Recently, bail-out cholecystectomy (BOC) during laparoscopic cholecystectomy to avoid severe complications, such as vasculobiliary injury, has become widely used and increased in prevalence. However, ...current predictive factors or scoring systems are insufficient. Therefore, in this study, we aimed to test the validity of existing scoring systems and determine a suitable cutoff value for predicting BOC.
We retrospectively assessed 305 patients who underwent laparoscopic cholecystectomy and divided them into a total cholecystectomy group (n = 265) and a BOC group (n = 40). Preoperative and operative findings were collected, and cutoff values for the existing scoring systems (Kama's and Nassar's) were modified using a prospectively maintained database.
The BOC rate was 13% with no severe complications. A logistic regression analysis revealed that the Kama's score (odds ratio, 0.93; 95% confidence interval 0.91-0.96; P < 0.01) was an independent predictor of BOC. A cutoff value of 6.5 points gave an area under the curve of 0.81, with a sensitivity of 87% and a specificity of 67%.
Kama's difficulty scoring system with a modified cutoff value (6.5 points) is effective for predicting BOC.
Early on, laparoscopic liver resection (LLR) was limited to partial resection, but major LLR is no longer rare. A difficulty scoring system is required to guide surgeons in advancing from simple to ...highly technical laparoscopic resections. Subjects were 90 patients who had undergone pure LLR at three medical institutions (30 patients/institution) from January 2011 to April 2014. Surgical difficulty was assessed by the operator using an index of 1–10 with the following divisions: 1–3 low difficulty, 4–6 intermediate difficulty, and 7–10 high difficulty. Weighted kappa statistic was used to calculate the concordance between the operators' and reviewers' (expert surgeon) difficulty index. Inter‐rater agreement (weighted kappa statistic) between the operators' and reviewers' assessments was 0.89 with the three‐level difficulty index and 0.80 with the 10‐level difficulty index. A 10‐level difficulty index by linear modeling based on clinical information revealed a weighted kappa statistic of 0.72 and that scored by the extent of liver resection, tumor location, tumor size, liver function, and tumor proximity to major vessels revealed a weighted kappa statistic of 0.68. We proposed a new scoring system to predict difficulty of various LLRs preoperatively. The calculated score well reflected difficulty.
Introduction
The impact of liver cirrhosis on the difficulty of minimal invasive liver resection (MILR) remains controversial and current difficulty scoring systems do not take in to account the ...presence of cirrhosis as a significant factor in determining the difficulty of MILR. We hypothesized that the difficulty of MILR is affected by the presence of cirrhosis. Hence, we performed a 1:1 matched-controlled study comparing the outcomes between patients undergoing MILR with and without cirrhosis including the Iwate system and Institut Mutualiste Montsouris (IMM) system in the matching process.
Methods
Between 2006 and 2019, 598 consecutive patients underwent MILR of which 536 met the study inclusion criteria. There were 148 patients with cirrhosis and 388 non-cirrhotics. One-to-one coarsened exact matching identified approximately exact matches between 100 cirrhotic patients and 100 non-cirrhotic patients.
Results
Comparison between MILR patients with cirrhosis and non-cirrhosis in the entire cohort demonstrated that patients with cirrhosis were associated with a significantly increased open conversion rate, transfusion rate, need for Pringles maneuver, postoperative, stay, postoperative morbidity and postoperative 90-day mortality. After 1:1 coarsened exact matching, MILR with cirrhosis were significantly associated with an increased open conversion rate (15% vs 6%,
p
= 0.03), operation time (261 vs 238 min,
p
< 0.001), blood loss (607 vs 314 mls,
p
= 0.002), transfusion rate (22% vs 9%,
p
= 0.001), need for application of Pringles maneuver (51% vs 34%,
p
= 0.010), postoperative stay (6 vs 4.5 days,
p
= 0.004) and postoperative morbidity (26% vs 13%,
p
= 0.029).
Conclusion
The presence of liver cirrhosis affected both the intraoperative technical difficulty and postoperative outcomes of MILR and hence should be considered an important parameter to be included in future difficulty scoring systems for MILR.
Introduction
The Japanese difficulty score (JDS) categorizes laparoscopic hepatectomy into low, intermediate, and high complexity procedures, and correlates with operative and postoperative outcomes. ...We sought to perform a validation study to determine if the JDS correlates with operative and postoperative indicators of surgical complexity for patients undergoing robotic-assisted hepatectomy.
Methods
Retrospective review of 657 minimally invasive hepatectomy procedures was performed between January 2008 through March 2019. Outcomes included operative time, estimated blood loss (EBL), blood transfusion, complications, post-hepatectomy liver failure (PHLF), length of stay, 30-day readmission, and 30-day and 90-day mortality. Patients were grouped based on JDS defined as: low (< 4), intermediate (4–6), and high (7 +) complexity procedures. Statistical comparisons were analyzed by ANOVA or
χ
2
test.
Results
241 of 657 patients underwent robotic-assisted resection. Of these patients, 137 were included in the analysis based on JDS: 25 low, 58 intermediate, and 54 high. High JDS was associated with more major resections (≥ 4 contiguous segments) versus minor resections (median JDS 8 vs. 5,
P
< 0.0001). High JDS was associated with significantly longer operative times, higher EBL, and more blood transfusions. High JDS was associated with higher rates of PHLF at 16.7%, compared with 5.2% intermediate and 0.0% low, (
P
= 0.018). Complication rates, 30-day readmissions, and mortality rates were similar between groups. Median LOS was longer in patients with high JDS compared with intermediate and low (4 days vs. 3 days vs. 2 days;
P
= 0.0005).
Discussion
Higher JDS was associated with multiple indicators of operative complexity, including greater extent of resection, increased operative time, EBL, blood transfusion, PHLF, and LOS. This validation study supports the ability of the JDS to categorize patients undergoing robotic-assisted hepatectomy by complexity.
Graphical abstract
Although the effectiveness of robotic hepatectomy (RH) has been evaluated in several studies, the superiority of RH over other approaches has not been definitely established. Therefore, in the ...present propensity score–matched cohort study, we compared RH and laparoscopic hepatectomy (LH) in terms of perioperative and oncologic outcomes.
This retrospective study included patients who underwent RH or LH for benign and malignant liver lesions at a single center in Taiwan at any time between 2014 and 2020. Confounding factors, specifically age, sex, body mass index, American Society of Anesthesiologists score, IWATE criteria, and Charlson comorbidity index, were adjusted through propensity score matching (PSM).
A total of 329 patients were finally included in this study. Two homogeneous groups (RH and LH; n, 72 each) were formed using PSM. The RH group had a longer operative time (median: 231 vs.180 min, respectively; P = .001) and lower conversion (to open surgery) rate (9.7% vs.0.0%, respectively; P = .013) than did the LH group. However, the two groups did not differ in terms of other perioperative outcomes, specifically blood loss, hospital stay, intensive care unit admission, mortality, morbidity, or tumor margin status.
The rate of conversion to open surgery is lower in RH than in LH. Although operative time is longer in RH than in LH, RH is feasible and safe for patients with benign or malignant liver lesion. Our study also demonstrated comparable oncological results in patients with hepatocellular carcinoma between LH and RH group.
Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is still challenging due to complex lesion morphology. Success rates may vary among the 3 major coronary arteries, influenced by ...clinical and angiographic characteristics.
This study sought to evaluate the differences in the predictors of unsuccessful PCI in first-attempt CTO lesions of the 3 major coronary arteries compared with the J-CTO (Japanese CTO) score.
This study assessed 6,408 first-attempt CTO patients from the Japanese CTO-PCI expert registry between January 2014 and December 2021, randomly assigned to derivation and validation sets. Difficulty scores for each artery were determined by assigning points to predictive unsuccessful factors.
The CTO lesions were distributed as follows: left anterior descending coronary artery: 2,245 (35%), left circumflex coronary artery: 1,131 (18%), and right coronary artery (RCA): 3,032 (47%). Regarding success rates, left circumflex coronary artery CTO had the lowest procedural success rate (90%) followed by RCA CTO (92%) and left anterior descending coronary artery CTO (94%). RCA CTO was significantly longer and more severely angulated, requiring more often the retrograde approach. A multivariate logistic analysis revealed that predictors of failed PCI were different in CTO lesions among the 3 major coronary arteries, respectively. Moreover, our difficulty score for RCA CTO was superior to the J-CTO score in predicting unsuccessful PCI.
Clinical and angiographic differences might explain the discrepancies of success rates in CTO lesions among the 3 major coronary arteries. Our novel difficulty score was comparable to the J-CTO score in predicting unsuccessful CTO-PCI with a superior discriminatory capacity.
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Background
A difficulty score for laparoscopic adrenalectomy (LA) is lacking in the literature. A retrospective cohort study was designed to develop a preoperative “difficulty score” for LA.
Methods
...A multicenter study was conducted involving four Italian tertiary centers for adrenal disease. The population was randomly divided into two subsets: training group and validation one. A multicenter study was undertaken, including 964 patients. Patient, adrenal lesion, surgeon’s characteristics, and the type of procedure were studied as potential predictors of target events. The operative time (pOT), conversion rate (cLA), or both were used as indicators of the difficulty in three multivariate models. All models were developed in a training cohort (70% of the sample) and validated using 30% of patients. For all models, the ability to predict complicated postoperative course was reported describing the area under the curve (AUCs). Logistic regression, reporting odds ratio (OR) with
p
-value, was used.
Results
In model A, gender (OR 2.04,
p
= 0.001), BMI (OR 1.07,
p
= 0.002), previous surgery (OR 1.29,
p
= 0.048), site (OR 21.8,
p
< 0.001) and size of the lesion (OR 1.16,
p
= 0.002), cumulative sum of procedures (OR 0.99,
p
< 0.001), extended (OR 26.72,
p
< 0.001) or associated procedures (OR 4.32,
p
= 0.015) increased the pOT. In model B, ASA (OR 2.86,
p
= 0.001), lesion size (OR 1.20,
p
= 0.005), and extended resection (OR 8.85,
p
= 0.007) increased the cLA risk. Model C had similar results to model A. All scores obtained predicted the target events in validation cohort (OR 1.99,
p
< 0.001; OR 1.37,
p
= 0.007; OR 1.70,
p
< 0.001, score A, B, and C, respectively). The AUCs in predicting complications were 0.740, 0.686, and 0.763 for model A, B, and C, respectively.
Conclusion
A difficulty score based on both pOT and cLA (Model C) was developed using 70% of the sample. The score was validated using a second cohort. Finally, the score was tested, and its results are able to predict a complicated postoperative course.
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