Short-term outcomes of laparoscopic and robotic limited resections of pancreatic neuroendocrine tumours of the uncinate process: Report of six cases and review of the literature.

INTRODUCTION: Minimally invasive surgery (MIS) for limited resections for pancreatic uncinate lesions is not widely performed but can adequately treat benign or low-grade malignant lesions. The aim of this study was to evaluate the short-term outcomes of MIS-limited pancreatic resections for patients with suspected pancreatic neuroendocrine tumours (PNETs). PATIENTS AND METHODS: This was a retrospective study of six consecutive patients who underwent MIS for PNET within a single institution between 2017 and 2022. RESULTS: Six patients underwent limited pancreas-preserving MIS of the uncinate process (uncinectomy or enucleation), of which two were performed through the robotic approach and four through laparoscopic approach. The median operation time was 212.5 (175-338.75) min, and the median blood loss was 50 (50-112.5) ml. The median post-operative hospital length of stay was 5.5 (3.75-11.5) days. Two patients (33.3%) had major post-operative morbidities (Clavien-Dindo ≥Grade 3). There were no open conversions or post-operative mortalities. Five patients had histologically proven Grade 1 neuroendocrine tumours. One was T2 and four were T1. CONCLUSIONS: This study suggests that limited MIS resections of pancreatic uncinate PNETs are a feasible procedure with good patient outcomes. It offers a safe alternative to radical surgical resections like pancreatoduodenectomies in selected patients with low-grade malignant or benign tumours.

Evaluation of the American College of Surgeons risk calculator in hepatectomy for metastatic colorectal cancer in a Southeast Asian population.

PURPOSE: This study evaluated the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) calculator in predicting outcomes after hepatectomy for colorectal cancer (CRC) liver metastasis in a Southeast Asian population. METHODS: Predicted and actual outcomes were compared for 166 patients undergoing hepatectomy for CRC liver metastasis identified between 2017 and 2022, using receiver operating characteristic curves with area under the curve (AUC) and Brier score. RESULTS: The ACS-NSQIP calculator accurately predicted most postoperative complications (AUC > 0.70), except for surgical site infection (AUC = 0.678, Brier score = 0.045). It also exhibited satisfactory performance for readmission (AUC = 0.818, Brier score = 0.011), reoperation (AUC = 0.945, Brier score = 0.002), and length of stay (LOS, AUC = 0.909). The predicted LOS was close to the actual LOS (5.9 vs. 5.0 days, P = 0.985). CONCLUSION: The ACS-NSQIP calculator demonstrated generally accurate predictions for 30-day postoperative outcomes after hepatectomy for CRC liver metastasis in our patient population.

Comparative cost-effectiveness of open, laparoscopic, and robotic liver resection: A systematic review and network meta-analysis.

BACKGROUND: This study evaluated the cost-effectiveness of open, laparoscopic, and robotic liver resection. METHODS: A comprehensive literature review and Bayesian network meta-analysis were conducted. Surface under cumulative ranking area values, mean difference, odds ratio, and 95% credible intervals were calculated for all outcomes. Cluster analysis was performed to determine the most cost-effective clustering approach. Costs-morbidity, costs-mortality, and costs-efficacy were the primary outcomes assessed, with postoperative overall morbidity, mortality, and length of stay associated with total costs for open, laparoscopic, and robotic liver resection. RESULTS: Laparoscopic liver resection incurred the lowest total costs (laparoscopic liver resection versus open liver resection: mean difference -2,529.84, 95% credible intervals -4,192.69 to -884.83; laparoscopic liver resection versus robotic liver resection: mean difference -3,363.37, 95% credible intervals -5,629.24 to -1,119.38). Open liver resection had the lowest procedural costs but incurred the highest hospitalization costs compared to laparoscopic liver resection and robotic liver resection. Conversely, robotic liver resection had the highest total and procedural costs but the lowest hospitalization costs. Robotic liver resection and laparoscopic liver resection had a significantly reduced length of stay than open liver resection and showed less postoperative morbidity. Laparoscopic liver resection resulted in the lowest readmission and liver-specific complication rates. Laparoscopic liver resection and robotic liver resection demonstrated advantages in costs-morbidity efficiency. While robotic liver resection offered notable benefits in mortality and length of stay, these were balanced against its highest total costs, presenting a nuanced trade-off in the costs-mortality and costs-efficacy analyses. CONCLUSION: Laparoscopic liver resection represents a more cost-effective option for hepatectomy with superior postoperative outcomes and shorter length of stay than open liver resection. Robotic liver resection, though costlier than laparoscopic liver resection, along with laparoscopic liver resection, consistently exceeds open liver resection in surgical performance.

Evaluating the economic efficiency of open, laparoscopic, and robotic distal pancreatectomy: an updated systematic review and network meta-analysis.

BACKGROUND: This study compared the cost-effectiveness of open (ODP), laparoscopic (LDP), and robotic (RDP) distal pancreatectomy (DP). METHODS: Studies reporting the costs of DP were included in a literature search until August 2023. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area (SUCRA) values, mean difference (MD), odds ratio (OR), and 95% credible intervals (CrIs) were calculated for outcomes of interest. Cluster analysis was performed to examine the similarity and classification of DP approaches into homogeneous clusters. A decision model-based cost-utility analysis was conducted for the cost-effectiveness analysis of DP strategies. RESULTS: Twenty-six studies with 29,164 patients were included in the analysis. Among the three groups, LDP had the lowest overall costs, while ODP had the highest overall costs (LDP vs. ODP: MD - 3521.36, 95% CrI - 6172.91 to - 1228.59). RDP had the highest procedural costs (ODP vs. RDP: MD - 4311.15, 95% CrI - 6005.40 to - 2599.16; LDP vs. RDP: MD - 3772.25, 95% CrI - 4989.50 to - 2535.16), but incurred the lowest hospitalization costs. Both LDP (MD - 3663.82, 95% CrI - 6906.52 to - 747.69) and RDP (MD - 6678.42, 95% CrI - 11,434.30 to - 2972.89) had significantly reduced hospitalization costs compared to ODP. LDP and RDP demonstrated a superior profile regarding costs-morbidity, costs-mortality, costs-efficacy, and costs-utility compared to ODP. Compared to ODP, LDP and RDP cost $3110 and $817 less per patient, resulting in 0.03 and 0.05 additional quality-adjusted life years (QALYs), respectively, with positive incremental net monetary benefit (NMB). RDP costs $2293 more than LDP with a negative incremental NMB but generates 0.02 additional QALYs with improved postoperative morbidity and spleen preservation. Probabilistic sensitivity analysis suggests that LDP and RDP are more cost-effective options compared to ODP at various willingness-to-pay thresholds. CONCLUSION: LDP and RDP are more cost-effective than ODP, with LDP exhibiting better cost savings and RDP demonstrating superior surgical outcomes and improved QALYs.

Propensity Score-Matching Analysis Comparing Robotic Versus Laparoscopic Limited Liver Resections of the Posterosuperior Segments: An International Multicenter Study.

OBJECTIVE: The purpose of this study was to compare the outcomes of robotic limited liver resections (RLLR) versus laparoscopic limited liver resections (LLLR) of the posterosuperior segments. BACKGROUND: Both laparoscopic and robotic liver resections have been used for tumors in the posterosuperior liver segments. However, the comparative performance and safety of both approaches have not been well examined in the existing literature. METHODS: This is a post hoc analysis of a multicenter database of 5446 patients who underwent RLLR or LLLR of the posterosuperior segments (I, IVa, VII, and VIII) at 60 international centers between 2008 and 2021. Data on baseline demographics, center experience and volume, tumor features, and perioperative characteristics were collected and analyzed. Propensity score-matching (PSM) analysis (in both 1:1 and 1:2 ratios) was performed to minimize selection bias. RESULTS: A total of 3510 cases met the study criteria, of whom 3049 underwent LLLR (87%), and 461 underwent RLLR (13%). After PSM (1:1: and 1:2), RLLR was associated with a lower open conversion rate [10 of 449 (2.2%) vs 54 of 898 (6.0%); P =0.002], less blood loss [100 mL [IQR: 50-200) days vs 150 mL (IQR: 50-350); P <0.001] and a shorter operative time (188 min (IQR: 140-270) vs 222 min (IQR: 158-300); P <0.001]. These improved perioperative outcomes associated with RLLR were similarly seen in a subset analysis of patients with cirrhosis-lower open conversion rate [1 of 136 (0.7%) vs 17 of 272 (6.2%); P =0.009], less blood loss [100 mL (IQR: 48-200) vs 160 mL (IQR: 50-400); P <0.001], and shorter operative time [190 min (IQR: 141-258) vs 230 min (IQR: 160-312); P =0.003]. Postoperative outcomes in terms of readmission, morbidity and mortality were similar between RLLR and LLLR in both the overall PSM cohort and cirrhosis patient subset. CONCLUSIONS: RLLR for the posterosuperior segments was associated with superior perioperative outcomes in terms of decreased operative time, blood loss, and open conversion rate when compared with LLLR.

The impact of hospital volume on liver resection: A systematic review and Bayesian network meta-analysis.

BACKGROUND: This study aims to compare the outcomes of high-volume, medium-volume, and low-volume hospitals performing hepatic resections using a network meta-analysis. METHODS: A literature search until June 2023 was conducted across major databases to identify studies comparing outcomes in high-volume, medium-volume, and low-volume hospitals for liver resection. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area values, odds ratio, and mean difference with 95% credible intervals were reported for postoperative mortality, failure-to-rescue, morbidity, length of stay, and hospital costs. RESULTS: Twenty studies comprising 248,707 patients undergoing liver resection were included. For the primary mortality outcome, overall and subgroup analyses were performed: group I: high-volume = 5 to 20 resections/year; group II: high-volume = 21 to 49 resections/year; group III: high-volume ≥50 resections/year. Results demonstrated a significant association between hospital volume and mortality (overall-high-volume versus medium-volume: odds ratio 0.66, 95% credible interval 0.49-0.87; high-volume versus low-volume: odds ratio 0.52, 95% credible interval 0.41-0.65; group I-high-volume versus low-volume: odds ratio 0.34, 95% credible interval 0.22-0.50; medium-volume versus low-volume: odds ratio 0.56, 95% credible interval 0.33-0.92; group II-high-volume versus low-volume: odds ratio 0.67, 95% credible interval 0.45-0.91), as well as length of stay (high-volume versus low-volume: mean difference -1.24, 95% credible interval -2.07 to -0.41), favoring high-volume hospitals. No significant difference was observed in failure-to-rescue, morbidity, or hospital costs across the 3 groups. CONCLUSION: This study supports a positive relationship between hospital volume and surgical outcomes in liver resection. Patients from high-volume hospitals experience superior outcomes in terms of lower postoperative mortality and shorter lengths of stay than medium-volume and low-volume hospitals.

Outcomes of laparoscopic, robotic, and open pancreatoduodenectomy: A network meta-analysis of randomized controlled trials and propensity-score matched studies.

BACKGROUND: This network meta-analysis was performed to determine the optimal surgical approach for pancreatoduodenectomy by comparing outcomes after laparoscopic pancreatoduodenectomy, robotic pancreatoduodenectomy and open pancreatoduodenectomy. METHODS: A systematic search of the PubMed, EMBASE, Scopus, and Web of Science databases was conducted to identify eligible randomized controlled trials and propensity-score matched studies. RESULTS: Four randomized controlled trials and 23 propensity-score matched studies comprising a total of 4,945 patients were included for analysis. Operation time for open pancreatoduodenectomy was shorter than both laparoscopic pancreatoduodenectomy (mean difference -57.35, 95% CI 26.25-88.46 minutes) and robotic pancreatoduodenectomy (mean difference -91.08, 95% CI 48.61-133.56 minutes), blood loss for robotic pancreatoduodenectomy was significantly less than both laparoscopic pancreatoduodenectomy (mean difference -112.58, 95% CI 36.95-118.20 mL) and open pancreatoduodenectomy (mean difference -209.87, 95% CI 140.39-279.36 mL), both robotic pancreatoduodenectomy and laparoscopic pancreatoduodenectomy were associated with reduced rates of delayed gastric emptying compared with open pancreatoduodenectomy (odds ratio 0.59, 95% CI 0.39-0.90 and odds ratio 0.69, 95% CI 0.50-0.95, respectively), robotic pancreatoduodenectomy was associated with fewer wound infections compared with open pancreatoduodenectomy (odds ratio 0.35, 95% CI 0.18-0.71), and laparoscopic pancreatoduodenectomy patients enjoyed significantly shorter length of stay compared with open pancreatoduodenectomy (odds ratio 0.43, 95% CI 0.28-0.95). There were no differences in other outcomes. CONCLUSION: This network meta-analysis of high-quality studies suggests that when laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy are performed in high-volume centers, short-term perioperative and oncologic outcomes are largely comparable, if not slightly improved, compared with traditional open pancreatoduodenectomy. These findings should be corroborated in further prospective randomized studies.

Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients.

BACKGROUND: Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another. METHODS: To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis. RESULTS: Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928). CONCLUSION: Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum.

Survival Advantage of Laparoscopic Versus Open Resection For Colorectal Liver Metastases: A Meta-analysis of Individual Patient Data From Randomized Trials and Propensity-score Matched Studies.

OBJECTIVE: To perform an individual participant data meta-analysis using randomized trials and propensity-score matched (PSM) studies which compared laparoscopic versus open hepatectomy for patients with colorectal liver metastases (CLM). BACKGROUND: Randomized trials and PSM studies constitute the highest level of evidence in addressing the long-term oncologic efficacy of laparoscopic versus open resection for CLM. However, individual studies are limited by the reporting of overall survival in ways not amenable to traditional methods of meta-analysis, and violation of the proportional hazards assumption. METHODS: Survival information of individual patients was reconstructed from the published Kaplan-Meier curves with the aid of a computer vision program. Frequentist and Bayesian survival models (taking into account random-effects and nonproportional hazards) were fitted to compare overall survival of patients who underwent laparoscopic versus open surgery. To handle long plateaus in the tails of survival curves, we also exploited "cure models" to estimate the fraction of patients effectively "cured" of disease. RESULTS: Individual patient data from 2 randomized trials and 13 PSM studies involving 3148 participants were reconstructed. Laparoscopic resection was associated with a lower hazard rate of death (stratified hazard ratio = 0.853, 95% confidence interval: 0.754-0.965, P = 0.0114), and there was evidence of time-varying effects (P = 0.0324) in which the magnitude of hazard ratios increased over time. The fractions of long-term cancer survivors were estimated to be 47.4% and 18.0% in the laparoscopy and open surgery groups, respectively. At 10-year follow-up, the restricted mean survival time was 8.6 months (or 12.1%) longer in the laparoscopy arm (P < 0.0001). In a subgroup analysis, elderly patients (≥65 years old) treated with laparoscopy experienced longer 3-year average life expectancy (+6.2%, P = 0.018), and those who live past the 5-year milestone (46.1%) seem to be cured of disease. CONCLUSIONS: This patient-level meta-analysis of high-quality studies demonstrated an unexpected survival benefit in favor of laparoscopic over open resection for CLM in the long-term. From a conservative viewpoint, these results can be interpreted to indicate that laparoscopy is at least not inferior to the standard open approach.

Minimally Invasive Versus Open Pancreatectomies for Pancreatic Neuroendocrine Neoplasms: A Propensity-Score-Matched Study.

BACKGROUND: Pancreatic neuroendocrine neoplasms (PNENs) are increasingly prevalent with modern imaging, and surgical excision remains mainstay of treatment. This study aims to perform a propensity-score-matched (PSM) comparison of perioperative and oncologic outcomes following minimally invasive pancreatectomy (MIP) versus open pancreatectomy (OP) for PNEN. METHODS: A retrospective review was performed on patients who underwent curative-intent surgery for PNEN at Singapore General Hospital from 1997 to 2018. A 1:1 PSM was performed between MIP and OP, after which both groups were balanced for baseline variables. RESULTS: We studied 134 patients who underwent surgery (36 MIP and 98 OP) for PNEN. Propensity-score-matched comparison between 35 MIP and 35 OP patients revealed that the MIP group had a longer operating time (MD = 75.0, 95% CI 15.2 to 134.8, P = 0.015), lower intraoperative blood loss (MD = - 400.0, 95% CI - 630.5 to - 169.5, P = 0.001), shorter median postoperative stay (MD = - 1.0, 95% CI - 1.9 to - 0.1, P = 0.029) and shorter median time to diet (MD = - 1.0, 95% CI - 1.9 to - 0.1, P = 0.039). There were no differences between both groups for short-term adverse outcomes and oncologic clearance. Overall survival (HR = 0.84, 95% CI 0.28 to 2.51, P = 0.761) and disease-free survival (HR = 0.57, 95% CI 0.20 to 1.64, P = 0.296) were comparable. CONCLUSION: MIP is a safe and feasible approach for PNEN and is associated with a lower intraoperative blood loss, decreased postoperative stay and time to oral intake, at the expense of a longer operative time compared to OP.

Systematic Review and Meta-analysis of Minimally Invasive Pancreatectomies for Solid Pseudopapillary Neoplasms of the Pancreas.

OBJECTIVES: We report the first systematic review and meta-analysis on minimally invasive pancreatectomy (MIP) for solid pseudopapillary neoplasms (SPPN) of the pancreas. METHODS: A systematic review of all studies reporting patient characteristics and outcomes of MIP for SPPN was conducted. RESULTS: We reviewed 27 studies comprising 149 patients with SPPN managed via MIP. Five were comparative retrospective cohort studies, comprising 46 and 60 patients in the minimally-invasive and open groups, respectively. Tumor size was smaller in the minimally-invasive group (mean difference, -2.20; 95% confidence interval (CI), -3.09 to -1.32; P < 0.001). The MI group had lower intraoperative blood loss (mean difference, -180.19; 95% CI, -344.28 to -16.09; P = 0.03) and transfusion requirement (relative risk, 0.24; 95% CI, 0.06-0.94; P = 0.04), and a shorter time to diet (mean difference, -2.99; 95% CI, -3.96 to -2.03; P < 0.001) and length of stay (mean difference, -3.61; 95% CI, -6.98 to -0.24; P = 0.04). There was no significant difference in operating time, margin positivity, postoperative morbidity, and postoperative pancreatic fistula rates. CONCLUSIONS: Minimally invasive pancreatectomy for SPPN is associated with decreased intraoperative blood loss and transfusion requirements and a shorter postoperative time to diet and hospital stay.

Outcome of minimally-invasive versus open pancreatectomies for solid pseudopapillary neoplasms of the pancreas: A 2:1 matched case-control study.

BACKGROUNDS/AIMS: Solid pseudopapillary neoplasm (SPPN) is typically seen in young healthy females who would likely benefit from minimally-invasive pancreatectomy (MIP). A few comparative studies have suggested that MIP is associated with favorable outcomes when compared to the open approach for SPPN. This study aims to mitigate potential selection bias by performing a matched case-control study comparing MIP vs open pancreatectomy (OP) for SPPN. METHODS: We performed a single-institution retrospective electronic chart review of all patients who underwent surgery for pathologically confirmed SPPN between 2000 and 2017. A 2:1 matched comparison using age, gender, tumor size and the type of pancreatectomy was performed between OP and MIP. RESULTS: A total of 40 patients with a median age of 40.3 years (range 16.5-64.4) and female sex predominance (n=34, 85.0%) underwent surgery during the study period. Nine patients underwent MIP. Matched comparison between 18 OP and 9 MIP demonstrated that MIP was associated with a longer median operating time (305 vs 180 min, p=0.046) and shorter median postoperative stay (6 vs 9 days, p=0.015). There were no significant differences in intraoperative blood loss, blood transfusion requirements, postoperative morbidity (including postoperative pancreatic fistula) and mortality, resection margins, lymph node yield and long-term survival. CONCLUSIONS: MIP is a safe and viable option in the management of SPPN with the benefit of a shorter postoperative length of stay at the expense of a longer operation time. There was no significant difference in oncologic outcomes between both groups of patients.

A set of molecular markers predicts chemosensitivity to Mitomycin-C following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastasis.

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with significant perioperative morbidity and mortality. We aim to generate and validate a biomarker set predicting sensitivity to Mitomycin-C to refine selection of patients with colorectal peritoneal metastasis (CPM) for this treatment. A signature predicting Mitomycin-C sensitivity was generated using data from Genomics of Drug Sensitivity in Cancer and The Cancer Genome Atlas. Validation was performed on CPM patients who underwent CRS-HIPEC (n = 62) using immunohistochemistry (IHC). We determined predictive significance of our set using overall survival as a surrogate endpoint via a logistic regression model. Three potential biomarkers were identified and optimized for IHC. Patients exhibiting lower expression of PAXIP1 and SSBP2 had poorer survival than those with higher expression (p = 0.045 and 0.140, respectively). No difference was observed in patients with differing DTYMK expression (p = 0.715). Combining PAXIP1 and SSBP2 in a set, patients with two dysregulated protein markers had significantly poorer survival than one or no dysregulated marker (p = 0.016). This set independently predicted survival in a Cox regression model (HR 5.097; 95% CI 1.731-15.007; p = 0.003). We generated and validated an IHC prognostic set which could potentially identify patients who are likely to benefit from HIPEC using Mitomycin-C.

Metastatic gastric cancer: Does the site of metastasis make a difference?

BACKGROUND: Metastatic gastric cancer has a poor prognosis. We aim to study how clinical features and prognosis differs between different metastatic sites, and to identify prognostic factors for overall survival. METHODS: We retrospectively reviewed patients with metastatic gastric adenocarcinoma managed at a tertiary referral cancer center over a 5-year period. We divided our cohort into three groups based on the site(s) of metastasis at presentation-peritoneal metastasis only (P), distant metastasis only (D), and peritoneal and distant metastases (PD). RESULTS: We studied 470 patients with 175 (37.2%), 193 (41.1%) and 102 (21.7%) patients in the P, D and PD groups, respectively. Patients with peritoneal disease (both P and PD) had higher proportions of patients experiencing chemotherapy disruption due to unplanned hospitalizations, which were also of a longer average duration. The P group had the longest overall median survival of 8.9 months compared to the PD and D groups with 7.4 and 5.5 months, respectively (P < 0.001). On multivariate Cox regression analysis, the presence of ≥1 metastatic site (hazard ratio [HR] 1.67; 95% confidence interval [CI], 1.23-2.28; P  =  0.001) was significantly associated with increased overall mortality, whereas palliative systemic chemotherapy (HR 0.29; 95% CI, 0.22-0.37; P < 0.001) and palliative gastrectomy (HR 0.24; 95% CI, 0.15-0.39; P < 0.001) were significantly associated with decreased overall mortality. CONCLUSION: Metastatic gastric cancer represents a heterogeneous disease, with specific disease complications and treatment outcomes unique to different metastatic sites. We can consider novel multimodality therapies for patient subgroups with isolated metastatic disease and good prognostic factors in a bid to improve long-term survival.

Frailty and functional decline after emergency abdominal surgery in the elderly: a prospective cohort study.

Background: Frailty has been associated with an increased risk of adverse postoperative outcomes in elderly patients. We examined the impact of preoperative frailty on loss of functional independence following emergency abdominal surgery in the elderly. Methods: This prospective cohort study was performed at a tertiary hospital, enrolling patients 65 years of age and above who underwent emergency abdominal surgery from June 2016 to February 2018. Premorbid variables, perioperative characteristics and outcomes were collected. Two frailty measures were compared in this study-the Modified Fried's Frailty Criteria (mFFC) and Modified Frailty Index-11 (mFI-11). Patients were followed-up for 1 year. Results: A total of 109 patients were prospectively recruited. At baseline, 101 (92.7%) were functionally independent, of whom seven (6.9%) had loss of independence at 1 year; 28 (25.7%) and 81 (74.3%) patients were frail and non-frail (by mFFC) respectively. On univariate analysis, age, Charlson Comorbidity Index and frailty (mFFC) (univariate OR 13.00, 95% CI 2.21-76.63, p < 0.01) were significantly associated with loss of functional independence at 1 year. However, frailty, as assessed by mFI-11, showed a weaker correlation than mFFC (univariate OR 4.42, 95% CI 0.84-23.12, p = 0.06). On multivariable analysis, only premorbid frailty (by mFFC) remained statistically significant (OR 15.63, 95% CI 2.12-111.11, p < 0.01). Conclusions: The mFFC is useful for frailty screening amongst elderly patients undergoing emergency abdominal surgery and is a predictor for loss of functional independence at 1 year. Including the risk of loss of functional independence in perioperative discussions with patients and caregivers is important for patient-centric emergency surgical care. Early recognition of this at-risk group could help with discharge planning and priority for post-discharge support should be considered.

Disseminated peritoneal leiomyomatosis: a devastating sequelae of unconfined laparoscopic morcellation.

There has been growing concern surrounding the use of unconfined power morcellation in laparoscopic surgeries for uterine leiomyoma due to its associated risks and long-term clinical sequelae, including parasitic leiomyomas and disseminated peritoneal leiomyomatosis (DPL). We present a case of DPL resulting from previous laparoscopic morcellation and a review of the existing literature. DPL is a potentially devastating consequence of unconfined laparoscopic morcellation in the surgical management of uterine fibroids. A multidisciplinary approach is recommended in the management of DPL, especially in cases of multivisceral involvement. Clinical caution ought to be exercised when using power morcellators; when unavoidable, confined laparoscopic morcellation offers a promising mitigation and should be adopted if practicable.