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Thesis Asif
Thesis Asif
MD
SUPERVISOR
Date,
CERTIFICATE
ii
direct supervision.
I have read the Dissertation and have found it satisfactory for FCPS
---------------------------------
--
FCPS.FRCS
MAYO HOSPITALLAHORE
DATED:
iii
DEDICATION
PART I
v
ACKNOWLEDGEMENTS
to select the topic for dissertation, and Dr. Nadeem Aslam associate
TABLE OF CONTENTS
Chapter page
1. ABSTRACT ……………………………………………………..2
2. INTRODUCTION…………………………………….……………………… 5
4. OBJECTIVE………….………………………………………………………. 45
5. HYPOTHESIS …………………………………………………………………46
6. OPERATIONAL DEFINATION………………………………………. 47
8. RESULTS…………………………………………………………........... 56
9. DISCUSSION…………………………………………………….……………84
10. CONCLUSION…………………………………………………..……………91
11. APPENDIX……………………………………………………………………..93
12. BIBLIOGRAPHY……………………………………………………….…….99
vii
LIST OF TABLES
TITLE
PAGE
LIST OF FIGURES/GRAPH
LIST OF ABBREVIATIONS
C.A: carcinoma
T.B: tuberculosis
risk patients.
OBJECTIVE
figures.
STUDY DESIGN
SETTING
was 6 months.
METHODS
RESULTS
CONCLUSION
KEY WORDS
a free man’s slave and kills him, the doctor must replace the
opened an abscess and the man goes blind, the man is to cut
whom we serve.
regularly use ASA for general patients and APACHE for the
of analysis is different.3
surgical audit.
3. REVIEW OF LITERATURE
7
Amory Codman)
England) 7
8
available(department of health).
8
of process.
local guidelines.
avoided in future.
measures all the skills of the medical and nursing staff, the
and morbidity.
MORBIDITY:
rate.
MORTALITY:
surgical audit.
Most series have measured in hospital mortality but recent
9
to 20% when compared to 30-day mortality rates.
of surgery.
is then tested in much the same way by using ROC curves and
calibration curves.
10
3.4.1. ASA GRADING
an Operation
3.4.2. APACHE
physiological variables.
APACHE II has been validated both in general and surgical
Specialty Registries’
These are few methods which are useful for comparative
also.
3.5.1. POSSUM
use, then POSSUM neatly fits into the gap, requiring only 12
Physiological Operative
Serum urea
Serum sodium
Serum potassium
Electrocardiogram
3.5.2. P-POSSUM
individual.
popular around the North England in, many authors use it all
17
during the following year for some surgical specialties.
4
for mortality were 0.66 and 0.88 respectively.
Another recently conducted study in center for the study of
lack of fit.3
superior.5
higher risk patients. The surgical risk score (SRS) has been
respectively.6
Oesophagogastric surgery
POSSUM score was 0.23. The O/E ratios for mortality from the
surgery.23
recovery.24
Abdaal W Khan, Sudeep R Shah and colleagues from
surgery.26
23.9. The mean FIS was 13.95 (12-22), and the mean IQ was
banded gastroplasty.30
to surgical audit.33, 34
CALCULATIONS
www.sfar.org/score2/P-POSSUM2.html .
POSSUM formula:
P-POSSUM formula:
PREDICTION EQUATIONS
The results are tested by using chi-square (χ²) test. The value
STUDY
4 . OBJECTIVES:
elective laparotomy.
5. HYPOTHESIS:
of:
2. MORBIDITY:
evacuation.
re-exploration.
chest radiograph.
purulent exudates.
5
2.5. Urinary infection: The presence of > 10 bacteria / ml
clear urine.
breakdown.
measures).
levels.
measurement.
2.14. Respiratory failure: Respiratory difficulty requiring
emergency ventilation.
prostate.
oesophagogast-rectomy.
factors evaluated.
6. POSSUM:
7. P-POSSUM:
synopsis.
SAMPLE SIZE:
is optimized).
SAMPLING TECHNIQUE:
STUDY DESIGN:
INCLUSION CRITERIA:
• Both genders
EXCLUSION CRITERIA:
before surgery
• Elective
cholecystectomy
• Mentally retarded
patients
• Appendicectomy
DATA COLLECTION:
Data analysis:
KG.
(table 5-7).
Pearson’s correlation in elective for POSSUM observed and
& .867 and for P-POSSUM was 1.000 & .901 (table 8-10).
(table 11).
Abdomen 20%, fire arm injury abdomen (FAI) 16% and blunt
was .78 and by P-POSSUM, the mortality was 1.00 (table 16-
18).
& .707 and for P-POSSUM was 1.000 & .858 (table 19-21).
N=50
Frequency
(%age)
CA. Colon 10(20)
T.B Abdomen 6(12)
Fibroid uterus 5 (10)
CA. Rectum 5(10)
CA. Ovary 4 (8)
Rectovaginal Fistula 2 (4)
Intestinal Obstruction 2 (4)
CA. Head of pancreas 2 (4)
Graham patch leak 1 (2)
Ovarian cyst 1 (2)
CA. Gall bladder 1 (2)
Pseudocyst 1 (2)
Typhoid perforation 1 (2)
Choledochal cyst 1 (2)
Perforated Appendicitis 1 (2)
Adhesive bowel disease 1 (2)
pelvic collection 1 (2)
vesicovaginal fistula 1 (2)
Liver Abscess 1 (2)
Intussusceptions 1 (2)
Liposarcoma 1 (2)
Gastric outlet obstruction 1 (2)
Total 50
N=50
Frequency
(%age)
Wound infection 5 (10)
Multiple* 2 (4)
Wound infection and deep
2 (4)
infection
Wound hemorrhage 1 (2)
Respiratory failure 1 (2)
Anastomotic leak and wound
1 (2)
dehiscence
Wound infection and UTI 1 (2)
Deep infection 1 (2)
Anastomotic leak 1 (2)
Total 15
N= 50
Frequency
PROFESSOR 7 (14)
ASSOCIATE
18 (36)
PROFSSOR
ASSISTANT PROF 9 (18)
SENIOR REGISTRAR 16 (32)
TOTAL 50
FEMALE MALE
52.0% 48.0%
Keys
O.mort: observed mortality
LAPAROTOMY
Range
O/p
of age Frequency O.mort P.mort
Ratio
in years
14-29 11 2 2.58 .775
30-44 16 1 1.12 .89
45-59 17 0 .88 0
60-74 6 0 .22 0
50 3 4.80 .625
Keys
O/P : Observed/predicted
LAPAROTOMY
Range
O/p
of age Frequency O.morb P.morb
Ratio
in years
14-29 11 8 5.44 1.47
30-44 16 2 3.92 .51
45-59 17 4 4.08 .98
60-74 6 1 1.23 .81
50 15 14.67 1.02
Keys
O/P : Observed/predicted
LAPAROTOMY
of age Ratio
in years
14-29 11 2 1.98 1.01
30-44 16 1 .95 1.05
45-59 17 0 0 0
60-74 6 0 0 0
TOTAL 50 3 2.93 1.02
Keys
O/P : Observed/predicted
Observed Predicted
morbidity morbidity
Observed Pearson 1.000 .707
morbidity Correlation
.000 .
Sig. (2-tailed)
50 50
mortality
Observed Predicted
mortality mortality
Observed Pearson 1.000 .867
mortality Correlation
.000 .
Sig. (2-tailed)
50 50
mortality
Observed Predicted
mortality mortality
Observed Pearson 1.000 .901
mortality Correlation
.000 .
Sig. (2-tailed)
50 50
Chi-Square df Sig.
morbidity
Predicted
mortality
Predicted
mortality
LAPAROTOMY
Frequency
Intussusceptions 1(2%)
*PID 1(2%)
Fecal fistula 1(2%)
Stab abdomen 1(2%)
CA. Testis 1(2%)
Perforated appendicitis 1(2%)
Total 50
Frequency
Wound infection 5(10%)
Anastomotic leak 2(4)%
Wound Dehiscence 3(6%)
Deep infection 2(4%)
Sepsis 1(2%)
Cardiac failure 1(2%)
Chest infection 1(2%)
Jaundice, Fistula 1(2%)
Urinary fistula 1(2%)
Pulmonary Embolus 1(2%)
Liver failure 1(2%)
Renal failure 1(2%)
Stomach leak 1(2%)
*UTI 1(2%)
Total 22
Frequency
Resident 27(54%)
SR 23(46%)
Total 50
FIGURE 2: GENDER DISTRIBUTION IN EMERGENCY
CASES
FEMALE
12.0%
MALE
88.0%
Table 15: SUM OF OBSERVED AND PREDICTED
Keys
O.mort: observed mortality
LAPAROTOMY
AGE IN RATIO
YEARS
15-30 27 1 4.45 .224
31-45 10 1 1.56 .64
46-60 7 0 0.36 0
61-75 6 4 2.63 1.52
50 6 9 .66
Keys
O/P : Observed/predicted
Table 17: COMPARISON OF OBSERVED AND PREDICTED
LAPAROTOMY
AGE IN RATIO
YEARS
15-30 27 9 15.04 .59
31-45 10 5 5.15 .97
46-60 7 1 2.16 .46
61-75 6 7 5.82 1.20
50 22 28.17 .78
Keys
O/P : Observed/predicted
Table 18: COMPARISON OF OBSERVED AND PREDICTED
EMERGENCY LAPAROTOMY
AGE IN RATIO
YEARS
15-30 27 1 2.41 .41
31-45 10 1 .67 1.49
46-60 7 0 0 0
61-75 6 4 2.92 1.36
50 6 6 1
Keys
O/P : Observed/predicted
Observed Predicted
morbidity morbidity
Observed Pearson 1.000 .736
morbidity Correlation
. .000
Sig. (2-tailed)
50 50
N
.000 .
Sig. (2-tailed)
50 50
mortality
Observed Predicted
mortality mortality
Observed Pearson 1.000 .707
mortality Correlation
. .000
Sig. (2-tailed)
50 50
N
.000 .
Sig. (2-tailed)
50 50
emergency mortality
Observed Predicted
mortality mortality
Observed Pearson 1.000 .858
mortality Correlation
. .000
Sig. (2-tailed)
50 50
N
.000 .
Sig. (2-tailed)
50 50
Chi-Square df Sig.
Predicted
mortality
Predicted
mortality
9. DISSCUSSION
males.35-39
45-59 years and main indication was Colon cancer (20%) and
46
(13.34%) and renal failure (1.34%). Ali AA et. al. (1996)
surgical patients.19
centre.25
low-risk groups.31
predicted well.
32
mortality in emergency surgery.
to surgical audit.33, 34
in both cases.
Weight# Profession#
Provisional diagnosis#
Final diagnosis#
Date of operation#
Procedure#
POSSUM DATA SHEET PHYSIOLOGICAL SCORE
1 2 4 8
AGE <60 61-70 >71
peripheral
diuretic, digoxin, oedema
Cardiac sign + raised JVP
no failure anti-anginal or warfarin
CXR cardiomegaly
anti-hypertensive borderline
cardiomegaly
81-100 >121
Pulse (Beats/min) 50-80 101-120
40-49 <40
Glasgow coma
15 12-14 9-11 <8
scale
15th 30th
1st day 3rd day 7th day
Complications day day
Y/N Y/N Y/N
Y/N Y/N
♦ Wound hemorrhage ♦
♦ Deep hemorrhage ♦
♦ Chest infection ♦
♦ Urinary infection ♦
♦ Wound infection ♦
♦ Deep infection ♦
♦ Septicemia ♦
♦ Pyrexia of unknown ♦
origin
♦ Wound dehiscence ♦
♦ Cardiac failure ♦
♦ Respiratory failure ♦
♦ Anastomotic leak ♦
POSSUM
Pulse
Urea Cardiac signs
(beats/min)
Potassium Sodium
Systolic Blood Pressure
(mEql/L) (mEql/L)
Physiologic Score
Peritoneal
Cancer Mode of surgery
soiling
Portsmouth – POSSUM
Potassium
Sodium (mEql/L) Systolic Blood Pressure
(mEql/L)
Physiologic Score
Operative
Multiple procedures Total Blood Loss
Severity
Peritoneal
Cancer Mode of surgery
soiling
Operative Score
3. Lam CM, Fan ST, Yuen AWC, Law WL, and Poon K.
Validation of Possum scoring system for audit of major
hepatectomy. Brj surg 2004; 91: 450-4.
Volume 5 Number 1
355-58.
27.
Surgery; 143:8-19.
94-100.
51:134-40.
Lange; 1994.
812-15.
2000; 43:1528-32.
11: 111-6.
47. Ali AA, Gondal KM, Ahmed I, Aslam MN, Chaudhry AM.