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Risk prediction tools for older general surgical patients

Published online by Cambridge University Press:  13 April 2015

M Middleton
School of Medicine, Cardiff University, UK
MJ Stechman
University Hospital of Wales, Cardiff, UK
S Moug
Royal Alexandra Hospital, Paisley, UK
K McCarthy
Southmead Hospital, Bristol, UK
J Hewitt*
School of Medicine, Cardiff University, UK
Address for correspondence: Dr Jonathan Hewitt, Department of Geriatric Medicine, 3rd Floor Academic Centre, Llandough Hospital, Penlan Road, Penarth CF64 2XX. Email:


This review identifies and examines the clinical application of risk prediction tools, including the American Society of Anaesthesiology (ASA) Classification System and POSSUM-based scores, in the older general surgical patient. Predicting outcomes in this patient group remains difficult; it is challenging to design a risk prediction tool that will apply to both emergency and elective surgery and that remains valid across the wide age range that this patient group encompasses. Risk prediction tools can have benefit but should be used in conjunction with the clinical assessment of those experienced in the care of this challenging patient group.

Review Article
Copyright © Cambridge University Press 2015 

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1Jones, HJ, de Cossart, L. Risk scoring in surgical patients. Br J Surg 1999; 86: 149–57.CrossRefGoogle ScholarPubMed
2Kwok, AC, Lipsitz, SR, Bader, AM, Gawande, AA. Are targeted preoperative risk prediction tools more powerful? A test of models for emergency colon surgery in the very elderly. J Am Coll Surg 2011; 213: 220–25.CrossRefGoogle ScholarPubMed
3Sevdalis, N, Jacklin, R. Opening the ‘black box’ of surgeons’ risk estimation: from intuition to quantitative modeling. World J Surg 2008; 32: 324–25.CrossRefGoogle Scholar
4Clavien, PA, Dindo, D. Surgeon's intuition: is it enough to assess patients’ surgical risk? World J Surg 2007; 31: 1909–11.CrossRefGoogle ScholarPubMed
5National Confidential Enquiry into Patient Outcome and Death. An Age Old Problem: a review of the care recieved by elderly patients undergoing surgery; 2010.Google Scholar
6Dhesi, J. Peri-operative Care for Older Patients Undergoing Surgery: British Geriatrics Society; 2013.Google Scholar
7Doyle, Y, McKee, M, Sherriff, M. A model of successful ageing in British populations. Eur J Public Health 2012; 22: 7176.CrossRefGoogle ScholarPubMed
8Bugeja, G, Kumar, A, Banerjee, AK. Exclusion of elderly people from clinical research: a descriptive study of published reports. BMJ 1997; 315: 1059.CrossRefGoogle Scholar
9Jacobs, JP, Mavroudis, C, Jacobs, MLet al.What is operative mortality? Defining death in a surgical registry database: a report of the STS Congenital Database Taskforce and the Joint EACTS-STS Congenital Database Committee. Ann Thorac Surg 2006; 81: 1937–41.CrossRefGoogle Scholar
10Ugolini, G, Rosati, G, Montroni, Iet al.Can elderly patients with colorectal cancer tolerate planned surgical treatment? A practical approach to a common dilemma. Colorectal Dis 2009; 11: 750–55.CrossRefGoogle ScholarPubMed
11Logeais, Y, Langanay, T, Roussin, Ret al.Surgery for aortic stenosis in elderly patients. A study of surgical risk and predictive factors. Circulation 1994; 90: 2891–98.CrossRefGoogle ScholarPubMed
12Turrentine, FE, Wang, H, Simpson, VB, Jones, RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg 2006; 203: 865–77.CrossRefGoogle Scholar
13Finlayson, EV, Birkmeyer, JD. Operative mortality with elective surgery in older adults. Eff Clin Pract 2001; 4: 172–77.Google ScholarPubMed
14Hurria, A. Geriatric assessment in oncology practice. J Am Geriatr Soc 2009; 57: S24649.CrossRefGoogle Scholar
15Janssen-Heijnen, ML, Maas, HA, Houterman, S, Lemmens, VE, Rutten, HJ, Coebergh, JW. Comorbidity in older surgical cancer patients: influence on patient care and outcome. Eur J Cancer 2007; 43: 2179–93.CrossRefGoogle Scholar
16Rodriguez-Molinero, A, Lopez-Dieguez, M, Tabuenca, AI, de la Cruz, JJ, Banegas, JR. Physicians’ impression on the elders’ functionality influences decision making for emergency care. Am J Emerg Med 2010; 28: 757–65.CrossRefGoogle ScholarPubMed
17Brighi, N, Balducci, L, Biasco, G. Cancer in the elderly: is it time for palliative care in geriatric oncology? J Geriatr Oncol 2014; 5: 197203.CrossRefGoogle ScholarPubMed
18Fried, LP, Kronmal, RA, Newman, ABet al.Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study. JAMA 1998; 279: 585–92.CrossRefGoogle ScholarPubMed
19Ozturk, E, Yilmazlar, T. Factors affecting the mortality risk in elderly patients undergoing surgery. ANZ J Surg 2007; 77: 156–59.CrossRefGoogle ScholarPubMed
20Fried, LP, Tangen, CM, Walston, Jet al.Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M14656.CrossRefGoogle Scholar
21Rockwood, K. What would make a definition of frailty successful? Age Ageing 2005; 34: 432–34.CrossRefGoogle ScholarPubMed
22Partridge, JS, Harari, D, Dhesi, JK. Frailty in the older surgical patient: a review. Age Ageing 2012; 41: 142–47.CrossRefGoogle ScholarPubMed
23Makary, MA, Segev, DL, Pronovost, PJet al.Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010; 210: 901–8.CrossRefGoogle ScholarPubMed
24Hewitt, J, Stechman, M, Moug, S, Middleton, M, Chakrabarti, M. Prevalence of frailty: its association with mortality in general surgery. Am J Surg. doi: 10.1016/j.amjsurg.2014.05.022Google ScholarPubMed
25Kim, SW, Han, HS, Jung, HWet al.Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA Surg 2014; 149: 633–40.CrossRefGoogle ScholarPubMed
26Saklad, M. Grading of patients for surgical procedures. Anesthesiology 1941; 2: 281–84.CrossRefGoogle Scholar
27Dripps, RD, Lamont, A, Eckenhoff, JE. The role of anesthesia in surgical mortality. JAMA 1961; 178: 261–66.CrossRefGoogle Scholar
28Klotz, HP, Candinas, D, Platz, Aet al.Preoperative risk assessment in elective general surgery. Br J Surg 1996; 83: 1788–91.CrossRefGoogle Scholar
29Cook, TM, Day, CJ. Hospital mortality after urgent and emergency laparotomy in patients aged 65 yr and over. Risk and prediction of risk using multiple logistic regression analysis. Br J Anaesth 1998; 80: 776–81.CrossRefGoogle ScholarPubMed
30Tekkis, PP, Poloniecki, JD, Thompson, MR, Stamatakis, JD. Operative mortality in colorectal cancer: prospective national study. BMJ 2003; 327: 1196–201.CrossRefGoogle ScholarPubMed
31Polanczyk, CA, Marcantonio, E, Goldman, Let al.Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med 2001; 134: 637–43.CrossRefGoogle Scholar
32Hamel, MB, Henderson, WG, Khuri, SF, Daley, J. Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc 2005; 53: 424–29.CrossRefGoogle ScholarPubMed
33Leung, JM, Dzankic, S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc 2001; 49: 1080–85.CrossRefGoogle ScholarPubMed
34Sokol, DK, Wilson, J. What is a surgical complication? World J Surg 2008; 32: 942–44.CrossRefGoogle ScholarPubMed
35Rampersaud, YR, Moro, ER, Neary, MAet al.Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols. Spine 2006; 31: 1503–10.CrossRefGoogle ScholarPubMed
36Mak, PH, Campbell, RC, Irwin, MG, American Society of Anesthesiologists. The ASA Physical Status Classification: inter-observer consistency. Anaesth Intens Care 2002; 30: 633–40.Google ScholarPubMed
37Barnett, S, Moonesinghe, SR. Clinical risk scores to guide perioperative management. Postgrad Med J 2011; 87: 535–41.CrossRefGoogle Scholar
38Edwards, AE, Seymour, DG, McCarthy, JM, Crumplin, MK. A 5-year survival study of general surgical patients aged 65 years and over. Anaesthesia 1996; 51: 310.CrossRefGoogle ScholarPubMed
39Bufalari, A, Ferri, M, Cao, P, Cirocchi, R, Bisacci, R, Moggi, L. Surgical care in octogenarians. Br J Surg 1996; 83: 1783–87.CrossRefGoogle ScholarPubMed
40Sutton, R, Bann, S, Brooks, M, Sarin, S. The Surgical Risk Scale as an improved tool for risk-adjusted analysis in comparative surgical audit. Br J Surg 2002; 89: 763–68.CrossRefGoogle ScholarPubMed
41Reiss, R, Deutsch, A, Nudelman, I. Surgical problems in octogenarians: epidemiological analysis of 1,083 consecutive admissions. World J Surg 1992; 16: 1017–20.CrossRefGoogle Scholar
42Reiss, R, Haddad, M, Deutsch, A, Lilos, P, Fuchs, C. Prognostic index: prediction of operative mortality in geriatric patients by use of stepwise logistic regression analysis. World J Surg 1987; 11: 248–51.CrossRefGoogle ScholarPubMed
43Leardi, S, De Santis, C, Ciuca, B, Risetti, A, Pietroletti, R, Simi, M. Risk indices in geriatric surgery: ASA index versus Reiss index. Minerva Chir 1997; 52: 255–60.Google ScholarPubMed
44Copeland, GP, Jones, D, Walters, M. POSSUM: a scoring system for surgical audit. Br J Surg 1991; 78: 355–60.CrossRefGoogle Scholar
45Whiteley, MS, Prytherch, DR, Higgins, B, Weaver, PC, Prout, WG. An evaluation of the POSSUM surgical scoring system. Br J Surg 1996; 83: 812–15.CrossRefGoogle ScholarPubMed
46Prytherch, DR, Whiteley, MS, Higgins, B, Weaver, PC, Prout, WG, Powell, SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. Br J Surg 1998; 85: 1217–20.CrossRefGoogle ScholarPubMed
47Tekkis, PP, Kessaris, N, Kocher, HM, Poloniecki, JD, Lyttle, J, Windsor, AC. Evaluation of POSSUM and P-POSSUM scoring systems in patients undergoing colorectal surgery. Br J Surg 2003; 90: 340–45.CrossRefGoogle ScholarPubMed
48Tran Ba Loc, P, du Montcel, ST, Duron, JJet al.Elderly POSSUM, a dedicated score for prediction of mortality and morbidity after major colorectal surgery in older patients. Br J Surg 2010; 97: 396403.CrossRefGoogle ScholarPubMed
49Prytherch, DR, Sirl, JS, Weaver, PC, Schmidt, P, Higgins, B, Sutton, GL. Towards a national clinical minimum data set for general surgery. Br J Surg 2003; 90: 1300–5.CrossRefGoogle ScholarPubMed
50Nichols, KG, Prytherch, DR, Fancourt, MF, Gilkison, WT, Kyle, SM, Mosquera, DA. Risk-adjusted general surgical audit in octogenarians. ANZ J Surg 2008; 78: 990–94.CrossRefGoogle Scholar
51Munro, J, Booth, A, Nicholl, J. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess 1997; 1: 162.Google Scholar
52Moyes, LH, Leitch, EF, McKee, RF, Anderson, JH, Horgan, PG, McMillan, DC. Preoperative systemic inflammation predicts postoperative infectious complications in patients undergoing curative resection for colorectal cancer. Br J Cancer 2009; 100: 1236–39.CrossRefGoogle ScholarPubMed
53Kennedy, RH, al-Mufti, RA, Brewster, SF, Sherry, EN, Magee, TR, Irvin, TT. The acute surgical admission: is mortality predictable in the elderly? Ann R Coll Surg Engl 1994; 76: 342–45.Google ScholarPubMed
54Vandromme, MJ, Griffin, RL, Weinberg, JA, Rue, LW 3rd, Kerby, JD. Lactate is a better predictor than systolic blood pressure for determining blood requirement and mortality: could prehospital measures improve trauma triage? J Am Coll Surg 2010; 210: 861–69.CrossRefGoogle ScholarPubMed
55Hasler, RM, Nuesch, E, Juni, P, Bouamra, O, Exadaktylos, AK, Lecky, F. Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: multicentre cohort study. Resuscitation 2012; 83: 476–81.CrossRefGoogle Scholar
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