Prehabilitation Program Improves Outcomes of Patients Undergoing Elective Liver Resection.

BACKGROUND: Preoperative phase can be effectively used by multidisciplinary teams to optimize the surgical candidate to improve perioperative outcomes. The aim of our study was to evaluate the impact of prehabilitation program (PP) in patients undergoing elective liver resection (LR). METHODS: This was a prospective study including patients undergoing elective LR from February 2016 to October 2017. Outcomes of patients enrolled into PP were compared with patients receiving standard care. PP involved physiotherapist, dietitian, and case managers along with surgical and anesthetic services. Postoperative morbidity, length of stay, 90-day mortality, readmission rate, quality of life, and cost were measured. RESULTS: Seventy patients were enrolled into PP and compared with 34 patients receiving standard care. Median Charlson comorbidity index was higher in PP group (4 versus 3, P = 0.03). PP showed reduction in overall morbidity (30% versus 52.9%, P = 0.02) and social issues (nil versus 3, P = 0.03). Quality of life survey showed improved social well-being. A tendency to cost savings was observed in prehabilitation group with 16.5% ($1359) cost reduction (median cost $6892 versus $8251, P = 0.07). CONCLUSIONS: PP improves outcomes in patients undergoing elective LR.

Subtotal cholecystectomy: early and long-term outcomes.

BACKGROUND: In difficult gallbladders, partial or subtotal cholecystectomy (SC) has been described as a reasonable procedure with safe outcomes. Our aim was to look at our data on SC with respect to safety, morbidity and long-term outcome. METHODS: A retrospective analysis was performed for 3560 patients undergoing cholecystectomy from January 2010 to June 2016. For patients who underwent SC, demographics, intra-operative and follow-up details were analysed. RESULTS: A total of 168 SC patients were included. 102 (60.7%) were male while 66 (39.3%) were female. The median age was 63 years (31-87). These patients were on follow-up for a median of 29 months (1.7-80). 153 were attempted laparoscopically and there were 25 (16.3%) patients which had open conversion. The rest of the 15 patients had open SC. Mean operative time 150 min (70-315) and average blood loss was 170 ml (50-1500). Median length of stay for these patients was 4 days (1-68). There were no common bile duct (CBD) injuries. We had 12 (7.1%) post-operative collections, 4 (2.4%) wound infections, 1 (0.6%) bile leak and 7 (4.2%) retained stones. Post-operative endoscopic retrograde cholangiopancreatography (ERCP) was performed on 4 (2.4%) patients with successful retrieval of CBD stones. One patient has spontaneous passage of CBD stone. The rest of the two patients with very small retained stones in remnant gallbladder were successfully managed conservatively. There was no 30-day or operation-related mortality. No patient required a second operation. CONCLUSIONS: SC is safe and feasible when encountering a difficult gallbladder.

Oral vs Intravenous Antibiotics for Patients With Klebsiella pneumoniae Liver Abscess: A Randomized, Controlled Noninferiority Study.

BACKGROUND: Klebsiella pneumoniae liver abscess (KLA) is emerging worldwide due to hypermucoviscous strains with a propensity for metastatic infection. Treatment includes drainage and prolonged intravenous antibiotics. We aimed to determine whether oral antibiotics were noninferior to continued intravenous antibiotics for KLA. METHODS: This noninferiority, parallel group, randomized, clinical trial recruited hospitalized adults with liver abscess and K. pneumoniae isolated from blood or abscess fluid who had received ≤7 days of effective antibiotics at 3 sites in Singapore. Patients were randomized 1:1 to oral (ciprofloxacin) or intravenous (ceftriaxone) antibiotics for 28 days. If day 28 clinical response criteria were not met, further oral antibiotics were prescribed until clinical response was met. The primary endpoint was clinical cure assessed at week 12 and included a composite of absence of fever in the preceding week, C-reactive protein <20 mg/L, and reduction in abscess size. A noninferiority margin of 12% was used. RESULTS: Between November 2013 and October 2017, 152 patients (mean age, 58.7 years; 25.7% women) were recruited, following a median 5 days of effective intravenous antibiotics. A total of 106 (69.7%) underwent abscess drainage; 71/74 (95.9%) randomized to oral antibiotics met the primary endpoint compared with 72/78 (92.3%) randomized to intravenous antibiotics (risk difference, 3.6%; 2-sided 95% confidence interval, -4.9% to 12.8%). Effects were consistent in the per-protocol population. Nonfatal serious adverse events occurred in 12/72 (16.7%) in the oral group and 13/77 (16.9%) in the intravenous group. CONCLUSIONS: Oral antibiotics were noninferior to intravenous antibiotics for the early treatment of KLA. CLINICAL TRIALS REGISTRATION: NCT01723150.

Patient reported outcomes in elective laparoscopic cholecystectomy.

BACKGROUNDS/AIMS: Traditional outcome measures (e.g., length of hospital stay, morbidity, and mortality) are used to determine the quality of care, but these may not be most important to patients. It is unclear which outcomes matter to patients undergoing elective laparoscopic cholecystectomy (ELC). We aim to identify patient-reported outcome measures (PROM) which patients undergoing ELC valued most. METHODS: A 45-item questionnaire with Four-point Likert-type questions developed from prior literature review, prospectively administered to patients treated with ELC at a tertiary institution in Singapore. RESULTS: Seventy-five patients participated. Most essential factors were technical skill and experience level of a surgeon, long-term quality of life (QoL), patient involvement in decision-making, communication skill of a surgeon, cleanliness of the ward environment, and standards of nursing care. Least important factors were hospitalization leave duration, length of hospital stay, a family's opinion of the hospital, and scar cosmesis. Employed patients were more likely to find hospitalization leave duration (p<0.001) and procedure duration (p=0.042) important. Younger patients (p=0.048) and female gender (p=0.003) were more likely to perceive scar cosmesis as important. CONCLUSIONS: Patients undergoing ELC value long-term QoL, surgeon technical skill and experience level, patient involvement in decision-making, surgeon communication skill, cleanliness of the ward environment, and nursing care standards. Day-case surgery, medical leave, family opinion of hospital, and scar cosmesis were least important. Understanding what patients value will help guide patient-centric healthcare delivery.

Are traditional scoring systems for severity stratification of acute pancreatitis sufficient?

BACKGROUNDS/AIMS: Ranson's score (RS) and Glasgow score (GS) have been utilized to stratify the severity of acute pancreatitis (AP). The aim of this study was to validate RS and GS for stratifying the severity of acute pancreatitis and audit our experience of managing AP. METHODS: We conducted a retrospective review of patients treated for AP from July 2009 to September 2016. Final severity was determined using the revised Atlanta classification. Mortality and complications were analyzed. RESULTS: From July 2009 to September 2016, a total of 675 patients with a diagnosis of AP were admitted at the hospital. Of them, 669 patients who had sufficient data were analyzed. Their average age±SD was 58.7±17.4 years (range, 21-98 years). There was a male preponderance (n=393, 53.8%). A total of 82 (12.3%) patients had eventual severe pancreatitis. RS demonstrated a sensitivity of 92.7% and a specificity of 52.8% with a positive predictive value (PPV) of 21.5% and a negative predictive value (NPV) of 98.1%. GS demonstrated a sensitivity of 76.8% and a specificity of 69.2% with a PPV of 25.8% and a NPV of 95.5%. For severity prediction, areas under the curve (AUCs) for RS and GS were 0.848 (95% CI: 0.819-0.875) and 0.784 (95% CI: 0.750-0.814), respectively (p=0.003). Twelve (1.6%) patients died in the hospital. CONCLUSIONS: RS has higher sensitivity, NPV and AUC for predicting severity of AP than GS.

Index admission laparoscopic cholecystectomy for acute cholecystitis restores Gastrointestinal Quality of Life Index (GIQLI) score.

BACKGROUNDS/AIMS: Previous studies have evaluated quality of life (QoL) in patients who underwent laparoscopic cholecystectomy (LC) for cholelithiasis. The purpose of this study was to evaluate QoL after index admission LC in patients diagnosed with acute cholecystitis (AC) using the Gastrointestinal Quality of Life Index (GIQLI) questionnaire. METHODS: Patients ≥21 years admitted to Tan Tock Seng Hospital, Singapore for AC and who underwent index admission LC between February 2015 and January 2016 were evaluated using the GIQLI questionnaire preoperatively and 30 days postoperatively. RESULTS: A total of 51 patients (26 males, 25 females) with a mean age of 60 years (24-86 years) were included. Median duration of abdominal pain at presentation was 2 days (1-21 days). 45% of patients had existing comorbidities, with diabetes mellitus being most common (33%). 31% were classified as mild AC, 59% as moderate and 10% as severe AC according to Tokyo Guideline 2013 (TG13) criteria. Post-operative complications were observed in 8 patients, including retained common bile duct stone (n=1), wound infection (n=2), bile leakage (n=2), intra-abdominal collection (n=1) and atrial fibrillation (n=2). 86% patients were well at 30 days follow-up and were discharged. A significant improvement in GIQLI score was observed postoperatively, with mean total GIQLI score increasing from 106.0±16.9 (101.7-112.1) to 120.4±18.0 (114.8-125.9) (p<0.001). Significant improvements were also observed in GIQLI subgroups of gastrointestinal symptoms, physical status, emotional status and social function status. CONCLUSIONS: Index admission LC restores QoL in patients with AC as measured by GIQLI questionnaire.

Predicting morbidity of liver resection.

PURPOSE: Multiple models have attempted to predict morbidity of liver resection (LR). This study aims to determine the efficacy of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and the Physiological and Operative Severity Score in the enUmeration of Mortality and Morbidity (POSSUM) in predicting post-operative morbidity in patients who underwent LR. METHODS: A retrospective analysis was conducted on patients who underwent elective LR. Morbidity risk was calculated with the ACS-NSQIP surgical risk calculator and POSSUM equation. Two models were then constructed for both ACS-NSQIP and POSSUM-(1) the original risk probabilities from each scoring system and (2) a model derived from logistic regression of variables. Discrimination, calibration, and overall performance for ACS-NSQIP and POSSUM were compared. Sub-group analysis was performed for both primary and secondary liver malignancies. RESULTS: Two hundred forty-five patients underwent LR. Two hundred twenty-three (91%) had malignant liver pathologies. The post-operative morbidity, 90-day mortality, and 30-day mortality rate were 38.3%, 3.7%, and 2.4% respectively. ACS-NSQIP showed superior discriminative ability, calibration, and performance to POSSUM (p = 0.03). Hosmer-Lemeshow plot demonstrated better fit of the ACS-NSQIP model than POSSUM in predicting morbidity. CONCLUSION: In patients undergoing LR, the ACS-NSQIP surgical risk calculator was superior to POSSUM in predicting morbidity risk.

Validity of the Barcelona Clinic Liver Cancer and Hong Kong Liver Cancer staging systems for hepatocellular carcinoma in Singapore.

BACKGROUND: Staging is vital in guiding therapeutic approach in patients diagnosed with hepatocellular carcinoma (HCC). Our study's goal is to compare paradigms in the Barcelona Clinic Liver Cancer (BCLC) and Hong Kong Liver Cancer (HKLC) systems, and evaluate the use of both in a local context, comparing their prognostic ability and therapeutic efficacy in the management of HCC. METHODS: Seven hundred and sixty-six patients diagnosed between 2010 and 2015 were identified and staged according to BCLC and HKLC. Both system's performances were compared using Akaike information criterion (AIC), bootstrap concordance-index (c-index), and through Kaplan-Meier survival curves of patients who came under HKLC stages 1, 2, and 3 and the individual BCLC stages. Independent prognostic factors of survival were identified using univariate and multivariate analyses. RESULTS: According to AIC and c-index, HKLC (AIC = 5,711, c-index = 0.74) has equivalent prognosticating value as BCLC (AIC = 5,764, c-index = 0.72). Through Kaplan-Meier curves, we determined that more aggressive treatments resulted in better outcomes. Particularly for patients under BCLC stage C, patients who followed the HKLC system's recommended treatments performed markedly better. CONCLUSIONS: In our patient population, the HKLC system is comparable to the BCLC system in prognosticating patients, but is suggested to have better performance in guiding treatment.

Tokyo Guidelines 2013 may be too restrictive and patients with moderate and severe acute cholecystitis can be managed by early cholecystectomy too.

OBJECTIVE: The aim of this study was to determine whether early laparoscopic cholecystectomy (LC) is safe and feasible for patients diagnosed with moderate (grade 2) and severe (grade 3) acute cholecystitis (AC) according to the Tokyo Guidelines 2013 (TG13). BACKGROUND: Early cholecystectomy is the current accepted standard of care for patients with mild (grade 1) and selected grade 2 AC based on TG13. For selected grade 2 and grade 3 AC, early percutaneous cholecystostomy (PC) followed by delayed cholecystectomy is recommended. METHODS: Patients diagnosed with AC over a 14-month period were identified and divided into three grades of AC based upon chart review using the grading and severity indicators according to TG13. RESULTS: A total of 149 patients underwent emergency LC. Eighty-two (55 %) patients were male. Eighty-four (56.4 %) patients were classified as grade 1 AC, 49 (32.9 %) as grade 2, and 16 (10.7 %) as grade 3. Eighty-three (98.8 %) patients with grade 1 AC underwent emergency LC, and 1 patient (1.2 %) underwent PC followed by emergency LC. The median length of hospital stay for grade 1 AC patients was 2 (1-11) days. There were 2 (2.4 %) readmissions with fever and no additional complications. Among the 65 patients identified with grade 2 or 3 AC, 6 (9.2 %) underwent PC followed by emergency LC. Fifty-nine (90.8 %) patients underwent emergency cholecystectomy: 58 (98.3 %) LC and one (1.7 %) open cholecystectomy. Among the 58 patients with LC, 3 (5.2 %) patients had open conversion and 10 (17.2 %) patients required subtotal cholecystectomy. One patient was converted to open due to bile duct injury and had hepaticojejunostomy repair. Two other patients were converted due to dense adhesions and inability to safely dissect Calot's triangle. The median length of hospital stay was 4 (1-28) days. There was one readmission for ileus. CONCLUSION: Severity grading of AC is not the sole determinant of early LC. Patient comorbidity also impacts clinical decision. Confirmation in a larger cohort is warranted.

Patients with culture negative pyogenic liver abscess have the same outcomes compared to those with Klebsiella pneumoniae pyogenic liver abscess.

BACKGROUND: Etiologic organism is not frequently isolated despite multiple blood and fluid cultures during management of pyogenic liver abscess (PLA). Such culture negative pyogenic liver abscess (CNPLA) is routinely managed by antibiotics targeted to Klebsiella pneumoniae. In this study, we evaluated the outcomes of such clinical practice. METHODS: All the patients with CNPLA and Klebsiella pneumoniae PLA (KPPLA) admitted from January 2003 to December 2011 were included in the study. A retrospective review of medical records was performed and demographic, clinical and outcome data were collected. RESULTS: A total of 528 patients were treated as CNPLA or KPPLA over the study period. CNPLA presented more commonly with abdominal pain (P=0.024). KPPLA was more common in older age (P=0.029) and was associated with thrombocytopenia (P=0.001), elevated creatinine (P=0.002), bilirubin (P=0.001), alanine aminotransferase (P=0.006) and C-reactive protein level (P=0.036). CNPLA patients tend to have anemia (P=0.015) and smaller abscess (P=0.008). There was no difference in hospital stay (15.7 vs 16.8 days) or mortality (14.0% vs 11.0%). No patients required surgical drainage after initiation of medical therapy. CONCLUSION: Despite demographic and clinical differences between CNPLA and KPPLA, overall outcomes are not different.

Does diabetes mellitus affect presentation, stage and survival in operable pancreatic cancer?

BACKGROUND: The aim of the study is to investigate differences in clinical presentation, disease stage and survival of operable pancreatic cancer patients with new onset DM compared to long standing diabetes mellitus (DM) and non diabetics. METHODS: A prospectively maintained pancreatic cancer surgery database of a tertiary care teaching hospital from January 2006 to August 2012 was reviewed. Only patients with a histological diagnosis of pancreatic carcinoma (PC) were included in final analysis. DM was defined as HbA1c >6.5% or any patient on anti-diabetic treatment regardless of HbA1c value. New onset DM was defined when diagnosed within two preceding years of surgery. Patients were stratified into two groups: DM and non DM. Among the DM patients, patients with new onset DM were further stratified and studied separately. Staging of PC was performed according to the 6(th) edition of AJCC. Survival of patients with PC was determined by reviewing medical records. Patients and their families were contacted if there was no existing follow-up. RESULTS: Eighty-six patients (n=55, 63.9% male) with a mean age of 62 years (range, 29-85 years) underwent pancreatic cancer surgery during the study period. Of the 86 patients, 30 (34%) had DM of which eight patients (9% overall) had new onset DM. DM patients tended to be older compared to non DM patients (67.8 vs. 58.5 years, P=0.0005). The majority of non DM patients were symptomatic (98.2%), and there was a tendency for DM group patients to be asymptomatic at presentation (13.3% vs. 1.8%, P=0.05). Abdominal pain was less common in DM patients compared to non DM patients (30% vs. 53.6%, P=0.04). The median duration of new onset DM prior to diagnosis of PC was 2 months (range, 1-23 months). There was a tendency for DM patients to present at an early stage (stage I and stage II) (P=0.08). There was no difference in survival (P=0.17) for new onset DM compared to long standing DM and non DM patients. CONCLUSIONS: DM patients tend to be older and are less likely to present with abdominal pain. Asymptomatic presentation and early stage disease tends to occur in DM patients. A larger sample size is required to determine if survival of new onset DM patients differs from long standing and non DM patients.

Outcomes of percutaneous cholecystostomy and predictors of eventual cholecystectomy.

BACKGROUND: Percutaneous cholecystostomy (PC) is an established treatment for high surgical risk patients with acute cholecystitis. This paper studies factors predictive of mortality and eventual cholecystectomy. METHODS: A retrospective review of all patients who underwent PC from March 2005 to March 2015 was performed. Patient demographics, clinical features, comorbidity profile, grade of cholecystitis, interval between cholecystitis diagnosis and PC, and method of PC were studied. Length of stay, complications, readmission rate, mortality and eventual cholecystectomy were studied. For patients with eventual cholecystectomy, operative data and perioperative outcomes were studied. RESULTS: One hundred and three patients with median age of 80 years (range 43-105) underwent PC. Median interval to PC was 2 days (range 0-15). 9.7% of patients had complications. Median length of stay was 19 days (range 3-206). 41% underwent eventual cholecystectomy. 30-day mortality rate was 10.7%. Higher APACHE II scores (P = 0.004), higher Charlson comorbidity index (CCI) (P = 0.009), and longer interval from diagnosis to PC (P = 0.037) were associated with in-hospital mortality. Younger age (P = 0.015), lower APACHE II scores (P = 0.043) and lower CCI (P = 0.002) were associated with eventual cholecystectomy. CONCLUSION: Percutaneous cholecystostomy is safe and effective in treatment of acute cholecystitis. Prompt PC improves survival in high risk surgical patients. Comorbidity severity is associated with mortality. Patients with lesser comorbidity are likely to receive eventual cholecystectomy.

Percutaneous drainage for giant pyogenic liver abscess--is it safe and sufficient?

BACKGROUND: Large size is a predictor of failure of percutaneous drainage (PD) for pyogenic liver abscess (PLA). This article serves to establish the safety and sufficiency of PD in giant PLA (GPLA). METHODS: A retrospective review of all GPLA patients treated at a tertiary care academic hospital from 2001 to 2011 was performed. A GPLA is defined as an abscess greater than or equal to 10 cm size based on imaging. RESULTS: Forty patients (24 men, 60%) were treated for GPLA. All but 1 patient (98%) was managed with PD and the mean duration of drainage was 9 days (range 1 to 23 days). One patient underwent operative drainage. Three patients (7.7%) needed secondary procedures after the initial PD. One patient (2.6%) failed PD and subsequently underwent operative drainage. Among the patients who underwent PD, the overall morbidity was 25%; the median length of hospital stay was 13 days (range 5 to 31 days) and 1 (2.6%) mortality. CONCLUSIONS: Large size itself is not a contraindication for PD. PD is safe and sufficient even in GPLA patients.

Outcomes of slit mesh in laparoscopic totally extraperitoneal inguinal hernia repair: Does it affect recurrence?

INTRODUCTION: The aim of this study was to compare outcomes between slit and non-slit mesh placement in laparoscopic totally extraperitoneal inguinal hernia repair. METHODS: This is a retrospective study of 113 patients who underwent laparoscopic totally extraperitoneal inguinal hernia repair with Ultrapro mesh between January 2010 and December 2011. Sixty-two and 82 hernias were operated on in the slit mesh and non-slit mesh groups, respectively. Postoperative complications, recurrence, and patient satisfaction levels were evaluated. RESULTS: One hernia in the slit mesh group (1/62, 1.6%) and one in the non-slit mesh group (1/82, 1.2%) developed recurrence (P = 1.00). The incidence of postoperative neuralgia was 4/62 (6.5%) and 7/82 (8.5%) in the slit mesh and non-slit mesh groups, respectively (P = 0.76). Satisfaction rates in the slit mesh and non-slit mesh groups were similar at 60/62 (96.8%) and 80/82 (97.6%), respectively (P = 1.00). CONCLUSION: No significant differences in outcomes were found between slit and non-slit mesh placement. Both have low complication rates, low recurrence rates, and high satisfaction levels.

Pyogenic Liver Abscess: Does Escherichia Coli Cause more Adverse Outcomes than Klebsiella Pneumoniae?

BACKGROUND: This paper aims to demonstrate if Escherichia coli pyogenic liver abscess (ECPLA) results in adverse outcomes compared to Klebsiella pneumoniae PLA (KPPLA). METHODS: A retrospective review of all patients admitted at a tertiary hospital in Singapore from 2003 to 2011 was performed. Patients with age <18 years, amoebic liver abscess, infected liver cyst, culture negative abscess or ruptured liver abscess requiring urgent surgical intervention were excluded. Only patients with blood or pus culture confirmation of ECPLA (n = 24) or KPPLA (n = 264) were included. Median length of hospital stay, failure of non-operative therapy and 30-day mortality are the reported outcomes. RESULTS: ECPLA affects older patients (68 vs. 62 years, p = 0.049). Ischemic heart disease was more common in ECPLA (29 vs. 14 %, p = 0.048) and there was no difference in diabetic state (42 vs. 38 %, p = 0.743). ECPLA is more commonly associated with hyperbilirubinemia (60 vs. 34 µmol/L, p = 0.003), increased gamma-glutamyl transpeptidase (236 vs. 16 IU/L, p = 0.038) and gallstones (58 vs. 30 %, p = 0.004). KPPLA are larger in size (6 vs. 4 cm, p = 0.006) and had percutaneous drainage (PD) more frequently (64 vs. 42 %, p = 0.034). There was no difference in median hospital stay (14 vs. 14 days, p = 0.110) or 30-day mortality (17 vs. 10 %, p = 0.307) between ECPLA and KPPLA. Among patients with ECPLA, antibiotic treatment with PD appeared to have higher mortality compared to antibiotic treatment alone (30 vs. 7 %) but this was not significant (p = 0.272). CONCLUSION: In the setting of multimodal care, outcomes of ECPLA are comparable to KPPLA.

Analysis of actual healthcare costs of early versus interval cholecystectomy in acute cholecystitis.

BACKGROUND: Healthcare cost modeling have favored early (ELC) over interval laparoscopic cholecystectomy (ILC) for acute cholecystitis (AC). However, actual costs of treatment have never been studied. The aim of the present study was to compare actual hospital costs involved in ELC and ILC in patients with AC. METHODS: Retrospective study of patients who underwent laparoscopic cholecystectomy for AC was conducted. Demographic, clinical, operative data and costs were extracted and analyzed. RESULTS: Between 2011 and 2013, 201 had laparoscopic surgery for AC at Tan Tock Seng Hospital, Singapore. One hundred and thirty-four (67%) patients underwent ELC (≤7 days of presentation, within index admission). Median total length of stay (LOS) was 4.6 and 6.8 days for ELC and ILC groups, respectively (P = 0.006). Patients who had ELC also had significantly lesser total number of admissions (P < 0.001). The median (IQR) total inpatient costs were €4.4 × 10(3) (3.6-5.6) and €5.5 × 10(3) (4.0-7.5) for ELC and ILC patients, respectively (P < 0.007). Costs associated with investigations were significantly higher in the ILC group (P = 0.039), of which serological costs made most difference (P < 0.005). The ward costs were also significantly higher in the ILC group. CONCLUSION: The cost differences reflect the significantly increased total LOS, and repeat presentations associated with ILC. Therefore, ELC should be the preferred management strategy for AC.

Incidence of venous thromboembolism and its pharmacological prophylaxis in Asian general surgery patients: a systematic review.

BACKGROUND: Venous thromboembolism (VTE) is a condition that has always been perceived to be rare in Asia. The aim of this systematic review was to gather the current available evidence on the incidence of VTE in this population. A secondary aim was to assess the efficacy of pharmacological prophylaxis, and hence determine its role, in the Asian population. METHODS: A comprehensive literature search was performed using MEDLINE, Embase, and the Cochrane Database of Systematic Reviews in June 2014. Articles found using search terms related to venous thromboembolism (VTE), Asian countries and general surgery procedures and pathologies were screened using the following inclusion criteria: (1) either the population studied was primarily Asian or the study was conducted in an Asian country, (2) the subjects studied underwent a major gastrointestinal or other general surgery procedure, (3) the primary outcome was the incidence of deep vein thrombosis (DVT) or pulmonary embolus (PE), and (4) secondary outcomes assessed included mortality and complications due to the VTE or prophylaxis against VTE. RESULTS: Fourteen publications with a total of 11,218 patients were analyzed. Nine of the fourteen were observational studies, with half being prospective in nature. There were five interventional studies of which two were randomized controlled trials. Among the observational studies, the median (range) incidence of above-knee DVT was 0.08 % (0-2.9 %), while the median (range) incidence of PE was 0.18 % (0-0.58 %). The rates of DVT in the control groups were reported to be between 0 and 7.4 %, while the incidence of PE in the control groups ranged from 0 to 1.9 %. Analysis of the comparative studies revealed that the incidence of bleeding-related complications varied from 0 to 18.1 % in the low-molecular-weight heparin (LMWH) group compared to 0-7.5 % in the control group. The difference in minor bleeding complications between the LMWH group and the control group was found to be statistically significant. CONCLUSION: Data from this systematic review suggest that the risk of VTE in Asian general surgery patients is low, even in the context of risk factors typically regarded as high risk.

Predictors of therapy failure in a series of 741 adult pyogenic liver abscesses.

BACKGROUND: Adult pyogenic liver abscess (PLA) is a major hepato-biliary infection. We aim to identify risk factors associated with therapy failure. METHODS: Retrospective study of 741 PLA patients (2001-2011) and comparison with earlier data (1994-1997). Risk factors associated with therapy failure were identified with multivariate analysis. RESULTS: Incidence of PLA is 86/100 000 admissions, with average size 5.75 cm. 68% of PLA were secondary to Klebsiella pneumoniae and there is increasing extended-spectrum beta-lactamase (ESBL) resistance. Compared with 1990s, there is an increasing annual incidence (from 18 to 67). Elderly age (≥55-years-old), presence of multiple abscesses, malignancy as etiology and patients who underwent endoscopic intervention are independent predictors for failure of antibiotics-only therapy while average intravenous antibiotics duration and average abscess size are not. ECOG performance status ≥2, pre-existing hypertension and hyperbilirubinaemia are independent predictors for failure of percutaneous therapy while the presence of multiple abscesses and average abscess size are not. CONCLUSION: There is an increasing PLA incidence with increasing ESBL resistance. Percutaneous drainage should be considered early for elderly patients (≥55-years-old), with multiple abscesses, malignancy as etiology or who required endoscopic intervention. We should have a low threshold for surgical intervention for patients with ECOG performance status ≥2, co-morbidity of hypertension or hyperbilirubinaemia.