Indicators of ADHD symptoms FECHA DE RECEPCIÓN: 23 de junio in virtual learning context using FECHA DE APROBACIÓN: 17 de julio Pp. 22-37 machine learning technics Laura Patricia Mancera Valetts* Indicadores de síntomas ADHD en Silvia Margarita Baldiris Navarro** el contexto de aprendizaje virtual,
Dans la pharmacie en ligne Viagra-représenté Paris large éventail de la dysfonction érectile anti-plus consommée. Générique Levitra (vardenafil), Cialis (tadalafil) et achat viagra pour homme, dont le prix est acceptable pour tous les budgets.1
Yo no soy un gran amante de pedir medicamentos por internet. Pero a veces la necesidad de herramientas, que en las farmacias regulares o no, o rara vez propecia Recibes como un paquete, todo montado y embalado.
IASGO HPB AND GI ONCOLOGY POST-GRADUATE COURSE
STRATEGIES FOR DIFFERENTIATING XANTHOGRANULOMATOUS CHOLECYSTITIS FROM
GALL BLADDER CARCINOMA- A TERTIARY CARE CENTRE EXPERIENCE
Kishore Rajaguru1, Samiran Nundy2
1Jurong Health, 2Sir Gangaram Hospital
Xanthogranulomatous cholecystitis (XGC) mimics Gallbladder carcinoma (GBC) in both
preoperative and intra-operative settings and the patient may undergo an unnecessary radical
cholecystectomy which is associated with a greater morbidityrather than a cholecystectomy
alone.We postulated that a pre-operative diagnosis of XGC might benefit patients by avoiding
radical procedures and attempted to identify the features of XGC which would differentiate it
from GBC before and during surgery.
All the patients who underwent gall bladder related operations (benign and malignant),over a
period of 5 years from 2010 to 2014 were reviewed in a tertiary centre hospital in Delhi,
India.After the histopathological reports the patients were placed into two groups - those with
XGC and GBC.The following parameters were recorded–clinical features,biochemical and
radiological findings including the presence of gall stones, common bile duct (CBD) stones,focal
or diffuse wall thickening of the GB,the presence of intramural bands or nodules in the wall,
lymph node enlargement,mucosal enhancement,and the status of the interface between the
liver bed and gall bladder. A comparison was made between the groups.
Patients with a long history of recurrent abdominal pain and who on imaging
were found to have a diffusely thickened gall bladder wall, with cholelithiasis,
choledocholithiasis and submucosal hypoattenuated nodules were likely to have XGC while
those with anorexia,weight loss,focal thickening of the gallbladder wall on imaging and dense
local organ infiltration were more likely to have GBC. The presence of lymph nodes on imaging
and the loss of a fat plane interface between the liver and gallbladder were not differentiating
The differentiation of XGC and GBC pre-operatively remains a challenge but is possible via
certain clinical and imaging characteristics.However the definitive diagnosis still remains a
frozen section histopathological examination to avoid a radical resection in patients who have a
Palliative chemotherapy is a dismal option compared to CRS and HIPEC for patients
with colorectal peritoneal carcinomatosis: Outcomes in a tertiary Asian Institution
Nita Thiruchelvam1, Claramae Chia2, Grace Tan2, Melissa Teo2
1Singapore General Hospital, 2National Cancer Centre Singapore
Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) provide
prolonged survival in selected patients with colorectal (CLR) peritoneal carcinomatosis.
However, many patients are offered palliative chemotherapy (PC) instead, due to perceived
morbidity of CRS and HIPEC. We hypothesize that PC is suboptimal due to complications arising
from peritoneal disease that disrupts chemotherapy. We aim to compare the overall survival
(OS) between the treatment arms of PC and that of CRS and HIPEC, and analyze the morbidity
experienced by patients in the PC arm.
We performed a retrospective review of a prospectively maintained database of 34 patients
who underwent CRS and HIPEC and 21 patients who underwent PC for CLR peritoneal
carcinomatosis, at the National Cancer Centre Singapore (NCCS), from Jan 2008 to Dec 2013. OS
was calculated from the date of diagnosis of peritoneal metastases till death. Secondary
outcomes of frequency of chemotherapy disruptions, need for invasive interventions, and
duration of hospitalization for complications of peritoneal disease were evaluated.
Median OS for the PC arm was 1.7 yrs (0.7-2.1), but that of CRS and HIPEC was not reached.
There was strong significant difference in OS. The hazard of death when treated with PC was 5.5
times that of CRS and HIPEC (p<0.05). Of the PC group, 71.4% (15) had chemotherapy
disruptions; 60.0% due to complications of peritoneal disease, most commonly intestinal
obstruction (I/O). 14.3% required emergency surgery for I/O and 23.8% required abdominal
cope loop and ureteric stent insertion. Median total duration of unforeseen hospitalization post-
CRS and HIPEC was 11 days (0-149) compared to 21 days (0-85) in the PC group.
CRS and HIPEC confer prolonged survival compared to PC in patients with CLR peritoneal
carcinomatosis. Patients treated with palliative chemotherapy suffer significant morbidity from
disease progression that disrupts chemotherapy and results in significantly longer
Laparoscopic-assisted Excision of a Mesenteric Paraganglioma
Yvonne Ng, Victor Ng, Siong San Tan, Adrian Chiow
Changi General Hospital
Paraganglioma is a rare tumour of neural crest cell origin that arises from sympathetic or
parasympathetic neural paraganglia. While the adrenal medulla is the most common site of
paragangliomas, 5-10% occur in extra-adrenal sites. Extra-adrenal paragangliomas usually occur
parallel to the autonomic nervous system, most commonly alongside the aorta, particularly in
an area known as the organ of Zuckerkandl. This can be attributed to the embryologic
development of the paraganglia from neural crest cells. Uncommonly, extra-adrenal
parangangliomas may occur aberrantly outside this anatomical spread.
We report a case of a paraganglioma arising in the mesentery, with only 18 other cases
discussed in the literature. To our knowledge, this represents the first report of a laparoscopic-
assisted excision of a mesenteric paraganglioma.
An 86-year old female had an incidental finding of a mesenteric mass on computed tomography
scan which showed an indeterminate 2.5 x 2.0 cm heterogeneously enhancing nodule in the
mesentery. Small central hypodense cystic spaces were noted within. Laparoscopy located the
mass in the small bowel mesentery and it was excised along with a small bowel segment.
Histological diagnosis was paraganglioma. The patient is disease-free at 9-month follow up.
Extra-adrenal paragangliomas usually arise in the third to fifth decade of life and tend to be
more aggressive with the incidence of malignant change ranging from 14% to 50%. Under the
Glenner and Grimely classification, our patient's mesenteric paraganglia may qualify as the
viscera-autonomic type, a group of poorly defined paraganglia that occur in association with
visceral organs or blood vessels. Recognition of paragangliomas as a mesenteric mass is
important as a functional tumour has the ability to secrete catecholamines, thus requiring
judicious perioperative management. Histologic appreciation of neuroendocrine features of the
tumour cells also help to avoid a wrong diagnosis of carcinoma or sarcoma.
Extrahepatic portal venous aneurysm: Report of 2 cases with review of current
Chua Khoon Han1, Lim Mei En Annabelle+1, Ho Chun Yin Derek2, Tay Jia Sheng2, Adrian Chiow2
1National University of Singapore Yong Loo Lin School of Medicine, 2Changi General Hospital
Worldwide, there are less than 200 cases of extra hepatic portal venous aneurysms (EHPVA)
reported to date. PVAs are commonly located the main portal vein and the confluence of
superior mesenteric vein and splenic vein. We discuss the presentation, aetiology and
management of 2 patients in Singapore in this report.
A retrospective case notes review identified 2 patients presenting to Changi General Hospital
from 2009 to 2010.
A 70-year-old Malay lady with a history of diabetes mellitus and hypertension presented to the
emergency department with vague abdominal pain. Clinical examination and initial
investigations were unremarkable. CT abdomen pelvis however confirmed an incidental EHPVA
measuring 6cm in diameter without thrombosis or compression of adjacent structures.
The 2nd patient is a 86-year-old Chinese male with history of recurrent Hepatocellular
Carcinoma (HCC) and liver cirrhosis treated with caudate lobe resection in 2009, Transhepatic
arterial chemoembolization (TACE)/Radiofrequency ablation (RFA) in 2011 and left lateral
sectionectomy in 2015. The 2.2cm EHPVA was noted on recent follow up for his HCC.
Both patients elected for non-operative management with close outpatient follow-up and have
shown no further progression of the EHPVA on latest review.
Majority of patients with EHPVA are asymptomatic with diagnosis made on incidental imaging.
Portal vein size of >2cm is considered aneurysmal. While congenital causes are most common,
acquired factors include portal hypertension, liver cirrhosis and instrumentation/trauma.
Surgery is indicated for symptomatic or complicated EHPVA. Portal aneurysmorrhaphy is the
treatment of choice in congenital causes with portocaval shunting or intrahepatic porto-
systemic shunting favoured for patients with background cirrhosis and portal hypertension.
Patients who are asymptomatic with significant comorbidities precluding surgical intervention
may be followed up closely with regular surveillance US imaging.
Laparoscopic Complex Liver Resection; Posterosuperior Versus Anterolateral Lesions-
A Cohort Comparison
Xiao Shuang Ling, Jin Yao Teo, Chung Yip Chan, Jen San Wong, Peng Chung Cheow, Ser Yee Lee
Singapore General Hospital
Laparoscopic liver resection (LLR) has evolved over the years, from resection of benign liver
lesions to major resection of malignant liver lesions in difficult locations, particularly in a
cirrhotic liver. This is our initial experience of laparoscopic liver resection in a local population,
focusing on approach for lesion in the posterosuperior (PS) segments of the liver (Segments 1,
4a, 7 and 8)
A retrospective review of patients who underwent LLR in a single institution from 2006 to
January 2015. Outcomes in patients who underwent LLR for PS vs. anterolateral lesions (AL)
were compared by analysing clinicopathological, operative and perioperative parameters.
LLR was performed in 197 patients with a mean age of 60 years. The main indication for
resection was hepatocellular carcinoma (n=105, 53.3%). A significant proportion of the patients
had underlying liver cirrhosis (n=51, 25.9%). Major resection was performed more frequently in
the PS group compared to AL group (p<0.001). Mean operative time and the conversion rate
were higher in the PS group (p<0.001 and 0.03 respectively). However, the estimated blood loss,
rate of blood transfusion and mean postoperative stay were similar in both groups. Mortality
and morbidity rate were 21.3% and 0.5%.
LLR, including in patient with cirrhotic liver with lesions in the PS segment, is technically feasible
Surgical Management of Intraductal Hepatocellular Carcinoma
Ye Xin Koh, Ser Yee Lee, Aik Yong Chok
Singapore General Hospital
Intraductal hepatocellular carcinomas are difficult to distinguish from perihilar
cholangiocarcinoma because of similar clinical and radiological findings. It is however an
important distinction to make as the management approach for is different for intraductal HCC
and a reasonable long-term survival can be achieved in these patients. In this study, we present
a series of patients with intraductal HCC presenting with obstructive jaundice, their clinico-
radiological features, surgical management and outcomes.
Retrospective review of clinical records in a single institution from 1998-2012
1158 patients underwent surgery for treatment HCC, four patients (0.34%) had icteric
intraductal HCC. One patient with previously resected HCC had a pre-operative diagnosis of
intraductal HCC. The other three patients were diagnosed pre-operatively to have hilar
cholangiocarcinomas(CCA). All three patients with primary presentation of disease had elevated
mean CA 19-9 at 1356μmol/L (range 467-4244μmol/L). All were HBsAg positive. Mean AFP
6.03UG/L (range 1.9-10.7UG/L). Mean bilirubin 136μmol/L (range 49-201μmol/L). All were
operated within 1 week of diagnosis. The type of surgery was based on preoperative
determination of the location of the primary tumor and tumor thrombus extension in the biliary
The oncological principle of surgical resection for icteric type HCC with bile duct obstruction is
enbloc resection of the tumor along with the obstructed bile duct. However, in our experience,
all our patients required an extended or hemihepatectomy to achieve R0 resection. This was
confirmed on histopathology showing that in 3 of 4 specimens, the 1st order intrahepatic bile
ducts at the epicenter of the tumor had extensive surrounding parenchymal involvement that
required bile duct and liver resection to achieve a R0 resection such that simple tumor
thrombectomy will not have sufficed. Therefore, good surgical outcomes can potentially be
achieved with aggressive policy including extended liver and/or bile duct enbloc resection to
achieve R0 resection.
Validation of the MSKCC Gastrointestinal Stromal Tumor Nomogram and Comparison
with Other Prognostication Systems: Single-Institution Experience with 289 Patients.
Aik Yong Chok, Brian Goh, Ye Xin Koh
Singapore General Hospital
To validate the Memorial Sloan Kettering Cancer Center (MSKCC) prognostic nomogram in a
single-institution cohort of patients with gastrointestinal stromal tumors (GISTs), and to
compare its predictive accuracy against other established risk classification systems, including
the National Institutes of Health (NIH), Armed Forces Institute of Pathology (AFIP), and Joensuu
We retrospectively reviewed 289 patients who underwent surgical resection for primary
localized GISTs without adjuvant imatinib therapy and compared the actuarial recurrence-free
survival (RFS) with the predicted RFS.
Tumors >5 cm in size, with high mitotic index, and which had ruptured were significantly
associated with recurrent disease. The 2-year RFS was 77.2 % [95 % confidence interval (CI)
71.6-81.8], and the 5-year RFS was 67.9 % (95 % CI 61.7-73.4). The concordance probability of
the nomogram of 2-year RFS was 0.71 (SE 0.02), and 5-year RFS was 0.71 (SE 0.19). The 2-year
and 5-year MSKCC nomogram probability calculations and the AFIP criteria gave a better
estimation of RFS compared to the NIH (p < 0.001) and Joensuu (p < 0.001) criteria. There was
no significant difference between the predictive accuracy of the nomogramcompared to the
The MSKCC nomogram slightly underestimated the probability of RFS after surgical resection of
GISTs. It was associated with a significantly better predictive accuracy compared to the NIH and
Joensuu. This study suggests that there is a wider than expected prognostic divergence between
gastric GISTs versus GISTs arising from the small intestine.
Percutaneous Cholecystostomy in Elderly or Poor Risk Patients with Acute
Cholecystitis and Suspected Mirizzi Syndrome
Christopher Worthley, Anthony Cheng, Mark Brook-Smith
Royal Adelaide Hospital
Percutaneous cholecystostomy (PC) for acute cholecystitis (AC) in elderly or poor risk patients
is well-established. A further indication for PC in AC may be suspected MS. The primary aim of
this prospective cohort study was to determine whether PC for unresolving AC with suspected
MS led to potentially improved outcome.
Consecutive patients undergoing PC for AC on a single unit between April 2007 to October
2011 were entered into the study. Those with AC and suspected MS (Gp 1) were compared with
AC alone (Gp 2).
Sixty patients (39 Gp 1 and 21 Gp 2) underwent PC. Ages (in years) were 69(19-92) and 81 (36-
101) [median(range)] and ASA scores were 3/4 in 31/39 and 15/21 respectively. PC was
successful in all with resolution of AC and (in GP1) cholestasis. 90 day mortality was 2/60 (3.3%).
Tube dislodgement occurred significantly more often in Gp 1 (8/39 vs 0/21). MS was
subsequently confirmed by tube choledochography or MRCP in 6/39 with suspected MS.
12/60 had choledocholithiasis (10/39 versus 2/21 respectively). None had cholecystobiliary
fistulation. With suspected MS, 9 underwent elective ERCP. Overall, 34/60 underwent
elective cholecystectomy, laparoscopic in 12/39 and 10/21 respectively. Significantly more in
Gp 1 underwent initial open cholecystectomy (8/21 versus 0/13). There were no bile duct
injuries nor procedure-related deaths.
PC is effective initial management of elderly and poor risk patients with AC and suspected
MS. Tube choledochography may confirm MS and help plan surgery, without ERCP. Tube
dislodgement must be prevented.
Synchronous colorectal liver metastases in pregnancy and post-partum
Danielle Robson1, Joel Lewin1, Anthony Cheng2, Nicholas O'rourke1, David Cavallucci1
1Royal Brisbane Hospital, 2Royal Adelaide Hospital
Metastatic colorectal cancer (mCRC) in pregnancy and post-partum is rare, but represents
significant diagnostic and therapeutic challenges for clinicians. A multidisciplinary team (MDT)
approach is essential. This study reports the first series in the Australasian literature, describing
our experience with and management of pregnant and post-partum patients diagnosed with
synchronous colorectal liver metastases (sCRLM).
A retrospective review of prospectively collected data for patients with sCRLM diagnosed during
pregnancy or post-partum, presenting to a tertiary referral hospital between 2009 and 2014,
was performed. Data regarding patient presentation, imaging, management, histopathology and
survival were analysed. Patient characteristics and outcomes were reviewed, including age,
presenting complaint and median survival.
Five patients were identified with sCRLM: three patients were diagnosed antepartum and two
post-partum. Median age was 31 years (range 26–34). All patients were diagnosed with
colorectal primary and synchronous liver lesions. All patients received folinic acid, fluorouracil,
oxaliplatin chemotherapy, two intrapartum. One patient had both the primary lesion and liver
metastases excised early post-partum. Second-line chemotherapy with folinic acid, fluorouracil,
irinotecan and other biological agents was used in some cases post-partum. One patient
suffered a fetal loss, while the other four had uncomplicated live births. Median survival was 7.6
months, with two patients dying shortly after delivery.
The diagnosis of mCRC in pregnancy is challenging and survival is
poor. A MDT approach to management is essential. Chemotherapy remains the mainstay of
treatment from the second trimester. Rapid confirmation of diagnosis and early chemotherapy,
followed by post-partum colorectal and liver resection may improve survival.
Hepatic hydatid cyst presenting with obstructive jaundice
North Eastern Indira Gandhi Regional Institute of Health and Medical Services
A fifty year old male presented with pain of upper abdomen off and on for about three weeks
duration with yellowish discolouration of eyes and generalised itchiness for the same duration.
Patient had associated fever with chills and rigor. Stool colour was normal and there was no
melena. On examination the patient was found to be deeply icteric with scratch marks in various
parts of the body. Gallbladder was palpable. No other organomegaly was found. Other systemic
examinations were normal. Serum bilirubin was found to be about fifteen with predominantly
conjugated hyperbilirubinemia. Serum alkaline phosphatase was also raised without significant
rise in AST and ALT. Ultrasonography of abdomen showed a large cystic mass occupying the left
lobe of liver. MRCP showed a well defined cystic lesion centered towards the left lobe of the
liver with folded membranes within suggesting hydatid cyst. The cyst was communicating with
the left main hepatic duct. Membrane from the cyst was prolapsing into the CHD and CBD
causing significant dilatation of the proximal biliary tree. The gallbladder was also distended.
The patient was started on broad spectrum antibiotic and albendazole. Once patient was
clinically stable for about a week, he was planned for surgery. On opening the abdomen the
peritoneal cavity was packed with povidone iodine soaked mops all around the liver. The cyst
cavity was punctured and all the fluid and membranes were sucked out. Cholecystectomy was
done followed by choledochotomy to suck out the remaining membranes from the bile ducts
and choledochoduodenostomy was done to allow for better drainage of any remnant cyst
contents. The communication to the liver surface was closed with prolene 4-0 sutures.
Postoperatively the patient recovered uneventfully and was discharged after ten days of surgery
with the advice to continue with albendazole for another three weeks and patient was.
Recurrent pyogenic cholangitis second to double common bile duct: A case report
Kalpana Vijaykumar, Adrian Chiow, Siong San Tan
Changi General Hospital
Anatomical variations of the biliary tree are not uncommon, with a reported 15% based on
surgical studies. Double common bile duct anomalies, however, are rare. We review this case of
a 43 year old Chinese gentleman with recurrent pyogenic cholangitis (RPC) due to a double
common bile duct anomaly.
He presented with a two day history of abdominal pain and fever and had epigastric tenderness
on examination. Initial investigations showed raised inflammatory markers and deranged liver
function tests. Further imaging studies revealed a segment II/IVa liver abscess with a double
common bile duct variant and features suggestive of RPC. He initially declined treatment but
was re-admitted after one month, critically ill and in septic shock. He was admitted to the
intensive care unit, intubated and on inotropic support. There, he underwent percutaneous
drainage of the liver abscess and the biliary system emergently to relieve the sepsis. MRI liver
with MRCP confirmed an anomalous double bile duct variant with evidence of left intrahepatic
biliary drainage into the stomach and the right lobe draining via the main common bile duct.
Upper endoscopy visualized the entry of the bile duct into the stomach. He then underwent a
left hepatectomy with caudate lobe resection with cholecystectomy with an uneventful
recovery. Histology confirmed RPC of the left liver and caudate lobe with no evidence of
This is the first reported case locally of a double common bile duct anomaly causing RPC.
Though double common bile duct anomalies may be uncommon, the potential complications
that can arise include choledocholithiasis, cholangitis and gastrointestinal malignancy if the site
of opening of the double common bile duct is in the stomach, duodenum or pancreatic duct.
Hence, it is important to recognize these potential complications and thoroughly evaluate such
patients with biliary tree anomalies.
IS PRE-OPERATIVE CHEMOTHERAPY A RISK FACTOR FOR POST-HEPATECTOMY LIVER
FAILURE IN PATIENTS WITH COLORECTAL LIVER METASTASIS?
Clarence Mak, Charing CN Chong, YS Cheung, John Wong, KF Lee, Paul BS Lai
Prince of Wales Hospital
To determine whether pre-hepatectomy chemotherapy was associated with an increased risk of
post-hepatectomy liver failure (PHLF), and other post-operative outcomes.
131 patients underwent hepatectomy for colorectal liver metastasis at the Prince of Wales
Hospital, Hong Kong, from 2002 to 2012. 64 patients received pre-hepatectomy chemotherapy.
50 patients had chemotherapy as adjuvant therapy after colectomy for the primary disease,
while 18 patients were given chemotherapy for downstaging of tumour before hepatectomy.
Incidence of PHLF, as defined by the International Study Group of Liver Surgery, was the primary
outcome, and compared between patients receiving and not receiving chemotherapy. Liver
fibrosis, steatosis, overall survival, disease-free survival, total blood loss, operation time,
recurrence and post-operative hospital stay were also compared between the two groups.
Other potential risk factors for PHLF were also determined.
Patient characteristics of the two groups are shown in Table 1. The mean follow-up time was
37.9 months . The overall incidence of PHLF was 19.1%, with no difference between the two
groups, with PHLF being 15.6% for chemotherapy and 22.4% for no chemotherapy groups. There
was also no difference in other post-operative outcomes (Figures 1&2, Table 2) and overall
survival or disease free survival. Multivariate analysis showed that pre-operative white cell
count (WCC) and the number of liver segments resected were associated with the chance of
having PHLF (Table 3 &4). ROC analysis showed that increasing WCC was related to a lower
chance of PHLF, with a cut-off of white cell count level at 5.75.
Pre-hepatectomy chemotherapy was not a determinant of PHLF and other outcomes. Our
results suggested that allowing time for recovery after pre-hepatectomy chemotherapy, and
waiting for WCC to rise to above 5.75 in patients with colorectal liver metastases could possibly
reduce the chance of having PHLF.
(figures and tables to be included)
A Case Study: A Laparoscopic Approach to Mirizzi's Syndrome Secondary to Cystic Duct
Stone from Aberrant Cystic Duct
Chee Hoe Koo, Ho Chun Yin Derek, Adrian Chiow
Changi General Hospital
Mirizzi's Syndrome has been estimated to occur in approximately 5% of patients who undergo
cholecystectomies(1). Case studies of an open approach to Mirizzi's Syndrome in aberrant cystic
duct anatomy have been described(2). We discuss the laparoscopic technique to this rare
A retrospective case review of a patient presenting to Changi General Hospital in July 2015.
A 27 year-old gentleman presented with cholangitis with raised bilirubin 150 umol/L. His initial
computed tomography (CT) scan showed prominent upper biliary tract dilatation with suspected
choledocholithiasis. Emergent ERCP showed extrinsic compression of mid CBD without main
duct stones for which he was stented for biliary decompression. Subsequent MRCP performed
confirmed Mirizzi's syndrome likely secondary to gallstones impacted in the aberrant long cystic
duct inserting posteromedially and low into the CBD.
The patient was planned for an early laparoscopic cholecystectomy and CBD exploration.
Intraoperative cholangiogram confirmed multiple impacted cystic duct stones. The cystic duct
was isolated and explored lateral to the CHD, and large impacted stones were removed under
choledochoscopic guidance, followed by laser lithotripsy. Check choledochoscopy visualised
complete clearance of the cystic duct to the CBD with stent in situ. The patient was discharged
well with subsequent repeat ERCP at 2 months showed complete clearance of stones.
A laparoscopic approach to this rare clinical presentation is safe and effective. The use of an
intra-operative cholangiogram is helpful in confirming biliary anatomy and a trans-cystic
choledochoscopic approach with lithotripsy can help to facilitate full clearance of stones from
the biliary system.
1) Beltran MA, Csendes A, Cruces KS. The relationship of Mirizzi syndrome and cholecysto-
enteric fistula: validation of a modified classification. World J Surg 2008; 32:2237.
2) Khoshnevis J, Akbari M. Mirizzi's Syndrome in a cystic duct variation. Gastroenterol Hepatol
Bed Bench. 2014 Winter;7(1):68-71
Traumatic Pancreatic Injuries - A retrospective review
Yang Yang Lee
Singhealth General Surgery
Pancreatic trauma remains a source of significant morbidity and mortality. These injuries are
commonly missed on perioperative imaging, with delayed presentation and diagnosis associated
with worse outcomes.
The trauma registries of three tertiary centres in Singapore were retrospectively reviewed for
patients with pancreatic injury. The morphology of pancreatic injury and other intraabdominal
injuries were assessed from either radiological imaging or laparotomy findings.
25 consecutive cases of trauma patients with pancreatic injuries were identified from
retrospective chart review. The most prevalent mechanism of injury was direct blunt trauma to
the abdomen. All patients had concomitant intraabdominal injuries. There were 7 deaths
(mortality 28%), with 5 deaths occurring in the first 24 hours of admission. Of the 20 patients
who survived beyond 24 hours, 7 patients had injuries to the main pancreatic duct, and 16
patients with parenchymal injuries. Early mortality during the first 24 hours was associated with
extensive major vessel injury. Complex pancreatoduodebal injuries and major transections of
the main pancreatic duct were rate, but were associated with increased complications and
A high index of suspicion for pancreatic injury must be considered in cases of blunt abdominal
trauma. Evaluation of ductal integrity and definitive therapy are required to reduce morbidity
An unusual cause of overt upper GI bleeding: Retrograde jejunogastric
Hilmi Elsiddig, Suliman Suliman, Omer Salim, Shakir Ibrahim
University of Khartoum Soba University Hospital
Retrograde Jejunogastric Intussusception is an uncommon but potentially life threatening
complication of gastrojejunostomy or partial gastrectomy. Around 200 cases have been
reported in English literature till now.
A 60 years old man presented with three days history bilious vomiting. On admission, he
vomited one liter of dark blood. There is no history of upper abdominal pain. He has undergone
vagotomy and gastrojejunostomy for peptic ulcer 30 years back. and he was asymptomatic until
his recent admission to the emergency department. He was dehydrated; with pulse rate
110/min. He has an upper mid-line scar. Epigastric region was distended and there was a vague
feeling of epigastric mass. Upper GIT endoscopy revealed a large clot obscuring the distal
stomach. CT abdomen with oral contrast showed small bowel loops in the stomach. Emergency
laparotomy was carried out immediately. He had retrograde jejunogastric intussusception with
gangrenous efferent loop. Resection and refashioning of the gastrojujenostomy was done. The
patient had an uneventful postoperative course and was discharged on day eight.
Retrograde jejunogastric intussusception was first described by Bozzi in a patient with
gastroenterostomy. A palpable abdominal mass can be observed in almost half of the cases. In
most of the case reports, severe epigastric pain is an important early symptom of jejunogastric
intussusception, however in this case report there is no history of epigastric pain in spite of a
gangrenous jejunum and the reason is not well known.
Retrograde JGI is a very serious life-threatening complication of gastric surgery. There is a wide
variation in the lapse time between the gastric surgery and occurrence of JGI, as seen in the
CURRENT MANAGEMENT OF INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM OF THE
Elena Usova, Grigory Karmazanovsky
A.V. Vishnevsky Institute of Surgery
The guidelines for intraductal papillary mucinous neoplasm (IPMN) management have been
changed over the past few years. Although its surgery is increased mostly due to advances in
radiology, many trends remain controversial.
The aim of this presentation is to discuss the current challenges and developments of IPMN
The recent advances in work-up and surgery of IPMN of the pancreas were summarized. The
guidelines for its management were highlighted. The diagnostic and treatment features from
single-institution experience for case series were demonstrated.
The Fukuoka Guidelines published in 2012 demanded to be reviewed over the past few years
because of obtaining surgical experiences for IPMN treatment at high volume centers
worldwide. The recent Recommendations of Verona Consensus Meeting provided the more
accurate definitions for different tumor types, and therefore work-up and treatment features
were reviewed and reported depending on a variety of factors. Based on our experience we
presented the controversial cases to distinguish the invasive carcinoma especially using modern
radiology techniques. The issues of routine frozen sections have been discussed.
The management of IPMN of the pancreas continues to be challenged. The results from the
literature support our institution data for its treatment. The current guidelines are expected to
be advanced the next few years.
Predictive Values of Acoustic Radiation Force Impulse Imaging of the Pancreas for
Pathological Fibrosis and Risk of Postoperative Pancreatic Fistula
Nobuhiro Harada1, Takeaki Ishizawa2, Junichi Arita2, Yoshihiro Sakamoto3, Kiyoshi Hasegawa3,
1Kohnodai Hospital National Center for Global Health and Medicine, 2Cancer Institute Hospital
Japanese Foundation for Cancer Research, 3The University of Tokyo
The aim of this study was to evaluate whether or not the shear wave velocity (SWV) of the
pancreas measured by preoperative acoustic radiation force impulse (ARFI) imaging correlated
with the pathologic degree of pancreatic fibrosis and pancreatic exocrine function in patients
undergoing pancreatic resection. The effect of SWV measurement of the pancreas in estimation
of a risk of postoperative pancreatic fistula (PF) was also assessed.
SWV of the pancreas was preoperatively measured by ARFI imaging in 62 patients undergoing
pancreatic resection. Correlations of SWV with pathologic degree of fibrosis in the resected
pancreas, exocrine function of the remnant pancreas, intraoperative manual palpation, and the
incidence of postoperative PF were evaluated.
The SWV was positively correlated with the degree of pancreatic fibrosis (Spearman's rank
correlation coefficient [ρ] = 0.660, p < 0.001) and inversely correlated with postoperative
amylase concentrations and daily output of pancreatic juice. SWV of patients with "hard"
pancreas by manual palpation was significantly higher than those with "soft" pancreas (p <
0.001). The incidence of postoperative PF was significantly higher in the 32 patients with soft
(SWV < 1.54 m/s) than in the 30 with hard (SWV ≧ 1.54 m/s) pancreas (63% vs 17%, p < 0.001).
Multivariate analysis showed that a soft pancreas (SWV < 1.54 m/s) was an independent
predictor of postoperative PF (odds ratio 38.3; 95% CI 5.82 to 445; p = 0.001).
Preoperative measurement of pancreatic elasticity by ARFI imaging accurately reflected the
pathological degree of fibrosis and exocrine function of the pancreas, enabling estimation of the
risk of postoperative PF in each patient undergoing pancreatic resection.
Comparison of outcome of billliary enteric anastomosis for different indications in a
university hospital over the past two years. Henok Seife - Fellow HPB surgery Addis Ababa
University College of Health Science Hiwot Zerihun - Masters in public health
Henok Haile1, Hiwot Adugna2
1Addis Ababa University College Of Health Science, 2Ras Desta Hospital
There are different types billiary enteric anastomosis done with literatures preferring one over
the other for different reasons. This study is conducted to compare and see the outcomes of the
commonly done billiary enteric bypass surgeries namely choledochoduodenostomy,
choledocojejunostomy ,hepaticojejunostomy , and cholecystojejunosstomy
All patients admitted and operated in the duration of January 1 2013 up to December 31 2014
are included and chart review done retrospectively to fill out a preformed questionnaire and the
data analyzed using 10.1 SPSS data processor.
39 patients were operated in the duration Out of these 28(71.8%) were females and 11(28.2)
were males. 18(46,2%) were in the age group 50 – 70 years and 14 patients age between 30 –
50 years . Over all 12 (30.7%) patient had postoperative complication 8 (20.5%) wound
infections, three (7.7%) billiary leaks and one sepsis of pulmonary origin. All 19 cases 0f
choledochoduodenostomies, had no billiary leak but 3 (15.8% )had wound infection. 7 cases of
choledochojejunostomies complicated with 2 (28.5% ) wound infection. Seven
cholecystojejunostomies done and there were two ( 28.8%) cases of wound infection and two
cases (28.8%) of temporary billiary leak. Six patients had hepaticojejunostomy . of which one
patient (16.7% ) had wound infection, one patient (16.7% )had transient billiary leak
Though the number of patients are small to induce deduction according to this study there is no
statistically significant different in the immediate outcome of patients operated with all four
types of billiay enteric anastomosis.
A rare cause acute abdomen - torsioned intra abdominal testicular tumor
Addis Ababa University College Of Health Science
To give an awareness in the evaluation of acute abdomen specially in patients with
undescended testes and consider a case of complicated or torsioned testicular tumor and have
a high index of suspicion
A patient presented to the emergency OPD as an acute abdomen was evaluated and admitted
as a case of acute abdomen secondary to complicated appendicitis with periappendicial abscess
or complicated undescended testes. Patient is prepared and taken to the Operation Room after
taking consent of possibility of orchidectomy.
The above mentioned patient was put on operation table and general anesthesia was given at
which time a big mass in the right abdomen became evident which originally could not be
palpated because of severe tenderness. With lower midline incision abdomen opened and a big
highly vascular testicular tumor was rotated 360 degrees around its mesentery and was
gangrenous and hence resected. There were no paraaortic LNs or local invasion. Histopathology
revealed seminoma and patient sent for oncology unit for further treatment.
Detecting such rare cases in the routine management of acute abdomen specially in hospitals
loaded with patients is usually difficult but the preoperative diagnosis of the case will give a lot
of room for beforehand preparation. A torsioned testicular tumor as a case of acute abdomen is
a very rare cause and it needs a high index of suspicion which is hugely aided by the a complete
physical examination like checking for descent of both testes. Our suspicion helped as to get the
patient's signature for possible orchidectomy.
HOW TO ESTABLISH A CENTER OF EXCELLENCE IN LIVER SURGERY AND
The liver surgery in Sudan for many reasons has never progressed compared to regional and
international achievements in this field.
The goal is to establish a centre of excellence in liver surgery according to modern series
definition a perioperative mortality <3% and 5-year survival rates above 50% are expected
.Particularly makuuchi al has emphasized the anatomical liver resection respects the
oncological principles minimizes blood loss and hence improves survival .
The liver surgery unit recently launched in Ibn Sina hospital which is a tertiary referral center in
Sudan . The staff recruitment was our main concern especially the anaesthetist radiologist ,
oncologist and gastroenterologist who were has the insight to progress in this track.
. Eight liver resection were done five cases were HCC , one hilar cholangiocarcinoma ,one
haemangioma and the eighth was right posterior lobe resection for breast cancer liver
metastasis from 24th of September 2014 to 28th of April 2015 . In all cases anatomical
resections were succeeded and the survival through out these cases we faced technical and
resources challenges that were managed successfully .
The liver surgery and transplantation center is a dream that must be achieved in Sudan and in
most Sub-Saharan Africa region . The corner stone of this project is the multidisciplinary team
work that has been created and it is behind this giant stride
Patients with Gallstones in a Tertiary Hospital – an Audit of Presentations and
Brent Cohen1, Anthony Cheng2
1Princess Alexandra Hospital, 2Royal Adelaide Hospital
Gallstones account for a large proportion of acute and elective surgery. Here we analyse the
workings of a high volume centre with an acute surgery unit.
A retrospective review of patients presenting to Princess Alexandra Hospital with symptomatic
gallstones (Jan-Dec 2012). Demographics, clinical variables, operative data and re-presentations
402 patients (44% male) presented with gallstone pathology. 279 (69%) were emergency
admissions and 123 patients had elective cholecystectomy. Of the emergency cases, 229 (82%)
proceeded to cholecystectomy; 88 were initially managed non-operatively; 25 had biliary
drainage; 8 had no procedure; 17 were lost to follow up. Emergency case theatre times are
significantly longer than in elective cases (190 vs 120 minutes, respectively). Bile duct
exploration rate was similar in both groups (16% vs 14%). Acute cholecystitis (AC) was the
diagnosis in 107 (56%) of the emergency surgery patients. AC operative times were longer than
for biliary colic (155 vs 125 minutes) with biliary obstruction operations significantly longer than
both (186 minutes). 122 (64%) emergency cases had surgery within 5 days. Patients with AC
were more likely to have early surgery compared to those with other gallstone pathologies (70%
vs 56%). Only 28 (7%) patients re-presented to hospital after their initial presentation.
Emergency presentations of gallstones accounted for a large proportion of biliary surgery.
Cholecystitis comprises the bulk of acute operating, which tends to be performed promptly and
has longer operating times. A low 7% re-presentation rate was likely facilitated by the acute
Surgical Management of Ampullary Somatostatinoma
Nicholas Philips1, Anthony Cheng2, Nicholas O'rourke1
1Royal Brisbane Hospital, 2Royal Adelaide Hospital
Somatostatinomas of the ampulla are rare neuroendocrine tumours. The classical presentation
with inhibitory syndrome is rare. There are few studies in the literature on which to base
optimal management of these patients. We report here a case series where complete surgical
resection of these tumours has enabled long-term survival.
A retrospective review of cases by a single surgeon involving ampullary somatostatinoma was
conducted, with data relating to patient presentation, imaging and staging, surgical
management, histopathology and survival obtained.
Three cases of ampullary somatostatinoma are described: two sporadic and one familial,
associated with neurofibromatosis type 1. The first patient presented with pruritus, the second
with recurrent pancreatitis and the third, with pelvic pain. Various preoperative localisation
pancreaticoduodenectomy (PD) and were disease free at most recent follow-up.
Long-term survival is achievable through PD for resectable ampullary somatostatinoma.
Literature on clinical presentation, useful diagnostic modalities and surgical options for the
management of somatostatinoma are discussed.
A novel laparoscopic liver resection difficulty score - a validation study
Deepa Chandra Segaran1, Jin Yao Teo2, Brian Goh2, Chung Yip Chan2, Alexander Chung2, Ser Yee
1National University of Singapore, 2Singapore General Hospital
Laparoscopic liver resection (LLR) was initially limited to small and accessible lesions but with
experience, major and complex LLR is not uncommon nowadays. Surgical expertise is based on
cumulative experience through procedures of increasing difficulty. Due to the complexity and
the different perspectives of LLR, various aspects of the procedure need to be relearned. These
pose new challenges as the difficulty of a procedure is not well translatable from an open to a
laparoscopic approach. We aim to validate a novel LLR difficulty score with our experience.
The LLR difficulty score is based on tumor location, size, procedure, cirrhosis and proximity to
major vessels with a total score of 0-10, grouped into 3 levels of difficulty. Clinical and operative
data of patients who underwent a LLR in our institution was reviewed. Surrogates of difficulty
such as operating time, intraoperative blood loss and conversion rate were used to validate the
From 2006-2015,239 patients underwent a LLR of which 58, 107 and 74 patients were scored as
low, intermediate and high index of difficulty ,respectively. In the low, intermediate and high
difficulty groups, proportion of non-pure LLR (e.g. conversion or hand-assisted) were 6.9 vs. 13.1
vs. 27 % (P=.004); Median intraoperative blood loss were 50 vs. 200 vs. 500mls (P<.001); Median
operative time were 143 vs. 210 vs. 358mins (P<.001), respectively. Surrogates of difficulty
correlated well with the difficulty index.
This is the first validation of a novel LLR difficulty score and based on our experience, it serves
well as a guide. This is useful for selecting patients according to the individual surgeon's phase in
his/her learning curve.
Preoperative splenic embolisation for left sided portal hypertension
Mrunalkant Panchal1, Amit Ganguly2
1Sarjanam Hospital, 2CHL Hospital
To make surgery in Lt sided portal hypertension safe.
We present our experience of managing a patient of Lt. sided portal hypertension due
pancreatic lesion compressing splenic vein, who underwent pre operative splenic artery
A 23 year old lady presented with complaints of pain / dargging sensation in abd mainly on the
Lt. side of abdomen ,increased menstrual bleeding and with one episode of hemetemsis . On
examination she was found to have massive splenomegaly up to umblicus. Blood investigations
showed anemia and thrombocytopenia. Abdominal imaging showed a mid body pancreatic
lesion approx. of 5 cm in size with massive splenomegaly and large collaterals in the region of
hilum , GE junction and retro peritoneum.Upper G.I. Endoscopy showed large varices in lower
In view Lt sided portal hypertension in order to decrease the blood loss patient was first
subjected to angioembolization of splenic artey. she underwent Distal pancreatectomy and
splenctomy. During surgery the collaterals were collapsed and the entaire procedure could be
completed with less than 100ml of blood loss.Biopsy of the lesion showed Solid pseudo-papillary
tumor of pancreas with congestive splenomegaly .
Splenectomy is curative for Lt. sided portal hypertension. During the period of 2010-2015 we
treated 6 cases of Lt. sided portal hypertension. Our avarage blood loss during these
splenectomy is approx. 750ml. Post angioembolisation patient's platelet counts also improved.
we found pre operative splenic artery embolization a useful adjunct to decrease intraoperative
blood loss and improved platlet counts.
Pre operative splenic artery embolization is a useful adjunct in patients of portal hypertension to
improve platlet counts and to decrease blood loss especially in cases where apart from
splenectomy other procedure also needs to be done .
Solid pseudopapillary tumour of the pancreas: case series on pancreatic malignancies
Solid pseudopapillary tumour of the pancreas (SPPT) is a rare tumour that accounts for less than
3% of all pancreatic tumours. It has a predilection for females in the 2nd and 3rd decade of life.
We report our experience (from 2002 – 2015) of 4 cases of solid pseudopapillary tumour of the
Data regarding clinicopathological features, surgery and outcome for patients with SPPT were
retrospectively collected and analysed.
All 4 patients were female with an age range of 16-32 years (mean 24.8 years). Symptoms were
variable but included non-specific abdominal pain, abdominal mass, nausea and vomiting.
Tumour size ranged from 2.5 to 17cm (mean 9.9cm), with 2 at the head of pancreas and 2 at the
tail. Diagnosis was done preoperatively with CT/MRI, and with EUS and FNAC or percutaneous
biopsy. All patients had curative resection (Whipple's or distal pancreatectomy). Pathologically
the tumours contained solid, cystic and papillary patterns in various proportions, with 3 tumours
containing intratumoral haemorrhage and necrosis. 3 had lymph nodes resections but all
specimens showed reactive nodes. 1 patient also had concurrent splenectomy. After a median
follow up of 59 months, all patients were alive with no evidence of recurrence of metastatic
Solid pseudopapillary tumour of the pancreas should be considered in young women with
pancreatic lesions. These tumours have a low malignant potential but has excellent prognosis
when coupled with radical resection with clear margins.
Comparisons of the RIPASA score with ALVARADO and Paediatric Appendicitis scores
for the diagnosis of acute appendicitis in paediatric patients.
Zahidah Ahmad, Amy Thien, Chong Vui Heng, Chong Chee Fui
To prospectively compare the RIPASA score with Alvarado score and Pediatric Appendicitis score
(PAS) for the diagnosis of acute appendicitis in pediatric patients presenting with right iliac fossa
Subgroup analysis of the original RIPASA vs Alvarado score study of 62 pediatric patients aged
between 1 years and 18 years old, presenting with RIF pain recruited to the Prospective study
comparing RIPASA and Alvarado score were included for analysis. RIPASA score, Alvarado score
and PAS were derived during admission. Receiver operating curve (ROC), sensitivity, specificity,
positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy and
likelihood ratios for all three clinical scoring systems (CSSs) were derived.
The optimal cut-off threshold score derived for RIPASA score, Alvarado score and PAS were 7.5,
7.0 and 6.0 respectively. At their respective optimal cut-off threshold score, the sensitivity,
specificity, PPV, NPV and diagnostic accuracy of the RIPASA score were 96.7%, 84.4%, 85.3%,
96.4% and 90.9%, 70.0%, 84.4%, 80.8%, 75.0% and 82.0% for Alvarado score, and 70.0%, 75.0%,
72.4%, 72.7% and 81.0% for PAS respectively. The likelihood ratio for RIPASA score at optimal
cut-off threshold was 5.8, which was higher than Alvarado score or PAS. The predicted negative
appendicectomy rate for the RIPASA score (14.7%) was lower than the observed rate (25%),
Alvarado score (19.2%) and PAS (27.5%).
The RIPASA score at a cut-off threshold score of 7.5 is a better CSSs for diagnosing acute
appendicitis in children, than Alvarado score or PAS.
Prevalence rates of Post Hepatectomy Liver Failure and Liver Dysfunction in Singapore
Ken Min Chin, Brian Goh, Chung Yip Chan, Peng Chung Cheow, Alexander Chung, Ser Yee Lee
Singapore General Hospital
Hepatocellular carcinoma (HCC) ranks in the top 5 deadly cancers in Singapore. Liver resection is
the major curative treatment modality for HCC. Liver failure is one of the most serious and
dreaded complications after major liver resection. The extent of liver resection is directly related
to incidence of liver failure and liver dysfunction, especially in patients with limited liver
functional reserve. We aim to evaluate the true prevalence rate of Post Hepatectomy Liver
Failure and Liver Dysfunction in our institution.
All patients who underwent a liver resection for HCC in Singapore General Hospital from 2001-
2013 were captured from a prospective database. Clinical and post-operative data of patients
who underwent a right or extended-right hepatectomy was reviewed as these procedures were
the two most extensive parenchymal resection in terms of volume. Three internationally
validated classifications for Post-Hepatectomy Liver Failure and Liver Dysfunction were used to
evaluate our prevalence rate. [(50-50 criteria; International Study Group for Liver Surgery
Criteria (ISGLS), Memorial-Sloan-Kettering Cancer Criteria (MSKCC)]
From the period of 2001 to 2013, 848 patients underwent a liver resection for HCC, of which 157
patients underwent a Right Hepatectomy (RH) or an Extended Right Hepatectomy (ERH). Overall
prevalence rate of PHLF in the whole group based on the 50-50, ISGLG and MSKCC criteria was
7%, 41%, 4% respectively. Prevalence of PHLF in the ERH group tend to be higher than the RH
group: (10 vs. 6%); (45 vs 40%); (3 vs 3%) based on the 50-50, ISGLS and MSKCC criteria
This is the first report of the true prevalence of Post-Hepatectomy Liver Failure and Liver
Dysfunction in our institution which is comparable with many high volume institutions. In future,
this information can be used pre-operatively for patient counselling and to assess the predictive
factors with a propensity matched controls.
Accuracy of ultrasonography in diagnosing acute appendicitis in RIPAS Hospital, Brunei
Kai Shing Koh, Amy Thien
Our objective is to evaluate the accuracy of ultrasonography in the diagnosis of acute
appendicitis in patients with suspected acute appendicitis admitted to RIPAS Hospital, Brunei
We reviewed the electronic medical records of patients aged 12 years and older admitted in the
General Surgery wards in RIPAS Hospital with clinically suspected acute appendicitis between
January 2015 and June 2015. A total of 106 patients underwent ultrasonography examination of
the abdomen and pelvis, and surgery was performed in 42 of 106 patients. The ultrasonography
reports were then correlated with the histopathological results. The remaining 64 of 106
patients who did not undergo surgery were not included in this study.
Ultrasonography correctly diagnosed acute appendicitis in 16 of 42 patients and accurately
excluded acute appendicitis in 10 of 42 patients. However 14 of 42 patients whose initial
ultrasonography results were negative, were found to have acute appendicitis from
histopathologic evaluation. The sensitivity of ultrasonography in the diagnosis of acute
appendicitis in our centre was 53% and the specificity was 83%. The positive predictive value
was calculated as 89% while the negative predictive value was found to be 42%.
In our centre, ultrasonography remains an important imaging modality in the diagnosis of acute
appendicitis. It is a useful adjunct when the diagnosis of acute appendicitis is uncertain clinically
and it aids the surgeon in decision-making. However an ultrasonography that is negative for
acute appendicitis may require further evaluation with another imaging modality, e.g. CT scan.
Safe Design of Custom Lithium Batteries By Paul Edwards, Steatite Batteries Introduction: The World's Favourite Battery Chemistry? Lithium battery technology is often preferred for portable equipment intended for use in harsh environments. Lithium batteries also have a wide operating temperature range, particularly at low temperatures, and are known to have high tolerance of pressure, shock and vibration. The batteries are