Affirul Chairil Ariffin

Important Research Elements in Aiding Training

We read with great interest the article by Waalewijn BP et al. [1]. The article describes a prospective research of postgraduate training. The trainees are required to observe and assist prior to performing any surgery alone. Fifty patients and more are the cut-off point to determine competency. This is the bread and butter of any surgery training. However, increasing medicolegal repercussions require changing this way of practice. Seniors are to accompany all cases throughout postgraduate training. Trainees only perform the designated simple cases after reasonable training. The study highlights the reduced operating time and blood loss with increasing competencies. This is a commendable aspect of any surgery, but other factors also need inclusion in the study design. Caesarean section remains a notable cause for maternal death. Although a recent article showed an inverse relationship between Caesarean section number and death, it is tricky to control the need for surgery in a real situation [2]. The mortality rate in this study is 1% which is low even by worldwide standard [3, 4]. However, the data reliability is contentious. These data are from the trainees’ logs and may not reflect the true numbers of outcome and mortality. The training rotation and surgery performed at 19 different centres could lead to loss of data and error. A software would help in capturing the missed data. A better study design is important to minimize these issues. It should include important and meaningful elements. The causes, complications, post-operative days and associated preoperative factors are some of the important ones that need to be highlighted. All these elements will serve better to determine the competencies and safety of trained surgeons. Without a suitable database, it is difficult to get the information after the study concludes. The patients’ characteristics such as age, comorbidities and numbers of previous Caesarean sections also influence the blood loss, duration of surgery and death. Not forgetting the anaesthesia and intraoperative findings will also affect the data [5]. Another suggestion we believe could improve this research significance is the use of the national database to supplement the logbooks findings during analysis. Although using trainees’ logbook is a reasonable choice to ease the data collection, this method introduces bias to the data. By comparing the national database and logbook data presented from the 19 different centres, we can confirm the elements such as complication, surgery volume and mortality. Besides that, the reliability of the data is unquestionable. We understand that it is a momentous task to collect the data from such a large nationwide database, but we believe that it will aid in solidifying and supporting the current training method. An improved and comprehensive study design is essential during the conception of questions. We would expect reading the next study on this matter.

Does Time Difference in CT Scan Causes More Mortality

We read with great interest the article by McKechnie et al. [1] discussing the role of computerised tomography (CT) in trauma. The article explains the differences in time for CT between trauma centres and non-trauma centres in Scotland. This issue is a common problem in the majority of hospitals worldwide. An organised trauma system has proven to be beneficial in reducing the time for CT scan significantly [2]. The data presented are consistent with materials available in the literature [2, 3]. CT scan proves to be an indispensable component in the evaluation of trauma patients, especially in haemodynamically stable patients [4]. Contrast-enhanced CT scan can detect liver and spleen lacerations, haematoma and active bleeding with a sensitivity up to 95% [5]. Hence, a difference of 9 min is significant, especially in abdominal injuries. Early diagnosis is imperative for an early intervention leading to a better outcome. Nonetheless, there are few issues which we believe will enhance the discussion further. The analysis did not include the implication of such differences in both centres. It is important to evaluate the outcome and conclude whether the delay in imaging has any influence on the morbidity and mortality. Without this evidence, the necessity of time improvement within nontrauma centres remains contentious. Besides that, causes of CT delay should not be overlooked. By understanding these factors, efforts can be put to improve the trauma management in non-trauma centres. It is intriguing whether a proper analysis of these factors can be performed on a large data such as this. Again, being a retrospective nature, it is a challenging task to obtain the appropriate data from a large multicenter national database. However, we do believe it is worthwhile considering the effect these findings might have towards the trauma care especially in non-trauma centres.

Post-hepatectomy Lactate: Should We Add More?

I read with great interest the article written by Lemke et al. [1]. This is indeed a topic of much interest due to the increase in hepatectomy cases annually. The rarity positive findings of the ‘50–50’ rule in post-hepatectomy patient requires a better surrogate as an addition. Multiple articles have proven the role of lactate in post-operative gastrointestinal surgery and hepatectomy specifically [2, 3]. However, there are few questions and issues that I think is important to discuss further. The article made a comparison between patients who had their lactate measured and not measured to establish any significant differences. However, the importance of this characteristic difference is uncertain. The physician took the lactate from patients with high risk of developing hyperlactatemia and complications that are standard practice in most centres. This figure only proves the selective indications applied to post-hepatectomy patients. By doing so, this leads to missed predictors which may be different as the non-lactate group has nearly similar mortality (6.3 vs. 5.5%) despite a better clinical profile. The authors use Charlson comorbidity index in defining the severity of the condition and relationship with mortality. It does not specify which comorbidities have the biggest influence on patients’ survival. Preoperative diabetes has a significant relationship with raise lactate [6 [2]. Diabetes is also shown to exacerbate liver injury after an inflow occlusion [4]. It is essential to control this confounding variable by ensuring optimal glucose level within each subject. This comorbidity is an essential criterion whereby it should have been reported separately. Four hepato-pancreato-biliary surgeons were involved in performing the surgeries with different techniques. One of the standard steps used is Pringle’s procedure. A minimum total ischaemic time is recommended to maintain good perfusion and prevents hypoxia. However, this method is associated significantly with raised lactate post-hepatectomy [5]. The prolonged and multiple application of Pringle’s can lead to reperfusion injury. More depth in the inflow occlusion techniques and time would show us a better insight into its effects towards the lactate level and outcome. Articles have shown the independent association between the number of segment resected and morbidity and mortality [2, 5]. An extended hepatectomy ([4) is strongly associated with high lactate post-operatively. This condition cause a higher metabolic demand towards the remnant of the liver, affecting the lactate clearance. It would be beneficial if the author could divide the resection into few groups of interests (\3, 4–6 and [6 segments). Furthermore, it is much advantageous if this study could evaluate the effects of functional liver assessment with lactate level. This information would give us invaluable information on which resection factors might contribute to the high postoperative lactate level and mortality. It will be a challenge to identify each factor, but I believe it is worthwhile to include those determinants that have been proven significant. It will also differentiate this study with previous articles which show similar or perhaps better results. & Affirul Chairil Ariffin mraffirul@gmail.com

Tube Thoracostomy Complications: More to Learn

I read with great interest the article written by Hernandez et al. [1] with regard to the high cost related to tube thoracostomy complication. Although cost is the main theme in this article, it does raise few questions with regard to the complications. Personally, we do come across this problem occasionally but not so often. The data showed a 37% cases with complications which mostly are related to technical problem. I do agree that these complications come with a higher cost, but the amount of these complications is somewhat worrying. Though the highest complication rate in trauma patients is 36%, data from the recent millennium suggest the range between 3 and 8–10% [2]. In the analysis of the data, only the interspace of ribs was included. Though it is one of the main ones, other major factors could contribute. The level of experience of the operators during insertion could be a factor. Kashani et al. [3] showed a 60% complication rate when performed by residents. An analysis of the knowledge, attitude and practice (KAP) of operators would shed some light on this matter. The technique used for insertion between ‘blind’ versus open method could be associated with the high complication [4]. Tube thoracostomy size is another common factor although it is debatable in most of the literature. An article even suggested the location of insertion matters whereby tube thoracostomy insertion in the ward has more complications then insertion in emergency departments [5]. Being a retrospective study, it would be challenging to obtain the appropriate data with regard to these factors to be included in the analysis. But I do believe it is worthwhile considering especially with a high complication rate such as this. I would be interested to know whether these factors play a significant role in such a high complication rate and aid other clinicians in preventing it.

Mechanical thrombolysis as an adjunct therapy to management of portal vein thrombosis following Radio Frequency Ablation

Radiofrequency ablation (RFA) has evolved to become the treatment of choice for non-resectable recurrent colorectal liver metastasis. It is however, not without complications. Portal vein thrombosis following RFA is rare but can be fatal to the outcome of the patient. Here, we present a case of a 66-year-old man who developed portal vein thrombosis following RFA. CT scan revealed a left portal vein thrombosis. This case report highlights the challenges and multimodal treatment of portal vein thrombosis following Radiofrequency ablation (RFA) in a cirrhotic patient.