Performance of the model for end-stage liver disease score for mortality prediction and the potential role of etiology

Bakground & aims Although discrimination of the model for end stage liver disease (MELD) is generally considered acceptable, its calibration is still unclear. In a validation study, we assessed the discrimination and calibration performance of 3 versions of the model: original MELD-TIPS, used to predict survival after transjugular intra-hepatic portosystemic shunt (TIPS); classic MELD-Mayo; MELD-UNOS, used by United Network for Organ Sharing (UNOS). Recalibration and model updating were also explored. Methods 776 patients submitted to elective TIPS (TIPS cohort), and 445 unselected patients (non-TIPS cohort) were included. Three, 6 and 12-month mortality predictions were calculated by the 3 MELD versions: discrimination was assessed by c-statistics and calibration by comparing deciles of predicted and observed risks. Cox and Fine and Grey models were used for recalibration and prognostic analyses. Results Major patient characteristics in TIPS/non-TIPS cohorts were: viral etiology 402/188, alcoholic 185/130, NASH 65/33; mean follow-up± SD 25±9/19±21months; 3-6-12 month mortality were respectively, 57-102-142/31-47-99. C-statistics ranged from 0.66 to 0.72 in TIPS and 0.66 to 0.76 in non-TIPS cohorts across prediction times and scores. A post-hoc analysis revealed worse c-statistics in non-viral cirrhosis with more pronounced and significant worsening in non-TIPS cohort. Calibration was acceptable with MELD-TIPS but largely unsatisfactory with MELD-Mayo and -UNOS whose performance improved much after recalibration. A prognostic analysis showed that age, albumin, and TIPS indication might be used for a MELD updating. Conclusions In this validation study the MELD performance was largely unsatisfactory, particularly in non-viral cirrhosis. MELD recalibration and candidate variables for a MELD updating are proposed. Lay summary While discrimination performance of the Model for End Stage Liver Disease (MELD) is credited to be fair to good, its calibration, the correspondence of observed to predicted mortality, is still unsettled. We found that application of 3 different versions of the MELD in two independent cirrhosis cohorts yielded largely imprecise mortality predictions particularly in non-viral cirrhosis and propose a validated model recalibration. Candidate variables for a MELD updating are proposed

Appendiceal mucocele: the importance of getting a preoperative diagnosis

Appendiceal mucocele is a rare disease, found in only 0.4% of all appendectomied specimens. Achieving a preoperative diagnosis is of paramount importance because it permits choosing the most appropriate surgical technique. The algorithm for the selection of the type of surgery was provided by Dhage-Ivatury and Sugarbaker in 2006: in brief, laparotomy should be preferred over laparoscopy and the more locally advanced the disease is, the more invasive the resection should be

Extra-mucosal enucleation of a giant circular leiomyoma of the middle esophagus

.IntroductionAlthough being the most frequent benign neoplasm of the esophagus, leiomyoma represents only 1%of all esophageal masses. In the vast majority of cases it measures less than 5 cm, is asymptomaticand requires no treatment (if < 2 cm in diameter) or enucleation (if up to 8 cm) through minimally toinvasive techniques (endoscopy, videothoracoscopy, videolaparoscopy or robotic-assisted excision).Only 5% of lesions is larger than 10 cm and causes frank symptoms: such tumors go under the nameof giant esophageal leiomyomas (GELs). Performing enucleation for GELs, although feasible, provedto be less safe than for smaller leiomyomas. In GELs, in fact, the tract of mucosa left exposed bythe iatrogenic muscular defect is often too large: on the one hand, if left uncovered, it is likely todevelop pseudo-diverticulum and dysphagia, on the other hand, if treated with a primary closureof the muscular edges, this is supposed not to be tension-free thereby resulting in achalasia anddysphagia. To obviate such and other complications, two surgical options are generally recommendedfor GELs: esophageal resection and extra-mucosal enucleation combined with several techniques ofplastic surgery for covering and buttressing the muscular defect

Extra-mucosal enucleation of a giant circular leiomyoma of the middle esophagus

.IntroductionAlthough being the most frequent benign neoplasm of the esophagus, leiomyoma represents only 1%of all esophageal masses. In the vast majority of cases it measures less than 5 cm, is asymptomaticand requires no treatment (if < 2 cm in diameter) or enucleation (if up to 8 cm) through minimally toinvasive techniques (endoscopy, videothoracoscopy, videolaparoscopy or robotic-assisted excision).Only 5% of lesions is larger than 10 cm and causes frank symptoms: such tumors go under the nameof giant esophageal leiomyomas (GELs). Performing enucleation for GELs, although feasible, provedto be less safe than for smaller leiomyomas. In GELs, in fact, the tract of mucosa left exposed bythe iatrogenic muscular defect is often too large: on the one hand, if left uncovered, it is likely todevelop pseudo-diverticulum and dysphagia, on the other hand, if treated with a primary closureof the muscular edges, this is supposed not to be tension-free thereby resulting in achalasia anddysphagia. To obviate such and other complications, two surgical options are generally recommendedfor GELs: esophageal resection and extra-mucosal enucleation combined with several techniques ofplastic surgery for covering and buttressing the muscular defect

Angiosarcoma of the breast: a rare and dismal complication of breast surgery associated with radiation

Currently, surgery associated with radiotherapy represents the treatment of choice for breast cancer patients since it can extend their life expectancy and ameliorate prognosis. On occasion, however, such a curative strategy can be complicated with a potentially ominous condition, the so-called secondary cutaneous angiosarcoma of the breast

Angiosarcoma of the breast: a rare and dismal complication of breast surgery associated with radiation

Currently, surgery associated with radiotherapy represents the treatment of choice for breast cancer patients since it can extend their life expectancy and ameliorate prognosis. On occasion, however, such a curative strategy can be complicated with a potentially ominous condition, the so-called secondary cutaneous angiosarcoma of the breast

Conservative management of pneumoperitonitis after percutaneous transhepatic insertion of metallic biliary stents

The occurrence of pneumoperitoneum after a percutaneous transhepatic intervention is an exceptionally rare event. Generally it resolves spontaneously or with minimally invasive management even in symptomatic conditions (pneumoperitonitis); resorting to surgical approach is exceptional. What is still unclear is the question as to whether the airflow has an intestinal or atmospheric source. Our report lends support to the former hypothesis, as argued hereafter