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Background Old age is associated with increased co-morbidities, resulting in reduced life expectancy. Primary endocrine therapy is an alternative to primary surgical therapy for patients with breast cancer and increased co-morbidities. The aim was to review outcomes of primary endocrine therapy versus primary surgical therapy in older women with breast cancer. Methods PubMed, Embase (Ovid), Scopus, and the Cochrane Library were searched systematically from January 2000 to May 2022. Single-arm studies were excluded. Primary outcomes were overall survival and breast cancer-specific survival. Secondary outcomes were local and regional failure of primary endocrine therapy, recurrence after primary surgical therapy, and health-related quality of life. Results There were 14 studies including 14 254 patients (primary endocrine therapy 2829, 19.8 per cent; primary surgical therapy 11 425, 80.2 per cent), with the addition of four major studies (9538 patients) compared with the latest review in 2014. Seven studies defined primary surgical therapy as surgery plus adjuvant endocrine therapy, and six studies included patients with oestrogen receptor-positive tumours only. Patients in the primary endocrine therapy group were older than the primary surgical therapy group (mean difference 2.43 (95 per cent c.i. 0.73 to 4.13) years). Primary endocrine therapy led to worse overall survival than primary surgical therapy (HR 1.42, 95 per cent c.i. 1.06 to 1.91). Subgroup analysis of RCTs and prospective studies, however, showed comparable overall survival. Breast cancer-specific survival was also comparable (HR 1.28, 95 per cent c.i. 0.87 to 1.87). At 6 weeks, operated patients had significant arm symptoms and illness burden following major breast surgery compared with patients receiving primary endocrine therapy. Health-related quality of life, measured by the European Organization for Research and Treatment of Cancer QLQ-C30 and EuroQol EQ-5D-5L™, was comparable in the two treatment groups. Conclusion Overall survival was worse among older women receiving primary endocrine therapy in an analysis including all studies, but comparable in RCTs and prospective studies. This may be due to confounding by age and co-morbidities in retrospective cohort studies of primary endocrine therapy.

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.

Surgical videos uploaded on social media platforms like YouTube augment the learning experience of advanced procedures like major laparoscopic liver resection (LLR). However, because of the heterogeneous quality, the educational value of such videos is unproven. This study assesses the educational value of YouTube's top 20 most viewed major LLR videos.The search terms "laparoscopic hemihepatectomy," "laparoscopic right hepatectomy," and "laparoscopic left hepatectomy" were searched on YouTube on October 7, 2020. Exclusion criteria were minor hepatectomy, open hepatectomy, live donor right and left hepatectomy, robotic hepatectomy videos, and nonstandard laparoscopic technique. Videos were graded based on adherence to key steps in LLR and compliance to the modified LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS); 29 of the original 37 consensus statements were used in our study.The videos have a median of 7647 views (range: 2675 to 67,449), a median of 34 likes (range: 3 to 67), and a median of 1 dislike (range: 0 to 22). The median duration of major LLR videos was 11.0 minutes (range: 6.38 to 223 min). Majority of the videos had duration of30 minutes (n=18/20, 90%). There were 14 videos (70%) demonstrating all defined surgical steps. The liver mobilization was shown in 17 videos (75%). Vascular inflow control of hepatic artery and portal vein and vascular outflow control were demonstrated in 18 videos (90%). Parenchymal transection and hemostasis were shown in all videos. The median LAP-VEGaS score across all 20 videos is 6 (range: 1 to 11) out of 29, translating to a median score of 20.6% (range: 3.4% to 37.9%). Thirteen out of 29 of the LAP-VEGaS criteria graded (44.8%) were not met by any of the 20 videos.The top 20 most viewed surgical videos on laparoscopic right and left hepatectomy may not be the ideal material for the educational value of surgical trainees. The LAP-VEGaS guidelines are too exhaustive for relevance to social media platforms as an educational tool.

SummaryMinimally invasive esophagectomy (MIE) has been shown to be superior to open esophagectomy with reduced morbidity, mortality, and comparable lymph node (LN) harvest. However, MIE is technically challenging. This study aims to perform a pooled analysis on the number of cases required to surmount the learning curve (LC), i.e. NLC in MIE. PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 2022. Inclusion criteria were articles that reported LC in video-assisted MIE (VAMIE) and/or robot-assisted MIE (RAMIE). Poisson means (95% confidence interval [CI]) was used to determine NLC. Negative binomial regression was used for comparative analysis. There were 41 articles with 45 data sets (n = 7755 patients). The majority of tumors were located in the lower esophagus or gastroesophageal junction (66.7%, n = 3962/5939). The majority of data sets on VAMIE (n = 16/26, 61.5%) used arbitrary analysis, while the majority of data sets (n = 14/19, 73.7%) on RAMIE used cumulative sum control chart analysis. The most common outcomes reported were overall operating time (n = 30/45) and anastomotic leak (n = 28/45). Twenty-four data sets (53.3%) reported on LN harvest. The overall NLC was 34.6 (95% CI: 30.4–39.2), 68.5 (95% CI: 64.9–72.4), 27.5 (95% CI: 24.3–30.9), and 35.9 (95% CI: 32.1–40.2) for hybrid VAMIE, total VAMIE, hybrid RAMIE, and total RAMIE, respectively. NLC was significantly lower for total RAMIE compared to total VAMIE (incidence rate ratio: 0.52, P = 0.032). Studies reporting NLC in MIE are heterogeneous. Further studies should clearly define prior surgical experiences and assess long-term oncological outcomes using non-arbitrary analysis.

The mainstay of surgical management of perforated peptic ulcer is omental patch repair. Advances in minimally invasive techniques have shown feasibility of laparoscopic omental patch repair (LOPR). Laparoscopic omental patch repair is limited by learning curve (LC), but there is a lack of reporting of LC in LOPR. This study aims to compare outcomes following LOPR versus open omental patch repair (OOPR) with reporting of LC.PubMed, Embase, The Cochrane Library, and Scopus were systematically searched from inception till January 2022 for randomized controlled trials (RCTs) and non-RCTs comparing LOPR and OOPR in perforated peptic ulcer. Exclusion criteria were primary repair without use of omental patch repair. Primary outcomes were 30-day mortality, postoperative leak, and LC analysis.There were a total of 29 studies including 5,311 patients (LOPR, n = 1,687; OOPR, n = 3,624), with 4 RCTs with 238 patients (LOPR, n = 118; OOPR, n = 120). Majority of ulcers were located in the duodenum (57.0%) followed by stomach (30.7%). Mean ulcer size ranged from 5 to 16.2 mm in LOPR and 4.7 to 15.8 mm in OOPR. Laparoscopic omental patch repair was associated with lower 30-day mortality (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.35-0.92; p = 0.02), overall morbidity (OR, 0.31; 95% CI, 0.18-0.53; p0.0001), surgical site infection (OR, 0.27; 95% CI, 0.18-0.42; p0.00001), and length of stay (mean difference, -2.84 days; 95% CI, -3.63 to -2.06; p0.00001). Postoperative leakage (OR, 1.06; 95% CI, 0.43-2.61; p = 0.90) was comparable between LOPR and OOPR. Only three studies analyzed the proportion of consultants to trainees; LOPR was performed mainly by consultants (range, 82.4-91.4%), while OOPR was mainly performed by trainees (range, 52.8-96.8%). One study showed that consultants who performed open conversion had shorter operating time compared with chief residents (85 vs. 186.6 minutes, p0.003).Laparoscopic omental patch repair has lower mortality, overall morbidity, length of stay, intraoperative blood loss, and postoperative pain compared with OOPR. More prospective studies should be conducted to evaluate LC in LOPR.Systematic Review and Meta-Analysis; Level IV.

Chronic venous insufficiency is a chronic disease of the venous system with a prevalence of 25% to 40% in females and 10% to 20% in males. Venous leg ulcers (VLUs) result from venous insufficiency. VLUs have a prevalence of 0.18% to 1% with a 1‐year recurrence of 25% to 50%, bearing significant socioeconomic burden. It is therefore important for regular assessment and monitoring of VLUs to prevent worsening. Our study aims to assess the intra‐ and inter‐rater reliability of a machine learning‐based handheld 3‐dimensional infrared wound imaging device (WoundAide [WA] imaging system, Konica Minolta Inc, Tokyo, Japan) compared with traditional measurements by trained wound nurse. This is a prospective cross‐sectional study on 52 patients with VLUs from September 2019 to January 2021 using three WA imaging systems. Baseline patient profile and clinical demographics were collected. Basic wound parameters (length, width and area) were collected for both traditional measurements and measurements taken by the WA imaging systems. Intra‐ and inter‐rater reliability was analysed using intra‐class correlation statistics. A total of 222 wound images from 52 patients were assessed. There is excellent intra‐rater reliability of the WA imaging system on three different image captures of the same wound (intra‐rater reliability ranging 0.978‐0.992). In addition, there is excellent inter‐rater reliability between the three WA imaging systems for length (0.987), width (0.990) and area (0.995). Good inter‐rater reliability for length and width (range 0.875‐0.900) and excellent inter‐rater reliability (range 0.932‐0.950) were obtained between wound nurse measurement and each of the WA imaging system. In conclusion, high intra‐ and inter‐rater reliability was obtained for the WA imaging systems. We also obtained high inter‐rater reliability of WA measurements against traditional wound measurement. The WA imaging system is a useful clinical adjunct in the monitoring of VLU wound documentation.

There is a lifetime risk of 15% to 25% of development of diabetic foot ulcers (DFUs) in patients with diabetes mellitus. DFUs need to be followed up on and assessed for development of complications and/or resolution, which was traditionally performed using manual measurement. Our study aims to compare the intra‐ and inter‐rater reliability of an artificial intelligence‐enabled wound imaging mobile application (CARES4WOUNDS [C4W] system, Tetsuyu, Singapore) with traditional measurement. This is a prospective cross‐sectional study on 28 patients with DFUs from June 2020 to January 2021. The main wound parameters assessed were length and width. For traditional manual measurement, area was calculated by overlaying traced wound on graphical paper. Intra‐ and inter‐rater reliability was analysed using intra‐class correlation statistics. A value of 0.9 indicates poor, moderate, good, and excellent reliability, respectively. Seventy‐five wound episodes from 28 patients were collected and a total of 547 wound images were analysed in this study. The median wound area during the first clinic consultation and all wound episodes was 3.75 cm2 (interquartile range [IQR] 1.40–16.50) and 3.10 cm2 (IQR 0.60–14.84), respectively. There is excellent intra‐rater reliability of C4W on three different image captures of the same wound (intra‐rater reliability ranging 0.933–0.994). There is also excellent inter‐rater reliability between three C4W devices for length (0.947), width (0.923), and area (0.965). Good inter‐rater reliability for length, width, and area (range 0.825–0.934) was obtained between wound nurse measurement and each of the C4W devices. In conclusion, we obtained good inter‐rater and intra‐rater reliability of C4W measurements against traditional wound measurement. The C4W is a useful adjunct in monitoring DFU wound progress.

BACKGROUND Acute cholangitis (AC) is a disease spectrum with varying extent of severity. Age ≥ 75 years forms part of the criteria for moderate (Grade II) severity in both the Tokyo Guidelines (TG13 and TG18). Aging is associated with reduced physiological reserves, frailty, and sarcopenia. However, there is evidence that age itself is not the determinant of inferior outcomes in elective and emergency biliary diseases. There is a paucity of reports comparing clinical outcomes amongst elderly patients vs non-elderly patients with AC. AIM To investigate the effect of age (≥ 80 years) on AC's morbidity and mortality using propensity score matching (PSM). METHODS This is a single-center retrospective cohort study of all patients diagnosed with calculous AC (January 2016 to December 2016) and ≥ 80 years old (January 2012 to December 2016) at a tertiary university-affiliated teaching hospital. Inclusion criteria were patients who were treated for suspected or confirmed AC secondary to biliary stones. Patients with AC on a background of hepatobiliary malignancy, indwelling permanent metallic biliary stents, or concomitant pancreatitis were excluded. Elderly patients were defined as ≥ 80 years old in our study. A 1:1 PSM analysis was performed to reduce selection bias and address confounding factors. Study variables include comorbidities, vital parameters, laboratory and radiological investigations, and type of biliary decompression, including the time for endoscopic retrograde cholangiopancreatography (ERCP). Primary outcomes include in-hospital mortality, 30-d and 90-d mortality. Length of hospital stay (LOS) was the secondary outcome. RESULTS Four hundred fifty-seven patients with AC were included in this study (318 elderly, 139 non-elderly). PSM analysis resulted in a total of 224 patients (112 elderly, 112 non-elderly). The adoption of ERCP between elderly and non-elderly was similar in both the unmatched (elderly 64.8%, non-elderly 61.9%, P = 0.551) and matched cohorts (elderly 68.8% and non-elderly 58%, P = 0.096). The overall in-hospital mortality, 30-d mortality and 90-d mortality was 4.6%, 7.4% and 8.5% respectively, with no statistically significant differences between the elderly and non-elderly in both the unmatched and matched cohorts. LOS was longer in the unmatched cohort [elderly 8 d, interquartile range (IQR) 6-13, vs non-elderly 8 d, IQR 5-11, P = 0.040], but was comparable in the matched cohort (elderly 7.5 d, IQR 5-11, vs non-elderly 8 d, IQR 5-11, P = 0.982). Subgroup analysis of patients who underwent ERCP demonstrated the majority of the patients (n = 159/292, 54.5%) had delayed ERCP (> 72 h from presentation). There was no significant difference in LOS, 30-d mortality, 90-d mortality, and in-hospital mortality in patients who had delayed ERCP in both the unmatched and matched cohort (matched cohort: in-hospital mortality [n = 1/42 (2.4%) vs 1/26 (3.8%), P = 0.728], 30-d mortality [n = 2/42 (4.8%) vs 2/26 (7.7%), P = 0.618], 90-d mortality [n = 2/42 (4.8%) vs 2/26 (7.7%), P = 0.618], and LOS (median 8.5 d, IQR 6-11.3, vs 8.5 d, IQR 6-15.3, P = 0.929). CONCLUSION Mortality is indifferent in the elderly (≥ 80 years old) and non-elderly patients (< 80 years old) with AC.

Ilio-femoral deep vein thrombosis (DVT) is rare in patients with lower limb arterio-venous grafts due to a state of high blood flow. May-Thurner syndrome (MTS) is an anomaly where the left common iliac vein is compressed by the right common iliac artery. We present a rare case of ilio-femoral deep vein thrombosis in a patient with May-Thurner Syndrome and an underlying arteriovenous graft in-situ who presented with acute lower limb swelling. The patient underwent catheter-directed thrombolysis, pharmaco-mechanical thrombectomy, venoplasty and iliac vein stenting. Follow-up surveillance duplex ultrasound showed patency of the iliac vein stent and arteriovenous graft at 1-year postoperatively.

Background Assessment of preoperative handgrip strength (HGS) is an objective and inexpensive bedside tool, which has been investigated to predict morbidity risk in elective surgery. However, its use is not validated in patients undergoing major elective hepatobiliary surgery (MEHS). The aim of this study is to investigate the use of HGS to predict morbidity in patients undergoing MEHS. Methods This is a single-center prospective study involving 81 patients who underwent MEHS over 21 mo from July 2014 to March 2016. MEHS was defined as any hepatobiliary surgery expected to last more than 2 h and/or with an anticipated blood loss of ≥500 mL. HGS was assessed in both dominant and nondominant hands with standardization and subsequently recorded and expressed as a percentage of a general, age- and gender-matched normative values. Results The mean age was 65.2 ± 9.5 y with male predominance (n = 52, 64.2%). Approximately, half of the patients underwent liver resection (n = 43, 53.1%). There was no difference in the incidence of Clavien–Dindo ≥ grade IIIA in both dominant HGS (impaired HGS 8/33 [24.2%], normal HGS 6/48 [12.5%]; P = 0.170) and nondominant HGS (impaired HGS 8/33 [21.1%], normal HGS 6/43 [14%]; P = 0.399). Dominant and nondominant HGS showed poor discriminatory ability in the prediction of Clavien–Dindo ≥ grade IIIA complications (dominant HGS area under the curve [AUC] = 0.572; nondominant HGS AUC 0.545). However, the use of dominant HGS showed moderate discriminatory ability to predict the length of hospital stay ≥21 d (AUC = 0.759). Conclusions The use of HGS may not predict Clavien–Dindo ≥ grade IIIA complications, but predicts a prolonged length of hospital stay ≥21 d.

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide [1]. Screening at-risk patients aid early diagnosis and improve survival. Tumor stage, liver (dys)function, patient co-morbi...

Splenosis is defined as the autotransplantation of viable splenic tissue throughout various anatomic compartments. Intrahepatic splenosis (IHS) is rare and diagnosis is often challenging. This study aims to provide a comprehensive review on IHS. A literature review was performed on PubMed database. Fifty-six articles with 59 reported cases were included. The majority of the patients were male (n = 49, 83.1%). Median age was 51 years. Risk factors for hepatocellular carcinoma (HCC) included hepatitis B (n = 8, 13.6%) and cirrhosis (n = 12, 20.3%). The majority of the patients were asymptomatic (62.7%) and did not have risk factors for HCC (55.9%). We report a diagnostic triad for IHS: 1) previous history of abdominal trauma or splenectomy, 2) absence of risk factors for liver malignancy and 3) typical imaging features. Non-invasive diagnostic tests such as technetium-99m-tagged heat-damaged red blood cell scintigraphy are useful in diagnosis. Malignancy should be ruled out in the presence of risk factors for HCC.

Patients with diabetes mellitus have a lifetime risk of 15% to 25% of developing diabetic foot ulcers (DFUs). DFU is associated with significant morbidity and mortality. Wound imaging systems are useful adjuncts in monitoring of wound progress. Our study aims to review existing literature on the available wound assessment and monitoring systems for DFU. This is a systematic review of articles from PubMed and Embase (1974 – March 2020). All studies related to wound assessment or monitoring systems in DFUs were included. Articles on other types of wounds, review articles, and non‐English texts were excluded. Outcomes include clinical use, wound measurement statistics, hospital system integration, and other advantages and challenges. The search identified 531 articles. Seventeen full‐text studies were eligible for the final analysis. Five modalities were identified: (a) computer applications or hand‐held devices (n = 5), (b) mobile applications (n = 2), (c) optical imaging (n = 2), (d) spectroscopy or hyperspectral imaging (n = 4), and (e) artificial intelligence (n = 4). Most studies (n = 16) reported on wound assessment or monitoring. Only one study reported on data capturing. Two studies on the use of computer applications reported low inter‐observer variability in wound measurement (inter‐rater reliability >0.99, and inter‐observer variability 15.9% respectively). Hand‐held commercial devices demonstrated high accuracy (relative error of 2.1%‐6.8%). Use of spectroscopy or hyperspectral imaging in prediction of wound healing has a sensitivity and specificity of 80% to 90% and 74%to 86%, respectively. Majority of the commercially available wound assessment systems have not been reviewed in the literature on measurement accuracy. In conclusion, most imaging systems are superior to traditional wound assessment. Wound imaging systems should be used as adjuncts in DFU monitoring.

Backgrounds/Aims: Prehabilitation aims for preoperative optimisation to reduce postoperative complications. However, there is a paucity of data on its use in patients undergoing pancreaticoduodenectomy (PD). Thus, this study aims to evaluate the outcomes of a home-based outpatient prehabilitation program (PP) versus no-PP in patients undergoing PD. Methods: This retrospective cohort study compared patients who underwent PP versus no-PP before elective PD from January 2016 to December 2020. Inclusion criteria for PP were < 65 years or 65–74 years with FRAIL score < 3. No-PP included dietician, case manager and anesthesia review. PP included additional physiotherapy sessions, caregiver training and interim phone consultation. Univariate and multivariate analysis were used to evaluate length of stay (LOS), morbidity, 30-day readmission, and 90-day mortality. Results: Seventy-one patients (PP: n = 50 [70.4%]; no-PP: n = 21 [29.6%]) were included in this study. Median age was 65 years (inter-quartile range [IQR]: 58–72 years). Majority (n = 58 [81.7%]) of patients underwent open surgery. Ductal adenocarcinoma was the most common histology (49.3%). Patient demographics were comparable between both groups. Overall median LOS was 11.0 days (IQR: 8.0–17.0 days). Compared to no-PP, PP was not independently associated with reduced intra-abdominal collections (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.03–6.11, p = 0.532), major morbidity (OR: 1.31; 95% CI: 0.09–19.47; p = 0.845) or 30-day readmission (OR: 3.16; 95% CI: 0.26–38.27; p = 0.365). There was one (1.4%) 30-day mortality. Conclusions: Our outpatient PP with unsupervised exercise regimes did not improve postoperative outcomes following elective PD. Published version

Phosphate is an essential electrolyte for proper mineralisation of bone, buffering of urine, and diverse cellular actions. Hypophosphatemia (HP) is a clinical spectrum which range from asymptomatic to severe complications such as neuromuscular and pulmonary complications, or even death. Post-hepatectomy HP (PHH) has been reported to be 55.5%-100%. Post-hepatectomy, there is rapid uptake of phosphate and increased mitotic counts to aid in regeneration of residual liver. Concurrently, PHH may be due to increased urinary phosphorous from activation of matrix extracellular phosphoglycoprotein in the injured liver, which decreases phosphate influx into hepatocytes to sustain adenosine triphosphate synthesis. A literature review was performed on PubMed till January 2022. We included 8 studies which reported on impact of PHH on post-operative outcomes. In patients with diseased liver, PHH was reported to have either beneficial or deleterious effects on post-hepatectomy liver failure (PHLF), morbidity and/or mortality in various cohorts. In living donor hepatectomy, PHLF was higher in PHH. Benefits of correction of PHH with reduced post-operative complications have been shown. Correction of PHH should be done based on extent of PHH. Existing studies were however heterogenous; further studies should be conducted to assess PHH on post-operative outcomes with standardized phosphate replacement regimes. Published version

The impact of obesity on trauma outcomes had been equivocal and the majority of these studies were conducted in the Western population. The aim of our study is to evaluate the impact of obesity on morbidity and mortality in Singaporean patients after trauma.A retrospective case control study of trauma patients admitted to a tertiary institution was performed. Patients admitted for both blunt and penetrating trauma who are aged 16 years and above were included. Propensity score matching (PSM) was performed to reduce selection bias.A total of 5239 patients were reviewed (obese 648, non-obese 4591). Median age was 76 (IQR 63-83) years. Median BMI was 22.8 kg/mObese trauma patients had fewer head injuries, fewer ICU admissions but comparable mortality rates. Obesity was also associated with higher incidence of venous thromboembolism in the matched cohort.

The use of glue as a mesh fixator in open Lichtenstein inguinal hernia repair (IHR) has gained popularity to reduce recurrence and postoperative complications. This meta-analysis aims to provide an up-to-date review to compare glue versus suture fixation in primary open Lichtenstein IHR.PubMed, Embase, The Cochrane Library, Web of Science, and Springer were systematically searched till June 2021 for randomized controlled trials (RCTs) comparing glue versus suture fixation in open Lichtenstein IHR. Primary outcomes were early (at 1 year) and late recurrence (5 years or more). Secondary outcomes were the length of operation, postoperative haematoma and seroma, and chronic pain at 1 year.A total of 17 RCTs with 3150 hernias (glue n = 1582, suture n = 1568) were included. Only three studies reported late recurrence. Glue fixation was associated with shorter operative duration (MD - 4.17, 95% CI - 4.82, - 3.52; p 0.001 and a lower incidence of haematoma formation (OR 0.51, 95% CI 0.32, 0.81; p = 0.004). There was no significant difference in postoperative seroma (OR 0.72, 95% CI 0.35, 1.49; p = 0.38), chronic pain after 1 year (OR 1.10, 95% CI 0.73, 1.65; p = 0.65), early recurrence (OR 1.11, 95% CI 0.45, 2.76; p = 0.81, IEarly and late recurrence were comparable between glue and suture fixation in open Lichtenstein IHR patients. Glue fixation had shorter operating time and lower haematoma formation than suture fixation. Chronic pain and seroma formation were comparable. More RCTs should report long-term outcomes.

Mortality of pyogenic liver abscess (PLA) is high ranging 10%-40%. Old age predicts outcomes in many diseases but there is paucity of data on PLA outcomes. We aim to compare the morbidity and mortality between elderly and non-elderly in PLA.This is a retrospective study from 2007-2011 comparing elderly (≥ 65 years old) and non-elderly (65 years old) with PLA. A 1:1 propensity score matching (PSM) was performed. Baseline clinical profile and outcomes were compared.There were 213 patients (elderly patients = 90 [42.3%], non-elderly patients = 123 [57.7%]). Overall median age is 62 (interquartile range [IQR] = 53-74) years old. PSM resulted in 102 patients (51 per arm). Length of hospitalisation stay (LOS) was significantly longer in elderly patients in both unmatched (16 [IQR = 10-24.5] versus 11 [IQR = 8-19] days;Age ≥ 65 years old is associated with longer LOS. In-hospital mortality though higher in elderly patients, was not statistically significant.

Incisional negative wound pressure therapy (iNPWT) use on closed incisions has been shown to improve wound outcomes, but no studies have evaluated the use of iNPWT following brachiobasilic transposition arteriovenous fistula (BBT‐AVF). We aim to investigate the efficacy of iNPWT vs conventional wound therapy in reducing surgical site infections (SSIs) for BBT‐AVF incisions. This is a retrospective cohort study of patients who underwent BBT‐AVF creation between January 2010 and December 2017. A 1:2 propensity score matching (PSM) was performed to reduce selection bias and address for confounding factors. Study outcomes included SSI and haematoma incidence, 30‐day readmission, and 30‐day mortality. A total of 154 patients were reviewed in this study: 47 (30.5%) had iNPWT and 107 (69.5%) had conventional wound therapy. The overall median age was 60.5 (interquartile range 54–69). PSM with a 1:2 ratio resulted in a total of 117 patients (39 iNPWT and 78 conventional wound therapy). In the unmatched cohort, SSI incidence was lower in the iNPWT group (n = 1/47 [2.1%] vs n = 14/107 [13.1%], P = .035). However, incidence of SSI was comparable between iNPWT and conventional wound therapy after matching (n = 1/39 [2.6%] vs n = 9/78 [11.5%], P = .102). There was no significant difference in 30‐day readmission and 30‐day mortality. Within our study population of patients with BBT‐AVF incisions, there is a non‐statistically significant reduction in SSI incidence for patients who received iNPWT as compared with conventional wound therapy. Further prospective randomised controlled studies should be conducted to validate these findings.

Cholecystectomy is considered a general surgical operation. However, general surgeons are not trained to manage severe complications such as bile duct injury (BDI) and should refer to hepatopancreatobiliary (HPB) surgeons when difficulty arises. This study aimed to investigate the outcomes of patients who had on-table HPB consults during cholecystectomy.This is an audit of 50 patients who required on-table HPB consult during cholecystectomy from 2011 to 2017. Consultations were classified as "proactive" and "reactive", where consults were made before or after surgical incision, respectively. Patient demographics and perioperative details were collected.The median age of the patients was 62.5 years [interquartile range (IQR) 50.8-71.3 years]. Eight (16%) patients had underlying HPB co-morbidity. Gallbladder wall was thickened in all patients (median 5 mm, IQR 4-7 mm), and common bile duct was of normal caliber in all patients (median 5 mm, IQR 4-6 mm). Median length of operation and length of stay were 165 min (IQR 124-209 min) and five days (IQR 3-7 days), respectively. Subtotal cholecystectomy was performed in 18 (36%) patients. Forty-eight patients were initially managed by laparoscopic approach, 15 (31%) required open conversion; majority (9/15, 60%) were initiated before on-table consult. Majority of referrals (98%) were reactive. Common reasons for referral included unclear anatomy or anatomical variations (30%), presence of dense adhesions and/or contracted gallbladder (18%) and impacted stones in Hartmann's pouch (16%). Three (6%) patients were referred for BDI (2 Strasberg D and 1 Strasberg E1), and two (4%) were referred for torrential bleeding from arterial injury (1 cystic artery and 1 right hepatic artery). Any morbidity and 30-day readmission were 22% and 6%, respectively. There was no 90-day mortality.Calling for help in BDI is obligatory, but in other instances is a personal choice. Calling for help prior to open conversion is lacking and this awareness should be raised. Whether surgical outcomes could be improved by early HPB consult needs to be determined by larger multicenter reports.

BACKGROUND The Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult. OBJECTIVE We report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic. METHODS We divided our study into 4 phases—phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post–CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post–CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%. RESULTS A total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre–CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%). CONCLUSIONS This follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.

BACKGROUND Studies show that patients often sign consent documents without fully comprehending the risks, benefits and potential complications. There is currently no Asian study performed analysing adequacy of informed consent. This study aims to assess adequacy of informed consent by evaluating patient understanding and retention of key information and complications pertaining to surgery via medical student-administered interview. METHODS A prospective study was performed on 48 patients undergoing groin hernia surgery, laparoscopic cholecystectomy and total thyroidectomy from 2017 to 2018 in a teaching hospital. Standardized assessment forms including major common complications and key details of the surgery were prepared. Structured one-to-one interviews between students and patients were performed and recorded on the morning of surgery. RESULTS Although 93.8% of the patients claimed to have understood the information regarding their surgery, only 19.4%, 44.4% and 62.5% of the patients could actually recall the serious complications of groin hernia surgery, laparoscopic cholecystectomy and thyroidectomy, respectively. Elderly patients (>65 years) had poorer understanding of surgical procedure compared to the young (80% versus 100%, respectively, P = 0.008) with 26.7% of elderly patients claiming that they did not understand the indication for surgery. High satisfaction rates with this preoperative interview were reported by both patients and students (95.8% and 97.9%, respectively). Time interval from informed consent to surgery did not make any difference. CONCLUSION Understanding of information and key complications was generally low, especially in the elderly population. The structured preoperative interview achieved the dual goal of reinforcing patient gaps in knowledge and improving student communication skills.

Background: Pancreatic ductal adenocarcinoma (PDAC) is the most common pancreatic neoplasm with 5-year survival as low as 6%. It is therefore imperative to explore potential treatment avenues to improve survival in these groups of patients. Anti-estrogenic hormone therapy (AEHT) is well-tolerated and has been used in estrogen receptor (ER) subgroups of breast cancer. ER is a type of sex hormone receptor which have been reported to be expressed inconsistently in pancreatic cancer. This study aims to identify the presence of ER in PDAC specimens to guide potential use of AEHT in the management of unresectable PDAC. Methods: This is a retrospective case control study of 10 patients (5 males, 5 females) who underwent pancreatic resections for PDAC from 2011 to 2012. Sections of the post-operative specimens were prepared and sent for ER staining. Pancreatic tissue specimens that were analysed included (I) ductal epithelial cells; (II) acinar cells; (III) islet cells; (IV) intralobular stromal cells; and (V) adenocarcinoma cells. Results: Intralobular stromal cells were positively stained for ER in 7/10 (70%) of the cases, but were of weak intensity and patchy in distribution. Islet cells (

Background Minimally invasive pancreatic resection has been shown recently in some randomized trials to be superior in selected perioperative outcomes compared with open resection when performed by experienced surgeons. However, minimally invasive pancreatic resection is associated with a long learning curve. This study aims to summarize the current evidence on the learning curve of minimally invasive pancreatic resection and define the number of cases required to surmount the learning curve. Methods A systematic search was performed on PubMed, Embase, Scopus, and the Cochrane database using a detailed search strategy. Studies that did not describe the learning curve were excluded from the study. Data on the method of learning curve analysis, single surgeon versus institutional learning curve, and outcome measures were extracted and analyzed. Results A total of 32 studies were included in the pooled analysis: 12 on laparoscopic pancreatoduodenectomy, 9 on robotic pancreatoduodenectomy, 12 on laparoscopic distal pancreatectomy, and 3 on robotic distal pancreatectomy. Sample population was comparable between laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy (median 63 vs 65). Six of 12 studies and 7 of 9 studies used nonarbitrary methods of analysis in laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy, respectively. Operating time was used as the single outcome measure in 4 of 12 studies in laparoscopic pancreatoduodenectomy and 5 of 9 studies in robotic pancreatoduodenectomy. Overall, there was no significant difference between the number of cases required to surmount the learning curve for laparoscopic pancreatoduodenectomy versus robotic pancreatoduodenectomy (laparoscopic pancreatoduodenectomy 34.1 [95% confidence interval 30.7–37.7] versus robotic pancreatoduodenectomy 36.7 [95% confidence interval 32.9–41.0]; P = .8241) and laparoscopic distal pancreatectomy versus robotic distal pancreatectomy (laparoscopic distal pancreatectomy 25.3 [95% confidence interval 22.5–28.3] versus robotic distal pancreatectomy 20.7 [95% confidence interval 15.8–26.5]; P = .5997.) Conclusion This study provides a detailed summary of existing evidence around the learning curve in minimally invasive pancreatic resection. There was no significant difference between the learning curve for robotic pancreatoduodenectomy versus laparoscopic pancreatoduodenectomy and robotic distal pancreatectomy versus laparoscopic distal pancreatectomy. These findings were limited by the retrospective nature and heterogeneity of the studies published to date.

Background: Gas-forming pyogenic liver abscess (GFPLA) occurs in 7%–24% of all PLAs and has been associated traditionally with high mortality rates. Studies have suggested that the use of a proacti...