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Background Liver resection is a major curative option in patients presenting with hepatocellular carcinoma. An inadequate functional liver remnant is a major limiting factor precluding liver resection. In recent years, hypertrophy of the functional liver remnant after selective internal radiation therapy hypertrophy has been observed, but the degree of hypertrophy in the early postselective internal radiation therapy period has not been well studied. Methods We conducted a prospective study on patients undergoing unilobar, Yttrium-90 selective internal radiation therapy for hepatocellular carcinoma to evaluate early hypertrophy at 4–6 weeks and 8–12 weeks after selective internal radiation therapy. Results In the study, 24 eligible patients were recruited and had serial volumetric measurements performed. The median age was 66 years (38–75 years). All patients were either Child-Pugh Class A or B, and 6/24 patients had documented, clinically relevant portal hypertension; 15 of the 24 patients were hepatitis B positive. At 4–6 weeks, modest hypertrophy was seen (median 3%; range −12 to 42%) and this increased at 8–12 weeks (median 9%; range −12 to 179%). No preprocedural factors predictive of hypertrophy were identified. Conclusion Hypertrophy of the functional liver remnant after selective internal radiation therapy with Yttrium-90 occurred in a subset of patients but was modest and unpredictable in the early stages. Selective internal radiation therapy cannot be recommended as a standard treatment modality to induce early hypertrophy for patients with hepatocellular carcinoma. (Surgery 2017;160:XXX-XXX.)

Introduction The aim of this study was to determine if neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were predictive of malignancy in mucin-producing pancreatic cystic neoplasms (MpPCN). Methods One hundred and twenty patients with MpPCN were retrospectively reviewed. Malignant neoplasms were defined as neoplasms harbouring invasive carcinoma or high grade dysplasia. A high NLR and PLR were defined as ≥2.551 and ≥208.1, respectively. Results High NLR was significantly associated with symptomatic tumors, larger tumors, solid component, main-duct IPMN, and Sendai high risk category. High PLR was significantly associated with jaundice and Sendai high risk category. On univariate analyses, symptomatic tumors, jaundice, solid component, dilated pancreatic duct, and both a high NLR and PLR were significant predictors of malignant and invasive MpPCN. On multivariate analyses, solid component and dilated pancreatic duct were independent predictors of malignant and invasive MpPCN. PLR was an independent predictor for invasive MpPCN. When MpPCN were stratified by the Fukuoka and Sendai Guidelines, both a high NLR and PLR were significantly associated with malignant neoplasms within the high risk categories. Conclusions PLR is an independent predictor of invasive carcinoma. The addition of PLR as a criterion to the FCG and SCG significantly improved the predictive value of these guidelines in detecting invasive neoplasms. J. Surg. Oncol. 2015; 112:366–371. © 2015 Wiley Periodicals, Inc.

Laparoscopic liver resection has been increasingly adopted worldwide as a result of the rapid advancement in surgical techniques and equipment. This study aims to determine the factors associated with and outcomes of open conversion after laparoscopic minor hepatectomy (LMH) based on a single center multi-surgeon experience.This is a retrospective review of the first 147 consecutive LMH performed between 2006 and April 2014 at a single institution. Data on patient demographics, pathology results, perioperative outcomes, and operative results were collected. Factors associated with open conversion were analyzed via univariate analysis and a P value.05 was considered statistically significant.LMH was performed for malignancy in 114 (77.6%) patients of which hepatocellular carcinoma (n = 82) and colorectal metastases (n = 16) were the most common pathologies. Forty-one (27.9%) patients had cirrhotic livers and 18 (15.7%) had fibrotic livers. Fifty patients (44%) had concomitant surgery in addition to LMH. Twenty (13.6%) procedures required open conversion and the most common reason was for bleeding (n = 12). Twenty-five patients (17%) experienced postoperative complications. Univariate analyses demonstrated that only individual surgeon volume (n ≤ 10 cases) [15 (24.2%) vs 5 (5.9%), P = .001] and institution volume (n ≤ 25 cases) [8 (32%) vs 12 (9.8%), P = .003] were factors associated with open conversion. Open conversion was significantly associated with increased intra-operative blood loss, increased intra-operative blood transfusion, increased postoperative morbidity, and longer postoperative stay.Individual surgeon and institution volumes were important factors associated with open conversion after LMH. Open conversion after LMH resulted in poorer outcomes compared to procedures that were successfully completed laparoscopically.

Minimally invasive surgery has been one of the recent developments in liver surgery, laparoscopic liver resection (LLR) was initially performed for benign lesions at easily accessible locations. As the surgical techniques, technology and experience improved over the past decades, LLR surgery had evolved to tackle malignant lesions, major resections and even in difficult locations without compromising safety and principles of oncology. It was also shown to be beneficial in cirrhotic patients. We describe our initial experience with LLR in a population with significant proportion having cirrhosis, emphasising our approach for lesions in the posterosuperior (PS) segments of the liver (segments 1, 4a, 7, and 8).A review of patients undergoing LLR in single institution from 2006 to 2015 was performed from a prospective surgical database. Clinicopathological, operative and perioperative parameters were analyzed to compare outcomes in patients who underwent LLR for PS vs. anterolateral lesions (AL).LLR was performed in consecutive 197 patients, with a mean age of 60 years. The indications for resection were hepatocellular carcinoma (HCC) (n=105; 53%), colorectal cancer liver metastasis (n=31; 16%), other malignancies (n=19; 10%) and benign lesions (n=42; 21%). A significant proportion had liver cirrhosis (25.9%). More females underwent surgery in the AL group and indications for surgery were similar between both groups. Major liver resection was performed more frequently for the PS group than for the AL group (P0.001) and significantly more PS resections was performed in our latter experience (P=0.02). The mean operative time and the conversion rate were significantly greater in the PS group than in the AL group (P≤0.001 and 0.03, respectively). However, the estimated blood loss (EBL), rate of blood transfusion and mean postoperative stay were similar in the two groups (P=0.04, 0.88 and 0.92, respectively). The overall 90-day morbidity and mortality rate was 21.3% and 0.5% respectively, with no differences between the two groups. Surrogates of difficulty such as operative time, blood loss, conversion and outcomes e.g., morbidity and mortality, were similar in patients who underwent PS resections with or without cirrhosis.LLR in selected patients is technically feasible and safe including cirrhotic patients with lesions in the PS segments.

Introduction Surgical debridement is the mainstay in the management of infected pancreatic necrosis. Minimally invasive techniques have been shown to minimize surgical insult. We aim to review our recent experience with minimally invasive retroperitoneal pancreatic necrosectomy (MIRP). Methods The medical records of consecutive patients between October 2007 and April 2008 who underwent MIRP at our hospital were reviewed. All the patients had a preoperative computed tomography-guided aspiration and positive bacteriologic culture of the peripancreatic collection. Results Five patients underwent MIRP during the 8-month period. Fourteen procedures were carried out, with a median of 3 (range, 1 to 5) procedures per patient. Only 1 patient required postoperative intensive care monitoring. One patient had a left renal contusion that resolved, and 2 patients developed pancreatic fistula owing to pancreatic duct disruption requiring stenting of the pancreatic duct. There were no mortalities. Conclusion MIRP is a good alternative technique in the management of selected patients with infected peripancreatic necrosis.

The aim of this study was to determine if neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were predictive of malignancy in mucin-producing pancreatic cystic neoplasms (MpPCN).One hundred and twenty patients with MpPCN were retrospectively reviewed. Malignant neoplasms were defined as neoplasms harbouring invasive carcinoma or high grade dysplasia. A high NLR and PLR were defined as ≥2.551 and ≥208.1, respectively.High NLR was significantly associated with symptomatic tumors, larger tumors, solid component, main-duct IPMN, and Sendai high risk category. High PLR was significantly associated with jaundice and Sendai high risk category. On univariate analyses, symptomatic tumors, jaundice, solid component, dilated pancreatic duct, and both a high NLR and PLR were significant predictors of malignant and invasive MpPCN. On multivariate analyses, solid component and dilated pancreatic duct were independent predictors of malignant and invasive MpPCN. PLR was an independent predictor for invasive MpPCN. When MpPCN were stratified by the Fukuoka and Sendai Guidelines, both a high NLR and PLR were significantly associated with malignant neoplasms within the high risk categories.PLR is an independent predictor of invasive carcinoma. The addition of PLR as a criterion to the FCG and SCG significantly improved the predictive value of these guidelines in detecting invasive neoplasms.

Objective Greater availability and utilization of modern radiological imaging modalities have resulted in an increase in the incidental discovery of renal cell carcinoma. Such tumours tend to be smaller than their symptomatic counterparts and may potentially be adequately treated using nephron-sparing surgery. Methods A retrospective review of all patients who were diagnosed with renal cell carcinoma of 4 cm or less between January 1990 and December 2001 was conducted to review clinical presentation, surgical management and survival. Results The cohort comprised 102 patients who underwent surgery, of 402 patients diagnosed with renal cell carcinoma over the study period. Sixty-eight patients (67%) had tumours detected incidentally. Thirty patients (29%) were managed with partial nephrectomy and 72 (71%) with radical nephrectomy. The median tumour size was 3.0 cm (range, 1.5-4.0 cm). Overall, median follow-up was 60 months (range, 1-148 months). Overall 5-year survival for patients who underwent partial nephrectomy and radical nephrectomy was 96.6% and 85.8%, respectively. Cancer-specific 5-year survival was 100%. Conclusion A significant proportion of patients had incidental diagnosis of small renal cell carcinoma. Local control may be achieved with either radical or partial nephrectomy, with excellent survival expected.

Background: The laparoscopic approach is increasingly adopted for liver resections today especially for lesions located in the left lateral liver section. This study was conducted to determine the impact of the introduction of laparoscopic liver resection (LLR) as a surgical option for suspected small- to medium-sized (

Laparoscopic liver surgery is gaining increasing acceptance worldwide, but its frontiers are constantly challenged. Laparoendoscopic single-site surgery (LESS) has been performed for various organs, but the feasibility of LESS hepatectomies has yet to be explored fully. From May 2010 to March 2011, seven patients underwent LESS minor hepatectomies. Patient demographic, operative, and clinical data were reviewed. Five left lateral sectionectomies, one segment 3, and one segment 5 resection were performed. The median operative time was 142 min (range, 104–171 min), and the median blood loss was 200 ml (range, 100–450 ml). The median hospital stay was 3 days (range, 1–11 days). For all the patients, the indications for surgery were suspected malignant tumors, and the surgical resection margins were clear for every patient. Laparoendoscopic single-site minor hepatectomy is a novel modification to traditional laparoscopic surgery. The method is safe and feasible without any compromise to oncologic safety for selected patients with hepatocellular carcinoma (HCC) and colorectal liver metastases that are peripheral and smaller than 5 cm in size.

The revised Human Organ Transplant Act (HOTA) was implemented in Singapore in July 2004. We aim to evaluate expanding the potential donor pool for liver transplant in Singapore with the inclusion of marginal donors.All donor referrals between July 2004 and June 2007 were studied. All potential deceased liver donors were heart-beating. After being reviewed by the transplant coordinator, potential donors were assessed by a transplant hepatologist and a transplant surgeon for suitability of organ donation strictly based on the programme's donor assessment protocol. Reasons for rejection as potential donors were documented. The clinical characteristics of all donor referrals were retrospectively reviewed, and an independent decision was made as to whether liver retrieval in each rejected case might have been possible.Among the 128 potential donor referrals, 20 donors (15.6%) underwent liver retrieval. Of the 20 livers retrieved, 16 were implanted and 4 were not implanted (3 unfit recipients, and 1 donor liver with 40% steatosis). Another 10 donor livers were assessed intraoperatively and were rejected because of varying levels of steatosis. Of these livers assessed, 5 donor livers had steatosis40% and 5 had steatosis40%. Of the remaining potential donors, 45 were deemed not possible because of prolonged hypotension (9), on-going or unresolved sepsis (13), high-risk behaviour (4), non-actualisation (8), or pre-existing medical conditions (11). Another 53 donors may potentially have been suitable donors but were rejected because of possible sepsis (13), no suitable recipients (12), transient hypotension (10), transient abnormal liver function test (6), history of alcohol ingestion (5), non-actualisation because of consent (4) and other reasons (3). Overall, it was deemed that 61 donors (47.7%) might potentially have been suitable liver donors.Despite new legislation (HOTA) in Singapore, the utilisation of cadaveric donor livers showed no increase in the last 3 years. By expanding our donor criteria to include marginal donors, we could potentially increase the availability of deceased donor livers to meet our waiting list demands.

Introduction A higher rate of conversion to open surgery is a well-known problem in patients with acute cholecystitis undergoing laparoscopic cholecystectomy. The aim of this study is to analyze factors which may impact on conversion rates, and to analyze our outcomes following implementation of a departmental strategy in reducing conversion rates. Materials and methods 122 patients with acute cholecystitis were considered for laparoscopic cholecystectomy from July 2003 to July 2007. An audit of the results of laparoscopic cholecystectomy was done in July 2005 and a departmental strategy aimed at reducing the conversion rates was introduced. The strategies included early laparoscopic cholecystectomy (within 72 hours of admission), performed or supervised by specialist hepatobiliary surgeons, and modifications of operative techniques. This study compares the conversion rates before and after that audit. Forty-eight patients (group A) were from the preaudit period and the remaining 74 (group B) were from the postaudit period. A multivariate analysis was performed to identify risk factors for conversion to open surgery and whether the strategies implemented resulted in decrease in conversion rates. Results In the group A patients, there was a conversion rate of 29.2%. Gallbladder wall thickness of greater than 5 mm was found to be a statistically significant (p = 0.028) risk factor for conversion to open surgery. In group B patients, the conversion rates were significantly lower at 6.75% (p = 0.001). Analyzing both groups of patients, using multivariate analysis, gallbladder wall thickness, increasing age, and preaudit operative period were found to be independently associated with conversion to open surgery. Conclusions This study demonstrated that, with specific strategies to decrease conversion and with technical improvements, the conversion rates can be decreased with no demonstrable difference in postoperative complications. Gallbladder wall thickness and increasing age are risk factors for conversion to open surgery.

Acute pancreatitis appears to be less prevalent in multi-ethnic Southeast Asia, where the aetiology also appears to be influenced by ethnicity. As with acute pancreatitis elsewhere, however, pancreatic necrosis is a cause of significant mortality and the aim of this study was to review our institutional experience with pancreatic necrosectomy.The records of all patients who underwent pancreatic necrosectomy from January 2000 to December 2004 were analysed. Indications for surgery were the presence of infected necrosis, unresolving sepsis attributable to ongoing pancreatitis or the presence of gas in the pancreatic bed on imaging. Surgical debridement was achieved by debridement with closure over drains or by debridement with open packing.The cohort comprised 14 of 373 patients admitted for acute pancreatitis (3.8%), with an overall mortality rate of 29%. All patients had infected necrosis with positive bacteriological cultures. Eight patients (57%) underwent debridement with closure over drains and 6 patients (43%) underwent debridement with open packing. All mortalities occurred in patients who underwent open packing, who were also associated with a higher mean Acute Physiology and Chronic Health Evaluation (APACHE) II score. The mortality rate in patients who underwent debridement less than 4 weeks after admission was 33% (2 of 6), compared with 25% (2 of 8) in patients who underwent debridement after 4 weeks. There were no mortalities in patients operated on after 6 weeks.Surgical debridement with closure of drains and a policy of performing delayed necrosectomy are viable in our population.

Perforation of duodenal diverticulum is a rare occurrence but has a potentially fatal outcome. It is a difficult surgical problem because of delayed diagnosis and the attendant risk of duodenal fistula following primary repair. We present a case of posterior perforation of duodenal diverticulitis, diagnosed on computed tomography and successfully repaired with a Roux loop duodenojejunostomy. We also discuss the rare pathology, diagnosis and surgical options with special reference to this alternative form of mucosal repair.

Molecular hybridization is a useful technique for identifying specific target sequences even when they are present as a single copy in a complex population. It can be performed either on a solid matrix on which pure DNA (or RNA) is bound (blot hybridization) or on tissue sections (in situ hybridization). Until recently, the probes used in hybridization were usually labeled with radioisotopes. However, the short half-life, disposal, and safety problems of radioactive probes stimulated the development of nonradioactive hybridization techniques. In these, the probes are labeled with nonradioactive reporter molecules, which can be haptens, proteins, digoxigenin, biotin, and so forth. These reporter molecules can then be detected by enzyme-labeled antibodies or streptavidin (in the case of biotinylated probes). Of these reporter molecules, biotin and digoxigenin have several advantages over the others because of their small size. Therefore, they minimally interfere with hybridization efficiency. In addition, the high affinity of the binding of biotin and streptavidin (K ( d ) = 10(-15) M) is almost equivalent to covalent bonds. In fact, the biotin system was the first nonradioactive hybridization technique sensitive enough for routine use on Mot hybridization (1) and in situ hybridization (2).

Although oncogenes and tumor suppressor genes have been implicated in carcinogenesis and tumor progression, their relationship to the development of genomic instability has not been elucidated. To examine this role, we transfected oncogenes (polyomavirus middle [Py] and large T [MT and LT]) and adenovirus serotype 5 E1A) into two NIH 3T3-derived cell lines, EN/NIH 2-4 and EN/NIH 2-20. Both cell lines contain two stable integrants of a variant of the retrovirus vector pZipNeoSV(x)1 that has been modified by deletion of the enhancer elements from the long terminal repeats. DNA rearrangements activating the silent neomycin phosphotransferase gene (neo) present in these integrants were identified by selection of cells in the antibiotic G418. Whereas control-transfected EN/NIH cell lines do not yield G418-resistant subclones (GRSs), a fraction of oncogene-transfected EN/NIH 2-4 (8 of 19 Py MT, 5 of 17 Py LT, and 11 of 19 E1A) and 2-20 (7 of 15 Py MT) cell lines gave rise to GRSs at differing frequencies (0.33 x 10(-6) to 46 x 10(-6) for line 2-4 versus 0.11 x 10(-6) to 1.3 x 10(-6) for line 2-20) independent of cell generation time. In contrast, a distinctly smaller fraction of mutant Py MT-transfected EN/NIH cell lines (1 of 10 MT23, 1 of 10 MT1015, and 0 of 10 MT59b) resulted in GRSs. Southern analysis of DNA from selected oncogene-transfected GRSs demonstrated genomic rearrangements of neo-containing cellular DNA that varied in type (amplification and/or novel fragments) and frequency depending on the specific oncogene and EN/NIH cell line used in transfection. Furthermore, only one of the two neo-containing genomic loci present in both EN/NIH cell lines appeared to be involved in these genomic events. In addition to effects related to the genomic locus, these observations support a role for oncogenes in the development of genetic changes associated with tumor progression.

Perforation of duodenal diverticulum is a rare occurrence but has a potentially fatal outcome. It is a difficult surgical problem because of delayed diagnosis and the attendant risk of duodenal fistula following primary repair. We present a case of posterior perforation of duodenal diverticulitis, diagnosed on computed tomography and successfully repaired with a Roux loop duodenojejunostomy. We also discuss the rare pathology, diagnosis and surgical options with special reference to this alternative form of mucosal repair.