The Marsden Morbidity Index: the derivation and validation of a simple risk index scoring system using cardiopulmonary exercise testing variables to predict morbidity in high-risk patients having major cancer surgery
Authors: Nawoor-Quinn Z. , Oliver A. , Raobaikady R. , Mohammad K. , Cone S. , Kasivisvanathan R. 
Published: September 2022

Abstract
Background
Morbidity and mortality risk prediction tools are increasingly being used as part of preoperative assessment of patients presenting for major abdominal surgery. Cardiopulmonary exercise testing (CPET) can predict which patients undergoing major abdominal surgery are at risk of complications. The primary objective of this study was to identify preoperative variables including those derived from CPET, which were associated with inpatient morbidity in high-risk patients following major abdominal cancer surgery. The secondary objective was to use these variables to derive and validate a morbidity risk prediction tool.

Methods
We conducted a retrospective cohort analysis of consecutive adult patients who had CPET as part of their preoperative work-up for major abdominal cancer surgery. Morbidity was a composite outcome, defined by the Clavien-Dindo score and/or the postoperative morbidity survey (POMS) score which was assessed on postoperative day 7. A risk prediction tool was devised using variables from the first analysis which was then applied prospectively to a matched cohort of patients.

Results
A total of 1398 patients were included in the first phase of the analysis between June 2010 and May 2017. Of these, 540 patients (38.6%) experienced postoperative morbidity. CPET variables deemed significant (p < 0.01) were anaerobic threshold (AT), maximal oxygen consumption at maximal exercise capacity (VO2 max), and ventilatory equivalent for carbon dioxide at anaerobic threshold (AT VE/VCO2). In addition to the CPET findings and the type of surgery the patient underwent, eight preoperative variables that were associated with postoperative morbidity were identified. These include age, WHO category, body mass index (BMI), prior transient ischaemic attack (TIA) or stroke, chronic renal impairment, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and cancer stage. Both sets of variables were then combined to produce a validated morbidity risk prediction scoring tool called the Marsden Morbidity Index. In the second phase of the analysis, this tool was applied prospectively to 424 patients between June 2017 and December 2018. With an area under the curve (AUC) of 0.79, this new model had a sensitivity of 74.2%, specificity of 78.1%, a positive predictive value (PPV) of 79.7%, and a negative predictive value of (NPV) of 79%.

Conclusion
Our study showed that of the CPET variables, AT, VO2 max, and AT VE/VCO2 were shown to be associated with postoperative surgical morbidity following major abdominal oncological surgery. When combined with a number of preoperative comorbidities commonly associated with increased risk of postoperative morbidity, we created a useful institutional scoring system for predicting which patients will experience adverse events. However, this system needs further validation in other centres performing oncological surgery.