Boon Koon Yoong

Robot-assisted radiofrequency ablation of primary and secondary liver tumours: early experience.

ObjectiveComputed tomography (CT)-compatible robots, both commercial and research-based, have been developed with the intention of increasing the accuracy of needle placement and potentially improving the outcomes of therapies in addition to reducing clinical staff and patient exposure to radiation during CT fluoroscopy. In the case of highly inaccessible lesions that require multiple plane angulations, robotically assisted needles may improve biopsy access and targeted drug delivery therapy by avoidance of the straight line path of normal linear needles.MethodsWe report our preliminary experience of performing radiofrequency ablation of the liver using a robotic-assisted CT guidance system on 11 patients (17 lesions).Results/ConclusionRobotic-assisted planning and needle placement appears to have high accuracy, is technically easier than the non-robotic-assisted procedure, and involves a significantly lower radiation dose to both patient and support staff.Key Points• An early experience of robotic-assisted radiofrequency ablation is reported• Robotic-assisted RFA improves accuracy of hepatic lesion targeting• Robotic-assisted RFA makes the procedure technically easier with significant lower radiation dose

Survival analysis of cholangiocarcinoma: A 10-year experience in Malaysia

AIM To investigate the clinical features and survival of patients treated for cholangiocarcinoma in our institution and to analyze the factors affecting their survival. METHODS This retrospective cohort study assessed patients diagnosed with cholangiocarcinoma between January 1997 and December 2007 at the University Malaya Medical Centre in Malaysia. The clinical data and associated outcomes were collected using a structured proforma. RESULTS Of the 69 patients diagnosed with cholangiocarcinoma, 38 (55%) were male; mean patient age was 61 years. Twelve patients (17%) had intrahepatic, 38 (55%) had perihilar and 19 (28%) had distal tumors. Only 12 patients underwent curative surgery, including seven R0 resections. Only one patient died within 30 d after surgery. The overall median survival was 4 mo, whereas the median survival of R0 resected patients was 16 mo. The overall 1-, 2- and 3-year cumulative survival rates were 67%, 17% and 17%, respectively. Survival rates were significantly associated with curative resection (P = 0.002), intrahepatic tumor (P = 0.003), negative margin status (P = 0.013), early tumor stage (P = 0.016), higher tumor differentiation (P = 0.032) and absence of jaundice (P = 0.038). Multivariate analysis showed that tumor location was a significant independent predictor of patient survival. CONCLUSION Curative, margin-negative resection of early stage, well-differentiated intrahepatic tumors is associated with improved patient survival.

Liver cancer in Malaysia: Epidemiology and clinical presentation in a multiracial Asian population

Hepatocellular carcinoma (HCC) is an important cancer in Malaysia. This study aimed to determine the epidemiological characteristics and clinical presentations of patients in a multiracial population consisting of three major Asian races: Malays, Chinese and Indians.

Education and imaging. Hepatobiliary and pancreatic: A huge liver paraganglioma.

A 48-year-old woman was investigated because of a 6-month history of pain in the upper abdomen and progressive abdominal distension. On examination, she had a large mass in the right upper quadrant that extended to the umbilicus. Routine blood tests including liver function tests and a serum level of alpha fetoprotein were within the reference range. A computerized tomography (CT) scan of the abdomen revealed a large mass in the right upper quadrant, approximately 12 ¥ 18 ¥ 18 cm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. A coronal view of the mass is shown in Figure 1. As a major liver resection was proposed, she underwent embolization of the right portal vein. A repeat CT scan did not demonstrate any reduction in the size of the tumor or hypertrophy of the left lobe of the liver. At laparotomy, she had a huge pedunculated mass arising from the inferior surface of segments 5 and 6 of the liver (Figure 2). Histological features were consistent with a paraganglioma and this was supported by immunohistochemical studies which showed positive staining for neuronspecific enolase, synaptophysin and glial fibrillary acidic protein. However, S100 was equivocal and immunohistochemical staining was negative for chromogranin, MNF 116, vimentin, actin and CD68. Paragangliomas are neoplasms of the sympatho-adrenal neuroendocrine system. The most common site for these neoplasms is the adrenal medulla (pheochromocytoma). Extra-adrenal paragangliomas are unusual and mostly follow the distribution of the sympathetic nervous system. Paragangliomas in abdominal organs are rare but have been reported in a number of sites including the bladder and gallbladder. Atypical features in the above case included the site of the tumor (liver) and the size of the tumor (many are relatively small). Clinical features of excess catecholamine secretion have been reported in 20–80% of patients. Only a minority undergo malignant change as determined by the development of metastases. Another notable feature in the above case was the presence of centripetal contrast enhancement that is normally thought to be a typical feature of a cavernous hemangioma.

Hepatobiliary and pancreatic:A huge liver paraganglioma

A 48-year-old woman was investigated because of a 6-month history of pain in the upper abdomen and progressive abdominal distension. On examination, she had a large mass in the right upper quadrant that extended to the umbilicus. Routine blood tests including liver function tests and a serum level of alpha fetoprotein were within the reference range. A computerized tomography (CT) scan of the abdomen revealed a large mass in the right upper quadrant, approximately 12 ¥ 18 ¥ 18 cm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. A coronal view of the mass is shown in Figure 1. As a major liver resection was proposed, she underwent embolization of the right portal vein. A repeat CT scan did not demonstrate any reduction in the size of the tumor or hypertrophy of the left lobe of the liver. At laparotomy, she had a huge pedunculated mass arising from the inferior surface of segments 5 and 6 of the liver (Figure 2). Histological features were consistent with a paraganglioma and this was supported by immunohistochemical studies which showed positive staining for neuronspecific enolase, synaptophysin and glial fibrillary acidic protein. However, S100 was equivocal and immunohistochemical staining was negative for chromogranin, MNF 116, vimentin, actin and CD68. Paragangliomas are neoplasms of the sympatho-adrenal neuroendocrine system. The most common site for these neoplasms is the adrenal medulla (pheochromocytoma). Extra-adrenal paragangliomas are unusual and mostly follow the distribution of the sympathetic nervous system. Paragangliomas in abdominal organs are rare but have been reported in a number of sites including the bladder and gallbladder. Atypical features in the above case included the site of the tumor (liver) and the size of the tumor (many are relatively small). Clinical features of excess catecholamine secretion have been reported in 20–80% of patients. Only a minority undergo malignant change as determined by the development of metastases. Another notable feature in the above case was the presence of centripetal contrast enhancement that is normally thought to be a typical feature of a cavernous hemangioma.

The Asia Pacific Consensus Statement on Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Report from the 7th Asia-Pacific Primary Liver Cancer Expert Meeting Held in Hong Kong

Background: Laparoscopic liver resection has been gaining momentum, and it has become an accepted practice after the two international consensus conferences where experts worked up guidelines to standardize this approach and improve its safety. However, most laparoscopic hepatectomies were performed in patients with liver metastases. The concurrent presence of liver cirrhosis with hepatocellular carcinoma (HCC) poses a great challenge to clinicians trying to establish a routine use of laparoscopic liver resection for HCC. Summary: The first Asia Pacific consensus meeting on laparoscopic liver resection for HCC was held in July 2016 in Hong Kong. A group of expert liver surgeons with experience in both open and laparoscopic hepatectomy for HCC convened to formulate recommendations on the role and perspective of laparoscopic liver resection for primary liver cancer. The recommendations consolidate the most recent evidence pertaining to laparoscopic hepatectomy together with the latest thinking of practicing clinicians involved in laparoscopic hepatectomy, and give detailed guidance on how to deploy the treatment effectively for patients in need. Key Message: The panel of experts gathered evidence and produced recommendations providing guidance on the safe practice of laparoscopic hepatectomy for patients with HCC and cirrhosis. The inherent advantage of the laparoscopic approach may result in less blood loss if the procedure is performed in experienced centers. The laparoscopic approach to minor hepatectomy, particularly left lateral sectionectomy, is a preferred practice for HCC at experienced centers. Laparoscopic major liver resection for HCC remains a technically challenging operation, and it should be carried out in centers of excellence. There is emerging evidence that laparoscopic liver resection produces a better oncological outcome for HCC when compared with radiofrequency ablation, particularly when the lesions are peripherally located. Augmented features in laparoscopic liver resection, including indocyanine green fluorescence, 3D laparoscopy, and robot, will become important tools of surgical treatment in the near future. A combination of all of these features will enhance the experience of the surgeons, which may translate into better surgical outcomes. This is the first consensus workforce on laparoscopic liver resection for HCC, which is a unique condition that occurs in the Asia Pacific region.

Jaundice and life‐threatening hemobilia: An uncommon presentation of choledochal cyst

Hemobilia with jaundice as a result of cholestasis and bleeding from choledochal cyst is uncommon. Ascertaining the diagnosis is often challenging and delayed diagnosis can lead to significant consequences due to hemodynamic instability, particularly in elderly patients. Although surgery remains the definitive treatment modality, interventional radiology for hemostasis has been increasingly recognized as an option. In this manuscript, we described two Malaysian cases of jaundice and hemobilia associated with choledochal cysts and the challenges related with clinical diagnosis and management.

Mediastinal hepatocellular carcinoma with unknown primary: an unusual and rare presentation.

This is an excerpt from the content Background Hepatocellular carcinoma (HCC) is a common cancer in Asia due to the high prevalence of hepatitis B and C infections in this region [1]. It often occurs in a cirrhotic liver as a sequalae of chronic hepatitis B and C infections as well as alcoholic liver or fatty liver disease. With improved treatment of HCC over the years, extrahepatic metastatic HCC are frequently reported, and its incidence is increasing [2]. Metastatic HCC has often been reported in common extrahepatic sites such as lungs, bones, lymph nodes and adrenals as a result of hematogenous or lymphatic spread as well as direct invasion of tumour tissue [3]. However, extrahepatic HCC presenting as a solitary mass is unusual when no primary liver tumour is detectable or identifiable. To our knowledge, there are numerous reports in the literature describing extrahepatic and metastatic HCC with no known primary occurring in various sites, but we report a rare case of mediastinal HCC with an unknown primary in a 46-yea ...

Hepatobiliary and Pancreatic: A huge liver paraganglioma: Education and Imaging

A 48-year-old woman was investigated because of a 6-month history of pain in the upper abdomen and progressive abdominal distension. On examination, she had a large mass in the right upper quadrant that extended to the umbilicus. Routine blood tests including liver function tests and a serum level of alpha fetoprotein were within the reference range. A computerized tomography (CT) scan of the abdomen revealed a large mass in the right upper quadrant, approximately 12 ¥ 18 ¥ 18 cm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. A coronal view of the mass is shown in Figure 1. As a major liver resection was proposed, she underwent embolization of the right portal vein. A repeat CT scan did not demonstrate any reduction in the size of the tumor or hypertrophy of the left lobe of the liver. At laparotomy, she had a huge pedunculated mass arising from the inferior surface of segments 5 and 6 of the liver (Figure 2). Histological features were consistent with a paraganglioma and this was supported by immunohistochemical studies which showed positive staining for neuronspecific enolase, synaptophysin and glial fibrillary acidic protein. However, S100 was equivocal and immunohistochemical staining was negative for chromogranin, MNF 116, vimentin, actin and CD68. Paragangliomas are neoplasms of the sympatho-adrenal neuroendocrine system. The most common site for these neoplasms is the adrenal medulla (pheochromocytoma). Extra-adrenal paragangliomas are unusual and mostly follow the distribution of the sympathetic nervous system. Paragangliomas in abdominal organs are rare but have been reported in a number of sites including the bladder and gallbladder. Atypical features in the above case included the site of the tumor (liver) and the size of the tumor (many are relatively small). Clinical features of excess catecholamine secretion have been reported in 20–80% of patients. Only a minority undergo malignant change as determined by the development of metastases. Another notable feature in the above case was the presence of centripetal contrast enhancement that is normally thought to be a typical feature of a cavernous hemangioma.

Massive subcapsular air collection in the liver: A rare life‐threatening complication following ERCP rendezvous procedure

When primary cannulation of the bile duct through the ampulla of Vater fails, endoscopists often resort to a rendezvous procedure whereby a guidewire is placed percutaneously into the biliary tree and the common bile duct and out through the ampulla of Vater. The wire is then retrieved through the biopsy channel of the duodenoscope and thread retrogradely through a catheter into the bile duct. This procedure necessitates a percutaneous puncture of the liver.