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Lim JSH, Lim ZY, Teo ZHT, Wang B, Tan YP, Junnarkar SP, Low JK, Huey CWT, Shelat V. Before and after COVID-19 pandemic: impact on hepatobiliary and pancreatic surgical services in a Singapore Tertiary Hospital. ANZ J Surg 2023; 93:2904-2909. [PMID: 37888881 DOI: 10.1111/ans.18748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Reallocation of healthcare resources to prioritize the COVID-19 pandemic-related incremental healthcare needs resulted in longer waiting times for routine elective clinical services. AIMS We aimed to analyze the effects of the pandemic on the hepatopancreatobiliary (HPB) unit's surgical workload. METHODS The HPB unit's surgical workload for the months of January-June from 2019 to 2022 was extracted, retrospectively compared, and analyzed. This study was registered in ClinicalTrials.gov (NCT05572866) and complies with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. RESULTS Benign elective surgeries were impacted adversely, with elective gallbladder operations decreasing by 45.2% (146 in 2019 vs 80 in 2020, p = 0.89) before slowly increasing to 120 cases in 2021 and rebounding to 179 cases in 2022 (p = 0.001). Elective oncology operations paradoxically increased, with liver resections rising by 12.9% (31 in 2019 vs 35 in 2020, p = 0.002) and maintaining 37 cases in 2021 (p = 0.0337) and 34 cases in 2022 (p = 0.69). Elective pancreatic resections increased by 171.4% (7 in 2019 vs 19 in 2020, p < 0.0001) and were maintained at 15 cases in 2021 (p = 0.013) and 18 cases in 2022 (p = 0.022). The overall emergency workload decreased from 2019 (n = 198) to 2020 (n = 129) to 2021 (n = 122) before recovering to baseline in 2022 (n = 184). The month-on-month volume generally showed similar trends compared to the other years except for February 2022 and May 2021. CONCLUSION This audit shows that despite large-scale disruption of the local healthcare system, essential surgeries can still proceed with careful resource planning by steadfast and vigilant clinical teams.
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Affiliation(s)
- Joshua S H Lim
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Zavier Yongxuan Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Bei Wang
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Yen Pin Tan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Vishal Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
- Surgical Science Training Centre, Tan Tock Seng Hospital, Singapore
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Chan KS, Baey S, Shelat VG, Junnarkar SP. Are outcomes for emergency index-admission laparoscopic cholecystectomy performed by hepatopancreatobiliary surgeons better compared to non-hepatopancreatobiliary surgeons? A 10-year audit using 1:1 propensity score matching. Hepatobiliary Pancreat Dis Int 2023:S1499-3872(23)00121-2. [PMID: 37586993 DOI: 10.1016/j.hbpd.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 08/02/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Emergency index-admission cholecystectomy (EIC) is recommended for acute cholecystitis in most cases. General surgeons have less exposure in managing "difficult" cholecystectomies. This study aimed to compare the outcomes of EIC between hepatopancreatobiliary (HPB) versus non-HPB surgeons. METHODS This is a 10-year retrospective audit on patients who underwent EIC from December 2011 to March 2022. Patients who underwent open cholecystectomy, had previous cholecystitis, previous endoscopic retrograde cholangiopancreatography or cholecystostomy were excluded. A 1:1 propensity score matching (PSM) was performed to adjust for confounding variables (e.g. age ≥ 75 years, history of abdominal surgery, presence of dense adhesions). RESULTS There were 1409 patients (684 HPB cases, 725 non-HPB cases) in the unmatched cohort. Majority (52.3%) of them were males with a mean age of 59.2 ± 14.9 years. Among 472 (33.5%) patients with EIC performed ≥ 72 hours after presentation, 40.1% had dense adhesion. The incidence of any morbidity, open conversion, subtotal cholecystectomy and bile duct injury were 12.4%, 5.0%, 14.6% and 0.1%, respectively. There was one mortality within 30 days from EIC. PSM resulted in 1166 patients (583 per group). Operative time was shorter when EIC was performed by HPB surgeons (115.5 min vs. 133.4 min, P < 0.001). The mean length of hospital stay was comparable. EIC performed by HPB surgeons was independently associated with lower open conversion [odds ratio (OR)= 0.24, 95% confidence interval (CI): 0.12-0.49, P < 0.001], lower fundus-first cholecystectomy (OR= 0.58, 95% CI: 0.35-0.95, P= 0.032), but higher subtotal cholecystectomy (OR= 4.19, 95% CI: 2.24-7.84, P < 0.001). Any morbidity, bile duct injury and mortality were comparable between the two groups. CONCLUSION EIC performed by HPB surgeons were associated with shorter operative time and reduced risk of open conversion. However, the incidence of subtotal cholecystectomy was higher.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore.
| | - Samantha Baey
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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Chan KS, Teo ZHT, Oo AM, Junnarkar SP, Shelat VG. Learning Curve of Laparoscopic Common Bile Duct Exploration: A Systematic Review. J Laparoendosc Adv Surg Tech A 2023; 33:241-252. [PMID: 36161969 DOI: 10.1089/lap.2022.0382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Single-stage laparoscopic common bile duct exploration (LCBDE) with cholecystectomy has superior outcomes over two-stage endoscopic retrograde cholangiopancreatogram with interval cholecystectomy. With decreasing trend of LCBDE, this study aims to summarize the literature on learning curve (LC) in LCBDE. Materials and Methods: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 3, 2022 (PROSPERO Ref No: CRD42022328451). Basic clinical demographics were collected. Poisson means (95% confidence interval [95% CI]) was used to determine the number of cases required to surmount the LC (NLC). Results: Eight articles (n = 2071 patients) reported LC outcomes in LCBDE with mean study period of 5.9 ± 2.8 years. Majority of studies (62.5%) used arbitrary methods of LC analysis. Most common outcomes reported were complications (any or major) (75%), open conversion (75%), length of stay (62.5%), and operating time (50%). Mean CBD diameter was 11.3 ± 4.8 mm (n = 1122 patients). Incidence of acute cholecystitis, acute cholangitis, and acute pancreatitis were 13.9% (n = 232/1668), 7.8% (n = 128/1629), and 13.7% (n = 229/1668), respectively. Pooled analysis of all the included studies showed NLC of 78.8 cases (95% CI: 71.9-86.3). Studies that used cumulative sum control chart analysis, nonarbitrary methods, and arbitrary-based LC had NLC of 152.0 (95% CI: 135.4-170.1), 108.0 (95% CI: 96.6-120.4), and 49.7 (95% CI: 42.0-58.3) cases, respectively. NLC was 37.0 cases (95% CI: 29.1-46.5) for single surgeon LC, and 99.8 cases (95% CI: 90.2-110.0) for institutional LC. Conclusion: Studies reporting NLC in LCBDE are heterogeneous. Further studies should use nonarbitrary methods of analysis for patient-reported outcome measures and procedure-specific morbidity.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Aung Myint Oo
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Chan KS, Junnarkar SP, Low JK, Huey CWT, Shelat VG. Aging is Associated with Prolonged Hospitalisation Stay in Pyogenic Liver Abscess-A 1:1 Propensity Score Matched Study in Elderly Versus Non-Elderly Patients. Malays J Med Sci 2022; 29:59-73. [PMID: 36474543 PMCID: PMC9680999 DOI: 10.21315/mjms2022.29.5.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/03/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Mortality of pyogenic liver abscess (PLA) is high ranging 10%-40%. Old age predicts outcomes in many diseases but there is paucity of data on PLA outcomes. We aim to compare the morbidity and mortality between elderly and non-elderly in PLA. METHODS This is a retrospective study from 2007-2011 comparing elderly (≥ 65 years old) and non-elderly (< 65 years old) with PLA. A 1:1 propensity score matching (PSM) was performed. Baseline clinical profile and outcomes were compared. RESULTS There were 213 patients (elderly patients = 90 [42.3%], non-elderly patients = 123 [57.7%]). Overall median age is 62 (interquartile range [IQR] = 53-74) years old. PSM resulted in 102 patients (51 per arm). Length of hospitalisation stay (LOS) was significantly longer in elderly patients in both unmatched (16 [IQR = 10-24.5] versus 11 [IQR = 8-19] days; P < 0.001) and matched cohorts (17 [IQR = 13-27] versus 11 [IQR = 7-19] days; P = 0.001). In-hospital mortality was significantly higher in elderly patients in the unmatched cohort (elderly patients = 21.1%, non-elderly patients = 7.3%; P = 0.003) but was insignificant following PSM (elderly patients = 15.7%, non-elderly patients = 9.8%; P = 0.219). Duration of antibiotic therapy and need for percutaneous drainage (PD) were comparable before and after PSM. CONCLUSION Age ≥ 65 years old is associated with longer LOS. In-hospital mortality though higher in elderly patients, was not statistically significant.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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Chan KS, Hwang E, Low JK, Junnarkar SP, Huey CWT, Shelat VG. On-table hepatopancreatobiliary surgical consults for difficult cholecystectomies: A 7-year audit. Hepatobiliary Pancreat Dis Int 2022; 21:273-278. [PMID: 35367147 DOI: 10.1016/j.hbpd.2022.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/07/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cholecystectomy is considered a general surgical operation. However, general surgeons are not trained to manage severe complications such as bile duct injury (BDI) and should refer to hepatopancreatobiliary (HPB) surgeons when difficulty arises. This study aimed to investigate the outcomes of patients who had on-table HPB consults during cholecystectomy. METHODS This is an audit of 50 patients who required on-table HPB consult during cholecystectomy from 2011 to 2017. Consultations were classified as "proactive" and "reactive", where consults were made before or after surgical incision, respectively. Patient demographics and perioperative details were collected. RESULTS The median age of the patients was 62.5 years [interquartile range (IQR) 50.8-71.3 years]. Eight (16%) patients had underlying HPB co-morbidity. Gallbladder wall was thickened in all patients (median 5 mm, IQR 4-7 mm), and common bile duct was of normal caliber in all patients (median 5 mm, IQR 4-6 mm). Median length of operation and length of stay were 165 min (IQR 124-209 min) and five days (IQR 3-7 days), respectively. Subtotal cholecystectomy was performed in 18 (36%) patients. Forty-eight patients were initially managed by laparoscopic approach, 15 (31%) required open conversion; majority (9/15, 60%) were initiated before on-table consult. Majority of referrals (98%) were reactive. Common reasons for referral included unclear anatomy or anatomical variations (30%), presence of dense adhesions and/or contracted gallbladder (18%) and impacted stones in Hartmann's pouch (16%). Three (6%) patients were referred for BDI (2 Strasberg D and 1 Strasberg E1), and two (4%) were referred for torrential bleeding from arterial injury (1 cystic artery and 1 right hepatic artery). Any morbidity and 30-day readmission were 22% and 6%, respectively. There was no 90-day mortality. CONCLUSIONS Calling for help in BDI is obligatory, but in other instances is a personal choice. Calling for help prior to open conversion is lacking and this awareness should be raised. Whether surgical outcomes could be improved by early HPB consult needs to be determined by larger multicenter reports.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, 308433, Singapore
| | - Elizabeth Hwang
- Department of General Surgery, Tan Tock Seng Hospital, 308433, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, 308433, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, 308433, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, 308433, Singapore.
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Wee JJ, Tee CL, Junnarkar SP, Low JK, Tan YP, Huey CW, Shelat VG. Outcomes of surgical resection of super-giant (≥15 cm) hepatocellular carcinoma: Volume does matter, if not the size. J Clin Transl Res 2022; 8:209-217. [PMID: 35813892 PMCID: PMC9260342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND AIM Resection for giant hepatocellular carcinoma (HCC) (≥10 cm) is deemed safe and feasible. However, a super-giant HCC (≥15 cm) poses unique technical complexity for hepatectomy with limited data suggesting feasibility and oncologic efficiency. This study aims to evaluate the short-term and long-term outcomes of hepatectomy in patients with super-giant HCC. METHODS A retrospective review was conducted on patients with super-giant HCC who underwent hepatectomy from 2011 to 2021. We report perioperative and oncologic outcomes such as length of stay (LOS), 30-day readmission, 90-day mortality, and cumulative survival rate. RESULTS Of the 18 patients, the median tumor diameter was 172.5 mm (range 150-250). The most common risk factor was chronic hepatitis B virus (HBV) infection (n=7, 38.9%). Most of the patients were Barcelona Clinic Liver Cancer (BCLC) Stage B (n=14, 77.8%) and Hong Kong Liver Cancer (HKLC) Stage IIb (n=15, 83.3%). Extended right hepatectomy was the most common procedure. The median LOS was 11 days (range 3-90). The most common post-operative complication was pneumonia (n=4, 22.2%). Fourteen patients were discharged well without any need for invasive therapy (n=7, 38.9% no complications, n=1, 5.6% Clavien Grade I, n=6, 33.3% Clavien Grade II). Thirty-day readmission rate was 5.6% (n=1) and 90-day mortality rate was 5.6% (n=1). There were 12 patients (66.7%) with microvascular invasion and three patients (16.7%) with macrovascular invasion. Most patients had Grade III (poorly differentiated) HCC (n=9, 50%). At a median follow-up of 11 months (range 2-95), 12 (66.7%) patients had local recurrence, and 9 (50%) developed distant metastasis. The 1-, 2-, and 3-year cumulative disease-free survival (DFS) was 36%, 18%, and 18%, respectively. The 1-, 2-, and 3-year cumulative overall survival was 49% and 39%, and 29%, respectively. CONCLUSION Primary hepatic resection is safe in patients with super-giant HCC. However, long-term outcomes are poor, and high tumor volume may be associated with inferior oncological outcomes in HCC. RELEVANCE FOR PATIENTS The presentation of super-giant HCCs may be asymptomatic and some patients are diagnosed late with limited treatment options. In some centers, this group of patients are denied surgical resection and recommended for only locoregional therapies like TACE. This paper demonstrates that hepatic resection is safe and may be an option in patients who present at an advanced stage with a high tumor burden.
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Affiliation(s)
- Jia Jia Wee
- 1Division of Hepatopancreatobilliary Surgery, General Surgery, Tan Tock Seng Hospital, Singapore,Corresponding author: Jia Jia Wee Division of Hepatopancreatobilliary Surgery, General Surgery, Tan Tock Seng Hospital, Singapore. Tel: +65-96255092 E-mail:
| | - Chin Li Tee
- 1Division of Hepatopancreatobilliary Surgery, General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sameer P. Junnarkar
- 1Division of Hepatopancreatobilliary Surgery, General Surgery, Tan Tock Seng Hospital, Singapore
| | - Jee Keem Low
- 1Division of Hepatopancreatobilliary Surgery, General Surgery, Tan Tock Seng Hospital, Singapore
| | - Yen Pin Tan
- 1Division of Hepatopancreatobilliary Surgery, General Surgery, Tan Tock Seng Hospital, Singapore
| | - Cheong Wei Huey
- 1Division of Hepatopancreatobilliary Surgery, General Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal G. Shelat
- 1Division of Hepatopancreatobilliary Surgery, General Surgery, Tan Tock Seng Hospital, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Sheriff S, Madhavan S, Lei GY, Chan YH, Junnarkar SP, Huey CW, Low JK, Shelat VG. Predictors of mortality within the first year post-hepatectomy for hepatocellular carcinoma. J Egypt Natl Canc Inst 2022; 34:14. [PMID: 35368234 DOI: 10.1186/s43046-022-00113-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 02/06/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hepatic resection (HR) for hepatocellular carcinoma (HCC) is safe with good perioperative and long-term oncologic outcomes. There is a paucity of data with regards to intermediate-term outcomes (i.e., beyond 90-day and within 1-year mortality). This paper studies the risk factors for within 1-year mortality after elective HR with curative intent in patients with HCC. METHODS An audit of patients who underwent curative HR for HCC from January 2007 to April 2016 was conducted. Univariate and multivariate analysis were sequentially performed on perioperative variables using Cox-regression analysis to identify factors predicting intermediate-term outcomes defined as within 1-year mortality. Kaplan-Meier survival curves and hazard ratios were obtained. RESULTS Three hundred forty-eight patients underwent HR during the study period and 163 patients had curative hepatectomy for HCC. Fifteen patients (9.2%) died within 1-year after HR. Multivariate analysis identified Child-Pugh class B/C (HR 5.5, p = 0.035), multinodularity (HR 7.1, p = 0.001), macrovascular invasion (HR 4.2, p = 0.04) postoperative acute renal failure (HR 5.8, p = 0.049) and posthepatic liver failure (HR 9.6, p = 0.009) as significant predictors of 1-year mortality. CONCLUSION One-year mortality following HR for HCC remains high and can be predicted preoperatively by multinodularity, Child-Pugh class, and macrovascular invasion. Postoperative acute renal failure and liver failure are associated with 1-year mortality.
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Affiliation(s)
| | | | | | - Yiong Huak Chan
- Biostatistics Unit, National University Health System, Singapore, Singapore
| | - Sameer P Junnarkar
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Cheong Wei Huey
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jee Keem Low
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishal G Shelat
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Teng TZJ, Tan JKT, Baey S, Gunasekaran SK, Junnarkar SP, Low JK, Huey CWT, Shelat VG. Sequential organ failure assessment score is superior to other prognostic indices in acute pancreatitis. World J Crit Care Med 2021; 10:355-368. [PMID: 34888161 PMCID: PMC8613719 DOI: 10.5492/wjccm.v10.i6.355] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/10/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is a common surgical condition, with severe AP (SAP) potentially lethal. Many prognostic indices, including; acute physiology and chronic health evaluation II score (APACHE II), bedside index of severity in acute pancreatitis (BISAP), Glasgow score, harmless acute pancreatitis score (HAPS), Ranson’s score, and sequential organ failure assessment (SOFA) evaluate AP severity and predict mortality.
AIM To evaluate these indices' utility in predicting severity, intensive care unit (ICU) admission, and mortality.
METHODS A retrospective analysis of 653 patients with AP from July 2009 to September 2016 was performed. The demographic, clinical profile, and patient outcomes were collected. SAP was defined as per the revised Atlanta classification. Values for APACHE II score, BISAP, HAPS, and SOFA within 24 h of admission were retrospectively obtained based on laboratory results and patient evaluation recorded on a secure hospital-based online electronic platform. Data with < 10% missing data was imputed via mean substitution. Other patient information such as demographics, disease etiology, and patient outcomes were also derived from electronic medical records.
RESULTS The mean age was 58.7 ± 17.5 years, with 58.7% males. Gallstones (n = 404, 61.9%), alcohol (n = 38, 5.8%), and hypertriglyceridemia (n = 19, 2.9%) were more common aetiologies. 81 (12.4%) patients developed SAP, 20 (3.1%) required ICU admission, and 12 (1.8%) deaths were attributed to SAP. Ranson’s score and APACHE-II demonstrated the highest sensitivity in predicting SAP (92.6%, 80.2% respectively), ICU admission (100%), and mortality (100%). While SOFA and BISAP demonstrated lowest sensitivity in predicting SAP (13.6%, 24.7% respectively), ICU admission (40.0%, 25.0% respectively) and mortality (50.0%, 25.5% respectively). However, SOFA demonstrated the highest specificity in predicting SAP (99.7%), ICU admission (99.2%), and mortality (98.9%). SOFA demonstrated the highest positive predictive value, positive likelihood ratio, diagnostic odds ratio, and overall accuracy in predicting SAP, ICU admission, and mortality. SOFA and Ranson’s score demonstrated the highest area under receiver-operator curves at 48 h in predicting SAP (0.966, 0.857 respectively), ICU admission (0.943, 0.946 respectively), and mortality (0.968, 0.917 respectively).
CONCLUSION The SOFA and 48-h Ranson’s scores accurately predict severity, ICU admission, and mortality in AP, with more favorable statistics for the SOFA score.
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Affiliation(s)
- Thomas Zheng Jie Teng
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Undergraduate Medicine, Lee Kong Chian School of Medicine, Singapore 308232, Singapore
| | | | - Samantha Baey
- Undergraduate Medicine, Yong Loo Lin School of Medicine, Singapore 119077, Singapore
| | | | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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Chan KS, Wang B, Tan YP, Chow JJL, Ong EL, Junnarkar SP, Low JK, Huey CWT, Shelat VG. Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study. JMIR Perioper Med 2021; 4:e30473. [PMID: 34559668 PMCID: PMC8496752 DOI: 10.2196/30473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult. OBJECTIVE We report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic. METHODS We divided our study into 4 phases-phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post-CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post-CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%. RESULTS A total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre-CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%). CONCLUSIONS This follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bei Wang
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yen Pin Tan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Ee Ling Ong
- Office of Clinical Governance, Tan Tock Seng Hospital, Singapore, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Mohan R, Wei Lynn Goh S, Tan GW, Tan YP, Junnarkar SP, Huey CWT, Low JK, Shelat VG. Validation of Tokyo Guidelines 2007 and Tokyo Guidelines 2013/2018 Criteria for Acute Cholangitis and Predictors of In-Hospital Mortality. Visc Med 2021; 37:434-442. [PMID: 34722727 PMCID: PMC8543341 DOI: 10.1159/000516424] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 04/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute cholangitis (AC) is a common emergency with a significant mortality risk. The Tokyo Guidelines (TG) provide recommendations for diagnosis, severity stratification, and management of AC. However, validation of the TG remains poor. This study aims to validate TG07, TG13, and TG18 criteria and identify predictors of in-hospital mortality in patients with AC. METHODS This is a retrospective audit of patients with a discharge diagnosis of AC in the year 2016. Demographic, clinical, investigation, management and mortality data were documented. We performed a multinomial logistic regression analysis with stepwise variable selection to identify severity predictors for in-hospital mortality. RESULTS Two hundred sixty-two patients with a median age of 75.9 years (IQR 64.8-82.8) years were included for analysis. TG13/TG18 diagnostic criteria were more sensitive than TG07 diagnostic criteria (85.1 vs. 75.2%; p < 0.006). The majority of the patients (n = 178; 67.9%) presented with abdominal pain, pyrexia (n = 156; 59.5%), and vomiting (n = 123; 46.9%). Blood cultures were positive in 95 (36.3%) patients, and 79 (83.2%) patients had monomicrobial growth. The 30-day, 90-day, and in-hospital mortality numbers were 3 (1.1%), 11 (4.2%), and 15 (5.7%), respectively. In multivariate analysis, type 2 diabetes mellitus (OR = 12.531; 95% CI 0.354-116.015; p = 0.026), systolic blood pressure <100 mm Hg (OR = 10.108; 95% CI 1.094-93.395; p = 0.041), Glasgow coma score <15 (OR = 38.16; 95% CI 1.804-807.191; p = 0.019), and malignancy (OR = 14.135; 95% CI 1.017-196.394; p = 0.049) predicted in-hospital mortality. CONCLUSION TG13/18 diagnostic criteria are more sensitive than TG07 diagnostic criteria. Type 2 diabetes mellitus, systolic blood pressure <100 mm Hg, Glasgow coma score <15, and malignant etiology predict in-hospital mortality in patients with AC. These predictors could be considered in acute stratification and treatment of patients with AC.
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Affiliation(s)
- Ramkumar Mohan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- *Vishal G. Shelat,
| | | | - Guan Wei Tan
- Ministry of Health Holdings, Singapore, Singapore
| | - Yen Pin Tan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Cheong Wei Terence Huey
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishal G. Shelat
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- *Vishal G. Shelat,
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12
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Lim M, Goh GB, Chang JP, Low J, Shelat VG, Huey TC, Dan Y, Kow A, Shridhar I, Tan P, Junnarkar SP, Tan C. A study of 3013 cases of hepatocellular carcinoma: Etiology and therapy before and during the current decade. JGH Open 2021; 5:1015-1018. [PMID: 34584969 PMCID: PMC8454472 DOI: 10.1002/jgh3.12624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/19/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIM Hepatocellular carcinoma (HCC) is a significant global problem. With advances in HCC diagnosis and therapy, our hypothesis is that there are significant differences in the clinical characteristics and treatment of HCC over the years. METHODS Patients with HCC between 1980 and 2018 from three major tertiary hospitals in Singapore were enrolled into a Research Electronic Data Capture database. Clinical characteristics and treatment of HCC were compared between those diagnosed before 2008 (cohort A) and during the current decade (ie from 2008 onwards) (cohort B). RESULTS There were 3013 patients. Mean age of HCC diagnosis was significantly older in cohort B (68.6 vs 61.2 years, P < 0.001). The most common etiology remained as chronic hepatitis B infection but the proportion due to hepatitis B was significantly lower in cohort B (46.6% vs 57.2%, P < 0.0001). The prevalence of cryptogenic/non-alcoholic steatohepatitis was significantly higher in cohort B than cohort A (27.1% vs 18.6%, P < 0.0001). More patients received curative therapy in cohort B (43.7% vs 27.1%, P < 0.0001. CONCLUSION In this largest collection of HCC patients in Singapore, patients are diagnosed with HCC at an older age and cryptogenic/non-alcoholic steatohepatitis is becoming more important as an etiology of HCC in the current decade. More patients also received curative therapy in the current decade.
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Affiliation(s)
- Miao‐Shan Lim
- Department of Hepatology and GastroenterologySingapore General HospitalSingapore
| | - George B‐B Goh
- Department of Hepatology and GastroenterologySingapore General HospitalSingapore
| | - Jason P‐E Chang
- Department of Hepatology and GastroenterologySingapore General HospitalSingapore
| | - Jee‐Keem Low
- Department of General Surgery (Hepato‐Pancreato‐Biliary Surgery Service)Tan Tock Seng HospitalSingapore
| | - Vishalkumar G Shelat
- Department of General Surgery (Hepato‐Pancreato‐Biliary Surgery Service)Tan Tock Seng HospitalSingapore
| | - Terence C‐W Huey
- Department of General Surgery (Hepato‐Pancreato‐Biliary Surgery Service)Tan Tock Seng HospitalSingapore
| | - Yock‐Young Dan
- Division of Gastroenterology and Hepatology, University Medicine ClusterNational University Health SystemSingapore
| | - Alfred Kow
- Division of Hepatobiliary and Pancreatic Surgery, University Surgical ClusterNational University Health SystemSingapore
| | - Iyer Shridhar
- Division of Hepatobiliary and Pancreatic Surgery, University Surgical ClusterNational University Health SystemSingapore
| | - Poh‐Seng Tan
- Division of Gastroenterology and Hepatology, University Medicine ClusterNational University Health SystemSingapore
| | - Sameer P Junnarkar
- Department of General Surgery (Hepato‐Pancreato‐Biliary Surgery Service)Tan Tock Seng HospitalSingapore
| | - Chee‐Kiat Tan
- Department of Hepatology and GastroenterologySingapore General HospitalSingapore
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13
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Tan YP, Lim C, Junnarkar SP, Huey CWT, Shelat VG. 3D Laparoscopic common bile duct exploration with primary repair by absorbable barbed suture is safe and feasible. J Clin Transl Res 2021. [PMID: 34667894 PMCID: PMC8520704 DOI: 10.18053/jctres.07.202104.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and aim Endoscopic retrograde cholangiopancreatography (ERCP), with interval laparoscopic cholecystectomy (LC), is the most common treatment approach for common bile duct (CBD) stones. However, recent studies show that single-stage laparoscopic CBD exploration (LCBDE) is safe and feasible. Three-dimensional (3D) laparoscopy enhances depth perception and facilitates intracorporeal suturing. The application of 3D technology for LCBDE is emerging, and we report our case series of 3D LCBDE. Methods We audited the 27 consecutive 3D LCBDE performed from July 2017 to January 2020. We have a liberal policy for magnetic resonance cholangiopancreatography (MRCP) in patients with deranged liver function tests (LFT). All CBD explorations were done through choledochotomy with a 5 mm flexible choledochoscope and primarily repaired with an absorbable barbed suture without a stent or T-tube. Results The mean age of patients was 68 (range 44-91) years, and 12 (44%) were male. The indications for surgery were choledocholithiasis 67% (n=18), cholangitis 22% (n=6), and gallstone pancreatitis 11% (n=3). About 67% (n=18) had pre-operative ERCP. About 37% (n=10) had pre-operative biliary stent. Pre-operative MRCP was done in 74% (n=20), and the mean diameter of CBD was 14.5 mm (range 7-30). The median operative time was 160 (range 80-265) min. The operative drain was inserted in 18 patients. One patient each (4%) had a bile leak and a retained stone. There was no open conversion, readmission, or mortality. Conclusion 3D LCBDE with primary repair by an absorbable barbed suture is safe and feasible. Relevance for patients This paper emphasized that one stage LCBDE should be a treatment option which is comparable with two stage ERCP followed by LC to treat CBD stones. In addition, 3D technology and barbed sutures use in LCBDE are safe and useful.
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Affiliation(s)
- Yen Pin Tan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Cheryl Lim
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | | | | | - Vishalkumar G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technology University, Singapore
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14
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Chan KS, Mohan R, Low JK, Junnarkar SP, Huey CWT, Shelat VG. Elderly patients (≥ 80 years) with acute calculous cholangitis have similar outcomes as non-elderly patients (< 80 years): Propensity score-matched analysis. World J Hepatol 2021; 13:456-471. [PMID: 33959227 PMCID: PMC8080552 DOI: 10.4254/wjh.v13.i4.456] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/06/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute cholangitis (AC) is a disease spectrum with varying extent of severity. Age ≥ 75 years forms part of the criteria for moderate (Grade II) severity in both the Tokyo Guidelines (TG13 and TG18). Aging is associated with reduced physiological reserves, frailty, and sarcopenia. However, there is evidence that age itself is not the determinant of inferior outcomes in elective and emergency biliary diseases. There is a paucity of reports comparing clinical outcomes amongst elderly patients vs non-elderly patients with AC.
AIM To investigate the effect of age (≥ 80 years) on AC's morbidity and mortality using propensity score matching (PSM).
METHODS This is a single-center retrospective cohort study of all patients diagnosed with calculous AC (January 2016 to December 2016) and ≥ 80 years old (January 2012 to December 2016) at a tertiary university-affiliated teaching hospital. Inclusion criteria were patients who were treated for suspected or confirmed AC secondary to biliary stones. Patients with AC on a background of hepatobiliary malignancy, indwelling permanent metallic biliary stents, or concomitant pancreatitis were excluded. Elderly patients were defined as ≥ 80 years old in our study. A 1:1 PSM analysis was performed to reduce selection bias and address confounding factors. Study variables include comorbidities, vital parameters, laboratory and radiological investigations, and type of biliary decompression, including the time for endoscopic retrograde cholangiopancreatography (ERCP). Primary outcomes include in-hospital mortality, 30-d and 90-d mortality. Length of hospital stay (LOS) was the secondary outcome.
RESULTS Four hundred fifty-seven patients with AC were included in this study (318 elderly, 139 non-elderly). PSM analysis resulted in a total of 224 patients (112 elderly, 112 non-elderly). The adoption of ERCP between elderly and non-elderly was similar in both the unmatched (elderly 64.8%, non-elderly 61.9%, P = 0.551) and matched cohorts (elderly 68.8% and non-elderly 58%, P = 0.096). The overall in-hospital mortality, 30-d mortality and 90-d mortality was 4.6%, 7.4% and 8.5% respectively, with no statistically significant differences between the elderly and non-elderly in both the unmatched and matched cohorts. LOS was longer in the unmatched cohort [elderly 8 d, interquartile range (IQR) 6-13, vs non-elderly 8 d, IQR 5-11, P = 0.040], but was comparable in the matched cohort (elderly 7.5 d, IQR 5-11, vs non-elderly 8 d, IQR 5-11, P = 0.982). Subgroup analysis of patients who underwent ERCP demonstrated the majority of the patients (n = 159/292, 54.5%) had delayed ERCP (> 72 h from presentation). There was no significant difference in LOS, 30-d mortality, 90-d mortality, and in-hospital mortality in patients who had delayed ERCP in both the unmatched and matched cohort (matched cohort: in-hospital mortality [n = 1/42 (2.4%) vs 1/26 (3.8%), P = 0.728], 30-d mortality [n = 2/42 (4.8%) vs 2/26 (7.7%), P = 0.618], 90-d mortality [n = 2/42 (4.8%) vs 2/26 (7.7%), P = 0.618], and LOS (median 8.5 d, IQR 6-11.3, vs 8.5 d, IQR 6-15.3, P = 0.929).
CONCLUSION Mortality is indifferent in the elderly (≥ 80 years old) and non-elderly patients (< 80 years old) with AC.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- MOH Holdings, Singapore 099253, Singapore
| | - Ramkumar Mohan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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15
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Affiliation(s)
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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16
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Lei GY, Shen L, Junnarkar SP, Huey CT, Low J, Shelat VG. Predictors of 90-Day Mortality following Hepatic Resection for Hepatocellular Carcinoma. Visc Med 2021; 37:102-109. [PMID: 33981750 PMCID: PMC8077452 DOI: 10.1159/000510811] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/10/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND/PURPOSE 90-day mortality is a key performance indicator for short-term perioperative outcome of hepatic resection (HR). Although many preoperative, intraoperative, and postoperative variables predict 90-day mortality following elective HR, only few are specific to hepatocellular carcinoma (HCC). This study aims to determine the predictors of 90-day mortality following elective HR for HCC. METHODS We report a retrospective analysis of patients who underwent elective HR between January 1, 2007, and December 31, 2017. Health status, perioperative variables, and the presence of post-hepatectomy liver failure (PHLF) were studied. Cox's regression evaluated factors predicting 90-day mortality. RESULTS Two hundred and forty-four patients diagnosed with HCC underwent HR; 102 (41.8%) underwent a major HR. The postoperative 90-day mortality rate was 5.3%. Multivariate analysis demonstrated that Child-Pugh score (p < 0.001), intraoperative blood loss (p = 0.013), the 50-50 criteria for PHLF (p < 0.001) on postoperative day 5, and peak serum bilirubin >119 µmol/L (p = 0.007) on postoperative day 3 predict 90-day mortality. CONCLUSION In patients with HCC undergoing HR, Child-Pugh score, intraoperative blood loss, the 50-50 criteria for PHLF on postoperative day 5, and peak serum bilirubin >119 µmol/L on postoperative day 3 predict 90-day mortality following elective HR for HCC.
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Affiliation(s)
- Geraldine Yanlei Lei
- Department of General Surgery, Ministry of Health Holdings, Singapore, Singapore
| | - Liang Shen
- Department of Biostatistics Unit, National University Health System, Singapore, Singapore
| | - Sameer P. Junnarkar
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - CheongWei Terence Huey
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - JeeKeem Low
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishal G. Shelat
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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17
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Mohan R, Shelat VG, Junnarkar SP. Large gallstone initially diagnosed as porcelain gallbladder with malignant change. Postgrad Med J 2021; 98:e60. [PMID: 37066581 DOI: 10.1136/postgradmedj-2020-139303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Ramkumar Mohan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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18
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Chan KS, Quek LHH, Pua U, Junnarkar SP. Silent time bomb: a case report of pancreatic head arteriovenous malformation presenting with obstructive jaundice. ANZ J Surg 2020; 89:1685-1686. [PMID: 31846563 DOI: 10.1111/ans.15501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/03/2019] [Accepted: 09/12/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Kai Siang Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Uei Pua
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore
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19
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Tay WM, Toh YJ, Shelat VG, Huey CW, Junnarkar SP, Woon W, Low JK. Subtotal cholecystectomy: early and long-term outcomes. Surg Endosc 2020; 34:4536-4542. [PMID: 31701285 DOI: 10.1007/s00464-019-07242-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/28/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND In difficult gallbladders, partial or subtotal cholecystectomy (SC) has been described as a reasonable procedure with safe outcomes. Our aim was to look at our data on SC with respect to safety, morbidity and long-term outcome. METHODS A retrospective analysis was performed for 3560 patients undergoing cholecystectomy from January 2010 to June 2016. For patients who underwent SC, demographics, intra-operative and follow-up details were analysed. RESULTS A total of 168 SC patients were included. 102 (60.7%) were male while 66 (39.3%) were female. The median age was 63 years (31-87). These patients were on follow-up for a median of 29 months (1.7-80). 153 were attempted laparoscopically and there were 25 (16.3%) patients which had open conversion. The rest of the 15 patients had open SC. Mean operative time 150 min (70-315) and average blood loss was 170 ml (50-1500). Median length of stay for these patients was 4 days (1-68). There were no common bile duct (CBD) injuries. We had 12 (7.1%) post-operative collections, 4 (2.4%) wound infections, 1 (0.6%) bile leak and 7 (4.2%) retained stones. Post-operative endoscopic retrograde cholangiopancreatography (ERCP) was performed on 4 (2.4%) patients with successful retrieval of CBD stones. One patient has spontaneous passage of CBD stone. The rest of the two patients with very small retained stones in remnant gallbladder were successfully managed conservatively. There was no 30-day or operation-related mortality. No patient required a second operation. CONCLUSIONS SC is safe and feasible when encountering a difficult gallbladder.
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Affiliation(s)
- Wee Ming Tay
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore.
| | - Ying Jie Toh
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishalkumar G Shelat
- Hepatic, Pancreatic and Biliary (HPB) Surgery Unit, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Cheong Wei Huey
- Hepatic, Pancreatic and Biliary (HPB) Surgery Unit, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Sameer P Junnarkar
- Hepatic, Pancreatic and Biliary (HPB) Surgery Unit, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Winston Woon
- Hepatic, Pancreatic and Biliary (HPB) Surgery Unit, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jee Keem Low
- Hepatic, Pancreatic and Biliary (HPB) Surgery Unit, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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20
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Wang B, Shelat VG, Chow JJL, Huey TCW, Low JK, Woon WWL, Junnarkar SP. Prehabilitation Program Improves Outcomes of Patients Undergoing Elective Liver Resection. J Surg Res 2020; 251:119-125. [PMID: 32135382 DOI: 10.1016/j.jss.2020.01.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/22/2019] [Accepted: 01/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Preoperative phase can be effectively used by multidisciplinary teams to optimize the surgical candidate to improve perioperative outcomes. The aim of our study was to evaluate the impact of prehabilitation program (PP) in patients undergoing elective liver resection (LR). METHODS This was a prospective study including patients undergoing elective LR from February 2016 to October 2017. Outcomes of patients enrolled into PP were compared with patients receiving standard care. PP involved physiotherapist, dietitian, and case managers along with surgical and anesthetic services. Postoperative morbidity, length of stay, 90-day mortality, readmission rate, quality of life, and cost were measured. RESULTS Seventy patients were enrolled into PP and compared with 34 patients receiving standard care. Median Charlson comorbidity index was higher in PP group (4 versus 3, P = 0.03). PP showed reduction in overall morbidity (30% versus 52.9%, P = 0.02) and social issues (nil versus 3, P = 0.03). Quality of life survey showed improved social well-being. A tendency to cost savings was observed in prehabilitation group with 16.5% ($1359) cost reduction (median cost $6892 versus $8251, P = 0.07). CONCLUSIONS PP improves outcomes in patients undergoing elective LR.
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Affiliation(s)
- Bei Wang
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore.
| | | | | | | | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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21
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Chan KS, Shelat VG, Tan CH, Tang YL, Junnarkar SP. Isolated gallbladder tuberculosis mimicking acute cholecystitis: A case report. World J Gastrointest Surg 2020; 12:123-128. [PMID: 32218895 PMCID: PMC7061240 DOI: 10.4240/wjgs.v12.i3.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/20/2019] [Accepted: 12/15/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Isolated tuberculosis of the gallbladder is extremely rare due to its intrinsic resistance to tuberculous infections. There are reports of gallbladder tuberculosis mimicking cholecystitis or malignancy. However, these presentations were chronic. The diagnosis of gallbladder tuberculosis warrants the need for investigation of additional sites of inoculation and contact tracing of all tuberculosis contacts. Gallbladder tuberculosis is a rare entity but should be suspected in patients from endemic regions with risk factors such as underlying immunosuppression or history of tuberculosis.
CASE SUMMARY We present a case of gallbladder tuberculosis presenting as acute cholecystitis. A 44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain which worsened after meals with no significant past medical history. She underwent laparoscopic cholecystectomy on the presumptive diagnosis of acute cholecystitis and diagnosed as gallbladder tuberculosis after histopathological examination. The patient did not have features of pulmonary or systemic tuberculosis nor was she immunocompromised. She recovered uneventfully. She was subsequently discharged and followed-up at a hospital in her home country due to financial and social reasons.
CONCLUSION Clinicians should have a high index of suspicion for patients in endemic regions presenting with cholecystitis.
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Affiliation(s)
- Kai Siang Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Cher Heng Tan
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Department of Pathology, Tan Tock Seng Hospital, Singapore 308433, Singapore
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Mak MHW, Low JK, Junnarkar SP, Huey TCW, Shelat VG. A prospective validation of Sepsis-3 guidelines in acute hepatobiliary sepsis: qSOFA lacks sensitivity and SIRS criteria lacks specificity (Cohort Study). Int J Surg 2019; 72:71-77. [PMID: 31678690 DOI: 10.1016/j.ijsu.2019.10.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/19/2019] [Accepted: 10/19/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Since its introduction in 2016, the Sepsis-3 guidelines, with emphasis on the quick Sequential Organ Failure Assessment (qSOFA) score, have generated much debate and controversy. It is recognised that the new definitions require validation in specific clinical settings and have yet to be universally adopted. We aim to validate new Sepsis-3 guidelines in acute hepatobiliary infection. MATERIAL AND METHODS A prospective cohort of patients admitted with acute hepatobiliary infection from the emergency department from July 2016 to June 2017 was studied. The Systemic Inflammatory Response Syndrome (SIRS) criteria, SOFA and qSOFA scores were calculated and predictive performance evaluated with area under the receiver operating characteristic (AUROC) curves for predictive ability of these indices for critical care unit admission and morbidity. RESULTS 124 patients with a median age of 64.5 years and majority males (n = 75, 60.5%) were admitted with acute hepatobiliary infection during the study period. Acute cholecystitis was the most common admission diagnosis (n = 83, 66.9%) and most patients were managed in general ward (n = 91, 73.3%) with median length of stay of 6 days (range 1-40). On multivariate analysis, diabetes mellitus (p = 0.003) predicted high dependency unit (HDU) admission, while age (p = 0.001), positive blood culture (p = 0.012), positive fluid culture (p = 0.015) and SOFA score (p = 0.002) predicted length of hospital stay. The sensitivity of SIRS in predicting HDU admission (60% vs. 4%), intensive care unit (ICU) admission (62.5% vs. 0%) and morbidity (66.7% vs. 0%) was higher than qSOFA score. The specificity of qSOFA in predicting HDU admission (100% vs. 49.5%), ICU admission (99.1% vs. 53.3%) and morbidity (99.2% vs. 47.9%) was higher than SIRS criteria. CONCLUSION The SIRS criteria has high sensitivity and the qSOFA score has high specificity in predicting outcomes of patients with acute hepatobiliary infection.
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Affiliation(s)
- Malcolm Han Wen Mak
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore.
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Madhavan S, Junnarkar SP, Koh NWC, Shelat VG. Inferior vena cava leiomyosarcoma in an octogenerian. Ann Hepatobiliary Pancreat Surg 2019; 23:274-277. [PMID: 31501817 PMCID: PMC6728244 DOI: 10.14701/ahbps.2019.23.3.274] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 11/07/2018] [Accepted: 11/15/2018] [Indexed: 11/17/2022] Open
Abstract
Inferior Vena Cava (IVC) leiomyosarcoma (LM) is a rare malignancy of mesenchymal origin with an incidence of 1/100,000. We present an 82-year-old lady with a past history of open cholecystectomy who presented with a large indeterminate mass on abdominal imaging. Open resection of the mass was performed and histology with immunohistochemical staining revealed leiomyosarcoma. She received adjuvant radiotherapy and remained disease free 4 years after.
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Mak MHW, Chew WL, Junnarkar SP, Woon WWL, Low JK, Huey TCW, Shelat VG. Patient reported outcomes in elective laparoscopic cholecystectomy. Ann Hepatobiliary Pancreat Surg 2019; 23:20-33. [PMID: 30863804 PMCID: PMC6405362 DOI: 10.14701/ahbps.2019.23.1.20] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/21/2018] [Accepted: 09/25/2018] [Indexed: 12/12/2022] Open
Abstract
Backgrounds/Aims Traditional outcome measures (e.g., length of hospital stay, morbidity, and mortality) are used to determine the quality of care, but these may not be most important to patients. It is unclear which outcomes matter to patients undergoing elective laparoscopic cholecystectomy (ELC). We aim to identify patient-reported outcome measures (PROM) which patients undergoing ELC valued most. Methods A 45-item questionnaire with Four-point Likert-type questions developed from prior literature review, prospectively administered to patients treated with ELC at a tertiary institution in Singapore. Results Seventy-five patients participated. Most essential factors were technical skill and experience level of a surgeon, long-term quality of life (QoL), patient involvement in decision-making, communication skill of a surgeon, cleanliness of the ward environment, and standards of nursing care. Least important factors were hospitalization leave duration, length of hospital stay, a family's opinion of the hospital, and scar cosmesis. Employed patients were more likely to find hospitalization leave duration (p<0.001) and procedure duration (p=0.042) important. Younger patients (p=0.048) and female gender (p=0.003) were more likely to perceive scar cosmesis as important. Conclusions Patients undergoing ELC value long-term QoL, surgeon technical skill and experience level, patient involvement in decision-making, surgeon communication skill, cleanliness of the ward environment, and nursing care standards. Day-case surgery, medical leave, family opinion of hospital, and scar cosmesis were least important. Understanding what patients value will help guide patient-centric healthcare delivery.
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Affiliation(s)
- Malcolm H W Mak
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Woon Ling Chew
- School of Biological Sciences, Nanyang Technological University, Singapore
| | | | - Winston W L Woon
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Jee-Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Terence C W Huey
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Huynh F, Junnarkar SP, Huey TCW, Punamiya SJ, Woon WWL. Spontaneous hepaticoduodenal fistula following extended right hemihepatectomy. ANZ J Surg 2018; 89:1659-1661. [PMID: 30203433 DOI: 10.1111/ans.14790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 07/01/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Frederick Huynh
- Hepato-Pancreato-Biliary Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sameer P Junnarkar
- Hepato-Pancreato-Biliary Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Terence C W Huey
- Hepato-Pancreato-Biliary Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sundeep J Punamiya
- Vascular and Interventional Radiology, Department of Radiology, Tan Tock Seng Hospital, Singapore
| | - Winston W L Woon
- Hepato-Pancreato-Biliary Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
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26
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Kiat TTJ, Gunasekaran SK, Junnarkar SP, Low JK, Woon W, Shelat VG. Are traditional scoring systems for severity stratification of acute pancreatitis sufficient? Ann Hepatobiliary Pancreat Surg 2018; 22:105-115. [PMID: 29896571 PMCID: PMC5981140 DOI: 10.14701/ahbps.2018.22.2.105] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUNDS/AIMS Ranson's score (RS) and Glasgow score (GS) have been utilized to stratify the severity of acute pancreatitis (AP). The aim of this study was to validate RS and GS for stratifying the severity of acute pancreatitis and audit our experience of managing AP. METHODS We conducted a retrospective review of patients treated for AP from July 2009 to September 2016. Final severity was determined using the revised Atlanta classification. Mortality and complications were analyzed. RESULTS From July 2009 to September 2016, a total of 675 patients with a diagnosis of AP were admitted at the hospital. Of them, 669 patients who had sufficient data were analyzed. Their average age±SD was 58.7±17.4 years (range, 21-98 years). There was a male preponderance (n=393, 53.8%). A total of 82 (12.3%) patients had eventual severe pancreatitis. RS demonstrated a sensitivity of 92.7% and a specificity of 52.8% with a positive predictive value (PPV) of 21.5% and a negative predictive value (NPV) of 98.1%. GS demonstrated a sensitivity of 76.8% and a specificity of 69.2% with a PPV of 25.8% and a NPV of 95.5%. For severity prediction, areas under the curve (AUCs) for RS and GS were 0.848 (95% CI: 0.819-0.875) and 0.784 (95% CI: 0.750-0.814), respectively (p=0.003). Twelve (1.6%) patients died in the hospital. CONCLUSIONS RS has higher sensitivity, NPV and AUC for predicting severity of AP than GS.
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Affiliation(s)
| | | | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Winston Woon
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Madhavan S, Shelat VG, Soong SL, Woon WWL, Huey T, Chan YH, Junnarkar SP. Predicting morbidity of liver resection. Langenbecks Arch Surg 2018; 403:359-369. [PMID: 29417211 DOI: 10.1007/s00423-018-1656-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/25/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE Multiple models have attempted to predict morbidity of liver resection (LR). This study aims to determine the efficacy of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and the Physiological and Operative Severity Score in the enUmeration of Mortality and Morbidity (POSSUM) in predicting post-operative morbidity in patients who underwent LR. METHODS A retrospective analysis was conducted on patients who underwent elective LR. Morbidity risk was calculated with the ACS-NSQIP surgical risk calculator and POSSUM equation. Two models were then constructed for both ACS-NSQIP and POSSUM-(1) the original risk probabilities from each scoring system and (2) a model derived from logistic regression of variables. Discrimination, calibration, and overall performance for ACS-NSQIP and POSSUM were compared. Sub-group analysis was performed for both primary and secondary liver malignancies. RESULTS Two hundred forty-five patients underwent LR. Two hundred twenty-three (91%) had malignant liver pathologies. The post-operative morbidity, 90-day mortality, and 30-day mortality rate were 38.3%, 3.7%, and 2.4% respectively. ACS-NSQIP showed superior discriminative ability, calibration, and performance to POSSUM (p = 0.03). Hosmer-Lemeshow plot demonstrated better fit of the ACS-NSQIP model than POSSUM in predicting morbidity. CONCLUSION In patients undergoing LR, the ACS-NSQIP surgical risk calculator was superior to POSSUM in predicting morbidity risk.
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Affiliation(s)
- Sudharsan Madhavan
- Ministry of Health Holdings, 1 Maritime Square, #11-25 HarbourFront Centre, Singapore, 099253, Republic of Singapore
| | - Vishal G Shelat
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Republic of Singapore
| | - Su-Lin Soong
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Republic of Singapore
| | - Winston W L Woon
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Republic of Singapore
| | - Terence Huey
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Republic of Singapore
| | - Yiong H Chan
- Biostatistics Unit, National University Health System, 1E Kent Ridge Road, Singapore, 119228, Republic of Singapore
| | - Sameer P Junnarkar
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Republic of Singapore.
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28
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Selby LKE, Tay RXY, Woon WWL, Low JK, Bei W, Shelat VG, Pang TCY, Junnarkar SP. Validity of the Barcelona Clinic Liver Cancer and Hong Kong Liver Cancer staging systems for hepatocellular carcinoma in Singapore. J Hepatobiliary Pancreat Sci 2017; 24:143-152. [PMID: 28012284 DOI: 10.1002/jhbp.423] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Staging is vital in guiding therapeutic approach in patients diagnosed with hepatocellular carcinoma (HCC). Our study's goal is to compare paradigms in the Barcelona Clinic Liver Cancer (BCLC) and Hong Kong Liver Cancer (HKLC) systems, and evaluate the use of both in a local context, comparing their prognostic ability and therapeutic efficacy in the management of HCC. METHODS Seven hundred and sixty-six patients diagnosed between 2010 and 2015 were identified and staged according to BCLC and HKLC. Both system's performances were compared using Akaike information criterion (AIC), bootstrap concordance-index (c-index), and through Kaplan-Meier survival curves of patients who came under HKLC stages 1, 2, and 3 and the individual BCLC stages. Independent prognostic factors of survival were identified using univariate and multivariate analyses. RESULTS According to AIC and c-index, HKLC (AIC = 5,711, c-index = 0.74) has equivalent prognosticating value as BCLC (AIC = 5,764, c-index = 0.72). Through Kaplan-Meier curves, we determined that more aggressive treatments resulted in better outcomes. Particularly for patients under BCLC stage C, patients who followed the HKLC system's recommended treatments performed markedly better. CONCLUSIONS In our patient population, the HKLC system is comparable to the BCLC system in prognosticating patients, but is suggested to have better performance in guiding treatment.
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Affiliation(s)
- Li Kim E Selby
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rosanna X Y Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Winston W L Woon
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Wang Bei
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Vishalkumar G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
| | - Tony C Y Pang
- Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Sameer P Junnarkar
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433
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Chia CLK, Lee AYS, Shelat VG, Ahmed S, Junnarkar SP, Woon WWL, Low JK. Does diabetes mellitus affect presentation, stage and survival in operable pancreatic cancer? Hepatobiliary Surg Nutr 2016; 5:38-42. [PMID: 26904555 PMCID: PMC4739944 DOI: 10.3978/j.issn.2304-3881.2015.07.04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of the study is to investigate differences in clinical presentation, disease stage and survival of operable pancreatic cancer patients with new onset DM compared to long standing diabetes mellitus (DM) and non diabetics. METHODS A prospectively maintained pancreatic cancer surgery database of a tertiary care teaching hospital from January 2006 to August 2012 was reviewed. Only patients with a histological diagnosis of pancreatic carcinoma (PC) were included in final analysis. DM was defined as HbA1c >6.5% or any patient on anti-diabetic treatment regardless of HbA1c value. New onset DM was defined when diagnosed within two preceding years of surgery. Patients were stratified into two groups: DM and non DM. Among the DM patients, patients with new onset DM were further stratified and studied separately. Staging of PC was performed according to the 6(th) edition of AJCC. Survival of patients with PC was determined by reviewing medical records. Patients and their families were contacted if there was no existing follow-up. RESULTS Eighty-six patients (n=55, 63.9% male) with a mean age of 62 years (range, 29-85 years) underwent pancreatic cancer surgery during the study period. Of the 86 patients, 30 (34%) had DM of which eight patients (9% overall) had new onset DM. DM patients tended to be older compared to non DM patients (67.8 vs. 58.5 years, P=0.0005). The majority of non DM patients were symptomatic (98.2%), and there was a tendency for DM group patients to be asymptomatic at presentation (13.3% vs. 1.8%, P=0.05). Abdominal pain was less common in DM patients compared to non DM patients (30% vs. 53.6%, P=0.04). The median duration of new onset DM prior to diagnosis of PC was 2 months (range, 1-23 months). There was a tendency for DM patients to present at an early stage (stage I and stage II) (P=0.08). There was no difference in survival (P=0.17) for new onset DM compared to long standing DM and non DM patients. CONCLUSIONS DM patients tend to be older and are less likely to present with abdominal pain. Asymptomatic presentation and early stage disease tends to occur in DM patients. A larger sample size is required to determine if survival of new onset DM patients differs from long standing and non DM patients.
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Ahmed S, Chia CLK, Junnarkar SP, Woon W, Shelat VG. Percutaneous drainage for giant pyogenic liver abscess--is it safe and sufficient? Am J Surg 2016; 211:95-101. [PMID: 26033361 DOI: 10.1016/j.amjsurg.2015.03.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 01/22/2015] [Accepted: 03/03/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Large size is a predictor of failure of percutaneous drainage (PD) for pyogenic liver abscess (PLA). This article serves to establish the safety and sufficiency of PD in giant PLA (GPLA). METHODS A retrospective review of all GPLA patients treated at a tertiary care academic hospital from 2001 to 2011 was performed. A GPLA is defined as an abscess greater than or equal to 10 cm size based on imaging. RESULTS Forty patients (24 men, 60%) were treated for GPLA. All but 1 patient (98%) was managed with PD and the mean duration of drainage was 9 days (range 1 to 23 days). One patient underwent operative drainage. Three patients (7.7%) needed secondary procedures after the initial PD. One patient (2.6%) failed PD and subsequently underwent operative drainage. Among the patients who underwent PD, the overall morbidity was 25%; the median length of hospital stay was 13 days (range 5 to 31 days) and 1 (2.6%) mortality. CONCLUSIONS Large size itself is not a contraindication for PD. PD is safe and sufficient even in GPLA patients.
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Affiliation(s)
- Saleem Ahmed
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore; Ministry of Health Holdings, 1 Maritime Square, Singapore, Singapore
| | - Clement L K Chia
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore; Ministry of Health Holdings, 1 Maritime Square, Singapore, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Winston Woon
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore.
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Chia CL, Su J, Hoe Y, Shelat VG, Junnarkar SP, Low J, Woon WW. Outcomes of slit mesh in laparoscopic totally extraperitoneal inguinal hernia repair: Does it affect recurrence? Asian J Endosc Surg 2015; 8:434-8. [PMID: 26315130 DOI: 10.1111/ases.12224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 07/16/2015] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The aim of this study was to compare outcomes between slit and non-slit mesh placement in laparoscopic totally extraperitoneal inguinal hernia repair. METHODS This is a retrospective study of 113 patients who underwent laparoscopic totally extraperitoneal inguinal hernia repair with Ultrapro mesh between January 2010 and December 2011. Sixty-two and 82 hernias were operated on in the slit mesh and non-slit mesh groups, respectively. Postoperative complications, recurrence, and patient satisfaction levels were evaluated. RESULTS One hernia in the slit mesh group (1/62, 1.6%) and one in the non-slit mesh group (1/82, 1.2%) developed recurrence (P = 1.00). The incidence of postoperative neuralgia was 4/62 (6.5%) and 7/82 (8.5%) in the slit mesh and non-slit mesh groups, respectively (P = 0.76). Satisfaction rates in the slit mesh and non-slit mesh groups were similar at 60/62 (96.8%) and 80/82 (97.6%), respectively (P = 1.00). CONCLUSION No significant differences in outcomes were found between slit and non-slit mesh placement. Both have low complication rates, low recurrence rates, and high satisfaction levels.
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Affiliation(s)
- Clement Lk Chia
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jun Su
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yingmin Hoe
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jeekeem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Winston Wl Woon
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Shelat VG, Chia CLK, Yeo CSW, Qiao W, Woon W, Junnarkar SP. Pyogenic Liver Abscess: Does Escherichia Coli Cause more Adverse Outcomes than Klebsiella Pneumoniae? World J Surg 2015; 39:2535-42. [PMID: 26133908 DOI: 10.1007/s00268-015-3126-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND This paper aims to demonstrate if Escherichia coli pyogenic liver abscess (ECPLA) results in adverse outcomes compared to Klebsiella pneumoniae PLA (KPPLA). METHODS A retrospective review of all patients admitted at a tertiary hospital in Singapore from 2003 to 2011 was performed. Patients with age <18 years, amoebic liver abscess, infected liver cyst, culture negative abscess or ruptured liver abscess requiring urgent surgical intervention were excluded. Only patients with blood or pus culture confirmation of ECPLA (n = 24) or KPPLA (n = 264) were included. Median length of hospital stay, failure of non-operative therapy and 30-day mortality are the reported outcomes. RESULTS ECPLA affects older patients (68 vs. 62 years, p = 0.049). Ischemic heart disease was more common in ECPLA (29 vs. 14 %, p = 0.048) and there was no difference in diabetic state (42 vs. 38 %, p = 0.743). ECPLA is more commonly associated with hyperbilirubinemia (60 vs. 34 µmol/L, p = 0.003), increased gamma-glutamyl transpeptidase (236 vs. 16 IU/L, p = 0.038) and gallstones (58 vs. 30 %, p = 0.004). KPPLA are larger in size (6 vs. 4 cm, p = 0.006) and had percutaneous drainage (PD) more frequently (64 vs. 42 %, p = 0.034). There was no difference in median hospital stay (14 vs. 14 days, p = 0.110) or 30-day mortality (17 vs. 10 %, p = 0.307) between ECPLA and KPPLA. Among patients with ECPLA, antibiotic treatment with PD appeared to have higher mortality compared to antibiotic treatment alone (30 vs. 7 %) but this was not significant (p = 0.272). CONCLUSION In the setting of multimodal care, outcomes of ECPLA are comparable to KPPLA.
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Affiliation(s)
- Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, 308433, Singapore,
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Lo JZW, Leow JJJ, Low JK, Junnarkar SP, Woon WWL. Re: Liver abscesses, elevated carbohydrate antigen 19-9 and concomitant malignancies. J Hepatobiliary Pancreat Sci 2015. [PMID: 26199179 DOI: 10.1002/jhbp.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joseph Zhi Wen Lo
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433.
| | - Jeffrey Jia Jun Leow
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433
| | - Winston Wei Liang Woon
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433
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Tan CHM, Pang TCY, Woon WWL, Low JK, Junnarkar SP. Analysis of actual healthcare costs of early versus interval cholecystectomy in acute cholecystitis. J Hepatobiliary Pancreat Sci 2014; 22:237-43. [PMID: 25450622 DOI: 10.1002/jhbp.196] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Healthcare cost modeling have favored early (ELC) over interval laparoscopic cholecystectomy (ILC) for acute cholecystitis (AC). However, actual costs of treatment have never been studied. The aim of the present study was to compare actual hospital costs involved in ELC and ILC in patients with AC. METHODS Retrospective study of patients who underwent laparoscopic cholecystectomy for AC was conducted. Demographic, clinical, operative data and costs were extracted and analyzed. RESULTS Between 2011 and 2013, 201 had laparoscopic surgery for AC at Tan Tock Seng Hospital, Singapore. One hundred and thirty-four (67%) patients underwent ELC (≤7 days of presentation, within index admission). Median total length of stay (LOS) was 4.6 and 6.8 days for ELC and ILC groups, respectively (P = 0.006). Patients who had ELC also had significantly lesser total number of admissions (P < 0.001). The median (IQR) total inpatient costs were €4.4 × 10(3) (3.6-5.6) and €5.5 × 10(3) (4.0-7.5) for ELC and ILC patients, respectively (P < 0.007). Costs associated with investigations were significantly higher in the ILC group (P = 0.039), of which serological costs made most difference (P < 0.005). The ward costs were also significantly higher in the ILC group. CONCLUSION The cost differences reflect the significantly increased total LOS, and repeat presentations associated with ILC. Therefore, ELC should be the preferred management strategy for AC.
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Affiliation(s)
- Cheryl H M Tan
- Department of General Surgery, Tan Tock Seng Hospital, Annex 1, 11 Jalan Tan Tock Seng, Singapore, 308433; School of Medicine, University of Aberdeen, Aberdeen, Scotland
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Lo JZW, Leow JJJ, Ng PLF, Lee HQ, Mohd Noor NA, Low JK, Junnarkar SP, Woon WWL. Predictors of therapy failure in a series of 741 adult pyogenic liver abscesses. J Hepatobiliary Pancreat Sci 2014; 22:156-65. [PMID: 25339111 DOI: 10.1002/jhbp.174] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Adult pyogenic liver abscess (PLA) is a major hepato-biliary infection. We aim to identify risk factors associated with therapy failure. METHODS Retrospective study of 741 PLA patients (2001-2011) and comparison with earlier data (1994-1997). Risk factors associated with therapy failure were identified with multivariate analysis. RESULTS Incidence of PLA is 86/100 000 admissions, with average size 5.75 cm. 68% of PLA were secondary to Klebsiella pneumoniae and there is increasing extended-spectrum beta-lactamase (ESBL) resistance. Compared with 1990s, there is an increasing annual incidence (from 18 to 67). Elderly age (≥55-years-old), presence of multiple abscesses, malignancy as etiology and patients who underwent endoscopic intervention are independent predictors for failure of antibiotics-only therapy while average intravenous antibiotics duration and average abscess size are not. ECOG performance status ≥2, pre-existing hypertension and hyperbilirubinaemia are independent predictors for failure of percutaneous therapy while the presence of multiple abscesses and average abscess size are not. CONCLUSION There is an increasing PLA incidence with increasing ESBL resistance. Percutaneous drainage should be considered early for elderly patients (≥55-years-old), with multiple abscesses, malignancy as etiology or who required endoscopic intervention. We should have a low threshold for surgical intervention for patients with ECOG performance status ≥2, co-morbidity of hypertension or hyperbilirubinaemia.
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Affiliation(s)
- Joseph Zhi Wen Lo
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433.
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Junnarkar SP, Tapuria N, Mani A, Dijk S, Fuller B, Seifalian AM, Davidson BR. Attenuation of warm ischemia-reperfusion injury in the liver by bucillamine through decreased neutrophil activation and Bax/Bcl-2 modulation. J Gastroenterol Hepatol 2010; 25:1891-9. [PMID: 21092002 DOI: 10.1111/j.1440-1746.2010.06312.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND AIM Liver transplantation and resection surgery involve a period of ischemia and reperfusion to the liver, which initiates an inflammatory cascade resulting in liver and remote organ injury. Bucillamine is a low molecular weight thiol antioxidant that is capable of rapidly entering cells. We hypothesized that bucillamine acts by replenishing glutathione levels, thus reducing neutrophil activation, modulating Bax/Bcl-2 expression, and subsequently, attenuating the effects of warm ischemia-reperfusion injury (IRI) in the liver. METHODS The effect of bucillamine was studied in a rat model of liver IRI with 45 min of partial (70%) liver ischemia and 3 h of reperfusion. Liver injury was assessed by measuring serum transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) and liver histology. Oxidative stress was quantified by measuring F(2) isoprostane and glutathione levels. Leukocyte adhesion was assessed by intravital microscopy, and inflammatory cytokine response was assessed by measuring serum cytokine-induced neutrophil chemoattractant-1 (CINC-1) levels. Bax and Bcl-2 expression was measured by reverse transcription-polymerase chain reaction. RESULTS The model produced significant liver injury with elevated transaminases and an acute inflammatory response. Bucillamine reduced the liver injury, as indicated by reduced AST (932 ± 200.8 vs 2072.5 ± 511.79, P < 0.05). Bucillamine reduced Bax expression, serum CINC-1 levels, and neutrophil adhesion, and upregulated Bcl-2. However, bucillamine did not affect tissue glutathione levels nor the levels of oxidative stress, as measured by plasma and hepatic F(2) isoprostane levels. CONCLUSIONS Bucillamine reduces warm ischemia-reperfusion in the liver by inhibiting neutrophil activation and modulating Bax/Bcl-2 expression.
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Affiliation(s)
- Sameer P Junnarkar
- Department of Surgery, Royal Free Hospital and University College London, London, UK.
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Junnarkar SP, Tapuria N, Dutt N, Fuller B, Seifalian AM, Davidson BR. Bucillamine improves hepatic microcirculation and reduces hepatocellular injury after liver warm ischaemia-reperfusion injury. HPB (Oxford) 2009; 11:264-73. [PMID: 19590658 PMCID: PMC2697901 DOI: 10.1111/j.1477-2574.2009.00054.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2008] [Accepted: 02/15/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation and resection surgery involve a period of ischaemia and reperfusion to the liver which initiates an inflammatory cascade resulting in liver and remote organ injury. Bucillamine is a low-molecular-weight thiol antioxidant that is capable of rapidly entering cells. METHODS The effect of bucillamine was studied in a rat model of liver ischaemia-reperfusion injury with 45 min of partial (70%) liver ischaemia and at 3 and 24 h of reperfusion. Controls included ischaemia-reperfusion (I/R) only, sham and bucillamine alone (without ischaemia reperfusion). Liver injury was assessed by serum transaminases (AST and ALT). Sinusoidal blood flow and hepatocyte apoptosis were measured using intravital microscopy (IVM). RESULTS The hepatocellular injury of I/R produced a markedly elevated serum AST which was reduced with bucillamine (2072.5 +/- 511.79 vs. 932 +/- 200.8, P < 0.05) at 3 h reperfusion. Bucillamine treatment with I/R also increased parenchymal blood flow [red blood cell (RBC) velocity 242.66 +/- 16.86 vs. 181.11 +/- 17.59, at the end of 3 h of reperfusion) and reduced hepatocyte necrosis/apoptosis at 3 h as well as 24 h (P > 0.001). CONCLUSION Bucillamine reduces the hepatocellular injury of liver ischaemia reperfusion and improves parenchymal perfusion.
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Affiliation(s)
- Sameer P Junnarkar
- University Department of Surgery, Royal Free Campus, Royal Free and University College Medical School, UCL and Royal Free hospitalLondon, UK
| | - Niteen Tapuria
- University Department of Surgery, Royal Free Campus, Royal Free and University College Medical School, UCL and Royal Free hospitalLondon, UK
| | | | - Barry Fuller
- University Department of Surgery, Royal Free Campus, Royal Free and University College Medical School, UCL and Royal Free hospitalLondon, UK
| | - Alexander M Seifalian
- University Department of Surgery, Royal Free Campus, Royal Free and University College Medical School, UCL and Royal Free hospitalLondon, UK
| | - Brian R Davidson
- University Department of Surgery, Royal Free Campus, Royal Free and University College Medical School, UCL and Royal Free hospitalLondon, UK
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Tapuria N, Junnarkar SP, Dutt N, Abu-Amara M, Fuller B, Seifalian AM, Davidson BR. Effect of remote ischemic preconditioning on hepatic microcirculation and function in a rat model of hepatic ischemia reperfusion injury. HPB (Oxford) 2009; 11:108-17. [PMID: 19590633 PMCID: PMC2697885 DOI: 10.1111/j.1477-2574.2009.00006.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2008] [Accepted: 08/30/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation involves a period of ischemia and reperfusion to the graft which leads to primary non-function and dysfunction of the liver in 5-10% of cases. Remote ischemic preconditioning (RIPC) has been shown to reduce ischemia reperfusion injury (IRI) injury to the liver and increase hepatic blood flow. We hypothesized that RIPC may directly modulate hepatic microcirculation and have investigated this using intravital microscopy. METHODS A rat model of liver IRI was used with 45 min of partial hepatic ischemia (70%) followed by 3 h of reperfusion. Four groups of animals (Sham, IRI, RIPC+IRI, RIPC+Sham) were studied (n= 6, each group). Intravital microscopy was used to measure red blood cell (RBC) velocity, sinusoidal perfusion, sinusoidal flow and sinusoidal diameter. Neutrophil adhesion was assessed by rhodamine labeling of neutrophils and cell death using propidium iodide. RESULTS RIPC reduced the effects of IRI by significantly increasing red blood cell velocity, sinusoidal flow and sinusoidal perfusion along with decreased neutrophil adhesion and cell death. CONCLUSIONS Using intravital microscopy, this study demonstrates that RIPC modulates hepatic microcirculation to reduce the effects of IRI. HO-1 may have a key role in the modulation of hepatic microcirculation and endothelial function.
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Affiliation(s)
- Niteen Tapuria
- Royal Free Hospital and Royal Free University College School of MedicineUCL, Pond street, Hampstead, London, UK
| | - Sameer P Junnarkar
- Royal Free Hospital and Royal Free University College School of MedicineUCL, Pond street, Hampstead, London, UK
| | - Neelanjana Dutt
- Department of histopathology, Kings CollegeDenmark Hill, London, UK
| | - Mahmoud Abu-Amara
- Royal Free Hospital and Royal Free University College School of MedicineUCL, Pond street, Hampstead, London, UK
| | - Barry Fuller
- Royal Free Hospital and Royal Free University College School of MedicineUCL, Pond street, Hampstead, London, UK
| | - Alexander M Seifalian
- Royal Free Hospital and Royal Free University College School of MedicineUCL, Pond street, Hampstead, London, UK
| | - Brian R Davidson
- Royal Free Hospital and Royal Free University College School of MedicineUCL, Pond street, Hampstead, London, UK
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Junnarkar SP, Reid J, Johnston LC, Lee B, Hannon RJ, Soong CV. Endovascular repair for acute symptomatic and ruptured abdominal aortic aneurysms. Ulster Med J 2001; 70:51-3. [PMID: 11428326 PMCID: PMC2449213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- S P Junnarkar
- Vascular Surgery Unit, Tower Block, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB
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Junnarkar SP, Sloan JM, Johnston BT, Laird JD, Irwin ST. Cronkhite-Canada syndrome. Ulster Med J 2001; 70:56-8. [PMID: 11428328 PMCID: PMC2449205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S P Junnarkar
- Department of Surgery, Royal Victoria Hospital, Belfast
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