 0.82 for Estimation of Physiologic Ability and Surgical Stress, 0.84 for modified Estimation of Physiologic Ability and Surgical Stress, 0.81 for POSSUM, 0.78 for colorectal POSSUM, 0.76 for Association of Coloproctology of Great Britain and Ireland score). British models, in general, overpredicted postoperative mortality rates by more than 10 times.

LIMITATIONS

The current study analyzed only the Japanese population treated in medium-volume centers.

CONCLUSIONS

Among the models, modified Estimation of Physiologic Ability and Surgical Stress was the most accurate in predicting postoperative mortality in colorectal carcinoma surgery. These findings should be validated in Western populations, because the Japanese population may differ from Western populations in terms of body shape or reserve capacity.

The revised ACPGBI model is a simple and accurate predictor of operative mortality after potentially curative resection of colorectal cancer

BACKGROUND

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) risk-adjustment model for colorectal cancer surgery has been recently revised. The aim of the present study was to compare the performance of the revised ACPGBI model, the original ACPGBI model, P-POSSUM, and CR-POSSUM, in the prediction of operative mortality after resection of colorectal cancer.

METHODS

A total of 423 patients who underwent potentially curative resection of colorectal cancer at a single institution (1997-2007) were included. Data used in the construction of the ACPGBI model was collected prospectively. The models were compared by examining observed to expected (O:E) ratios, the Hosmer-Lemeshow (H-L) goodness-of-fit test, and area under the receiver operator characteristic curve (AUC) analysis.

RESULTS

The 30-day mortality rate was 4%. The performance of the models was as follows: revised ACPGBI model (O:E ratio = 1.05, AUC = 0.73, H-L = 11.02), original ACPGBI model (O:E ratio = 0.58, AUC = 0.76, H-L = 14.23), P-POSSUM (O:E ratio = 0.87, AUC = 0.79, H-L = 10.63), and CR-POSSUM (O:E ratio = 0.63, AUC = 0.84, H-L = 15.84). In subgroup analysis, the revised ACPGBI model performed well in both elective cases (O:E ratio = 1.06) and emergency cases (O:E ratio = 0.91).

CONCLUSIONS

The revised ACPGBI model is simple to construct and accurately predicts operative mortality after potentially curative resection of colorectal cancer.

Predictive value of POSSUM and ACPGBI scoring in mortality and morbidity of colorectal resection: a case-control study

BACKGROUND

Preoperative risk prediction to assess mortality and morbidity may be helpful to surgical decision making. The aim of this study was to compare mortality and morbidity of colorectal resections performed in a tertiary referral center with mortality and morbidity as predicted with physiological and operative score for enumeration of mortality and morbidity (POSSUM), Portsmouth POSSUM (P-POSSUM), and colorectal POSSUM (CR-POSSUM). The second aim of this study was to analyze the accuracy of different POSSUM scores in surgery performed for malignancy, inflammatory bowel diseases, and diverticulitis. POSSUM scoring was also evaluated in colorectal resection in acute vs. elective setting. In procedures performed for malignancy, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) score was assessed in the same way for comparison.

METHODS

POSSUM, P-POSSUM, and CR-POSSUM predictor equations for mortality were applied in a retrospective case-control study to 734 patients who had undergone colorectal resection. The total group was assessed first. Second, the predictive value of outcome after surgery was assessed for malignancy (n = 386), inflammatory bowel diseases (n = 113), diverticulitis (n = 91), and other indications, e.g., trauma, endometriosis, volvulus, or ischemia (n = 144). Third, all subgroups were assessed in relation to the setting in which surgery was performed: acute or elective. In patients with malignancy, the ACPGBI score was calculated as well. In all groups, receiver operating characteristic (ROC) curves were constructed.

RESULTS

POSSUM, P-POSSUM, and CR-POSSUM have a significant predictive value for outcome after colorectal surgery. Within the total population as well as in all four subgroups, there is no difference in the area under the curve between the POSSUM, P-POSSUM, and CR-POSSUM scores. In the subgroup analysis, smallest areas under the ROC curve are seen in operations performed for malignancy, which is significantly worse than for diverticulitis and in operations performed for other indications. For elective procedures, P-POSSUM and CR-POSSUM predict outcome significantly worse in patients operated for carcinoma than in patients with diverticulitis. In acute surgical interventions, CR-POSSUM predicts mortality better in diverticulitis than in patients operated for other indications. The ACPGBI score has a larger area under the curve than any of the POSSUM scores. Morbidity as predicted by POSSUM is most accurate in procedures for diverticulitis and worst when the indication is malignancy.

CONCLUSION

The POSSUM scores predict outcome significantly better than can be expected by chance alone. Regarding the indication for surgery, each POSSUM score predicts outcome in patients operated for diverticulitis or other indications more accurately than for malignancy. The ACPGBI score is found to be superior to the various POSSUM scores in patients who have (elective) resection of colorectal malignancy.

Risk-adjusted scoring systems in colorectal surgery

Consequent to recent advances in surgical techniques and management, survival rate has increased substantially over the last 25 years, particularly in colorectal cancer patients. However, post-operative morbidity and mortality from colorectal cancer vary widely across the country. Therefore, standardised outcome measures are emphasised not only for professional accountability, but also for comparison between treatment units and regions. In a heterogeneous population, the use of crude mortality as an outcome measure for patients undergoing surgery is simply misleading. Meaningful comparisons, however, require accurate risk stratification of patients being analysed before conclusions can be reached regarding the outcomes recorded. Sub-specialised colorectal surgical units usually dedicated to more complex and high-risk operations. The need for accurate risk prediction is necessary in these units as both mortality and morbidity often are tools to justify the practice of high-risk surgery. The Acute Physiology And Chronic Health Evaluation (APACHE) is a system for classifying patients in the intensive care unit. However, APACHE score was considered too complex for general surgical use. The American Society of Anaesthesiologists (ASA) grade has been considered useful as an adjunct to informed consent and for monitoring surgical performance through time. ASA grade is simple but too subjective. The Physiological & Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and its variant Portsmouth POSSUM (P-POSSUM) were devised to predict outcomes in surgical patients in general, taking into account of the variables in the case-mix. POSSUM has two parts, which include assessment of physiological parameters and operative scores. There are 12 physiological parameters and 6 operative measures. The physiological parameters are taken at the time of surgery. Each physiological parameter or operative variable is sub-divided into three or four levels with an exponentially increasing score. However, POSSUM and P-POSSUM over-predict mortality in patients who have had colorectal surgery. Discrepancies in these models have led to the introduction of a specialty-specific POSSUM: the ColoRectal POSSUM (CR-POSSUM). CR-POSSUM only uses six physiological parameters and four operative measures for prediction of mortality. It is much simplified to allow ease of use.

A systematic review of POSSUM and its related models as predictors of post-operative mortality and morbidity in patients undergoing surgery for colorectal cancer

INTRODUCTION

The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model and its Portsmouth (P-POSSUM) and colorectal (CR-POSSUM) modifications are used extensively to predict and audit post-operative mortality and morbidity. This aim of this systematic review was to assess the predictive value of the POSSUM models in colorectal cancer surgery.

METHODS

Major electronic databases, including Medline, Embase, Cochrane Library and Pubmed were searched for original studies published between 1991 and 2010. Two independent reviewers assessed each study against inclusion and exclusion criteria. All data was specific to colorectal cancer surgery. Predictive value was assessed by calculating observed to expected (O/E) ratios.

RESULTS

Nineteen studies were included in final review. The mortality analysis included ten studies (4,799 patients) on POSSUM, 17 studies (6,576 patients) on P-POSSUM and 14 studies (5,230 patients) on CR-POSSUM. Weighted O/E ratios for mortality were 0.31 (CI 0.31-0.32) for POSSUM, 0.90 (CI 0.88-0.92) for P-POSSUM and 0.64 (CI 0.63-0.65) for CR-POSSUM. The morbidity analysis included four studies (768 patients) on POSSUM with a weighted O/E ratio of 0.96 (CI 0.94-0.98).

CONCLUSIONS

P-POSSUM was the most accurate model for predicting post-operative mortality after colorectal cancer surgery. The original POSSUM model was accurate in predicting post-operative complications.

The relationship between patient physiology, the systemic inflammatory response and survival in patients undergoing curative resection of colorectal cancer

Background:

It is increasingly recognised that host-related factors may be important in determining cancer outcome. The aim was to examine the relationship between patient physiology, the systemic inflammatory response and survival after colorectal cancer resection.

Methods:

Patients undergoing potentially curative resection of colorectal cancer were identified from a prospectively maintained database. Patient physiology was assessed using the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) criteria. The systemic inflammatory response was assessed using the modified Glasgow Prognostic Score (mGPS). Multivariate 5-year survival analysis was carried out with calculation of hazard ratios (HR).

Results:

A total of 320 patients were included. During follow-up (median 74 months), there were 136 deaths: 83 colorectal cancer related and 53 non-cancer related. Independent predictors of cancer-specific survival were age (HR: 1.46, P<0.01), Dukes stage (HR: 2.39, P<0.001), mGPS (HR: 1.78, P<0.001) and POSSUM physiology score (HR: 1.38, P=0.02). Predictors of overall survival were age (HR: 1.64, P<0.001), smoking (HR: 1.52, P=0.02), Dukes stage (HR: 1.64, P<0.001), mGPS (HR: 1.60, P<0.001) and POSSUM physiology score (HR: 1.27, P=0.03). A relationship between mGPS and POSSUM physiology score was also established (P<0.006).

Conclusion:

The POSSUM physiology score and the systemic inflammatory response are strongly associated and both are independent predictors of cancer specific and overall survival in patients undergoing potentially curative resection of colorectal cancer.

Preoperative evaluation and risk management

All colorectal operations carry significant associated risk. To facilitate the best outcomes it is essential to perform a comprehensive evaluation of patient risk preoperatively. Once risk factors are identified the appropriate steps must be taken to minimize their effects. The evaluation of the patient can be broken down by organ systems such as cardiac, pulmonary, hepatic, renal, and gastrointestinal. Additionally, one can assess whether the patient is at risk for infection, hyperglycemia, malnutrition, venous thromboembolism, and anemia. There are many preemptive steps that can be taken to improve patient outcomes in all of these categories.

Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients

BACKGROUND

Several scores have been developed to evaluate surgical unit mortality and morbidity. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and derivatives use preoperative and intraoperative factors, whereas the Surgical Risk Scale (SRS) and Association Française de Chirurgie (AFC) score use four simple factors. To allow for advanced age in patients undergoing colorectal surgery, a dedicated score-the Elderly (E) POSSUM-has been developed and its accuracy compared with these scores.

METHODS

From 2002 to 2004, 1186 elderly patients, at least 65 years old, undergoing major colorectal surgery in France were enrolled. Accuracy was assessed by calculating the area under the receiver operating characteristic curve (AUC) (discrimination) and calibration.

RESULTS

The mortality and morbidity rates were 9 and 41 per cent respectively. The E-POSSUM had both a good discrimination (AUC = 0.86) and good calibration (P = 0.178) in predicting mortality and a reasonable discrimination (AUC = 0.77) and good calibration (P = 0.166) in predicting morbidity. The E-POSSUM was significantly better at predicting mortality and morbidity than the AFC score (P(c) = 0.014 and P(c) < 0.001 respectively).

CONCLUSION

The E-POSSUM is a good tool for predicting mortality, and the only efficient scoring system for predicting morbidity after major colorectal surgery in the elderly.

[Postoperative mortality risk factors in colorectal cancer: follow up of a cohort in a specialised unit]

INTRODUCTION

The treatment of colorectal cancer (CRC) is usually surgical and involves morbidity-mortality. The aim of this study is to quantify the postoperative mortality in our hospital and to determine their risk factors.

MATERIALS AND METHODS

Prospective observational study from 1996 to 2007 included 1017 patients who underwent surgery for CRC in our hospital. Identification of independent risk factors for postoperative mortality by multivariate analysis.

RESULTS

The mean age was 67.8 years. The surgery was elective in 879 (86.5%) and was considered curative in 878 (86.1%). The postoperative mortality was 3.6% (37 patients), 2.5% in the elective surgery and 10.9% in the urgent. The independent risk factors identified were: type of surgery (odds ratio for urgent vs. elective=2.8), American Society of Anesthesiologists (ASA) grade (odds ratio for ASA III-IV vs. I-II=2.4), age (odds ratio for age > or = 85 vs. < or = 74=7.6 and age 75-84 vs. < or = 74=2.4).

CONCLUSIONS

We found a low postoperative mortality, which was mainly associated with age over 75 years, ASA III or IV stages and urgent surgery.

Perioperative outcome of colorectal cancer and validation of CR-POSSUM in a Caribbean country

OBJECTIVE

To evaluate the risk-adjusted perioperative outcome of colorectal cancer surgery, applying the Colorectal Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (CR-POSSUM).

METHODS

A retrospective chart review of patients who underwent colorectal cancer surgery from 2004 to 2007 was done. Data including demographics and physiological data for CR-POSSUM were recorded. Predicted mortality was calculated; validation of CR-POSSUM was done using Hosmer-Lemeshow goodness-of-fit and Receiver Operating Characteristic (ROC) Curve analyses.

RESULTS

232 patients were studied. The overall mean CR-POSSUM score was 18.3+/-3.8 (SD). Predicted mortality was 7.7%, observed mortality was 6.9% and the standardized mortality ratio was 0.9. 34.4% of patients presented with Duke's Stage C or D and had a higher risk of mortality (Odds Ratio (OR) 3.1, 95% Confidence Intervals (CI) 1.1, 9.1). Emergency surgery was associated with a higher risk of mortality (OR 4.7, 95% CI 1.5, 14.1). CR-POSSUM calibrated well (Hosmer-Lemeshow Chi-square value 4.3; df: 8; p=0.82) and fairly discriminated outcome as shown by the area under the ROC Curve 0.69, (Standard Error: 0.07).

CONCLUSIONS

Perioperative outcome of colorectal surgery in Trinidad and Tobago is comparable to the developed countries as evaluated by the CR-POSSUM. Patients presenting for emergency surgery and those with advanced stages of cancer had higher perioperative mortality.

Can elderly patients with colorectal cancer tolerate planned surgical treatment? A practical approach to a common dilemma

AIM

Analysing the effectiveness of a surgical procedure is mandatory in every modern health-care system. The aging of the population stresses the need for a good standard of care. This study tests the hypothesis that porthsmouth-physiologic operative severity score for enumeration of morbidity and mortality (P-POSSUM) and colorectal-POSSUM (CR-POSSUM) would be useful clinical auditing tools in colorectal cancer surgery for aged patients.

METHOD

One hundred and seventy-seven consecutive patients over 70 years of age underwent emergency or elective surgery from January 2003 to December 2005. Demographic, clinical and surgical information, score systems' prediction, complications and 30-day mortality data were prospectively entered in a comprehensive database. The observed over expected morbidity and mortality rate was calculated.

RESULTS

Thirty-day observed mortality was 10.3% (19/177) while P-POSSUM and CR-POSSUM expected mortality were, respectively, 11.21% (P = NS) and 13.08% (P = NS). Overall observed morbidity was 42.7%, P-POSSUM prediction was 59.3% (P = 0.002). Morbidity and mortality data were analysed for specific subgroups of patients (resection and anastomosis/resection and stoma/palliative; emergency/elective).

CONCLUSION

P-POSSUM and CR-POSSUM are useful tools to predict mortality in elderly patients. P-POSSUM significantly overestimated the risk of complications. A more accurate tool for preoperative assessment for aged patients is probably needed to predict the post-surgical outcome.