Structural Insights into the Broad Substrate Specificity of a Novel Endoglycoceramidase I Belonging to a New Subfamily of GH5 Glycosidases.

Endoglycoceramidases (EGCases) specifically hydrolyze the glycosidic linkage between the oligosaccharide and the ceramide moieties of various glycosphingolipids, and they have received substantial attention in the emerging field of glycosphingolipidology. However, the mechanism regulating the strict substrate specificity of these GH5 glycosidases has not been identified. In this study, we report a novel EGCase I from Rhodococcus equi 103S (103S_EGCase I) with remarkably broad substrate specificity. Based on phylogenetic analyses, the enzyme may represent a new subfamily of GH5 glycosidases. The X-ray crystal structures of 103S_EGCase I alone and in complex with its substrates monosialodihexosylganglioside (GM3) and monosialotetrahexosylganglioside (GM1) enabled us to identify several structural features that may account for its broad specificity. Compared with EGCase II from Rhodococcus sp. M-777 (M777_EGCase II), which possesses strict substrate specificity, 103S_EGCase I possesses a longer α7-helix and a shorter loop 4, which forms a larger substrate-binding pocket that could accommodate more extended oligosaccharides. In addition, loop 2 and loop 8 of the enzyme adopt a more open conformation, which also enlarges the oligosaccharide-binding cavity. Based on this knowledge, a rationally designed experiment was performed to examine the substrate specificity of EGCase II. The truncation of loop 4 in M777_EGCase II increased its activity toward GM1 (163%). Remarkably, the S63G mutant of M777_EGCase II showed a broader substrate spectra and significantly increased activity toward bulky substrates (up to >1370-fold for fucosyl-GM1). Collectively, the results presented here reveal the exquisite substrate recognition mechanism of EGCases and provide an opportunity for further engineering of these enzymes.

p38delta/MAPK13 as a diagnostic marker for cholangiocarcinoma and its involvement in cell motility and invasion.

Cholangiocarcinoma (CC) and hepatocellularcarcinoma (HCC) are two main forms of liver malignancies, which exhibit differences in drug response and prognosis. Immunohistotochemical staining for cytokeratin markers has been used to some success in the differential diagnosis of CC from HCC. However, there remains a need for additional markers for increased sensitivity and specificity of diagnosis. In this study, we have identified a p38 MAP kinase, p38delta (also known as MAPK13 or SAPK4) as a protein that is upregulated in CC relative to HCC and to normal biliary tract tissues. We performed microarray gene expression profiling on 17 cases of CC, 12 cases of adjacent normal liver tissue, and three case of normal bile duct tissue. p38delta was upregulated in 16 out of 17 cases of CC relative to normal tissue. We subsequently performed immunohistochemical staining of p38delta in 54 cases of CC and 54 cases of HCC. p38delta staining distinguished CC from HCC with a sensitivity of 92.6% and a specificity of 90.7%. To explore the possible functional significance of p38delta expression in CC, we examined the effects of overexpression and knockdown of p38delta expression in human CC cell lines. Our results indicate that p38delta is important for motility and invasion of CC cells, suggesting that p38delta may play an important role in CC metastasis. In summary, p38delta may serve as a novel diagnostic marker for CC and may also serve as a new target for molecular based therapy of this disease.

Qidong Yixin Oral Liquid for Viral Myocarditis: A Systematic Review and Meta-Analysis.

OBJECTIVE: This study aimed to evaluate the efficacy and safety of Qidong Yixin (QY) oral liquid in the treatment of viral myocarditis (VMC). METHODS: We searched seven databases for randomized clinical trials on QY for treating VMC. The retrieval period was from database establishment to December 31, 2019. Cochrane risk of bias tool in the Cochrane Handbook was used to assess the methodological quality. Review Manager (RevMan) 5.3 was used to analyze the results. RESULTS: We included 19 studies comprising 2,608 patients, albeit with low methodological quality. Our meta-analysis revealed that combination therapy with QY and western medicine was more effective than western medicine alone (QY vs other Chinese patent medicines: RR = 1.37, 95% Cl: 1.23∼1.52, P < 0.00001; QY + coenzyme Q10 + routine treatment vs coenzyme Q10 + routine treatment: RR = 1.20, 95% Cl: 1.14∼1.27, P < 0.00001; QY + trimetazidine + acyclovir vs trimetazidine + acyclovir: RR = 1.59, 95% Cl: 1.38∼1.83, P < 0.00001; QY + routine treatment vs routine treatment: RR = 1.09, 95% Cl: 1.03∼1.15, P < 0.003). A study on posttreatment myocardial enzyme levels revealed that QY with western medicine downregulated creatine kinase isoenzyme (CK-MB) (QY + antiviral treatment + routine treatment vs antiviral treatment + routine treatment group: MD = -11.28, 95% CI: -13.33∼-9.22, P < 0.00001; QY + routine treatment vs routine treatment: MD = -4.96, 95% CI: -5.56∼-4.32, P < 0.00001), creatine kinase (CK) (MD = -32.10, 95% CI: -35.63∼-28.57, P < 0.00001), and lactate dehydrogenase (LDH) (QY + antiviral treatment + routine treatment vs antiviral treatment + routine treatment: MD = -48.76 95% CI: -58.18∼-39.33, P < 0.00001; QY + routine treatment vs routine treatment: MD = -23.52, 95% CI: -30.10-16.94, P < 0.00001) rather than western medicine alone, with no evidence of aspartate aminotransferase (AST) downregulation on treatment with QY with western medicine (MD = 2.88, 95% CI: -0.95∼6.71, P < 0.00001) in patients. Two studies reported adverse events, indicating that QY is relatively safe. CONCLUSION: Although QY may have potential advantages in treating VMC, they remain unclear owing to the poor methodological quality of most studies. Larger, multicenter, high-quality randomized controlled trials are required to verify the effectiveness of QY.

Banxia Xiexin Decoction Ameliorates t-BHP-Induced Apoptosis in Pancreatic Beta Cells by Activating the PI3K/AKT/FOXO1 Signaling Pathway.

BACKGROUND: Banxia Xiexin Decoction (BXXD) reportedly regulates glycolipid metabolism and inhibits pancreatic ß-cell apoptosis. This study is aimed at investigating the protective effect of BXXD on tert-butyl hydroperoxide- (t-BHP-) induced apoptosis in MIN6 cells and the underlying mechanisms. METHODS: MIN6 cells were preincubated with BXXD or liraglutide (Li) with or without PI3K inhibitor LY294002 (LY) for 12 h, following which t-BHP was added to induce MIN6 cell apoptosis. The protective effects of BXXD on MIN6 cells were evaluated by detecting cell viability and proliferation and glucose-stimulated insulin secretion (GSIS). The antiapoptotic effects were evaluated by Hoechst 33342 staining and terminal deoxynucleotidyl transferase dUTP nick end labeling assay (TUNEL). Malondialdehyde and glutathione peroxidase content and superoxide dismutase activity were measured using commercial kits. The expression of PI3K/AKT/FOXO1 signaling pathway-related signal molecules, and that of apoptotic indicators Bax, P27, and Caspase-3, was quantified using western blotting. RESULTS: Preincubation with BXXD significantly improved t-BHP-induced proliferation inhibition and apoptosis and enhanced GSIS. t-BHP induced the generation of reactive oxygen species and inhibited the activities of antioxidant enzymes, which could be neutralized by pretreatment with BXXD. BXXD promoted the phosphorylation of AKT and FOXO1 in t-BHP-induced MIN6 cells. Moreover, BXXD attenuated the expression of related apoptotic indicators Bax, P27, and Caspase-3. LY abolished these effects of BXXD. CONCLUSION: BXXD protected MIN6 cells against t-BHP-induced apoptosis and improved insulin secretory function through modulation of the PI3K/AKT pathway and the downstream FOXO1, thus suggesting a novel therapeutic approach for type 2 diabetes mellitus (T2DM).

Outcome of distal pancreatectomy for pancreatic adenocarcinoma.

OBJECTIVES: To determine the outcome of patients undergoing distal pancreatectomy for pancreatic adenocarcinoma. METHODS: A retrospective review of 39 patients undergoing distal pancreatectomy for adenocarcinoma. RESULTS: Thirty patients underwent surgery for ductal adenocarcinoma, 5 for malignant intraductal papillary mucinous neoplasm and 4 for mucinous cystadenocarcinoma. Malignant cystic neoplasms were significantly less likely to demonstrate perineural invasion, more likely to be well-differentiated, of lower T stage and of lower AJCC staging compared to ductal adenocarcinoma. These had a longer median disease-specific survival (42 (3-144) vs. 15 (14-16) months, p = 0.002). Eight patients underwent extended resections. These were associated with longer operating times compared to standard resections but there was no difference in surgical morbidity or mortality, blood transfusions, length of hospitalization or long-term survival. Univariate analysis demonstrated that R2 resection, size >30 mm, lymph node involvement, need for perioperative blood transfusion, serum albumin <40 g/l and platelet count <200/microl were predictors of survival for ductal adenocarcinoma. CONCLUSIONS: Malignant cystic neoplasms have less aggressive behavior and more favorable outcome compared to ductal adenocarcinoma. R2 resection, larger tumor size, lymph node involvement, perioperative transfusion, decreased serum albumin and low platelet count are factors associated with decreased survival in patients with ductal adenocarcinoma undergoing distal pancreatectomy.

A study into the risk of exacerbation of chronic hepatitis B after liver resection for hepatocellular carcinoma.

Liver resection is commonly performed for solitary hepatocellular carcinoma (HCC) in well-compensated cirrhotic and noncirrhotic patients. Data concerning exacerbation of chronic hepatitis B (ECHB) post-liver resection are scant. To determine the incidence, risk factors, and clinical outcomes of ECHB in patients who underwent hepatic resection for HCC. The methods consisted of a retrospective review of consecutive patients with chronic hepatitis B virus (HBV) infection who had undergone liver resection for HCC from January 2002 to December 2004. Seventy-seven patients underwent 82 liver resections; the mean age was 58.0 +/- 12.1 years; 87% male; 20% hepatitis B e-antigen positive. Incidence of all causes of postoperative hepatitis was 25.6% (n = 21), and ECHB was 8.5% (n = 7). Both groups had their peak alanine aminotransferases, 231.0 IU/L (74-1,400) and 312 IU/L (147-1,400), respectively, observed at day 84 postresection. Three patients died as a result of ECHB within 4 months postsurgery. One- and 2-year survival rates were poorest for the ECHB group at 42.9 and 21.4%, compared with those with postoperative hepatitis due to other causes at 60.3 and 45.2% and those without postoperative hepatitis at 87.7 and 73.5% (p < 0.001). Liver resection for HCC in patients with chronic HBV infection carries a risk for ECHB, and affected patients have poorer clinical outcomes. There is a need for close monitoring of these patients preoperatively and in the early postoperative period.

GATA4 loss of function in liver cancer impedes precursor to hepatocyte transition.

The most frequent chromosomal structural loss in hepatocellular carcinoma (HCC) is of the short arm of chromosome 8 (8p). Genes on the remaining homologous chromosome, however, are not recurrently mutated, and the identity of key 8p tumor-suppressor genes (TSG) is unknown. In this work, analysis of minimal commonly deleted 8p segments to identify candidate TSG implicated GATA4, a master transcription factor driver of hepatocyte epithelial lineage fate. In a murine model, liver-conditional deletion of 1 Gata4 allele to model the haploinsufficiency seen in HCC produced enlarged livers with a gene expression profile of persistent precursor proliferation and failed hepatocyte epithelial differentiation. HCC mimicked this gene expression profile, even in cases that were morphologically classified as well differentiated. HCC with intact chromosome 8p also featured GATA4 loss of function via GATA4 germline mutations that abrogated GATA4 interactions with a coactivator, MED12, or by inactivating mutations directly in GATA4 coactivators, including ARID1A. GATA4 reintroduction into GATA4-haploinsufficient HCC cells or ARID1A reintroduction into ARID1A-mutant/GATA4-intact HCC cells activated hundreds of hepatocyte genes and quenched the proliferative precursor program. Thus, disruption of GATA4-mediated transactivation in HCC suppresses hepatocyte epithelial differentiation to sustain replicative precursor phenotype.

CT in the preoperative diagnosis of fish bone perforation of the gastrointestinal tract.

OBJECTIVE: Foreign body perforation of the gastrointestinal (GI) tract has diverse clinical manifestations, and the correct preoperative diagnosis is seldom made. We report our experience with the use of CT in the preoperative diagnosis of fish bone perforation of the GI tract in seven patients. To our knowledge, this series is the largest to date addressing the role of CT in the diagnosis of fish bone perforation. CONCLUSION: Clinical presentation and radiography are unreliable in the preoperative diagnosis of fish bone perforation of the GI tract. This limitation can be overcome with the use of CT, which is accurate in showing the offending fish bone. The accuracy of CT is limited by observer dependence. A high index of suspicion should always be maintained for the correct diagnosis to be made.

Cystic lesions of the pancreas: an appraisal of an aggressive resectional policy adopted at a single institution during 15 years.

BACKGROUND: Although an aggressive resectional approach toward pancreatic cysts has been advocated in the past, many clinicians now deem this therapeutic strategy impractical given the rapidly increasing incidence of incidentally detected pancreatic cystic lesions. The aim of this study was to review the aggressive resectional policy toward pancreatic cysts adopted at our institution during the past 15 years. METHODS: One hundred nine consecutive patients who underwent surgical resection of a cystic lesion of the pancreas during a 15-year period were retrospectively reviewed. To determine subsets of patients at lower risk of having a malignant cyst, the clinicopathologic features (in particular, the malignant potential) of these patients were compared as a function of 3 variables, ie, presence of symptoms, patient age, and cyst size, using univariate analyses. Results were expressed as median and range and P < .05 was considered statistically significant. RESULTS: Forty-three (39%) of 109 patients were asymptomatic. Incidental cysts were smaller (28 [10 to 240] vs 59 [10 to 200] mm, P < .001) and were found in older patients (55.0 [18 to 77] vs 45.5 [14 to 82] years, P = .003). Overall, 14% of asymptomatic cysts, versus 35% of symptomatic cysts, were malignant (P = .016). Incidental cysts were also less likely to be premalignant or malignant compared with symptomatic cysts (47% vs 70%, P = .015). Twenty (18%) patients were elderly (73.0 [70 to 82] years old). Elderly patients had a more equal sex distribution (45% vs 76% female, P = .005) and had smaller cysts (26 [10 to 200] vs 55 [10 to 240] mm, P = .003) that involved the head of the pancreas more frequently (8 [40%] vs 17 [19%], P = .045) compared with their younger counterparts. The cohort of elderly patients also had a higher median American Society of Anesthesiologists score (2 [1 to 3] vs 1 [1 to 3], P < .001), and a higher proportion had undergone a "more" major procedure (Whipple's or total pancreatectomy) (55% vs 18%, P < .001). Not unexpectedly, surgical morbidity in the elderly was significantly higher (10 [50%] vs 24 [27%], P = .045). The operative mortality in both groups was not significantly different (1 [5%] vs 1 [1%], P = .324). The proportion of premalignant or malignant lesions in elderly patients was also similar to that in younger patients (11 [55%] vs 55 [62%], P = .574). The size of a cyst in asymptomatic patients had no correlation with its potential for malignancy. CONCLUSIONS: Reliance on preoperative characteristics alone such as the presence of symptoms, cyst size, and patient age are not sufficiently reliable in determining the malignant potential and thus management approach toward pancreatic cysts.

Retroperitoneal schwannoma.

BACKGROUND: Retroperitoneal schwannomas are rare, benign tumors. The aim of this study is to present our surgical experience with 7 such tumors. METHODS: Between 1989 and 2004, 7 patients with pathologically proven retroperitoneal schwannomas were reviewed retrospectively. RESULTS: There were 6 male patients and 1 female patient, with a mean age of 43 years (range, 23 to 58 years). Two patients were symptomatic and presented with abdominal discomfort, and none of the patients suffered from von Recklinghausen's disease. All the patients underwent computed tomography scanning, which showed a heterogenous retroperitoneal mass, 4 of which were thought to arise from the adrenals. In 2 patients, calcification was seen in the tumors. All 7 of the patients had a preoperative diagnosis of a retroperitoneal tumor including 3 patients who were thought to have adrenal neoplasms (1 patient had a diagnosis of an adrenal neoplasm excluded on magnetic resonance imaging). Laparotomy and complete excision of tumors were performed in all the patients, and there was no morbidity or mortality. The schwannomas had a mean maximum diameter of 7.3 cm (range, 4 to 14 cm), and they were all benign. At a mean follow-up of 17 months (range, 3 to 48 months) postresection, all the patients remained free from recurrence. CONCLUSION: Retroperitoneal schwannomas are rare tumors that are difficult to diagnose preoperatively. Radiologic findings are usually nondiagnostic. The treatment of choice is complete surgical excision.

Metastectomy for non-colorectal, non-neuroendocrine liver secondaries.

BACKGROUND: The role of metastectomy for colorectal and neuroendocrine liver secondaries is well established. Significant palliation and survival have been reported after aggressive surgical resection. However, the role of liver resection for secondaries from other primary tumours is less well defined. In this study, we aim to describe our experience, including indications and selection criteria, operative strategy and clinical outcome of liver resection, for non-colorectal, non-neuroendocrine liver metastases. METHODS: A review of prospectively collected operative database was conducted and patients who underwent liver resection of secondaries from non-colorectal, non-neuroendocrine primary tumours were studied. Eighteen patients were included in the study. There were 4 men and 14 women with a median age of 48 years (range, 37-78 years). RESULTS: Liver resection was carried out either for cure or for palliation of debilitating symptoms. Selection criteria included: (i) absence of extrahepatic disease and (ii) functional status of the liver and volume of remnant liver after hepatectomy. The median follow up was 24 months (range, 7-81 months) for 17 patients, excluding the one who defaulted after surgery. Cancer-specific survival and recurrence-free interval was calculated from the date of hepatectomy. Liver resection was considered curative in 13 patients. There was no 30-day mortality in this cohort of patients. The median recurrence-free survival time was 13 months (95% confidence interval (CI), 8-18 months). The median follow-up time for the 12 patients was 23.5 months (range, 7-35 months). Only five patients died due to cancer-specific causes and one died from acute myocardial infarction. The median cancer-specific survival time was 30 months (95% CI, 25-35 months). The 2-year survival rate was 77.1% (95% CI, 48.9-100%). CONCLUSION: The results are encouraging and suggest that with appropriate selection criteria, there is a role for metastectomy of non-colorectal, non-neuroendocrine liver secondaries.

Adult choledochal cysts: an audit of surgical management.

BACKGROUND: Choledochal cysts are rare congenital cystic dilatations of the biliary tree. Surgical management has evolved with regards to timing and surgical procedure of choice. We conducted a retrospective review of clinical presentation and surgical management of adult choledochal cysts. METHODS: Thirty-two patients with choledochal cysts who underwent surgery between April 1991 and January 2005 were reviewed. There were 27 Todani Type I, 2 Type II, 2 Type IVA and 1 Type V cysts. Eighty-four per cent of patients underwent complete cystectomy and hepaticojejunostomy. Seven patients had revision surgery comprising completion cystectomy and hepaticojejunostomy. RESULTS: There were no perioperative mortalities. Perioperative morbidity rate was 44% and the commonest complication perioperatively was wound infection (19%). Malignancy was noted in one histological specimen. This patient was disease free for 1 year postoperatively and was subsequently lost to follow up. No further malignancy was found on median follow up of 3.9 years (range, 1-14 years) for the other 31 patients. CONCLUSION: Adult choledochal cysts are rare and are often non-specific in their clinical presentation. In managing patients with choledochal cysts, it is important to first treat complications such as sepsis and pancreatitis before imaging of the biliary tree with endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography to evaluate the full extent and type of choledochal cyst. Surgical management should be planned single-stage surgery comprising complete cyst resection, cholecystectomy and Roux-en-Y hepaticojejunostomy and should be carried out by hepatobiliary specialists. Excellent perioperative morbidity and mortality results are possible with this strategy. Malignancy is rare and was only noted in 3% but close follow up is warranted.

Factors affecting early mortality in spontaneous rupture of hepatocellular carcinoma.

BACKGROUND: Spontaneous rupture of hepatocellular carcinoma (HCC) is a catastrophic surgical emergency with high mortality rates. The aim of this study is to determine the factors associated with the prognosis and to assess the outcome of different management strategies. METHODS: A retrospective study of 34 consecutive patients with spontaneous rupture of HCC was conducted from January 1996 to January 2004. Clinical, biochemical and operative factors influencing 30-day mortality were analysed. RESULTS: In our study, 30-day mortality rate was 32% (n = 11). Presence of cirrhosis, Child's C status, shock on admission, higher blood transfusion requirement, raised alpha-fetoprotein, raised alkaline phosphatase, raised aspartate transaminase, and raised indocyanine green at 15 min were all associated with increased risk of 30-day mortality on univariate analysis (P < 0.05). On multivariate analysis, only shock on admission (P = 0.001) and higher blood transfusion requirement (P = 0.01) were significant independent factors affecting early mortality. Surgical intervention was associated with a better 30-day survival as compared with medical therapy or transarterial embolization. The median survival time of patients undergoing curative resection was significantly longer than that of patients who had surgery for haemostasis only (420 vs 205 days). The overall median survival was 161 days. CONCLUSIONS: Spontaneous rupture of HCC is a potentially salvageable complication of HCC. Poor prognosis is associated with poor liver reserve, advanced disease and severity of haemorrhage. Shock and blood transfusion requirement are the only independent factors affecting early mortality.

Non-neoplastic cystic and cystic-like lesions of the pancreas: may mimic pancreatic cystic neoplasms.

BACKGROUND: Cystic lesions of the pancreas consist of a broad range of pathological entities. With the exception of the pancreatic pseudocyst, these are usually caused by pancreatic cystic neoplasms. Non-neoplastic pancreatic cystic and cystic-like lesions are extremely rare. In the present article, the surgical experience with these unusual entities over a 14-year period is reported. METHODS: Between 1991 and 2004, all patients who underwent surgical exploration for a cystic lesion of the pancreas were retrospectively reviewed. Patients with a pancreatic pseudocyst were excluded. There were 106 patients of whom 8 (7.5%) had a final pathological diagnosis consistent with a non-neoplastic pancreatic cystic or cystic-like lesion, including 3 patients with a benign epithelial cyst, 2 with a pancreatic abscess (one tuberculous and one foreign body), 2 with mucous retention cysts and 1 with a mucinous non-neoplastic cyst. These eight patients are the focus of this study. RESULTS: There were six female and two male patients with a median age of 61.5 years (range, 41-71 years). All the patients were of Asian origin including seven Chinese and one Indian. Four of the patients were asymptomatic and their pancreatic cysts were discovered incidentally on radiological imaging for other indications. All the patients underwent preoperative radiological investigations, including ultrasonography, computed tomography or magnetic resonance imaging, which showed a cystic lesion of the pancreas. Three patients, all of whom were symptomatic, were diagnosed preoperatively with a malignant cystic neoplasm on the basis of radiological imaging. Two patients were eventually found to have a pancreatic abscess, one tuberculous and the other, secondary to foreign body perforation. The third patient was found on final histology to have chronic pancreatitis with retention cysts. The remaining five patients had a preoperative diagnosis of an indeterminate cyst; on pathological examination, they were found to have a benign epithelial (congenital) cyst (n = 3), retention cyst (n = 1) and mucinous non-neoplastic cyst (n = 1). At a median follow up of 20 months (range, 3-34 months), none of the patients had any evidence of recurrent disease. CONCLUSION: Non-neoplastic cystic and cystic-like lesions of the pancreas are rare causes of pancreatic cystic lesions that are generally benign and do not require surgery when asymptomatic. However, despite advances in diagnostic investigations such as endoscopic ultrasound with fluid aspirate and magnetic resonance imaging, the preoperative diagnosis remains unreliable. Hence, the challenge for all clinicians is to recognize these lesions preoperatively and to avoid 'unnecessary' surgery.

Utility of fusion CT-PET in the diagnosis of small pancreatic carcinoma.

Pancreatic carcinoma has a poor prognosis and early detection is essential for potentially curative resection. Despite the wide array of diagnostic tools, preoperative detection of small pancreatic carcinomas remains difficult. We report a case of small pancreatic carcinoma of the head of pancreas with indeterminate findings on US, ERCP, MRI and EUS which was successfully diagnosed via fusion CT-PET. This case illustrates the utility of CT-PET in the diagnosis of patients with small pancreatic carcinoma with equivocal findings on conventional diagnostic modalities.

Mucinous nonneoplastic cyst of the pancreas: a truly novel pathological entity?

Recently, a novel and distinct pancreatic cystic tumor termed "mucinous nonneoplastic" cyst was described in the literature. We report our experience with a 71-year-old female with a cystic tumor in the body of the pancreas demonstrating features suggestive of this diagnosis. We also review the literature regarding this "novel" pathological entity and discuss critically its existence and its differential diagnoses.

Severe acute respiratory syndrome in surgical patients: a diagnostic dilemma.

BACKGROUND: The diagnosis of severe acute respiratory syndrome (SARS) in surgical patients can potentially be missed based on current World Health Organization (WHO) case definitions. METHOD: We report a retrospective case series of 10 surgical inpatients diagnosed with SARS following an outbreak in the surgical wards. Patients were included if they fulfilled the WHO case definition of probable SARS, had an active surgical problem and were admitted to the surgical wards during the outbreak period. Clinical histories, laboratory investigations and radiological findings were reviewed and analyzed. RESULTS: The mean age of the cohort was 57.6 years (range: 38-78 years). Nine patients had concomitant medical conditions. Three patients were in the early postoperative period, while the remaining seven were admitted for surgical related infections. All patients presented with fever, but only eight had accompanying respiratory symptoms. Lymphopenia and raised lactate dehydrogenase (LDH) was seen in seven patients. Eight patients had positive bacterial cultures. The primary abnormality on chest radiograph was air-space opacification. Rapid progression of radiological changes was seen in seven patients. Mortality rate for our cohort is 20%. CONCLUSION: The diagnosis of SARS in surgical patients differs from that previously described in normal patients. An apparent cause of fever and positive blood cultures cannot exclude a diagnosis of SARS. The current WHO case definition could result in delayed or even missed diagnosis. Early isolation of febrile patients with a positive contact history must be undertaken, even in the face of another identifiable cause.

Role of fenestration and resection for symptomatic solitary liver cysts.

BACKGROUND: Symptomatic liver cysts can be managed surgically by fenestration or by hepatic resection. The present study was designed to investigate the current role of each surgical technique in the management of this benign condition. METHODS: Forty consecutive patients with symptomatic liver cyst (non-parasitic and non-malignant) surgically treated by fenestration or resection were identified from a prospectively collected database. An analysis of primary outcome measures including operative parameters, morbidity and mortality rates, length of postoperative stay and recurrence rates in months was carried out. RESULTS: The laparoscopic fenestration group had the best perioperative outcome. At median follow up of 20 months, there were no recurrences in the resection group but recurrence occurred in 6/27 (22%) in the fenestration group. Four of these recurrences were asymptomatic and were managed conservatively while two symptomatic recurrences required a resection. CONCLUSION: Laparoscopic fenestration is the best treatment for symptomatic liver cysts as the primary operation. It is associated with the lowest blood loss, lowest morbidity and shortest hospital stay. Liver resection is best reserved for recurrent symptomatic cysts and cystic lesions suspicious of tumours where it can be safely performed and associated with a zero recurrence rate.

Endoscopic ultrasound diagnosis and laparoscopic excision of an omental lymphangioma.

Omental lymphangiomas are rare intra-abdominal tumors. We describe a case of an omental lymphangioma which appeared on computed tomography scan as a possible gastric duplication cyst. The lesion was correctly diagnosed preoperatively via endoscopic ultrasound and complete excision of the cyst was performed laparoscopically.

Highly symptomatic adult polycystic liver disease: options and results of surgical management.

BACKGROUND: The majority of patients afflicted with adult polycystic liver disease (APLD) are asymptomatic. For those who are symptomatic, there are a variety of treatment procedures that have been proposed but these lack verification through long-term studies with respect to safety and long-term effectiveness. Choice of surgical procedure is related to the severity of APLD and morphology of the cysts within the liver. The aim of the present study was to analyse the immediate and long-term results of fenestration and combined resection-fenestration at Singapore General Hospital. METHODS: A retrospective analysis of clinical, operative, imaging and follow-up data was carried out for 12 patients (10 women and two men) with symptomatic APLD who underwent surgery from January 1992 to December 2000. The primary outcome measures assessed were postoperative alleviation of symptoms, performance status, complications, mortality and long-term recurrence of symptoms. RESULTS: Nine patients underwent 12 fenestration procedures and three patients had combined resection-fenestration. Fenestration was carried out for eight of nine patients with a dominant cyst morphology and combination resection-fenestration was carried out for those three patients with diffuse cyst morphology. There was no operative mortality and all patients were discharged from hospital free of their preoperative symptoms. Overall morbidity rate was 58%. The mean follow up for the present cohort was 29.3 months. Only two patients had recurrence of symptoms. One patient with dominant cyst morphology who underwent laparoscopic fenestration had recurrence at 26 and 43 months but this was successfully treated finally with open fenestration. The other patient had diffuse cyst morphology and was treated with fenestration for recurrent cyst infection that recurred 1 month postoperatively. This required subsequent intravenous antibiotics and percutaneous drainage for resolution of symptoms. CONCLUSION: Treatment for symptomatic APLD should be based on the morphology of the liver cysts. Fenestration is a safe and acceptable procedure for patients with a dominant cyst pattern where liver size can be reduced after the cysts collapse. A combination of resection-fenestration is suitable for those with a diffuse cyst pattern where grossly affected segments are resected in combination with fenestration to allow for reduction in liver size.