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Jung HM, Paik J, Lee M, Kim YW, Kim TY. Clinical Utility of the Tokyo Guidelines 2018 for Acute Cholangitis in the Emergency Department and Comparison with Novel Markers (Neutrophil-to-Lymphocyte and Blood Nitrogen Urea-to-Albumin Ratios). J Clin Med 2024; 13:2306. [PMID: 38673579 PMCID: PMC11051285 DOI: 10.3390/jcm13082306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction: The Tokyo Guidelines 2018 (TG2018) is a scoring system used to recommend the clinical management of AC. However, such a scoring system must incorporate a variety of clinical outcomes of acute cholangitis (AC). In an emergency department (ED)-based setting, where efficiency and practicality are highly desired, clinicians may find the application of various parameters challenging. The neutrophil-to-lymphocyte ratio (NLR) and blood urea nitrogen-to-albumin ratio (BAR) are relatively common biomarkers used to assess disease severity. This study evaluated the potential value of TG2018 scores measured in an ED to predict a variety of clinical outcomes. Furthermore, the study also compared TG2018 scores with NLR and BAR scores to demonstrate their usefulness. Methods: This retrospective observational study was performed in an ED. In total, 502 patients with AC visited the ED between January 2016 and December 2021. The primary endpoint was to evaluate whether the TG2018 scoring system measured in the ED was a predictor of intensive care, long-term hospital stays (≥14 days), percutaneous transhepatic biliary drainage (PTBD) during admission care, and endotracheal intubation (ETI). Results: The analysis included 81 patients requiring intensive care, 111 requiring long-term hospital stays (≥14 days), 49 requiring PTBD during hospitalization, and 14 requiring ETI during hospitalization. For the TG2018 score, the adjusted OR (aOR) using (1) as a reference was 23.169 (95% CI: 9.788-54.844) for (3) compared to (1). The AUC of the TG2018 for the need for intensive care was 0.850 (95% CI: 0.815-0.881) with a cutoff of >2. The AUC for long-term hospital stays did not exceed 0.7 for any of the markers. the AUC for PTBD also did not exceed 0.7 for any of the markers. The AUC for ETI was the highest for BAR at 0.870 (95% CI: 0.837-0.899) with a cutoff value of >5.2. Conclusions: The TG2018 score measured in the ED helps predict various clinical outcomes of AC. Other novel markers such as BAR and NLR are also associated, but their explanatory power is weak.
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Affiliation(s)
- Hyun-Min Jung
- Department of Emergency Medicine, Inha University Hospital, College of Medicine, Inha University, 27, Inhang-ro, Jung-gu, Incheon 22332, Republic of Korea; (H.-M.J.); (J.P.)
| | - Jinhui Paik
- Department of Emergency Medicine, Inha University Hospital, College of Medicine, Inha University, 27, Inhang-ro, Jung-gu, Incheon 22332, Republic of Korea; (H.-M.J.); (J.P.)
| | - Minsik Lee
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang 10326, Republic of Korea; (M.L.); (Y.W.K.)
| | - Yong Won Kim
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Goyang 10326, Republic of Korea; (M.L.); (Y.W.K.)
| | - Tae-Youn Kim
- Department of Emergency Medicine, Inha University Hospital, College of Medicine, Inha University, 27, Inhang-ro, Jung-gu, Incheon 22332, Republic of Korea; (H.-M.J.); (J.P.)
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Belyaev AM, Thwaite P, Rossaak J, Chen J, Smith B. The Use of Inflammatory Markers for Treatment Response Monitoring in Acute Cholangitis: A Retrospective Cohort Study. J Surg Res 2024; 293:14-21. [PMID: 37690382 DOI: 10.1016/j.jss.2023.07.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/07/2023] [Accepted: 07/25/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION In acute cholangitis (AC), monitoring treatment response to antimicrobial therapy allows for making timely decisions on early biliary decompression. The aims of this study were to compare the discriminating powers of traditional blood inflammatory markers and propose new inflammatory markers that have a better ability to distinguish between patients with and without biliary tract infection. METHODS This was a retrospective cohort study. Patients who underwent endoscopic retrograde cholangio-pancreaticography for AC and those without biliary tract inflammation were randomly selected in the 4:3 ratio of their hospital admissions from our hospital endoscopic retrograde cholangio-pancreaticography database. The exclusion criterion was the absence of C-reactive protein (CRP) measurements. RESULTS The discriminating powers of the neutrophil count, lymphocytes, albumin, neutrophil-to-lymphocyte ratio, and CRP were superior to that of white blood cell (P1 < 0.005; P2 = 0.004; P3 < 0.0005; P4 < 0.0005; P5 < 0.0005). In monitoring treatment response in AC, lymphocyte count, albumin, neutrophil-to-lymphocyte ratio, and CRP were better than neutrophil count (P6 = 0.037, P7 < 0.005, P8, 9 < 0.0005). The area under the receiver operating characteristic curve (AUC) of CRP was higher than the AUC for lymphocytes, 96% (95% confidence interval [CI]: 94-98%) versus 81% (95% CI: 76-86%) (P < 0.0005), and larger than the AUC for albumin, 88% (95% CI: 84-92%) (P < 0.0005), indicating a greater discriminating power of CRP. However, the discriminating power of CRP-to-lymphocyte ratio (CLR) was more than that for CRP (P = 0.006) but equal to CRP-to-(lymphocytes∗albumin) ratio (CLAR) (P = 0.249). The AUCs of CLR and CLAR were both 98% (95% CI: 96-99%). CONCLUSIONS CLR and CLAR have superior discriminating powers than traditional inflammatory markers used for monitoring treatment response in AC.
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Affiliation(s)
- Andrei M Belyaev
- General Surgery Department, Tauranga Hospital, Tauranga, New Zealand.
| | - Phillip Thwaite
- General Surgery Department, Tauranga Hospital, Tauranga, New Zealand
| | - Jeremy Rossaak
- General Surgery Department, Tauranga Hospital, Tauranga, New Zealand
| | - Jonathan Chen
- Intensive Care Unit, Tauranga Hospital, Tauranga, New Zealand
| | - Barnaby Smith
- General Surgery Department, Tauranga Hospital, Tauranga, New Zealand
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Srinu D, Shah J, Jena A, Jearth V, Singh AK, Mandavdhare HS, Sharma V, Irrinki S, Sakaray YR, Gupta R, Gautam V, Rana S, Dutta U. Conventional vs Short Duration of Antibiotics in Patients With Moderate or Severe Cholangitis: Noninferiority Randomized Trial. Am J Gastroenterol 2024; 119:176-182. [PMID: 37732816 DOI: 10.14309/ajg.0000000000002499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Successful biliary drainage and antibiotics are the mainstays of therapy in management of patients with acute cholangitis. However, the duration of antibiotic therapy after successful biliary drainage has not been prospectively evaluated. We conducted a single-center, randomized, noninferiority trial to compare short duration of antibiotic therapy with conventional duration of antibiotic therapy in patients with moderate or severe cholangitis. METHODS Consecutive patients were screened for the inclusion criteria and randomized into either conventional duration (CD) group (8 days) or short duration (SD) group (4 days) of antibiotic therapy. The primary outcome was clinical cure (absence of recurrence of cholangitis at day 30 and >50% reduction of bilirubin at day 15). Secondary outcomes were total days of antibiotic therapy and hospitalization within 30 days, antibiotic-related adverse events, and all-cause mortality at day 30. RESULTS The study included 120 patients (the mean age was 55.85 ± 13.52 years, and 50% were male patients). Of them, 51.7% patients had malignant etiology and 76.7% patients had moderate cholangitis. Clinical cure was seen in 79.66% (95% confidence interval, 67.58%-88.12%) patients in the CD group and 77.97% (95% confidence interval, 65.74%-86.78%) patients in the SD group ( P = 0.822). On multivariate analysis, malignant etiology and hypotension at presentation were associated with lower clinical cure. Total duration of antibiotics required postintervention was lower in the SD group (8.58 ± 1.92 and 4.75 ± 2.32 days; P < 0.001). Duration of hospitalization and mortality were similar in both the groups. DISCUSSION Short duration of antibiotics is noninferior to conventional duration in patients with moderate-to-severe cholangitis in terms of clinical cure, recurrence of cholangitis, and overall mortality.
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Affiliation(s)
- Deshidi Srinu
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Anupam K Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harshal S Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Santosh Irrinki
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Yashwant Raj Sakaray
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vikas Gautam
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Surinder Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Lim KPK, Lee AJL, Jiang X, Teng TZJ, Shelat VG. The link between Helicobacter pylori infection and gallbladder and biliary tract diseases: A review. Ann Hepatobiliary Pancreat Surg 2023; 27:241-250. [PMID: 37357161 PMCID: PMC10472116 DOI: 10.14701/ahbps.22-056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 03/02/2023] [Accepted: 03/08/2023] [Indexed: 06/27/2023] Open
Abstract
Helicobacter pylori is a gram-negative pathogen commonly associated with peptic ulcer disease and gastric cancer. H. pylori infection has also been reported in cholelithiasis, cholecystitis, gallbladder polyps, and biliary tract cancers. However, the association between H. pylori and gallbladder and biliary tract pathologies remains unclear due to the paucity of literature. In response to the current literature gap, we aim to review and provide an updated summary of the association between H. pylori with gallbladder and biliary tract diseases and its impact on their clinical management. Relevant peer-reviewed studies were retrieved from Medline, PubMed, Embase, and Cochrane databases. We found that H. pylori infection was associated with cholelithiasis, chronic cholecystitis, biliary tract cancer, primary sclerosing cholangitis, and primary biliary cholangitis but not with gallbladder polyps. While causal links have been reported, prospective longitudinal studies are required to conclude the association between H. pylori and gallbladder pathologies. Clinicians should be aware of the implications that H. pylori infection has on the management of these diseases.
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Affiliation(s)
- Klay Puay Khim Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Aaron Jia Loong Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Xiuting Jiang
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Thomas Zheng Jie Teng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Liu JJ, Sun YM, Xu Y, Mei HW, Guo W, Li ZL. Pathophysiological consequences and treatment strategy of obstructive jaundice. World J Gastrointest Surg 2023; 15:1262-1276. [PMID: 37555128 PMCID: PMC10405123 DOI: 10.4240/wjgs.v15.i7.1262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/29/2023] [Accepted: 05/31/2023] [Indexed: 07/21/2023] Open
Abstract
Obstructive jaundice (OJ) is a common problem in daily clinical practice. However, completely understanding the pathophysiological changes in OJ remains a challenge for planning current and future management. The effects of OJ are widespread, affecting the biliary tree, hepatic cells, liver function, and causing systemic complications. The lack of bile in the intestine, destruction of the intestinal mucosal barrier, and increased absorption of endotoxins can lead to endotoxemia, production of proinflammatory cytokines, and induce systemic inflammatory response syndrome, ultimately leading to multiple organ dysfunction syndrome. Proper management of OJ includes adequate water supply and electrolyte replacement, nutritional support, preventive antibiotics, pain relief, and itching relief. The surgical treatment of OJ depends on the cause, location, and severity of the obstruction. Biliary drainage, surgery, and endoscopic intervention are potential treatment options depending on the patient's condition. In addition to modern medical treatments, Traditional Chinese medicine may offer therapeutic benefits for OJ. A comprehensive search was conducted on PubMed for relevant articles published up to August 1970. This review discusses in detail the pathophysiological changes associated with OJ and presents effective strategies for managing the condition.
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Affiliation(s)
- Jun-Jian Liu
- Department of Hepatobiliary and Pancreatic Surgery, Tianjin Medical University Nankai Hospital, Tianjin 300102, China
| | - Yi-Meng Sun
- Graduate School, Tianjin Medical University, Tianjin 300070, China
| | - Yan Xu
- Graduate School, Tianjin Medical University, Tianjin 300070, China
| | - Han-Wei Mei
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Wu Guo
- Graduate School, Tianjin Medical University, Tianjin 300070, China
| | - Zhong-Lian Li
- Department of Hepatobiliary and Pancreatic Surgery, Tianjin Medical University Nankai Hospital, Tianjin 300102, China
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Hedjoudje A, Cheurfa C, Et Talby M, Levy P, Prat F, Piton G. Outcomes and predictors of delayed endoscopic biliary drainage for severe acute cholangitis due to choledocholithiasis in an intensive care unit. Dig Liver Dis 2023; 55:763-770. [PMID: 36842843 DOI: 10.1016/j.dld.2023.01.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/17/2022] [Accepted: 01/20/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Acute cholangitis (AC) is an infection of the biliary tract secondary to biliary obstruction requiring biliary drainage through endoscopic retrograde cholangiopancreatography. This study aims to compare the outcome between the early and delayed ERCP in patients with severe AC. METHODS Patient with severe AC due to choledocholithiasis admitted to intensive care unit were included. Early ERCP was defined was as ERCP performed within 24 h following hospital admission. Propensity-score matching was used to reduce the imbalance between groups. The primary outcome was 30-day mortality. Secondary outcomes included length of hospital and ICU stay, onset or persistent organ failure. RESULTS The delayed ERCP group had a higher mortality rate at 30 days (45,5 versus 13%, <0.001) and at 1 year (59,7% versus 15,6%, p <0.001). Delayed ERCP had also a higher rate of respiratory adverse events (54,5 versus 27,8%, p = 0,002), longer ICU (7.41 versus 4.61, p = 0,004) and hospital (11,88 versus 9,22, p = 0,042) length of stay. Predictors of delayed ERCP were cardiac arrythmias, liver disease, creatinine value and white blood cell count at baseline. CONCLUSIONS Delays in ERCP for patients with severe AC appear to be associated with higher mortality rate and prolonged ICU and hospital stays.
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Affiliation(s)
- Abdellah Hedjoudje
- Assistance Publique des Hôpitaux de Paris, DMU Digestif, Hôpital Beaujon, Clichy, France; Equipe d'Accueil 3920, Université de Bourgogne-Franche Comté, France
| | - Chérifa Cheurfa
- Service de réanimation chirurgicale, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Mohamed Et Talby
- Service de réanimation chirurgicale, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Philippe Levy
- Assistance Publique des Hôpitaux de Paris, DMU Digestif, Hôpital Beaujon, Clichy, France
| | - Frédéric Prat
- Assistance Publique des Hôpitaux de Paris, DMU Digestif, Hôpital Beaujon, Clichy, France
| | - Gaël Piton
- Equipe d'Accueil 3920, Université de Bourgogne-Franche Comté, France; Service de réanimation médicale, CHRU Jean Minjoz, Besançon, France.
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Mistry NP, Zeng W. Intense FDG Uptake in the Common Bile Duct Post-ERCP Mimics Acute Infectious Cholangitis. Tomography 2022; 8:2946-2951. [PMID: 36548540 PMCID: PMC9785686 DOI: 10.3390/tomography8060248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/04/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
In patients with obstructive pancreatitis due to choledocholithiasis, endoscopic retrograde cholangiopancreatography (ERCP) is the standard of care. ERCP-induced inflammation or infection of the common bile duct (i.e., cholangitis) is a rare complication with a high mortality rate in severe cases. We report an unusual case of incidental findings of intense FDG uptake in the common bile duct one month post-ERCP without clinical features of acute cholangitis, indicative of inflammation of CBD associated with or exaggerated by ERCP.
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Affiliation(s)
- Neel P. Mistry
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Wanzhen Zeng
- Division of Nuclear Medicine, Department of Medicine, The Ottawa Hospital, Ottawa, ON K1Y 4E9, Canada
- Correspondence:
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Implications of Type 2 Diabetes Mellitus in Patients with Acute Cholangitis: A Systematic Review of Current Literature. Healthcare (Basel) 2022; 10:healthcare10112196. [PMID: 36360537 PMCID: PMC9691116 DOI: 10.3390/healthcare10112196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction: Type 2 diabetes mellitus (T2DM) has been associated with higher rates and poorer prognosis of infections, mainly due to poor glycemic control, reduced response of T-cells and neutrophils, and impaired migration, phagocytosis, and chemotaxis of leukocytes. However, the impact of T2DM on acute cholangitis (AC) has not been assessed so far. Thus, we aimed to explore this association by means of a systematic review of the literature. Methods: This systematic review was carried out based on the recommendations stated in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the PubMed/MEDLINE, Web of Science and SCOPUS databases to identify relevant publications depicting an association between T2DM and AC from the inception of these search services up to present. Results: We detected a total of 435 eligible records. After we applied the inclusion and exclusion criteria, a total of 14 articles were included in the present systematic review. Included manuscripts focused on the potential role of T2DM as a risk factor for the development of AC and on its contribution to a worse prognosis in AC, e.g., development of sepsis or other complications, the risk of AC recurrence and the impact on mortality. Conclusions: As compared to non-diabetic individuals, patients with T2DM have a higher risk of AC as a complication of choledocholithiasis or gallstone pancreatitis. Several oral hypoglycemic drugs used in the management of T2DM may also be involved in the onset of AC. Diabetic patients who suffer from AC have a higher likelihood of longer hospital stays and sepsis, as well as a higher risk of mortality and more severe forms of AC as compared to non-diabetic individuals.
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Lee BJH, Yap QV, Low JK, Chan YH, Shelat VG. Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis. World J Clin Cases 2022; 10:10399-10412. [PMID: 36312509 PMCID: PMC9602237 DOI: 10.12998/wjcc.v10.i29.10399] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/13/2022] [Accepted: 09/01/2022] [Indexed: 02/05/2023] Open
Abstract
Gallstones are a common public health problem, especially in developed countries. There are an increasing number of patients who are diagnosed with gallstones due to increasing awareness and liberal use of imaging, with 22.6%-80% of gallstone patients being asymptomatic at the time of diagnosis. Despite being asymptomatic, this group of patients are still at life-long risk of developing symptoms and complications such as acute cholangitis and acute biliary pancreatitis. Hence, while early prophylactic cholecystectomy may have some benefits in selected groups of patients, the current standard practice is to recommend cholecystectomy only after symptoms or complications occur. After reviewing the current evidence about the natural course of asymptomatic gallstones, complications of cholecystectomy, quality of life outcomes, and economic outcomes, we recommend that the option of cholecystectomy should be discussed with all asymptomatic gallstone patients. Disclosure of material information is essential for patients to make an informed choice for prophylactic cholecystectomy. It is for the patient to decide on watchful waiting or prophylactic cholecystectomy, and not for the medical community to make a blanket policy of watchful waiting for asymptomatic gallstone patients. For patients with high-risk profiles, it is clinically justifiable to advocate cholecystectomy to minimize the likelihood of morbidity due to complications.
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Affiliation(s)
- Brian Juin Hsien Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore S308232, Singapore
| | - Qai Ven Yap
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore S117597, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore S308433, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore S117597, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore S308433, Singapore
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Khim LP, Jie Teng TZ, Junnarkar SP. Letter to the Editor: Shewanella algae: An Emerging Pathogen Implicated in Acute Cholangitis. Surg Infect (Larchmt) 2022; 23:607-608. [PMID: 35584251 DOI: 10.1089/sur.2022.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Thomas Zheng Jie Teng
- Lee Kong Chian School of Medicine, NTU, Singapore.,Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Wang YL, Chan XW, Chan KS, Shelat VG. Omental patch repair of large perforated peptic ulcers ≥25 mm is associated with higher leak rate. J Clin Transl Res 2021; 7:759-766. [PMID: 34988327 PMCID: PMC8710357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/02/2021] [Accepted: 11/07/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND AIM Omental patch repair is the present gold-standard technique for patients with perforated peptic ulcers (PPUs). Data are lacking regarding the safe ulcer size for omental patch repair leak (OPL). We analyze our experience in managing PPU to identify an ulcer size cut-off for predicting OPL. METHODS Patients who had undergone omental patch repair for PPU between Jan 2004 and Apr 2016 were included. Demographic data, the American Society of Anesthesiologists score, ulcer size, operative approach, post-operative complications, and length of stay were recorded. OPL, intra-abdominal collection, repeat surgery, and 30-day mortality were recorded. The relationship between ulcer size, pre-operative characteristics, and OPL were investigated with univariate and multivariate logistic regression. Receiver operating characteristic curve analysis derived the ulcer size cut-off to predict OPL. In addition, we analyzed if ulcer size predicted mortality or malignancy. RESULTS Six hundred and ninety patients with a mean age of 55.1 years (range 16-94) were managed for PPU during the study period. Free air on X-ray was evident in 417 (60.4%) patients. Mean ulcer size was 7.8 mm (range 1-50). OPL occurred in 15 patients (2.2%) and 30-day mortality was 7.4% (n=51). Multivariate analysis found ulcer size increase of 10 mm (OR 3.30, 95% CI 1.81-6.02, P<0.001) predicted increased risk of OPL. At 25 mm cut-off, sensitivity was 26.7%, specificity was 97.2%, positive likelihood ratio was 9.47, and negative likelihood ratio was 0.76 for OPL. CONCLUSION Ulcer size increase in 10 mm increases leak rate by 3.3 times. Ulcer size ≥25 mm predicts OPL. RELEVANCE FOR PATIENTS Increased risk of OPL for ≥25 mm warrants need for close post-operative monitoring and lowers threshold for investigations in event of clinical deterioration. Decision for omental patch repair versus gastrectomy however should not be based on ulcer size alone.
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Affiliation(s)
- Yi Liang Wang
- 1Department of General Surgery, Khoo Teck Puat Hospital, Singapore
| | - Xue Wei Chan
- 2Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Kai Siang Chan
- 2Department of General Surgery, Tan Tock Seng Hospital, Singapore
- Corresponding author Kai Siang Chan Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore. E-mail:
| | - Vishal G. Shelat
- 2Department of General Surgery, Tan Tock Seng Hospital, Singapore
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