Biomedical subjects
Publications and source records attributed to P M Goh.
We present three patients with bleeding duodenal tumors who were managed by laparoscopic excision. This represents the largest study of such an experience. The literature is reviewed, and the various technical approaches are discussed.
The present study evaluated the significance of nitric oxide synthase (NOS), cyclooxygenase (COX) expression and p53 status in 55 patients with gastric adenocarcinoma and relationship of these molecular markers to tumor characteristics and metastatic potential. Immunohistochemical technique was used to identify the cellular location and distribution of the enzymes in the specific cells of gastric tumors. In gastric cancer tissue, the expression of inducible enzymes, iNOS and COX-2, increased significantly with increasing tumor stage (P=0.015, P=0.001, respectively), size (P=0.025, P=0.001, respectively) and the presence of metastases (P=0.002, P=0.015, respectively). The expression of constitutive enzymes, ecNOS and COX-1, followed the opposite pattern. COX-1 was significantly reduced in advanced gastric tumors (P=0.007) and tumors larger than 5 cm (P=0.007). Reduced expression of ecNOS was also observed in advanced gastric tumors; however, this did not reach statistical significance. 53% of gastric tumors showed accumulation of p53. This was significantly higher in advanced tumors (P=0.004), larger than 5 cm (P=0.015) with metastases (P<0.001). Gastric tumors positive for accumulation of p53 had significantly stronger expression of iNOS (P=0.018) and COX-2 (P=0.01) enzymes than tumors negative for this nucleophosphoprotein. We conclude, that tumor-associated nitric oxide production, as well as COX-2 overexpression, may promote gastric cancer progression by providing a selective growth advantage to tumor cells with non-functioning p53.
Diaphragmatic rupture may occur after blunt or penetration trauma caused by the application of a powerful external force. Diaphragmatic rupture usually is repaired via laporotomy and/or thoracotomy, depending on the associated organ injury. The case of a 49-year-old man with traumatic rupture of the left hemidiaphragm is presented. Preoperatively, diaphragmatic rupture with herniation of the stomach into the left thoracic cavity was confirmed by computed tomography scan of the thorax. Under thoracoscopic guidance, the stomach, spleen, and omentum were repositioned in the abdominal cavity, and the rupture site (10 cm) was closed by nonabsorbable suture. A subsequent laparoscopy was performed to assess the efficacy of the repair and the absence of any abdominal organ injury. The patient was discharged from hospital without any respiratory or abdominal symptoms. Our report confirms that in the case of a patient with penetration injuries to the lower chest and upper abdomen, a combined thoracoscopic and laparoscopic approach may offer both diagnostic and therapeutic benefits with reduced surgical trauma. We conclude that thoracoscopic repair of traumatic diaphragmatic rupture can be used safely when no abdominal organ injuries are found.
HYPOTHESIS: Since the advent of laparoscopic surgery in 1987 and the introduction of robotics into medicine in 1991, medical technology has advanced to robotic applications in performing surgery. In our study, we investigated the feasibility of performing simple laparoscopic maneuvers and laparoscopic cholecystectomy using a robotic surgical system. DESIGN: The study used a ZEUS robotic system (Computer Motion Inc, Goleta, Calif), consisting of 3 interactive robotic arms fixed at the operating table and remotely controlled by the surgeon. After initial training, using a bench model and 3 isolated porcine livers to perform cholecystectomy, 7 female pigs underwent robotically assisted laparoscopic cholecystectomy. The surgeon, seated at the console, manipulated the 3-mm laparoscopic instruments and performed the surgery. RESULTS: Robotically assisted laparoscopic cholecystectomy was accomplished in all 7 pigs, with a mean operative time of 46 minutes (range, 30-62 minutes). There were no complications. The mean time to setup of the robotic system decreased from 30 minutes to 14 minutes. All the robotic maneuvers were performed without any particular difficulties, and the movements were stable, accurate, and reliable, with good control. CONCLUSIONS: Our preliminary experimental study showed that robotically reproduced laparoscopic maneuvers, such as tying, suturing, dissection, clipping, and cautery, seemed to be as accurate and as fast as maneuvers made without robotics. We conclude that our initial experimental and animal study confirmed the feasibility of robotically assisted laparoscopic cholecystectomy. Further reports are needed to show that robotics can be used for clinical applications in surgery.
BACKGROUND: Several studies have reported the feasibility of using 'needlescopic' instruments with a diameter less than 3 mm in minimally invasive surgery. This study reports a comparison of needlescopic cholecystectomy and laparoscopic cholecystectomy. METHODS: Seventy-five patients with symptomatic chronic cholelithiasis were randomized to needlescopic (n = 37) or laparoscopic (n = 38) cholecystectomy. RESULTS: The duration of surgery in the two groups was similar. Patients in the needlescopic group had less pain (mean visual analogue score 2.2 versus 3.6; P < 0.003) and had smaller scars (median length 17.0 versus 25.0 mm; P < 0.001). In addition, patients in the needlescopic group tended to require fewer intramuscular pethidine injections (P = 0.05). However, oral analgesic requirements in the two groups were similar. There were no complications in either group. CONCLUSION: Needlescopic cholecystectomy resulted in less postoperative pain and a smaller surgical scar than laparoscopic cholecystectomy in patients with chronic cholecystitis.
Use of the laparoscopic approach for the management of gastric cancer is still in the developmental phase. The authors present their experience with laparoscopic radical gastrectomy for advanced gastric cancer. Between September 1997 and August 1999, four laparoscopic gastrectomies for gastric carcinoma were performed on two male and two female patients (mean age, 61.5 years). One D2 total radical gastrectomy and three D2 subtotal distal gastrectomies were performed, using a totally laparoscopic approach. Mean operative time was 210 minutes. There were no intraoperative complications. All four patients recovered uneventfully from surgery and began oral feeding on the third postoperative day. Median postoperative stay was 7 days (range, 6-9). All patients were alive 8 months to 3 years after the operation, with no cancer recurrences. This series shows that laparoscopic radical gastrectomy for moderately advanced cancers can produce good results in terms of safety and oncologic adequacy.
Telesurgery is a form of operative videoconferencing in which a remotely located surgeon observes a procedure through a camera and provides visual and auditory feedback to the operative site. With the use of more robotic devices in laparoscopic surgery, various forms of telesurgery have been tried. We describe the first two international telesurgical, telementored, robot-assisted laparoscopic cholecystectomies performed in the world, between the Johns Hopkins Institute, Baltimore, Maryland, USA, and the National University Hospital, Singapore.
BACKGROUND: Open thoracic sympathectomy has been the established option for patients with essential hyperhidrosis. Recently, video-assisted endoscopic sympathectomy has provided a simple, safe, reliable, and cost-effective alternative to the earlier technique. With advances in instrumentation, performing the procedure through 2-mm and 3-mm needlescopic ports is now possible. The authors evaluate the effectiveness of so-called needlescopic thoracic sympathectomy for the treatment of primary hyperhidrosis. METHODS: Thirty five consecutive patients with a mean age of 24 years, including 23 men and 12 women, underwent bilateral needlescopic thoracic sympathectomies at the National University Hospital of Singapore. RESULTS: The mean operative duration was 56 minutes, and the mean hospital stay was 1.2 days. In no patient did Horner's syndrome or significant pneumothorax develop. The rate of success, defined as completely dry hands, was 97%. Two patients had unilateral recurrences that responded well to repeat needlescopic sympathectomies. We performed a total of 72 sympathectomies. CONCLUSIONS: Our study demonstrates that the use of miniature port access sites produces excellent medical and cosmetic results and is associated with a short hospital stay and low risk of complications.
BACKGROUND: Emergency gastric resection for complicated peptic ulcer and gastric cancer is a major challenge for general surgeons. This study aimed to evaluate the results of emergency gastrectomy and to examine the factors that predict the operative outcome. METHODS: A total of 82 consecutive patients who underwent emergency gastrectomy were studied. The following variables were assessed: pathology, mortality rate, morbidity, reasons for reoperation and factors related to the outcome. RESULTS: There were 64 men and 18 women with a median age of 62 (range 30-90) years. The indications were bleeding and perforated gastric or duodenal ulcers in 45 and 20 patients respectively, and bleeding and perforated gastric tumours in seven and ten patients respectively. The overall mortality rate was 17 per cent (n = 14). The complication rate was 63 per cent and 11 patients (13 per cent) required reoperation. By multivariate analysis, age greater than 65 years and blood haemoglobin level less than 10 g/dl on admission were predictive of complications after emergency gastrectomy. Postoperative pulmonary and cardiac complications and hypotension on admission were independent risk factors associated with operative death. CONCLUSION: Age more than 65 years, haemoglobin level less than 10 g/dl and hypotension on admission were associated with a poor outcome after emergency gastrectomy. The operative result was not affected by the underlying gastric pathology.
The use of laparoscopy for staging and treatment of gastric cancer has evolved in the past decade along with other advanced laparoscopic procedures. Laparoscopic staging of gastric cancer, especially with the addition of laparoscopic ultrasonography, has been shown more reliable than radiologic modalities and it effectively decreases the incidence of unnecessary laparotomy. Although it is not commonly performed in Western countries, the use of laparoscopic curative resection for gastric cancer is growing, especially in Japan. Laparoscopic resection of early gastric cancer has been shown to be safe and effective in many retrospective series though no prospective randomized studies comparing it to open resection have been performed. Despite being more controversial, laparoscopic curative resection of advanced gastric cancer also has been performed at multiple institutions with encouraging early results. This review will present the current worldwide experience of laparoscopy for gastric cancer.
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A patient swallowed a fish bone that perforated the stomach wall and embedded in the head of the pancreas. This was confirmed by computed tomographic imaging. We describe a case of successful fish bone removal using a laparoscopic technique, thus avoiding a laparotomy. The patient recovered well and was discharged from the hospital the next day. This is the first description of such a case.
BACKGROUND AND STUDY AIMS: Hematochezia is a common clinical problem. When the bleeding is brisk and continuous it requires prompt hospital admission and careful diagnostic evaluation and management. Colonoscopy has become the first-line investigative modality in patients presenting with severe hematochezia in many centers, including ours. A retrospective review was carried out to evaluate the effectiveness of colonoscopy in determining the cause of severe hematochezia in our Oriental population. PATIENTS AND METHODS: One hundred and ninety patients with severe hematochezia underwent colonoscopy at the National University Hospital, Singapore, from 1 January 1988 to 31 December 1994. Their records were retrieved and the data analyzed for sex, age, presentation, concomitant medical conditions, prevalence of recent non-steroidal anti-inflammatory drugs ingestion, past history of hematochezia, investigations, subsequent interventions and outcome. RESULTS: Colonoscopy as the fist-line investigative modality identified the site and cause of hematochezia in 78% (148/190) of cases. The site of bleeding remained "obscure" even after additional investigations in 15% (29/190) of cases. The commonest cause of severe hematochezia in our Oriental population was diverticular disease (30%, 57/190) with right-sided diverticular bleeding constituting 44% (25/57) of these cases. Overall, bleeding stopped spontaneously in 81% (154/190) of cases. Surgery was performed in 16% (30/190) of cases. The mortality related to severe hematochezia in this series was 5% (9/190). CONCLUSIONS: The diagnostic efficiency of colonoscopy in defining the site and cause of severe hematochezia in the Oriental population is comparable to most Western series. The commonest cause of severe hematochezia in our population was diverticular disease.
A double papilla of Vater, with separate openings for the bile duct and the pancreatic duct, is a rare anatomic anomaly observed in endoscopic retrograde cholangiopancreatography (ERCP). We report the case of a 45-year-old Chinese man with obstructive jaundice due to common bile duct stones and gallbladder stones. During ERCP, a double papilla of Vater with separate drainage for the bile duct and the pancreatic duct was observed. As the anatomy was unusual, no sphincterotomy was performed, but a biliary stent was inserted. Subsequently, the patient underwent cholecystectomy and exploration of the common bile duct. On the 15th postoperative day, he was asymptomatic and was discharged. Common bile duct-Pancreatic duct.
BACKGROUND: Adhesion formation between viscera and mesh is almost inevitable following incisional hernia repair with prosthetic mesh. Such adhesions may lead to intestinal obstruction and enterocutaneous fistulae formation and make further laparotomies extremely difficult. Sodium carboxymethylcellulose (SCMC) and Interceed TC7 (oxidized regenerated cellulose) as physical barriers have been shown to be effective in reducing postoperative adhesions. MATERIALS AND METHODS: To evaluate the effects of SCMC and Interceed TC7, we used an incisional hernia model in rats. A ventral abdominal defect (15 x 25 mm) was created in each of 36 male rats which were then divided into three equal groups. In Group I (control) the defect was repaired with polypropylene mesh (PPM) only; in Group II the defect was repaired after a layer of Interceed TC7 was laid over the viscera with Interceed TC7-covered PPM; in Group III the defect was repaired after a layer of SCMC was laid over the viscera with SCMC-coated PPM. Six of the animals from each group were sacrificed at Postoperative Day 7 and the adhesions were scored. The remaining 6 were sacrificed at Day 30 and histological evaluation was made in addition to the adhesion score. RESULTS: Animals in the SCMC-treated group developed significantly less adhesions (P = 0.0002) compared with control and Interceed TC7-treated groups. However, histological analysis revealed poor fibroblast proliferation with impaired wound healing in the SCMC group. CONCLUSION: SCMC prevented adhesion formation but seriously impaired wound healing, and Interceed TC7 was ineffective in preventing adhesion in this model.
BACKGROUND: The first totally laparoscopic Billroth II gastrectomy was performed in 1992. To date, laparoscopic gastrectomy has been performed by a small number of surgeons around the world and the laparoscopic approach has been extended to Billroth I and total gastrectomy. The aim of this study is to review the state of laparoscopically performed gastrectomies in the international scene. METHODS: Questionnaires were prepared and sent to every surgeon in the world known by the authors or their contacts to have performed a laparoscopic gastrectomy. A questionnaire survey was started in July 1994 and completed by November 1994. Data collected included age, sex, type of gastric resection, technique of reconstruction after resection, average duration of surgery, time to liquid and solid intake, postoperative hospital stay, complications, and opinions of the surgeons. RESULTS: Sixteen surgeons contributed to this study. A total number of 118 cases of laparoscopic gastrectomies, comprising Billroth I (11), Billroth II (87), vagotomy and antrectomy (10), and total gastrectomy (10) had been performed. The indications were gastric and/or duodenal ulcers and benign and malignant gastric tumors. CONCLUSIONS: Laparoscopic gastrectomy was found to be superior to the open technique by 10 of 16 surgeons because of faster recovery, less pain, and better cosmesis. The procedure was an expensive and long operation according to four. Two surgeons were uncertain of any benefit because of limited experience.
BACKGROUND: To determine the predictive factors of synchronous common bile duct (CBD) stones, data from 878 consecutive patients who underwent cholecystectomy in a university clinic from June 1991 to June 1996 were retrospectively analyzed. METHODS: Based on clinical, biochemical, and ultrasonographic criteria, 194 patients were selected for ERCP, 180 preoperative and 14 postoperative. RESULTS: Cannulation of CBD was successful in 192 (99%) patients. Stones were identified in 62 (32%) patients and sphincterotomy was performed in 56 (90%). Duct clearance was achieved in 43 (77%) cases. There was a high predictive value for the presence of CBD stones in patients with cholangitis, present jaundice, and dilated CBD with evidence of stones on ultrasound (75%, 72%, and 67% respectively). A dilated CBD without stone on ultrasound and elevated liver enzymes had less than 40% positive predictive value. History of previous jaundice, pancreatitis, previously raised liver enzymes, and present pancreatitis was predictive in less than 20% of the cases. Univariate analyses revealed that clinical findings of cholangitis and obstructive jaundice, elevated liver enzymes (previous and present), and ultrasonographic findings of stones in a dilated CBD were significant positive predictors. Subanalysis of each elevated liver enzyme revealed that alanine transaminase, aspartate transaminase, alkaline phosphatase, and gamma glutamyl transpeptidase were significant predictors. Both elevated conjugated and total bilirubins were also significant predictors for CBD stones. CONCLUSION: Multivariate logistic regression analysis on these significant predictors showed that cholangitis (odds ratio [OR]: 10.5), dilated CBD with evidence of stones on ultrasound (OR: 7.4), elevated aspartate transaminase (OR: 2.9), and conjugated bilirubin (OR: 5.3) were jointly significant. The likelihood of having stones in the duct without any of these predictors was 7%, but 99% when all the predictors were positive.