Cessation vs No Cessation of Acetylsalicylic acid Preoperatively in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair (CAPTAIN): Final Report from a Multi-Center, Single-Blinded, Randomized-Controlled Trial. The CAPTAIN trial is a prospective multi-center randomized-controlled trial evaluating the safety of continuing acetylsalicylic acid preoperatively in patients undergoing elective laparoscopic inguinal hernia mesh repair (LIHR). Patients undergoing LIHR were eligible for inclusion. Patients unfit for general anesthesia, patients who had obstructed hernias or patients who underwent open operation were excluded. Participants were randomized by the trial coordinator using allocation concealment to either acetylsalicylic acid-cessation or continuation group, without the surgeon knowing. Primary outcome was the incidence of bleeding complications evidenced by the presence of postoperative hematomas before the patient was discharged from hospital. Secondary outcomes include incidence of major cardiovascular events, post-operative thromboembolic events, seroma formation and length of hospital stay. 100 patients were recruited between April 2016 and June 2024. 5 patients were excluded because they 3 underwent open operation, 1 withdrew consent and 1 had their operation cancelled, leaving 45 patients in the acetylsalicylic acid-continuation group and 50 patients in the cessation group. We found that significantly more patients who continued acetylsalicylic acid had hematomas in the index admission (11 vs 5, p = 0.018). There was no difference in the amount of intraoperative blood loss between the two groups, 12.9 vs 9.3ml (p = 0.130). Both groups of patients had short postoperative stay—an average of less than a day. There were no postoperative thromboembolic events or major adverse cardiac events in either group. The rates of postoperative seroma were similar between both groups, 28.9

Objectives Family caregivers play a fundamental role in the care of the older blunt trauma patient. We aim to identify risk factors for negative and positive experiences of caregiving among family caregivers. Design Prospective, nationwide, multi-center cohort study. Setting and participants 110 family caregivers of Singaporeans aged≥55 admitted for unintentional blunt trauma with an Injury Severity Score (ISS) or New Injury Severity Score (NISS)≥10 were assessed for caregiving-related negative (disturbed schedule and poor health, lack of family support, lack of finances) and positive (esteem) experiences using the modified-Caregiver Reaction Assessment (m-CRA) three months post-injury. Methods The association between caregiver and patient factors, and the four m-CRA domains were evaluated via linear regression. Results Caregivers of retired patients and caregivers of functionally dependent patients (post-injury Barthel score <80) reported a worse experience in terms of disturbed schedule and poor health (β-coefficient 0.42 [95% Confidence Interval 0.10, 0.75], p = .01; 0.77 [0.33, 1.21], p = .001), while male caregivers and caregivers who had more people in the household reported a better experience (-0.39 [-0.73, -0.06], p = .02; -0.16 [-0.25, -0.07], p = .001). Caregivers of male patients, retired patients, and patients living in lower socioeconomic housing were more likely to experience lack of family support (0.28, [0.03, -0.53], p = .03; 0.26, [0.01, 0.52], p = .05; 0.34, [0.05, -0.66], p = .02). In the context of lack of finances, caregivers of male patients and caregivers of functionally dependent patients reported higher financial strain (0.74 [0.31, 1.17], p = .001; 0.84 [0.26, 1.43], p = .01). Finally, caregivers of male patients reported higher caregiver esteem (0.36 [0.15, 0.57], p = .001). Conclusions and implications Negative and positive experiences of caregiving among caregivers of older blunt trauma patients are associated with pre-injury disability and certain patient and caregiver demographics. These factors should be considered when planning the post-discharge support of older blunt trauma patients.

Purpose Value driven outcome (VDO) initiative is a value-based, patient-focused tool which utilizes a clinical outcome-based approach to optimize value of care based on clinically relevant quality indicators and costs required to achieve the care. In this study, we evaluate the impact of a VDO initiative on groin hernia repair, a commonly performed elective surgery in our hospital. Methods A VDO initiative was implemented in 2019 to encourage elective inguinal hernia repair to be performed at a day surgery setting. A comparison of outcomes was made between hernia surgeries performed in 2019 with those in 2020 and 2021. Pre-defined criteria were used to select patients that can be operated at a day surgery setting. Patients' expectations were addressed preoperatively about day surgery procedure and postoperative recovery. Day surgery bundles were used to standardize pre- and post-surgery protocols. Pain control was optimized using a specialized local anesthesia regime. Results A total of 263 laparoscopic hernia surgeries were performed between May 2019 and December 2021. After implementation of VDO initiative, the percentage of patients discharged within 24 h increased from 78% in year 2019 to 97% in year 2020 and 99% in year 2021. Conversion rate for day surgery to short stay decreased from 9% in year 2019 to 1% in year 2020 and 2% in year 2021. In 2019 to 2021, there were no 30-day readmission, no hernia recurrence in 90 days, no conversion to open surgery. Conclusion VDO initiative is a promising tool to deliver better value-based care for patients undergoing endo-laparoscopic inguinal hernia repair.

OBJECTIVE:Frailty is associated with morbidity and mortality in older injured patients. However, for older blunt-trauma patients, increased frailty may not manifest in longer length of stay at index admission. We hypothesized that owing to time spent in hospital from readmissions, frailty would be associated with less total time at home in the 1-year postinjury period. DESIGN:Prospective, nationwide, multicenter cohort study. SETTING AND PARTICIPANTS:All Singaporean residents aged ≥55 years admitted for blunt trauma with an Injury Severity Score (ISS) or New Injury Severity Score (NISS) ≥10 from March 2016 to July 2018. METHODS:Frailty (by modified Fried criteria) was assessed at index admission, based on questions on preinjury weight loss, slowness, exhaustion, physical activity, and grip strength at the time of recruitment. Low time at home was defined as >14 hospitalized days within 1 year postinjury. The contribution of planned and unplanned readmission to time at home postinjury was explored. Functional trajectory (by Barthel Index) over 1 year was compared by frailty. RESULTS:Of the 218 patients recruited, 125 (57.3%) were male, median age was 72 years, and 48 (22.0%) were frail. On univariate analysis, frailty [relative to nonfrail: odds ratio (OR) 3.45, 95% confidence interval (CI) 1.33-8.97, P = .01] was associated with low time at home. On multivariable analysis, after inclusion of age, gender, ISS, intensive care unit admission, and surgery at index admission, frailty (OR 5.21, 95% CI 1.77-15.34, P < .01) remained significantly associated with low time at home in the 1-year postinjury period. Unplanned readmissions were the main reason for frail participants having low time at home. Frail participants had poorer function in the 1-year postinjury period. CONCLUSIONS AND IMPLICATIONS:In the year following blunt trauma, frail older patients experience lower time at home compared to patients who were not frail at baseline. Screening for frailty should be considered in all older blunt-trauma patients, with a view to being prioritized for postdischarge support.

Background Patients suffering moderate or severe injury after low falls have higher readmission and long-term mortality rates compared to patients injured by high-velocity mechanisms such as motor vehicle accidents. We hypothesize that this is due to higher pre-injury frailty in low-fall patients, and present baseline patient and frailty demographics of a prospective cohort of moderate and severely injured older patients. Our second hypothesis was that frailty was associated with longer length of stay (LOS) at index admission. Methods This is a prospective, nation-wide, multi-center cohort study of Singaporean residents aged ≥55 years admitted for ≥48 hours after blunt injury with an injury severity score or new injury severity score ≥10, or an Organ Injury Scale ≥3, in public hospitals from 2016–2018. Demographics, mechanism of injury and frailty were recorded and analysed by Chi-square, or Kruskal-Wallis as appropriate. Results 218 participants met criteria and survived the index admission. Low fall patients had the highest proportion of frailty (44, 27.3%), followed by higher level fallers (3, 21.4%) and motor vehicle accidents (1, 2.3%) (p < .01). Injury severity, extreme age, and surgery were independently associated with longer LOS. Frail patients were paradoxically noted to have shorter LOS (p < .05). Conclusion Patients sustaining moderate or severe injury after low falls are more likely to be frail compared to patients injured after higher-velocity mechanisms. However, this did not translate into longer adjusted LOS in hospital at index admission.

The incidence of umbilical hernias in adults ranges from 10% to 25% in the literature and is increased in females. Some predisposing factors for umbilical hernia development include pregnancy, obesity, ascites and large abdominal tumors leading to increased abdominal pressure. Although tension-free mesh repair is widely-accepted as the gold standard in the repair of ventral hernia, there are some controversies over the best approach especially for small defects in the umbilical region, women of childbearing age and obese patients. The aim of this review is to shed light on how and when to repair umbilical hernias in the face of the most recent publications, as well as to discuss unique situations such as pregnancy, cirrhotic patients and in the emergency setting.

# Needs assessment for postgraduate trauma training in general surgery: a qualitative study {#article-title-2} Trauma is considered a key component of surgical training. However, recent changes in practice patterns and training paradigms have resulted in a critical review of curricula for surgical

Annals Academy of Medicine Dear Editor, Blunt cardiac injury refers to injury sustained due to blunt trauma to the heart. It encompasses a spectrum of pathologies ranging from myocardial contusion; myocardial, pericardial and valvular rupture/aneurysm to coronary artery injuries (dissection, thrombosis or rupture). The clinical manifestations range from clinically silent, transient arrhythmias, to acute myocardial infarction (AMI) and sudden cardiac death. The true incidence of blunt chest injury is unknown as reported rates vary greatly in the literature, ranging between 8% and 71%.1

We would like to report a rare case of salpingo-appendiceal fistula occurring as a complication of acute suppurative appendicitis, and provide a brief opinion of this condition. An appendiceal fistula is an abnormal connection between the appendix and another epithelial surface. There are various types of appendiceal fistulae, including appendicovesical, appendico-enteric, appendicocutaneous and appendico-uterine, usually secondary to acute or associated appendicitis [ [1] Nanni G. Bergamini C. Bertoncini M. Nanni G. Spontaneous appendicocutaneous fistula: case report and literature review. Dis Colon Rectum. 1981; 24: 187-190 Crossref PubMed Scopus (13) Google Scholar ]. Although these spontaneous appendiceal fistulae are rare, spontaneous salpingo-appendiceal fistulae occur even less frequently.

1University Surgical Cluster, National University Hospital, Singapore Address for Correspondence: A/Prof So Bok Yan, University Surgical Cluster, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074. Email: jimmy_so@nuhs.edu.sg Since the dawn of mankind, the survival of the species theory mandates the adaptation of complex mammalian bodies to harsh climates and unfavourable environments. With abundant nutrition, sedentary lifestyle and modern transportation amongst many other comforts of urbanisation, many of the overweight and obese men today would be unrecognisable from the common man in the days of Socrates, Leonardo Da Vinci and even Thomas Edison. Modern healthcare facilities are plagued with diseases of the metabolic syndrome as the rate of obesity in Singapore and most developed countries rises unchecked. This is now a global public health problem, a pandemic plaguing the rich and the poor, the young and the old, the movers and shakers and even the downtrodden. According to the Ministry of Health, Singapore, the overall prevalence of obesity in 2010 is 11%, with 1.7 million of Singaporeans being at risk of obesity-related health problems.1 Body mass index (BMI) is commonly used to objectively measure the status of weight. BMI is calculated as weight in kilograms divided by the height in meters squared (m2). According to the WHO classifi cation of overweight and obese in Asian countries, an overweight individual has a BMI between 23 and 27.5 kg/m2. In Singapore and Asia-Pacifi c countries, an obese person is defi ned as a person with BMI of 27.5 kg/m2 or more.2 Obesity is classifi ed by WHO as a chronic disease, a multisystemic disease resulting from complex interaction between the human genotype and the environment. Morbid obesity is defi ned as patients whose weight is more than twice their ideal body weight and/or 100 pounds or more overweight. As part of the 1998 National Health Survey in Singapore, a study by Deurenberg-Yap et al from the Ministry of Health was published. It showed that for the same amount of body fat as Caucasians, the BMI in Chinese, Malays or Indians would be lower. For example, the BMI cut-off points for obesity would have to be about 27 kg/m2 for Chinese and Malays and 26 kg/m2 for Indians compared to the BMI of 30 kg/m2 in Caucasians (cut-off for obesity as defi ned by WHO). This is the paradox of low BMI and high body fat percentage among Chinese, Malays and Indians in Singapore.3 Morbid obesity may affect every organ system such as the cardiovascular, respiratory, metabolic, musculoskeletal, gastrointestinal, urological, endocrine and reproductive, dermatological, neurological and psychological systems, thus increasing the risks of developing many diseases. High BMI is on average associated with about 30% higher overall mortality — 40% increased mortality rate for vascular mortality, 60% to 120% for diabetic, renal, and hepatic mortality, 10% for neoplastic mortality and 20% for respiratory and for all other mortality.4 Various comorbid conditions coexist or are common in the obese such as: • hypertension, atherosclerotic heart and peripheral vascular disease with myocardial infarction and cerebral vascular accidents, peripheral venous insuffi ciency, thrombophlebitis, pulmonary embolism • asthma, obstructive sleep apnea, obesityhypoventilation syndrome • type 2 diabetes, impaired glucose tolerance, dyslipidemia • cholelithiasis, gastroesophageal refl ux disease • non-alcoholic fatty liver disease or steatohepatitis, hepatic cirrhosis • hepatic carcinoma, colorectal carcinoma, cancer of the endometrium, breast, ovary, prostate, pancreas • back strain, disc disease, osteoarthritis of the hips, knees, ankles, feet • polycystic ovary syndrome, increased risk of pregnancy and foetal abnormalities, male hypogonadism • intertriginous dermatitis • pseudotumour cerebri • carpal tunnel syndrome • depression, eating disorders, body image disturbance.

Dear Editor, Oesophageal duplication cysts are rare congenital maldevelopments of the posterior primitive foregut and mostly present in childhood.1 Patients usually present with dysphagia and sometimes chest discomfort. Complete surgical excision is the standard treatment. In this case report, we describe a laparoscopic transperitoneal approach to surgical excision of a duplication cyst of the intrathoracic oesophagus. This case report is the fi rst account of laparoscopic transhiatal excision of intrathoracic oesophageal duplication cyst among adults in Singapore.