Development of a Prognostic Model That Predicts Survival After Pancreaticoduodenectomy for Ampullary Cancer.

Objectives: The aims of this study were to i) identify independent predictors of survival following pancreaticoduodenectomy for ampullary cancer and ii) develop a prognostic model of survival. Methods: Data were analysed retrospectively on 110 consecutive patients who underwent pancreaticoduodenectomy between 2002-2013. Subjects were categorised into 3 nodal sub-groups as per the recently proposed nodal sub-classification: N0 (node negative), N1 (1-2 metastatic nodes) or N2 (≥3 metastatic nodes). Clinicopathological features and overall survival were compared by Kaplan Meier and Cox regression analyses. Results: The overall 1-, 3- and 5-year survival rates were 79.8%, 42.2% and 34.9% respectively. The overall 1-, 3- and 5-year survival rates for the N0 group were 85.2%, 71.9% and 67.4% respectively. The 1-,3-,5-year survival rates for the N1 and N2 subgroups were 84.6%, 58.4%, 56.4% and 80.2%, 38.8% and 8.0% respectively (log rank, p<0.0001). After performing a multivariate Cox regression analysis vascular invasion and lymph node ratio were the only independent predictors of survival. Hence a prediction model of survival was constructed based on those 2 variables. Conclusion: Using data from a carefully selected cohort of patients we created a pilot prognostic model of post-resectional survival. The proposed model may help clinicians to guide treatments in the adjuvant setting.Mr Siong S. Liau is funded by the Medical Research Council (MRC) and Academy of Medical Sciences Clinician Scientist Fellowship

Global overview of the management of acute cholecystitis during the COVID-19 pandemic (CHOLECOVID study)

Background: This study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic. Methods: CHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality. Results: This study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P = 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P = 0.121). Conclusion: CHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the first months of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non-COVID cost of this pandemic

Postoperative Ascites of Unknown Origin following Laparoscopic Appendicectomy: An Unusual Complication of Laparoscopic Surgery.

Postoperative ascites is a very rare complication of laparoscopic surgery. Significant iatrogenic injuries to the bowel, the urinary tract, and the lymphatic system should be excluded promptly to avoid devastating results for the patient. In some cases, in spite of investigating patients extensively, no definitive causative factor for the accumulation of fluid can be identified. In such cases, idiopathic allergic or inflammatory reaction of the peritoneum may be responsible for the development of ascites. We present a case of ascites of an unknown origin in a young female patient following a laparoscopic appendicectomy

Elective “True Day Case” Laparoscopic Inguinal Hernia Repair in a District General Hospital: Lessons Learned from 1000 Consecutive Cases

Introduction. Laparoscopic inguinal hernia repair (LIHR) is ideal for day case surgery. It is recommended that at least 70% should be day cases as a measure of cost-effectiveness. The aims of this study were to (i) assess the rate of true day case (TDC) surgery and (ii) identify predictors associated with unexpected overnight stay (UOS). Methods. Data was collected prospectively on 1000 consecutive elective LIHR performed in a District General Hospital (DGH) over a 7-year period. Data was collected on baseline patient demographics, ASA grade, and intraoperative details. A multivariate analysis was performed in order to identify predictors of UOS. Results. 1000 patients (927 males) underwent elective LIHR. Mean age was 57.3±15.2 years. 915 patients were planned as day case procedures. 822/915 day cases (89.8%) were discharged on the same day and 93 (10.2%) stayed overnight unexpectedly. Patient age, duration of procedure, and patient slot in the operating list were found to be independent predictors (p<0.05) of UOS. Conclusion. Our results demonstrate that LIHR is a “true” day case procedure in a DGH. Although some factors associated with UOS cannot be altered, careful patient selection and operating list planning are of paramount importance in order to minimise the burden on healthcare resources

Delayed presentation of ilio-iliac arteriovenous fistula following laparoscopic cholecystectomy treated with percutaneous graft-covered stent placement

Major vascular injuries during laparoscopic cholecystectomy are rare, usually readily apparent, and immediately treated. We report a case of delayed presentation of a retroperitoneal vascular injury. The patient presented with abdominal pain and increasing edema of the lower extremities 1 year after laparoscopic cholecystectomy and was found to have an ilio-iliac arteriovenous fistula. Endovascular treatment was accomplished using a graft-covered polytetrafluoroethylene stent. The patient remained free of symptoms at 1-year follow-up

Macular hole surgery with short-acting gas and short-duration face-down positioning

Tina Xirou,1 Panagiotis G Theodossiadis,2 Michael Apostolopoulos,3 A Stamatina Kabanarou,1 Elias Feretis,1 Ioannis D Ladas,3 Chrysanthi Koutsandrea31Vitreoretinal Unit, Red Cross Hospital, 2B Department of Ophthalmology, University of Athens, Greece; 3A Department of Ophthalmology, University of Athens, GreecePurpose: To report on the outcomes of vitrectomy and sulfur hexafluoride (SF6) gas tamponade for idiopathic macular holes with 2 days of face-down positioning.Patients and methods: This was a prospective, nonrandomized, observational sequential case-series study on 23 consecutive patients receiving macular hole surgery using 20% SF6 and advised to stay in a face-down position for 2 days postoperatively (SF6 group). These patients were compared to 23 consecutive patients who had previously undergone macular hole surgery, had received 14% C3F8, and were advised to maintain a face-down position for 2 days (C3F8 group). Patients in both groups underwent vitrectomy, internal limiting membrane peeling, and fluid gas exchange using either SF6 or C3F8. Preoperative and postoperative data included best corrected visual acuity recorded in LogMAR units, slit-lamp biomicroscopy, and optical coherence tomography.Results: At a 6-month follow-up, macular hole closure was noted in 23/23 eyes (100%) and in 22/23 eyes (96%) in the SF6 and C3F8 groups, respectively. The improvement in visual acuity (measured through Snellen acuity lines both preoperatively until 6 months postoperatively) was 4.08 &amp;plusmn; 2.31 (95% confidence interval [CI]: 3.08&amp;ndash;5.08) for the SF6 group and 2.87 &amp;plusmn; 2.30&amp;nbsp;(95% CI: 1.87&amp;ndash;3.86) for the C3F8 group; this difference was not statistically significant (P = 0.06).Conclusion: Vitrectomy with internal limiting membrane peeling and a short-acting gas tamponade using SF6 with posture limitation for 2 days may give a high success rate in macular hole surgery.Keywords: idiopathic macular holes, SF6 gas tamponade, C3F8 gas tamponad