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The era of geriatric surgery has arrived with increased global life expectancy. The need to optimize outcomes in this group of patients goes beyond traditional outcomes such as postoperative morbidity and mortality indicators. Recognizing risk factors that impact adverse surgical outcomes such as frailty and sarcopenia, individualizing optimization strategies such as prehabilitation and a multidisciplinary geriatric surgical service have been shown to improve postoperative outcomes and help the older surgical patient regain premorbid function and maintain quality of life. There needs to be a concerted effort to increase awareness of this increasingly important topic in practicing surgeons around the world to meet the challenges of the aging population.

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INTRODUCTION: Endoscopic submucosal dissection (ESD) in the colon and rectum has been developed with good reported outcomes. The main advantage of ESD is the ability to perform en bloc resection, which has implications for complete excision and pathological analysis. Locally, the use of ESD in colonic lesions has seen recent traction. Our study aimed to review the outcomes of the first 50 cases of endoscopic excision of advanced colonic lesions using ESD at our institution. METHODS: This was a retrospective study of all patients who underwent ESD at our institution from September 2010 to October 2016. Data collected included patient demographics, resection technique, conversion rate and morbidity. RESULTS: 51 patients underwent ESD during the study period. All patients were of American Society of Anesthesiologists (ASA) class 1-3. Their median age was 60.0 years and the majority (n = 36) were male. The mean procedure time was 80.9 minutes. 36 (76.6%) of cases underwent en bloc resection. 4 (7.8%) cases required conversion to surgery, mainly due to difficulty in raising the colonic lesions. 3 (5.9%) patients had malignancy as the final histology. 2 (4.3%) patients had recurrence during surveillance scope. No cases of early mortality were reported. CONCLUSION: Our results suggest that ESD for advanced colonic lesions can be safely performed. Expertise needs to be developed to achieve satisfactory en bloc resection rates.

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BACKGROUND: Etiologic organism is not frequently isolated despite multiple blood and fluid cultures during management of pyogenic liver abscess (PLA). Such culture negative pyogenic liver abscess (CNPLA) is routinely managed by antibiotics targeted to Klebsiella pneumoniae. In this study, we evaluated the outcomes of such clinical practice. METHODS: All the patients with CNPLA and Klebsiella pneumoniae PLA (KPPLA) admitted from January 2003 to December 2011 were included in the study. A retrospective review of medical records was performed and demographic, clinical and outcome data were collected. RESULTS: A total of 528 patients were treated as CNPLA or KPPLA over the study period. CNPLA presented more commonly with abdominal pain (P=0.024). KPPLA was more common in older age (P=0.029) and was associated with thrombocytopenia (P=0.001), elevated creatinine (P=0.002), bilirubin (P=0.001), alanine aminotransferase (P=0.006) and C-reactive protein level (P=0.036). CNPLA patients tend to have anemia (P=0.015) and smaller abscess (P=0.008). There was no difference in hospital stay (15.7 vs 16.8 days) or mortality (14.0% vs 11.0%). No patients required surgical drainage after initiation of medical therapy. CONCLUSION: Despite demographic and clinical differences between CNPLA and KPPLA, overall outcomes are not different.

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INTRODUCTION: Laparoscopic Hartmann reversal (LHR) has decreased postoperative recovery time and a lower wound infection rate compared to open HR. However its technical difficulty and high conversion rates make it a challenging procedure. We aim to demonstrate the technique of LHR via a video presentation. Our patient, a 64 year old Chinese man with no history of previous surgery underwent a Hartmann procedure for an obstructing sigmoid stricture secondary to diverticular disease. Three months later, he underwent an elective LHR. MATERIALS AND SURGICAL TECHNIQUE: A 10 mm port was initially inserted in the right iliac fossa under direct vision away from expected adhesions due to the previous midline incision. Additional 5mm working ports were inserted in the right flank and right hypochondrium. An additional 10mm optical port was then inserted in the epigastrium and the laparoscopic camera was switched to the epigastric port. Omental adhesions to abdominal wall were taken down. The left colon was then brought down to the pelvis to ensure adequate length of bowel for anastomosis. A colorectal side to end anastomosis was then performed. The stoma wound was closed and the patient was discharged well on post-operative day 5. DISCUSSION: LHR can be adopted as an initial approach to visualize intra-abdominal adhesions and determine feasibility of operation. With experienced hands, LHR can achieve good patient outcomes.

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INTRODUCTION: The aim of this study was to compare outcomes between slit and non-slit mesh placement in laparoscopic totally extraperitoneal inguinal hernia repair. METHODS: This is a retrospective study of 113 patients who underwent laparoscopic totally extraperitoneal inguinal hernia repair with Ultrapro mesh between January 2010 and December 2011. Sixty-two and 82 hernias were operated on in the slit mesh and non-slit mesh groups, respectively. Postoperative complications, recurrence, and patient satisfaction levels were evaluated. RESULTS: One hernia in the slit mesh group (1/62, 1.6%) and one in the non-slit mesh group (1/82, 1.2%) developed recurrence (P = 1.00). The incidence of postoperative neuralgia was 4/62 (6.5%) and 7/82 (8.5%) in the slit mesh and non-slit mesh groups, respectively (P = 0.76). Satisfaction rates in the slit mesh and non-slit mesh groups were similar at 60/62 (96.8%) and 80/82 (97.6%), respectively (P = 1.00). CONCLUSION: No significant differences in outcomes were found between slit and non-slit mesh placement. Both have low complication rates, low recurrence rates, and high satisfaction levels.

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