Background Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0•9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0•9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124.

No abstract

Background: The independent influence of advanced age on outcomes in contemporary series treated by early cholecystectomy is undetermined. Methods: Elderly patients, aged 80 years and older, with histology proven acute cholecystitis treated by cholecystectomy on initial presentation between 2005 and 2011 were compared to all others. Results: In total, 411 patients had histologically proven acute cholecystitis, of whom 71 (17%) were aged 80 years and older. Elderly patients were more likely to have ischaemic heart disease, underlying diabetes and chronic renal failure. There was greater conversion from laparoscopic to open surgery in the elderly (21% versus 7%; P = 0.001). Elderly patients were more likely to have gangrenous cholecystitis (44% versus 31%; P = 0.033) and common bile duct stones (27% versus 17%; P = 0.048). Elderly patients had more complications (31% versus 13%; P < 0.001), a higher mortality rate (4% versus 1%; P = 0.038) and a longer median post-operative length of stay (7 days versus 3 days; P < 0.001). Age ≥ 80 (P = 0.004) was an independent risk factors for complications. Conclusion: Age 80 years and older is independently associated with increased morbidity following cholecystectomy for treatment acute cholecystitis at initial presentation.

This study represents the largest series to date of single-incision laparoscopic cholecystectomies with routine IOC via the umbilical port and is the first study to demonstrate that the laparoscopic management of choledocholithiasis during SILC is feasible.

Primary liver leiomyoma (PLL) should be considered in the differential diagnosis of liver lesions. A literature review has been completed and two cases are reported. The first is a 45-year-old white woman complaining of vague abdominal pain. She was initially evaluated with abdominal ultrasonography (US) that revealed a heterogeneous liver mass measuring 18 cm in greatest diameter. The tumour demonstrated hypointensity on T1-weighted and hyperintensity on T2-weighted magnetic resonance imaging. The second case is a 45-year-old Asian male who had undergone kidney transplantation 16 years ago for IgA glomerulonephritis and who developed mild, self-limiting epigastric pain. US showed a 4.3-cm-diameter lesion that was predominantly hypoechoic and was either compressing or arising from segment 2 of the liver. Computed tomography showed a well-circumscribed 4-cm-diameter mass that appeared to be arising from segments 2/3 of the liver and was adjacent to the anterior gastric wall. He underwent an uneventful laparoscopic left lateral sectionectomy and discharged on post-operative day 3. Pathological examination of the resection specimen confirmed the lesion as a PLL in each case. Herein, we report two cases of PLL and review the literature regarding this uncommon disorder.

Purpose Continuing employment or returning to work (RTW) as a cancer survivor can be meaningful and financially necessary, yet challenging. However, there is a lack of qualitative research on RTW experiences and financial wellbeing of people with advanced colorectal cancer (CRC-A). This study aimed to fill this gap. Methods Adults treated for CRC-A were recruited 0.5–2 years post-surgery (or post-diagnosis of CRC-A for palliative chemotherapy participants). Semi-structured telephone interviews, exploring RTW and finances, were subjected to framework analysis. Demographic, clinical, and quality of life data (FACT-C, Distress Thermometer, COST measure) were collected to characterise the sample and inform the framework analysis. Results Analysis of 38 interviews revealed five overarching themes: work as a struggle, work as my identity, work as my saviour, work as a financial necessity, and employer and colleague response. Many survivors with CRC-A desired to, and had the capacity to, continue work or RTW, yet faced unique challenges from compounded stigma of both cancer and toileting issues. Inability to RTW negatively impacted financial and psychosocial wellbeing. Workplace support was an important facilitator of RTW. Conclusion For survivors with CRC-A, continuing or RTW is fraught with challenges, including physical functioning challenges, financial anxiety, and unsupportive workplace environments. Survivors require psychosocial, financial, and employer support to manage these difficulties. This paper recommends a multiprong approach, including education programmes (facilitated through workers’ union groups, human resource institutions, and/or large consumer CRC groups) and policies, to support workers and for employers to understand the unique challenges of employees with CRC-A.

Background To determine the effectiveness of an individualised, daily targeted step count intervention and usual care compared with usual care alone on improving surgical and patient reported outcomes. Methods The Fit‐4‐Home trial was a pragmatic, randomised controlled trial conducted from April 2019 to February 2021. Patients undergoing elective surgery for liver, stomach or pancreatic cancer in two Australian hospitals were recruited. Participants were randomly allocated to receive an individualised, targeted step count intervention and usual care (intervention) or usual care alone (control). A wearable activity tracker was provided to the intervention group to monitor their daily step count target. Primary outcome was the length of stay in the gastrointestinal ward. Secondary outcomes included postoperative complication rates, discharge destination, quality of life, physical activity, pain, fatigue, distress and hospital re‐admission within 30 days. Outcome measures were compared between groups using non‐parametric statistics. Results Of the 96 patients recruited, 47 were randomised to the intervention group and 49 were randomised to the control group. The median (interquartile) length of stay in the ward was 7 days (5.0–13.0) in the intervention group and 7 days (5.0– 12.0) in the control group (p = 0.330). Fatigue scores were worse in the intervention group when compared to control (p = 0.018). No other differences between groups were observed. Conclusions An individualised, daily targeted step count intervention and usual care did not confer additional benefits in reducing the length of stay in the ward compared to usual care alone for patients undergoing gastrointestinal cancer surgery. Trial Registration Registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12619000194167).

A focal intrahepatic stricture requires thorough investigation to exclude malignancy even in patients with a history of biliary surgery, hepatolithiasis or parasitic infection. If during the investigative process a diagnosis or suspicion of malignancy is demonstrated then surgical resection should be performed. If all diagnostic modalities suggest a benign aetiology, then cholangioscopy with targeted biopsies should be performed.