BACKGROUND Acute pancreatitis (AP) is a common surgical condition, with severe AP (SAP) potentially lethal. Many prognostic indices, including; acute physiology and chronic health evaluation II score (APACHE II), bedside index of severity in acute pancreatitis (BISAP), Glasgow score, harmless acute pancreatitis score (HAPS), Ranson’s score, and sequential organ failure assessment (SOFA) evaluate AP severity and predict mortality. AIM To evaluate these indices' utility in predicting severity, intensive care unit (ICU) admission, and mortality. METHODS A retrospective analysis of 653 patients with AP from July 2009 to September 2016 was performed. The demographic, clinical profile, and patient outcomes were collected. SAP was defined as per the revised Atlanta classification. Values for APACHE II score, BISAP, HAPS, and SOFA within 24 h of admission were retrospectively obtained based on laboratory results and patient evaluation recorded on a secure hospital-based online electronic platform. Data with < 10% missing data was imputed via mean substitution. Other patient information such as demographics, disease etiology, and patient outcomes were also derived from electronic medical records. RESULTS The mean age was 58.7 ± 17.5 years, with 58.7% males. Gallstones ( n = 404, 61.9%), alcohol ( n = 38, 5.8%), and hypertriglyceridemia ( n = 19, 2.9%) were more common aetiologies. 81 (12.4%) patients developed SAP, 20 (3.1%) required ICU admission, and 12 (1.8%) deaths were attributed to SAP. Ranson’s score and APACHE-II demonstrated the highest sensitivity in predicting SAP (92.6%, 80.2% respectively), ICU admission (100%), and mortality (100%). While SOFA and BISAP demonstrated lowest sensitivity in predicting SAP (13.6%, 24.7% respectively), ICU admission (40.0%, 25.0% respectively) and mortality (50.0%, 25.5% respectively). However, SOFA demonstrated the highest specificity in predicting SAP (99.7%), ICU admission (99.2%), and mortality (98.9%). SOFA demonstrated the highest positive predictive value, positive likelihood ratio, diagnostic odds ratio, and overall accuracy in predicting SAP, ICU admission, and mortality. SOFA and Ranson’s score demonstrated the highest area under receiver-operator curves at 48 h in predicting SAP (0.966, 0.857 respectively), ICU admission (0.943, 0.946 respectively), and mortality (0.968, 0.917 respectively). CONCLUSION The SOFA and 48-h Ranson’s scores accurately predict severity, ICU admission, and mortality in AP, with more favorable statistics for the SOFA score.
Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.
Choledochoscopy, or cholangioscopy, is an endoscopic procedure for direct visualization within the biliary tract for diagnostic or therapeutic purposes. Since its conception in 1879, many variations and improvements are made to ensure relevance in diagnosing and managing a range of intrahepatic and extrahepatic biliary pathologies. This ranges from improved visual impression and optical guided biopsies of indeterminate biliary strictures and clinically indistinguishable pathologies to therapeutic uses in stone fragmentation and other ablative therapies. Furthermore, with the evolving understanding of biliary disorders, there are significant innovative ideas and techniques to fill this void, such as nuanced instances of biliary stenting and retrieving migrated ductal stents. With this in mind, we present a review of the current advancements in choledo-choscopy with new supporting evidence that further delineates the role of choledochoscopy in various diagnostic and therapeutic interventions, complications, limitations and put forth areas for further study.
BACKGROUND Hepatic resection (HR) results in an inflammatory response that can be modified by perioperative steroid administration. However, it remains to be determined if this response's attenuation translates to a reduction in complications. AIM To evaluate if perioperative administration of steroids reduces complications following HR. METHODS A systematic review of randomized controlled trials (RCTs) was conducted on PubMed, Embase, and Cochrane Central Register of Controlled Trials to evaluate the effect of perioperative steroid (compared to placebo or no intervention) use in patients undergoing HR. Clinical outcomes were extracted, and meta-analysis was performed. RESULTS 8 RCTs including 590 patients were included. Perioperative steroid administration was associated with significant reduction in postoperative complications [odds ratios: 0.58; 95% confidence intervals (CI): 0.35-0.97, P = 0.04]. There was also improvement in biochemical and inflammatory markers, including serum bilirubin on postoperative day 1 [MD: -0.27; 95%CI: (-0.47, -0.06), P = 0.01], C-reactive protein on postoperative day 3 [MD: -4.89; 95%CI: (-5.83, -3.95), P < 0.001], and interleukin-6 on postoperative day 1 [MD: -54.84; 95%CI: (-63.91, -45.76), P < 0.001]. CONCLUSION Perioperative steroids administration in HR may reduce overall complications, postoperative bilirubin, and inflammation. Further studies are needed to determine the optimal dose and duration and patient selection.
550 L e t t e r t o t h e E d i t o rDear Sir, Persimmons contain large amounts of soluble tannin, which may interact with gastric acid to form a conglomerate that is harder than other phytobezoars. (1) The presence of ingestible fruit tannins, cellulose, hemicellulose and lignins in persimmons make such a phytobezoar more difficult to dissolve or segment into smaller divisions due to its hard consistency. (2) This makes persimmon phytobezoars particularly difficult to manage. We report a case of multiple persimmon phytobezoars causing simultaneous small bowel and gastric outlet obstruction.A 39-year-old woman was admitted to our hospital with symptoms of nausea, vomiting and epigastric pain. She had no past medical illness. On examination, she had a distended abdomen without scars and no external hernias. Blood investigations and imaging established a diagnosis of intestinal obstruction. Computed tomography established a diagnosis of small bowel intestinal obstruction with grossly distended stomach. There was no reporting of 'bezoar' by the on-duty radiologist. However, the surgical team adjudged the possibility of an intraluminal mass in the distal bowel and retrospectively asked the patient about her dietary history. She confirmed that she had eaten four persimmons from her own farm ten days ago. A clinical diagnosis of small bowel obstruction secondary to persimmon phytobezoar was established.A 5-cm phytobezoar obstruction in the distal small bowel was retrieved through an enterotomy with primary repair. Another 15 cm × 6 cm sausage-shaped phytobezoar was retrieved from the stomach through a gastrotomy and primary repair (Fig. 1). We postulated that the small bowel phytobezoar in our patient represented the 'daughter' phytobezoar from the 'parent' giant gastric phytobezoar. Her postoperative recovery was uncomplicated, and the patient remained well at the sixmonth follow-up.Old age, poor dentition, previous gastrectomy, diabetes mellitus and hypothyroidism can increase the risk of bezoar formation due to problems with digestion or gut motility. The clinical manifestation of the bezoar is dependent on the location of the obstruction. Small bowel obstruction is the most common manifestation. The majority of phytobezoars pass spontaneously (80%-90%); some can be retrieved through an endoscopy (10%-20%) and surgery is rarely needed (< 1%). (3,4) Recently, the use of effervescent aerated drinks such as Coca-Cola has been reported in the management of phytobezoars. (5) This is an attractive management option, as it avoids surgical intervention and its resultant morbidity. However, there is an increased risk of the occurrence of secondary 'daughter' phytobezoars.In our patient, endoscopy and Coca-Cola were not advocated due to her small bowel obstruction. In patients with multiple bezoars causing intestinal obstruction, laparotomy is considered more effective to concurrently remove all the bezoars. One should also check for the possibility of more bezoars to avoid early recurrent obstruction from the 'missed' bezoar...
Background Helicobacter pylori (HP) infection is endemic and causes peptic ulcer disease and gastric cancer. There is a lack of data related to awareness of the general public about HP and associated health risks. The objective of this study was to investigate the awareness and public perceptions about HP and the attitudes towards screening. Methods This cross‐sectional study included a structured 19‐item questionnaire targeting members of the general public at a restructured acute hospital in Singapore. Results Out of 504 participants, 152 (30.2%) were aware of HP. Higher education was associated with HP awareness (p < 0.001, OR 7.4, 95% CI 1.6–32.6). A third, 175 (34.7%) of the respondents identified the stomach as the primary site of infection. 131 (26.0%) respondents identified the fecal‐oral route as a mode of transmission. 178 (35.3%) respondents were aware of available screening modalities, with around half of them willing to be screened with blood (n = 256, 50.8%) or breath tests (n = 265, 52.6%). 430 (85.3%) participants were keen to learn more about HP, and this was associated with age (p < 0.05, OR 3.9, 95% CI 2.1–7.1). Conclusion Awareness about HP infection is low, and acceptance of screening tests is high. Educational efforts are needed to improve awareness.
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