Safely Implementing a Program of Pure Laparoscopic Donor Right Hepatectomy: The Experience From a Southeast Asian Center.

Laparoscopic donor right hepatectomy (LDRH) is a technically challenging procedure. There is increasing evidence demonstrating the safety of LDRH in high-volume expert centers. We report our center's experience in implementing an LDRH program in a small- to medium-sized transplantation program. Methods: Our center systematically introduced a laparoscopic hepatectomy program in 2006. We started with minor wedge resections followed by major hepatectomies with increasing complexities. In 2017, we performed our first laparoscopic living donor left lateral sectionectomy. Since 2018, we have performed 8 cases of right lobe living donor hepatectomy (laparoscopy-assisted: 4 and pure laparoscopic: 4). Results: The median operative time was 418 (298-540) min, whereas the median blood loss was 300 (150-900) mL. Two patients (25%) had surgical drain placed intraoperatively. The median length of stay was 5 (3-8) d, and the median time to return to work was 55 (24-90) d. None of the donors sustained any long-term morbidity or mortality. Conclusions: Small- to medium-sized transplant programs face unique challenges in adopting LDRH. Progressive introduction of complex laparoscopic surgery, a mature living donor liver transplantation program, appropriate patient selection, and the invitation of an expert to proctor the LDRH are necessary to ensure success.

Prevalence and factors associated with sexual dysfunction among middle-aged women in a multi-ethnic country: A cross sectional study in Malaysia.

Introduction: This study aimed to determine the prevalence and factors associated with female sexual dysfunction in an outpatient clinic in Malaysia. Methods: The study was conducted among female patients aged 50 years and older who attended the outpatient clinic of a public hospital in Malaysia. A self-administered questionnaire was used that was based on the Malay version of the Female Sexual Function Index questionnaire. The predictors of female sexual dysfunction were identified using multivariate logistic regression analysis. Results: A total of 263 females were recruited in this study, with a mean age of 60.6 ± 6.7 years. The distribution of the respondents' ethnicities was mostly Malay (42.2%), followed by Chinese (41.8%) and Indian (16.0%). The prevalence of female sexual dysfunction among participants was 68.8%. The prevalence of the subscales of female sexual dysfunction was as follows: desire (85.2%), satisfaction (74.9%), arousal (71.1%), lubrication (66.9%), pain (61.2%), and orgasm (60.8%). According to multivariate logistic regression, patients of Indian ethnicity had an increased risk of female sexual dysfunction (0R=16.60, 95% CI=2.54-108.63), and a higher frequency of sexual intercourse was correlated with a lower risk of female sexual dysfunction (0R=0.13, 95% CI=0.08-0.24). Conclusion: Seven-tenths of the middle-aged female patients attending the outpatient clinic suffered from female sexual dysfunction. Indian ethnicity and having a lower frequency of sexual intercourse were predictors of female sexual dysfunction. Future intervention studies are needed to address this problem.

Salt content of instant noodles in Malaysia: a cross-sectional study.

OBJECTIVE: To determine the salt content in instant noodles sold in Malaysia. STUDY DESIGN: A cross-sectional survey was done involving 707 different flavours and packaging of instant noodles sold in six hypermarkets and retailer chains in Malaysia and the corresponding brand's official websites in 2017. METHODS: The salt content (gram per serving and per 100 g) was collected from the product packaging and corresponding brand's official website. RESULTS: Of the 707 different packaging and flavours of instant noodles, only 62.1% (n=439) provided the salt content in their food label.The mean (±SD) salt per 100 g of instant noodles was 4.3±1.5 g and is nearly four times higher than the salt content of food classified in Malaysia as a high salt content (>1.2 g salt per 100 g). The salt content for instant noodle per packaging ranged from 0.7 to 8.5 g. 61.7% of the instant noodles exceeded the Pacific Salt Reduction Target, 11.8% exceeded the WHO recommended daily salt intake of <5.0 per day and 5.50% exceeded Malaysia Salt Action Target. 98% of instant noodles will be considered as high salt food according to the Malaysia Guidelines.The probability of the instant noodles without mixed flavour (n=324) exceeding the Pacific Salt Reduction Target was tested on univariate and multivariate analysis. Instant noodles with soup, Tom Yam flavour, pork flavour and other flavours were found to be predictors of instant noodles with the tendency to exceed Pacific Salt Reduction Target when compared with instant noodles without mixed flavours (p<0.05). CONCLUSION: Only 62% of instant noodles displayed the salt content on their food label. Salt content in instant noodles is very high, with 90% exceeding the daily salt intake recommended by WHO. Prompt action from regulatory and health authorities is needed to reduce the salt content in instant noodles.

The influence of the middle hepatic vein and its impact on outcomes in right lobe living donor liver transplantation.

BACKGROUND: In adult right lobe living donor liver transplantation, the decision to include the middle hepatic vein (MHV) remains controversial. METHODS: A retrospective analysis of 50 R-LDLTs between January 2008 and June 2016 was performed. RESULTS: Twenty-one procedures were performed using a MHV+ graft (42.0%) and 29 procedures using a MHV- graft (58%). MHV- donors were taller (173 vs 166 cm, p = 0.004) with a larger standard liver volume (1351 vs 1245 mls, p = 0.014) compared to MHV+ donors. The duration of operation for donors was significantly longer in the MHV+ group (530 (313-975) mins) compared to the MHV- group (489 (336-708) mins) (p = 0.029). Similarly, the operative time for recipients was longer in the MHV+ group (660 (428-831) mins) compared to MHV- (579 (359-1214) mins) (p = 0.023). MHV- grafts were heavier compared to MHV+ grafts (918 vs 711 g, p = 0.017). Recipient mortality rates and Kaplan-Meier survival analysis were comparable (p = 0.411). All donors were well at last review. CONCLUSION: Both MHV+ and MHV- grafts are safe for the donor and recipient. The decision to take the MHV should be based on specific donor-recipient characteristics.

Bridging therapies to liver transplantation for hepatocellular carcinoma: A bridge to nowhere?

BACKGROUNDS/AIMS: Liver Transplantation (LT) is a recognized treatment for Hepatocellular Carcinoma (HCC). The role of Bridging Therapies (BT) remains controversial. METHODS: From January 2001 to October 2012, 192 patients were referred to the National University Hospital, Singapore for consideration of LT for HCC. Sixty-five patients (33.8%) were found suitable for transplant and were placed on the waitlist. Analysis was performed in these patients. RESULTS: The most common etiology of HCC was Hepatitis B (n=28, 43.1%). Thirty-six patients (55.4%) received BT. Seventeen patients (47.2%) received TACE only, while 10 patients (27.8%) received radiofrequency ablation (RFA) only. The remaining patients received a combination of transarterial chemoembolization (TACE) and RFA. Baseline tumor and patient characteristics were comparable between the two groups. The overall dropout rate was 44.4% and 31.0% in the BT and non-BT groups, respectively (p=0.269). The dropout rate due to disease progression beyond criteria was 6.9% (n=2) in the non-bridged group and 22.2% (n=8) in the bridged group (p=0.089). Thirty-nine patients (60%) underwent LT, of which all patients who underwent Living Donor LT did not receive BT (n=4, 21.1%, p=0.030). The median time to LT was 180 days (range, 20-558 days) in the non-BT group and 291 days (range, 17-844 days) in the BT group (p=0.214). There was no difference in survival or recurrence between the BT and non-BT groups (p=0.862). CONCLUSIONS: BT does not influence the dropout rate or survival after LT but it should be considered in patients who are on the waitlist for more than 6 months.

Single-Incision Laparoscopic Transgastric Underrunning and Closure of Cameron Ulcers in Acute Gastrointestinal Bleeding.

INTRODUCTION: Endoscopic therapy remains the cornerstone of hemostasis for gastrointestinal bleeding. In situations where hemostasis cannot be achieved via endoscopic or radiological methods, surgery is necessary. Traditional open surgery for bleeding gastric ulcers can be very morbid and unsuitable especially in hemodynamically unstable patients in extremis. We describe a minimally invasive, transgastric approach for underrunning and closure of Cameron ulcers. METHODS: Our patient is a 75-year-old Chinese lady, who presented to the emergency department with fresh melena. She was hemodynamically unstable with severe metabolic acidosis. CT angiography revealed blood clots within the stomach, with no active blush. On urgent gastroscopy, large blood clots obscured the site of hemorrhage. A Mallory-Weiss tear was noted. Our patient subsequently underwent a successful single-incision laparoscopic transgastric (SLT) underrunning and closure of two Cameron ulcers. RESULTS: Our patient had an uneventful recovery and subsequently underwent a successful laparoscopic para-esophageal hernia repair on postoperative day 9. CONCLUSION: A SLT approach is a suitable minimally invasive option for the surgical management of hemostasis and closure of bleeding gastric ulcers not amenable to endoscopic or radiological interventions.

Liver lesions detected in a hepatitis B core total antibody-positive patient masquerading as hepatocellular carcinoma: a rare case of peliosis hepatis and a review of the literature.

Peliosis Hepatis (PH) is a rare vascular disorder of the liver, characterized by the presence of cystic blood-filled cavities distributed throughout the hepatic parenchyma. The pathogenesis of PH remains controversial. The preoperative diagnosis of PH is difficult, due to the non-specific imaging characteristics of PH and almost all cases are diagnosed on histology post resection. This study presents a case of PH masquerading as hepatocellular carcinoma (HCC). The patient is a 45-year old Chinese lady, who presented with transaminitis. She was found to be hepatitis B virus core total antibody-positive with an alpha-fetoprotein (AFP) of 29.4 ng/ml. Triphasic liver computed tomography showed several arterial hypervascular lesions and hypoenhancing lesions on the venous phase, particularly in the segments 6/7. Subsequently, a magnetic resonance imaging scan showed multiple lesions in the right hemiliver with an indeterminate enhancement patterns. Subsequently, she decided to undergo a resection procedure. Histopathology revealed findings consistent with PH with some unusual features. This case demonstrates a clinical conundrum, in which PH presented with a raised AFP, in a patient with risk factors for the development of HCC. The clinical suspicion of PH should be high in patients, who present with multiple hepatic lesions with variable enhancement patterns.

Laparoscopic Anterior Resection with Transvaginal Specimen Extraction (TVSE) for Colorectal Cancer and Concomitant Total Hysterectomy and Bilateral Salpingo-Oophrectomy (THBSO): A Technical Description.

BACKGROUND: Natural orifice specimen extraction (NOSE) has evolved to circumvent the need for a specimen extraction site. Transvaginal specimen extraction (TVSE) for colorectal disease has been shown to be safe and feasible in selected cases.1 , 2 We describe our technique of TVSE in a case of laparoscopic ultra-low anterior resection (ULAR) with defunctioning ileostomy (DI) with a concomitant total hysterectomy and bilateral salpingo-oophrectomy (THBSO). METHODS AND RESULTS: A 74-year-old Chinese female was diagnosed with a mid-rectal cancer following colonoscopic evaluation for a change in bowel habits. Preoperative magnetic resonance imaging (MRI) suggested T2N0 disease and the patient was recommended for upfront surgery following multidisciplinary discussion. Computed tomography (CT) scan confirmed a 4.3 × 3.4 cm right adnexal cystic lesion, without enhancing septations or soft tissue component. No metastatic disease was identified. The patient underwent a laparoscopic ULAR with DI and THBSO with TVSE; operative time was 469 min. The specimen showed a 2.5 cm mid-rectal tumour. Histology revealed a pT3N1a moderately differentiated adenocarcinoma of the mid rectum, with 1 of 20 lymph nodes involved by metastatic carcinoma. The quality of the total mesorectal excision (TME) was good, with no breach in the mesorectal fascia. The distal and radial margins were 1.5 and 3.0 cm, respectively. The patient recovered well postoperatively, with minimal wound site pain, and was discharged well on postoperative day 5. CONCLUSION: TVSE is oncologically safe and feasible in certain malignant colorectal pathologies. It is an option to consider in selected cases that require a concomitant gynecological procedure.

Outcomes of Percutaneous Cholecystostomy for Acute Cholecystitis.

BACKGROUND: Acute cholecystitis (AC) is an important cause of emergency admissions among the elderly. The use of percutaneous cholecystostomy (PC) as bridging therapy among high-risk patients is widely accepted. However, the use of PC as definitive treatment is controversial. AIM: To determine the characteristics, clinical outcomes and predictors of recurrence of AC among patients who underwent PC. METHODS: A retrospective case series of 71 consecutive patients [73 (38-96) years, 43/71 males] treated with PC for AC at a tertiary hospital from 2007 to 2013, with data collected from case records. RESULTS: Patients were followed up for 37.0 (0.1-110.8) months after PC. Mortality rate was 8.5 % (6/71) during the index admission and 32.4 % (23/71) at the end of follow-up. Recurrence rate for AC was 11.9 % (7/59). Median time to recurrence was 62 (13-464) days. PC was definitive treatment in 33/59. Predictors of recurrence were higher serum alkaline phosphatase (ALP) at diagnosis (OR = 1.01, 95 % CI 1.00-1.02, p = 0.021) and acute myocardial infarction (AMI) during index admission (OR = 8.00, 95 % CI 1.19-54.0, p = 0.033). Fifteen patients (26.3 %, 15/71) had post-procedural complications including dislodgement (14 %, 10/71), tube obstruction (7.0 %, 5/71), bile leaks (2.8 %, 2/71), gallbladder perforation (1.4 %, 1/71), bowels perforation (1.4 %, 1/71) and severe post-procedural haemorrhage (1.4 %, 1/71). CONCLUSION: PC is effective and relatively safe in high-risk patients with AC. However, patients with higher ALP or AMI during index admission have higher risk of recurrence and might benefit from definitive cholecystectomy.