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.

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.

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.

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.