Incidence of vaginal erosion with different synthetic materials for suburethral sling in the treatment of Stress Urinary Incontinence: A systematic review.

INTRODUCTION: The aim of this systematic review is to compare the vaginal erosion rates in different synthetic materials used in suburethral slings in Tension Free Vaginal Tape (TVT-O /TOT) procedures in management of female stress urinary incontinence. METHODS: PRISMA 2009 framework was adopted for study design. Scholarly literature search was done using MEDLINE, EMBASE, the Cochrane Library and Clinical Trials.gov using selected keywords. Five articles fulfilled the inclusion and exclusion criteria. Our main outcome of interest is to review the ideal properties of the suburethral sling, procedure of insertion and post-surgical complication following the sling insertion primarily vaginal erosion. Results were compared using one way-ANOVA test and independent T- test. RESULTS: Total of 1725 subjects were available for analysis in the five studies. Monofilament polypropylene constituted 92.5% of the total sample size from one study alone. Polyester (n= 16/51) causes higher incidence rate of vaginal erosion compared to monofilament polypropylene (31.4 vs., 4.7; p = 0.01). There was no difference in the vaginal erosion rate between monofilament polypropylene and multifilament polypropylene (4.7 vs, 14.1; p=0.055) as well as between multifilament polypropylene and polyester (14.1 vs, 31.4; p=0.068). Although there was a marginally lower rate of vaginal erosion in TVT-O over TVT, the difference was not significant. (5.6 vs., 6.4, p=0.468). Common presentations of vaginal erosion were vaginal discharge, perineal pain and dyspareunia. CONCLUSION: Given the limited sample size, polyester sling material appears to cause higher rates of vaginal erosion. No difference in erosion rate was seen between TVT and TVT-O.

Management delays for early gastric cancer in a country without mass screening.

BACKGROUND/AIMS: To examine the symptoms of early gastric cancer and the time scale of management delays in a country without a mass screening program. METHODOLOGY: Retrospective review of 44 patients with early gastric cancer. RESULTS: Epigastric pain (63.3%) and gastrointestinal hemorrhage (27.3%) were the main symptoms found. Total delay was made up of patient delay (48.6%), doctor delay (25.5%) and treatment delay (25.9%). Median patient delay (from symptom onset to medical consult) was 30 days (inter-quartile range 2 to 365). Patient delay of more than 6 months was associated with patients aged 50 and younger (P = 0.04) and those presenting with pain (P = 0.05). Median doctor delay (consult to diagnosis) was 21 days (1 to 35) and median treatment delay (diagnosis to surgery) was 8 days (2 to 21). Doctor delay of more than 6 months was associated with a negative gastroscopy or barium meal in the previous 12 months (P = 0.03). CONCLUSIONS: The detection of early gastric cancer at the symptomatic-detectable stage is possible and this potential window for diagnosis can be more than 1 year for up to one third of cases. Efforts to reduce management delays should be aimed at public education and improving the quality and accessibility of endoscopic evaluation.

Post-operative pain in needlescopic versus conventional laparoscopic cholecystectomy: a prospective randomised trial.

BACKGROUND: Needlescopic cholecystectomy (NC) utilises instruments and ports smaller than 3 mm in diameter compared with the 5 mm ones used in conventional laparoscopic cholecystectomy (LC). Post-operative pain control and recovery has been thought to be superior in NC, when compared with historical controls with LC, but has not been proven in a prospective fashion. PATIENTS AND METHODS: A prospective randomised trial of NC versus LC for patients with symptomatic gallstone disease, with standardisation of post-operative analgesia and daily assessment of post-operative pain, using a 5-point visual analogue scale. RESULTS: There were 64 eligible patients randomised into NC (28) and LC (36). Four patients who had NC were converted to LC due to technical problems. Another three and six patients from the NC and LC groups, respectively, had conversion to open surgery. Post-operative pain scores were low in both groups. Mean pain scores for those with successful NC and LC were: 1.24 versus 1.43 for the day of operation (P = 0.49), 0.86 versus 0.83 for the first day post-operatively (P = 0.92) and 0.75 versus 0.81 for the second post-operative day (P = 0.87). The mean number of intra-muscular analgesic injections required were 0.76 versus 0.83 after NC and LC, respectively (P = 0.93). There were no significant differences between the two groups in the time taken to return to feeding, eating a normal diet and discharge from hospital. CONCLUSION: There is no advantage of NC over LC in terms of post-operative pain or recovery. Nevertheless, NC can be performed safely and expediently and has an excellent cosmetic outcome and high patient acceptability.

Adjuvant postoperative 5-fluorouracil chemotherapy combined with pelvic radiation for rectal cancer: results from an Asian population.

Prospective randomized clinical trials have shown the effectiveness of combined adjuvant 5-fluorouracil-based chemotherapy and radiotherapy after surgical resection of rectal cancer. To assess toxicity of this therapy, prospective data were collected from 236 Asian rectal cancer patients treated with combined 5-fluorouracil-based chemotherapy and radiotherapy after surgery. Almost 82% of patients completed planned therapy. Grade 3 and 4 diarrhea, stomatitis, and granulocytopenia occurred in approximately 18-21% of patients. There were two treatment-related deaths from granulocytopenia and sepsis. With median follow-up of 3.5 years, median disease-free and overall survival was 75 and 88 months, respectively. In conclusion, combined adjuvant 5-fluorouracil-based chemotherapy and radiotherapy after surgical resection of rectal cancer is tolerable in Asian patients with moderate toxicity.

Melioidosis splenic abscess--an unusual presentation as osteomyelitis of rib.

INTRODUCTION: We report an unusual case of splenic melioidosis abscess presenting as osteomyelitis. CLINICAL PICTURE: A 74-year-old nondiabetic gentleman presents with a non-healing left chest wall abscess from osteomyelitis. TREATMENT: He underwent rib resection and the infection was found to involve the underlying pleura, lung, adjacent stomach, liver and diaphragm with a splenic abscess. Splenectomy was performed. Histology showed suppurative granulomas and cultures grew Burkholderia pseudomallei. OUTCOME: The patient recovered well with antibiotics. CONCLUSION: Melioidosis should not be forgotten as a cause of chronic suppurative infections in our endemic population.

Hypoglycaemia from islet cell hyperplasia and nesidioblastosis in a patient with type 2 diabetes mellitus--a case report.

INTRODUCTION: We report the first case of hypoglycaemia from beta cell hyperplasia with nesidioblastosis in an Asian adult with pre-existing type 2 diabetes. CLINICAL PICTURE: A 57-year-old Chinese woman presented with hyperinsulinaemic hypoglycaemia despite discontinuation of oral hypoglycaemic agents 4 months after diagnosis of type 2 diabetes. Preoperative portal venous sampling suggested regionalisation to the neck of the pancreas. Intraoperative ultrasound and palpation of the fully mobilised pancreas were non-localising. TREATMENT: A subtotal 85% pancreatectomy was performed with success. OUTCOME: Histology showed no evidence of tumour, but revealed islet hyperplasia and nesidioblastosis. Her diabetes was subsequently well controlled on metformin therapy. CONCLUSION: Endogenous hyperinsulinism from beta cell hyperplasia with nesidioblastosis may rarely occur in type 2 diabetics. However, this remains a diagnosis of exclusion that is confirmed only on surgical pathology. In affected individuals, preoperative portal venous sampling may be falsely localising, especially if selective sampling of the smaller peri-pancreatic veins is omitted. Definite treatment involves pancreatectomy, although the extent of surgical resection is not well established.

Removal of a dinner fork from the stomach by double-snare endoscopic extraction.

Long and pointed foreign objects in the stomach are difficult to remove by endoscopy, and they can cause complications such as perforation and impaction. The endoscopic removal of long and pointed objects involves the following principles: (1) presenting the blunt end cephalad to prevent perforation or impaction during extraction; (2) orienting the long axis of the object in the line of extraction; and (3) applying traction to the foreign body without losing grip. Currently practised methods of extraction, which use a protector hood or an overtube, do not address these three principles. We report on a case in which an ingested metal dinner fork was removed from the stomach by using a double wire-loop snare technique. This method uses two snares to hold the object and allows the endoscopist to change the presentation, orient the axis, and maintain traction to allow the safe removal of long and pointed objects.

10th Chapter of Surgeons' Lecture: the challenges in surgery--past, present and future, and in search of the 4Cs.

Challenges facing surgical practice in the immediate future will not only be in the fields of clinical and operative surgical techniques, but will also involve a new complexity of clinical, para-clinical and economical issues. The impact of casemix, clinical carepaths, evidence-based medicine, high-technological advances, minimally invasive surgery, teleconferencing, robotic surgery, etc will transform the scene of surgical advancement in a dynamic way. Whatever the winds of change may be, ultimately patient's good and welfare must be uppermost in our minds. The challenge is how to maintain and achieve the 4Cs in this age of medical and surgical revolutionary changes. Commitment, Continuing medical education, Consistency, Compassion and a Caring spirit are the Cs we must always keep alive in our clinical practice.

Subjective visual experience during phacoemulsification and intraocular lens implantation under topical anesthesia.

OBJECTIVE: The aim of this study was to investigate the subjective visual experience of patients during phacoemulsification and intraocular lens (IOL) implantation under topical anesthesia. DESIGN: Postoperative questionnaire survey. PARTICIPANTS: The study cohort consisted of 52 patients with cataracts. There were 18 male (34.6%) and 34 female (65.4%) patients. Their mean (+/- SD) age was 67.5 (+/-10.8) years. INTERVENTION: The patients underwent routine phacoemulsification and IOL implantation under topical anesthesia. MAIN OUTCOME MEASURES: The patients were interviewed on the same day after their operation regarding their visual experience in the operated eye during surgery. RESULTS: All patients (100%) reported that they could see at least some light during the surgery. Some patients reported they could also see one or more colors (50 patients, 96.2%), movements (32 patients, 61.5%), flashes (24 patients, 46.2%), the surgeon's fingers/hands (13 patients, 25%), instruments (12 patients, 23.1%), and/or the surgeon (4 patients, 7.7%). The colors seen included red (24 patients, 46.2%), yellow (23 patients, 44.2%), blue (12 patients, 23.1%), green (7 patients, 13.5%), and orange (6 patients, 11.5%). Eight patients (15.4%) saw the spectrum of colors similar to that of the rainbow. Twenty-four patients (46.2%) reported that the brightness of light changed during the course of the operation. Eight patients (15.4%) found their visual experience frightening. There was no statistically significant association between those who found the visual experience frightening and the sex or age of the patient, a history of cataract operation in the fellow eye, the type of visual sensation experienced, or the presence of coexisting ocular pathology. CONCLUSION: All patients undergoing phacoemulsification under topical anesthesia experience a variety of visual sensations that may be frightening in a small proportion of patients.

Bile duct injuries during laparoscopic cholecystectomy: a collective experience of four teaching hospitals and results of repair.

BACKGROUND: Laparoscopic cholecystectomy has been performed in Singapore since 1990 and, up until the end of 1997, a total of 4445 procedures had been performed in the four major teaching hospitals. Although bile duct injuries were thought to have increased following the introduction of laparoscopic cholecystectomy, there have been no reviews done on the incidence of these injuries in the Singapore context. METHODS: The present retrospective review aimed to audit the rate of bile duct injuries in the four major teaching hospitals in Singapore and to document the results of management of these injuries. RESULTS: Of the 4445 procedures performed, there were 19 (0.43%) cases of bile duct injuries. These involved the common hepatic duct (n = 8), common bile duct (n = 10), and the right hepatic duct (n = 1). The underlying gall bladder pathology included non-inflamed gall bladders (n = 10), acute cholecystitis (n = 4), Mirrizzi's syndrome (n = 3) and mucocele of the gall bladder (n = 2). Transection of the duct accounted for the majority of the injuries. Eleven bile duct injuries were identified at the time of operation. These were primarily repaired over a T tube (n = 4) or by a bilio-enteric bypass (n = 7). The remainder were diagnosed at a median of 7 days (range: 1-556 days) after surgery with a presentation of jaundice or pain. These were repaired by bilio-enteric anastomosis (n = 7) and closure over a T tube (n = 1). Three patients developed strictures subsequently, two following bilio-enteric repair after delayed diagnosis and one following immediate primary repair over a T tube. One patient developed intrahepatic stones and required a left lateral segmentectomy. CONCLUSIONS: The experience of a 0.43% bile duct injury rate is comparable to the best results from most large series in the West. Inflammation at Calot's triangle is an important associated factor for injury. Early recognition and prompt repair affords good results, and hepaticojejunostomy is recommended as the repair of choice.

Excimer laser photorefractive keratectomy for the correction of myopia.

AIM OF STUDY: To ascertain the efficacy, predictability, safety and stability of photorefractive keratectomy (PRK) for the correction of myopia. METHODS: Nine-hundred and seventy-one eyes of 628 patients had PRK performed for the correction of myopia. The mean pre-operative myopia was -5.7 D +/- 2.21 D (range -1.0 D to -15.25 D). The mean attempted correction was -5.0 D +/- 1.9 D (range -1.0 D to -9.90 D). RESULTS: Four-hundred and sixty-seven eyes had a follow-up of 6 months or more. Ninety-three percent of low myopic eyes (pre-operative myopia of less than or equal to 6.0 D) and 75% of high myopic eyes (pre-operative myopia of more than 6.0 D) attained an unaided visual acuity of 6/12 or better. Seventy-four percent of low myopic and 50% of high myopic eyes were within 1 D of the intended correction. The mean post-operative refraction at 6 months was 0.60 D +/- 1.46 D. Eight eyes in the high myopia group and 1 eye in the low myope group lost 2 or more lines or best-corrected visual acuity. CONCLUSION: PRK was safer and produced better results for low myopes.

p53 point mutation and survival in colorectal cancer patients: effect of disease dissemination and tumour location.

The relationship between p53 point mutation and patient survival was examined in 328 colorectal cancer patients. Point mutation was detected in 51% (166/328) of cases and was associated with a poorer prognosis in univariate and multivariate analysis. However, subcohort analysis showed that this relationship was restricted to patients with lymphatic dissemination, patients without evident distant metastatic lesions at the time of presentation and in tumours confined to the distal colorectum. These results suggest that the utility of p53 point mutation as a specific, patient based prognostic marker may be restricted to certain classes of patients.

Haemorrhage into non-functioning adrenal cysts--report of two cases and review of the literature.

Adrenal cysts are a rare condition and are usually non-functioning and asymptomatic. Most of the reported cases were incidental findings or discovered at autopsy. However, large cysts have a tendency to develop complications such as intracystic haemorrhage and rupture, which can present as an acute surgical emergency. We report two cases of adrenal cysts with intracystic haemorrhage. One patient presented with persistent non-specific upper abdominal pain, investigations with ultrasound (US) scan and computed tomographic (CT) scan revealed a left adrenal cyst and gallstones. Simultaneous cholecystectomy and adrenalectomy was performed with resultant relief of symptoms. The second patient presented with acute abdominal pain simulating acute surgical abdomen. Preoperative CT scan showed a large cystic lesion in the region of the tail of the pancreas with radiological evidence of haemorrhage but was unable to confirm its origin. The cyst was found to have arisen from the left adrenal gland at laparotomy; left adrenalectomy with complete excision of the cyst was done. Histology showed pseudocyst with haemorrhage in both cases. Pseudocyst is the commonest histological type encountered clinically. We believe the second case is related to pregnancy and childbirth as the patient presented during puerperium and the cyst, even though very large in size (25 x 15 x 15 cm), was not noted during antenatal screening with US scan.

Adjuvant chemotherapy for patients with resected Dukes' C and high-risk B2 colon cancer with fluorouracil and levamisole.

Carcinoma of the large bowel is the second leading cause of cancer mortality in Singapore. Although the great majority of patients are discovered at a stage where resection with curative intent is possible, almost half of the patients afflicted will die of it. The combination of 5-fluorouracil + levamisole used in patients with curatively resected high risk Dukes B2 and all Dukes' C colon cancers has been shown to reduce cancer recurrence rate and improve overall survival. Since 1990 adjuvant chemotherapy has been recommended for this group of patients. This report describes patients treated in Singapore, their toxicities and their outcome. A total of 341 patients were treated between 1990 and 1996. Treatment compliance was 71.8%. Toxicity was moderate with mainly grade 1-2 nausea and vomiting, diarrhoea, stomatitis, alopecia, and neutropenia. There was 1 treatment-related death. Median recurrence-free interval was 81 months and median survival was not reached at 90 months. This regimen is tolerable. Until further randomised reports comparing 5-fluorouracil + levamisole to other combinations are available, this combination chemotherapy is recommended to patients after surgical resection of the high risk Dukes' B2 and Dukes' C colon cancer to reduce cancer recurrence and improve overall survival.

Cystic tumours of the pancreas: a diagnostic dilemma.

BACKGROUND: Cystic neoplasm of the pancreas is an uncommon entity that encompasses a range of tumours with varying potential for malignancy. These tumours are frequently misdiagnosed as pseudocysts and are inappropriately managed. METHODS: A retrospective review was undertaken of 18 cases of cystic tumours of the pancreas over an 8-year period in two large hospitals in Singapore. RESULTS: All patients were Asian, with a younger age group (mean 43.5 years) and a lesser degree of female predominance (3.5:1 ratio) compared to other series. Pain was the most common symptom. Pre-operative diagnosis using ultrasound and computed tomography was not diagnostic in half of the cases and misdiagnosed as pseudocyst in a sixth. There were five serous cystadenomas, four mucinous cystadenomas, two mucinous cystadenocarcinomas, one mucinous cystadenocarcinoma with cystic degeneration in a ductal adenocarcinoma, three Frantz tumours, one acinar cell tumour, one glucagonoma, and one benign epithelial cyst. Two-thirds of tumours were malignant or had the potential to become malignant. Resection was curative in all cases, and no recurrence was noted at a mean follow-up of 34.5 months. CONCLUSIONS: The difficulties with pre-operative diagnosis, the high incidence of tumours with potential malignancy, and the good outcome with resection, suggest that all suspected cystic tumours of the pancreas should be resected.

Photorefractive keratectomy for the treatment of compound myopic astigmatism using the ablatable mask.

Eight eyes of 8 patients with compound myopic astigmatism were treated with excimer laser photorefractive keratectomy (PRK) using a hand-held ablatable mask in conjunction with the Summit excimer laser. The attempted correction ranged from -1.25 to -400 dioptres (D) of astigmatism and 0 to -8.00 D of myopia. All eyes had attained at least 6 months of postoperative follow-up. Five of the 8 eyes achieved an unaided visual acuity of 6/12 or better. Postoperative refractions ranged from -0.50 to -3.50 D of refractive cylinder and from +0.50 to -3.75 D of spherical error. Decentration of the ablation zone was encountered in 3 eyes due to shifts in patients' fixation. Technical difficulty with the use of the hand-held ablatable mask limited the widespread application of this procedure and it has now been superseded by newer excimer laser systems which can correct astigmatism without having to employ a mask. Despite this, because of the theoretical ability of the mask to correct any form of refractive error, the concept of the mask shape transfer process will remain as a potential alternative in refractive surgery, especially for correction of hyperopia and hyperopic astigmatism.