The modified frailty index-11 predicts medium-term outcomes after endovascular revascularisation for chronic limb threatening ischaemia in Asian patients.

OBJECTIVE: The aim was to evaluate the utility of frailty, as defined by the modified Frailty Index-1 1 (mFI-11) on predicting outcomes following endovascular revascularisation in Asian patients with chronic limb-threatening ischaemia (CLTI). METHODS: CLTI patients who underwent endovascular revascularisation between January 2015 and March 2017 were included. Patients were retrospectively scored using the mFI-11 to categorise frailty as low, medium or high risk. Observed outcomes included 30-day complication rate and unplanned readmissions, 1-, 6- and 12-month mortality, and ambulation status at 6- and 12 months post-intervention. RESULTS: A total of 233 patients (250 procedures) were included; 137 (58.8%) were males and the mean age was 69.0 (±10.7) years. 202/233 (86.7%) were diabetic and 196/233 (84.1%) had a prior diagnosis of peripheral arterial disease (PAD). The mean mFI-11 score was 4.2 (±1.5). 28/233 (12.0%), 155/233 (66.5%), and 50/233 (21.5%) patients were deemed low (mF-11 score 0-2), moderate (mFI-11 score 3-5) and high (mFI-11 score 5-7) frailty risk, respectively. High frailty was associated with an increased 12-month mortality (OR 8.54, 95% CI 1.05-69.5; p = 0.05), 30-day complication rate (OR 9.41, 95% CI 2.01-44.1; p < 0.01) and 30-day unplanned readmission (OR 5.06, 95% CI 1.06-24.2; p = 0.04). Furthermore, a high score was associated with a significantly worse 6- (OR 0.320, 95% CI 0.120-0.840; p = 0.02) and 12-month (OR 0.270, 95% CI 0.100-0.710; p < 0.01) ambulatory status. CONCLUSION: The mFI-11 is a useful, non-invasive tool that can be readily calculated using readily available patient data, for prediction of medium-term outcomes for Asian CLTI patients following endovascular revascularisation. Early recognition of short- and mid-term loss of ambulation status amongst high-frailty patients in this challenging cohort of patients could aid decision-making for whether a revascularisation or amputation-first policy is appropriate, and manage patient and caregiver expectations on potential improvement in functional outcome.

The Modified Frailty Index Does Not Predict Mortality After Major Lower Extremity Amputation for Peripheral Arterial Disease in an Asian Population.

BACKGROUND: Patients with critical limb ischemia (CLI) who undergo major lower extremity amputation (LEA) have been associated with high one-year mortality rates. Previous western-based studies have identified risk factors that exponentiate these poor outcomes, including nonambulatory status and cardiovascular morbidity. We assessed the effect of frailty, using the modified frailty index (mFI) in a cohort undergoing major LEA for CLI to predict mortality, perioperative complications, and unplanned readmissions in a tertiary institution from Singapore. METHODS: Data on patients who had undergone major LEA from January 2016 to December 2017 were collected retrospectively. Inclusion criteria were below-knee amputations (BKAs) or above-knee amputations (AKAs) performed for peripheral arterial disease-related tissue loss or sepsis only. Patients were categorized into 3 risk groups based on the 11-variable mFI: low mFI, 0-0.27; moderate mFI, 0.36-0.54; and high mFI ≥0.63. Univariate and multivariate analysis was performed using logistic regression analysis. RESULTS: 211 patients underwent major LEA, of whom 133 (63.0%) had undergone BKA. The mean mFI was 0.41 (range 0-0.81). 84/211 (39.8%) died within 1 year after the procedure, with mortality rates of 25/65 (38.4%), 49/127 (38.6%), and 10/19 (52.6%) in the low-, moderate-, high-mFI categories, respectively. High and moderate mFI had failed to demonstrate an increased risk of mortality when compared with the low-mFI group (P > 0.05). 91/211 (43.1%) patients had perioperative complications, whereas 27/211 (12.8%) patients were readmitted within 30 days of discharge. Myocardial infarction, chronic kidney disease, and atrial fibrillation were found to be predictive of poor outcomes after major LEA. CONCLUSIONS: Frailty as measured with the mFI did not predict outcome after major LEA. This could be due to confounding effects such as high prevalence of renal dysfunction and the constancy of diabetes and peripheral vascular disease in this population that would reduce the differentiation of patients using the mFI.

Somatostatin analogues and the risk of post-operative pancreatic fistulas after pancreatic resection - A systematic review & meta-analysis.

BACKGROUND: Post-operative pancreatic fistula (POPF) is a common complication of pancreatic resection. Somatostatin analogues (SA) have been used as prophylaxis to reduce its incidence. The aim of this study is to appraise the current literature on the effects of SA prophylaxis on the prevention of POPF following pancreatic resection. METHODS: The review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data from studies that reported the effects of SA prophylaxis on POPF following pancreatic resection were extracted, to determine the effect of SA on POPF morbidity and mortality. RESULTS: A total of 15 studies, involving 2221 patients, were included. Meta-analysis revealed significant reductions in overall POPF (Odds ratio: 0.65 (95% CI 0.53-0.81, p < 0.01)), clinically significant POPF (Odds ratio: 0.53 (95% CI 0.34-0.83, p < 0.01)) and overall morbidity (OR: 0.69 (95% CI: 0.50-0.95, p = 0.02)) following SA prophylaxis. There is no evidence that SA prophylaxis reduces mortality (OR: 1.10 (95%CI: 0.68-1.79, p = 0.68)). CONCLUSION: SA prophylaxis following pancreatic resection reduces the incidence of POPF. However, mortality is unaffected.

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.

Catheter-directed foam sclerotherapy, an alternative to ultrasound-guided foam sclerotherapy for varicose vein treatment: A systematic review and meta-analysis.

PURPOSE: Catheter-directed foam sclerotherapy is a new addition to the treatment modalities available for varicose veins. As a modification of ultrasound-guided foam sclerotherapy, catheter-directed foam sclerotherapy has been purported to offer higher complete ablation rates and an improved safety profile. The aim of this study is to appraise the current literature on the outcomes of catheter-directed foam sclerotherapy compared to ultrasound-guided foam sclerotherapy in chronic venous insufficiency. METHODS: The review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data from studies that reported the outcomes of catheter-directed foam sclerotherapy and ultrasound-guided foam sclerotherapy were extracted, to determine the pooled proportion of complete ablation rates, using a random effect meta-analysis model. RESULTS: A total of 62 studies, involving 3689 patients, were included in the systematic review. Higher rates of complete ablation were reported in catheter-directed foam sclerotherapy compared to ultrasound-guided foam sclerotherapy during the short- and medium-term follow-ups (Relative Risk = 1.06, Relative Risk = 1.15, Relative Risk = 1.19, p < 0.05). Fewer major and minor complications were also reported in patients who underwent catheter-directed foam sclerotherapy (Relative Risk = 0.23, Relative Risk= 0.43-0.76, p < 0.05). CONCLUSION: Catheter-directed foam sclerotherapy has been demonstrated to have many advantages over ultrasound-guided foam sclerotherapy, offering superior complete ablation rates in the short-, medium- and long-term follow-ups. It also has a better safety profile, conferring a lower risk of major and minor complications. The conclusions should however be viewed in the context of significant limitations imposed by limited study data.

Risk factors for distal stent graft-induced new entry in type B aortic dissections: Systematic review and meta-analysis.

BACKGROUND: After the use of thoracic endovascular aortic repair in the management of type B aortic dissection (TBAD), there has been increasing recognition of the phenomenon of stent graft-induced new entry (SINE) as a late complication of thoracic endovascular aortic repair, with risk factors for SINE identified. We performed a meta-analysis of contemporary studies to establish the risk factors for distal SINE (dSINE). METHODS: A systematic search of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to investigate the risk factors for dSINE. Data from population-cohort and case-control studies were extracted to compute a conventional meta-analysis by combining the odds ratio using the generic inverse variance function on RevMan 5.3. Furthermore, a meta-analysis of proportions using the Freeman-Tukey double arcsine transformation was performed to compare the incidence of acute and chronic TBAD. RESULTS: Seventeen studies assessing the data of 3962 patients met the eligibility requirements and were included in the review. The pooled proportion of dSINE in TBAD cases treated with thoracic endovascular aortic repair is 10.1%. The relative risk of incidence of dSINE in chronic TBAD compared to acute TBAD is 3.12. The chronicity of TBAD and excessive distal oversizing ratio was demonstrated to be positively associated with dSINE with odds ratios of 2.25 and 2.06, respectively. Stent grafts with connecting bars were also positively associated with dSINE, but this lacked statistical significance. CONCLUSIONS: This meta-analysis demonstrated that chronic TBAD and an excessive distal oversizing ratio are both positively and independently associated with the incidence of dSINE tears in TBAD. This should be taken into consideration when planning interventions in these patient cohorts.

Ectopic retained gallstone causing an abdominal wall abscess.

A 67-year-old lady was managed with percutaneous cholecystostomy for severe acute cholecystitis with septic shock. An interval laparoscopic subtotal cholecystectomy was done at 8 weeks. Her post-operative phase was complicated by intra-abdominal abscess requiring radiologically guided percutaneous drain insertion. Five days following the removal of the drain, she presented with a right abdominal wall abscess. A computerized tomography scan showed an abdominal wall ectopically-retained gallstone. The gallstone was retrieved along with drainage of abscess.

The association between diabetes and thoracic aortic aneurysms.

OBJECTIVE: The negative correlation between diabetes mellitus (DM) and abdominal aortic aneurysms (AAAs) is well described. The etiologic similarities and differences between AAAs and thoracic aortic aneurysms (TAAs) have also been documented. We aimed to evaluate the relationship between DM and TAA by performing a meta-analysis of contemporary clinical studies. METHODS: A systematic search of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to investigate the relationship of DM and TAA. Data from population cohort and case-control studies were extracted and computed together to determine a pooled unadjusted odds ratio (OR) with corresponding 95% confidence intervals (CIs) using random-effects meta-analysis. RESULTS: Five population cohort studies and five case-control studies involving 1,006,360 patients met eligibility requirement and were included. Unadjusted pooled analysis of all 10 studies demonstrated an inverse association of DM with TAA (OR, 0.77; 95% CI, 0.61-0.98). Primary analysis of the five cohort studies demonstrated a statistically significant negative association between DM and TAA (OR, 0.70; 95% CI, 0.59-0.84). However, primary analysis of the five case-control studies demonstrated a negative association between DM and TAA (OR, 0.86; 95% CI, 0.50-1.47) with no statistical significance. CONCLUSIONS: This meta-analysis demonstrated a statistically significant inverse association between DM and TAA, similar to that of AAA. Further research is required into the potentially protective mechanisms that DM may confer and whether there is biologic plausibility to exploit these mechanisms further to prevent aneurysm expansion and rupture.

Endovascular treatment of cephalic arch stenosis in brachiocephalic arteriovenous fistulas: A systematic review and meta-analysis.

PURPOSE: The aim of this study is to appraise the current literature on the endovascular management options and their outcomes of cephalic arch stenosis in the setting of a failing brachiocephalic fistula for hemodialysis. METHODS: A systematic search of the literature was performed using PubMed, Embase, and Google Scholar from January 2000 to December 2017 in accordance with the PRISMA guidelines to investigate the outcomes of endovascular management of cephalic arch stenosis. Data from randomized controlled trials and observational studies, published in the English language, were extracted to determine pooled proportion of primary and secondary patency, using a random-effects meta-analysis. Subgroup analyses of stent grafts, bare metal stents, and percutaneous transluminal angioplasty outcomes were performed. RESULTS: Of the 125 total studies, 11 were included for analysis by consensus. Overall, 457 patients were reviewed and analyzed for primary and secondary patency rates at 6 and 12 months post-treatment. There was significantly higher primary patency at both 6 and 12 months in the stent graft group compared to those who received bare metal stents or percutaneous transluminal angioplasty (relative risk = 0.30-0.31, relative risk = 0.34-0.59, respectively; p < 0.01). Higher secondary patency rates were noted in the bare metal stents cohort compared to the percutaneous transluminal angioplasty cohort at 12 months (relative risk = 0.17, 95% confidence interval = 0.07-0.26; p < 0.01). CONCLUSION: This study demonstrated a significant benefit in using stent grafts in cephalic arch stenosis compared to bare metal stents or percutaneous transluminal angioplasty with higher primary and secondary patency rates.

Severe ischemic cytomegalovirus proctocolitis with multiple perforation.

Cytomegalovirus (CMV) typically causes gastrointestinal infections in immunocompetent patients. Colonic perforations secondary to CMV are exceeding rare. We describe a 88-year-old male presenting with a week-long history of intractable abdominal discomfort, bloating, nausea and diarrhea. Flexible sigmoidoscopy revealed significant ulceration with yellowish slough. Emergency surgery was performed subsequently in view of multiple perforations in the rectosigmoid junction. CMV gastrointestinal infections demonstrated an ischemic process secondary to vasculitis, which accelerated the pathway to colonic perforation. CMV gastrointestinal infection should be considered as a differential diagnosis in patients with colonoscopy findings similar to ischemic colitis and Clostridium difficile infections.