Abstract
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.
Similar content being viewed by others
References
Whiteley MS, Prytherch DR, Higgins B, Weaver PC, Prout WG (1996) An evaluation of the POSSUM surgical scoring system. Br J Surg 83(6):812–815
Copeland GP, Jones D, Walters M (1991) POSSUM: a scoring system for surgical audit. Br J Surg 78(3):355–360
Farooq N, Patterson AJ, Walsh SR, Prytherch DR, Justin TA, Tang TY (2011) Predicting outcome following colorectal cancer surgery using a colorectal biochemical and haematological outcome model (colorectal BHOM). Colorectal Dis 13(11):1237–1241
Tekkis PP, Prytherch DR, Kocher HM, Senapati A, Poloniecki JD, Stamatakis JD, Windsor AC (2004) Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM). Br J Surg 91(9):1174–1182
Menon KV, Farouk R (2002) An analysis of the accuracy of P-POSSUM scoring for mortality risk assessment after surgery for colorectal cancer. Colorectal Dis 4(3):197–200
Tekkis PP, Kessaris N, Kocher HM, Poloniecki JD, Lyttle J, Windsor AC (2003) Evaluation of POSSUM and P-POSSUM scoring systems in patients undergoing colorectal surgery. Br J Surg 90(3):340–345
Bromage SJ, Cunliffe WJ (2007) Validation of the CR-POSSUM risk-adjusted scoring system for major colorectal cancer surgery in a single center. Dis Colon Rectum 50(2):192–196
Hariharan S, Chen D, Ramkissoon A, Taklalsingh N, Bodkyn C, Cupidore R, Ramdin A, Ramsaroop A, Sinanan V, Teelucksingh S, Verma S (2009) Perioperative outcome of colorectal cancer and validation of CR-POSSUM in a Caribbean country. Int J Surg 7(6):534–538
Leung E, Ferjani AM, Stellard N, Wong LS (2009) Predicting post-operative mortality in patients undergoing colorectal surgery using P-POSSUM and CR-POSSUM scores: a prospective study. Int J Colorectal Dis 24(12):1459–1464
Tez M, Yoldas O, Gocmen E, Kulah B, Koc M (2006) Evaluation of P-POSSUM and CR-POSSUM scores in patients with colorectal cancer undergoing resection. World J Surg 30(12):2266–2269
Yan J, Wang YX, Li ZP (2011) Predictive value of the POSSUM, p-POSSUM, cr-POSSUM, APACHE II and ACPGBI scoring systems in colorectal cancer resection. J Int Med Res 39(4):1464–1473
Horzic M, Kopljar M, Cupurdija K, Bielen DV, Vergles D, Lackovic Z (2007) Comparison of P-POSSUM and Cr-POSSUM scores in patients undergoing colorectal cancer resection. Arch Surg 142(11):1043–1048
Oomen JL, Cuesta MA, Engel AF (2007) Comparison of outcome of POSSUM, p-POSSUM, and cr-POSSUM scoring after elective resection of the sigmoid colon for carcinoma or complicated diverticular disease. Scand J Gastroenterol 42(7):841–847
Senagore AJ, Warmuth AJ, Delaney CP, Tekkis PP, Fazio VW (2004) POSSUM, p-POSSUM, and Cr-POSSUM: implementation issues in a United States health care system for prediction of outcome for colon cancer resection. Dis Colon Rectum 47(9):1435–1441
Vather R, Zargar-Shoshtari K, Adegbola S, Hill AG (2006) Comparison of the possum, P-POSSUM and Cr-POSSUM scoring systems as predictors of postoperative mortality in patients undergoing major colorectal surgery. ANZ J Surg 76(9):812–816
Fukuda N, Wada J, Niki M, Sugiyama Y, Mushiake H (2012) Factors predicting mortality in emergency abdominal surgery in the elderly. World J Emerg Surg 7(1):12
Wakabayashi H, Sano T, Yachida S, Okano K, Izuishi K, Suzuki Y (2007) Validation of risk assessment scoring systems for an audit of elective surgery for gastrointestinal cancer in elderly patients: an audit. Int J Surg 5(5):323–327
Ugolini G, Rosati G, Montroni I, Zanotti S, Manaresi A, Giampaolo L, Blume JF, Taffurelli M (2009) Can elderly patients with colorectal cancer tolerate planned surgical treatment? A practical approach to a common dilemma. Colorectal Dis 11(7):750–755
Guigoz Y, Vellas B, Garry PJ (1996) Assessing the nutritional status of the elderly: the mini nutritional assessment as part of the geriatric evaluation. Nutr Rev 54(1 Pt 2):S59–S65
Folstein MF, Folstein SE, McHugh PR (1975) “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12(3):189–198
Association of Coloproctology of Great Britain & Ireland (2014) Risk prediction in surgery. http://www.riskprediction.org.uk/index.php. Accessed 2013
Chen T, Wang H, Wang H, Song Y, Li X, Wang J (2013) POSSUM and P-POSSUM as predictors of postoperative morbidity and mortality in patients undergoing hepato-biliary-pancreatic surgery: a meta-analysis. Ann Surg Oncol 20(8):2501–2510
Ferjani AM, Griffin D, Stallard N, Wong LS (2007) A newly devised scoring system for prediction of mortality in patients with colorectal cancer: a prospective study. Lancet Oncol 8(4):317–322
Richards CH, Leitch EF, Anderson JH, McKee RF, McMillan DC, Horgan PG (2011) The revised ACPGBI model is a simple and accurate predictor of operative mortality after potentially curative resection of colorectal cancer. Ann Surg Oncol 18(13):3680–3685
Al-Homoud S, Purkayastha S, Aziz O, Smith JJ, Thompson MD, Darzi AW, Stamatakis JD, Tekkis PP (2004) Evaluating operative risk in colorectal cancer surgery: ASA and POSSUM-based predictive models. Surg Oncol 13(2–3):83–92
Tan KY, Kawamura Y, Mizokami K, Sasaki J, Tsujinaka S, Maeda T, Konishi F (2009) Colorectal surgery in octogenarian patients—outcomes and predictors of morbidity. Int J Colorectal Dis 24(2):185–189
Sheikh AA, Joel AS, Johnson MA, Vimalachandran D (2013) Outcome of colorectal cancer resection in octogenarians. S Afr J Surg 51(2):68–72
Racz J, Dubois L, Katchky A, Wall W (2012) Elective and emergency abdominal surgery in patients 90 years of age or older. Can J Surg 55(5):322–328
Tei M, Ikeda M, Haraguchi N, Takemasa I, Mizushima T, Ishii H, Yamamoto H, Sekimoto M, Doki Y, Mori M (2009) Postoperative complications in elderly patients with colorectal cancer: comparison of open and laparoscopic surgical procedures. Surg Laparosc Endosc Percutan Tech 19(6):488–492
Tsar’kov PV, Nikoda VV, Stamov VI, Markar’ian DR, Tulina IA (2012) The efficacy of the multidisciplinary approach in colorectal cancer surgery in elderly patients. Khirurgiia (Mosk) (2):4–13
Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF (1999) Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA surgical risk study. Arch Surg 134(1):36–42
Koertzen M, Punjabi P, Lockwood G (2013) Pre-operative serum albumin concentration as a predictor of mortality and morbidity following cardiac surgery. Perfusion 28(5):390–394
Lohsiriwat V, Lohsiriwat D, Boonnuch W, Chinswangwatanakul V, Akaraviputh T, Lert-Akayamanee N (2008) Pre-operative hypoalbuminemia is a major risk factor for postoperative complications following rectal cancer surgery. World J Gastroenterol 14(8):1248–1251
Conflict of interest
None of the authors has any conflicts of interest regarding this paper.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Gomes, A., Rocha, R., Marinho, R. et al. Colorectal surgical mortality and morbidity in elderly patients: comparison of POSSUM, P-POSSUM, CR-POSSUM, and CR-BHOM. Int J Colorectal Dis 30, 173–179 (2015). https://doi.org/10.1007/s00384-014-2071-z
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-014-2071-z