The influence of frailty on outcomes for older adults admitted to hospital with benign biliary disease: a single-centre, observational cohort study.

INTRODUCTION: The prevalence and complications of biliary disease increase with age. Frailty has been associated with adverse outcomes in the hospital setting. We describe the prevalence of frailty in older patients hospitalised with benign biliary disease and its association with duration of hospital stay, and 90-day and 1-year mortality. METHODS: We performed a retrospective cohort study of patients aged 75 years and over admitted with acute biliary disease between 17 September 2014 and 20 March 2017. Clinical Frailty Scale (CFS) score was recorded on admission. RESULTS: We included 200 patients with a median age of 82 (75-99) years, 60% were female; 154 (77%) were independent for personal activities of daily living (ADLs) and 99 (49.5%) for instrumental ADLs. Cholecystitis was the most common diagnosis (43%) followed by cholangitis (36%) and pancreatitis (21%). Ninety-nine patients were non frail (NF; CFS 1-4) and 101 were frail (F; CFS 5-9). Some 104 patients received medical treatment only. Surgery was more common in NF patients (11% vs F 2%), percutaneous drainage more frequently performed in F patients (15% vs NF 5%) and endoscopic cholangiopancreatography was similar in both groups (F 32% vs NF 31%). Frailty was associated with worse clinical outcomes in F vs NF: functional deconditioning (34% vs 11%), increased care level (19% vs 3%), length of stay (12 vs 7 days), 90-day mortality (8% vs 3%) and 1-year mortality (48% vs 24%). CONCLUSIONS: Half of patients in our cohort were frail and spent longer in hospital, were less likely to undergo surgery and were less likely to remain alive at 1 year after discharge.

Totally extraperitoneal repair for the 'sportsman's groin' via 'the Manchester Groin Repair': a comparison of elite versus amateur athletes.

BACKGROUND: Surgery has a recognised role in the treatment of 'sportsman's groin'. This study hypothesises that elite athletes have a superior advantage in both pre- and post-op rehabilitation and therefore will present and resume sporting activities quicker. METHODS: A retrospective analysis on a secure database of athletes presenting with groin pain that underwent surgery for 'inguinal disruption'. All data were explored via appropriate descriptive statistics and comparisons made between elite and amateur athletes. RESULTS: All patients were male (n = 144). The median age 33 years (range 14-72). The median return to sporting activity was 4.5 weeks (range 2.0-16.0) with one amateur athlete being unable to return to sporting activity. Using the mean of both sides, a comparison of VAS pain scores at pre-operative and 1 month post-operative time points showed a significant reduction (p < 0.001). Comparing 'elite' versus 'amateur' athletes, significant differences were seen in patient age (median 26 vs 40 years; p < 0.001), lead time to clinic presentation (median 62.0 vs 111.5 days; p = 0.004), and time to return to sporting activity (4 vs 5 weeks; p = 0.019). Additional MRI findings within the groin girdle were found in 89 patients (66.4%) and 34 patients (23.6%) had an MRI finding within the adductor tendon. CONCLUSION: The Manchester Groin Rrepair is an effective surgical management for 'inguinal disruption'. Elite athletes present quicker and return to sport sooner. Given the prevalence of other findings, a multidisciplinary approach to the 'sportsman's groin' is required.

Colorectal cancer with synchronous hepatic metastases: Systematic review of reports comparing synchronous surgery with sequential bowel-first or liver-first approaches.

BACKGROUND: The management of colorectal cancer with synchronous liver-limited metastases currently lacks randomised trial evidence to inform case selection for any of the bowel-first, liver-first or synchronous surgery routes. We examine the literature to report outcome data from reports utilising all three approaches. METHODS: A systematic review was conducted using OvidSP (including Embase, EBM Reviews and MEDLINE databases) to find articles reporting discrete peri-operative and long-term outcomes for patients undergoing sequential bowel-first, liver-first surgery or synchronous liver and bowel surgery. RESULTS: Of 223 unique citations, 3 cohort studies were identified comprising a pooled population of 1203 patients who completed treatment protocols between 1982 and 2011. Patients were allocated to bowel-first surgery (748 patients, 62.2%), liver-first surgery (75, 6.2%) or synchronous liver/bowel surgery (380, 31.6%). Minor complications were similar between procedures. Major complications were consistent with a pooled fixed estimate of 9.1% (95%CI: 7.6%-10.8%, I(2) = 48%). Post-operative death was rare and consistent with a pooled fixed effect estimate of 3.1% (95%CI: 2.2%-4.3%, I(2) = 0%). Median follow-up ranged from 25.1 to 40.0 months, with a pooled underlying 5-year survival fixed effect estimate of 44% (I(2) = 39%). CONCLUSION: This review assesses outcomes of patients with colorectal cancer with synchronous liver metastases managed by either synchronous, sequential liver-first or bowel-first surgery. Overall treatment-related mortality is low and survival is similar among the three groups. These findings provide support for the continued use of all three pathways until better evidence to guide selection of an individual treatment option is available.

Complicated liver echinococcosis: 30 years of experience from an endemic area.

BACKGROUND AND AIMS: Although declining, cystic echinococcosis is still a serious public health issue in Greece. This study evaluated the clinical features, management, and short-term outcome of patients with complicated liver echinococcosis. MATERIAL AND METHODS: A total of 227 patients who were operated on for 322 echinococcal cysts of the liver were retrospectively evaluated. Patients were divided into those with complicated disease (53.7%) and those with noncomplicated disease (46.3%). Intrabiliary rupture (34.4%), cyst infection (32.7%), and their combination (24.5%) were the most common complications. Demographic characteristics, previous hydatid cyst surgery, cyst multiplicity and location, presenting symptoms and signs, types of complicated disease, operative procedures performed, postoperative complications, and hospital stay were assessed. RESULTS: Patient demographics and cyst characteristics demonstrated no significant difference between the two groups. The complicated disease group had significantly more pronounced clinical presentations and higher postoperative morbidity. Choice of surgical procedure depended upon cyst location and surgeon preference. Both conservative and radical procedures were performed, supplemented with additional management of the biliary tree when indicated. CONCLUSIONS: Complicated liver echinococcosis demonstrates several distinct features that differentiate it from the noncomplicated disease. Frequently severe clinical manifestations, complexity of surgical management, and the increased postoperative complications characterize complicated liver echinococcal disease.

Current management of diverticular disease complications.

Diverticular disease is a common problem in the western population and sometimes leads to serious complications such as hemorrhage, bowel stenosis, obstruction, abscesses, fistulae, bowel perforation, and peritonitis. The severity of these complications can differ, and it is not always clear which procedure is indicated in each case and what measures should be followed before bringing the patient into the operating room. Certain operations have high rates of morbidity and mortality, especially in compromised patients. Along with advancements in imaging and minimally invasive techniques, the indications for surgery have currently being adapted to "damage limitation" or "down-staging" protocols, which seem to offer improved results. There are still some questions to be solved in the following years by prospective studies, such as the usefulness of laparoscopic lavage in purulent peritonitis or of Hartmann's procedure in fecal peritonitis. These indications, based on current literature, are systematically discussed in the present review.

Clinical features of colonic diverticular disease.

Colonic diverticular disease is extremely common in developed countries. Although the majority of patients with diverticulosis remain asymptomatic, about one-third of the patients manifest the disease with either hemorrhage or inflammation. Diverticulitis may be uncomplicated or complicated by abscess formation, perforation with peritonitis, fistula, intestinal obstruction, or stricture. Controversy exists regarding the aggressiveness of diverticulitis during recurrent attacks of the disease as well as in special groups of patients including immunocompromised patients, young patients, and patients with right-sided disease. Clinical characteristics of symptomatic uncomplicated disease can be similar to irritable bowel syndrome, while acute diverticulitis is sometimes difficult to distinguish from segmental colitis associated with diverticulosis. The considerable clinical overlap between those entities with diverticular disease demonstrates that there are still areas of uncertainty in their physiopathology.

Tension-free by mesh-plug technique for inguinal hernia repair in elderly patients.

BACKGROUND: elderly patients are steadily becoming a growing part of the population. The aim of this study is to evaluate the outcome of open inguinal hernia repair in patients aged over 65 years. METHODS: from January 1999 to December 2008, a total of 719 patients underwent open tension-free inguinal hernia repair with mesh-plug; 301 among them were ≥ 65 years old. RESULTS: elderly patients had a mean age of 72.4 years (women 3.3%), while the mean age of younger patients was 48.7 years (women 5.7%). According to the ASA score, patients aged ≥ 65 years were at significantly higher risk than the younger patients. Spinal anesthesia was used most frequently in both groups. No significant differences were found in postoperative pain, mortality and recurrence. Morbidity and hospital stay were significantly higher in patients aged ≥ 65 years. CONCLUSIONS: open hernia repair in the elderly is safe and well tolerated, but it is associated with higher morbidity and longer hospitalization.