BackgroundThis study aimed to externally validate and upgrade the recent difficulty scoring system (DSS) proposed by Halls et al. to predict intraoperative complications (IOC) during laparoscopic liver resection (LLR).MethodsThe DSS was validated in a cohort of 128 consecutive patients undergoing pure LLRs between 2008 and 2019 at a single tertiary referral center. The validated DSS includes four difficulty levels based on five risk factors (neoadjuvant chemotherapy, previous open liver resection, lesion type, lesion size and classification of resection). As established by the validated DSS, IOC was defined as excessive blood loss (> 775 mL), conversion to an open approach and unintentional damage to surrounding structures. Additionally, intra- and postoperative outcomes were compared according to the difficulty levels with usual statistic methods. The same five risk factors were used for validation done by linear and advanced nonlinear (artificial neural network) models. The study was supported by mathematical computations to obtain a mean risk curve predicting the probability of IOC for every difficulty score.ResultsThe difficulty level of LLR was rated as low, moderate, high and extremely high in 36 (28.1%), 63 (49.2%), 27 (21.1%) and 2 (1.6%) patients, respectively. IOC was present in 23 (17.9%) patients. Blood loss of >775 mL occurred in 8 (6.2%) patients. Conversion to open approach was required in 18 (14.0%) patients. No patients suffered from unintentional damage to surrounding structures. Rates of IOC (0, 9.5, 55.5 and 100%) increased gradually with statistically significant value among difficulty levels (P < 0.001). The relations between the difficulty level, need for transfusion, operative time, hepatic pedicle clamping, and major postoperative morbidity were statistically significant (P < 0.05). Linear and nonlinear validation models showed a strong correlation (correlation coefficients 0.914 and 0.948, respectively) with the validated DSS. The Weibull cumulative distribution function was used for predicting the mean risk probability curve of IOC.ConclusionThis external validation proved this DSS based on patient’s, tumor and surgical factors enables us to estimate the risk of intra- and postoperative complications. A surgeon should be aware of an increased risk of complications before starting with more complex procedures.
Background This study aimed to quantitatively evaluate the learning curve of laparoscopic liver resection (LLR) of a single surgeon. Patients and methods A retrospective review of a prospectively maintained database of liver resections was conducted. 171 patients undergoing pure LLRs between April 2008 and April 2021 were analysed. The Halls difficulty score (HDS) for theoretical predictions of intraoperative complications (IOC) during LLR was applied. IOC was defined as blood loss over 775 mL, unintentional damage to the surrounding structures, and conversion to an open approach. Theoretical association between HDS and the predicted probability of IOC was utilised to objectify the shape of the learning curve. Results The obtained learning curve has resulted from thirteen years of surgical effort of a single surgeon. It consists of an absolute and a relative part in the mathematical description of the additive function described by the logarithmic function (absolute complexity) and fifth-degree regression curve (relative complexity). The obtained learning curve determines the functional dependency of the learning outcome versus time and indicates several local extreme values (peaks and valleys) in the learning process until proficiency is achieved. Conclusions This learning curve indicates an ongoing learning process for LLR. The proposed mathematical model can be applied for any surgical procedure with an existing difficulty score and a known theoretically predicted association between the difficulty score and given outcome (for example, IOC).
Namen: Rak debelega črevesa in danke (RDČD) je v svetovnem merilu tretja najpogostejša maligna bolezen in najpogosteje zaseva v jetra. Namen raziskave je predstaviti možnosti kirurškega zdravljenja jetrnih zasevkov in rezultate zdravljenja. Metode: Opravili smo retrospektivni pregled prospektivno vodene datoteke resekcij jetrnih zasevkov RDČD na Kliničnem oddelku za abdominalno in splošno kirurgijo Univerzitetnega kliničnega centra Maribor. Raziskava temelji na principu pristopa k zdravljenju z namenom ozdravitve. Analizirali smo število posegov, ponovne posege, zaplete in preživetje. Rezultati: Od januarja 2000 do decembra 2020 je bilo izvedenih 631 kirurških posegov zaradi jetrnih zasevkov RDČD. 352 (74,4 %) bolnikov je bolnikov več kot enega. Resekcij jeter je bilo 541 (85,7 %), in sicer 389 manjših in 152 velikih resekcij. Radiofrekvenčno ablacijo smo opravili v 61 (9,7 %) in eksploracijo v 29 (4,6 %) primerih. Ponovnih posegov je bilo 138 (21,9 %). Hudi zapleti (stopnja ≥ 3a po klasifikaciji Clavien-Dindo) so se pojavili po 84 (13,3 %) posegih. 90-dnevna pooperativna smrtnost je znašala 3,8 %. Mediano preživetje pri seštevku 0 v Clinical Risk Score je 69 mesecev; 5- in 10-letni preživetji sta 57-% oziroma 38-%. Zaključek: Kirurška odstranitev jetrnih zasevkov v celoti in ugodni prognostični dejavniki omogočajo dolgoročno preživetje bolnikov z jetrnimi zasevki RDČD.
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