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Anemia is a significant public health concern, particularly among young female adults due to its potential impact on reproductive health. This study investigated the association between anemia-related knowledge, attitudes, menstrual health, and anemia status among Malaysian university students. This was a cross-sectional study named "SCARF" - Study to Combat Anemia - Research for Female Students, involving 674 university students in Malaysia. Anemia status was determined based on haemoglobin level, while knowledge, attitude and menstrual health were measured using validated questionnaires. The mean menarche age of students in this study was 12.1 ± 1.21 years. Students who were anemic had significantly longer menstrual cycle duration (P = 0.034) and more days with heavy flow (P = 0.038). Most students had poor knowledge (44.5%) and attitudes (84.1%) towards anemia. Students with good knowledge were 1.1 times more likely to have better anemia status compared to those with poor knowledge (95% CI: 1.0-1.2, P = 0.049). This study highlighted a lack of practical application of the knowledge to dietary habits. Collaborative efforts between educators and healthcare providers are crucial in developing a comprehensive strategy, such as interventions to prioritise educational initiatives and practical support to enhance overall menstrual health among female students., (© 2024. The Author(s).)

Background: In the current situation of COVID-19, dietary intake that incorporates functional foods may potentially be a preventive measure for defence against viral infection. This study aimed to determine the consumption of functional foods and its associated factors among university students during COVID-19., Methods: This was a cross-sectional study conducted among 284 Malaysian university students in Kuala Lumpur, Malaysia. An online self-administered questionnaire was employed to assess subjects' nutrition knowledge, dietary habits, attitude towards functional foods, recognition and consumption of functional food products., Results: Out of 284 respondents, 41.9% had poor level of nutrition knowledge and 57% had moderate level of functional food-related attitude, with seven types of functional foods consumed on average (57.0%). Binary logistic regression showed that university students who consumed fruits at least three times per day (aOR = 11.18; 95% CI: 1.46, 80.17), salty snacks (aOR = 2.90; 95% CI: 1.43, 5.86), soft drinks/sugar-sweetened beverages (SSB) (aOR = 3.12; 95% CI: 1.53, 5.26) and pure juice (aOR = 2.80; 95% CI: 1.48, 5.30) were more likely to consume functional foods during COVID-19 ( P < 0.05)., Conclusion: The findings could provide information to public and private sectors in terms of creating a supportive environment to encourage and promote the awareness and consumption of functional foods and their associated health benefits., Competing Interests: Conflict of interest: None., (© Penerbit Universiti Sains Malaysia, 2023.)

Background: One of the key importance of vegetable consumption is to obtain sufficient micronutrients, dietary fibre, and for the prevention of childhood obesity. Most Malaysian children did not meet the recommended intake of vegetable consumption, and this is especially vulnerable among the urban poor population due to food insecurity. Efforts are needed to promote vegetable consumption that fall short of the recommended intake level. Aim: This trial aims to examine the effectiveness of the "GrowEat" project, as a nutrition intervention programme integrated with home gardening activities to improve vegetable consumption among urban poor children in Kuala Lumpur, Malaysia. Methods: This is a single-blinded parallel two-arm cluster randomised controlled trial (RCT) that include 134 children. Two zones in Kuala Lumpur will be randomly selected, and three low-cost housing flats from each zone will be selected as the intervention and control groups respectively. The trial is designed based on the social cognitive theory (SCT). Children from the intervention group ( n  = 67) will attend a 12-week programme, which consists of home garden-based activities, gardening and nutrition education session. Assessment will be conducted for both groups at three time points: baseline, post-intervention and follow-up phase at 3 months after the intervention. Conclusion: We anticipate positive changes in vegetable consumption and its related factors after the implementation of the "GrowEat" project. The current intervention may also serve as a model and can be extended to other urban poor population for similar interventions in the future to improve vegetable consumption, agriculture and nutrition awareness.

Objective: This study explored how different hospital volumes and surgeon volumes affect thyroidectomy outcomes in terms of length of stay (LOS), costs, and in-hospital mortality., Data Sources: MEDLINE and EMBASE databases., Review Methods: This study retrospectively analyzed a cohort of 125,037 thyroidectomy patients treated at Taiwan hospitals from 1996 to 2010. Relationships between hospital/surgeon volume and patient outcomes were retrospectively analyzed by propensity score matching. In conjunction with the retrospective study, a systematic review and meta-analysis of the relevant literature also were performed., Results: The mean LOS for all thyroidectomies performed during the study period was 3.3 days, and the mean cost was $1193.5. Both high-volume hospitals and high-volume surgeons were associated with significantly shorter LOS and lower costs compared with their low-volume counterparts (P < .001). Different volume groups had similar in-hospital mortality rates. The meta-analysis results consistently showed that the benefits of high-volume hospitals/surgeons are reduced LOS and costs. However, low in-hospital mortality rates were associated with high-volume surgeons but not with high-volume hospitals., Conclusions: This meta-analysis showed that patients who received thyroidectomies performed by high-volume hospitals and surgeons had shorter LOS and lower costs compared with those treated by low-volume hospitals and surgeons. In addition, in-hospital survival rates were better in patients treated by high-volume surgeons. Further research is needed to define the learning curve for thyroidectomy and to clarify how hospital volume and surgeon volume affect its success rate., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Aim: To demonstrate that administering heparanase inhibitor PI-88 at 160 mg/d is safe and promising in reducing hepatocellular carcinoma (HCC) recurrence for up to 3 year following curative resection., Methods: A total of 143 patients (83.1% of the 172 participants in the phase II study) participated in the follow-up study. Of these patients, 50 had received no treatment, 48 had received 160 mg/d PI-88, and 45 had received 250 mg/d PI-88 during the phase II trial. Safety parameters and the following efficacy endpoints were investigated: (1) time to recurrence; (2) disease-free survival; and (3) overall survival., Results: PI-88 at 160 mg/d delayed the onset and frequency of HCC recurrence, and provided a clinically significant survival advantage for up to 3 years after treatment compared with those of the control group: (1) the recurrence-free rate increased from 50% to 63%, and (2) time to recurrence at the 36th percentile was postponed by 78%. The efficacy of administering PI-88 at 250 mg/d was confounded by a high dropout rate (11 out of 54 patients). Additionally, subgroup analyses of patients with (1) multiple tumors or a single tumor ≥ 2 cm; and (2) hepatitis B or C revealed that administering PI-88 at 160 mg/d conferred the most significant survival advantage (56.8% improvement in disease-free survival, P = 0.045) for patients with both risk factors for recurrence., Conclusion: Administering PI-88 at 160 mg/d is a safe and well-tolerated dosage that may confer significant clinical benefits for patients with HCC.

Objective: To investigate the association between glycemic variability (GV) and both length of stay (LOS) and 90-day mortality in noncritically ill hospitalized patients., Research Design and Methods: This study retrospectively analyzed 4,262 admissions to the general medicine or surgery services during a 2 year period. Patients with point-of-care glucose monitoring and a minimum of two glucose values per day on average were selected. GV was assessed by SD and coefficient of variation (CV). Data were analyzed with linear and logistic multivariate regression analysis in separate models for SD and CV. Analysis was performed with generalized estimating equations to adjust for correlation between multiple admissions in some individual cases., Results: After exclusions, 935 admissions comprised the sample. Results of adjusted analysis indicate that for every 10 mg/dL increase in SD and 10-percentage point increase in CV, LOS increased by 4.4 and 9.7%, respectively. Relative risk of death in 90 days also increased by 8% for every 10-mg/dL increase in SD. These associations were independent of age, race, service of care (medicine or surgery), previous diagnosis of diabetes, HbA1c, BMI, the use of regular insulin as a sole regimen, mean glucose, and hypoglycemia occurrence during the hospitalization., Conclusions: Our results indicate that increased GV during hospitalization is independently associated with longer LOS and increased mortality in noncritically ill patients. Prospective studies with continuous glucose monitoring are necessary to investigate this association thoroughly and to generate therapeutic strategies targeted at decreasing GV.

Background: The aim of this study was to evaluate the recurrence pattern after skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) using transverse rectus abdominis musculocutaneous (TRAM) flap in patients with invasive breast cancer., Methods: From 1995 to 2010, patients with invasive breast cancer who underwent SSM followed by IBR using TRAM flap were retrospectively reviewed. The pattern of the first recurrence event was recorded., Results: We identified 249 consecutive patients with invasive breast cancer, two-thirds of whom (67.1%) were diagnosed with stage II or stage III disease. During a median follow-up period of 53 months, three (1.2%) local, 13 (5.2%) regional, 34 (13.7%) distant, and five (2.0%) concurrent locoregional and distant recurrences were observed. The median time to recurrences was 26 months (range, 2 to 70 months) for all recurrences, 23 months (range, 2 to 64 months) for locoregional recurrences, and 26 months (range, 8 to 70 months) for distant recurrences. All local recurrent lesions were detectable by careful physical examination, and detection of local recurrence suggested the presence of distant metastasis (60.0%). In contrast to distant metastasis, the risk of locoregional recurrence did not increase significantly with an increase in disease stage. The 5-year overall, locoregional relapse-free, and distant relapse-free survival rates were 89.7%, 90.8%, and 81.6%, respectively., Conclusions: SSM followed by immediate reconstruction using TRAM flap is an oncologically safe procedure even in patients with advanced-stage disease. Detection of local recurrence is crucial and can be aided by a thorough physical examination.

Background: To evaluate hyperthermic intraperitoneal chemotherapy (HIPEC) as an adjuvant chemotherapy in advanced gastric cancer (AGC) patients with serosal invasion., Methods: Patients who received radical surgery and palliative surgery between January 2002 and December 2010 were retrospectively examined. Patients were divided into two groups, namely, one group that underwent surgery and another group that underwent surgery with HIPEC. All patients who received HIPEC had suspected serosal invasion on an abdominal computed tomography or by the surgeon's assessment during the operation., Results: The prophylactic groups included 83 patients who underwent gastrectomy alone. A total of 29 patients underwent gastrectomy with HIPEC. The 5-year survival rates were 10.7% and 43.9%, respectively. The 5-year mean survival times were 22.66 (17.55-25.78) and 34.81 (24.97-44.66) months (p = 0.029), respectively. There were 52 patients who had a recurrence of carcinomatosis among 133 patients who had resections (52/133, 39.1%). The 3-year disease-free survival rate for carcinomatosis was 28.87% in the group that received surgery alone, whereas it was 66.03% in the group that received HIPEC. There was no significant difference in the rate of complication between the two groups in the prophylactic group (p = 0.542). Thus, curative surgery with HIPEC had a better prognosis for AGC with serosal invasion. The carcinomatosis recurrence time was longer in patients who underwent gastrectomy with HIPEC and received R0 resection., Conclusion: The survival benefit of HIPEC as an adjuvant therapy for gastric cancer patients with serosal invasion should be validated in a large cohort., (Copyright © 2013. Published by Elsevier B.V.)

Background: The significance of lymph node involvement regarding the prognosis of primary duodenal adenocarcinoma remains controversial. This study aims to evaluate the prognostic accuracy of nodal metastasis using the seventh edition American Joint Committee on Cancer staging system in patients with primary duodenal adenocarcinoma., Methods: Between 1993 and 2010, 36 patients who had undergone surgical resection for primary duodenal adenocarcinoma at the Kaohsiung Veterans General Hospital were retrospectively reviewed., Results: The median disease-free survival for all patients was 19 months and the median overall survival was 21 months. Lymph node metastases were found in 26 (72%) of the patients, and 14 patients (39%) patients had in excess of three positive lymph nodes (N2). Patients with N2 disease had significantly reduced overall survival, as compared to patients with three or fewer positive lymph nodes (N1; p = 0.036). In univariate analysis, factors including age >75 years, body weight loss, tumor size ≤ 4 cm, N2 disease and lymph node ratio >0.4 predicted shorter overall survival. Multivariate analysis demonstrated that N2 and lymph node ratio >0.4 are significant risk factors associated with overall survival (p = 0.026 and p = 0.042 respectively). N2 is also the only independent predictive factor for disease-free survival (p = 0.023)., Conclusion: Subdivision of metastatic lymph nodes into N1 and N2 improves predictive ability. The seventh edition American Joint Committee on Cancer staging system is applicable in the present study with regard to the prediction of the prognosis for primary duodenal adenocarcinoma., (Copyright © 2012. Published by Elsevier B.V.)

Objective: To investigate the clinical efficacy of adjuvant interferon alfa-2b (IFNα-2b) therapy on recurrence-free survival (RFS) of patients with postoperative viral hepatitis-related hepatocellular carcinoma (HCC)., Background: Despite most individual trials have failed to meet their primary endpoint, recent pooled-data meta-analyses suggest that adjuvant IFN therapy may significantly reduce the incidence of recurrence in curatively ablated HCC., Methods: Patients with curative resection of viral hepatitis-related HCC were eligible, and were stratified by underlying viral etiology and randomly allocated to receive either 53 weeks of adjuvant IFNα-2b treatment or observation alone. The primary endpoint of this study was RFS., Results: A total of 268 patients were enrolled with 133 in the IFNα-2b arm and 135 in the control arm. Eighty percent of them were hepatitis B surface antigen seropositive. At a median follow-up of 63.8 months, 154 (57.5%) patients had tumor recurrence and 84 (31.3%) were deceased. The cumulative 5-year recurrence-free and overall survival rates of intent-to-treat cohort were 44.2% and 73.9%, respectively. The median RFS in the IFNα-2b and control arms were 42.2 (95% confidence interval [CI], 28.1-87.1) and 48.6 (95% CI, 25.5 to infinity) months, respectively (P = 0.828, log-rank test). Adjuvant IFNα-2b treatment was associated with a significantly higher incidence of leucopenia and thrombocytopenia. Thirty-four (24.8%) of treated patients required dose reduction, and 5 (3.8%) of these patients subsequently withdrew from therapy because of excessive toxicity. Adjuvant IFNα-2b only temporarily suppressed viral replication during treatment period., Conclusions: In this study, adjuvant IFNα-2b did not reduce the postoperative recurrence of viral hepatitis-related HCC. More potent antiviral therapy deserves to be explored for this patient population. This study is registered at ClinicalTrials.gov and carries the identifier NCT00149565.

Background: Genotype B and C are the predominant hepatitis B virus (HBV) strains in Taiwan. We aimed to investigate the role of genotype in HBV-related hepatocellular carcinoma (HCC) after resection., Study Design: From October 2005 to November 2008, 64 patients who underwent liver resection for HBV-related HCC were enrolled. HBV genotypes were determined by molecular method. Patient characteristics, biochemical, tumor, and viral factors were evaluated for their prognostic significance., Results: During a mean follow-up of 26.6 ± 13.2 months, patients infected with genotype C had higher HBV viral load (p = 0.007) and worse disease-free survival rate (p = 0.028) than patients with genotype B. By univariate analysis, genotype C, alanine transaminase >50 U/L, tumor size ≥5 cm, and microvascular invasion were associated with tumor recurrence. Further multivariate analysis demonstrated genotype C remained a significant risk factor (p = 0.034)., Conclusions: Genotype C is a strong risk factor for HCC recurrence after resection. More intensive monitoring for recurrence should be considered in patients with genotype C., (Copyright © 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background/aims: Hepatocellular carcinoma recurrence after curative treatment adversely influences clinical outcome. It is important to explore adjuvant therapies. This phase II/stage 1 multi-center, randomized trial investigated the safety, optimal dosage and preliminary efficacy of PI-88, a novel heparanase inhibitor, in the setting of post-operative recurrence of HCC according to a Simon's 2-stage design., Methods: Three groups were included: one untreated arm (Group A) and two PI-88 arms (Group B: 160 mg/day; Group C: 250 mg/day). Treatment groups received PI-88 over nine 4-week treatment cycles, followed by a 12-week treatment-free period. Safety and optimal dosage were assessed., Results: Overall, 172 patients were randomized and 168 were included in the intention-to-treat (ITT) population. Treatment-related adverse effects included cytopenia, injection site hemorrhage, PT prolongation, etc. Four serious adverse events were possibly related to PI-88 treatment. One (1.8%) group B patients and six (10.5%) group C had hepatotoxicity-related withdrawals. Among the ITT population, 29 patients (50%) in Group A, 35 (63%) in Group B, and 22 (41%) in Group C remained recurrence-free at completion. Calculated T(1) value suggested 160 mg/day treatment satisfied the criteria for the next stage of the trial., Conclusions: PI-88 at 160 mg/day is optimal and safe, and shows preliminary efficacy as an adjunct therapy for post-operative HCC.

Background/purpose: Hepatectomy remains the standard treatment for primary hepatocellular carcinoma (HCC). However, its role in the treatment of multinodular HCC (MNHCC) is unknown., Methods: The study consisted of 599 patients undergoing curative hepatic resection for HCC between October 1990 and June 2006, in which 112 patients had MNHCC (tumor number > or = 2). The type of MNHCC was classified into: A, nodules involving one or two adjoining segments; B, large tumor with satellite nodules involving three or more segments; C, three or fewer nodules that are scattered in remote segments; and D, more than three separate tumors. Univariate and multivariate analyses were used to identify the prognostic factors related to postoperative survival. During the same period of time, and from our database of 178 patients with pathologically proven MNHCC who were undergoing nonsurgical multidisciplinary therapy, 48 patients with serum albumin level > or = 3.5 g/dL, total bilirubin < 2 mg/dL, tumor number < or = 3, and tumor size < or = 5 cm were compared with 38 patients with the same condition treated with hepatectomy, in which 16 received one-block resection and 22 underwent multiple-site resection., Results: The overall 1-, 3- and 5-year survival rates for patients with single-tumor HCC and MNHCC were 88.0%, 69.2% and 58.4%, and 86.1%, 55.5% and 29.9%, respectively (p < 0.001). Alpha-fetoprotein > 400 ng/mL, total tumor size > 5 cm, largest tumor size > 5 cm, total tumor number > 3, microvascular invasion, non-A type MNHCC and multiple-site resection were poor prognostic factors for MNHCC in the hepatectomy group. Multivariate analysis revealed that only multiple-site hepatic resection was an independent adverse factor related to postoperative survival. In addition, patients who underwent one-block resection had significantly better survival compared with the nonsurgical group (p = 0.0016), but the multiple-site resection subgroup did not., Conclusion: The prognosis of MNHCC is poor in comparison with that of single-nodular HCC. Hepatectomy is the treatment of choice if the tumors can be removed by one-block resection and liver function reserve is acceptable.

Angiosarcoma is a rare soft-tissue neoplasm that occurs most often in the skin and the subcutaneous tissues but very rarely in the gastrointestinal tract. We report a case of primary intestinal angiosarcoma with severe gastrointestinal bleeding. This patient was referred to our institute for shock with tarry-bloody stool and severe anemia. Panendoscopy revealed multiple duodenal polypoid tumors, and initial biopsy specimen showed poorly differentiated adenocarcinoma. The tumors were treated with pancreaticoduodenectomy, but the patient died 2 weeks after the operation as a result of acute respiratory distress syndrome. The pathology was consistent with angiosarcoma of the duodenum. In our experience, this tumor may cause severe bleeding, and surgery should be performed as soon as possible to prevent complications of hypovolemic shock.

Inflammatory myofibroblastic tumor (IMT) of the alimentary tract often occurs in children or young adults, but may occur at any age. Symptoms are nonspecific and depend on the location of the tumor. The most often involved sites are small bowel mesentery especially the distal ileum, mesotransverse colon, or great omentum. Recurrence appears to be more frequent in the extrapulmonary lesion. Herein we demonstrate a 63-year-old male patient with mesenteric IMT, with an early recurrence after his first operation. We should be aware that if the tumor is larger than 8 cm, multinodular, omental, with ill-defined margin, with pathologically atypia, or ganglion-like cells, a close surveillance after primary surgery with image study might be necessary to detect the tumor recurrence early. Tumor recurrence may be asymptomatic, and it may act like a malignant tumor with a poor prognosis.

Objective: Our purpose was to evaluate the safety and therapeutic efficacy of single-session prolonged alcohol sclerotherapy in treating large hepatic cysts. A therapeutic comparison between 4-hour and 2-hour retention techniques was also studied., Materials and Methods: Twenty-seven patients with 31 hepatic cysts were enrolled in this study. Seventeen patients (18 cysts) were treated by alcohol retention for 4 hours (group 1) and 10 patients (13 cysts) for 2 hours (group 2). The mean diameter of the hepatic cysts was 12.4 cm (range, 8-23 cm) with a comparable size range in each group. The sclerosing agent used was 95% alcohol, and the maximum amount was limited to 200 mL. Patients changed position and vital signs were monitored every 10-15 minutes. The blood alcohol concentrations were checked hourly for 5 consecutive hours in the initial nine patients. The nonparametric Mann-Whitney U test was used to compare the difference in characteristics and treatment results of the subjects between these two groups. The level of statistical significance was set at a p value of less than 0.05., Results: All but one patient in group 2 tolerated the entire course of sclerotherapy. The mean aspirated volume and mean injected alcohol volume of the hepatic cysts were 730 mL and 138.3 mL, respectively, in group 1 patients, and 931 mL and 139 mL, respectively, in group 2 patients. The mean maximum blood alcohol concentration was 128.2 mg/dL (range, 60-199 mg/dL) at 3-4 hours after alcohol instillation. The mean posttherapy residual cystic diameter was 2.5 cm (range, 0-6 cm), with an average volume reduction rate of 98.3% and 97.7%, respectively, for patients in group 1 and group 2 after a mean follow-up period of 29.6 months (9-59 months). No statistical differences of the mean reduction rate between the two groups were noted., Conclusion: Long retention of the alcohol in a single-injection technique is safe and effective. Two-hour alcohol retention has a comparable efficacy to that of 4-hour retention.

Background: Intestinal obstruction is one of the most common surgical emergencies. The aim of this study was to identify important management information from the evaluation of patients with intestinal obstruction who had undergone previous laparotomy for non-malignancy., Methods: Data from 176 patients with previous laparotomy for non-malignancy, and who were operated on for intestinal obstruction, were collected and analyzed retrospectively., Results: Gastroduodenal operations, appendectomy, and obstetric/gynecologic procedures were the 3 most common previous abdominal surgeries. More than half of all bowel obstructions developed within 10 years after previous laparotomy, and particularly within the first 5 years. Most obstructions were related to adhesion, although their etiologies were diverse. The rate of bowel strangulation was much higher in patients with internal herniation, volvulus, intussusception, closed loop, and diaphragmatic hernia than in patients with simple adhesion, bezoar, tumor, and inflammation (48.3% vs 12.2%). The surgical mortality rate correlated significantly with bowel strangulation: the overall rate was 6.8%, that in patients with strangulation was 18.8%, and that in patients without strangulation was 4.2%., Conclusion: The etiologies of intestinal obstruction were not only significantly related to bowel strangulation, but were also an important determinant of therapeutic strategy.

Background: Intestinal obstruction has remained one of the most common surgical emergencies, and its clinical spectrum has shifted in past decades. The factors contributing to its surgical mortality were studied in these selected patients with a view to finding pointers which help surgeons to identify patients with high surgical risk of mortality., Methods: Those adult patients who had prior laparotomy for non-malignancy and were operated on for intestinal obstruction were included and studied retrospectively. Thirteen possible risk factors, including co-existing medical illness, tachycardia, preoperative shock, age, bowel ischemia, operative complication, leukocytosis, durations from symptom onset to hospitalization, from hospitalization to operation, and from symptom onset to operation, prior laparotomy number, time interval from last laparotomy to this operation, and operation method, were analyzed using univariate analysis and, then, multivariate analysis to find out the independent risk factors for surgical death., Results: Adhesion-related etiologies were the most common. Still, one-tenth of cases were not adhesion-related. Obstruction in the small bowel (172/176) was more frequent than in the large bowel (4/176). The surgical mortality rate was 6.8% (12/176). The independent risk factors of mortality after surgical treatment were co-existing medical illness, bowel ischemia, preoperative shock, and operative complication. Old age seemed to be a risk factor on univariate anlaysis, but not on multivariate analysis. Duration from symptom onset to hospitalization, from hospitalization to operation, or from symptom onset to operation was not significantly related to surgical mortality., Conclusions: High risk patients could be identified by 4 independent factors: coexisting medical illness, bowel ischemia, preoperative shock, and operative complication. Old age itself was not an independent risk factor.

Background: Hepatic resection for huge hepatocellular carcinoma (HCC) is challenging. The role of multimodality nonsurgical therapy for HCC larger than 10 cm is unclear., Study Design: We retrospectively investigated 131 HCC patients with main tumors larger than 10 cm in diameter seen between October 1990 and October 2001. Fifty-six patients (group A) underwent hepatectomy and 75 patients (group B) underwent nonsurgical multidisciplinary therapy including hepatic arterial infusion, transcatheter arterial embolization, and percutaneous acetic acid injection., Results: Patients in group B were older, had lower serum albumin levels, and there were more patients with liver cirrhosis and great vessel invasion. Median survivals of group A and B patients were 17 months and 7 months, respectively (p < 0.001). But the 1-, 3-, 5-year survival rates in group B using 38 patients undergoing 3 or more sessions of nonsurgical treatment were not significantly worse than those for group A using 53 patients with followup (57.1%, 19.0%, 16.3% versus 60.7%, 24.5%, 24.5%, respectively). Group A patients had 37.7% and 71.7% recurrence rates at 6 and 12 months, respectively, after operation, and they had a significantly higher frequency of overall extrahepatic recurrence compared with group B patients (43.4% versus 18.7%, p = 0.005). In group B, only 3 of 35 patients younger than 60 years had tumor shrinkage after nonsurgical treatment modalities in comparison to 17 of 40 patients in the elderly group (p = 0.003). Younger patients had a significantly higher prevalence of hepatitis B surface antigen positivity (85.7% versus 47.5%) and infiltrating tumor growth pattern (74.3% versus 45.0%) compared with older patients., Conclusions: Our study suggests that the advantage of hepatic resection in patients with huge HCC is marginal. An effective adjuvant therapy is needed to improve outcomes after hepatic resection. The experience in using nonsurgical treatment shows that the result is poor in young patients compared with that in elderly patients.

Gastroenterologists are often frustrated in their efforts to deliver a feeding tube by endoscopic guidance into the small bowel because of retrograde migration during the withdrawal of the endoscope. We describe a clip assisted endoscopic method whereby a nasoenteric feeding tube can be reliably delivered into the distal duodenum. A nasoduodenal tube with a 3-0 silk suture sewn on its distal tip is inserted into the stomach. The suture on the feeding tube is grasped by a clip-fixing device. Then, the endoscope with feeding tube is advanced into the distal duodenum and the tube is fixed on a mucosal fold by clipping. We used this technique to successfully place nasoenteric tubes into the distal duodenum in 9 patients. There were no procedure-related complications, and no bleeding or perforation due to removal of the feeding tubes was observed. We conclude that this clip-assisted endoscopic method is a reliable modality for placing nasoenteric tubes.

Background: The compartment theory has not been well investigated in gastric carcinogenesis. This study was aimed at examining the compartment alterations through the Helicobacter pylori (H. pylori)-related chronic gastritis-intestinal metaplasia-carcinoma sequence, and investigating the long-term effect of bacterial eradication on the compartment changes., Patients and Methods: Gastric biopsy specimens were obtained from subjects with H. pylori-negative normal mucosa (N = 12), H. pylori-positive non-metaplastic gastritis (N = 42), H. pylori-positive intestinal metaplasia (N = 21) and intestinal-type adenocarcinoma (N = 20). The specimens were immnostained for monocloncal antibodies against the proliferating cell nuclear antigen (PCNA) for proliferating analysis. Additionally, 50 patients with H. pylori-positive gastritis were enrolled to investigate the long-term effect of bacterial eradication on the compartment changes of gastric epithelium., Results: The mean PCNA labeling indices (L.I.) of non-metaplastic gastritis, intestinal metaplasia and adenocarcinoma were significantly higher than that of normal mucosa (31.1, 49.2 and 40.7 vs. 21.4; p < 0.01, 0.001 and 0.001, respectively). The proliferating zone was principally located in the lower compartment of normal mucosa. In patients with intestinal metaplasia, there was a full expansion (phase 1 change) of proliferating zone to the middle compartment of gastric pits (ratio of L.I. between middle and lower compartment = 1.00). The proliferating cells were evenly distributed in adenocarcinoma (complete loss of compartmentalization). Eradiation of H. pylori led to a reversion of compartment changes of gastric epithelium in patients with chronic gastritis., Conclusion: H. pylori-related gastric carcinogenesis is a multistep process involving progressive alterations of proliferating activity as well as loss of compartmentalization. Eradication of H. pylori reverses the changes in growth kinetics of gastric epithelium.

Superior mesenteric arteriovenous fistula is rarely encountered. Unrecognized in early stage, it can cause hazardous sequelae of portal hypertension. Herein we report a rare case of portal obstruction associated with an aneurysmal dilatation of the superior mesenteric vein, which was caused by a superior mesenteric arteriovenous fistula. The patient was a 74-year-old woman admitted for continuous hemetemesis, presenting with a palpable abdominal mass. The computed tomogram revealed a 6.5 cm superior mesenteric venous aneurysm and thrombotic portal venous obstruction. On account of impending shock, an emergent portal venous thrombectomy and portocaval shunt was carried out. Superior mesenteric arterial angiography performed 4 months later confirmed the diagnosis. Being without symptoms, the patient was clinically followed and remained in stable condition for 3 and a half years. The clinical presentation of a mesenteric arteriovenous fistula varies, with occasional gastrointestinal tract hemorrhage. When complicated with portal obstruction, the condition can be disastrous. We believe that creation of a porto-systemic shunt with resection of the arterio-venous fistula is the proper treatment. This patient is now under close observation.

This study investigates the importance of intestinal bile flow in cellular immunity. Sprague-Dawley rats undergoing bile duct ligation (BDL) and sham ceiliotomy (Sham) for 14 and 21 days were investigated. Experimental animals following BDL were further divided into an external drainage (ED) group, an ED group with rat chow mixed with 2:2:1 cholic acid, chenodeoxycholic acid, and deoxycholic acid (ED + BF), and an internal drainage (ID) group. Fourteen days later, they were killed and analyzed for spleen lymphocytic [3H] thymidine uptake (LHU) under mitogen stimulation with phytohemagglutinin, blood biochemistry, hemogram, and liver pathology. In the 14-day BDL experiment, LHU and serum albumin level were decreased in the BDL group (P < 0.05). After drainage, they were not significantly different among sham, ED, ED + BF, and ID groups. In the 21-day BDL experiment, the red cell volume was decreased (P < 0.05). After drainage, the ED, ED + BF, and ID groups still had a significantly lower LHU than the sham group (P < 0.05). However, the ID group had higher LHU than the ED and ED + BF groups (P < 0.05). The ED + BF group had a slightly higher LHU than the ED group but not statistically significant. Liver pathology returned to normal after drainage in the 14-day BDL model. In contrast, the 21-day BDL group had prominent periportal necrosis and developed periportal fibrosis after drainage. The present study reveals the duration of BDL determines the severity of hepatic damage. In the 14-day BDL groups, all kinds of drainage completely reverse the impaired liver function and cellular immunity. In the 21-day BDL group, 14-day drainage is inadequate for recovery because irreversible pathological changes are found. The reversal of cellular immunity in ID is better and faster, because it provides a better hepatic functional, nutritional, and hematological recovery besides the presence of primarily secreted bile acids.

Background: Cathepsin E is found mainly over the gastric surface and foveolar epithelial cells, and it also is found in the metaplastic pyloric glands and cancer cells. The exact function of cathepsin E in gastric mucosa remains unclear. The colonic type (type III) of intestinal metaplasia (IM) is strongly associated with intestinal-type gastric carcinoma. IM is considered to be a precancerous lesion. The aim of this study was to find out the role of cathepsin E in IM, dysplasia and cancer of stomach., Methods: Sixty nine biopsy specimens with IM and dysplasia and 33 gastrectomy specimens with gastric carcinoma were fixed, sectioned and stained with PAS-alcian blue stain, high iron-diamine alcian blue stain to classify IM and immunohistochemical stain to localize cathepsin E. Those patients with dysplastic gastric lesions received regular endoscopic follow-up., Results: Fifteen of 69 patients with gastric dysplasia developed cancer in a median 10.5 months follow-up. Severe dysplasia developed carcinoma significantly higher than mild dysplasia (12/20 vs. 1/25, p < 0.001), and type III intestinal metaplasia seemed to have significantly predilection for severe dysplasia and gastric cancer. Cathepsin E was stained in intestinal metaplasia with dysplastic change in 44/69 specimens (63.8%), and carcinoma in 28/48 (58.3%) specimens, there was no significant difference between intestinal type and diffuse type carcinoma in cathepsin E staining. The positive staining for cathepsin E decreased significantly in severe dysplastic gastric mucosa., Conclusions: Type III IM is commonly associated with severe dysplasia and cancer; it may be a precancerous lesion. The positive staining of cathepsin E decreased with the severity of gastric dysplasia, representing dedifferentiation of the cells.

Objective: To assess the risk factors that influence mortality from perforated peptic ulcer., Design: Retrospective study., Setting: General hospital, Taiwan., Subjects: 179 patients who had their perforated peptic ulcers operated on and who had minimum follow-up of one year., Main Outcome Measures: Mortality., Results: The overall mortality was 15% (26/179). Of the 26 patients who died, the cause of death was uncontrolled systemic infection in 21 (81%), hypovolaemic shock in 2, and fatal arrhythmia and heart failure in 1 each. 15 of the patients who died of sepsis did not have fulminant abdominal sepsis. Most deaths occurred early after operation, (range 1-96 days). Old age, preoperative shock, and type of operation seemed to be related to these deaths on univariate analysis, but multivariate analysis showed that coexisting medical illness, delayed treatment, and low albumin concentration were independent risk factors for mortality., Conclusions: To improve the result of treatment of perforated peptic ulcer, the diagnosis and treatment should not be delayed, the associated medical illnesses should be treated, and nutritional support should be given.

Background: We conducted a retrospective review of all early-stage breast cancer patients treated at the Veterans General Hospital-Kaohsiung to determine overall and disease-free survival rates, and to evaluate prognostic factors for these outcomes., Methods: During the period of October, 1990, to December, 1997, 332 patients with early-stage breast cancer were treated at our institution. Cox's multivariate regression analysis was used to select prognostic factors significant for overall survival and disease-free survival., Results: The survival rate for breast cancer patients was 88.35% at five years. Prognostic factors predicting breast cancer mortality included poorly differentiated histologic grade, four or more lymph nodes positive for metastasis and negative progesterone-receptor status. For disease recurrence, prognostic factors included positive nodes, aneuploidy and poorly differentiated histologic grading., Conclusions: We conclude that a combination of lymph node status, DNA ploidy, histologic grading and progesterone-receptor status help to evaluate the possible outcomes for patients with breast cancer and to plan for optimal therapy.

We report two patients with primary non-Hodgkin's lymphoma of the breast who were treated with breast conservation therapy. These two patients were diagnosed with primary breast lymphoma by fine-needle aspiration cytology and underwent tumorectomy followed by adjuvant chemoradiation therapy. Follow-up studies showed that the two patients were free of disease for two and three years, respectively. To date, there exists no therapeutic standard for this disease and there is no survival advantage for patients who undergo radical mastectomy. Despite the rarity of lymphoma in the breast, a preoperative accurate diagnosis is essential so that unnecessary, extended breast ablation or delayed treatment is avoided. Cytologic diagnosis of breast lymphoma is an easy procedure and provides guidance for appropriate preoperative management. Early diagnosis combined with breast conservation therapy and systemic adjuvant therapy results in a favorable outcome for patients with breast lymphoma.

A total of 18 families with multiple cases of breast cancer were identified from southern Taiwan, and 5 of these families were found to carry cancer-associated germline mutations in the BRCA1 and BRCA2 genes. One novel cryptic splicing mutation of the BRCA1 gene, found in two unrelated families, was shown to be a deletion of 10 bp near the branch site in intron 7. This mutation causes an insertion of 59 nucleotides derived from intron 7 and results in a frameshift, leading to premature translational termination of BRCA1 mRNA in exon 8. Deletions of 2670delC, 3073delT and 6696-7delTC in the BRCA2 gene were found in three other breast cancer families. All three deletions are predicted to generate frameshifts and to result in the premature termination of BRCA2 protein translation. Several genetic polymorphisms in both BRCA1 and BRCA2 genes were also detected in this investigation.

Background: Operating for bleeding gastric ulcer remains controversial. Gastric resection bears a higher surgical risk while limited operation may result in more postoperative hemorrhage. There has been little discussion of effective risk assessment of patients. The aim of this study is to define surgical risk by using the APACHE II scoring system, and to determine optimal management., Study Design: Records from October 1990 to December 1996 were retrospectively reviewed for patients (n=101) with bleeding gastric ulcer who had undergone emergency operation after failed endoscopic therapy. Mortality rates were examined according to different APACHE II scores, and the surgical risk was defined. From January 1997 to December 1997, 35 consecutive patients were enrolled for prospective study. Partial gastric resection (PGR) was performed for patients with huge ulcers (>2 cm) and for low-risk patients with ulcers at the antrum or angularis, while limited operation (oversewing or excision of bleeding ulcer) was reserved for others. The results were compared with the retrospective study., Results: In the retrospective study, the mortality rates for the group with a score < 15 and > or = 15 were 5% (3 of 63) and 58% (22 of 38), respectively (p < 0.05). In the group with a score < 15, PGR was performed on 27 patients, and one died. For those patients with a score > or = 15, PGR carried a lower mortality than limited operation, although this was not statistically significant (47% vs 65%). Limited operation resulted in an overall rate of 22% postoperative hemorrhage and 12% reoperation rate, in which all patients with a score > or = 15 died. In the prospective study, the mortality rates in those scoring <15 and > or = 15 were 6% and 50%, respectively. This is not significantly different than the retrospective study. However, the rate of postoperative hemorrhage was diminished (5%)., Conclusions: APACHE II score is a useful tool for assessing risk in patients with bleeding gastric ulcer. The mortality is minimal in those with a score <15, and PGR can be performed with low risk. Although high-risk patients have dreadful outcomes, limited operation cannot improve them if postoperative hemorrhage occurs. Decision making in emergency operation for such patients should be based on the ulcer conditions and the patient's hemodynamic status.

Breast carcinoma metastases to the eye occur more frequently than is clinically recognized. The prevalence of this lesion is not appreciated because of the dominant clinical picture of metastases occurring in other organs or because a number of eye lesions are small and asymptomatic. With the increasing length of survival, more breast cancer patients will require care for ocular metastases. A thorough ophthalmic evaluation, aided by computed tomography or magnetic resonance imaging, usually confirms the diagnosis. Rapid progression of a lesion demands emergency therapy since the dysfunction produced by progressive disease may not otherwise be corrected. Early diagnosis of ocular metastases in patients with breast cancer is important because timely treatment may improve vision and quality of life in the time remaining to patients. Experience with two cases of metastases to the eye from breast cancer are presented, with a review of the literature.

Background: Laparoscopic herniorrhaphy (LH) shares the same repair principle as open preperitoneal prosthetic herniorrhaphy (PPH). Theoretically, the recurrence rate of LH for recurrent inguinal hernia will match the low recurrence rate of PPH (1.2-3%)., Methods: One-hundred forty-five cases of recurrent inguinal hernia were retrospectively studied between 1990 and 1994. Forty-two cases receiving LH were compared to 103 cases receiving PPH., Results: There were no differences in operative time, hospital stay, morbidity rate, satisfaction scale and recurrence rate between the LH group and the PPH group. The LH group showed significantly less postoperative pain and 2 times shorter convalescence (p<0.01). Unsuspected asymptomatic contralateral hernia was found in 4.8% of patients receiving LH. 11.9% of patients had bilateral hernia repairing at the same time in the LH group., Conclusions: LH is suitable for recurrent inguinal hernia, but further investigation of this technique is required before its wide application.

Hepatocyte growth factor (HGF) has been found to stimulate proliferation and migration of human gastric carcinoma cells. Whether the HGF-induced responses are correlated with the expressed level of HGF receptors or the changes of ionic currents is not clear. The present study investigated the effects of HGF on the proliferation and ionic currents of two human gastric adenocarcinoma cell lines, which were found to express different amounts of HGF receptor. Results showed that HGF induced a dose-dependent growth stimulation and accelerated cell cycle progression in SC-M1 cells. In patch clamp study, HGF treatment induced an outward K+ current and increased the slope conductance at -80 mV from 110+/-15 pS/pF to 207+/-15 pS/pF. The HGF-induced K+ current was abolished when tetraethylammonium chloride was added in bathing solution or a low Ca2+ solution was included in the recording pipette. Furthermore, HGF (10 ng/ml) induced an oscillatory Ca2+-activated K+ current with a lag period of 5+/-3 min in SC-M1 cells. In contrast, HGF did not induce mitogenesis, cell cycle progression and changes in ionic currents in KATO-III cells, although this cell line expressed a higher level of HGF receptors than SC-M1 cells did. These findings provide evidence that the activity of Ca2+-activated K+ channel may be involved in the HGF-induced cell proliferation in human gastric cancer cells, but it did not correlate with the density of HGF receptors.

Eleven patients with T4 breast cancer received induction intraarterial chemotherapy (IACT) as the first step in multidisciplinary therapy. The IACT agents (epirubicin and mitomycin C), were delivered weekly in the outpatient department by bolus injection through an implantable port-catheter system. A modified technique of port-catheter system implantation was used. The precise localization of the catheter was dually confirmed by angiography and dye test. The effectiveness of the treatment was evaluated by clinical appearance, image study, and microscopic examination. A 91% response rate was obtained, and the lesions were resectable in < or = 8 weeks. No obvious systemic toxicity resulted from the IACT. Our results show that weekly IACT by bolus injection through a port-catheter system for treating locally advanced T4 breast cancer is feasible and efficacious.

Hepatocyte growth factor (HGF) was found to stimulate the growth and progression of gastric cancer cells through hepatocyte growth factor receptor (HGFR). In the present study, the effects of HGF on the expression of HGFR in relation to cell cycle progression of human gastric cancer cells were investigated by two-parameter flow cytometric analysis. We found that the expression of HGFR in SC-M1 and KATO-III gastric cancer cells was cycle dependent, the level of HGFR increased from GO-G1 to S phase and the highest level of HGFR was found in G2-M phases. The level of HGFR was higher in KATO-III than SC-M1 cells. However, HGF treatment induced a dose-dependent stimulation of growth as well as down-regulation of HGFR in SC-M1 cells but not in KATO-III cells. These results suggest that functional HGFR rather than overexpressed HGFR may be more important for the growth of gastric cancer cells.

Cytomegalovirus (CMV) infection occurs predominantly in immunocompromised hosts. Involvement of the gastrointestinal tract in acquired immunodeficiency syndrome (AIDS) patients is frequent. Nevertheless, CMV appendicitis is exceeding rare. This report describes a patient with AIDS who presented with right lower quadrant abdominal pain, high fever, nausea and vomiting, but without leukocytosis. Diagnosis of CMV appendicitis was confirmed by appendectomy and histopathological examination. Problems related to the diagnosis and therapeutic management of CMV appendicitis in AIDS patients are discussed. The importance of early surgical intervention is emphasized, as is postoperative ganciclovir therapy for treatment of such patients.

Background: This study examined the usefulness of computed tomography (CT) scan for cases of organic intestinal obstruction, with two simple criteria., Methods: One hundred and thirteen patients with clinical suspicion of bowel obstruction were referred for CT scans. A line was drawn between the dilated proximal, and the collapsed distal bowels. A careful search was conducted on this line for obstructive lesions. The results were reported to be organic obstruction if there was an abrupt change of caliber (Criterion I) or a soft tissue mass around the dilated bowel (Criterion II). The judgement based on the CT findings., Results: Eighty-eight cases proved to have bowel obstruction. With Criterion I, the sensitivity was 59.1%, and specificity, 88% with Criterion II, the sensitivity was 56.3% and specificity 100%. If either of them was considered to be a positive sign of organic obstruction, the sensitivity was 100%, the specificity 88% and the accuracy 97.3%. The nature of the obstructions were precisely predicted in 76 patients (86%)., Conclusions: With these two simple criteria, CT scan can achieve high accuracy and is a recommendation in virtually every instance when intestinal obstruction is suspected.

Treatment is always abandoned in those HCC with jaundice, because it is usually attributed to the underlying liver cirrhosis and extensive tumor. In this series, 7 cases (0.8%) of HCC with jaundice were caused by bile duct invasion and tumor thrombi (BTT). 57% of cases showed Charcot's triad. 57% of BTT were small HCC, significantly higher than the 1.7% of total cases (p<0.05). The growth pattern of BTT was all spreading type, significantly higher than the 42% of total operation cases (p<0.05). The DNA ploidy of BTT was all aneuploid. 57% of BTT had AFP level higher than 400 IU/ml, but it was 27% in total cases. The prognosis is poor in those treated with palliative tube drainage. Aggressive hepatic resection was proved to be safe and achieved the best results in our limited experience. Choledochotomy to remove tumor thrombi is contraindicated because it easily causes tumor seeding. It is advocated to search BTT for resection from the group of HCC with jaundice.

One case of bile duct obstruction because of calcified thrombosis of the portal vein is described. The patient had received splenectomy 20 years previously. He was admitted for fever, right upper abdominal pain and jaundice. The initial sonography and computed tomography showed dilatation of bilateral intrahepatic ducts and common bile duct with adjacent calcified portal vein mimicking common bile duct stones. Endoscopic retrograde cholangio-pancreatography showed external compression of the common bile duct by the calcified portal vein. Because of the patient's poor liver condition, biliary endoprosthesis was performed to relieve obstruction. This was an indication that the possibility of portal venous thrombosis should be included in the differential diagnosis of patients with obstructive jaundice who had previously received splenectomy.

Hepatic dysfunction is commonly encountered during total parenteral nutrition (TPN), but it is likely that factors other than TPN play an important role. This study divides TPN patients, before TPN administration, into two groups according to whether the pre-TPN liver function test was normal or abnormal. Among the 729 cases studied, liver function impairment was progressively downhill in patients with abnormal pre-TPN liver function, but liver function maintained normal in most patients with normal pre-TPN liver function test. The TPN formula did not differ between the two groups. Thus, TPN formula itself is probably not a crucial causal factor for hepatic dysfunction. Instead, the etiology of that dysfunction is more likely a result of multiple factors. From this study, it is suggested that digestive disease, nothing per os, and infections all play an important role (P < 0.001). The rates of morbidity, mortality, and organ failure are significantly increased in the group with abnormal pre-TPN liver function (P < 0.05). Aggressive treatment of underlying disease and early restoration of enteral feeding are suggested to reduce TPN-induced hepatic dysfunction.

This study examines the pathophysiology of hepatobiliary complications induced by total parenteral nutrition (TPN) by using animal models that underwent cecal ligation to produce intra-abdominal infection and received an enterostomy to mimic a high-output fistula, which causes the interruption of enterohepatic circulation of bile salt. Aspartate transaminase was elevated after TPN (p < .05). Alkaline phosphatase was increased in animals receiving TPN plus an enterostomy (p < .05). Serum albumin was significantly decreased in animals receiving TPN plus undergoing cecal ligation or enterostomy (p < .05). Liver weight and liver protein and water content decreased in animals receiving TPN alone (p < .05). Liver water content increased in animals receiving TPN plus undergoing cecal ligation (p < .05). Liver lipid content increased after TPN and to a significant degree in rats receiving TPN plus undergoing cecal ligation or enterostomy (p < .05). Bile flow diminished after TPN and to a level reaching significance in animals receiving TPN plus undergoing cecal ligation or enterostomy (p < .05). Reduction of bile flow, decrease of biliary cholesterol secretion, and increase of biliary bilirubin secretion, which may be the cause of TPN-induced bilirubinate stones, were most significant in animals receiving TPN plus undergoing cecal ligation (p < .05). In conclusion, TPN can induce hepatic dysfunction and bilirubinate stones, but these complications are more common in animals with associated intra-abdominal infection or high-output fistula.

The adverse effects of long-term total parenteral nutrition (TPN) are well documented. Lack of gastrointestinal (GI) stimulation from oral feeding, reduction of GI hormone secretion, and interruption of enterohepatic circulation of bile may be found. TPN results in atrophy of the digestive system, intestinal bacterial overgrowth and translocation, liver cell damage, and gallstone formation. In addition, the increase incidence of sepsis of gut origin may lead to an increase in mortality. In some studies, results of the administration of GI hormones to patients receiving prolonged TPN suggest the possibility of reducing some of the adverse effects of long-term TPN. To evaluate the role of GI hormone in the prevention of adverse effects of TPN, we designed the following study: 50 young adult male Wistar rats, weighing approximately 200 g, were divided into five equal groups. All animals received identical TPN infusate for 7 days. GI hormone was added to the TPN infusate as follows: Group A (control) received no GI hormone, group B was given glucagon at a dosage of 330 micrograms/kg per day, group C was administered cholecystokinin 2 Ivy dog units twice a day, group D received secretin 2 clinical units twice a day, and group E was given both cholecystokinin and secretin at the dosages stated for groups C and D. Maintenance of mucosal brush-border hydrolase activity was found in group B. Neither atrophy of the pancreas nor hypoplasia of intestinal villi was observed in groups C and D. Group C showed improvement of liver function-associated tests, better weight gain, and acceleration of enterohepatic circulation of bile.(ABSTRACT TRUNCATED AT 250 WORDS)

One hundred consecutive patients underwent laparoscopic cholecystectomy from May 1991 to February 1992 at Veterans General Hospital--Kaohsiung. Ninety-seven of them presented on an elective basis, including eight patients undergoing endoscopic sphincterotomy with extraction of common bile duct stone before laparoscopic cholecystectomy. The remaining 3 patients were operated during acute cholecystitis episode. Two patients with biliary injuries during laparoscopic cholecystectomy were converted to laparotomy, with a conversion rate of 2%. Intraoperative cystic cholangiogram was done selectively in 7 patients. Major complications occurred in 3 patients, including two biliary injuries and one residual CBD stone. Minor complications of wound infection were found in 7 patients. The overall morbidity rate was 10%. No operative mortality was found. Mean operation time was 112 minutes and mean blood loss was 90 ml. The mean hospital stay (3.1 days) and the mean time of returning to normal activity (14.7 days) were longer than those of Western series, but were shorter than those of open cholecystectomy. Laparoscopic cholecystectomy is a safe and effective procedure that can be performed with minimal risk. However, the importance of accurate preoperative screening and surgical experience should be emphasized for this new procedure. In patients with gall stone plus CBD stone, combined endoscopic sphincterotomy with extraction of CBD stone and laparoscopic cholecystectomy may offer a new therapeutic approach but the long term effect of endoscopic sphincterotomy needs further evaluation.

A total of 4056 consecutive patients operated for benign biliary tract disease between January 1983 and June 1990 were reviewed retrospectively. There were 71 in-hospital deaths, representing 1.75% of morality rate. Cholecystectomy was performed in 2275 patients; common bile duct exploration was carried out in 1494, with operative mortality rates of 0.4% and 3.1% respectively. Sepsis was the leading cause of mortality. The second common cause of death was hepatic failure, and respiratory failure the third. Cardiovascular problems accounted for 11.3% of death, which was much lower than reports from western series. Other causes of mortality included hypovolemic shock, anaphylactic shock, epilepsy and hypoglycemia. Of the total 4056 patients, 28.5% underwent emergency surgery. The mortality rate for emergency surgery was 3.6 times higher than for those who underwent elective operations (p less than 0.005) Significantly higher mortality rates were also seen for those aged over 70 years and of male gender. Because the mortality rate of patients who underwent emergency operation due to acute inflammatory or obstructive complications were much higher than that of elective operation group, we suggested early surgical intervention for the symptomatic patients before complications occurred.