Application of POSSUM and P-POSSUM in Surgical Risk Assessment of Elderly Patients Undergoing Hepatobiliary and Pancreatic Surgery

Figures & data

Table 1 Parameters Used to Calculate the POSSUM Score

Parameters	Physiological Score
	1	2	4	8
Age (years)	≤60	61–70	≥71
Cardiac signs	No failure	Diuretic, digoxin, antianginal, or hypertensive therapy	Peripheral edema, warfarin therapy, or borderline cardiomegaly	Raised jugular venous pressure or cardiomegaly
Respiratory signs	No dyspnea	Dyspnea on exertion, mild chronic obstructive airway disease	Limiting dyspnea (one flight), moderate chronic obstructive airway disease	Dyspnea at rest (rate≥30/min), fibrosis or consolidation
Systolic blood pressure (mmHg)	110–130	131–170 100–109	≥171 90–99	≤89
Pulse (beats/min)	50–80	81–100 40–49	101–120	≥121 ≤39
Glasgow coma score	15	12–14	9–11	≤8
Hemoglobin (g/dL)	13–16	11.5–12.9 16.1–17.0	10.0–11.4 17.1–18.0	≤9.9 ≥18.1
White cell count (10^9/L)	4–10	10.1–20.0 3.1–4.0	≥20.1 ≤3.0
Urea (mmol/L)	≤7.5	7.6–10.0	10.1–15.0	≥15.1
Sodium (mmol/L)	≥136	131–135	126–130	≤125
Potassium (mmol/L)	3.5–5.0	3.2–3.4 5.1–5.3	2.9–3.1 5.4–5.9	≤2.8 ≥6.0
Electrocardiogram	Normal		Atrial fibrillation (rate 60–90)	Any other abnormal rhythm
				or ≥5 ectopics/min or Q waves or ST/T wave changes
Operative severity score
Operative severity	Minor	Moderate	Major	Major+
Multiple procedures	1		2	>2
Total blood loss (mL)	≤100	101–500	501–999	≥1000
Peritoneal soiling	None	Minor (serous fluid)	Local pus	Free bowel contest, pus, or blood
Malignancy	None	Primary only	Nodal metastasis	Distant metastasis
Mode of surgery	Elective		Emergency resuscitation of > 2 h possible, operation < 24 h after admission	Emergency (immediate surgery <2 h needed)

Abbreviation: POSSUM, physiological and operative severity score for the enumeration of mortality and morbidity.

Table 2 Comparison of Predicted and Actual Values of POSSUM and P-POSSUM

Group	Complication Rate (%)	No. of Complications	Mortality (%)	No. of Deaths
POSSUM	22.57	62	4.61*	13
P-POSSUM	–	–	1.42	4
Actual value	17.88	49	1.09	3

Note: *Indicates P<0.05 compared with actual value.

Abbreviations: POSSUM, physiological and operative severity score for the enumeration of mortality and morbidity; P-POSSUM, Portsmouth-POSSUM.

Table 3 Types, Number, and Incidence of Complications

Types	No. of Cases	Complication Rate (%)
Intestinal obstruction	2	0.73
Pancreatic fistula with bleeding	1	0.37
Pancreatic fistula	1	0.37
Arrhythmia	2	0.73
Pleural effusion	1	0.37
Postoperative bleeding	3	1.09
Acute renal impairment	2	0. 73
Deep venous thrombosis	3	1.09
Incision infection	5	1.82
Cerebral infarction	2	0.73
Urinary tract infection	5	1.82
Septic shock	1	0.37
Liver abscess	1	0.37
Liver dysfunction	5	1.82
Peritoneal effusion	2	0.73
Celiac infection	2	0.73
Pulmonary embolism	1	0.37
Lung infection	5	1.82
Biliary fistula	5	1.82
Total	49	17.88

Table 4 Comparison of the Complication and Non-Complication Groups

Group	No. of Cases	PS	OS	POSSUM
Complication group	49	18.55 ± 4.98	12.10 ± 2.64	30.65 ± 6.74
Non-complication group	225	15.67 ± 2.91*	9.79 ± 2.03*	25.46 ± 4.14*

Note: *Indicates P<0.05 compared with the complication group.

Abbreviations: PS, physiology score; OS, operative severity score; POSSUM, physiological and operative severity score for the enumeration of mortality and morbidity.

Table 5 Comparison of the Mortality and Survival Groups

Group	No. of Cases	PS	OS	POSSUM
Mortality group	3	29.33 ± 7.36	17.67 ± 2.49	47.00 ± 5.89
Survival group	271	16.04 ± 3.20	10.12±2.18	26.16 ± 4.60

Abbreviations: PS, physiology score; OS, operative severity score; POSSUM, physiological and operative severity score for the enumeration of mortality and morbidity.

Table 6 Stratified Analysis of Predicted Complication Rate

R1 (%)	No. of Cases	Average Complication Rate	Predicted Number of Complications	Actual Number of Complications	O/E
0–10	40	0.08	3	2	0.67
11–20	119	0.14	17	14	0.82
21–30	48	0.26	12	8	0.67
31–40	35	0.34	12	9	0.75
41–50	17	0.44	8	6	0.75
51–60	8	0.56	4	5	1.25
61–70	2	0.68	1	1	1
71–80	2	0.77	2	1	0.5
81–90	1	0.83	1	1	1
91–100	2	0.95	2	2	1
Total	274	–	62	49	–

Abbreviations: R1, the complication rate predicted by the physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM); O/E, observed/expected.

Figure 1 Comparison of the predicted and actual complication numbers in different subgroups.

Figure 2 Comparison of the O/E in different subgroups.

Abbreviation: O/E, observed/expected.

Figure 3 ROC curve to predict complication rate with POSSUM.

Abbreviations: ROC, receiver operating characteristic; POSSUM, physiological and operative severity score for the enumeration of mortality and morbidity.