Ngian Chye Tan

A picture speaks a thousand words: the use of digital photography and the Internet as a cost-effective tool in monitoring free flaps.

Microsurgical free tissue transfer is progressing rapidly and is being used more frequently the world over. Monitoring these cases is crucial for a satisfactory outcome. More sophisticated methods are available for monitoring, though they are often expensive. We propose a novel technique using digital photography and the Internet to offer a reliable and cost-effective method to monitor free-tissue transfers. During an 8-month period, 163 microvascular procedures were monitored using this technique. Serial photographs taken were stored in a separate case folder and sent to the surgeon as deemed necessary. Analysis of the 67 cases is presented. Five reexplorations were done. The early diagnosis of venous congestion was possible using this technique. Timely intervention contributed to the success of the reexplorations, and these flaps could be salvaged. The file size of images was in the range of 1 MB to 6 MB. The file size of a set of photographs was usually around 7 MB to 9 MB. These were sent across the asymmetric digital subscriber line Internet lines. The use of the digital images and the Internet allows reconstructive surgeons to have a reliable picture of the state of their free-tissue transfers. This allows decreasing observer error and saves valuable time which otherwise needs to be spent to verify situations of doubt.

Triple-Layer Duct-to-Mucosa Pancreaticojejunostomy after Pancreaticoduodenectomy

Background: Pancreaticoduodenectomy is associated with a high degree of morbidity; the main cause is failure of the pancreatic anastomosis. It is imperative that this is performed safely and is secure. Pancreatic leaks will lead to serious morbidity and even mortality. Here we describe the use of a new surgical triple-layer pancreaticojejunostomy in a group of patients with minimal morbidity. Methods: This is a retrospective review from a prospective database. Fifty-one consecutive patients underwent a pancreaticoduodenectomy (either pylorus-preserving (PPPD) or classical Whipple’s) from May 1999 to December 2005 and had the pancreaticojejunostomy reconstructed as described below. Results: The mean age of the 51 patients was 56.71 ± 9.0 years; 32 (62.7%) were female and 19 (37.3%) were males. The mean operating time was 368.55 ± 57.94 min; the average blood loss was 396 ± 236 ml with 15 patients (29.4%) requiring postoperative blood transfusions. The mean pancreatic duct size was 4.94 ± 2.6 mm. In terms of pancreatic texture, there were 33 (64.7%) hard pancreas and 18 (35.3%) soft pancreas. PPPD was performed on 28 (54.9%) and the classical Whipple’s procedure on 23 (45.1%). Twelve patients had postoperative complications; only 1 patient had a pancreatic fistula which was treated conservatively. Conclusion: This method is safe and reliable. It can be used for a myriad of pancreas remnants with a wide range of pancreatic duct sizes.

Analysis of a structured training programme in laparoscopic cholecystectomy

BackgroundLaparoscopic cholecystectomy is an established treatment for almost all gallbladder diseases with bile duct injury rates similar to open cholecystectomy. These laparoscopic skills must be passed on to junior surgeons without compromising patient safety.Materials and methodsWe analysed our structured training programme over 6years (May 2000 to May 2006) by following three trainee surgeons during their training and beyond. During this period, 1,000 laparoscopic cholecystectomies were carried out with five consultant surgeons supervising and three new trainees who completed their accreditation in laparoscopic cholecystectomy.ResultsThere were 694 patients operated on by consultant surgeons (Group 1), 202 by trainee surgeons (Group 2) and 104 by newly trained surgeons (Group 3). There were no differences between the groups in terms of age and gender. However, there was a significant difference in gallbladder disease among the three groups; Group 2 had more gallstone pancreatitis patients (P < 0.019). There were no differences among the three groups in conversion rates, bile duct injury rates, general complication rates or length of stay. However, the duration of operation in Group 2 was significantly longer compared to the other two groups (P < 0.0001).ConclusionThis programme is effective in training junior surgeons and does not compromise patient safety.

Nutrition in Head and Neck Cancer Patients

Anorexia and cachexia frequently complicate the late stages of malignancy and can be a prominent feature of early disease. The resulting weight loss significantly affects the morbidity and mortality of the cancer patient. A fundamental understanding of nutrition and the pathophysiology of cancer cachexia will aid in diligent treatment decisions to achieve optimal results. The pathophysiology of cancer cachexia is discussed, together with methods of nutritional assessment, nutritional requirements, and postoperative nutritional support. The advantages and disadvantages of the various modes of parenteral and enteral feeding are presented, together with information about enteral feeding in the home.

Multidisciplinary treatment of head and neck cancer.

Head and neck cancer remains a significant cause of morbidity worldwide. Multimodality treatment is often the only way to achieve improved function, quality of life, and survival, calling for a multidisciplinary team approach, particularly in view of the rapid advances being made in various fields. The roles of the head and neck surgeon and reconstructive surgeon are discussed, together with the input afforded by specialists in areas such as diagnostic imaging, radiation therapy, medical oncology, and gene therapy. Telemedicine is of importance in centers where multidisciplinary expertise is not available.

Emerging Role of PET Scan in the Management of Melanoma-A Case Report

Management of metastatic melanoma has changed over the recent years with a better understanding of the disease and newer diagnostic tools like the PET scan. Metastasectomy is becoming an accepted modality in the treatment of metastatic disease, when the primary has been well controlled. The diagnosis of metastases has been promising using PET scan as compared with conventional CT scan or MRI. We report here a case of recurrent melanoma with metastases diagnosed using PET scan and subsequent metastasectomy done affording the patient good control of the disease.

An Unusual Presentation of Dextran Related Anaphylactic Reaction

Dextran is frequently used following microsurgical free tissue transfer and replantation. The incidence of dextran induced pulmonary edema has been reported sporadically. We report here a case of dextran induced non cardiogenic pulmonary edema having a late presentation. The rare presentation of an anaphylactic reaction presenting with hypertension is also discussed.

Extraperitoneal approach for closure of epithelized enterocutaneous fistulas following late removal of jejunostomy tube.

Epithelized enterocutaneous fistulas will form if feeding jejunostomy tubes are kept for a lengthy period. Such fistulas may not close spontaneously, and thus surgical closure will be necessary. An intraperitoneal surgical approach is most commonly used but is often difficult and a major undertaking. A novel, simple, and safe technique to close such enterocutaneous fistulas extraperitoneally under local anesthesia is devised.