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Background After clinical evaluation in the emergency department (ED), facial burn patients are usually intubated to protect their airways. However, the possibility of unnecessary intubation or delayed intubation after admission exists. Objective criteria for the evaluation of inhalation injury and the need for airway protection in facial burn patients are needed. Methods Facial burn patients between January 2013 and May 2016 were reviewed. Patients who were and were not intubated in the ED were compared. All the intubated patients received routine bronchoscopy and laboratory tests to evaluate whether they had inhalation injuries. The patients with and without confirmed inhalation injuries were compared. Multivariate logistic regression analysis was used to identify the independent risk factors for inhalation injuries in the facial burn patients. The reasons for intubation in the patients without inhalation injuries were also investigated. Results During the study period, 121 patients were intubated in the ED among a total of 335 facial burn patients. Only 73 (60.3%) patients were later confirmed to have inhalation injuries on bronchoscopy. The comparison between the patients with and without inhalation injuries showed that shortness of breath (odds ratio = 3.376, p = 0.027) and high total body surface area (TBSA) (odds ratio = 1.038, p = 0.001) were independent risk factors for inhalation injury. Other physical signs (e.g., hoarseness, burned nostril hair, etc.), laboratory examinations and chest X-ray findings were not predictive of inhalation injury in facial burn patients. All the patients with a TBSA over 60% were intubated in the ED even if they did not have inhalation injuries. Conclusions In the management of facial burn patients, positive signs on conventional physical examinations may not always be predictive of inhalation injury and the need for endotracheal tube intubation in the ED. More attention should be given to facial burn patients with shortness of breath and a high TBSA. Airway protection is needed in facial burn patients without inhalation injuries because of their associated injuries and treatments.

Numerous strategies for perioperative nutrition therapy for patients undergoing pancreaticoduodenectomy (PD) have been proposed. This systematic review aimed to summarize the current relevant published randomized controlled trials (RCTs) evaluating different nutritional interventions via a traditional network meta-analysis (NMA) and component network meta-analysis (cNMA). EMBASE, MEDLINE, the Cochrane Library, and ClinicalTrials.gov were searched to identify the RCTs. The evaluated nutritional interventions comprised standard postoperative enteral nutrition by feeding tube (Postop-SEN), preoperative enteral feeding (Preop-EN), postoperative immunonutrients (Postop-IM), preoperative oral immunonutrient supplement (Preop-IM), and postoperative total parenteral nutrition (TPN). The primary outcomes were general, infectious, and noninfectious complications; postoperative pancreatic fistula (POPF); and delayed gastric emptying (DGE). The secondary outcomes were mortality and length of hospital stay (LOS). The NMA and cNMA were conducted with a frequentist approach. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Two primary outcomes, infectious complications and POPF, were positively influenced by nutritional interventions. Preop-EN plus Postop-SEN (OR 0.11; 95% CI 0.02~0.72), Preop-IM (OR 0.22; 95% CI 0.08~0.62), and Preop-IM plus Postop-IM (OR 0.11; 95% CI 0.03~0.37) were all demonstrated to be associated with a decrease in infectious complications. Postop-TPN (OR 0.37; 95% CI 0.19~0.71) and Preop-IM plus Postop-IM (OR 0.21; 95% CI 0.06~0.77) were clinically beneficial for the prevention of POPF. While enteral feeding and TPN may decrease infectious complications and POPF, respectively, Preop-IM plus Postop-IM may provide the best clinical benefit for patients undergoing PD, as this approach decreases the incidence of both the aforementioned adverse effects.

The survival benefits of conversion surgery in patients with metastatic gastric cancer (mGC) remain unclear. Thus, this study aimed to determine the outcomes of conversion surgery compared to in-front surgery plus palliative chemotherapy (PCT) or in-front surgery alone for mGC. We recruited 182 consecutive patients with mGC who underwent gastrectomy, including conversion surgery, in-front surgery plus PCT, and in-front surgery alone at Linkou Chang Gung Memorial Hospital from 2011 to 2019. The tumor was staged according to the 8th edition of the American Joint Committee on Cancer. Patient demographics and clinicopathological factors were assessed. Overall survival (OS) was evaluated using the Kaplan–Meier curve and compared among groups. Conversion surgery showed a significantly longer median OS than in-front surgery plus PCT or in-front surgery alone (23.4 vs. 13.7 vs. 5.6 months; log rank p < 0.0001). The median OS of patients with downstaging (pathological stage I–III) was longer than that of patients without downstaging (stage IV) (30.9 vs. 18.0 months; p = 0.016). Our study shows that conversion surgery is associated with survival benefits compared to in-front surgery plus PCT or in-front surgery alone in patients with mGC. Patients who underwent conversion surgery with downstaging had a better prognosis than those without downstaging.

Background: Concurrent acute cholecystitis and acute cholangitis is a unique clinical situation. We tried to investigate the optimal timing of cholecystectomy after adequate biliary drainage under this condition. Methods: From January 2012 to November 2017, we retrospectively screened all in-hospitalized patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and then identified patients with concurrent acute cholecystitis and acute cholangitis from the cohort. The selected patients were stratified into two groups: one-stage intervention (OSI) group (intended laparoscopic cholecystectomy at the same hospitalization) vs. two-stage intervention (TSI) group (interval intended laparoscopic cholecystectomy). Interrogated outcomes included recurrent biliary events, length of hospitalization, and surgical outcomes. Results: There were 147 patients ultimately enrolled for analysis (OSI vs. TSI, 96 vs. 51). Regarding surgical outcomes, there was no significant difference between the OSI group and TSI group, including intraoperative blood transfusion (1.0% vs. 2.0%, p = 1.000), conversion to open procedure (3.1% vs. 7.8%, p = 0.236), postoperative complication (6.3% vs. 11.8%, p = 0.342), operation time (118.0 min vs. 125.8 min, p = 0.869), and postoperative days until discharge (3.37 days vs. 4.02 days, p = 0.643). In the RBE analysis, the OSI group presented a significantly lower incidence of overall RBE (5.2% vs. 41.2%, p < 0.001) than the TSI group. Conclusions: Patients with an initial diagnosis of concurrent acute cholecystitis and cholangitis undergoing cholecystectomy after ERCP drainage during the same hospitalization period may receive some benefit in terms of clinical outcomes.

BackgroundAfter clinical evaluation in the emergency department (ED), facial burn patients are usually intubated to protect their airways. However, the possibility of unnecessary intubation or delayed intubation after admission exists. Objective criteria for the evaluation of inhalation injury and the need for airway protection in facial burn patients are needed.MethodsFacial burn patients between January 2013 and May 2016 were reviewed. Patients who were and were not intubated in the ED were compared. All intubated patients received routine bronchoscopy to evaluate whether they had inhalation injuries. Patients with and without confirmed inhalation injuries were compared. Multivariate logistic regression analysis was used to identify the independent risk factors for inhalation injuries in facial burn patients. The reasons for intubation in patients without inhalation injuries were also investigated.ResultsDuring the study period, 121 patients were intubated in the ED among a total of 335 facial burn patients. Only 73 (60.3%) patients were later confirmed to have inhalation injuries on bronchoscopy. The comparison between patients with and without inhalation injuries showed that shortness of breath (odds ratio=3.376, p=0.027) and high total body surface area (TBSA) (odds ratio=1.038, p=0.001) were independent risk factors for inhalation injury. Other physical signs (e.g., hoarseness, burned nostril hair, etc.), laboratory examinations and chest X-ray findings were not predictive of inhalation injury in facial burn patients. All patients with a TBSA over 60% were intubated in the ED even if they did not have inhalation injuries.ConclusionIn the management of facial burn patients, positive signs on conventional physical examinations may not always be predictive of inhalation injury and the need for endotracheal tube intubation in the ED. More attention should be paid to facial burn patients with shortness of breath and a high TBSA because they have an increased risk of inhalation injuries. Airway protection is needed in facial burn patients without inhalation injuries because of their associated injuries and treatment.