Khoon-Hean Tay

Predictive Factors of Malignancy in Adults with Intussusception

Adult intussusception is an unusual entity, and its etiology differs from that in pediatric patients. The aim of this study was to evaluate our experience of 60 adult patients with intussusception and determine if there are any preoperative factors predictive of malignancy. The records of 60 adult patients (> 18 years of age) with a diagnosis of intussusception surgically treated at Singapore General Hospital and Changi General Hospital between 1990 and 2004 were retrospectively reviewed. The intussusceptions were classified as enteric or colonic. Preoperative predictive factors of malignancy were analyzed using univariate and multivariate analyses, and P < 0.05 was considered statistically significant. There were 60 patients with a median age of 57.5 years (range 21–85 years). Altogether, 34 (56.7%) patients were male, and there were 31 enteric and 29 colonic intussusceptions. A lead point was identified in 54 patients (90%). A total of 22 (36.7%) patients presented with intestinal obstruction, and the correct preoperative diagnosis of intussusception was made in 31 patients (51.7%). Computed tomography was the most useful diagnostic modality, correctly identifying an intussusception in 24 of 30 patients. A malignant pathology was present in 8 of 31 (26%) enteric versus 20 of 29 (69%) colonic intussusceptions. Age (P = 0.009), the presence of anemia (P < 0.001), and the site of the intussusception (P = 0.001) showed significant differences between the benign and malignant groups by univariate analyses. On multivariate analysis, intussusception in the colon (P = 0.004) and the presence of anemia (P = 0.001) were independent predictive factors of malignancy. Adult intussusception is most commonly secondary to a pathologic lead point. The site of intussusception in the colon and the presence of anemia are independent preoperative predictors of malignancy. All colonic intussusceptions should be resected en bloc without reduction, whereas a more selective approach can be applied for enteric intussusceptions.

Delayed presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma.

Rupture of the diaphragm is almost always due to major trauma and is most commonly associated with road-traffic accidents. We report a case of delayed presentation of a 35-year-old woman with a ruptured diaphragm, 11 days following apparent minor blunt trauma. This case illustrates how the diagnosis of ruptured diaphragm can be missed and demonstrates the importance of considering this diagnosis in all cases of blunt trauma to the trunk. It also demonstrates the potential pitfall of misinterpreting the chest radiograph, and the value of repeat imaging after insertion of a nasogastric tube.

Which Octogenarians Do Poorly After Major Open Abdominal Surgery in Our Asian Population

As the elderly population grows and surgeons are faced with more octogenarians, there is a need to know how our Asian patients fair after major surgery. A retrospective review of 125 octogenarians who underwent major abdominal surgery between January 1997 and September 2003 was performed. Preoperative condition was assessed using a weighted index of comorbidity used in Charlson Comorbidity Index and classification of patients according to the American Society of Anaesthesiologists (ASA). Outcome was measured as to whether complications developed, 30-day mortality and whether there was return to premorbid function. The patients had a mean age of 84.6 years (range: 80–106). Nearly half (48.8%, n = 61) the cases were emergency cases. The median index of comorbidity was 3, and 29.6% of patients were classified either ASA III or IV. The operations were mostly stomach, small bowel or large bowel resection. Multivariate analysis revealed that emergency operations were associated with significantly increased odds of morbidity. The overall 30-day mortality was 5.6%, being only 4.7% for elective cases, despite high morbidity rates. ASA classification, comorbidity index >5, development of acute coronary syndrome and anastomotic leakage were found on multivariate analysis to significantly increase the odds of mortality. For elective cases, 82.8% of patients were able to return to their premorbid functional status. Development of complications and comorbidity index >5 were found to predict failure of its occurrence. Low serum albumin and haemoglobin and renal impairment were also predictors of adverse outcome. Efforts to improve outcome in geriatric surgery patients should emphasize a shift of attitude towards elective surgery rather than doing emergency operations when complications occur and also target the optimization of predictors of adverse outcome. Octogenarians should not be denied elective surgery.

Randomized clinical trial of 0·2 per cent glyceryl trinitrate ointment for wound healing and pain reduction after open diathermy haemorrhoidectomy

Open haemorrhoidectomy is associated with considerable postoperative pain and discomfort. This study assessed whether glyceryl trinitrate (GTN) ointment promotes wound healing and reduces pain after open haemorrhoidectomy.

AN EASTERN PERSPECTIVE ON OESOPHAGEAL PERFORATION: A HIGH INCIDENCE OF INGESTED BONES

Background:  Oesophageal perforation is uncommon, with controversy surrounding its optimal management. Our local experience shows a high incidence of oesophageal perforation secondary to ingested bones.

BREAST SPECIMEN ULTRASOUND AND MAMMOGRAPHY IN THE PREDICTION OF TUMOUR‐FREE MARGINS

Background:  Adequacy of margins is important for local recurrence control in breast‐conserving surgery for breast cancer. This study aims to compare the accuracy of intraoperative specimen ultrasonography (IOUS) and specimen mammography in the prediction of achieving adequate histologically tumour‐free margins during breast‐conserving surgery.

Endoscopic retrograde cholangiopancreatography management of common bile duct stones in a surgical unit

Background:  Choledocholithiasis, if left untreated, can lead to significant morbidity and mortality. The management of such a problem has progressed tremendously but controversy still exists as to ideal management, laparoscopic exploration or endoscopic retrograde pancreatography with sphincterotomy. The purpose of this study is to evaluate the results of endoscopic retrograde cholangiopancreatography (ERCP) in a surgical unit.

Surgical complications and treatment during resection for malignancy of the high bile duct.

Abstract. From January 1968 to January 1997 a series of 50 of 109 patients had undergone resection for high bile duct cancer in our institution in Rennes, France. The overall operative mortality was 12%, but there were no deaths among those who had only tumor resection or those with hepatectomy with vascular reconstruction. The early complications were biliary fistula (four cases) and subphrenic abscess (three cases), of which two of the biliary fistulas resulted in mortality. There were three gastrointestinal hemorrhages; one was due to gastritis related to hepatorenal insufficiency and was fatal. Two other deaths were due to respiratory failure and ascites associated with hepatic insufficiency. In one patient after liver transplantation with cluster resection, a biliary leak and ileocolic fistula were the cause of postoperative mortality. Another patient suffered a ruptured mycotic aneurysm after pretransplant transtumoral intubation, which emphasizes the risk of infection in an immunosuppressed patient. The main late complication was cholangitis (8 cases). This complication is most often a symptom of recurrence (four cases). Some are due to benign causes (intrahepatic lithiasis, intrahepatic foreign body granuloma). Surgical exploration is mandatory to exclude benign complications, which can then be treated palliatively. Four patients presented with recurrence but without cholangitis. In conclusion, the causes of complications after resection of high bile duct cancer should be carefully assessed to choose the correct treatment. Late cholangitis is a symptom of recurrence, but it should be explored and managed precisely.

Metastatic Malignant Phaeochromocytoma: A Rare Entity that Underlies a Therapeutic Quandary

Phaeochromocytoma is a rare condition that provides a diagnostic challenge as a result of its variable presentation. Treatment of metastatic malignant phaeochromocytoma is also not well defined owing to its rarity. We present four such cases and a review of the literature. The database of the Singapore Cancer Registry was used to trace all cases of metastatic malignant phaeochromocytoma from 1984 to 2004, and the case records were then reviewed retrospectively. There were four patients with metastatic malignant phaeochromocytoma seen in Singapore in the last 20 years. Their variable clinical courses were reviewed and compared with current knowledge and overseas experience in the literature. We further discuss the difficulties in diagnosis, and the dilemma in appropriate management of such cases. Phaeochromocytoma remains a commonly missed diagnosis unless a high index of suspicion is maintained. Malignant phaeochromocytoma has a variable clinical course. There is a place for radical surgery if this can render the patient free of gross disease, or when it can achieve symptom control for palliation and improvement in quality of life. In the metastatic context, debulking surgery does not appear to be of curative benefit, although it may be undertaken for good palliation.

The posterior intrahepatic approach to liver resection

Background Hepatic resectional surgery has rapidly evolved since the realisation of the segmental anatomy of the liver and the intrahepatic distribution of the portal trinity (the hepatic artery, hepatic duct and portal vein). This portal trinity is enveloped by a sheath, derived from Glissons capsule. In the classical intrafascial or extrahepatic approach, the appropriate branch of the portal vein, hepatic artery and the hepatic duct is isolated outside the liver substance, whereas in the extrafascial approach the whole sheath of the pedicle is dissected, after division of a substantial amount of hepatic tissue. In the transfissural or intrahepatic approach, these sheaths can be approached either anteriorly (after division of the main, right or umbilical fissure) or posteriorly, from behind the porta hepatis, through the distal fissure. Methods We describe the technique of the intrahepatic posterior approach to the glissonian sheath, with its contained hepatic pedicle structures and branches. Results This technique allows early delineation of a liver segment, without the need for ancillary manoeuvres. Discussion The indications for the use of this technique in an oncological setting are also discussed.