Assessing the impact of frailty in elderly patients undergoing emergency laparotomies in Singapore.

Introduction: The global rise in ageing populations poses challenges for healthcare systems. By 2030, Singapore anticipates a quarter of its population to be aged 65 or older. This study addresses the dearth of research on frailty's impact on emergency laparotomy (EL) outcomes in this demographic, emphasising the growing significance of this surgical intervention. Method: Conducted at 2 tertiary centres in Singapore from January to December 2019, a retrospective cohort study examined EL outcomes in patients aged 65 or older. Frailty assessment, using the Clinical Frailty Scale (CFS), was integrated into demographic, diagnostic and procedural analyses. Patient data from Tan Tock Seng Hospital and Khoo Teck Puat Hospital provided a comprehensive view of frailty's role in EL. Results: Among 233 participants, 26% were frail, revealing a higher vulnerability in the geriatric population. Frail individuals exhibited elevated preoperative risk, prolonged ICU stays, and significantly higher 90-day mortality (21.3% versus 6.4%). The study illuminated a nuanced connection between frailty and adverse outcomes, underlining the critical need for robust predictive tools in this context. Conclusion: Frailty emerged as a pivotal factor influencing the postoperative trajectory of older adults undergoing EL in Singapore. The integration of frailty assessment, particularly when combined with established metrics like P-POSSUM, showcased enhanced predictive accuracy. This finding offers valuable insights for shared decision-making and acute surgical unit practices, emphasising the imperative of considering frailty in the management of older patients undergoing emergency laparotomy.

A meta-analysis of idiopathic granulomatous mastitis treatments for remission and recurrence prevention.

Purpose: The major aim of our meta-analysis was to review the effectiveness of various treatment modalities for achieving successful remission and preventing recurrence for women with idiopathic granulomatous mastitis (IGM). This knowledge is instrumental in developing evidence-based guidelines for clinicians to improve management strategies and outcomes for patients with IGM. Methods: A systematic literature search was performed on MEDLINE (Ovid), Embase (Elsevier), PubMed, Cochrane Library, Web of Science, and Google Scholar; studies published to 19 January 2022 were included. A meta-analysis of 57 observational studies was performed. The results of two randomized controlled trials were also examined. Results: There were 3,035 IGM patients across the observational and randomised studies. Overall recurrence and remission rates across all treatment strategies in 59 studies are 87.9% (2,667/3035) and 13.5% (359/2667), respectively. The studies reported 19 different treatment strategies, comprising observation, medical monotherapies, surgery, and combinations involving medical therapies, with and without surgery. Among monotherapy treatment, surgical management had the highest pooled remission rate (0.99 [95% confidence interval (CI) = 0.97-1.00]); among combination therapy, this was steroids and surgery (0.99 [0.94-1.00]). Antibiotic monotherapy had the lowest remission rate (0.72 [0.37-0.96]). The highest recurrence rates belonged to treatments that combined antibiotics and surgery (0.54 [0.02-1.00]), and antibiotics, steroids, and surgery (0.57 [0.00-1.00]). Most successful for preventing recurrence were observation (0.03 [0.00-0.10]), methotrexate (0.08 [0.00-0.24]), and steroids and surgery (0.05 [0.01-0.12]). There is a significant association between longer follow-up duration and recurrence rate reported, p = 0.002. Conclusion: Combination therapies, especially those incorporating antibiotics, steroids, and surgery, have demonstrated higher remission rates, challenging the use of antibiotic monotherapy. There is an increased emphasis on the need for personalised, multi-pronged approach for preventing IGM recurrence, with longer follow-up care. More prospective future work in IGM research, with standardised diagnostic criteria, treatment protocols, and reporting guidelines will be important for developing treatment protocols and guidelines clinicians can adhere to in the clinical management of IGM patients.Systematic review registration: PROSPERO (CRD42022301386).

Sustained improved emergency laparotomy outcomes over 3 years after a transdisciplinary perioperative care pathway-A 1:1 propensity score matched study.

BACKGROUND: Emergency laparotomy is associated with high morbidity and significant global health burden. This study aims to compare postoperative outcomes of patients who underwent emergency laparotomy before and after implementation of a emergency laparotomy pathway. METHODS: This is a single-center study of all patients who presented with an acute abdomen and/or conditions requiring emergency laparotomy during pre-emergency laparotomy pathway (retrospective cohort from January 2016 to December 2018) and after the emergency laparotomy pathway (prospective cohort from January 2019 to December 2021). Patients who underwent emergency laparotomy for trauma or vascular surgery were excluded. A 1:1 propensity score matching was performed to address for confounding factors. RESULTS: There were 888 patients (emergency laparotomy pathway, n = 428, and pre-emergency laparotomy pathway, n = 460) in the unmatched cohort. The mean age was 63.0 ± 15.4 years, and 43.8% had predicted mortality >10% using Portsmouth-Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity. The most common indication for emergency laparotomy was intestinal obstruction (30.5%). Overall incidence rates of major morbidity and 30-day mortality were 16.2% and 3.5%, respectively. There were 736 patients (n = 368 patients per arm) after propensity score matching. Demographic characteristics were comparable after propensity score matching. The emergency laparotomy pathway was associated with more patients assessed by geriatric medicine (odds ratio = 15.22; P < .001), reduced major morbidity (odds ratio = 0.63; P = .024), reduced intra-abdominal collection (odds ratio = 0.39; P = .006), and need for unplanned radiological and/or surgical intervention after index emergency laparotomy (odds ratio = 0.63; P = .024). Length of stay and 30-day mortality were comparable between the emergency laparotomy pathway and pre-emergency laparotomy pathway in both the unmatched and propensity score matched cohort. CONCLUSION: Sustained improved postoperative outcomes were achieved 3 years postimplementation of the emergency laparotomy pathway .

Oncologic outcomes after breast-conserving surgery with radiotherapy versus mastectomy in patients with Paget's disease of the breast: systematic review and meta-analysis.

BACKGROUND: The conventional approach to treatment for Paget's disease of the breast has been mastectomy, but there is an increasing trend to consider breast-conserving surgery (BCS) followed by radiotherapy (RT) in these patients. This study aimed to provide an updated systematic review and meta-analysis comparing outcomes after BCS with RT versus mastectomy in the treatment of Paget's disease of the breast. METHODS: Studies before May 2021 were included. Primary outcomes were overall survival and local recurrence. Separate analyses of Paget's disease associated with ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) were undertaken. Meta-regression was used to adjust for imbalance in the proportion of IDC among patients selected to undergo BCS versus mastectomy. RESULTS: Overall survival in patients with Paget's disease who underwent BCS with RT was higher than for those who underwent mastectomy with pooled mortality hazard ratio (HR) of 0.68, (95% per cent c.i. 0.45 to 1.01). Patients with Paget's disease with DCIS had higher overall survival after BCS with or without RT versus mastectomy, with adjusted HR of 0.14 (0.10 to 0.20) and 0.28 (0.22 to 0.36), respectively. For patients with Paget's disease and IDC, overall survival was lower for BCS with or without RT versus mastectomy, with adjusted HR of 0.84 (0.57 to 1.25) and 1.64 (1.04 to 2.58), respectively. In Paget's disease and IDC, local recurrence risk was much higher for BCS with RT, RR 26.8 (1.60 to 456) versus without RT, RR 51.8 (6.80 to 391). In patients with Paget's disease and DCIS, risk of local recurrence versus mastectomy was lower for BCS with RT 0.72 (0.11 to 4.50) but slightly higher for BCS alone 1.38 (0.09 to 21.20). CONCLUSION: BCS with RT may be a comparable treatment alternative to mastectomy for patients with Paget's disease with DCIS, and for selected patients with Paget's disease and IDC.

Use of preinjury antiplatelet and oral anticoagulant agents on outcomes following blunt trauma in an Asian population: a 1:2 propensity score matched study.

BACKGROUND: Bleeding is a feared complication of antiplatelets (APTs) and oral anti-coagulants (OACs) use. Asians are at higher risk of bleeding from APT/OAC compared to Western population. Our study aims to investigate the impact of preinjury APT/OAC use on outcomes of moderate to severe blunt trauma. METHODS: This is a retrospective cohort study from Jan 2017 - Dec 2019 of all patients with moderate to severe blunt trauma. A 1:2 propensity score matching (PSM) analysis was performed to address for confounding factors. Our primary outcome was in-hospital mortality. Our secondary outcomes were severity of head injury and need for emergency surgery within the first 24 hours. RESULTS: There were 592 patients (APT/OAC n=72, no APT/OAC n=520) included in our study. The median age was 74 years in APT/OAC and 58 years in no APT/OAC. PSM resulted in 150 patients (APT/OAC n=50, no APT/OAC n=100). In the PSM cohort, more patients with APT/OAC use had ischemic heart disease (76% vs 0%, P<0.001). APT/OAC use was independently associated with higher in-hospital mortality (22.0% vs 9.0%, Odds ratio (OR) 3.00, 95% Confidence interval (CI): 1.05, 8.56, P=0.040) Severity of head injury (abbreviated injury scale in APT/OAC: 3.33 ± 1.53, vs 2.97 ± 1.43, P=0.380) and need for emergency surgery (APT/OAC 16.2% vs 11.0%, P=0.434) was comparable between APT/OAC and no APT/OAC. CONCLUSIONS: Preinjury APT/OAC use was associated with higher in-hospital mortality. Severity of head injury and need for emergency surgery within 24 hours from admission were comparable between APT/OAC use and no APT/OAC use.

Elective incisional hernia repair: lower risk of postoperative wound infection with laparoscopic versus open repair.

Introduction: The superiority of laparoscopic repair over open repair of incisional hernias (IHs) in the elective setting is still controversial. Our study aimed to compare the postoperative outcomes of laparoscopic and open elective IH repair in an Asian population. Methods: This retrospective study was conducted in an acute general hospital in Singapore between 2010 and 2015. Inclusion criteria were IH repair in an elective setting, IHs with diameter of 3-15 cm, and location at the ventral abdominal wall. We excluded patients who underwent emergency repair, had recurrent hernias or had loss of abdominal wall domain (i.e. hernia sac containing more than 30% of abdominal contents or any solid organs). Postoperative outcomes within a year such as recurrence, pain, infection, haematoma and seroma formation were compared between the two groups. Results: There were 174 eligible patients. The majority were elderly Chinese women who were overweight. Open repair was performed in 49.4% of patients, while 50.6% underwent laparoscopic repair. The mean operation time for open repair was 116 minutes (116 ± 60.6 minutes) and 139 minutes (136 ± 64.1 minutes) for laparoscopic repair (P = 0.079). Within a year after open repair, postoperative wound infection occurred in 15.1% of the patients in the open repair group compared to 1.1% in the laparoscopic group (P = 0.0007). Postoperative pain, recurrence and haematoma/seroma formation were comparable. Conclusion: Elective laparoscopic IH repair has comparable outcomes with open repair and may offer the advantage of reduced postoperative wound infection rates.

Open versus laparoscopic intraperitoneal on-lay mesh repair: A comparison of outcomes in small ventral hernia.

PURPOSE: The ideal surgical treatment of small ventral hernias (defect less than 4 cm) is still debatable. In our study, we sought to compare the outcomes of open versus laparoscopic intraperitoneal on-lay mesh (IPOM) repair in small ventral hernias. METHODS: Patients with a single ventral hernia defect of less than 4 cm undergoing surgical mesh repair between January 2016 and September 2018 were prospectively registered for this study. The minimum follow-up duration was 12 months. Patient demographics, operative findings and regular post-operative follow-up details including recurrence rates and complications were recorded and analysed. RESULTS: 41 patients underwent laparoscopic IPOM repair and 47 patients underwent open IPOM repair. The mean age for both groups is similar with no significant difference. The mean hernia defect size for the laparoscopic group is 2.8 cm (±0.8) whereas the mean hernia defect size for the open repair group is 2.1 cm (±0.4). The mean surgery duration for open IPOM repair was significantly shorter (59 min (±17) vs 74 min (±26); p = 0.001). There was no significant difference in the incidence of seroma formation and surgical site infections post-operatively. There was also no significant difference in both groups in terms of chronic pain and recurrence at 1-year follow-up. CONCLUSION: Open IPOM repair for small ventral hernias may be superior to laparoscopic IPOM repair due to the shorter operative duration, single incision, and no additional risk of port-site hernias. There was no difference in chronic pain, wound infection and recurrence rate between the two groups.

Prednisolone induced pneumatosis coli and pneumoperitoneum.

Pneumatosis intestinalis (PI) is defined as the presence of gas within the submucosal or subserosal layer of the gastrointestinal tract. It is a radiologic sign suspicious for bowel ischemia, hence non-viable bowel must be ruled out in patients with PI. However, up to 15% of cases with PI are not associated with bowel ischemia or acute abdomen. We described an asymptomatic patient with prednisolone-induced PI and modified the Naranjo score to aid in a surgeon's decision-making for emergency laparotomy vs non-operative management with serial assessment in patients who are immunocompromised due to long-term steroid use.

Improving outcomes in geriatric surgery: Is there more to the equation?

The era of geriatric surgery has arrived with increased global life expectancy. The need to optimize outcomes in this group of patients goes beyond traditional outcomes such as postoperative morbidity and mortality indicators. Recognizing risk factors that impact adverse surgical outcomes such as frailty and sarcopenia, individualizing optimization strategies such as prehabilitation and a multidisciplinary geriatric surgical service have been shown to improve postoperative outcomes and help the older surgical patient regain premorbid function and maintain quality of life. There needs to be a concerted effort to increase awareness of this increasingly important topic in practicing surgeons around the world to meet the challenges of the aging population.

The impact of obesity on Singaporean trauma patients and their venous thromboembolism risk.

BACKGROUND: The impact of obesity on trauma outcomes had been equivocal and the majority of these studies were conducted in the Western population. The aim of our study is to evaluate the impact of obesity on morbidity and mortality in Singaporean patients after trauma. METHODS: A retrospective case control study of trauma patients admitted to a tertiary institution was performed. Patients admitted for both blunt and penetrating trauma who are aged 16 years and above were included. Propensity score matching (PSM) was performed to reduce selection bias. RESULTS: A total of 5239 patients were reviewed (obese 648, non-obese 4591). Median age was 76 (IQR 63-83) years. Median BMI was 22.8 kg/m2 (IQR 20.4-25.2). The overall median ISS was 10 (IQR 9-14). Median ISS was higher in non-obese patients, 10 (IQR 9-14) as compared to obese patients of ISS 9 (IQR 9-13), p = 0.003. Obese patients had more abdominal injuries, n = 27/648 (4.2%) than non-obese n = 114/4591 (2.5%), p = 0.013. Non-obese patients had more head injuries, n = 1698/4591 (37%) as compared to the obese n = 195/648 (30.1%), p = 0.001. In-hospital mortality was comparable in the matched cohort (obese n = 11/645 (1.7%), (non-obese, n = 39/1290 (3.0%), OR 0.56 [0.28-1.09], p = 0.085). ICU admission was shorter for the obese (n = 36/645 (5.6%) versus n = 108/1290 (8.4%), OR 0.65 [0.44-0.96], p = 0.027). Obese patients had higher incidence of venous thromboembolism (n = 16/645 (2.5%) versus n = 12/1290 (0.9%), OR 2.71 [1.27-5.76], p = 0.007). CONCLUSION: Obese trauma patients had fewer head injuries, fewer ICU admissions but comparable mortality rates. Obesity was also associated with higher incidence of venous thromboembolism in the matched cohort.

A systematic review and network meta-analysis of randomized controlled trials on choice of central venous access device for delivery of chemotherapy.

OBJECTIVE: Ensuring reliable central venous access with the fewest complications is vital for cancer patients receiving chemotherapy. A systematic review and network meta-analysis was conducted to compare the safety, quality of life, and cost-effectiveness of different types of central venous access devices (CVADs) for patients receiving chemotherapy. METHODS: The PubMed, EMBASE, and Cochrane databases were searched from inception to August 20, 2021 for randomized controlled trials comparing the various CVADs (ie, nontunneled central venous catheters [CVCs], peripherally inserted CVCs [PICCs], totally implantable venous access ports [TIVAPs], and tunneled CVCs). RESULTS: A total of 11 eligible randomized controlled trials of 2585 patients were identified. TIVAPs were associated with a lower odds of overall complications, device removal due to complications, and thrombotic and mechanical complications compared with PICCs (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.43-0.69; OR, 0.49; 95% CI 0.26-0.93; OR, 0.37; 95% CI, 0.23-0.62; and OR, 0.35; 95% CI, 0.13-0.95, respectively). Tunneled CVCs were associated with a higher odds of overall complications, device removal due to complications, and infective complications compared with TIVAPs (OR, 1.68; 95% CI, 1.30-2.17; OR, 2.52; 95% CI, 1.34-4.73; and OR, 2.11; 95% CI, 1.14-3.90, respectively). The ranking probability using the surface under the cumulative ranking curve values indicated that TIVAPs had the lowest probability of overall complications, removal due to complications, and thrombotic complications. CONCLUSIONS: TIVAPs were found to be superior in terms of complications and quality of life compared with other CVADs, without compromising cost-effectiveness, and should be considered the standard of care for patients receiving chemotherapy.

A systematic review of penetrating perineal trauma in a civilian setting.

PURPOSE: Penetrating injuries to the perineum and associated pelvic organs have largely been reported in the military. Given the rarity of presentation and unique clinical characteristics of these injuries, we set out to address the gap in the literature in civilian settings. METHODS: A systematic review of studies addressing penetrating perineal trauma from January 2000 to April 2021 was performed. Outcomes of interest were the epidemiology, associated injuries, management, follow-up, and patient outcomes. RESULTS: 26 studies were included in this review, reporting on a total of 2316 patients. Most injuries occurred in males (88.1%), with gunshot wounds (88.2%) representing the most common aetiology, followed by knife wounds (5.0%), impalement (3.1%), coital injuries/sexual assault (1.5%), and others (2.4%). Regarding associated injuries, anorectal (n = 1419, 69.4%), bladder (n = 351, 32.4%), penile (n = 282, 20.8%), scrotal (n = 375, 27.7%), and testicular (n = 229, 16.9%) occurred frequently. Bony injuries involved the pelvis (n = 88, 8.1%) and femoral fractures (n = 5, 0.5%), while soft-tissue injuries involved the inguinal region (n = 19, 1.6%) and buttocks (n = 14, 1.3%). Vascular injuries occurred in 79 (7.8%) patients. Regarding patient outcomes, 65 (4.8%) deaths were reported, and significant morbidity was detected with a mean injury severity score of 18.4 detected in the cohort. In terms of complications of injury, wound/infective complications (n = 135, 61.3%) and fistula formation/leakage (n = 16, 0.7%) featured prominently. CONCLUSION: Penetrating perineal trauma in the civilian population poses a considerable challenge to clinicians, compounded by the potential for multisystem injury requiring involvement of different medical and surgical specialties.

Initial emergency laparotomy outcomes following a transdisciplinary perioperative care pathway in Singapore.

AIM: Emergency laparotomy (EL) is a common surgery associated with high morbidity and mortality. An enhanced care pathway incorporates evidence-based care bundles with the aim of providing standardized perioperative care. Prior to 2019, EL management in our institution was not standardized. This study aims to assess whether implementation of a transdisciplinary perioperative Emergency Laparotomy (ELAP) pathway improves clinical and efficiency outcomes of EL. METHODS: A prospective single-center audit was undertaken between 1 January and 31 December, 2019 following the implementation of the ELAP pathway. Comparisons were made with retrospective data from the preimplementation period between 1 January and 31 December, 2017. Demographics and clinical and efficiency outcomes were compared for patients (age > 16 years old) requiring EL for acute abdominal conditions. RESULTS: There were 152 and 162 patients from preimplementation and postimplementation periods, respectively. There was a nonsignificant reduction of 30-day mortality in the intervention group receiving perioperative pathway care compared with the preintervention group (3.1% versus 5.3%, respectively; P = 0.40). There was a decrease in postoperative complications in the intervention group, in particular for Clavien-Dindo IV complications (11.2% versus 3.1%, p < 0.01). Efficiency outcomes improved postimplementation with increased consultant surgeon and anesthetist presence in operating theater and postoperative geriatric assessment for elderly patients. There was an overall reduction in cost of hospital stay from S$32,128 to $27,947 (p = 0.24). CONCLUSION: Implementation of a transdisciplinary perioperative care pathway was associated with significant reduction in postoperative complications, improvement in 30-day mortality and efficiency outcomes at reduced hospital costs for patients following EL in our institution.

Trends and Clinical Outcomes in Young-onset Colorectal Cancer Patients.

INTRODUCTION: Young individuals with colorectal cancer (CRC) tend to be diagnosed at advanced stages and are not routinely included in screening programmes. This study describes the incidence, disease pattern and factors affecting overall survival in young-onset CRC. METHODS: A retrospective study of young-onset CRC patients diagnosed between 2010 and 2017 in a tertiary hospital was conducted. RESULTS: There were 99 patients, 69.7% had left-sided while 30.3% had right-sided CRC. The mean age was 43.3 years (43.3±5.0) and 62 patients (62.6%) were male. The incidence of young-onset CRC has been on the rise since 2014. Out of 99 patients, 65 (65.7%) underwent elective surgery, 30 (30.3%) underwent emergency surgery and the remainder 5 (4.0%) were palliated. The most common presenting complaints for patients who underwent elective surgery were abdominal pain, per-rectal bleeding and altered bowel habits. For patients who required emergency surgery, 20 (66.6%) presented with intestinal obstruction and 10 (33.3%) had intestinal perforation. There were 42 (42.4%) stage III CRC and 20 (20.2%) stage IV CRC. The most frequent metastatic site was the liver (20/20, 100%). Five patients had signet ring cells (5.1%) in their histology while 15 (15.2%) had mucinous features. The overall 5-year survival of young-onset CRC was 82.0%. Advanced overall stage (hazard ratio (HR) 6.1, CI 1.03-3.62) and signet ring histology (HR 34.2, CI 2.24-5.23) were associated with poor prognosis. CONCLUSION: Young-onset CRC tend to be left-sided with advanced presentations. However, their 5-year survival remains favourable as compared to the general population.

Impact of a dedicated emergency surgical service on appendicitis outcomes.

AIM: The Emergency Surgery and Trauma (ESAT) team is a dedicated consultant-led service to streamline the emergency surgical workload in Singapore. As acute appendicitis is one of the most common acute surgical conditions, we aim to compare outcomes of patients with appendicitis in the ESAT model as compared to the traditional on-call model. METHODS: A retrospective review of patients admitted to Khoo Teck Puat Hospital, Singapore, with acute appendicitis between two periods: May-October 2014 (6 months pre-ESAT) versus January-June 2017 (post-ESAT). Patient demographics, operative details, efficiency, clinical outcomes, and hospital bill savings were evaluated. RESULTS: There were 192 patients in the pre-ESAT period and 179 patients in the post-ESAT period. Patient demographics and comorbidities were comparable (P > 0.05). Time from emergency department referral to surgical review was significantly reduced in the ESAT period: 77.8 ± 46.9 min versus 127 ± 102 in the pre-ESAT period (P = 0.002). Time from case booking to operating theatre was significantly shorter in the ESAT period: 72.4 ± 55.2 min compared to 157.3 ± 209.1 (P < 0.01). More cases were carried out in the daytime during the ESAT period, 50.2% versus 39.1% (P = 0.029). The majority underwent laparoscopic appendectomy 156/179 (87.2%) in the ESAT period, with fewer open appendectomies 3/179 (1.7%) as compared to the pre-ESAT period (P = 0.062). There were higher intraoperative consultant supervision rates during the ESAT period, 38/166 (22.9%) as compared to 12/166 (6.7%) in the pre-ESAT period (P = 0.001). There were fewer complications (Clavien-Dindo grade II and above) in the ESAT period, 1 (0.6%) as compared to 6 (3.4%) pre-ESAT (P = 0.07). CONCLUSION: The ESAT service is associated with better efficiency outcomes for patients with acute appendicitis.