Evaluation of the POSSUM, P-POSSUM and E-PASS scores in the surgical treatment of hilar cholangiocarcinoma

BACKGROUND: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model, its Portsmouth (P-POSSUM) modification and the Estimation of physiologic ability and surgical stress (E-PASS) are three surgical risk scoring systems used extensively to predict postoperative morbidity and mortality in general surgery. The aim was to undertake the first study of the predictive value of these models in patients undergoing surgical treatment of hilar cholangiocarcinoma. METHODS: A retrospective analysis was performed on data collected prospectively over a 10-year interval from January 2003 to December 2012. The morbidity and mortality risks were calculated using the POSSUM, P-POSSUM and E-PASS equations. RESULTS: One hundred patients underwent surgical treatment of hilar cholangiocarcinoma. Complications were seen in 52 of 100 patients (52.0%). There were 10 postoperative in-hospital deaths (10.0%). Of 31 preoperative and intraoperative variables studied, operative type (P = 0.000), preoperative serum albumin (P = 0.003) and aspartate aminotransferase (P = 0.029) were found to be factors multivariate associated with postoperative complications. Intraoperative blood loss (P = 0.015), Bismuth-Corlette classification (P = 0.033) and preoperative hemoglobin (P = 0.041) were independent factors multivariate associated with in-hospital death. The POSSUM system predicted morbidity risk effectively with no significant lack of fit (P = 0.488) and an area under the ROC curve (AUC) of 0.843. POSSUM, P-POSSUM and E-PASS scores showed no significant lack of fit in calculating the mortality risk (P >0.05) and all yielded an AUC value exceeding 0.8. POSSUM had significantly more accuracy in predicting morbidity after major and major plus operations (O:E (observed/expected) ratio 0.98 and AUC 0.901) than after minor and moderate operations (O:E ratio 1.13 and AUC 0.759). CONCLUSIONS: POSSUM, P-POSSUM and E-PASS scores effectively predict morbidity and mortality in surgical treatment of hilar cholangiocarcinoma. However, improvements are still needed in the future because none of these scoring systems yielded an AUC value exceeding 0.9 for operations with all different levels of severity. Only POSSUM had more accuracy in predicting postoperative morbidity after operations with higher severity. TRIAL REGISTRATION: This study was undertaken after obtaining approval from the ethics committee of School of Medicine, Shanghai Jiao Tong University with a trial registration number of http://09411960800.