Clinical Research
Copyright ©2005 Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 28, 2005; 11(16): 2450-2455
Published online Apr 28, 2005. doi: 10.3748/wjg.v11.i16.2450
Risk-adjustment in hepatobiliarypancreatic surgery
Hemant M Kocher, Paris P Tekkis, Palepu Gopal, Ameet G Patel, Simon Cottam, Irving S Benjamin
Hemant M Kocher, Paris P Tekkis, Ameet G Patel, Irving S Benjamin, Academic Department of Surgery, King’s College Hospital, Denmark Hill, London SE5 9RY, UK
Palepu Gopal, Simon Cottam, Department of Anaesthesia, King’s College Hospital, Denmark Hill, London SE5 9RY, UK
Author contributions: All authors contributed equally to the work.
Correspondence to: Hemant Kocher MS, MD, FRCS, Department of Health National Clinician Scientist, Senior Lecturer Tumour Biology Laboratory, Cancer Research UK Clinical Centre, Queen Mary’s School Of Medicine and Dentistry at Barts and The London, John Vane Science Centre, Charterhouse Square, London EC1M 6BQ, UK. hemant.kocher@cancer.org.uk
Telephone: +44-207-346-5163 Fax: +44-207-346-3575
Received: June 19, 2004
Revised: June 20, 2004
Accepted: August 22, 2004
Published online: April 28, 2005
Abstract

AIM: The present study evaluates the performance of the POSSUM, the American Society of Anesthetists (ASA), APACHE and Childs classification in predicting mortality and morbidity in hepatopancreaticobiliary (HPB) surgery. We describe especially the limitations and advantages of risk in stratifying the patients.

METHODS: We investigated 177 randomly chosen patients undergoing elective complex HPB surgery in a single institution with a total of 71 pre-operative and intra-operative risk factors. Primary endpoint was in-hospital mortality and morbidity. Ordered logistic regression analysis was used to identify individual predictors of operative morbidity and mortality.

RESULTS: The operative mortality in the series was 3.95%. This compared well with the p-POSSUM and APACHE predicted mortality of 4.31% and 4.29% respectively. Post-operative complications amounted to 45% with 24 (13.6%) patients having a major adverse event. On multivariate analysis the pre-operative POSSUM physiological score (OR = 1.18, P = 0.009) was superior in predicting complications compared to the ASA (P = 0.108), APACHE (P = 0.117) or Childs classification (P = 0.136). In addition, serum sodium, creatinine, international normalized ratio (INR), pulse rate, and intra-operative blood loss were independent risk factors. A combination of the POSSUM variables and INR offered the optimal combination of risk factors for risk prognostication in HPB surgery.

CONCLUSION: Morbidity for elective HPB surgery can be accurately predicted and applied in everyday surgical practice as an adjunct in the process of informed consent and for effective allocation of resources for intensive and high-dependency care facilities.

Keywords: Hepatobiliarypancreatic surgery; Risk adjustment; Operative mortality; Operative morbidity; Regression models