Comparison of POSSUM scoring systems and the surgical risk scale in patients undergoing surgery for complicated diverticular disease

Emergency Surgery in Acute Diverticulitis: A Systematic Review

BACKGROUND

Acute diverticulitis is a common disease with public health significance. Many studies with a high level of evidence have been published recently on the surgical management of acute diverticulitis.

OBJECTIVE

The aim of this systematic review was to define the accurate surgical management of acute diverticulitis.

DATA SOURCES

Medline, Embase, and the Cochrane Library were sources used.

STUDY SELECTION

One reviewer conducted a systematic study with combinations of key words for the disease and the surgical procedure. Additional studies were searched in the reference lists of all included articles. The results of the systematic review were submitted to a working group composed of 13 practitioners. All of the conclusions were obtained by full consensus and validated by an external committee.

INTERVENTIONS

The interventions assessed were laparoscopic peritoneal lavage, primary resection with anastomosis with or without ileostomy, and the Hartmann procedure, with either a laparoscopic or an open approach.

MAIN OUTCOME MEASURES

Morbidity, mortality, long-term stoma rates, and quality of life were measured.

RESULTS

Seventy-one articles were included. Five guidelines were retrieved, along with 4 meta-analyses, 14 systematic reviews, and 5 randomized controlled trials that generated 8 publications, all with a low risk of bias, except for blinding. Laparoscopic peritoneal lavage showed concerning results of deep abscesses and unplanned reoperations. Studies on Hinchey III/IV diverticulitis showed similar morbidity and mortality. A reduced length of stay with Hartmann procedure compared with primary resection with anastomosis was reported in the short term, and in the long term, more definite stoma along with poorer quality of life was reported with Hartmann procedure. No high-quality data were found to support the laparoscopic approach.

LIMITATIONS

Trials specifically assessing Hinchey IV diverticulitis have not yet been completed.

CONCLUSIONS

High-quality studies showed that laparoscopic peritoneal lavage was associated with an increased morbidity and that Hartmann procedure was associated with poorer long-term outcomes than primary resection with anastomosis with ileostomy, but Hartmann procedure is still acceptable, especially in high-risk patients.

The applicability of POSSUM and P-POSSUM scores as predictors of morbidity and mortality in colorectal surgery

OBJECTIVE

to apply the POSSUM and P-POSSUM scores as a tool to predict morbidity and mortality in colorectal surgery.

METHODS

we conducted a prospective cohort study of 551 patients submitted to colorectal surgery in a colorectal surgery tertiary referral hospital in Brazil. We grouped patients into pre-established risk categories for comparison between expected and observed morbidity and mortality rates by the POSSUM and P-POSSUM scores.

RESULTS

in the POSSUM morbidity analysis, the overall expected morbidity was significantly higher than that observed (39.2% vs. 15.6%). The same occurred with patients grouped in categories II (28.9% x 10.5) and III (64.6% x 24.5%). In category I, the expected and observed morbidities were similar (13.7% x 9.1%). Regarding the evaluation of mortality, it was statistically higher than that observed in category III patients and in the total number of patients (11.3% vs. 5.6%). In categories I and II, we observed the same pattern of category III, but without statistical significance. When evaluating mortality by the P-POSSUM score, the overall expected and observed mortality was similar (5.8% x 5.6%). Of the 31 patients who died, 20.2% underwent emergency procedures and sepsis was the main cause of death.

CONCLUSION

the P-POSSUM score was an accurate tool to predict mortality and could be safely used in this population profile, unlike the POSSUM score.

O-POSSUM score predicts morbidity and mortality in patients undergoing hip fracture surgery

PURPOSE

The aim of this study is to evaluate the O-POSSUM score capacity to predict the morbidity and mortality of patients undergoing hip fracture surgery.

MATERIAL AND METHODS

We retrospectively reviewed the clinical records of patients older than 65years old, operated on for hip fractures between January 2012 and December 2013. Of 229 patients, the mean age was 82.3years and 170 were women. We collected comorbidities, type of surgery, and expected morbidity and mortality O-POSSUM values.

RESULTS

After a minimum follow up of one year, 38 deaths were reported and 77 patients had complications. The expected mortality according to the O-POSSUM was 35 patients and expected morbidity 132.

CONCLUSION

By comparing the observed results with those predicted, the O-POSSUM scale is reliable in predicting mortality and overestimates morbidity.

The HARM score for gastrointestinal surgery: Application and validation of a novel, reliable and simple tool to measure surgical quality and outcomes

BACKGROUND

The HospitAl length of stay, Readmissions and Mortality (HARM) score is a simple, inexpensive quality tool, linked directly to patient outcomes. We assess the HARM score for measuring surgical quality across multiple surgical populations.

METHODS

Upper gastrointestinal, hepatobiliary, and colorectal surgery cases between 2005 and 2009 were identified from the Healthcare Cost and Utilization Project California State Inpatient Database. Composite and individual HARM scores were calculated from length of stay, 30-day readmission and mortality, correlated to complication rates for each hospital and stratified by operative type.

RESULTS

71,419 admissions were analyzed. Higher HARM scores correlated with higher complication rates for all cases after risk adjustment and stratification by operation type, elective or emergent status.

CONCLUSIONS

The HARM score is a simple and valid quality measurement for upper gastrointestinal, hepatobiliary and colorectal surgery. The HARM score could facilitate benchmarking to improve patient outcomes and resource utilization, and may facilitate outcome improvement.

What is the predictor of surgical mortality in adult colorectal perforation? The clinical characteristics and results of a multivariate logistic regression analysis

PURPOSE

Colorectal perforations are a serious condition associated with a high mortality. The aim of this study was to describe the clinical characteristics and identify predictors for the surgical mortality in adult patients with colorectal perforation, thereby achieving better outcomes.

METHODS

A retrospective study of adult patients diagnosed with colorectal perforation operated was performed. The clinical variables that might influence the surgical mortality were first analyzed, and the significant variables were then analyzed using a logistic regression model.

RESULTS

A total of 423 patients were identified, and the surgical mortality rate was 36.9 %. The most common etiology was diverticulitis (38.2 %). The highest etiology-specific mortality was for colorectal cancer (61.5 %) and ischemic proctocolitis (59.8 %). In a logistic analysis, the significant predictors for the surgical mortality were ≥3 comorbidities (p = 0.034), preoperation American Society of Anesthesiologists score ≥4 (p = 0.025), preoperative sepsis or septic shock (p < 0.001), colorectal cancer or ischemic proctocolitis (p = 0.035), reoperation (p = 0.041), and Hinchey classification grade IV (p = 0.024).

CONCLUSION

We demonstrated that ≥3 comorbidities, a preoperation American Society of Anesthesiologists score ≥4, preoperative sepsis or septic shock, colorectal cancer or ischemic proctocolitis, reoperation, and Hinchey classification grade IV are predictors for the surgical mortality in the adult cases of colorectal perforation. These predictors should be taken into consideration to prevent surgical mortality and to reduce potentially unnecessary medical expenses.

The current status of emergent laparoscopic colectomy: a population-based study of clinical and financial outcomes

BACKGROUND

Population-based studies evaluating laparoscopic colectomy and outcomes compared with open surgery have concentrated on elective resections. As such, data assessing non-elective laparoscopic colectomies are limited. Our goal was to evaluate the current usage and outcomes of laparoscopic in the urgent and emergent setting in the USA.

METHODS

A national inpatient database was reviewed from 2008 to 2011 for right, left, and sigmoid colectomies in the non-elective setting. Cases were stratified by approach into open or laparoscopic groups. Demographics, perioperative clinical variables, and financial outcomes were compared across each group.

RESULTS

A total of 22,719 non-elective colectomies were analyzed. The vast majority (95.8 %) was open. Most cases were performed in an urban setting at non-teaching hospitals by general surgeons. Colorectal surgeons were significantly more likely to perform a case laparoscopic than general surgeons (p < 0.001). Demographics were similar between open and laparoscopic groups; however, the disease distribution by approach varied, with significantly more severe cases in the open colectomy arm (p < 0.001). Cases performed laparoscopically had significantly better mortality and complication rates. Laparoscopic cases also had significantly improved outcomes, including shorter length of stay and hospital costs (all p < 0.001).

CONCLUSIONS

Our analysis revealed less than 5 % of urgent and emergent colectomies in the USA are performed laparoscopically. Colorectal surgeons were more likely to approach a case laparoscopically than general surgeons. Outcomes following laparoscopic colectomy in this setting resulted in reduced length of stay, lower complication rates, and lower costs. Increased adoption of laparoscopy in the non-elective setting should be considered.

Postoperative complications in elderly patients with colorectal cancer: comparison of open and laparoscopic surgical procedures

BACKGROUND

Surgery is associated with higher morbidity and mortality rates in elderly patients with colorectal cancer compared with younger patients. The aim of this study was to examine preoperative evaluation for selecting operative procedure in elderly patients with colorectal cancer.

METHODS

The study of all patients who underwent open surgery (OS) or laparoscopically assisted surgery (LAS) for colorectal cancer from January 2004 to December 2007 were aged > or =71 years. Preoperative evaluation, operative factors, morbidity, and mortality were analyzed by the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) and Prognostic Nutritional Index (PNI).

RESULTS

A total of 129 patients were included in this study. Fifty-one patients underwent OS, and LAS was performed on 78 patients. The morbidity rate was 51.3% (40 patients) for the OS group and 23.5% (12 patients) for the LAS group. Three LAS patients (5.9%) subsequently required OS. One LAS patient died postoperatively. There were significant differences in the Operative Severity Score (OSS) in POSSUM and PNI, but not Physiologic Score (PS) in POSSUM, between the two groups. In the OS group, there were significant differences in PS, OSS, and PNI between those with or without complications, whereas in the LAS group, OSS, but not PS or PNI, was significantly lower in those without than in those with complications.

CONCLUSIONS

Compared with OS, LAS is associated with a lower incidence of complications in elderly patients with colorectal cancer. The nutritional status correlated with postoperative complications in the OS group.

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.

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.

Laparoscopic peritoneal lavage or primary anastomosis with defunctioning stoma for Hinchey 3 complicated diverticulitis: results of a comparative study

PURPOSE

This study was designed to compare postoperative outcomes of laparoscopic peritoneal lavage and open primary anastomosis with defunctioning stoma in the management of Hinchey 3 diverticulitis.

METHODS

From 1994 to 2006, 35 patients underwent laparoscopic peritoneal lavage for Hinchey 3 diverticulitis in three institutions. Data prospectively collected were compared with those of a retrospective series of 24 patients matched for Hinchey's classification and who underwent primary anastomosis with defunctioning stoma.

RESULTS

There was no postoperative death. Postoperative morbidity was not different between the two groups. One patient in the laparoscopic peritoneal lavage group required a Hartmann's procedure because of a colonic fistula. One patient in the primary anastomosis with defunctioning stoma group underwent a reoperation for incisional dehiscence. The median hospital stay was lower in patients treated by laparoscopic peritoneal lavage (8 vs. 17 days, P < 0.0001). Twenty-five patients in the laparoscopic peritoneal lavage group underwent elective laparoscopic resection. One of them required conversion to laparotomy. All patients in the primary anastomosis with defunctioning stoma group have had their ileostomy closed. Cumulative surgical morbidity (16 vs. 37.5 percent, P = 0.0507) and hospital stay (14 vs. 23 days, P < 0.0001) were lower in the laparoscopic peritoneal lavage group.

CONCLUSION

In the management of Hinchey 3 diverticulitis, laparoscopic peritoneal lavage does not result in excess morbidity or mortality, it reduces the length of hospital stay and avoids a stoma in most patients, and it is, therefore, a reasonable alternative to primary anastomosis with defunctioning stoma.

Can SAPS II predict operative mortality more accurately than POSSUM and P-POSSUM in patients with colorectal carcinoma undergoing resection?

BACKGROUND

This study assessed the APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score-II), POSSUM (Physiologic and Operative Severity Score for Enumeration of Morbidity and Mortality), and P-POSSUM (Portsmouth-POSSUM) in patients with colorectal cancer undergoing curative or palliative resection.

METHODS

Predicted mortality rates and the observed/expected mortality ratio were computed by means of each scoring system. The results were compared between survivors and nonsurvivors and between elective and emergency operations. Each model was assessed for its accuracy to predict the risk of death using receiver operator characteristic (ROC) curve analysis, and risk stratification was generated as well.

RESULTS

Some 224 patients were enrolled in the study. The overall 30-day mortality rate was 3.6% (n = 8). Predicted mortality rates generated by APACHE II, SAPS II, POSSUM, and P-POSSUM were 9.1%, 3.7%, 13.4%, and 5.2%, respectively. All the scoring systems assigned higher scores to those patients who died than to those who survived. Areas under the curve calculated by ROC curve analysis for APACHE II, SAPS II, POSSUM, and P-POSSUM were 0.786, 0.854, 0.793, and 0.831, respectively. Best stratification was achieved by the SAPS II score.

CONCLUSIONS

SAPS II and P-POSSUM were determined to be better predictors for patients with colorectal cancer undergoing resection. SAPS II also was found to have a higher degree of discriminatory power in colorectal resection for carcinoma. The predictive value of this useful severity score in several surgical subgroups must be examined to evaluate its routine use in risk-adjusted audit.

Complicated diverticular disease of the colon, do we need to change the classical approach, a retrospective study of 110 patients in southeast England

BACKGROUND

Complicated diverticular disease of the colon imposes a serious risk to patient's life, challenge to surgeons and has cost implications for health authority. The aim of this study is to evaluate the management outcome of complicated colonic diverticular disease in a district hospital and to explore the current strategies of treatment.

METHODS

This is a retrospective study of all patients who were admitted to the surgical ward between May 2002 and November 2006 with a diagnosis of complicated diverticular disease. A proforma of patients' details, admission date, ITU admission, management outcomes and the follow up were recorded from the patients case notes and analyzed. The mean follow-up was 34 months (range 6-60 months)

RESULTS

The mean age of patients was 72.7 years (range 39-87 years). Thirty-one men (28.18 %) and Seventy-nine women (71.81%) were included in this study. Male: female ratio was 1:2.5.Sixty-eight percent of patients had one or more co-morbidities. Forty-one patients (37.27%) had two or more episodes of diverticulitis while 41.8% of them had no history of diverticular disease.Eighty-six percent of patients presented with acute abdominal pain while bleeding per rectum was the main presentation in 14%. Constipation and erratic bowel habit were the commonest chronic symptoms in patients with history of diverticular disease. Generalized tenderness was reported in 64.28% while 35.71% have left iliac fossa tenderness. Leukocytosis was reported in 58 patients (52.72%).The mean time from the admission until the start of operative intervention was 20.57 hours (range 4-96 hours). Perforation was confirmed in 59.52%. Mortality was 10.90%. Another 4 (3.63%) died during follow up for other reasons.

CONCLUSION

Complicated diverticular disease carries significant morbidity and mortality. These influenced by patient-related factors. Because of high mortality and morbidities, we suggest the need to target a specific group of patients for prophylactic resection.

Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann's procedures

OBJECTIVE

To compare primary resection and anastomosis (PRA) with and without defunctioning stoma to Hartmann's procedure (HP) as the optimal operative strategy for patients presenting with Hinchey stage III-IV, perforated diverticulitis.

SUMMARY BACKGROUND DATA

The choice of operation for perforated diverticulitis lies between HP and PRA. Postoperative mortality and morbidity can be high, and the long-term consequences life-altering, with no established criteria guiding clinicians towards selecting a particular procedure.

METHODS

Probability estimates for 6879 patients with Hinchey III-IV perforated diverticulitis were obtained from two databases (n = 204), supplemented by expert opinion and summary data from 12 studies (n = 6675) published between 1980 and 2005. The primary outcome was quality-adjusted life-years (QALYs) gained from each strategy. Factors considered were the risk of permanent stoma, morbidity, and mortality from the primary or reversal operations. Decision analysis from the patient's perspective was used to calculate the optimal operative strategy and sensitivity analysis performed.

RESULTS

A total of 135 PRA, 126 primary anastomoses with defunctioning stoma (PADS), and 6619 Hartmann's procedures (HP) were considered. The probability of morbidity and mortality was 55% and 30% for PRA, 40% and 25% for PADS, and 35% and 20% for HP, respectively. Stomas remained permanent in 27% of HP and in 8% of PADS. Analysis revealed the optimal strategy to be PADS with 9.98 QALYs, compared with 9.44 QALYs after HP and 9.02 QALYs after PRA. Complications after PRA reduced patients QALYs to a baseline of 2.713. Patients with postoperative complications during both primary and reversal operations for PADS and HP had QALYs of 0.366 and 0.325, respectively. HP became the optimal strategy only when risk of complications after PRA and PADS reached 50% and 44%, respectively.

CONCLUSION

Primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis as may represent a good compromise between postoperative adverse events, long-term quality of life and risk of permanent stoma. HP may be reserved for patients with risk of complications >40% to 50% after consideration of long-term implications.