Background: s/Aims: Postoperative pancreatic fistulas (POPF) remain a major cause of morbidity and mortality following pancreatoduodenectomy (PD). Pancreatogastrostomy (PG) and pancreatojejunostomy (PJ) are the two most commonly used reconstruction techniques, yet evidence favoring one over the other is inconclusive. This study evaluates postoperative outcomes following open PD at a single institution that transitioned from PG to PJ as the preferred reconstruction method. Methods: This retrospective comparative study included patients who underwent PD between April 2005 and August 2022. Of 757 patients identified, 522 met the inclusion criteria. Propensity score matching (PSM) was performed to adjust for clinically relevant covariates. Primary endpoints were clinically relevant (CR) POPF (grade B/C) and Clavien–Dindo (CD) grade ≥ 3 POPFs. Secondary outcomes included post-pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), systemic complications, length of hospital stay, and mortality. Results: Overall, CR-POPF and CD grade ≥ 3 POPFs occurred in 21.3% and 8.0% of patients, respectively. Thirty-day and in-hospital mortality rates were 3.1% and 4.2%. After PSM, 368 patients (184 PG and 184 PJ) were analyzed. Grade B POPFs were more frequent following PJ than PG (24.5% vs. 15.8%, p < 0.001). Although CR-POPF and CD grade ≥ 3 POPFs were numerically higher in the PJ group, differences were not statistically significant. In contrast, DGE, PPH, and in-hospital mortality were significantly higher following PG (37.0% vs. 25.0%, p = 0.025; 16.3% vs. 8.7%, p = 0.025; and 7.6% vs. 2.7%, p = 0.049, respectively). Conclusions PG was associated with a lower incidence of grade B POPFs but higher rates of DGE, PPH, and in-hospital mortality.

Even though the combined use of ultrasound (US) and alpha-fetoprotein (AFP) is recommended for the surveillance of hepatocellular carcinoma (HCC), the utilization of AFP has its challenges, including accuracy dependent on its cut-off levels, degree of liver necroinflammation, and etiology of liver disease. Though various studies have demonstrated the utility of protein induced by vitamin K absence II (PIVKA-II) in surveillance, treatment monitoring, and predicting recurrence, it is still not recommended as a routine biomarker test. A panel of 17 experts from Asia-Pacific, gathered to discuss and reach a consensus on the clinical usefulness and value of PIVKA-II for the surveillance and treatment monitoring of HCC, based on six predetermined statements. The experts agreed that PIVKA-II was valuable in the detection of HCC in AFP-negative patients, and could potentially benefit detection of early HCC in combination with AFP. PIVKA-II is clinically useful for monitoring curative and intra-arterial locoregional treatments, outcomes, and recurrence, and could potentially predict microvascular invasion risk and facilitate patient selection for liver transplant. However, combining PIVKA-II with US and AFP for HCC surveillance, including small HCC, still requires more evidence, whilst its role in detecting AFP-negative HCC will potentially increase as more patients are treated for hepatitis-related HCC. PIVKA-II in combination with AFP and US has a clinical role in the Asia-Pacific region for surveillance. However, implementation of PIVKA-II in the region will have some challenges, such as requiring standardization of cut-off values, its cost-effectiveness and improving awareness among healthcare providers.

INTRODUCTIONNon-alcoholic fatty liver disease (NAFLD) is frequently associated with cholelithiasis. The prevalence of NAFLD in Asia has been on the rise, but the magnitude of this increase had not been studied previously.

METHODSA retrospective cohort study was conducted on consecutive patients who underwent laparoscopic or open cholecystectomy from November 2001 to November 2004 (Cohort 1) and from November 2011 to November 2014 (Cohort 2) at Singapore General Hospital. Preoperative diagnostic scans (e.g. ultrasonography, computed tomography and magnetic resonance imaging) and clinical data were reviewed for the presence of fatty liver. Statistical analysis was performed.

RESULTSIn Cohorts 1 and 2, 127 patients and 99 patients were operated on, respectively. Cohort 2 had significantly higher proportions of patients with NAFLD (56.6% vs. 40.2%; p < 0.015) and hyperlipidaemia (45.5% vs. 18.9%; p < 0.001) as compared to Cohort 1. Binary logistic regression analysis showed that hypertension (odds ratio [OR] 2.558; p < 0.004) and Indian ethnicity (OR 5.448; p < 0.043) were significantly associated with NAFLD.

CONCLUSIONSimilar to other international studies, we found a significant increase in the prevalence of patients with NAFLD presenting symptomatically for cholecystectomy over an interval of ten years in Singapore. Hypertension and Indian ethnicity were significantly associated with NAFLD in both time periods. This trend supports the need for concerted public health intervention to stem the increasing incidence of NAFLD and prevent its progression to more advanced liver disease.

Although portobiliary fistula is a recognised complication of percutaneous transhepatic biliary drainage, it is extremely uncommon and can result in haemobilia. Herein, we present a case of complicated transhepatic biliary drainage catheter insertion in a patient with underlying hepatitis B liver cirrhosis, which resulted in a portobiliary fistula. The patient had a preoperative transhepatic biliary drainage procedure done prior to a Whipple's operation for a large, obstructive, gastrointestinal stromal tumour of the duodenum. To the best of our knowledge, this is the first case in the English medical literature reporting the successful treatment of portobiliary fistula by embolisation of its tract with embolisation coils, without compromising the portal vein or bile ducts.
Anemia ; complications ; Bile Ducts ; pathology ; Catheterization ; Cholangiography ; methods ; Embolization, Therapeutic ; methods ; Fistula ; etiology ; therapy ; Hepatitis B ; complications ; Humans ; Liver ; pathology ; Liver Cirrhosis ; complications ; Male ; Middle Aged ; Portal Vein ; pathology ; Tomography, X-Ray Computed ; Treatment Outcome