Comparison of P-POSSUM and O-POSSUM in predicting mortality after oesophagogastric resections.

BACKGROUND: P-POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity) predicts mortality and morbidity in general surgical patients providing an adjunct to surgical audit. O-POSSUM was designed specifically to predict mortality and morbidity in patients undergoing oesophagogastric surgery. AIM: To compare P-POSSUM and O-POSSUM in predicting surgical mortality in patients undergoing elective oesophagogastric cancer resections. METHODS: 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. The power to discriminate between patients who died and those who survived was assessed using the area under the receiver-operator characteristic (ROC) curve. RESULTS: 313 patients underwent oesophagogastric resections. 32 died within 30 days (10.2%). P-POSSUM predicted 36 deaths (chi2 = 15.19, df = 6, p = 0.019, Hosmer-Lemeshow goodness-of-fit test), giving a standardised mortality ratio (SMR) of 0.89. O-POSSUM predicted 49 deaths (chi2 = 16.51, df = 6, p = 0.011), giving an SMR of 0.65. The area under the ROC curve was 0.68 (95% confidence interval 0.59 to 0.76) for P-POSSUM and 0.61 (95% confidence interval 0.50 to 0.72) for O-POSSUM. CONCLUSION: Neither model accurately predicted the risk of postoperative death. P-POSSUM provided a better fit to observed results than O-POSSUM, which overpredicted total mortality. P-POSSUM also had superior discriminatory power.

Penetration of the left ventricular myocardium by benign peptic ulceration: two cases and a review of the published work.

Two cases of penetration of the left ventricular myocardium by benign peptic ulcer are reported. Twenty five similar cases in the world published work are reviewed. The condition is only possible when there are fibrous adhesions between the stomach and diaphragm and the pericardium. In addition, the left lobe of the liver may be small. Alternatively, an ulcer within a hiatus hernia may erode into the left ventricle.

Peroperative flow and pressure measurements in profundaplasty.

In twelve patients, the fluid resistance across the origin of the profunda femoris artery was assessed by flow and pressure recordings, before reconstructive profundaplasty was performed. There was a considerable range of resistance values obtained and in the eight patients having repeat flow and pressure recordings following the reconstruction in only five patients was there a reduction in the fluid resistance. This suggests that not all atheromatous plaques at the profunda femoris origin produce a blood flow disturbance to warrant profundaplasty, and may explain the variable results reported following this operation.

Second closed mitral valvotomy for recurrent mitral stenosis.

Sixty-seven patients undergoing a second closed mitral valvotomy between 1957 and 1974 have been reviewed. Since 1951, 510 patients have had a primary closed valvotomy in the same unit. The incidence of restenosis severe enough to warrant further surgery is higher after a finger fracture procedure (40%) than after a Tubbs dilator valvotomy (9.2%). There is an operative mortality of 10.4%, and a further late mortality of 23.8% after a second closed valvotomy. Of the surviving patients, 70.5% have had a good or excellent result. The group with poor results is characterised by the presence of a calcified fixed valve, making valvotomy difficult and incomplete. In the presence of a non-calcified valve, a second valvotomy still has a place when surgery for restenosis is required.

Closed mitral valvotomy.

The results of closed mitral valvotomy operations in 359 patients operated on from August 1957 to October 1974 were assessed at July 1975. About 60% of the patients were in good health. These results suggest that there is still a place for closed mitral valvotomy in carefully selected cases.