Classification and stratification in pilonidal sinus disease: findings from the PITSTOP cohort.

AIM: Research in pilonidal disease faces several challenges, one of which is consistent and useful disease classification. The International Pilonidal Society (IPS) proposed a four-part classification in 2017. The aim of this work was to assess the validity and reliability of this tool using data from the PITSTOP cohort study. METHOD: Face validity was assessed by mapping the items/domains in the IPS tool against tools identified through a systematic review. Key concepts were defined as those appearing in more than two-thirds of published tools. Concurrent and predictive validity were assessed by comparing key patient-reported outcome measures between groups at baseline and at clinic visit. The outcomes of interest were health utility, Cardiff Wound Impact Questionnaire (CWIQ) and pain score between groups. Significance was set at p = 0.05 a priori. Interrater reliability was assessed using images captured during the PITSTOP cohort. Ninety images were assessed by six raters (two experts, two general surgeons and two trainees), and classified into IPS type. Interrater reliability was assessed using the unweighted kappa and unweighted Gwet's AC1 statistics. RESULTS: For face validity items represented in the IPS were common to other classification systems. Concurrent and predictive validity assessment showed differences in health utility and pain between groups at baseline, and for some treatment groups at follow-up. Assessors agreed the same classification in 38% of participants [chance-corrected kappa 0.52 (95% CI 0.42-0.61), Gwet's AC1 0.63 (95% CI 0.56-0.69)]. CONCLUSION: The IPS classification demonstrates key aspects of reliability and validity that would support its implementation.

Research and practice priorities in pilonidal sinus disease: a consensus from the PITSTOP study.

AIM: Pilonidal sinus disease is a common condition treated by colorectal surgeons. There is a lack of literature in the field to guide optimal management of this condition. As part of the PITSTOP study, we aimed to identify policy and research priorities to provide direction to the field. METHOD: Patients and surgeons were invited to participate. A 'So what, now what' exercise was conducted, informed by data from PITSTOP. This generated statements for research and practice priorities. A three-round online Delphi study was conducted, ranking statements based on policy and research separately. Statements were rated 1 (not important) to 9 (important). Statements that were rated 7-9 by more than 70% of participants were entered into the consensus meeting. Personalized voting feedback was shown between rounds. A face-to-face meeting was held to discuss statements, and participants were asked to rank statements using a weighted choice vote. RESULTS: Twenty-two people participated in the focus group, generating 14 research and 19 policy statements. Statements were voted on by 56 participants in round 1, 53 in round 2 and 51 in round 3. A total of 15 policy statements and 19 research statements were discussed in the consensus round. Key policy statements addressed treatment strategies and intensity, surgeon training opportunities, need for classification and the impact of treatment on return to work. Research recommendations included design of future trials, methodology considerations and research questions. CONCLUSION: This study has identified research and policy priorities in pilonidal sinus disease which are relevant to patients and clinicians. These should inform practice and future research.

Real-world practice and outcomes in pilonidal surgery: Pilonidal Sinus Treatment Studying The Options (PITSTOP) cohort.

BACKGROUND: Numerous surgical approaches exist for the treatment of pilonidal disease. Current literature on treatment is of poor quality, limiting the ability to define optimal intervention. The aim of this study was to provide real-world data on current surgical practice and report patient and risk-adjusted outcomes, informing future trial design. METHODS: This UK-wide multicentre prospective cohort study, including patients (aged over 16 years) who had definitive treatment for symptomatic pilonidal disease, was conducted between May 2019 and March 2022. Patient and disease characteristics, and intervention details were analysed. Data on patient-reported outcomes, including pain, complications, treatment failure, wound issues, and quality of life, were gathered at various time points up to 6 months after surgery. Strategies were implemented to adjust for risk influencing different treatment choices and outcomes. RESULTS: Of the 667 participants consenting, 574 (86.1%) were followed up to the study end. Twelve interventions were observed. Broadly, 59.5% underwent major excisional surgery and 40.5% minimally invasive surgery. Complications occurred in 45.1% of the cohort. Those who had minimally invasive procedures had better quality of life and, after risk adjustment, less pain (score on day 1: mean difference 1.58, 95% c.i. 1.14 to 2.01), fewer complications (difference 17.5 (95% c.i. 9.1 to 25.9)%), more rapid return to normal activities (mean difference 25.9 (18.4 to 33.4) days) but a rate of higher treatment failure (difference 9.6 (95% c.i. 17.3 to 1.9)%). At study end, 25% reported an unhealed wound and 10% had not returned to normal activities. CONCLUSION: The burden after surgery for pilonidal disease is high and treatment failure is common. Minimally invasive techniques may improve outcomes at the expense of a 10% higher risk of treatment failure.

An international survey exploring the management of pilonidal disease.

AIM: Pilonidal disease (PD) is a common debilitating condition frequently seen in surgical practice. Several available treatments carry different benefit/risk balances. The aim of this study was to snapshot the current management of PD across European countries. METHOD: Members affiliated to the European Society of Coloproctology were invited to join the survey. An invitation was extended to others via social media. The predictive power of respondents' and hospitals' demographics on the change of therapeutic approach was explored. RESULTS: Respondents (n = 452) were mostly men (77%), aged 26-60 years, practising in both academic and public hospitals and with fair distribution between colorectal (51%) and general (48%) surgeons. A total of 331 (73%) respondents recommended surgery at first presentation of the disease. Up to 80% of them recommended antibiotic therapy and 95% did not use any classification of PD. A primary closure technique was the preferred procedure (29%), followed by open technique (22%), flap creation (7%), sinusectomy (7%) and marsupialization (7%). Approximately 27% of subjects would choose the same surgical technique even after a failure. Almost half (46%) perform surgery as office based. A conservative approach was negatively associated with acutely presenting PD (p < 0.001). Respondents who were not considering tailored surgery based on patient presentation tended to change their approach in the case of a failed procedure. CONCLUSION: With the caveat of a heterogeneous number of respondents across countries, the results of our snapshot survey may inform the development of future guidelines.

Cleft closure (the Bascom cleft lift) for 714 patients-treatment of choice for complex and recurrent pilonidal disease (a cohort study).

AIM: Pilonidal disease is a benign condition that affects mainly the young. In existing literature, there is no consensus for best treatment, with multiple operative techniques described, some complex, resulting in a high proportion of failure and/or morbidity. The cleft closure (or cleft lift) described by Bascom and Bascom (Arch Surg, 137, 2002, 1146-50), by comparison, is a simple operation, resulting in healing in the majority and good cosmesis. METHOD: This is a single surgeon series, with the aim of evaluating outcomes for consecutive patients who underwent cleft closure surgery at two centres (St Mark's Hospital, London, and Queen Alexandra Hospital, Portsmouth) between 1995 and 2021 for either extensive, complex or recurrent pilonidal disease. Primary study outcomes that were measured included rate of primary healing, time to complete healing and rate of recurrence. RESULTS: Some 714 patients had a cleft closure of whom 656 had documented follow-up. Primary healing occurred in 60.7% (n = 398) rising to 88.5% by 12 weeks (n = 562) and 91.8% by 16 weeks. The remaining patients healed over the following weeks with only 19 wounds failing to heal completely (3%), requiring further surgery to achieve healing. After complete healing 5.3% of patients developed recurrent disease at a median of 12 months. CONCLUSION: Cleft closure is an effective operation for pilonidal disease. Overall, 97% of patients healed without further surgery. A 3% failure rate and 5.3% recurrence rate were observed. This technique could be considered as an alternative procedure to complex flaps or midline excision, in extensive, recurrent and unhealed pilonidal disease.

Changing patterns of multidisciplinary team treatment, early mortality, and survival in colorectal cancer.

BACKGROUND: This study reports early mortality and survival from colorectal cancer in relation to the pattern of treatments delivered by the multidisciplinary team (MDT) meeting at a high-volume institution in England over 14 years. METHODS: All patients diagnosed with colorectal cancer and discussed during MDT meetings from 2003 to 2016 at a single institution were reviewed. Three time intervals (2003-2007, 2008-2012, and 2013-2016) were compared regarding initial surgical management (resection, local excision, non-resection surgery, and no surgery), initial oncological therapy, 90-day mortality, and crude 2-year survival for the whole cohort. Sub-analyses were performed according to age greater or less than 80 years. RESULTS: The MDT managed 4617 patients over 14 years (1496 in the first interval and 1389 in the last). Over this time, there was a reduction in emergency resections from 15.5 per cent to 9.0 per cent (P < 0.0001); use of oncological therapies increased from 34.6 per cent to 41.6 per cent (P < 0.0001). The 90-day mortality after diagnosis of colorectal cancer dropped from 14.8 per cent to 10.7 per cent (P < 0.001) and 2-year survival improved from 58.6 per cent to 65 per cent (P < 0.001). Among patients aged 80 years or older (425 and 446, in the first and last intervals respectively) there was, in addition, a progressive increase in 'no surgery' rate from 33.6 per cent to 50.2 per cent (P < 0.0001) and a reduction in elective resections from 42.4 per cent to 33.9 per cent (P = 0.010). The 90-day mortality after elective resection fell from 10.0 per cent (18 of 180) to 3.3 per cent (5 of 151; P = 0.013). CONCLUSIONS: Survival from colorectal cancer improved significantly over 14 years. Among patients aged ≥80 years, major changes in the type of treatment delivered were associated with a decrease in postoperative mortality.

A Multicenter Randomized Controlled Trial Comparing Safety, Efficacy, and Cost-effectiveness of the Surgisis Anal Fistula Plug Versus Surgeon's Preference for Transsphincteric Fistula-in-Ano: The FIAT Trial.

OBJECTIVE: To undertake a randomized comparison of the Biodesign Surgisis anal fistula plug against surgeon's preference in treating cryptoglandular transsphincteric fistula-in-ano. SUMMARY BACKGROUND DATA: The efficacy of the Biodesign Surgisis anal fistula plug in healing anal fistulae is uncertain. METHODS: Participants were randomized to the fistula plug with surgeon's preference (advancement flap, cutting seton, fistulotomy, Ligation of the Intersphincteric Fistula Tract procedure). The primary outcome was faecal incontinence quality of life (FIQoL) at 12-months. Secondary outcomes were fistula healing, incontinence rates, and complication and reintervention rates. RESULTS: Between May 2011 and March 2016, 304 participants were randomized to fistula plug or surgeon's preference. No differences were seen in FIQoL between the 2 groups at 12 months. Clinical fistula healing was reported in 66/122 (54%) of the fistula plug and 66/119 (55%) of the surgeon's preference groups at 12 months. Fecal incontinence rates improved marginally in both the groups. Complications and reinterventions were frequent, with significantly more complications in the fistula plug group at 6-weeks (49/142, 35% vs 25/137, 18%; P=0.002). The mean total costs were £2738 (s.d. £1151) for the fistula plug and £2308 (s.d. £1228) for the surgeon's preference group (mean difference +£430, P=0.0174). The average total quality adjusted life years (QALYs) gained was marginally higher in the fistula plug group. The fistula plug was 35% to 45% likely to be cost-effective across a willingness to pay threshold of £20,000 to £30,000 / QALY. CONCLUSIONS: The Biodesign Surgisis anal fistula plug is associated with similar FIQoL and healing rates to surgeon's preference at 12 months. Higher costs and highly uncertain gains in QALYs mean that the fistula plug may not be considered as a cost-effective treatment in the UK NHS.

Laparoscopic surgical treatment of ileocecal Crohn's disease: Impact of obesity on short term results. / Cirugía laparoscópica en el tratamiento de la enfermedad de Crohn del área ileocecal: impacto de la obesidad en los resultados postoperatorios inmediatos.

INTRODUCTION: The aim of our study was to analyse the short-term outcomes of laparoscopic surgery for a no medical responding ileocolic Cohn's disease in a single centre according to the presence of obesity. METHODS: A cross-sectional study was performed including all consecutive patients who underwent laparoscopic resection for ileocecal Crohn's disease from November 2006 to November 2015. Patients were divided according to body mass index ≥ 30 kg/m2 in order to study influence of obesity in the short-term outcomes. The following variables were studied: characteristics of patients, surgical technique and postoperative results (complications, reintervention, readmission and mortality) during first 30 postoperative days. RESULTS: A total of 100 patients were included (42 males) with a mean age of 39.7±15.2 years (range 18-83). The overall complication rate was 20% and only 3 patients had an anastomotic leak. Seven patients needed reoperation in the first 30 days postop (7%). The median postoperative length of hospitalization was 5.0 days. Operative time was significantly longer in patients with obesity (130 vs. 165minutes, P=.007) but there were no significant differences among the postoperative results in patients with and without obesity. CONCLUSIONS: This study confirmed that laparoscopic approach for ileocecal Cohn's disease is a safety and feasible technique in patients with obesity. In this last group of patients we only have to expect a longer operative time.

Predictive factors for extraction site hernia after laparoscopic right colectomy.

PURPOSE: Incisional hernia at the extraction site (ESIH) is a common complication after laparoscopic colorectal resections. The aim of this study was to evaluate the prevalence and potential risk factors for ESIH in a large cohort study having standardized technique. METHODS: A cross-sectional study was performed including all patients who underwent elective laparoscopic right or extended right colectomy for cancer from November 2006 to October 2013 using a standard technique. All patients have been followed up for a minimum of 1 year with abdominal CT scan. RESULTS: A total of 292 patients were included with a median follow-up of 42 months. Twenty patients (6.8 %) developed ESIH. Obesity (odds ratio (OR) = 3.76, 95 % confidence interval (CI) 1.39-10.15; p = 0.009) and incision length (OR 2.86, 95 % CI 1.077-7.60; p = 0.035) significantly predisposed to the development of ESIH. CONCLUSION: This study identified that the risk of ESIH is significant after colonic resections and there are several risk factors responsible for the development of ESIH.

The surgeon's view.

Diverticular disease affects up to 50% of people by the time they reach the age of 80. The major complications of diverticular disease (abscess, perforation, fistula, obstruction and bleeding) have their own management pathways, but the treatment of uncomplicated diverticulitis is controversial. On initial presentation, diverticulitis is always treated conservatively. Whether this should be followed by resectional surgery has been the subject of speculation for many decades. The American Society of Colon and Rectal Surgeons recommended in 2000 that an elective resection should follow two attacks of acute diverticulitis. Much of the work underpinning their policy was based on seminal studies by Parks in the 1960s and 1970s who followed cohorts of patients with diverticular disease and examined their outcomes. However, many of these studies were based on inaccurate diagnostic data where the diagnosis was made primarily on clinical grounds. Investigations such as barium enema or colonoscopy are not reliable in confirming the presence of inflammation. Since CT scanning has become routine, the diagnosis of acute diverticulitis can now be made accurately. In recent years much work has been done, such as by Ambrosetti, who has produced evidence predicting the outcome of diverticulitis based on CT findings. More recent papers, in which the diagnosis of acute diverticulitis is likely to have been made more accurately, confirm that although recurrent attacks of diverticulitis are fairly common, there is a very low incidence of serious complications after long-term follow-up. It has also become apparent that the majority of patients who present with the major complications of diverticulitis, specifically abscess, perforation and fistula, do so as their first presentation of the disease, without previous episodes of diverticulitis. The corollary of this is that patients having had acute diverticulitis do not run the risk of developing life-threatening complications without elective surgery. The complications of left-sided colonic resection are not inconsiderable with anastomotic leaks, the formation of a stoma, either temporary or permanent, as well as mortality. When these data are put alongside the very low risk of serious harm to the patient after diverticulitis, the balance of opinion has now swung heavily in favour of a more conservative approach. In addition to this there are modern and innovative medical therapeutic approaches to the treatment of diverticulitis such as 5ASAs, poorly absorbed antibiotics and probiotics.

Laparoscopic colorectal surgery produces better outcomes for high risk cancer patients compared to open surgery.

BACKGROUND AND OBJECTIVES: The excellent outcomes reported for laparoscopic colorectal surgery in selected patients could also be potentially advantageous for high risk patients. This prospective study was designed to examine the feasibility and safety of laparoscopic resection in high risk patients with colorectal cancer. METHODS: Between 2006 and 2008 consecutive patients undergoing elective surgery for colorectal cancer were stratified into high and low risk groups. High risk was defined as >or=80 years, American Society of Anesthesiologists >or=3, preoperative radiotherapy, T4 tumor and BMI >or=30. Outcomes included median length of stay, lymph node yield, resection margins, 30-day hospital readmission, postoperative mortality and major postoperative complications requiring reoperation within 30 days of surgery. RESULTS: A total of 424 patients underwent elective laparoscopic (224) and open (200) resections. Overall mortality rate for laparoscopic resection was 1 of 224 (0.4%) versus 4 of 200 (2%) for open resection. Median length of stay was 4 (2-33) versus 10 (1-69) days (P < 0.0001), and rate of complications requiring reoperation was 2 of 224 (0.8%) compared with 10 of 200 (5%) (P = 0.02).Among the 280 (66%) "high risk" patients, 146 had laparoscopic resection (8 conversions; 5%) and 134 had open resections. Median hospital stay was 4 (2-33) days in the laparoscopic group versus 11 (1-69) days in the open group (P < 0.0001). Complications requiring reoperation were 2 of 146 (1.4%) after laparoscopic resection versus 7 of 134 (5.2%) after open resection (P < 0.09). Readmission rate after laparoscopic resection was 12.3% versus 5.2% after open resection (P = 0.06). CONCLUSION: Laparoscopic resection of colorectal cancer can achieve excellent results even in "high risk" patients and is associated with significant reductions in length of stay compared with open resection.

Bowel obstruction following deep circumflex iliac artery free flap harvesting.

The deep circumflex iliac artery flap (DCIA) has been well described as an autograft flap used in head and neck reconstructions, particularly for large maxillary and mandibular defects. Complications, particularly at the donor site, have been well documented. Although it is considered a minor complication, herniation should not be underestimated as it can potentially lead to bowel obstruction, necessitating an emergency operation. We report a case of acute obstruction of the small bowel secondary to herniation at the donor site after harvesting a DCIA free flap for a maxillary defect, a complication that to our knowledge has been reported only once. We review the pathogenesis and possible ways to reduce the likelihood of developing this serious complication.

A prospective randomized controlled trial of simple Bascom's technique versus Bascom's cleft closure for the treatment of chronic pilonidal disease.

BACKGROUND: The aim of this study was to determine which of Bascom's simple techniques, Bascom's simple surgery or Bascom's cleft closure, is preferred in the management of moderate-severity pilonidal disease. METHODS: Fifty-five patients with chronic pilonidal disease were randomized to receive Bascom's simple surgery (n = 29) or cleft closure (n = 26) under local anesthetic. The primary end point was time to healing. Patients were followed up for a median of 3 years (range, .7-4 y). RESULTS: After Bascom's simple surgery, 5 of 29 patients did not heal and proceeded to cleft closure. The remaining patients healed at a median of 4 weeks (range, 3-35 wk). After cleft closure, 21 of 26 wounds healed primarily on removal of sutures at 10 to 13 days. The remaining 5 wounds healed at a median of 4.5 weeks (range, 2-5 wk). Fifty of 55 (91%) patients were contacted for follow-up evaluation, disease recurrence occurred in 2 of 24 after Bascom's simple surgery and in 0 of 26 after cleft closure. CONCLUSIONS: Cleft closure offers more predictable healing than Bascom's simple surgery, with less need for re-operation. Disease recurrence is more prevalent after Bascom's simple surgery.

Operative strategies for diverticular peritonitis: a decision analysis between primary resection and anastomosis versus Hartmann's procedures.

OBJECTIVE: To compare primary resection and anastomosis (PRA) with and without defunctioning stoma to Hartmann's procedure (HP) as the optimal operative strategy for patients presenting with Hinchey stage III-IV, perforated diverticulitis. SUMMARY BACKGROUND DATA: The choice of operation for perforated diverticulitis lies between HP and PRA. Postoperative mortality and morbidity can be high, and the long-term consequences life-altering, with no established criteria guiding clinicians towards selecting a particular procedure. METHODS: Probability estimates for 6879 patients with Hinchey III-IV perforated diverticulitis were obtained from two databases (n = 204), supplemented by expert opinion and summary data from 12 studies (n = 6675) published between 1980 and 2005. The primary outcome was quality-adjusted life-years (QALYs) gained from each strategy. Factors considered were the risk of permanent stoma, morbidity, and mortality from the primary or reversal operations. Decision analysis from the patient's perspective was used to calculate the optimal operative strategy and sensitivity analysis performed. RESULTS: A total of 135 PRA, 126 primary anastomoses with defunctioning stoma (PADS), and 6619 Hartmann's procedures (HP) were considered. The probability of morbidity and mortality was 55% and 30% for PRA, 40% and 25% for PADS, and 35% and 20% for HP, respectively. Stomas remained permanent in 27% of HP and in 8% of PADS. Analysis revealed the optimal strategy to be PADS with 9.98 QALYs, compared with 9.44 QALYs after HP and 9.02 QALYs after PRA. Complications after PRA reduced patients QALYs to a baseline of 2.713. Patients with postoperative complications during both primary and reversal operations for PADS and HP had QALYs of 0.366 and 0.325, respectively. HP became the optimal strategy only when risk of complications after PRA and PADS reached 50% and 44%, respectively. CONCLUSION: Primary anastomosis with defunctioning stoma may be the optimal strategy for selected patients with diverticular peritonitis as may represent a good compromise between postoperative adverse events, long-term quality of life and risk of permanent stoma. HP may be reserved for patients with risk of complications >40% to 50% after consideration of long-term implications.

Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: a systematic review.

PURPOSE: This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. METHODS: Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. RESULTS: Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. CONCLUSIONS: Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.

Comparison of POSSUM scoring systems and the surgical risk scale in patients undergoing surgery for complicated diverticular disease.

PURPOSE: This study was designed to evaluate the accuracy of the Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, and the Surgical Risk Scale for the treatment of patients with complicated diverticular disease. METHODS: Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity variables were prospectively recorded for 324 patients undergoing colorectal resections in 42 hospitals in the United Kingdom from January to December 2003. The accuracy of each model was evaluated by measures of discrimination, calibration, and subgroup analysis. RESULTS: The overall operative mortality was 10.8 percent (Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 21.9 percent; Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 10.5 percent; colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity-estimated mortality rate, 10 percent; Surgical Risk Scale-estimated mortality rate, 38.2 percent). Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity and the Surgical Risk Scale over-predicted mortality in young patients (P < 0.001) and Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity underpredicted mortality in elderly patients (P < 0.001). Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity and the Surgical Risk Scale overpredicted mortality in patients with generalized peritonitis (Hinchey III and IV). There was no significant difference between the observed and colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity predicted mortality across patient subgroups and when the overall sample was considered. CONCLUSIONS: The study suggested a lack of calibration of Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, Portsmouth-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity, and the Surgical Risk Scale at the extreme of age and for patients with severe peritoneal contamination. Colorectal-Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity was found to accurately evaluate mortality arising from complicated diverticular disease.