Surgical resection for hepatocellular carcinoma: a single-centre's one decade of experience

Background and aims

Liver cancer is the third leading cause of global cancer deaths, and hepatocellular carcinoma is its most common type. Liver resection is one of the treatment options for hepatocellular carcinoma (HCC). This study aims to explore our hospital's more than a decade of experience in liver resection for HCC patients.

Methods

This is a retrospective cohort study on HCC patients undergoing resection from 2010 to 2021 in a tertiary-level hospital in Jakarta, Indonesia. Mortality rates were explored as the primary outcome of this study. Statistical analysis was done on possible predictive factors using Pearson's χ2. Survival analysis was done using the Log-Rank test and Cox Regression.

Results

Ninety-one patients were included in this study. The authors found that the postoperative mortality rates were 8.8% (in hospital), 11.5% (30 days), and 24.1% (90 days). Excluding postoperative mortalities, the long-term mortality rates were 44.4% (first year), 58.7% (3 years), and 69.7% (5 years). Cumulatively, the mortality rates were 46.4% (1 year), 68.9% (3 years), 77.8% (5 years), and 67.0% (all time). Significant predictive factors for cumulative 1-year mortality include large tumour diameter [odds ratio (OR) 14.06; 95% CI: 2.59-76.35; comparing <3 cm and >10 cm tumours; P<0.01], positive resection margin (OR 2.86; 1.17-77.0; P=0.02), and tumour differentiation (P=0.01). Multivariate analysis found hazard ratios of 6.35 (2.13-18.93; P<0.01) and 1.81 (1.04-3.14; P=0.04) for tumour diameter and resection margin, respectively.

Conclusion

The mortality rate of HCC patients undergoing resection is still very high. Significant predictive factors for mortality found in this study benefit from earlier diagnosis and treatment; thus, highlighting the importance of HCC surveillance programs.

The enhanced recovery after surgery (ERAS) protocol implementation in a national tertiary-level hospital: a prospective cohort study

Introduction

Successful colorectal surgery is determined based on postoperative mortality and morbidity rates, complication rates, and cost-effectiveness. One of the methods to obtain an excellent postoperative outcome is the enhanced recovery after surgery (ERAS) protocol. This study aims to see the effects of implementing an ERAS protocol in colorectal surgery patients.

Methods

Eighty-four patients who underwent elective colorectal surgery at National Tertiary-level Hospital were included between January 2021 and July 2022. Patients were then placed into ERAS (42) and control groups (42) according to the criteria. The Patients in the ERAS group underwent a customized 18-component ERAS protocol and were assessed for adherence. Postoperatively, both groups were monitored for up to 30 days and assessed for complications and readmission. The authors then analyzed the length of stay and total patient costs in both groups.

Results

The length of stay in the ERAS group was shorter than the control group [median (interquartile range) 6 (5-7) vs. 13 (11-19), P<0.001], with a lower total cost of [USD 1875 (1234-3722) vs. USD 3063 (2251-4907), P<0.001]. Patients in the ERAS group had a lower incidence of complications, 10% vs. 21%, and readmission 5% vs. 10%, within 30 days after discharge than patients in the control group; however, the differences were not statistically significant. The adherence to the ERAS protocol within the ERAS group was 97%.

Conclusion

Implementing the ERAS protocol in colorectal patients reduces the length of stay and total costs.

Caecopexy as management for caecal volvulus: An evidence-based case report

INTRODUCTION AND IMPORTANCE

The incidence of caecal volvulus (CV) reaches 2.8-7.1 per million per year. CV is a surgical emergency that must be treated immediately because the mortality rate can reach 30 %, and the recurrence rate is 40 %. This study showed a case illustration of caecal volvulus with evidence-based recommendations for indications and management of caecopexy based on postoperative outcomes.

CASE PRESENTATION

33-Year-old male came with chief complaints of persistent acute abdominal pain one day before hospital admission. Pain is felt suddenly throughout the abdomen. On physical examination, palpable pain in the entire abdomen is obtained, accompanied by the muscular defence with increased bowel sounds. The laboratory only showed increased white blood cells. Abdominal computed tomography (CT) with contrast showed closed-loop obstruction (CLO) signs.

CLINICAL DISCUSSION

Caecopexy technique use is supported in a case series because it can be done safely, quickly, and without the need to open intestinal segments. Based on previous researches, there were none to low rate of morbidity, mortality, and recurrence. In this patient, caecopexy was carried out and showed good output with no complications.

CONCLUSION

Caecopexy is a safe, simple, and less invasive procedure. The advantages of the caecopexy technique are low morbidity, mortality, and recurrence. The patient's outcome in this illustration is consistent with other literature. Thus it can be used as evidence-based recommendations in the management of the next case of caecal volvulus.

Characteristics of living liver donors in a national referral hospital in Indonesia: a 13-year experience with living donor liver transplantation

Background

Hepatocellular carcinoma and biliary atresia lead to end-stage liver disease, which requires liver transplantation and is linked to increased mortality. Dr. Cipto Mangunkusumo Hospital is the national referral center in Indonesia and is the only center that routinely performs living donor liver transplantation (LDLT). This study presents the characteristics of living liver donors (LLDs) in Indonesia.

Methods

Using the LDLT registry, we conducted a retrospective analysis of all approved donors from 2010 to 2022. The variables included clinical characteristics of the donors, graft types, and intraoperative and postoperative characteristics.

Results

The LDLT rate has increased from 5.8 to 8.8 procedures/year in the last 8 years. The average age of the 76 LLDs was 31.8 years. They were predominantly female (59%) and lived within a family relationship (90%). Pediatric LDLT was more frequent than adult LDLT (88% vs. 12%, respectively). Most grafts (86%) were obtained by left lateral sectionectomy, with a median ratio of remnant liver volume to total liver volume of 79.5% (range, 47.7%-85.8%) and a mean graft-to-recipient weight ratio of 2.65%±1.21%. The median intensive care unit length of stay (LOS) was 2 days (range, 1-5 days) and the total hospital LOS was 7 days (range, 4-28 days). The complication rate was 23%. No donor mortality was reported.

Conclusions

LDLT in Indonesia has increased over the years. The shortage of donors for adult-to-adult liver transplantation is due to cultural differences and challenges in finding eligible donors. This study aims to explain the eligibility criteria of LLDs and contribute to creating a national policy.

Keep It or Leave It? Comparison of Preoperative Scoring as Mortality Predictor Post-Pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy (PD) is the common procedure in resectable periampullary malignancies. However, the postoperative mortality rate for PD is relatively high. Mortality scoring system helps surgeons to decide patients' eligibility for surgery to minimize mortality risk. This study aimed to compare four scoring systems for mortality prediction after PD in the Indonesian population.

METHODS

In this cross-sectional study, data were retrospectively collected from medical records for patients who underwent PD due to periampullary malignancy between January 2010 and January 2022. We assessed scoring accuracy, cut-off, sensitivity, specificity, negative predictive value, positive predictive value, and area under the curve (AUC) of Naples prognostic score (NPS), Whipple-ABACUS (WA), modified Pitt score (MPS), and Pitt score.

RESULT

Of the 116 patients who met the criteria, the mortality rate was 12.1%. Mean age was 51.64 ± 10.22 years consist of 75.9% group <60 years and 24.1% ≥60 years, with 46.6% male and 53.4% female. The AUC from highest to lowest were Pitt Score 0.890 (p<0.001), MPS 0.775 (p 0.001), WA 0.627 (p 0.123), and NPS 0.505 (p 0.949) with the level of accuracy of each score were Pitt Score and MPS 67.2%, WA 50.0%, and NPS 59.5%.

CONCLUSION

Pitt and MPS scores have the highest accuracy of all the scoring systems in this study. MPS has the advantage of having fewer components, making it easy to implement. MPS can replace the role of the Pitt Score in predicting post-procedure PD mortality in Indonesia. Further studies that include the intraoperative factors are needed to increase the scoring accuracy.

Surgical site infection after digestive surgery in a single tertiary hospital in Indonesia: six years of data

BACKGROUND Surgical site infection (SSI) is responsible for increasing cost, morbidity, and mortality related to surgical operations, and has continued to be a significant problem even in hospitals with advanced facilities. This study aimed to describe the SSI among patients after digestive surgery. METHODS From 2012 to 2017, all abdominal surgeries with SSI in Cipto Mangunkusumo Hospital, except obstetrics and gynecology cases, were included in the study. Demographic characteristics, nutritional status, preoperative and intraoperative conditions, wound contamination/SSI type, and mortality data were reported. RESULTS From 4,893 abdominal surgeries during the period, 135 subjects (2.8%) developed SSI with 42.2% of cases were the clean-contaminated type. Most of the cases were males (66.7%), aged between 25–65 years old (80.0%), subjective goal assessment B (46.7%), had normal weight (57.8%), had longer duration of surgery (70.4%), and had preoperative stay between 2–15 days (65.2%). Most of the SSI patients survived (77.8%). CONCLUSIONS Even though the SSI in Cipto Mangunkusumo Hospital was low, it still needs improvement in preoperative care, intraoperative care, and SSI awareness. Therefore, further studies are required to understand how to reduce the incidence, risk, and SSI-related mortality.

The outcome of laparoscopic subtotal cholecystectomy in difficult cases - A case series

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSC) is a widely used technique for managing cholelithiasis with severe cholecystitis. The increasing popularity its utilization is due to the good safety profile and acceptable results. This case series evaluates the short- and long-term results of Indonesian patients who underwent LSC with an objective to determine whether the procedure can be a standard approach for difficult cholecystectomy in our institution.

PRESENTATION OF CASE

Thirty-four Indonesian patients (26 men, 8 women) with the mean age of 54.6 years (median 54 years, range 30-84 years) who underwent LSC were retrospectively analyzed. Nineteen patients are suffering from type II diabetes mellitus and fourteen patients with suspected choledocoholithiasis underwent ERCP prior to LSC. The major postoperative diagnosis was acute cholecystitis (16 patients), followed by gallbladder empyema (10 patients), chronic cholecystitis (5 patients), history of cholangitis (1 patient), Mirizzi's syndrome (1 patient) and stone retention post-ERCP (1 patient).

DISCUSSION

The mean operating time was 158minutes (median 150minutes, range 60-240minutes), mean length of hospital stay of 4.6days (median 3days, range 2-33days) and drain usage for 3.6days (median 3.0days, range 1-19days). Postoperatively there was one case of bilioenteric fistula, one case of stone retention and two cases of prolonged upper gastrointestinal symptoms. There is no case of biliary leakage, peritonitis or wound infection.

CONCLUSION

The outcome of LSC in this case series is comparable with other publications showing a general favorability of LSC. Further studies are needed to elucidate the clinical benefits of several LSC technical points such as stump closure, posterior wall diathermy and drain usage. Based on this preliminary finding, LSC can be applied as a standard procedure for difficult cases in our institution.