Gastrointestinal surgical procedures are sometimes required in emergencies such cases are often associated with higher mortality and morbidity. The postoperative sequelae are highly influenced by surgical pathology and due to limited period for optimizing existing co-morbidities in the patients. 1 Although the basic aim of any surgical procedure is a reduction in morbidity and mortality rates adverse outcomes do occur in case of emergency surgical procedures. An assessment of the efficiency of a procedure must be available because crude morbidity and mortality rates comparison does not give a clear picture due to the variability of patients' conditions. [ 234 To combat these problems a scoring system is required which would help in calculating the mortality and morbidity rates effectively in elderly and high-risk patients. This leads to the development of what is called a 'Physiological and Operative Severity Score for enumeration of Mortality and Morbidity or POSSUM scoring system. A recent modification called Portsmouth-POSSUM or P-POSSUM scoring system with more predictable results is used currently. 5 This risk scoring quantifies a patient's risk of adverse outcome based on the severity of illness which is derived from data available at an early stage of the hospital stay. 6 This helps the surgeons to plan and implement more effective treatment options available at their disposal. It has been found that P-POSSUM has predicted morbidity and mortality accurately in various settings and indirectly assesses the quality of health care provided. 7 It is often used as a tool to assess and audit the performance

of individuals or institutions. 789 It is operating surgeon-based score greater used in general surgeries, vascular surgeries, colorectal surgeries, oesophageal surgeries, laparoscopic and hepatic resections. 1011 Many studies involving the system have been conducted from developed countries and only very few studies have been undertaken in developing countries as a result the available data is very less. 12 Hence, we decided to study the score in our cases to assess the surgical outcome, either as morbidity or mortality in patients keeping in mind the different categories of patients seeking surgical care at our hospital including emergency GI surgeries.

This cross-sectional study was conducted in the Department of General Surgery, Prathima Institute of Medical Sciences, Naganoor, Karimnagar. Institutional ethical committee permission was obtained for the study. Written consent was obtained from all the participants of the study. Based on the inclusion and exclusion criteria n=50 consecutive patients were enrolled in the study. They included all forms of an emergency such as the acute abdomen, acute appendicitis, hollow viscus perforation, acute intestinal obstruction, and blunt abdominal injuries. The selected patients underwent thorough clinical examination and a detailed history including similar complaints in the past or any previous surgeries were taken. All patients were simultaneously evaluated for any systemic disease. Patients presenting with shock or hypotension was adequately resuscitated before surgery.Routine investigations like Hb, TLC, BT, CT, Urine analysis, and blood grouping andcross-matching were done. All cases underwent ECG, Random Blood Sugar, blood ureaand serum creatinine, HIV/ HbsAg investigations. Chest X-ray and USG abdomen and pelvis, erect x-ray abdomen was done in all cases. A broad-spectrum antibiotic was given to all patients in the operation theatre at the time ofinduction of anesthesia.In all cases of hollow viscus perforation, acute intestinal obstruction & blunt injuryabdomen, midline laparotomy incision was given. All cases of acute appendicitis wereoperated on through McBurney's incision.The physiological component of the P-POSSUM data set was collected from parameters atadmission before starting any kind of treatment intervention. The operative componentwas computed after laparotomy and revised if the patient underwent re-laparotomy. Patientswere treated as per their individual needs throughout their hospital stay. Previouslygiven definitions of postoperative complications were used while recording morbidity asyes or no. Mortality was also recorded. Patients were discharged from thehospital only after satisfactory recovery. All discharged patients were followed up inthe surgical outpatient department for a minimum of one month for treating earlypostoperative complaints (mostly wound related) and recording death within this period ifany. Expected mortality was calculated from P-POSSUM mortality and morbidityequations using linear analysis.Chi-square test was used to deduce whether the variables advocated in the P-POSSUM score had a significant association with morbidity and mortality.

In the present study, it was observed that the maximum numbers of cases undergoingemergency GI surgeries were those of acute appendicitis, accounting for about 52%. The next commonest were those of hollow viscus perforation 28%, followed by acute intestinal obstruction 12% and blunt injury abdomen with the incidence of 8%. The details of incidence are given in Table 1. Of the n=3 cases in which mortality was observed, one case underwent emergency appendectomy for acute appendicitis. One case underwent exploratory laparotomy for hollow viscus perforation and one case was of acute intestinal obstruction. The cause of death was septicemia in n=1 case another cause of death in n=1 case was Aspiration pneumonitis.More cases of morbidity were observed from acute appendicitis at 6% followed by hollow viscus perforation in 4% cases. The total number of cases with postoperative complications were n=7(14%), wound infection was in n=4 cases, wound dehiscence, hypotension, and chest infection was in one case each. They have managed adequately.

Out of n=50 cases, n=45 was below aged below 60 years and 5 cases were in the range of 61 to 70 years. N=3 cases in which mortality was observed were below the age of 60 years.

No significant association was noted between age and incidence of mortality. Postoperative complications in n=12 cases(24%) out of which n=10 cases were below 60 years and n=2 cases were from the age group of 61-70 years Significant association noted between age group and morbidity with P = 0.04. Table 3: significance between the age, morbidity, and mortality Portsmouth-POSSUM' or 'P-POSSUM' scoring system in which linear regression was applied to produce more predictable results. In this scoring system, twelve physiological and six operative parameters are recorded. The parameters are scored by 4-grade exponential scales such as 1, 2, 4, and 8. 13The range of 9.9% risk was done to categorize into 10 different groups with increasing order of scores. The highest frequency was observed in 20.1 -30.0% which was 22% lower frequency scores were observed in higher extremes indicated in table 4. The morbidity risk scores show the highest frequency in 32% in the range of > 90.0 cases followed by 80.1 -90.0 having cases of 28% depicted in table 5. Similarly, the increased frequency of cases was in the higher extreme of the morbidity risk range. The reason was in cases of emergency and major gastrointestinal surgeries the operative scores increase to a higher level. The analysis of mortality risk was calculated by P-POSSUM scoring, logistic regression was done, and the significance value calculation was done.

The basic concept in health is to provide quality health care with a reduction in an adverse outcomes. By comparing adverse outcome rates, assessment of the adequacy of health care provided, and evolves new strategies for a better outcome. However, a comparison using crude mortality rate can be inaccurate as it does not consider the patients' condition andthe disease process. To overcome this shortcoming, POSSUM a risk-adjusted scoring system was proposed. 13 Later P-POSSUM, a modification of POSSUM, was proposed, as it correlates better with the observed mortality rate. 1415 But POSSUM must be correlated to the general condition of the local population for it to be effective. 212 This is important for patients in developing countries like India where the general health of the population is variable and presentation frequently variable and delayed. 9 The validity of P-POSSUM scores was compared in 50 cases of emergency gastrointestinal surgeries. In this study. postoperative complications were n=7(14%), wound infection was in n=4 cases, wound dehiscence, hypotension, and chest infection was in one case each. Mohil RS et al; 16 found 20% cases of chest infection and wound infection in 35% cases. Rana DS et al; 17 found 58.65% cases of postoperative complication in which 27% were chest infections and 17% were wound infections. The crude morbidity rate in the study was 18% and the P-POSSUM scores expected morbidity was 61.25% statistically significant difference in observed and expected morbidity rates were observed X2=14.25 p=0.0414. It was also noted that the P-POSSUM score over-estimates risk for morbidity in low-risk groups while it accurately predicts the risk in higher-risk groups. Copeland GP et al; 18 found a POSSUM system for comparative audit in 344 cases of reconstructive vascular surgeries. The estimated mortality rate was 10.2%. For unit A and 9.4% for unit B 20.2% and using ROC curves, it was shown that no statistically significant differences between the two units. They concluded that the POSSUM scoring system was a better guide for comparing the efficiency of quality of care rather than crude mortality rates. Rana DS et al; found no statistically significant difference was found between the observed and expected morbidity rates. Similar findings were observed in Chieng et al; 19 and SunilKumar et al; 20 . Application of POSSUM scoring system to compare adverse outcome following colorectal resections was done by Sagar PM et al; 2 The crude mortality rates were from 5.6% to 6.9% and morbidity rates varied from 13.6% to 30.6% the risk-adjusted analysis by POSSUM scores showed no statistically significant difference in overall mortality rates. Comparison of POSSUM and P-POSSUM was done by ML Echara et al; 21 in patients undergoing emergency laparotomy. They observed mortality was 12.0% and while POSSUM predicted 40% mortality the P-POSSUM 27%. Similarly, the morbidity rates were 69% the POSSUM expected the morbidity to 79%. The test of correlation showed no significance.

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