title: Risk adjustment is crucial in comparing outcomes of various surgical modalities in patients with ileal perforation.
abstract: BACKGROUND
  Using crude mortality and morbidity rates for comparing outcomes can be misleading. The aim of the present study was to compare the outcome of various surgical modalities without and with risk adjustment using Physiologic and Operative Severity Scoring for the enUmeration of Mortality and morbidity (POSSUM) score in cases of ileal perforations.
  
  
  METHODS
  Prospective study on 125 patients of ileal perforations. Resection anastamosis (Group I) was done in 38 patients, primary repair (Group II) in 42 patients and 45 patients had an ileostomy (Group III). The disease severity was assessed in all patients using POSSUM score. The odds of death without and with risk adjustment using POSSUM mortality score were calculated for all groups
  
  
  RESULTS
  Seventeen patients (14%) patients died and 99 (79%) developed postoperative complications. Using crude mortality rates Group I appeared to be the best treatment option with only 2 (5%) deaths followed by Group II with 5 (12%) deaths where as Group III had the worst outcome with 10 deaths (22%). However, Group III (ileostomy) patients had higher mean POSSUM mortality and morbidity score (55.55%, 91.33%) than Group I (28%, 75.26%) and Group II (27%, 73.59%). Taking Group I as the reference (odds ratio, OR1) odds of death were greatest in Group III (OR 5.14, p = 0.043) followed by Group II (OR 2.43, p = 0.306). With risk adjustment using POSSUM mortality score the odds of death decreased in Group III (OR 1.16 p = 0.875). For the whole group, there was a significant association between the POSSUM score and postoperative complications and deaths. Mean POSSUM mortality and morbidity score of those who died (63.40 vs.33.68, p = 0.001) and developed complications (66.32 vs.84.20, p = 0.001) was significantly higher. For every percent increase in severity score the risk of postoperative complications and death increased by 1.10 (p = 0.001) and1.06 (p = 0.001) respectively.
  
  
  CONCLUSIONS
  Despite ileostomy patients having highest crude mortality and complication rates, after risk adjustment it was equally safe. Severity of the disease rather than the surgical option had a significant impact on the outcome in patients with ileal perforations.
authors.affiliation: Department of Surgery, V,M, Medical College and Safdarjang Hospital, New Delhi 110029, India. rsmohil@yahoo.com.
authors.forename: Ravindra Singh
authors.initials: RS
authors.lastname: Mohil
authors.forename: Tanveer
authors.initials: T
authors.lastname: Singh
authors.forename: Satyavrat
authors.initials: S
authors.lastname: Arya
authors.forename: Dinesh
authors.initials: D
authors.lastname: Bhatnagar