Postoperative Outcomes After Gastrointestinal Surgery in Patients Receiving Chronic Kidney Replacement Therapy: A Population-based Cohort Study.

OBJECTIVE: This study evaluated the postoperative mortality and morbidity outcomes following the different subtypes of gastrointestinal (GI) surgery over a 15-year period. BACKGROUND: Patients receiving chronic kidney replacement therapy (KRT) experience higher rates of general surgery compared with other surgery types. Contemporary data on the types of surgeries and their outcomes are lacking. KRT was defined as patients requiring chronic dialysis (hemodialysis or peritoneal dilaysis) or having a functioning kidney transplant long-term. METHODS: All incident and prevalent patients aged greater than 18 years identified in the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry as receiving chronic KRT were linked with jurisdictional hospital admission datasets between January 1, 2000 until December 31, 2015. Patients were categorized by their KRT modality [hemodialysis (HD), peritoneal dialysis (PD), home hemodialysis (HHD), and kidney transplant (KT)]. GI surgeries were categorized as upper gastrointestinal (UGI), bowel (small and large bowel), anorectal, hernia surgery, cholecystectomy, and appendicectomy. The primary outcome was the rates of the different surgeries, estimated using Poisson models. Secondary outcomes were risks of 30-day/in-hospital postoperative mortality risk and nonfatal outcomes and were estimated using logistic regression. Independent predictors of 30-day mortality were examined using comorbidity-adjusted Cox models. RESULTS: Overall, 46,779 patients on chronic KRT were linked to jurisdictional hospital datasets, and 9,116 patients were identified as having undergone 14,540 GI surgeries with a combined follow-up of 76,593 years. Patients on PD had the highest rates of GI surgery (8 per 100 patient years), with hernia surgery being the most frequent. Patients on PD also had the highest risk of 30-day postoperative mortality following the different types of GI surgery, with the risk being more than 2-fold higher after emergency surgery compared with elective procedures. Infective postoperative complications were more common than cardiac complications. This study also observed a U-shaped association between body mass index (BMI) and mortality, with a nadir in the 30 to 35 kg/m 2 group. CONCLUSIONS: Patients on chronic KRT have high rates of GI surgery and morbidity, particularly in those who receive PD, are older, or are either underweight or moderately obese.

Immune checkpoint inhibitors in HCC: Cellular, molecular and systemic data.

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer related deaths in the world, and for patients with advanced disease there are few therapeutic options available. The complex immunological microenvironment of HCC and the success of immunotherapy in several types of tumours, has raised the prospect of potential benefit for immune based therapies, such as immune checkpoint inhibitors (ICIs), in HCC. This has led to significant breakthrough research, numerous clinical trials and the rapid approval of multiple systemic drugs for HCC by regulatory bodies worldwide. Although some patients responded well to ICIs, many have failed to achieve significant benefit, while others showed unexpected and paradoxical deterioration. The aim of this review is to discuss the pathophysiology of HCC, the tumour microenvironment, key clinical trials evaluating ICIs in HCC, various resistance mechanisms to ICIs, and possible ways to overcome these impediments to improve patient outcomes.

Paediatric pancreatic trauma in North Queensland: a 10-year retrospective review.

PURPOSE: To establish the incidence of pancreatic trauma in North Queensland to the region's only tertiary paediatric referral centre, and to determine the patient's outcomes based on their management. METHODS: A single centre, retrospective cohort study of patients < 18 years with pancreatic trauma from 2009 to 2020 was performed. There were no exclusion criteria. RESULTS: Between 2009 and 2020 there were 145 intra-abdominal trauma cases, 37% from motor vehicle accidents (MVA), 18.6% motorbike or quadbike, and 12.4% bicycle or scooter accidents. There were 19 cases of pancreatic trauma (13%), all from blunt trauma and with associated injuries. There were 5 AAST grade I, 3 grade II, 3 grade III, 3 grade IV injuries, and 4 with traumatic pancreatitis. Twelve patients were managed conservatively, 2 were managed operatively for another reason, and 5 were managed operatively for the pancreatic injury. Only 1 patient with a high grade AAST injury was successfully managed non-operatively. Complications included pancreatic pseudocyst (n = 4/19; 3 post-op), pancreatitis (n = 2/19; 1 post op), and post-operative pancreatic fistula (POPF) (n = 1/19). CONCLUSION: Due to North Queensland's geography, diagnosis and management of traumatic pancreatic injury is often delayed. Pancreatic injuries requiring surgery are at high risk for complications, prolonged length of stay, and further interventions.

Isolated abdominal wall recurrence of pancreatic ductal adenocarcinoma: a rare case report.

A 76-year-old woman was investigated for epigastric pain on a background of a laparoscopic distal pancreatectomy and splenectomy for pancreatic ductal adenocarcinoma 4 years prior. Imaging revealed an isolated 32 mm fluorodeoxyglucose avid lesion contacting both the anterior abdominal wall and greater curvature of the stomach. Immunohistochemistry and fine needle biopsy confirmed a phenotype consistent with metastatic pancreatic adenocarcinoma. Laparoscopic excision of the mass and partial gastrectomy for clearance of margins was performed. Histopathology demonstrated a poorly differentiated pancreatic ductal adenocarcinoma, and the patient received adjuvant gemcitabine/capecitabine following an uncomplicated postoperative course. This article presents a rare case of isolated abdominal wall recurrence of pancreatic ductal adenocarcinoma, which was successfully treated with surgical resection and adjuvant chemotherapy.

Emergency Gastrectomy for Oesophageal and Gastric Polyps With Massive Bleeding Induced by Anticoagulation.

We report the management dilemma of a patient with known gastric polyposis requiring anticoagulation for a submassive pulmonary embolism and haemodynamic compromise. This occurred in a comorbid patient with iron deficiency anaemia and previous venous thromboembolism. The patient had repeated episodes of gastrointestinal bleeding post-thrombolysis for which the cause was not seen on gastroscopy and required an emergency gastrectomy to control the bleeding. A keyword search was done across Scopus, PubMed, MEDLINE, and Embase; in the case of gastric polyposis causing significant bleeding, current practice is to identify and treat such cases with endoscopy. This case report delineates the first case in literature of haemorrhagic bleeding in gastric polyposis secondary to therapeutic anticoagulation which has gone on to require definitive surgical management.

Post-cholecystectomy clip migration-a unique method of retrieval.

Post-cholecystectomy clip migration with formation of bile duct stones is a known but rare complication of laparoscopic cholecystectomy. This report discusses the case of a 64-year-old lady who presented with biliary colic symptoms 12 years post laparoscopic cholecystectomy. Computed tomography of the abdomen demonstrated one surgical clip located in the distal common bile duct, with a bile stone formed around it. This was removed via ERCP with spyglass cholangioscopy and lithotripsy.

Do we need to change empiric antibiotic use following natural disasters? A reflection on the Townsville flood.

INTRODUCTION: Skin and soft tissue infections have the potential to affect every patient admitted to a surgical service. Changes to the microbiota colonizing wounds during natural disasters, such as the Townsville floods of 2019, could impact empiric antibiotic choice and need for return to theatre. METHODS: This retrospective observational cohort study reviews culture data and demographics for patients undergoing surgical debridement of infected wounds over a six-month period starting in November 2018 to May 2019 at the Townsville Hospital. RESULTS: Of the 408 patients requiring operative intervention, only 61 patients met the inclusion criteria. The groups were comparative in terms of age and gender, but a greater proportion of patients (40.5% versus 29.1%, P = 0.368) in the post-flood group were diabetic. Common skin commensals, such as Staphylococcus aureus, were the most common pathogen in both groups, however the post-flood group had a higher proportion of atypical organisms (14 versus 8 patients), and an increased need for repeated debridement for infection control (24 versus 14 patients). CONCLUSION: Wound swabs and tissue culture are imperative during surgical debridement and may guide the use of more broad-spectrum coverage following a significant flooding event.

Impact of establishing a specialized hepatobiliary unit on liver resections in a non-specialized tertiary centre in regional Australia.

BACKGROUND: In April 2018, a dedicated hepatobiliary unit was established in a tertiary hospital in North Queensland. Changes included the employment of a hepatobiliary-trained surgeon, centralized referrals, and formalized multidisciplinary team meetings. This study aimed to evaluate the impact of establishing a hepatobiliary unit on outcomes after liver resection, in a regional centre where such procedures were previously performed by non-specialist general surgeons. METHODS: Adult patients who underwent elective liver resection in Townsville from 2013 to 2020 were included in the study. Outcomes after liver resection were collected across two study periods - before and after the hepatobiliary unit was established. The primary end points were a before and after comparison of the 90-day morbidity and mortality and the R1 margin rates. RESULTS: Across the two study periods, 76 and 77 patients, respectively, underwent liver resection. Rates of R1 resection, 90-day mortality and major complications were not significantly different between the two study periods. Primary tumours (14.5% before versus 50.6% after) and cirrhosis (1.3% before versus 14.3% after) were significantly higher in the latter period, as was the median length of stay (4 days before versus 6 days after). Annual surgical volume increased by 75% in the period after 2018 compared to the 5 years preceding it. CONCLUSION: Establishing a centralized hepatobiliary unit in a tertiary regional centre resulted in increased surgical volume and case complexity, with no change in early outcomes after liver resection. Overall, this dedicated unit improved the accessibility of a subspecialty surgical service in regional Australia.

Routine Computed Tomography Versus Selective Imaging: An Audit of Negative Appendicectomy Rates in Two Hospitals.

Introduction There are a variety of conflicting recommendations in the literature for pre-operative imaging in acute appendicitis. There is debate over what the ideal imaging protocol is to lower the negative appendicectomy rate (NAR) without increasing missed appendicitis. The aim of this study is to compare the audited NAR between two groups with different imaging approaches: (i) mandatory pre-operative computed tomography (CT) imaging and (ii) selective imaging with CT, ultrasound (US), or no imaging prior to appendicectomy. Materials and methods A retrospective chart audit was conducted of 400 patients who underwent an appendicectomy at two hospitals with different approaches to pre-operative imaging (hospital A and hospital B). The primary outcome measure was histologically confirmed appendicitis. It was also documented whether there was radiological (CT or US) evidence of appendicitis.  Results At hospital A, all 200 patients underwent CT imaging prior to appendicectomy. The total histologically confirmed NAR for this group was 9.5% (19/200). At hospital B, 97 (48.5%) patients underwent CT, 41 (25.5%) underwent US, 10 (5%) had both US and CT, and 52 (26%) had no imaging. The total NAR was 11.5% (23/200). Conclusion There was no statistically significant difference (p=0.62) in audited NARs when comparing clinician-guided selective imaging versus routine CT imaging for all patients undergoing appendicectomy.

Targeting the PI3K/Akt/mTOR Pathway in Hepatocellular Carcinoma.

Despite advances in the treatment of cancers through surgical procedures and new pharmaceuticals, the treatment of hepatocellular carcinoma (HCC) remains challenging as reflected by low survival rates. The PI3K/Akt/mTOR pathway is an important signaling mechanism that regulates the cell cycle, proliferation, apoptosis, and metabolism. Importantly, deregulation of the PI3K/Akt/mTOR pathway leading to activation is common in HCC and is hence the subject of intense investigation and the focus of current therapeutics. In this review article, we consider the role of this pathway in the pathogenesis of HCC, focusing on its downstream effectors such as glycogen synthase kinase-3 (GSK-3), cAMP-response element-binding protein (CREB), forkhead box O protein (FOXO), murine double minute 2 (MDM2), p53, and nuclear factor-κB (NF-κB), and the cellular processes of lipogenesis and autophagy. In addition, we provide an update on the current ongoing clinical development of agents targeting this pathway for HCC treatments.

Hepatic tuberculosis masquerading as cholangiocarcinoma: an unusual differential for a liver mass.

A 54-year-old woman presented with an incidentally identified asymptomatic liver lesion with imaging characteristics suspicious for malignancy. She underwent a left hemihepatectomy for presumed cholangiocarcinoma. Histopathology revealed granulomas with microbiological investigations later revealing a diagnosis of isolated hepatic tuberculosis. There were no pulmonary or other disease sites identified. The patient has been medically managed for primary hepatic tuberculosis and remains well postoperatively. This case identifies a rare differential for a liver mass that needs to be considered in the clinicians' workup.

Incidental finding of heterotopic supradiaphragmatic liver.

Here we describe a case of heterotopic, supradiaphragmatic liver in a 65-year-old woman who was referred for investigation of a soft tissue gallbladder mass. Contrast-enhanced magnetic resonance imaging revealed adenomyomatosis of the gallbladder and supradiaphragmatic accessory liver tissue. This is a remarkably rare normal variant.