A prospective randomized controlled trial evaluating the short-term outcomes of transanal hemorrhoidal dearterialization versus tissue-selecting technique.

BACKGROUND: Tissue-selecting technique (TST) is a novel stapled hemorrhoidectomy technique which targets the hemorrhoids, leaving uninvolved mucosal bridges intact and avoiding circumferential circular stapling. The aim of this study was to compare the short-term outcomes of TST and transanal hemorrhoidal dearterialization (THD). METHODS: Patients presenting with symptomatic hemorrhoids were recruited. Patients were randomized into two groups: (1) TST and (2) THD. Patient demographics, perioperative data, postoperative pain scores, recurrence and patient satisfaction scores were evaluated. Patients with acute thrombosed hemorrhoids, external hemorrhoids only, or other concomitant anal diseases were excluded. RESULTS: From January 2013 to December 2015, 80 patients were included in the study, 40 in each group. There were no significant differences between groups as regards demographic data, perioperative data and postoperative pain scores. The median symptom scores for bleeding and prolapse were significantly lower in the TST group at 1 year (bleeding 1 vs. 2, p = 0.001; prolapse 1 vs. 2, p = 0.025). There was significantly less recurrence requiring reintervention in the TST group (4/40 vs. 17/40, p = 0.001). Satisfaction was significantly greater after TST. The median satisfaction scores after TST and THD were 4 and 3 (on a scale of 1-4; 4 = excellent satisfaction) (p < 0.00001), respectively. CONCLUSIONS: Both THD and TST are safe, and they appear to have similar short-term outcomes; however, TST is associated with better improvement in symptoms, lower recurrence rates and greater patient satisfaction.

Can surgical need in patients with Naja atra (Taiwan or Chinese cobra) envenomation be predicted in the emergency department?

OBJECTIVES: To investigate the clinical predictors and the aetiologies for surgery in patients with Naja atra (Taiwan or Chinese cobra) envenomation. METHODS: This case series was conducted in the only tertiary care centre in eastern Taiwan. Patients who presented to the emergency department with Naja atra bite between January 2008 and September 2014 were included. Clinical information was collected and compared between surgical and non-surgical patients. RESULTS: A total of 28 patients with Naja atra envenomation presented to the emergency department during the study period. Of these, 60.7% (n=17) required surgery. Necrotising fasciitis (76.5%) was the main finding in surgery. Comparisons between surgical and non-surgical patients showed skin ecchymosis (odds ratio=34.36; 95% confidence interval, 2.20-536.08; P=0.012) and a high total dose of antivenin (≥6 vials; odds ratio=14.59; 95% confidence interval, 1.10-192.72; P=0.042) to be the most significant predictors of surgery. The rate of bacterial isolation from the surgical wound was 88.2%. Morganella morganii (76.5%), Enterococcus faecalis (58.8%), and Bacteroides fragilis (29.4%) were the most common pathogens involved. Bacterial susceptibility testing indicated that combined broad-spectrum antibiotics were needed to cover mixed aerobic and anaerobic bacterial infection. CONCLUSIONS: Patients with Naja atra envenomation who present with skin ecchymosis or the need for a high dose of antivenin may require early surgical assessment. Combined broad-spectrum antibiotics are mandatory.

Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review.

BACKGROUND: The aim of this study was to evaluate and compare transanal haemorrhoidal dearterialisation (THD) and stapled haemorrhoidopexy [also called procedure for prolapsed haemorrhoids (PPH)] in the management of haemorrhoidal disease, in terms of short-term outcomes and efficacy. METHODS: Patients presenting with symptomatic haemorrhoids were treated with THD. Patient demographics, pre-operative data, post-operative pain scores, complications, recurrence, and patient satisfaction scores were evaluated and recorded. Patients with acute thrombosed haemorrhoids, external haemorrhoids only, or other concomitant anal diseases were excluded. These data were compared with the historical data of PPH. RESULTS: Forty consecutive patients underwent THD from February 2012 to July 2013 and were compared to 37 patients who underwent PPH taken from a medical records database. There were no significant differences in terms of demographic data, type of anaesthesia, operative time, and blood loss. Length of hospital stay, time to first post-operative bowel movement, and complications were similar between the two groups. The median pain score after THD and PPH was 1.71 and 5.00, respectively, on a scale of 0-10 (10 = worst possible pain) (p = 0.000). There was a significant improvement in bleeding and prolapse scores after THD. THD patients had an earlier return to normal daily activities (3.13 vs. 6.78 days, p = 0.001) when compared with the PPH group. Upon follow-up, patients in both groups had similar satisfaction scores, and complication and recurrence rates. CONCLUSIONS: Both THD and PPH appear to be safe procedures for haemorrhoidal disease, and they appear to have similar short-term outcomes. In particular, THD seems to be associated with a lower pain score than PPH, an earlier return to normal daily activities, and similar rates of complication and recurrence.

Severe acute pyelonephritis: a review of clinical outcome and risk factors for mortality.

OBJECTIVE. To review demographics of patients with acute pyelonephritis, their outcomes of severe upper urinary tract infection, and to identify risk factors for long hospital stay and mortality. DESIGN. Case series. SETTING. A regional hospital in Hong Kong. PATIENTS. Patients admitted between June 2007 and June 2012 for acute pyelonephritis were identified. Those with the most severe outcomes were analysed of their mortality, need for care in the intensive care unit, or necessitation of urological intervention. RESULTS. Overall, 68 patients fulfilled our criteria for severe acute pyelonephritis. The female-to-male ratio was 7:3. Their mean age was 58 years. Overall, 57% of the patients had impaired renal function and 37% were diabetic; 47% developed shock after admission and 56% required further intensive care unit care; 75% of the patients demonstrated radiological evidence of urinary tract obstruction and required subsequent drainage procedures. Five patients died due to severe acute pyelonephritis. The prevalence of bacteraemia and bacteriuria was 57% and 74%, respectively. Escherichia coli accounted for the majority of causative organisms. Four risk factors-bacteraemia, shock, need for intensive care, and suppurative pyelonephritis-were associated with hospital stay of longer than 14 days. Old age (≥65 years), male sex, deranged renal function, and presence of disseminated intravascular coagulation were associated with mortality. CONCLUSION. There was high prevalence of bacteraemia and septic shock in patients with severe acute pyelonephritis. The factors of old age (≥65 years), male sex, deranged renal function, and presence of disseminated intravascular coagulation were associated with mortality. With the support of intensive care, early recognition of urinary tract obstruction and timely drainage, patients with severe acute pyelonephritis generally carry a good prognosis.

Curative treatment for recurrent tumour implantation after ruptured hepatocellular carcinoma.

Spontaneous rupture of hepatocellular carcinoma with intraperitoneal haemorrhage is a life-threatening condition. Intraperitoneal spread of the tumour after rupture occurs uncommonly. We report two cases of curative management for recurrent tumour implantation after ruptured hepatocellular carcinoma. The two patients presented with ruptured hepatocellular carcinoma and were treated with transarterial embolisation in the acute episode. Interval partial hepatectomy of the carcinoma was performed after the acute episodes. The first patient presented with a large epigastric mass 2 years after rupture. The mass was found to be adherent to the stomach and omentum. Distal gastrectomy was performed. The second patient presented with a right upper quadrant mass 4 months after rupture, and had a huge tumour attached to the ascending colon. Right hemicolectomy and omentectomy were performed. On histological examination, both tumours were confirmed to be recurrent hepatocellular carcinomas with clear surgical margins. After resection, both patients had no tumour recurrence at 1 year and 3 years, respectively.

Immunoglobulin G4-associated sclerosing cholangitis mimicking cholangiocarcinoma.

Immunoglobulin G4-related lymphoplasmacytic sclerosing disease is an emerging disease. Recently, it has been shown to be responsible for autoimmune pancreatitis-induced strictures of the bile duct mimicking cholangiocarcinoma. Making a diagnosis of immunoglobulin G4-associated sclerosing cholangitis requires a high index of suspicion. The differential diagnoses include primary sclerosing cholangitis, cholangiocarcinoma, and pancreatic cancer. The preoperative diagnosis is likely to be missed due to the lack of specific symptoms; a clinical presentation that may mimic other disorders, especially malignant biliary strictures; and the lack of specific imaging features. This article reports on a 51-year-old man with immunoglobulin G4-associated sclerosing cholangitis without autoimmune pancreatitis. He underwent resection of his extrahepatic bile duct with a hepaticojejunostomy. The diagnosis was confirmed after a histopathological examination. This case highlights the obstacles to making a preoperative diagnosis of immunoglobulin G4-associated sclerosing cholangitis.

Laparoscopic exploration of common bile duct in post-gastrectomy patients.

BACKGROUND/AIMS: To evaluate the results of laparoscopic exploration of the common bile duct (LECBD) in patients with previous gastrectomy. METHODOLOGY: This study is a retrospective review of a prospectively maintained database of LECBD during the period 1994-2005. Those cases of LECBD with previous open gastrectomy were sorted out and analyzed. Indications of operation included unsuccessful endoscopic extraction due to altered anatomy and some explorations were performed together with side-to-side choledochoduodenostomy so as to eliminate biliary stasis and decrease stone recurrence. The operation steps involved open insertion of trocar and creation of pneumoperitoneum, meticulous adhesiolysis, direct choledochotomy followed by clearance of biliary stones. After confirmed ductal clearance, the common bile duct was routinely closed with t-tube diversion. The perioperative parameters of these patients were analyzed and compared to those receiving open exploration of common bile duct due to previous gastrectomy during the same study period. RESULTS: Of the 184 LECBD performed between 1994 and 2005, 33 patients had previous open upper gastrointestinal operations and among them 18 LECBD were performed in post-gastrectomy patients (2 with previous classical Whipple's operation). There were 10 male and 8 female patients with mean age of 77.5 (58-97 years). Of the 14 patients undergoing preoperative endoscopic retrograde cholangiopancreatography, there were 10 failed cannulations and 4 failed extractions. Altogether 17 choledochotomies and 1 transcystic duct exploration was performed whereas 4 patients with recurrent primary stones received additional choledochoduodenostomy. Median operating time was 120 min (60-390 min). Open conversion was required in 3 patients (16.6%) because of jammed basket, extensive adhesion and "through & through" bile duct injury respectively. Postoperative complications occurred in 4 patients (22.2%), which included 3 bile leaks and also the previously mentioned bile duct injury. The median hospital stay was 9 days (4-82 days). Upon a median follow-up of 17.5 months, there was only 1 patient found to have recurrent common bile duct stone and he was managed by laparoscopic exploration and choledochoduodenostomy. When the results were compared to those 12 open explorations because of previous open gastrectomy, longer operation time (120 vs. 75 min, p=0.004) and slightly shorter hospital stay (9 vs. 14 days, p=0.104) were noted in the LECBD group but without increased complication rate (22.2 vs. 25%, p=1). CONCLUSIONS: These results suggest that LECBD is worth attempting even in patients with previous open gastrectomy.

Cholecystectomy or not after percutaneous cholecystostomy for acute calculous cholecystitis in high-risk patients.

BACKGROUND/AIMS: This study aims to evaluate the outcomes of percutaneous cholecystostomy for acute calculous cholecystitis in patients with high surgical risk and determine whether subsequent cholecystectomy is beneficial and necessary. Percutaneous cholecystostomy has been shown to be a safe treatment option for patients suffering from acute cholecystitis but at high risk for emergency surgery. Controversies still exist on the approach of the cholecystostomy and the subsequent management of these patients. METHODOLOGY: From January 1996 to March 2004, percutaneous cholecystostomy was performed on 65 patients that suffered from acute calculous cholecystostomy but were considered high risk for emergency surgery (American Society of Anesthesiologists grade III or IV). Their clinical outcomes were described and risk factors for in-hospital mortality and recurrence of cholecystitis were identified by univariate and multivariate analysis. RESULTS: Percutaneous cholecystostomy was successfully performed in all patients (100%). The clinical response rate was 91%. The in-hospital mortality was 12.3%. Shock on admission was found to be a single independent risk factor for in-hospital death (p=0.006; odd ratio = 16.5; 95% CI = 2.2-123.1). Twenty-four patients underwent subsequent cholecystectomy whereas 33 did not. The 1-year and 3-year recurrence of acute cholecystitis were 35% and 46% respectively in patients who did not have subsequent cholecystectomy. Stone size > or = 1cm was independently associated with higher recurrence of acute cholecystitis (p=0.01; hazard ratio = 6.3, 95% CI 1.6-25.5). However, there was no difference in 1-year and 3-year overall survival between patients with or without cholecystectomy (82% Vs 81% and 59% Vs 63%, p=0.79). CONCLUSIONS: Percutaneous cholecystostomy is a safe and promising treatment for acute calculous cholecystitis in patients who are at high risk for emergency surgery. Cholecystectomy after the resolution of cholecystitis and optimization of associated medical illnesses is always advisable in order to prevent recurrent cholecystitis. However, the limited survival of these patients because of their old age and medical co-morbidities should be taken into consideration.

Laparoscopic distal pancreatectomy: a comparative study.

BACKGROUND/AIMS: This article aims to describe the different techniques of laparoscopic distal pancreatectomy and to compare the results of our series of 9 laparoscopic resections against the historical open control in the same institution. With the advent of laparoscopic surgery, there is an increasing number of patients with different pancreatic pathologies that can now be managed by minimal access surgery. The initial results of laparoscopic pancreatectomy are quite promising particularly for those small neuroendocrine and cystic neoplasms located at the body and tail of pancreas. METHODOLOGY: The different techniques of laparoscopic distal pancreatectomy are described in detail with special emphasis on the need of "hand assistance" and the different methods of splenic preservation. The perioperative data of 9 laparoscopic distal pancreatectomies are analyzed and compared against the 5 historical open controls in the same institution. RESULTS: There were 9 laparoscopic pancreatic resections performed in our institution since 1999. Indications for surgery included 5 cystic neoplasms (1 patient with concomitant splenic artery aneurysm), 1 chronic pancreatitis with pancreatic duct stricture and a small pseudocyst, 1 pseudopancreatic tumor secondary to seal off perforated posterior gastric ulcer, 1 pseudopapillary tumor and 1 neuroendocrine tumor. There were 6 females and 3 males with median age of 61 years (range 18-79). The majority of patients was of low anesthetic risk (ASA 1 or 2). Total laparoscopic resection was performed in 7 cases and 2 resections were performed using the hand-assisting technique. Out of the 4 cases with splenic preservation, only one patient had both splenic artery and vein successfully preserved, whereas the other 3 cases had to rely on the short gastric arcade. Median operating time was 180 minutes (range 120-250) and median blood loss was 100cc (range 50-500). Pancreatic leak occurred in two patients (22.2%) and 1 patient developed intraabdominal collection, all of which settled upon conservative treatment. In our series, clear resection margin was obtained for all the neoplastic cases. Median hospital stay was 7 days (4-53). Postoperatively, patients consumed an average of 15 tablets of dologesic. No other complications were observed upon a median follow-up of 15 months (1-50). When results were compared to the 5 historical open controls (excluding those malignant tumors), patients managed with this new approach had significantly less intraoperative blood loss (100 vs. 450 mL, P = 0.021). CONCLUSIONS: Our initial experience not only confirmed the feasibility oflaparoscopic pancreatectomy, but also demonstrated the promising results of this approach in selected patients.

Laparoscopic biliary bypass--a single centre experience.

BACKGROUND/AIMS: To review the results of laparoscopic biliary bypass for both benign and malignant pathologies in a minimal access surgery training center. METHODOLOGY: Retrospective review of a prospectively maintained database of laparoscopic biliary bypass during the period 1995-2004. RESULTS: During the review period 1995-2004, there were 26 laparoscopic biliary bypasses performed in our center which included 23 laparoscopic choledochoduodenostomy (LCD), 2 laparoscopic roux-en-Y choledochojejunostomy (LCJ) and 1 laparoscopic cholecystojejunostomy (LCCJ). Of the 23 LCD, all except 1 patient were operated for recurrent pyogenic cholangitis (RPC). The 2 LCJ and 1 LCCJ were performed for patients with advanced carcinoma in the periampullary region and simultaneous laparoscopic gastrojejunostomy (LGJ) was also performed to relieve the gastric outflow obstruction. Among the 23 LCD, there were 2 open conversions (7.7%) for lost broken tip of ultrasonic dissector and significant bleeding during choledochotomy respectively. Major complications occurred in 6 patients (23%), which included 3 bile leaks (11.5%), 1 intraabdominal collection (3.8%). 1 wound infection (3.8%) and 1 gastric stasis (3.8%). The only mortality in our series was a patient with carcinoma of head of pancreas undergoing simultaneous roux-en-Y LCCJ and LGJ. He had persistent gastric stasis after operation and required revision surgery for the kinked cholecystojejunostomy anastomosis. He finally died of myocardial ischemia after the second operation. As for the postoperative pain control, the mean pethidine consumption was 243.4 +/- 254.7 mg (range 0-1200 mg) and mean dologesic usage was 16.2 +/- 20.4 tablets (range 0-94 tablets). The average postoperative hospital stay was 12.6 +/- 11.5 days (range 5-60 days). The long-term functional results were satisfactory and only 1 patient had recurrent stone upon a mean follow-up of 32.3 months. Among the patients with malignant biliary obstruction, the only mishap was as previously mentioned and the remaining 2 patients could enjoy satisfactory palliation for more than a year before death. CONCLUSIONS: Laparoscopic bypass is not only feasible but also highly effective in relieving biliary obstruction with good postoperative results in both benign and malignant conditions.

Bleeding pseudoaneurysms complicating upper abdominal surgery.

OBJECTIVE: To review the management of ruptured pseudoaneurysms following upper abdominal surgery. DESIGN: Retrospective study. SETTING: Minimal access surgery centre, Hong Kong. PATIENTS: Patients who were diagnosed to have a pseudoaneurysm after undergoing major upper abdominal surgery were recruited during the period of 1998 to 2006. MAIN OUTCOME MEASURES: Success rate of haemostasis, re-bleeding rate, re-intervention rate, and mortality. RESULTS: During the study period, a total of eight patients (median age, 61 years) were managed in our department for bleeding pseudoaneurysms following cholecystectomy, gastrectomy, or Whipple's operation. Five patients underwent upper endoscopy as the initial investigation. In four of these five patients, visceral artery pseudoaneurysms were identified by angiography and haemostasis was achieved without re-bleeding. The one for whom angiographic identification of the bleeding source failed, was successfully treated subsequently by open plication. In three other patients, open surgical haemostasis was resorted to and achieved in two of them. However, one of the latter had re-bleeding, which was successfully treated by embolisation. The one who failed open identification of the bleeding source, was eventually also treated successfully by embolisation. The overall success rates of embolisation and open surgery were 80% and 67%, respectively, and the re-bleeding rates were 0% and 33%, respectively. The corresponding mortality rates were 20% and 33%; both deaths were associated with multi-organ failure. There were no procedure-related complications following embolisation. CONCLUSIONS: Based on our experience, visceral angiography can enable the diagnosis and treatment of ruptured pseudoaneurysm in a single session. The procedure is safe, the re-bleeding rate is low, and it is as effective as alternative treatments, and should be considered a first-line intervention in patients with bleeding pseudoaneurysms complicating upper abdominal surgery.

An alternative gallbladder extraction technique in laparoscopic cholecystectomy.

In this era of minimally invasive surgery, the challenge remains in finding techniques to reduce access trauma in terms of fewer and smaller size trocar ports. Our new described technique will allow a smaller subxiphoid port to be used to achieve extraction of the gallbladder without the need to change to a 5 mm laparoscope. We believe this method is easy to learn, safe and with no observable complications from our experience.

Antegrade biliary stenting versus T-tube drainage after laparoscopic choledochotomy--a comparative cohort study.

BACKGROUND/AIMS: Laparoscopic exploration of the common bile duct (LECBD) has been proven to be an effective and preferred treatment approach for uncomplicated common bile duct stones. However there is still controversy regarding the choice of biliary decompression after laparoscopic choledochotomy. METHODOLOGY: This is a retrospective comparison between the use of antegrade biliary stenting and T-tube drainage following successful laparoscopic choledochotomy. During the period between January 1995 and July 2003, biliary decompression was achieved by either antegrade biliary stenting or T-tube drainage based on the discretion of the operating surgeon. For antegrade biliary stenting, a 10-Fr Cotton-Leung biliary stent was inserted through the choledochotomy and passed down across the papilla. The stent position was confirmed by on-table choledochoscopy before interrupted single-layered closure of the common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the stent 4 weeks after operation and at the same time to check for any residual stones or other complications like stricture or leak. In the T-tube group, a 16-Fr latex T-tube was used and the long limb was brought out through the subcostal trocar port followed by the same method of bile duct closure. Cholangiogram through the T-tube was performed on day 7 and the tube would be taken off 1 week later (about 2 weeks after operation) if the cholangiogram did not reveal any abnormality. The two groups were compared according to the demographic data, operation time, length of hospital stay and complication rates. RESULTS: During the study period, 108 laparoscopic explorations of the common bile duct were performed in our centre of which 95 were attempted laparoscopic choledochotomies and 13 were transcystic duct explorations. Of the 95 patients with attempted laparoscopic choledochotomy, there were 9 open conversions, 17 laparoscopic bilioenteric bypasses and 6 primary closures of the common bile duct. All of these patients together with those receiving transcystic duct explorations were excluded and the remaining 63 patients having postoperative bile diversion by either antegrade biliary stenting or T-tube drainage were included in this study. Bile diversion was achieved by antegrade biliary stenting in 35 patients whereas 28 patients had T-tube drainage. There was no difference between the two groups in terms of age, clinical presentation, bilirubin level, length of hospital stay, follow-up duration, common bile duct size, size of common bile duct stones, incidence of residual/recurrent stone and complication rate. It was observed that more patients in the stenting group developed bile leak (14.2% vs. 3.5%) and required more intramuscular pethidine injections (182.86 +/- 139.30 vs. 92.81+/-81.15mg, P=0.000). On the other hand, the T-tube group had longer operation time (141.4+/-45.1 vs. 11 1.1+/-33.9 minutes, P=0.006) and had a longer postoperative hospital stay (10.0+/-7.4 vs. 8.8+/-9.3 days, P=0.020) reaching statistical significance. CONCLUSIONS: Postoperative bile diversion by antegrade biliary stenting after laparoscopic choledochotomy is shown to shorten operation duration and postoperative stay as compared to T-tube drainage, but the problem of bile leak needs further refinement of insertion technique.

Laparoscopic exploration of the common bile duct: 10-year experience of 174 patients from a single centre.

OBJECTIVES: To evaluate the role of laparoscopic exploration of the common bile duct in the management of common bile duct stones. DESIGN: Retrospective study. SETTING: Regional minimal access surgery training centre in Hong Kong. PATIENTS: Patients undergoing laparoscopic exploration of the common bile duct from 1995 to 2005. MAIN OUTCOME MEASURES: Demographic information, reasons for failed endoscopic retrograde cholangiopancreatography and open conversions, and operative morbidity and mortality. RESULTS: A total of 174 laparoscopic explorations of the common bile duct were performed. Indications for surgery (some overlapping) included: concomitant gallstones and common bile duct stones (n=68, 39%) in young persons (<60 years), previously failed endoscopic extraction (n=59, 34%), large (>2 cm) or multiple common bile duct stones (n=40, 23%), and need for laparoscopic bypass to improve bile drainage (n=34, 20%). Mean patient age was 63 (standard deviation, 16) years and 103 were female. Altogether 156 choledochotomies and 18 transcystic duct explorations were performed, with 12 (7%) open conversions. The mean operating time was 129 (standard deviation, 57) minutes. Additional procedures included: 54 laparoscopic operative cholangiographies, 34 laparoscopic biliary bypasses, and 31 instances of adhesiolysis in patients with a history of open upper gastro-intestinal surgery. Complete stone clearance was achieved in 160 (92%) patients. Non-lethal complications occurred in 34 (20%) patients and one died of sepsis after a major bile leak. The mean postoperative stay was 9 (standard deviation, 9) days. Stone recurrence ensued in seven (4%) patients after a mean follow-up of 37 (standard deviation, 29) months. CONCLUSIONS: Laparoscopic exploration of the common bile duct is highly successful and can achieve satisfactory ductal clearance even after unsuccessful endoscopic extraction and previous upper gastro-intestinal surgery. In skilled hands, for selected patients laparoscopic bypass can also achieve improved bile drainage.

A single-centre experience of 40 laparoscopic liver resections.

OBJECTIVE: To review results of laparoscopic liver resections, particularly in those patients with hepatic malignancy and recurrent pyogenic cholangitis. DESIGN: Retrospective analysis. SETTING: Minimal access surgery training centre, Hong Kong. PATIENTS: Patients with pathologies located at anterio-inferio-lateral segments (Couinaud segments 2, 3, 4b, 5, 6) for laparoscopic resection were recruited during the period 1998 to 2005. Patients were excluded from review if they had: pathologies at central locations and the superior and posterior segments (4a, 7, 8), large tumours (>5 cm in diameter), and those close to major vasculature or the liver hilum. RESULTS: During the study period, we attempted 40 such laparoscopic liver resections, excluding marsupialisations and resections for simple liver cysts. There were 20 female and 20 male patients, with a mean age of 57 (standard deviation, 13; range, 29-81) years. All but one underwent a successful laparoscopic operation. Pathology included hepatocellular carcinoma (n=17), recurrent pyogenic cholangitis (n=14), colorectal liver metastasis (n=4), benign liver tumour (n=4), and intrahepatic cholangiocarcinoma (n=1). All except four were hand-assisted laparoscopic liver resections. The mean operating time was 169 (range, 60-290) minutes and mean blood loss amounted to 270 mL (range, 0-1000 mL). Complications occurred in eight (20%) patients, which included six wound infections, one postoperative bile leak, and two incisional hernias. There was no operative or hospital mortality. For hepatocellular carcinoma, clear resection (>10 mm) was achieved in all except five patients, and the 1-year and 2-year survival rates were 86% and 59% respectively. Favourable results were also obtained for resections in patients with recurrent pyogenic cholangitis; after a mean (standard deviation) follow-up of 29 (23) months, only one was readmitted (for cholangitis). CONCLUSION: In appropriately selected patients, laparoscopic liver resection is feasible and safe, and achieves acceptable survival among individuals with hepatic malignancy and very favourable long-term outcomes in those with recurrent pyogenic cholangitis undergoing hand-assisted laparoscopic segmentectomy.

Laparoscopic management of acute torsion of the omentum in adults.

BACKGROUND: Acute torsion of the greater omentum is a rare cause of acute abdomen in adults. We report our experience on the clinical presentation, diagnosis, treatment, and outcome of this condition. METHOD: This is a retrospective review of 9 patients who had a clinicopathologic diagnosis of acute torsion of the greater omentum and were treated at the Department of Surgery, Pamela Youde Nethersole Eastern Hospital from January 1994 to March 2004. Eight patients were male and 1 was female with a median age of 43 years (range, 24 to 65). Median body mass index was 24 kg/m(2) (range, 22 to 24). All presented with acute abdominal pain with a median temperature of 36.8 degrees C (range, 36.5 to 37.2) and a median white cell count of 9.5 x 10(9)/L (range, 7.4 to 15.1 x 10(9)). Preoperative ultrasound was done in 5 patients. RESULTS: All diagnoses were made during surgery. Resection of the infarcted omentum was performed for all patients (5 laparoscopic resections and 4 open resections). No postoperative complications occurred. The overall median time from admission to operation was 23 hours (range, 2 to 98). The overall median operating time and postoperative stay were 70 minutes (range, 38 to 105) and 3 days (range, 1 to 6), respectively. The median oral and parenteral analgesic requirement for postoperative pain control was less and the median hospital stay was shorter in patients who underwent laparoscopic resection. CONCLUSION: Acute torsion of the greater omentum is an uncommon cause of acute abdomen in adults, and preoperative diagnosis is usually difficult. Laparoscopy seems a safe and minimally invasive technique for both diagnosis and treatment of this rare disease entity.

Laparoscopy versus open left lateral segmentectomy for recurrent pyogenic cholangitis.

BACKGROUND: Recurrent pyogenic cholangitis (RPC) is a common disease in Southeast Asia. Its classical presentation is repeated attacks of cholangitis with multiple recurrences of bile duct stones. The stones are commonly located in the left lateral segments (2 and 3) and therefore complete clearance is difficult to achieve by either endoscopic retrograde cholangiopancreatography or surgical exploration of the common bile duct. The definitive treatment usually involves resection of the stone-harboring segments. The recent advent in laparoscopic surgery has shown that hand-assisted laparoscopic segmentectomy is a safe and feasible, alternative. This study aimed to compare hand-assisted laparoscopic segmentectomy with open segmentectomy in patients with recurrent, RPC. METHODS: This study retrospectively reviewed a prospectively maintained database of both open and laparoscopic treatments for RPC in a single center between 1994 and 2004. During this period, patients with RPC and left intrahepatic (segments 2 and 3) ductal stones not amendable to endoscopic treatment were recruited for analysis. Patients with concomitant gallbladder stones and common bile duct stones were offered left lateral segmentectomy with cholecystectomy and exploration of the common bile duct. Selected patients would have choledochoduodenostomy drainage during the same operation. The operations were performed via either the hand-assisted laparoscopic approach or the open approach using an ultrasonic surgical aspirator. The two cohorts were compared with respect to perioperative parameters to determine whether there would be any advantage in attempting hand-assisted laparoscopic segmentectomy. RESULTS: During the study period from 1994 to 2004, 17 patients underwent left lateral segmentectomy for RPC. Of the 17 patients, 10 had hand-assisted laparoscopic resections, and 7 underwent open resections. All open resections were performed before 1999. Despite the small number of patients and potential type 2 error, there were no differences in age, sex distribution, number of cholangitic attacks, sessions of endoscopic retrograde cholangiopancreatography before surgery, or number of previous operation between the two groups. The median operating time was shorter in the open group (232.5 vs 150 min; p = 0.007), whereas the median blood loss was similar (350 vs 400 ml; p = 0.551). The median postoperative stay was 8 days for hand-assisted laparoscopic group versus 14 days for the open group. This difference was statistically significant (p = 0.019). There was one open conversion in the hand-assisted laparoscopic group because of intraoperative bleeding from the left hepatic vein. Postoperative complication rates were lower in hand-assisted laparoscopic group, but the difference was not statistically significant (20% vs 57%; p = 126). The intramuscular pethidine requirement again was less in hand-assisted laparoscopic group (0 vs 600 mg; p = 0.002). There was no operative mortality in either group of patients. No recurrent cholangitis was noted in either groups during the median follow-up period of more than 3 years. CONCLUSION: This study not only confirmed the feasibility of hand-assisted laparoscopic segmentectomy for recurrent pyogenic cholangitis, but also showed that this treatment approach is associated with less pain and shorter hospital stay. However, hand-assisted laparoscopic segmentectomy is a lengthier operation and technically more challenging. Nevertheless, the authors believe that with more experience and further improvement of ancillary technology, this procedure can become a standard treatment for recurrent pyogenic cholangitis in selected cases.

Endo-laparoscopic approach in the management of obstructive jaundice and malignant gastric outflow obstruction.

BACKGROUND/AIMS: Only a minority of patients with tumor at the pancreaticoduodenal junction is suitable for resection, palliation is however often required relieving the obstructive jaundice and gastric outflow obstruction (GOO). This study evaluates endo-laparoscopic approach as a palliative treatment of obstructive jaundice and malignant gastric outflow obstruction. METHODOLOGY: A retrospective review of a prospectively maintained database. During the period from 1992-2002, patients with diagnosis of unresectable tumor at the pancreaticoduodenal junction were evaluated. If the tumor was confirmed to be unresectable, patients would be offered either open double bypass or laparoscopic gastrojejunostomy (LGJ) +/- endoscopic or percutaneous transhepatic stenting for any obstructive jaundice, the choice of approach would depend on whether the endoscopic access was still maintained. RESULTS: Out of 942 patients with tumors around the pancreaticoduodenal junction during the study period from 1992-2002, there were 34 patients (13 male & 21 female) with median age 69 years (range, 48-87) selected for LGJ. Of these 34 patients, 3 of them underwent endoscopic biliary stenting whereas 16 jaundice patients were palliated by transhepatic biliary drainage. When the results were compared to the 35 open double bypass (roux-en-Y choledochojejunostomy and gastrojejunostomy) during the same study period, the median operation time was significantly shorter (80 vs. 135 minutes; P=0.0001) and median intraoperative bleeding was significantly less in the endo-laparoscopic group (0 vs. 100mL; P=0.0001). Two patients in the endo-laparoscopic group were converted to open because of tumor infiltration of the small bowel mesentery causing difficulty in construction of gastrojejunostomy. Although the overall complication rate (13 vs. 17; P=0.387) and incidence of delayed gastric emptying (7 vs. 7, P=0.952) were similar in both groups, the incidence of wound infection was remarkably less common in the endo-laparoscopic group (0 vs. 6, P=0.012). The 15 postoperative complications (13 patients) in the endo-laparoscopic group (38.2%) included prolonged gastric stasis (7), biliary sepsis (2), chest infection (2), myocardial ischemia (2), gastrointestinal bleeding (1) and extensive ischemic stroke (1). Median time to resume diet was statistically shorter in endo-laparoscopic group (5 vs. 7 days, P=0.009) however the hospital stay was similar in both groups (11.5 vs. 14 days, P=0.238). The hospital mortality rate was again comparable between the two groups (6 vs. 5, P=0.703). The short median survival in the endolaparoscopic group (3 vs. 7 months; P=0.0001) might just be a reflection of selection bias. CONCLUSIONS: With the advent of laparoscopic and endoscopic surgery, palliation of both gastric outflow obstruction and obstructive jaundice can also be accomplished using the endo-laparoscopic approach. In comparing to the open double bypass, operation time, intraoperative blood loss and incidence of wound infection are significantly less and patients can have early resumption of diet. However, the results can be improved further with a better patient selection and perioperative optimization.