Tài liệu POSSUM: a scoring system for surgical audit docx

78, March, surgical audit POSSUM, a Physiological and Operative Severity Score f o r the enumeration of Mortality and morbidity, is described.. The scoring system produced assessments

Br J Surg 1991, Vol 78, March,

surgical audit

POSSUM, a Physiological and Operative Severity Score f o r the

enumeration of Mortality and morbidity, is described This system has been devised f r o m both a retrospective and prospective analysis and the present paper attempts to validate it prospectively Logistic regression analysis yielded statistically sign ficant equations f o r 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 f o r morbidity

Correspondence to:

and mortality rates which did not significantly differ f r o m 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 t o 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 c a r d i o v a ~ c u l a r ~ ~ ~ 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 1 3 ) 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 t e c h n i q ~ 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 a n 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 t o all patients admitted during a 6-month period, equivalent t o 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

-

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

6 60

No failure

61-70 Diuretic, digoxin, antianginal

or hypertensive therapy

No dyspnoea

110-130 50-80

15 13-16

4 1 0

< 7.5

2 I36

3.5-5.0 Normal

Dyspnoea on exertion Mild COAD 10&109 81-100

12-14 11.5-12'9 16.1-1 7.0 10.1-20.0

3 1 4 0 7.6-1 0.0 131-135 131-170

3.2-3.4 5.1-5.3

2 7 1 Peripheral oedema;

warfarin therapy Borderline cardiomegaly Limiting dyspnoea (one flight) Moderate COAD

2 171

9 e 9 9 101-120 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

blood

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

Surgical audit: G P Copeland e t 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

1 2 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

Operative severity score

Distribution ofpatients with regard to operative severity score

Figure 2

Each bar represents the number of patients in that score range

Surgical audit: G P Copeland et at

Discussion

Surgical audit has increased in importance over the past few years, both as a n 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

"

Physiological score Figure 3

regression analysis

Zones of increasing mortality rate derived from the logistic

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

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

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

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

0 2 0 4 0 6 0 8 1 .o 1-specificity (false positive ra te )

Figure 5 Receiver operating characteristic curlie for mortality

- 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

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

*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 ~ d g e m e n t ' ~ 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: 1 W 7 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

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

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

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

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 U K

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' T h e incidence of

malignancy complicating primary sclerosing cholangitis is

high'; nearly all tumours that occur with the condition are

cholangiocellular carcinomas T h e association of hepatocellular

carcinoma occurring in a patient with chronic liver disease

secondary t o primary sclerosing cholangitis h a s 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 T h e fibrolamellar variant of hepatocellular carcinoma associated with ulcerative colitis a n d primary sclerosing cholangitis has recently been reported3 T h e 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 h a s been reported5 Although n o 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

t u m o u r recurrence in the graft following retransplantation for chronic rejection rather than the uniqueness of this occurrence Combined hepatocellular a n d cholangiocellular carcinoma was found in o n e of eight patients with hepatobiliary tumours associated with primary sclerosing cholangitis a n d ulcerative colitis in a M a y o series'

T h e finding of hepatocellular carcinoma complicating primary sclerosing cholangitis h a s 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 d u e to primary sclerosing cholangitis, liver transplantation is now an accepted treatment option Although cholangiocellular carcinoma is well recognized t o occur in association with the condition, there appears t o be a risk of hepatocellular carcinoma developing Investigations should therefore include abdominal computed tomography a n d estimation of serum tumour m a r k e r s (a-fetoprotein, neurotensiri a n d vitamin B, binding protein levels) in addition to routine screening Intraoperative ultrasonography should be employed routinely a t the time of hepatobiliary surgery