Data from this systematic review suggest that the risk of VTE in Asian general surgery patients is low, even in the context of risk factors typically regarded as high risk.

Backgrounds/AimsGas-forming pyogenic liver abscess (GFPLA) has an incidence of up to 30% of all pyogenic liver abscesses (PLA). GFPLA has higher mortality compared to non-GFPLA. Mere presence of gas within abscess may not determine clinical outcome. Hence it is important to study biologic characteristics that make GFPLA a distinct clinical entity. The aim of this study was to conduct a world review on GFPLA.MethodsWe conducted literature searches in PubMed using the following MeSH terms: “gas forming” AND “Liver abscess, pyogenic”, “gas” AND “Liver abscess, pyogenic”, “gas” AND “Liver abscess”, “gas forming” AND “Liver abscess”. Thirteen case series including 313 GFPLA patients were included. Age, gender, diabetes mellitus (DM), bacteriology, underlying etiology, symptoms, investigations, operative indications, and mortality rates were tabulated.ResultsGFPLA is often cryptogenic. There was no difference in age, gender, or symptomatology between GFPLA and non-GFPLA patients. DM was more common in patients with GFPLA compared to that in non-GFPLA patients (mean: 83.5% vs. 38.3%). Klebsiella pneumoniae is the most common causative pathogen. GFPLA has higher mortality compared to non-GFPLA (mean: 30.3% vs. 9%).ConclusionsGFPLA is associated with DM and monomicrobial Klebsiella pneumoniae infection. GFPLA has high mortality. It needs to be recognized as a distinct clinical entity.

BackgroundEarly mobilisation reduces postoperative complications such as pneumonia, deep vein thrombosis and hospital length of stay. Many authors have reported poor compliance with early mobilisation within Enhanced Recovery After Surgery initiatives.ObjectivesThe primary objective was to increase postoperative day (POD) 2 mobilisation rate from 23% to 75% in patients undergoing elective major hepatopancreatobiliary (HPB) surgery within 6 months.MethodsWe report a multidisciplinary team clinical practice improvement project (CPIP) to improve postoperative mobilisation of patients undergoing elective major HPB surgery. We identified the common barriers to mobilisation and analysed using the fishbone or cause-and-effect diagram and Pareto chart. A series of Plan–Do–Study–Act cycles followed this. We tracked the rate of early mobilisation and mean distance walked. In the post hoc analysis, we examined the potential cost savings based on reduced hospital length of stay.ResultsMobilisation rate on POD 2 following elective major HPB surgery improved from 23% to 78.9%, and this sustained at 6 months after the CPIP. Wound pain was the most common reason for failure to ambulate on POD 2. Hospital length of stay reduced from a median of 8 days to 6 days with an estimated cost saving of S$2228 per hospital stay.ConclusionMultidisciplinary quality improvement intervention effort resulted in an improved POD 2 mobilisation rate for patients who underwent elective major HPB surgery. This observed outcome was sustained at 6 months after completion of the CPIP with potential cost savings.

<b><i>Background:</i></b> Acute cholangitis (AC) is a common emergency with a significant mortality risk. The Tokyo Guidelines (TG) provide recommendations for diagnosis, severity stratification, and management of AC. However, validation of the TG remains poor. This study aims to validate TG07, TG13, and TG18 criteria and identify predictors of in-hospital mortality in patients with AC. <b><i>Methods:</i></b> This is a retrospective audit of patients with a discharge diagnosis of AC in the year 2016. Demographic, clinical, investigation, management and mortality data were documented. We performed a multinomial logistic regression analysis with stepwise variable selection to identify severity predictors for in-hospital mortality. <b><i>Results:</i></b> Two hundred sixty-two patients with a median age of 75.9 years (IQR 64.8–82.8) years were included for analysis. TG13/TG18 diagnostic criteria were more sensitive than TG07 diagnostic criteria (85.1 vs. 75.2%; <i>p</i> &#x3c; 0.006). The majority of the patients (<i>n</i> = 178; 67.9%) presented with abdominal pain, pyrexia (<i>n</i> = 156; 59.5%), and vomiting (<i>n</i> = 123; 46.9%). Blood cultures were positive in 95 (36.3%) patients, and 79 (83.2%) patients had monomicrobial growth. The 30-day, 90-day, and in-hospital mortality numbers were 3 (1.1%), 11 (4.2%), and 15 (5.7%), respectively. In multivariate analysis, type 2 diabetes mellitus (OR = 12.531; 95% CI 0.354–116.015; <i>p</i> = 0.026), systolic blood pressure &#x3c;100 mm Hg (OR = 10.108; 95% CI 1.094–93.395; <i>p</i> = 0.041), Glasgow coma score &#x3c;15 (OR = 38.16; 95% CI 1.804–807.191; <i>p</i> = 0.019), and malignancy (OR = 14.135; 95% CI 1.017–196.394; <i>p</i> = 0.049) predicted in-hospital mortality. <b><i>Conclusion:</i></b> TG13/18 diagnostic criteria are more sensitive than TG07 diagnostic criteria. Type 2 diabetes mellitus, systolic blood pressure &#x3c;100 mm Hg, Glasgow coma score &#x3c;15, and malignant etiology predict in-hospital mortality in patients with AC. These predictors could be considered in acute stratification and treatment of patients with AC.

Letter to the Editor Dear Editor, The COVID-19 pandemic has brought about profound challenges in Singapore 1 with surgery drawing scrutiny due to the need to conserve personal protection equipment (PPE), ventilators, intensive care unit (ICU) beds as well as concerns of concurrent COVID-19 infection in surgical patients with reported mortality rate of up to 20%. 2 Given the scarcity of resources and risks associated with concurrent COVID-19 infection in the surgical patient, international guidelines have recommended medical treatment for acute issues related to cholelithiasis that are normally treated surgically. 3 This stance has implications on the management of acute cholecystitis (AC) with meta-analyses demonstrating conclusive benefits of index admission early laparoscopic cholecystectomy (ELC) over interval delayed laparoscopic cholecystectomy (DLC) that include decreased total length of stay, decreased readmission for persistent pain and gallstone-related morbidity, earlier return to work, improved quality of life and increased cost-effectiveness. 4,5 The need to balance the surgical risk and resource considerations of acute cholecystitis with the obligations of delivering optimal outcomes and avoiding morbidity thus poses an ethical dilemma during this pandemic. With the rapidly evolving pandemic coupled with different subspecialty surgeons managing AC in Singapore, opinions and practices may inevitably vary among institutions and surgeons. Resource and manpower constraints would also translate to changing practices on the ground. Thus, the aim of this study is to evaluate the impact of COVID-19 on the management of AC in Singapore. An anonymous online survey was developed and disseminated across all seven public restructured hospitals in Singapore in April 2020 via electronic mail. Inclusion criteria was consultant specialist surgeons who perform laparoscopic cholecystectomy in Singapore. The survey was administered through an online platform, Google Forms (Google LLC, Menlo Park, California, USA). The survey includes questions on demographics of survey respondents, impact of the

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...

Backgrounds/Aims: Prehabilitation aims for preoperative optimisation to reduce postoperative complications. However, there is a paucity of data on its use in patients undergoing pancreaticoduodenectomy (PD). Thus, this study aims to evaluate the outcomes of a home-based outpatient prehabilitation program (PP) versus no-PP in patients undergoing PD. Methods: This retrospective cohort study compared patients who underwent PP versus no-PP before elective PD from January 2016 to December 2020. Inclusion criteria for PP were < 65 years or 65-74 years with FRAIL score < 3. No-PP included dietician, case manager and anesthesia review. PP included additional physiotherapy sessions, caregiver training and interim phone consultation. Univariate and multivariate analysis were used to evaluate length of stay (LOS), morbidity, 30-day readmission, and 90-day mortality.Results: Seventy-one patients (PP: n = 50 [70.4%]; no-PP: n = 21 [29.6%]) were included in this study. Median age was 65 years (interquartile range [IQR]: 58-72 years). Majority (n = 58 [81.7%]) of patients underwent open surgery. Ductal adenocarcinoma was the most common histology (49.3%). Patient demographics were comparable between both groups. Overall median LOS was 11.0 days (IQR: 8.0-17.0 days). Compared to no-PP, PP was not independently associated with reduced intra-abdominal collections (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.03-6.11, p = 0.532), major morbidity (OR: 1.31; 95% CI: 0.09-19.47; p = 0.845) or 30-day readmission (OR: 3.16; 95% CI: 0.26-38.27; p = 0.365). There was one (1.4%) 30-day mortality. Conclusions: Our outpatient PP with unsupervised exercise regimes did not improve postoperative outcomes following elective PD.

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