Intraoperative Scoring Research Articles

Preoperative Prediction of Difficult Laparoscopic Cholecystectomy: A Scoring Method

Abstract Background: Laparoscopic cholecystectomy is the most frequent operation nowadays for gallbladder stones. It is associated with faster recovery and shorter hospital stay. On the wide use of laparoscopic cholecystectomy, various com-plications appeared. This made researches work on studies to predict the difficulty of laparoscopic cholecystectomy through different scoring system. This study validates the usage of a scoring system for preoperative prediction of intraoperative difficulties of lapar-oscopic cholecystectomy that may help the patient as well as surgeon in being better prepared for intraoperative challenges. Gallbladder-related disease is one of the common surgical elective and emergency indications. Laparoscopic cholecys-tectomy (LC) is the gold standard nowadays for gallbladder removal. The frequency of complications associated with laparo-scopic cholecystectomy varies from 0.5-6%. Complications of cholecystectomy include iatrogenic perforation of gallblad-der with spilt gallstones that is considered the most common, bile duct injury, bile leaks, bleeding and bowel injury. Con-version rate was about 5% of all laparoscopic cholecystecto-mies. Many risk factors have been found to be associated with difficult laparoscopic cholecytectomy. These result in part from patient selection, surgical inexperience, and the technical constraints that are inherent to the minimally invasive approach. Scoring proposed by Randhawa and Pujahari in 2008 is the most used currently. They found its statistically and clinically good test for predicting outcome in LC. This score had positive predictive value of 88.8% and 92.2% for easy and difficult. One of the unique features in this score is the inclusion of palpable Gallbladder that was not reported earlier. But there was no correlation of score and conversion in this study as all cases of conversion were due to anomalous ducts that could have been predicted by MRCP. It included various clinical and ultrasonographic parameters. Aim of Study: To validate a risk score based on the patient's history, physical examination and abdominal ultrasonography parameters for preoperative prediction of difficult laparoscopic cholecystectomy. Patients and Methods: Our study included 30 patients underwent laparoscopic cholecystectomy in Ain Shams Hos-pital and Alamria Hospital. Results: In our study, males were more predominant than females (73.3% vs 26.7%) with mean age of (40.23±13.64) years. Our patients had mean BMI of (28.43±4.03) kg/m2 with most of them were obese (63.3%). Intra operative diffi-culty showed significant relation with sex and BMI. 13.3% of patients had leukocytosis and all our patients had normal alkaline phosphatase. 56.7% of the study patients were presented with previous acute attacks, 20% presented with fever, 6.7% had palpable GB and 33.3% had abdominal scar. Intra operative difficulty showed significant relation with previous acute attack, abdominal scar and GB wall thickness. We found that preoperative scoring had a sensitivity of 89.5%, specificity of 100%, positive predictive value of 100%, negative predictive value of 84.6%, diagnostic accuracy of 93.3%, and Kappa agreement of 0.862 compared to the intraoperative scoring system. Conclusion: We strongly recommend using the preoper-ative scoring system for predicting the degree of difficulty for laparoscopic cholecystectomy.

Comparative Study between Preoperative Ultrasonographic Based Scoring System and Intraoperative Scoring System for Predicting Difficult Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy (LC) has become the treatment of choice for cholelithiasis. Still some patients required conversion to open cholecystectomy (OC). The condition of the patient, the level of experience of the surgeon and technical factors all play a role in the decision for conversion. Inability to define the anatomy and difficult dissection are the leading reasons for conversion. Aims and objectives: To compare between and to validate: preoperative ultrasonographic based scoring system and intraoperative scoring system (SURGUE ET AL, IRELAND) as predictors for difficult laparoscopic cholecystectomy. Materials and Methods: This prospective randomized study was conducted at Kempegowda Institute of Medical Sciences Hospital, Bangalore after obtaining the Hospital Ethical Committee clearance for a period of 6 months from AUGUST 2018-JANUARY 2019. Pre-operative Ultrasonographic based scoring system was compared with Intra-operative scoring system to predict laparoscopic cholecystectomy. Results: In the study among those with Easy Pre-operative score, 90.9% had easy, 9.1% had moderate Intra-operative score. Among those with difficult pre-operative score, 33.3% had easy, 11.1% had moderate, 22.2% had difficult and 33.3% had extreme Intra-operative score. There was significant association between Pre-operative score and Intra-operative score. Conclusion: With the help of accurate prediction, high risk patient may be informed beforehand regarding the probability of conversion and hence they may have a chance to make arrangements accordingly. Surgeons can also be aware about the possible complications that may arise in high risk patients. Our study also concludes that radiological parameters are good predictors of difficulty.

Feasibility and safety in difficult laparoscopic cholecystectomies; a single surgeon experience.

Background: laparoscopic cholecystectomy is commonly used for the treatment of gallstones. Objective: To determine the feasibility and safety of difficult laparoscopic cholecystectomies. Methodology: This cross sectional study was based on retrospective collection of data from patient records, including 323 patients with difficult laparoscopic cholecystectomies was conducted in Department of Surgery, Sharif Medical City Hospital, and Rasheed Hospital, Lahore from June 2010 to December 2019. Difficult cholecystectomy was defined on intraoperative findings based on Nassar intraoperative scoring system. Feasibility was defined as successful accomplishment of procedure without complication and safety was defined as having no intraoperative or postoperative complications. Results: There were 75 (23.21%) male and mean age was 48±8 years. Class I difficulty was observed in 185 (57.3%) patients, class II difficulty in 83 (25.7%) patients, class III difficulty in 44 (13.6%) patients and class IV difficulty in 11 (3.4%) patients. Mean duration of surgery and mean hospital stay were 98.87±11.76 minutes and 1.91±1 days, respectively. Conversion to open cholecystectomy was done in 10 (3.1%). The procedure was feasible in 313 (96.9%) patients. Overall complications were seen in 19 (5.9%) patients. The complications included Common Bile Duct injury in 1 (0.31%) patient, intraoperative bleeding in 1 (0.3%) patients, bile leakage in 2 (0.62%) patients, postoperative jaundice in 3 (0.93%) patients, superficial infections in 10 (3.1%) patients and deep infections in 2 (0.62%) patients. Safety of laparoscopic surgery was seen in 304 (94.1%) patients. Conclusion: Laparoscopic cholecystectomy in difficult situations was found to be feasible and safe in majority of patients. However, it was associated with a longer operative time.

Grading operative findings at laparoscopic cholecystectomy following the new scoring system in Duhok governorate: Cross sectional study

IntroductionNumerous preoperative scoring systems predict difficult laparoscopic cholecystectomy. Recently, the intraoperative difficulties which are facing surgeons are studied. A new scoring system categorize patients according to many intraoperative findings with a final outcome whether converting to open cholecystectomy or continuing laparoscopically. Patients and methodsThis prospective study included 120 patients admitted for laparoscopic cholecystectomy for symptomatic gallstones from October 2019 to August 2020. Intraoperative difficulties were evaluated and patients were categorized according to intraoperative scoring for cholecystitis severity and compared depending to the rate of conversion to the open technique. ResultsMost patient were middle aged females having multiple gallstones, the mean operation time was 35 min and 7.8% of patients were converted to open cholecystectomy because of intraoperative difficulty.There was a significant correlation between the conversion rate and each of distended and/or contracted gall bladder, inability to grasp the gall bladder with traumatic forceps, stone ≥1 cm impacted in Hartman's pouch, and bile or pus outside gallbladder (P values: 0.002, 0.000, 0.008 and 0.015) respectively, and no significant correlation with gallbladder adhesions, adhesions from previous upper abdominal surgery, BMI>30, and Time to identify cystic artery and duct >90 min (P values: 0.123, 1, 1, 0.078) respectively. ConclusionNew intraoperative scoring systems are valuable in predicting difficulties and preventing increase operation time and possible injuries. The main points of difficulties are distended or contracted gallbladder, large stone impaction, difficult grasping the wall of the gall bladder and the presence of bile or pus outside the gall bladder.

ARoCuS Web application promotes standardized treatment and documentation of rotator cuff tears

PurposeTo program a Web application for simplified calculation of the Advanced Rotator Cuff tear Score (ARoCuS), which is a 5-part, 18-item treatment-oriented intraoperative scoring system for intraoperative evaluation of rotator cuff tears.MethodsARoCuS characteristics (torn tendon, tear size, tissue quality and tear pattern) were assessed intraoperatively on 40 consecutive patients with rotator cuff tears for calculation of defect category ΔV. Video recordings were used to re-calculate the ARoCuS after surgery and to assess inter-observer reliability.ResultsThe Web application “ARoCuS App” was built using Angular and transformed to a native iOS application. The intraoperative use of the app proved to be simple and intuitive. There were inter-/intra-observer differences neither in ARoCuS defect categories ΔV nor in ARoCuS characteristics (p > 0.05).ConclusionThe ARoCuS app is a supportive tool for integration of standardized treatment procedures and documentation of rotator cuff tears in clinical routine.

Radiological and Surgical Correlation of Disease Burden in Advanced Ovarian Cancer Using Peritoneal Carcinomatosis Index

The study aims to identify the accuracy of computed tomography (CT) in preoperative characterization and staging of ovarian cancer using peritoneal carcinomatosis index (PCI) and compare it with the PCI determined at the time of surgery and to see the accuracy in individual abdominopelvic regions. Forty patients with presumed Stage IIIc/IV ovarian cancer were included in the study sample. Tumor localization and size was objectively documented using Sugarbaker’s PCI which divided the entire abdominopelvic region into 13 spaces, scores assigned based on lesion size (LS) and summed up (range 0–39). PCI scoring was first done using CECT (16 slice Siemens Somatom Emotion CT machine). Intra-operative PCI scoring was done during explorative laparotomy following a standard procedure and protocol. There was a statistically significant correlation between the intra-operative and radiological observations which showed Pearson’s correlation coefficient of 0.642. The correlation was more in the middle and lower abdominopelvic regions. The best correlations were seen in right flank with a correlation coefficient of 0.835. The worst assessed areas were right upper (liver and subhepatic area) and lower jejunum. Sensitivity, specificity, PPV and NPV were also assessed for individual areas and found to be significant in most areas. Radiological PCI has a good correlation with surgical PCI and, hence, is useful in predicting patients with potentially unresectable disease. The routine use of a standardized PCI form may lead to a more objective assessment and systematic multi-quadrant analysis and will lead to enhanced patient care and good outcome.

Intra-Operative Predictors of difficult cholecystectomy and Conversion to Open Cholecystectomy - A New Scoring System.

Objective:To evaluate the intra-operative scoring system to predict difficult cholecystectomy and conversion to open surgery.Methods:This descriptive study was conducted from March 2016 to August, 2016 in the Department of Surgery, Shalimar Hospital. The study recruited 120 patients of either gender, age greater than 18 years and indicated for laparoscopic cholecystectomy (LC). Intra-operatively all patients were evaluated using the new scoring system. 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. The scoring system ranges from 0 to 10, classified as score of <2 being considered easy, 2 to 4 moderate, 5–7 very difficult, and 8 to 10, extreme. Patient demographic data (i.e. age, gender), co-morbidities, intra-operative scores using the scoring system and conversion to open were recorded. The data was analysed using statistical analysis software SPSS (IBM).Results:Among one hundred and twenty participants, sixty seven percent were females and the mean age (years) was 43.05 ± 14.16. Co-morbidities were present in twenty percent patients with eleven diagnosed with diabetes, six with hypertension and five with both hypertension and diabetes. The conversion rate to open surgery was 6.7%. The overall mean intra-operative scores were 3.52 ± 2.23; however significant difference was seen in mean operative score of converted to open and those not converted to open (8.00 ± 0.92 Vs. 3.20 V 1.92; p-value = 0.001). Among eight cases converted to open, three (37.5%) were in very difficult category while five (62.5%) were in extreme category. Moreover, age greater than 40 years and being diabetic were also the risk factors for conversion to open surgery.Conclusion:The new intra-operative scoring system is a valuable assessment tool to predict difficult laparoscopic cholecystectomy and conversion parameters to open surgery and its utility could improve patient's clinical outcome indicated for laparoscopic cholecystectomy.

Evaluation of preoperative predictive factors for difficult laparoscopic cholecystectomy in comparison with intraoperative parameters

Objective The aim was to assess the preoperative predictive factors that determine difficult laparoscopic cholecystectomy (LC) in comparison with intraoperative parameters and outcome. Patients and methods This prospective study include 100 patients having symptomatic cholelithiasis. All patients underwent elective LC in Department of General Surgery in Aswan University Hospital. The collected data include the parameters of preoperative scoring system, which were male sex, old age, history of hospitalization, obesity (BMI), abdominal scar, palpable gallbladder (GB), wall thickness of GB, pericholecystic collection, and impacted stone. The difficulty levels according to preoperative score were easy (0–5), difficult (6–10), and very difficult (11–15). Various intraoperative parameters were faced while doing LC that were considered for intraoperative scoring system, which categorizes the patients into easy, difficult, and very difficult surgical procedure on the basis of time taken in minutes, bile/stone spillage, injury to duct, and conversion to open cholecystectomy. Results In this study, previous history of hospitalization (P=0.001 and 0.01) and wall thickness (P=0.007 and 0.02) were found to be statistically significant in predicting difficult LC in both univariate and multivariate analyses. Other factors such as age (P=0.002), BMI greater than 27.5 (P=0.02), palpable GB (P=0.003), and impacted stone (P=0.01) were found to be statistically significant in univariate analysis in predicting difficult LC. Remaining factors such as sex, abdominal scar, and pericholecystic collection were not found to be statistically significant in predicting difficult LC. Receiver operating characteristic curve for prediction of intraoperative outcome based on preoperative score for difficult/very difficult versus easy cases at cutoff point greater than 5 and area under the curve of 0.86, with 95% confidence interval=0.77–0.92, showed sensitivity of 74.3, specificity of 96.9, positive predictive value of 92.9, negative predictive value of 87.5, and accuracy of 85.6. Conclusion We concluded that the preoperative scoring system is statistically and clinically a good test for predicting the operative outcome in LC.

Classifying glenohumeral synovitis: a novel intraoperative scoring system

Synovitis of the shoulder is a common entity that is poorly described. This study aims to create a simple and reliable classification system for glenohumeral synovitis, which would benefit further research related to synovitis and outcomes. Twenty 30-second shoulder arthroscopy videos were distributed to 19 fellowship-trained orthopedic surgeons. The observers responded with their years in practice, fellowship type, whether synovitis affects outcomes, and whether synovitis affects plans. The surgeons then rated the videos based on the following: color of capsule (pale, pink, or red); villous projections (none, few, or extensive); capillaries in capsule (scattered or hypertrophied); and axillary recess (normal or contracted). Scores ranging from 0 to 6 were assigned. The videos were randomized and redistributed at a later date. Statistical analysis used an intraclass correlation coefficient with a mixed-effects model to calculate variability based on observer. Nineteen observers completing the survey twice resulted in 760 videos being scored. There were 12 shoulder surgeons and 7 sports surgeons. Only 4 surgeons believed that synovitis did not affect outcomes, and the remaining 15 believed that it did. The intraclass correlation coefficient showed that 68% of the variation in measured scores was due to variation among patients and only 4% was due to variation among observers. There was no significant variation seen in scores due to surgeon experience, surgeon specialty, or first and second viewing. This interclass observer reliability shoulder synovitis study defined a system with excellent reliability among a range of surgeons with diverse training and experience. In addition, there was excellent reliability for the same surgeon between viewings.

Intraoperative Scoring System to Predict Postoperative Remission in Endoscopic Endonasal Transsphenoidal Surgery for Growth Hormone-Secreting Pituitary Adenomas.

To determine the predictive factors for endocrinological remission of patients with growth hormone (GH)-secreting pituitary adenomas. In 47 patients with GH-secreting pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery with intraoperative GH measurements from 2002 to 2011, the relationship between the intraoperative GH levels and postoperative remission was analyzed, and 2 items that predicted remission (GH half-life obtained 30 minutes or less after removal and a minimum surgical GH level less than 2.5 ng/mL) were determined. In addition, 2 surgical observations (endoscopic confirmation of no tumor remnants and pathologic confirmation of the absence of tumor remnants in the bordering tissue) were also considered. Positive items resulted in one point, and scores ranged from 0 to 4. For 27 patients who underwent surgery from 2012 onwards, this scoring system was applied by 3 independent operators, and the remission rates and predictive values were estimated. Twenty-six of the 47 (55.3%) patients achieved remission. The remission rates were significantly different for different scores. In the 27 patients treated from 2012 onward, repeat residual tumor examinations were performed if the GH score did not reach 2 at the end of the removal. Nine patients had final scores of 3 or 4. All of these patients achieved remission. In 16 patients with final scores of 2 or less, only 2 with Knosp grades of 0 and 1 achieved remission. Our scoring system, which incorporated GH measurements and surgical observations, predicted postoperative remission. Complete tumor removal was critical to achieve intraoperative scores over3.

A preoperative and intraoperative scoring system to predict nodal metastasis in endometrial cancer.

To develop a scoring system that guides surgical decision-making regarding the need to perform lymphadenectomy. A retrospective study was performed of patients who underwent complete surgical staging of endometrial cancer between 2003 and 2014 at three centers in Brazil. Preoperative and intraoperative risk factors were used to develop a scoring system to predict lymph node metastasis. Among 329 patients included, 71 (21.6%) had positive lymph nodes and 259 (78.4%) had negative lymph nodes. The characteristics associated with nodal metastasis in univariate analysis included the level of cancer antigen 125 (P<0.001), preoperative histological grade (P<0.001), endometrial thickness (P=0.012), and pathologic features including tumor size (P<0.001), tumor extension (P<0.001), and lower uterine segment involvement (P<0.001). On multivariate logistic regression analysis, tumor grade, tumor extension, and lower uterine segment involvement remained significantly associated. The resulting scoring system showed good accuracy as demonstrated by an area under the receiver operating characteristic curve of 0.858 (95% confidence interval 0.804-0.913). A highly accurate scoring system for the prediction of lymph node metastasis was developed on the basis of three preoperative and intraoperative risk factors. After validation, this model could greatly aid clinicians in the surgical management of endometrial cancer.

Development, validation and clinical application of Pelvic Lymphadenectomy Assessment and Completion Evaluation: intraoperative assessment of lymph node dissection after robot‐assisted radical cystectomy for bladder cancer

To develop a scoring tool, Pelvic Lymphadenectomy Appropriateness and Completion Evaluation (PLACE), to assess the intraoperative completeness and appropriateness of pelvic lymph node dissection (PLND) following robot-assisted radical cystectomy (RARC). A panel of 11 open and robotic surgeons developed the content and structure of PLACE. The PLND template was divided into three zones. In all, 21 de-identified videos of bilateral robot-assisted PLNDs were assessed by the 11 experts using PLACE to determine inter-rater reliability. Lymph node (LN) clearance was defined as the proportion of cleared LNs from all PLACE zones. We investigated the correlation between LN clearance and LN count. Then, we compared the LN count of 18 prospective PLNDs using PLACE with our retrospective series performed using the extended template (No PLACE). A significant reliability was achieved for all PLACE zones among the 11 raters for the 21 bilateral PLND videos. The median (interquartile range) for LN clearance was 468 (431-545). There was a significant positive correlation between LN clearance and LN count (R2 = 0.70, P < 0.01). The PLACE group yielded similar LN counts when compared to the No PLACE group. Pelvic Lymphadenectomy Appropriateness and Completion Evaluation is a structured intraoperative scoring system that can be used intraoperatively to measure and quantify PLND for quality control and to facilitate training during RARC.

Assessment of Degree of Difficulty in Laparoscopic Cholecystectomy using Intraoperative Scoring System

Assessment of Degree of Difficulty in Laparoscopic Cholecystectomy using Intraoperative Scoring System

Airway Obstruction during Drug‐Induced Sleep Endoscopy Correlates with Apnea‐Hypopnea Index and Oxygen Nadir in Children

To determine if standardized intraoperative scoring of anatomic obstruction in children with obstructive sleep apnea correlates with the apnea-hypopnea index (AHI) and lowest oxygen saturation on preprocedural polysomnogram (PSG). A secondary objective was to determine if age, presence of a syndrome, or previous adenotonsillectomy affect this correlation. Case series with chart review. Two tertiary care children's hospitals. Patients with a preprocedural PSG who underwent drug-induced sleep endoscopy (DISE) over a 4-year period. All DISEs were graded in a systematic manner with the Chan-Parikh (C-P) scoring system. AHI and nadir oxygen saturations were extracted from preprocedural PSG. Data were analyzed with a multivariate linear regression model that controlled for age at time of sleep endoscopy, syndrome diagnosis, and previous adenotonsillectomy. A total of 127 children underwent PSG prior to DISE: 56 were syndromic, and 21 had a previous adenotonsillectomy. Mean AHI was 13.6 ± 19.6 (± SD), and mean oxygen nadir was 85.4% ± 9.4%. Mean C-P score was 5.9 ± 2.7. DISE score positively correlated with preoperative AHI (r = 0.36, P < .0001) and negatively correlated with oxygen nadir (r = -0.26, P = .004). The multivariate linear regression models estimated that for every 1-point increase in C-P score, there is a 2.6-point increase in AHI (95% confidence interval: 1.4-3.8, P < .001) and a 1.1% decrease in the lowest oxygen saturation (95% confidence interval: -1.7 to -0.6, P < .001). The C-P scoring system for pediatric DISE correlates with both AHI and lowest oxygen saturation on preprocedural PSG.

Validation of a Novel Virtual Reality Training Curriculum for Robotic Cardiac Surgery: A Randomized Trial.

Robotic cardiac surgery training has relied entirely on classical methods of surgical teaching. We sought to evaluate the impact of a virtual reality (VR) simulation curriculum to improve skill acquisition in robotic cardiac surgery. We randomly assigned 20 surgical trainees to undergo a 9-exercise VR curriculum on a robotic surgical simulator or a control group that received no additional training. The trainees were then evaluated in a blinded fashion by assessing their de-identified video recordings of the following: (1) standardized robotic internal thoracic artery harvest and (2) mitral valve annuloplasty performed in porcine models, using a validated time-based scoring system and an objective intraoperative scoring tool. Postintervention assessments were compared to baseline. Trainees randomized to the VR group were faster than the control group for both the internal thoracic artery harvest (957.3 ± 98.9 vs. 749.1 ± 171.9; P = 0.004) and mitral annuloplasty (580.4 ± 14.4 vs. 463.8 ± 86.4; P < 0.001) and scored significantly higher with the intraoperative scoring tool (22.8 ± 2.7 vs. 11.0 ± 4.5; P < 0.001). Additionally, the VR group achieved a proficiency level similar to our experts for both time-based scores (P = 0.624 and P = 0.967), and the intraoperative assessment (P = 0.110), whereas the control group was not able to meet this level of proficiency for any of the primary outcomes. The average duration of training to successfully complete all required tasks was 9.3 hours. We have demonstrated that a VR simulation curriculum can significantly improve the efficiency and quality of learning in robotic cardiac surgery. Further evaluation of this curriculum is required for its widespread implementation in surgical training (ClinicalTrials.gov, NCT#02357056).

Risk-stratification of endometrial carcinomas revisited: A combined preoperative and intraoperative scoring system for a reliable prediction of an advanced disease

ObjectiveThe aim of this study is to develop a risk-scoring system for predicting lymph node and distant metastasis in endometrial carcinoma. MethodsA total of 1166 patients, treated at a single institution between 1-2007 and 12-2013, were included in the study. The association of stage IIIC–IV disease with demographic factors (age, body mass index), biochemical factors (complete blood count, serum CA125), preoperative histology and tumor size was examined in unadjusted analyses. Logistic regression analysis was used for the identification of variables that independently predict an advanced disease. ResultsThrombocytosis, serum CA125>35U/mL, preoperative high-risk histology (nonendometrioid or grade 3 endometrioid carcinoma) and tumor size ≥3cm were independently associated with an advanced disease. These predictors were internally validated by a bootstrapping method with statistical significance. A risk-scoring system with an area under the receiver operating characteristic curve of 0.852 (95% confidence interval, 0.821–0.883) was developed. Total risk score points ranged from 0 to 8 for individual patients. With a cut-off of 1 point, stratifying 66.3% of patients to surgical staging, the model predicted stage IIIC–IV carcinomas with a sensitivity of 100%, specificity of 38.0%, positive predictive value of 17.1%, and negative predictive value of 100%. With the same cut-off, the corresponding values were 100%, 34.7%, 16.5% and 100% in predicting stage IIIC carcinomas in a subgroup that underwent lymphadenectomy and had a stage I–IIIC disease. ConclusionsThis risk-scoring system is highly sensitive in predicting an advanced stage endometrial carcinoma at a cut-off of risk score points that is associated with an acceptable lymphadenectomy rate.

The Centricity Score: A Novel Measurement to Aid in Conservative Breast Cancer Surgery

Introduction: This study describes an intra-operative scoring system to advise the surgeon of the centricity of the tumour in the excised specimen. Methods: Spatial estimations were prospectively made in 10 consecutive patients undergoing wide local excision (WLE) using Bioptics intra-operative digital specimen imaging. The centricity score was defined as 100 – (ICD/SD × 100), where ICD is the inter-centre distance between the specimen’s centre and the tumour’s centre. Results: 10 patients with invasive breast cancer (T1b to T4a), mean age 56 years (range 44 - 71) were studied. The mean tumour and specimen diameter was 24 mm ± 10 (range 12 - 48) and 101 mm ± 22 (range 64 - 140). The mean centricity score was 86 ± 9 (range 65 - 95). Conclusion: This study successfully describes an intraoperative radiological spatial scoring system for patients undergoing WLE. Tumours were well centered in specimens with an overall score of 86/100. The centricity score could be used to guide excision and potentially set benchmarks for conservative breast surgery.

Factors affecting acid base status during hepatectomy in cirrhotic patients

ObjectiveTo study acid base changes during hepatectomy in cirrhotic patients and their relations to intraoperative variables and different preoperative scoring systems used to asses hepatic patients.MethodsAfter obtaining approval of the Ethics and Research Committee of the National Liver Institute – Menoufia University and written informed patient consent, 80 patients scheduled for hepatectomy for hepatocellular carcinoma were included in the study. Anesthesia was induced with propofol, fentanyl, and rocuronium then maintained with desflurane and 50% O2 in air. Samples for arterial blood gases and serum lactate were withdrawn from a left radial artery catheter just before the start of resection of liver parenchyma and immediately after its completion. Intraoperative events were recorded including use of Pringle maneuver and fluids and blood products infusions.ResultsNo differences were found in study parameters between Child class A and B patients except for the preresection lactate (p = 0.02). Patients with MELD score <11 had higher preresection HCO3 (p = 0.004), higher BE (p = 0.002), and lower lactate (p = 0.001) than patients with MELD score ⩾11. These findings were true also for patients with MELD-Na score <11 as they had higher preresection HCO3 (p = 0.001), higher BE (p = 0.001), and lower lactate (p < 0.001) than patients with MELD-Na score ⩾11. All patients had significant decrease in pH (p < 0.001), HCO3 (p < 0.001), and BE (p < 0.001) and significant increase in lactate (p < 0.001). These changes were augmented by intraoperative RBCs and FFP transfusion, using Pringle maneuver, but type of hepatectomy had significant effect only on HCO3 and BE. Again these changes in pH, HCO3, BE, and lactate were more obvious in patients with preoperative MELD score ⩾11, and this was also true in patients with preoperative MELD-Na score ⩾11 only with HCO3, BE, and lactate, but not with pH.ConclusionChanges occurred in acid base status during hepatectomy in cirrhotic patients are affected by the preoperative condition of the patient (MELD and MELD-Na scores) as well as by intraoperative transfusion of blood products, use of Pringle maneuver and to a lesser extent by major versus minor hepatectomy.

Which is the ideal point of time to perform intraoperative 3D imaging in dorsal stabilisation of thoracolumbar spine fractures? A matched pair analysis

Introduction After dorsal stabilisation of vertebral fractures by an internal fixateur the postoperative computed tomography is a standard procedure to control the positions of the pedicle screws, the success of the reposition, the clearance of the spinal canal and to plane an additive secondary ventral stabilisation. An intraoperative scan with a 3D image intensifier may clarify these questions directly after the implantation with the possibility of an immediate correction of the implants. The aim of this study was to find out the optimal point of time to perform an intraoperative 3D scan and if a postoperative computed tomography is dispensable. Patients and methods Intraoperative 3D scans were carried out on 33 patients with thoracolumbar spine fractures (T11-L5) after bi-segmental fixateur interne montage (Group 1). A matched pair group of 33 patients (Group 2) with a 3D scan after implantation of pedicle screws was built. A postoperative computed tomography of the instrumented spinal section was done in all patients. The following measurements were done in sagittal and axial reconstruction planes and were compared: classification of screw positions, maximal axial diameter of pedicles, cortical perforation of the screws. Additionally in Group 1 the distance between the upper and lower end plates of the injured section, the height of posterior vertebral body wall, the dislocation of the posterior wall and the minimal diameter of the spinal canal were measured. Results The intraoperative scoring of pedicle screws positions and the measurement of pedicle width showed in both groups a significant accordance with the computed tomography determinations. The measurements “posterior wall dislocation” and “diameter of spinal canal” were only possible in 24 3D scans and showed a significant difference compared with the CT data. The picture quality in Group 2 was scored significantly better than for Group 1 with the complete assembly of the fixateur. Conclusion The ideal point of time for an intraoperative 3D imaging with the present intensifier generation is directly after pedicle screw insertion. The reliable determination of the spinal canal diameter, of posterior wall fragments and of the exact fracture morphology is only possible by postoperative computed tomography.

409 ROLE OF THE EXTENT OF FASCIA PRESERVATION AND ERECTILE FUNCTION AFTER ROBOT-ASSISTED LAPAROSCOPIC PROSTATECTOMY

To test a simple intraoperative scoring system for the circumferential extent of fascia preservation (FP) for the prediction of postoperative erectile function. With the advent of robotic and endoscopic surgery for prostate cancer, more extensive FP has emerged as a method to improve postoperative erectile function.A total of 107 consecutive cases with normal preoperative erectile function were treated using robot-assisted laparoscopic prostatectomy for localized prostate cancer. The erectile, sexual, and global quality of life outcomes using the European Organization for Research and Treatment and Cancer Quality of Life questionnaire-C30 and prostate cancer-specific 25-item questionnaire were assessed at 6 months postoperatively.At 6 months postoperatively, 57 men (53%) reported no or minimal effects on erectile function with or without the use of a phosphodiesterase type 5 inhibitor. The patient age at surgery, prostate size, and FP score were associated with erectile function at 6 months postoperatively. The mean FP score was 9.2 +/- 2.8 and 4.7 +/- 2.4 for patients without and with erectile dysfunction postoperatively, respectively. On multivariate analysis, the FP score and patient age at surgery were the best predictors of postoperative erectile function. No correlation between the FP score and positive surgical resection margin rate was observed. A greater FP score predicted for greater questionnaire-based libido, sexual activity, and sexual function scores.A scoring system for the extent of circumferential FP during prostatectomy is a stronger predictor of postoperative erectile function recovery than is laterality (bilateral or unilateral) or fascial depth (interfascial or intrafascial). More ventral FP significantly contributed to postoperative erectile function recovery.