Thesis Asif

i
EVALUATION OF PHYSIOLOGIC AND OPERATIVE SEVERITY

SCORE FOR ENUMERATION OF MORTALITY AND MORBIDITY
AND PORTSMOUTH PREDICTOR MODIFICATION IN PATIENTS
UNDERGOING EMERGENCY AND ELECTIVE LAPAROTOMY
DR. NAVEED ABBAS AKBAR
MD
SUPERVISOR
DR. SYED ASGHAR NAQI
FCPS, FRCS Ed.
South Surgical ward, Mayo Hospital
King Edward Medical University, Lahore.
Date,
CERTIFICATE
ii
I, hereby, certify that Dr. Naveed Abbas Akbar having Enrolment
Number: 62102 & RTMC Number: SGR-2006-066-3213 has been
working under my direct supervision with effect from 06/12/2005 to
date in West & South surgical wards, Mayo hospital Lahore.
The enclosed Dissertation titled:
‘EVALUATION OF PHYSIOLOGIC AND OPERATIVE SEVERITY SCORE
FOR ENUMERATION OF MORTALITY AND MORBIDITY AND
PORTSMOUTH PREDICTOR MODIFICATION IN PATIENTS
UNDERGOING EMERGENCY AND ELECTIVE LAPAROTOMY’ IS
prepared according to the “FCPS Dissertation-Guidelines” under my
direct supervision.
I have read the Dissertation and have found it satisfactory for FCPS
Part II examination in the subject.
---------------------------------
--
DR SYED ASGHAR NAQI
FCPS.FRCS
MAYO HOSPITALLAHORE
DATED:
iii
DEDICATION
To my mother, who is spirit of my life
To my brother who is really our soul

iv
PART I
v
ACKNOWLEDGEMENTS
It is a great pleasure to acknowledge the help of many individuals
without whose help this dissertation could not have been
completed. First and foremost I am indebted to Dr. Khalid Masood
Gondal Professor of South Surgical Ward Mayo Hospital, who
moulded me into a surgeon. His ultimate effort, attention and
valuable suggestions were vital in preparation of this dissertation.
I am thankful to Dr. Asghar Naqi associate professor for helping me
to select the topic for dissertation, and Dr. Nadeem Aslam associate
professor, Dr. Salman Akhtar consultant surgeons, for critical
review of my research work. I am indebted to Dr. Hassan
Muhammad Khan and Dr. Muhammad Zahid, Dr. Zakryia, Dr.
Junaid, Dr. Samina Consultant Surgeons, for imparting their lifetime
experience and for eagerness to help at every step. I owe plentiful
thanks to many people. To name few of them are my colleagues Dr.
Mohsin and Dr. Abrar who helped me in collecting data. Special
thanks are owed to Dr. Kaleen Abbas Asghar, my younger brother
for helpful tips on statistical analysis. I am very grateful to all my
beloved patients who kindly consented for my study. It would be
remiss if I failed to acknowledge my family. I am thankful for their
tolerance of my absences, for their freely offered encouragement.
Dr. Naveed Abbas Akbar

vi
TABLE OF CONTENTS
Chapter page
1. ABSTRACT ……………………………………………………..2
2. INTRODUCTION…………………………………….……………………… 5
3. LITERATURE REVIEW …………………………………….…………. 11
4. OBJECTIVE………….………………………………………………………. 45
5. HYPOTHESIS …………………………………………………………………46
6. OPERATIONAL DEFINATION………………………………………. 47
7. MATERIAL AND METHODS………………………………………….. 51
8. RESULTS…………………………………………………………........... 56
9. DISCUSSION…………………………………………………….……………84
10. CONCLUSION…………………………………………………..……………91
11. APPENDIX……………………………………………………………………..93
12. BIBLIOGRAPHY……………………………………………………….…….99
vii
LIST OF TABLES
TITLE
PAGE
1. Indications for elective laparotomy…………………………………………60
2. Complications in elective surgery ……………………………………………61
3. Surgeons on elective list …..……………………………………………………..62
4. Sum of observed and predicted outcomes in elective cases....64
5. Comparison of observed and predicted mortality using POSSUM
equation in elective laparotomy ………………………………………………….65
6. Comparison of observed and predicted morbidity using POSSUM
7. Comparison of observed and predicted mortality using P-POSSUM
8. Pearson’s correlation in elective morbidity……………………………68
9. Pearson correlation in POSSUM elective mortality……………….69
10. Pearson correlation in P-POSSUM elective mortality……………70
11. Hosmer and Lemeshow test………………………………………………………71

viii
12. Indications for emergency laparotomy…………………………………….72
13. Complications in emergency laparotomy…………………………………73
14. Surgeons in emergency……………………………………………………………74
15. Sum of observed and predicted outcomes in emergency cases76
16. Comparison of observed and predicted mortality using POSSUM
equation in emergency laparotomy ……………………………………………….77
17. Comparison of observed and predicted morbidity using POSSUM
equation in emergency laparotomy ……………………………………………….78
18. Comparison of observed and predicted mortality using P-
POSSUM equation in emergency laparotomy ……………………………….79
19. Pearson’s correlation in emergency morbidity ……………………….80
20. Pearson’s correlation in POSSUM emergency mortality………….81
21. Pearson’s correlation in P-POSSUM emergency mortality…….82
22. Hosmer and Lemeshow test…………………………………………………….83

ix
LIST OF FIGURES/GRAPH
1. Gender distribution in elective cases…………………………63
2. Gender distribution in emergency cases……………………75

x
LIST OF ABBREVIATIONS
POSSUM: physiologic and operative severity score for enumeration
of mortality and morbidity.
P-POSSUM: Portsmouth predictor modification.
O.mort: Observed mortality
O.morb: Observed morbidity
P.mort: Predicted mortality by POSSUM
P.morb: Predicted morbidity by POSSUM
PP.mort: Predicted mortality by p-possum
T.B ABDOMEN: Tuberculosis abdomen
FAI: fire arm injury
PID: Pelvic inflammatory disease
OPD: out door patients
C.A: carcinoma
T.B: tuberculosis
UTI: urinary tract infection

PART 2
1. ABSTRACT
INTRODUCTION
Crude morbidity and mortality rates are inaccurate and
misleading indicators of quality of care. Physiological and
Operative severity score for the enumeration of mortality and
morbidity (POSSUM) is currently the most tested system for
assessing outcomes in risk adjusted analysis. This is used
widely to predict 30 days mortality and morbidity. The
Portsmouth predictor modification (P-POSSUM) was developed
to overcome the overpredicted mortality of POSSUM in low
risk patients.
OBJECTIVE
The aim of my study was to evaluate the predictive accuracy
of POSSUM and P-POSSUM scoring systems in patients
undergoing emergency and elective laparotomy.
MAIN OUTCOME MEASURES
The main outcome studied was observed and predicted
mortality and morbidity, and the comparison of both these
figures.
STUDY DESIGN
Prospective observational follow up study
SETTING
South Surgical unit Mayo Hospital Lahore, duration of study
was 6 months.
METHODS
Total 100 cases, 50 from emergency and 50 from
elective cases undergoing elective or emergency laparotomy
meeting the inclusion criteria were taken for study.
Comparison of observed and predicted mortality and
morbidity was carried out by using Pearson’s correlation.
RESULTS
In elective laparotomy observed mortality was 3(6%) and
morbidity was 15 (30%) while predicted mortality and
morbidity by POSSUM was 4.8 (9.6%) and 14.67(29.34%)
and P-POSSUM predicted mortality was 2.93(5.96%).
In emergency laparotomy observed mortality was 6(12%)
and morbidity was 22(44%) while predicted mortality and

morbidity by POSSUM was 9 (18%) and 28.17(57.34%) and
P-POSSUM predicted mortality was 6(12%).
CONCLUSION
POSSUM scoring system can predict morbidity well in both
elective and emergency laparotomy but it overpredicts
mortality in low risk patients while P-POSSUM is more
accurate in predicting mortality.
KEY WORDS
POSSUM, P-POSSUM, mortality, morbidity

2. INTRODUCTION:
‘If a doctor inflicts a serious wound with his operation knife on
a free man’s slave and kills him, the doctor must replace the
slave with another. If a doctor has treated a free man but
caused a serious injury from which the man dies, or if he has
opened an abscess and the man goes blind, the man is to cut
off his hands’. King Hammurabi of Babylon, 1750 BC
[Engraved on black diorite stone discovered in Susa in Iran].1
The notion that every doctor, especially surgeon, must be
completely accountable for the outcome of the treatment has
been continuing from ancient times. But the outcome of any
surgical intervention whether in form of mortality or morbidity
is not only dependent on the performance of the surgeon but
status of the patient is also quite important for the final
outcome of the patient. . His acute and chronic physiological
status, current illness that requires surgical correction, nature
and extent of surgical intervention and co- morbid conditions
have a major impact on the outcome.1
We live in challenging and changing times. No longer can we,
as surgeon, work and operate with the autonomy to which we
have historically been accustomed. The healthcare system as

a whole especially surgeons are increasingly accountable for
their actions to local multidisciplinary teams, to their own
professional organizations through re-validation, to health
authorities, the government, the media and the population
whom we serve.
In the last few years surgical practice has moved to objective
assessment and accountability in the context of clinical
governance. Since the introduction of the NHS Plan (national
health services), it became more important to show that one
is following accepted evidence based practice and also that
one is striving to perform towards nationally accepted
standards of practice. The focus of clinical effectiveness and
quality improvement now lies with the individual patient which
now defines the patient centered approach.2
Since outcome of the patient does not solely depend upon
damage inflicted by the surgeon, raw morbidity and mortality
rate are not true reflection of a particular surgeon. Raw
mortality and morbidity rate will ignore the effect of case-mix
i.e. different sorts of patients, both fit and unfit, undergoing
treatment. For example if a surgeon operates on relatively fit
patients, his mortality and morbidity will be low but if another

surgeon working in a tertiary referral center operates on
relatively unfit patients, his outcome will be dismal.1
It is well accepted that the use of crude mortality and
morbidity rates are inaccurate and misleading for comparative
surgical audit when results of emergency surgery are
compared between different units and hospitals.3, 4
An accurate system to predict mortality and morbidity is
essential for auditing surgical patients.3 For this purpose a
scoring system that classifies the patients on the basis of
severity of their illness before surgery may be a meaningful
tool for predicting mortality and morbidity.4
POSSUM stands for physiologic and operative Severity Score
for the enumeration of Mortality and Morbidity. It was
developed by Copeland et al in 1991 and has since been
applied to a number of surgical groups including orthopedics
patients, vascular surgery (AAA, carotid endarterectomy etc),
head and neck surgery and GI/Colorectal surgery.3, 4

In a recent surgical review article on the subject of Risk
Scoring in Surgical Patients (Jones 1999a) it was concluded
that "the POSSUM Score is the most appropriate of the
currently available scores for general surgical practice" in the
estimation of risk of dying. Despite first being reported in
1991 (Copeland 1991), POSSUM has not become widely used
in the UK although it is more popular in the North West of
England, close to its original base, and has been adopted by a
few enthusiasts across the world. A data base of 250,000
patients has apparently been gathered. Surgeons seem to be
generally more aware of POSSUM than anesthetists who
regularly use ASA for general patients and APACHE for the
critically ill. This is probably because most of the relevant
publications have been in surgical journals.1
The ideal risk assessment tool would be quick and easy to
use, widely applicable, include elective and emergency work
and accurately predict outcome. The initial researchers
examined 62 factors. As in many similar areas of
mathematical prediction, multi-variate analysis was able to
identify the most powerful predictors and reduced these to
just 12 physiological and 6 operative parameters. Other

factors no doubt do predict Outcome but so strongly duplicate
these 18 that they offer no additive predictive power. Each of
these 18 factors were divided into two, three or four levels
and computer analysis calculated that a weighting of 1,2,4 or
8 approximated well to the relative predictive power, much
simplifying the calculation.
It is valuable for risk adjustment and comparison.4 It was
devised specially from surgical patients and is used for
surgical audit. In this scoring system all 12 physiological and
six operative variables are used to predict 30 days mortality
and morbidity.3,7-8 These variables are basic medical
information that should be present in the medical record of
every patient. The Portsmouth predictor modification
(P.POSSUM) was developed to overcome the over prediction
of mortality by possum in low risk patients.3, 4

In p-possum
same physiologic variables are used but equation and method
of analysis is different.3
Since 1990, this scoring system has been used extensively in
UK and in some other countries to compare surgical patients
treated in different health care systems.5 The Variety of cases
undergoing emergency and elective laparotomy in developing

countries is different from UK. Their nutritional status, low
socioeconomic status and delayed presentation also affect
their prognosis. Comparing the outcome of such patients
using data from developed countries may be misleading.6
The aim of present study is to evaluate the predictive
accuracy of possum and p-possum in predicting mortality and
morbidity in patients undergoing emergency and elective
laparotomy in our circumstances. It will also compare the
results of possum and p-possum scores in emergency and
elective surgery. This system may be useful to audit different
surgeons, units and hospitals in future.
The need for accountability, the desire of professional bodies
to maintain standards and wish of the patients for ever more
information is leading to increasingly sophisticated
information appearing in the public domain. In this culture of
increased scrutiny, surgeons must be able to demonstrate
clearly and accurately how they perform through comparative
surgical audit.
3. REVIEW OF LITERATURE
3.1. SURGICAL AUDIT
Surgeons view on audit
We must formulate some method of hospital report showing
as nearly as possible what the results of treatment obtained
at different institution are. This report must be made out and
published by each hospital in a uniform manner, so that
comparison will be possible. With such report as a starting
point, those interested can begin to ask questions as to
management and efficiency. (Taken from lecture by Ernest
7
Amory Codman)
Surgery with out audit is like playing cricket without keeping
the score. (H.B. Devlin, founding director of the surgical
epidemiology and audit unit, Royal College of surgeons of
England) 7
The roots of modern audit lie in the regular morbidity and
mortality meetings held in many hospitals of USA, when
transferred to British Isles in 1950, the American drive for
change based on findings and the educational importance
were missing. Until 1990 there was no funding or allocation of

time for audit activity. Health authorities are now agreed to
audit every specialty, particularly surgery.8
Clinical audit is defined by the UK department of health as:
the systemic, critical analysis of the quality of medical care,
including the procedures used for diagnosis and treatment,
the use of resources and the resulting outcome and the
quality of life for the patient and states that an effective
program of medical audit will also help to provide reassurance
to doctors, their patients and managers that the best quality
of service is being achieved, having regard to the resources
8
available(department of health).
Clinical audit is a process used by clinician to improve patient
care. This process involves comparing aspect of care, if care
falls short of the criteria chosen, some change in the way of
care is proposed. This change may be at individual,
institutional, national or international level.
3.2. METHODS OF AUDIT8
Donabedian identified three main elements in the delivery of
health care: structure, process, and outcome. Structures
include the quality and type of resources available and are

generally easy to measure. Process defines what is done to
the patient. It includes way of operation and prescribed
medications, the adequacy of notes. Outcome is the result of
clinical intervention and may represent the success or failure
8
of process.
A number of audit techniques have evolved and found a place
in the regular assessment of clinical practice.
Basic clinical audit: It analyzes and assesses complications,
morbidity, and mortality. A review of such data is undertaken
every 3rd month. The essential feature is to find any deviation
from the accepted norm and then to investigate the reason
for this observation.
Incident review: It involves discussing strategies to be
adopted under certain clinical situations. Incident may be
leaking aortic aneurysm. The discussion may lead to clear
policies for future actions and use with the construction of
local guidelines.
Clinical record review: A member of another firm of the
same or similar specialty reviews a random selection of case

notes and compares it with specific standard given. It is
simple and requires little time or resources.
Criterion audit: it is more advanced and structured form of
incident audit. Retrograde analysis of clinical records is made
and judged against a number of carefully chosen criteria.
It can compare, waiting time, investigations ordered,
treatment given, and outcome and follow-up strategies.
Adverse occurrence screening: it identifies the adverse
events like wound infection, unplanned readmission, delayed
or wrong diagnosis. Occurrences are recorded, reviewed and
avoided in future.
Comparative audit: it implies the collection of data and its
comparison across units, health authorities and even through
whole region. The Royal College of surgeons set up a
comparative audit service in which all surgeons supply
information under a confidential number for comparison with
their peers at regular meetings. This regional audit
significantly influences and improves surgical practice.
National studies: this was used first to study perinatal
mortality in obstetric. First report of the perioperative death,

considered the factors involved in death of patients who died
with in 30 days of surgery. Much was learned to upgrade the
training of the doctors to prevent disasters.
Outcome audit: it is a review of the whole process of
healthcare delivery during a patient’s hospital contact. It
measures all the skills of the medical and nursing staff, the
hospital administration and all those who are in contact with
patient. Commonly used measures of outcome are mortality
and morbidity.
MORBIDITY:
It is a valuable end point for assessing surgical performance
and has implication for both patient’s quality of life as well as
consumption of healthcare resources. It is most important for
those operations and specialties which have a low mortality
rate.
MORTALITY:
It is a more finite and indisputable end-point than morbidity
has been used to greater extent and success in competitive
surgical audit.
Most series have measured in hospital mortality but recent
work suggests that this may underestimate true mortality up
9
to 20% when compared to 30-day mortality rates.
3.3. RISK ADJUSTED ANALYSIS
Simple collection of crude numbers of the dead or the injured
alone is insufficient to reflect quality of care as, to compare
morbidity or mortality directly; the original population should
be identical. True comparison can only be made if risk
adjustment is used to allow for the difference in case mix
between units and surgeons. This is termed risk adjusted
analysis. It is based upon the principle of identifying those
variables that affect outcome like mode of presentation,
physiological parameters and the nature, extent and difficulty
of surgery.
In this model multivariate logistic regression analysis is used.
It identifies outcome affecting variables and generates an
equation which predicts the likelihood of the outcome
occurring in any given patient.
An alternative approach to risk stratification is to use a
Bayesian model.13 Rather than producing a rigid equation, this

method allows the probability of an event to be revised as
additional relevant information is obtained. The Bayes, model
is then tested in much the same way by using ROC curves and
calibration curves.
3.4. RISK SCORING SYSTEMS
Risk scoring systems used to predict complicated outcome or
mortality are not a new phenomenon and there are many
examples (ASA, APACHE, Ranson, SAPS, Cardiac index,
Revised trauma score).however they were not designed
specifically for the purpose of comparative surgical audit.
10
3.4.1. ASA GRADING
The best and most widely used example is the classification of
preoperative physical status described by American society of
Anesthesiologists (ASA score) in 1963.Patients are allocated
to one of five categories based on general medical history and
examination with out requiring any specific investigation.
I. Normal healthy patients
II. Mild systemic disease
III. Severe systemic disease, not incapacitating

IV. Incapacitating systemic disease that is threat to life
V. Moribund, not expected to survive 24 h with or without
an Operation
“E” can be added to denote emergency surgery and signifies a
worse prognosis. This score is simple and already in universal
use. There is potential for interobsever subjective error. This
is effective in predicting mortality when used alone.11
3.4.2. APACHE
The acute physiology and chronic health evaluation score
(APACHE) scoring system has been used extensively in the
intensive care setting. Its aim is to allow for classification of
patients’ on the basis of severity of illness to facilitate
comparison of outcome, the evaluation of new therapies and
as an indicator of daily progress. The original APACHE system
had 34 physiological variables, taking the worst value
obtained in first 24 h of admission in intensive care, combined
with a simple evaluation of chronic health. More recently the
APACHE system has been modified and simplified to create
APACHE II12 APACHE III13 although these still require 12 or 18
physiological variables.
APACHE II has been validated both in general and surgical
intensive care patients with some success, although results
have not always been accurate. It is limited for risk adjusted
analysis in comparative surgical audit due to its complexity
and requirement to collate variables over 24 h.
3.5. METHODS OF RISK ADJUSTED ANALYSIS IN
COMPARATIVE SURGICAL AUDIT
A number of methods have been proposed for standardizing
patient’s data to permit direct, meaningful comparisons of
patient outcome irrespective of differences in population for
the purpose of audit.
POSSUM (physiology and operative severity score for
enumeration of morbidity and mortality)
Surgical Risk Scale
E –PASS (estimation of physiologic ability and surgical stress)
National Veterans Affairs Surgical Risk Study
Specialty Registries’
These are few methods which are useful for comparative
surgical audit. All these methods include operative variables
also.
3.5.1. POSSUM
A Physiological and Operative Severity Score for the
enumeration of Mortality and Morbidity was developed by G P
Copland et al. Driven by the need to develop a simple risk
scoring system applicable to diverse general surgical
populations, whose main use would be in surgical audit,
POSSUM scoring system was developed. It was first published
in British Journal of Surgery March 1991; 78:356-360.
Copland et al conducted a prospective study over a period of
six months in 1372 patients undergoing operation in general
surgery units. It is an attempt to quantify the quality of
surgical care and to allow comparison between different
surgeons, units, hospitals and regions. Authors also stressed
the usefulness of POSSUM as an adjunct to surgical audit.14
It is currently the most tested system for assessing outcomes
by risk-adjusted analysis in the UK. It is simple, easy and
applicable to all general surgical procedures. It is more

popular in the North West of England, close to its original
base, and has been adopted by a few enthusiasts across the
world. A data base of 250,000 patients has apparently been
gathered. Surgeons seem to be generally more aware of
POSSUM than anesthetists who regularly use ASA for general
patients and APACHE for the critically ill. This is probably
because most of the relevant publications have been in
surgical journals. If ASA is considered to be too simplistic and
highly subjective whilst APACHE is too complex for general
use, then POSSUM neatly fits into the gap, requiring only 12
physiological and 6 operative facts, all easily available from
routine admission and operation data.
Possum was developed as a tool to compare morbidity and
mortality in a wide ranging basket of general surgical
procedures and should be applied at the time of induction of
anesthesia before operation to patients of all risk categories.
However it is of relevance to mortality audits as an objective
and qualitative assessment of risk in patients who died after
surgery. Some Scottish surgical centers have taken an
interest in POSSUM and took the opportunity of piloting
POSSUM more widely at the same time.

COMPONENTS OF POSSUM
POSSUM is a two part scoring system that includes a
physiological assessment and measure of operative severity.
There are 12 physiological and 6 operative variables which are
divided into 4 grades with an increase in score. The
physiological variables are those that are present at the time
of surgery. These include symptoms and signs, results of
simple biochemical and hematological investigations and
electrocardiographic changes. If a variable is not present, a
score of 1 is allocated. Some variables are assessed by means
of changes on chest radiograph.
Physiological Operative
Age Operative severity
Cardiac history Multiple procedures
Respiratory history Total blood loss
Blood pressure peritoneal soiling
Pulse rate Presence of malignancy
Glasgow coma score Mode of surgery Hemoglobin

White blood count
Serum urea
Serum sodium
Serum potassium
Electrocardiogram
The minimum score is 12, with a maximum of 88.once these
scores are known, it is possible to estimate the predicted risk
of mortality and morbidity using complex equation.
3.5.2. P-POSSUM
In his article Whitely et al in 1996 showed that the original
POSSUM regression equation failed to work in patients in
Portsmouth.15 He found that POSSUM over predicted mortality
of low risk patients in a study of 1485 patients. It was still
possible to use the POSSUM y data set, but a different
regression equation was needed. This regression equation
became the Portsmouth predictor equation, or P-POSSUM. It
used a different constant and weighted value for physiology
and operative scores.

P-Possum used standard method of analysis described by
Hosmer and Lemeshow. In this system, the risk applies to an
individual.
A lively correspondence between the Portsmouth group and
the originators of POSSUM appeared in British Journal of
Surgery. The debate culminated in a direct comparison of the
two possible methods of analysis. Wijisinghe et al explained
how the original POSSUM equation used exponential analysis,
while P-POSSUN used linear analysis. They employed both
methods in a series of 312 patients who had vascular surgical
procedure and showed that each was effective if appropriate
analysis was used. Both scoring systems failed when the
incorrect analysis was used.16
3.5.1.1. POSSUM IN GENERAL SURGERY
Since first published, POSSUM scoring system has been
validated by many authors. Although this system is more
popular around the North England in, many authors use it all
over the worlds. A review article was published in 1999
annual report of SASM (Scottish Audit of Surgical Mortality)
describing POSSUM scoring system. The aim of that review

was to increase the general awareness of POSSUM across
Scottish surgeons and anesthetics.
It was recommended to include POSSUM in SASM forms
17
during the following year for some surgical specialties.
Possum also used in developing countries like India and
Pakistan. A study conducted recently by R.S. Mohil and
colleagues in India. In their study 120 patients who
underwent emergency laparotomy in a single unit studied.
Predicted mortality and morbidity rates were calculated by
POSSUM and P-POSSUM equation using both linear and
exponential method of analysis. When the linear method of
analysis was used POSSUM over predicted morbidity, and
there was a significant difference between the observed and
predicted values (observed to expected (O: E) ratio 0.68).
The prediction was more accurate when the exponential
method was used (O: E ratio0.91). Possum also significantly
over predicted mortality when analyzed by the linear method
(O: E ratio 0.39), but the prediction improved when
exponential analysis was used (O: E ratio 0.62). Applying
linear and exponential analyses for P-POSSUM, the O: E ratios
4
for mortality were 0.66 and 0.88 respectively.
Another recently conducted study in center for the study of
liver disease and department of surgery, university of Hong
Kong, C.M. Lam and colleagues used POSSUM scoring
systems for audit of major hepatectomy. A retrospective
analysis was performed on data collected prospectively over a
6 year interval from January 1997 to December 2002.the
mortality risk was calculated using POSSUM and the P-
POSSUM equations. In this study 259 patients underwent
major hepatectomy. There were 6.6% postoperative deaths.
On multivariate analysis only the physiological and operative
severity scores were independent variables. The POSSUM
system over predicted mortality (14.2%) and there was
significant lack of fit in these patients. The mortality rate
predicted by P-POSSUM was 4.2% and showed no significant
lack of fit.3
In another study in academic department of surgery, king, s
college hospital London, UK, Tekkis PP and colleagues studied
risk-adjusted prediction of operative mortality in
oesophagogastric surgery with O-POSSUM. This was designed
to develop a dedicated oesophagogastric model for prediction
of risk adjusted postoperative mortality in upper

gastrointestinal surgery. Using 1042 patients undergoing
esophageal surgery between 1994 and 2000, the Portsmouth
predictor equation for mortality scoring system was compared
with a standard logistic regression O-POSSUM model. The
overall mortality was 12% (elective 9.4 and emergency
26.9).P-POSSUM over predicted mortality 14.5%, particularly
in elective group of patients. The multilevel model offered
higher discrimination than single level O-POSSUM and P-
POSSUM models. When observed to expect outcomes were
evaluated, the multilevel O-POSSUM model was found
superior.5
R. Sutton, S. Sarin and Brooks compared the surgical risk
score, POSSUM and p-POSSUM in higher risk patients. The
aim of study was to compare the accuracy of mortality
prediction using that of POSSUM and p-POSSUM in a cohort of
higher risk patients. The surgical risk score (SRS) has been
show equivalent accuracy but was validated using a cohort
that contained a high proportion of patients. Some 949
inpatients undergoing procedures in a district general hospital
under the care of surgeon were analyzed. The observed
mortality rate was 8.4%.mean mortality predicted by SRS,

POSSUN and p-POSSUM were 5.9, 12.6, and 7.3%
respectively.6
Gocmen E, Koc M and Tez M from fifth department of surgery,
Ankara Numune Education and research hospital Turkey
evaluated O-POSSUM and P-POSSUM scores in patients with
gastric cancer undergoing resection. They studied
retrospectively 126 patients undergoing elective resection in
stomach cancer. They compared observed and predicted
mortality using both these models. Overall fourteen deaths
were observed-POSSUM predicted 15 deaths and P-POSSUM
predicted 20.this data suggest that O-POSSUM predicts
mortality more accurately than P-POSSUM.18
Mahesh Gopashetty, Gabriel Rodrigues and colleagues
Evaluated P-Possum Mortality Predictor Equation and Its Use
as a Tool in Surgical Audit. Patients admitted and operated
over a period of four months in six general surgery units of
Kasturba Medical College and Hospital, Manipal, India were
included in the study. Copeland's scoring system was used to
classify patients and the data was analyzed using P-POSSUM
mortality equation. Predicted mortality rate was calculated
and was compared with observed mortality rate. Results were

evaluated by χ2 test. A total of 493(n) patients were operated
during this period of study. Of these, 103 patients underwent
emergency surgeries. Among 493 patients operated, had a
mortality of 26. The raw mortality rate in surgical unit II was
3.96% and 5.45% in unit VI. It was lowest in unit V (1.69%)
and highest in unit IV (6.41%). After adjusting for risk, it was
noted that Observed: Expected mortality ratio was almost
equal in unit II and unit VI (0.83 and 0.8 respectively), while
it ranged from 0.66 in unit V to 1.25 in unit IV. It was also
observed that mortality rates were not significantly different
from predicted mortality rates. Thus, at the end of the study it
was concluded that P-POSSUM mortality predictor equation
predicts death accurately in general surgical patients.
Comparing risk adjusted mortality rate is more meaningful
than comparing "raw" mortality rate.19
3.5.1.2. POSSUM in specialties
Oesophagogastric surgery
In Department of Surgery, Crosshouse Hospital, Kilmarnock,
UK University Department of Surgery, Glasgow Royal

Infirmary, Glasgow, UK Comparison of P-POSSUM and O-
POSSUM in predicting mortality after oesophagogastric
resections made. Elective oesophagogastric cancer resections
in a district general hospital from 1990 to 2002 were scored
by P-POSSUM and O-POSSUM methods. Observed mortality
rates were compared to predicted mortality rates in six risk
groups for each model using the Hosmer–Lemeshow
goodness-of-fit test. 313 patients underwent
oesophagogastric resections. 32 died within 30 days (10.2%).
P-POSSUM predicted 36 deaths, O-POSSUM predicted 49.
Neither model accurately predicted the risk of postoperative
death. P-POSSUM provided a better fit to observed results
than O-POSSUM, which over predicted total mortality. P-
POSSUM also had superior discriminatory power.20
Hisao Wakabayashi and colleagues in their study validated the
usefulness of POSSUM and-POSSUM for a surgical audit in
elective digestive surgery for elderly patients. This study
involved 153 patients aged 75years and older who underwent
elective gastric or colorectal surgery between July 2004 and
June 2006. A retrospective analysis was performed on data
collected prior to each surgery. The predicted mortality and

morbidity rates were calculated using each of the scoring
systems and were used to obtain the observed/predicted
(O/E) mortality and morbidity ratios. New logistic regression
equations for morbidity and mortality were then calculated
using the scores from the POSSUM system and applied
retrospectively. The O/E ratio for morbidity obtained from
POSSUM score was 0.23. The O/E ratios for mortality from the
POSSUM score and the P-POSSUM were 0.15 and 0.38,
respectively. Utilizing the new equations using scores from the
POSSUM, the O/E ratio increased to 0.88. Both the POSSUM
and P-POSSUM over-predicted the morbidity and mortality in
elective gastrointestinal surgery for malignant tumors in
elderly patients. However, if a surgical unit makes appropriate
calculations using its own patient series and updates these
equations, the POSSUM system can be useful in the risk
assessment for surgery in elderly patients.21
3.5.1.3. COLORECTAL SURGERY
Department of Surgery of Queen Mary Hospital, HONG-KONG,
they examined the accuracy of (P-POSSUM) in predicting the
mortality of patients who underwent operations for
obstructing colorectal cancer. They attempted to analyze the

actual mortality and the predicted P-POSSUM mortality of
different surgical options for obstructing left-sided cancer.
They studied 160 patients from 1998 to 2002. 18 patients
died postoperatively. The operative mortality was 11.3
percent. P-POSSUM predicted overall mortality of 15 percent.
The observed and predicted mortality was found to have no
significant difference. They concluded that P-POSSUM system
is valid for prediction of overall mortality in patients with
operations for obstructing colorectal cancer.22
Watanabe Makoto and colleagues from Isesaki Municipal
Hospital, Japan, Estimated Mortality and Morbidity Risk in
Colorectal Surgery using POSSUM Predictor Equation.
Physiological and operative severity scores in 119 patients
undergoing elective and emergency colorectal surgery were
recorded retrospectively. Observed morbidity and mortality
were compared with the prediction by POSSUM or P-POSSUM
using linear analysis. The Hosmer-Lemeshow goodness of fit
test indicated that the POSSUM morbidity equation had a
significant lack of fit with observed complications. The
POSSUM mortality equation overestimated deaths with this
analysis. But the mortality rate estimated by P-POSSUM did

not differ significantly from the observed death rate. These
results suggest that the POSSUM scoring system for morbidity
risk must be modified, and the P-POSSUM scoring system for
mortality risk is useful for patients undergoing colorectal
surgery.23
3.5.1.4. PANCREATIC SURGERY
W. Pratt and S. Joseph in their article studied the predictive
accuracy of POSSUM in pancreatic resection. 326 consecutive
pancreatic resections (227 pancreaticoduodenectomies, 87
distal, 7 central, and 5 total pancreatectomies) were
performed between October 2001 and January 2007. Logistic
regression analysis was used to identify specific POSSUM
parameters predictive of postoperative morbidity. Observed
and Expected morbidity rates were equivalent (53.1% vs.
55.5%) with an overall O/E ratio of 0.96. they concluded that
POSSUM is a valuable perioperative scoring system for
pancreatic resections and outcomes, and can be employed to
guide management decisions that impact postoperative
recovery.24
Abdaal W Khan, Sudeep R Shah and colleagues from
Department of Surgery, Royal Free and University College
Medical School, London, UK Evaluated the POSSUM scoring
system for comparative audit in pancreatic surgery. They
analyzed Retrospectively 50 patients undergoing partial
pancreaticoduodenectomy (PD) with POSSUM and P-POSSUM
equations. The predicted results compared with observed
values. The POSSUM-predicted mortality was 26%, and P-
POSSUM predicted mortality was 6%, while actual mortality
was 4%.Using POSSUM for morbidity, the predicted value was
76%. The observed morbidity was 46%.While P-POSSUM
appeared satisfactory for predicting mortality risk; POSSUM
overestimated morbidity and mortality for
pancreaticoduodenectomies in a specialist centre.
Modifications are needed prior to its application for
comparative audit in pancreatic surgery.25
3.5.1.5. VASCULAR SURGERY
In Vascular Unit of Derriford Hospital, Derriford Plymouth,
Midwinter M. J Tytherleigh M., ASHLEY S, estimated vascular
mortality and morbidity by using POSSUM and P-POSSUM

equations. Physiological and operative severity scores in 221
patients undergoing elective and emergency arterial surgery
in a pure vascular practice under a single consultant were
recorded prospectively. Observed morbidity and mortality
rates were compared with the rates predicted by POSSUM and
P-POSSUM using a linear method of analysis. The POSSUM
overestimated deaths but the mortality rate estimated by P-
POSSUM was not significantly different from the observed
death rate. The risk of morbidity predicted by POSSUM was
not significantly different from the observed complication rate.
They concluded that POSSUM combined with the P-POSSUM
adjustment for death allows satisfactory prediction of
mortality and morbidity rates in patients undergoing vascular
surgery.26
Prytherch, Sutton, and Boyle in their study evaluated P-
PSSUM model for abdominal aortic aneurysm surgery.
Patients with a ruptured abdominal aortic aneurysm (AAA)
are, however, very different from elective patients and it may
be hypothesized that they require their own specific risk
model. They studied 444 (213 emergency, 231 elective)
admissions for AAA surgery between August 1993 and July

2000 and analyzed using the P-POSSUM equation for general
surgery and the P-POSSUM equations developed for vascular
surgery. All models failed in emergency aneurysms while
predicted successfully the elective aneurysms. They
suggested that admission method is an important factor for
patients with AAA. They concluded that Ruptured AAAs
appears to be different from elective AAAs and other vascular
cases and require their own risk model.27
3.5.1.6. ORTHOPEDICS SURGERY
A cohort study was conducted in Queen's Medical Centre,
Nottingham over a period of nearly 2 years .in their study,
they assessed the predictive capability of POSSUM for 30-day
mortality after surgery for fractured neck of femur. Complete
data from 1164 patients were analyzed to compare the
mortality predicted by POSSUM and the observed mortality.
POSSUM risk of death was calculated using the original
POSSUM equation, with modifications to the operative score
appropriate for orthopaedic surgery. POSSUM predicted 181
(15.6%) deaths and the observed mortality was 119
(10.2%).POSSUM overpredicts mortality in hip fracture

patients. It should be used with caution whether as an audit
tool or for preoperative triage.28
An article published in Chinese journal of traumatology in
2006 Evaluated P. POSSUM scoring system in predicting
mortality in patients with hip joint arthroplasty. A total of
141 patients (75 males and 66females, aged 63.22 years
± 14.45 years on an average) undergoing hip joint
arthroplasty during January 2002 and March 2005 were
studied retrospectively with P-POSSUM. Their average
physiological score and operative severity score were
17.48 ± 5.16 and 12.43 ± 3.05, respectively. The
predicted postoperative mortality with P-POSSUM was
compared with the observed value. Analysis was
performed to investigate the predictive capability of P-
POSSUM. POSSUM scoring system was used as the
control. The average physiological scores were 32.33
±9.87 in the death group and 17.16 ±4.56 in the survival
group. The former was obviously higher than the latter,
which showed statistical difference between the two
groups but a strong relation was found between the
observed death number and the predicted death number

calculated by P-POSSUM, though POSSUM overestimated
the overall mortality.
3.5.1.7. GYNECOLOGICAL SURGERY
DAS N, TALAAT A. S in their article published in European
journal of surgical oncology, assessed POSSUM and its validity
for use in gynecological oncology surgery. All patients
undergoing gynecological oncology surgery at the Northern
Gynecological Oncology Centre (NGOC) Gateshead, UK over a
period of 12 months (2002-2003) were assessed
prospectively. Mortality and morbidity predicted by P-POSSUM
were compared to the actual outcomes. During this period
468 patients were assessed. It predicted a 7% mortality rate
while observed rate was 2% (35 predicted deaths in
comparison to 10 observed deaths), a difference that was
statistically significant. They concluded that P-POSSUM
overestimates the risk of mortality for gynecological oncology
patients undergoing surgery and it needs further modifications
prior to adoption for gynecological cancer surgery as a risk
adjusted surgical audit tool.29
3.5.1.8. BARIATRIC SURGERY

Cagigas and Escalante studied the Application of POSSUM
System in Bariatric Surgery. 20 patients were scored by the
POSSUM system. All underwent elective bariatric surgery
during 1997. All patients were scored at the time of surgery
with the physiologic score (FIS) and at discharge with the
operative severity score (IQ). The mean POSSUM score was
23.9. The mean FIS was 13.95 (12-22), and the mean IQ was
9.4 (7-16). The distribution of patients was performed for
BMI. The group with BMI 35-45 (n = 4 patients) had a mean
POSSUM score of 22.75, a mean FIS of 13.75, and a mean IQ
of 9.0. The group with BMI >45 (n = 16 patients) had a mean
POSSUM score of 24.18, a mean FIS of 14.62, and a mean IQ
of 9.5. The morbidities were gastric fistula with peritonitis and
deep venous thrombosis. The two complications had similar
POSSUM scores with different BMIs. No mortality was
observed. According to their experience, the POSSUM scoring
system appears to provide an indicator of minor risk of
morbidity and mortality in bariatric surgery with vertical
banded gastroplasty.30
3.5.1.9. OTOLARYNGOLOGYL SURGERY

Department of ENT and the Head and Neck Unit, University
Hospital of Wales, they studied applicability of POSSUM in
head and neck surgery. They also applied the P-Possum
(Portsmouth Possum) equation for mortality. They compared
observed with the predicted outcomes. They introduced two
new variables, radiotherapy and previous surgery to the
operative site, to test their association with outcome. They
found that Possum is valid for morbidity but predicts more
accurately for high-risk than for low-risk groups. Neither
Possum nor P-Possum accurately predicts mortality.31
3.5.1.10. EMERGENCY SURGERY
Hobson and. Sutton in Department of General and Colorectal
Surgery, Leicester General Hospital, studied the comparison
of POSSUM and P-POSSUM with clinical assessment of
mortality following emergency surgery. Data were collected
prospectively from 163 patients. Details of the physiological
and operative severity scores were recorded for POSSUM and
P-POSSUM. The estimates of both the surgeon and anesthetist
for 30-day and in-hospital mortality were also recorded pre-
operatively. The accuracies of the four predictions were then

compared with actual mortalities using linear and exponential
analysis and receiver operator characteristics (ROC). Results:
P-POSSUM gave the most accurate prediction of 30-day
mortality using linear analysis [observed to expected ratio (O:
E) = 1.0]. POSSUM gave the most accurate prediction using
exponential analysis (O: E = 1.15). Clinical judgment of
mortality from both operating surgeons and anesthetists
compared favorably with the scoring systems for 30-day
mortality (O:E = 0.83 and O: E = 0.93, respectively). They
conclude POSSUM and P-POSSUM appear to be useful
indicators for the prediction of mortality. Clinical judgment
compares strongly with scoring systems in predicting post-
operative mortality, but may underestimate mortality in very
high-risk patients with more than 90% mortality.32
3.5.1.11. POSSUM IN PAKISTAN
Qamar Hafeez Kiani et al conducted a study on the topic of
Surgical Audit Using POSSUM Scoring System. A total of 500
case were studied. The scoring system provided the
assessments for mortality and morbidity, which did not
significantly differ from observed rates (p<0.001).The

POSSUM score provided a reasonably effective means of
achieving comparison among the two-thirds of patients who
underwent surgical procedure. It was concluded that POSSUM
provides a good assessment of the risk of mortality and
morbidity in general surgical patients. This score can be
effectively applied in all surgical setups in Pakistan and can be
used as an adjunct to surgical and can be used as an adjunct
to surgical audit.33, 34
3.6. COMPUTER PROGRAM FOR POSSUM AND P-POSSUM
CALCULATIONS
There is a computer program freely available that provides a
single screen to calculate the POSSUM and P-POSSUM
morbidity and mortality risk .This is available on the site
www.sfar.org/score2/P-POSSUM2.html .
POSSUM formula:
Morbidity: ln R/1-R = –5.91 + (0.16 * physiological score) +

(0.19 * operative score)
Mortality: Ln R/1-R = -7.04 + (0.13 x physiological score) +

(0.16 x operative severity score)
P-POSSUM formula:
Mortality: Ln R/1-R = -9.065 + (0.1692 x physiological score)

+ (0.1550 x operative severity score)
Where R = predicted risk of mortality
3.7. VALIDATION OF POSSUM AND P-POSSUM
PREDICTION EQUATIONS
Observed and predicted outcomes, derived from POSSUM and
P-POSSUM equation, correlated by using Pearson correlation
coefficient. The resultant of Pearson correlation is shown in
tables. Pearson correlation coefficient(r) measures the
strength of association between two variables.
The value of r ranges between +1 and –1
+1=A positive or direct correlation
-1=A negative or inverse correlation
0=A zero correlation (no relationship)
The results are tested by using chi-square (χ²) test. The value
of P≤0.05 is taken as significant. The result of chi-square is
illustrated in table no.11 and 22.

THE
STUDY
4 . OBJECTIVES:
THE OBJECTIVE OF THIS STUDY IS TO:
Evaluate the predictive accuracy of POSSUM and P-POSSUM
scoring systems in patients undergoing emergency and
elective laparotomy.
5. HYPOTHESIS:
P-POSSUM scoring system is better than POSSUM in
predicting mortality in patients undergoing
emergency and elective laparotomy.

6. OPERATIONAL DEFINITIONS:
1. PREDICTIVE ACCURACY: This will be measured in terms
of:
2. MORBIDITY:
2.1. Wound haemorrhage: Local haematoma requiring
evacuation.
2.2. Deep haemorrhage: Postoperative bleeding requiring
re-exploration.
2.3. Chest infection: Production of purulent sputum with
positive bacteriological cultures, with or without chest
radiography changes or pyrexia, or consolidation seen on
chest radiograph.
2.4. Wound infection: Wound cellulites or the discharge of
purulent exudates.
5
2.5. Urinary infection: The presence of > 10 bacteria / ml
with the presence of white cells in the urine, in previously
clear urine.
2.6. Deep infection: The presence of an intra-abdominal
collection confirmed clinically or radiologically.

2.7. Septicemia: Positive blood culture.
2.8. Pyrexia of unknown origin: Any temperature above
37°C for more than 24 h occurring after the original pyrexia
following surgery (if present) had settled, for which no
obvious cause could be found.
2.9. Wound dehiscence: Superficial or deep wound
breakdown.
2.10. Deep venous thrombosis and pulmonary embolus:
when suspected, confirmed radiologically by venography or
ventilation/ perfusion scanning or diagnosed at post mortem.
2.11. Cardiac failure: Symptoms or signs of left ventricular
or congestive cardiac failure (alteration from preoperative
measures).
2.12. Impaired renal function: Arbitrarily defined as an
increase in blood urea of > 5mmol / l from preoperative
levels.
2.13. Hypotension: A fall in systolic blood pressure below
90mmHg for more than 2 H as determined by
sphygmomanometry or arterial pressure transducer
measurement.
2.14. Respiratory failure: Respiratory difficulty requiring
emergency ventilation.
2.15. Anastomotic leak: Discharge of bowel content via the
drain, wound or abnormal orifice.
2.16. Moderate surgery: Cholecystectomy,
appendicectomy, mastectomy, transurethral resection of
prostate.
2.17. Major surgery: Any laparotomy, bowel resection,
cholecystectomy with choledochotomy, peripheral vascular
procedure or major amputation.
2.18. Major surgery+: Any aortic procedure,
abdominoperineal resection, pancreatic or liver resection,
oesophagogast-rectomy.
3. Mortality: Number of deaths with in 30 days of surgery.
4. Emergency Laparotomy: Laparotomy which is done with
in 24 hours of presentation to emergency department

5. Elective Laparotomy: Laparotomy for etiologies, which
can be postponed till patient, is fully optimized and risk
factors evaluated.
6. POSSUM:
Physiology and operative severity score for enumeration of
morbidity and mortality.
7. P-POSSUM:
Portsmouth- Physiology and operative severity score for
enumeration of morbidity and mortality

7. MATERIAL AND METHODS:
SETTING: South Surgical Unit, Mayo Hospital, Lahore.
DURATION OF STUDY: 6 months after the approval of the
synopsis.
SAMPLE SIZE:
50 emergency laparotomies (done within 24 hours of
presentation) and 50 laparotomies elective (done after patient
is optimized).
SAMPLING TECHNIQUE:
Non Probability convenience sampling.
STUDY DESIGN:
It is a prospective, observational follow-up study

SAMPLE SELECTION:
INCLUSION CRITERIA:
• All adult cases being admitted to Mayo Hospital through
emergency or OPD for etiologies requiring laparotomy
• Both genders
• Cases above 13 years of age.
EXCLUSION CRITERIA:
• Patients unfit for GA
• Patients requiring CPR
before surgery
• Elective
cholecystectomy
• Mentally retarded
patients
• Appendicectomy
DATA COLLECTION:
Total 100 cases, 50 from emergency and 50 from elective list
undergoing elective or emergency laparotomy meeting the
inclusion criteria were taken for study. An informed consent
was obtained from patients. Their demographic information’s
(age, sex, weight, etc) was recorded. The physiological
variables like pulse rate, systolic blood pressure, respiratory
rate, cardiac signs and Glasgow coma scale, hemoglobin,
white blood count, Urea, Sodium, Potassium, ECG and CXR
were recorded just before surgery. During the surgical
procedure six operative variables including operative severity,
total blood loss, multiple procedures, peritoneal soiling,
cancer and mode of surgery were recorded by the operating
surgeons. Their final physiological and operative score
calculated from possum data sheet (attached). The predicted
mortality and morbidity was calculated by POSSUM and P-
POSSUM equations. After surgery the patient’s observed
mortality and morbidity were noted for one month and
compared with the predicted outcomes. The patients were
followed up for 1 month on 1st, 3rd, 7th, 15th, 30th post

operative days for morbidity (list attached in operational
definitions) and mortality.
Data analysis:
All the information’s gathered will be entered in the SPSS
version 10.0 and analyzed. The source of the data will be
emergency and elective laparotomy. 12 physiological
variables i.e. age, pulse rate, systolic ,blood pressure,
respiratory rate, cardiac signs, and Hb, W.B.C, Urea, Sodium,
Potassium, and ECG & six operative variables i.e. operative
severity, total blood loss, multiple procedures, peritoneal
soiling, cancer and mode of surgery were recorded.
Demographic variables of the patients included in this study
were analyzed using the simple descriptive statistics.
Frequency distribution tables were made for source of data
(emergency/elective). Final prediction of the mortality and
morbidity of each patient was calculated using POSSUM and
P-POSSUM calculator available on the internet and recorded.
The observed mortality and morbidity was recorded within 30
days post-operatively and compared with predicted outcomes
Mortality and morbidity tables were made to calculate the
observed/predicted (O/P) ratios. Pearson correlation was used

to correlate the observed and predicted morbidity and
mortality. Chi-square analysis was made for the test of
significance. A p-value of .05 or less was taken as significant.

RESULTS
8. RESULTS
The main indications of surgery on elective list were C.A Colon
(20%), T. B Abdomen (12%) and Fibroid Uterus (10%)
respectively and the main complication was wound infection
10% (table 1, 2). Most of the surgeries were performed by
associate professor and consultants, 36% and 32%
respectively (table 3).
In elective cases 26(52%) were female and 24(48%) were
male (Figure 1). Mean age of elective patients was 40.58
years (SD +14.34) with age range 14 to 70 years and mean
weight was 54.48 KG (SD+ 6.72) with weight range 50 to 68
KG.
On elective, sum of observed mortality and morbidity was 3(6
%) & 15(30%) while predicted mortality and morbidity by
POSSUM was 4.8(9.6%) & 14.67(29.34%) and P-POSSUM
2.93(5.86%).The O/P ratio (observed / predicted) of mortality
by POSSUM in elective laparotomy was .625 and for morbidity
was 1.02 and by using P-POSSUM, the mortality was 1.02
(table 5-7).
Pearson’s correlation in elective for POSSUM observed and
predicted morbidity was 1.000 &.707 and mortality was 1.00
& .867 and for P-POSSUM was 1.000 & .901 (table 8-10).
On elective, there was no significant difference between the
observed and predicted values for morbidity(x2 =66.4, 27 df.
p=. 000), for POSSUM mortality(x2 =88.240, 15 df. p=. 000),
and for P-POSSUM mortality(x2 =114.160, 11 df. p=. 000),
(table 11).
The main indication of surgery in emergency was T.B
Abdomen 20%, fire arm injury abdomen (FAI) 16% and blunt
trauma abdomen 14% and major complication was wound
infection (table 12,13).Most of the surgeries in emergency
were performed by residents (54%) and consultants (46%).
Mostly patients in emergency were male (88%). Mean age of
the emergency patients was 36 years (SD + 16.50) with age
range 15 to 75 years and weight was 62.00 KG (SD+ 11.78)
with weight range 40 to 100 KG.
In emergency, sum of observed mortality and morbidity was
6(12 %) & 22(44%) while predicted mortality and morbidity
by POSSUM was 9(18%) & 28.17(56.34%) and P-POSSUM

6(12%).The O/P ratio (observed / predicted) of mortality by
POSSUM in emergency laparotomy was .66 and for morbidity
was .78 and by P-POSSUM, the mortality was 1.00 (table 16-
18).
Pearson’s correlation in emergency for POSSUM observed and
predicted morbidity was 1.000 &.736 and mortality was 1.00
& .707 and for P-POSSUM was 1.000 & .858 (table 19-21).
In emergency also, there was no significant difference
between the observed and predicted values for morbidity(x2
=45.00, 24 df. p=. 006), for POSSUM mortality(x2 =34.840,
20 df. p=. 021), and for P-POSSUM mortality(x2 =104.160, 14
df. p=. 000), (Table 22).

Table 1: INDICATIONS FOR ELECTIVE LAPAROTOMY
N=50
Frequency
(%age)
CA. Colon 10(20)
T.B Abdomen 6(12)
Fibroid uterus 5 (10)
CA. Rectum 5(10)
CA. Ovary 4 (8)
Rectovaginal Fistula 2 (4)
Intestinal Obstruction 2 (4)
CA. Head of pancreas 2 (4)
Graham patch leak 1 (2)
Ovarian cyst 1 (2)
CA. Gall bladder 1 (2)
Pseudocyst 1 (2)
Typhoid perforation 1 (2)
Choledochal cyst 1 (2)
Perforated Appendicitis 1 (2)
Adhesive bowel disease 1 (2)
pelvic collection 1 (2)
vesicovaginal fistula 1 (2)
Liver Abscess 1 (2)
Intussusceptions 1 (2)
Liposarcoma 1 (2)
Gastric outlet obstruction 1 (2)
Total 50
TABLE 2: COMPLICATIONS IN ELECTIVE SURGERY
N=50
Frequency
(%age)
Wound infection 5 (10)
Multiple* 2 (4)
Wound infection and deep
2 (4)
infection
Wound hemorrhage 1 (2)
Respiratory failure 1 (2)
Anastomotic leak and wound
1 (2)
dehiscence
Wound infection and UTI 1 (2)
Deep infection 1 (2)
Anastomotic leak 1 (2)
Total 15
*Multiple: wound infection, deep infection, dehiscence,

Table 3: SURGEON ON ELECTIVE LIST
N= 50
Frequency
PROFESSOR 7 (14)
ASSOCIATE
18 (36)
PROFSSOR
ASSISTANT PROF 9 (18)
SENIOR REGISTRAR 16 (32)
TOTAL 50
FIGURE 1: GENDER DISTRIBUTION IN ELECTIVE CASES

N: 50
FEMALE MALE
52.0% 48.0%
Table 4: SUM OF OBSERVED AND PREDICTED
OUTCOMES IN ELECTIVE CASES

O.mort O.morb P.mort P.morb PP.mort
Sum Sum Sum Sum Sum

3.00 15.00 4.80 14.67 2.93
Keys
O.mort: observed mortality
O.morb: observed morbidity
P.mort: predicted mortality by POSSUM
P.morb: predicted morbidity by POSSUM
PP.mort: predicted mortality by p-possum

TABLE 5: COMPARISON OF OBSERVED AND PREDICTED
MORTALITY USING POSSUM EQUATION IN ELECTIVE
LAPAROTOMY
Range
O/p
of age Frequency O.mort P.mort
Ratio
in years
14-29 11 2 2.58 .775
30-44 16 1 1.12 .89
45-59 17 0 .88 0
60-74 6 0 .22 0
50 3 4.80 .625
Keys
O/P : Observed/predicted
Table 6: COMPARISON OF OBSERVED AND PREDICTED
MORBIDITY USING POSSUM EQUATION IN ELECTIVE
LAPAROTOMY
Range
O/p
of age Frequency O.morb P.morb
Ratio
in years
14-29 11 8 5.44 1.47
30-44 16 2 3.92 .51
45-59 17 4 4.08 .98
60-74 6 1 1.23 .81
50 15 14.67 1.02
Keys
MORTALITY USING P-POSSUM EQUATION IN ELECTIVE
LAPAROTOMY
Range Frequency O.mort PP.mort O/p
of age Ratio
in years
14-29 11 2 1.98 1.01
30-44 16 1 .95 1.05
45-59 17 0 0 0
60-74 6 0 0 0
TOTAL 50 3 2.93 1.02
Keys
PP.mort: predicted mortality by P-POSSUM
TABLE 8: Pearson’s correlation in elective morbidity
Observed Predicted
morbidity morbidity
Observed Pearson 1.000 .707
morbidity Correlation
Sig. (2-tailed) . .000

50 50
N
Predicted .707 1.000

Pearson
morbidity
Correlation
.000 .
Sig. (2-tailed)
50 50
** Correlation is significant at the 0.01 level (2-tailed).
TABLE 9: Pearson’s correlation in POSSUM elective
mortality
Observed Predicted
mortality mortality
mortality Correlation

50 50
N

Pearson
mortality
Correlation
.000 .
Sig. (2-tailed)
50 50
TABLE 10: Pearson’s correlation in P-POSSUM elective
mortality
Observed Predicted
mortality mortality

50 50
N

Pearson
mortality
Correlation
.000 .
Sig. (2-tailed)
50 50

GOODNESS OF FIT TEST
TABLE 11: Hosmer and Lemeshow Test in elective cases
Chi-Square df Sig.
Predicted 66.480 27 .000
morbidity
POSSUM 88.240 15 .000
Predicted
mortality
P-POSSUM 114.160 11 .000
Predicted
mortality
Table 12: INDICATIONS FOR EMERGENCY
LAPAROTOMY
Frequency
T.B Abdomen 10(20%)
FAI Abdomen 8(16%)
Blunt trauma abdomen 7(14%)
Duodenal ulcer Perforation 6(12%)
Typhoid perforation 3(6%)
Mesenteric ischemia 2(4%)
CA. Colon 2(4%)
liver abscess 1(2%)
Band obstruction 1(2%)
Intussusceptions 1(2%)
Adhesive bowel disease 1(2%)
Post appendectomy peritonitis 1(2%)
Ectopic pregnancy 1(2%)
Rectal injury 1(2%)
*PID 1(2%)
Fecal fistula 1(2%)
Stab abdomen 1(2%)
CA. Testis 1(2%)
Perforated appendicitis 1(2%)
Total 50
*PID: pelvic inflammatory disease

Table 13: Complications of Emergency Laparotomy
Frequency
Wound infection 5(10%)
Anastomotic leak 2(4)%
Wound Dehiscence 3(6%)
Deep infection 2(4%)
Sepsis 1(2%)
Cardiac failure 1(2%)
Chest infection 1(2%)
Jaundice, Fistula 1(2%)
Urinary fistula 1(2%)
Pulmonary Embolus 1(2%)
Liver failure 1(2%)
Renal failure 1(2%)
Stomach leak 1(2%)
*UTI 1(2%)
Total 22
*UTI: urinary tract infection

Table 14: SURGEONS IN EMERGENCY
Frequency
Resident 27(54%)
SR 23(46%)
Total 50
FIGURE 2: GENDER DISTRIBUTION IN EMERGENCY
CASES
FEMALE
12.0%
MALE
88.0%
Table 15: SUM OF OBSERVED AND PREDICTED
OUTCOMES IN EMERGENCY CASES
O.morb O.mort P.morb P.mort PP.mort
Sum Sum Sum Sum Sum

22.00 6.00 28.17 9.00 6.00
Keys
PP.mort: predicted mortality by p-possum

MORTALITY USING POSSUM EQUATION IN EMERGENCY
LAPAROTOMY
RANGE OF FREQUENCY O.MORT P.MORT O/P
AGE IN RATIO
YEARS
15-30 27 1 4.45 .224
31-45 10 1 1.56 .64
46-60 7 0 0.36 0
61-75 6 4 2.63 1.52
50 6 9 .66
Keys
MORBIDITY USING POSSUM EQUATION IN EMERGENCY
LAPAROTOMY
RANGE OF FREQUENCY O.MORB P.MORB O/P
AGE IN RATIO
YEARS
15-30 27 9 15.04 .59
31-45 10 5 5.15 .97
46-60 7 1 2.16 .46
61-75 6 7 5.82 1.20
50 22 28.17 .78
Keys
MORTALITY USING P-POSSUM EQUATION IN
EMERGENCY LAPAROTOMY
RANGE OF FREQUENCY O.MORT PP.MORT O/P
AGE IN RATIO
YEARS
15-30 27 1 2.41 .41
31-45 10 1 .67 1.49
46-60 7 0 0 0
61-75 6 4 2.92 1.36
50 6 6 1
Keys
PP.mort: predicted mortality by P-POSSUM
Table 19: Pearson’s correlation in emergency morbidity
Observed Predicted
morbidity morbidity
morbidity Correlation
. .000
Sig. (2-tailed)
50 50
N

Pearson
morbidity
Correlation
.000 .
Sig. (2-tailed)
50 50
TABLE 20: Pearson’s correlation in POSSUM emergency
mortality
Observed Predicted
mortality mortality
. .000
Sig. (2-tailed)
50 50
N

Pearson
mortality
Correlation
.000 .
Sig. (2-tailed)
50 50
TABLE 21: Pearson’s correlation in P-POSSUM
emergency mortality
Observed Predicted
mortality mortality
. .000
Sig. (2-tailed)
50 50
N

Pearson
mortality
Correlation
.000 .
Sig. (2-tailed)
50 50
GOODNESS OF FIT TEST
TABL 22: Hosmer and Lemeshow Test in elective cases
Chi-Square df Sig.
Predicted 45.000 24 .006

morbidity
POSSUM 34.840 20 .021
Predicted
mortality
P-POSSUM 104.800 14 .000
Predicted
mortality
9. DISSCUSSION
In this culture of increased scrutiny surgeons must be able to
demonstrate clearly and accurately how they perform through
comparative audit of mortality and morbidity rates. Thus audit
of an individual surgeon, a unit or a hospital can be done
simply by monthly meetings of mortality and morbidity or by

many sophisticated scoring systems. POSSUM is such a
scoring system which predicts mortality & morbidity.
The main indication of laparotomy in emergency was trauma
32% (16 % FAI & 14 % blunt trauma abdomen, & 2% stab
abdomen) and abdomen tuberculosis (20%). Main bulk of the
patients were younger 27(54 %) between 15-30 years and
trauma was more common in young patients. Joosse P et al,
Talwar S et al, Qureshi MA, Aharonson-Daniel L et al, Nijboer
JMet al. shown that trauma is more prevalent in young
males.35-39
On elective most patients were older 17(34%) between
45-59 years and main indication was Colon cancer (20%) and
abdominal tuberculosis was second major cause
(12%).Wound infection was major complication in both
elective and emergency cases (10%). Bhatti AA et al. (2004)
reported post operative complications in trauma patients in
frequency of wound infection (24%), chest infections
46
(13.34%) and renal failure (1.34%). Ali AA et. al. (1996)
reported that wound infection and respiratory complications
were the most common (18%) in blunt trauma patients.47

Saidi HS et al. reported complication rate of 15%.48 This
indicates low complication rate in our set up.
On elective surgery observed mortality was 3(6 %), morbidity
was 15(30%) and predicted mortality and morbidity by
POSSUM was 4.8(9.6%) and 14.67(29.34%) while P-POSSUM
predicted mortality was 2.93(5.86%).In my study it was
shown that POSSUM predicted morbidity well but
overpredicted mortality while P-POSSUM predicted mortality
more accurately in elective cases.
Lam CM et al. reported the observed mortality rate in major
hepatectomy 6.6% and POSSUM system over predicted
mortality (14.2%).The mortality rate predicted by P-POSSUM
was 4.2%.3 This shows P-POSSUM is more accurate.
Tekkis pp et al. reported that in oesophagogastric surgery O-
POSSUM was superior.5
Sutton R et al. reported the observed mortality rate 8.4%
while mean mortality predicted by SRS (surgical risk score),
POSSUN and p-POSSUM were 5.9, 12.6, and 7.3%
respectively.6 This shows P-POSSUM is more accurate.

Gocmen E et al. reported that O-POSSUM predicts mortality
more accurately than P-POSSUM.18
Mahesh G et al. also reported that P-POSSUM mortality
predictor equation predicts death accurately in general
surgical patients.19
Nagabhushsn S et al. also reported that in elective
oesophagogastric cancer surgery, observed mortality was
32(10.2%) and P-POSSUM predicted 36 and O-POSSUM
49.They concluded neither model accurately predicted the risk
of postoperative death. P-POSSUM provided a better fit to
observed results than O-POSSUM, which over predicted total
mortality. P-POSSUM also had superior discriminatory power.20
Wakabayashi H et al. reported that in elective digestive
surgery, the POSSUM system can be useful in the risk
assessment for surgery in elderly patients.21
Jensen TC et al, Watanabe M et al, also found that in
colorectal cancer surgery P-POSSUM predicted mortality well
while POSSUM over-predicted mortality.22, 23
Pratt W et al. reported that POSSUM is a valuable
perioperative scoring system for pancreatic resections and

outcomes, and can be employed to guide management
decisions that impact postoperative recovery.24
Abdul wk et al. also reported that The POSSUM-predicted
mortality was 26%, and P-POSSUM predicted mortality was
6%, while actual mortality was 4%.Using POSSUM for
morbidity, the predicted value was 76%. The observed
morbidity was 46%. While P-POSSUM appeared satisfactory
for predicting mortality risk; POSSUM overestimated morbidity
and mortality for Pancreaticoduodenectomies in a specialist
centre.25
Midwinter M et al, Khan AW et al, found that POSSUM over-
predicted mortality while P-POSSUM predicted well.26, 28
Das N et al. reported that P-POSSUM overestimates the risk of
mortality for gynecological cancer.29
In my study mortality and morbidity was highest between 14
to 29 years of patients because most of these had
complicated form of tuberculosis (fecal fistula). In this age
group observed mortality was 2(4%) and POSSUM predicted
2.58(5.16%) and P-POSSUM 1.98(3.96%).In age groups
between 45 to 59 and 60 to 74, there was no observed

mortality and P-POSSUM also predicted zero mortality while
POSSUM predicted .88 and .22 respectively. This shows the
inaccuracy of POSSUM in predicting the mortality in low risk
patients because the lowest rate of mortality is 2% in major
surgery like laparotomy.
Griffiths H et al. also reported that Possum is valid for
morbidity but predicts more accurately for high-risk than for
low-risk groups.31
Prytherch DR et al, Whitely MS et al, Sagar PM et al, Tekkis PP
et al also shown this in accuracy of POSSUM.41-44
In emergency surgery observed mortality was 6 (12%),
morbidity was 22 (44 %) while POSSUM predicted 9 (18%)
deaths and 28.12 (56.24 %) and P-POSSUM predicted
mortality 6(12%).In emergency most of the patients were
between 15-30 years (54%) and their observed mortality (1)
and morbidity (9) was minimum compared to other groups
but their predicted mortality(4.45) and morbidity (15.04) by
POSSUM and P-POSSUM (2.41) was high. These patients were
younger, relatively fit with out any co morbid condition. The
predicted outcomes were higher because in gut perforation

minimum morbidity was more then 40% and mortality was
10%.In older age group 61 to 75, observed mortality (4) and
morbidity (7) was high and POSSUM and P-POSSUM both
predicted well.
Mohil R.S et al. (2004) in their study on emergency
laparotomy reported O/P ratio of POSSUM mortality 0.62 and
morbidity 0.92 and P-POSSUM 0.88. He found both POSSUM
and P-POSSUM predicted well. 4
Hobson and Sutton concluded that both POSSUM and P-
POSSUM appeared to be useful indicators for the prediction of
32
mortality in emergency surgery.
Qamar HK et al. reported that POSSUM score can be
effectively applied in all surgical setups in Pakistan and can be
used as an adjunct to surgical and can be used as an adjunct
to surgical audit.33, 34
In my study, we observed that P-POSSUM predicted mortality
more accurately in both elective (O/P 1.02) and emergency

(O/P 1) while POSSUM over predicted mortality and morbidity
in both cases.
Whilst POSSUM and P-POSSUM have performed well in
mortality and morbidity prediction and comparative surgical
audit, it does have certain limitations. Most notably it
persistently over predicts mortality in low risk patients.
Secondly the formula used in this system is complex and still
matter of some debate. Thirdly data required for it, is not
available for every patient.

10. CONCLUSION.
Based on this study, POSSUM and P-POSSUM can be used to
predict 30 days mortality and morbidity in general surgical
procedures. How ever P-POSSUM predicts mortality equally
well in both emergency and elective setups and is more
accurate compared to POSSUM. POSSUM over-predicts
mortality in both elective and emergency cases but predicts
morbidity well. However application of the POSSUM and P-
POSSUM scoring systems in larger patient setup is required to
rectify its prediction tendency.
This scoring system also can be used for risk-adjusted audit in
general surgery department. It can be used for predicting
outcome and pre-operative counseling of patients and their
careers, as a part of the process of informed consent and can
be used to evaluate the technique of pre -optimization in high
risk patients. Application of this tool would allow valid
comparison between surgeons and hospitals
This study showed that although POSSUM overpredicts
mortality but both these scores are good methods of risk
evaluation in general surgery ward in our set up as its

predicted morbidity and mortality matched with the observed
mortality rates. This scoring system can be applied in our set
up for the surgical audit.

11. PROFORMA
EVALUATION OF PHYSIOLOGIC AND OPERATIVE SEVERITY

SCORE FOR ENUMERATION OF MORTALITY AND MORBIDITY
AND PORTSMOUTH PREDICTOR MODIFICATION IN PATIENTS
UNDERGOING EMERGENCY AND ELECTIVE LAPAROTOMY.
Case no # Registration no#

Date#
Name of patient# Age#

Sex#
Socio economic status#
Weight# Profession#
Provisional diagnosis#
Final diagnosis#
Mode of admission # OPD / Emergency
Type of surgery # Elective/emergency
Date of operation#
Procedure#
POSSUM DATA SHEET PHYSIOLOGICAL SCORE
1 2 4 8
AGE <60 61-70 >71
peripheral
diuretic, digoxin, oedema
Cardiac sign + raised JVP
no failure anti-anginal or warfarin
CXR cardiomegaly
anti-hypertensive borderline
cardiomegaly
limiting dyspnoea at rest

Respiratory dyspnoea on dyspnoea (one RR>30min
no dyspnoea
History +CXR exertion flight) moderate fibrosis or
COAD consolidation
Blood pressure 131-170 >171

110-130 <90
(Systolic mmHg) 100-109 90-99
81-100 >121
Pulse (Beats/min) 50-80 101-120
40-49 <40
Glasgow coma
15 12-14 9-11 <8
scale
Haemoglobin 11.5-12.9 10.0-11.4 <9.9

13-16
g/100ml 16.1-17.0 17.1-18.0 >18.1
White cell count 10.1-20.0 >20.1

4-10
(x1012/L) 3.1-4.0 <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 3.2-3.4 2.9-3.1 <2.8

3.5-5.0
(mmol/L) 5.1-5.3 5.4-5.9 >6.0
any abnormal
rhythm
Atrial fibrillation
>5 ectopics /
ECG Normal (rate 60-
min, Q waves
90/min)
ST/T wave
changes
POSSUM DATA SHEET OPERATIVE SEVERITY SCORE
1 2 4 8
Operative
MINOR MODERATE MAJOR MAJOR +
severity score
Multiple
1 2 >2
procedures
Total blood loss
< 100 101-500 501-999 >999
(mls)
Free bowel
Minor (serous
Contamination None Local pus content, pus
fluid)
or blood
Presence of nodal Distant
None Primary only
malignancy metastases metastases
Emergency
Emergency
Resus >2hrs
Mode of (Immediate
Elective Possible op
surgery surgery <
<24 hrs after
2hrs needed
admission
Possum score: Physiological ______________

Operative: ______________
OBSERVED MORBIDITY:
15th 30th
1st day 3rd day 7th day
Complications day day
Y/N Y/N Y/N
Y/N Y/N
♦ Wound hemorrhage ♦
♦ Deep hemorrhage ♦
♦ Chest infection ♦
♦ Urinary infection ♦
♦ Wound infection ♦
♦ Deep infection ♦
♦ Septicemia ♦
♦ Pyrexia of unknown ♦
origin
♦ Wound dehiscence ♦
♦ DVT and P. Embolus ♦
♦ Cardiac failure ♦
♦ Impaired renal function ♦

♦ Hypotension ♦
♦ Respiratory failure ♦
♦ Anastomotic leak ♦
POSSUM
(Physiologic and Operative Severity Score for the

enumeration of Mortality and Morbidity)
Age Glasgow Respiratory
Pulse
Urea Cardiac signs
(beats/min)
Hb (g/dL) W.B.C. ECG
Potassium Sodium
Systolic Blood Pressure
(mEql/L) (mEql/L)
Physiologic Score
Operative Multiple Total Blood Loss

Severity procedures
Peritoneal
Cancer Mode of surgery
soiling
Predicted Morbidity Rate Predicted Mortality Rate

(Definitions are following)
x = (0.16* physiologic score) y=(0.13* physiologic score)
+(0.19*operative score)- 5.91 +(0.16*operative score)-7.04
Predicted Morbidity Rate = 1/ Predicted Mortality Rate = 1/(1+ e(-
(1+ e(-x)) y)
)
Portsmouth – POSSUM
(Physiologic and Operative Severity Score for the enumeration

of Mortality and Morbidity)
Age Glasgow Respiratory
Urea Pulse (beats/min) Cardiac signs
Hb (g/dL) W.B.C. ECG
Potassium
Sodium (mEql/L) Systolic Blood Pressure
(mEql/L)
Physiologic Score
Operative
Multiple procedures Total Blood Loss
Severity
Peritoneal
Cancer Mode of surgery
soiling
Operative Score
Predicted Death Rate R= (0.1692 * physiologic score)+(0.1550

*operative score)-9.065
Predicted Death Rate = 1 / ( 1+ e(-R) )
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i

EVALUATION OF PHYSIOLOGIC AND OPERATIVE SEVERITY

DR. NAVEED ABBAS AKBAR

DR. SYED ASGHAR NAQI

FCPS, FRCS Ed.

South Surgical ward, Mayo Hospital

King Edward Medical University, Lahore.

I, hereby, certify that Dr. Naveed Abbas Akbar having Enrolment

Number: 62102 & RTMC Number: SGR-2006-066-3213 has been

working under my direct supervision with effect from 06/12/2005 to

date in West & South surgical wards, Mayo hospital Lahore.

The enclosed Dissertation titled:

‘EVALUATION OF PHYSIOLOGIC AND OPERATIVE SEVERITY SCORE

FOR ENUMERATION OF MORTALITY AND MORBIDITY AND

PORTSMOUTH PREDICTOR MODIFICATION IN PATIENTS

UNDERGOING EMERGENCY AND ELECTIVE LAPAROTOMY’ IS

prepared according to the “FCPS Dissertation-Guidelines” under my

Part II examination in the subject.

DR SYED ASGHAR NAQI

To my mother, who is spirit of my life

To my brother who is really our soul

It is a great pleasure to acknowledge the help of many individuals

without whose help this dissertation could not have been

completed. First and foremost I am indebted to Dr. Khalid Masood

Gondal Professor of South Surgical Ward Mayo Hospital, who

moulded me into a surgeon. His ultimate effort, attention and

valuable suggestions were vital in preparation of this dissertation.

I am thankful to Dr. Asghar Naqi associate professor for helping me

professor, Dr. Salman Akhtar consultant surgeons, for critical

review of my research work. I am indebted to Dr. Hassan

Muhammad Khan and Dr. Muhammad Zahid, Dr. Zakryia, Dr.

Junaid, Dr. Samina Consultant Surgeons, for imparting their lifetime

experience and for eagerness to help at every step. I owe plentiful

thanks to many people. To name few of them are my colleagues Dr.

Mohsin and Dr. Abrar who helped me in collecting data. Special

thanks are owed to Dr. Kaleen Abbas Asghar, my younger brother

for helpful tips on statistical analysis. I am very grateful to all my

beloved patients who kindly consented for my study. It would be

remiss if I failed to acknowledge my family. I am thankful for their

tolerance of my absences, for their freely offered encouragement.

Dr. Naveed Abbas Akbar

3. LITERATURE REVIEW …………………………………….…………. 11

7. MATERIAL AND METHODS………………………………………….. 51

1. Indications for elective laparotomy…………………………………………60

2. Complications in elective surgery ……………………………………………61

3. Surgeons on elective list …..……………………………………………………..62

4. Sum of observed and predicted outcomes in elective cases....64

5. Comparison of observed and predicted mortality using POSSUM

equation in elective laparotomy ………………………………………………….65

6. Comparison of observed and predicted morbidity using POSSUM

equation in elective laparotomy ………………………………………………….66

7. Comparison of observed and predicted mortality using P-POSSUM

equation in elective laparotomy ………………………………………………….67

8. Pearson’s correlation in elective morbidity……………………………68

9. Pearson correlation in POSSUM elective mortality……………….69

10. Pearson correlation in P-POSSUM elective mortality……………70

11. Hosmer and Lemeshow test………………………………………………………71

12. Indications for emergency laparotomy…………………………………….72

13. Complications in emergency laparotomy…………………………………73

14. Surgeons in emergency……………………………………………………………74

15. Sum of observed and predicted outcomes in emergency cases76

16. Comparison of observed and predicted mortality using POSSUM

equation in emergency laparotomy ……………………………………………….77