Surgical resection for hepatocellular carcinoma: a single-centre's one decade of experience.

Background and aims: Liver cancer is the third leading cause of global cancer deaths, and hepatocellular carcinoma is its most common type. Liver resection is one of the treatment options for hepatocellular carcinoma (HCC). This study aims to explore our hospital's more than a decade of experience in liver resection for HCC patients. Methods: This is a retrospective cohort study on HCC patients undergoing resection from 2010 to 2021 in a tertiary-level hospital in Jakarta, Indonesia. Mortality rates were explored as the primary outcome of this study. Statistical analysis was done on possible predictive factors using Pearson's χ2. Survival analysis was done using the Log-Rank test and Cox Regression. Results: Ninety-one patients were included in this study. The authors found that the postoperative mortality rates were 8.8% (in hospital), 11.5% (30 days), and 24.1% (90 days). Excluding postoperative mortalities, the long-term mortality rates were 44.4% (first year), 58.7% (3 years), and 69.7% (5 years). Cumulatively, the mortality rates were 46.4% (1 year), 68.9% (3 years), 77.8% (5 years), and 67.0% (all time). Significant predictive factors for cumulative 1-year mortality include large tumour diameter [odds ratio (OR) 14.06; 95% CI: 2.59-76.35; comparing <3 cm and >10 cm tumours; P<0.01], positive resection margin (OR 2.86; 1.17-77.0; P=0.02), and tumour differentiation (P=0.01). Multivariate analysis found hazard ratios of 6.35 (2.13-18.93; P<0.01) and 1.81 (1.04-3.14; P=0.04) for tumour diameter and resection margin, respectively. Conclusion: The mortality rate of HCC patients undergoing resection is still very high. Significant predictive factors for mortality found in this study benefit from earlier diagnosis and treatment; thus, highlighting the importance of HCC surveillance programs.

The enhanced recovery after surgery (ERAS) protocol implementation in a national tertiary-level hospital: a prospective cohort study.

Introduction: Successful colorectal surgery is determined based on postoperative mortality and morbidity rates, complication rates, and cost-effectiveness. One of the methods to obtain an excellent postoperative outcome is the enhanced recovery after surgery (ERAS) protocol. This study aims to see the effects of implementing an ERAS protocol in colorectal surgery patients. Methods: Eighty-four patients who underwent elective colorectal surgery at National Tertiary-level Hospital were included between January 2021 and July 2022. Patients were then placed into ERAS (42) and control groups (42) according to the criteria. The Patients in the ERAS group underwent a customized 18-component ERAS protocol and were assessed for adherence. Postoperatively, both groups were monitored for up to 30 days and assessed for complications and readmission. The authors then analyzed the length of stay and total patient costs in both groups. Results: The length of stay in the ERAS group was shorter than the control group [median (interquartile range) 6 (5-7) vs. 13 (11-19), P<0.001], with a lower total cost of [USD 1875 (1234-3722) vs. USD 3063 (2251-4907), P<0.001]. Patients in the ERAS group had a lower incidence of complications, 10% vs. 21%, and readmission 5% vs. 10%, within 30 days after discharge than patients in the control group; however, the differences were not statistically significant. The adherence to the ERAS protocol within the ERAS group was 97%. Conclusion: Implementing the ERAS protocol in colorectal patients reduces the length of stay and total costs.

Association Preoperative Protein Adequacy and Post Elective Laparotomy Surgical Site Infection.

Background/Aims: Postoperative complications tend to occur in high-risk populations, including those undergoing major surgery. Surgical site infections (SSI) are some of the most common postoperative complications in laparotomy procedures. Surgery induces a postoperative stress response, triggering an inflammatory process that increases muscle protein proteolysis. Preoperative protein intake increases muscle protein reserves and supports postoperative wound healing and immunity. This study analyzed the association between preoperative protein adequacy and post-elective laparotomy SSI. Methods: A prospective cohort study was conducted on 93 subjects with an adequate protein group of 48 subjects and an inadequate protein group of 45 subjects undergoing elective laparotomy at Dr. Cipto Mangunkusumo Hospital, Jakarta. The protein adequacy was analyzed using an interview method for seven days preoperatively. Patient monitoring was carried out for 30 days postoperatively to assess the complications in the form of SSIs. The association between protein adequacy and SSI was analyzed using a Chi-Square test, and multivariate analysis was performed to assess the factors most associated with post-elective laparotomy SSI. Results: An association was observed between preoperative protein adequacy and post-elective laparotomy SSI (RR 3.413; 95% CI, 1.363-8.549; p=0.004). Multivariate analysis showed that the preoperative protein adequacy and preoperative albumin levels were strongly predictive of the occurrence of SSI. Conclusions: The preoperative protein adequacy and albumin levels were strongly related to predicting the post-elective laparotomy SSI.

Characteristics of living liver donors in a national referral hospital in Indonesia: a 13-year experience with living donor liver transplantation.

Background: Hepatocellular carcinoma and biliary atresia lead to end-stage liver disease, which requires liver transplantation and is linked to increased mortality. Dr. Cipto Mangunkusumo Hospital is the national referral center in Indonesia and is the only center that routinely performs living donor liver transplantation (LDLT). This study presents the characteristics of living liver donors (LLDs) in Indonesia. Methods: Using the LDLT registry, we conducted a retrospective analysis of all approved donors from 2010 to 2022. The variables included clinical characteristics of the donors, graft types, and intraoperative and postoperative characteristics. Results: The LDLT rate has increased from 5.8 to 8.8 procedures/year in the last 8 years. The average age of the 76 LLDs was 31.8 years. They were predominantly female (59%) and lived within a family relationship (90%). Pediatric LDLT was more frequent than adult LDLT (88% vs. 12%, respectively). Most grafts (86%) were obtained by left lateral sectionectomy, with a median ratio of remnant liver volume to total liver volume of 79.5% (range, 47.7%-85.8%) and a mean graft-to-recipient weight ratio of 2.65%±1.21%. The median intensive care unit length of stay (LOS) was 2 days (range, 1-5 days) and the total hospital LOS was 7 days (range, 4-28 days). The complication rate was 23%. No donor mortality was reported. Conclusions: LDLT in Indonesia has increased over the years. The shortage of donors for adult-to-adult liver transplantation is due to cultural differences and challenges in finding eligible donors. This study aims to explain the eligibility criteria of LLDs and contribute to creating a national policy.

A six years' experience with 41 cases of enterovesical fistula in a Tertiary National Hospital in Indonesia: A retrospective study.

INTRODUCTION: The incidence of Enterovesical Fistula (EVF) is relatively low. Currently, there is no agreement about the best methods for EVF management. This study was performed to investigate the characteristics of EVF to find the optimal diagnostic and management pattern. METHODS: Data were collected retrospectively from the medical record at Cipto Mangunkusumo Hospital. Patients diagnosed with EVF between January 2014 and April 2019 were included. They were evaluated for demographics, characteristics, diagnostic modalities, and treatment modalities. RESULTS: From 41 patients, 26 (63.3%) are male, and 15 (36.6%) are female. Peak incidence was 51-60 years old. The most common symptoms are fecaluria found in 32 (78%) patients. The common etiology is gastrointestinal cancer found in 17 (41.5%) patients, followed by gynecologic cancer and diverticulitis found in both 9 (22%) patients. The rectovesical fistula was seen in 25 (61%) patients with an advanced stage rectosigmoid cancer, followed by colovesical in 14 (34.1%) of patients with sigmoid diverticulitis (p 0.038). The common diagnostic modalities performed are cystoscopy in 32 (78%), followed by colonoscopy in 11 (26.8%) patients. The preferred modalities that were used in most cases were surgery in 35 (85.4%) patients. A two-stage surgical approach was used in 28 (68.3%) patients. CONCLUSION: The incidence of EVF is uncommon. Malignancy was the leading cause of EVF in this study. Combined diagnostic modalities are recommended in EVF cases. The two-stage surgical approach was the preferred modality. Further prospective studies are mandatory to analyze this condition.

Isolated spleen tuberculosis in an immunocompetent patient, a rare case report.

INTRODUCTION: Tuberculosis (TB), as a major public health concern, is affecting almost 10 million people globally. At present, diagnostic and screening efforts mainly focus on positive smear results. Therefore, the number of extra pulmonary and negative sputum TB is rising and hampering the diagnosis and treatment process due to the large number of false negatives. Rare cases such as solitary splenic TB are usually seen in patients with splenic abnormalities, spleen trauma, immunosuppression, sickle cell disease, pyogenic infections, etc. PRESENTATION OF CASE: A 40-year-old female with no comorbidity came with chief complaint of early satiety every mealtime and epigastric pain in the last 6 months prior to admission. There was no significant positive examination except for positive IGRA test and enlargement of spleen with multiple cystic lesions on abdominal CT. We performed laparotomy with splenectomy followed by a histopathology examination which showed features of primary tubercular abscess. DISCUSSION: In the immunocompromised patient, the visceral abdomen is usually involved and a part of miliary TB. However, this case revealed the rare possibility of a healthy person with primary isolated tubercular splenic abscess while being immunocompetent and lacking any comorbidity. CONCLUSION: Splenic TB diagnosis is difficult in patients lacking pulmonary involvement and without specific symptoms. Thorough examinations and clinical expertise are needed to provide accurate diagnosis and treat uncommon forms of TB and cases with negative smear results in consideration of rising prevalence and difficult disease control.

Intact Glycocalyx of Intestinal Mucosa in Intraabdominal Infection: an Investigation Using Blood Group Antigen.

BACKGROUND: intestinal glycocalyx plays a role in bacterial translocation as the pathogenesis sepsis derived from intra-abdominal infections that vulnerable in certain blood types. However, the link between intestinal glycocalyx in specific types of blood groups and abdominal infections remains unknown. This study aims to find out the condition of intestinal glycocalyx in certain blood types with intraabdominal sepsis. METHODS: descriptive study involved subjects with intraabdominal infections who underwent laparotomy. Samples are in the form of intestinal specimens. The measurement of intestinal glycocalyx proceeded by the ELISA method using blood group antigens (A and B). Expression data on the secretors were analyzed using the Kolmogorov - Smirnov test followed by parametric comparisons using ANOVA and t-tests. RESULTS: there were 32 subjects with intra-abdominal infections studied in this study. All of them are secretors and express A and B antigens strongly. We found no difference between intraabdominal infections in those with complications or without complications. Blood type O is a predominant blood type found (43.8%). Escherichia coli is the most commonly found microbe in the culture (61.3%). CONCLUSION: this study shows there is no disrupted intestinal glycocalyx of sepsis patients caused by intraabdominal infection.