Comparative study between Portsmouth Physiological and Operative Severity Score for the Enumeration of mortality and morbidity (P-POSSUM) and the Acute Physiology and Chronic Health Evaluation (APACHE II) scores in predicting Mortality in patients of perforation peritonitis undergoing exploratory laparotomy in tertiary care centre in Eastern India

Comparative study between Portsmouth Physiological and Operative Severity Score for the Enumeration of mortality and morbidity (P-POSSUM) and the Acute Physiology and Chronic Health Evaluation (APACHE II) scores in predicting Mortality in patients of perforation peritonitis undergoing exploratory laparotomy in tertiary care centre in Eastern India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative study between Portsmouth Physiological and Operative Severity Score for the Enumeration of mortality and morbidity (P-POSSUM) and the Acute Physiology and Chronic Health Evaluation (APACHE II) scores in predicting Mortality in patients of perforation peritonitis undergoing exploratory laparotomy in tertiary care centre in Eastern India Gautami Suresh Narla, Ketan Prabhunath Gupta, Shuvam Chandi Prasad Pati, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9342693/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Perforation peritonitis is a common surgical emergency associated with significant morbidity and mortality. Early risk stratification using scoring systems such as Acute physiology and chronic health evaluation II (APACHE-II) and Portsmouth modification of Physiological and operative severity for the enumeration of mortality and morbidity (P-POSSUM) helps guide management and predict outcomes. This study aimed to compare the effectiveness of these scoring systems in predicting postoperative mortality in patients undergoing emergency laparotomy. This case series analysis included 89 patients with hollow viscus perforation undergoing emergency laparotomy at a tertiary care centre over 15 months. APACHE II scores were calculated within 24 hours of admission, while P-POSSUM scores incorporated both physiological and operative parameters. Patients were followed for 30 days. Statistical analysis included Receiver Operating Characteristic (ROC) curve analysis to evaluate predictive accuracy. The most common aetiologies were acid peptic disease (24.7%), trauma (21.3%), and appendicular perforation (13.5%). The overall 30 days mortality was 6.7%. Both APACHE II and P-POSSUM scores were significantly higher among non-survivors (p 9.5. P-POSSUM also showed excellent accuracy (AUC 0.939) with sensitivity 98.3% and specificity 83.1% at a cutoff > 46.7. Both APACHE II and P-POSSUM were reliable predictors of postoperative mortality. APACHE II showed slightly better sensitivity and ease of use, while P-POSSUM demonstrated higher specificity. Given comparable performance, APACHE II may be preferred for early risk stratification. General Surgery Gastrointestinal Surgery Critical Care & Emergency Medicine Perforation Peritonitis Emergency Laparotomy APACHE II P-POSSUM Mortality Figures Figure 1 Figure 2 Figure 3 Introduction Perforation peritonitis is one of the most common surgical emergencies. It is a serious condition with a mortality rate of up to 20% and is a leading cause of acute abdomen, after appendicitis and intestinal obstruction [ 1 ]. Treatment includes resuscitation, surgery, and intensive care. Early prognostic evaluation helps identify high-risk patients who require aggressive treatment. Awareness of risk factors improves perioperative care and optimal use of resources. Regular clinical audit and continuous improvement are essential for quality care. It requires a scoring system for risk stratification to explain prognosis to the relatives objectively and mobilise essential medical resources beforehand. Preoperative risk assessment helps decide between damage control surgery and definitive procedure and identifies patients needing postoperative intensive care and organ support [ 2 ]. P-POSSUM and the APACHE-II have been the most widely used scoring systems for emergency laparotomies. APACHE assesses critically ill patients, and APACHE II is a simplified, practical version validated for surgical and ICU patients. APACHE II is being used very commonly, predicts mortality using only preoperative 12 physiological parameters [ 3 ]. POSSUM predicts postoperative morbidity and mortality using physiological and operative factors, while P-POSSUM refines this for better mortality prediction. P-POSSUM being used commonly in the United Kingdom for national emergency laparotomy audit [ 2 ], which includes both preoperative and operative factors, potentially offering more accurate predictions. 12 physiological and 6 operative parameters (number of procedures, total blood loss, peritoneal soiling, operative severity, malignancy, mode of surgery) [ 3 ]. There are limited studies evaluating these scoring systems in Eastern India, and there is no standard scoring system that exists for mortality risk stratification in emergency laparotomy for perforation peritonitis. This study aims to assess and compare the effectiveness of P-POSSUM and APACHE II scores in predicting mortality in patients with hollow viscus perforation undergoing exploratory laparotomy in a tertiary centre in Eastern India to help select a standard risk assessment scoring method. Patients and Methods Study Design and Setting This was a prospective, observational hospital-based study conducted over a 15-month period from October 2024 to December 2025. The study was carried out in the Department of General Surgery at IMS and SUM Hospital, a tertiary care teaching centre in Bhubaneswar, Eastern India. A total of 89 patients who presented to the emergency department with clinical features of acute peritonitis and were subsequently diagnosed with hollow viscus perforation were enrolled. Ethical Consideration This study has been approved by the Institutional Ethics Committee of IMS SUM Hospital Bhubaneswar, with reference number ref.no/IEC/IMS.SH/SOA/2024/878. The identities of the participants were strictly protected, with all data collected used solely for research purposes. Patients were assured that their participation would not affect their medical care or incur additional costs. To further protect patient privacy, all records were de-identified during data entry. Participation in the study did not influence the provision of medical services to patients, nor were any additional costs incurred by them. Patient Selection and Data Collection The study included 89 patients with a study period of 15 months, which was calculated using the WHO standard formula for prevalence studies. A reported prevalence of 57.3% for perforation peritonitis was used [ 4 ]. With a 95% confidence level (Z = 1.96) and 20% relative error (d = 0.2), the sample size was calculated as 74. After accounting for a 20% loss to follow-up, the final sample size was set at 89. Accordingly, 89 patients who presented to the emergency department of IMS and SUM Hospital, Bhubaneswar, and fulfilled the inclusion criteria were enrolled in the study. Patients who presented with acute peritonitis due to hollow viscus perforation, were ≥ 18 years of age, and underwent their first laparotomy were included. Patients were excluded if they refused consent, were under 18 years of age, required re-exploratory surgery, or were discharged against medical advice within 24 hours. After obtaining informed consent, all enrolled patients were followed for 30 days. All patients were assessed using the APACHE II score within 24 hours of admission. The physiological parameters for the P-POSSUM score were also recorded during this period. At the time of scheduling for emergency surgery, these physiological components, along with one operative parameter-emergency/elective surgery, were documented. The remaining operative variables for the P-POSSUM score, namely operative severity category, number of procedures, estimated blood loss, and degree of peritoneal contamination, were recorded intraoperatively. The final operative component, relating to malignancy, was determined postoperatively upon receipt of histopathology reports. Following adequate resuscitation patients underwent surgical management which included site-specific repair: omental patch for gastric/duodenal perforations, anastomosis or stoma formation for bowel perforations, and appendectomy for appendiceal perforations. Peritoneal lavage and intra-abdominal drains were routinely applied. Patients were discharged when they were able to tolerate oral feeds, had adequate pain control with oral medications, and showed no significant local or systemic complications and were followed for 30 days postoperatively. APACHE II was calculated using 12 physiological variables along with age and chronic health status, each assigned weighted scores, giving a total score ranging from 0 to 71. P-POSSUM used 12 physiological parameters and 6 operative variables, each graded on a scale (typically 1, 2, 4, or 8) which were combined in a regression equation to predict mortality. Data Analysis Data analysis was performed using Microsoft Excel and SPSS version 29. Categorical data were expressed as percentages, while continuous data were presented as mean with standard deviation or median as appropriate. The independent t-test was used to analyse P-POSSUM scores, whereas the Mann-Whitney U test was applied for APACHE II scores due to skewed data distribution. The chi-square test compared categorical variables between groups. ROC curves were generated to determine cutoff points for APACHE II and P-POSSUM scores in predicting outcomes. The AUC was compared for both scores to evaluate their accuracy in predicting mortality risk. A p-value of less than 0.05 was considered statistically significant. Results A total of 89 patients were included, with a mean age of 44.5 SD 19.1 years (range: 18–91 years). The cohort was predominantly male (86.5%), with a male to female ratio of 6.4:1 (Table 1 ). Approximately 20.2% of patients were aged 60 years or older. The leading aetiologies of perforation peritonitis were acid peptic disease (24.7%), trauma (21.3%), and appendicular perforation (13.5%) (Table 2 ). The most common sites of perforation were the duodenum, ileum, stomach, and jejunum, in descending order of frequency (Fig. 1 ). The overall mortality rate within 1-month post-surgery was 6.7%. Mortality was notably higher among patients with colorectal, jejunal, and multiple perforations, whereas gastric and appendicular perforations were associated with comparatively lower mortality rates. Non-survivors had higher mean APACHE II scores and mean P-POSSUM operational severity scores than survivors (Table 3 ), and this difference was statistically significant (p < 0.05), demonstrating a strong association with mortality risk. The P-POSSUM physiological severity score (r = 0.909, p < 0.001) and operative severity score (r = 0.509, p < 0.001) showed a positive and statistically significant correlation with the APACHE II score. ROC analysis demonstrated that the APACHE II scoring system (Fig. 2 ) had excellent accuracy in predicting mortality, with an AUC of 0.948 (p 9.5, it showed a sensitivity of 98.9% and a specificity of 79.5%. ROC analysis showed that the P-POSSUM scoring system (Fig. 3 ) had excellent accuracy in predicting mortality, with an AUC of 0.939 (p 46.7, it demonstrated a sensitivity of 98.3% and a specificity of 83.1%. Table 1 Gender distribution of study participants (n = 89), presented as frequency (n) and percentage (%) Table 1 : Gender (n = 89) Frequency n (%) Male 77 (86.5) Female 12 (13.5) Table 2 aetiology of peritonitis among study participants (n = 89), presented as frequency(n) and percentage (%) aetiology of peritonitis (N = 89) Frequency n (%) Acid peptic disease 38 (42.7) Trauma 19 (21.3) Appendicular perforation 12 (13.5) Intestinal obstruction 9 (10.2) Malignancy 6 (6.7) Typhoid 3 (3.4) Tuberculosis 1 (1.1) Sigmoid volvulus 1 (1.1) Table 3 Comparison of APACHE II and P-POSSUM between survivors(n = 83) and non survivors (n = 6), presented as mean (SD) Survivors and Non-Survivors (N = 89) Parameters Survivor (n = 83) n (%) Non-survivor (n = 6) n (%) p value* APACHE II score (mean ± SD) 8.1 (7.5) 9.4 (4.2) 0.041 P-POSSUM physiological severity score (mean ± SD) 25.8 (9.2) 30.2 (6.1) 0.465 P-POSSUM operative severity score (mean SD) 18.3 (5.0) 19.5 (0.8) 0.033 *p < 0.05 considered statistically significant Discussion In the present study, a total of 89 patients were included, which had patients with mean age of 44.5 SD 19.1 years (range: 18–91 years), which is comparable to other studies where perforation peritonitis predominantly affected middle-aged individuals [ 1 ]. However, some studies have reported a relatively younger population, indicating regional variation in age distribution [ 4 ]. The current study demonstrated a marked male predominance (86.5%) with a male-to-female ratio of 6.4:1, which is higher but consistent with previously reported ratios ranging from 3:1 to 5:1, likely due to greater exposure of males to risk factors such as smoking, alcohol consumption, and NSAID use [ 1 , 4 ]. Regarding aetiology, acid peptic disease (24.7%) was the most common cause in the present study, followed by trauma (21.3%) and appendicular perforation (13.5%). This finding is in agreement with several studies where peptic ulcer perforation was identified as the leading cause of perforation peritonitis [ 2 , 3 , 6 ]. However, the relatively higher proportion of traumatic perforations in the present study may reflect an increasing trend of abdominal injuries. In the present study, the overall 1-month postoperative mortality was 6.7%, which is lower than reported in some previous studies, where mortality ranged from 10% to 30% depending on patient population and perforation site [ 2 , 5 , 4 ]. Consistent with the literature, mortality was higher in patients with colorectal, jejunal, and multiple perforations, while gastric and appendicular perforations were associated with lower mortality [ 4 ]. Non-survivors in this cohort had significantly higher mean APACHE II scores and P-POSSUM operative severity s cores compared to survivors (p < 0.05), reflecting a strong association between higher severity scores and mortality risk, which aligns with earlier reports demonstrating that both scoring systems reliably predict outcomes in perforation peritonitis [ 2 , 6 , 9 ]. Earlier studies showed mixed results regarding the comparative performance of APACHE II and P-POSSUM. Some studies reported that APACHE II was slightly superior in predicting mortality due to its stronger assessment of physiological derangements [ 2 , 3 , 5 ], while others suggested that P-POSSUM better reflected operative severity and sometimes overpredicted mortality in low-risk cohorts [ 6 , 7 , 8 ].The present study demonstrated that both APACHE II and P-POSSUM scoring systems had excellent accuracy in predicting 30 days postoperative mortality, as reflected by their high AUC values (0.948 and 0.939, respectively). At the defined cutoff values, APACHE II showed slightly higher sensitivity (98.9%), indicating it was better at identifying patients who were truly at risk of mortality, reflecting its strength in assessing physiological derangements. P-POSSUM, however, had slightly higher specificity (83.1%), suggesting it was more accurate in identifying patients who survived, likely due to its inclusion of operative factors. Thus, unlike earlier reports of overprediction by P-POSSUM, both scores performed comparably in this study. The strengths of this study include its prospective design, standardized data collection, and direct comparison of two widely used scoring systems within the same cohort. The use of ROC curve analysis further strengthens the validity of the findings by objectively assessing predictive accuracy. However, certain limitations must be acknowledged. The relatively small sample size and single-centre design may limit the generalizability of the results. The short follow-up period of 30 days may also not capture late postoperative outcomes. In terms of clinical implications, the present study supports the use of both APACHE II and P-POSSUM as effective tools for early risk stratification in perforation peritonitis. Their high sensitivity makes them particularly useful for identifying high-risk patients who may benefit from intensive monitoring and aggressive management. Future research should focus on larger, multicentric studies to validate these findings and explore the integration of scoring systems with dynamic biomarkers, such as serum lactate, to further improve prognostic precision. Conclusion In conclusion both APACHE II and P-POSSUM demonstrated excellent predictive accuracy for mortality in this study. However, APACHE II showed a marginally higher discriminative ability (higher AUC), indicating that it may be slightly better as a standalone predictor of mortality. Nonetheless, P-POSSUM demonstrated comparable performance with better specificity, suggesting that it remains a valuable and reliable alternative. Declarations Author Contribution All authors contributed to the study conception and design. Material preparation was performed by Gautami Suresh Narla. Data collection was done by Shuvam CP Pati and Alim Shaikh, analysis was performed by Gautami Suresh Narla and Ketan Prabhunath Gupta. The first draft of the manuscript was written by Gautami Suresh Narla and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Funding : The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests : The authors have no relevant financial or non-financial interests to disclose. Compliance with Ethical Standards All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical approval was officially granted by the Institutional Ethics Committee of IMS and SUM Hospital, Bhubaneswar (Reference number: ref.no/IEC/IMS.SH/SOA/2024/878). Informed consent was obtained from all individual participants included in the study prior to their enrollment and subsequent 30-day follow-up. Consent to Participate : Informed consent was obtained from all individual participants included in the study. Data Availability : The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. References Neupane S, Koirala DP, Kharel S, Silwal S, Yadav KK (2022) Clinical profile and management of perforation peritonitis in Bharatpur hospital, Nepal: A prospective study. Annals Med Surg 82:104528 Nag DS, Dembla A, Mahanty PR, Kant S, Chatterjee A et al (2019) Comparative analysis of APACHE-II and P-POSSUM scoring systems in predicting postoperative mortality in patients undergoing emergency laparotomy. World J Clin Cases 7(16):2227 Kumar L, Singh S, Pratap D, Singh KK, Nayak S et al (2022) Comparison of predictive values of Mannheim Peritonitis Index, Acute Physiology and Chronic Health Evaluation-II and Portsmouth-POSSUM scoring systems for prognosis of mortality in patients with perforation peritonitis. Int J Res Med Sci 10:1059–1065 Subedi RP, Kumar N, Karn S, Arunkumar V, Raj N et al (2025) Prognostic value of the combination of serial APACHE II with serum lactate for predicting post-operative mortality in gastrointestinal perforation peritonitis: a prospective cohort study. BMC Surg 25(1):374 Situ OO, Badejo OA, Gwaram UA, Badejo O (2024) Predictive role of acute physiology and chronic health evaluation II (APACHE II) in patients with peritonitis at the National Hospital Abuja. Cureus. ;16(4) Yelamanchi R, Gupta N, Durga CK, Korpal M (2020) Comparative study between P-POSSUM and Apache II scores in predicting outcomes of perforation peritonitis: prospective observational cohort study. Int J Surg 83:3–7 Eswaravaka S, Suhrid C, Rao B, Prabhakar S, Pandya J (2024) Revisiting physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scores: are they valid in cases of ileal perforation. Cureus. ;16(7) Kumar A, Suman S, Kundan K, Kumar P (2016) Evaluation of POSSUM scoring system in patients with perforation peritonitis. Int Surg J 3(4):2181–2186 Echara ML, Singh A, Sharma G (2019) Risk–Adjusted Analysis of Patients Undergoing Emergency Laparotomy Using POSSUM and P–POSSUM Score: A Prospective Study. Nigerian J Surg 25(1):45–51 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9342693","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":618817447,"identity":"5570a41f-345c-4dd7-a99b-0679d1a3f5e0","order_by":0,"name":"Gautami Suresh Narla","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYHACxgMw1oEPQIKNnQg9YC08QHxwBkgLMylamEEEAyEt5uxnHxz48csucT/76cTDNr+2yfMxMzB++JiDW4tlT7rBwd6+5MQentwNh3P7bhu2MTMwS87chluLwYE0hgO8PcyJPQwgLT23GYFa2Jh58Wk5/4zh4N+e+sQe/rcbDlv23LYnrOVGGsNhnh+HE3skgLYw/LidSISWZwyHZRuOG/fceLvhYG/D7eQ2ZsZm/H45n8b48M2fatn2/tzNH378uW07v7354IePeLSAAWMbCoOxgYB6EPiDwRgFo2AUjIJRgAAAJlNa7T8+390AAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0007-5491-4042","institution":"Institute of Medical Sciences \u0026 SUM Hospital, Siksha 'O' Anusandhan University","correspondingAuthor":true,"prefix":"","firstName":"Gautami","middleName":"Suresh","lastName":"Narla","suffix":""},{"id":618817448,"identity":"e91c5962-216a-43da-84c9-93e0f24cc4a8","order_by":1,"name":"Ketan Prabhunath Gupta","email":"","orcid":"https://orcid.org/0009-0005-0859-8224","institution":"Institute of Medical Sciences \u0026 SUM Hospital, Siksha 'O' Anusandhan University","correspondingAuthor":false,"prefix":"","firstName":"Ketan","middleName":"Prabhunath","lastName":"Gupta","suffix":""},{"id":618817449,"identity":"a10babbb-91f4-427d-b1e6-d249f9c9065d","order_by":2,"name":"Shuvam Chandi Prasad Pati","email":"","orcid":"https://orcid.org/0009-0006-4658-6926","institution":"Institute of Medical Sciences \u0026 SUM Hospital, Siksha 'O' Anusandhan University","correspondingAuthor":false,"prefix":"","firstName":"Shuvam","middleName":"Chandi Prasad","lastName":"Pati","suffix":""},{"id":618817450,"identity":"77935a47-2a07-4258-be87-af8374844b40","order_by":3,"name":"Alim Shaikh","email":"","orcid":"https://orcid.org/0009-0002-2127-0029","institution":"Institute of Medical Sciences \u0026 SUM Hospital, Siksha 'O' Anusandhan University","correspondingAuthor":false,"prefix":"","firstName":"Alim","middleName":"","lastName":"Shaikh","suffix":""}],"badges":[],"createdAt":"2026-04-07 09:33:39","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9342693/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9342693/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106399876,"identity":"0287e626-e676-4bf3-9500-4fc6187a026d","added_by":"auto","created_at":"2026-04-08 08:32:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35825,"visible":true,"origin":"","legend":"\u003cp\u003eBar diagram showing distribution of site of perforation among study participants(n=89) presented as frequency(n).x-axis shows site of perforation. y-axis shoes frequency (number of participants)\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9342693/v1/4a728918df24a33cc7c515d2.jpg"},{"id":106404889,"identity":"8bb97e01-6343-4878-96ee-ac42ad07bf3c","added_by":"auto","created_at":"2026-04-08 09:17:21","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":256276,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver Operating Characteristic curve showing the predictive accuracy of APACHE II score for mortality among study participants. Area under curve (AUC) =0.948, x-axis represents 1-specificity and y axis represents sensitivity. The optimal cutoff value in this study: \u0026gt;9.5(sensitivity:98.9%, specificity:79.5%).\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9342693/v1/46a2cbe00bf1d32605f6c9a4.jpeg"},{"id":106399877,"identity":"cccb78f6-77b9-4c41-babf-27cc1606807f","added_by":"auto","created_at":"2026-04-08 08:32:53","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":262313,"visible":true,"origin":"","legend":"\u003cp\u003eReceiver Operating Characteristic curve showing the predictive accuracy of P-POSSUM score for mortality among study participants. Area under curve (AUC) =0.939, x-axis represents 1-specificity and y axis represents sensitivity. The optimal cutoff value in this study: \u0026gt;46.7(sensitivity:98.3%, specificity:83.1%)\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9342693/v1/f3ed96bf0d90d1148a1b1dd4.jpeg"},{"id":106405971,"identity":"a7391abd-6105-4495-91dc-cdc74008a1e8","added_by":"auto","created_at":"2026-04-08 09:29:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1139612,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9342693/v1/9d48b90f-afd1-4abe-a2e9-5d91dd72bd03.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eComparative study between Portsmouth Physiological and Operative Severity Score for the Enumeration of mortality and morbidity (P-POSSUM) and the Acute Physiology and Chronic Health Evaluation (APACHE II) scores in predicting Mortality in patients of perforation peritonitis undergoing exploratory laparotomy in tertiary care centre in Eastern India\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePerforation peritonitis is one of the most common surgical emergencies. It is a serious condition with a mortality rate of up to 20% and is a leading cause of acute abdomen, after appendicitis and intestinal obstruction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Treatment includes resuscitation, surgery, and intensive care. Early prognostic evaluation helps identify high-risk patients who require aggressive treatment. Awareness of risk factors improves perioperative care and optimal use of resources. Regular clinical audit and continuous improvement are essential for quality care. It requires a scoring system for risk stratification to explain prognosis to the relatives objectively and mobilise essential medical resources beforehand. Preoperative risk assessment helps decide between damage control surgery and definitive procedure and identifies patients needing postoperative intensive care and organ support [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. P-POSSUM and the APACHE-II have been the most widely used scoring systems for emergency laparotomies. APACHE assesses critically ill patients, and APACHE II is a simplified, practical version validated for surgical and ICU patients. APACHE II is being used very commonly, predicts mortality using only preoperative 12 physiological parameters [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. POSSUM predicts postoperative morbidity and mortality using physiological and operative factors, while P-POSSUM refines this for better mortality prediction. P-POSSUM being used commonly in the United Kingdom for national emergency laparotomy audit [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], which includes both preoperative and operative factors, potentially offering more accurate predictions. 12 physiological and 6 operative parameters (number of procedures, total blood loss, peritoneal soiling, operative severity, malignancy, mode of surgery) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. There are limited studies evaluating these scoring systems in Eastern India, and there is no standard scoring system that exists for mortality risk stratification in emergency laparotomy for perforation peritonitis. This study aims to assess and compare the effectiveness of P-POSSUM and APACHE II scores in predicting mortality in patients with hollow viscus perforation undergoing exploratory laparotomy in a tertiary centre in Eastern India to help select a standard risk assessment scoring method.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis was a prospective, observational hospital-based study conducted over a 15-month period from October 2024 to December 2025. The study was carried out in the Department of General Surgery at IMS and SUM Hospital, a tertiary care teaching centre in Bhubaneswar, Eastern India. A total of 89 patients who presented to the emergency department with clinical features of acute peritonitis and were subsequently diagnosed with hollow viscus perforation were enrolled.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Consideration\u003c/h3\u003e\n\u003cp\u003e This study has been approved by the Institutional Ethics Committee of IMS SUM Hospital Bhubaneswar, with reference number ref.no/IEC/IMS.SH/SOA/2024/878. The identities of the participants were strictly protected, with all data collected used solely for research purposes. Patients were assured that their participation would not affect their medical care or incur additional costs. To further protect patient privacy, all records were de-identified during data entry. Participation in the study did not influence the provision of medical services to patients, nor were any additional costs incurred by them.\u003c/p\u003e\n\u003ch3\u003ePatient Selection and Data Collection\u003c/h3\u003e\n\u003cp\u003eThe study included 89 patients with a study period of 15 months, which was calculated using the WHO standard formula for prevalence studies. A reported prevalence of 57.3% for perforation peritonitis was used [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. With a 95% confidence level (Z\u0026thinsp;=\u0026thinsp;1.96) and 20% relative error (d\u0026thinsp;=\u0026thinsp;0.2), the sample size was calculated as 74. After accounting for a 20% loss to follow-up, the final sample size was set at 89. Accordingly, 89 patients who presented to the emergency department of IMS and SUM Hospital, Bhubaneswar, and fulfilled the inclusion criteria were enrolled in the study. Patients who presented with acute peritonitis due to hollow viscus perforation, were \u0026ge;\u0026thinsp;18 years of age, and underwent their first laparotomy were included. Patients were excluded if they refused consent, were under 18 years of age, required re-exploratory surgery, or were discharged against medical advice within 24 hours. After obtaining informed consent, all enrolled patients were followed for 30 days. All patients were assessed using the APACHE II score within 24 hours of admission. The physiological parameters for the P-POSSUM score were also recorded during this period. At the time of scheduling for emergency surgery, these physiological components, along with one operative parameter-emergency/elective surgery, were documented. The remaining operative variables for the P-POSSUM score, namely operative severity category, number of procedures, estimated blood loss, and degree of peritoneal contamination, were recorded intraoperatively. The final operative component, relating to malignancy, was determined postoperatively upon receipt of histopathology reports. Following adequate resuscitation patients underwent surgical management which included site-specific repair: omental patch for gastric/duodenal perforations, anastomosis or stoma formation for bowel perforations, and appendectomy for appendiceal perforations. Peritoneal lavage and intra-abdominal drains were routinely applied. Patients were discharged when they were able to tolerate oral feeds, had adequate pain control with oral medications, and showed no significant local or systemic complications and were followed for 30 days postoperatively. APACHE II was calculated using 12 physiological variables along with age and chronic health status, each assigned weighted scores, giving a total score ranging from 0 to 71. P-POSSUM used 12 physiological parameters and 6 operative variables, each graded on a scale (typically 1, 2, 4, or 8) which were combined in a regression equation to predict mortality.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using Microsoft Excel and SPSS version 29. Categorical data were expressed as percentages, while continuous data were presented as mean with standard deviation or median as appropriate. The independent t-test was used to analyse P-POSSUM scores, whereas the Mann-Whitney U test was applied for APACHE II scores due to skewed data distribution. The chi-square test compared categorical variables between groups. ROC curves were generated to determine cutoff points for APACHE II and P-POSSUM scores in predicting outcomes. The AUC was compared for both scores to evaluate their accuracy in predicting mortality risk. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 89 patients were included, with a mean age of 44.5 SD 19.1 years (range: 18\u0026ndash;91 years). The cohort was predominantly male (86.5%), with a male to female ratio of 6.4:1 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Approximately 20.2% of patients were aged 60 years or older. The leading aetiologies of perforation peritonitis were acid peptic disease (24.7%), trauma (21.3%), and appendicular perforation (13.5%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The most common sites of perforation were the duodenum, ileum, stomach, and jejunum, in descending order of frequency (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The overall mortality rate within 1-month post-surgery was 6.7%. Mortality was notably higher among patients with colorectal, jejunal, and multiple perforations, whereas gastric and appendicular perforations were associated with comparatively lower mortality rates. Non-survivors had higher mean APACHE II scores and mean P-POSSUM operational severity scores than survivors (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), and this difference was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), demonstrating a strong association with mortality risk. The P-POSSUM physiological severity score (r\u0026thinsp;=\u0026thinsp;0.909, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and operative severity score (r\u0026thinsp;=\u0026thinsp;0.509, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) showed a positive and statistically significant correlation with the APACHE II score. ROC analysis demonstrated that the APACHE II scoring system (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) had excellent accuracy in predicting mortality, with an AUC of 0.948 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). At a cutoff value of \u0026gt;\u0026thinsp;9.5, it showed a sensitivity of 98.9% and a specificity of 79.5%. ROC analysis showed that the P-POSSUM scoring system (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) had excellent accuracy in predicting mortality, with an AUC of 0.939 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). At a cutoff value of \u0026gt;\u0026thinsp;46.7, it demonstrated a sensitivity of 98.3% and a specificity of 83.1%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGender distribution of study participants (n\u0026thinsp;=\u0026thinsp;89), presented as frequency (n) and percentage (%)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: Gender (n\u0026thinsp;=\u0026thinsp;89)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77 (86.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (13.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eaetiology of peritonitis among study participants (n\u0026thinsp;=\u0026thinsp;89), presented as frequency(n) and percentage (%)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eaetiology of peritonitis (N\u0026thinsp;=\u0026thinsp;89)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcid peptic disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (42.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (21.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendicular perforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (13.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntestinal obstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (10.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTyphoid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (3.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTuberculosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSigmoid volvulus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of APACHE II and P-POSSUM between survivors(n\u0026thinsp;=\u0026thinsp;83) and non survivors (n\u0026thinsp;=\u0026thinsp;6), presented as mean (SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurvivors and Non-Survivors (N\u0026thinsp;=\u0026thinsp;89) Parameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurvivor (n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-survivor (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAPACHE II score (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.1 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.4 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP-POSSUM physiological severity score (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.8 (9.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.2 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP-POSSUM operative severity score (mean SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.3 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.5 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, a total of 89 patients were included, which had patients with mean age of 44.5 SD 19.1 years (range: 18\u0026ndash;91 years), which is comparable to other studies where perforation peritonitis predominantly affected middle-aged individuals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, some studies have reported a relatively younger population, indicating regional variation in age distribution [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The current study demonstrated a marked male predominance (86.5%) with a male-to-female ratio of 6.4:1, which is higher but consistent with previously reported ratios ranging from 3:1 to 5:1, likely due to greater exposure of males to risk factors such as smoking, alcohol consumption, and NSAID use [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Regarding aetiology, acid peptic disease (24.7%) was the most common cause in the present study, followed by trauma (21.3%) and appendicular perforation (13.5%). This finding is in agreement with several studies where peptic ulcer perforation was identified as the leading cause of perforation peritonitis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the relatively higher proportion of traumatic perforations in the present study may reflect an increasing trend of abdominal injuries. In the present study, the overall 1-month postoperative mortality was 6.7%, which is lower than reported in some previous studies, where mortality ranged from 10% to 30% depending on patient population and perforation site [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consistent with the literature, mortality was higher in patients with colorectal, jejunal, and multiple perforations, while gastric and appendicular perforations were associated with lower mortality [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Non-survivors in this cohort had significantly higher mean APACHE II scores and P-POSSUM operative severity \u003cb\u003es\u003c/b\u003ecores compared to survivors (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), reflecting a strong association between higher severity scores and mortality risk, which aligns with earlier reports demonstrating that both scoring systems reliably predict outcomes in perforation peritonitis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Earlier studies showed mixed results regarding the comparative performance of APACHE II and P-POSSUM. Some studies reported that APACHE II was slightly superior in predicting mortality due to its stronger assessment of physiological derangements [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], while others suggested that P-POSSUM better reflected operative severity and sometimes overpredicted mortality in low-risk cohorts [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].The present study demonstrated that both APACHE II and P-POSSUM scoring systems had excellent accuracy in predicting 30 days postoperative mortality, as reflected by their high AUC values (0.948 and 0.939, respectively). At the defined cutoff values, APACHE II showed slightly higher sensitivity (98.9%), indicating it was better at identifying patients who were truly at risk of mortality, reflecting its strength in assessing physiological derangements. P-POSSUM, however, had slightly higher specificity (83.1%), suggesting it was more accurate in identifying patients who survived, likely due to its inclusion of operative factors. Thus, unlike earlier reports of overprediction by P-POSSUM, both scores performed comparably in this study. The strengths of this study include its prospective design, standardized data collection, and direct comparison of two widely used scoring systems within the same cohort. The use of ROC curve analysis further strengthens the validity of the findings by objectively assessing predictive accuracy. However, certain limitations must be acknowledged. The relatively small sample size and single-centre design may limit the generalizability of the results. The short follow-up period of 30 days may also not capture late postoperative outcomes. In terms of clinical implications, the present study supports the use of both APACHE II and P-POSSUM as effective tools for early risk stratification in perforation peritonitis. Their high sensitivity makes them particularly useful for identifying high-risk patients who may benefit from intensive monitoring and aggressive management. Future research should focus on larger, multicentric studies to validate these findings and explore the integration of scoring systems with dynamic biomarkers, such as serum lactate, to further improve prognostic precision.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion both APACHE II and P-POSSUM demonstrated excellent predictive accuracy for mortality in this study. However, APACHE II showed a marginally higher discriminative ability (higher AUC), indicating that it may be slightly better as a standalone predictor of mortality. Nonetheless, P-POSSUM demonstrated comparable performance with better specificity, suggesting that it remains a valuable and reliable alternative.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation was performed by Gautami Suresh Narla. Data collection was done by Shuvam CP Pati and Alim Shaikh, analysis was performed by Gautami Suresh Narla and Ketan Prabhunath Gupta. The first draft of the manuscript was written by Gautami Suresh Narla and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e: The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical approval was officially granted by the Institutional Ethics Committee of IMS and SUM Hospital, Bhubaneswar (Reference number: ref.no/IEC/IMS.SH/SOA/2024/878). Informed consent was obtained from all individual participants included in the study prior to their enrollment and subsequent 30-day follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e: Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e: The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNeupane S, Koirala DP, Kharel S, Silwal S, Yadav KK (2022) Clinical profile and management of perforation peritonitis in Bharatpur hospital, Nepal: A prospective study. Annals Med Surg 82:104528\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNag DS, Dembla A, Mahanty PR, Kant S, Chatterjee A et al (2019) Comparative analysis of APACHE-II and P-POSSUM scoring systems in predicting postoperative mortality in patients undergoing emergency laparotomy. World J Clin Cases 7(16):2227\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar L, Singh S, Pratap D, Singh KK, Nayak S et al (2022) Comparison of predictive values of Mannheim Peritonitis Index, Acute Physiology and Chronic Health Evaluation-II and Portsmouth-POSSUM scoring systems for prognosis of mortality in patients with perforation peritonitis. Int J Res Med Sci 10:1059\u0026ndash;1065\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubedi RP, Kumar N, Karn S, Arunkumar V, Raj N et al (2025) Prognostic value of the combination of serial APACHE II with serum lactate for predicting post-operative mortality in gastrointestinal perforation peritonitis: a prospective cohort study. BMC Surg 25(1):374\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSitu OO, Badejo OA, Gwaram UA, Badejo O (2024) Predictive role of acute physiology and chronic health evaluation II (APACHE II) in patients with peritonitis at the National Hospital Abuja. Cureus. ;16(4)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYelamanchi R, Gupta N, Durga CK, Korpal M (2020) Comparative study between P-POSSUM and Apache II scores in predicting outcomes of perforation peritonitis: prospective observational cohort study. Int J Surg 83:3\u0026ndash;7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEswaravaka S, Suhrid C, Rao B, Prabhakar S, Pandya J (2024) Revisiting physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scores: are they valid in cases of ileal perforation. Cureus. ;16(7)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar A, Suman S, Kundan K, Kumar P (2016) Evaluation of POSSUM scoring system in patients with perforation peritonitis. Int Surg J 3(4):2181\u0026ndash;2186\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEchara ML, Singh A, Sharma G (2019) Risk\u0026ndash;Adjusted Analysis of Patients Undergoing Emergency Laparotomy Using POSSUM and P\u0026ndash;POSSUM Score: A Prospective Study. Nigerian J Surg 25(1):45\u0026ndash;51\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Institute of Medical Sciences and Sum Hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Perforation, Peritonitis, Emergency, Laparotomy, APACHE II, P-POSSUM, Mortality","lastPublishedDoi":"10.21203/rs.3.rs-9342693/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9342693/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePerforation peritonitis is a common surgical emergency associated with significant morbidity and mortality. Early risk stratification using scoring systems such as Acute physiology and chronic health evaluation II (APACHE-II) and Portsmouth modification of Physiological and operative severity for the enumeration of mortality and morbidity (P-POSSUM) helps guide management and predict outcomes. This study aimed to compare the effectiveness of these scoring systems in predicting postoperative mortality in patients undergoing emergency laparotomy. This case series analysis included 89 patients with hollow viscus perforation undergoing emergency laparotomy at a tertiary care centre over 15 months. APACHE II scores were calculated within 24 hours of admission, while P-POSSUM scores incorporated both physiological and operative parameters. Patients were followed for 30 days. Statistical analysis included Receiver Operating Characteristic (ROC) curve analysis to evaluate predictive accuracy. The most common aetiologies were acid peptic disease (24.7%), trauma (21.3%), and appendicular perforation (13.5%). The overall 30 days mortality was 6.7%. Both APACHE II and P-POSSUM scores were significantly higher among non-survivors (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). APACHE II demonstrated excellent predictive accuracy area under the ROC curve (AUC) 0.948 with sensitivity 98.9% and specificity 79.5% at a cutoff\u0026thinsp;\u0026gt;\u0026thinsp;9.5. P-POSSUM also showed excellent accuracy (AUC 0.939) with sensitivity 98.3% and specificity 83.1% at a cutoff\u0026thinsp;\u0026gt;\u0026thinsp;46.7. Both APACHE II and P-POSSUM were reliable predictors of postoperative mortality. APACHE II showed slightly better sensitivity and ease of use, while P-POSSUM demonstrated higher specificity. Given comparable performance, APACHE II may be preferred for early risk stratification.\u003c/p\u003e","manuscriptTitle":"Comparative study between Portsmouth Physiological and Operative Severity Score for the Enumeration of mortality and morbidity (P-POSSUM) and the Acute Physiology and Chronic Health Evaluation (APACHE II) scores in predicting Mortality in patients of perforation peritonitis undergoing exploratory laparotomy in tertiary care centre in Eastern India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-08 08:32:45","doi":"10.21203/rs.3.rs-9342693/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3360caa8-a86d-4a19-b985-1b21a6ed21bd","owner":[],"postedDate":"April 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":65910226,"name":"General Surgery"},{"id":65910227,"name":"Gastrointestinal Surgery"},{"id":65910228,"name":"Critical Care \u0026 Emergency Medicine"}],"tags":[],"updatedAt":"2026-04-08T08:32:45+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-08 08:32:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9342693","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9342693","identity":"rs-9342693","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}