A simple difficulty scoring system for laparoscopic total mesorectal excision

Splenic flexure mobilization: does body topography matter?

BACKGROUND

Splenic flexure mobilization can be technically challenging, and its oncological benefits remain uncertain. This study aims to explore the relationship between patient and clinical characteristics and splenic flexure mobilization time as well as the implications of prolonged splenic flexure mobilization duration.

METHODS

This retrospective cohort study includes 105 patients who underwent laparoscopic distal colorectal cancer surgery between 2013 and 2018. The study analyzed patient characteristics, duration of surgical steps, and postoperative outcomes. Splenic flexure mobilization time was assessed using operation videos, and the impact of patient-related factors on splenic flexure mobilization complexity was examined.

RESULTS

The study identified significant correlations of higher body mass index (BMI) (p = 0.0086), weight (p = 0.002), and height (p = 0.043) with longer splenic flexure mobilization time. Gender did not significantly influence splenic flexure mobilization duration. Splenic flexure mobilization time was correlated with the durations of other individual surgical steps (Step 1: medial-to-lateral dissection [p = 0.0013], Step 2: pelvic dissection [p = 0.067], Step 3: dissection of white line and mobilization of descending colon [p = 0.0088], Step 5: stapling, resection, extraction of the specimen, and anastomosis [p = 0.04]) and the overall operation time (p < 0.0001). A 10-min cutoff point predicts the total operation time more efficiently than other potential thresholds.

CONCLUSION

This research suggests that patient characteristics including BMI, weight, and height may serve as indicators for prolonged splenic flexure mobilization time in laparoscopic distal colorectal cancer surgery. Longer splenic flexure mobilization durations were correlated with extended durations of other surgical steps. A BMI-based approach to anticipate SFM duration may enhance preoperative planning, potentially aiding in surgical decision-making.

TRIAL REGISTRATION

E-10840098-772.02-61604 2.2.2019.

Development and validation of a nomogram for predicting operating time in laparoscopic anterior resection of rectal cancer

Aims

The goal of this study is to create and verify a nomogram estimate operating time in rectal cancer (RC) patients based on clinicopathological factors and MRI/CT measurements before surgery.

Materials and Methods

The nomogram was developed in a cohort of patients who underwent laparoscopic anterior resection (L-AR) for RC. The clinicopathological and pelvis parameters were collected. Risk factors for a long operating time were determined by univariate and multivariate logistic regression analyses, and a nomogram was established with independent risk factors. The performance of the nomogram was evaluated. An independent cohort of consecutive patients served as the validation dataset.

Results

The development group recruited 159 RC patients, while 54 patients were enrolled in the validation group. Independent risk factors identified in multivariate analysis were a distance from the anal verge <5 cm (P = 0.024), the transverse diameter of the pelvic inlet (P < 0.001), mesorectal fat area (P = 0.017), and visceral fat area (P < 0.001). Then, a nomogram was built based on these four independent risk factors. The C-indexes of the nomogram in the development and validation group were 0.886 and 0.855, respectively. And values of AUC were the same with C-indexes in both groups. Besides, the calibration plots showed satisfactory consistency between actual observation and nomogram-predicted probabilities of long operating time.

Conclusions

A nomogram for predicting the risk of long operating duration in L-AR of RC was developed. And the nomogram displayed a good prediction effect and can be utilized as a tool for evaluating operating time preoperatively.

Development and validation of a preoperative difficulty scoring system for endoscopic resection of gastric gastrointestinal stromal tumor: a multi-center study

BACKGROUND

Endoscopic resection (ER) is a promising technique for resecting gastric gastrointestinal stromal tumors (gGISTs); however, ER is technically challenging. This study aimed to develop and validate a difficulty scoring system (DSS) to determine the difficulty for ER of a gGIST.

METHODS

This retrospective study enrolled 555 patients with gGISTs in multi-centers from December 2010 to December 2022. Data on patients, lesions, and outcomes of ER were collected and analyzed. A difficult case was defined as an operative time ≥ 90 min, or the occurrence of severe intraoperative bleeding, or conversion to laparoscopic resection. The DSS was developed in the training cohort (TC) and validated in the internal validation cohort (IVC) and external validation cohort (EVC).

RESULTS

The difficulty occurred in 97 cases (17.5%). The DSS comprised the following: tumor size ≥ 3.0 cm (3 points) or 2.0-3.0 cm (1 point); location in the upper third of the stomach (2 points); invasion depth beyond the muscularis propria (2 points); lack of experience (1 point). The area under the curve (AUC) of DSS in IVC and EVC was 0.838 and 0.864, respectively, and the negative predictive value (NPV) was 0.923 and 0.972, respectively. The proportions of difficult operation in easy (score 0-3), intermediate (score 4-5), and difficult (score 6-8) categories were 6.5%, 29.4%, and 88.2% in the TC, 7.7%, 45.8%, and 85.7% in the IVC, and 7.0%, 29.4%, and 85.7% in the EVC, respectively.

CONCLUSIONS

We developed and validated a preoperative DSS for ER of gGISTs based on tumor size, location, invasion depth, and endoscopists' experience. This DSS can be used to grade the technical difficulty before surgery.

Subjective Difficulty Scale in Liver Transplantation: A Prospective Observational Study

The predictive value of a subjective difficulty scale (DS) after surgical procedures is unknown. The objective of this study was to evaluate the prognostic value of a DS after liver transplantation (LT) and to identify predictors of difficulty. Surgeons prospectively evaluated the difficulty of 441 consecutive liver transplantations from donation after brain death at the end of the surgery by using a DS from 0 to 10 (“the easiest to the hardest you can imagine”). DS was associated with severe morbidity. The risk of graft loss at 1 year remained unchanged from 0 to 6 but increased beyond 6. Graft survival and patient survival of group with DS 7–10 was significantly impaired compared to groups with DS: 0–3 or DS: 4–6 but were significantly impaired for the group with DS: 7–10. Independent predictors of difficult LT (DS ≥ 7) were annular segment 1, transjugular intrahepatic portosystemic shunt, retransplantation beyond 30 days, portal vein thrombosis, and ascites. Of them, ascites was a borderline non-significant covariate (p = .04). Vascular complications occurred more often after difficult LT (20.5% vs. 5.9%), whereas there was no difference in the other types of complications. DS can be used to tailor monitoring and anticipate early complications. External validation is needed.