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

Usefulness of scoring systems in outcome prediction for older cancer patients undergoing abdominal surgery

BACKGROUND

Several postoperative outcome scoring systems have been developed and validated, combining both pre- and intraoperative factors. Among others are the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), the Estimation of Physiologic Ability and Stress (E-PASS) and the Surgical Apgar Score combined with the American Society of Anesthesiologists physical status classification (SASA). The aim of this study was to compare the above scoring systems in the prediction of 30-day postoperative outcome in older patients with cancer undergoing abdominal surgery.

METHODS

Consecutive patients ≥70 years were prospectively enrolled. Pre- and intraoperative variables were used to calculate the scores, the ROC and perform logistic regression analysis.

RESULTS

The study sample comprised 201 patients with a median age of 77 (range 70-93) years. The most common surgical procedure was for colorectal (75%), followed by gastric (10.4%) pancreas (7.0%), gall bladder (3.5%), small bowel (2.5%), and other (1.5%) types of cancer. All scores were independent predictors of 30-day postoperative mortality. In case of 30-day morbidity only SASA turned to be significant. The ROC curves were highly valid and area under the curve showed fair to good discriminatory ability (0.60-0.77) for 30-day postoperative mortality and fair (AUC 0.6) in case of SASA for the 30-day postoperative.

CONCLUSION

The SASA, E-PASS, and P-POSSUM were confirmed to be predictive of 30-day postoperative mortality in older patients undergoing abdominal elective cancer surgery. Only SASA demonstrated as independent factor predicting postoperative 30-day major morbidity.

Is there a role for specialized geriatric centers in treating geriatric cancer patients?

As the population with colorectal cancer ages, the tailored approach required to manage older patients becomes all the more important for all providers and institutions treating colorectal cancer to adopt and improve the outcomes and well-being of this important and increasingly prevalent population. Joint guidelines from the American College of Surgeons and American Geriatric Association should be followed. Older cancer patients undergoing colorectal cancer surgery should be referred to centers with expertise in minimally invasive surgery. Likewise, older rectal cancer patients should be referred to centers with expertise in treating rectal cancer.

Highly stable near-infrared dye conjugated cerasomes for fluorescence imaging-guided synergistic chemo-photothermal therapy of colorectal cancer

Dye-conjugated cerasome loaded with DOX exhibited high stability and controllable drug release, holding great promise in colorectal cancer photothermal chemotherapy.

Post-Acute Care among Older Adults with Stage I to III Colorectal Cancer

BACKGROUND

Little information is available on the long-term use of post-acute care among older patients with colorectal cancer (CRC), relative to individuals without cancer. This study examines the use of post-acute care among older cancer survivors (>65 y) with CRC and compares it with noncancer patients up to 5 years from surgery.

DESIGN

Retrospective cohort.

SETTING

SEER-Medicare.

PARTICIPANTS

Patients treated for stage I to III CRC between January 1, 2000, and December 31, 2011 (n = 40 812) and noncancer Medicare beneficiaries hospitalized for noncancer treatment matching on age, sex, race, comorbidity, and Medicaid dual eligibility.

MEASUREMENTS

Incident post-acute care claims (skilled nursing, long-term care facility, and home health) from 0 to 100 days, 101 to 365 days, and 1 to 5 years from hospitalization.

RESULTS

The median age was 77 years. All patients had surgery, 34% received chemotherapy, and 27% received surgery and adjuvant therapy. The cumulative incidence of any post-acute care within 100 days of hospitalization was 45.7% for stage III, 37.9% for stage I/II, and 39% for controls (p < .001). Within the CRC cohort only, the cumulative incidence of post-acute care was 2.9% (stage I/II) and 4.2% (stage III, p < .001) from 101 to 365 days and 15.8% (stage I/II) and 16.9% (stage III, p < .001) from 1 to 5 years. Increasing age, ostomies, and neoadjuvant or adjuvant therapy were associated with increased hazard of all post-acute patients within 100 days from hospitalization. From 1 to 5 years from diagnosis, adjuvant therapy was associated with greater exclusive home health care use.

CONCLUSIONS

Survivorship planning among older CRC patients should include discussions of post-acute care following cancer therapy, even several years after treatment. J Am Geriatr Soc 67:937-944, 2019.

Comparison of long-term outcome between hemicolectomy and partial colectomy in the elderly: a large population-based study

Due to large progress has been achieved in surgical techniques, anesthesia and perioperative care, it is accepted that the very elderly colon cancer (CC) patient is not contraindication for surgery. However, it is a controversy that an extended or a less aggressive surgical approach should be performed for this population. Here, we identified 28110 CC patients aged ≥80 from Surveillance, Epidemiology, and End-Results (SEER) database. The surgical approaches included extended hemicolectomy (HC) and partial colectomy (PC). 5-year cancer specific survival (CSS) was obtained. Kaplan-Meier methods and Cox regression models were used to assess the correlations between prognostic factors and long-term survival. The 5-year CSS for patients treated with HC were 45.6%, which were similar to patients who received PC (44.8%), the survival difference has no statistical significance (P=0.087). The result following propensity score matching further confirmed long-term survival were equal between HC and PC. However, patients in AJCC T3/T4 stage and with tumor size ≥5cm could obtain survival benefit from the extended surgery. In conclusion, most of elderly CC patients could not obtain survival benefit from extended resection. Partial colectomy should also be considered as an alternative approach for this group of patients.

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.

A systematic review of outcome reporting in colorectal cancer surgery

AIM

Evaluation of surgery for colorectal cancer (CRC) is necessary to inform clinical decision-making and healthcare policy. The standards of outcome reporting after CRC surgery have not previously been considered.

METHOD

Systematic literature searches identified randomized and nonrandomized prospective studies reporting clinical outcomes of CRC surgery. Outcomes were listed verbatim, categorized into broad groups (outcome domains) and examined for a definition (an appropriate textual explanation or a supporting citation). Outcome reporting was considered inconsistent if results of the outcome specified in the methods were not reported. Outcome reporting was compared between randomized and nonrandomized studies.

RESULTS

Of 5644 abstracts, 194 articles (34 randomized and 160 nonrandomized studies) were included reporting 766 different clinical outcomes, categorized into seven domains. A mean of 14 ± 8 individual outcomes were reported per study. 'Anastomotic leak', 'overall survival' and 'wound infection' were the three most frequently reported outcomes in 72, 60 and 44 (37.1%, 30.9% and 22.7%) studies, respectively, and no single outcome was reported in every publication. Outcome definitions were significantly more often provided in randomized studies than in nonrandomized studies (19.0% vs 14.9%, P = 0.015). One-hundred and twenty-seven (65.5%) papers reported results of all outcomes specified in the methods (randomized studies, n = 21, 61.5%; nonrandomized studies, n = 106, 66.2%; P = 0.617).

CONCLUSION

Outcome reporting in CRC surgery lacks consistency and method. Improved standards of outcome measurement are recommended to permit data synthesis and transparent cross-study comparisons.

Personalized surgical management of colorectal cancer in elderly population

Colorectal cancer (CRC) in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population. In this phase of the life cycle, treatment is frequently suboptimal. Despite the fact that, nowadays, older people tend to be healthier than in previous generations, surgical undertreatment is frequently encountered. On the other hand, surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability. Unfortunately, due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors (heterogeneity, frailty, etc.), there is a dearth of evidence-based clinical guidelines for the management of these patients. The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly. More than in any other patient group, both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC. Although cure and sphincter preservation are the primary goals, many other variables need to be taken into account, such as maintenance of cognitive status, independence, life expectancy and quality of life.

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.

Colorectal cancer treatment and follow-up in the elderly: an inexplicably different approach

The incidence of colorectal cancer increases as age progresses. At present, elderly patients have received substandard cancer treatment not supported by "evidence." Geriatric assessment should be performed preoperatively and selected elderly patients must be offered standard surgical treatment receiving the same complementary therapies as a younger patient. It should be stressed that elderly patients should not be deprived of their decision-making role. In our experience, more than 43% of patients with colorectal cancer are ≥70 years of age, and we believe that they should receive the same type of follow-up. This would allow for the detection and removal of polyps, treatment of malignant tumors, and psychological support similarly to younger patients. Significantly, in our experience, the incidence of reoperation for neoplastic disease is similar in the two patient populations.

Predictive value of the POSSUM, p-POSSUM, cr-POSSUM, APACHE II and ACPGBI scoring systems in colorectal cancer resection

This study investigated the ability of the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) scoring system to predict postoperative morbidity (complication rate) and compared the ability of POSSUM and four other scoring systems (Portsmouth POSSUM [p-POSSUM], colorectal POSSUM [cr-POSSUM], Association of Coloproctology of Great Britain and Ireland [ACPGBI] and Acute Physiology and Chronic Health Evaluation II [APACHE II]) to predict mortality within 30 days in 1695 patients undergoing surgery for colorectal cancer. Receiver operating characteristic (ROC) curve, Student's t-test and the χ(2)-test were used to estimate the predictive ability of these scoring systems. The observed complication rate of 38.7% was not significantly different to the rate of 36.3% predicted by the POSSUM scoring system (observed : expected [O : E] ratio 1.07). The observed mortality rate was 3.0%. For predicting mortality, POSSUM had an O : E ratio of 0.37, compared with p-POSSUM O : E ratio 1.00, cr-POSSUM O : E ratio 0.91, APACHE II O : E ratio 0.31 and ACPGBI O : E ratio 1.41. It was concluded that the POSSUM scoring system had high value for predicting the risk of morbidity following colorectal cancer resection. For predicting postoperative mortality, p-POSSUM, cr-POSSUM and ACPGBI were superior to POSSUM and APACHE II, however ROC curve analysis showed that cr-POSSUM and ACPGI discriminated best between survivors and non-survivors, so were more accurate predictors of postoperative mortality than the other three scoring systems.

Impact of age on outcome after colorectal cancer surgery in the elderly - a developing country perspective

BACKGROUND

Colorectal cancer (CRC) is a major source of morbidity and mortality in the elderly population and surgery is often the only definitive management option. The suitability of surgical candidates based on age alone has traditionally been a source of controversy. Surgical resection may be considered detrimental in the elderly solely on the basis of advanced age. Based on recent evidence suggesting that age alone is not a predictor of outcomes, Western societies are increasingly performing definitive procedures on the elderly. Such evidence is not available from our region. We aimed to determine whether age has an independent effect on complications after surgery for colorectal cancer in our population.

METHODS

A retrospective review of all patients who underwent surgery for pathologically confirmed colorectal cancer at Aga Khan University Hospital, Karachi between January 1999 and December 2008 was conducted. Using a cut-off of 70 years, patients were divided into two groups. Patient demographics, tumor characteristics and postoperative complications and 30-day mortality were compared. Multivariate logistic regression analysis was performed with clinically relevant variables to determine whether age had an independent and significant association with the outcome.

RESULTS

A total of 271 files were reviewed, of which 56 belonged to elderly patients (≥ 70 years). The gender ratio was equal in both groups. Elderly patients had a significantly higher comorbidity status, Charlson score and American society of anesthesiologists (ASA) class (all p < 0.001). Upon multivariate analysis, factors associated with more complications were ASA status (95% CI = 1.30-6.25), preoperative perforation (95% CI = 1.94-48.0) and rectal tumors (95% CI = 1.21-5.34). Old age was significantly associated with systemic complications upon univariate analysis (p = 0.05), however, this association vanished upon multivariate analysis (p = 0.36).

CONCLUSION

Older patients have more co-morbid conditions and higher ASA scores, but increasing age itself is not independently associated with complications after surgery for CRC. Therefore patient selection should focus on the clinical status and ASA class of the patient rather than age.

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.

A Preliminary Audit Experience of Surgery for Rectal Cancer after Neoadjuvant Chemoradiation Therapy

Aims and background

A surgical audit is a systematic critical analysis of surgical performance, with the goal to improve the quality of patient care. Rectal cancer surgery is one of the most delicate procedures in the field of surgical oncology, with significant variations in terms of complications from center to center. Neoadjuvant chemoradiation therapy leads to a significant reduction in local recurrences in patients with locally advanced lower and medium rectal cancer. The aim of the study was to evaluate the influence of neoadjuvant chemoradiation therapy on postoperative morbidity and mortality in patients with rectal cancer.

Methods and study design

From January 1,2003, to December 31, 2007, patients who underwent elective surgical resection for lower and medium rectal cancer in our Surgical Unit were prospectively analyzed. Patients (n = 42) were divided into two groups: 1) those treated with neoadjuvant chemotherapy and consequent surgical resection (19/42); 2) those treated with primary surgical treatment (23/42). P-POSSUM (Portsmouth Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity) and CR-POSSUM (ColoRectal-POSSUM) scores were calculated for each patient group. Thirty-day mortality and morbidity rates were prospectively collected in a comprehensive data base. Data were evaluated by comparing the predictions of the two scoring systems in both study groups with clinically observed mortality and morbidity rates.

Results

In group 1, no death was registered (0/19). The P-POSSUM and CR-POSSUM expected mortality was 2.43% and 4.52%, respectively (P >0.05). In group 2, a single death was documented (1/23, 4.35%). The P-POSSUM and CR-POSSUM expected mortality was 2.1% and 4.94%, respectively. The postoperative complications rate for group 1 was 10.52% (2/19) compared to 34.88% as expected from the P-POSSUM score (P <0.05). In group 2, a postoperative complication rate of 39.13% (9/23) was observed compared to 34.26% as expected from the P-POSSUM score (P >0.05).

Conclusions

No significant influence on morbidity or mortality was detected in patients who underwent neoadjuvant radio-chemotherapy.

Predicting post-operative mortality in patients undergoing colorectal surgery using P-POSSUM and CR-POSSUM scores: a prospective study

INTRODUCTION

POSSUM and its variants Portsmouth POSSUM (P-POSSUM) and Colorectal POSSUM (CR-POSSUM) equations were derived from a heterogeneous general surgical population, which have been used successfully to provide risk-adjusted operative mortality rates. CR-POSSUM utilises fewer parameters, allowing ease of use. The aim of this study was to predict the mortality outcome in colorectal surgery using these scoring systems compared to the observed mortality and to devise a new scoring system with improved accuracy.

METHODS

The study was conducted prospectively on all consecutive patients requiring elective and emergency colorectal surgery between April 2002 and May 2005. The outcome parameter was defined as 30-day mortality. The observed mortality was compared with predicted mortality by the scoring systems. Hosmer and Lemeshow test was used to assess statistical accuracy of POSSUM.

RESULTS

Eight hundred ninety-nine patients underwent colorectal surgery during the study period. There were 619 elective and 281 emergency patients. Observed 30-day mortality rate was 9%, compared with predicted mortality rate of 13.5% with POSSUM, 5% with P-POSSUM and 9.5% with CR-POSSUM.

CONCLUSION

POSSUM's mortality rate was overestimated, while P-POSSUM's mortality rate was underestimated. CR-POSSUM, the simplest system of all three, most accurately predicted mortality in our unit.