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Ruthenium (Ru) is the most widely used metal as an electrocatalyst for nitrogen (N 2 ) reduction reaction (NRR) because of the relatively high N 2 adsorption strength for successive reaction. Recently, it has been well reported that the homogeneous Ru-based metal alloys such as RuRh, RuPt, and RuCo significantly enhance the selectivity and formation rate of ammonia (NH 3 ). However, the metal combinations for NRR have been limited to several miscible combinations of metals with Ru, although various immiscible combinations have immense potential to show high NRR performance. In this study, an immiscible combination of Ru and copper (Cu) is first utilized, and homogeneous alloy nanoparticles (RuCu NPs) are fabricated by the carbothermal shock method. The RuCu homogeneous NP alloys on cellulose/carbon nanotube sponge exhibit the highest selectivity and NH 3 formation rate of ≈31% and -73 μmol h -1 cm -2 , respectively. These are the highest values of the selectivity and NH 3 formation rates among existing Ru-based alloy metal combinations., (© 2022 Wiley-VCH GmbH.)

Introduction: Therapeutic plasma exchange (TPE) is mainstay therapy for thrombotic thrombocytopenic purpura (TTP). However, it remains controversial if ABO type influences diagnosis or time to remission., Materials and Methods: We investigated if ABO type influences length of TPE regimen in TTP patients with ADAMTS13 deficiency at our institution. Seventy out of 71 patients with suspected TTP who had ADAMTS13 activity measured were included. ADAMTS13 activity <10% defined those with idiopathic/acquired TTP (41/70)., Results: We found that among patients with ADAMTS13 deficiency, non-O patients required a significantly greater number of TPE (NoP) compared to O patients (p = 0.039). Additionally, patients with ADAMTS13 deficiency regardless of ABO type needed more TPE to achieve platelet recovery compared to those patients without deficiency (p = 0.00002). In regard to other variables that may affect response to therapy in TTP patients, we found no association between obesity and NoP; however, obesity rate was higher among ADAMTS13 deficient patients compared to overall obesity rate of our regional general population. Likewise, were found that blood group O did not occur with greater frequency in our cohort., Conclusions: Our data indicates that ABO may affect the NoP patients required for disease remission. We found that non-O patients needed more procedures to overcome their disease. Further work with greater number of patients will be needed to determine if specific non-O blood types require more procedures to recover their platelet count., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Heparin-induced-thrombocytopenia (HIT) is a disease mediated by antibodies to platelet factor 4 (PF4)-heparin complexes. Immature platelet fraction (%-IPF) and absolute immature platelet count (A-IPC) measure newly-released platelets into circulation and can prove useful in differentiating patients with thrombocytopenic presentations due to consumptive or hypoproduction processes. Therefore, we evaluated utility of A-IPC in a cohort of thrombocytopenic patients suspected of HIT., Patients and Methods: Twenty-six thrombocytopenic patients (<150 × 10 9 /L) tested for anti-PF4-heparin and 36 non-thrombocytopenic controls were included. Platelet count, %-IPF, and A-IPC were determined at time of anti-PF4-heparin testing., Results: Sixteen patients tested anti-PF4-heparin negative and 10 tested positive. Patients with positive anti-PF4-heparin did not differ in A-IPC from normal range (7.2 ± 2.9 × 10 9 /L vs. 7.1 ± 3.2 × 10 9 /L respectively; p = 0.97). However, there was a significant A-IPC decrease in patients negative for anti-PF4-heparin compared to normal range and those testing anti-PF4-heparin positive (4.2 ± 3.1 × 10 9 /L vs. 7.1 ± 3.2 × 10 9 /L vs. 7.2 ± 2.9 × 10 9 /L respectively, p < 0.01). An A-IPC of greater than 5 × 10 9 /L characterized 80% of anti-PF4-heparin positive cases., Conclusion: A-IPC measurements can complement anti-PF4-heparin testing of patients suspected of HIT while potentially predicting anti-PF4-heparin immunoassay results., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: GATA-3 is a potential marker for detection of metastatic breast carcinoma, reportedly more sensitive than mammaglobin (MAM) and GCDFP-15. We aim to compare the sensitivity of GATA-3, MAM and GCDFP-15 in determining the breast origin of malignant effusions., Methods: Cell blocks from 27 cases of serous effusions positive for metastatic breast cancer were retrieved. Immunohistochemistry for GATA-3, MAM, gross cystic disease fluid protein 15 (GCDFP-15), estrogen receptor (ER) and progesterone receptor (PR) was performed on cell-block micro-array. Statistical analysis using two ways Chi square, one-way ANOVA and multiple regression was performed., Results: The detection rate of breast cancer in serous fluid was significantly higher with GATA-3 (88.8 %, X2=15.9, p=0.00034) than with MAM (51.8 %) and GCDFP-15 (37.0 %). All ER positive cases (19) were GATA-3 positive. Conversely, all GATA-3 negative cases (3) were ER negative. The intensity of stain and percentage of positive cells were significantly higher with GATA-3 (p<0.0001) than with MAM and GCDFP-15. The intensity and percentage of positive cells score of GATA-3 were statistically associated with ER stain intensity and percentage of positive cell scores., Conclusions: GATA3 is a sensitive marker, superior to MAM and GCDFP-15 in determining the breast origin of metastatic adenocarcinoma. It is also strongly associated with ER expression.

Background and Objectives: Thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are characterized by microangiopathic hemolytic anemia and thrombocytopenia. Interestingly, markedly different survival rates have been reported despite increases in survivability. We studied TTP-HUS 30-day mortality and relapse rates of patients who received TPE at our institution and compared them to published data., Patients and Methods: Retrospective study analyzed 30-day mortality and relapse rates attributed to TTP-HUS from 01/01/2008 to 12/31/2012 and compared them to comparable literature reporting mortality and survival. Studies describing other etiologies for TPE and different mortality time interval were excluded., Results: Fifty-nine patients were analyzed and all were initially treated with TPE and corticosteroids. Eleven patients were classified as not having TTP-HUS due to testing or clinical reassessment which ruled in other etiologies, and 18/59 patients had ADAMTS13 activity <10%. Of remaining patients, 36/48 (75%) were diagnosed as idiopathic and 12/48 (25%) as secondary TTP-HUS. Patients received a mean of 12 TPEs (range 1-42); 42/48 (87.5%) patients had ADAMTS13 activity measured; complete response obtained in 39/48 (81.2%) patients (platelet count >100 x 10(9)/L); partial response in 4/48 (8%); and 5/48 (10.4%) did not have increases in platelet counts (2/5 of these patients died within the study period). Forty percent of patients obtained platelet counts >150 x 10(9)/L. Overall 30-day mortality for our patient cohort was 6.7% (4/59). Comparison of our mortality rate to combined data of five published studies of 16% (92/571) showed a significant difference, p = 0.04. Our relapse rate was 18.6% (11/59) similar to previous reports., Conclusions: Wide differences in mortality may be due to grouping of two distinct pathologic entities under TTP-HUS; and presence of confounding factors in the patient populations under study such as co-morbidities, promptness of TPE initiation, delay in diagnosis and therapeutic practice.

Background and Purpose: The purpose of this study was to develop an instrument that assesses perceived susceptibility and perceived severity for individuals at risk but not yet diagnosed with type 2 diabetes living in Appalachia., Methods: From 168 surveys, Cronbach's alpha and item-total correlations assessed reliability, confirmatory factor analysis confirmed construct validity (convergent and discriminant), and multiple linear regression determined concurrent criterion-related validity of perceived susceptibility and perceived severity scales. There were 22 in-depth interviews conducted to triangulate meaning of the scales' results., Results: Discriminant validity was demonstrated via low interfactor covariation. Concurrent criterion-related validity was also established via significant regression coefficients and supplemental qualitative data., Conclusions: This prediabetes screening instrument provides a strong foundation for measuring perceived susceptibility and perceived severity in Appalachian individuals who have prediabetes.

Hypothesis: Laparoscopic hepatectomy and open hepatectomy for hepatocellular carcinoma (HCC) have the same surgical outcome., Design: Nonrandomized comparative study., Setting: Tertiary referral center., Patients: Twenty-five consecutive patients with HCC undergoing laparoscopic hepatectomy from January 1, 1998, through December 31, 2007, and a retrospective control group of 33 patients who underwent open hepatectomy for HCC during the same period. The 2 groups were matched in terms of demographic data, tumor size, and severity of cirrhosis., Interventions: Laparoscopic hepatectomy., Main Outcome Measures: Surgical morbidity rate, mortality rate, and survival., Results: One patient in the laparoscopic group underwent conversion to an open approach. The median operating time and blood loss were 150 minutes and 200 mL, respectively. The resections were R0 in 22 patients (88%) and R1 in 3 (12%). The hospital mortality and morbidity rates were 0% and 16% (4 patients), respectively. The 3-year overall and disease-free survival rates were 60% and 52%, respectively. There was no difference in surgical morbidity rate, hospital mortality rate, and midterm survival results between the 2 groups. The laparoscopic approach resulted in a shorter hospital stay., Conclusions: Laparoscopic hepatectomy for HCC is feasible and safe in selected patients. Midterm survival is also favorable. The laparoscopic approach has the benefit of a shorter hospital stay. However, the procedure should be performed by a surgical team expert in hepatobiliary and laparoscopic surgery in properly selected patients.

Background: With the recent introduction of laparoscopic partial hepatectomy and laparoscopic/open radiofrequency ablation for hepatocellular carcinoma (HCC), the role of preoperative laparoscopic staging may be expanded. The objective of this study was to determine the role of preoperative laparoscopy and laparoscopic ultrasonography (USG) in patients with HCC., Methods: From January 2001 to April 2007, a cohort of 122 consecutive patients with a diagnosis of potentially resectable HCC underwent staging laparoscopy with laparoscopic USG before performing a major laparotomy in a tertiary referral center. The patients' data were collected prospectively. We have retrospectively analyzed the effect of implementation of this staging technique in our center., Results: Preoperative laparoscopy and laparoscopic USG was successful in 119 patients (97.5%). Forty-four patients were found to be unresectable after laparoscopic staging, whereas 2 patients were found to be unresectable after exploratory laparotomy. The total number of patients who underwent curative liver resection was 73 (laparoscopic partial hepatectomy, 22 patients; open partial hepatectomy, 51 patients). The median hospital stay of the laparoscopic liver resection group was significantly shorter than that of the open resection group (8 vs 13 d; P = .002). Intraoperative treatment for patients with unresectable HCC, including local ablative therapy, or combined liver resection and local ablative therapy, was performed in 27 of 45 inoperable patients (60%) (laparoscopic approach, 8 patients; open approach, 19 patients). The median hospital stay of the laparoscopic treatment group was significantly shorter than for the open treatment group for patients with unresectable HCC (5 vs 7 d; P = .003). In this study, a laparoscopic treatment approach for HCC was performed in 25.2% of the study population., Conclusions: Laparoscopy and laparoscopic USG have a significant effect both on identifying surgically untreatable disease and in selecting the optimal treatment strategy. Some patients will benefit from a laparoscopic therapy approach. Therefore, it argues for more widespread use in laparoscopic staging procedures for patients with potentially resectable HCC.

Background/aims: This study aims to evaluate the outcomes of percutaneous cholecystostomy for acute calculous cholecystitis in patients with high surgical risk and determine whether subsequent cholecystectomy is beneficial and necessary. Percutaneous cholecystostomy has been shown to be a safe treatment option for patients suffering from acute cholecystitis but at high risk for emergency surgery. Controversies still exist on the approach of the cholecystostomy and the subsequent management of these patients., Methodology: From January 1996 to March 2004, percutaneous cholecystostomy was performed on 65 patients that suffered from acute calculous cholecystostomy but were considered high risk for emergency surgery (American Society of Anesthesiologists grade III or IV). Their clinical outcomes were described and risk factors for in-hospital mortality and recurrence of cholecystitis were identified by univariate and multivariate analysis., Results: Percutaneous cholecystostomy was successfully performed in all patients (100%). The clinical response rate was 91%. The in-hospital mortality was 12.3%. Shock on admission was found to be a single independent risk factor for in-hospital death (p=0.006; odd ratio = 16.5; 95% CI = 2.2-123.1). Twenty-four patients underwent subsequent cholecystectomy whereas 33 did not. The 1-year and 3-year recurrence of acute cholecystitis were 35% and 46% respectively in patients who did not have subsequent cholecystectomy. Stone size > or = 1cm was independently associated with higher recurrence of acute cholecystitis (p=0.01; hazard ratio = 6.3, 95% CI 1.6-25.5). However, there was no difference in 1-year and 3-year overall survival between patients with or without cholecystectomy (82% Vs 81% and 59% Vs 63%, p=0.79)., Conclusions: Percutaneous cholecystostomy is a safe and promising treatment for acute calculous cholecystitis in patients who are at high risk for emergency surgery. Cholecystectomy after the resolution of cholecystitis and optimization of associated medical illnesses is always advisable in order to prevent recurrent cholecystitis. However, the limited survival of these patients because of their old age and medical co-morbidities should be taken into consideration.

Background: Cytoreductive surgery (debulking surgery) as a multidisciplinary treatment approach for inoperable advanced hepatocellular carcinoma has been shown to prolong survival and provide symptomatic relief for good surgical risks patients in non-randomized studies before., Methods: A non-randomized comparative study was performed in a tertiary referral centre between January 2001 and December 2006. The outcome of a consecutive series of patients with inoperable advanced hepatocellular carcinoma who received cytoreductive surgery was compared with a control group of patients who received palliative treatment without surgery. Two techniques of cytoreductive surgery were used: (i) partial hepatectomy for the main tumour plus intraoperative local ablative therapy for the smaller tumour nodules in the liver remnant; and (ii) partial hepatectomy for the main tumour plus postoperative transarterial chemoembolization., Results: The overall survival of cytoreductive surgery group (n = 18) was significantly better than that of the palliative treatment group (n = 15) (3-year overall survival, 54% vs 22%; median survival, 18 vs 11 months) (P =0.038). In the cytoreductive surgery group, there was no operative mortality. Postoperative morbidity rate was 16.7%. The mean hospital stay was 8 days., Conclusion: Cytoreductive treatment strategy for advanced hepatocellular carcinoma can be considered as one of the options in selected patients with low operative risks and reasonable liver function. Further prospective randomized trials are required to validate this aggressive surgical approach.

Background/aims: To evaluate the results of laparoscopic exploration of the common bile duct (LECBD) in patients with previous gastrectomy., Methodology: This study is a retrospective review of a prospectively maintained database of LECBD during the period 1994-2005. Those cases of LECBD with previous open gastrectomy were sorted out and analyzed. Indications of operation included unsuccessful endoscopic extraction due to altered anatomy and some explorations were performed together with side-to-side choledochoduodenostomy so as to eliminate biliary stasis and decrease stone recurrence. The operation steps involved open insertion of trocar and creation of pneumoperitoneum, meticulous adhesiolysis, direct choledochotomy followed by clearance of biliary stones. After confirmed ductal clearance, the common bile duct was routinely closed with t-tube diversion. The perioperative parameters of these patients were analyzed and compared to those receiving open exploration of common bile duct due to previous gastrectomy during the same study period., Results: Of the 184 LECBD performed between 1994 and 2005, 33 patients had previous open upper gastrointestinal operations and among them 18 LECBD were performed in post-gastrectomy patients (2 with previous classical Whipple's operation). There were 10 male and 8 female patients with mean age of 77.5 (58-97 years). Of the 14 patients undergoing preoperative endoscopic retrograde cholangiopancreatography, there were 10 failed cannulations and 4 failed extractions. Altogether 17 choledochotomies and 1 transcystic duct exploration was performed whereas 4 patients with recurrent primary stones received additional choledochoduodenostomy. Median operating time was 120 min (60-390 min). Open conversion was required in 3 patients (16.6%) because of jammed basket, extensive adhesion and "through & through" bile duct injury respectively. Postoperative complications occurred in 4 patients (22.2%), which included 3 bile leaks and also the previously mentioned bile duct injury. The median hospital stay was 9 days (4-82 days). Upon a median follow-up of 17.5 months, there was only 1 patient found to have recurrent common bile duct stone and he was managed by laparoscopic exploration and choledochoduodenostomy. When the results were compared to those 12 open explorations because of previous open gastrectomy, longer operation time (120 vs. 75 min, p=0.004) and slightly shorter hospital stay (9 vs. 14 days, p=0.104) were noted in the LECBD group but without increased complication rate (22.2 vs. 25%, p=1)., Conclusions: These results suggest that LECBD is worth attempting even in patients with previous open gastrectomy.

Background/aims: To review the results of laparoscopic biliary bypass for both benign and malignant pathologies in a minimal access surgery training center., Methodology: Retrospective review of a prospectively maintained database of laparoscopic biliary bypass during the period 1995-2004., Results: During the review period 1995-2004, there were 26 laparoscopic biliary bypasses performed in our center which included 23 laparoscopic choledochoduodenostomy (LCD), 2 laparoscopic roux-en-Y choledochojejunostomy (LCJ) and 1 laparoscopic cholecystojejunostomy (LCCJ). Of the 23 LCD, all except 1 patient were operated for recurrent pyogenic cholangitis (RPC). The 2 LCJ and 1 LCCJ were performed for patients with advanced carcinoma in the periampullary region and simultaneous laparoscopic gastrojejunostomy (LGJ) was also performed to relieve the gastric outflow obstruction. Among the 23 LCD, there were 2 open conversions (7.7%) for lost broken tip of ultrasonic dissector and significant bleeding during choledochotomy respectively. Major complications occurred in 6 patients (23%), which included 3 bile leaks (11.5%), 1 intraabdominal collection (3.8%). 1 wound infection (3.8%) and 1 gastric stasis (3.8%). The only mortality in our series was a patient with carcinoma of head of pancreas undergoing simultaneous roux-en-Y LCCJ and LGJ. He had persistent gastric stasis after operation and required revision surgery for the kinked cholecystojejunostomy anastomosis. He finally died of myocardial ischemia after the second operation. As for the postoperative pain control, the mean pethidine consumption was 243.4 +/- 254.7 mg (range 0-1200 mg) and mean dologesic usage was 16.2 +/- 20.4 tablets (range 0-94 tablets). The average postoperative hospital stay was 12.6 +/- 11.5 days (range 5-60 days). The long-term functional results were satisfactory and only 1 patient had recurrent stone upon a mean follow-up of 32.3 months. Among the patients with malignant biliary obstruction, the only mishap was as previously mentioned and the remaining 2 patients could enjoy satisfactory palliation for more than a year before death., Conclusions: Laparoscopic bypass is not only feasible but also highly effective in relieving biliary obstruction with good postoperative results in both benign and malignant conditions.

Background/aims: This article aims to describe the different techniques of laparoscopic distal pancreatectomy and to compare the results of our series of 9 laparoscopic resections against the historical open control in the same institution. With the advent of laparoscopic surgery, there is an increasing number of patients with different pancreatic pathologies that can now be managed by minimal access surgery. The initial results of laparoscopic pancreatectomy are quite promising particularly for those small neuroendocrine and cystic neoplasms located at the body and tail of pancreas., Methodology: The different techniques of laparoscopic distal pancreatectomy are described in detail with special emphasis on the need of "hand assistance" and the different methods of splenic preservation. The perioperative data of 9 laparoscopic distal pancreatectomies are analyzed and compared against the 5 historical open controls in the same institution., Results: There were 9 laparoscopic pancreatic resections performed in our institution since 1999. Indications for surgery included 5 cystic neoplasms (1 patient with concomitant splenic artery aneurysm), 1 chronic pancreatitis with pancreatic duct stricture and a small pseudocyst, 1 pseudopancreatic tumor secondary to seal off perforated posterior gastric ulcer, 1 pseudopapillary tumor and 1 neuroendocrine tumor. There were 6 females and 3 males with median age of 61 years (range 18-79). The majority of patients was of low anesthetic risk (ASA 1 or 2). Total laparoscopic resection was performed in 7 cases and 2 resections were performed using the hand-assisting technique. Out of the 4 cases with splenic preservation, only one patient had both splenic artery and vein successfully preserved, whereas the other 3 cases had to rely on the short gastric arcade. Median operating time was 180 minutes (range 120-250) and median blood loss was 100cc (range 50-500). Pancreatic leak occurred in two patients (22.2%) and 1 patient developed intraabdominal collection, all of which settled upon conservative treatment. In our series, clear resection margin was obtained for all the neoplastic cases. Median hospital stay was 7 days (4-53). Postoperatively, patients consumed an average of 15 tablets of dologesic. No other complications were observed upon a median follow-up of 15 months (1-50). When results were compared to the 5 historical open controls (excluding those malignant tumors), patients managed with this new approach had significantly less intraoperative blood loss (100 vs. 450 mL, P = 0.021)., Conclusions: Our initial experience not only confirmed the feasibility oflaparoscopic pancreatectomy, but also demonstrated the promising results of this approach in selected patients.

Objective: To review results of laparoscopic liver resections, particularly in those patients with hepatic malignancy and recurrent pyogenic cholangitis., Design: Retrospective analysis., Setting: Minimal access surgery training centre, Hong Kong., Patients: Patients with pathologies located at anterio-inferio-lateral segments (Couinaud segments 2, 3, 4b, 5, 6) for laparoscopic resection were recruited during the period 1998 to 2005. Patients were excluded from review if they had: pathologies at central locations and the superior and posterior segments (4a, 7, 8), large tumours (>5 cm in diameter), and those close to major vasculature or the liver hilum., Results: During the study period, we attempted 40 such laparoscopic liver resections, excluding marsupialisations and resections for simple liver cysts. There were 20 female and 20 male patients, with a mean age of 57 (standard deviation, 13; range, 29-81) years. All but one underwent a successful laparoscopic operation. Pathology included hepatocellular carcinoma (n=17), recurrent pyogenic cholangitis (n=14), colorectal liver metastasis (n=4), benign liver tumour (n=4), and intrahepatic cholangiocarcinoma (n=1). All except four were hand-assisted laparoscopic liver resections. The mean operating time was 169 (range, 60-290) minutes and mean blood loss amounted to 270 mL (range, 0-1000 mL). Complications occurred in eight (20%) patients, which included six wound infections, one postoperative bile leak, and two incisional hernias. There was no operative or hospital mortality. For hepatocellular carcinoma, clear resection (>10 mm) was achieved in all except five patients, and the 1-year and 2-year survival rates were 86% and 59% respectively. Favourable results were also obtained for resections in patients with recurrent pyogenic cholangitis; after a mean (standard deviation) follow-up of 29 (23) months, only one was readmitted (for cholangitis)., Conclusion: In appropriately selected patients, laparoscopic liver resection is feasible and safe, and achieves acceptable survival among individuals with hepatic malignancy and very favourable long-term outcomes in those with recurrent pyogenic cholangitis undergoing hand-assisted laparoscopic segmentectomy.

Background: Acute torsion of the greater omentum is a rare cause of acute abdomen in adults. We report our experience on the clinical presentation, diagnosis, treatment, and outcome of this condition., Method: This is a retrospective review of 9 patients who had a clinicopathologic diagnosis of acute torsion of the greater omentum and were treated at the Department of Surgery, Pamela Youde Nethersole Eastern Hospital from January 1994 to March 2004. Eight patients were male and 1 was female with a median age of 43 years (range, 24 to 65). Median body mass index was 24 kg/m(2) (range, 22 to 24). All presented with acute abdominal pain with a median temperature of 36.8 degrees C (range, 36.5 to 37.2) and a median white cell count of 9.5 x 10(9)/L (range, 7.4 to 15.1 x 10(9)). Preoperative ultrasound was done in 5 patients., Results: All diagnoses were made during surgery. Resection of the infarcted omentum was performed for all patients (5 laparoscopic resections and 4 open resections). No postoperative complications occurred. The overall median time from admission to operation was 23 hours (range, 2 to 98). The overall median operating time and postoperative stay were 70 minutes (range, 38 to 105) and 3 days (range, 1 to 6), respectively. The median oral and parenteral analgesic requirement for postoperative pain control was less and the median hospital stay was shorter in patients who underwent laparoscopic resection., Conclusion: Acute torsion of the greater omentum is an uncommon cause of acute abdomen in adults, and preoperative diagnosis is usually difficult. Laparoscopy seems a safe and minimally invasive technique for both diagnosis and treatment of this rare disease entity.

Objectives: To evaluate the role of laparoscopic exploration of the common bile duct in the management of common bile duct stones., Design: Retrospective study., Setting: Regional minimal access surgery training centre in Hong Kong., Patients: Patients undergoing laparoscopic exploration of the common bile duct from 1995 to 2005., Main Outcome Measures: Demographic information, reasons for failed endoscopic retrograde cholangiopancreatography and open conversions, and operative morbidity and mortality., Results: A total of 174 laparoscopic explorations of the common bile duct were performed. Indications for surgery (some overlapping) included: concomitant gallstones and common bile duct stones (n=68, 39%) in young persons (<60 years), previously failed endoscopic extraction (n=59, 34%), large (>2 cm) or multiple common bile duct stones (n=40, 23%), and need for laparoscopic bypass to improve bile drainage (n=34, 20%). Mean patient age was 63 (standard deviation, 16) years and 103 were female. Altogether 156 choledochotomies and 18 transcystic duct explorations were performed, with 12 (7%) open conversions. The mean operating time was 129 (standard deviation, 57) minutes. Additional procedures included: 54 laparoscopic operative cholangiographies, 34 laparoscopic biliary bypasses, and 31 instances of adhesiolysis in patients with a history of open upper gastro-intestinal surgery. Complete stone clearance was achieved in 160 (92%) patients. Non-lethal complications occurred in 34 (20%) patients and one died of sepsis after a major bile leak. The mean postoperative stay was 9 (standard deviation, 9) days. Stone recurrence ensued in seven (4%) patients after a mean follow-up of 37 (standard deviation, 29) months., Conclusions: Laparoscopic exploration of the common bile duct is highly successful and can achieve satisfactory ductal clearance even after unsuccessful endoscopic extraction and previous upper gastro-intestinal surgery. In skilled hands, for selected patients laparoscopic bypass can also achieve improved bile drainage.

Background/aims: Laparoscopic exploration of the common bile duct (LECBD) has been proven to be an effective and preferred treatment approach for uncomplicated common bile duct stones. However there is still controversy regarding the choice of biliary decompression after laparoscopic choledochotomy., Methodology: This is a retrospective comparison between the use of antegrade biliary stenting and T-tube drainage following successful laparoscopic choledochotomy. During the period between January 1995 and July 2003, biliary decompression was achieved by either antegrade biliary stenting or T-tube drainage based on the discretion of the operating surgeon. For antegrade biliary stenting, a 10-Fr Cotton-Leung biliary stent was inserted through the choledochotomy and passed down across the papilla. The stent position was confirmed by on-table choledochoscopy before interrupted single-layered closure of the common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the stent 4 weeks after operation and at the same time to check for any residual stones or other complications like stricture or leak. In the T-tube group, a 16-Fr latex T-tube was used and the long limb was brought out through the subcostal trocar port followed by the same method of bile duct closure. Cholangiogram through the T-tube was performed on day 7 and the tube would be taken off 1 week later (about 2 weeks after operation) if the cholangiogram did not reveal any abnormality. The two groups were compared according to the demographic data, operation time, length of hospital stay and complication rates., Results: During the study period, 108 laparoscopic explorations of the common bile duct were performed in our centre of which 95 were attempted laparoscopic choledochotomies and 13 were transcystic duct explorations. Of the 95 patients with attempted laparoscopic choledochotomy, there were 9 open conversions, 17 laparoscopic bilioenteric bypasses and 6 primary closures of the common bile duct. All of these patients together with those receiving transcystic duct explorations were excluded and the remaining 63 patients having postoperative bile diversion by either antegrade biliary stenting or T-tube drainage were included in this study. Bile diversion was achieved by antegrade biliary stenting in 35 patients whereas 28 patients had T-tube drainage. There was no difference between the two groups in terms of age, clinical presentation, bilirubin level, length of hospital stay, follow-up duration, common bile duct size, size of common bile duct stones, incidence of residual/recurrent stone and complication rate. It was observed that more patients in the stenting group developed bile leak (14.2% vs. 3.5%) and required more intramuscular pethidine injections (182.86 +/- 139.30 vs. 92.81+/-81.15mg, P=0.000). On the other hand, the T-tube group had longer operation time (141.4+/-45.1 vs. 11 1.1+/-33.9 minutes, P=0.006) and had a longer postoperative hospital stay (10.0+/-7.4 vs. 8.8+/-9.3 days, P=0.020) reaching statistical significance., Conclusions: Postoperative bile diversion by antegrade biliary stenting after laparoscopic choledochotomy is shown to shorten operation duration and postoperative stay as compared to T-tube drainage, but the problem of bile leak needs further refinement of insertion technique.

Background: Bezoar-induced small-bowel obstruction (SBO) is an uncommon surgical emergency. Accurate preoperative diagnosis is notoriously difficult, and conventional management often necessitates laparotomy. Recent articles demonstrate the feasibility of laparoscopy in the management of SBO. This study compares the outcomes of a series of cases managed laparoscopically with the outcomes of matched open cases., Hypothesis: Laparoscopic management of bezoar-induced SBO is safe and effective when compared with traditional laparotomy treatment., Patients and Methods: A retrospective study was conducted from November 1, 1998, to November 30, 2003, to compare laparoscopic vs open treatment for bezoar-induced SBO. Patients' demographics, operative details, and surgical outcomes were evaluated., Results: During the study period, 24 patients (16 men and 8 women) with a mean age of 68.2 years underwent operative treatments for bezoar-induced SBO. Ten patients received laparoscopic treatments and the other 14 received laparotomy treatments. The patients were comparable in age, sex, and physiological status. There were 3 conversions in the laparoscopy group owing to technical difficulties. The laparoscopic approach was associated with statistically significant shorter operative time (P = .048), fewer postoperative complications (P = .04), and reduced hospital stay (P = .009)., Conclusions: When expertise is available, laparoscopy is safe and effective in the management of bezoar-induced SBO and is associated with superior postoperative outcomes when compared with the conventional open approach.

Background: Recurrent pyogenic cholangitis (RPC) is a common disease in Southeast Asia. Its classical presentation is repeated attacks of cholangitis with multiple recurrences of bile duct stones. The stones are commonly located in the left lateral segments (2 and 3) and therefore complete clearance is difficult to achieve by either endoscopic retrograde cholangiopancreatography or surgical exploration of the common bile duct. The definitive treatment usually involves resection of the stone-harboring segments. The recent advent in laparoscopic surgery has shown that hand-assisted laparoscopic segmentectomy is a safe and feasible, alternative. This study aimed to compare hand-assisted laparoscopic segmentectomy with open segmentectomy in patients with recurrent, RPC., Methods: This study retrospectively reviewed a prospectively maintained database of both open and laparoscopic treatments for RPC in a single center between 1994 and 2004. During this period, patients with RPC and left intrahepatic (segments 2 and 3) ductal stones not amendable to endoscopic treatment were recruited for analysis. Patients with concomitant gallbladder stones and common bile duct stones were offered left lateral segmentectomy with cholecystectomy and exploration of the common bile duct. Selected patients would have choledochoduodenostomy drainage during the same operation. The operations were performed via either the hand-assisted laparoscopic approach or the open approach using an ultrasonic surgical aspirator. The two cohorts were compared with respect to perioperative parameters to determine whether there would be any advantage in attempting hand-assisted laparoscopic segmentectomy., Results: During the study period from 1994 to 2004, 17 patients underwent left lateral segmentectomy for RPC. Of the 17 patients, 10 had hand-assisted laparoscopic resections, and 7 underwent open resections. All open resections were performed before 1999. Despite the small number of patients and potential type 2 error, there were no differences in age, sex distribution, number of cholangitic attacks, sessions of endoscopic retrograde cholangiopancreatography before surgery, or number of previous operation between the two groups. The median operating time was shorter in the open group (232.5 vs 150 min; p = 0.007), whereas the median blood loss was similar (350 vs 400 ml; p = 0.551). The median postoperative stay was 8 days for hand-assisted laparoscopic group versus 14 days for the open group. This difference was statistically significant (p = 0.019). There was one open conversion in the hand-assisted laparoscopic group because of intraoperative bleeding from the left hepatic vein. Postoperative complication rates were lower in hand-assisted laparoscopic group, but the difference was not statistically significant (20% vs 57%; p = 126). The intramuscular pethidine requirement again was less in hand-assisted laparoscopic group (0 vs 600 mg; p = 0.002). There was no operative mortality in either group of patients. No recurrent cholangitis was noted in either groups during the median follow-up period of more than 3 years., Conclusion: This study not only confirmed the feasibility of hand-assisted laparoscopic segmentectomy for recurrent pyogenic cholangitis, but also showed that this treatment approach is associated with less pain and shorter hospital stay. However, hand-assisted laparoscopic segmentectomy is a lengthier operation and technically more challenging. Nevertheless, the authors believe that with more experience and further improvement of ancillary technology, this procedure can become a standard treatment for recurrent pyogenic cholangitis in selected cases.

Adult onset diaphragmatic hernia is a rare condition with variable clinical manifestations. The majority of adult-onset diaphragmatic hernia is associated with trauma. Blunt thoracic and abdominal trauma associated with a 5% to 7% incidence of diaphragmatic injury, and in 3% to 15% for those with penetrating injury. These injuries may be left unrecognized when they occur but often are uncovered months later during work up for related symptoms. Prompt diagnosis and surgical repair is recommended by most authorities. Traditionally, diaphragmatic hernia is repaired by laparotomy or thoracotomy, or both. Herein, we report a case of adult onset diaphragmatic hernia presented with dyspepsia that was successfully repaired via laparoscopy. Operative approach and technique of diaphragmatic defect closure is elucidated.

Background/aims: Only a minority of patients with tumor at the pancreaticoduodenal junction is suitable for resection, palliation is however often required relieving the obstructive jaundice and gastric outflow obstruction (GOO). This study evaluates endo-laparoscopic approach as a palliative treatment of obstructive jaundice and malignant gastric outflow obstruction., Methodology: A retrospective review of a prospectively maintained database. During the period from 1992-2002, patients with diagnosis of unresectable tumor at the pancreaticoduodenal junction were evaluated. If the tumor was confirmed to be unresectable, patients would be offered either open double bypass or laparoscopic gastrojejunostomy (LGJ) +/- endoscopic or percutaneous transhepatic stenting for any obstructive jaundice, the choice of approach would depend on whether the endoscopic access was still maintained., Results: Out of 942 patients with tumors around the pancreaticoduodenal junction during the study period from 1992-2002, there were 34 patients (13 male & 21 female) with median age 69 years (range, 48-87) selected for LGJ. Of these 34 patients, 3 of them underwent endoscopic biliary stenting whereas 16 jaundice patients were palliated by transhepatic biliary drainage. When the results were compared to the 35 open double bypass (roux-en-Y choledochojejunostomy and gastrojejunostomy) during the same study period, the median operation time was significantly shorter (80 vs. 135 minutes; P=0.0001) and median intraoperative bleeding was significantly less in the endo-laparoscopic group (0 vs. 100mL; P=0.0001). Two patients in the endo-laparoscopic group were converted to open because of tumor infiltration of the small bowel mesentery causing difficulty in construction of gastrojejunostomy. Although the overall complication rate (13 vs. 17; P=0.387) and incidence of delayed gastric emptying (7 vs. 7, P=0.952) were similar in both groups, the incidence of wound infection was remarkably less common in the endo-laparoscopic group (0 vs. 6, P=0.012). The 15 postoperative complications (13 patients) in the endo-laparoscopic group (38.2%) included prolonged gastric stasis (7), biliary sepsis (2), chest infection (2), myocardial ischemia (2), gastrointestinal bleeding (1) and extensive ischemic stroke (1). Median time to resume diet was statistically shorter in endo-laparoscopic group (5 vs. 7 days, P=0.009) however the hospital stay was similar in both groups (11.5 vs. 14 days, P=0.238). The hospital mortality rate was again comparable between the two groups (6 vs. 5, P=0.703). The short median survival in the endolaparoscopic group (3 vs. 7 months; P=0.0001) might just be a reflection of selection bias., Conclusions: With the advent of laparoscopic and endoscopic surgery, palliation of both gastric outflow obstruction and obstructive jaundice can also be accomplished using the endo-laparoscopic approach. In comparing to the open double bypass, operation time, intraoperative blood loss and incidence of wound infection are significantly less and patients can have early resumption of diet. However, the results can be improved further with a better patient selection and perioperative optimization.

Background/purpose: We reviewed the selective use of hand-assisted laparoscopic segmentectomy (HALS) and laparoscopic choledochoduodenostomy (LCD) in the management of recurrent pyogenic cholangitis (RPC)., Methods: We carried out a retrospective review of a prospectively maintained database of laparoscopic treatment of RPC during the period 1995 to 2004. The perioperative data were analyzed., Results: There were 33 laparoscopic procedures performed in 30 patients with RPC during the period 1995--2004. There were 23 female and 7 male patients, with a mean age of 63.2+/-14.9 years (range, 29--92 years). All these patients had a history of repeated attacks of cholangitis, and multiple sessions of endoscopic lithotripsy or operative retrieval had previously been attempted. Of these 33 procedures, there were 23 LCDs and 10 HALS. Three patients underwent simultaneous LCD and HALS in the same operation. The mean operative time was 172+/-63.5 min (range, 75--290 min) and there were three open conversions (10%), due to (1) intraoperative bleeding from the left hepatic vein, (2) lost broken tip of ultrasonic dissector, and (3) significant bleeding during choledochotomy, respectively. Average hospital stay was 11.4+/-11.1 days (range, 5--60 days). Eight complications (26.6%) were encountered, which included four bile leaks, three wound infections, and one intraabdominal collection. Complete stone clearance was achieved in all but 1 patient (rate, 96.6%), in whom the residual stones were extracted through a postoperative combined endoscopic and percutaneous approach. Long-term results were satisfactory, and only one stone recurrence was detected, upon a mean follow-up of 34.7 months (range, 1--107 months)., Conclusions: Both LCD and HALS are safe, feasible, and effective treatments for patients with RPC.

Background/aims: To demonstrate the safety and feasibility of primary closure of the common bile duct (CBD) after laparoscopic choledochotomy in patients with CBD stones. Traditionally, the CBD is closed with T-tube drainage after choledochotomy and removal of CBD stones. However, the insertion of a T-tube is not without complication and the patients have to carry it for several weeks before removal. In the laparoscopic era, surgery is performed with minimally invasive techniques in order to reduce the trauma inflicted on patients, hasten their recovery and hence reduce the hospital stay. T-tube insertion seems to negate these benefits and we believe that primary closure can be as safe as closure with T-tube drainage., Methodology: This is a retrospective analysis of patients who underwent primary closure of the CBD after successful laparoscopic choledochotomy for ductal stones between January 2000 and December 2003. A concurrent control group of patients who underwent T-tube drainage was used for comparison., Results: Of the 64 patients that underwent laparoscopic exploration of the CBD, 24 (37%) underwent transcystic duct approach and 40 (63%) underwent choledochotomy. There were three open conversions (5%). Stone clearance was achieved in all patients with successful laparoscopic choledochotomy (100%). Of the 38 successful laparoscopic choledochotomies, 12 had primary closure of the CBD and 26 had closure with T-tube drainage. There was no mortality in both groups. One patient in the primary closure group suffered from paralytic ileus and small subhepatic collection which was treated conservatively. The median operative time (90 vs. 120 minutes, p=0.002) and postoperative stay (5 vs. 8.5 days, p=0.003) were shorter in the primary closure group when compared with the T-tube group., Conclusions: Primary closure of the CBD is feasible and as safe as T-tube insertion after laparoscopic choledochotomy for stone disease.

We report a patient with gastric outlet obstruction due to gallstone, with clinical and imaging features mimicking Bouveret's syndrome. However, the obstruction was simply due to extrinsic compression by a gallstone without cholecystoduodenal fistula formation. Laparoscopic cholecystectomy cured the patient.

Background: This review investigated the role played by laparoscopic exploration of the common bile duct (LECBD) in the management of difficult choledocholithiasis., Methods: This retrospective study reviewed a prospective database of LECBD for difficult choledocholithiasis during the period 1995 to 2003., Results: Of the 97 LECBDs performed in the authors' center from 1995 to 2003, 25 were performed for difficult choledocholithiasis. Difficult choledocholithiasis was defined as failure of endoscopic stone retrieval for the following reasons: access and cannulation difficulty, the difficult nature of common bile duct (CBD) stones, and the presence of endoscopic retrograde cholangiopancreatography (ERCP)-related complications. There were seven unsuccessful cannulations because of previous gastrectomy (n = 5) and periampullary diverticulum (n = 2). Among the 18 patients with failed endoscopic extraction, there were 10 impacted stones, 2 incomplete stone clearances after multiple attempts, 2 type 2 Mirizzi syndromes, 1 proximal stent migration, 1 repeated post-ERCP pancreatitis, 1 situs inversus, and 1 stricture at the distal common bile duct. There were 14 male and 11 female patients with a mean age of 67.8 +/- 15 years. Initial presentations included cholangitis (n = 14, 56%), biliary colic (n = 3, 12%), jaundice/deranged liver function ( n = 5, 20%), cholecystitis (n = 2, 8%), and pancreatitis (n = 1, 4%). Regarding the approach for LECBD, there were 2 transcystic duct explorations and 23 choledochotomies. The mean operative time was 149.4 +/- 49.3 min, and there were three conversions (12%). The stone clearance rate was 100%, and no recurrence was detected during a mean follow-up period of 16.8 months. Five complications were encountered, which included bile leak (3 patients) and wound infection (2 patients). When the results were compared with the remaining 72 LECBDs for nondifficult stones during the same period, the complication rate, conversion rate, and rate of residual stones were similar despite a longer operation time (149.4 +/- 49.4 min vs 121.6 +/- 50.5 min)., Conclusion: When ERCP is impossible or stone retrieval is incomplete, LECBD is the solution to difficult CBD stones.

Background: This article reports the technical aspects of laparoscopic choledochoduodenostomy (LCD) in patients with recurrent pyogenic cholangitis (RPC) and the perioperative results are also evaluated. This is a retrospective review of a prospectively maintained database., Methods: Twelve patients diagnosed to have RPC with the absence of intrahepatic stricture were selected for LCD during the period from 1995 to 2002. The majority of our patients had repeated attacks of cholangitis and had already undergone multiple sessions of endoscopic and operative lithotripsy. The LCD was performed using a five-port approach with the patient lying in the supine position. The stones were first cleared through the longitudinal supraduodenal choledochotomy followed by construction of a side-to-side diamond-shaped anastomosis of at least 15 mm between the bile duct and the first part of the duodenum using 2/0 monocryl in the single-layer method., Results: During the period from 1995 to 2002, 12 patients with RPC underwent LCD. There were 3 male and 9 female patients with a mean age of 62 (40-77). The median operation time was 137.5 min (90-270) and the median postoperative stay was 7.5 days (5-20). All cases were successful using the laparoscopic approach. Average analgesic requirement post operation was 126 mg (50-200 mg) intramuscular pethidine. There was one postoperative bile leak, and this complication was settled by conservative measures. Upon a mean follow-up of 37.6 months (6-91), there was no recurrent attack of cholangitis or any evidence of sump syndrome in this group of patients., Conclusion: LCD is a safe and effective drainage procedure for patients with RPC. Complications are uncommon and postoperative results are promising.

Objective: To study the safety and efficacy of laparoscopic cholecystectomy for acute cholecystitis in elderly patients by comparing the results with open cholecystectomy., Design: Retrospective study., Setting: Regional hospital, Hong Kong., Subjects and Methods: Patients aged 75 years or older undergoing laparoscopic cholecystectomy for acute cholecystitis between January 1994 and December 1999 were selected from the database. The comparison group comprised patients from the same age-group who underwent open cholecystectomy for acute cholecystitis during the same period., Main Outcome Measures: Operating time, hospital stay, morbidity, and mortality. RESULTS. Thirty-one patients underwent laparoscopic surgery and 42 had open surgery. The demographic data and co-morbidities were comparable between the two groups. The postoperative hospital stay was significantly shorter for patients undergoing laparoscopy (P=0.03). The overall morbidity rate was significantly lower for patients undergoing laparoscopy (P<0.05). There was, however, no statistical significant difference in the mortality rate. There was no major bile duct injury for patients in either group., Conclusion: Laparoscopic cholecystectomy is a safe procedure for acute cholecystitis in elderly patients, resulting in fewer complications and shorter hospital stay than open cholecystectomy.

Purpose: The aim of this study was to compare the outcome of patients receiving hemorrhoidectomy using Harmonic Scalpel, bipolar scissors, and the conventional scissors excision-ligation technique., Methods: Eighty-six patients with irreducible prolapsing piles were randomly assigned to receive 1) Milligan-Morgan hemorrhoidectomy using scissors excision-ligation technique or 2) bipolar scissors hemorrhoidectomy and Harmonic Scalpel hemorrhoidectomy. Neither the patient nor the independent assessor were aware of the technique used at operation. Patients were followed up at 4 and 12 weeks after operation. The measured outcomes included 1) operation time; 2) blood loss; 3) postoperative hospital stay; 4) pain score; 5) pain expectation score; 6) date of first bowel movement; 7) number of pethidine injections; 8) number of dologesic tablets taken; 9) time off work or normal activity; 10) wound healing; 11) satisfaction score; and 12) postoperative complications, including anal stenosis and fecal or flatus incontinence., Results: There was no difference among the three groups in the operation time, hospital stay, pain expectation score, day of first bowel movement, number of dologesic tablets taken, time off work or normal activity, wound healing, and satisfaction score. The complication rate also did not differ in the three groups. Both Harmonic Scalpel hemorrhoidectomy and bipolar scissors hemorrhoidectomy were superior to Milligan-Morgan hemorrhoidectomy in terms of reduced blood loss. Harmonic Scalpel hemorrhoidectomy had the best pain score when compared with bipolar scissors hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy, and patients required significantly less pethidine injection after Harmonic Scalpel hemorrhoidectomy than after Milligan-Morgan hemorrhoidectomy. Although the time required to return to work or normal activity remained similar, patients after Harmonic Scalpel hemorrhoidectomy had the best satisfaction score among the three groups., Conclusion: The study shows that Harmonic Scalpel hemorrhoidectomy is as good as bipolar scissors hemorrhoidectomy in terms of reduced blood loss but is superior because it is associated with less postoperative pain and hence, better patient satisfaction. However, these observed benefits are small, and the time off work or normal activity remains similar.

Background: Total mesorectal excision (TME) and colonic J pouch reconstruction has been widely practiced for mid- or low-rectal cancer. However, the laparoscopic version of TME has never been described., Methods: Five patients suffering from newly diagnosed mid- to low-rectal cancer were seen between March and July 1999. These five patients were selected for laparoscopic TME and colonic J pouch reconstruction because preoperative investigations revealed resectable tumor without extrarectal disease., Results: There were three men and two women with a mean age of 61 years. The average body weight was 69 kg (range, 57-80). None of the patients had had previous abdominal operations. In all five patients, the tumor was located within 9 cm from anal verge. The average size of the main incision was 5 cm. All patients had a covering ileostomy at the end of the procedure. The mean operating time was 208 min; average blood loss was 158 ml; and mean hospital stay was 10.6 days. Three patients had Dukes' B disease and two had Dukes' C disease. The resection margins (proximal, circumferential, and distal) were all clear. There were no deaths or major complications. Two patients suffered from transient urinary retention. After ileostomy closure, the median frequency of bowel motion was twice per day at 6-month follow-up. Neither incontinence nor nocturnal soiling was reported., Conclusion: To the best of our knowledge, this is the first published series of such an operation. With good patient selection, laparoscopic-assisted TME and colonic J pouch-anal anastomosis is safe and feasible.

Gastric stromal tumors display a bewildering array of immunohistological and ultrastructural features as well as variable biological behavior. These tumors are rare as compared with ones that arise from the gastric epithelium. Moreover, they have been the subjects of controversy because of their uncertain histogenesis. We report the pathological features of gastric stromal tumors we recently encountered in three patients.