Risk-adjustment in hepatobiliary pancreatic surgery

Area of Science:

• Surgical Oncology
• Gastroenterology
• Critical Care Medicine

Background:

• Accurate risk stratification is crucial for patients undergoing complex hepatopancreaticobiliary (HPB) surgery.
• Existing scoring systems (POSSUM, ASA, APACHE, Childs) have varying performance in predicting outcomes for HPB procedures.
• Understanding the limitations and advantages of these tools is essential for clinical decision-making.

Purpose of the Study:

• To evaluate the predictive performance of POSSUM, American Society of Anesthetists (ASA), APACHE, and Childs classification for mortality and morbidity in HPB surgery.
• To identify the most effective risk stratification tools for HPB surgery patients.
• To highlight the advantages and limitations of different risk assessment models in this surgical context.

Main Methods:

• A retrospective analysis of 177 patients undergoing elective complex HPB surgery.
• Inclusion of 71 pre-operative and intra-operative risk factors.
• Utilized ordered logistic regression to identify predictors of in-hospital mortality and morbidity.

Main Results:

• Operative mortality was 3.95%, closely matching predicted rates from p-POSSUM (4.31%) and APACHE (4.29%).
• Post-operative complications occurred in 45% of patients, with 13.6% experiencing major adverse events.
• The pre-operative POSSUM physiological score demonstrated superior prediction of complications compared to ASA, APACHE, and Childs classifications (P=0.009 vs. P=0.108, P=0.117, P=0.136 respectively).
• Independent risk factors included serum sodium, creatinine, international normalized ratio (INR), pulse rate, and intra-operative blood loss.
• A combination of POSSUM variables and INR provided optimal risk prognostication.

Conclusions:

• Morbidity in elective HPB surgery can be accurately predicted using validated scoring systems.
• These predictions can enhance informed consent processes for patients.
• Effective risk stratification facilitates better allocation of intensive and high-dependency care resources.