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Our dissertation evaluated the outcomes of cardiac surgery in the context of an increasingly high-risk patient cohort. It demonstrated the utility of clinical registries and risk-assessment tools in optimizing outcomes of high-risk patients. These tools have allowed comparative analyses to be performed which have demonstrated the safety and efficacy of novel surgical techniques in high-risk patients. Our dissertation also established the increased risk of early and mid-term mortality associated with AF across a spectrum of cardiac surgery procedures. There are two major implications of this finding. Firstly, AF warrants consideration as an independent risk factor in future risk stratification tools. Secondly, surgeons should consider treating AF at the time of cardiac surgery with a concomitant AF surgery procedure. The safety and efficacy of this procedure has been demonstrated in many studies but it is currently underutilized. Finally, we demonstrated the safety and efficacy of cardiac surgery performed by trainee surgeons. This is a relevant finding in the contemporary era where surgeons may be reluctant to provide training opportunities to junior surgeons because of the increased scrutiny on outcomes and the perception of increased risk. Our data demonstrated that properly supervised trainees achieve equivalent outcomes to their consultant peers. Nevertheless, given the gradual shift of cardiac surgery into a specialty which incorporates more minimally invasive procedures and percutaneous interventions, there is an urgent need to train surgeons in these approaches. Moreover, the training deficit in AF surgery needs to be rectified. These actions will ensure that the future generation of cardiac surgeons is trained to deal with the increasingly high-risk patient cohort that they will encounter.

Despite advances in chemotherapy and radiotherapy, gastrectomy is the only curative intervention for gastric carcinoma. This study reviews post-operative health-related quality of life (HRQOL) after gastrectomy.A literature search was conducted on PubMed for all studies published after January 2000 matching strict eligibility criteria. Bibliographies of included studies were also reviewed. Quality appraisal and data tabulation were performed using pre-determined forms. Results were synthesised by narrative review according to PRISMA guidelines with full tabulation of results of all included studies.A total of 21 studies (3,575 patients) were included. Post-operative HRQOL improvements were demonstrated across most or all domains in different HRQOL instruments. Patients experienced declines in HRQOL 1 month after surgery, but reached at least pre-operative levels with recovery by 1 year. The greatest improvements were demonstrated in the emotional health domain with favourable functional benefits. Partial gastrectomy appears to be superior to total gastrectomy in physical, emotional and functional health domains. However, patients remain susceptible to gastrointestinal symptoms following surgery, which negatively impact upon HRQOL. Post-operative complications did not appear to affect HRQOL. Most studies were prospective, but data is heterogeneous.Gastrectomy results in significant HRQOL benefits across a broad range of health domains. This is critical outcome of surgery and an important consideration in pre-operative decision making.

Unresectable intrahepatic cholangiocarcinoma (ICC) portends a poor prognosis despite standard systemic treatments which confer minimal survival benefits and significant adverse effects. This study aimed to assess clinical outcomes, complications and prognostic factors of TAE therapies using chemotherapeutic agents or radiation.A literature search and article acquisition was conducted on PubMed (MEDLINE), OVID (MEDLINE) and EBSCOhost (EMBASE). Original articles published after January 2000 on trans-arterial therapies for unresectable ICC were selected using strict eligibility criteria. Radiological response, overall survival, progression-free survival, safety profile, and prognostic factors for overall survival were assessed. Quality appraisal and data tabulation were performed using pre-determined forms. Results were synthesized by narrative review and quantitative analysis.Twenty articles were included (n=929 patients). Thirty three percent of patients presented with extrahepatic metastases. After treatment, the average rate of complete and partial radiological response was 10% and 22.2%, respectively. Overall median survival time was 12.4 months with a median 30-day mortality and 1-year survival rate of 0.6% and 53%, respectively. Acute treatment toxicity (within 30 days) was reported in 34.9% of patients, of which 64.3% were mild to moderate in severity. The most common clinical toxicities were abdominal pain, nausea and vomiting, and fatigue. Multiplicity, localization and vascularity of the tumor may predict worse overall survival.Trans-arterial therapies are safe and effective treatment options which should be considered routinely for unresectable ICC. Consistent and standardized methodology and data collection is required to facilitate a meta-analysis. Randomized controlled trials will be valuable in the future.