Skip to main content Skip to main navigation menu Skip to site footer

A novel scoring system to predict postoperative mortality after colorectal cancer surgery: a retrospective cohort study

  • Anita Hartono ,
  • Tomy Lesmana ,


Background: Many scoring systems have been developed to predict outcomes after surgery, but it has limitations due to differences in population, comorbidity, type of surgery, or hospital effects. External validation from these scoring systems sometimes failed to achieve good discriminatory power consistently. This study aims to develop a novel scoring system for predicting postoperative mortality and comparing its performance with the AFC, CR-POSSUM, IRCS, and ACS-NSQIP SRC model.

Methods: Data were collected retrospectively from all consecutive patients (n=1,294) undergoing colorectal cancer surgery in Dr. Soetomo Hospital between 2011 and 2020. After excluding missing data and 215 patients who did not satisfy the inclusion criteria, multivariate logistic regression analysis was performed in 1,079 patients to estimate odds ratios (ORs) and 95% confidence intervals (CIs) linking the explanatory variable postoperative mortality, and a Surabaya scoring system was constructed. Data were analyzed using SPSS version 23 for Windows.

Results: Variables identified as the strongest predictors based on Odds Ratio (OR) postoperative mortaliy were albumin < 3.4 g/dL (6.93; 95%CI: 4.37-10.99; p< 0.001), pulse > 120 times per-minute (5.49; 95%CI: 2.11-14.29; p< 0.001), totally dependent functional status (4.43; 95%CI 2.06-9.49; p<0.001) or partially dependent (2.34: 95%CI: 1.28-4.28; p< 0.001), ascites (3.58; 95%CI: 1.84-6.94; p=0.001), major procedure (2.48; 95%CI: 1.38-4.33; p=0.009), dyspnea (2.40; 95%CI: 1.19-4.84; p=0.014), and haemoglobin < 10 g/dL (1.85; 95%CI: 1.12-3.04; p=0.016). The Surabaya model predicted postoperative mortality with a predictive performance (0.831; 95%CI: 0.790-0.871) in the validation population. In this population the predictive performance of the AFC score was 0.630 (95%CI: 0.498-0.762), CR-POSSUM 0.698 (95%CI: 0.563-0.833), IRCS 0.564 (95%CI: 0.426-0.702), and ACS-NSQIP SRC 0.674 (95%CI: 0.541-0.806).

Conclusion: The Surabaya score has been shown as a good predictor of postoperative mortality after colorectal cancer surgery despite the relatively low number of risk factors. 


  1. GlobalSurg Collaborative and National Institute for Health Research Global Health Research Unit on Global Surgery. Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries Lancet. 2021;397(10272):387-397.
  2. Bainbridge D, Martin J, Arango M, Cheng D; Evidence-based Peri-operative Clinical Outcomes Research (EPiCOR) Group. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet. 2012;380(9847):1075-1081.
  3. Tekkis PP, Prytherch DR, Kocher HM, Senapati A, Poloniecki JD, Stamatakis JD, et al. Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM). Br J Surg. 2004;91(9):1174-82.
  4. García-Torrecillas JM, Olvera-Porcel MC, Ferrer-Márquez M, Rosa-Garrido C, Rodríguez-Barranco M, Lea-Pereira MC, et al. Predictive Model of the Risk of In-Hospital Mortality in Colorectal Cancer Surgery, Based on the Minimum Basic Data Set. Int J Environ Res Public Health. 2020;17(12):4216.
  5. Hariharan S, Chen D, Ramkissoon A, Taklalsingh N, Bodkyn C, Cupidore R, et al. Perioperative outcome of colorectal cancer and validation of CR-POSSUM in a Caribbean country. Int J Surg. 2009;7(6):534-8.
  6. Herawati S, Kandarini Y, Prabawa IPY. The Correlation between Estimated Glomerular Filtration Rate and Parathyroid Hormone Levels in Predialysis-chronic Kidney Disease Adult Patients at Sanglah General Hospital, Bali, Indonesia. Open Access Macedonian Journal of Medical Sciences. 2021;9(B):470-474.
  7. Alves A, Panis Y, Mantion G, Slim K, Kwiatkowski F, Vicaut E. The AFC score: validation of a 4-item predicting score of postoperative mortality after colorectal resection for cancer or diverticulitis: results of a prospective multicenter study in 1049 patients. Ann Surg. 2007;246(1):91-96.
  8. Chiang JM, Chang CJ, Jiang SF, Yeh CY, You JF, Hsieh PS, et al. Pre-operative serum albumin level substantially predicts post-operative morbidity and mortality among patients with colorectal cancer who undergo elective colectomy. Eur J Cancer Care (Engl). 2017;26(2):1-8.
  9. Oumer KE, Ahmed SA, Tawuye HY, Ferede YA. Outcomes and associated factors among patients undergone emergency laparotomy: A retrospective study. Int J Surg Open. 2021;36:100413.
  10. Gilbert T, Neuburger J, Kraindler J, Keeble E, Smith P, Ariti C, et al. Development and validation of a Hospital Frailty Risk Score focusing on older people in acute care settings using electronic hospital records: an observational study. Lancet. 2018;391(10132):1775-1782.
  11. Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833-42.e1-3.
  12. Morris EJ, Taylor EF, Thomas JD, Quirke P, Finan PJ, Coleman MP, et al. Thirty-day postoperative mortality after colorectal cancer surgery in England. Gut. 2011;60(6):806-13.
  13. Fowler AJ, Ahmad T, Phull MK, Allard S, Gillies MA, Pearse RM. Meta-analysis of the association between preoperative anaemia and mortality after surgery. Br J Surg. 2015;102(11):1314-1324.
  14. Ramkumar T, Ng V, Fowler L, Farouk R. A comparison of POSSUM, P-POSSUM and colorectal POSSUM for the prediction of postoperative mortality in patients undergoing colorectal resection. Dis Colon Rectum. 2006;49(3):330-335.
  15. Senagore AJ, Warmuth AJ, Delaney CP, Tekkis PP, Fazio VW. POSSUM, p-POSSUM, and Cr-POSSUM: implementation issues in a United States health care system for prediction of outcome for colon cancer resection. Dis Colon Rectum. 2004;47(9):1435-1441.
  16. Anwar MA, D'Souza F, Coulter R, Memon B, Khan IM, Memon MA. Outcome of acutely perforated colorectal cancers: experience of a single district general hospital. Surg Oncol. 2006;15(2):91-96.

How to Cite

Hartono, A., & Lesmana, T. (2022). A novel scoring system to predict postoperative mortality after colorectal cancer surgery: a retrospective cohort study. Bali Medical Journal, 11(1), 96–102.




Search Panel