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.

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.

Photorefractive keratectomy for myopia of 6 to 12 diopters.

To conduct a prospective, nonrandomized clinical trial to assess the efficacy, stability and safety of the use of excimer laser photorefractive keratectomy (PRK) to correct myopia of greater than -6.00 diopters (D) in Singapore. Two hundred thirty-three eyes of 176 patients with a mean preoperative spherical equivalent refraction of -8.70 +/- 2.3 D (range, -5.75 D to -18.13 D) underwent PRK with a 193nm ArF excimer laser (ExciMed, Summit) for myopic corrections of between -6.20 D and -11.90 D. The first 66 of 233 eyes that reached at least 1 year of postoperative follow up are reported. One year postoperatively, the mean manifest spherical equivalent refraction was -1.50 D +/- 1.90 D (range -6.25 D to +3.25 D); 34% of eyes were within +/- 1.00 D of attempted correction; uncorrected visual acuity was 20/40 or better in 75% of eyes. No eyes lost two or more Snellen lines of spectacle corrected visual acuity. Central corneal haze was mild in 20% of eyes and moderate in 3% of eyes. Five eyes developed ocular hypertension that subsequently resolved with treatment. Excimer laser PRK is reasonably effective and safe in the treatment of -6.00 D to -12.00 D of myopia. However, it is less accurate than PRK in eyes with low to moderate myopia and is more likely to result in significant corneal haze.

Relative risks of complications in giant and nongiant gastric ulcers.

There are two divergent views regarding giant gastric ulcers. Traditionally, they have been regarded as a virulent disease prone to massive hemorrhage, intractability, and perforation. Recently, an entirely opposing viewpoint has developed that considers them no different from ordinary gastric ulcers. In this study between 1984 and 1989, 62 patients with giant ulcers (greater than or equal to 3 cm) were compared with 476 benign gastric ulcer patients to evaluate their relative risks of ulcer complications. The results showed that giant ulcers are more prone to severe hemorrhage (44% versus 27%; chi 2 test: p less than 0.009) but not more prone to free perforation. Penetration into contiguous organs occurred more frequently with giant gastric ulcers (45% versus 10%; chi 2 test: p less than 0.0001). The risk of the presence of microscopic malignancy in the macroscopically benign-looking giant ulcer is significantly greater than in the nongiant type (13% versus 3%; Fisher's exact test: p = 0.0013). The data showed that patients with giant gastric ulcers are more at risk for the development of life-threatening complications and, hence, more likely to require surgery.

Gastric carcinoid: a rare form of gastrointestinal carcinoids. A report on three cases.

The stomach is an uncommon site for carcinoid tumors, the incidence of which is about 2% of all carcinoids. During a five-year period, from 1988 to 1992, three patients with gastric carcinoid tumors were diagnosed at the Tan Tock Seng Hospital, Singapore. Their ages ranged from 59 to 68 years, and all were male. Two patients were referred for investigation of anemia, and one patient presented with massive hematemesis and an advanced ulcerated tumor requiring emergency total gastrectomy. Of the other two patients, one had pernicious anemia with multiple carcinoid polyps, and the other had sessile carcinoid nodules. None of the patients had carcinoid syndrome. Two patients underwent gastrectomy, while the patient with polyps had an endoscopic polypectomy. Follow-up ranged from one to three years. Two patients remained well, but the patient who presented with an advanced tumor with serosal invasion and nodal involvement had hepatic recurrence and died two years after the diagnosis of recurrence.

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.

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.

Emergency surgery for bleeding oesophageal varices.

PURPOSE OF STUDY--This case-series reviews patients who underwent emergency transgastric ligation or oesophageal transection for uncontrolled bleeding oesophageal varices despite initial conservative therapy with vasoactive drugs, balloon tamponade and injection sclerotherapy. The study seeks to identify factors determining outcome of surgery and the problems of transection surgery following endoscopic sclerotherapy. SELECTION OF STUDY SUBJECTS--One hundred and ninety-eight patients (median age 54.6 years) were treated for bleeding varices between 1981 and 1991. Of these, 36 (18%) required emergency surgery and they formed the cohort under study. OBSERVATIONAL METHODS AND MAIN FINDINGS--Twenty-three patients underwent transabdominal oesophageal devascularisation and oesophageal transection while 13 had transgastric ligation. Nine patients were graded Child-Pugh's A, 20 Child-Pugh's B and 7 Child-Pugh's C-mortality was 11%, 25% and 100% respectively. Of all the risk factors, the Child-Pugh's grade was the single most important factor determining outcome (Chi-square test; 2 degrees of freedom, p < 0.0005). The data also showed that patients who were transfused less than 3 litres of blood had a mortality of 18% compared to 55% for those requiring 3 or more liters (Fisher's exact test p = 0.0155). There was no difference in mortality between transgastric ligation and oesophageal transection when patients were evaluated according to the Child-Pugh's grade. The results indicate that oesophageal transection is to be recommended for better control of bleeding (0% vs 23% post procedure) but conversely is associated with higher anastomotic leakage rate (8.7% vs 0%). PRINCIPAL CONCLUSIONS--We conclude that the decision to operate on bleeding variceal patients should be made early as procrastination is detrimental to their surgical outcome. In view of the extremely poor results with Child-Pugh's C patients, emergency surgery is best offered to the Child's A and B cases.

Perforated leiomyosarcoma of Meckel's diverticulum.

Two cases of perforated leiomyosarcoma of Meckel's diverticulum are presented. There are only 59 cases reported in current literature, including 4 perforations. Although the condition is rare, leiomyosarcoma is the commonest tumour of Meckel's diverticulum. Its clinical presentation include abdominal pain, intestinal bleeding, abdominal mass, intestinal obstruction and less commonly, acute perforations. Both our cases presented with perforations which is unusual. Despite this late presentations both were resectable and both had no distant or local metastasis. One of our patients was 89 years old at presentation and has been disease-free 3 years after resection. The other patient was 69 years old and has also been disease-free.

Breast carcinoma-in-situ: an emerging problem in Singapore.

Breast carcinoma-in-situ constitutes 4.1% of 707 breast cancers diagnosed between 1988 and 1990. Among these 30 patients, intraductal carcinoma-in-situ (DCIS) outnumbers lobular carcinoma-in-situ (LCIS) by 9-fold. They are mostly symptomatic - 87% present as breast lumps and/or nipple discharge, with 52% of lumps exceeding 2cm size. Three patients were detected by screening mammography and it is expected that more breast carcinoma-in-situ will be detected through mammographic screening. Two-thirds of the patients had mastectomy while the rest had lesser procedures. The different surgical procedures and adjuvant therapy instituted for the patients are reflections of the differing opinions regarding optimum therapy for carcinoma-in-situ and the differing rationale for DCIS and LCIS lesions.

Case report--ocular rosacea.

Rosacea is an uncommon disease of the eye and facial skin. Ocular rosacea is often undiagnosed by the ophthalmologist especially when skin manifestations are not evident yet. Early diagnosis and treatment is important to decrease morbidity of this potentially blinding disease. A case of ocular rosacea in a 14-year-old Chinese girl is reported. Our patient presented with chronic non-specific keratoconjunctivitis. Only much later did the characteristic corneal and facial skin lesions appear. She responded to guttae prednisolone, oral and guttae tetracycline. This case illustrates the difficulty of early diagnosis when ocular manifestations precede those of the skin. We believe this is the first case of ocular rosacea reported in Singapore.

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.

Excimer laser photorefractive keratectomy in Singapore--a new treatment modality for myopia.

BACKGROUND: Myopia is a national epidemic in Singapore. Photorefractive Keratectomy (PRK) for the treatment of myopia using the Argon Fluoride Excimer Laser commenced in January 1992 at the Singapore National Eye Centre. METHODS: An open, prospective, non randomised clinical trial to assess the efficacy, predictability, stability, and safety of PRK for the correction of myopia between -2.0 to -6.0 dioptres. RESULTS: One hundred and fifty-five eyes of one hundred and thirty-five patients underwent PRK between January and September 1992, of which thirty-one had completed at least six months of follow-up. Twenty-nine of the thirty-one patients (93.5%) achieved an unaided visual acuity of at least 6/12. Twenty-six patients (83.9%) were within 1 dioptre of emmetropia. There was an initial over-correction in all patients which regressed to a plateau at around three or four months. Corneal haze did not pose a significant problem. Three patients had ocular hypertension, and another developed a mild allergic reaction to the antibiotic-steroid ointment. CONCLUSIONS: Excimer Laser Photorefractive Keratectomy is a very effective, fairly predictable, stable and safe surgical method for the treatment of myopia.

Three year results of radial keratotomy surgery at the National University Hospital, Singapore.

This paper presents the three year results of radial keratotomy (RK) surgery on 51 of the first 59 consecutive eyes at the National University Hospital in Singapore. Before surgery, uncorrected visual acuity was worse than 6/24 in all eyes with 33.3% worse than 6/60. The average pre-operative spherical equivalent (SE) was -4.56 Dioptres(D). Three years after surgery the mean SE was -0.66D, a change of 3.9D; and 72.5% of eyes were within 1D of emmetropia. 70.6% had uncorrected visual acuity of at least 6/12 with no eyes having worse than 6/60 visual acuity. Analysis based on levels of pre-operative myopia showed that the best visual and refractive results were obtained in patients with SE of -6D or less. None of the patients were troubled by complications such as glare, fluctuating vision, irritation and discomfort three years after surgery. Our results indicate that RK surgery is safe and effective through the three years and more following surgery.

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.

Necrotising fasciitis in leukaemic children.

This is a report of necrotising subcutaneous infection in the perineum of three young girls with acute lymphoblastic leukaemia (ALL). This occurred during induction therapy when they were granulocytopenic. Pseudomonas aeroginosa was isolated from both blood and affected sites. With aggressive chemotherapy and extensive surgical debridement, two patients were salvaged but one perished from the septicaemia. Necrotizing Fasciitis is an uncommon progressive infection of the subcutaneous tissue. It occurs more frequently in adults following surgery or trauma and rarely arises spontaneously. In the paediatric literature, reports are few and mainly in healthy children occurring post-operatively. There was only one case of this occurring in a boy with Aplastic anaemia. Early recognition and aggressive therapy helps to improve the morbidity and mortality of this devastating condition.

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.

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.

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.

Malignant tumours of the undescended testis: a report of three cases.

Three cases of testicular malignancies arising in undescended testes were treated in the Department of Surgery, Singapore General Hospital. The patients were all adult Chinese male who presented with tumours arising in unilateral, intra-abdominal undescended testes. Two of the tumours were seminomas while the third was a choriocarcinoma. In all 3 cases, the tumours were large and at an advanced stage at the time of presentation. The treatment in these cases was surgical excision of the primary lesion followed by radiotherapy or chemotherapy. The patient with choriocarcinoma died soon after chemotherapy was initiated while the other two cases are alive, one for over 6 years with no recurrence.