Tài liệu POSSUM: a scoring system for surgical audit docx

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Tài liệu POSSUM: a scoring system for surgical audit docx

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Br. J. Surg. 1991, Vol. 78, March, 356-360 POSSUM: a scoring system for surgical audit POSSUM, a Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, is described. This system has been devised from both a retrospective and prospective analysis and the present paper attempts to validate it prospectively. Logistic regression analysis yielded statistically sign ficant equations for both mortality and G. P. Copeland, D. Jones and M. Walters Department of Surgery, Broadgreen Hospital, Thomas Drive, Liverpool L 14 3LB, UK morbidity (P < 0.001). When displayed graphically zones of increasing morbidity and mortality rates could be defined which could be of value in surgical audit. The scoring system produced assessments for morbidity Correspondence to: Mr G. P. Copeland rates. and mortality rates which did not significantly differ from observed While data regarding the access of patients to care and outcome (presented as overall mortality and morbidity rates) are relatively easy to derive, ‘quality of care’ has proved a more elusive determinant. In most hospitals, quality of care is assessed by discussion of individual cases or by review of series of patients undergoing particular types of surgical procedure. Comparisons between different surgeons, units, hospitals and regions are bedevilled by differences in patient presentation, general fitness of the local populace and the nature of the surgery undertaken. The Royal College of Surgeons of England has defined audit as the ‘systematic appraisal of the implementation and outcome of any process in the context of prescribed targets and standards”. The difficulty in this definition rests in the interpretation of prescribed targets and standards, and it infers that outcome for individuals and series of patients can be predicted. In this context morbidity is probably as important as mortality, certainly when discussing quality of care. Perhaps of parallel importance in audit is the discussion of individuals in whom death or complications could have been expected, but did not occur. Thus audit should include discussion of ‘surgical success’, in addition to mortality and morbidity rates, if it is to be educational. The ideal scoring system for surgical audit purposes should assess mortality and morbidity and should allow audit retrieval of the surgical success. It should be quick and easy to use and should be applicable to all general surgical procedures in both the emergency and elective setting. It should be of use in all types of hospital and should provide educational information. Finally it should be possible to integrate the scoring system into pre-existing audit programmes with the minimum of disruption. There are many scoring systems that predict the risk of mortality with varying degrees of accuracy. However, morbidity is almost universally ignored. Many scores have been devised which are ideally suited to special types of surgical procedure or to assessing particular types of complication. Some scores are ideal for assessing the risk of mortality and to a lesser extent morbidity in particular groups of surgical patients, such as those with cardiova~cular~~~ and gastrointestinalL8 disease, or for assessing the risk of developing particular complication^^^^^. Others are of use in particular surgical settings, such as patients requiring intensive care””’. Probably the best known and most widely used scoring system is APACHE I1 which is ideal for the intensive care patient but requires 24 h of observation and weighting tables for individual disease states”. Whereas such a score can be applied to the majority of general surgical patients it only assesses the risk of mortality. Theoretically the smaller the number of variables the easier the scoring system. Indeed some systems have reduced the number of variables to two (age and lymphocyte count 13) but this reduction clearly has disadvantages if one factor is not available. Other scoring systems have reduced variables by multifactorial analysis and have derived complex mathematical equations to assess the risk of mortality, but few surgeons carry calculators in everyday practice. We identified the need for a simple scoring system that could be used across the general surgical spectrum, whose main use would be in surgical audit. Our present system has been in development over the past 2 years. Initially 62 individual factors (48 preoperative factors and 14 operative and postoperative factors) were assessed by a multivariate discriminant retrospective analysis over a 6-month period, to reduce the number of variables. Of these, 35 factors were assessed prospectively for a further 6 months to produce the present scoring system. In this later prospective analysis all variables were subjected to multivariate discriminant analysis and, using this linear discriminant techniq~e’~, multivariate discriminant function coefficients were obtained for each set of variables. Only significant independent factors were included in the final score design. The multivariate discriminant function coefficients of those remaining factors were divided by a constant and rounded to the nearest whole number to derive a point value on an exponential score (1, 2, 4, 8) for the variable. Thus a 12-factor, four-grade, physiological score was developed. Any decrease in score variables below this level resulted in a loss of predictive ability for mortality or morbidity. While this preoperative physiological score yields a statistically predictive risk of morbidity and mortality for the patients overall, there were intergroup differences depending on the nature of the surgical procedure. Logistic regression analysis of all data enabled a six-factor, surgical, operative severity score to be evolved which compensated for the type of surgical procedure. In the present prospective study we have applied this dual scoring system to all patients admitted during a 6-month period, equivalent to our periods of previous study. During this period the present POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and morbidity) system has been assessed. Patients and methods During the 6 months from August 1988 to February 1989 all patients admitted for inpatient surgery were scored using the POSSUM system at Walton Hospital, Liverpool. In all, 1440 patients underwent elective or emergency surgery during this period and required inpatient care for at least 24 h after operation. Patients undergoing surgery for trauma (12 patients) and those in whom no outpatient review at 6 weeks was available (56 patients) were excluded. Thus 1372 prospectively scored patients were available for study. All patients were scored before operation (using the physiological score) and at discharge (using the operative severity score). The physiological score reflects the indices at the time of surgery rather than at the time of admission. All patients had blood samples taken for determination of urea and electrolyte levels, haemoglobin concentration - 0007-1 323/91/03035546 0 1991 Butterworth-Heinemann Ltd 355 Surgical audit: G. P. Copeland et al. Table 1 Physiological score (to be scored at the time ofsurgery) Score Age (years) Cardiac signs Chest radiograph Respiratory history Chest radiograph Blood pregsure (systolic) (mmHg) Pulse (beats/min) Glasgow coma score Haemoglobin (Silo0 ml) White cell count (x 10'*/1) Urea (mmol/l) Sodium (mmol/l) Potassium (mmol/l) Electrocardiogram 1 2 4 8 6 60 No failure 61-70 Diuretic, digoxin, antianginal or hypertensive therapy No dyspnoea 110-130 50-80 15 13-16 410 < 7.5 2 I36 3.5-5.0 Normal Dyspnoea on exertion Mild COAD 10&109 81-100 a9 12-14 11.5-12'9 16.1-1 7.0 10.1-20.0 3.140 7.6-1 0.0 131-135 131-170 3.2-3.4 5.1-5.3 271 Peripheral oedema; warfarin therapy Borderline cardiomegaly Limiting dyspnoea (one flight) Moderate COAD 2 171 9e99 101-120 9-1 1 10.0-11.4 17.1 - 18.0 220.1 6 3.0 10.1-1 5.0 126130 2'9-3.1 5.4-5.9 Atrial fibrillation (rate 6&90) Raised jugular venous pressure Card i o m e g a 1 y Dyspnoea at rest (rate > 30/min) Fibrosis or consolidation - < 89 2 121 < 39 68 69.9 2 18.1 2 15.1 < I25 < 2.8 > 6.0 Any other abnormal rhythm or 2 5 ectopics/min Q waves or ST/T wave changes COAD, chronic obstructive airways disease Table 2 should be selected) Operative severity score. (Definitions of surgical procedures with regard to severity are guidelines; not all procedures are listed and the closest Score 1 2 4 8 Operative severity* Minor Moderate Major Major + Multiple procedures 1 2 >2 Total blood loss (ml) < 100 101-500 501-999 2 1000 Peritoneal soiling None Minor (serous fluid) Local pus Free bowel content, pus or blood Presence of malignancy None Primary only Nodal metastases Distant metastases Mode of surgery Elective Emergency resuscitation Emergency (immediate surgery of > 2 h possiblet Operation < 24 h after admission <2 h needed) * Surgery of moderate severity includes appendicectomy, cholecystectomy, mastectomy, transurethral resection of prostate; major surgery includes any laparotomy, bowel resection, cholecystectomy with choledochotomy, peripheral vascular procedure or major amputation; major + surgery includes any aortic procedure, abdominoperineal resection, pancreatic or liver resection, oesophagogastrectomy; indicates that resuscitation is possible even if this period is not actually utilized and white cell count, and all had electrocardiography performed. A chest radiograph was obtained in 69.7 per cent of patients. Scores were awarded according to Tables I and 2. Complications were recorded on a separate sheet (Table 3). For the purposes of study the following definitions were used: Wound haemorrhage: local haematoma requiring evacuation Deep haemorrhage: postoperative bleeding requiring re-exploration Chest infection: production of purulent sputum with positive bacteriological cultures, with or without chest radiography changes or pyrexia, or consolidation seen on chest radiograph Woundinfection: wound cellulitis or the discharge ofpurulent exudate Urinary infection: the presence of z lo5 bacteria/ml with the presence of white cells in the urine, in previously clear urine Deep infection: the presence of an intra-abdominal collection confirmed clinically or radiologically Septicaemia: positive blood culture Pyrexia of unknown origin: any temperature above 37°C for more than 24 h occurring after the original pyrexia following surgery (if present) had settled, for which no obvious cause could be found Wound dehiscence: superficial or deep wound breakdown Deep venous thrombosis and pulmonary embolus: when suspected, confirmed radiologically by venography or ventilation/perfusion scanning, or diagnosed at post mortem Cardiac failure: symptoms or signs of left ventricular or congestive cardiac failure which required an alteration from preoperative therapeutic measures Impaired renal function: arbitrarily defined as an increase in blood urea of > 5 mmol/l from preoperative levels Hypotension: a fall in systolic blood pressure below 90 mmHg for more than 2 h as determined by sphygmomanometry or arterial pressure transducer measurement 356 Br. J. Surg., Vol. 78, No. 3, March 1991 Surgical audit: G. P. Copeland et al. Logistic regression analysis yielded statistically significant equations for both morbidity and mortality. For morbidity this was In R/1- R = - 5.91 + (0-16 x physiological score)+ (0.19 x operative severity score) (P<O.OOl). For mortality this was In R/1 -R= -7.04+ (0.13 x physiological score)+ (0.16 x opera- tive severity score) (P <0901). Using the physiological score as the x axis and the operative severity score as the y axis it was possible from these equations to generate graphically zones of increasing mortality (Figure 3) and morbidity (Figure 4) rates. The predictive accuracy of these equations was assessed by the determination of receiver operating characteristic curves (ROC curves), by determining classification matrices for Table 3 Information to be included on a complications record sheet ~ ~~~ .~ ~~ ~~~ Name Hospital no. Diagnosis Operation Date of admission Date of operation Date of discharge Surgeon Anaesthetist Outcome* Haemorrhage Wound Deep Other Infection? Chest Wound Urinary tract Deep Septicaemia Pyrexia of unknown origin Other Superficial Deep Wound dehiscence Anastomotic leak Thrombosis Deep vein thrombosis Pulmonary embolus Other Cerebrovascular accident Myocardial infarct Cardiac failure Impaired renal function (urea increase > 5 mmol/l from preoperative level) Hypotension (<90mmHg for 2 h) Respiratory failure Any other complication In the event of death give date Post-mortem findings *Give dates for all complications; t for infection give bacteria cultured if known Respiratoryfailure: respiratory difficulty requiring emergency ventilation Anastomotic leak: discharge of bowel content via the drain, wound or abnormal orifice. Many of these complications have been arbitrarily set for the purposes of this study, and were assessed and recorded by one of the three authors in all cases. Complications were assessed by clinical observation. Routine bacteriological screening and postoperative radiological scanning were not carried out, but confirmatory bacteriological and radiological tests were carried out where clinical suspicion existed. Method of analysis Using outcome (dead/alive or complicated/uncomplicated) as a dichotomous dependent variable, we have derived multiple logistic regression equations for both morbidity and mortality. Significance was assessed using model x2. Differences between observed and expected outcomes were assessed using xz tests. Results The types of surgical procedure performed are illustrated in Table4. The overall mortality rate was 4.0 per cent and the overall morbidity rate was 16.6 per cent. The range of physiological scores obtained is shown in Figure 1 and that of operative severity scores can be seen in Figure 2. Table 4 patients (833 elective and 539 emergency procedures) Types of surgical procedure performed in the 1372 assessed No. of procedures Vascular procedures Gastrointestinal procedures Hepatobiliary Urological Miscellaneous 101 432 120 105 614 600 f 400 al m Q u- Y L 2 5 200 z 0 1111II I 12 15 18 21 24 27 30 33 36 39 42 40 54 Physiological score Figure 1 Each bar represents the number of patients in that score range Distribution of patients with regard to physiological score. 1000 u) 800 Y c Y X 600 u- 0 400 2 5 200 t 0 6 10 14 18 22 26 30 34 Operative severity score Distribution ofpatients with regard to operative severity score. Figure 2 Each bar represents the number of patients in that score range Br. J. Surg., Vol. 78, No. 3, March 1991 357 Surgical audit: G. P. Copeland et at. Discussion Surgical audit has increased in importance over the past few years, both as an educational process and as a means of assessing the quality of surgical care. We felt that a need existed to allow assessment of the 'quality' of care: but to do so it must 9) 0 u Y L al al : - Y 9 al Q 0 56 t 46 36 26 16 c " 12 22 32 42 52 62 72 Physiological score Figure 3 regression analysis Zones of increasing mortality rate derived from the logistic 12 22 32 42 52 62 72 Physiological score Figure 4 regression analysis Zones qf increasing morbidity rate derived, from the logistic Table 5 (prediclions are derived.from the logistic equation) Clussificution matrix of 50 per cent predicted risk of death Status Alive Dead Total Alive 1278 39 Dead 9 46 Total 1287 85 1317 55 1372 Negative predictive value, 83.6 per cent; positive predictive value, 97.0 per cent; specificity, 99.3 per cent; sensitivity, 54-1 per cent; total correct classification, 96.5 per cent different levels of predicted mortality and morbidity. Such a matrix for the 50 per cent prediction of risk of mortality is shown in Table 5 and for risk of morbidity is shown in Table 6. The resultant ROC curves are illustrated in Figures 5 and 6. The comparison between predicted and observed rates of morbidity and mortality expressed numerically are illustrated in Table 7. 358 Table 6 Clas.rification matrirc of 50 per cenf predicted risk of complication resulting from surgery (predictions are derived from (he appropriate logistic equation) ~~ ~ ~ Status Uncomplicated Complicated Total Uncomplicated 1021 123 1144 Complicated 94 134 228 Total 1115 257 1372 Yegative predictive value, 58.8 per cent; positive predictive value, 89.2 per cent; specificity, 92.4 per cent; sensitivity, 52.1 per cent; total correct classification, 84.2 per cent 1 .o - 0.8 c m >" Y 'i 0.6 a 9) 2 L c Y .+ 0.4 c > c v) C ; 0.2 V I I I I I 0.2 0.4 0.6 0.8 1 .o 1-specificity (false positive rate) Figure 5 Receiver operating characteristic curlie for mortality 1 .o - 0.8 e m L P c '; 0.6 0 Q 0 L e v 0.4 e > e 2 $ 0.2 0.2 0.4 0.6 0.8 1 .o 1-specificity (false positive rate) Figure 6 Receiver operating characteristic curve, for morbidity Br. J. Surg Vol. 78, No. 3, March 1991 Surgical audit: G. P. Copeland et al. and urological procedures is obviously low, hence mortality prediction in these groups has yet to be validated. However, because the morbidity predictive ability for these groups requires no additional weighting, it is probable that mortality is also adequately predicted. Thus, for the most part, the scoring system appears to cover the range of general surgical procedures, both elective and emergency, and allows prediction of both mortality and morbidity. The use of increasing zones of mortality and morbidity rates, in particular the 10, 50 and 90 per cent prediction levels, can be useful when considering the expected mortality/morbidity risk for individual patients. It may be more important, and potentially more educational, to concentrate discussion of mortality and morbidity on patients falling below the 90 per cent line, rather than engaging in extensive discussion of those falling above the 90 per cent line. Equally profitable discussion could be extended to surgical success, for example the uncomplicated or surviving patient falling above an arbitrary line, say the 50 per cent line, where potential improvements in policy and management may be more apparent. Obviously no regression equation for assessment of risk of morbidity and mortality should remain static over time; hopefully improvements in surgical management will occur. Logistic regression analysis of the observed mortality and morbidity rates on a hospital, district or regional basis would allow the 10-90 per cent ranges to be updated at regular intervals. The extrapolated score values (both physiological and operative severity scores) of 50 per cent risk of mortality and morbidity may potentially allow comparison between units or hospitals. Indeed comparison of physiological and operative severity scores of patients undergoing similar procedures in different units may be of benefit by highlighting different operative and management practices, and also differing modes of presentation. Although POSSUM may not be able to replace highly specific scoring systems for individual disease states or the intensive care patient it does appear to provide an efficient indicator of the risk of morbidity and mortality in the general surgical patient. We should stress that our main intention is that POSSUM be used as an adjunct to surgical audit. It was never intended to affect the decision to operate, a decision that must always remain clinical. It could theoretically assist in the direction of resuscitative efforts. The present study is our assessment of POSSUM at one hospital. We are at present assessing POSSUM in five different types of hospital across the Mersey Region. In addition we are comparing POSSUM with a range of other scoring systems and examining the impact of physiological score manipulation, by preoperative resuscitative measures, on mortality and morbidity rates. Table 7 Predicied versus observed rates for mortality and morbidity* Observed rate (YO) Predicted risk (YO ) Mortality Morbidity 85 86.5 84.3 75 78.3 75.7 65 67-7 67.3 55 56.4 56.9 45 46.0 47.5 35 38.5 37.4 25 29.3 26.4 *There was good correlation between observed and predicted rates for morbidity and mortality (P <0.001) be possible to set norms for any particular surgical procedure and to allow its comparison with other dissimilar procedures. Scoring would seem to be the best method available for assessing the risk of mortality and morbidity, but existing scoring systems did not completely meet our expectations as being readily applicable to audit. One worrying feature of scores that estimate the risk of mortality and morbidity preoperatively, or in the immediate perioperative stage, was that they could be used to decide on the continuance of resuscitative measures. Our intention was to develop a score to aid audit and we therefore devised a method in which the full score, and the numerical estimate of risk of mortality and morbidity, was not available until outcome was known; in this way we hoped to minimize the risk of inappropriate score usage. The physiological score variables and individual factor weightings were devised by a linear multivariant discriminant technique which has been recommended as the statistical method that best simulates the formation of clinical j~dgement'~. A similar technique has been used by others to assess risk factors". The information obtained from this analysis was combined with both linear discriminant and logistic regression analysis to produce the present physiological and operative severity score. We attempted to devise a scoring system applicable to all general surgical patients in all surgical settings. The present scores were developed from the clinically observed mortality and morbidity rates, rather than fitting the score to the data by the application of weighting tables. The present score is both quick and easy to use. The clinical features scored are all assessed as part of the usual admitting clinical history and examination, and all the biochemical, radiological and cardiological investigations are readily available in all clinical settings. This means that, with practice, both scores can be gauged within 3 min by all grades of staff. In 50 patients scored by three different individuals there was complete agreement in 47 cases. In the remaining three cases there was variation in score in only four different variables (but this did not adversely affect the score's usefulness). Complications were assessed by observation. While this means that some subclinical complications may have been missed, we felt that these would be unlikely to be of clinical significance, especially as we had adopted a 6-week follow-up period. To be of use in surgical audit the scoring system must produce a valid assessment of the risk of mortality and morbidity. That the present scoring system achieves these aims is well demonstrated by the ROC curves obtained for mortality and morbidity and by comparing the actual rates uersus predicted rates (Figures5 and 6; Table 7) for these two parameters. It should be stressed that the assessment obtained for a particular score combination relates to a group of patients with that particular score combination rather than an individual. Certainly, with regard to patients undergoing vascular and gastrointestinal procedures, no additional weighting to the logistic regression equation is required to improve its statistical predictive ability for morbidity and mortality. The mortality rate for patients undergoing minor References 1. 2. 3. 4. 5. 6. 7. 8. 9. Todd I. Guidelines to Clinical Audit in Surgical Practice. Advice Document. London: Royal College ofsurgeons ofEngland, 1989. Cooperman M, Pflug B, Martin EW et al. Cardiovascular risk factors in patients with peripheral vascular disease. Surgery 1978; Domaingue CM, Davies MJ, Cronin KD et al. Cardiovascular risk factors in patients for vascular surgery. Anaesth Intensiue Care 1982; 10: 324-7. Mullen JL, Buzby GP, Waldman TG et al. Prediction of operative morbidity and mortality by preoperative nutritional assessment. Surg Forum 1979; 30: 80-2. Greenburg AG, Saik RP, Pridham D. Influence of age on mortality of colon surgery. Am J Surg 1985; 150: 65-70. Linn BS. A protein energy malnutrition scale (PEMS). Ann Surg Buzby GP, Mullen JL, Matthews DC et al. Prognostic nutritional index in gastrointestinal surgery. Am J Surg 1980; 139: 1W7. Boyd JB, Bradford B, Watne AL. Operative risk factors of colon resection in the elderly. Ann Surg 1980; 192: 743-6. Goldman L, Caldera DL, Southwick FS et al. Cardiac risk factors 84: 505-9. 1984; 200: 747-52. Br. J. Surg., Vol. 78, No. 3, March 1991 359 Surgical audit: G. P. Copeland et al. and complications in non-cardiac surgery. Medicine 1978; 57: ofdisease classification system. Crit Cure Med 1985; 13: 818-29. 357-70. 13. Ramsay G, MacGregor JR, Murray GD, Neithercut D, Goldman L, Caldera DL, Nussbaum SB et al. Multifactorial Ledingham IMcA, George WD. Prediction of surgical risk in index of cardiac risk in non-cardiac surgical procedures. N Engl adults. Surg Res Comm 1988; 3: 95-103. J Med 1971; 297: 845250. Overall JE, Williams CM. Models for medical diagnosis. Behuv LeGall J, Loirat P, Alperovitch A et ul. A simplified acute Sci 1961; 6: 13441. physiology score for ITU patients. Crit Cure Med 1984; 12: 975-7. Knaus WA, Draper EA, Wagner DP et ul. Apache 11: a severity 10. 14. 11. 12. Paper accepted 8 August 1990 Case report Br. J. Surg. 1991, Vol. 78, March, 360-361 Hepatocel lu lar carci noma corn pl icat i ng primary scl e rosi ng cholangitis T. Ismail, L. Angrisani, S. Hubscher* and P. McMaster The Liver Unit, Queen Elizabeth Hospital and *Department of Pathology, University of Birmingham,. Birmingham, UK Correspondence to; Mr T. Ismail, Liver Research Laboratories, Queen Elizabeth Hospital, Birmingham 815 2TH. UK Primary sclerosing cholangitis is a condition of unknown aetiology and ill-defined progression. Although a rare cause of chronic liver disease, it is the third most common indication for orthotopic liver transplantation'. The incidence of malignancy complicating primary sclerosing cholangitis is high'; nearly all tumours that occur with the condition are cholangiocellular carcinomas. The association of hepatocellular carcinoma occurring in a patient with chronic liver disease secondary to primary .sclerosing cholangitis has not previously been well documented. We describe a case of well differentiated hepatocellular carcinoma arising in a cirrhotic liver associated with primary sclerosing cholangitis. Case report A 39-year-old male Caucasian cabinet-maker presented in 1972 with pruritus and progressive jaundice. There was no history of alcohol abuse, blood transfusion or previous jaundice. At subsequent laparotomy, an operative cholangiogram was consistent with primary sclerosing cholangitis. Cholecystectomy and sphincterotomy were performed to improve biliary drainage. The patient then remained well until 1981 when he retired from his work because of increasing tiredness, fatigue and intermittent diarrhoea. Biopsies at colonoscopy confirmed ulcerative colitis throughout the colon. He settled on treatment with steroids and Salazopyrins (Pharmacia, Milton Keynes, UK). His general health gradually deteriorated and endoscopic retrograde cholangiopancreatography in 1984 confirmed changes consistent with primary sclerosing cholangitis with a major stricture at the hilum. This was initially managed by nasobiliary intubation and saline lavage without success. In 1987, the patient presented with hepatosplenomegaly, gross ascites and variceal bleeding. This precipitated encephalopathy and he was referred to our unit for further assessment. On admission, he was thin, wasted, and had a soft irregular enlarged liver. Investigations included serum bilirubin (47 pmol/l; normal range 5-20 pmol/l); alkaline phosphatase (1260 units/l; normal range 7C290 units/l); aspartate transaminase (91 units/l; normal range 5-20 units/l); haemoglobin (12.5 g/dl); prothrombin time (17/16 s); cc-fetoprotein (58 kilounits/l; normal range < 5 kilounits/l). Hepatitis B surface antigen and autoantibodies were negative and an isotope liver scan shovted general reduction of uptake but no focal lesion. Percutaneous needle liver biopsy showed fibrous expansion of portal tracts with a lymphoid infiltrate and concentric fibrosis around medium-sized bile ducts. After evaluation, the patient was accepted for the liver transplant programme. At transplantation in October 1987, a cirrhotic liver with gross portal hypertension and massive gastric varices were found. Total hepatectomy and liver replacement with a gallbladder conduit to a Roux-en-Y small bowel loop were performed. After operation the patient developed cardiorespiratory failure and septicaemia, and he died 17 days after transplantation. Gross examination revealed a green cirrhotic liver weighing 1060 g. On slicing, there were several discrete, pale brown nodules, the largest measuring 4 cm in diameter. Histological examination confirmed the presence of established cirrhosis with a mixed pattern of nodularity. There were occasional fibro-obliterative duct lesions and cystic dilations of intrahepatic bile ducts consistent with primary sclerosing cholangitis. The nodules seen macroscopically showed neoplastic transformation in the form of a well differentiated hepatocellular carcinoma with permeation of small vascular channels in surrounding fibrous septa. In addition, there was widespread liver cell dysplasia. Excision was complete with tumour negative nodes in the porta hepatis. Discussion As far as we are aware, this is the first case of classical hepatocellular carcinoma occurring in a cirrhotic liver complicating primary sclerosing cholangitis. The fibrolamellar variant of hepatocellular carcinoma associated with ulcerative colitis and primary sclerosing cholangitis has recently been reported3. The fibrolamellar variant of hepatoma generally occurs in young adults with non-cirrhotic livers and is said to have a relatively favourable prognosis4. One other case of hepatocellular carcinoma in a 26-year-old patient with primary sclerosing cholangitis has been reported5. Although no comment was made on the histological type, it may also have been a fibrolamellar variant as the liver parenchyma was non-cirrhotic with normal carcinoembryonic antigen and a-fetoprotein levels. The authors made particular reference to tumour recurrence in the graft following retransplantation for chronic rejection rather than the uniqueness of this occurrence. Combined hepatocellular and cholangiocellular carcinoma was found in one of eight patients with hepatobiliary tumours associated with primary sclerosing cholangitis and ulcerative colitis in a Mayo series'. The finding of hepatocellular carcinoma complicating primary sclerosing cholangitis has potentially important implications in the management of the condition. Management by means of reconstructive surgery or endoscopic manipulation is controversial. For end-stage liver disease due to primary sclerosing cholangitis, liver transplantation is now an accepted treatment option. Although cholangiocellular carcinoma is well recognized to occur in association with the condition, there appears to be a risk of hepatocellular carcinoma developing. Investigations should therefore include abdominal computed tomography and estimation of serum tumour markers (a-fetoprotein, neurotensiri and vitamin B, binding protein levels) in addition to routine screening. Intraoperative ultrasonography should be employed routinely at the time of hepatobiliary surgery. 360 0007-1323/91/0303$02 0 1991 Butterworth-Heinemann Ltd . importance over the past few years, both as an educational process and as a means of assessing the quality of surgical care. We felt that a need. biochemical, radiological and cardiological investigations are readily available in all clinical settings. This means that, with practice, both scores can

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