Intraoperative Scoring Research Articles

Utility of intraoperative scoring system in rhino-orbital mucormycosis as a prognostic tool.

To assess the utility of an intraoperative scoring system for mucormycosis and to predict prognosis by comparing the score with postoperative outcomes. This study was conducted among 80 patients with mucormycosis who underwent surgical management with mandatory pterygopalatine fossa and infratemporal fossa exploration. All cases were scored using our intraoperative scoring assessment tool. Postoperative outcomes in terms of favourable prognosis and mortality were evaluated and compared with demographics, clinical history and intraoperative findings. An intraoperative score of more than 25 was statistically significant in predicting mortality (p < 0.0001). In all, 86.7% of patients with a score above 25 succumbed to the disease. Statistical significance of mortality (p < 0.05) was observed in those with involvement of pterygopalatine fossa (78.9%), orbit (73.7%), infratemporal fossa (57.9%), cribriform plate (36.8%) and those with history of intake of antiviral drugs (47.4%), use of supplemental oxygen (31.6%) and renal failure (26.3%). This study enabled better prediction of postoperative prognosis in mucormycosis and reiterated the importance of exploration of pterygopalatine fossa and infratemporal fossa in management and prognostication of invasive fungal sinusitis.

Correlation of G-10 Scoring &amp; Per Operative Outcomes in Laparoscopic Cholecystectomy: A Tertiary Care Centre Experience

Laparoscopic cholecystectomy is one of the most commonly performed surgeries worldwide and has only recently achieved a perioperative predictive score. This study aims to document our experience as a tertiary care hospital regarding the use of the same. 250 patients were considered in a prospective observational study, subsequently recording the intraoperative findings and postoperative complications based on G10 scoring put forward by the WSES based on the Sugrue study. They were classified as easy, moderate, difficult, and extremely difficult. The mean operative time was 48.58 min (range 30 to 190). The conversion rate was 2%. A p value of &lt;0.0001 shows G10 scoring is significantly related to open conversion. Overall, 19 (7.60%) patients were found to have a difficult or extreme degree of operative difficulty as judged by a G10 score of 5 or greater. A significant relationship was found with respect to bile duct injury, biliary fistula, vessel injury, abscess formation, and readmission in view of G10-based scoring difficulty. Validation and widespread adaptation may provide a standard for understanding and improving care and enable more standardization in global comparisons of care for cholecystectomy. This study is a single institution experience validating the significance of intraoperative scoring for biliary disease management.

ASO Visual Abstract: Assessment of Intraoperative Scoring Systems for Predicting Cytoreduction Outcome in Peritoneal Metastatic Disease-A Systematic Review and Meta-analysis.

ASO Visual Abstract: Assessment of Intraoperative Scoring Systems for Predicting Cytoreduction Outcome in Peritoneal Metastatic Disease-A Systematic Review and Meta-analysis.

Assessment of Intraoperative Scoring Systems for Predicting Cytoreduction Outcome in Peritoneal Metastatic Disease: A Systematic Review and Meta-analysis.

Cytoreductive surgery (CRS) is a widely acknowledged treatment approach for peritoneal metastasis, showing favorable prognosis and long-term survival. Intraoperative scoring systems quantify tumoral burden before CRS and may predict complete cytoreduction (CC). This study reviews the intraoperative scoring systems for predicting CC and optimal cytoreduction (OC)and evaluates the predictive performance of the Peritoneal Cancer Index (PCI) and Predictive Index Value (PIV). Systematic searches were conducted in Embase, MEDLINE, and Web of Science. Meta-analyses of extracted data were performed to compare the absolute predictive performances of PCI and PIV. Thirty-eight studies (5834 patients) focusing on gynecological (n = 34; 89.5%), gastrointestinal (n = 2; 5.3%) malignancies, and on tumors of various origins (n = 2; 5.3%) were identified. Seventy-seven models assessing the predictive performance of scoring systems (54 for CC and 23 for OC) were identified with PCI (n = 39/77) and PIV (n = 16/77) being the most common. Twenty models (26.0%) reinterpreted previous scoring systems of which ten (13%) used a modified version of PIV (reclassification). Meta-analyses of models predicting CC based on PCI (n = 21) and PIV (n = 8) provided an AUC estimate of 0.83 (95% confidence interval [CI] 0.79-0.86; Q = 119.6, p = 0.0001; I2 = 74.1%) and 0.74 (95% CI 0.68-0.81; Q = 7.2, p = 0.41; I2 = 11.0%), respectively. Peritoneal Cancer Index models demonstrate an excellent estimate of CC, while PIV shows an acceptable performance. There is a need for high-quality studies to address management differences, establish standardized cutoff values, and focus on non-gynecological malignancies.

Bedside preoperative predictors of difficult laryngeal exposure in microlaryngeal surgery.

Successful microlaryngeal surgery relies on an adequate laryngeal exposure. Recognizing the likelihood of challenging exposure prior to microlaryngeal surgery may assist in selecting the appropriate surgical approach and even prompt consideration of alternative treatment options. We aim to apply the mini-Laryngoscore, a preoperative assessment tool, to our study population and incorporate novel variables to optimize the prediction model. This single-center prospective cohort study included 80 consecutive patients undergoing elective microlaryngeal surgery, from January 1, to June 30, 2023. Each patient underwent a presurgical evaluation of 15 parameters and an intraoperative scoring of the anterior commissure visualization. These parameters were assessed for their association with difficult laryngeal exposure, using multiple logistic regression analysis. We created a novel prediction model for DLE and compared it with the existing model, the mini-Laryngoscore. Out of 80 patients, 24 (30%) patients had difficult laryngeal exposure, including 3 cases (3.8%) in which visualization of the anterior commissure was not possible. A large neck diameter (OR, 1.4; CI 1.1-1.9) and the presence of upper teeth (OR, 8.9; CI 1.3-62.8) were independent risk factors for a difficult laryngeal exposure, while a larger interincisors gap was the only independent protector factor (OR, 0.3; CI 0.1-0.8). The logistic regression model combining these three independent risk factors displayed a high discriminative value AUC = 0.89 (CI 0.81-0.97). The predictive performance of the mini-Laryngoscore was 0.73 (CI 0.62-0.85). Combining two parameters from the mini-Laryngoscore (upper jaw dental state and interincisors gap distance) with neck circumference measurement can accurately predict the risk of difficult laryngeal exposure.

Assessment of G10 Intraoperative Scoring System for Conversion in Patients Undergoing Laparoscopic Cholecystectomy: A Cross-Sectional Study From Nepal.

Various preoperative risk factors for conversion in laparoscopic cholecystectomy (LC) have been well studied. However, the assessment of intraoperative factors for conversion in patients with cholecystitis is unclear. The G10 scoring system, which incorporates 10 parameters, has tried to fill this void by developing a scoring system for the most commonly encountered surgical illnesses. So, we aimed to assess the utility of the G10 scoring system among patients presenting for LC for symptomatic cholelithiasis (both acute and chronic cholecystitis) in the clinical setting of a low- and middle-income country. All the patients undergoing LC were assigned a G10 value. Gallbladder surgery was considered easy if the G10 score was <2, moderate (2 ≦ 4), difficult (5 ≦ 7), and extreme (8 ≦ 10). All 10 risk factors were analyzed into a binary logistics model, and statistically significant risk factors were assessed. Among 177 patients, there were 36 males and 141 females. The median age of the patient was 42 years (range 11-79). There were 70 easy, 89 moderate, and 18 difficult cases. The overall mean G10 score was 2.32±1.5, which significantly increased as the severity progressed, with a mean value of 5.5±0.51 for difficult cases(P=0.0001). The mean G10 score for surgeries completed laparoscopically was 2.1±1.4, while it was 3.71±1.4 for open conversions[P=0.0001, AUC=0.79, CI=0.70-0.87]. There were 18 patients with G10 ≥5 with a conversion rate of 27.7%, while the overall conversion rate was 13.6%. Multivariate analysis showed free bile or pus outside the gallbladder [P=0.02, OR=5.1, CI=1.2-21.1] and fistula [P=0.01, OR=15.8, CI=1.9-129.8] as significant risk factors for conversion. Intraoperative risk factors for the prediction of conversion included the presence of free bile or pus outside the gallbladder and cholecystoenteric fistula. Based on the F1 score analysis, complemented with the Youden Index, the optimal cutoff value for conversion, based on the G10 score, lies around 4. Broader application and validation of the G10 scoring system are mandated to assess the utilization of this novel intraoperative scoring system.

Predicting Conversion from Laparoscopic to Open Cholecystectomy Using a Perioperative Gallbladder Scoring System

Background: Gallstones and associated consequences are a leading cause of elective and emergency laparoscopic and open surgical procedures. Since the first laparoscopic Cholecystectomy in 1985, laparoscopic Cholecystectomy has been the gold standard for treating symptomatic gallstones. Several pre-operative scoring systems can tell you if a laparoscopic cholecystectomy for gall bladder surgery will be difficult based on different anatomical, imaging, and laboratory findings. However, few intraoperative scoring systems can tell if the surgery will be complicated. Some authors recently considered the most prominent essentials confronting surgeons during laparoscopic Cholecystectomy. Aim of the study: This study attempted a planned assessment of a recently reported intra-operative gallbladder scoring framework (G10) to decide if it might predict the result of surgery, essentially the ability to complete the operation laparoscopically. Patient and methods: Eight hundred thirty-seven patients admitted to laparoscopic Cholecystectomy for symptomatic gall stones were enrolled in this prospective study from 1st January 2018 to 31st 2021, performed in Rizgary and Hawler Teaching hospitals in Erbil, Iraq. Results: Among 837 patients, the mean age was 42.3 (range 14–71), 581 (69.4%) were female, and 256 (30.6%) were male. The mean operation time was 32.7 minutes, ranging from 15 to 150 minutes, and 63 (7.6%) patients were converted to open Cholecystectomy because of intraoperative difficulties. The most significant correlations were found with distended and/or contracted gall bladders, the inability to grasp the wall with traumatic forceps, an impacted stone in the Hartman's pouch, and pus or bile outside the gall bladder. Conclusion: New intraoperative scoring systems are valuable in predicting difficulties and preventing increased operation time and possible injuries; the main points of difficulties are distended or contracted gallbladder, large stone impaction, difficulty grasping the wall of the gall bladder, and the presence of bile or pus outside the gall bladder.

The Role of CT Angiography to Predict the Shamblin Group in Carotid Body Tumors.

Carotid body tumors (CBTs) are uncommon benign head and neck neoplasms. Surgical resection is the treatment of choice for CBTs. However, the anatomical structures adjacent to the tumor tissue may encounter serious injuries during the surgery. Shamblin grading system is a surgical intra-operative scoring system to determine the risks associated with the surgery. Therefore, we aimed to evaluate the correlation of pre-surgical imaging parameters with Shamblin grades and intra-operative complications. In this cross sectional study, we enrolled 36 patients with CBTs. Preoperative cervical CT angiography was acquired in each participant and following parameters were reported in each case: Tumor volume, tumor distance to the base of the skull (TDBS), tumor contact with the internal carotid artery (ICA), and external carotid artery (ECA) and tumor density. Finally, we assessed the relation of pre-surgical imaging parameters with Shamblin grades, and intra-operative complications. Only tumor volume was significantly correlated with Shamblin grades (P < 0.05). The tumor contact with ECA was marginally correlated with Shamblin grades (P = 0.103); however, other imaging parameters were not significantly correlating with Shamblin grades. There was a statistically significant correlation between ICA contact and tumor volume with ECA injury. In addition, the tumor density significantly correlated with cranial nerves injury. The results of STATA analysis were indicative for 69.44% accordance between radiologic typing and Shamblin grading system. We found that tumor volume correlates significantly with Shamblin grading system, and there is significant correlation between tumor ICA contact, and tumor density and intra-operative complications.

Intraoperative Scoring System to Assess the Difficult Laparoscopic Cholecystectomy: A Prospective Study From a Tertiary Care Centre.

Background In comparison to a traditional cholecystectomy (open), the laparoscopic cholecystectomy approach provides a number of benefits and has been demonstrated in some studies to have a greater complication rate. The conversion rate from laparoscopic to open surgery ranged between 2% and 15%. A preoperative scoring or grading system (based on age, sex, history, clinical examination, laboratory, and sonographic results)was developed byNassar et al., to anticipate the challenge of laparoscopic cholecystectomy. So, we conducted this study to assess the degree of difficulty in faced during laparoscopic cholecystectomy using an intraoperative scoring system and validate the same using the preoperative scoring system. Methods We conducted this study in the department of General Surgery among 105 patients who underwent laparoscopic cholecystectomy during the defined study period of one year. We performed the preoperative workup for all patients. A preoperative scoring or grading system developed by Nassar et al., in 2020was used. In our study, laparoscopic cholecystectomy was performed by surgeons having a minimum of eight years of hands-on experience in laparoscopic surgeries. An intraoperative scoring or grading system for the degree of difficulty during laparoscopic cholecystectomy, developed by Sugrue et al., in 2015 was used. The Chi-square test was applied to assess the association between preoperative variables and the intraoperative score grading. We have also performed the receiver operating characteristic (ROC) curve analysis to validate the preoperative score in predicting the intraoperative findings. All tests were considered statically significant if the p-value was < 0.05. Results In our study, a total of 105 patients were included in the study and the mean age of patients was 57.6±16.4 years. The male patients were 58.1% and the remaining 41.9% were females. The primary diagnosis was cholecystitis among 44.8% of patients and 2.9% of patients were diagnosed with pancreatitis. Among enrolled patients, laparoscopic cholecystectomy was done on an emergency basis among 2.9% of subjects. During the laparoscopic cholecystectomy, among 21.0% and 30.5% of patients, there was a severe and extreme degree of difficulty respectively. In our study, the conversion rate from laparoscopic to open cholecystectomy was 8.6%. In our study, we found that at a preoperative score of 6, the sensitivity and specificity for predicting easy cases were 88.2% and 73.8%, respectively, and had an accuracy of 88.6% for easy cases and 68.5% for difficult cases. Conclusion When grading the difficulties of doing a laparoscopic cholecystectomy and determining the severity of cholecystitis, this intraoperative scoring system is effective and accurate. Additionally, it signifies the need for conversion from laparoscopic to open cholecystectomyin cases of severe cholecystitis.

8977 The Use and (Potential) Misuse of the AAGL Endometriosis Classification System

<h3>Study Objective</h3> To demonstrate use and (potential) misuse of the AAGL 2021 Endometriosis Classification Scoring System, an anatomy-based surgical complexity scoring system - with the goal of optimizing future endometriosis staging. <h3>Design</h3> A case report applying the new AAGL 2021 Endometriosis Classification and use of the App. <h3>Setting</h3> A university hospital based in Detroit, Michigan; Wayne State University/ Detroit Medical Center. <h3>Patients or Participants</h3> A case report of a Stage 2 Endometriosis based on the Scoring System with a patient presenting for infertility. <h3>Interventions</h3> Application and utilization of the AAGL 2021 Endometriosis Classification for a Stage 2 Endometriosis Classification. <h3>Measurements and Main Results</h3> Scoring system demonstrated feasibility, applied utility to the correlation that was discussed regarding the Scoring System, but also limitations and potential misuses of the scoring system. <h3>Conclusion</h3> The AAGL Endometriosis Scoring System is a feasible intraoperative scoring system correlated with pain. It is critical to be cognizant of staging parameters while scoring the endometriotic lesions and remaining consistent.

Validation of intra-operative scoring system for difficult laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is the procedure of choice for most patients with gallbladder disease. The key, as in open surgery, is the identification and safe dissection of Calot’s triangle. Surgeons performing laparoscopic cholecystectomy should not think of conversion to open operation as a complication, but rather a sound clinical judgment.Methods: This is an observational, single center study. The scoring system included five aspects; appearance and adhesion of gall bladder (GB), distension or contracture degree of GB, ease in access, local or septic complications, and time required for cystic artery and duct identification. A score of &lt;2 would imply mild difficulty, 2–4 moderate, 5–7 severe and 8–10 extreme. The scores were compared in each patient to conclude the practicality of intra operative predictive score.Results: The most common reason for conversion to open surgery was found to be difficulties in dissection of cystic duct and artery in Calot’s triangle. The moderate and severe category was found to be statistically insignificant to predict the conversion, therefore, one can consider to merge these 2 categories into a single category to forfeit the prediction for conversion.Conclusions: The extreme category was found to be statistically significant for prediction of conversion, therefore, the patients falling into this category forfeits the chances of increased risk of injury and therefore, should be converted early.

Development and validation of a pre- and intra-operative scoring system that distinguishes between non-advanced and advanced axillary lymph node metastasis in breast cancer with positive sentinel lymph nodes: a retrospective study

BackgroundThere are currently no scoring-type predictive models using only easily available pre- and intraoperative data developed for assessment of the risk of advanced axillary lymph node metastasis (ALNM) in patients with breast cancer with metastatic sentinel lymph nodes (SLNs). We aimed to develop and validate a scoring system using only pre- and intraoperative data to distinguish between non-advanced (≤ 3 lymph nodes) and advanced (> 3 lymph nodes) ALNM in patients with breast cancer with metastatic SLNs.MethodsWe retrospectively identified 804 patients with breast cancer (cT1-3cN0) who had metastatic SLNs and had undergone axillary lymph node dissection (ALND). We evaluated the risk factors for advanced ALNM using logistic regression analysis and developed and validated a scoring system for the prediction of ALNM using training (n = 501) and validation (n = 303) cohorts, respectively. The predictive performance was assessed using the receiver operating characteristic (ROC) curve, area under the curve (AUC), and calibration plots.ResultsUltrasound findings of multiple suspicious lymph nodes, SLN macrometastasis, the ratio of metastatic SLNs to the total number of SLNs removed, and the number of metastatic SLNs were significant risk factors for advanced ALNM. Clinical tumor size and invasive lobular carcinoma were of borderline significance. The scoring system based on these six variables yielded high AUCs (0.90 [training] and 0.89 [validation]). The calibration plots of frequency compared to the predicted probability showed slopes of 1.00 (training) and 0.85 (validation), with goodness-of-fit for the model. When the cutoff score was set at 4, the negative predictive values (NPVs) of excluding patients with advanced ALNM were 96.8% (training) and 96.9% (validation). The AUC for predicting advanced ALNM using our scoring system was significantly higher than that predicted by a single independent predictor, such as the number of positive SLNs or the proportion of positive SLNs. Similarly, our scoring system also showed good discrimination and calibration ability when the analysis was restricted to patients with one or two SLN metastases.ConclusionOur easy-to-use scoring system can exclude advanced ALNM with high NPVs. It may contribute to reducing the risk of undertreatment with adjuvant therapies in patients with metastatic SLNs, even if ALND is omitted.

Preference and grading by operating surgeons for maxillectomies in mucormycosis cases

Aim: The purpose of the present research was to assess the preference as well as grading of maxillectomies in the Mucormycosis cases by operating surgeons. Methodology: An observational study conducted among 43 cases of confirmed CAM which included 35 males and 8 females, with an average age of 56 years. The surgical approach adopted in our cases included endoscopic surgical debridement with Denker’s approach including mandatory pterygopalatine and infratemporal fossa exploration. All cases were intraoperatively scored using our designed intraoperative scoring assessment tool for mucormycosis. Postoperatively patient recovery was assessed using C reactive protein levels and weekly imaging. Results: Although an early observation in the post op period we observed higher mortality among cases reporting with high scores as per our intraoperative reporting system. At the end of 2 months of completed treatment we report 6 cases of mortality among whom 5 cases were found to have scores (&gt;25) and one reported with a score of 18. Conclusion: This assessment helped to grade the disease severity and also gives an insight about the postoperative prognosis too.

Evaluation of the Factors Influencing on Intraoperative Difficulty Scores of Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair.

Background: Inguinal hernias are the leading surgical diseases in the world. There are different surgical procedures reported for the treatment. Some problems are thought to be encountered when performing laparoscopic surgery in these patients, such as risk of severe complications and the prolonged operative duration. Aim: The objective of this study was to specify the complexity of the transabdominal preperitoneal (TAPP) procedure by using an intraoperative scoring system and examine the scores with these patients' predictive factors. Materials and Methods: A prospective study was conducted in patients who underwent inguinal hernia surgery with TAPP. Previous lower abdominal surgery, previous (open) hernia surgery, body mass index (BMI), type of hernia, duration of the surgery, scoring the difficulty of the operation in five various stages using the visual analog scale (VAS) score (1. Mobilizing the peritoneum/dissection of the inferior peritoneal flap. 2. Dissection of internal ring or vas deference or hernia sac. 3. Visualization of Cooper's ligament. 4. Mesh placement. 5. Peritoneal closure.) and the time of discharge were recorded. Results: In this study, 137 patients were included. "BMI" and "previous lower abdominal surgery" have significantly higher scores, time of surgery, and hospital stay compared with other risk factors (P < .005). Conclusion: This study showed that patient's BMI and previous lower abdominal surgery could create technical difficulty with the TAPP procedure, but it is not necessary to avoid this laparoscopic technique because of these situations and can be performed safely.

PREDICTION OF SURGICAL OUTCOMES OF LAPAROSCOPIC CHOLECYSTECTOMY USING INTRAOPERATIVE GRADING SCALE IN PATIENTS UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY

The gold standard for gall bladder disease is Laparoscopic cholecystectomy (LC).2 Conversion of LC to open is a signicant component in terms of conducting a safe surgery, an improved knowledge of factors contributing to conversion and complications post-surgery would be useful and helpful.1 In this study, a validated scoring system based on intraoperative ndings during LC has been used which allows scoring of these ndings and standardizes the degree and severity of gall bladder related disease, also predicting the level of difculty in performing the surgery. G10 is a simple grading scale based on intraoperative parameters, predicts likely difculty in performing the surgery, various surgical outcomes such as conversion to open cholecystectomy, intraoperative complications, requirement and duration of a drain, duration of hospital stay, and postoperative complications. G10 score helps the surgeon and team to be better prepared with possible surgical outcomes, need for conversion to laparoscopic cholecystectomy and can be used as a tool in counselling the patient. G10 score of 5 was considered as the optimum point to predict conversion of LC to open. Intraoperative decision of conversion from laparoscopic to open cholecystectomy is neither a complication nor should it be considered as a failure, but rather to be considered as a decision taken to prevent possible intraoperative or postoperative complication and to ensure patient safety which can be achieved using G10 intraoperative scoring scale.

Intraoperative Scoring Assessment as a Prognostic Tool in Covid-19 Associated Mucormycosis: A Short-Term Observational Study

To introduce an intraoperative scoring system for covid-19 associatedmucormycosis An observational study conducted among 43 cases of confirmed CAM whichincluded 35 males and 8 females, with an average age of 56 years. The surgicalapproach adopted in our cases included endoscopic surgical debridement withDenker’s approach including mandatory pterygopalatine and infratemporal fossaexploration. All cases were intraoperatively scored using our designed intraoperativescoring assessment tool for mucormycosis. Postoperatively patient recovery wasassessed using C reactive protein levels and weekly imaging. Although an early observation in the post op period we observed highermortality among cases reporting with high scores as per our intraoperative reportingsystem. At the end of 2 months of completed treatment we report 6 cases of mortalityamong whom 5 cases were found to have scores (> 25) and one reported with a scoreof 18. This assessment helped us in grading the disease severity and also gaveus an insight about the postoperative prognosis too. Global scientific collaboration andreporting of a validated tool for CAM is of paramount importance to increase theknowledge with regard to this emerging disease.

Evaluation of intra-operative gall bladder scoring for predicting conversion of laparoscopic to open cholecystectomy: A prospective observational study in a tertiary care centre in North India

Introduction: Laparoscopic cholecystectomy has become the gold-standard treatment for symptomatic cholelithiasis replacing open cholecystectomy. Surprisingly, it has variable outcomes and conversion rates. This single centre, prospective study uses the intra-operative scoring system, devised by Michael Sugrue et al to grade difficulty of laparoscopic cholecystectomy intraoperatively. This score has also been used to predict conversion rates. Methods: A prospective observational cross-sectional study was undertaken in Department of General Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh; enrolling all patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis and acute mild gall stone induced pancreatitis from October 1, 2019 to September 30, 2020. Case reporting forms and intra-operative severity scoring system devised by Michael Sugrue et al were used. Demographics about the patient and other variables were recorded and intra-operative score was compared with the variables and conversion rates. Results: A total of 640 patients were enrolled in the study, in which laparoscopic cholecystectomy was attempted, with a mean age of 44.84 years (range 10 to 82 years). The mean duration of surgery was 33.56 minutes. 545 patients (85.2%) had moderate difficulty (score 2-4) in surgery, 39 patients had mild difficulty (score

Use of magnetic resonance elastography to gauge meningioma intratumoral consistency and histotype

ObjectiveTo determine whether tumor shear stiffness, as measured by magnetic resonance elastography, corresponds with intratumoral consistency and histotype. Materials and methodsA total of 88 patients with 89 meningiomas (grade 1, 74 typical [13 fibroblastic, 61 non-fibroblastic]; grade 2, 12 atypical; grade 3, 3 anaplastic) were prospectively studied, each undergoing preoperative MRE in conjunction with T1-, T2- and diffusion-weighted imaging. Contrast-enhanced T1-weighted sequences were also obtained. Tumor consistency was evaluated as heterogeneous or homogenous, and graded on a 5-point scale intraoperatively. MRE-determined shear stiffness was associated with tumor consistency by surgeon’s evaluation and whole-slide histologic analyses. ResultsMean tumor stiffness overall was 3.81+/-1.74 kPa (range, 1.57–12.60 kPa), correlating well with intraoperative scoring (r = 0.748; p = 0.001). MRE performed well as a gauge of tumor consistency (AUC = 0.879, 95 % CI: 0.792–0.938) and heterogeneity (AUC = 0.773, 95 % CI: 0.618–0.813), significantly surpassing conventional MR techniques (DeLong test, all p < 0.001 after Bonferroni adjustment). Shear stiffness was independently correlated with both fibrous content (partial correlation coefficient = 0.752; p < 0.001) and tumor cellularity (partial correlation coefficient = 0.547; p < 0.001). MRE outperformed other imaging techniques in distinguishing fibroblastic meningiomas from other histotypes (AUC = 0.835 vs 0.513 ∼ 0.634; all p < 0.05), but showed limited ability to differentiate atypical or anaplastic meningiomas from typical meningiomas (AUC = 0.723 vs 0.616 ∼ 0.775; all p > 0.05). Small (<2.5 cm, n = 6) and intraventricular (n = 2) tumors displayed inconsistencies between MRE and surgeon’s evaluation. ConclusionsThe results of this prospective study provide substantial evidence that preoperative evaluation of meningiomas with MRE can reliably characterize tumor stiffness and spatial heterogeneity to aid neurosurgical planning.

Intraoperative scoring system for grading severity of cholecystitis at laparoscopic cholecystectomy

Background: Various studies had been carried out to evaluate the risk of preoperative conversion in laparoscopic cholecystectomy. However, there was no grading or scoring of operative findings during surgery at present, making it difficult to compare the publications citing outcomes, including the conversion to open surgery. Sugrue in 2015 devised a scoring system based upon the intraoperative findings in Laparoscopic cholecystectomy. Aim of the study was to grade the severity of cholecystitis during laparoscopic cholecystectomy using intraoperative scoring system, to evaluate the spectrum of cholecystitis in cases of laparoscopic cholecystectomy in a tertiary center using the grades of intraoperative scores and to validate the scoring system devised by Michael Sugrue.Methods: This prospective cross sectional observatory study of 200 patients admitted for laparoscopic cholecystectomy was conducted in the Department of Surgery, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India over a period of 12 months. All patients directly planned for open cholecystectomy and carcinoma gall bladder were excluded from the study. Patients were subjected to the intra operative grading system for cholecystitis severity as devised by Micheal Sugrue and the grades were classified with a score of &lt;2 - mild; 2 to 4 -moderate, 5– 7- severe and 8 to 10 – extreme.Results: The operative grading system showed a positive correlation with the severity of cholecystitis.Conclusions: Use of this intra-operative scoring system will help us to provide a trigger for a prompt early conversion to avoid intra-operative complications associated with difficult laparoscopic cholecystectomy.

Intraoperative pathologically-calibrated diagnosis of lymph nodes involved by breast cancer cells based on electrical impedance spectroscopy; a prospective diagnostic human model study

BackgroundNodal status evaluation is a crucial step in determining prognostic factors and managing treatment strategies for breast cancer patients. Preoperative (CNB), intraoperative (SLNB), and even postoperative techniques (Formalin-Fixed Paraffin-Embedded sectioning, FFPE) have definite limitations of precision or sometimes are time-consuming for the result declaration. The primary purpose of this prospective study is to provide a precise complementary system for distinguishing lymph nodes (LNs) involved by cancerous cells in breast cancer patients intraoperatively. MethodsThe proposed system, Electrical Lymph Scoring(ELS), is designed based on the dielectric properties of the under-test LNs. The system has a needle-shaped 2-electrode probe entered into SLNs or ALNs dissected from patients through standard surgical guidelines. Impedance magnitude in f = 1 kH (Z1kHz) and Impedance Phase Slope in frequency ranges of 100 kHz–500 kHz (IPS) were then extracted from the impedance spectroscopy data in a cohort study of 77 breast cancer patients(totally 282 dissected LNs) who had been undergone surgery before (n = 55) or after (n = 22) chemical therapies (non-neoadjuvant or neoadjuvant chemotherapy). A new admittance parameter(Yn′) also proposed for LN detection in neoadjuvant chemotherapy patients. ResultsConsidering the permanent pathology result as the gold standard checked by two independent expert pathologists, a significant correlation was observed between the presence of cancerous cells in LNs and individual ranges of the ELS electrical responses. Compared with normal LNs containing fatty ambient and immune cells, LNs involved by cancerous clusters would reduce the Z1kHz and increase the IPS. These changes correlate with fat metabolism by cancer cells due to their Fatty Acid Oxidation (FAO) in LN, which results in different dielectric properties between high and low-fat content of normal and cancerous LNs, respectively. ConclusionsBy finding the best correlation between our defined impedimetric parameters and pathological states of tested LNs, a real-time intraoperative detection approach was developed for highly-sensitive (92%, P<0.001) diagnosis of involved sentinel or axillary LNs. The impact of real-time intraoperative scoring of SLNs would make a pre-estimation about the necessity of excising further LNs to help the surgeon for less invasive surgery, especially in the absence of frozen-section equipment.