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On-table hepatopancreatobiliary surgical consults for difficult cholecystectomies:A 7-year audit

Hepatobiliary & Pancreatic Diseases International 2022年第3期21卷 273-278页

作者： Kai Siang Chan Elizabeth Hwang JeeKeem Low sameerp junnarkar Cheong Wei Terence Huey Vishal G Shelat Department of General Surgery Tan Tock Seng Hospital308433Singapore

Background: Cholecystectomy is considered a general surgical operation. However, general surgeons are not trained to manage severe complications such as bile duct injury(BDI) and should refer to hepatopancreatobiliary(HPB) surgeons when difficulty arises. This study aimed to investigate the outcomes of patients who had on-table HPB consults during cholecystectomy. Methods: This is an audit of 50 patients who required on-table HPB consult during cholecystectomy from 2011 to 2017. Consultations were classified as “proactive” and “reactive”, where consults were made before or after surgical incision, respectively. Patient demographics and perioperative details were collected. Results: The median age of the patients was 62.5 years [interquartile range(IQR) 50.8–71.3 years]. Eight(16%) patients had underlying HPB co-morbidity. Gallbladder wall was thickened in all patients(median 5 mm, IQR 4–7 mm), and common bile duct was of normal caliber in all patients(median 5 mm, IQR 4–6 mm). Median length of operation and length of stay were 165 min(IQR 124–209 min) and five days(IQR 3–7 days), respectively. Subtotal cholecystectomy was performed in 18(36%) patients. Forty-eight patients were initially managed by laparoscopic approach, 15(31%) required open conversion;majority(9/15, 60%) were initiated before on-table consult. Majority of referrals(98%) were reactive. Common reasons for referral included unclear anatomy or anatomical variations(30%), presence of dense adhesions and/or contracted gallbladder(18%) and impacted stones in Hartmann’s pouch(16%). Three(6%) patients were referred for BDI(2 Strasberg D and 1 Strasberg E1), and two(4%) were referred for torrential bleeding from arterial injury(1 cystic artery and 1 right hepatic artery). Any morbidity and 30-day readmission were 22% and 6%, respectively. There was no 90-day mortality. Conclusions: Calling for help in BDI is obligatory, but in other instances is a personal choice. Calling for help prior to open conversion i

关键词： Bile duct injury Cholecystectomy Cholecystitis On-table consult Quality indicators Hepatopancreatobiliary surgery

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Are outcomes for emergency index-admission laparoscopic cholecystectomy performed by hepatopancreatobiliary surgeons better compared to non-hepatopancreatobiliary surgeons?A 10-year audit using 1:1 propensity score matching

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Hepatobiliary & Pancreatic Diseases International 2024年第6期23卷 586-594页

作者： Kai Siang Chan Samantha Baey Vishal G Shelat Sameer P junnarkar Department of General Surgery Tan Tock Seng HospitalSingapore 308433Singapore Lee Kong Chian School of Medicine Nanyang Technological UniversitySingapore 308232Singapore Yong Loo Lin School of Medicine National University of SingaporeSingapore 117597Singapore

Background:Emergency index-admission cholecystectomy(EIC)is recommended for acute cholecystitis in most *** surgeons have less exposure in managing“difficult”*** study aimed to compare the outcomes of EIC between hepatopancreatobiliary(HPB)versus non-HPB ***:This is a 10-year retrospective audit on patients who underwent EIC from December 2011 to March *** who underwent open cholecystectomy,had previous cholecystitis,previous endoscopic retrograde cholangiopancreatography or cholecystostomy were excluded.A 1:1 propensity score matching(PSM)was performed to adjust for confounding variables(***≥75 years,history of abdominal surgery,presence of dense adhesions).Results:There were 1409 patients(684 HPB cases,725 non-HPB cases)in the unmatched ***(52.3%)of them were males with a mean age of 59.2±14.9 *** 472(33.5%)patients with EIC performed≥72 hours after presentation,40.1%had dense *** incidence of any morbidity,open conversion,subtotal cholecystectomy and bile duct injury were 12.4%,5.0%,14.6%and 0.1%,*** was one mortality within 30 days from *** resulted in 1166 patients(583 per group).Operative time was shorter when EIC was performed by HPB surgeons(115.5 vs.133.4 min,P<0.001).The mean length of hospital stay was *** performed by HPB surgeons was independently associated with lower open conversion[odds ratio(OR)=0.24,95%confidence interval(CI):0.12–0.49,P<0.001],lower fundus-first cholecystectomy(OR=0.58,95%CI:0.35–0.95,P=0.032),but higher subtotal cholecystectomy(OR=4.19,95%CI:2.24–7.84,P<0.001).Any morbidity,bile duct injury and mortality were comparable between the two ***:EIC performed by HPB surgeons were associated with shorter operative time and reduced risk of open ***,the incidence of subtotal cholecystectomy was higher.

关键词： Bail-out Cholecystectomy Cholecystitis Open conversion Tokyo guidelines

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Haemoxygenase modulates cytokine induced neutrophil chemoattractant in hepatic ischemia reperfusion injury

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World Journal of Gastroenterology 2016年第33期22卷 7518-7535页

作者： Niteen Tapuria Sameer junnarkar Mahmoud Abu-amara Barry Fuller Alexander M Seifalian Brian R Davidson Department of HPB Surgery and Liver transplantation Royal Free Hospital

AIM To investigate the hepatic microcirculatory changes due to Haemoxygenase(HO),effect of HO inhibition on remote ischemic preconditioning(RIPC) and modulation of *** Eight groups of animals were studied- Sham,ischemia reperfusion injury(IRI) the animals were subjected to 45 min of hepatic ischemia followed by three hours of reperfusion,RIPC(remote ischemic preconditioning) + IRI group,remote ischemic preconditioning in sham(RIPC + Sham),PDTC + IR(Pyridodithiocarbamate,HO donor),Zn PP + RIPC + IRI(Zinc protoporphyrin prior to preconditioning),IR-24(45 min of ischemia followed by 24 h of reperfusion),RIPC+IR-24(preconditioning prior to. After 3 and 24 h of reperfusion the animals were killed by exsanguination and samples were taken. RESULTS Velocity of flow(160.83 ± 12.24 μm/s),sinusoidal flow(8.42 ± 1.19) and sinusoidal perfusion index(42.12 ± 7.28) in hepatic IR were lower(P < 0.05) in comparison to RIPC and PDTC(HO inducer). RIPC increased velocity of flow(328.04 ± 19.13 μm/s),sinusoidal flow(17.75 ± 2.59) and the sinusoidal perfusion index(67.28 ± 1.82)(P < 0.05). PDTC(HO induction) reproduced the effects of RIPC in hepatic IR. PDTC restored RBC velocity(300.88 ± 22.109 μm/s),sinusoidal flow(17.66 ± 3.71) and sinusoidal perfusion(82.33 ± 3.5) to near sham levels. Zn PP(HO inhibition) reduced velocity of flow of RBC in the RIPC group(170.74 ± 13.43 μm/s and sinusoidal flow in the RIPC group(9.46 ± 1.34). Zn PP in RIPC(60.29 ± 1.82) showed a fall in perfusion only at 180 min of reperfusion. Neutrophil adhesion in IR injury is seen in both postsinusoidal venules(769.05 ± 87.48) and sinusoids(97.4 ± 7.49). Neutrophil adhesion in RIPC + IR injury is reduced in both postsinusoidal venules(219.66 ± 93.79) and sinusoids(25.69 ± 9.08)(P < 0.05). PDTC reduced neutrophil adhesion in both postsinusoidal venules(89.58 ± 58.32) and sinusoids(17.98 ± 11.01)(P < 0.05) reproducing the effects of RIPC. Zn PP(HO inhibition) increased venular(589.04 ± 144.36) and sinusoida

关键词： Reperfusion injury CINC Microcirculation Ischaemic preconditioning Remote preconditioning Haemoxygenase

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Prehabilitation in elderly patients scheduled for liver resection and protocol for Recovery Of Surgery in Elderly

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Hepatoma Research 2020年第3期6卷 50-59页

作者： Ramkumar Mohan Cheong Wei Terence Huey Sameer junnarkar Jee Keem Low Vishal G.Shelat Yong Loo Lin School of Medicine National University of SingaporeSingapore Senior Consultant Hepatopancreaticobiliary SurgeryTan Tock Seng HospitalSingapore

Ageing population of first world economies pose unique challenges to surgical *** recovery after surgery protocols and pathways do not attempt to optimize or enhance physical function of patients by customized program of physical ***,prehabilitation programs(PP)have gained momentum in orthopaedics,urology,colorectal surgery and hepatopancreaticobiliary *** evidence of PP in various elective surgical procedures have shown improved outcomes with minimal to none drawback or *** is emerging evidence of role of PP in elective liver *** aim of this paper is to review the basis of PP and share local multidisciplinary team protocol specifically customized to frail and elderly population-Recovery Of Surgery in Elderly.

关键词： Prehabilitation liver resection hepatocellular carcinoma pre-operative exercise ageing

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Isolated gallbladder tuberculosis mimicking acute cholecystitis:A case report

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World Journal of Gastrointestinal Surgery 2020年第3期12卷 123-128页

作者： Kai Siang Chan Vishal G Shelat Cher Heng Tan Yee Lin Tang Sameer P junnarkar Kong Chian School of Medicine Nanyang Technological UniversitySingapore 308232Singapore Department of General Surgery Tan Tock Seng HospitalSingapore 308433Singapore Department of Diagnostic Radiology Tan Tock Seng HospitalSingapore 308433Singapore Department of Pathology Tan Tock Seng HospitalSingapore 308433Singapore

BACKGROUND Isolated tuberculosis of the gallbladder is extremely rare due to its intrinsic resistance to tuberculous *** are reports of gallbladder tuberculosis mimicking cholecystitis or ***,these presentations were *** diagnosis of gallbladder tuberculosis warrants the need for investigation of additional sites of inoculation and contact tracing of all tuberculosis *** tuberculosis is a rare entity but should be suspected in patients from endemic regions with risk factors such as underlying immunosuppression or history of *** SUMMARY We present a case of gallbladder tuberculosis presenting as acute cholecystitis.A 44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain which worsened after meals with no significant past medical *** underwent laparoscopic cholecystectomy on the presumptive diagnosis of acute cholecystitis and diagnosed as gallbladder tuberculosis after histopathological *** patient did not have features of pulmonary or systemic tuberculosis nor was she *** recovered *** was subsequently discharged and followed-up at a hospital in her home country due to financial and social *** Clinicians should have a high index of suspicion for patients in endemic regions presenting with cholecystitis.

关键词： Cholecystectomy Cholecystitis Gallbladder Extra-pulmonary tuberculosis Case report

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Elderly patients(≥80 years)with acute calculous cholangitis have similar outcomes as non-elderly patients(<80 years):Propensity score-matched analysis

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World Journal of Hepatology 2021年第4期13卷 456-471页

作者： Kai Siang Chan Ramkumar Mohan Jee Keem Low Sameer P junnarkar Cheong Wei Terence Huey Vishal G Shelat Department of General Surgery Tan Tock Seng HospitalSingapore 308433Singapore MOH Holdings Singapore 099253Singapore Yong Loo Lin School of Medicine National University of SingaporeSingapore 117597Singapore

BACKGROUND Acute cholangitis(AC)is a disease spectrum with varying extent of ***≥75 years forms part of the criteria for moderate(Grade II)severity in both the Tokyo Guidelines(TG13 and TG18).Aging is associated with reduced physiological reserves,frailty,and ***,there is evidence that age itself is not the determinant of inferior outcomes in elective and emergency biliary *** is a paucity of reports comparing clinical outcomes amongst elderly patients vs non-elderly patients with *** To investigate the effect of age(≥80 years)on AC's morbidity and mortality using propensity score matching(PSM).METHODS This is a single-center retrospective cohort study of all patients diagnosed with calculous AC(January 2016 to December 2016)and≥80 years old(January 2012 to December 2016)at a tertiary university-affiliated teaching *** criteria were patients who were treated for suspected or confirmed AC secondary to biliary *** with AC on a background of hepatobiliary malignancy,indwelling permanent metallic biliary stents,or concomitant pancreatitis were *** patients were defined as≥80 years old in our study.A 1:1 PSM analysis was performed to reduce selection bias and address confounding *** variables include comorbidities,vital parameters,laboratory and radiological investigations,and type of biliary decompression,including the time for endoscopic retrograde cholangiopancreatography(ERCP).Primary outcomes include in-hospital mortality,30-d and 90-d *** of hospital stay(LOS)was the secondary *** Four hundred fifty-seven patients with AC were included in this study(318 elderly,139 non-elderly).PSM analysis resulted in a total of 224 patients(112 elderly,112 non-elderly).The adoption of ERCP between elderly and non-elderly was similar in both the unmatched(elderly 64.8%,non-elderly 61.9%,P=0.551)and matched cohorts(elderly 68.8%and non-elderly 58%,P=0.096).The overall in

关键词： Cholangitis Choledocholithiasis Cholelithiasis Aged 80 and over Geriatrics Cholangiopancreatography Endoscopic retrograde

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Sequential organ failure assessment score is superior to other prognostic indices in acute pancreatitis

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World Journal of Critical Care Medicine 2021年第6期10卷 355-368页

作者： Thomas Zheng Jie Teng Jun Kiat Thaddaeus Tan Samantha Baey Sivaraj K Gunasekaran Sameer P junnarkar Jee Keem Low Cheong Wei Terence Huey Vishal G Shelat Department of General Surgery Tan Tock Seng HospitalSingapore 308433Singapore Undergraduate Medicine Lee Kong Chian School of MedicineSingapore 308232Singapore Department of General Surgery Singapore General HospitalSingapore 169608Singapore Undergraduate Medicine Yong Loo Lin School of MedicineSingapore 119077Singapore

BACKGROUND Acute pancreatitis(AP)is a common surgical condition,with severe AP(SAP)potentially *** 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 *** To evaluate these indices'utility in predicting severity,intensive care unit(ICU)admission,and *** A retrospective analysis of 653 patients with AP from July 2009 to September 2016 was *** demographic,clinical profile,and patient outcomes were *** was defined as per the revised Atlanta *** 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 *** with<10%missing data was imputed via mean *** patient information such as demographics,disease etiology,and patient outcomes were also derived from electronic medical *** The mean age was 58.7±17.5 years,with 58.7%***(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 ***’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 i

关键词： Pancreatitis Severity scoring Intensive care unit Mortality Sequential Organ Failure Assessment score Ranson’s score

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Impact of diabetes mellitus on mortality in pulmonary hypertension:A systematic review and meta-analysis

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World Journal of Critical Care Medicine 2024年第4期13卷 99-111页

作者： Smitesh Padte Priyal Mehta Vikas Bansal Niti singh Rayyan Sunasra Vidhi Goyal Raunaq B Chaudhary Yash junnarkar Vidhi Shah Zara Arshad Faisal A Nawaz Salim Surani Rahul Kashyap Department of Research Global Remote Research Scholar ProgramPrinceton JunctionPrincetonNJ 08550United States Department of Internal Medicine WellSpan York HospitalYorkPA 17403United States Department of Internal Medicine St.Vincent HospitalWorchesterMA 01608United States Department of Nephrology and Hypertension Mayo ClinicRochesterMN 55902United States Department of Anesthesiology and Critical Care Seth G.S.Medical College and K.E.M.HospitalMumbai 400012MahārāshtraIndia Department of Medicine Hinduhridaysamrat Balasaheb Thackeray Medical College and Dr.R.N Cooper HospitalMumbai 400056India Department of Medicine HBT Medical College and Dr.RN Cooper HospitalMumbai 400056MahārāshtraIndia Department of Psychiatry Al Amal Psychiatry HospitalDubai 50262DubayyUnited Arab Emirates Department of Medicine&Pharmacology Texas A&M UniversityCollege StationTX 77843United States Department of Research Wellspan HealthYorkPA 17403United States

BACKGROUND Pulmonary hypertension(PH)is a progressive disease characterized by endothelial dysfunction and vascular remodeling and is a leading cause of mortality *** it is independently associated with multiple comorbidities,the impact of diabetes mellitus(DM)on mortality in patients with PH remains *** address this issue,we conducted a systematic review and meta-analysis to investigate the effect of DM on survival in patients with pulmonary *** To investigate the impact of diabetes mellitus on mortality in pulmonary hypertension *** We conducted a comprehensive search of four major electronic bibliographic databases like PubMed,Google Scholar,Scopus,and Embase,and identified 106 relevant studies,out of 1561 articles,published since the year 2000 for full-text *** retrospective and prospective cohort studies that compared survival between patients with DM and those without DM in the context of PH were deemed eligible for inclusion in our *** study was registered on PROSPERO with the identifier *** A total of 116455 patients with PH were included in the meta-analysis,of whom 41228 suffered from DM and 75227 did *** results of our meta-analysis indicate an elevated mortality rate among PH patients with diabetes mellitus in comparison to those without DM[odds ratio(OR)=1.40,95%CI:1.15–1.70,P=0.0006].The metaregression analysis unveiled a statistically significant negative association between mean age and effect size(coefficient=-0.036,P value=0.018).Conversely,a statistically significant positive association was detected between female proportion and effect size(coefficient=0.000,P value<0.001).CONCLUSION Our meta-analysis,which included approximately 116500 PH patients,revealed that the presence of diabetes mellitus was associated with increased odds of mortality when compared to non-diabetic *** metaregression analysis indicates that studies with older partici

关键词： Pulmonary hypertension Diabetes mellitus Mortality Systematic review Meta-analysis

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