Preoperative Scoring Research Articles

Construction of a preoperative scoring system to predict the difficulty level of colorectal endoscopic submucosal dissection.

BackgroundWe attempted to examine the factors contributing to the difficulty in performance of colorectal ESD, with the aim of constructing a scoring system that could help in prediction of the difficulty level of the procedure.Methods and materialsThe data were analyzed from two viewpoints: to determine the factors contributing to 1) non-en bloc resection and the factors contributing to 2) a slow resection speed. Factors falling under these two categories contributing to difficulty in performance of ESD were extracted and used to construct a scoring system. The validity of this scoring system was evaluated by calculating the correlation between the score and the resection speed in a different dataset.ResultsBased on the results of our analysis, we assigned scores for various factors as follows: 4 points for EMR of a scarred lesion, 1 point for tumors with a diameter of ≥ 30 mm, 2 points for lesions located in the liver/splenic flexure, 1 point for lesions located in the transverse colon, 3 points for LST-NG-PD/depressed lesions, 1 point for protruded lesions and LST-NG-F lesions (range 0–10). In the validation study, the rank correlation coefficient between the score according to the scoring system and the resection speed was -0.130, representing a weak and negative correlation (P = 0.03). We defined the difficulty level depending on the sum of the scores: 0–2, low difficulty level; 3–5, intermediate difficulty level; ≥ 6, high difficulty level. The average resection speed was 12.6 mm2/min in the group with scores of 0–2, 8.1 mm2/min in the group with scores of 3–5, and 5.5 mm2/min in the group with scores of ≥ 6 (11.2 mm2/min in all lesions).ConclusionOur colorectal ESD scoring system would be useful for selection of operators with the appropriate skill level in the procedure for colorectal ESD cases.

A novel prognostic score model based on combining systemic and hepatic inflammation markers in the prognosis of HBV-associated hepatocellular carcinoma patients

Objectives: The study aimed to evaluate the prognostic value of systemic inflammation markers [neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), Prognostic Nutritional Index (PNI)] and hepatic inflammation markers [aspartate aminotransferase-to-platelet ratio index (APRI), γ-glutamyl transferase (γ-GT)/alanine aminotransferase (ALT)] in patients with hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) and further to develop a novel prognostic score model.Methods: A total of 401 cases with HBV-associated HCC who underwent hepatectomy as initial therapy were included in the analysis. Kaplan–Meier was performed to construct survival curves and receiver operating characteristic (ROC) analysis was used to detect the optimal cut-off value of markers. The prognostic score model was constructed using significant inflammation markers in the Cox model. Each factor was given a score of 1 and patients were stratified according to the scores.Results: In the Cox model, α-fetoprotein (AFP), ALT, tumour differentiation, maximum size of tumours, TNM stage, PNI and γ-GT/ALT were independently prognostic factors. We established a preoperative inflammation-based prognostic scoring model combining PNI and γ-GT/ALT. The novel preoperative inflammation-based prognostic score was superior (area under the curve [AUC], 0.659) to 7th tumour-node-metastasis (TNM) stage (AUC, 0.600) despite no statistical significance (p = .1036).Conclusion: PNI and γ-GT/ALT are independent predictors for prognosis. The novel prognostic score model based on systemic and hepatic inflammation markers is suitable for the prognosis evaluation in patients with HBV-associated HCC.

Effectiveness of preoperative scoring in predicting the difficult and extremely difficult laparoscopic cholecystectomy

Background: To reduce the complications and conversion rate among the patients undergoing laparoscopic cholecystectomy, preoperative scores have been developed based upon the experience of surgeons and experience of the surgeries. Certain preoperative factors are thought to predict the difficult or extremely difficult laparoscopic cholecystectomy. Studies have shown the utility of the preoperative scoring to predict the difficult or extremely difficult laparoscopic cholecystectomy. To study the effectiveness of pre operative scoring in predicting the difficult and extremely difficult laparoscopic cholecystectomy.Methods: Present study was hospital based cross sectional diagnostic evaluation study carried out among 50 patients who were posted for laparoscopic cholecystectomy. The parameters which defined pre operative scoring as well as parameters which defined intra operative scoring were recorded and based on the total score, the difficulty level was assessed preoperatively and confirmed intraoperatively. The efficacy of preoperative scoring was determined by comparing it with intra operative scoring.Results: History of previous hospitalization, Palpable gall bladder, impacted stone and USG wall thickness/pericholecystic collection were significant preoperative factors. The overall diagnostic accuracy of preoperative scoring in predicting difficult laparoscopic cholecystectomy was 80%. Sensitivity was 94.44%, the specificity was 84.38%, positive predictive value was 77.27%, negative predictive value was 96.43%, likelihood ratio of a positive test was 6.044, and likelihood ratio of a negative test was 0.06584. Thus it can be said that the efficacy of preoperative scoring in predicting difficult laparoscopic cholecystectomy was very good.Conclusions: The efficacy of preoperative scoring in predicting difficult laparoscopic cholecystectomy was very good.

Quantified pre-operative neurological dysfunction predicts outcome after coronary artery bypass surgery.

Patients undergoing coronary artery bypass grafting (CABG) surgery may experience neurological impairment. We examined whether intraoperative regional cerebral oxygen saturation (rSO2) and neurological dysfunction prior to surgery, measured by robotic technology, are important predictors of post-operative performance following CABG surgery. Adult patients undergoing CABG surgery were recruited for this single-center prospective observational study. Intraoperative rSO2 was captured using the FORESIGHT cerebral oximeter. Neurological assessment was performed pre-operatively and 3months following surgery using robotic technology and a standardized pen-and-paper assessment. Linear regression models were generated to determine the predictive ability of both intraoperative rSO2 and pre-operative performance on post-operative neurological outcome. Forty patients had complete data available for analysis. Quantified pre-operative performance accounted for a significantly larger amount of variance in post-operative outcome compared to intraoperative rSO2. In particular, pre-operative scoring on a cognitive visuospatial task accounted for 82.2% of variance in post-operative performance (b = 0.937, t(37) = 12.98, p = 1.28e-5). Our results suggest that pre-operative performance is a stronger indicator of post-operative neurological outcome than intraoperative rSO2, and should be included as an important variable when elucidating the relationship between cerebral oxygen levels and post-operative neurological impairment. Rigorous neurological assessment prior to surgery can provide valuable information about each individual patient's path to recovery. Using robotic technology, quantified neurological impairment prior to CABG surgery may better predict post-operative neurological outcomes, compared to intraoperative rSO2 values.

Predicting operative difficulties during laparoscopic cholecystectomy using clinical and imaging criteria.

Introduction: Laparoscopic cholecystectomy has become the procedure of choice for the management of symptomatic gallstone disease. Difficulty in laparoscopic cholecystectomy is often encountered by surgeons and is associated with complications and a higher conversion rate. This study aims at identifying difficult laparoscopic cholecystectomies by clinical and imaging assessment and determining the utility of a pre-operative difficulty scoring system based on intra-operative findings. 
 PATIENTS and METHODS: A hospital based observational study was conducted including all patients above age 18 years undergoing laparoscopic cholecystectomy. Randhawa’s preoperative score was calculated for every patient based on history, clinical and imaging parameters and the degree of operative difficulty was predicted. Another scoring was done using Sugrue’s scoring system based on intra-operative findings. The outcome factors studied were degree of operative difficulty or need for conversion and intra-operative and post-operative complications. The statistical analysis was done by using EPI INFO software version 7.
 RESULTS: A total 84 patients with mean age 42.96 +14.34 years with 58 females and 26 males were enrolled. Of them 28 (33.33%) had difficult laparoscopic cholecystectomies. The conversion rate to open cholecystectomy was 9.52%. Age above 50 years, prior history of acute cholecystitis, thickened gall bladder wall and stone impaction of Hartmann’s pouch were statistically significant pre-operative risk factors. The sensitivity of the preoperative score in identifying difficult cases was 85.7% with the specificity of 96.43%; positive predictive value of 92.31% and the negative predictive value of 93.10% and the accuracy was 92.86%. 
 CONCLUSION: Pre-operative score and intra-operative findings are helpful in identifying difficult laparoscopic cholecystectomy.

Assessment of the difficulties in laparoscopic cholecystectomy among patients at Baghdad province.

BackgroundLaparoscopic surgery for gallbladder cholecystectomy has become the typical procedure for symptomatic gallbladder stone diseases treatment as a type of minimal invasiveness surgery associated with less pain and early recovery as there is minimal trauma of access without shrinking the exposure of operative field. The current study aimed to assess factors associated with difficult LC.MethodologyA cross sectional study was conducted at medical city complex (Baghdad Teaching Hospital) from October 2015 to October 2016, in which all patients that were admitted for LC were examined preoperatively, underwent LC and followed postoperatively to study factors associated with difficult LC. All LC were operated by qualified senior surgeons and supervised by well-trained resident doctors. A pre-operative score system parameters were obtained from history, clinical examination and investigation findings.ResultsLaparoscopic cholecystectomy was performed for 100 patients, 78% were females and 49% were among 40–59 years of age. The preoperative scoring revealed that in 58% of the patients the score indicate difficulty, and very difficult in only 7% of the patients. Difficult and very difficult operations were significantly associated with high difficult scoring preoperatively, gender, BMI and cause of admission.ConclusionHigh difficult scoring preoperatively, gender, BMI and cause of admission can be used as predictors for difficult LC.

Predicting difficulty in laparoscopic cholecystectomy preoperatively using a scoring system

Background: Laparoscopic cholecystectomy (LC), one of the most commonly performed surgical procedures worldwide. Preoperative assessment of difficulty is needed for frequent procedures such as LC in order to avoid complications, preparedness and to guarantee an efficient course of surgery. But there is no scoring system available to predict the difficulty preoperatively.Methods: In our study we have tried to predict a difficult LC preoperatively using a modified scoring system proposed by Randhawa et al. Patients diagnosed to have GB stones requiring LC were evaluated with following factors age, gender, duration of illness, h/o previous GB disease, underwent ERCP, BMI, abdominal scar whether infra umbilical or supraumbilical, palpable gallbladder, sonographic findings - gall bladder wall thickness, pericholecystic collection, impacted stone. Various clinical and radiological and intra-operative parameters were scored. Procedure is graded based on individual surgeon’s opinion as easy/difficult/very difficult. The parameters were analyzed to find their correlation to predicting difficult LC. Degree of difficulty was analyzed.Results: Preoperative scoring system proposed by Randhawa et al that we modified was found to be appropriate for predicting operative outcome in LC, having overall p value for the scoring system of <0.001, with sensitivity of 90.9, specificity of 73.1% and area under RoC of 0.876. In present study, palpable gall bladder, history of previous cholecystitis, and the radiological parameters i.e. GB wall thickness, pericholecystic fluid and impacted stone to be statistically significant.Conclusions: Present modified Randhawa and Pujahari scoring system is valuable and appropriate for predicting operative outcome in laparoscopic cholecystectomy. This, in turn, facilitates better preparedness.

Predictive Value of Chromogranin A and a Pre-Operative Risk Score to Predict Recurrence After Resection of Pancreatic Neuroendocrine Tumors

IntroChromogranin A (CgA) may be prognostic for patients with neuroendocrine tumors; however, the clinical utility of this test is unclear. MethodsPatients undergoing resection for pancreatic neuroendocrine tumors (pNET) were selected from the eight institutions of the US Neuroendocrine Tumor Study Group database. Cox regression was used to identify pre-operative variables that predicted recurrence-free survival (RFS), and those with p < 0.1 were included in a risk score. The risk score was tested in a unique subset of the overall cohort. ResultsIn the entire cohort of 287 patients, median follow-up time was 37 months, and 5-year RFS was 73%. Cox regression analysis identified four variables for inclusion in the risk score: CgA > 5x ULN (HR 4.3, p = 0.01), tumor grade 2/3 (HR 3.7, p = 0.01), resection for recurrent disease (HR 6.2, p < 0.01), and tumor size > 4 cm (HR 4.5, p = 0.1). Each variable was assigned 1 point. Risk-score testing in the unique validation cohort of 63 patients revealed a 95% negative predictive value for recurrence in patients with zero points. DiscussionThis simple pre-operative risk scoring system resulted in a high degree of specificity for identifying patients at low-risk for tumor recurrence. This test can be utilized pre-operatively to aid informed decision-making.

A retrospective analysis with quality of life assessment of nasal surgery for nasal obstruction

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Nasal obstruction is a common health problem that disrupts a person’s quality of life (QoL). The Nasal Obstruction Symptom Evaluation scale (NOSE) is a QoL scale with questions specific to nasal obstruction symptoms. This study aimed to evaluate surgical success in patients who underwent nasal septal deviation surgery by using a NOSE assessment, thus determining the importance and efficacy of surgery in this group of patients.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This study was conducted in between January 2016 and June 2017, including a total of 60 patients. The age range of the patients was 18–57 (mean, 34.4±9.9 years). The preoperative and postoperative scoring and surgeries were performed by the same investigator. The surgeries were septoplasty and radiofrequency applied to the inferior concha to overcome conchal hypertrophy. Preoperative mean scores were compared with postoperative second-month values. The importance of difference was evaluated with the Wilcoxon signed-rank test. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Preoperative minimum, maximum and mean scores were 65.0, 100.0 and 83.4 (83.41±8.15), respectively. Postoperative minimum, maximum and mean scores were 10.0, 35.0 and 21.6 (21.66±8.06), respectively. The difference in mean scores was significant (Z=−6.778; p&amp;lt;0.001).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The difficulty in evaluating patient satisfaction and postoperative success stems from differences in each surgeon’s approach and the comparison of preoperative and postoperative findings. This study, which was carried out by the same researcher for all steps, differs it from similar studies.&lt;/p&gt;

Formulating a preoperative risk scoring system for elderly patients with hip fracture

Objective To establish a preoperative risk scoring system for elderly patients with hip fracture on the basis of investigation into the factors influencing their mortality during hospitalization. Methods The data were collected from the database of hospitalization summary reports (HSR) of Beijing Public Health Commission concerning the 14,577 patients who had been 55 years old or older and hospitalized for hip fracture from January 1, 2006 throughout December 31, 2010 at the 35 top-rank hospitals in Beijing. They were divided into a surgery group and a non-surgery group. Two multivariable risk-adjustment models were established for the 2 groups on the basis of an investigation into the factors influencing their mortality during hospitalization. Finally a preoperative risk scoring system for elderly patients with hip fracture was formulated according to the valuation of the least common multiples of β coefficients of the risk factors. Results Besides senior age and male gender, 10 different comorbidities were independently associated with in-hospital mortality, particularly pulmonary embolism, respiratory failure, renal failure and diabetes. The risk for inpatient mortality associated with a specific comorbidity was relatively higher in the surgery group than in the non-surgery group. The risk-adjustment models based on the variables had better accuracy in predicting in-hospital mortality (ROC=0.91 in surgery group versus ROC=0.85 in non-surgery group). In our preoperative risk scoring system for elderly patients with hip fracture, 10 points were for an age of 65 to 74 years old, 14 points for an age of 75 to 84 years old, 18 points for an age beyond 85 years old, 4 points for male gender, 20 points for pulmonary embolism, 18 points for respiratory failure, 10 points for renal insufficiency, 8 points for diabetes, 8 points for heart failure, 7 points for malignant tumor, 7 points for lung infection, 7 points for disturbance of water, electrolyte and acid-base balance, 6 points for arrhythmia, and 6 points for cerebral infarction, totaling 119 points. Conclusions The primary risk factors for in-hospital mortality in the elderly patients with hip fracture seem to be senior age, male gender and 10 different comorbidities. A preoperative risk scoring system has been successfully established for elderly patients with hip fracture. Key words: Hip; Fracture, bone; Aged; Comorbidities; Mortality

Surgical treatment of old die-punch fractures of distal radius

Objective To report the effects of surgical treatment of old die-punch fractures of the distal radius. Methods A retrospective study of case series was made of the 21 old die-punch fractures of the distal radius which had been surgically treated from January 2012 to January 2017 at Department of Orthopaedics, Shandong Provincial Hospital. There were 13 males and 8 females, aged from 34 to 63 years (average, 46.9 years). According to the preoperative definite diagnoses by the X-ray and CT images, there were 14 metacarpal compression fractures and 7 dorsal compression fractures. The palmar approach was used in 13 cases, the dorsal approach in 7 and the combined approach in one. Autogenous iliac bone grafting was performed for all the cases. Their preoperative and postoperative Cooney scoring and visual analogue scale (VAS) of the wrist, and postoperative complications as well, were observed and recorded. Results This cohort was followed up for 8 to 14 months (average, 9.2 months). All their postoperative wounds healed by the first intention. Their Cooney functional scores of the wrist were, respectively, 58.5±4.2 and 84.0±3.1 points preoperatively and at the final follow-up, and their corresponding VAS scores 7.6±0.9 and 3.4±1.3 points, showing significant differences between preoperation and the final follow-up (P<0.05). Carpal arthritis was observed in one case. Conclusion For old die-punch fractures of the distal radius, surgical treatment can obviously reduce pain, improve function of the wrist and enhance the quality of life of the patients. Key words: Wrist joint; Fracture fixation, internal; Range of motion, articular; Die-punch fractures

A novel preoperative scoring system for the indication of unicompartmental knee arthroplasty, as predictor of clinical outcome and satisfaction.

Proper patient selection is a crucial factor for the outcome of the unicompartmental knee arthroplasty (UKA). However, there is still not a clear consensus on which patients could benefit the utmost from a UKA. The purpose of this prospective study was to introduce a novel, preoperative, predictive score (Unicompartmental Indication Score, UIS) to aid proper patient selection in UKA. A total of 152 patients with an average age of 68years and a mean follow-up of 27months were evaluated preoperatively with the UIS and postoperative at every follow-up. Correlation analysis was applied to identify potential relationships between the UIS, functional outcomes, pain relief, patient satisfaction, and range of motion. The ROC analysis was used to identify the best cutoff value of the UIS, which would have predicted an optimal outcome following UKA. The majority of the patients (91%) were satisfied with the operation, with 61% reporting excellent and 30% good satisfaction. The UIS was positively correlated to the postoperative Knee Society Score (KSS) for both pain (r = 0.26, p < 0.001) and function (r = 0.31, p < 0.001). The UIS was also positively correlated to the patient satisfaction (p = 0.46, p < 0.001) and maximum postoperative flexion (r = 0.25, p < 0.001). The ROC analysis provided an ideal cutoff for UIS at 25 points (sensitivity: 75%, sensibility: 93%, area under the curve: 86%). At a mean follow-up of 27months (range 24-37), we observed three revisions in 152 consecutive UKA with a mean UIS of 27 points (range 20-30). The newly introduced UIS score might be a reliable preoperative scoring system to predict patients with excellent satisfaction, functional outcome, pain relief and possibly implant survivorship following UKA, and therefore, could help the proper patient selection and decision-making in UKA. Prospective study, II.

Glottic exposure for transoral laser microsurgery: Proposal of a mini-version of the laryngoscore.

Good laryngeal exposure (GLE) is typically regarded as an essential prerequisite for transoral laser microsurgery (TLM). The Laryngoscore is a preoperative scoring system aimed at predicting glottic visualization through the laryngoscope using easy patient-derived parameters. However, the presence of subjective variables may hamper its reliability and reproducibility. The aim of the present study was to provide a validation of the Laryngoscore and to develop a revised mini-version of the same, called mini-Laryngoscore (mLS), which could allow even quicker, yet sufficiently accurate, preoperative prediction of GLE. Prospective cohort study. We prospectively evaluated 310 consecutive patients submitted to TLM between 2014 and 2017, grading each patient according to the variables considered in the Laryngoscore. Among the 11 variables of the previous Laryngoscore, three were confirmed as statistically significant at validation: interincisors gap, thyromental distance, and upper jaw dental status. We chose these three variables as part of the revised mLS (ranging from 0 to 4). In our cohort, 30% of the patients obtained a score of 0, 57% a score of 1, 11% a score of 2, and 2% a score of ≥3. GLE was achieved in 97%, 85%, 65%, and 20% of cases, respectively. Our validation confirmed the predictive ability of the Laryngoscore. Furthermore, although composed of only three clinical parameters, the mLS was still able to convey useful information regarding the possibility of obtaining GLE. 2 Laryngoscope, 129:1617-1622, 2019.

Predictors of distant metastasis on exploration in patients with potentially resectable pancreatic cancer

BackgroundPatients with potentially resectable pancreatic ductal adenocarcinoma (PDAC) are frequently found to be unresectable on exploration due to small distant metastasis. This study was to investigate predictors of small distant metastasis in patients with potentially resectable PDAC.MethodsPatients who underwent surgical exploration for potentially resectable PDAC from 2013 to 2014 were reviewed retrospectively and divided into two groups according to whether distant metastases were encountered on exploration. Then, univariate and multivariate logistic regression analyses were used to identify predictors of distant metastasis. A scoring system to predict distant metastasis of PDAC on exploration was constructed based on the regression coefficient of a multivariate logistic regression model.ResultsA total of 235 patients were included in this study. Mean age of the study population was 61.7 ± 10.4 years old. Upon exploration, distant metastases were found intraoperatively in 62 (26.4%) patients, while the remaining 173 were free of distant metastases. Multivariate logistic regression analysis identified that age ≤ 62 years old (p < 0.001), male sex (p = 0.011), tumor size ≥4.0 cm (p < 0.001), alanine aminotransferase level (ALT) < 125 U/L (p < 0.001), and carbohydrate antigen (CA19–9) level ≥ 385 U/mL (p < 0.001) were independent risk factors for occult distant metastasis of PDAC. A preoperative scoring system (0–8 points) for distant metastasis on exploration was constructed using these five factors. The receiver operating characteristic curves showed that the area under the curve of this score was 0.85. A score of 6 points was suggested to be the optimal cut-off value, and the sensitivity and specificity were 85% and 69%, respectively.ConclusionsDistant metastasis is still frequently encountered on exploration for patients with potentially resectable PDAC. Younger age, male sex, larger tumor size, low ALT level and high CA19–9 level are independent predictors of unexpected distant metastasis on exploration.

Laparoscopic Tissue Extraction: A McBurney's Approach

Objective: Tissue extraction has evolved over the past decades to move away from power morcellation and favor a more conservative approach, taking into consideration malignant potential of pre-operatively evaluated uterine pathology. We thoroughly demonstrate a safe and dynamic alternative laparoscopic tissue extraction technique, fortifying our scope of patient assessment with the Pre-Operative Sarcoma Scoring System (PRESS) score.

Preoperative PROSTATE scoring system: a potential predictive tool for the risk of biochemical recurrence after radical prostatectomy.

PurposeTo study the association between the preoperative PROSTATE scoring system and the prediction of biochemical recurrence (BCR) risk, after radical prostatectomy (RP) in prostate cancer patients.Patients and methodsA total of 340 patients who underwent a laparoscopic radical prostatectomy in Peking University First Hospital between November 2007 and March 2016 were included in the study. The preoperative PROSTATE scoring system was measured and calculated. The performance of the scoring system to predict BCR risk was estimated using the receiver operating characteristic curve (ROC curve). BCR-free survival was analyzed using the Kaplan– Meier method, and the log-rank test was applied to compare the differences in risk among the patient groups. The Cox proportional hazards regression was used to analyze the performance of the grouped PROSTATE scores.ResultsOf the total population, 91 (26.8%) patients had BCR. The PROSTATE score was significantly different between the BCR-developed and BCR-free groups (P<0.001). The ROC curve analysis of the scoring system showed an accuracy of 70.7% (95% CI 0.643–0.771) (P<0.001). The percentage of BCR in the high-risk (10–15), moderate-risk (5–9) and low-risk (0–4) groups was 63.3%, 24.6% and 10.3% respectively (P<0.001). The Cox proportional hazards regression analysis revealed that the grouped score was an independent predictor of BCR after RP (HR=2.002; 95% CI 1.222–3.280) (P=0.006).ConclusionThe PROSTATE scoring system performed adequately in predicting the risk of BCR after RP. The scoring system can assist in decision-making about the operation and post- operative follow-up for patients with high-risk.

Pre-operative Prediction of Difficulties in Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy (LC) is one of the most common laparoscopic procedures being performed by general surgeons all over the world. Preoperative prediction of the risk of conversion or difficulty of operation is an important aspect of planning laparoscopic surgery. The purpose of our prospective study was to analyze various risk factors and to predict difficulty and degree of difficulty preoperatively by the use of a scoring system. Objective: The objective of this study is to evaluate a Scoring system to predict difficult laparoscopic Cholecystectomy. Patients and Methods: Laparoscopic cholecystectomy was done in the department of surgery, EL Hussin University Hospital. The parameters considered in the preoperative scoring method were old age, male sex, history of hospitalization, obesity, previous abdominal surgery scar, and palpable gall bladder, wall thickness of gall bladder, pericholecystic collection and impacted stone. A total of 50 patients were included in the study. Results: We found that history of hospitalization; palpable gall bladder, impacted stone and gall bladder wall thickness were statistically significant factors for prediction of difficult laparoscopic cholecystectomy. Conversion rate from laparoscopic to open cholecystectomy was found to be 4%. Conclusion: High risk patient may be informed beforehand regarding the probability of conversion and hence they may have a chance to make arrangements. Surgeons can also be aware about the possible complications that may arise in high risk patients.

A Preoperative Prognostic Scoring System to Predict Prognosis for Resectable Pancreatic Cancer: Who Will Benefit from Upfront Surgery?

BackgroundUpfront surgery is recommended in patients with potentially resectable pancreatic ductal adenocarcinoma (R-PDAC) by National Comprehensive Center Network (NCCN) guidelines. However, even among R-PDACs, there is a subset that demonstrates extremely poor prognosis. The purpose of this study was to identify preoperative prognostic factors for upfront surgical resection of R-PDACs. MethodsThe records of 278 consecutive patients with PDAC who underwent curative resection between 2001 and 2015 in a single institution were retrospectively reviewed. Preoperative factors to predict prognosis in patients with R-PDAC according to the NCCN guidelines were analyzed. ResultsOf the 278 patients who underwent resection, 153 R-PDACs received upfront surgery with a median survival time (MST) of 26.4 months. Tumor location (pancreatic head) (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.14–3.40; P = 0.015), preoperative cancer antigen 19–9 (CA19–9) > 100 U/mL (OR 1.92, 1.31–2.80; P = 0.0009), and tumor size > 20 mm (OR 1.50, 1.02–2.19; P = 0.038) were identified as preoperative independent predictive risk factors for poor prognosis in patients with R-PDACs. In the patients with R-PDAC, 5-year survival was 60.7%, 21.5%, and 0% in patients with 0, 1 or 2, and 3 risk factors, respectively. There were significant differences in overall survival between the three groups (P < .0001). ConclusionsA preoperative prognostic scoring system using preoperative tumor location, tumor size, and CA19-9 enables preoperative prediction of prognosis and facilitates selection of appropriate treatment for resectable pancreatic cancer.

Role of a pre-operative radiological scoring system in determining resectability for potentially resectable hilar cholangiocarcinoma

AimsCholangiocarcinoma is a rare cancer arising from the biliary tree. Case series indicate that 25–40% of all borderline resectable primary tumours are potentially resectable. The Memorial Sloane Kettering System (MSKCC) stratifies patients for resectability by longitudinal and radial extension of the hilar tumour. The Bismuth-Corlette system describes the longitudinal extension of the tumour within the biliary duct system. We sought to validate and, if possible, augment these two scores within an independent validation cohort. MethodsPatients diagnosed with hilar cholangiocarcinoma between January 2009 and December 2016 were analysed from a prospectively held database. Patients with distal cholangiocarcinoma, peripheral cholangiocarcinoma and gallbladder cancer were excluded. Comparison of surgical findings to pre-operative radiological imaging was undertaken at the time of surgery. ResultsThe validation cohort was formed of 198 patients, of which, 55 (27.8%) patients underwent resection. Logistic regression analyses identified that BC score, MSKCC score, age at diagnosis and left artery involvement were all significant independent predictor's univariately. BC score explained 28% of the variability in resectability compared to 26% explained by MSKCC. In combination, the model consisting of BC score, age at diagnosis and left artery involvement explained 39% of variability in resectability compared to the 34% explained same model including MSKCC score instead of BC score. ConclusionIn this cohort an augmented BC score, incorporating left hepatic artery involvement, is more discriminative in predicting resectability than the current MSKCC system.

Cystic Appearance on Imaging Methods (Bosniak III-IV) in Histologically Confirmed Papillary Renal Cell Carcinoma is Mainly Characteristic of Papillary Renal Cell Carcinoma Type 1 and Might Predict a Relatively Indolent Behavior of Papillary Renal Cell Carcinoma

Aim: The aim of this study was to determine the proportion of cystic tumors according to preoperative CT (Bosniak III, IV) among surgically treated patients with histologically confirmed papillary renal cell carcinoma (pRCC) and to assess progression rates among patients with and without cystic appearance on imaging. Methods: A total of 138 patients with pRCC histology surgically treated in the period of January 2007–March 2017 were included. Clinical and radiological characteristics, type of surgery, histopathology results, and follow-up data were recorded and statistically evaluated. Results: Forty-one cases (29.7%) of cystic lesions (10× BIIF, 14× BIII, 17× BIV) were detected by CT. Patients with pRCC1 significantly more frequently presented with cystic appearance on CT (33/78; 42.3%) in comparison to other papillary types (8/60; 13.3%; p = 0.0002). During a median follow-up time of 49.4 months, only 2 patients with cystic lesions progressed after surgery. Conclusions: Cystic appearance on imaging methods is mainly a characteristic of pRCC1 (42.3%). Cystic morphology on imaging might predict a relatively indolent behavior of all pRCC types. Preoperative scoring systems including tumor growth patterns (cystic vs. solid) are needed for further classification.