Surgery in Singapore--the Scottish link.
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General Surgery↗
Biomedical subjects
R Nambiar
Publications and source records attributed to R Nambiar.
Primary torsion of the greater omentum. Case report.
Four cases of primary torsion of the greater omentum are reported. The most common clinical picture in this condition mimics acute appendicitis. Primary torsion with spontaneous derotation of the greater omentum may be an important cause of right iliac fossa pain of obscure origin. Scrutiny of the omentum during negative appendiceal exploration is extremely important. Treatment is excision of the twisted, infarcted omentum.
Emergencies↗
Fine needle aspiration cytology in the management of solitary thyroid nodules--a comparison with other diagnostic modalities in cost-effectiveness.
This paper assesses the cost effectiveness of fine needle aspiration cytology (FNAC) as a selection criteria for surgery in solitary thyroid nodules compared to scintigraphy and ultrasonography. 98 patients who had FNAC and histological confirmation, scintigraphy and/or ultrasonography were studied. The use of combined diagnostic discriminants of positive FNAC, clinical suspicion and age above 50 years detected all malignancies and would have resulted in fewer patients being subjected to surgery--51% (FNAC) vs 90% (Scans, U/S). This resulted in cost savings of $800 per patient seen. We conclude therefore that FNAC should be the diagnostic modality of choice and that the routine use of scintigraphy and ultrasonography is not justifiable.
Biopsy, Needle↗
Adenocarcinoma associated with chronic anal fistula.
Adenocarcinoma in association with chronic anal fistula is a rare disease entity with a male preponderence in most reported series. The patient typically presents with a long history of perianal disease. Diagnosis is often delayed because of failure to obtain biopsy evidence of the condition. A chronic anal fistula may become malignant. However, despite delay in diagnosis, complete removal which usually entails abdominoperineal resections with wide excision of perianal skin and ischiorectal fossa is necessary to achieve good results. We relate our experience with two such rare cases and a literature review on the current views on the relationship between adenocarcinoma and the occurrence of anal fistula is presented.
Adenocarcinoma↗
Multiple splenic abscesses following Pseudomonas sepsis.
Splenic abscess is an unusual clinical entity, which in most cases is secondary to metastatic spread of bacteria from a primary site of infection. Before the antibiotic era, Salmonella typhi was a common offending organism but now staphylococci and streptococci are predominant organisms. We report two rare cases of multiple splenic abscesses caused by Pseudomonas infection. One case followed Pseudomonas septicaemia and the other was secondary to Pseudomonas pseudomallei osteomyletis of the femur. Both cases underwent splenectomy and promptly recovered.
Abscess↗
Major surgery in the elderly--a study of outcome in 295 consecutive cases.
The results of major surgery in 295 consecutive patients over the age of sixty years were analysed. In this series, 70% were electives and 30% emergency cases with a male preponderance of 3:2. The overall mortality was 11.2%. Mortality following emergency operations was three times more than electives. Seventy percent (70%) of deaths after elective surgery followed palliative operations for advanced cancer. For elective surgery, complications of peptic ulcers were associated with a high mortality rate whereas deaths were fairly uniform in the emergency group. In general, concomitant medical diseases and postoperative complications were the major determinants of outcome of surgery in the elderly.
Aged↗
Synchronous primary hepatocellular carcinoma and multiple early gastric cancer--a case report.
A rare case of synchronous primary hepatocellular carcinoma and multiple early gastric cancer in a patient is reported. Both the tumours were successfully resected at one operation.
Adenocarcinoma↗
Cholangiocarcinoma in a choledochal cyst--a case report and review of the literature.
A rare case of cholangiocarcinoma occurring in a choledochal cyst in an adult woman is reported. Unlike the few previous reports this case was diagnosed pre-operatively and treated radically by an extended Whipple's operation.
Adenoma, Bile Duct↗
Breast cancer--the need for early diagnosis.
A retrospective study was undertaken of 265 women with breast cancer treated at the Department of Surgery, Toa Payoh Hospital, Singapore, during 8 years from 1977 to 1985. The average patient was aged 51.0 years, with a tumour 4.9 cm in diameter, staged at T2aN1bMO (Stage II). In comparison with an earlier series from the same Unit, an increase in the number of younger patients was noted, although overall a larger proportion of 'early' cases (TNM Stage I) was found. In contrast to recent western series, breast cancer in Singapore is diagnosed at a later stage and generally unsuitable for conservative treatment by lumpectomy and radiotherapy. The standard treatment was modified radical mastectomy, or simple mastectomy with axillary clearance, followed by Radiotherapy if ipsilateral axillary lymphnodes were histologically involved.
Age Factors↗
Gastrointestinal and retroperitoneal sarcoma--local experience and review of the literature.
Gastrointestinal and retroperitoneal sarcoma are uncommon tumours. Out of 26 cases treated over the last 6 years, there were 16 smooth muscle tumours (SMT) and 10 non Hodgkin Lymphomas (ML). 7 cases of SMT were leiomyosarcoma. The majority of the cases were found in the stomach. 8 cases presented as acute emergencies while the non acute cases had non specific complaints. Despite the use of barium studies, gastroscopy and CT scan, only 5 cases were diagnosed preoperatively. The majority underwent curative resection. ML cases had a combination of radiotherapy and chemotherapy. 2 patients with large and high grade leiomyosarcomas have died. 4 patients with ML have also died, 2 with locally advanced disease and 2 with distant metastases. We conclude that most cases are not diagnosed preoperatively due to their rarity and nonspecific clinical presentation. The important prognostic factors are size and mitotic index for SMT and stage of the disease for ML.
Female↗
The use of serum transferrin in the evaluation of protein-calorie malnutrition in cancer patients.
Forty-five patients with various malignancies of the gastrointestinal tract had their nutritional status assessed pre-operatively to determine the prevalence of malnutrition and to establish the correlation of malnutrition with post-operative outcome. Ten nutritional parameters were assessed. Based on these markers, we found a significant degree of malnutrition. Half of the study population developed some form of post-operative complication and nearly one quarter died. Of the ten nutritional markers studied, only serum transferrin had predictive value in determining post-operative outcome. The mean level of serum transferrin for patients with major complications was 162.0 mg/dl as compared with 221.2 mg/dl for those with none or minor complications. Patients with a serum transferrin level below the reference range of 200 mg/dl had most of the major life threatening complications and deaths. The other nutritional markers studied did not correlate well with post-operative outcome. We feel that serum transferrin is a useful nutritional marker to predict post-operative outcome and also to monitor the effect of nutritional support. However, based on a preliminary study, nutritional support may be required for periods longer than two weeks to show significant improvement in protein-calorie malnutrition. We will consider giving adequate support for a longer period on a further study using serum transferrin as a marker to determine its value in monitoring any reversal of malnutrition.
Female↗
Solitary thyroid nodules for surgery--the role of fine-needle aspiration biopsy cytology.
The diagnostic accuracy of fine needle aspiration biopsy cytology (FNAC) was assessed in 46 patients, all of whom had histological verification. In the group of patients with microscopic foci of carcinomas excluded, diagnostic sensitivity was 75% and specificity 100%. No false positives were recorded, the false negative rate was 5.0% and the overall accuracy, 95%. Although 6 of the 10 carcinomas were correctly diagnosed by cytology, the correct morphological type of tumor was only identified in three of them. Using clinical suspicion of malignancy alone as a criterion for surgery, 13% of patients would have required surgery with 50% of malignancies still remaining undetected. However using FNAC, clinical suspicion and patients above 50 years of age as combined criteria, 40% of patients would have been subjected to surgery with a resulting yield of malignancy of 100%. These promising results from a initial experience with FNAC confirm its usefulness in the appropriate selection of patients for surgery.
Adult↗
Thyroid carcinoma--problems in management.
A retrospective review of surgically treated cases of thyroid carcinomas in this department during a 10 year period of 1976 to 1985 was performed. From a detailed analysis of 71 cases three features are highlighted. Firstly, the rising incidence of thyroid carcinomas and papillary carcinomas with age has been clearly demonstrated. Secondly, with current clinical and investigative modalities using thyroid scans, ultrasonography and frozen section histology, the preoperative and operative diagnosis of malignancy has been limited resulting in only 27% of patients confirmed to have carcinoma histologically. This resulted in 35% of patients requiring staged procedures to achieve total thyroidectomy. Finally from the prognostic factors of survival that were evaluated, age at diagnosis, local invasiveness, and distant metastases were found to be significant factors.
Adenocarcinoma↗
Transsacral approach to the rectum.
While the proximal or upper third of the rectum is readily accessible through the lower abdomen, lesions of the distal rectum are difficult to reach both from abdomen and the perineum. The transsacral approach (Kraske) gives excellent exposure of the mid and lower rectum. The experience using this approach in sixteen cases for various indications which include local excision of benign tumours, segmental excision, repair of recto-vesical fistula, perineal excision of rectum and abdominal excision of rectal carcinoma and low colo-rectal anastomosis with preservation of ano rectal sphincters is reported. In some cases where wider exposure of the rectum is required, this was easily achieved by excising the last three pieces of sacrum and/or extending below by dividing the external sphincter. While incontinence is not a long term problem, attention to technical details and creation of a temporary colostomy are necessary for all cases of excision and end-to-end anastomosis to prevent leakage and septic complications. Temporary colostomy is not required for excision of part of the circumference of the rectum as in the treatment of most benign lesions.
Adult↗
Is preoperative shaving really necessary?
A randomised prospective study was done to assess the necessity of shaving before operation. Seven hundred and sixteen cases were included in this study. The traditional method of preoperative skin preparation which employs routine shaving and using cetrimide and chlorhexidine in alcohol for cleansing was compared with an alternate method without preoperative shaving. The clean wound infection rate was 5.08% for the traditional method group and 5.56% for the alternate method group. The results suggest that routine shaving, as part of preoperative preparation, has no advantage in reducing wound infection rate.
Adolescent↗
Benign insulinoma--a diagnostic challenge: a case report.
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Adenoma, Islet Cell↗
A simple technique of palliative oesophageal bypass operation.
Twelve consecutive oesophageal bypass operations using stomach, in which both the upper and the lower ends of the oesophagus proximal and distal to the growth were suture-closed are reported. There were no complications directly attributable to the closure of the oesophagus. The longest surviving patient with a benign stricture is well and eating a normal diet 40 months after operation. Suture closure of the oesophageal ends is a safe procedure. It avoids a difficult subdiaphragmatic anastomosis, saves on the number of anastomoses required and therefore improves the chances of survival.
Esophageal Neoplasms↗