POSSUM scoring for laparoscopic cholecystectomy in the elderly

Effect of antithrombotic therapy on postoperative outcome of 538 consecutive emergency laparoscopic cholecystectomies for acute cholecystitis: two Italian center's study

The risk of developing hemorrhagic complications during or after emergency cholecystectomy (EC) for acute cholecystitis (AC) in patients with antithrombotic therapy (ATT) remains uncertain. In this double-center study, we evaluated post-operative outcomes in patients with ATT undergoing EC. We retrospectively evaluated 538 patients who underwent laparoscopic EC for AC between May 2015 and December 2019 at two referral centers. 89 of them (17%) were on ATT. We defined postoperative complication rates, including bleeding, as our primary outcome. Mortality was higher in the ATT group. Morbidity was higher in the ATT group as well; however, the difference was not statistically significant. 12 patients (2%) experienced intraoperative blood loss over 500 ml and ten (2%) had postoperative bleeding complications. Two patients (< 1%) experienced both intraoperative and postoperative bleeding. On multivariate analysis, ATT was not significantly associated with worse postoperative outcomes. Antithrombotic therapy is not an independently associated factor of severe postoperative complications (including bleeding) or mortality. However, these patients still represent a challenging group and must be carefully managed to avoid postoperative bleeding complications.

Preoperative Assessment of Geriatric Surgical Patients: Update on Clinical Scales Used for Elective General and Digestive Surgery

BACKGROUND

Higher life expectancy in the general population entails a growing interest in the surgical management of diseases affecting elderly patients. Preoperative assessment when planning surgery needs to carefully evaluate physical and functional status of the patient. This review aims to describe the most commonly used scales in the evaluation of elderly patients scheduled for surgery and provides a useful tool to decide the scales that would be better to assess these specific patients.

METHODS

According to the PRISMA statement of publications published, we have carried out a systematic review focused on elderly patients who underwent surgical procedures in General and Surgery. Using Medline, Embase, and Cochrane library, a systematic search of the literature from 1992 to 2018 was performed. This enabled us to retrieve information from the selected articles on scales to evaluate medical fitness, functional status, or both, in the elderly or frail patients.

RESULTS

We reviewed 102 articles and selected the most frequently used assessment scales or indexes. After this extensive analysis, we selected 4 functional scales (Katz Index, Barthel Scale, Karnofsky Performance Score, and Vulnerable Elders Survey), 4 clinical scales (American Society of Anaesthesiologists Index, Charlson Comorbidity Index, Pfeiffer Test, and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity Scale) and finally, 2 mixed scales (American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator and Edmonton Frail Scale).

CONCLUSIONS

No consensus on the use of a unified assessment scale for elderly patients exists. However, with this review, we provide a brief guideline about the most useful and used scales to perform a comprehensive assessment of geriatric patients undergoing surgery.

Risk Factors of Postoperative Complications in Laparoscopic Cholecystectomy for Acute Cholecystitis

Introduction:

There are often cases with postoperative complications after laparoscopic cholecystectomy (LC), resulting in severe consequences. This study aimed to identify potential risk factors of postoperative complications in cases of LC for acute cholecystitis.

Materials and Methods:

A total of 423 patients with cholecystitis underwent LC. We divided the patients into two groups: group without postoperative complications (Group A) and group with postoperative complications (Group B). Pre-operative findings, surgical findings, and the methods for evaluating the risk of peri-operative complications were compared between the two groups with a univariate analysis. Independent risk factors of postoperative complications were then evaluated in a multivariate analysis with the factors shown to be statistically significant in the univariate analysis.

Results:

A Physiological and Operative severity Score for enUmeration of Mortality and morbidity (POSSUM) of ≥ 48.3 and moderate or severe cholecystitis were independent risk factors of postoperative complications in LC.

Conclusions:

This study indicated that POSSUM morbidity and moderate or severe cholecystitis were potential risk factors of postoperative complications. The pre-operative management of the general condition and cholecystitis using antibiotics, infusion, percutaneous transhepatic gallbladder drainage, and other approaches may be significant for the prevention of postoperative complications. Once the POSSUM morbidity reaches the threshold after LC, postoperative management becomes difficult, so strict control of the general condition should be performed.

Perioperative outcomes after laparoscopic cholecystectomy in elderly patients: a systematic review and meta-analysis

BACKGROUND

Laparoscopic cholecystectomy is increasingly performed in an ever ageing population; however, the risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population compared to younger patients.

METHOD

A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted including studies reporting laparoscopic cholecystectomy in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were conversion to open surgery, bile leaks, postoperative mortality and length of stay.

RESULTS

This review identified 99 studies incorporating 326,517 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.37, CI95% 2.00-2.78), major complication (OR 1.79, CI95% 1.45-2.20), risk of conversion to open cholecystectomy (OR 2.17, CI95% 1.84-2.55), risk of bile leaks (OR 1.50, CI95% 1.07-2.10), risk of postoperative mortality (OR 7.20, CI95% 4.41-11.73) and was significantly associated with increased length of stay (MD 2.21 days, CI95% 1.24-3.18).

CONCLUSION

Postoperative outcomes such as overall and major complications appear to be significantly higher in all age cut-offs in this meta-analysis. This study demonstrated there is a sevenfold increase in perioperative mortality which increases by tenfold in patients > 80 years old. This study appears to confirm preconceived suspicions of higher risks in elderly patients undergoing cholecystectomy and may aid treatment planning and informed consent.

Safety and outcomes of laparoscopic cholecystectomy in the extremely elderly: a systematic review and meta-analysis

Background: Gallstones are a common cause of morbidity in the elderly. Operative treatment is often avoided due to concerns about poor outcomes but the evidence for this is unclear. We aim to consolidate available evidence assessing laparoscopic cholecystectomy outcomes in the extreme elderly (>80s) compared to younger patients. Methods: Studies comparing laparoscopic cholecystectomy in >80s with younger patients were considered. Total complications, mortality, conversion, bile duct injury, and length of stay were compared between the two groups. Results: Twelve studies including 366,522 patients were included. They were of moderate overall quality. The elderly group had more complicated gallbladder disease and also had more co-morbidities and a higher ASA grade. The risk of morbidity was lower in the younger group (RR 0.58 (95% CI 0.58-0.59)) with a slightly lower risk of conversion (RR 0.96 (0.94-0.98)) Length of stay was significantly longer for the elderly patients. Differences in mortality and bile duct injury were non-significant in all but one study. Conclusion: Laparoscopic cholecystectomy is safe and effective in the extreme elderly. Higher complication rates are predominantly related to increased co-morbidities and more complex gallbladder disease. Patients should be carefully selected, and cholecystectomy performed at an earlier stage to minimize these problems.

Cholecystectomy for acute cholecystitis in octogenarians: impact of advanced age on postoperative outcome

BACKGROUND

The number of surgical operations in elderly patients is increasing due to the aging demographics of western populations. The aim of the present study was to investigate the peri-operative outcome of octogenarian patients undergoing cholecystectomy for acute cholecystitis.

METHODS

We performed a retrospective analysis including all patients who underwent cholecystectomy for acute cholecystitis from January 2013 to December 2017. Records were collected prospectively from two centers: 1) Unit of Emergency Surgery, St. Orsola University Hospital, Alma Mater Studiorum University, Bologna; 2) "Advanced Surgical Technologies" Department of Surgical Sciences, Umberto I University Hospital, La Sapienza University, Rome. Patients were divided by age (≥ or <80 years) and peri-operative outcomes were compared.

RESULTS

During the study period, 464 patients were operated for acute cholecystitis in the two centers. Sixty-three (14%) patients were octogenarians (group 1) and median age was 84.8±3.9 years. Four hundred and one patients (86%) were younger than 80 years (group 2) with median age of 55.3±15.3 years. Forty-four per cent of group-1 patients underwent laparoscopic cholecystectomy versus 81% of the younger group (P<0.01). Elderly patients had a higher percentage of overall complications (25% vs. 9%; P=0.03) and a longer median postoperative length of stay (7.2±6.8 vs. 4.6±7.7; P=0.04). Overall mortality was 1%: two patients died in group-1 and one in group-2 (P=0.50). However, on multivariate analysis age older than 80 years was not found to be an independent risk factor for postoperative morbidity and mortality.

CONCLUSIONS

The results of this study suggest that cholecystectomy for acute cholecystitis in octogenarians is a relatively safe procedure with an acceptable risk of complications and a postoperative hospital stay comparable to younger ones.

Comparison of the risk prediction systems POSSUM and P-POSSUM with the Surgical Risk Scale: A prospective cohort study of 721 patients

INTRODUCTION

The outcomes of surgery are subject to variability and difficult to be accurately predicted. Different score systems have been developed to estimating the risk of undergoing a surgical procedure. The aim of this study was to assess the predictive ability of POSSUM and P-POSSUM scoring systems, compared to the Surgical Risk Scale (SRS), in Spanish patients undergoing general surgery.

PATIENTS AND METHODS

In this prospective observational study, 721 consecutive patients needing a surgical procedure were included. Observed morbidity and mortality after surgery were compared to the expected ones obtained by applying POSSUM, P-POSSUM and SRS.

RESULTS

Mean age was 59.2 years (standard deviation (SD): 17.4 years), 43.5% were women. 616 (85.5%) patients underwent elective general surgery and 105 (14.5%) emergency surgery. The 30-day morbidity was 15.4%. The reintervention rate was 2.1% and mortality was 2.1%. The discrimination ability was excellent in predicting mortality. The Area Under the Curve (AUC) values were: POSSUM: AUC = 0.97, C.I.95%: 0.948-0.992, p < 0.0001; P-POSSUM: AUC = 0.966, C.I.95%: 0.941-0.991, p < 0.0001; SRS: AUC = 0.91, C.I.95%:0.853-0.967, p < 0.0001. POSSUM was also discriminative in the prediction of morbidity (AUC = 0.772, C.I.95%: 0.719-0.826, p < 0.0001). POSSUM predicted morbidity and mortality were higher than the observed ones (p = 0.01 and p = 0.04). Predicted and observed mortality were very similar for P-POSSUM (p = 0.93) and SRS (p = 0.37).

CONCLUSIONS

Expected morbidity and mortality determined by POSSUM score showed values significantly above the observed ones. P-POSSUM and SRS systems were effective in predicting mortality. The SRS application is simple and may contribute to appropriate medical decision making.

POSSUM: A Scoring System for Perforative Peritonitis

BACKGROUND AND OBJECTIVES

Perforative peritonitis carries considerable morbidity and mortality with the postoperative period unpredictable most of the times. It therefore becomes necessary for a scoring system that predicts the post-operative outcome. POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity) helps in predicting the post-operative morbidity and mortality in these patients. POSSUM scores are based on 12 physiological factors and 6 operative factors. In our study, we included two more factors, which are specifically important in perforative peritonitis; they are, perforation to operation time and the presence of co-morbidity. The presence of these factors significantly affects the post-operative status. Through this prospective study, we can predict which patients are at a higher risk of death or complication and give appropriate management as necessary.

MATERIALS AND METHODS

Our sample size was 50 patients with perforative peritonitis. The study was conducted in single unit from September 2013 to August 2014. Data was collected based on POSSUM scoring system. Outcome of the patients was recorded as death / alive; complicated / uncomplicated and statistical analysis was done by comparing the expected and observed outcomes.

RESULTS

By applying linear analysis, an observed to expected ratio of 1.005 was obtained for mortality and 1.001 for morbidity. There was no statistically significant difference between the observed and expected mortality rates (χ(2) = 3.54, p = 0.316) and morbidity rates (χ(2) = 2.40, p = 0.792). It was found to be comparable with other studies. The factors independently studied; perforation to operation time and presence of co-morbidity were statistically significant with respect to outcome (p<0.05).

CONCLUSION

Although a small sample size is the limitation of this study, POSSUM scoring system is a good indicator of postoperative outcome in patients with perforative peritonitis and was applicable in our setup. It is useful in identifying high risk patients and give preferential care to them for better outcome. Inclusion of factors like perforation to operation time and co-morbid status can improve the scoring system and better care can be provided.

Perioperative mortality and morbidity prediction using POSSUM, P-POSSUM and APACHE II in Chinese gastric cancer patients: surgical method is a key independent factor affecting prognosis

INTRODUCTION

Gastric cancer is the fourth most common cancer worldwide. Predicting morbidity and mortality is important in deciding timing of surgery and type of surgery offered. APACHE II, POSSUM, and P-POSSUM are the most reliable scoring methods in use today. This is the first paper to evaluate the utility of all three scoring systems in China.

METHODS

We collected data on 851 patients (583 male and 268 female) who underwent surgery between 1991 and 2011. Physiological and pathological data was entered in spreadsheet format and analyzed using STATA version 11.0 to generate ROC curves for each scoring system.

RESULTS

In predicting mortality, P-POSSUM and POSSUM were most effective and APACHE II was ineffective. POSSUM predicted a higher morbidity risk than was actually encountered. Age and type of operation were found to be independent risk factors for mortality.

DISCUSSION

The utility of the APACHE II score in gastric cancer patients is limited. APACHE II is suitable for considering group versus individual effect. The POSSUM score is useful in general surgery, but needs improvement. We found the P-POSSUM score to be superior for morbidity and mortality prediction. P-POSSUM is useful for both the general population and for a specific cohort. The type of surgery is a key decision point for surgeons, and independently affects prognosis. Based upon these findings and clinical scoring systems, clinicians can develop individualized treatment algorithms.

The need for new "patient-related" guidelines for the treatment of acute cholecystitis

Heterogeneity of patients affected by acute cholecystitis, and their co-morbidities make very difficult to standardize the therapy for this very common condition. The staging system suggested in the recent "Tokyo guidelines", did not show a relevant impact on the management of patients and on the outcome of the disease. The relation among local pathological picture, patient clinical status and treatment algorithm, has to be better studied.

Emergency laparoscopic cholecystectomy in an unselected cohort: a safe and viable option in a specialist centre

INTRODUCTION

Patients presenting acutely with symptomatic gallstone-related disease have historically had their laparoscopic cholecystectomy (LC) deferred due to perceived increased operative risks in the acute setting, particularly conversion to open surgery. The aim of this study was to compare morbidity and mortality between unselected cohorts of patients undergoing elective and 'emergency' LC in a District General Hospital.

METHODS

All gallstone-related elective and emergency admissions under the care of two specialist laparoscopic surgeons during a two-year period were included. Patients admitted acutely with a diagnosis of biliary colic, acute cholecystitis or gallstone pancreatitis underwent 'emergency' LC during the same admission. Data were collected prospectively on patient demographics, inpatient stay, post-operative course and POSSUM scores.

RESULTS

423 patients underwent LC, of which 301 (71.1%) were elective and 122 (28.9%) were 'emergency' procedures. ASA grades and POSSUM physiologic scores were similar between the two groups. The overall morbidity rates were similar in the emergency and elective groups (13.1% vs. 7.3%, p = 0.088), and there was no significant difference in the rates of major complications including conversion to open surgery (0% vs. 0.3%, NS), bile leak or re-operation between the two groups. 30-day mortality rates were similar in the two groups (0.8% vs. 0%, NS).

CONCLUSION

When performed by specialist laparoscopic surgeons, LC in the acute setting is safe with mortality and morbidity rates, including conversion to open surgery, comparable to elective LC.

Patient-related risk factors for postoperative adverse events

PURPOSE OF REVIEW

The risk of adverse outcome in patients undergoing major surgery is affected both by cardiorespiratory fitness, and the presence and severity of comorbidities. Accurate risk stratification is essential for the identification of patients who may benefit from specific perioperative management strategies or from an augmented level of perioperative care. Risk stratification techniques include risk prediction models, assessment of functional capacity and novel biochemical markers. This review examines the evidence for the use of these different techniques in perioperative patients.

RECENT FINDINGS

There remains considerable variation in the predictive ability of risk stratification models, in part due to the subjective nature of some of the component variables. Whereas a basic assessment of functional capacity using structured questionnaires may be helpful, in patients thought to be at high risk, the most accurate technique may be cardiopulmonary exercise testing, although the strength of the hypothesized relationship between functional capacity and perioperative outcome has not been fully defined. There have been advances in the identification and refinement of biochemical markers for risk prediction, in particular, brain natriuretic peptide and C-reactive protein. Currently, few centres routinely systematically utilize these strategies to risk stratify perioperative patients.

SUMMARY

The development of improved risk stratification techniques would be assisted by large-scale epidemiological studies. Improvements to currently used risk prediction models are likely to result from the use of variables which more objectively measure patient health and fitness than current tools, and may use a combination of all the above techniques to improve predictive accuracy.

Systematic review of cholecystostomy as a treatment option in acute cholecystitis

OBJECTIVES

Percutaneous cholecystostomy (PC) is an established low-mortality treatment option for elderly and critically ill patients with acute cholecystitis. The primary aim of this review is to find out if there is any evidence in the literature to recommend PC rather than cholecystectomy for acute cholecystitis in the elderly population.

METHODS

In April 2007, a systematic electronic database search was performed on the subject of PC and cholecystectomy in the elderly population. After exclusions, 53 studies remained, comprising 1918 patients. Three papers described randomized controlled trials (RCTs), but none compared the outcomes of PC and cholecystectomy. A total of 19 papers on mortality after cholecystectomy in patients aged >65 years were identified.

RESULTS

Successful intervention was seen in 85.6% of patients with acute cholecystitis. A total of 40% of patients treated with PC were later cholecystectomized, with a mortality rate of 1.96%. Procedure mortality was 0.36%, but 30-day mortality rates were 15.4 % in patients treated with PC and 4.5% in those treated with acute cholecystectomy (P < 0.001).

CONCLUSIONS

There are no controlled studies evaluating the outcome of PC vs. cholecystectomy and the papers reviewed are of evidence grade C. It is not possible to make definitive recommendations regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis. Low mortality rates after cholecystectomy in elderly patients with acute cholecystitis have been reported in recent years and therefore we believe it is time to launch an RCT to address this issue.

Risk adjusted auditing of postop complications in gastric cancer patients by POSSUM

POSSUM (Physiological and Operative Severity Score for the enUmeration of Morbidity and mortality) has been proposed as a promising system for risk adjusted audit in surgical practice. However it has not been generalized in gastric cancer surgery. Present study evaluates the POSSUM on malignant gastric cases in Chinese hospital where patient population or healthcare system might be different than United Kingdom (UK) where the formula was devised. Total of 389 patients who underwent surgical intervention for gastric cancer and malignant gastric lymphomas during the year 2006 were included in the study. Median age was 58 years, with male:female ratio of 7:3. POSSUM data were collected according to standard criteria described by the original authors. Exponential analysis method was used for morbidity predictions. POSSUM predicted satisfactorily for morbidity, observed morbidity was not significantly different than estimated morbidity (p=0.962). Overall, 176 cases were observed to have postoperative complications (including death). The observed to expect ratio (O:E) was 0.99. There was no significant increase in complication rate with increasing age (chi(2)=3.75, 4 d.f, p=0.44). Overall 176 cases were observed to have postop complications (including death). Age was not a risk factor for early postoperative complication. POSSUM predicted well in this study, which means it is a valid system for gastric cancer surgery. However, overall complication rate considered being higher if it is recorded according to POSSUM criteria. Modification in POSSUM equation with revised morbidity definition may be more feasible for major operations.

Considerations concerning laparoscopic cholecystectomy in the extremely elderly

BACKGROUND

Since octogenarians become a growing part of the population and surgical care is possible in them, this study was conducted to evaluate the outcome of laparoscopic cholecystectomy in patients 80 years of age and over.

METHODS

From June 1993 to May 2006, a total of 1263 patients underwent a laparoscopic cholecystectomy, applying the four-trocar American technique; 21 among them were >/=80 years. We retrospectively reviewed patients' age, gender, indication for surgery, comorbid conditions, American Society of Anesthesiologists (ASA) score, conversion to open procedure, postoperative complications, and length of hospital stay.

RESULTS

The mean age in the >/=80 group was 82.5+/-3 and 57% were women, while in the <80 group 72% of patients were women. Recurrent biliary colic was the most frequent (62%) indication for surgery among the elderly patients. Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed preoperatively in 6 elderly patients (29%); there were 4 cases of acute calculus pancreatitis and 2 cases of acute cholangitis. A high surgical risk (ASA score of III and IV) was estimated in 11 patients (52%) from the >/=80 group versus 32% in the <80 group (P =0.047). Conversion rate was higher (19%) and hospital stay was longer (4.9 days) in the >/=80 group, compared to younger patients (P =0.01). Mortality was zero and morbidity was 14% versus 3% in the <80 group (P =0.03), including 1 case of postoperative bleeding, 1 case of wound infection, and 1 case of pulmonary atelectasis, respectively.

CONCLUSIONS

Laparoscopic cholecystectomy in the extremely elderly is safe and well tolerated; however, it is associated with a higher conversion rate, increased morbidity, and a longer hospital stay.

Sistema POSSUM. Un instrumento de medida de la calidad en el paciente quirúrgico

INTRODUCTION

The POSSUM scale (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) is a scoring system that is used to predict risk-adjusted mortality and morbidity rates in a wide variety of surgical procedures. In this prospective study, the validity of the POSSUM scale was evaluated in patients undergoing laparotomy in a general surgery department.

PATIENTS AND METHODS

The POSSUM scale was prospectively applied in all patients undergoing elective and emergency laparotomy in the general surgery department of a level II hospital over 8 months. A total of 105 patients were included, of which 24 underwent emergency laparotomy and 81 underwent elective surgery. Predicted mortality and morbidity rates were calculated by using the POSSUM scale. These results were compared with actual outcomes by using Fisher's test.

RESULTS

The mean physiological score was 23.4 points (range: 12-40 points), while the mean surgical score was 11.3 points (range: 6-24 points). Three patients died during the postoperative period and 47 had morbidity. When the observed results for mortality were compared with those predicted by the POSSUM scoring system, no significant differences were observed in the analysis by risk groups, except in the risk group < 20 %, in which the POSSUM scale overestimated mortality. The risk of morbidity was underestimated by the POSSUM scale in the risk group < 20 %.

CONCLUSION

The POSSUM scoring system is a useful predictor of morbidity and mortality in patients undergoing emergency and elective laparotomy.