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Introduction Pancreaticoduodenectomy is technically challenging with high risk of major morbidity. Morbidity is associated with patient comorbidities and reduced functional reserves. Prehabilitation aims to restore and enhance physiologic function with intent to reduce post-operative morbidity, and improve clinical outcomes. This study aims to compare the impact of an outpatient prehabilitation program (PP) in patients undergoing elective pancreaticoduodenectomy versus standard care (SC). Methods This is a prospective cohort study comparing patients who underwent PP versus SC prior to elective pancreaticoduodenectomy from January 2016 to December 2020. The PP includes dietician, physiotherapist, case manager and anaesthesia services. Outcomes evaluated include post-operative morbidity, length of stay and 30-day mortality. Results Fifty (68.5%) and 23 (31.5%) patients with median age of 65 years (interquartile range [IQR], 58-71 years) received PP and SC respectively. Sixty (82.2%), four (5.5%), and nine (12.3%) patients underwent open, laparoscopic surgery, and laparoscopic surgery with open conversion respectively. Ductal adenocarcinoma was the most common histology (50.7%). Patient demographics were comparable between both groups. Length of stay (days) (PP: 12.5 [IQR 9-17.3], SC: 10 [IQR 8-16]; p = 0.162), overall morbidity (PP: n = 28/50 [56.0%]; SC: n = 11/23 [47.8%]; p = 0.516), postoperative pancreatic fistula (PP: n = 12/50 [24.0%], SC: n = 3/23 [13.0%]; p = 0.289), intra-abdominal collection (PP: n = 11/50 [22.0%], SC: 6/23 [26.1%], p = 0.701) and delayed gastric emptying (PP: n = 4/50 [8.0%], SC: 3/23 [13.0%], p = 0.501) were similar. Overall 30-day readmission rate was 24.7% (n = 18) and 30-day mortality was 1.4% (n = 1). Conclusions Prehabilitation for patients undergoing pancreaticoduodenectomy did not improve post-operative outcomes, possibly due to selection bias. Exercise program compliance, functional capacity and quality of life should be assessed for future studies evaluating prehabilitation programs.

Backgrounds/aims Gas-forming pyogenic liver abscess (GFPLA) has an incidence of up to 30% of all pyogenic liver abscesses (PLA). GFPLA has higher mortality compared to non-GFPLA. Mere presence of gas within abscess may not determine clinical outcome. Hence it is important to study biologic characteristics that make GFPLA a distinct clinical entity. The aim of this study was to conduct a world review on GFPLA. Methods We conducted literature searches in PubMed using the following MeSH terms: "gas forming" AND "Liver abscess, pyogenic", "gas" AND "Liver abscess, pyogenic", "gas" AND "Liver abscess", "gas forming" AND "Liver abscess". Thirteen case series including 313 GFPLA patients were included. Age, gender, diabetes mellitus (DM), bacteriology, underlying etiology, symptoms, investigations, operative indications, and mortality rates were tabulated. Results GFPLA is often cryptogenic. There was no difference in age, gender, or symptomatology between GFPLA and non-GFPLA patients. DM was more common in patients with GFPLA compared to that in non-GFPLA patients (mean: 83.5% vs. 38.3%). Klebsiella pneumoniae is the most common causative pathogen. GFPLA has higher mortality compared to non-GFPLA (mean: 30.3% vs. 9%). Conclusions GFPLA is associated with DM and monomicrobial Klebsiella pneumoniae infection. GFPLA has high mortality. It needs to be recognized as a distinct clinical entity.

A 67-year-old lady was managed with percutaneous cholecystostomy for severe acute cholecystitis with septic shock. An interval laparoscopic subtotal cholecystectomy was done at 8 weeks. Her post-operative phase was complicated by intra-abdominal abscess requiring radiologically guided percutaneous drain insertion. Five days following the removal of the drain, she presented with a right abdominal wall abscess. A computerized tomography scan showed an abdominal wall ectopically-retained gallstone. The gallstone was retrieved along with drainage of abscess.

Follicular dendritic cell sarcoma (FDCS) is a rare tumor, and it is even rarer for FDCS, to affect liver. FDCS is recognized as a distinct entity by the World Health Organization (WHO). Diagnosis is usually post resection and based on typical immunohistochemical stains. Resection with histologic negative margins is proposed, as a mainstay of therapy. We report a 63-year-old woman with large FDCS of the liver, managed with right hemihepatectomy. She remains disease-free at 48 months.

Percutaneous transhepatic biliary drainage (PTBD) is safe treatment for biliary decompression given certain indications. However, this is temporary until definitive drainage is established. We report on a 76-year-old lady with recurrent pyogenic cholangitis and PTBD catheter fracture. She had hepatitis B virus-related Child-Pugh class A liver cirrhosis, hypothyroidism, hyperlipidaemia, and previous atrial fibrillation with a background of mild mitral, tricuspid and aortic valvular regurgitation. She had history of laparoscopic cholecystectomy in the past. She was deemed to be a high operative risk and declined hepatic resection. She had undergone multiple endoscopic and percutaneous biliary interventions to control sepsis and stone burden. A bilateral PTBD catheter was left in situ with plans for 3-monthly change. However, she defaulted follow-up and presented 11 months later with complaints of pain over the drain site and inability to flush the right catheter. Abdominal X-ray and computed tomography scans detected right catheter fracture at two places, making three fragments. She underwent percutaneous removal of the proximal fragment by an interventional radiology team. A temporary 4 Fr catheter was inserted to maintain biliary access. Endoscopic removal of the intra-biliary fragments was done the next day. Complete removal was confirmed on fluoroscopy. Finally, the 4 Fr catheter was replaced by a new 12 Fr catheter. The patient was discharged well.

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.

We report a 75-year old patient, presenting with acute abdomen and hemorrhagic shock. He provided history of right hemihepatectomy performed 5 years ago, for ruptured hepatocellular carcinoma on a background of Hepatitis B virus associated liver cirrhosis. A computerized tomography scan showed 5 cm-sized mass exophytic lesion, in the small bowel with haemoperitoneum. An emergency laparotomy and small bowel resection, with primary anastomosis was performed. Histology showed Hep Par 1 stain reactive cells, on the serosal surface of the small bowel. A final diagnosis of metastatic hepatocellular carcinoma was made.

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