Winson Jianhong Tan

Prospective Comparison of the Alvarado Score and CT Scan in the Evaluation of Suspected Appendicitis: A Proposed Algorithm to Guide CT Use

BACKGROUND Although computed tomography (CT) has reduced negative appendectomy rates, its radiation risk remains a concern. We compared the performance statistics of the Alvarado Score (AS) with those of CT scan in the evaluation of suspected appendicitis, with the aim of identifying a subset of patients who will benefit from CT evaluation. STUDY DESIGN We performed prospective data collection on 350 consecutive patients with suspected appendicitis who were evaluated with CT scans. The AS for each patient was scored at admission and correlated with eventual histology and CT findings. The sensitivity, specificity, and positive likelihood ratios were determined for various AS and for CT scan. The AS ranges that benefitted most from CT evaluation were determined by comparing the positive likelihood ratios of CT scan with each of the AS cutoff values. RESULTS The study included 134 males (38.3%) and 216 females (61.7%). The overall prevalence of appendicitis was 44.3% in the total study population; 37.5% in females and 55.2% in males. There were 168 patients (48%) who underwent surgery, with a negative appendectomy rate of 7.7%. Positive likelihood ratio of disease was significantly greater than 1 only in patients with an AS of 4 and above. An AS of 7 and above in males and 9 and above in females has a positive likelihood ratio comparable to that of CT scan. CONCLUSIONS Evaluation by CT is beneficial mainly in patients with AS of 6 and below in males and 8 and below in females. We propose an objective management algorithm with the AS guiding subsequent evaluation.

Alvarado score: a guide to computed tomography utilization in appendicitis

Although useful in evaluation of suspected appendicitis, not all patients require computed tomography (CT) evaluation. Clinical stratification of patients who benefit from CT evaluation is essential. We utilize the Alvarado score (AS) to stratify patients with suspected appendicitis into subgroups who benefit from CT evaluation and propose an objective algorithm with AS guiding CT utilization.

Palliative surgical intervention in metastatic colorectal carcinoma: a prospective analysis of quality of life.

Quality of life (QOL) was assessed after palliative surgery for incurable metastatic colorectal cancer (CRC).

Critical appraisal of laparoscopic vs open rectal cancer surgery

AIM To evaluate the long-term clinical and oncological outcomes of laparoscopic rectal resection (LRR) and the impact of conversion in patients with rectal cancer. METHODS An analysis was performed on a prospective database of 633 consecutive patients with rectal cancer who underwent surgical resection. Patients were compared in three groups: Open surgery (OP), laparoscopic surgery, and converted laparoscopic surgery. Short-term outcomes, long-term outcomes, and survival analysis were compared. RESULTS Among 633 patients studied, 200 patients had successful laparoscopic resections with a conversion rate of 11.1% (25 out of 225). Factors predictive of survival on univariate analysis include the laparoscopic approach (P = 0.016), together with factors such as age, ASA status, stage of disease, tumor grade, presence of perineural invasion and vascular emboli, circumferential resection margin < 2 mm, and postoperative adjuvant chemotherapy. The survival benefit of laparoscopic surgery was no longer significant on multivariate analysis (P = 0.148). Neither 5-year overall survival (70.5% vs 61.8%, P = 0.217) nor 5-year cancer free survival (64.3% vs 66.6%, P = 0.854) were significantly different between the laparoscopic group and the converted group. CONCLUSION LRR has equivalent long-term oncologic outcomes when compared to OP. Laparoscopic conversion does not confer a worse prognosis.

A Novel Derivation Predicting Survival After Primary Tumor Resection in Stage IV Colorectal Cancer: Validation of a Prognostic Scoring Model and an Online Calculator to Provide Individualized Survival Estimation

BACKGROUND: A prognostic scoring model has been devised previously to predict survival following primary tumor resection in patients with metastatic colorectal cancer and unresectable metastases. This has yet to be validated. OBJECTIVE: The main objectives of this study are to validate the proposed prognostic scoring model and create an interactive online calculator to estimate an individual’s survival after primary tumor resection. DESIGN: Clinical data and survival outcomes of patients were extracted from a prospectively maintained database. Patients were categorized into good, moderate, or poor survivor groups based on the previously proposed scoring algorithm. Discrimination was assessed and recalibration was performed, with the recalibrated model implemented as an interactive Web application to provide individualized survival probability. SETTINGS: This study was conducted at a tertiary referral center. PATIENTS: The study included 324 consecutive patients with metastatic colorectal carcinoma and unresectable metastases who underwent primary tumor resection between January 2008 and December 2013. MAIN OUTCOME MEASURES: The primary outcome measured was overall survival. RESULTS: Three hundred twenty-four patients were included in the study. Median survival in the good, moderate, and poor prognostic groups was 56.8, 25.7, and 19.9 months (log rank test, p = 0.003). The &kgr; statistic was 0.638 and R2D was 0.101. Significant differences in survival were found between the moderate and good prognostic groups (HR, 2.79; 95% CI, 1.51–5.15; p = 0.001) and between poor and good prognostic groups (HR, 4.12; 95% CI, 1.98–8.55; p < 0.001). The model was implemented as an interactive online calculator to provide individualized survival estimation after primary tumor resection (http://bit.ly/Stage4PrognosticScore). LIMITATIONS: Selection bias and single-center data preclude the generalizability of the proposed model. Information regarding the severity or likelihood of developing symptoms from the primary tumor were also not accounted for in the prognostic scoring model proposed. CONCLUSIONS: The prognostic scoring model provides good prognostic stratification of survival after primary tumor resection and may be a useful tool to predict survival after primary tumor resection. See Video Abstract at http://links.lww.com/DCR/A330.

Evaluating Suspected Appendicitis: In reply to Muralidharan and colleagues

We read with interest the article titled, “Prospective comparison of Alvarado score and CT scan in the evaluation of suspected appendicitis: A proposed algorithm to guide CT use” by Tan and colleagues. We have the following comments to offer: Computed tomography scan and ultrasonography (USG) are the 2 imaging modalities used in the early detection of acute appendicitis in patients presenting with equivocal findings. There is no doubt about CT being more accurate as compared with USG in the diagnosis of acute appendicitis. Ultrasonography has the inherent advantages of easy availability, absence of ionizing radiation, and lower cost to the patient. It is also the preferred modality in young and pregnant patients. It is surprising to note that there is no mention of USG as an imaging modality for the diagnosis of acute appendicitis by the authors. In this study, of the 450 patients admitted for suspected appendicitis, 350 underwent CT evaluation. Among the 350 patients, 155 (44.3%) were diagnosed as appendicitis and 19 had equivocal findings. How many patients diagnosed with acute appendicitis by CT could also have been diagnosed by USG alone? Also, as with CT, even USG will provide an alternative diagnosis, reducing the rate of negative appendectomy. In view of these, issues, we tend to differ with the algorithm suggested by the authors for management of suspected appendicitis. In our opinion, in all cases of Alvarado scores of 4 to 6, CT should be preceded by USG. This will reduce the risk of ionizing radiation to a great number of patients. In fact, the time has come to incorporate USG results into the Alvarado score to develop a clinico-patho-radiologic scoring system for the diagnosis of acute appendicitis and also to decide when to do a CT scan.

A rare cause of gastrointestinal haemorrhage: gastric invasion by hepatocellular carcinoma

Patients with hepatocellular carcinoma (HCC) are predisposed to upper gastrointestinal (GI) haemorrhage with bleeding gastro-oesophageal varices and peptic ulcers being the common aetiologies. On rare occasions, HCC with direct invasion into the upper GI tract can lead to haemorrhage. Recognizing the possibility of invasive HCC causing upper GI haemorrhage is of paramount importance as acute management differs from the usual aetiologies. We describe a 76-year-old lady with long-standing liver cirrhosis who presented with upper GI haemorrhage due to an HCC invading into the greater curvature of the stomach. Trans-arterial embolization was performed which led to successful cessation of bleeding. Direct invasion of the GI tract by HCC causing haemorrhage is an extremely rare condition. Compared with endoscopic therapy, trans-arterial embolization offers the best chance of successful haemostasis and should be considered first-line therapy in these patients.

EP01.08: Asherman's syndrome in pregnancy: case reports: Electronic Poster Abstracts

Pregnant D: 43-year old, 16th pregnancy, 2 deliveries, in 2009 operative delivery, one late miscarriage on the 20th week and 12 medical abortions without complications. Medical conclusion about full or partial adherent of placenta has been done in the 1st trimester, at 12/1 weeks, and it was confirmed by all US, the growth of features of vein bulge in pelvis, uterus and cervix. CS has been performed at the 37th-38th weeks of gestation, and the new born delivered with weight of 3.030 grams and height of 55 cm. During the operation, placenta percreta was identified: a part of chorionic villi was embedded into myometrium, CS scar and the back wall of a bladder. A radical operation was performed hysterectomy without adnexas as well as a plastic surgery of the bladder. The usage of two-dimensional ultrasound in combination with different variations of colour Doppler allows to assume the adherent placenta in the 1st trimester of pregnancy and it also contributes to prevention of serious complications in pregnancy and maternal mortality.

EP10.21: Fetal aortic and pulmonary artery diameters in normal pregnancy: Electronic Poster Abstracts

Introduction Abnormal diameters of the great vessels are known to be markers of congenital heart diseases, e.g. tetralogy of Fallot, truncus arteriosus and coarctation of aorta. In order to improve prenatal detection of these forms of congenital heart defects, we include the great vessels diameter in the routine fetal ultrasound examination. Objective To construct centile nomograms for aortic and pulmonary artery diameters in the second and third trimesters. Method The patients recruited all fulfilled the following criteria : (1) known last menstrual period with regular cycles, (2) no fetal anomalies, (3) no pregnancy complications, (4) live birth at term, (5) birth weight above the 5th and below the 95th centile for gestation. Pulmonary and aortic diameters were measured by transabdominal ultrasound on long-axis views of the great vessels. Measurements of the great vessels were taken at the level just above the aortic and pulmonary valves during ventricular systole. The relationship between the mean of each measurement and gestational age was modelled by a fractional polynomial regression. Results 150 cases were recruited. Diameters range from 2.1mm (aortic) and 2.5mm (pulmonary artery) at 18 weeks of gestation to 6.5mm ( aortic) and 9.7mm ( pulmonary artery ) at 39 weeks of gestation. Conclusion We conclude that the diameter of the great vessels grows linearly with gestational age in normal fetuses. The procedure for selecting the best fitting model was based on minimising the deviance as in the appendix of Royston and Wright (1998). Similarly a standard deviation (SD) curve for each measurement was estimated by regressing the ‘scale absolute residuals’ on gestational age, again using fractional polynomial. The 5th and 95th percentile of the measurement at each gestational age is given by means ± 1.645 SD. All analyses and graphics were made using software STATA version 13. 0 1 2 3 4 5 6 7 8

Ovarian preservation with subcutaneous transposition in the setting of cytoreductive surgery

INTRODUCTION In recent years, cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has gained increasing acceptance as a treatment modality for peritoneal carcinomatosis. In female patients, this procedure involves a total hysterectomy and bilateral saphingo-oophorectomy to remove the pelvic peritoneum. We present a case of an unfortunate female adolescent with peritoneal carcinomatosis who underwent cytoreductive surgery and HIPEC. In view of the compelling circumstance, an innovative surgical technique was used to attempt ovarian preservation. PRESENTATION OF CASE A 14 year old girl with carcinoma of the sigmoid colon and peritoneal metastases was offered cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy. In view of her age, ovarian preservation with subcutaneous transposition was performed during cytoreductive surgery. She is currently well 6 months post surgery and has resumed normal menstruation. We review the literature regarding ovarian preservation with subcutaneous transposition and discuss its benefit in pre-menopausal women undergoing peritonectomy and cytoreductive surgery for peritoneal carcinomatosis. DISCUSSION Subcutaneous transposition of the ovary in pre-menopasual patients requiring cytoreductive surgery spares them the sequelae of surgical castration. The subcutaneous location of the transposed ovary conveys advantages such as the ease of ultrasound surveillance and removal in event of disease recurrence. It also retains the possibility of future conception as the transposed ovary can easily be accessed for ovum extraction with assisted reproductive techniques. CONCLUSION Ovarian preservation with subcutaneous transposition is a technique worth considering in the treatment of pre-menopausal women who require cytoreductive surgery for peritoneal carcinomatosis.