The risk and predictors of gallbladder cancer in patients with gallbladder polyps: A retrospective cohort study with an insight into confounding by indication.

BACKGROUND AND AIM: We aimed to determine the risk and predictors of gallbladder cancer in all individuals with gallbladder polyps (GP) including those who did not have cholecystectomy. METHODS: The STROCSS guideline was followed to conduct a retrospective cohort study. All individuals with GP between 2010 and 2019 were followed up to determine the risk and predictors of gallbladder cancer. The primary outcomes were gallbladder cancer and gallbladder dysplasia, and the secondary outcomes included polyp growth rate and polyp disappearance rate. Binary logistic regression analysis and receiver operating characteristic curve analysis were conducted to evaluate the outcomes. RESULTS: Analysis of 438 patients showed risk of gallbladder cancer was 0.7% in all polyps (0% in polyps < 10 mm; 5.9% in polyps ≥ 10 mm). The risk of gallbladder dysplasia or cancer was 1.1% in all polyps (0% in polyps < 10 mm; 10% in polyps ≥ 10 mm). The polyp size (P = 0.0001) was predictor of cancer; however, patient's age (P = 0.1085), number of polyps (P = 0.9983), symptomatic polyps (P = 0.3267), and change in size (P = 0.9012) were not. Size of 21 mm was cut-off for risk of cancer (area under the curve [AUC]: 0.995, P < 0.001) and 11.8 mm for risk of dysplasia or cancer (AUC: 0.986, P < 0.001). The mean polyp growth rate was 0.3 mm/year and polyp disappearance rate was 16%. CONCLUSIONS: The GP size remains the only predictor of malignant changes regardless of patient's age, patient's symptoms and number of polyps. The polyp growth rate is unremarkable, and a significant proportion disappears during follow-up. We changed our follow-up protocol with reduced number of scans and early discharge policy.

Partial ALPPS with a longer wait between procedures is safe and yields adequate future liver remnant hypertrophy.

BACKGROUNDS/AIMS: Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has generated controversy due to high morbidity and mortality. We present our series of patients with 30-40% parenchymal transection and minimal hilar dissection. METHODS: Patients who had partial ALPPS between April 2015 and April 2016 were included. Patients with colorectal liver metastases (CRLM) had their future liver remnants (FLR) cleared with metastasectomies. The liver was divided along the future line of transection to 30-40%, right portal vein was stapled and divided without extensive hilar dissection, with minimal handling of right liver, which was not mobilised. We preserved the middle hepatic vein. Data were collected prospectively for hypertrophy of the FLR, morbidity and mortality. RESULTS: Among the 8 patients (age 25-68) investigated, one patient with cholangiocarcinoma had portal vein embolization prior to partial ALPPS. All patients completed two stages with adequate FLR hypertrophy at a median of 28 days. No mortality was found. The median length of stay after stages 1 and 2 was 9 and 9.6 days, respectively. The median increase in FLR was 38%. CONCLUSIONS: A limited transection of 30-40%, minimal hilar dissection and longer wait between stages yielded adequate FLR hypertrophy with low morbidity and no mortality.

Acute Abdomen in the Emergency Department: Is CT a Time-Limiting Factor?

OBJECTIVE: The purpose of this study was to quantify and integrate key emergency department (ED) and radiology department workflow time intervals within the ED length of stay (LOS) for patients presenting with acute abdomen who require CT. MATERIALS AND METHODS: An 11-month retrospective review was performed of all patients presenting to the ED with an acute abdomen who required abdominal CT. Nine key time points associated with ED LOS and CT workflow were collected: triage, physician assessment, CT request, porter schedule, CT start, CT complete, provision of first CT report, ED disposition decision, and physical discharge. The median and 90th percentile times for each interval were reported. RESULTS: Ninety-six percent (2194/2292) of ED encounters during the study period met the inclusion criteria. The median ED LOS was 9.22 hours (90th percentile, 15.7 hours). Intervals associated with CT workflow accounted for 29% of the total LOS. Radiology turnaround time accounted for 32% of the entire CT workflow interval. Timeline analysis found three unique patterns of ED disposition: disposition after initial imaging report, disposition before report, and disposition before CT. CONCLUSION: To our knowledge, this study is the first to quantify the contribution of CT-related workflow time intervals within the context of ED LOS. We have shown that patients do not have identical ED transit pathways, and this may under- or overestimate time interval calculations. These results show the importance of site-specific ED LOS timeline analysis to identify potential targets for quality improvement and serve as baseline targets for measuring future quality improvement initiatives.

Inter- and intra-operator reliability and repeatability of shear wave elastography in the liver: a study in healthy volunteers.

This study assessed the reproducibility of shear wave elastography (SWE) in the liver of healthy volunteers. Intra- and inter-operator reliability and repeatability were quantified in three different liver segments in a sample of 15 subjects, scanned during four independent sessions (two scans on day 1, two scans 1 wk later) by two operators. A total of 1440 measurements were made. Reproducibility was assessed using the intra-class correlation coefficient (ICC) and a repeated measures analysis of variance. The shear wave speed was measured and used to estimate Young's modulus using the Supersonics Imagine Aixplorer. The median Young's modulus measured through the inter-costal space was 5.55 ± 0.74 kPa. The intra-operator reliability was better for same-day evaluations (ICC = 0.91) than the inter-operator reliability (ICC = 0.78). Intra-observer agreement decreased when scans were repeated on a different day. Inter-session repeatability was between 3.3% and 9.9% for intra-day repeated scans, compared with to 6.5%-12% for inter-day repeated scans. No significant difference was observed in subjects with a body mass index greater or less than 25 kg/m(2).

Episiotomy endometrioma masquerading as peri-anal sepsis: surgeons beware!

A 34-year-old woman with peri-anal pain and swelling was operated in the emergency setting assuming a diagnosis of a perianal abscess. No pus was revealed. Later magnetic resonance imaging (MRI) suggested induration and a mass effect in the peri-anal region. Examination under anaesthesia was repeated which revealed a mobile but firm mass. Histology from trucut biopsies diagnosed it as a peri-anal endometrioma arising from an episiotomy scar. Peri-anal endometrioma can rarely developin episiotomy scars and can be easily mistaken as an abscess by junior surgeons.

Tissue-specific differences in 2-fluoro-2-deoxyglucose metabolism beyond FDG-6-P: a 19F NMR spectroscopy study in the rat.

2-Fluoro-[(18)F]-2-deoxy-glucose (FDG) is a positron-emitting analogue of glucose used clinically in positron emission tomography (PET) to assess glucose utilization in diseased and healthy tissue. Originally developed to measure local cerebral glucose utilization rates, it has now found applications in tumour diagnosis and in the study of myocardial glucose uptake. Once taken up into the cell, FDG is phosphorylated to FDG-6-phosphate (FDG-6-P) by hexokinase and was originally believed to be trapped as a terminal metabolite. This 'metabolic trapping' of FDG-6-P forms the basis of the analysis of PET data. In this study, we have used (19)F NMR spectroscopy to investigate FDG metabolism following the injection of a bolus of the glucose tracer into the rat (n=6). Ninety minutes after the (19)FDG injection, the brain, heart, liver and kidneys were removed and the (19)FDG metabolites in each were extracted and quantified. We report that significant metabolism of FDG occurs beyond FDG-6-P in all organs examined and that the extent of this metabolism varies from tissue to tissue (degree of metabolism beyond FDG-6-P, expressed as percentage of total organ FDG content, was brain 45 +/- 3%; heart 29 +/- 2%; liver 22+/-3% and kidney 17 +/- 3%, mean +/- SEM n=6). Furthermore, we demonstrate that the relative accumulation of each metabolite was tissue-dependent and reflected the metabolic and regulatory characteristics of each organ. Such inter-tissue differences may have implications for the mathematical modelling of glucose uptake and phosphorylation using FDG as a glucose tracer.