Laparoscopic subtotal cholecystectomy outcomes across a low-and middle-income country metropolitan health service.

BACKGROUND: Laparoscopic subtotal cholecystectomy (LSC) is a safe alternative for difficult cholecystectomies to prevent bile duct injury and open conversion. The primary aim was to detail the use and outcomes on LSCs. METHODS: Retrospective analysis of a prospectively maintained database of laparoscopic cholecystectomy (LC). Relative clinical factors, outcomes, and 30-day follow-up between LSC and LC were compared using univariate and multivariate analyses. RESULTS: Six hundred and twenty four cholecystectomies were performed and 53 (8.5%) required LSC. 81.8% were fenestrating LSC. Male sex was significantly overrepresented in the LSC group (p < 0.01) and patients requiring LSC were significantly older (p < 0.01). Same admission cholecystectomy was associated with a higher risk of LSC (p < 0.01). Patients with a history of previous surgery, preoperative ERCP, or percutaneous cholecystostomy had an increased risk of undergoing LSC (p < 0.01). A necrotic gallbladder was the most significant predictor of the need for a LSC (p < 0.001). A contracted gallbladder, extensive adhesions, gallbladder empyema, and severe inflammation were significant predictors of difficulty (all p < 0.01). Postoperative complications occurred in 26.4% of LSC patients. There were ten (18.9%) Clavien-Dindo Grade III complications, 5.7% required ERCPs, and 9.4% required relook laparotomies. Significantly, more patients in the LSC group developed bile leaks (n = 8, 15%) (p < 0.001). There were two readmissions within 30 days, one mortality, and no BDIs occurred in the LSC cohort. CONCLUSION: LSC provides a feasible surgical option that should be utilized in complex cholecystitis.

Indications and Outcomes for Non-Trauma Emergency Laparotomy: A Comparison of Rwanda, South Africa, and the USA.

BACKGROUND: Emergency conditions requiring exploratory laparotomy (EL) can be challenging. The objective of this study is to describe indications, outcomes, and risk factors for perioperative mortality (POMR) after non-trauma EL. METHODS: This was a prospective study of patients undergoing non-trauma EL at four hospitals in Rwanda, South Africa, and the USA. Multivariate logistic regression was used to determine factors associated with POMR. RESULTS: Over one year, there were 632 EL with the most common indications appendicitis (n = 133, 21%), peptic ulcer disease (PUD) (n = 101, 16%), and hernia (n = 74, 12%). In Rwanda, the most common indications were appendicitis (n = 41, 19%) and hernia (n = 37, 17%); in South Africa appendicitis (n = 91, 28%) and PUD (n = 60, 19%); and in the USA, PUD (n = 16, 19%) and adhesions from small bowel obstruction (n = 16, 19%). POMR was 11%, with no difference between countries (Rwanda 7%, South Africa 12%, US 16%, p = 0.173). Risk factors associated with increased odds of POMR included typhoid intestinal perforation (adjusted odds ratio (aOR): 16.48; 95% confidence interval (CI): 4.31, 62.98; p value < 0.001), mesenteric ischemia (aOR: 13.77, 95% CI: 4.21, 45.08, p value < 0.001), cancer (aOR: 5.84, 95% CI: 2.43, 14.05, p value < 0.001), other diagnoses (aOR: 3.97, 95% CI: 3.03, 5.20, p value < 0.001), high ASA score (score ≥ 3) (aOR: 3.95, 95% CI: 3.03, 5.15, p value < 0.001), peptic ulcer disease (aOR: 2.82, 95% CI: 1.64, 4.85, p value < 0.001), age > 60 years (aOR: 2.32, 95% CI: 1.41, 3.83, p value = 0.001), and ICU admission (aOR: 2.23, 95% CI: 1.24, 3.99, p value = 0.007). Surgery in the US was associated with decreased odds of POMR (aOR: 0.41, 95% CI: 0.21, 0.80, p value = 0.009). CONCLUSIONS: Indications for EL vary between countries and POMR is high. Differences in mortality were associated with patient and disease characteristics with certain diagnoses associated with increased risk of mortality. Understanding the risk factors and outcomes for patients with EL can assist providers in judicious patient selection, both for patient counselling and resource allocation.

Percutaneous Cholecystostomy Placement in Cases of Non-operative Cholecystitis: A Retrospective Cohort Analysis.

BACKGROUND: Acute (calculous) cholecystitis (AC) is an extremely common surgical presentation, managed by cholecystectomy. Percutaneous cholecystostomy (PC) is an alternative; however, its safety and efficacy, along with subsequent cholecystectomy, are underreported in South Africa, where patients often present late and access to emergency operating theatre is constrained. The aim of the study was to demonstrate the outcomes of PC in patients with AC not responding to antimicrobials. MATERIALS AND METHODS: A retrospective cohort review of patient records, who underwent PC in Groote Schuur Hospital, Cape Town, between May 2013 and July 2016, was performed. Patients with PC for malignancy or acalculous cholecystitis were excluded. Technical success, clinical response, procedure-related morbidity and mortality were recorded. Interval LC parameters were investigated. RESULTS: Technical success and clinical improvement was seen in 29 of 37 patients (78.38%) who had PC. Malposition (8.11%) was the most common complication. Two patients required emergency surgery (5.4%), while one tube was dislodged. Median tube placement duration was 25 days (range 1-211). Post-procedure, 16 patients (43.24%) went on to have LC, of which 50% (eight patients) required conversion to open surgery and 25% (four) had subtotal cholecystectomy. Median surgical time was 130 min. There were no procedure-related mortalities but eight patients (21.62%) died in the 90-day period following tube insertion. CONCLUSION: In patients with AC, PC is safe, with high technical success and low complication rate. Subsequent cholecystectomy should be performed, but is usually challenging. The requirement for PC may predict a more complex disease process.

The role of national population-based registries in pancreatic cancer surgery research.

Research and innovation are critical for advancing the multidisciplinary management of pancreatic cancer. Registry-based studies (RBSs) are a complement to randomized clinical trials (RCTs). Compared with RCTs, RBSs offer cost-effectiveness, larger sample sizes, and representation of real-world clinical practice. National population-based registries (NPBRs) aim to cover the entire national population, and studies based on NPBRs are, compared to non-NPBRs, less prone to selection bias. The last decade has witnessed a dramatic increase in NPBRs in pancreatic cancer surgery, which has undoubtedly added invaluable knowledge to the body of evidence on pancreatic cancer management. However, several methodological shortcomings may compromise the quality of registry-based studies. These include a lack of control over data collection and a lack of reporting on the quality of the source registry or database in terms of validation of coverage and data completeness and accuracy. Furthermore, there is a significant risk of double publication from the most commonly used registries as well as the inclusion of historical data that is not relevant or representative of research questions addressing current practices.

Novel CABIN score outperforms other prognostic models in predicting in-hospital mortality after salvage transjugular intrahepatic portosystemic shunting.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is now established as the salvage procedure of choice in patients who have uncontrolled or severe recurrent variceal bleeding despite optimal medical and endoscopic treatment. AIM: To analysis compared the performance of eight risk scores to predict in-hospital mortality after salvage TIPS (sTIPS) placement in patients with uncontrolled variceal bleeding after failed medical treatment and endoscopic intervention. METHODS: Baseline risk scores for the Acute Physiology and Chronic Health Evaluation (APACHE) II, Bonn TIPS early mortality (BOTEM), Child-Pugh, Emory, FIPS, model for end-stage liver disease (MELD), MELD-Na, and a novel 5 category CABIN score incorporating Creatinine, Albumin, Bilirubin, INR and Na, were calculated before sTIPS. Concordance (C) statistics for predictive accuracy of in-hospital mortality of the eight scores were compared using area under the receiver operating characteristic curve (AUROC) analysis. RESULTS: Thirty-four patients (29 men, 5 women), median age 52 years (range 31-80) received sTIPS for uncontrolled (11) or refractory (23) bleeding between August 1991 and November 2020. Salvage TIPS controlled bleeding in 32 (94%) patients with recurrence in one. Ten (29%) patients died in hospital. All scoring systems had a significant association with in-hospital mortality (P < 0.05) on multivariate analysis. Based on in-hospital survival AUROC, the CABIN (0.967), APACHE II (0.948) and Emory (0.942) scores had the best capability predicting mortality compared to FIPS (0.892), BOTEM (0.877), MELD Na (0.865), Child-Pugh (0.802) and MELD (0.792). CONCLUSION: The novel CABIN score had the best prediction capability with statistical superiority over seven other risk scores. Despite sTIPS, hospital mortality remains high and can be predicted by CABIN category B or C or CABIN scores > 10. Survival was 100% in CABIN A patients while mortality was 75% for CABIN B, 87.5% for CABIN C, and 83% for CABIN scores > 10.

Surgical Trainee Supervision During Non-Trauma Emergency Laparotomy in Rwanda and South Africa.

OBJECTIVE: The primary objective was to describe the level of surgical trainee autonomy during non-trauma emergency laparotomy (NTEL) operations in Rwanda and South Africa. The secondary objective was to identify potential associations between trainee autonomy, and patient mortality and reoperation. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective, observational study of NTEL operations at 3 teaching hospitals in South Africa and Rwanda over a 1-year period from September 1, 2017 to August 31, 2018. The study included 543 NTEL operations performed by the acute care and general surgery services on adults over the age of 18 years. RESULTS: Surgical trainees led 3-quarters of NTEL operations and, of these, 72% were performed autonomously in Rwanda and South Africa. Notably, trainee autonomy was not significantly associated with reoperation or mortality. CONCLUSIONS: Trainees were able to gain autonomous surgical experience without impacting mortality or reoperation outcomes, while still providing surgical support in a high-demand setting.

Logistical factors associated with adverse outcomes following emergency surgery in an acute care surgical unit.

PURPOSE: The Acute Care Surgical Unit at Groote Schuur Hospital was established in 2010 and is the first of its kind in Africa. The aim of this study was to describe the outcomes of emergency surgical cases, as well as determine the logistical factors associated with adverse outcomes following surgery within the unit. METHODS: This study was a retrospective audit which reviewed the folders of adult patients who underwent an emergency surgical procedure from July 2016 to July 2017. The primary outcome was a major adverse event (AE) which was defined by a Clavien-Dindo score of 3-5. A number of logistical factors related to patient admission and operation were evaluated for association with outcomes. RESULTS: A total of 271 patients were included with a mean age of 47 years, with 48% females and 52% males. A major AE was recorded for 13% of patients. The following factors were found to be predictive of a major AE: referral from outside the hospital, urgent booking colour code, reoperation, and consultant most senior surgeon present during procedure. Patient admission/surgery performed outside of normal working hours, being booked for surgery on admission, as well as delay to surgery beyond colour code were not associated with a major AE. CONCLUSION: Apart from the traditional clinical parameters, factors related to perioperative logistics may contribute to the risk of a major AE after emergency surgery and should be considered for inclusion in more comprehensive predictive models for adverse outcomes within an acute care surgery unit.

Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication.

BACKGROUND: Bleeding esophageal varices (BEV) is a potentially life-threatening complication in patients with portal hypertension with mortality rates as high as 25% within six weeks of the index variceal bleed. After control of the initial bleeding episode patients should enter a long-term surveillance program with endoscopic intervention combined with non-selective ß-blockers to prevent further bleeding and eradicate EV. AIM: To assess the efficacy of endoscopic variceal ligation (EVL) in controlling acute variceal bleeding, preventing variceal recurrence and rebleeding and achieving complete eradication of esophageal varices (EV) in patients who present with BEV. METHODS: A prospectively documented single-center database was used to retrospectively identify all patients with BEV who were treated with EVL between 2000 and 2018. Control of acute bleeding, variceal recurrence, rebleeding, eradication and survival were analyzed using Baveno assessment criteria. RESULTS: One hundred and forty patients (100 men, 40 women; mean age 50 years; range, 21-84 years; Child-Pugh grade A = 32; B = 48; C = 60) underwent 160 emergency and 298 elective EVL interventions during a total of 928 endoscopy sessions. One hundred and fourteen (81%) of the 140 patients had variceal bleeding that was effectively controlled during the index banding procedure and never bled again from EV, while 26 (19%) patients had complicated and refractory variceal bleeding. EVL controlled the acute sentinel variceal bleed during the first endoscopic intervention in 134 of 140 patients (95.7%). Six patients required balloon tamponade for control and 4 other patients rebled in hospital. Overall 5-d endoscopic failure to control variceal bleeding was 7.1% (n = 10) and four patients required a salvage transjugular intrahepatic portosystemic shunt. Index admission mortality was 14.2% (n = 20). EV were completely eradicated in 50 of 111 patients (45%) who survived > 3 mo of whom 31 recurred and 3 rebled. Sixteen (13.3%) of 120 surviving patients subsequently had 21 EV rebleeding episodes and 10 patients bled from other sources after discharge from hospital. Overall rebleeding from all sources after 2 years was 21.7% (n = 26). Sixty-nine (49.3%) of the 140 patients died, mainly due to liver failure (n = 46) during follow-up. Cumulative survival for the 140 patients was 71.4% at 1 year, 65% at 3 years, 60% at 5 years and 52.1% at 10 years. CONCLUSION: EVL was highly effective in controlling the sentinel variceal bleed with an overall 5-day failure to control bleeding of 7.1%. Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV, of whom 62% recurred, there was a significant reduction in subsequent rebleeding.

Mind the gap! Extraluminal percutaneous-endoscopic rendezvous with a self-expanding metal stent for restoring continuity in major bile duct injury: A case series.

INTRODUCTION: Treatment of major iatrogenic and non-iatrogenic bile duct injury (BDI) often requires delayed surgery with interim external biliary drainage. Percutaneous transhepatic cholangiography (PTC) with biliary catheter placement and endoscopic retrograde cholangiography (ERC) with stent placement have been used to bridge defects. In some patients, bridging the defect cannot be achieved through ERC or PTC alone. MATERIALS AND METHODS: Two patients with major BDIs, one iatrogenic and one non-iatrogenic underwent an extraluminal PTC/ERC rendezvous with placement of a fully covered self-expandable metal stent (SEMS) for the acute management of BDI with substantial loss of bile duct length. RESULTS: In both patients the intraperitoneal PTC/ERC rendezvous with SEMS placement was successful with no complications after 12 and 18 months follow-up, respectively. DISCUSSION: This study is the first to report a standardized approach to the acute management of iatrogenic and non-iatrogenic major BDIs using extraluminal intraperitoneal PTC/ERC rendezvous with placement of a fully covered SEMS. The described technique may serve as a "bridge to surgery" strategy for patients where definitive management of BDIs are deferred. However, long-term data of the success of this technique, specifically the use of a SEMS to bridge the defect, are lacking and further investigation is required to determine its role as a definitive treatment of BDIs with substance loss. CONCLUSION: PTC/ERC rendezvous with restoration of biliary continuity and internalization of bile flow is particularly useful for patients who have previously failed ERC and/or PTC alone, and in whom immediate surgical repair is not an option.