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 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.

Sequential organ failure assessment score is superior to other prognostic indices in acute pancreatitis.

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.

Trans-arterial chemoembolization + radiofrequency ablation versus surgical resection in hepatocellular carcinoma - A meta-analysis.

BACKGROUND: Hepatocellular Carcinoma (HCC) remains the third most common cause of cancer death worldwide, with countries in Asia being affected the most. The mainstay of curative therapy for early HCC is radiofrequency ablation (RFA) or surgery; either surgical resection (SR) or liver transplantation. Latest evidence however suggests that combination of TACE+ RFA may provide outcomes comparable to SR. AIM: To compare oncologic outcomes and safety profile of TACE + RFA to SR alone in HCC. MATERIALS AND METHODS: A systematic review was conducted through Pubmed, EMBASE and Cochrane Library for literature published before April 2019. Outcomes measured were disease-free survival(DFS), overall survival(OS) and major complications. DFS was further divided into local tumour progression(LTP), intrahepatic distant recurrence(IDR) and distant metastasis(DM). RESULTS: Eight retrospective studies and one randomized controlled trial, involving 1892 patients met eligibility criteria and were included. Unadjusted pooled analysis demonstrated no significant difference in 1-year, 3-year and 5-year OS and 1-year DFS between TACE+RFA and SR. SR had superior 3-year DFS (OR 0.78, 95% CI 0.62-0.98, p = 0.03) and 5-year DFS (OR 0.74, 95% CI 0.58-0.95, p = 0.02) compared to TACE+RFA. When analysing only the propensity matched data, the difference in 3-year DFS and 5-year DFS was not significant. TACE+RFA had a higher LTP rate (OR 2.48, 95% CI 1.05-5.86, p = 0.04) compared to SR but IDR and DM rates were not significant. DISCUSSION AND CONCLUSION: TACE+RFA offer comparable oncologic outcomes in patients with HCC as compared with SR and with added benefit of lower morbidity.