A protocol for the development of the STROCSS guideline: Strengthening the Reporting of Cohort Studies in Surgery

Predictive value of Hajibandeh index in determining peritoneal contamination in acute abdomen: A cohort study and meta-analysis

BACKGROUND

Hajibandeh index (HI), derived from combined levels of C-reactive protein, lactate, neutrophils, lymphocytes and albumin, is a modern predictor of peritoneal contamination and mortality in patients with acute abdominal pathology.

AIM

To validate the performance of HI in predicting the presence and nature of peritoneal contamination in patients with acute abdominal pathology in a larger cohort study and to synthesis evidence in a systematic review and meta-analysis.

METHODS

The STROBE guidelines and the PRISMA statement standards were followed to conduct a cohort study (ChiCTR2200056183) and a meta-analysis (CRD42022306018), respectively. All adult patients undergoing emergency laparotomy for acute abdominal pathology were eligible. The accuracy of the HI was evaluated using receiver operating characteristic (ROC) curve analysis in the cohort study and using weighted summary area under the curve (AUC) under the fixed and random effects modelling in the meta-analysis. The Quality Assessment of Diagnostic Accuracy Studies 2 criteria were used for methodological quality assessment of the included studies.

RESULTS

A total of 1437 patients were included (700 from the cohort study and 737 from the literature search). ROC curve analysis of the cohort study showed that the AUC of HI for presence of contamination, purulent contamination and feculent contamination were 0.79 [95% confidence interval (CI): 0.76-0.82, P < 0.0001], 0.76 (95%CI: 0.72-0.80, P < 0.0001), and 0.83 (95%CI: 0.79-0.86, P < 0.0001), respectively. The meta-analysis showed that the pooled AUC of HI for presence of contamination, purulent contamination and feculent contamination were 0.79 (95%CI: 0.75-0.83), 0.78 (95%CI: 0.74-0.81), and 0.80 (95%CI: 0.77-0.83), respectively.

CONCLUSION

The HI is a strong and accurate predictor of intraperitoneal contamination. Although the available evidence is robust, it is limited to the studies conducted by our evidence synthesis group. We encourage other researchers to validate performance of HI in predicting the presence of intraperitoneal contamination and more importantly in predicting mortality following emergency laparotomy.

Does Timing of Completion Radical Cholecystectomy Determine the Survival Outcome in Incidental Carcinoma Gallbladder: A Single-Center Retrospective Analysis

Introduction

Incidental discovery of gallbladder cancer (GBC) on postoperative histopathology or intra-operative suspicion is becoming increasingly frequent since laparoscopic cholecystectomy became the standard of care for gallstone disease. Incidental GBC (IGBC) portends a better survival than primarily detected GBC. Various factors affect the outcome of re-resection with the timing of re-intervention an important determinant of survival.

Methods

All patients of IGBC who underwent curative resection from January 2009 to December 2018 were considered for analysis. Details of demographic profile, index surgery, and operative findings on re-resection, histopathology and follow-up were retrieved from the prospectively maintained database. Patients were evaluated in three groups based on the interval between index cholecystectomy and re-resection: Early (<4 weeks), Intermediate (4-12 weeks) and Late (>12 weeks), using appropriate statistical tests.

Results

Ninety-one patients were admitted with IGBC during the study period of which 48 underwent re-resection with curative intent. The median age of presentation was 55 years (31-77 years). The median duration of follow-up was 40.6 months (Range: 1.2-130.6 months). Overall and disease-free survival among the above-mentioned three groups was the best in the early group (104 and 102 months) as compared to the intermediate (84 and 83 months) and late groups (75 and 73 months), though the difference failed to achieve statistical significance (p=0.588 and 0.581). On univariate analysis, factors associated with poor outcome were node metastasis, need for common bile duct (CBD) excision and high-grade tumor. However, on multivariate analysis, poor differentiation was the only independent factor affecting survival.

Conclusion

Early surgery, preferably within four weeks, possibly entails better survival in incidentally detected GBC. The grade of a tumor, however, is the most important determinant of survival in IGBC.

Diagnostic accuracy of 3D imaging combined with intra-operative ultrasound in the prediction of post-hepatectomy liver failure

Background

The risk of post-hepatectomy liver failure (PHLF) is difficult to predict preoperatively. Accurate preoperative assessment of residual liver volume is critical in PHLF. Three-dimensional (3D) imaging and intra-operative ultrasound (IOUS) offer significant advantages in calculating liver volume and have been widely used in hepatectomy risk assessment. Our research aimed to explore the accuracy of 3D imaging technique combining IOUS in predicting PHLF after hepatectomy.

Methods

We used a retrospective study design to analyze patients who underwent hepatectomy with 3D imaging combined with IOUS between 2017 and 2020. Utilizing 3D reconstruction, the patient's residual liver volumes (PRLVs) and ratio of PRLV to standard liver volume (SLV) were calculated preoperatively. Hepatectomy were performed and actual hepatectomy volume (AHV) were measured. Consistency between preoperative planned hepatectomy volume (PPHV) and AHV was quantified postoperatively by Bland-Altman analysis. Multiple logistic regression and receiver-operating characteristic (ROC) curves were utilized to discuss the predictive value of PRLV/SLV in PHLF.

Results

Among the 214 included patients, 58 (27.1%) had PHLF. Patients with PHLF had significantly higher residual rates of ICG-R15 (%) (P=0.000) and a lower PRLV/SLV ratio (P=0.000). Bland-Altman analysis showed that PPHV was consistent with AHV (P=0.301). Multivariate analysis confirmed that PRLV/SLV ratio >60% (OR, 0.178; 95% CI: 0.084-0.378; P<0.01) was a protective factor for PHLF. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 75.8% (95% CI: 64.5.3-87.2%), 66.6% (95% CI: 59.1-74.1%), 45.8%, and 88.1%, respectively. The area under the ROC curve (AUC) was 73.7% (95% CI: 65.7-85.8%) and the diagnostic accuracy of PRLV/SLV for PHLF was moderate (P<0.001). These results were validated in the validation cohort perfectly. The primary cohort included 214 patients with a PHLF rate of 27.1% (n=58, 28 grade B and 13 grade C). The validation cohort included 135 patients with a PHLF rate of 35.6% (n=48, 24 grade B and 11 grade C).

Conclusions

The calculation of PRLV/SLV has predictive value in PHLF and can be exploited as a predictive factor. The 3D imaging technique combined with IOUS may be useful for PHLF risk assessment in hepatectomy patients.

Semen Analysis and Insight into Male Infertility

Objectives: Semen analysis is the cornerstone for the valuation of the male partner in the infertile couples. This test has been standardized throughout the world through the World Health Organization (WHO) since the1970s by producing, editing, updating, and disseminating a semen analysis manual and guidelines. A retrospective study to give an insight about  male infertility. Methods: This retrospective study assessed the semen findings of 1000 men evaluated at the  Department of Urology, Al-Kindy Teaching Hospital in Baghdad-Iraq  between January 2016 and May 2019. Semen analysis were done for them. Results: According to WHO standard for semen normality, 1000 samples that were analyzed, normospermia was shown in 835 (83.5%)males (95% CI=0.811-0.857) and 12% had oligospermia and the rest 4.5% was azospermia. The normospermic samples had significantly higher levels regarding the following parameters: count per ml (51.30±1.24) (P= 0.001), volume(3.34±2.31)(P=0.0001), pus cell (8.04±1.02)(P=0.0001), motility (22.81±5.8)(P=0.0001), abnormal motility (22.81±5.8)(P=0.0001) and  normal (V)(P=0.0001)or abnormal morphology (25.86 ±12.4)(P=0.0002) when compared with oligospermia. Conclusions: Semen analysis is the keystone of infertile couple. Semen parameters like sperm concentration, motility and morphology, are indicators for male reproductive function. Sperm concentration is declining and there is a significant association between sperm concentration and sperm parameters.

A snapshot of Ischemic stroke risk factors, sub-types, and its epidemiology: Cohort study

The burden of stroke can be substantially studied by establishing the functional consequences of stroke and its predictors on the population, economy and to guide rehabilitation efforts. This study aims to determine the subtypes, risk factors, and epidemiology of stroke in Jordan. Methods: A retrospective cohort study design was carried out to determine the risk factors and subtypes of stroke during 2017-2018. The study sample included 176 ischemic stroke patients of the King Abdullah University Hospital. Data was collected through medical records, which was then statistically analysed through frequencies and percentages. Results: Total 176 cases were identified out of which 101 (57.38%) were males and 75 (42.61%) were females and male to female ratio was 1.9:1. Hypertension was the commonest risk factor identified (50.56%), followed by diabetes mellitus (19.88%), hyperlipidaemia (15.34%), coronary artery disease (6.25%), atrial fibrillation (4.54%), and past history of stroke (1.13%). Risk factors such as hypertension (p = 0.007), diabetes (p = 0.000), coronary artery disease (p = 0.000) were significantly associated with subtypes of ischemic strokes. Conclusion: The study concludes that mean age of men was higher as compared to women in small vessel occlusion. The risk of ischemic stroke in patients with dyslipidaemia, diabetes mellitus, and hypertension was higher in middle-aged and old patients.

To Evaluate the Accuracy of Axillary Staging Using Ultrasound and Ultrasound-Guided Fine-Needle Aspiration Cytology (USG-FNAC) in Early Breast Cancer Patients-a Prospective Study

In breast cancer, axillary lymph node involvement directly impacts the patient survival and prognosis. Sentinel lymph node biopsy (SLNB) is a procedure of choice for axillary staging in early breast cancer. Currently, management options for axilla management are axillary lymph node dissection and sentinel node biopsy in node positive and in node negative respectively. Accuracy of current clinical methods for evaluating axilla is low. Hence, to select patients for appropriate procedure, ultrasound (USG) combined with fine-needle aspiration cytology (USG-FNAC) using vascular pedicle-based nodal mapping method is emerging as a good tool to address above issues. We evaluated the feasibility of ultrasound and needle aspiration cytology in a tertiary care center. All early breast cancer patients with clinically node-negative axilla and having palpable nodes with less than or equal to 5 cm tumor size in breast were screened by ultrasound of axilla to categorize the nodes as suspicious or non-suspicious based on radiological features and vascular pedicle-based nodal mapping method of axilla. Patients having suspicious nodes underwent ultrasound of axilla and needle aspiration; if found positive, patient underwent axillary node dissection. Sentinel node biopsy (SLNB) performed in all patients found negative on needle aspiration and in all patients having non-suspicious nodes on ultrasound axilla. Final histopathology was taken as gold standard. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for ultrasound (USG) and ultrasound-guided needle aspiration (USG-FNAC). A total of 100 patients were included in which 58 had non-suspicious and 42 had suspicious nodes on ultrasound of axilla. Among suspicious group, 24 were positive on ultrasound-guided needle aspiration cytology and 18 were negative. In non-suspicious nodes, sentinel node biopsy was performed. Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasound were 61.5%, 75.6%, 69.5%, and 68.5% respectively. For ultrasound-guided needle aspiration (USG-FNAC), sensitivity, specificity, and positive and negative predictive value are 83%, 100%, 100%, and 72.6% respectively. The accuracy of ultrasound (USG) and ultrasound-guided needle aspiration (USG-FNAC) was 69% and 88.1%. The result of our study indicates the feasibility of USG and USG-FNAC in a high-volume center with good accuracy of around 70-80%. Approximately one-fourth (24%) of the total patients were taken up for axillary lymph node dissection (ALND) without performing SLNB.

ICU Risk Stratification Models Feasible for Use in Sub-Saharan Africa Show Poor Discrimination in Malawi: A Prospective Cohort Study

BACKGROUND

Critical illness disproportionately affects people in low-income countries (LICs). Efforts to improve critical care in LICs must account for differences in demographics and infrastructure compared to high-income settings. Part of this effort includes the development and validation of intensive care unit (ICU) risk stratification models feasible for use in LICs. The purpose of this study was to validate and compare the performance of ICU mortality models developed for use in sub-Saharan Africa.

MATERIALS AND METHODS

This was a prospective, observational cohort study of ICU patients in a referral hospital in Malawi. Models were selected for comparison based on a Medline search for studies which developed ICU mortality models based on cohorts in sub-Saharan Africa. Model discrimination was evaluated using the area under the curve with 95% confidence intervals (CI).

RESULTS

During the study, 499 patients were admitted to the study ICU, and after exclusions, there were 319 patients. The cohort was 62% female, with the mean age 31 years (IQR: 23-41), and 74% had surgery preceding ICU admission. Discrimination for hospital mortality ranged from 0.54 (95% CI 0.48, 0.60) for the Universal Vital Assessment (UVA) to 0.72 (95% CI 0.66, 0.78) for the Malawi Intensive care Mortality Evaluation (MIME). After tenfold cross-validation, these results were unchanged.

CONCLUSIONS

The MIME outperformed other models in this prospective study. Most ICU models developed for LICs had poor to modest discrimination for hospital mortality. Future research may contribute to a better risk stratification model for LICs by refining and enhancing the MIME.

The STROCSS statement: Strengthening the Reporting of Cohort Studies in Surgery

INTRODUCTION

The development of reporting guidelines over the past 20 years represents a major advance in scholarly publishing with recent evidence showing positive impacts. Whilst over 350 reporting guidelines exist, there are few that are specific to surgery. Here we describe the development of the STROCSS guideline (Strengthening the Reporting of Cohort Studies in Surgery).

METHODS AND ANALYSIS

We published our protocol apriori. Current guidelines for case series (PROCESS), cohort studies (STROBE) and randomised controlled trials (CONSORT) were analysed to compile a list of items which were used as baseline material for developing a suitable checklist for surgical cohort guidelines. These were then put forward in a Delphi consensus exercise to an expert panel of 74 surgeons and academics via Google Forms.

RESULTS

The Delphi exercise was completed by 62% (46/74) of the participants. All the items were passed in a single round to create a STROCSS guideline consisting of 17 items.

CONCLUSION

We present the STROCSS guideline for surgical cohort, cross-sectional and case-control studies consisting of a 17-item checklist. We hope its use will increase the transparency and reporting quality of such studies. This guideline is also suitable for cross-sectional and case control studies. We encourage authors, reviewers, journal editors and publishers to adopt these guidelines.