Efficacy of Possum and P Possum Scoring System to Assess
Outcomes in Emergency Gastrointestinal Surgeries
AuAkarsh Bullagan, Tanweer Karim, Atul Jain, Vaishali Saxena, Sumit
Chakravarti and Suhas Agarwal*
Department of Surgery, ESI-PGIMSR, Basaidarapur, New Delhi-110015
Receive: 4 June 2024
Accepted: 27 October 2024
DOI 10.5001/omj.2025.43
Abstract
Objectives: The aim of the study was to assess outcome in terms of morbidity and mortality using POSSUM
and P-POSSUM scores in patients undergoing emergency gastrointestinal surgeries and also to compare
POSSUM and P-POSSUM scores in predicting mortality and morbidity.
Methods: In this study, 45 patients presenting to general surgery emergency department and undergoing
emergency gastrointestinal surgery were included in accordance with pre-defined inclusion and exclusion
criteria.
Results: Among the patients included in the study 62.2% patients were of the age group of 18-40 years, 28.9%
were of 41-60 years age group, 8.9% were of >60 years age group. The most common diagnosis for which
patients underwent exploratory laparotomy in the study was intestinal perforation, 15 out of 45 patients
presented with this diagnosis. Physiological component of POSSUM and P-POSSUM score was calculated pre-
operatively and the operative component was calculated with the intra-op findings. Cutoff of POSSUM
morbidity score was 87.5% with a sensitivity and specificity of 83.3 and 92.6% while cut off of P-POSSUM
morbidity score was 88.6% with a sensitivity and specificity of 88.9 and 96.3%.Cut off of POSSUM mortality
score in was 56.7% with a sensitivity and specificity of 87.5 and 94.6% while cut off of P-POSSUM mortality
score was 22.7% with a sensitivity and specificity of 100 and 81.1% respectively.
Conclusions: Wecan conclude that both POSSUM and P-POSSUM scores can be used for prediction of
morbidity and mortality in patients undergoing emergency gastrointestinal surgeries with significant sensitivity
and specificity.
Keywords: Possum; P Possum; Mortality; Morbidity; Prediction; Score.
Introduction
To audit the surgical intervention surgical risk prediction models have proven to be an invaluable tool for the
surgeon. Appropriate risk-stratification can enable patients to be better informed, improve patient selection and
make improved treatment plan; and therefore, improve overall outcomes.1-3 In order to quantify the risk of
perioperative morbidity and mortality different scoring systems have been developed which include
Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM) and
Portsmouth POSSUM(P POSSUM).4 Early prognostic evaluation would aid in selection of high-risk patients for
an aggressive treatment and optimum utilization of resources.5
Although surgeons remain the most relevant factor, other variables include previous health condition,
underlying disease requiring surgical intervention and peri operative care. POSSUM scoring system was
designed to combine the three aspects and predict the patient’s outcome. The risk of a surgical procedure could
be calculated based on a patient’s physiological condition and operative findings and then pooled. 6POSSUM
combines a physiological score with an operative severity score to give a risk of mortality and morbidity. It
processes the clinical data in a logarithmic model that derives morbidity and mortality risk. Possum score
includes 12 physiological parameters and 6 operative parameters. The mortality of all the patients can be
calculated using the linear method of analysis as described by Copeland.6 Later, a modification to the predictor
equation was proposed as the P-POSSUM that claimed to produce a closer fit with the observed in hospital
mortality in low-risk groups. In India, P-POSSUM has been verified among different population groups and
possibly surgical practice.7-9
The studies mostly have been done in developed countries where patient characteristics, presentation and
hospital resources differ from our setup. Hence, there is a need to validate POSSUM in Indian scenario,
particularly lower socioeconomic group, where problems like delayed presentation and limited resources can
affect the outcome even with adequate quality care. By using these scoring methods, we will be able to predict
the risk of morbidity and mortality in a patient requiring surgical intervention at the time of presentation. This
will help us to plan the management accordingly.
Methods
This Prospective Observational study was carried out in the Department of General Surgery, ESIC PGIMSR &
Hospital, New Delhi after obtaining clearance from the ethical and the scientific committee for a period of two
years.Written and informed consent was taken from the enrolled patients.
Sample size for the study is being calculated using the formula-
N = Z21-α/2*[Sn(1-Sn)]
------------------------------
L2 (1-P)
Where Zα is 1.96 at a confidence level of 95%
Sn is the sensitivity; L is margin of error and p is the mortality rate in patients with emergency laparotomy
The sensitivity of P-POSSUM score to predict mortality was found to be 91.3% by Deb Sanjay Nag et al. 5
So, taking 91.3% sensitivity with 10% margin of error the minimal required sample size required is 41. So, we
took the sample size of 45 taking into account the attrition factor.
All patients above 18 years of age undergoing emergency gastrointestinal surgeries were included in the
study.Patients with multiorgan failure, polytrauma and not willing to participate in study were excluded.Based
on clinical examination and other investigations a diagnosis was made and decision for emergency
gastrointestinal surgery was taken.
Physiologicalscore was calculated as per parameters and scoring in table 1 and operative score was
calculated as per parameters and scoring in table 2. Then these scores were used in the equation given below to
calculate the POSSUM score.
Table 1: Calculation of Physiological Score.
Score 1 2 4 8
Age(years) <60 61-70 >=71
Cardiac signs Normal Diuretic,digoxin,antianginal or Peripheral Raised JVP
anti-hypertensive edema,warfarin
therapy
Chest radiograph Normal ____ Borderline Cardiomegaly
cardiomegaly
Respiratory Normal Dyspnea on exertion Limiting Dyspnea at rest
history dyspnea(one flight
of stairs)
Chest radiograph Normal Mild COPD Moderate COPD Fibrosis or
consolidation
Systolic BP 110-130 131-170 or >=171 or =<89
(mm Hg) 100-109 90-99
Pulse 50-80 81-100 or 100-120 >=121 or
(beats/min) 40-49 =<89
Glasgow coma 15 12-14 9-11 <9
score
Haemoglobin 13-16 11.5-12.9 or 10-11.4 or <10
(g/dl) 16.1-17 17.1-18
White cell 4-10 10.1-20 or >20 or
count(x1012/l) 3.1-4 <4
Bloodurea <7.5 7.6-10 10.1-15 >15
(mmol/l)
Sodium >135 131-135 126-130 <126
(mmol/l)
Potassium 3.5-5.5 3.2-3.4 or 2.9-3.1 or <2.9 or
(mmol/l) 5.2-5.3 5.4-5.9 >5.9
ECG Normal Atrial fibrillation Any other change
Table 2: Calculation of Operative score.
Score 1 2 4 8
Operative severity Minor Intermediate Major Major
No of operations 1 2 >2
within 30 days
Blood loss per <101 101-500 501-999 >999
surgery (ml)
Peritoneal None Serous fluid Local pus Free bowel
contamination content/pus/blood
Presence of None Primary only Nodal metastasis Distant metastasis
malignancy
Mode of surgery Elective Emergency Emergency (within
resuscitation of > 2 2 hours of
hours possible/ admission)
Surgery within 24
hours of admission
POSSUM equation for Morbidity
Logn R1/1-R1= -5.91 + (0.16 x Physiological score) + (0.19 x Operative severity score), where R1 is the
predicted risk of morbidity.
POSSUM equation for Mortality
Logn R2/1-R2 = -7.04 + (0.13 x Physiological score) + (0.16 x Operative severity score), where R2 is the
predicted risk of mortality.
P POSSUM equation for mortality
In [R / (1-R)] = −9.37 + (0.19 × physiological score) + (0.15 × operative severity score)
Where R is the predicted risk of mortality.
Each patient was followed up for a period of 30 days post-surgical intervention to look for post op morbidity
and mortality.
Morbidity was assessed using the ClaveinDindo classification.10Outcome measures for morbidity were
assessed as wound complications, local or systemic infections, organ dysfunction, shock, thromboembolism and
anastomotic failure.
Statistical Evaluation was done using SPSS-20 version.Quantitative data was expressed by mean, standard
deviation or median with interquartile range and depends on normality distribution, difference between two
means was tested by student t test and Mann Whitney U test. Qualitative data was expressed in percentage and
difference between the proportions were tested by chi square test and Fisher’s exact test. Pearson correlation
coefficient was used to see the correlation between two quantitative variables. The ROC curve was prepared
using P-POSSUM score and POSSUM score to predict mortality and based on that optimum cut off value was
calculated. Sensitivity, specificity, positive predictive value and negative predictive value of P-POSSUM score
and POSSUM score was calculated. ‘P’ value less than 0.05 was considered statistically significant.
Results
The mean (SD) of age (in years) was 37.87 (15.73). The median (IQR) of age was 32.00 (26-47). The age
ranged from 18 - 72. 62.2% of the participants had age group: 18-40 years. 28.9% of the participants had age
group: 41-60 Years. 8.9% of the participants had age group: > 60 years. [Table 3].
Table 3: Summary of All Parameters.
All Parameters Mean ± SD || Median (IQR) || Min-Max || Frequency (%)
Diagnosis
Acute Appendicitis 8 (17.8%)
Abdominal Koch’s 1 (2.2%)
Acute necrotizing pancreatitis 2 (4.4%)
SAIO 7 (15.6%)
Liver Abscess 3 (6.7%)
Intestinal Perforation 15 (33.3%)
Blunt Trauma Abdomen 1 (2.2%)
Pyoperitoneum 3 (6.7%)
Sigmoid Volvulus 1 (2.2%)
Strangulated Inguinal Hernias 1 (2.2%)
Ruptured Hydatid Cyst 1 (2.2%)
Gastrointestinal Malignancies 2 (4.4%)
Age (Years) 37.87 ± 15.73 || 32.00 (26.00-47.00) || 18.00 - 72.00
Age Group
18-40 Years 28 (62.2%)
41-60 Years 13 (28.9%)
> 60 Years 4 (8.9%)
Cardiac Signs (None) 45 (100.0%)
Chest X-Ray
None 31 (68.9%)
Normal 6 (13.3%)
Cardiomegaly 1 (2.2%)
Cavitary Lesion 1 (2.2%)
Fibrosis 1 (2.2%)
Pleural Effusion 5 (11.1%)
Respiratory History: None (Yes) 38 (84.4%)
Respiratory History: Dyspnea (Yes) 5 (11.1%)
All Parameters Mean ± SD || Median (IQR) || Min-Max || Frequency (%)
Respiratory History: Dyspnea at
3 (6.7%)
Rest (Yes)
Systolic BP (mmHg) 117.49 ± 16.32 || 116.00 (106.00-130.00) || 86.00 - 150.00
Pulse Rate (BPM) 105.82 ± 18.83 || 105.00 (90.00-120.00) || 78.00 - 140.00
GCS 14.98 ± 0.15 || 15.00 (15.00-15.00) || 14.00 - 15.00
Hemoglobin (gm/dL) 11.12 ± 2.06 || 11.20 (9.70-12.30) || 7.60 - 16.20
12102.22 ± 7000.24 || 9800.00 (7700.00-16000.00) || 1900.00 -
TLC (/mm3)
36000.00
Blood Urea (mmol/L) 3.40 ± 1.46 || 3.50 (2.50-4.30) || 0.60 - 7.80
S. Sodium (mEq/L) 132.76 ± 5.33 || 134.00 (128.00-136.00) || 122.00 - 144.00
S. Potassium (mEq/L) 4.16 ± 0.73 || 4.10 (3.80-4.60) || 2.60 - 6.20
ECG
None 1 (2.2%)
Normal 17 (37.8%)
S. Tachycardia 26 (57.8%)
Others 1 (2.2%)
Operative Severity
Minor 0 (0.0%)
Intermediate 12 (26.7%)
Major 33 (73.3%)
Number Of Operations (30 Days)
1 44 (97.8%)
2 1 (2.2%)
Blood Loss 204.44 ± 147.64 || 175.00 (50.00-300.00) || 50.00 - 650.00
Peritoneal Contamination
None 17 (37.8%)
Bowel Content 14 (31.1%)
Local Pus 2 (4.4%)
Blood 1 (2.2%)
Pus 11 (24.4%)
Presence Of Malignancy
None 40 (88.9%)
Primary Malignancy 4 (8.9%)
Malignancy With Distant Mets 1 (2.2%)
Mode Of Surgery (Emergency) 45 (100.0%)
Physiologic Score 24.00 ± 8.25 || 23.00 (16.00-29.00) || 13.00 - 49.00
Operative Score 17.42 ± 5.02 || 20.00 (13.00-20.00) || 10.00 - 27.00
POSSUM Mortality (%) 30.56 ± 24.35 || 27.30 (6.20-45.00) || 2.30 - 89.80
POSSUM Morbidity (%) 66.64 ± 31.06 || 80.40 (34.30-91.50) || 12.70 - 99.50
P POSSUM Morbidity (%) 67.26 ± 31.69 || 82.80 (30.80-93.60) || 12.70 - 99.70
P POSSUM Mortality (%) 18.68 ± 21.56 || 12.20 (1.50-27.10) || 0.50 - 92.30
ClaveinDindo Grade
1 14 (31.1%)
2 11 (24.4%)
3 10 (22.2%)
4 2 (4.4%)
5 8 (17.8%)
Mortality (Yes) 8 (17.8%)
Major Complication (Yes) 18 (40.0%)
The diagnosis with which different patients were treated is given in table 3. Intestinal Perforation (33.3%)
was the most frequent one, followed by Acute Appendicitis (17.8%)and SAIO (15.6%).[Table 3]
The mean (SD) of blood loss in patients with major complication was 263.89ml. The mean (SD) of blood
loss in patients without major complication was 164.81ml. The blood loss in patients with major complications
ranged from 50 – 650ml. The blood loss in patients without major complications ranged from 50 – 500ml.
[Table 3]
There was a significant difference between the 2 groups in terms of blood loss (W = 337.000, p = 0.028),
with the median blood loss being highest in patients with major complications.
In this study, 37.8% of the participants had peritoneal contamination, 31.1% of the participants had feculent
peritoneal contamination. 4.4% of the participants had local pus collection. 2.2% of the participants had
haemoperitoneum. 24.4% of the participants had peritoneal contamination with pus. [Table 3]
88.9% of the participants had no malignancy. 8.9% of the participants had primary malignancy. 2.2% of the
participants had malignancy with distant metastasis. [Table 3]
The mean (SD) of Physiologic Score was 24.00 (8.25). The median (IQR) of Physiologic Score was 23.00
(16-29). The Physiologic Score ranged from 13 - 49. [Table 3]
The mean (SD) of Operative Score was 17.42 (5.02). The median (IQR) of Operative Score was 20.00 (13-
20). The Operative Score ranged from 10 - 27. [Table 3]
No study participants had cardiac pathology.Only 7 patients had history of some respiratory disease.3
patients had history of dyspnea at rest. 31 patients had normal chest x-Ray. 1 patient had cavitary lesion on chest
x-ray. 1 patient had lung fibrosis on chest x-ray. 5 patients had pleural effusion on chest x-ray. [Table 3]
The vitals of patients recorded is shown in table 3, 31.1% of the participants had ClaveinDindo Grade: 1.
24.4% of the participants had ClaveinDindo Grade: 2. 22.2% of the participants had ClaveinDindo Grade: 3.
4.4% of the participants had ClaveinDindo Grade: 4. 17.8% of the participants had ClaveinDindo Grade: 5.
[Table 3]
Mortality was seen in 17.8% of the patients and 40.0% of the participants had Major Complication. There
was a significant difference between the various groups in terms of distribution of Peritoneal Contamination (χ2
= 9.814, p = 0.024).Patients without any major complications had the larger proportion of patients without any
peritoneal Contamination. Most of the patients who developed major complications, had the larger proportion of
peritoneal contamination with faecal matter. [Table 3]
The area under the ROC curve (AUROC) for POSSUM mortality risk (%) predicting Mortality was 0.961
(95% CI: 0.906 - 1), thus demonstrating excellent diagnostic performance. It was statistically significant (p =
<0.001). At a cut-off of POSSUM Mortality risk (%) ≥56.7, it predicts mortality, with a sensitivity of 88%, and
a specificity of 95%. [Table 4].
Table 4: ROC Curve Analysis Showing Diagnostic Performance of POSSUM Mortality (%) in Predicting
Mortality (n = 45).
Parameter Value (95% CI)
Cut-off (p value) ≥ 56.7 (<0.001)
AUROC 0.961 (0.906 - 1)
Sensitivity 87.5% (47-100)
Specificity 94.6% (82-99)
Positive Predictive Value 77.8% (40-97)
Negative Predictive Value 97.2% (85-100)
Diagnostic Accuracy 93.3% (82-99)
Positive Likelihood Ratio 16.19 (4.1-63.9)
Negative Likelihood Ratio 0.13 (0.02-0.83)
Diagnostic Odds Ratio 122.5 (9.72-1543.84)
The odds ratio (95% CI) for Mortality when POSSUM mortality risk (%) is ≥56.7 was 52.5 (6.16-447.46).
The relative risk (95% CI) for mortality when POSSUM mortality risk (%) is ≥56.7 was 13.88 (3.77-52.19).
The area under the ROC curve (AUROC) for P POSSUM Mortality risk (%) predicting Mortality was 0.944
(95% CI: 0.879 - 1), thus demonstrating excellent diagnostic performance. It was statistically significant (p =
<0.001). At a cut-off of P POSSUM Mortality risk (%) ≥22.7, it predicts Mortality with a sensitivity of 100%,
and a specificity of 81%. [Table 5].
Table 5: ROC Curve Analysis Showing Diagnostic Performance of P POSSUM Mortality (%) in Predicting
Mortality (n = 45).
Parameter Value (95% CI)
Cut-off (p value) ≥ 22.7 (<0.001)
AUROC 0.944 (0.879 - 1)
Sensitivity 100.0% (63-100)
Specificity 81.1% (65-92)
Positive Predictive Value 53.3% (27-79)
Negative Predictive Value 100.0% (88-100)
Diagnostic Accuracy 84.4% (71-94)
Positive Likelihood Ratio 5.29 (2.71-10.3)
Negative Likelihood Ratio 0 (0-NaN)
Diagnostic Odds Ratio Inf (NaN-Inf)
The odds ratio (95% CI) for Mortality, when P POSSUM Mortality risk (%) is ≥22.7 was 36.17 (3.74-
350.19). The relative risk (95% CI) for Mortality, when P POSSUM Mortality risk (%) is ≥22.7 was 17.23
(3.12-101.46).
The area under the ROC curve (AUROC) for POSSUM morbidity risk (%) predicting major complications
was 0.945 (95% CI: 0.886 - 1), thus demonstrating excellent diagnostic performance. It was statistically
significant (p = <0.001). [Table 6].
Table 6: ROC Curve Analysis Showing Diagnostic Performance of POSSUM Morbidity (%) in Predicting
Major Complications (n = 45).
Parameter Value (95% CI)
Cut-off (p value) ≥ 87.5 (<0.001)
AUROC 0.945 (0.886 - 1)
Sensitivity 83.3% (59-96)
Specificity 92.6% (76-99)
Positive Predictive Value 88.2% (64-99)
Negative Predictive Value 89.3% (72-98)
Diagnostic Accuracy 88.9% (76-96)
Positive Likelihood Ratio 11.25 (2.92-43.37)
Negative Likelihood Ratio 0.18 (0.06-0.51)
Diagnostic Odds Ratio 62.5 (9.35-417.98)
At a cut-off of POSSUM morbidity risk (%) ≥87.5, it predicts major complications, with a sensitivity of
83%, and a specificity of 93%.
AUROC for P POSSUM morbidity risk (%) predicting major complications was 0.958 (95% CI: 0.903 - 1),
thus demonstrating excellent diagnostic performance. It was statistically significant (p = <0.001). [Table 7].
Table 7: ROC Curve Analysis Showing Diagnostic Performance of P POSSUM Morbidity (%) in Predicting
Major Complication (n = 45).
Parameter Value (95% CI)
Cut-off (p value) ≥ 88.6 (<0.001)
AUROC 0.958 (0.903 - 1)
Sensitivity 88.9% (65-99)
Specificity 96.3% (81-100)
Positive Predictive Value 94.1% (71-100)
Negative Predictive Value 92.9% (76-99)
Diagnostic Accuracy 93.3% (82-99)
Positive Likelihood Ratio 24 (3.48-165.39)
Negative Likelihood Ratio 0.12 (0.03-0.43)
Diagnostic Odds Ratio 208 (17.42-2483.6)
At a cut-off of P POSSUM morbidity risk (%) ≥88.6, it predicts major complications, with a sensitivity of
89%, and a specificity of 96%.
There was a significant difference between the 5 groups in terms of POSSUM Morbidity (%) (χ2 = 35.539, p
= <0.001), with the median POSSUM Morbidity (%) being highest in the ClaveinDindo Grade: 5 group. [Table
8].
Table 8: Comparison of the 5 Subgroups of the Variable ClaveinDindo Grade in Terms of POSSUM Morbidity
(%) (n = 45).
POSSUM Morbidity ClaveinDindo Grade Kruskal Wallis Test
(%) 1 2 3 4 5 χ2 p value
26.21 74.42
Mean (SD) 86.10 (7.70) 92.05 (0.78) 96.04 (3.43)
(14.82) (18.51)
92.05
19.25 82.8 (66-87.2 (79.8- 96.8 (95.17-35.539 <0.001
Median (IQR) (91.78-
(15.12-31.4) 86.9) 91.08) 98.23)
92.32)
Range 12.7 - 57.2 34.3 - 91.5 74.8 - 97.5 91.5 - 92.6 88.6 - 99.5
There was a significant difference between the 5 groups in terms of P POSSUM Morbidity (%) (χ2 = 36.602,
p = <0.001), with the median P POSSUM Morbidity (%) being highest in the ClaveinDindo Grade: 5 group.
[Table 9].
Table 9: Comparison of the 5 Subgroups of the Variable ClaveinDindo Grade in Terms of P POSSUM
Morbidity (%) (n = 45).
P POSSUM ClaveinDindo Grade Kruskal Wallis Test
Morbidity (%) 1 2 3 4 5 χ2 p value
24.56 76.90
Mean (SD) 87.31 (8.05) 96.15 (0.35) 96.42 (3.03)
(11.36) (16.80)
96.15
22.8 (17.27-82.8 (77.6-89.2 (80- 96.9 (94.42-36.602 <0.001
Median (IQR) (96.03-
28.5) 86.35) 93.75) 99.08)
96.28)
Range 12.7 - 57.2 34.3 - 91.5 74.8 - 96.5 95.9 - 96.4 91.5 - 99.7
Discussion
This study comprised of patients who presented to surgery casualty prepared for emergency gastrointestinal
surgery. Physiological component of the POSSUM score was calculated pre-operatively. The patients were
operated and intra op findings were noted and the operative component of the POSSUM score was calculated.
The physiological and operative scores were compiled and POSSUM and P-POSSUM scores were calculated
which predicted morbidity and mortality of the patient. Patients were observed for a period of 30 days post-op to
look for grade of morbidity which was defined by Clavein-dindo grade of morbidity.
Mean age of the patients participating in the study was 37.8 years with the range being 18 years-72
years.62.2% of the patients were of the age group of 18-40 years with 95% confidence interval being 46.5%-
75.8%.28.9% patients were of 41-60 years while 8.9% of them were of >60 years of age. Yelamanchi et al.,
2020 conducted a similar study which had similar age distribution with a mean age of 37.1 years. 11
Out of 45 patients included in the study 8 had mortality. Mortality rate being 17.8%. Age group 18-40 had
7% mortality,40-60 age group had 30% mortality,>60 age group had 50% mortality, p value being 0.027 which
was significant. So, with advancing age mortality rate increased which could be due to increase in co-
morbidities with advancing age. Study conducted by Simpson k et al.,2020 in elderly patients undergoing
emergencies laparotomies had similar 30 day mortality rate of 16.3%. 12
Mean Physiologic score of the patients participating in the study was 24.00, median was 23 and the range
was between 13-49. The data was positively skewed. Mean physiologic score of patients who had mortality was
34.75 and the range being 23-49, while the mean physiologic score of patients who did not have mortality was
21.68 and the range was 13-34, p value<0.001 which suggests significant difference between two groups in
terms of physiologic score. Physiologic score was also a good predictor of major complications post operatively.
ROC curve analysis showed a cut off value of 26 in prediction of major complications with a sensitivity of
83.3% and specificity of 88.9%.ROC curve analysis for diagnostic performance of physiologic score in
predicting mortality showed a cut off value of 28 with a sensitivity of 87.5% and specificity of 75.7%,thus
demonstrating excellent diagnostic performance.(p value<0.001).Ngulube A et al 13., in 2019 conducted a similar
study in which physiologic score correlated significantly with patient morbidity(p=0.002) and
mortality(p<0.00001).It supported the observation from other papers that physiological score can be used in
isolation for risk stratification of patients pre-operatively.14,15
Mean Operative score of the patients participating in the study was 17.42, median was 20 and the range was
between 10-27. The data was normally distributed. Mean operative score of patients who had mortality was
21.38 and the range being 13-27, while the mean operative score of patients who did not have mortality was
16.57 and the range was 10-26, p value 0.006 which suggests significant difference between two groups in terms
of operative score. Mean operative score calculated by González-Martínez S et al.,2016 was 8, and
physiological score was 16.16 Study by Shekhar et al.,2023found mean physiological score of 24.57 and mean
operative time of 19.01 which was similar with our study. 4 Operative score was also a good predictor of major
complications post operatively. ROC curve analysis showed a cut off value of 19 in prediction of major
complications with a sensitivity of 88.9% and specificity of 55.6%, demonstrating good diagnostic performance.
ROC curve analysis for diagnostic performance of operative score in predicting mortality showed a cut off value
of 21 with a sensitivity of 50% and specificity of 94.6%, thus demonstrating good diagnostic performance. (p
value 0.006). In study by Ngulube A et al13operative score correlated significantly with patient
morbidity(p=0.007) and mortality(p<0.0036). It supported the observation from other papers that operative
score can be used in isolation for risk stratification of patients pre-operatively.12,15
28% patients of the age group of 18-40 years had major complications,46% patients of age group of 40-60
years had major complications and of age of >60 years 100% patients had major complications, p-value 0.020
which suggested significant difference between various groups in terms of distribution of age group.
Peritoneal contamination was another determining factor in development of major complications in patients.
Among the patients who had major complications in post operative period 44.4% had bowel content
contaminating the peritoneal cavity,38.9% had generalized purulent fluid while only 16.7% had no peritoneal
contamination.
Mean physiologic score in patients who had major complications was 31.33, range being 21-49 while in
those who did not have any major complications was 19.11, range being 13-28. There was a significant
difference between the 2 groups in terms of physiologic score p-value <0.001.
Mean operative score in patients who had major complications was 20.67, range being 13-27 while in those
who did not have any major complications was 15.26, range being 10-20. There was a significant difference
between the 2 groups in terms of operative score p-value <0.001.
Mean POSSUM morbidity score in patients who had major complications was 91.76%, median was 93.7%
range being from 77.7-99.5%, while among the patients who did not have any major complications mean
POSSUM morbidity score was 49.9%, median was 52%, range being from 12.7-91.5%. There was a significant
difference between the two groups in terms of POSSUM morbidity (%), p value <0.001.
Mean P-POSSUM morbidity score in patients who had major complications was 93.06%, median was
94.65% range being from 76.9-99.7%, while among the patients who did not have any major complications
mean POSSUM morbidity score was 50.05%, median was 34.3%, range being from 12.7-91.5%. There was a
significant difference between the two groups in terms of POSSUM morbidity (%), p value <0.001.
The area under the ROC curve for POSSUM morbidity (%)was 0.945 (95% CI:0.886-1), demonstrating
excellent diagnostic performance. It was statistically significant (p <0.001). Cut off value of POSSUM
morbidity score was >=87.5%with a sensitivity of 83% and a specificity of 93%. Positive predictive value was
88.2% and relative risk for having major complications when POSSUM morbidity score was >=87.5% was
6.34.
The area under the ROC curve for P-POSSUM morbidity (%) for prediction of major complication was
0.958 (95% CI:0.903-1), which demonstrated excellent diagnostic performance. It was statistically significant (p
<0.001). Cut off value of P-POSSUM morbidity score for prediction of major complications was >=88.6%with
a sensitivity of 88.9% and a specificity of 96.3%. Positive predictive value was 94.1% and relative risk for
having major complications when POSSUM morbidity score was >=88.6% was 9.06.
The area under the ROC curve for POSSUM mortality was 0.961 (95% CI:0.906-1), demonstrating excellent
diagnostic performance. It was statistically significant (p <0.001). Cut off value of POSSUM morbidity score
was >=56.7%with a sensitivity of 87.5% and a specificity of 94.6%. Positive predictive value was 77.8% and
relative risk when POSSUM mortality score was >=56.7% was 13.88. Chatterjee AS et al. 17 in 2015 conducted a
study in which POSSUM score was as a predicting tool in patients of perforation peritonitis. POSSUM had a
positive predictive value of 100% for mortality which was much better than observed in this study and 94% for
morbidity which was also higher than observed in this study. Area under ROC curve for POSSUM predicting
mortality and morbidity was 0.943 and 0.93 respectively which was less accurate compared to this study.The
area under the ROC curve was 0.818 and 0.836 for mortality prediction by POSSUM and P-POSSUM,
respectively, thus showing the accuracy to be higher (Shekar et al.) 4
The area under the ROC curve for P-POSSUM mortality was 0.944 (95% CI:0.879-1), demonstrating
excellent diagnostic performance. It was statistically significant (p <0.001). Cut off value of P-POSSUM
morbidity score for prediction of patient mortality was >=22.7%with a sensitivity of 100% and a specificity of
81.1%.Positive predictive value was 53.3% and negative predictive value was 100% and relative risk of patient
mortality when P-POSSUM mortality score was >=22.7% was 17.23.In a study conducted by Nag DS et
al.,5comparing APACHE-II and P-POSSUM scores in predicting mortality in patients undergoing emergency
laparotomy, cut off value of p-POSSUM to predict mortality was 63 which was higher than what was observed
in this study and the area under the ROC was 0.989 which suggested excellent diagnostic performance which
was similar to this study.In the study conducted by Ngulube A et al., 13 AUROC for P-POSSUM predicting
mortality was 0.814 which was much less compared to this study and it showed a poor diagnostic performance
in their study.
LIMITATIONS OF THE STUDY:
1. Small sample size.
2. Single centered study.
3. Patientin our study were of low economic status and thus different strata could not be validated.
Conclusion
We find that the POSSUM and P-POSSUM scores can be used to predict morbidity and mortality in patients
undergoing emergency gastrointestinal procedures with high sensitivity and specificity. In our study, POSSUM
score was shown to be the better parameter for predicting mortality, but P-POSSUM was found to be the better
parameter for predicting serious complications, but the difference was not statistically significant.
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