Zymogen-poor acinic cell carcinoma of the soft palate with high-grade transformation.

Acinic cell carcinoma is an uncommon malignant salivary gland tumour accounting for approximately 6-7% of all salivary gland neoplasms. The key diagnostic feature of acinic cell carcinoma is the presence of acinar cell differentiation characterised by cytoplasmic zymogen secretory granules. This tumour shows a variety of growth patterns, including solid, microcystic, follicular and papillary cystic patterns. Acinic cell carcinoma is typically a cytologically low-grade malignancy. Acinic cell carcinomas with high-grade transformation (HGT) are exceedingly rare and are reported to have a more aggressive clinical course than conventional acinic cell carcinoma. This is a case report of this uncommon entity with high-grade transformation arising on the soft palate in a 64-year-old woman.

Coronoid hyperplasia: A review.

Coronoid hyperplasia is one of the rare causes of progressive limitation of mouth opening due to impingement of the enlarged coronoid process of the mandible on the zygomatic bone. A review was performed on all cases reports and case series on coronoid hyperplasia. Gender, age at treatment, age of onset, types of hyperplasia (unilateral/bilateral), associated history, treatment, surgical approach, preoperative mouth opening, intraoperative mouth opening, mouth opening at follow up and follow up period were recorded and analyzed. A total of 82 articles which reported 115 cases were included. Coronoid hyperplasia was commonly reported at mean age of 22.64 years old with male preponderance. Most of the cases were diagnosed and treated between the age of 11-20 years old. This condition commonly involved bilateral coronoid process of mandible. The mean width of preoperative mouth opening was 16.5mm and was improved to a mean mouth opening of 36.3mm intraoperatively. Mean mouth opening was 34.8mm at an average follow up of 19 months. While the etiopathogenesis of coronoid hyperplasia is still not conclusive, treatment with either coronoidectomy or coronoidotomy produced good improvement in mouth opening.

Parenchyma-stromal interleukin-1 alpha and interleukin-6 overexpressions in ameloblastoma correlate with the aggressive phenotype.

INTRODUCTION: Ameloblastoma is a benign but locally invasive odontogenic epithelial neoplasm with a high recurrence rate after treatment. The two main subsets encountered clinically are unicystic (UA) and solid/multicystic ameloblastoma (SMA). Currently neoplastic progression of many tumour types are believed to be related to parenchyma-stromal cell-cell interactions mediated by cytokines notably interleukins (IL). However their roles in ameloblastoma remain ill-understood. MATERIALS AND METHODS: Thirty-nine formalin-fixed paraffin-embedded ameloblastoma cases comprising unicystic ameloblastoma (n=19) and solid/multicystic ameloblastoma (n=20) were subjected to IHC staining for IL-1α, IL-1ß, IL-6 and IL-8. A semi-quantitative method was used to evaluate the expression levels of these cytokines according to cell types in the tumoural parenchyma and stroma. RESULTS: Major findings were upregulations of IL-1α and IL-6 in SMA compared to UA. Both cytokines were heterogeneously detected in the tumoural parenchyma and stroma. Within the neoplastic epithelial compartment, IL-1α expression was more frequently detected in PA-like cells in UA whereas it was more frequently encountered in SR-like cells in SMA. IL-6 demonstrated higher expression levels in the stromal compartment of SMA. IL-1ß and IL-8 were markedly underexpressed in both tumour subsets. CONCLUSIONS: Overexpression of IL-1α in SMA suggests that this growth factor might play a role in promoting bone resorption and local invasiveness in this subtype. The expression levels of IL-1α and IL-6 in three cellular localizations indicate that parenchymal-stromal components of ameloblastoma interact reciprocally via IL-1α and IL-6 to create a microenvironment conducive for tumour progression.

Outcome after laparoscopic versus open wedge resection for suspected gastric gastrointestinal stromal tumors: A matched-pair case-control study.

BACKGROUND: Laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) has been shown by several retrospective studies to be technically feasible and associated with favorable outcomes when compared to the open approach. This study aims to mitigate potential selection bias by performing a case control study of laparoscopic (LWR) versus open wedge resection (OWR) matched by resection type, location and tumor size. METHODS: We retrospectively identified 50 consecutive patients who underwent LWR for a suspected gastric GIST from a prospective database and matched this cohort with 50 patients who underwent OWR. RESULTS: There was no statistical difference between the key baseline clinicopathological features of patients' who underwent LWR versus OWR. Patients who underwent LWR had longer operating times [150 (range, 65-270) minutes vs 92.5 (25-200) minutes, P < .001] but decreased median blood loss [0 (0-300) ml vs 0 (0-1200) ml, P = .015], decreased frequency of intraoperative or postoperative blood transfusion [1 (2%) vs 8 (16%), P = .031], decreased median time to liquid diet [2 (0-5) vs 3 (1-7) days, P < .001], decreased median time to solid diet [3 (1-6) vs 5 (2-11) days, P < .001] and decreased postoperative stay [4 (2-10) vs 4.5 (3-17), P < .001] compared to OWR. There was no difference in oncological outcomes such as frequency of close margins (≤ 1 mm) and recurrence-free survival. CONCLUSION: This matched case-control study provides supporting evidence that LWR results in superior perioperative outcomes compared to OWR without compromising on oncological outcomes.

Chicken bone perforation of an irreducible inguinal hernia: a case report and review of the literature.

Foreign bodies causing perforation of hernias are extremely uncommon with only a few cases reported in the literature. Here, we present a case of a patient with ingestion of a foreign body, which was initially managed expectantly but developed a perforation due to the foreign body impacting and causing perforation of an irreducible inguinal hernia. Management of this condition usually involves resection of the involved loop of bowel with repair of the hernia defect at the time of surgery. Patients with ingested foreign bodies who have irreducible hernias have altered anatomy and should be considered for early surgical intervention to prevent complications.

Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding.

BACKGROUND: Rebleeding from peptic ulcers is a major contributor to death. This study compared standard (40-mg intravenous infusion of omeprazole once daily for 3 days) and high-dose (80-mg bolus of omeprazole followed by 8-mg/h infusion for 72 h) in reducing the rebleeding rate (primary endpoint), need for surgery, duration of hospital stay and mortality in patients with peptic ulcer bleeding after successful endoscopic therapy. METHODS: This was a single-institution prospective randomized controlled study based on a postulated therapeutic equivalence of the two treatments. All patients who had successful endoscopic haemostasis of a bleeding peptic ulcer (Forrest classification Ia, Ib, IIa or IIb) were recruited. Informed consent was obtained and patients were randomized to receive standard- or high-dose infusions of intravenous omeprazole. RESULTS: Two (3 per cent) of 61 patients in the high-dose group and ten (16 per cent) of 61 in the standard-dose group exhibited rebleeding, a difference of - 13 (95 per cent confidence interval - 25 to - 2) per cent. The upper limit of the one-sided confidence interval exceeded a predefined equivalence absolute difference of 16 per cent. Equivalence of standard- and high-dose omeprazole in preventing rebleeding was not demonstrated. CONCLUSION: Intravenous standard-dose omeprazole was inferior to high-dose omeprazole in preventing rebleeding after endoscopic haemostasis for peptic ulcer bleeding. REGISTRATION NUMBER: NCT00519519 (http://www.clinicaltrials.gov).

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.

Early postoperative results of a prospective series of laparoscopic vs. Open anterior resections for rectosigmoid cancers.

PURPOSE: This study was undertaken to compare postoperatively laparoscopic (LAR) with open (OAR) anterior resection in patients with rectosigmoid cancers. METHODS: Forty consecutive patients were divided into two groups: 20 patients (9 males) were allocated to LAR and 20 patients (6 males) to OAR. RESULTS: Median age in the LAR group was 62 (range, 39-77) years, and in the OAR group, it was 61 (range, 43-84) years (P = 0.9). Median lengths of the distal margin of clearance beyond the tumor were 4 (range, 2-8) cm and 4.5 (range, 3-7.5) cm in the LAR and OAR groups, respectively (P = 0.35). Median numbers of lymph nodes harvested were 20 (range, 7-49) and 19 (range, 7-97) for the LAR and OAR groups, respectively (P = 0.44). Median operating times were 90 (range, 55-185) minutes and 73 (range, 40-140) minutes in the LAR and OAR groups, respectively (P = 0.08). Blood losses were 50 (range, 50-800) ml and 50 (range, 50-1,500) ml in the LAR and OAR groups, respectively. There was no intraoperative complication in either group, and no laparoscopic patient was converted to an open procedure. Median length of extraction site incision in the LAR group was 5.5 (4-13) cm, and length of incision in the OAR group was 18 (8-25) cm (P < 0.002). CONCLUSION: There were no significant differences between the two groups with regard to duration of parenteral analgesia, starting of fluid and solid diet after surgery, or time to first bowel movement and time to discharge from the hospital.