Segmentation-based BI-RADS ensemble classification of breast tumours in ultrasound images.

BACKGROUND: The development of computer-aided diagnosis systems in breast cancer imaging is exponential. Since 2016, 81 papers have described the automated segmentation of breast lesions in ultrasound images using artificial intelligence. However, only two papers have dealt with complex BI-RADS classifications. PURPOSE: This study addresses the automatic classification of breast lesions into binary classes (benign vs. malignant) and multiple BI-RADS classes based on a single ultrasonographic image. Achieving this task should reduce the subjectivity of an individual operator's assessment. MATERIALS AND METHODS: Automatic image segmentation methods (PraNet, CaraNet and FCBFormer) adapted to the specific segmentation task were investigated using the U-Net model as a reference. A new classification method was developed using an ensemble of selected segmentation approaches. All experiments were performed on publicly available BUS B, OASBUD, BUSI and private datasets. RESULTS: FCBFormer achieved the best outcomes for the segmentation task with intersection over union metric values of 0.81, 0.80 and 0.73 and Dice values of 0.89, 0.87 and 0.82, respectively, for the BUS B, BUSI and OASBUD datasets. Through a series of experiments, we determined that adding an extra 30-pixel margin to the segmentation mask counteracts the potential errors introduced by the segmentation algorithm. An assembly of the full image classifier, bounding box classifier and masked image classifier was the most accurate for binary classification and had the best accuracy (ACC; 0.908), F1 (0.846) and area under the receiver operating characteristics curve (AUROC; 0.871) in the BUS B and ACC (0.982), F1 (0.984) and AUROC (0.998) in the UCC BUS datasets, outperforming each classifier used separately. It was also the most effective for BI-RADS classification, with ACC of 0.953, F1 of 0.920 and AUROC of 0.986 in UCC BUS. Hard voting was the most effective method for dichotomous classification. For the multi-class BI-RADS classification, the soft voting approach was employed. CONCLUSIONS: The proposed new classification approach with an ensemble of segmentation and classification approaches proved more accurate than most published results for binary and multi-class BI-RADS classifications.

Image Quality Assessment Tool for Conventional and Dynamic Magnetic Resonance Imaging Acquisitions.

Image quality assessment of magnetic resonance imaging (MRI) data is an important factor not only for conventional diagnosis and protocol optimization but also for fairness, trustworthiness, and robustness of artificial intelligence (AI) applications, especially on large heterogeneous datasets. Information on image quality in multi-centric studies is important to complement the contribution profile from each data node along with quantity information, especially when large variability is expected, and certain acceptance criteria apply. The main goal of this work was to present a tool enabling users to assess image quality based on both subjective criteria as well as objective image quality metrics used to support the decision on image quality based on evidence. The evaluation can be performed on both conventional and dynamic MRI acquisition protocols, while the latter is also checked longitudinally across dynamic series. The assessment provides an overall image quality score and information on the types of artifacts and degrading factors as well as a number of objective metrics for automated evaluation across series (BRISQUE score, Total Variation, PSNR, SSIM, FSIM, MS-SSIM). Moreover, the user can define specific regions of interest (ROIs) to calculate the regional signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR), thus individualizing the quality output to specific use cases, such as tissue-specific contrast or regional noise quantification.

Documenting the de-identification process of clinical and imaging data for AI for health imaging projects.

Artificial intelligence (AI) is revolutionizing the field of medical imaging, holding the potential to shift medicine from a reactive "sick-care" approach to a proactive focus on healthcare and prevention. The successful development of AI in this domain relies on access to large, comprehensive, and standardized real-world datasets that accurately represent diverse populations and diseases. However, images and data are sensitive, and as such, before using them in any way the data needs to be modified to protect the privacy of the patients. This paper explores the approaches in the domain of five EU projects working on the creation of ethically compliant and GDPR-regulated European medical imaging platforms, focused on cancer-related data. It presents the individual approaches to the de-identification of imaging data, and describes the problems and the solutions adopted in each case. Further, lessons learned are provided, enabling future projects to optimally handle the problem of data de-identification. CRITICAL RELEVANCE STATEMENT: This paper presents key approaches from five flagship EU projects for the de-identification of imaging and clinical data offering valuable insights and guidelines in the domain. KEY POINTS: ΑΙ models for health imaging require access to large amounts of data. Access to large imaging datasets requires an appropriate de-identification process. This paper provides de-identification guidelines from the AI for health imaging (AI4HI) projects.

Attention-Based Deep Learning System for Classification of Breast Lesions-Multimodal, Weakly Supervised Approach.

Breast cancer is the most frequent female cancer, with a considerable disease burden and high mortality. Early diagnosis with screening mammography might be facilitated by automated systems supported by deep learning artificial intelligence. We propose a model based on a weakly supervised Clustering-constrained Attention Multiple Instance Learning (CLAM) classifier able to train under data scarcity effectively. We used a private dataset with 1174 non-cancer and 794 cancer images labelled at the image level with pathological ground truth confirmation. We used feature extractors (ResNet-18, ResNet-34, ResNet-50 and EfficientNet-B0) pre-trained on ImageNet. The best results were achieved with multimodal-view classification using both CC and MLO images simultaneously, resized by half, with a patch size of 224 px and an overlap of 0.25. It resulted in AUC-ROC = 0.896 ± 0.017, F1-score 81.8 ± 3.2, accuracy 81.6 ± 3.2, precision 82.4 ± 3.3, and recall 81.6 ± 3.2. Evaluation with the Chinese Mammography Database, with 5-fold cross-validation, patient-wise breakdowns, and transfer learning, resulted in AUC-ROC 0.848 ± 0.015, F1-score 78.6 ± 2.0, accuracy 78.4 ± 1.9, precision 78.8 ± 2.0, and recall 78.4 ± 1.9. The CLAM algorithm's attentional maps indicate the features most relevant to the algorithm in the images. Our approach was more effective than in many other studies, allowing for some explainability and identifying erroneous predictions based on the wrong premises.

Fluorescence use in minimally invasive metabolic and bariatric surgery - a systematic review of the literature.

PURPOSE: This review aims to explore and summarise current knowledge of indocyanine green (ICG) fluorescence application in metabolic and bariatric surgery (MBS) and assess its potential in improving patient safety. METHODS: The review was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Evidence from PubMed, ScienceDirect and Ovid MEDLINE databases was independently screened in October 2022. The primary information and outcomes were the type of fluorescence application with potential patient benefit and the complication rate. The secondary outcomes consisted of the kind of dye, the application protocol, and the equipment used. RESULTS: Thirteen publications were included, with six prospective observational studies, five case reports and two retrospective cohort studies and involved a total of 424 patients. The publications were categorized into four groups based on the method of fluorescence application. Sixty-six percent of the cases used fluorescence for LSG, 32.3% used it for RYGB, 1.2% for revisional surgery, 0.2% during removal of an adjustable gastric band, and 0.2% for LSG combined with Rossetti fundoplication. ICG was used on its own in the majority of studies, although in one case, it was used in combination with methylene blue. ICG administration protocols varied significantly. Complications occurred in three patients (0.71%): leaks were diagnosed in two cases, and one patient required a blood transfusion. CONCLUSION: The most popular type of use is intraoperative assessment of the blood supply. ICG application may reduce the risk of complications, with potential benefits in detecting ischemia and leaks, searching for bleeding in areas inaccessible to endoscopy, and non-invasive hepatopathy evaluation.

Considerations for artificial intelligence clinical impact in oncologic imaging: an AI4HI position paper.

To achieve clinical impact in daily oncological practice, emerging AI-based cancer imaging research needs to have clearly defined medical focus, AI methods, and outcomes to be estimated. AI-supported cancer imaging should predict major relevant clinical endpoints, aiming to extract associations and draw inferences in a fair, robust, and trustworthy way. AI-assisted solutions as medical devices, developed using multicenter heterogeneous datasets, should be targeted to have an impact on the clinical care pathway. When designing an AI-based research study in oncologic imaging, ensuring clinical impact in AI solutions requires careful consideration of key aspects, including target population selection, sample size definition, standards, and common data elements utilization, balanced dataset splitting, appropriate validation methodology, adequate ground truth, and careful selection of clinical endpoints. Endpoints may be pathology hallmarks, disease behavior, treatment response, or patient prognosis. Ensuring ethical, safety, and privacy considerations are also mandatory before clinical validation is performed. The Artificial Intelligence for Health Imaging (AI4HI) Clinical Working Group has discussed and present in this paper some indicative Machine Learning (ML) enabled decision-support solutions currently under research in the AI4HI projects, as well as the main considerations and requirements that AI solutions should have from a clinical perspective, which can be adopted into clinical practice. If effectively designed, implemented, and validated, cancer imaging AI-supported tools will have the potential to revolutionize the field of precision medicine in oncology.

High-resolution synthesis of high-density breast mammograms: Application to improved fairness in deep learning based mass detection.

Computer-aided detection systems based on deep learning have shown good performance in breast cancer detection. However, high-density breasts show poorer detection performance since dense tissues can mask or even simulate masses. Therefore, the sensitivity of mammography for breast cancer detection can be reduced by more than 20% in dense breasts. Additionally, extremely dense cases reported an increased risk of cancer compared to low-density breasts. This study aims to improve the mass detection performance in high-density breasts using synthetic high-density full-field digital mammograms (FFDM) as data augmentation during breast mass detection model training. To this end, a total of five cycle-consistent GAN (CycleGAN) models using three FFDM datasets were trained for low-to-high-density image translation in high-resolution mammograms. The training images were split by breast density BI-RADS categories, being BI-RADS A almost entirely fatty and BI-RADS D extremely dense breasts. Our results showed that the proposed data augmentation technique improved the sensitivity and precision of mass detection in models trained with small datasets and improved the domain generalization of the models trained with large databases. In addition, the clinical realism of the synthetic images was evaluated in a reader study involving two expert radiologists and one surgical oncologist.

Comparison of stump closure techniques during laparoscopic appendectomies for complicated appendicitis - results from Pol-LA (Polish laparoscopic appendectomy) multicenter large cohort study.

Background: In general, the three main options for stump closure in laparoscopic appendectomy are clips, endoscopic staplers and endoloops. However, there is no gold standard, especially regarding complicated acute appendicitis which is generally associated with worse outcomes.Objectives: We aimed to assess the outcomes of different stump closure techniques during laparoscopic appendectomies for complicated appendicitisMethods: Our multicenter observational study of 18 surgical units assessed the outcomes of 1269 laparoscopic appendectomies for complicated appendicitis that used the three main stump closure techniques: clips, staplers and endoloops. Groups were compared in terms of peri- and postoperative outcomes.Results: Staplers were superior in terms of overall morbidity (9.79 vs. 3.29% vs. 7.41%, p = .017) and length of stay (4 vs. 3 vs. 4 days, p < .001) respectively for clips, staplers and endoloops. However, no differences in major complication rates, postoperative intraabdominal abscess formation, reintervention rates and readmission rates were found.Conclusion: Although our results show some clinical benefits of staplers for appendix stump closure, they are based on a non-randomized group of patients and are therefore prone to selection bias. Further well-designed trials taking into consideration not only the clinical benefits, but also, the economic aspects of the surgical treatment of complicated acute appendicitis are needed to confirm our results.

Author Correction: Risk factors for serious morbidity, prolonged length of stay and hospital readmission after laparoscopic appendectomy - results from Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Risk factors for serious morbidity, prolonged length of stay and hospital readmission after laparoscopic appendectomy - results from Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study.

Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32-12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74-7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95% CI: 1.53-5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33-10.75, p < 0.001), conversions (OR 6.48, 95% CI: 3.48-12.08, p < 0.001) and reinterventions after primary procedure (OR 8.79, 95% CI: 3.2-24.14, p < 0.001) in the multivariate model. Third, although several risk factors for hospital readmissions were found in univariate analysis, in the multivariate model only the presence of postoperative complications (OR 10.33, 95% CI: 4.27-25.00), reintervention after primary procedure (OR 5.62, 95% CI: 2.17-14.54), and LA performed by resident (OR 1.96, 95% CI: 1.03-3.70) remained significant. Laparoscopic appendectomy is a safe procedure associated with low rates of complications, prolonged LOS, and readmissions. Risk factors for these adverse events include complicated appendicitis, postoperative morbidity, conversion, and re-intervention after the primary procedure. Any occurrence of these factors during treatment should alert the healthcare team to identify the patients that require more customized treatment to minimize the risk for adverse outcomes.

Complicated appendicitis: Risk factors and outcomes of laparoscopic appendectomy - Polish laparoscopic appendectomy results from a multicenter, large-cohort study.

BACKGROUND: Preoperative classification of complicated and uncomplicated appendicitis (AA) is challenging. However, the differences in surgical outcomes necessitate the establishment of risk factors in developing, complicated AA. This study was an analysis of the clinical outcomes of laparoscopic appendectomies (LA), as well as preoperative risk factors for the development of complicated AA. METHODS: The data of 618 patients who underwent LA in 18 surgical units across Poland and Germany were collected in an online web-based database created by the Polish Videosurgery Society. The surgical outcomes of patients with complicated and uncomplicated appendicitis were compared. Uni- and multivariate logistic regression models were used to establish risk factors for the development of complicated appendicitis. RESULTS: In all, 1269 (27.5%) patients underwent LA for complicated appendicitis (Group 1) and 3349 (72.5%) for uncomplicated appendicitis (Group 2). The conversion rate, number of intra-operative adverse events, re-intervention rate, postoperative complications, and readmission rate was greater in Group 1. The preoperative risk factors associated with complicated appendicitis were: female sex (Odds ratio [OR]: 1.58), obesity (OR: 1.51), age >50 years (OR: 1.51), symptoms >48 hours (OR: 2.18), high Alvarado score (OR: 1.29 with every point), and C-reactive protein level >100 mg/L (OR: 3.92). CONCLUSION: Several demographic and clinical risk factors for complicated AA were identified. LA for complicated appendicitis was associated with poorer outcomes.

Risk factors for intraabdominal abscess formation after laparoscopic appendectomy - results from the Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study.

INTRODUCTION: According to meta-analyses laparoscopic appendectomy is associated with many benefits. However, in comparison to open surgery an increased rate of intraabdominal abscesses (IAA) has been reported. Identification of predictive factors for this complication may help to identify patients with higher risk of IAA. AIM: To identify potential risk factors for intraabdominal abscess after laparoscopic appendectomy (LA). MATERIAL AND METHODS: Eighteen surgical units in Poland and Germany submitted data of patients undergoing LA to the online web-based database created by the Polish Videosurgery Society of the Association of Polish Surgeons. It comprised 31 elements related to the pre-, intra- and postoperative period. Surgical outcomes were compared among the groups according to occurrence of IAA. Univariate and multivariate logistic regression models were used to identify potential risk factors for IAA. RESULTS: 4618 patients were included in the analysis. IAA were found in 51 (1.10%) cases. Although several risk factors were found in univariate analysis, in the multivariate model, only the presence of complicated appendicitis was statistically significant (OR = 2.98, 95% CI: 1.11-8.04). Moreover, IAA has a significant influence on postoperative reintervention rate (OR = 126.95, 95% CI: 67.98-237.06), prolonged length of stay > 8 days (OR = 41.32, 95% CI: 22.86-74.72) and readmission rate (OR = 33.89, 95% CI: 18.60-34.73). CONCLUSIONS: Intraabdominal abscesses occurs relatively rarely after LA. It is strongly associated with complicated appendicitis. Occurrence of this complication has a great influence on the postoperative period and due to the nature of its treatment is associated with the need for reintervention, prolonged length of stay and by extension possible readmission.

The significant impact of age on the clinical outcomes of laparoscopic appendectomy: Results from the Polish Laparoscopic Appendectomy multicenter large cohort study.

Acute appendicitis (AA) is the most common surgical emergency and can occur at any age. Nearly all of the studies comparing outcomes of appendectomy between younger and older patients set cut-off point at 65 years. In this multicenter observational study, we aimed to compare laparoscopic appendectomy for AA in various groups of patients with particular interest in the elderly and very elderly in comparison to younger adults.Our multicenter observational study of 18 surgical units assessed the outcomes of 4618 laparoscopic appendectomies for AA. Patients were divided in 4 groups according to their age: Group 1-<40 years old; Group 2-between 40 and 64 years old; Group 3-between 65 and 74 years old; and Group 4-75 years old or older. Groups were compared in terms of peri- and postoperative outcomes.The ratio of complicated appendicitis grew with age (20.97% vs 37.50% vs 43.97% vs 56.84%, P < .001). Similarly, elderly patients more frequently suffered from perioperative complications (5.06% vs 9.3% vs 10.88% vs 13.68%, P < .001) and had the longest median length of stay (3 [Interquartile Range (IQR) 2-4] vs 3 [IQR 3-5], vs 4 [IQR 3-5], vs 5 [IQR 3-6], P < .001) as well as the rate of patients with prolonged length of hospital stay (LOS) >8 days. Logistic regression models comparing perioperative results of each of the 3 oldest groups compared with the youngest one showed significant differences in odds ratios of symptoms lasting >48 hours, presence of complicated appendicitis, perioperative morbidity, conversion rate, prolonged LOS (>8 days).The findings of this study confirm that the outcomes of laparoscopic approach to AA in different age groups are not the same regarding outcomes and the clinical picture. Older patients are at high risk both in the preoperative, intraoperative, and postoperative period. The differences are visible already at the age of 40 years old. Since delayed diagnosis and postponed surgery result in the development of complicated appendicitis, more effort should be placed in improving treatment patterns for the elderly and their clinical outcome.

Patient with metastatic breast cancer presenting as acute cholecystitis with one-year survival on hormonotherapy.

Breast cancer has high metastatic potential with distant metastases involving mainly lungs, liver and bones. Less frequently it gives distant spread to other organs. Herein we would like to present a very rare case of an acute cholecystitis which turned out to be a metastatic breast cancer in previously healthy woman. A female patient, 64-years old, presented to the emergency department with symptoms of biliary colic and acute abdomen. During the emergency cholecystectomy, we diagnosed the gallbladder empyema with thickened wall. There were also multiple metastatic nodules in the peritoneal cavity and an excessive amount of free fluid. The emergency physicians diagnosing female patient with the acute abdominal symptoms and a breast cancer history might suspect malignant spread into abdominal organs including gallbladder. On the other hand, acute cholecystitis symptoms might be the first symptoms of metastatic process in the gallbladder from the unknown primary source, which may be breast.

Antibiotic prophylaxis in open inguinal hernia repair: a literature review and summary of current knowledge.

More than 1 million inguinal hernia repairs are performed in Europe and the US annually. Although antibiotic prophylaxis is not required in clean, elective procedures, the routine use of implants (90% of inguinal hernia repairs are performed with mesh) makes the topic controversial. The European Hernia Society does not recommend routine antibiotic prophylaxis for elective inguinal hernia repairs. However, the latest randomized controlled trial, published by Mazaki et al., indicates that the use of prophylaxis is effective for the prevention of surgical site infection. Unnecessary prophylaxis contributes to the development of bacterial resistance and significantly increases healthcare costs. This review documents clinical trials on inguinal hernia repairs with mesh and summarizes the current knowledge. It also tries to solve certain problems, namely: what constitutes a real risk factor, late-onset infection, and how the "surgical environment" impacts on the need to use antibiotic prophylaxis.

Prognostic value of 5-microRNA based signature in T2-T3N0 colon cancer.

The role of adjuvant chemotherapy in stage T2-T3N0 colon cancer (CC) is controversial and there are currently no reliable factors allowing for individual selection of patients with high risk of relapse for such therapy. We searched for microRNA-based signature with prognostic significance in this group. We assessed by qRT-PCR expression of 754 microRNAs (miRNAs) in tumour samples from 85 stage pT2-3N0 CC patients treated with surgery alone. MiRNA expression was compared between two groups of patients: 40 and 45 patients who did and did not develop distant metastases after resection, respectively. Additionally, miRNA expression was compared between CC and normal colon mucosa samples and between the mismatch repair (MMR) competent and deficient tumours. Low expression of miR-1300 and miR-939 was significantly correlated with shorter distant metastasis-free survival (DMFS) in Cox univariate analysis (p.adjusted = 0.049). The expression signature of five miRNAs (miR-1296, miR-135b, miR-539, miR-572 and miR-185) was found to be prognostic [p = 1.28E-07, HR 8.4 (95 % CI: 3.81-18.52)] for DMFS and cross-validated in a leave-one-out analysis, with the sensitivity and specificity of 74 and 78 %, respectively. The expression of miR-592 was significantly associated with the MMR status (p.adjusted <0.01). The expression of several novel miRNAs were found to be tumour specific, e.g. miR-888, miR-523, miR-18b, miR-302a, miR-423-5p, miR-582-3p (p < 0.05). We developed a miRNA expression signature that may be predictive for the risk of distant relapse in early stage CC and confirmed previously reported association between miR-592 expression and MMR status.

Keratin 7 expression in lymph node metastases but not in the primary tumour correlates with distant metastases and poor prognosis in colon carcinoma.

Colorectal carcinoma (CRC) is one of the leading causes of cancer-related deaths worldwide. Alterations in keratin expression, including keratin 7 (K7), are frequent findings in multiple cancers, and they constitute a prognostic factor. The aim of our study was to evaluate the prognostic significance of K7 in the primary tumour and lymph node metastases in two separate cohorts of patients: the first one with lymph node involvement (LN+, 129 cases) and the second one free of LN metastases (LN-, 85 cases). Keratin 7 expression in CRC was analysed on tissue microarrays with immunohistochemistry and evaluated using the h-score. In the LN+ group K7 positivity was identified in 7/129 (5.4%) of primary tumours (PT) and lymph node metastases (LNM); concordance between them was 94% ( 0.396). Keratin 7 was expressed in 8/85 cases (9.4%) in the LN- group. K7 expression in LNM of the LN+ cohort correlated with shorter overall survival (OS) (p = 0.047) and presence of distant metastases at diagnosis (p = 0.005). Expression of K7 in the primary tumour in both cohorts did not correlate with survival. We conclude that the status of K7 expression in metastatic lymph nodes from CRC is a poor prognostic factor.

A numerical scale to assess the outcomes of metabolic/bariatric surgery (NOMS).

INTRODUCTION: Absent today is a simple numerical system of outcomes assessment that recognizes that bariatric surgery is metabolic surgery and incorporates weight loss, hypertension control, and type 2 diabetes control. AIM: To introduce a simple, new Numerical Scale to Assess the Outcomes of Metabolic Surgery (NOMS). MATERIAL AND METHODS: For the stratification of weight outcomes, we used the percentage excess weight loss (%EWL); for hypertension, the systolic blood pressure (SBP) and diastolic blood pressure (DBP) combined with medication usage; and for type 2 diabetes, the hemoglobin A1c (HbA1c) value combined with medication usage. RESULTS: Utilizing the guidelines of the American Diabetes Association, the Working Group of the European Society of Hypertension, the European Society of Cardiology, and the American College of Cardiology/American Heart Association, we propose for %EWL: W1 ≥ 50, W2 > 25 and < 50, and W3 ≤ 25; for hypertension H1 SBP/DPB < 140/90 mm Hg on no medication, H2 SBP/DBP ≥ 140/90 mm Hg with improvement of SBP or possible reduction of antihypertensive medication, and H3 no change or SBP higher than before surgery; for diabetes mellitus D1 HbA1c ≤ 7% and no medication, D2 HbA1c > 7% with a decrease of the HbA1c level or possible reduction of medication, D3 no change in HbA1c or HbA1c higher than before surgery. Designations of H0 and D0 are given if hypertension or diabetes was not present before surgery. Patient examples for numerical scores are provided. CONCLUSIONS: The introduction of our numerical scale (NOMS) can be of benefit in metabolic/bariatric outcomes assessment; communications among metabolic/bariatric surgery centers, physicians, and patients; and for more precise reporting in the evidence-based literature.

Extracorporeal staple technique: an alternative approach to the treatment of critical colostomy stenosis.

We describe an extracorporeal staple technique used to treat severe colostomy stenosis under analgo-sedation, thus avoiding relaparotomy. The surgery is performed under short-term sedation. The orifice of the stoma is widened and overgrowing skin is excised. The volume and diameter of the stoma are assessed. The anvil of a circular stapler device is inserted into the lumen of the colostomy. First bowel layers and then skin are closed with purse-string sutures. One firing of the stapler is used to reshape the stoma. The procedure takes around 20-30 min. One circular stapler is used. The patient can be discharged the same day or a day after surgery. No complications were noted in operated patients. At 6- and 12-month follow-ups, a slight narrowing of the colostomy was visible, but no recurrence of the stricture was noted. The described technique is an interesting, easy and safe alternative to previous methods of treatment for stenosed end-colostomy. Importantly, it is an extra-abdominal procedure and may be offered to patients with a history of multiple abdominal operations or with serious coexisting medical conditions in the one-day surgery setting.

Preoperative nutritional support in cancer patients with no clinical signs of malnutrition--prospective randomized controlled trial.

PURPOSE: Preoperative nutrition is beneficial for malnourished cancer patients. Yet, there is little evidence whether or not it should be given to nonmalnourished patients. The aim of this study was to assess the need to introduce preoperative nutritional support in patients without malnutrition at qualification for surgery. METHODS: This was a prospective, two-arm, randomized, controlled, open-label study. Patients in interventional group received nutritional supplementation for 14 days before surgery, while control group kept on to their everyday diet. Each patient's nutritional status was assessed twice--at qualification (weight loss in 6 months, laboratory parameters: albumin, total protein, transferrin, and total lymphocyte count) and 1 day before surgery (change in body weight and laboratory parameters). After surgery, all patients were followed up for 30 days for postoperative complications. RESULTS: Fifty-four patients in interventional and 48 in control group were analyzed. In postoperative period, patients in control group suffered from significantly higher (p < 0.001) number of serious complications compared with patients receiving nutritional supplementation. Moreover, levels of all laboratory parameters declined significantly (p < 0.001) in these patients, while in interventional arm were stable (albumin and total protein) or raised (transferrin and total lymphocyte count). CONCLUSIONS: Preoperative nutritional support should be introduced for nonmalnourished patients as it helps to maintain proper nutritional status and reduce number and severity of postoperative complications compared with patients without such support.