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Introduction: Splenic abscess is an uncommon clinical problem. Traditionally, the "gold standard" treatment has been splenectomy. However, there is increasing use of non-operative treatments worldwide., Materials and Methods: A 10-year (1996-2005) retrospective review of case records from a single centre (an 800-bed general hospital) was performed. Information regarding demographics, clinical presentation, aetiological agents and management was gathered and analysed., Results: There were 21 cases from 1996 to 2005. Nineteen (90%) had multiple abscesses. Disseminated melioidosis was the most common aetiological agent (15 cases, 71%). Only 3 patients underwent splenectomy. The remainder were treated conservatively with antibiotics. Almost all the patients (19, 90%) also suffered from diabetes mellitus., Conclusions: The most common aetiological agent encountered was Burkholderia pseudomallei. Diabetes mellitus may be an important co-factor in the pathogenesis of splenic abscesses. The majority of our patients were managed conservatively and splenectomy was only occasionally required.

Objective: This study reviews the functional outcome and satisfaction of patients after subtotal or total colectomy (STTC)., Methods: A retrospective review of patients who underwent STTC between June 1999 and September 2003 was performed. A standardized questionnaire was formulated and phone interviews were conducted with these patients., Results: There were 50 patients who underwent STTC during this period. The most common indications were bleeding diverticular disease, patients with synchronous colorectal cancers or polyps and left-sided colonic obstruction. The presence of ischaemic heart disease and the development of perioperative acute coronary syndrome were found to be statistically significant predictors of 30 day mortality with P = 0.01 and 0.05, respectively. Phone interviews were successfully conducted in 33 patients. The patients interviewed were between 4 and 54 months postsurgery. Ninety-four percent reported that they were either happy or satisfied. Cleveland Clinic Incontinence Score (CCIS) revealed good or perfect continence in 94% of patients. Less than one-quarter of those interviewed had five or more bowel movements in a day while most had either two or three bowel movements a day. Patient satisfaction after STTC correlated strongly with the severity of CCIS and number of bowel movements a day (P < 0.01). Also, those with less than five bowel movements a day were more likely to report a better satisfaction (P < 0.01)., Conclusion: Subtotal or total colectomy is associated with a good functional outcome and most patients were satisfied with their bowel function on follow-up.

Background: Breast cancer in young patients is often associated with a poorer prognosis, but there has been a paucity of published data in an Asian population., Methods: One hundred and six patients (12.6%) under the age of 40 years with breast cancer (group V) were compared with 737 patients with breast cancer aged 40 years or more (group W). Demographics, presentations, pathological profiles, treatment and survival measures were analysed., Results: Median tumour size was similar in both groups. Group V had more patients with grade 3 tumours and nodal involvement compared to group W (51.5% vs 38.1%, P = 0.012 and 52.5% vs 41.8%, P = 0.045). The mean Nottingham prognostic index (NPI) score was significantly higher in group V compared to group W (4.75 vs 4.26, P < 0.001). The incidences of chemotherapy and radiotherapy in group V were higher than group W (69.2% vs 35.2%, P < 0.001 and 41.1% vs 24.4%, P = 0.002). There were no differences in overall survival and disease-free survival (local recurrence)., Conclusion: Patients below 40 years with breast cancer have tumours with a poorer prognostic profile. However, this did not translate into a poorer overall survival, and this might be attributable to more aggressive adjuvant treatment of younger patients.

Background: Mirizzi syndrome is uncommon. It is, however, clinically important, as it is associated with an increased incidence of bile duct injury and demands more complex surgical techniques., Methods: A retrospective review of 24 consecutive cases of Mirizzi syndrome that arose between January 1997 and July 2002 was performed. A total of 1881 cholecystectomies were performed during that period., Results: Of the 24 patients, 19 (79.2%) had Mirizzi type I, four (16.7%) had type II, while one (4.2%) had type III disease. Only 54.2% of patients were symptomatic prior to presentation. One-third of patients had normal liver function tests. Ultrasonography and computed tomography were not helpful in diagnosing this entity. Endoscopic retrograde cholangiopancreatography (ERCP) was useful to identify cholecystocholedochal fistulas and to allow therapeutic endoscopic stenting but failed to pick up the syndrome in half of the patients. Inadvertent bile duct injury occurred in four patients (16.7%), all occurred in patients without a preoperative diagnosis. Three of the four injuries occurred during operations by a senior registrar rather than a consultant. Mirizzi type I was managed with either total or subtotal cholecystectomy, while types II and III cases were managed with either T-tube insertion or biliary bypass procedures. Bile duct injury was managed with T-tube successfully in one patient while the rest went on to biliary bypass operations. All except one patient had good functional outcomes on follow up., Conclusion: The preoperative diagnosis of Mirizzi syndrome is a challenge. Only constant vigilance during intraoperative dissection of the Calot's triangle will reduce the incidence of bile duct injury in Mirizzi syndrome that can occur in both open and laparoscopic surgery.

Introduction: Gastrointestinal intussusception is an uncommon clinical entity in adults and is interestingly distinct from its paediatric form. In adults an identifiable lead lesion is found in the majority of cases, of which a significant percentage are malignant. Its treatment is thus different from that of paediatric intussusception. The present study reviews our experience of treating adult intussusception., Methods: A retrospective review of patients with a postoperative diagnosis of gastrointestinal intussusception between January 1997 and December 2002 was conducted. All patients under the age of 18 and cases of rectal prolapse were excluded., Results: During the 5-year period, there were nine cases of intussusception. There were four male and five female patients, with a mean age of 63.8 years (range 37-85 years). Less than half of the patients (44.4%) presented with acute symptoms. The most common symptoms were abdominal pain and distension. The symptoms were intermittent in 77.8% (7 of 9) of patients. Only two patients had a palpable abdominal mass, while another had signs of acute intestinal obstruction. Computed tomography was the most useful imaging modality, identifying intussusception in six out of six patients. Eight patients had lead lesions occurring at the ileocaecal junction resulting in ileo-colonic intussusception. Of these eight, four were malignant (two adenocarcinomas and two lymphomas). There was one sigmoid-rectal intussusception secondary to adenocarcinoma. All patients were treated operatively. Seven patients were treated with en bloc resection., Conclusion: Although uncommon, surgeons need to be aware of the epidemiology and treatment options for adult intussusception. The symptoms and signs are often non-specific and the surgeon might be faced with the diagnosis only at laparotomy. Computed tomography is the most useful imaging modality. An identifiable organic lesion is present in most cases, of which more than 50% are malignant (especially in the large bowel). Operative treatment is thus prudent. En bloc resection is recommended for ileo-colonic and colo-colonic intussusception. There is, however, a role of initial reduction in selected patients with ileo-ileal intussusception.

Methylene blue is a vital dye that is used in the treatment of methaemoglobinaemia. It is also used to delineate tissues to facilitate identification during surgery. Discoloration of the urine is known after oral and intravenous administration of the dye. We have used it routinely to detect the presence of defects after colorectal anastomosis. However, there have not been any previous reports of urinary discoloration after brief rectal instillation of the dye. We report a case of self-limiting urinary discoloration after anterior resection with colorectal anastomosis.

Introduction: A rare case of adrenal myelolipoma presenting with spontaneous rupture and retroperitoneal haemorrhage is described., Clinical Picture: A 51-year-old Caucasian male presented with acute onset of right loin pain. Preliminary diagnosis of haemorrhagic adrenal tumour was made on computed tomography (CT) and angiography., Treatment: Vascular embolisation was performed to stabilise the patient prior to definitive surgery. Tumour resection was subsequently performed. Histology confirmed ruptured adrenal myelolipoma., Outcome: The patient made an uneventful recovery., Conclusion: Ruptured adrenal myelolipoma should be considered in cases of spontaneous retroperitoneal haemorrhage. Vascular embolisation may be useful in stabilising the patient prior to definitive surgery.

Carcinoma of the large bowel is the second leading cause of cancer mortality in Singapore. Although the great majority of patients are discovered at a stage where resection with curative intent is possible, almost half of the patients afflicted will die of it. The combination of 5-fluorouracil + levamisole used in patients with curatively resected high risk Dukes B2 and all Dukes' C colon cancers has been shown to reduce cancer recurrence rate and improve overall survival. Since 1990 adjuvant chemotherapy has been recommended for this group of patients. This report describes patients treated in Singapore, their toxicities and their outcome. A total of 341 patients were treated between 1990 and 1996. Treatment compliance was 71.8%. Toxicity was moderate with mainly grade 1-2 nausea and vomiting, diarrhoea, stomatitis, alopecia, and neutropenia. There was 1 treatment-related death. Median recurrence-free interval was 81 months and median survival was not reached at 90 months. This regimen is tolerable. Until further randomised reports comparing 5-fluorouracil + levamisole to other combinations are available, this combination chemotherapy is recommended to patients after surgical resection of the high risk Dukes' B2 and Dukes' C colon cancer to reduce cancer recurrence and improve overall survival.

Background: The mainstay of the management of liver abscesses has been intravenous antibiotics and radiologically guided percutaneous drainage. However, not all abscesses are treated successfully in this way, and some require surgical drainage. Laparoscopic drainage of liver abscesses may be an alternative to open surgical drainage., Methods: Twenty consecutive patients with liver abscesses treated by laparoscopic drainage in combination with intravenous antibiotics were studied prospectively. Fifteen had had failed percutaneous drainage previously., Results: There were 13 right lobe and seven left lobe abscesses ranging from 6 to 25 cm in diameter. Mean operating time was 38 min. Seventeen patients were drained successfully. Three patients developed recurrent symptoms of which two resolved with conservative measures, but one required a second laparoscopic procedure. There were no intraoperative or other postoperative complications in the 20 patients. Follow-up ranged from 5 to 12 months., Conclusions: Laparoscopic drainage of liver abscesses, in combination with systemic antibiotics, is a safe and viable alternative in all patients who require surgical drainage following failed medical or percutaneous treatment, and in those with large abscesses.

Objective: To assess the advantages of patient-controlled analgesia (PCA)-in patients undergoing extracorporeal shockwave lithotripsy (ESWL) for urinary stones., Patients and Methods: Between December 1995 and May 1996, a prospective study was carried out on 100 patients who underwent ESWL for urinary stones. The patients were assigned to two equal groups, one receiving PCA and the other pethidine (control). Patients in the PCA group self-administered varying doses of intravenous alfentanil according to their pain tolerance, while those in the control group were given a single bolus dose of 1 mg/kg body weight intravenous pethidine by the attending urologist before the start of the procedure. The stone site, maximum energy level achieved, number of shock waves given, duration of procedure, pain scores, patient tolerance and acceptance were recorded to assess the efficacy of PCA compared with analgesia controlled by the physician., Results: Both groups were matched for age, body weight, stone location and number of shocks given. The PCA group received a mean of 1.03 mg alfentanil while the control group received a mean of 62.5 mg pethidine. The maximum discharge voltage of 16 kV was achieved in all but one patient (98%) in the PCA group whereas only 21 patients (42%) in the control group attained this level. The mean treatment duration was less in the PCA group (32.8 min) than in the control group (44.5 min), the mean pain score lower (3.76 and 4.62, respectively) and the incidence of nausea and vomiting much less (22% and 60%, respectively). In addition, all 21 patients in the PCA group who had received intravenous pethidine during previous sessions of ESWL chose PCA as the better form of analgesia. There were no adverse effects in the PCA group except for one patient whose arterial oxygen saturation decreased transiently., Conclusion: PCA enables the urologist to achieve better patient compliance through better pain control; its application has maximized the use of lithotripsy and the patients' acceptability for this form of analgesia is confirmed. We recommend that this form of analgesia be used for ESWL.

Background: The objective of our study was to assess the efficacy and safety of glutaraldehyde cross-linked collagen injection in the treatment of female urinary stress incontinence., Methods: We conducted a retrospective analysis of the records of 105 women who underwent collagen injection for urinary stress incontinence between March 1991 and April 1995. Preoperative assessment included uroflowmetry, residual urine determination, and urodynamic studies., Results: Of the 105 women in our series, 95 patients (90.5%) had initial successful results at 3 months (61.0% cured, 29.5% significantly improved) while 4 patients (3.8%) had slight improvement and 6 (5.7%) failed surgical correction. One year after the procedure, the success rate dropped to 81.9% (86 patients) with 46.7% cured and 35.2% significantly improved. Nine patients (8.6%) had slight improvement and 10 patients (9.5%) failed surgical correction. Eight patients (7.6%) with initial unsatisfactory results underwent additional sessions of collagen injection and were subsequently either cured or had significant improvement. Twenty-three patients (21.9%) suffered a relapse. The mean time to relapse was 13.3 months, and 6 of those who relapsed underwent repeated injections with favorable results. Complications were minimal; 6 patients had temporary retention of urine, and 2 patients had urinary tract infections., Conclusions: We conclude that glutaraldehyde cross-linked collagen injection is a simple and safe method of treatment for urinary stress incontinence. A longer follow-up period is necessary to assess the long-term efficacy of this treatment.

Background: The prevalence of benign prostatic hyperplasia (BPH) is believed to be highly significant in most communities. In our country, many elderly men are unaware that something can be done for their troublesome urinary symptoms. The main objective of our prostate health screening was to educate our elderly male population that this is an abnormality, for which treatment is readily available. At the same time, we attempted to determine the prevalence of BPH, to detect possible prostate cancer, and to derive normal prostate specific antigen (PSA) and uroflow values for our population., Methods: Over an eight-day period in April 1994, 799 men above the age of 50 years volunteered to participate in a free prostate screening exercise held at our hospital. The parameters assessed were PSA level, American Urological Association (AUA) symptom score, uroflowmetry, and digital rectal examination (DRE) of the prostate., Results: Elevated PSA levels of more than 4 micrograms/L were detected in 105 men (13.1%). Of these, 23 men (2.9%) had PSA values above 10 micrograms/L. Abnormal AUA symptom scores of more than eight (moderate and severe categories) were noted in 540 men (67.6%). Clinically enlarged prostate glands of more than 20 g on DRE were noted in 80 men (10.0%), and abnormal DRE findings were detected in 48 men (6.01%). Impaired maximal uroflow rates of less than 10 mL/s were recorded in 224 men (39%), while another 167 men (29.1%) had maximal uroflow values in the equivocal zone (between 10 to 15 mL/s). The reference PSA levels at the 5th percentile, 10th percentile, median, mean, 90th percentile and 95th percentile were 0.38, 0.47, 1.05, 1.57, 3.27 and 4.25 micrograms/L, respectively. The age-specific PSA values were 3.51, 3.78 and 6.02 micrograms/L in the 50 to 59, 60 to 69, and 70 to 79 years age groups, respectively, and the reference mean maximal uroflow rates was 14.8 mL/s., Conclusions: Although controversial, our experience with prostate screening was generally positive. As far as our population is concerned, the free prostate screening exercise generated publicity, and succeeded in enhancing public awareness for better prostate health.

A retrospective analysis was performed on 34 female patients who underwent corrective surgery for stress urinary incontinence over a 4-year period at the Toa Payoh Hospital. These patients were offered surgery only after an adequate trial of medical therapy, pelvic floor exercises and weight reduction. Bladder neck suspension operations were performed via the Burch, Stamey and modified Pereyra techniques. Towards the later part of this study, endoscopic injection of Collagen was performed as a salvage procedure in 2 patients. The Burch colposuspension gave uniformly good results, with all patients being completely dry. Seventy percent and sixty percent complete continence were achieved via the modified Pereyra and Stamey techniques respectively. Three patients required additional surgical procedures. Using these techniques, the overall results showed that 27 patients (79.4%) had complete urinary continence following surgery, while the remaining 7 patients (20.6%) experienced significant improvement of symptoms.

Objective: To determine the safety and efficacy of laparoscopic varicocelectomy in the treatment of symptomatic varicocele., Patients and Methods: Indications for surgery were subfertility in 98 patients and pain in nine. All varicoceles were confirmed on Doppler ultrasound. Seventy-two per cent of the patients had left-sided varicoceles and bilateral varicoceles were seen in 27%. A three-puncture technique was used with carbon dioxide insufflation. The spermatic vessels were individually identified and clips were used to ligate the veins. The spermatic artery was preserved in all cases. The operation was performed on a day surgery basis with an average operative time of 61.4 min (56.6 min for unilateral and 75.8 min for bilateral varicocelectomy)., Results: Morbidity was low, with pneumoscrotum in two patients and wound infection in two others. Sixty-one patients for whom pre- and post-operative seminal analyses were available showed improvement in sperm count and motility, with a concomitant fall in the percentage of abnormal sperm forms., Conclusion: Laparoscopic varicocelectomy is safe and effective, causing minimal discomfort and allowing patients an early return to activity.

An unusual case of tuberculosis paronychia with skin infection of the big toe was recently seen in a patient returning from Kalimantan. This was complicated by inguinal lymphadenitis and tuberculosis abscess formation. The diagnosis was made on culture of the pus from the abscess and upon biopsy and histological examination of the skin lesion from the toe. The patient responded to surgical treatment and chemotherapy with ethambutol, rifampicin and isoniazid.

Tuberculosis of the stomach is a rarity. Its diagnosis is difficult as it is often unsuspected or unrecognised. This is a case report of an elderly man who presented with active upper gastrointestinal tract bleeding. The diagnosis was made postoperatively following gastrectomy for bleeding gastric ulcers. The histological specimens showed caseating epithelioid granulomas with Langerhan's giant cells centrally. The authors reviewed the recent literature on tuberculosis of the stomach, and suggest ways to identify the patients at risk.

Small bowel malignancies are very uncommon and adenosquamous carcinomas of the small intestine are extremely rare. We report the second case of an adenosquamous carcinoma of the ileum in a 77-year-old Chinese male.

A retrospective analysis was done of 88 cases of laparoscopic cholecystectomy performed by the first author from November 1990 to March 1992 at the Toa Payoh Hospital. There were 61 female and 27 male patients; the average age was 47.1 years. The most common presenting symptom was biliary colic (85.3%), followed by acute cholecystitis (10.2%) and gallstone pancreatitis (4.5%). In the vast majority of patients, the diagnosis was established by ultrasound (96.6%) while the remainder was diagnosed by oral cholecystography (3.4%). The operation was performed using the usual 4 puncture approach with the single-handed technique of dissection. Antibiotic prophylaxis with a broad-spectrum agent was used in all patients and there was no incidence of wound infection. A low complication rate of 4.5% was experienced--consisting of 1 case each of subcutaneous emphysema, abdominal colic, fever and bile duct injury. There was no mortality in our series. The conversion rate was 9.1% and this was due to our policy of performing laparotomy whenever the safety of laparoscopic surgery was in doubt. The mean duration of postoperative hospitalisation was 3 days and 7 days after laparoscopic and converted cholecystectomies respectively. The majority of patients (61.4%) returned to work after 2 weeks.

Retrospective analysis of 174 operative cholangiograms done over a 3-year period confirms its substantial benefit when used selectively in patients with clinical criteria for common bile duct exploration. A low incidental ductal stone rate of 1.6%, together with a 3.3% false positive cholangiogram rate and a case of bile duct injury resulting from the procedure makes its routine application appear superfluous.

We report our experience with pulsed dye laser lithotripsy in the treatment of 100 ureteric stones in 95 patients over a 14-month period from July 1989 to September 1990. The overall rate of successful stone fragmentation was 97%. There was a low incidence of minor complications--mild haematuria, ureteric colic and urinary tract infection; ureteric perforation occurred in only 3 patients, all of whom were successfully treated conservatively. Pulsed dye laser lithotripsy is a safe and effective mode of treatment for ureteric stones. Current indications for laser fragmentation of stones are ureteric stones, impacted pelviureteric junction stones and Steinstrasse.

The first 100 patients with ureteric calculi to undergo planned ureteroscopy and lithotripsy were retrospectively studied to evaluate the factors which influenced the success of the procedure. All 75 males and 25 females who underwent this procedure had surgical indications to treat the stones. The factors influencing a successful outcome were studied over four different time frames. It was found that the procedure was more successful in females, and lower ureteric stones. The stone size did not affect the outcome as expected. The learning curve was very evident as increased experience produced higher success rates for ureteric access and lithotripsy, less morbidity, shorter operating time and lower open surgery rates. The introduction of the miniscope and laser lithotripsy was however the most significant factor in ensuring a successful outcome.

A study was made of 30 cases of acute urethral trauma treated over a 7-year period. There were 10 anterior and 20 posterior urethral injuries, the majority of these being partial ruptures. Posterior urethral injuries were caused by road traffic accidents in 75% of cases while 80% of the anterior urethral injuries were of the "straddle" type. There was only 1 case of iatrogenic injury to the anterior urethra. During follow-up, all patients required periodic dilatations for stricture except for the single case of iatrogenic injury. An average of 5 dilatations controlled all of the strictures except for 2 that required urethroplasties.

Four patients with pyogenic hepatic abscesses are reported. There were three females and one male with an age range of 36-75 years. In all the cases, diabetes mellitus was associated. Confirmation of the abscesses was obtained by liver scanning or ultrasonography, or both. In one patient, the clinical course was complicated by sympathetic pericardial effusion with right heart failure. Two patients had percutaneous transhepatic drainage of the abscesses under fluoroscopy. All four patients eventually required laparotomy and open drainage of the abscesses. Diabetic control was achieved with insulin therapy. The common causative organism in all instances was the Klebsiella species. Three patients recovered. The remaining one developed hypotension post-operatively and died of brain-stem infarction and the hepato-renal syndrome.