Adjuvant hepatic intra-arterial iodine-131-lipiodol following curative resection of hepatocellular carcinoma: a prospective randomized trial.

BACKGROUND: The purpose of the present study was to determine whether intrahepatic injection of (131)I-lipiodol (Lipiodol) is effective against recurrence of surgically resected hepatocellular carcinoma (HCC). METHODS: From June 2001 through March 2007, this nationwide multi-center prospective randomized controlled trial enrolled 103 patients 4-6 weeks after curative resection of HCC with complete recovery (52: Lipiodol, 51: Control). Follow-up was every 3 months for 1 year, then every 6 months. Primary and secondary endpoints were recurrence-free survival (RFS) and overall survival (OS), respectively, both of which were evaluated by the Kaplan-Meier technique and summarized by the hazard ratio (HR). The design was based on information obtained from a similar trial that had been conducted in Hong Kong. RESULTS: The Lipiodol group showed a small, and nonsignificant, improvement over control in RFS (HR = 0.75; 95 % confidence interval [95 % CI] 0.46-1.23; p = 0.25) and OS (HR = 0.88; 95 % CI 0.51-1.51; p = 0.64). Only two serious adverse events were reported, both with hypothyroidism caused by (131)I-lipiodol and hepatic artery dissection during angiography. CONCLUSIONS: The randomized trial provides insufficient evidence to recommend the routine use of (131)I-lipiodol in these patients.

Mirizzi syndrome: a diagnostic and operative challenge.

INTRODUCTION: Mirizzi syndrome (MS) is an unusual complication of gallstone disease. The majority of cases are not identified pre-operatively, despite advances in imaging techniques. MATERIALS AND METHODS: Eighteen cases of MS were treated between January 1997 and April 2002. The clinical presentation, modes of investigation, surgical management and outcome are retrospectively reviewed. RESULTS: There were 13 female and 5 male patients, with a mean age of 60 years. Seven patients presented with the classical Charcot's triad. Ultrasonography (US) was the first imaging investigation in 13 patients and computerised tomography (CT) in the other five cases. Eleven patients had a successful endoscopic retrograde cholangio-pancreatography (ERCP) carried out. Diagnosis of MS was arrived at in seven patients following pre-operative imagings. Overall, 11 patients had Type 1 and seven patients had Type 2 MS. In the group with Type 1 MS, nine patients underwent open cholecystectomy, of whom six had concomitant common bile duct (CBD) exploration for stones and one patient with biliary stenosis had a hepaticojejunostomy bypass. Laparoscopic cholecystectomy was attempted in two patients, with successful completion in one case. In the group with Type 2 MS, four fistulas were closed surgically, the other three had biliary bypass procedures. CONCLUSION: Mirizzi syndrome is an unusual condition that poses diagnostic and operative challenges to the surgeon. With a judicious approach during dissection and early recognition of its presence, bile duct injury can be avoided. Good outcome can be achieved with an appropriate surgical procedure.

A rare case of metastatic ovarian carcinoma originating from primary intrahepatic cholangiocarcinoma. Case report.

BACKGROUND: A rare case of metastatic ovarian carcinoma arising from intrahepatic cholangiocarcinoma is reported and the literature reviewed. CASE: A 49-year-old woman presented with ascites and a left pelvic mass. Optimal debulking surgery was carried out including a segmental resection of segment 5/6 of the liver. Histopathology confirmed an intrahepatic cholangiocarcinoma metastatic to the ovaries and omentum. CONCLUSION: Distinguishing a metastatic tumor from a primary ovarian tumoris critical for appropriate management. A high index of suspicion intraoperatively and subsequent expert pathological review are essential in making the correct diagnosis.

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.

Reliability of computerised electrocardiographic reports.

The aim of this study is to assess the reliability of computerised reporting of electrocardiograms (ECG). Fifty ECG performed consecutively at the outpatient department of the Penang Adventist Hospital on the Marquette 12SL-SC were studied. Two physicians independently reviewed the ECG and the manual readings were compared with each other and to the computer reports. There was no significant difference in the measurement of rate. The PR and QT intervals measured by the two physicians were similar but each was significantly different from the computer reading. The QRS duration assessed by Physician 1 was similar to the computer reading but each was significantly different from that of Physician 2. The overall diagnosis was the same between the two physicians in 76%, between Physician 1 and the computer in 68%, and between Physician 2 and the computer in 78%. No ECG was reported as normal by the computer and said to be abnormal by either physician. Thus, the computer programme is reasonably reliable in ECG reporting with computer-physician variability being comparable to inter-physician variability.

Laparoscopic fenestration of a simple hepatic cyst.

Hepatic cysts are usually asymptomatic, most being detected incidentally during imaging. Distinction has to be made between a simple hepatic cyst from more sinister types such as a parasitic cyst and a cyst occurring as part of a neoplastic process. Intervention in a simple hepatic cyst is only indicated when they become symptomatic or when they grow at a rapid rate. Surgery is the mainstay of treatment, with laparoscopic intervention becoming more and more widely accepted. We present here the first case of laparoscopic fenestration of liver cyst performed in our hospital and also review the literature on this modality of treatment.

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.

Hepatolithiasis--a case series.

INTRODUCTION: Hepatolithiasis is an uncommon entity in Singapore. We reviewed the cases presented to our institution (a 1200-bedded restructured hospital) over a 5-year period. MATERIAL AND METHODS: Twelve cases of hepatolithiasis were treated between December 1995 and July 2000 representing 0.77% of gallstone disease operated on in the same period. The clinical presentation, investigations, treatment and subsequent progress are presented. RESULTS: The patients' ages ranged from 28 to 82 years. There was a male to female ratio of 5:7. All patients had upper abdominal pain at presentation; 10 patients had clinical evidence of cholangitis. Ultrasound was the commonest first line investigation but additional investigations, such as computed tomographic (CT) scan and various forms of cholangiography, were frequently necessary for complete delineation of the biliary disease. The intrahepatic stones were located predominantly in the left lobe of the liver. Parenchymal atrophy was seen in 83% of patients. Two patients underwent a biliary bypass operation only, 5 had a hepatic resection only, and 5 had combined procedures. Follow-up ranged from 4 to 50 months. Postoperative recovery was generally unremarkable. Complications included subphrenic abscess (1 patient), recurrent stricture (1 patient) and recurrent stones (1 patient). One patient had an elevated serum CA 19-9 preoperatively; a small villous adenoma was noted at the biliary stricture in the resected left lateral segment of the liver. There was no operative mortality. CONCLUSION: Hepatolithiasis is uncommon in Singapore. Complete diagnosis requires a combination of imaging modalities. Surgery remains the mainstay of definitive treatment. With adequate treatment, good outcome is possible.

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.

Striving for a better operative outcome: 101 pancreaticoduodenectomies.

Pancreaticoduodenectomy (PD), once carried high morbidity and mortality, is now a routine operation performed for lesions arising from the pancreatico-duodenal complex. This study reviews the outcome of 101 pancreaticoduodenectomies performed after formalization of HepatoPancreatoBiliary (HPB) unit in the Department of Surgery. A prospective database comprising of patients who underwent PD was set up in 1999. Retrospective data for patients operated between 1996 and 1999 was included. One hundred and one cases accrued over 10 years from 1996 to 2006 were analysed using SPSS (Version 12.0). The mean age of our cohort of patients was 61+/-12 years with male to female ratio of 2:1. The commonest clinical presentations were obstructive jaundice (64%) and abdominal pain (47%). Majority had malignant lesions (86%) with invasive adenocarcinoma of the head of pancreas being the predominant histopathology (41%). Median operative time was 315 (180-945) minutes. Two-third of our patients had pancreaticojejunostomy (PJ) while the rest had pancreaticogastrostomy (PG). There were five patients with pancreatico-enteric anastomotic leak (5%), three of whom (3%) were from PJ anastomosis. Overall, in-hospital and 30-day mortality were both 3%. The median post-operative length of stay (LOS) was 15 days. Using logistic regressions, the post-operative morbidity predicts LOS following operation (p<0.005). The strategy in improving the morbidity and mortality rates of pancreaticoduodenectomies lies in the subspecialization of surgical services with regionalization of such complex surgeries to high volume centers. The key success lies in the dedication of staffs who continues to refine the clinical care pathway and standardize management protocol.

Prospective randomized trial of drainage alone vs. drainage and fistulotomy for acute perianal abscesses with proven internal opening.

PURPOSE: Incision and drainage (I & D) with concurrent or delayed fistulotomy is the usual treatment for abscess-fistula with a demonstrated internal opening. We compared incision and drainage alone vs. with concurrent fistulotomy for perianal abscesses with a demonstrated internal opening. METHODS: Consecutive patients with acute perianal abscesses and a demonstrated internal opening were prospectively randomized into either the I & D group or drainage with concurrent fistulotomy group. They were followed up at one month, three months, and one year. RESULTS: The I & D group had 21 patients, and the fistulotomy group had 24 patients. Thirteen patients had low intersphincteric abscess-fistula, and seven had low transsphincteric fistulas in the I & D group. The fistulotomy group had 9 intersphincteric abscess-fistula compared with 14 low transsphincteric ones. Median duration of surgery, hospital stay, and continence at final follow-up were the same in the two groups. Three had recurrent abscess-fistula in the I & D group compared with none in the fistulotomy group (P = 0.09). CONCLUSION: I & D alone for acute anal abscess-fistula with demonstrated internal opening showed a tendency to recurrence that did not reach a statistically significant difference compared with concurrent fistulotomy. I & D, therefore, puts only a few patients at risk for recurrence.

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.

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.

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.