Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer:A 9-year review

BACKGROUND Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide.About 5%-10%of patients are diagnosed with locally advanced rectal cancer(LARC)on presentation.For LARC invading into other structures(i.e.T4b),multivisceral resection(MVR)and/or pelvic ex-enteration(PE)remains the only potential curative surgical treatment.MVR and/or PE is a major and complex surgery with high post-operative morbidity.Minimally invasive surgery(MIS)has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies,but there is little evi-dence on its use in MVR,especially so for robotic MVR.This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023.Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR,or stage 4 disease with resectable systemic metastases.Pa-tients who underwent curative MVR for locally recurrent rectal cancer,or me-tachronous rectal cancer were also included.Exclusion criteria were patients with systemic metastases with non-resectable disease.All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery.Complex sur-gery was defined based on technical difficulty of surgery(i.e.total PE,bladder-sparing prostatectomy,pelvic lymph node dissection or need for flap creation).Our primary outcomes were the margin status,and complication rates.Cate-gorical values were described as percentages and analysed by the chi-square test.Continuous variables were expressed as median(range)and analysed by Mann-Whitney U test.Cumulative overall survival(OS)and recurrence-free survival(RFS)were analysed using Kaplan-Meier estimates with life table analysis.Log-rank test was performed to determine statistical significance between cumulative estimates.Statistical significance was defined as P<0.05.Meier estimates with life table analysis.Log-rank test was performed to determine statistical significance between cumulative estimates.Statistical significance was defined as P<0.05.RESULTS A total of 46 patients were included in this study[open MVR(oMVR):12(26.1%),miMVR:36(73.9%)].Patients’American Society of Anesthesiologists score,body mass index and co-morbidities were comparable between oMVR and miMVR.There is an increasing trend towards robotic MVR from 2015 to 2023.MiMVR was associated with lower estimated blood loss(EBL)(median 450 vs 1200 mL,P=0.008),major morbidity(14.7%vs 50.0%,P=0.014),post-operative intra-abdominal collections(11.8%vs 50.0%,P=0.006),post-operative ileus(32.4%vs 66.7%,P=0.04)and surgical site infection(11.8%vs 50.0%,P=0.006)compared with oMVR.Length of stay was also shorter for miMVR compared with oMVR(median 10 vs 30 d,P=0.001).Oncological outcomes-R0 resection,recurrence,OS and RFS were comparable between miMVR and oMVR.There was no 30-d mortality.More patients underwent robotic compared with laparoscopic MVR for complex cases(robotic 57.1%vs laparoscopic 7.7%,P=0.004).The operating time was longer for robotic compared with laparoscopic MVR[robotic:602(400-900)min,laparoscopic:Median 455(275-675)min,P<0.001].Incidence of R0 resection was similar(laparoscopic:84.6%vs robotic:76.2%,P=0.555).Overall complication rates,major morbidity rates and 30-d readmission rates were similar between la-paroscopic and robotic MVR.Interestingly,3-year OS(robotic 83.1%vs 58.6%,P=0.008)and RFS(robotic 72.9%vs 34.3%,P=0.002)was superior for robotic compared with laparoscopic MVR.CONCLUSION MiMVR had lower post-operative complications compared to oMVR.Robotic MVR was also safe,with acceptable post-operative complication rates.Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.

Outcomes of liver resection in hepatitis C virus-related intrahepatic cholangiocarcinoma:A systematic review and meta-analysis

BACKGROUND Cholangiocarcinoma is the second most common primary liver malignancy.Its incidence and mortality rates have been increasing in recent years.Hepatitis C virus(HCV)infection is a risk factor for development of cirrhosis and cholan-giocarcinoma.Currently,surgical resection remains the only curative treatment option for cholangiocarcinoma.We aim to study the impact of HCV infection on outcomes of liver resection(LR)in intrahepatic cholangiocarcinoma(ICC).AIM To study the outcomes of curative resection of ICC in patients with HCV(i.e.,HCV+)compared to patients without HCV(i.e.,HCV-).METHODS We conducted a systematic review and meta-analysis of randomized controlled trials(RCTs)and observational studies to assess the outcomes of LR in ICC in HCV+patients compared to HCV-patients in tertiary care hospitals.PubMed,EMBASE,The Cochrane Library and Scopus were systematically searched from inception till August 2023.Included studies were RCTs and non-RCTs on patients≥18 years old with a diagnosis of ICC who underwent LR,and compared outcomes between patients with HCV+vs HCV-.The primary outcomes were overall survival(OS)and recurrence-free survival.Secondary outcomes include perioperative mortality,operation duration,blood loss,intrahepatic and extrahepatic recurrence.RESULTS Seven articles,published between 2004 and 2021,fulfilled the selection criteria.All of the studies were retrospective studies.Age,incidence of male patients,albumin,bilirubin,platelets,tumor size,incidence of multiple tumors,vascular invasion,bile duct invasion,lymph node metastases,and stage 4 disease were comparable between HCV+and HCV-group.Alanine transaminase[MD 22.20,95%confidence interval(CI):13.75,30.65,P<0.00001]and aspartate transaminase levels(MD 27.27,95%CI:20.20,34.34,P<0.00001)were significantly higher in HCV+group compared to HCV-group.Incidence of cirrhosis was significantly higher in HCV+group[odds ratio(OR)5.78,95%CI:1.38,24.14,P=0.02]compared to HCV-group.Incidence of poorly differentiated disease was significantly higher in HCV+group(OR 2.55,95%CI:1.34,4.82,P=0.004)compared to HCV-group.Incidence of simultaneous hepatocellular carcinoma lesions was significantly higher in HCV+group(OR 8.31,95%CI:2.36,29.26,P=0.001)compared to HCV-group.OS was significantly worse in the HCV+group(hazard ratio 2.05,95%CI:1.46,2.88,P<0.0001)compared to HCV-group.CONCLUSION This meta-analysis demonstrated significantly worse OS in HCV+patients with ICC who underwent curative resection compared to HCV-patients.

Diagnosis,severity stratification and management of adult acute pancreatitis–current evidence and controversies

Acute pancreatitis(AP)is a disease spectrum ranging from mild to severe with an unpredictable natural course.Majority of cases(80%)are mild and self-limiting.However,severe AP(SAP)has a mortality risk of up to 30%.Establishing aetiology and risk stratification are essential pillars of clinical care.Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause.Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence.In SAP,patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit.Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP.Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition.If unable to tolerate per-orally,nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit.Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis.Delayed step-up strategy including percutaneous retroperitoneal drainage,endoscopic debridement,or minimal-access necrosectomy are sufficient in most SAP patients.Patients should be monitored for diabetes mellitus and pseudocyst.

On-table hepatopancreatobiliary surgical consults for difficult cholecystectomies:A 7-year audit

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.

Elderly patients(≥80 years)with acute calculous cholangitis have similar outcomes as non-elderly patients(<80 years):Propensity score-matched analysis

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.

Outcomes of patients with post-hepatectomy hypophosphatemia:A narrative review

Phosphate is an essential electrolyte for proper mineralisation of bone,buffering of urine,and diverse cellular actions.Hypophosphatemia(HP)is a clinical spectrum which range from asymptomatic to severe complications such as neuromuscular and pulmonary complications,or even death.Post-hepatectomy HP(PHH)has been reported to be 55.5%-100%.Post-hepatectomy,there is rapid uptake of phosphate and increased mitotic counts to aid in regeneration of residual liver.Concurrently,PHH may be due to increased urinary phosphorous from activation of matrix extracellular phosphoglycoprotein in the injured liver,which decreases phosphate influx into hepatocytes to sustain adenosine triphosphate synthesis.A literature review was performed on Pub Med till January 2022.We included 8 studies which reported on impact of PHH on post-operative outcomes.In patients with diseased liver,PHH was reported to have either beneficial or deleterious effects on post-hepatectomy liver failure(PHLF),morbidity and/or mortality in various cohorts.In living donor hepatectomy,PHLF was higher in PHH.Benefits of correction of PHH with reduced postoperative complications have been shown.Correction of PHH should be done based on extent of PHH.Existing studies were however heterogenous;further studies should be conducted to assess PHH on post-operative outcomes with standardized phosphate replacement regimes.

Carbon footprints in minimally invasive surgery:Good patient outcomes,but costly for the environment

Advancements in technology and surgical training programs have increased the adaptability of minimally invasive surgery(MIS).Gastrointestinal MIS is superior to its open counterparts regarding post-operative morbidity and mortality.MIS has become the first-line surgical intervention for some types of gastrointestinal surgery,such as laparoscopic cholecystectomy and appendicectomy.Carbon dioxide(CO_(2))is the main gas used for insufflation in MIS.CO_(2)contributes 9%-26%of the greenhouse effect,resulting in global warming.The rise in global CO_(2)concentration since 2000 is about 20 ppm per decade,up to 10 times faster than any sustained rise in CO_(2)during the past 800000 years.Since 1970,there has been a steady yet worrying increase in average global temperature by 1.7℃ per century.A recent systematic review of the carbon footprint in MIS showed a range of 6-814 kg of CO_(2)emission per surgery,with higher CO_(2)emission following robotic compared to laparoscopic surgery.However,with superior benefits of MIS over open surgery,this poses an ethical dilemma to surgeons.A recent survey in the United Kingdom of 130 surgeons showed that the majority(94%)were concerned with climate change but felt that the lack of leadership was a barrier to improving environmental sustainability.Given the deleterious environmental effects of MIS,this study aims to summarize the trends of MIS and its carbon footprint,awareness and attitudes towards this issue,and efforts and challenges to ensuring environmental sustainability.

Occam’s razor or Hickam’s dictum-COVID-19 is not a textbook aetiology of acute pancreatitis:A modified Naranjo Score appraisal

BACKGROUND Acute pancreatitis(AP)is a disease spectrum ranging from mild to severe disease.During the coronavirus disease 2019(COVID-19)pandemic,numerous reports of AP have been published,with most authors concluding a causal relationship between COVID-19 and AP.Retrospective case reports or small case series are unable to accurately determine the cause-effect relationship between COVID-19 and AP.AIM To establish whether COVID-19 is a cause of AP using the modified Naranjo scoring system.METHODS A systematic review was conducted on PubMed,World of Science and Embase for articles reporting COVID-19 and AP from inception to August 2021.Exclusion criteria were cases of AP which were not reported to be due to COVID-19 infection,age<18 years old,review articles and retrospective cohort studies.The original 10-item Naranjo scoring system(total score 13)was devised to approximate the likelihood of a clinical presentation to be secondary to an adverse drug reaction.We modified the original scoring system into a 8-item modified Naranjo scoring system(total score 9)to determine the cause-effect relationship between COVID-19 and AP.A cumulative score was decided for each case presented in the included articles.Interpretation of the modified Naranjo scoring system is as follows:≤3:Doubtful,4-6:Possible,≥7:Probable cause.RESULTS The initial search resulted in 909 articles,with 740 articles after removal of duplicates.A total of 67 articles were included in the final analysis,with 76 patients which had AP reported to be due to COVID-19.The mean age was 47.8(range 18-94)years.Majority of patients(73.3%)had≤7 d between onset of COVID-19 infection and diagnosis of AP.There were only 45(59.2%)patients who had adequate investigations to rule out common aetiologies(gallstones,choledocholithiasis,alcohol,hypertriglyceridemia,hypercalcemia and trauma)of AP.Immunoglobulin G4 testing was conducted in 9(13.5%)patients to rule out autoimmune AP.Only 5(6.6%)patients underwent endoscopic ultrasound and/or magnetic resonance cholangiopancreatogram to rule out occult microlithiasis,pancreatic malignancy and pancreas divisum.None of the patients had other recently diagnosed viral infections apart from COVID-19 infection,or underwent genetic testing to rule out hereditary AP.There were 32(42.1%),39(51.3%)and 5(6.6%)patients with doubtful,possible,and probable cause-effect relationship respectively between COVID-19 and AP.CONCLUSION Current evidence is weak to establish a strong link between COVID-19 and AP.Investigations should be performed to rule out other causes of AP before establishing COVID-19 as an aetiology.

Isolated gallbladder tuberculosis mimicking acute cholecystitis:A case report

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.

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

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 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.Conclusions: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.