Tony Pang

To examine the safety and effectiveness of a low-molecular-weight heparin in the prevention of thromboembolism in patients with recent spinal cord injury and complete motor paralysis.Randomized evaluation of two heparin regimens in 41 consecutive patients meeting eligibility requirements for anticoagulant prophylaxis. Daily bedside examinations were supplemented by serial venous flow studies; suspicious or positive tests were confirmed by venography.Standard heparin, 5000 units subcutaneously three times a day; low-molecular-weight heparin 3500 anti-Xa units subcutaneously once daily.Five patients in the standard heparin group had thrombotic events, including two patients with fatal pulmonary embolism; two other patients had bleeding severe enough to necessitate withdrawing the heparin. The cumulative event rate was 34.7% (95% CI, 13.7% to 55.2%). None of the patients treated with low-molecular-weight heparin had thrombosis or bleeding (CI, 0% to 14%). The difference between the two groups was significant (P = 0.006, log-rank test).Low-molecular-weight heparin is safe and effective in the prevention of thromboembolism in selected patients with spinal cord injury and complete motor paralysis, and is superior to standard heparin in fixed doses of 5000 units three times a day.

AIM:To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy. METHODS:A retrospective study of records of 63 PLA patients presenting between 1998 and 2008 to Australian tertiary referral centre, were reviewed.Amoebic and hydatid abscesses were excluded.Demographic, clinical, radiological, and microbiological characteristics, as well as surgical/radiological interventions, were recorded. RESULTS:Sixty-three patients (42 males, 21 females) aged 65 (± 14) years [mean ± (SD)] had prodromal symptoms for a median (interquartile range; IQR) of 7 (5-14) d.Only 59% of patients were febrile at presentation; however, the serum C-reactive protein was elevated in all 47 in whom it was measured.Liver function tests were non-specifically abnormal.67% of patients had a solitary abscess, while 32% had > 3 abscesses with a median (IQR) diameter of 6.3 (4-9) cm.Causative organisms were: Streptococcus milleri 25%, Klebsiella pneumoniae 21%, and Escherichia coli 16%.A presumptive cryptogenic cause was most common (34%).Four patients died in this series: one from sepsis, two from advanced cancer, and one from acute myocardial infarction.The initial procedure was radiological aspiration ± drainage in 54 and surgery in two patients.17% underwent surgical management during their hospitalization.Serum hypoalbuminaemia [mean (95% CI): 32 (29-35) g/L vs 28 (25-31) g/L, P = 0.045] on presentation was found to be the only factor related to failure of initial percutaneous therapy on univariate analysis. CONCLUSION:PLA is a diagnostic challenge, because the presentation of this condition is non-specific.Intravenous antibiotics and radiological drainage in the first instance allows resolution of most PLAs; However, a small proportion of patients still require surgical drainage.

The strategy for preoperative management of biliary obstruction in hilar cholangiocarcinoma (HCCA) patients with regards to drainage by endoscopic (EBD) or percutaneous (PTBD) methods is not clearly defined. The aim of this study was to investigate the utility, complications and therapeutic efficacy of these methods in HCCA patients, with a secondary aim to assess the use of portal vein embolization (PVE) in patients undergoing drainage.Studies incorporating HCCA patients undergoing biliary drainage prior to curative resection were included (EMBASE and Medline databases). Analyses included baseline drainage data, procedure-related complications and efficacy, post-operative parameters, and meta-analyses where applicable.Fifteen studies were included, with EBD performed in 536 patients (52%). Unilateral drainage of the future liver remnant was undertaken in 94% of patients. There was a trend towards higher procedure conversion (RR 7.36, p = 0.07) and cholangitis (RR 3.36, p = 0.15) rates in the EBD group. Where specified, 134 (30%) drained patients had PVE, in association with a major hepatectomy in 131 patients (98%). Post-operative hepatic failure occurred in 22 (11%) of EBD patients compared to 56 (13%) of PTBD patients, whilst median 1-year survival in these groups was 91% and 73%, respectively.The accepted practice is for most jaundiced HCCA patients to have preoperative drainage of the future liver remnant. EBD may be associated with more immediate procedure-related complications, although it is certainly not inferior compared to PTBD in the long term.

Hepatocellular carcinoma (HCC) is the second most common cause of death from cancer worldwide. Standard potentially curative treatments are either resection or transplantation. The aim of this paper is to provide an overview of the surgical management of HCC, as well as highlight current issues in hepatic resection and transplantation. In summary, due to the relationship between HCC and chronic liver disease, the management of HCC depends both on tumour-related and hepatic function-related considerations. As such, HCC is currently managed largely through non-surgical means as the criteria, in relation to the above considerations, for surgical management is still largely restrictive. For early stage tumours, both resection and transplantation offer fairly good survival outcomes (5 years overall survival of around 50%). Selection therefore would depend on the level of hepatic function derangement, organ availability and local expertise. Patients with intermediate stage cancers have limited options, with resection being the only potential for cure. Otherwise, locoregional therapy with transarterial chemoembolization or radiofrequency ablation are viable options. Current issues in resection and transplantation are also briefly discussed such as laparoscopic resection, ablation vs resection, anatomical vs non-anatomical resection, transplantation vs resection, living donor liver transplantation and salvage liver transplantation.

BackgroundSince the liver metastases rather than the colorectal cancer itself is the main determinant of patient's survival, the ‘Liver‐First Approach (LFA)’ with upfront chemotherapy followed by a hepatic resection of colorectal liver metastases (CLM) and finally a colorectal cancer resection was proposed. The aim of this review was to analyse the evidence for LFA in patients with colorectal cancer and synchronous CLM.MethodsA literature search of databases (MEDLINE and EMBASE) to identify published studies of LFA in patients with colorectal cancer and synchronous CLM was undertaken focussing on the peri‐operative regimens of LFA and survival outcomes.ResultsThree observational studies and one retrospective cohort study were included for review. A total of 121 patients with colorectal cancer and synchronous CLM were selected for LFA. Pre‐operative chemotherapy was used in 99% of patients. One hundred and twelve of the initial 121 patients (93%) underwent a hepatic resection of CLM. In total, 60% had a major liver resection and the R0 resection rate was 93%. Post‐operative morbidity and mortality after the hepatic resection were 20% and 1%, respectively. Ultimately, 89 of the initial 121 (74%) patients underwent a colorectal cancer resection. Post‐operative morbidity and mortality after a colorectal resection were 50% and 6%, respectively. The median overall survival was 40 months (range 19–50) with a recurrence rate of 52%.ConclusionsCurrent evidence suggests that LFA is safe and feasible in selected patients with colorectal cancer and synchronous CLM. Future studies are required to further define patient selection criteria for LFA and the exact role of LFA in the management of synchronous CLM.

Abstract Background Stromal–tumour interactions facilitate pancreatic cancer (PC) progression. The hepatocyte growth factor (HGF)/c-MET pathway is upregulated in PC and mediates the interaction between cancer cells and stromal pancreatic stellate cells (PSCs). This study assessed the effect of HGF/c-MET inhibition plus gemcitabine (G) on the progression of advanced PC. Methods Orthotopic PC was produced by implantation of luciferase-tagged human cancer cells + human PSCs into mouse pancreas. Tumours were allowed to develop without treatment for 4 weeks. Mice were then treated for 6 weeks with one of the following: IgG, G, HGF inhibitor (Hi), c-MET inhibitor (Ci), Hi + Ci, Hi + G, Ci + G, or Hi + Ci + G. Results Bioluminescence imaging showed similar tumour sizes in all mice at the initiation of treatments. Triple therapy (Hi + Ci + G): (1) completely eliminated metastasis; (2) significantly reduced tumour size as assessed by bioluminescence and at necropsy; (3) significantly reduced proliferating cancer cell density and stem cell marker DCLK1 expression in tumours. In vitro 3D culture studies supported our in vivo findings. Conclusion Even at an advanced disease stage, a two-pronged approach, targeting (a) HGF/c-MET with relevant inhibitors and (b) cancer cells with chemotherapy, completely eliminated metastasis and significantly decreased tumour growth, suggesting that this is a promising treatment approach for PC.

Online education has been increasingly utilized over the past decades. The COVID-19 pandemic accelerated the transition of conventional face-to-face curricula to online platforms, with limited evidence for its teaching efficacy. This systematic review aims to assess the effectiveness of online video-based education compared with standard conventional education in teaching basic surgical skills to surgical trainees and students undergoing medical training.We performed a literature search in Embase, Medline, Cochrane CENTRAL and Scopus from inception until February 2022. Studies included were randomised controlled trials (RCTs) and observational studies. We included randomised controlled trials only for meta-analysis. The primary outcome was surgical skill proficiency. The secondary outcomes were participant perception, confidence and satisfaction. Two authors independently assessed the search results for eligibility, extracted the data and assessed the risk of bias using the Cochrane Risk of Bias tool 2. Where appropriate, we performed random effects meta-analyses of the pooled study data to calculate a standardized mean difference.A total of 11 studies met the inclusion criteria totaling 715 participants; 603 were included in qualitative analysis and 380 in meta-analysis. All included studies were assessed as having a low risk of bias. The majority of studies found no significant difference between conventional and video-based education in teaching basic surgical skills, three studies found video-based education was superior and one study found conventional education was superior. There was no statistically significant difference in skill proficiency between the two groups (standardized mean difference of -0.02 (95% CI: -0.34, 0.30); p=0.90). Video-based education results in an equivalent improvement in confidence and satisfaction rates. Additional benefits of video-based education include convenience, accessibility and efficiency.Basic surgical skills can be taught as effectively through online video-based education as conventional teaching methods. Online education should be utilized as an adjunct to medical curricula beyond the COVID-19 era.

Background Previous studies have revealed the role of dysregulated urokinase plasminogen activator (encoded by PLAU ) expression and activity in several pathways associated with cancer progression. However, systematic investigation into the association of PLAU expression with factors that modulate PDAC (pancreatic ductal adenocarcinoma) progression is lacking, such as those affecting stromal (pancreatic stellate cell, PSC)-cancer cell interactions, tumour immunity, PDAC subtypes and clinical outcomes from potential PLAU inhibition. Methods This study used an integrated bioinformatics approach to identify prognostic markers correlated with PLAU expression using different transcriptomics, proteomics, and clinical data sets. We then determined the association of dysregulated PLAU and correlated signatures with oncogenic pathways, metastatic phenotypes, stroma, immunosuppressive tumour microenvironment (TME) and clinical outcome. Finally, using an in vivo orthotopic model of pancreatic cancer, we confirmed the predicted effect of inhibiting PLAU on tumour growth and metastasis. Results Our analyses revealed that PLAU upregulation is not only associated with numerous other prognostic markers but also associated with the activation of various oncogenic signalling pathways, aggressive phenotypes relevant to PDAC growth and metastasis, such as proliferation, epithelial-mesenchymal transition (EMT), stemness, hypoxia, extracellular cell matrix (ECM) degradation, upregulation of stromal signatures, and immune suppression in the tumour microenvironment (TME). Moreover, the upregulation of PLAU was directly connected with signalling pathways known to mediate PSC-cancer cell interactions. Furthermore, PLAU upregulation was associated with the aggressive basal/squamous phenotype of PDAC and significantly reduced overall survival, indicating that this subset of patients may benefit from therapeutic interventions to inhibit PLAU activity. Our studies with a clinically relevant orthotopic pancreatic model showed that even short-term PLAU inhibition is sufficient to significantly halt tumour growth and, importantly, eliminate visible metastasis. Conclusion Elevated PLAU correlates with increased aggressive phenotypes, stromal score, and immune suppression in PDAC. PLAU upregulation is also closely associated with the basal subtype type of PDAC; patients with this subtype are at high risk of mortality from the disease and may benefit from therapeutic targeting of PLAU .

Background: Primary hyperaldosteronism is a frequent cause of resistant hypertension and is amenable to surgical intervention when caused by a unilateral aldosterone‐producing adenoma. The aim of this study was to investigate the long‐term results of laparoscopic adrenalectomy in the control of hypertension caused by primary hyperaldosteronism. Methods: A prospective case series of patients undergoing laparoscopic adrenalectomy for hyperaldosteronism was studied. Blood pressure (BP), serum aldosterone levels, plasma renin activity, serum potassium and antihypertensive requirement were measured before and after adrenalectomy. Results: Sixty‐two patients with hyperaldosteronism underwent laparascopic adrenalectomy in the period from December 1995 to August 2005. The median follow up was 59 months. There was a significant decrease in both systolic blood pressure and diastolic blood pressure at final follow up compared with that before operation. Systolic blood pressure decreased from 149 mmHg to 129 mmHg at final follow up ( P < 0.0001). Diastolic blood pressure decreased from 89 mmHg to 80 mmHg ( P < 0.0001). Antihypertensive requirement was decreased from an average of 2.6 separate medications preoperatively to 1.4 medications at final follow up ( P < 0.0001). Serum aldosterone levels were significantly lower (698 (confidence interval 534–862) pg/mL vs 181 (confidence interval 139–225) pg/mL, P < 0.0001). Overall, 34% of patients had cure of hypertension and did not require any antihypertensive agent. A further 51% had improvement in BP control, whereas 5% had no change or had worsening hypertension. Multivariate regression analysis showed that age and gland size were independent factors predicting sustained hypertension after surgery. Conclusion: In appropriately selected patients with primary hyperaldosteronism, laparoscopic adrenalectomy is effective in improving long‐term BP control. Larger adrenal gland size and older age at time of surgery are predictors of persisting hypertension.

Peripancreatic pseudoaneurysms can arise in a number of different clinical settings but are associated mostly with pancreatitis and pancreatobiliary surgery. The aim of this study is to review the current literature and to propose a management classification system based on the pathophysiological processes and the exact anatomical site of peripancreatic pseudoaneurysms.A systematic review of the literature from 1995 to 2012 was performed. Articles on studies describing peripancreatic pseudoaneurysms in the setting of pancreatitis or major hepatic or pancreatic surgery with more than ten patients were included. Seventeen eligible studies were identified and reviewed.The demographic characteristics of the patients in all studies were similar with a predominance of males and a mean age of 55 years. The overall mortality rate varied greatly among the studies, ranging from 0 to 60%. Embolisation was the first line of management in the majority of the studies, with surgery reserved for failed embolisation or for haemodynamically unstable cases. Embolisation of the hepatic artery or its branches was associated with high rates of morbidity (56%) and hepatic failure (19%). More recent studies show that stents are used increasingly for vessels that cannot be embolised safely. Late bleeding, a major cause of mortality and morbidity, is generally underreported. The proposed classification system is based on three factors: (1) the type of artery from which the pseudoaneurysm arises, (2) whether communication with the gastrointestinal tract is present, and (3) whether there is high concentration of pancreatic juice at the bleeding site.The management of peripancreatic pseudoaneurysms usually comprises a combination of interventional radiology and surgery and this may be assisted by a logical classification system.

Abstract Background Minimally invasive parathyroidectomy (MIP) involves scan-directed removal of a single adenoma through a 2·0-cm mini-incision without intraoperative monitoring. The aim of this study was to analyse the outcomes of MIP using such a simplified technique. Methods The study group comprised 500 consecutive patients undergoing MIP via a lateral mini-incision from August 2000 to September 2005. Levels of parathyroid hormone (PTH) were measured after operation solely to aid informed discharge. Results Some 97·4 per cent of patients were initially cured by MIP. Eight patients remained hypercalcaemic and a further five were normocalcaemic on the day after surgery but became hypercalcaemic again within 3 months of the procedure. Eleven of these patients were cured with subsequent re-exploration. Analysis of postoperative PTH data indicated that, at best, the use of intraoperative PTH measurement during surgery would have increased the cure rate by only a further 1 per cent. Three (0·6 per cent) of 500 patients had permanent recurrent laryngeal nerve palsy after MIP. Conclusion MIP performed by the lateral focused mini-incision technique, without the use of intraoperative PTH monitoring, is a safe and effective procedure that results in outcomes equal to those of bilateral neck exploration.

The use of frozen section to assess resection margins intrao-peratively during pancreaticoduodenectomy facilitates further resection. However, it is unclear whether this actually improves patient survival. We reviewed the overall survival and resection margin status in consecutive pancreaticoduodenectomies performed for carcinoma. An R1 resection was defined as an incomplete excision (≤1 mm margin); R0(p) resection as complete excision without re-resection and R0(s) resection as an initially positive neck margin which was converted to R0 resection after re-resection. Between 2007 and 2012, 116 pancreatoduodenectomies were performed for adenocarcinoma; 101 (87%) underwent frozen section of the neck margin which was positive in 19 (19%). Sixteen of these patients had negative neck margins after re-excision but only seven patients had no other involved margins [true R0(s) resections]. Median survival for the R0(p), R0(s) and R1 groups were 29, 16, 23 months, respectively (p = 0.049; R0(p) versus R0(s) p = 0.040). Intra-operative frozen section increased the overall R0 rate by 7% but this did not improve survival. Our findings question the clinical benefit of intraoperative margin assessment, particularly if re-excision cannot be performed easily and safely.

Background Hepatocellular cancer (HCC) is a leading cause of mortality worldwide. Liver resection or transplantation offer the best chance of long-term survival. The aim of this study was to perform a survival and prognostic factor analysis on patients who underwent resection of HCC at two major tertiary referral hospitals, and to investigate a pre-operative prediction model for microvascular invasion (MVI). Methods Clinico-pathological and survival data were collected from all patients who underwent liver resection for HCC at two tertiary referral centres (Royal North Shore/North Shore Private Hospitals and Westmead Hospital) from 1998 to 2012. An overall and disease-free survival analysis was performed and a predictive model for MVI identified. Results The total number of patients in this series was 125 and the 5-year overall and disease-free survival rates were 56% and 37%, respectively. MVI was the only factor to be independently associated with a poor prognosis on both overall and disease-free survival. Age ≥64 years, a serum alpha-fetoprotein (AFP) ≥400 ng/ml (×40 above normal) and tumor size ≥50 mm were independently associated with MVI. An MVI prediction model using these three pre-operative factors provides a good assessment of the risk of MVI. Conclusion MVI in the resected specimen of patients with HCC is associated with a poor prognosis. A preoperative MVI prediction model offers a useful way to identify patients at risk of relapse. However, more precise predictive models using molecular and genetic variables are needed to improve selection of patients most suitable for radical surgical treatment.

Purpose of review Pancreatic stellate cells (PSCs) play an integral role in the pathogenesis of pancreatitis and pancreatic cancer. With the developing knowledge of this important cell type, we are at the cusp of developing effective therapies for the above diseases based upon targeting the PSC and modulating its function. Recent findings The major themes of the recent PSC literature include: PSC interactions with the extracellular matrix and other stromal components; intracellular calcium physiology as drivers of mechanical interactions and necrosis; the relationship between proinflammatory, protumoural, angiogenic, and metabolic pathways in pancreatic necrosis, fibrosis, and carcinogenesis; and targeting of the stroma for antitumoural and antifibrotic effects. Summary Traditionally, there have been few treatment options for pancreatitis and pancreatic cancer. The elucidation of the wide-ranging functions of PSCs provide an opportunity for treatments based on stromal reprogramming.

According to the Tokyo Guidelines, recommendation on management of moderate and severe cholecystitis are cholecystostomy in severe cases and either cholecystostomy or emergency cholecystectomy in moderate cases depending on surgical experience. The rationale for this is that percutaneous cholecystostomy is a short procedure while laparoscopic cholecystectomy may be associated with a larger physiological insult. The aim of this study was to determine the safety and efficacy of cholecystectomy in moderate and severe acute calculous cholecystitis (ACC) at our institution.A retrospective review of patients presenting to Westmead Hospital with ACC between 2011 and 2012 was performed. Patients were classified according to the Tokyo Guidelines and only grade II and grade III patients were included. Clinical and complication details were recorded from the clinical notes.Of the 84 patients, 60 had grade II and 24 had grade III ACC. The mean age was 52 years and 59% were female. In both groups, index cholecystectomy was performed in 88% of patients. None of the grade II ACC patients and three (12%) of grade III ACC underwent cholecystostomy. Length of stay (5 versus 12, P < 0.001) and conversion rate (2% versus 27%, P = 0.006) was higher in the grade III group. There were no deaths in patient who underwent surgery in either group. Severe complications were not significantly different (2% versus 9%, P = 0.219).Index cholecystectomy is feasible with low morbidity and no mortality even in severe ACC. Emergency cholecystectomy in the setting of severe cholecystitis appear to be safe and technically feasible option.

Abstract Background and study aims Adenomas of the duodenum and ampulla are uncommon. For lesions ≤ 20 mm in size and confined to the papillary mound, endoscopic resection is well supported by systematic study. However, for large laterally spreading lesions of the duodenum or papilla (LSL-D/P), surgery is often performed despite substantial associated morbidity and mortality. We aimed to compare actual endoscopic outcomes of such lesions and costs with those predicted for surgery using validated prediction tools. Patients and methods Patients who underwent endoscopic resection of LSL-D/P were analyzed. Two surgeons assigned the hypothetical surgical management. The National Surgical Quality Improvement Program (NSQIP), and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were used to predict morbidity, mortality, and length of hospital stay. Actual endoscopic and hypothetical surgical outcomes and costs were compared. Results A total of 102 lesions were evaluated (mean age of patients 69 years, 52 % male, mean lesion size 40 mm). Complete endoscopic resection was achieved in 93.1 % at the index procedure. Endoscopic adverse events occurred in 18.6 %. Recurrence at first surveillance endoscopy was seen in 17.7 %. For patients with ≥ 2 surveillance endoscopies (n = 55), 90 % were clear of disease and considered cured (median follow-up 27 months). Compared with hypothetical surgical resection, endoscopic resection had less morbidity (18 % vs. 31 %; P = 0.001) and shorter hospital stay (median 1 vs. 4.75 days; P &lt; 0.001), and was less costly than surgery (mean $ 11 093 vs. $ 19 358; P &lt; 0.001). Conclusion In experienced centers, even extensive LSL-D/P can be managed endoscopically with favorable morbidity and mortality profiles, and reduced costs, compared with surgery.

Infectious complications are common after pancreatoduodenectomy, which in turn are associated with preoperative biliary drainage. Current guidelines recommend a first-generation cephalosporin as perioperative antibiotic prophylaxis. However, some studies support the use of targeted antibiotics. The aim of this systematic review and meta-analysis is to evaluate the role of prophylactic targeted antibiotics compared to standard antibiotics in reducing postoperative infections after pancreatoduodenectomy.A search from MEDLINE, EMBASE, and Cochrane library from 1946 to July 2020 was conducted. Studies were included if they compared targeted antibiotics with standard perioperative antibiotics while including outcome data on surgical site infections (SSI). Targeted therapy was defined as perioperative antibiotics targeting organisms prevalent in bile instrumentation or by culture data obtained from the patient or institution. Outcomes assessed were the rate of SSIs and their microbiology profile. Analyses included demographic data, perioperative antibiotics, postoperative outcomes including microbiology data, and meta-analysis was performed where applicable.Seven studies were included, with a total of 849 patients undergoing pancreatoduodenectomy. Targeted antibiotics were associated with a significantly lower rate of postoperative SSI compared to standard antibiotic therapy [21.1% vs 41.9%; risk ratios (RR) 0.55, 95% confidence interval 0.37-0.81]. Wound/incisional site infections and organ space infections were lower in patients receiving targeted antibiotic prophylaxis (RR 0.33, P = 0.0002 and RR 0.54, P = 0.0004, respectively). Enterococcus species were the most common bacteria reported.There was a significant reduction in overall SSI rates when targeted antibiotics was used. Current standard antibiotic prophylaxis is inadequate in covering microbes prevalent in postoperative infections developing after pancreatoduodenectomy.

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.

Chemical burns account for a small proportion of total burns in children, but may require specific first aid and different modes of prevention.A retrospective study between 2006 and 2012 of children ≤16 years treated with chemical burns at a specialist paediatric burn centre. Data were extracted from a prospectively maintained database.56 episodes of chemical burns occurred during the study period. The majority (54%) occurred in boys. There were 39 (72%) patients <10 years and 17 (39%) ≥10 years. Median total body surface area burnt was 1% with nine (16%) patients requiring skin grafting. Only 24 (45%) had adequate first aid. The majority (n=46, 82%) of chemical burns occurred in the domestic setting, especially in the <10 years age group (P=0.052). Non-intentional exposure of chemicals by an unattended child accounted for half of all (n=22, 49%) chemical burns <10 years of age. Eight (47%) burns in patients ≥10 years resulted from self-harm. The most common aetiological agents were household cleaners and aerosols in the younger and older age groups respectively.Chemical burns remain infrequent but potentially preventable. These burns mainly occur in the domestic setting due to non-intentional exposure of household chemicals in children <10, and due to deliberate self-harm in children ≥10. The use of child-resistant packaging, similar to that used for medications, and improved parental practices could help decrease the incidence of burns in children <10.

Abstract Introduction Primary hyperaldosteronism ( PA ) is a common cause of secondary hypertension. Two recurrent mutations ( G151R and L168R ) in the potassium channel gene KCNJ5 have been identified that affect the K ir3.4 potassium channel found in the cells of the zona glomerulosa of the adrenal gland. The aim of this study was to determine the prevalence of KCNJ5 mutations in an Australian cohort of patients and to correlate these findings with clinical outcome data, in order to describe the clinical impact on patients who harbour this mutation. Methods D irect S anger sequencing for KCNJ5 on DNA from adrenal tumour tissue of 83 patients with PA in a cohort study was undertaken and mutation status correlated with clinical outcome data. Results Seventy‐one of 83 patients (86%) had adrenocortical adenomas and 12 patients (14%) had bilateral adrenal hyperplasia. A total of 34 (41%) patients were found to have heterozygous somatic mutations in KCNJ5 , G151R and L168R . No germ line mutations were identified. Patients with mutations were predominately female (68% versus 49%) and significantly younger at presentation (48 versus 55 years). When correlated with clinical data, our results demonstrated that patients with KCNJ5 mutations were more likely to be cured following surgery without the requirement for ongoing medications. Conclusions Our findings in a large Australian cohort show that patients with mutations in KCNJ5 present earlier with the signs and symptoms of PA benefit from surgical intervention. Moreover, our results highlight the importance of a thorough workup and management plan for younger patients who present with hypertension.

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. The aim of this study was to identify novel protein signatures that would predict clinical outcomes in a large cohort of patients with ACC based on data from previous gene expression microarray studies.A tissue microarray was generated from the paraffin tissue blocks of 61 patients with clinical outcomes data. Selected protein biomarkers based on previous gene expression microarray profiling studies were selected, and immunohistochemistry staining was performed. Staining patterns were correlated with clinical outcomes, and a multivariate analysis was undertaken to identify potential biomarkers of prognosis.Median overall survival was 45 months, with a 5-year overall survival rate of 44%. Median disease-free survival was 58 months, with a 5-year disease-free survival rate of 44%. The proliferation marker Ki-67 and DNA topoisomerase TOP2A were associated with significantly poorer overall and disease-free survival. The results also showed strong correlation between the transcriptional repressor EZH2 and TOP2A expression, suggesting a novel role for EZH2 as an additional marker of prognosis. In contrast, increased expression of the BARD1 protein, with its ubiquitin ligase function, was associated with significantly improved overall and disease-free survival, which has yet to be documented for ACC.We present novel biomarkers that assist in determining prognosis for patients with ACC. Ki-67, TOP2A, and EZH2 were all significantly associated with poorer outcomes, whereas BARD1 was associated with improved overall survival. It is hoped that these biomarkers may help tailor additional therapy and be potential targets for directed therapy.

Pancreatic stellate cells (PSCs) are known to play an important role in facilitating pancreatic cancer progression-both in terms of local tumour growth as well as the establishment of metastases. We have previously demonstrated that PSCs from the primary cancer seed to distant metastatic sites. We therefore hypothesise that PSCs circulate along with pancreatic cancer cells (circulating tumour cells-CTCs) to help create a growth permissive microenvironment at distant metastatic sites. This review aims to explore the concept of circulating PSCs in pancreatic cancer and suggests future directions for research in this area.

The detection and quantification of circulating tumour cells (CTCs) in pancreatic cancer (PC) has the potential to provide prognostic information. The aim of this review was to provide an overview of the literature surrounding CTCs in PC.A systematic literature review on CTCs in PC between 2005-2020 was performed. Data based on peripheral vein samples were used to determine the positivity rate of CTCs, their prognostic significance and their relative numbers compared to portal vein (PV) samples.The overall CTC detection rate in forty-four articles was 65% (95%CI: 55-75%). Detection rate for CellSearch was 26% (95%CI: 14-38%), which was lower than for both filtration and microfluidic techniques. In nine studies with >50 patients, overall survival was worse with CTC positivity (HR 1.82; 95%CI: 1.61-2.05). Five of seven studies which described PV CTC collection provided patient-level data. PV CTC yield was 7.7-fold (95%CI 1.35-43.9) that of peripheral blood.CTCs were detected in the peripheral circulation of most patients with PC and may be related to prognosis and disease stage. PV blood contains more CTCs than peripheral blood sampling. This review points to the maturation of techniques of CTC enrichment, and its evidence base for eventual clinical deployment.

Pancreatic cancer (PC) is a deadly cancer with a high mortality rate. The unique characteristics of PC, including desmoplasia and immunosuppression, have made it difficult to develop effective treatment strategies. Pancreatic stellate cells (PSCs) play a crucial role in the progression of the disease by interacting with cancer cells. One of the key mediators of PSC - cancer cell interactions is the hepatocyte growth factor (HGF)/c-MET pathway. Using an immunocompetent in vivo model of PC as well as in vitro experiments, this study has shown that a combined approach using HGF/c-MET inhibitors to target stromal-tumour interactions and chemotherapy (gemcitabine) to target cancer cells effectively decreases tumour volume, EMT, and stemness, and importantly, eliminates metastasis. Notably, HGF/c-MET inhibition decreases TGF-β secretion by cancer cells, resulting in an increase in cytotoxic T-cell infiltration, thus contributing to cancer cell death in tumours. HGF/c-MET inhibition + chemotherapy was also found to normalise the gut microbiome and improve gut microbial diversity. These findings provide a strong platform for assessment of this triple therapy (HGF/c-MET inhibition + chemotherapy) approach in the clinical setting.

BACKGROUND Postoperative complications remain a paramount concern for surgeons and healthcare practitioners. AIM To present a comprehensive analysis of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system’s efficacy in predicting postoperative complications following abdominal surgery. METHODS A systematic search of published studies was conducted, yielding 17 studies with pertinent data. Parameters such as preoperative risk score (PRS), surgical stress score (SSS), comprehensive risk score (CRS), postoperative complications, postoperative mortality, and other clinical data were collected for meta-analysis. Forest plots were employed for continuous and binary variables, with χ 2 tests assessing heterogeneity (P value). RESULTS Patients experiencing complications after abdominal surgery exhibited significantly higher E-PASS scores compared to those without complications [mean difference and 95% confidence interval (CI) of PRS: 0.10 (0.05-0.15); SSS: 0.04 (0.001-0.08); CRS: 0.19 (0.07-0.31)]. Following the exclusion of low-quality studies, results remained valid with no discernible heterogeneity. Subgroup analysis indicated that variations in sample size and age may contribute to heterogeneity in CRS analysis. Binary variable meta-analysis demonstrated a correlation between high CRS and increased postoperative complication rates [odds ratio (OR) (95%CI): 3.01 (1.83-4.95)], with a significant association observed between high CRS and postoperative mortality [OR (95%CI): 15.49 (3.75-64.01)]. CONCLUSION In summary, postoperative complications in abdominal surgery, as assessed by the E-PASS scoring system, are consistently linked to elevated PRS, SSS, and CRS scores. High CRS scores emerge as risk factors for heightened morbidity and mortality. This study establishes the accuracy of the E-PASS scoring system in predicting postoperative morbidity and mortality in abdominal surgery, underscoring its potential for widespread adoption in effective risk assessment.

Perihilar cholangiocarcinoma (pCCA) is an uncommon malignancy with generally poor prognosis. Surgery is the primary curative treatment; however, the perioperative mortality and morbidity rates are high, with a low 5-year survival rate. Use of preoperative prognostic biomarkers to predict survival outcomes after surgery for pCCA are not well-established currently. This systematic review aimed to identify and summarise preoperative biomarkers associated with survival in pCCA, thereby potentially improving treatment decision-making. The Embase, Medline, and Cochrane databases were searched, and a systematic review was performed using the PRISMA guidelines. English-language studies examining the association between serum and/or tissue-derived biomarkers in pCCA and overall and/or disease-free survival were included. Our systematic review identified 64 biomarkers across 48 relevant studies. Raised serum CA19-9, bilirubin, CEA, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and tumour MMP9, and low serum albumin were most associated with poorer survival; however, the cutoff values used widely varied. Several promising molecular markers with prognostic significance were also identified, including tumour HMGA2, MUC5AC/6, IDH1, PIWIL2, and DNA index. In conclusion, several biomarkers have been identified in serum and tumour specimens that prognosticate overall and disease-free survival after pCCA resection. These, however, require external validation in large cohort studies and/or in preoperatively obtained specimens, especially tissue biopsy, to recommend their use.

Abstract Background The COVID-19 pandemic has brought significant changes to medical education, particularly for procedural and surgical skills, which inherently require face-to-face education. The utility of adding an instructional video remains uncertain. To guide future curricula, our aim was to assess whether the addition of an optional instructional video improves the acquisition and retention of one-handed surgical knot-tying. Methods Naïve year one medical students were randomised to video before face-to-face instruction versus face-to-face instruction only. Blinded surgeons assessed their performance at the end of a workshop and 4 weeks later by counting the number of knots tied in 1 min and a global Likert score assessing knot quality. The students also completed surveys for qualitative assessment and feedback. Results Students with access to the video tied significantly more knots in 1 min than the control group (median ± IQR: 15 ± 4 N = 14, vs 12.5 ± 10 N = 15, p = 0.012). After 4 weeks, the intervention group showed a non-significant trend towards being able to tie more knots (16.5 ± 6 N = 6, vs 3.5 ± 16 N = 8, p = 0.069), and the knots tied were of significantly better quality (global score: 3 ± 1.4 vs 1 ± 1.8, p = 0.027). Compared to the control group, the intervention group expressed greater confidence in their ability to retain their skills after the workshop and at follow-up (p = 0.04). Additionally, they experienced significantly less stress during the workshop (p = 0.028). Conclusion A non-interactive video can improve learning and retention of single-handed knot tying. As medical education continues to evolve, supplementary videos should be considered an important part of new surgical skill curricula.

The global incidence of acute pancreatitis (AP) is increasing, but little information exists about trends in Australia. This study aimed to describe incidence trends, along with clinical and socio-demographic associations, in the state of Tasmania over a recent 12-year period.

Background: Transmembrane emp24 trafficking protein 3 (TMED3) is associated with the development of several tumors; however, whether TMED3 regulates the progression of prostate cancer remains unclear.Materials and Methods: Short hairpin RNA was performed to repress TMED3 in prostate cancer cells (DU145 cells) and in a prostate cancer mice model to determine its function in prostate cancer in vitro and in vivo.Results: In the present study, we found that TMED3 was highly expressed in prostate cancer cells.In vitro, shTMED3 treatment suppressed the proliferation, invasion, and migration and promoted the apoptosis of DU145 cells.Additionally, the Kyoto Encyclopedia of Genes and Genomes pathway enrichment analysis showed a strong correlation between TMED3 and forkhead box O transcription factor (FOXO) pathway.Furthermore, TMED3 inhibition efficiently decreased FOXO1a and FOXO3a phosphorylation.In vivo, TMED3 downregulation suppressed the apoptosis, growth, and metastasis of prostate cancer cells via FOXO1a and FOXO3a.Conclusion: The present findings show that TMED3 participates in the regulation of prostate cancer progression via FOXO1a and FOXO3a phosphorylation, thereby revealing a novel mechanism underlying prostate cancer development and suggesting that TMED3 inhibition may serve as a novel strategy for prostate cancer treatment.

It has been suggested that adverse postoperative outcomes may have a negative impact on longterm survival in patients with colorectal liver metastases.This study was conducted to evaluate the prognostic impact of postoperative complications in patients submitted to a potentially curative resection of colorectal liver metastases.A retrospective analysis of outcomes in 199 patients submitted to hepatic resection with curative intent for metastatic colorectal cancer during 1999-2008 was conducted.The overall complication rate was 38% (n = 75). Of all complications, 79% were minor (Grades I or II). There were five deaths (3%). The median length of follow-up was 39 months. Rates of 5-year overall and disease-free survival were 44% and 27%, respectively. Univariate analysis demonstrated that an elevated preoperative level of carcinoembryonic antigen (CEA), intraoperative blood loss of > 300 ml, multiple metastases, large (≥ 35 mm) metastases and resection margins of < 1 mm were associated with poor overall and disease-free survival. In addition, male sex and synchronous metastases were associated with poor disease-free survival. Postoperative complications did not have an impact on either survival measure. The multivariate model did not include complications as a predictive factor.Postoperative complications were not found to influence overall or disease-free survival in the present series. The number and size of liver metastases were confirmed as significant prognostic factors.

Of all thyroid nodules assessed by fine needle aspiration cytology (FNAC), 10-20% are classified as indeterminate/atypical. Traditionally, this group is considered to primarily represent follicular neoplasia. We hypothesize that papillary carcinoma accounts for a significant proportion of lesions classified as "atypical" on FNAC.This retrospective study includes 228 patients who had an atypical FNAC result and who were subsequently found to have a malignancy on histologic examination of the excised thyroid lesion. Patients with papillary microcarcinomas, defined as lesions less than 10-mm diameter, were excluded. The study period was from 1987 to 2005. The patients were divided chronologically into 3 groups (n = 76) for analysis: group 1, December 1987-March 1997; group 2, July 1997-October 2002; and group 3, October 2002-December 2005.Age- and sex-distribution of the 3 groups were not significantly different. Median nodule size of group 3 was significantly smaller. The distributions of histopathology of the 3 time periods were significantly different overall (P = .0325). Prevalence of papillary carcinoma was not statistically significant (33/76 vs 34/76 vs 46/76; P = .0636), but showed a statistical significant trend to increase over time (P = .0349). Prevalence of follicular variant papillary carcinoma was also found to be significantly different between the groups (7/76 vs 12/76 vs 19/76; P = .0320; P = .0349).Papillary carcinoma accounted for most histopathologically confirmed cancers that had an atypical cytology. Papillary cancer in this group of patients trended up, probably due to a significant increase in the diagnosis of follicular variant of papillary cancer.

Anastomosing the renal artery and vein in transplant recipients without a cooling mechanism exposes the kidney to temperatures exceeding the metabolic threshold (15°C to 18°C), at which the protective effects of renal hypothermia are lost. This anastomotic time, or second warm ischemic time, can be deleterious to graft outcomes, especially if it is prolonged. Techniques to ameliorate organ warming prior to reperfusion have been designed, and range from simpler surface cooling techniques, to organ immersion in bags of ice slush, and the application of 'jackets' that incorporate their own internal cooling mechanism. The efficacy of these methods with respect to the minimization of kidney temperature prior to reperfusion and subsequent effects on graft outcomes are discussed using clinical and experimental data, in the setting of open, laparoscopic, and robotic kidney transplantation.

Background Laparoscopic cholecystectomy (LC) is the standard of treatment for symptomatic cholelithiasis. Although intraoperative cholangiography (IOC) is widely used as an adjunct to LC, there is still no worldwide consensus on the value of its routine use. Anatomical studies have shown that variations of the biliary tree are present in approximately 35% of patients with variations in right hepatic second‐order ducts being especially common (15–20%). Approximately, 70–80% of all iatrogenic bile duct injuries are a consequence of misidentification of biliary anatomy. The purpose of this study was to assess the adequacy of and the reporting of IOCs during LC. Methods IOCs obtained from 300 consecutive LCs between July 2014 and July 2016 were analysed retrospectively by two surgical trainees and confirmed by a radiologist. Biliary tree anatomy was classified from IOC films as described by Couinaud (1957) and correlated with documented findings. The accuracy of intraoperative reporting was assessed. Biliary anatomy was correlated to clinical outcome. Results A total of 95% of IOCs adequately demonstrated biliary anatomy. Aberrant right sectoral ducts were identified in 15.2% of the complete IOCs, and 2.6% demonstrated left sectoral or confluence anomalies. Only 20.4% of these were reported intraoperatively. Bile leaks occurred in two patients who had IOCs (0.73%) and two who did not (7.4%). Conclusion Surgeons generally demonstrate biliary anatomy well on IOC but reporting of sectoral duct variation can be improved. Further research is needed to determine whether anatomical variation is related to ductal injury.

There are ongoing controversies about the routine use of computed tomography (CT) in the evaluation of acute abdominal pain (AAP), our study was designed to evaluate the impacts of early routine use CT (erCT) and selective CT (sCT) on clinical outcomes.We conducted a meta-analysis of randomized trials. We included non-quadrant and non-region-specific studies only. The primary outcomes were the number of correct diagnoses at 24 h, mortality, and length of stay (LOS). The secondary outcomes were the number of corrected diagnoses from an initial misdiagnosis, major changes in management, and non-specific abdominal pain (NSAP).6 Studies from 3 RCTs were included, enrolling 570 patients. erCT showed a higher number of correct diagnoses and corrected diagnoses at 24 h, [risk ratio (RR) 1.13, 95% confidence interval (CI) 1.01-1.26, P = 0.03] and [RR 1.36, 95% CI 1.01-1.85, P = 0.04] respectively, and a lower mortality at 6 months [RR 0.36, 95% CI 0.15-0.87, P = 0.02]. However, no differences were shown in LOS [mean difference (MD) -0.65, 95% CI -2.88 - 1.58, P = 0.57], major changes in management [RR 1.45, 95% CI 0.94-2.22, P = 0.09] and NSAP [RR 0.92, 95% CI 0.57-1.50, P = 0.74].erCT has demonstrated both diagnostic and survival benefits by having more correct diagnoses at 24 h and lower mortality at 6 months. Further study should focus on determining the subpopulation that would most benefit from the potentially differential effects of erCT.

Background:To determine the extent of discrepancies between ambulatory blood pressure measurement (ABPM) devices and mercury sphygmomanometry in pre-use testing in routine clinical practice and whether such discrepancies are associated with patient characteristics and subsequent 24-h ABPM readings.

Abstract Background Surgical resection for Bismuth‐Corlette type IV (BC‐IV) hilar cholangiocarcinomas, also termed Klatskin tumours are technically challenging and were once considered unresectable tumours. Following advances in hepatobiliary imaging and surgical techniques, emerging evidence suggests that surgical resection is a viable avenue for long‐term survival. We aimed to identify factors affecting survival outcomes of hepatic resections for BC‐IV cholangiocarcinomas. Method A systematic review was performed across multiple databases and several clinical trial registries. Two reviewers independently screened and selected papers that contained survival data on BC‐IV cholangiocarcinoma after hepatic resections. Results Of 13 499 papers from our search result, 21 papers satisfied the inclusion criteria. The median post‐operative survival was 30.8 months. The average 1‐ and 5‐year post‐operative survivals were 61.6 and 33.3%, respectively. Predictors of long‐term survival included achievement of R0 margins, minimisation of operative time and reduction intra‐operative blood loss. Conclusion Our analysis demonstrates improving post‐operative outcomes and survival in surgical resection of BC‐IV cholangiocarcinoma and suggests that radical surgical resection is a valid treatment option for the disease.

Abstract 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 T an T ock S eng H ospital, S ingapore. 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 &lt; 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 &lt; 0.007). Costs associated with investigations were significantly higher in the ILC group ( P = 0.039), of which serological costs made most difference ( P &lt; 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 .

Peroxisome proliferator-activated receptors (PPARs) are a family of nuclear receptors involved in lipid metabolism and liver response to injury. We hypothesised that differences in the expression of PPARs may reflect differences in the cellular microenvironment of the liver and, consequently, in the behaviour of colorectal liver metastases. Of the 145 patients who underwent hepatectomy for colorectal liver metastases between 1998 and 2007, 103 had adequate tissue for PPAR staining and histological re-evaluation. The histological characteristics evaluated included sinusoidal dilatation, perisinusoidal fibrosis, ballooning and steatosis. PPAR- α and-γ staining was performed and the results were correlated with clinical and survival data. Lobular inflammation and sinusoidal dilatation were the most common histopathological abnormalities. A total of 50% of the patients were PPAR- α-negative and 34% were PPAR- γ-negative. More patients exhibited lobular inflammation in the PPAR- α -positive group (P=0.023) compared to patients with negative PPAR- α staining, as seen on the multivariate analysis. PPAR- γpositivity was associated with oxaliplatin use, surgical margins ≥1 mm and a trend towards a lesser degree of fibrosis. The median follow-up in this cohort of patients was 48 months. Patients with PPAR- α staining had a worse overall survival (median, 36 vs. 79 months, P=0.037) compared to those with no PPAR- α staining. There was no correlation between PPAR- α or-γpositivity and disease-free survival. In conclusion, PPAR- α staining is associated with lobular inflammation and worse overall survival in patients with colorectal liver metastases. The exact mechanism underlying this finding remains unclear and further research into the diagnostic and therapeutic implications is required.

Inhibition of hepatocyte growth factor (HGF)/c-MET pathway, a major mediator of pancreatic stellate cell (PSC)-PC cell interactions, retards local and distant cancer progression. This study examines the use of this treatment in preventing PC progression after resection. We further investigate the postulated existence of circulating PSCs (cPSCs) as a mediator of metastatic PC.Two orthotopic PC mouse models, produced by implantation of a mixture of luciferase-tagged human pancreatic cancer cells (AsPC-1), and human PSCs were used. Model 1 mice underwent distal pancreatectomy 3-weeks post-implantation (n = 62). One-week post-resection, mice were randomised to four treatments of 8 weeks: (i) IgG, (ii) gemcitabine (G), (iii) HGF/c-MET inhibition (HiCi) and (iv) HiCi + G. Tumour burden was assessed longitudinally by bioluminescence. Circulating tumour cells and cPSCs were enriched by filtration. Tumours of Model 2 mice progressed for 8 weeks prior to the collection of primary tumour, metastases and blood for single-cell RNA-sequencing (scRNA-seq).HiCi treatments: (1) reduced both the risk and rate of disease progression after resection; (2) demonstrated an anti-angiogenic effect on immunohistochemistry; (3) reduced cPSC counts. cPSCs were identified using immunocytochemistry (α-smooth muscle actin+, pan-cytokeratin-, CD45-), and by specific PSC markers. scRNA-seq confirmed the existence of cPSCs and identified potential genes associated with development into cPSCs.This study is the first to demonstrate the efficacy of adjuvant HGF/c-Met inhibition for PC and provides the first confirmation of the existence of circulating PSCs.

Abstract Background Bowel ischaemia significantly increases morbidity and mortality from adhesional small bowel obstruction. Current biomarkers and clinical parameters have poor predictive value for ischaemia. Our study investigated whether neutrophil‐lymphocyte ratio (NLR) and platelet‐lymphocyte ratio (PLR) could be used to predict bowel ischaemia in adhesional small bowel obstruction. Methods This single‐centre retrospective study collected clinical, biochemical and radiological data from patients with adhesional small bowel obstruction between 2017 and 2020 who underwent operative management. The presence or absence of bowel ischaemia/infarction was used to distinguish two populations. Biochemical markers on admission and immediately prior to operation were collected to give platelet‐lymphocyte ratio (PLR 0 and PLR PRE‐OP , respectively) and neutrophil‐lymphocyte ratio (NLR 0 and NLR PRE‐OP , respectively). SAS 9.4 (SAS Institute Inc., Cary, NC) software was used for data analysis with Mann–Whitney U testing for continuous variables and Pearson Chi‐square test for categorical variables. Sensitivity and specificity for PLR and NLR were calculated by means of receiver operating characteristic (ROC) curve analysis. Results Twenty‐seven patients had intra‐operative bowel ischaemia whilst the remaining 73 had no evidence of bowel ischaemia. Both median PLR PRE‐OP and NLR PRE‐OP were significantly higher in patients with bowel ischaemia compared to those without (PLR PRE‐OP 272 [IQR 224–433] and 231 [IQR 146–295] respectively, P = 0.027; NLR PRE‐OP 12.5 [IQR 8.6–21.3] v. 5.5 [IQR 3.5–10.2] respectively, P ≤ 0.001). Area under the receiver operator characteristic curve (AUC) was 0.762 for NLR PRE‐OP , with a sensitivity of 85.1% and specificity of 63% for NLR 7.4. Conclusion Raised NLR is predictive of bowel ischaemia in patients with adhesional small bowel obstruction.

Abstract Background Skin abscesses are a common emergency presentation often requiring incision and drainage; however, issues with theatre access lead to delays in management and high costs. The long‐term impact in a tertiary centre of a standardised day‐only protocol is unknown. The aim was to evaluate the impact of day‐only skin abscess protocol (DOSAP) for emergency surgery of skin abscesses in a tertiary institution in Australia and to provide a blueprint for other institutions. Methods A retrospective cohort study analysed several time periods: Period A (July 2014 to 2015, n = 201) pre‐DOSAP implementation, Period B (July 2016 to 2017, n = 259) post‐DOSAP, and Period C (July 2018 to 2022, n = 1,625) prospectively analysed four 12‐month periods to assess long‐term utilisation of DOSAP. Primary outcomes were length of stay and delay to theatre. Secondary outcome measures included theatre start time, representation rates and total costs. Statistical analysis using nonparametric methods was used to analyse the data. Results There was a significant decrease in ward length of stay (1.25 days vs. 0.65 days, P &lt; 0.0001), delay to theatre (0.81 days vs. 0.44 days, P &lt; 0.0001) and theatre start time before 10AM (44 cases vs. 96 cases, P &lt; 0.0001) after implementation of DOSAP. There was a significant decrease in median cost of admission of $711.74 after accounting for inflation. Period C reported 1,006 abscess presentations successfully managed by DOSAP over the four‐year period. Conclusion Our study demonstrates the successful implementation of DOSAP in an Australian tertiary centre. The ongoing utilisation of the protocol demonstrates the ease of applicability.

ANZ Journal of SurgeryVolume 82, Issue 10 p. 747-749 IMAGES FOR SURGEONS Novel technique for isolating and dressing enteroatmospheric fistulae Tony C. Pang FRACS, Tony C. Pang FRACS Colorectal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, AustraliaSearch for more papers by this authorJonathan Morton MBBS, MRCS, Jonathan Morton MBBS, MRCS Colorectal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, AustraliaSearch for more papers by this authorStuart Pincott FRACS, Stuart Pincott FRACS Colorectal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, AustraliaSearch for more papers by this author Tony C. Pang FRACS, Tony C. Pang FRACS Colorectal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, AustraliaSearch for more papers by this authorJonathan Morton MBBS, MRCS, Jonathan Morton MBBS, MRCS Colorectal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, AustraliaSearch for more papers by this authorStuart Pincott FRACS, Stuart Pincott FRACS Colorectal Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, AustraliaSearch for more papers by this author First published: 02 October 2012 https://doi.org/10.1111/j.1445-2197.2012.06214.xCitations: 7Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume82, Issue10October 2012Pages 747-749 RelatedInformation

Seroma formation in breast cancer patients who have undergone axillary lymph node dissection (ALND) is a source of significant discomfort and morbidity. We aimed to ascertain seroma incidence after ALND, when Harmonic Focus (HF) scalpel is used for dissection instead of conventional diathermy (CD). This retrospective study was carried out in a single hospital over 6 years. Patients were allocated into HF group (HFG) or CD group (CDG). Seroma volume, hospital stay, and complications were evaluated. Of 94 patients, 42 were in the HFG and 52 in the CDG. Two day median seroma volume was 205 ml (IQR 95-265) for HF, and 227.5 ml (IQR 149-385) for CD. The total median seroma output was 270 ml (IQR 160-478) for HF, and 385 ml (IQR 220-558) for CD. No statistically significant differences between HFG and CDG were identified in these data, as well as patient demographics, operative time, and complication rates. Duration of surgery >2.5 h increased seroma formation (p < 0.001). Mastectomy and ALND increased seroma formation compared to wide local excision (WLE) and ALND (p < 0.05). Nodal involvement, number of lymph nodes resected, and extra nodal spread did not influence seroma formation. In our hands, HF use was not superior to CD in limiting seroma formation in ALND for breast cancer. Increased seroma formation in surgeries >2.5 h in duration is commensurate with surgeries involving mastectomy and ALND (>2.5 h in our study), which entails greater and sustained tissue and lymphovascular trauma.

Aims: Laparoscopic cholecystectomy (LC) is currently the standard treatment for symptomatic gallstones. In the presence of moderate to severe inflammation when dissection of the cholecystohepatic triangle cannot be safely achieved, laparoscopic partial cholecystectomy (LPC) has been proposed as an alternative to open conversion to prevent bile duct injuries. The aim of this study is to review our experience of the technique. Materials and Methods: A retrospective review of all patients who underwent laparoscopic cholecystectomy under the upper gastrointestinal surgical unit at Westmead Hospital was undertaken. The study included all emergency and elective cases during a period from February 2012 to February 2014. Demographic, clinical, operative and postoperative characteristics including operative technique, placement of a drain, complications, length of hospital stay and histopathology were collected. Results: A total of 404 patients underwent LC during the two year study period of which 23 were LPC's. Patients who underwent LPC tended to be older and more likely of the male gender. These patients were also more likely to be an emergency operation and have a higher ASA grade compared to the LC group. Length of stay and operative time tended to be longer. There were five (22%) bile leaks postoperatively and all were successfully managed with postoperative ERCP and stenting. The major complication rate was 35% (8/23) with no bile duct injury or perioperative mortality. Conclusion: This current case series adds further evidence to suggest that LPC is a viable alternative to conversion in cases of difficult LC.

Achieving primary fascial closure after damage control laparostomy can be challenging. A number of devices are in use, with none having yet emerged as best practice. In July 2013, at Westmead Hospital, we started using the abdominal reapproximation anchor (ABRA; Canica Design, Almonte, Ontario, Canada) device. We report on our experience.A retrospective review of medical records for patients who had open abdomens managed with the ABRA device between July to December 2013 was done. Data extracted included age, sex, body mass index (BMI), reason for the open abdomen, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of laparostomies prior to ABRA placement, duration of placement, device complications, length of hospital and intensive care unit (ICU) stay, and outcomes.Four cases of open abdomens managed using the ABRA device were identified, with 3 a consequence of intra-abdominal sepsis and 1 a consequence of penetrating trauma. Mean BMI was 33.5 kg/m2, APACHE II score was 14.5, duration with open abdomen prior to ABRA placement was 11.75 days, duration with ABRA in situ was 9 days, duration of hospital stay was 64.25 days, and ICU stay was 37.75 days. Three patients (75%) achieved fascial closure, and 1 achieved skin closure. No incidences of enterocutaneous fistulae occurred.The ABRA is a unique emerging alternative to aid in achieving fascial closure in patients managed with open abdomens. Our case series demonstrates that it can be used effectively in selected patients. Studies are needed to compare its efficacy with more traditional methods.

Quality improvement in surgery requires accurate, reliable, risk-adjusted and comparative data. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) takes reliable clinical data and provides risk-adjusted comparisons with more than 800 hospitals. This paper describes the early outcomes of introducing this programme into New South Wales (NSW).Four NSW hospitals formed a collaborative. Surgical clinical reviewers were trained and data collected. Risk-adjusted reports were returned to individual hospitals and the NSW Collaborative.The results identified that the NSW Collaborative were outliers for the following causes of morbidity: urinary tract infections, surgical site infections, pneumonia and 30-day readmissions.We have shown that ACS-NSQIP can be adapted to Australia and there is a plan to widen the programme in NSW.

Kidney transplantation is the optimum treatment for kidney failure in carefully selected patients. Technical surgical complications and second warm ischemic time (SWIT) increase the risk of delayed graft function (DGF) and subsequent short- and long-term graft outcomes including the need for post-transplant dialysis and graft failure. Intraoperative organ thermal regulation could reduce SWIT, minimizing surgical complications due to time pressure, and limiting graft ischemia-reperfusion injury. A novel ischemic-injury thermal protection jacket (iiPJ) was designed and fabricated in silicone composite and polyurethane (PU) elastomer prototypes. Both were compared with no thermal insulation as controls. Time to reach ischemic threshold (15°C) and thermal energy transfer were compared. A water bath model was used to examine the thermal protective properties of porcine kidneys, as a feasibility study prior to in vivo translation. In both iterations of the iiPJ, the time taken to reach the warm ischemia threshold was 35.2 ± 1.4 minutes (silicone) and 38.4 ± 3.1 minutes (PU), compared with 17.2 ± 1.5 minutes for controls (n = 5, P < .001 for both comparisons). Thermal energy transfer was also found to be significantly less for both iiPJ variants compared with controls. There was no significant difference between the thermal performance of the 2 iiPJ variants. Protection from SWIT by using a protective insulation jacket is feasible. With clinical translation, this novel strategy could facilitate more optimal surgical performance and reduce transplanted organ ischemia-reperfusion injury, in particular the SWIT, potentially affecting delayed graft function and long-term outcomes.

Sentinel lymph node biopsy (SLNB) is being increasingly used worldwide as a minimally invasive option to stage the clinically node-negative neck (N0) in patients with early oral cavity squamous cell carcinomas (OCSCC). We performed this trial to assess the reliability and validity of the technique.We did this prospective interventional nonrandomized study in patients with early (cT1-T2 OCSCC) and with negative neck. All patients underwent preoperative lymphoscintigraphy; SLNB was followed immediately by completion neck dissection (CND), thus each patient serving as their own control. The primary outcomes evaluated are sentinel lymph node (SLN) detection rate, SLN retrieval rate, and SLN status (positive or negative) compared with pathology of CND specimen to detect any false negatives. The secondary outcomes included SLN analyses (tumor burden, location in different levels of the neck, laterality, extracapsular spread, and total nodes positive) and overall survival.Of 60 patients, 59 (98%) had successful SLN detection with the lymphoscintigram failing to localize in 1 patient. Of the remaining 59 patients, 58 (96%) had all the SLNs retrieved, resulting in 96.4% sentinel node retrieval rate. In total, 24 (41%) SLNs were positive with 1 false negative. Using a combination of SLN and CND findings as the gold standard for lymph node involvement status, SLNB had a sensitivity of 96% (95% confidence interval [CI]: 80-100%), a specificity of 100% (95% CI: 90-100%), and negative predictive value of 97% (95% CI: 85-100%).The results of this study suggest that SLNB is an accurate technique to assess the nodal status in patients with cT1-T2 N0 OCSCC and should be considered for eligible patients.

Peribiliary cysts are cystic dilatations of the extramural glands of the intrahepatic biliary tree. This disorder is uncommon and is usually asymptomatic. However, it may cause extrinsic biliary compression and consequently, obstructive jaundice. This paper describes 2 such cases presenting with jaundice. The etiology, natural history, investigation findings and treatment of this disorder are also discussed.

Abstract Background Laparoscopic pancreaticoduodenectomy (LPD) is gaining interest with several series reporting favourable outcomes. However, there are significant limitations to the successful implementation of LPD programmes in Australian and New Zealand (ANZ) settings. This study presents a local series of consecutive hybrid LPD (HLPD) and a suggested protocol for implementation of an LPD programme in ANZ settings. Methods A retrospective review of consecutive patients undergoing HLPD with a laparoscopic resection and open reconstruction performed by a single surgeon at two centres in Sydney, Australia, between February 2014 and October 2019 was undertaken. Data were collected from a prospectively maintained database and patient records. Results Eighteen patients underwent HLPD. Median operative time was 370 min, with a median laparoscopic resection time of 253 min. Median length of stay was 11 days. There was no mortality within 90 days. Post‐operative complications included two patients requiring a return to operating theatre for post‐operative pancreatic fistula, and five patients with delayed gastric emptying. Median number of lymph nodes harvested was 13 (interquartile range 11–15.8). Resection margins were negative in 15 patients (83.3%). Conclusion HLPD is associated with satisfactory perioperative outcomes and may be feasible as a first step towards eventual implementation of LPD in ANZ hospitals.

Solitary necrotic nodule of the liver (SNNL) is a rare benign lesion with an uncertain aetiology. There are no typical diagnostic clinical or radiological features, and this lesion is usually detected incidentally during imaging for other purposes.We describe the clinical and radiological findings in three patients with histologically confirmed SNNL. The pertinent presenting features were documented and subsequent serological testing for parasites was performed.All three patients underwent resection because it was not possible to exclude a solitary malignancy on preoperative imaging. All three nodules had a serpiginous shape with areas of necrosis that showed marked staining for eosinophil granules. However, no viable parasites were seen in any specimen. There were no specific radiological features that were present in all three patients. Two patients had travelled to areas where parasitic infections are endemic and one patient had an eosinophilia on presentation. The histopathological findings in conjunction with the clinical presentation suggest that SNNL may be parasitic in origin.The diagnosis of SNNL is usually made after surgical excision. A preoperative diagnosis is difficult to make even with the use of multiple imaging modalities. The clinical and histopathological findings described in our three patients suggest that a transient parasitic infection is likely to be the cause in many cases. A history of potential exposure to parasites and serological testing for an eosinophilia or parasitic antibodies may help make the diagnosis of SNNL without the need for resection.

Postoperative pancreatic fistula (POPF) remains a significant complication of pancreatic resection with recent evidence showing a strong association between post-operative pancreatitis and subsequent development of POPF. Incidence and severity of pancreatitis following endoscopic therapy has been effectively reduced with indomethacin prophylaxis, however further agents require evaluation. We present a systematic literature review and meta-analysis of the prophylactic treatment with corticosteroids or n-acetyl cysteine (NAC) of induced pancreatitis in rodent models.A systematic literature search was conducted using Pubmed, Medline, Embase and Cochrane library to identify eligible randomized control trials (RCT) involving animal models that examined NAC or corticosteroids. The primary outcome was the subsequent effect on serum amylase and IL-6 and the histopathological markers of severity such as pancreatic oedema and necrosis.Four RCTs (n = 178) met inclusion criteria examining NAC and eight RCTs (n = 546) examining corticosteroid agents (dexamethasone, hydrocortisone, methylprednisolone). Prophylactic administration of all corticosteroid agents showed a net effect in favour of reducing markers of severity of pancreatitis. NAC showed a significant reduction in severity of amylase and necrosis.The RCTs examined suggest that prophylactic administration of corticosteroid agents and NAC can reduce the severity of pancreatitis as indicated by histopathologic markers, serum amylase and IL-6 levels.

There is lack of consensus in the literature regarding the comparative efficacy of in situ aortic-only compared with dual (aortic and portal venous) perfusion for retrieval and transplantation of the liver. Recipient outcomes from the Australia/New Zealand Liver Transplant Registry (2007-2016), including patient and graft survival and causes of graft loss, were stratified by perfusion route. Subgroup analyses were conducted for higher-risk donors. A total of 1382 liver transplantation recipients were analyzed (957 aortic-only; 425 dual perfusion). There were no significant differences in 5-year graft and patient survivals between the aortic-only and dual cohorts (80.1% versus 84.6% and 82.6% versus 87.8%, respectively) or in the odds ratios of primary nonfunction, thrombotic graft loss, or graft loss secondary to biliary complications or acute rejection. When analyzing only higher-risk donors (n = 369), multivariate graft survival was significantly less in the aortic-only cohort (hazard ratio, 0.49; 95% confidence interval, 0.26-0.92). Overall, there was a trend toward improved outcomes when dual perfusion was used, which became significant when considering higher-risk donors alone. Inferences into the ideal perfusion technique in multiorgan procurement will require further investigation by way of a randomized controlled trial, and outcomes after the transplantation of other organs will also need to be considered.

There is a lack of satisfactory animal models to study adjuvant and/or neoadjuvant therapy in patients being considered for surgery of pancreatic cancer (PC). To address this deficiency, we describe a mouse model involving orthotopic implantation of PC followed by distal pancreatectomy and splenectomy. The model has been demonstrated to be safe and suitably flexible for the study of various therapeutic approaches in adjuvant and neo adjuvant settings. In this model, a pancreatic tumor is first generated by implanting a mixture of human pancreatic cancer cells (luciferase-tagged AsPC-1) and human cancer associated pancreatic stellate cells into the distal pancreas of Balb/c athymic nude mice. After three weeks, the cancer is resected by re-laparotomy, distal pancreatectomy and splenectomy. In this model, bioluminescence imaging can be used to follow the progress of cancer development and effects of resection/treatments. Following resection, adjuvant therapy can be given. Alternatively, neoadjuvant treatment can be given prior to resection. Representative data from 45 mice are presented. All mice underwent successful distal pancreatectomy/splenectomy with no issues of hemostasis. A macroscopic proximal pancreatic margin greater than 5 mm was achieved in 43 (96%) mice. The technical success rate of pancreatic resection was 100%, with 0% early mortality and morbidity. None of the animals died during the week after resection. In summary, we describe a robust and reproducible technique for a surgical resection model of pancreatic cancer in mice which mimics the clinical scenario. The model may be useful for the testing of both adjuvant and neoadjuvant treatments.

Unplanned surgical readmissions are an important indicator of quality care and are a key focus of improvement programs. The aims of this study were to evaluate the factors that lead to unplanned hospital readmissions in patients undergoing general surgical procedures and to identify preventable readmissions.A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database from 2016 to 2020 at a tertiary hospital was conducted to identify patients undergoing a general surgical procedure. Various perioperative parameters were studied to identify risk factors and reasons for unplanned readmission. Preventable readmissions were identified.A total of 3069 patients underwent a general surgical procedure. Of these, the overall unplanned readmission rate was 8.8% (n = 247). The most common reason for readmission was associated with surgical site infections (n = 112, 44.3%) followed by pain (n = 50, 20.2%), with over 45% deemed as preventable readmissions. Factors associated with increased risk of readmission included older age, longer index length of stay, prolonged operative time, elective procedures, higher ASA score and contaminated procedures.Unplanned readmissions are more likely to occur in patients who develop postoperative complications. Understanding factors associated with readmissions may facilitate targeted quality improvement projects that reduce hospital readmission after surgery.

Background Pneumonectomy in the adult patient is associated with a mortality of 1–9%. Death is often due to post pneumonectomy pulmonary oedema (PPPO). The use of balanced chest drainage system (BCD) in the setting of post pneumonectomy has been reported to be of benefit in the prevention of PPPO. This study seeks to compare the incidence of PPPO in patients who underwent pneumonectomy and whose empty pleural space was managed either with CRD or BCD. Methods This retrospective observational cohort study involved 98 patients who were operated on by one surgeon at Liverpool Hospital, Sydney, Australia from 1997 to 2019. The patients were divided into two groups according to the era in which they had their pneumonectomy. Group 1 consisted of 18 patients managed with clamp-release drainage between 1997 and 2002. Group 2 consisted of 80 patients managed with balanced chest drainage between 2003 and 2019. The primary outcomes of interest were the development of PPPO and death. Demographic and clinico-pathological variables between the groups were compared including whether the phrenic nerve was sacrificed, volume of infused intraoperative fluid, duration of single lung ventilation, intraoperative tidal volumes, agents of anaesthetic induction and maintenance, mean urine output in the first 4 postoperative hours, institution of a postoperative 1.5 L fluid restriction, total chest drainage, day of chest drain removal, presence of radiological postoperative mediastinal shift, post-pneumonectomy pulmonary oedema and death. Group characteristics were compared using t-test and chi-squared for continuous and categorical variables respectively. Univariate and multivariate analysis was also undertaken using the Firth method of logistic regression for rare occurrences in a stepwise fashion. Results Through univariate analysis, balanced chest drainage, postoperative fluid restriction and intraoperative fluid infusion showed significant effect on PPPO. Through multivariate analysis, balanced chest drainage was found to have independent protective value for PPPO and mortality. Conclusion Compared with clamp-release drainage, balanced chest drainage results in a lower incidence of post-pneumonectomy pulmonary oedema and death. Pneumonectomy in the adult patient is associated with a mortality of 1–9%. Death is often due to post pneumonectomy pulmonary oedema (PPPO). The use of balanced chest drainage system (BCD) in the setting of post pneumonectomy has been reported to be of benefit in the prevention of PPPO. This study seeks to compare the incidence of PPPO in patients who underwent pneumonectomy and whose empty pleural space was managed either with CRD or BCD. This retrospective observational cohort study involved 98 patients who were operated on by one surgeon at Liverpool Hospital, Sydney, Australia from 1997 to 2019. The patients were divided into two groups according to the era in which they had their pneumonectomy. Group 1 consisted of 18 patients managed with clamp-release drainage between 1997 and 2002. Group 2 consisted of 80 patients managed with balanced chest drainage between 2003 and 2019. The primary outcomes of interest were the development of PPPO and death. Demographic and clinico-pathological variables between the groups were compared including whether the phrenic nerve was sacrificed, volume of infused intraoperative fluid, duration of single lung ventilation, intraoperative tidal volumes, agents of anaesthetic induction and maintenance, mean urine output in the first 4 postoperative hours, institution of a postoperative 1.5 L fluid restriction, total chest drainage, day of chest drain removal, presence of radiological postoperative mediastinal shift, post-pneumonectomy pulmonary oedema and death. Group characteristics were compared using t-test and chi-squared for continuous and categorical variables respectively. Univariate and multivariate analysis was also undertaken using the Firth method of logistic regression for rare occurrences in a stepwise fashion. Through univariate analysis, balanced chest drainage, postoperative fluid restriction and intraoperative fluid infusion showed significant effect on PPPO. Through multivariate analysis, balanced chest drainage was found to have independent protective value for PPPO and mortality. Compared with clamp-release drainage, balanced chest drainage results in a lower incidence of post-pneumonectomy pulmonary oedema and death.

Abstract Background Day‐only laparoscopic cholecystectomy (DOLC) has been shown to be safe and feasible yet has not been widely implemented in Australia. This study explores the introduction of routine DOLC to Westmead Hospital, and highlights the barriers to its implementation. Methods Routine day‐only cholecystectomy protocol was introduced at Westmead Hospital in 2014. A retrospective review of patients who underwent elective laparoscopic cholecystectomy during a 12‐month period in 2014 was compared to a 12‐month period in 2018, to examine the changes in practice after implementation of a unit protocol. Data were collected on patient demographics, admission category, outcomes and re‐presentations. Results A total of 282 patients were included in the study, of these 169 were booked as day procedures, with 124 (73%) successfully discharged on the same day. There was a significant increase in the proportion of patients booked as day‐only from 2014 to 2018 (48% versus 73%, P &lt; 0.001). Day‐only failure rates (unplanned overnight admissions), readmissions and complication rates were comparable between the two periods. The most common reason for unplanned overnight admissions were due to intraoperative findings ( n = 28/45). Conclusion Routine DOLC can be adopted in Australian hospitals without compromise to patient safety. Unplanned overnight admission is predominantly due to unexpected surgical pathology and can be reduced by protocols for the use of drains and planned outpatient endoscopic retrograde cholangiopancreatography. Unplanned outpatient review can be minimized by optimizing both intra‐ and post‐operative pain management. Individual surgeon and anaesthetist preferences remain an obstacle to a standardized protocol in the Australian setting.

In melanoma patients, we define incomplete sentinel node biopsy (I-SNB) as when fewer lymph nodes are removed during sentinel node biopsy (SNB) than identified on preoperative lymphoscintigraphy (LS). This study quantifies the frequency of I-SNB and evaluates any correlation with patient outcomes.Evaluation of a prospective database of consecutive patients having LS and negative SNB from 1996 to 2006. Additional LS information was obtained from a nuclear medicine database. All statistical analyses were performed using the IBM SPSS Statistic 19.0 software package.I-SNB occurred in 20% of the cohort (n = 2007). For axillary (n = 895), groin (n = 569), and neck/axial patients (n = 334) I-SNB occurred in 12%, 26%, and 28% of cases, respectively (P < .001). On univariate analysis, there was a significant association between I-SNB and worse disease-free survival (DFS), P = .007 and trend toward worse melanoma-specific survival (MSS), P = .056. I-SNB was not associated with worse regional recurrence-free survival (RRFS), P = .144. There was no relationship between I-SNB and worse DFS, RRFS, or MSS on multivariate analysis. Sentinel node region (axilla better than groin and neck/axial) had a significant association with RRFS (P = .039) on univariate analysis and DFS on univariate (P = .009) and multivariate analysis. Significantly worse outcomes for MSS, DFS, and RRFS were seen with male gender, increasing age, high mitotic count, ulceration, and increasing Breslow thickness.This study demonstrates no statistically significant relationship between I-SNB and patient outcomes when adjusting for known prognostic factors. These data do not exclude the possibility that I-SNB may have a weak association with worse outcomes.

Renal artery aneurysms (RAA) can be repaired with endovascular exclusion (EVR), open repair (OR), or ex-vivo repair with renal autotransplantation (ERAT). This systematic review compares repair indications, aneurysm characteristics, and complications following these interventions.A systematic review of databases including MEDLINE, PUBMED, and EMBASE by two independent reviewers for studies from January 2000-November 2022. All studies evaluating repair indications, RAA morphology, morbidity and mortality following EVR, OR, and ERAT were included.A total of 38 studies were included with 1540 EVR, 2377 OR and 109 ERAT subjects. Increasing aneurysm size, or diameters >20 mm, were the most common repair indications across EVR and OR (n = 537; 48%), and ERAT (n = 23; 52%). All ERAT repairs were at or distal to renal artery bifurcations (n = 46). Meta-analyses demonstrated significantly shorter length of stay (LOS) with EVR compared to OR (mean difference -4.06, 95% confidence interval (CI) -5.69 to -2.43, P < 0.001). No significant differences were found in mean aneurysm diameter (P = 0.23), total complications (P = 0.17), and mortality (P = 0.85). Major complications (Clavien-Dindo ≥III) across studies most commonly included acute renal failure (EVR 4.9% vs. OR 7.0%). Nephrectomy was the most common major complication in ERAT (5.5%).Outcomes following EVR and OR of RAAs are comparable. EVR offers a shorter LOS, with no difference in morbidity or mortality. ERAT is currently only utilized for distal RAAs, however carries higher risk of infarction and nephrectomy necessitating specialized expertise or algorithms to assist appropriate selection of repair methods.

Pancreatic ductal adenocarcinoma (PDAC), one of the most devastating cancers of our time, has a dismal prognosis. PDAC is characterized by a prominent desmoplastic reaction and typically cold immune microenvironment. This “cold immune” status is a result of several factors, including a relative dearth of neoantigens in cancer cells and an active interplay between carcinoma-associated fibroblasts (CAFs), tumor-associated macrophages (TAMs), and cancer cells that facilitates immune evasion and immunosuppression, which further potentiates cancer progression. This chapter focuses on the cell types that play a key role in the PDAC tumour microenvironment, particularly CAFs and TAMs, with their inherent heterogeneity and versatile functions that contribute to an immunosuppressive environment. It also addresses the key steps involved in the host antitumor response mediated by natural killer (NK) and cytotoxic T cells, and the immune evasion mechanisms mediated by CAFs and TAMs which hinder NK and T-cell responses. Lastly, the chapter highlights the importance of targeted immunotherapy and/or combinations of immunotherapy with other conventional treatments with an overview of currently available therapeutic interventions attacking the immunosuppressive milieu.

Abstract Background Despite its proposed benefits, laparoscopic pancreaticoduodenectomy (LPD) has not been widely adopted due to its technical complexity and steep learning curve. The aim of this study was to report a single surgeon's experience in the stepwise implementation of LPD and evolution of technique over a nine‐year period in a moderate‐high volume unit. Methods Carefully selected patients underwent LPD initially by hybrid approach (laparoscopic resection and open reconstruction), which evolved into a total LPD (laparoscopic resection and reconstruction). Data was prospectively collected to include patient characteristics, intraoperative data, evolution of technique and postoperative outcomes. Results A total of 25 patients underwent hybrid LPD (HLPD) and 20 patients underwent total LPD (TLPD). There was no 90‐day mortality. Three patients developed a postoperative pancreatic fistula (POPF), all of which occurred in patients undergoing HLPD. There was no POPF in 20 consecutive TLPD. There was no evidence of anastomotic strictures in the hepaticojejunostomy in patients undergoing TLPD at long term follow up. Conclusion A gradual and cautious progression from HLPD to TLPD is essential to ensure safe implementation into a unit. LPD should only be considered in carefully selected patients, with outcomes subjected to regular and rigorous independent audit.

Hepatic artery pseudoaneurysms are an uncommon complication of blunt hepatic trauma typically presenting in a delayed fashion. A 40-year-old male presented to a trauma centre after a 6-metre fall from a construction site with multiple injuries including a grade IV liver laceration centred around the porta hepatis. This liver injury was managed non-operatively. On day sixteen of admission, he had a sudden cardiac arrest from haemorrhagic shock with a subsequent CT demonstrating a ruptured extrahepatic proper hepatic artery pseudoaneurysm. Despite laparotomy and vessel repair, he died from pulmonary complications of aspiration pneumonia and acute lung injury associated with massive transfusion. The literature demonstrates conflicting views regarding the utility of repeat CT to detect a pseudoaneurysm in asymptomatic, non-operatively managed patients with blunt hepatic trauma. In particular, the literature does not distinguish the utility of repeat routine CT for intrahepatic and extrahepatic hepatic artery pseudoaneurysm, the latter if which is rarer. Current guidelines recommend against it, but there are observational studies suggesting utility, particularly in high grade (≥IV) liver injury. In patients with a high-grade injury extending to the porta hepatis, repeat imaging should be considered to detect possible pseudoaneurysm.

Abstract Background The National Surgical Quality Improvement Program (NSQIP) is widely used in North America for benchmarking. In 2015, NSQIP was introduced to four New South Wales public hospitals. The aim of this study is to investigate the agreement between NSQIP and administrative data in the Australian setting; to compare the performance of models derived from each data set to predict 30‐day outcomes. Methods The NSQIP and administrative data variables were mapped to select variables available in both data sets where coding may be influenced by interpretation of the clinical information. These were compared for agreement. Logistic regression models were fitted to estimate the probability of adverse outcomes within 30 days. Models derived from NSQIP and administrative data were compared by receiver operating characteristic curve analysis. Results A total of 2240 procedures over 21 months had matching records. Functional status demonstrated poor agreement (kappa 0.02): administrative data recorded only one (1%) patient with partial‐ or total‐dependence as recorded by NSQIP data. The American Society of Anesthesiologists class demonstrated excellent agreement (kappa 0.91). Other perioperative variables demonstrated poor to fair agreement (kappa 0.12–0.61). Predictive model based on NSQIP data was excellent at predicting mortality but was less accurate for complications and readmissions. The NSQIP model was better in predicting mortality and complications (receiver operating characteristic curve 0.93 versus 0.87; P = 0.029 and 0.71 versus 0.64; P = 0.027). Conclusions There is poor agreement between NSQIP data and administrative data. Predictive models associated with NSQIP data were more accurate at predicting surgical outcomes than those from administrative data. To drive quality improvement in surgery, high‐quality clinical data are required and we believe that NSQIP fulfils this function.

Kaposiform lymphangiomatosis (KLA) is a rare and novel disorder of the lymphatic vascular system which was first described by Debelenko, Perez-Atayde, and Croteau et al.1Debelenko L. Marler J. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis (KLA): an aggressive variant of lymphangiomatosis.Lab Invest. 2004; 84: 269Google Scholar, 2Perez-Atayde AR, Croteau SE, Trenor CC, et al. Kaposiform lymphangiomatosis: a new entity distinct from generalized lymphatic anomaly, kaposiform hemangioendothelioma, lymphedema-associated angiosarcoma, and lymphangioma-like kaposi sarcoma. International Society of Vascular Anomalies Meeting, 2012, Malmo, Sweden.Google Scholar, 3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar at the Boston Children's Hospital. It has been described as a distinct histopathological entity within the subtype of generalised lymphatic anomalies (GLA) characterised by foci of ‘kaposiform’ spindled lymphatic endothelial cells surrounding malformed lymphatic channels.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar To date, all reported cases have included thoracic involvement, with other reported sites including bone, spleen and retroperitoneum in addition to thoracic disease. An otherwise healthy 22-year-old Vietnamese woman presented with a 2 day history of epigastric pain radiating to her right abdomen. The pain was exacerbated by meals and was associated with nausea and vomiting. Her bowels were opening with no issues and she reported no fevers, dysuria or other infective symptoms. On examination, her abdomen was soft and she was tender in the epigastrium and right upper quadrant. Initial blood tests were unremarkable, including a normal platelet count 303 × 109/L and fibrinogen of 3.2 g/L. Ultrasound of her abdomen showed a mass in the mid abdomen, with associated lymphadenopathy. Further evaluation with computed tomography (CT) of her abdomen and pelvis confirmed a 11×4.5×11 cm mass encasing the superior mesenteric artery and vein at the root of the mesentery (Fig. 1A,B). Magnetic resonance imaging (MRI) demonstrated a lobulated, well defined mesenteric root mass which was hyperintense on T2-weighted sequences (Fig. 1C). Given the suspicion for malignancy, staging CT scans of her chest and neck were performed which showed no lung lesions or other lymphadenopathy. With the aim of obtaining tissue diagnosis, endoscopic ultrasonography was performed, but was unable to visualise the lesion. Finally, a diagnostic laparoscopy was performed. Intra-operatively, the mass had the appearance of oedematous fatty tissue (Fig. 1D,E). As it was not possible to safely resect the mass or perform a core biopsy, an incisional biopsy was performed with ultrasonic shears. Histopathology of the biopsy showed vascularised adipose tissue in keeping with mesentery. Within the mesentery were dilated malformed thin walled vessels, some with discontinuous mural bundles of smooth muscle, and with scattered lymphoid aggregates in the adjacent stroma, in keeping with malformed lymphatic vessels (Fig. 2A). Clusters of short spindle cells with small slit-like vascular channels were also present in areas accentuated around malformed lymphatic vessels (Fig. 2B). Occasional mast cells were present, but no plasma cells, granulomas or large or atypical lymphocytes were seen. The spindle cells were confirmed to be of lymphatic endothelial origin, staining strongly positive for markers CD34, ERG and D2-40 (Fig. 2C–F). The endothelial cells lining the smaller vascular spaces stained positive for CD34 and D2-40, and the endothelial lining of all sizes of vascular spaces stained positive for ERG, further confirming a lymphatic vascular process (Fig. 2C–F). Smooth muscle actin was positive only in the smooth muscle within walls of the larger vascular spaces, and S-100 staining was positive in adipocytes only, with both negative within the spindle cells. The spindle cells were also negative for Melan-A, HMB45, keratin AE1/AE3, SOX 10 and MDM2. The overall histological features were consistent with KLA, with immunohistochemistry confirming the lymphatic endothelial nature of the malformed vessels and spindled lesional cells. Further X-rays of her skull, long bones, spine, pelvis and chest found no osseous involvement. She has since had improvements in her abdominal symptoms following commencement of treatment with sirolimus. KLA represents a rare and relatively novel lymphatic disorder which predominantly affects children, with a median age of symptom onset and diagnosis of 6.5 and 8.5 years, respectively, with ages ranging from birth to 44 years.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar The oldest reported age of diagnosis in the literature is 50 years.4Safi F. Gupta A. Adams D. et al.Kaposiform lymphangiomatosis, a newly characterized vascular anomaly presenting with hemoptysis in an adult woman.Ann Am Thorac Soc. 2014; 11: 92-95Crossref PubMed Scopus (26) Google Scholar Of the 20 cases described by Croteau et al., 50% initially presented with respiratory symptoms such as cough or dyspnoea, and 50% presented with bleeding.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Ultimately, 95% of patients in this series developed pericardial and/or pleural effusions with all but one requiring drainage.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Consumptive coagulopathy was also described as an uncommon complication.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar With regards to anatomical distribution, the authors found thoracic involvement in all patients (100%) with bone (50%) and spleen (50%) being the next most common regions being involved.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Another large case series of 20 patients by Goyal et al. similarly found 100% intrathoracic involvement, 35% of patients had splenic involvement and 80% had evidence of retroperitoneal disease.5Goyal P. Alomari A.I. Kozakewich H.P. et al.Imaging features of kaposiform lymphangiomatosis.Pediatr Radiol. 2016; 46: 1282-1290Crossref PubMed Scopus (23) Google Scholar The retroperitoneal disease was characterised by enhancing infiltrative soft tissue, almost always involving the retrocrural region with extension into the mesentery (56% of retroperitoneal cases).5Goyal P. Alomari A.I. Kozakewich H.P. et al.Imaging features of kaposiform lymphangiomatosis.Pediatr Radiol. 2016; 46: 1282-1290Crossref PubMed Scopus (23) Google Scholar On imaging with MRI, they were hyperintense on fluid weighted sequences.5Goyal P. Alomari A.I. Kozakewich H.P. et al.Imaging features of kaposiform lymphangiomatosis.Pediatr Radiol. 2016; 46: 1282-1290Crossref PubMed Scopus (23) Google Scholar Consistent with this case series, other smaller studies have found invariably thoracic involvement.4Safi F. Gupta A. Adams D. et al.Kaposiform lymphangiomatosis, a newly characterized vascular anomaly presenting with hemoptysis in an adult woman.Ann Am Thorac Soc. 2014; 11: 92-95Crossref PubMed Scopus (26) Google Scholar,6Raam M.S. Festekjian A. Elkhunovich M.A. Point-of-care thoracic ultrasonography in the diagnosis and management of kaposiform lymphangiomatosis.Pediatr Emerg Care. 2016; 32: 888-891Crossref PubMed Scopus (4) Google Scholar, 7Fernandes V.M. Fargo J.H. Saini S. et al.Kaposiform lymphangiomatosis: unifying features of a heterogeneous disorder.Pediatr Blood Cancer. 2015; 62: 901-904Crossref PubMed Scopus (25) Google Scholar, 8Radzikowska E. Blasinska-Przerwa K. Szolkowska M. et al.Kaposiform lymphangiomatosis with human papillomavirus infection.Am J Respir Crit Care Med. 2017; 195: e47-e48Crossref PubMed Scopus (3) Google Scholar, 9Wang Z. Li K. Yao W. et al.Successful treatment of kaposiform lymphangiomatosis with sirolimus.Pediatr Blood Cancer. 2015; 62: 1291-1293Crossref PubMed Scopus (24) Google Scholar Therefore, this case is unique in that involvement at diagnosis was confined to the abdominal cavity with involvement of the retroperitoneum extending into the root of the mesentery, and no evidence of intrathoracic disease. Histopathologically, KLA is distinguished by foci of ‘kaposiform’ spindled lymphatic endothelials cells, often arranged in parallel fashion either as dispersed, poorly marginated clusters or anastomosing strands.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Further immunohistochemical staining, such as with PROX-1, D2-40, ERG, CD31 or CD34 can confirm the presence of these lymphatic endothelial cells.7Fernandes V.M. Fargo J.H. Saini S. et al.Kaposiform lymphangiomatosis: unifying features of a heterogeneous disorder.Pediatr Blood Cancer. 2015; 62: 901-904Crossref PubMed Scopus (25) Google Scholar,9Wang Z. Li K. Yao W. et al.Successful treatment of kaposiform lymphangiomatosis with sirolimus.Pediatr Blood Cancer. 2015; 62: 1291-1293Crossref PubMed Scopus (24) Google Scholar,10Ordonez N.G. Immunohistochemical endothelial markers: a review.Adv Anat Pathol. 2012; 19: 281-295Crossref PubMed Scopus (42) Google Scholar This is distinct from kaposiform haemangioendothelioma (KHE), another disorder associated with abnormal lymphatic channels and spindled cells, however the histological architecture is of more defined solid confluent tumour, often with microthombi.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Clinically, KHE differs further as the lesions are typically unifocal vascular tumours presenting in infancy, which may involve skin and soft tissues, retroperitoneum or viscera,3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar with larger lesions commonly associated with thrombocytopenia resulting in consumptive coagulopathy (Kasabach–Merritt phenomenon). There is currently no standard treatment for KLA and management is directed at symptom control and management of complications such as drainage of pericardial or pleural effusions.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar,7Fernandes V.M. Fargo J.H. Saini S. et al.Kaposiform lymphangiomatosis: unifying features of a heterogeneous disorder.Pediatr Blood Cancer. 2015; 62: 901-904Crossref PubMed Scopus (25) Google Scholar,9Wang Z. Li K. Yao W. et al.Successful treatment of kaposiform lymphangiomatosis with sirolimus.Pediatr Blood Cancer. 2015; 62: 1291-1293Crossref PubMed Scopus (24) Google Scholar Pharmacotherapy options such as sirolimus, an mTOR inhibitor, have been utilised in other vascular anomalies with promising results.11Triana P. Dore M. Cerezo V.N. et al.Sirolimus in the treatment of vascular anomalies.Eur J Pediatr Surg. 2017; 27: 86-90PubMed Google Scholar Croteau et al. reported clinical improvement in three patients following sirolimus therapy,3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar and other case studies have also reported reduction in lesion size or improvement in symptoms6Raam M.S. Festekjian A. Elkhunovich M.A. Point-of-care thoracic ultrasonography in the diagnosis and management of kaposiform lymphangiomatosis.Pediatr Emerg Care. 2016; 32: 888-891Crossref PubMed Scopus (4) Google Scholar,8Radzikowska E. Blasinska-Przerwa K. Szolkowska M. et al.Kaposiform lymphangiomatosis with human papillomavirus infection.Am J Respir Crit Care Med. 2017; 195: e47-e48Crossref PubMed Scopus (3) Google Scholar,9Wang Z. Li K. Yao W. et al.Successful treatment of kaposiform lymphangiomatosis with sirolimus.Pediatr Blood Cancer. 2015; 62: 1291-1293Crossref PubMed Scopus (24) Google Scholar or stable disease.7Fernandes V.M. Fargo J.H. Saini S. et al.Kaposiform lymphangiomatosis: unifying features of a heterogeneous disorder.Pediatr Blood Cancer. 2015; 62: 901-904Crossref PubMed Scopus (25) Google Scholar One patient in a case series by Fernandes et al., showed initial response to sirolimus and a 5 month period of remission before subsequent reaccumulation of pleural and pericardial effusion, and development of epidural haemorrhage resulting in fatal cardiac arrest.7Fernandes V.M. Fargo J.H. Saini S. et al.Kaposiform lymphangiomatosis: unifying features of a heterogeneous disorder.Pediatr Blood Cancer. 2015; 62: 901-904Crossref PubMed Scopus (25) Google Scholar Limited survival and prognostic data exist for KLA; however, Croteau et al. reported a 5 year survival of 51% and an overall survival of 34%.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Mean interval between diagnosis and death was reported as 2.75 years with cardiorespiratory failure being the most common cause.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Of note, there was one patient in the series who presented as an adult, never required any interventions, and denied any issues on follow-up.3Croteau S.E. Kozakewich H.P. Perez-Atayde A.R. et al.Kaposiform lymphangiomatosis: a distinct aggressive lymphatic anomaly.J Pediatr. 2014; 164: 383-388Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar In conclusion, KLA is a rare but emerging entity classically presenting as intrathoracic lesions in young patients. However, this diagnosis should also be considered in patients with infiltrating masses in the retroperitoneum even when intrathoracic disease is not present, as demonstrated with this case. The authors state that there are no conflicts of interest to disclose.

A previously healthy 20-year-old man presented with a 2-day history of right lower quadrant pain radiating into the right groin and testis. He was afebrile with no other associated symptoms. He had no previous operations and no known allergies. On examination, he had right iliac fossa tenderness and

Throughout the COVID-19 pandemic, there has been worldwide debate regarding whether open surgery should be performed in preference to laparoscopic surgery due to the theoretical higher risk of viral aerosolization by the release of pneumoperitoneum. We aimed to assess the consistency of national and international surgical society recommendations regarding the choice of surgical approach; assess the quality of evidence of viral emission in surgical aerosol; and assess the quality of evidence comparing aerosol generation by different surgical energy devices.A systematic review of PubMed, Medline, Embase and Cochrane databases was performed. Three search strategies were employed. Twenty-eight studies were included in the final analysis and quality appraised. Confidence in review findings was assessed using the GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) tool.Worldwide recommendations regarding open versus laparoscopic surgery are consistent, with a majority recommending that surgical approach is decided on a case-by-case, risk minimization approach. There is limited, low-quality evidence that viral particles can be emitted in surgical aerosol. There is a paucity of literature on the quantity of aerosol produced by different surgical energy devices, and no evidence to support the use of certain surgical instruments to minimize aerosol production.There is considerable consistency among worldwide recommendations regarding the choice of surgical approach, although the evidence base is lacking. To inform clinical recommendations, further research examining viral emission, transmission, infectivity and amount of surgical aerosol produced is required.

Sporadic non-invasive adenomas of the duodenum and ampulla are uncommon. For small lesions (≤20mm and confined to the papillary mound) endoscopic resection is the standard of care and is well supported by systematic study. However for large lateral spreading lesions (LSLs) (≥25mm and extending beyond the papillary mound), little endoscopic evidence exists. Surgery is often performed as the initial treatment of choice and while curative is associated with substantial morbidity (30%-40%) and mortality (1%-4%). Endoscopic resection may offer a superior safety profile and reduced costs without sacrificing long-term outcomes. We aimed to compare actual endoscopic to predicted surgical outcomes and costs using validated clinical prediction tools.

Obesity represents a growing global health threat, which generally portends increased morbidity and mortality in the context of traumatic injuries. We hypothesized that there may exist a protective effect related to increased weight and truncal girth provided for obese patients in penetrating torso injuries, although this may not exert a significant positive impact overall upon clinical outcomes.A comprehensive review of the literature was conducted across five databases up to March 2021 (Medline, Pubmed, Embase, Web of Science and the Cochrane library) to examine the effect of obesity on penetrating thoracoabdominal injuries. The primary outcome was to determine the rate of nonsignificant injury and injury patterns. Secondary outcomes examined were lengths of stay, complications, and mortality. Comparisons were drawn by meta-analysis. The study protocol was registered with PROSPERO under CRD42020216277.There were 2,952 publications assessed with 12 meeting the inclusion criteria for review. Nine studies were included for quantitative analysis, including 5,013 patients sustaining penetrating thoracoabdominal injuries, of which 29.6% were obese. Obese patients that sustained stab injuries underwent more nontherapeutic operations. Obese patients that sustained gunshot injuries had longer intensive care and total hospital length of stay. Obese patients suffered more respiratory complications and were at an increased risk of death during their admission.The "armor phenomenon" does not truly protect obese patients, a population that experiences increased morbidity and mortality following penetrating thoracoabdominal injuries.Systematic Review and Meta-Analysis; Level IV.

Introduction: the incidence of venous thromboembolism (VtE) is not well defined in Asian population after major hepatobiliary and pancreatic (HPb) surgery.the use of pharmacological prophylaxis is debatable due to postoperative coagulopathy.Aim: to determine the incidence of clinically significant VtE events in Asian undergoing major HPb surgery.Methods: A retrospective review of patients undergoing major HPb surgery between January 2010 to August 2013 at tan tock seng Hospital, singapore was conducted.clinical notes and radiology reports were reviewed to screen for patients who developed VtE.A secondary endpoint was 30-day and 90-day mortality.results: 224 patients had major HPb surgery with median age of 61 years and bMI of 22.3.143 patients were male.Majority of the patients were chinese and most underwent open hepatic surgery for malignancy.A few had a past history of VtE.No patient developed DVt, whilst a single patient

Introduction: Incidental common bile duct (CBD) calculi is found in approximately 11% of routine intra-operative cholangiograms (IOC) during laparoscopic cholecystectomy (LC). An uncertain proportion of these may remain asymptomatic or pass spontaneously, and therefore not require invasive intervention. We aim to explore the natural history of retained CBD calculi in asymptomatic patients to guide management for this common incidental operative finding. Methods: Retrospective analysis of LC performed at an Australian tertiary hospital from 2014 to 2018 was undertaken. Records of patients with filling defects noted on IOC were reviewed. Incidental patients were defined by preoperative bilirubin< 40μmol/L and gamma-glutamyl transferase< 500U/L. The main endpoint was the passage of CBD calculus, determined by the absence of choledocholithiasis on postoperative magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). Results: 1453(87%) patients underwent IOC with LC and filling defects were noted in 116(8%) of these. 75 incidental patients underwent postoperative cholangiography within 30 days at a median of 3(IQR=2-6) days following LC. 32(43%) patients had no residual choledocholithiasis. The median time to stone passage was estimated at 10(95%CI 5.6-14.3) days. Retained choledocholithiasis was detected in 72% of patients where no contrast passed into the duodenum and 48% with duodenal contrast passage but filling defects on IOC (p=0.049). Conclusion: A significant proportion of incidental CBD calculi pass spontaneously within 14 days from LC. Expectant management with follow-up non-invasive imaging may reduce unnecessary ERCP and minimise its associated complications. However, failure of contrast passage into the duodenum on IOC may predict non-passage of choledocholithiasis.

ANZ Journal of SurgeryVolume 85, Issue 12 p. 992-993 LETTER TO THE EDITOR Response to Re: Index cholecystectomy in grade II and III acute calculous cholecystitis is feasible and safe Tony C. Y. Pang MS, FRACS, Tony C. Y. Pang MS, FRACS Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorArthur Richardson DClinSurg, FRACS, Arthur Richardson DClinSurg, FRACS Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorVincent W. T. Lam MS, DClinSurg, FRACS, Vincent W. T. Lam MS, DClinSurg, FRACS Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this author Tony C. Y. Pang MS, FRACS, Tony C. Y. Pang MS, FRACS Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorArthur Richardson DClinSurg, FRACS, Arthur Richardson DClinSurg, FRACS Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorVincent W. T. Lam MS, DClinSurg, FRACS, Vincent W. T. Lam MS, DClinSurg, FRACS Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this author First published: 01 December 2015 https://doi.org/10.1111/ans.13361Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Nguyen CL, Mittal A, Hugh TJ. Re: index cholecystectomy in grade II and III acute calculous cholecystitis is feasible and safe. ANZ J. Surg. 2015; 85: 992. 2Kamalapurkar D, Pang TCY, Siriwardhane M et al. Index cholecystectomy in grade II and III acute calculous cholecystitis is feasible and safe. ANZ J. Surg. 2015; 85: 854–859. 3Yokoe M, Takada T, Strasberg SM et al. New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo guidelines. J. Hepatobiliary Pancreat. Sci. 2012; 19: 578–585. 4Melloul E, Denys A, Demartines N, Calmes JM, Schafer M. Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter? World J. Surg. 2011; 35: 826–833. 5Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta-analysis of randomized controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br. J. Surg. 2010; 97: 141–150. 6Borzellino G, Sauerland S, Minicozzi AM et al. Laparoscopic cholecystectomy for severe acute cholecystitis. A meta-analysis of results. Surg. Endosc. 2008; 22: 8–15. Volume85, Issue12December 2015Pages 992-993 ReferencesRelatedInformation

Lee, Nicholas C. MBBS; Spillane, Andrew J. MD; Pang, Tony MBBS; Haydu, Lauren E. BSCHE, MIPH; Uren, Roger F. MD

14 Background 16 Hypothesis 18 Aims of the study 18 Methods 19 Brief scientific methods 19 Definitions 20 Data acquisition and management 21 Data cleaning 22 Statistical methods 24 Results 28 Description of subjects 28 Overall survival and disease-free survival 30 Multivariate modelling of overall survival 36 Model diagnostics (for overall survival model) 39 Multivariate modelling of disease-free survival 46 Model diagnostics for the disease-free survival model 47 Comparison with complete data only analysis 52 Interpretation of results for a non-statistical audience 53 Discussion 57 Missing data 57 Limitations of results 59 Conclusion 62 References 63 Appendix – Excel data manipulation 65

Small intestine lipomatosis is rare but may be associated with pain, intussusception, and gastrointestinal bleeding. In this report, we examine the case of a 41-year-old man who had recurrent presentations to the emergency department with non-specific abdominal pain. Preoperative imaging suggested extensive infiltration of small intestine with macroscopic fat. At surgery, extensive and confluent small bowel lipomatosis were seen. The affected ileal segment was resected, and the patient remained symptom-free after surgery. Abdominal lipomatosis is a rare condition which can be completely treated by resection of the affected gut segment but is often unsuspected and difficult to diagnose. In this report, we describe a case with the most extensive lipomatosis on record with more than 70 cm of gut with confluent lipomatosis. Magnetic resonance Enterography (MRE) is a useful non-invasive diagnostic modality, although laparoscopy/laparotomy may be necessary for assessment of the extent of disease. Symptomatic cases should be treated with segmental small bowel resection, which is curative.

Introduction: Kidney transplantation is the optimal treatment for suitable patients with end-stage renal disease. The duration of surgical vascular anastomosis time, also known as second warm ischaemic time (SWIT) has now been identified as impacting both delayed graft function as well as long term graft survival in kidney transplantation, with temperatures above 15-18°C regarded as the threshold for ischaemic injury. There is currently no commercially available method of overcoming the SWIT period through intraoperative thermal insulation. This study aims to analyse the effect of a novel biomedically engineered thermally insulating jacket, the ischemic injury protective jacket (iiPJ) as a solution to overcoming this second warm ischemia. The iiPJ has been previously validated with porcine kidney and this study aims to test whether the iiPJ is able to thermally insulate non-utilised human donor kidneys in an ex vivo transplant model. Methods: An ex vivo transplantation model using a water bath regulated at 37°C to replicate average human body temperature was utilised for this study. Non-utilised kidneys were obtained and tested with and without the insulation of the iiPJ to measure the average core temperature of a kidney at 30-second intervals for 60 minutes on a temperature-time graph. Results: The control kidney core temperature reaches the 15°C threshold temperature at 17.3±1.8 minutes and the 18°C threshold at 20.9±2.0 minutes. This time to reach the warm ischemia threshold temperature is below the average global surgical time of 40.5±17.5 minutes. The iiPJ protected kidney reaches the 15°C threshold temperature at 44.5±1.9 minutes and remains within the 18°C threshold till 53.3±1.3 minutes. This amounts to an additional thermal protection of 27.2±3.7 minutes (n=5, p=0.0017) for the iiPJ protected kidneys when compared to the current surgical practices represented by the control kidneys.Implication and Conclusion: The iiPJ is significantly effective in reducing the thermal profile of the kidney, increasing the time available for transplantation, and minimising the time pressure on surgeons in order to reduce the occurrence of surgical complications. The iiPJ is a single-use, low-cost medical device that has the potential to become the standard of care in renal transplants. Further research regarding the biological effect of the iiPJ on the expression of biomarkers of ischemia shall be undertaken to further strengthen the case for intraoperative thermal insulation, prior to a clinical trial, as the ideal surgical practice for kidney transplantation, surgical training, and robotic transplantation.

Abstract Background Kidney transplantation is the current optimal treatment for suitable patients with end‐stage renal disease. The second warm ischemic time (SWIT) is known to negatively impact delayed graft function, and long‐term graft survival, and methods are required to ameliorate the impacts of SWIT on transplantation outcomes. Materials and Methods This study primarily focused on determining the effect of a novel thermally insulating jacket on the thermal profile of the human kidney and quantifying the reduction in thermal energy experienced using this device (KPJ™). An ex vivo simulated transplantation model was developed to determine the thermal profiles of non‐utilized human kidneys with and without KPJ™ ( n = 5). Control kidney temperature profiles were validated against the temperature profiles of n = 10 kidneys during clinical kidney transplantation. Results Using the ex‐vivo water bath model, the thermally insulated human kidney reached the 15°C metabolic threshold temperature at 44.5 ± 1.9 min (vs control: 17.3 ± 1.8 min ( p = 0.00172)) and remained within the 18°C threshold until 53.3 ± 1.3 min (vs control: 20.9 ± 2.0 min ( p = 0.002)). The specific heat capacity of KPJ™ protected kidney was four‐fold compared to the control kidney. The clinical temperature audit, closely correlated with the water bath model, hence validating this ex‐vivo human kidney transplant model. Conclusion Intraoperative thermal protection is a simple and viable method of reducing the thermal injury that occurs during the SWIT and increasing the specific heat capacity of the system. Such technology could easily be translated into clinical kidney transplant practice.

Background Fine needle aspiration cytology (FNAC) is a useful technique for the investigation of thyroid lesions. However, about 15% of FNAC results are classified as ‘atypical follicular’– a dilemma for the surgeon. Purpose To investigate the relationship between ‘atypical follicular’ FNAC results and final histolopathological diagnosis. Methodology Retrospective review of patients who underwent thyroid FNAC at the University of Sydney endocrine surgical unit. Results Study period – 1985 to 2005; Study population – 424 patients with an atypical FNAC and a malignancy on final histopathology. This accounted for 21% of all atypical FNAC results (n = 1956). Demographics – 342 females, 82 males with a mean age of 47.2 (SD 16.7). The most common presentation in this group was a single thyroid nodule n = 252, followed by multinodular goiter n = 155. Overall, 269 (63.4%) had papillary/mixed (papillary and follicular) carcinoma, 106 (25%) had follicular carcinoma and 49 (11.6%) other malignant pathology. Of the subjects with papillary cancers, 34% had papillary microcarcinoma. Demographics were not predictors of pathology. Over the study period of 20 years, no changes in the pattern of histopathology findings were noted. Conclusion Although the ‘atypical follicular’ FNAC has traditionally been considered to be either follicular adenoma or carcinoma, a great proportion of subjects actually have a papillary carcinoma demonstrated on histopathology. A significant proportion of this was accounted for by the presence of incidental papillary microcarcinoma.

Introduction In situ perfusion of preservation fluid during donation after brain death (DBD) liver retrieval can be conducted via the aorta alone, or aorta and portal vein (dual perfusion). There is considerable disagreement in the literature with regards to the comparative efficacy of each perfusion route for both normal and expanded criteria liver donors, and the few existing studies are disadvantaged by low patient numbers and short periods of follow-up. Materials/Methods DBD whole liver transplants (initial) in Australia were included from 2007-2016, and stratified by aortic (n = 957) or dual (n = 425) perfusion routes. Data points were obtained from the Australia and New Zealand (ANZ) Liver Transplant Registry, the ANZ Organ Donation Registry, and a national survey of senior donor surgeons. University of Wisconsin (UW) solution was given via the aorta and/or portal vein, followed by organ transport in the same fluid. Missing data was handled by multiple imputations. Graft and patient survival were compared using Kaplan-Meier curves and Cox proportional hazards. Causes of graft loss, including primary non-function (PNF), hepatic artery (HAT) and portal vein thrombosis (HAT), biliary complications (BC) and acute rejection (AR) were compared using logistic regression. Results Baseline characteristics between study groups were similar, except for a lower mean cold ischemic time (CIT; 6.3 vs 7.0 hrs), mean secondary warm ischemic time (SWIT; 37.8 vs 45.4 mins), and median recipient MELD score (14 vs 18) in the dual-perfused patient cohort compared to the aortic-only perfusion group (p < 0.001). Actuarial 5-year graft and patient survivals in aortic and dual perfusion cohorts were 80.1% vs 84.6% (p = 0.066, univariate log-rank test), and 82.6% vs 87.8% (p = 0.026, univariate log-rank test), respectively. Multivariate Cox proportion hazards models, accounting for CIT, SWIT, MELD, and other donor/recipient factors with a p-value < 0.1 in univariate analyses, showed that graft survival after aortic vs dual perfusion was not significantly different (HR 0.81, 95% CI 0.60-1.11, p = 0.188). Similarly, overall patient survival was not different between the aortic and dual groups (HR 0.74, 95% CI 0.52-1.05, p = 0.087). There were no significant differences between aortic and dual perfusion groups with respect to causes of graft loss, including PNF, HAT, PVT, BC, and AR. Discussion After accounting for confounders, there were no significant differences in causes of graft loss, graft survival, and patient survival between liver transplants performed after aortic-only or dual in situ liver perfusion at retrieval. Subgroup analyses will need to be conducted to compare high-risk donors. Conclusion The retrieval technique employed does not impact outcomes for standard risk donors. Future RCTs should focus on the efficacy of either technique in liver donors with a high donor risk index, and also consider the impact on other organs, in particular the pancreas. Royal Australasian College of Surgeons.

ANZ Journal of SurgeryVolume 89, Issue 11 p. E531-E532 IMAGES FOR SURGEONS Cystic lesion in the left upper quadrant Sukhwant S. Khanijaun MS, Sukhwant S. Khanijaun MS orcid.org/0000-0002-6256-2522 Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorTony C. Y. Pang MS, MBiostat, FRACS, Tony C. Y. Pang MS, MBiostat, FRACS orcid.org/0000-0003-1327-9189 Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this author Sukhwant S. Khanijaun MS, Sukhwant S. Khanijaun MS orcid.org/0000-0002-6256-2522 Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorTony C. Y. Pang MS, MBiostat, FRACS, Tony C. Y. Pang MS, MBiostat, FRACS orcid.org/0000-0003-1327-9189 Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this author First published: 21 September 2018 https://doi.org/10.1111/ans.14858Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume89, Issue11November 2019Pages E531-E532 RelatedInformation

There is a lack of satisfactory animal models to study adjuvant and/or neoadjuvant therapy in patients being considered for surgery of pancreatic cancer (PC). To address this deficiency, we describe a mouse model involving orthotopic implantation of PC followed by distal pancreatectomy and splenectomy. The model has been demonstrated to be safe and suitably flexible for the study of various therapeutic approaches in adjuvant and neo adjuvant settings. In this model, a pancreatic tumor is first generated by implanting a mixture of human pancreatic cancer cells (luciferase-tagged AsPC-1) and human cancer associated pancreatic stellate cells into the distal pancreas of Balb/c athymic nude mice. After three weeks, the cancer is resected by re-laparotomy, distal pancreatectomy and splenectomy. In this model, bioluminescence imaging can be used to follow the progress of cancer development and effects of resection/treatments. Following resection, adjuvant therapy can be given. Alternatively, neoadjuvant treatment can be given prior to resection. Representative data from 45 mice are presented. All mice underwent successful distal pancreatectomy/splenectomy with no issues of hemostasis. A macroscopic proximal pancreatic margin greater than 5 mm was achieved in 43 (96%) mice. The technical success rate of pancreatic resection was 100%, with 0% early mortality and morbidity. None of the animals died during the week after resection. In summary, we describe a robust and reproducible technique for a surgical resection model of pancreatic cancer in mice which mimics the clinical scenario. The model may be useful for the testing of both adjuvant and neoadjuvant treatments.

Epidemiological studies of lymphoid malignancies show remarkable differences amongst populations of different geographical locations and socioeconomic conditions [1]. An earlier survey by us showed the Virtual nonexistence of chronic lymphocytic leukaemia and follicular non-Hodgkin’s lymphoma in Malaysians [2]. All patients with acute lymphoblastic leukaemia (ALL) are being studied under an international leukaemia subtyping study organized by Dr. M. Greaves. This is a preliminary review of ALL subtypes.

Data sharing is not applicable for this article.