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Inferior vena cava leiomyosarcoma in an octogenerian
Sudharsan Madhavan,Sameer P Junnarkar,Nicholas Wee Chong Koh,Vishalkumar G Shelat 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.3
Inferior Vena Cava (IVC) leiomyosarcoma (LM) is a rare malignancy of mesenchymal origin with an incidence of 1/100,000. We present an 82-year-old lady with a past history of open cholecystectomy who presented with a large indeterminate mass on abdominal imaging. Open resection of the mass was performed and histology with immunohistochemical staining revealed leiomyosarcoma. She received adjuvant radiotherapy and remained disease free 4 years after.
Patient reported outcomes in elective laparoscopic cholecystectomy
Malcolm H.W. Mak,Woon Ling Chew,Sameer P. Junnarkar,Winston W.L. Woon,Jee-Keem Low,Terence C.W. Huey,Vishalkumar G. Shelat 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.1
Backgrounds/Aims: Traditional outcome measures (e.g., length of hospital stay, morbidity, and mortality) are used to determine the quality of care, but these may not be most important to patients. It is unclear which outcomes matter to patients undergoing elective laparoscopic cholecystectomy (ELC). We aim to identify patient-reported outcome measures (PROM) which patients undergoing ELC valued most. Methods: A 45-item questionnaire with Four-point Likert-type questions developed from prior literature review, prospectively administered to patients treated with ELC at a tertiary institution in Singapore. Results: Seventy-five patients participated. Most essential factors were technical skill and experience level of a surgeon, long-term quality of life (QoL), patient involvement in decision-making, communication skill of a surgeon, cleanliness of the ward environment, and standards of nursing care. Least important factors were hospitalization leave duration, length of hospital stay, a family’s opinion of the hospital, and scar cosmesis. Employed patients were more likely to find hospitalization leave duration (p<0.001) and procedure duration (p=0.042) important. Younger patients (p=0.048) and female gender (p=0.003) were more likely to perceive scar cosmesis as important. Conclusions: Patients undergoing ELC value long-term QoL, surgeon technical skill and experience level, patient involvement in decision-making, surgeon communication skill, cleanliness of the ward environment, and nursing care standards. Day-case surgery, medical leave, family opinion of hospital, and scar cosmesis were least important. Understanding what patients value will help guide patient-centric healthcare delivery.
Predictive value of post-operative drain amylase levels for post-operative pancreatic fistula
Tang Ee Ling Serene,Shelat Vishalkumar G,Junnarkar Sameer Padmakumar,Huey Cheong Wei Terence,Low Jee Keem,Wang Bei,Woon Wei Liang Winston 한국간담췌외과학회 2018 Annals of hepato-biliary-pancreatic surgery Vol.22 No.4
Backgrounds/Aims: Traditionally, surgically placed pancreatic drains are removed, at the discretion of the operating surgeon. Moving towards enhanced recovery after surgery (ERAS), we looked for predictors for early drain removal. The purpose of this paper was to establish which postoperative days’ (POD) drain amylase is most predictive against post-operative pancreatic fistula (POPF). Methods: We conducted a retrospective study of 196 patients who underwent pancreatic resection at our institute from January 2006 to October 2013. Drain amylase levels were routinely measured. The International Study Group of Pancreatic Fistula (ISGPF) definition of POPF, and clinical severity grading were used. Results: 5.1% (10 of 196) patients developed ISGPF Grades B and C POPF. Negative predictive value of developing significant POPF, if drain amylase values were low on PODs 1 and 3 was 98.7% (95% CI: 0.93-1.00). This translated to confidence in removing surgically placed pancreatic drains, at POD 1 and 3 when drain amylase values are low. Conclusions: Patients with low drain amylase values on POD 1 and 3, are unlikely to develop POPF and may have pancreatic drains removed earlier.
Are traditional scoring systems for severity stratification of acute pancreatitis sufficient?
Thaddaeus Tan Jun Kiat,Sivaraj K Gunasekaran,Sameer P Junnarkar,Jee Keem Low,Winston Woon,Vishal G Shelat 한국간담췌외과학회 2018 Annals of hepato-biliary-pancreatic surgery Vol.22 No.2
Backgrounds/Aims: Ranson’s score (RS) and Glasgow score (GS) have been utilized to stratify the severity of acute pancreatitis (AP). The aim of this study was to validate RS and GS for stratifying the severity of acute pancreatitis and audit our experience of managing AP. Methods: We conducted a retrospective review of patients treated for AP from July 2009 to September 2016. Final severity was determined using the revised Atlanta classification. Mortality and complications were analyzed. Results: From July 2009 to September 2016, a total of 675 patients with a diagnosis of AP were admitted at the hospital. Of them, 669 patients who had sufficient data were analyzed. Their average age±SD was 58.7±17.4 years (range, 21-98 years). There was a male preponderance (n=393, 53.8%). A total of 82 (12.3%) patients had eventual severe pancreatitis. RS demonstrated a sensitivity of 92.7% and a specificity of 52.8% with a positive predictive value (PPV) of 21.5% and a negative predictive value (NPV) of 98.1%. GS demonstrated a sensitivity of 76.8% and a specificity of 69.2% with a PPV of 25.8% and a NPV of 95.5%. For severity prediction, areas under the curve (AUCs) for RS and GS were 0.848 (95% CI: 0.819-0.875) and 0.784 (95% CI: 0.750-0.814), respectively (p=0.003). Twelve (1.6%) patients died in the hospital. Conclusions: RS has higher sensitivity, NPV and AUC for predicting severity of AP than GS.
Nicholas George Mowbray,Carven Chin,Patricia Duncan,David O’Reilly,Zsolt Kaposztas,Sameer Junnarkar,Nagappan Kumar 한국간담췌외과학회 2021 Annals of hepato-biliary-pancreatic surgery Vol.25 No.1
Backgrounds/Aims: As populations age, an increased incidence of colorectal cancer will generate an increase in colorectal cancer liver metastases (CRLM). In order to guide treatment decisions, this study aimed to identify the contemporary complication rates of elderly patients undergoing liver resection for CRLM in a, centralised, UK centre. Methods: All patients undergoing operative procedures for CRLM between January 2013 and January 2019 were included. Patient, tumour and operative data were analysed, including the prognostic marker; tumour burden score. Results: 339 operations were performed on 289 consecutive patients with CRLM (272 patients <75 years old, 67 patients ≥75 years old). Median age was 66 years (range 20-93). There was no difference in major complication rates between the two age cohorts (6.65 vs. 6.0%, p=0.847) or operative mortality (1.1% vs. 1.4%, p=0.794). Younger patients had higher R1 resection rates (20.4% vs. 4.5%, p=0.002) and post-operative chemotherapy rates (60.3% vs. 35.8%, p< 0.001). The 1, 3 and 5-year OS was 90.2%, 70.5% and 52.3% respectively, median 70 months, with no difference between age cohorts (p=0.772). Tumour Burden score and operation type were independent predictors of overall survival. Conclusions: Liver resection for CRLM in patients 75 years and older is feasible, safe and confers a similar 5-year survival rate to younger patients. The current outcomes from surgery are better than historical datasets.
Nagappan Kumar,Trish Duncan,David O’Reilly,Zsolt Kaposztas,Craig Parry,John Rees,Sameer Junnarkar 한국간담췌외과학회 2019 Annals of hepato-biliary-pancreatic surgery Vol.23 No.1
Backgrounds/Aims: Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) has generated controversy due to high morbidity and mortality. We present our series of patients with 30-40% parenchymal transection and minimal hilar dissection. Methods: Patients who had partial ALPPS between April 2015 and April 2016 were included. Patients with colorectal liver metastases (CRLM) had their future liver remnants (FLR) cleared with metastasectomies. The liver was divided along the future line of transection to 30-40%, right portal vein was stapled and divided without extensive hilar dissection, with minimal handling of right liver, which was not mobilised. We preserved the middle hepatic vein. Data were collected prospectively for hypertrophy of the FLR, morbidity and mortality. Results: Among the 8 patients (age 25-68) investigated, one patient with cholangiocarcinoma had portal vein embolization prior to partial ALPPS. All patients completed two stages with adequate FLR hypertrophy at a median of 28 days. No mortality was found. The median length of stay after stages 1 and 2 was 9 and 9.6 days, respectively. The median increase in FLR was 38%. Conclusions: A limited transection of 30-40%, minimal hilar dissection and longer wait between stages yielded adequate FLR hypertrophy with low morbidity and no mortality.