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A girl who was born at 40 weeks of gestation weighing 3800 g presented with bilious vomiting and abdominal distension shortly after birth. A lower gastrointestinal contrast study showed a microcolon with small bowel atresia. Subsequently, laparotomy, small bowel resection and anastomosis were done. Intra-operative findings noted jejunal atresia type 3a. Post-operatively, the patient developed persistent conjugated hyperbilirubinaemia and hence, magnetic resonance cholangiopancreatography (MRCP) was performed. MRCP revealed possible biliary atresia (BA) of which the patient underwent Kasai hepato-porto-enterostomy. We reported a rare case of double pathology involving jejunal atresia and BA, describing its aetiology, characteristics and treatment availability based on literature., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Choong Yew Hoe et al.)

Objectives: Cholecystectomy with or without intraoperative cholangiogram (IOC) is an accepted treatment for cholelithiasis. Up to 11.6 % of cholecystectomies have incidental common bile duct (CBD) stones on IOC and 25.3 % of undiagnosed CBD stones will develop life-threatening complications. These will require additional intervention after primary cholecystectomy, further straining the healthcare system. We seek to examine the role of IOC in patients with normal LFTs by evaluating its predictive values, intending to treat undiagnosed CBD stones and therefore ameliorate these issues., Methods: All patients who underwent cholecystectomies with normal LFTs from October 2019 to December 2020 were prospectively enrolled. IOC was done, ERCPs were performed for filling defects and documented as "true positive" if ERCP was congruent with the IOC. "False positives" were recorded if ERCP was negative. "True negative" was assigned to normal IOC and LFT after 2 weeks of follow-up. Those with abnormal LFTs were subjected to ERCP and documented as "false negative". Sensitivity, specificity, and predictive values were calculated., Results: A total of 180 patients were analysed. IOC showed a specificity of 85.5 % and a NPV of 88.1 % with an AUC of 73.7 %. The positive predictive value and sensitivity were 56.5 and 61.9 % respectively., Conclusions: Routine IOC is a specific diagnostic tool with good negative predictive value. It is useful to exclude the presence of CBD stones when LFT is normal. It does not significantly prolong the length of hospitalization or duration of the cholecystectomy hence reducing the incidence of undetected retained stones and preventing its complications effectively., Competing Interests: Competing interests: The authors state no conflict of interests., (© 2024 the author(s), published by De Gruyter, Berlin/Boston.)

Introduction: Endoscopic sphincterotomy (EST) plus endoscopic papillary large balloon dilatation (EPLBD) has been reported as a valid alternative to EST alone in removing common bile duct (CBD) stone. The aim of this study is to compare efficacy, and safety of these two groups of patients in removing CBD stone in Hospital Universiti Sains Malaysia (HUSM)., Materials and Methods: This is a prospective single centre randomised single blinded comparative study conducted in HUSM. The primary endpoints for this study are the overall complete stone clearance rate and complication rate, while the secondary outcome for this study are duration of procedure and rate of usage of adjunct methods. Objective data analysis is conducted using independent sample t-test and chi-squared test., Results: A total of 66 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis which is CBD stone. 34 patients were allocated to EST plus EPLBD arm (n=34), and 32 patients were in EST alone arm (n=32) using randomisation method. For intention to treat, patients from EST alone arm that unable to achieve complete stone clearance will be switched to EST plus EPLBD arm. The overall complete stone removal rate for both groups were comparable (EST plus EPLDB: 100% versus EST alone: 93.8%; p= 0.139). The two patients from EST alone group (6.2%) that unable to achieve complete stone clearance were converted to EST plus EPLBD group for intention to treat and able to achieve complete stone clearance by EST plus EPLBD. For procedural time, both arms are comparable as well (EST plus EPLDB: 15.8 minutes vs EST alone: 15.5 minutes; p= 0.860). Complications such as pancreatitis occurred in one patient in EST plus EPLBD arm (EST plus EPLDB: 2.9 % vs EST alone: 0 %; p= 0.328), and bleeding occurred in one patient in EST alone arm (EST plus EPLDB: 0 % vs EST alone: 3.1 %; p= 0.299) , but it is not statistically significant. No perforation or cholangitis complication occurred in both groups. No adjunct usage was observed in both groups., Conclusion: In this study with limited sample size, both EST plus EPLBD and EST alone are effective and has comparable procedural time in removing CBD stone. Even though both methods are equally effective, EPLBD plus EST is an alternative solution if complete stone clearance is unable to achieve via EST alone.

Background: Hepatocellular carcinoma (HCC) among type-2 diabetes (T2D) patients is an increasing burden to diabetes management. This study aims to develop and select the best machine learning (ML) classification model for predicting HCC in T2D for HCC early detection., Methods: A case-control study was conducted utilising computerised medical records in two hepatobiliary centres. The predictors were chosen using multiple logistic regression. IBM SPSS Modeler® was used to assess the discriminative performance of support vector machine (SVM), logistic regression (LR), artificial neural network (ANN), chi-square automatic interaction detection (CHAID), and their ensembles., Results: Subjects (N = 424) were split into 60% training (n = 248) and 40% testing (n = 176) groups. The independent predictors identified were race, viral hepatitis, abdominal pain/discomfort, unintentional weight loss, statins, alcohol consumption, non-alcoholic fatty liver, platelet <150 ×10 3 /μL, alkaline phosphatase >129 IU/L, and alanine transaminase ≥25 IU/L. The performances of all models differed significantly (Cochran's Q-test,p = 0.001) but not between the ensembled and SVM model (McNemar test, p = 0.687). SVM model was selected as the best model due to its simplicity, high accuracy (85.28%), and high AUC (0.914). A web-based application was developed using the best model's algorithm for HCC prediction., Conclusions: If further validation studies confirm these results, the SVM model's application potentially augments early HCC detection in T2D patients., Competing Interests: The authors declare no conflict of interest., (© 2022 The Author(s).)

Maintaining hepatopancreatobiliary (HPB) services during the initial phase of a pandemic in a state referral hospital for COVID-19 presents a few challenges, especially when a nationwide, government-issued partial lockdown is in enforcement. We describe the adaptations to our practice to maintain the services whilst ensuring safety of patients and staff, by postponing non-urgent clinic cases, grouping our staff to two mutually exclusive teams that work on alternate shifts and selecting HPB operative cases according to the modified Risk Urgency Decision Matrix.

WHO declared worldwide outbreak of COVID-19 a pandemic on 11 March 2020. Healthcare authorities have temporarily stopped all elective surgical and endoscopy procedures. Nevertheless, there is a subset of patients who require emergency treatment such as aerosol-generating procedures. Herein, we would like to discuss the management of a patient diagnosed with impending biliary sepsis during COVID-19 outbreak. The highlight of the discussion is mainly concerning the advantages of concurrent use of aerosol protective barrier in addition to personal protective equipment practice, necessary precautions to be taken during endoscopy retrograde cholangiopancreatography and handling of the patient preprocedure and postprocedure., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A biliary fistula which may occur spontaneously or after surgery, is an abnormal communication from the biliary system to an organ, cavity or free surface. Spontaneous biliary-enteric fistula is a rare complication of gallbladder pathology, with over 90% of them secondary to cholelithiasis. Approximately 6% are due to perforating peptic ulcers. Symptoms of biliary-enteric fistula varies widely and usually non-specific, mimicking any chronic biliary disease. Cholecystoduodenal fistula causing severe upper gastrointestinal (UGI) bleed is very rare. Bleeding cholecystoduodenal fistula commonly requires surgical resection of the fistula and repair of the duodenal perforation. We describe the case of a previously healthy older patient who initially presented with symptoms suggestive of UGI bleeding. Bleeding could not be controlled endoscopically. When a laparotomy was performed, a cholecystoduodenal fistula was discovered and bleeding was noted to originate from the superficial branch of cystic artery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Various techniques and instruments have been developed to provide safe and secure closure of laparoscopic wounds. Herein we describe a simple method to close laparoscopic supraumbilical wounds with the aid of a laparoscopic port., Method: This was a retrospective review of prospective data, which were from 151 patients who underwent laparoscopic cholecystectomy for symptomatic gallstone disease from December 2009 to December 2010 in Sultanah Bahiyah Hospital. A senior consultant hepato-pancreato-biliary (HPB) surgeon and two HPB trainee surgeons performed the operations. Postoperatively, all patients were followed up at 4 weeks., Results: All patients successfully underwent closure of the supraumbilical wound with the assistance of a 5mm laparoscopic port. None of the patients had incisional hernia on follow up., Conclusion: Port assisted closure of supraumbilical laparoscopic wounds is a feasible and safe technique.