Abstract: Single-port or uniport video-assisted thoracic surgery (VATS) has been gaining popularity in simple thoracic surgical procedures, such as sympathectomy, and pleural or lung biopsies. Recently, a Spanish group reported its successful attempt in performing singleport major lung resections, including lobectomy and pneumonectomy, in the literature. We describe our approach and surgical technique in single-port VATS right lower lobe lobectomy for early-stage nonsmall cell lung carcinoma.

Abstract: Huscher from Germany was the first to publish an article on endoscopic thyroidectomy. My paper, paper on a slightly different cervical approach, was published 3 months later in the same journal. Over the past one and a half decades, at least 20 modifications have emerged in which the access wounds move further and further away from the prominent exposed part of the body; from the supraclavicular and infraclavicular region, to the anterior chest, the breast, the axilla, and more recently, to the postauricular area. In retrospect, we have been striving to achieve cosmesis at the expense of invasiveness. Therefore, it is particularly exciting to learn of transoral endoscopic thyroidectomy (TOET), which has the appeal of getting the best of both worlds. On 23 May 2012, under the auspices of the Hong Kong Thyroid Society, we undertook the task of refining the TOET technique.

Abstract: Thyroidectomy is one of the common surgical operations performed in Hong Kong. The use of an endoscopic approach provides an alternative to traditional open surgery, which is widely practice in South–East Asian countries. The cosmetic outcome is excellent. Since the use of the robotic da Vinci system for thyroidectomy in 2008 in Korea, it provides a stable alternative for endoscopic thyroidectomy. We hereby present one case of robotic right hemithyroidectomy using the bilateral axillo-breast approach (BABA).

Abstract: Aim To develop a clinical strategy for the interposition of portomesenteric vein (PMV) by means of allograft in pancreatic surgery. Patients and Methods Between January 2004 and September 2011, nine patients had PMV interposition using allograft for massive vascular involvement by pancreatic tumour during pancreaticoduodenectomy. Their clinical outcomes were reviewed. Results After anastomosis of the allografts, three of which were fresh portal venous allografts, and six of which were cryopreserved iliac arterial allografts harvested from cadaveric donors, follow-up Doppler ultrasonography revealed neither thrombosis nor stenosis. Conclusions The allografts might provide a feasible and clinically-attractive option in PMV interposition in the radical resection of pancreatic tumours.

Abstract: Aim The minimally-invasive Nuss procedure has become the preferred technique for pectus excavatum repair. This procedure is still associated with significant postoperative pain, and an optimal pain-management strategy is yet to be determined. The purpose of this study was to compare the efficacy of patient-controlled analgesia (PCA) to thoracic epidural analgesia (TEA). Patients and Methods We retrospectively reviewed 112 charts from a single paediatric centre. Patients were grouped according to pain-management strategy: 90 patients received a PCA, and 22 patients received TEA. Outcomes included length of hospitalization and daily pain scores, operating room time and duration of Foley catheterization. Results Demographic data were similar between the two groups. The daily pain scores were not statistically different between the groups. Length of hospitalization was similar (PCA: 4.6 days, epidural: 4.3 days, P = 0.33). The PCA group required less operating room time (2:44 vs 2:58, P = 0.04) and shorter Foley catheter duration (2.1 days vs 2.5 days, P = 0.04). Conclusion In our patient population, TEA for the Nuss procedure does not offer an advantage over PCA-centred analgesia in terms of subjective daily pain scores or length of hospital stay. The potential risks of TEA need to be carefully considered in this patient population.

Abstract: Aim Increasing studies have reported on the feasibility of laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) for pancreatic diseases; however, the therapeutic efficacies between the two procedures remain controversial. The aim of the present study was to conduct a meta-analysis to evaluate the efficacy and safety of LDP for pancreatic diseases. Patients and Methods Searches of the Medline, Embase, Cochrane Library, Chinese Biomedical Database, and CNKI were performed to identify relevant studies published between January 2001 and December 2011. Results Sixteen studies involving 1796 participants were included. LDP was associated with longer operative time [mean difference (MD): −13.45, 95 per cent confidence interval (95 per cent CI): 8.18–18.17, P < 0.00001] and fewer lymph nodes harvested (MD:−6.05, 95 per cent CI: −6.54 to −5.56, P < 0.00001), but higher spleen preservation rates [odds ratio (OR): 3.38, 95 per cent CI: 1.93–5.9, P < 0.00001], less estimated blood loss (MD: −389.75, 95 per cent CI: −407.96 to −371.55, P < 0.00001), shorter hospital stay (MD: −3.95, 95 per cent CI: −4.0 to −3.9, P < 0.00001) and less complications (OR: 0.47, 95 per cent CI: 0.25–0.88), P = 0.02] compared with patients undergoing ODP. There were no significant differences between the two groups in postoperative mortality and long-term survival. Conclusion The short-term outcomes of LDP for pancreatic diseases were comparable with the open approach. Although ODP might be associated with shorter operative time and more lymph nodes harvested, individuals considering LDP might benefit from a shorter hospital stay and a faster resumption without an increase in postoperative morbidity and mortality.

Abstract: Aim Invasive thymomas are rare tumours of the anterior mediastinum. These tumours' clinical features have been the subject of much controversy. Therefore, it is necessary to elucidate the optimal management of invasive thymomas. Patients and Methods A total of 61 patients with invasive thymoma were retrospectively reviewed. Results The study group comprised 38 males (62.3 per cent) and 23 females (37.7 per cent), with a median age of 55 years (range: 28–79 years). According to the Masaoka staging, 31 patients had stage II disease (50.8 per cent), 21 patients had stage III disease (34.4 per cent), four patients had stage IVa disease (6.6 per cent) and five patients had stage IVb disease (8.2 per cent). A statistically-significant difference in the survival rate was observed between stages II and III (P < 0.001) and between III and IV (P < 0.001). Complete resection was performed in 43 patients (70.5 per cent). Patients who underwent complete resection showed significantly better prognosis than those with incomplete resection (P < 0.001) and inoperable/biopsy (P < 0.001). After initial treatment, a total of 20 patients (32.8 per cent) relapsed. The recurrence rates in stages II, III and IV were 3.2 per cent, 66.7 per cent and 55.5 per cent, respectively. Treatment for recurrence was performed in all 20 patients. Conclusion The outcome of invasive thymoma was correlated with the Masaoka stage and the extent of tumour resection. Salvage treatment for recurrent thymoma might give a moderate response rate and improve survival. A large-scale study is warranted for evaluating the role of the multimodality therapeutic approach in patients with invasive thymoma.

Abstract: Aim Glutamine administration influences intestinal permeability (IP). Enteral and parenteral glutamine supplementations have different metabolic pathways. In the present study, we investigated the effect of the route of glutamine supplementation on IP. The infection rate, inflammatory parameters and treatment outcome were the secondary end-points in this study. Patients and Methods A prospective, single-blind study was performed in mechanically-ventilated, early enterally-fed, mixed-surgery, intensive care unit (ICU) patients, randomly assigned to the parenteral group (group P) or enteral group (group E). The supplemented groups were treated with glutamine for 5 days. IP was measured using the lactulose/mannitol (L/M) test at the end of the study. Results A total of 81 patients completed the study; 39 from group P and 42 from group E. We found no difference in the L/M index (0.492 ± 0.68 group P, 0.521 ± 0.86 group E; P = 0.88) and the ICU-acquired infection rate (38 per cent group P, 28 per cent group E; P = 0.34). A positive correlation between the start of enteral feeding and the L/M index was confirmed (correlation coefficient: 0.36, P = 0.003), but not with the dose (correlation coefficient: −0.019, P = 0.9) of glutamine supplementation. The outcome data also showed no statistical significant difference. Conclusions The results of this pilot study showed no difference in the IP, infection rate and 6 months' survival between the parenteral or enteral glutamine-supplemented patients.

Abstract: Because of the underreporting and poor documentation of the complication of accessory nerve palsy, there are no local data on this, even after a thorough search through the computerized medical record system and hospital records. This is due to unawareness of the complication. Therefore, we suggest that every patient should be assessed after neck lymph node biopsy. This review aims to bring about awareness of iatrogenic accessory nerve injury and its consequences, so as to avoid delays in diagnosis and treatment.

Abstract: Peliosis hepatis (PH) is a rare benign liver lesion, characterized by the presence of multiple blood-filled cavities and marked dilation of the hepatic sinusoids throughout the hepatic parenchyma. It is often confirmed after the liver resection or liver biopsy. In the present study, we report a case of a 41-year-old woman who presented with a asymptomatic right hepatic mass. The imaging findings of the mass, including computed tomography and magnetic resonance imaging, showed centrifugal progression of enhancement during the portal and delayed phases. Because of the possibility of hepatic malignancy, partial resection of the liver was performed. The final pathological diagnosis was PH. By referring to the relevant literature, we conclude that, as a result of insignificant clinical manifestation and imaging features, PH should be kept in mind for patients with hepatic mass.

Abstract: Aim Postoperative urinary retention is the most common complication after elective inguinal and anorectal surgical procedures. The risk factors identified in the literature were inconsistent. We conducted this study to identify independent risk factors for postoperative urinary retention and to develop a model for predicting urinary retention. Patients and Methods A retrospective case-control study of medical records of patients who underwent elective benign inguinal and perianal operations at Siriraj Hospital between 2006 and 2008 was done. The risk factors identified from the univariate analyses (χ2-test and t-test) were examined together in a logistic regression analysis. Results We reviewed 77 records of patients with urinary retention and 168 records of patients with no urinary retention. We identified three independent risk factors for postoperative urinary retention, including spinal anaesthesia (odds ratio: 4.41), limitation of activity (odds ratio: 6.47) and pain score (odds ratio: 1.80). We developed a model for making prediction of postoperative urinary retention, based on these three variables. Conclusion To avoid postoperative urinary retention, a patient who receives an inguinal or perianal operation should avoid spinal anaesthesia, and have early ambulation and effective pain control.

Abstract: Aim Hospital-acquired urinary tract infection (HAUTI) is an important issue that causes morbidity/mortality. We present a prospective study to identify the risk factors of HAUTI in catheterized patients hospitalized in a paediatric surgery unit. Methods Patients catheterized before/after surgery were evaluated. A total of 112 patients were followed up. Simultaneous urine analysis was conducted, and urine culture was obtained 0, 3, 6, 9, 12 days after catheterization. Patients taking antibiotics just before hospitalization or those who had urinary tract infections (UTI) just before catheterization were excluded. The age, sex, date of hospitalization, timing of catheterization, duration of catheterization, associating urinary tract anomalies, history of UTI, conditions at time of catheterization and antibiotic usage of patients were noted. The frequency of UTI and duration of catheterization were crossed. Patients catheterized during same period of time, who had UTI, were evaluated according to conditions at time of catheterization, associating urinary tract anomalies and antibiotic usage. Results Patients who had positive culture results were catheterized longer (13.4 ± 9.8 days vs 6 ± 5 days, P = 0.042). The duration of preoperative antibiotic usage was greater in cases with positive culture results (3.8 ± 5.2 days vs 0.8 ± 4.8 days, P = 0.003). The infection rate detected was higher in patients who were catheterized in units, rather than in an operating room (P = 0.030). Conclusion The most important risk factors of catheter-associated UTI (CAUTI) are increased duration of catheterization, inappropriate conditions during catheterization and preoperative antibiotic usage. Urinary catheterization is an important risk factor of HAUTI in paediatric surgery units. The length of catheterization and antibiotic usage should be much shorter, and conditions during catheterization should be strictly sterile in order to prevent CAUTI.

Abstract: The video describes a laparoscopic right hepatectomy performed on a 45-year-old woman. Diagnostic laparoscopy and laparoscopic ultrasound were first carried out. After cholecystectomy, the right portal pedicle was isolated with the Glissonian sheath approach. The whole right Glissonian sheath was slung with a nylon tape and transiently clamped. An ischaemic demarcation line was shown on the anterior liver surface. and marked with diathermy. Intraoperative ultrasound was then performed to ascertain the flow patency of the left portal vein and left hepatic artery. The right Glissonian sheath was occluded temporarily with a vascular loop, and superficial hepatotomy was performed using a Harmonic shear device (Olympus, Tokyo, Japan). The first venous structure to be identified during the early phase of hepatotomy was the segment 5 hepatic vein branch. It was then traced towards the middle hepatic vein (MHV), the important landmark for subsequent hepatotomy. It was at this juncture that the whole right Glissonian sheath was transected using linear endostaplers, in order to facilitate retraction and separation of the two hemilivers. The terminal part of the MHV now served as the important reference point for navigating further deep liver parenchymal transection. From this reference point, the transection plane went anteriorly towards the marked ischaemic line on anterior liver surface and posteriorly towards the anterior surface of the inferior vena cava (IVC). The anterior surface of the IVC was exposed caudal cranially after controlling several short hepatic veins that drain directly from the right hepatic lobe into the IVC. The whole course of the MHV was exposed carefully using the clamp-crush technique. The segment 8 hepatic vein was then encountered, and was isolated and clipped at the point of its join to the MHV. When hepatotomy proceeded further cranially, the last vascular structure encountered was the right hepatic vein, which was divided with linear endostaplers. The rest of the liver was mobilized, and the specimen retrieved with a plastic bag through a separate suprapubic incision. There are several advantages of performing laparoscopic hemihepatectomy with exposure of the MHV. Early identification of MHV enables more precise hepatotomy. It is important because anatomic resection can be secured and we can avoid leaving behind too much ischaemic liver tissue. MHV exposure can also provide the best visual guide to the laparoscopic surgeon, so that the right transection plane can be followed. In addition, this plane should contain the minimal cross-over of structures of the portal pedicle. Bleeding from the portal vein or hepatic artery should be minimal, and Pringle is not necessary. One precaution and potential shortcoming of this technique is that we might encounter more bleeding from branches of the MHV, but this can be avoided with meticulous and careful dissection.

Abstract: Aim The aim of the present study was to describe intraoperative underwater colonoscopy (IUC) and recommend the use of this new technique in emergency settings for the management of acute left-sided colonic obstruction. Patients and Methods IUC was performed with a laparoscope attached to a video-camera system after in-sleeve, on-table colonic irrigation. The colon was transected proximally to the tumour, and a nylon camera drape was sutured tightly to the proximal colonic end. Following colonic irrigation, the washout was stopped, and IUC was accomplished by introducing a laparoscope into the bowel. Finally, the laparoscope was withdrawn and formal surgery was performed. Results IUC was successfully used in nine patients who underwent emergency colon surgery; eight patients had colonic obstructions due to adenocarcinomas, and one patient had colonic perforation. IUC revealed three synchronous lesions in the obstructed colonic segments which one of them was an adenocarcinoma in three patients. Another patient had a polyp located distally to the tumour, which was determined preoperatively. Primary resection and stapling anastomosis were performed in all cases. Postoperative complications were atelectasis and delay of intestinal motility in two patients; both recovered well. There was no complication due to IUC or primary operation; for example, anastomotic leakage or wound infection. During the follow up, one patient died 10 months after primary operation due to a cardiac event. Conclusion IUC following in-sleeve, on-table irrigation is safe and quick to perform, and enables the assessment of colonic mucosa with good visibility. This method was found to be helpful to perform intraoperative colonoscopy when indicated in the emergency surgery of the obstructed left-sided colon when conventional endoscopy was not available at the theatre.

Abstract: Aim To explore and discuss the necessity of integrating the history of medicine within the medical curriculum. Methods International peer-reviewed academic journals, PubMed and MedLine databases and secondary sources were explored to review historical events that revolutionalized the practice of medicine, surgery, pharmaceuticals and robotics, among others. Results Numerous case studies have been presented in chronological order, which have made a sustainable impact on clinical practice. The profiles of pioneers and the historical events that led to a chain reaction of advancement in the history of medicine have been discussed, with a view to their impact on future achievements. History should still play an integral role within undergraduate and postgraduate medical education.

Abstract: Primary spontaneous pneumothorax is a common condition encountered by thoracic surgeons. The majority of patients are young, tall and fit males. Surgical pleurodesis is a very effective treatment and serves to prevent future recurrence. A standard surgical pleurodesis is done via thoracotomy for mechanical pleurodesis. Nowadays, with the availability of the thoracoscope, the usual practice is video-assisted thoracic surgery (VATS) for excision of subpleural blebs, mechanical pleurodesis by abrasion and sometimes partial parietal pleurectomy. Similar to other VATS procedures, VATS pleurodesis is conventionally performed using three ports; one for videoscope, and the other two for surgical instruments. This allows triangulation of the instruments for the convenient manipulation and handling of lung tissue. A new technique using a single port has been introduced by Dr Rocco and others, with good preliminary results. We report our modified technique of single-port VATS pleurodesis using special curved, nonroticulating instruments introduced through a single surgical port.

Abstract: Aim The purpose of this study was to test the hypothesis that video-assisted thyroidectomy (VAT) affords comparable safety and efficacy compared to open conventional thyroidectomy (CT). Patients and Methods Randomized, controlled trials comparing VAT with CT were ascertained by a methodical search using the MEDLINE, Pubmed, Ovid, Embase and Cochrane Library electronic databases. Primary meta-analysis outcomes were operative time, intraoperative blood loss and complications, including transient recurrent laryngeal nerve palsy (TRP), transient hypoparathyroidism (TH), permanent recurrent laryngeal nerve palsy (PRP), permanent hypoparathyroidism (PH) and wound infection (WI). The secondary outcomes were postoperative pain within 12, 24 and 48 h after the operation, length of hospital stay and cosmetic result. Results Operative time was significantly less with CT than with VAT, while VAT was associated with better cosmetic result and less pain at 24 h, postoperatively. Blood loss, TRP, TH, PRP, PH, WI and postoperative pain at 48 h did not reach significance between procedures. Comparisons between two procedures concerning postoperative pain within 12 h and length of hospital stay depicted statistically-significant differences in favour of VAT, but only in the fixed-effects model. Conclusions VAT is a safe procedure that produces outcomes; in view of short-term adverse events, similar to CT, it needs a longer operative time and produces better cosmetic results and less postoperative pain in the early phase.

Abstract: Pelvic–uretero junction obstruction (PUJO) is most often a congenital problem, but it can present clinically at any time of life. After diagnosis of PUJO is confirmed anatomically with computed tomography (CT) scan and functionally with isotope diuretic renography, surgical treatment should be offered when symptoms or complications associated with obstruction are present. Treatment options include endopyelotomy or pyeloplasty. Pyeloplasty is usually preferred, as it has a better long-term success rate and can be applied to almost any anatomic variation of PUJO. Laparoscopic pyeloplasty with three-to-four ports is currently widely practised, with success rates comparable to open pyeloplasty, and with lower patient morbidity. We report our initial experience of laparoendoscopic single-site (LESS) pyeloplasty in recurrent PUJO.

Abstract: Aim With the availability of multidetector computed tomography, 3-D display and measurements of cerebral aneurysms can be performed routinely. Although the 3-D method is more intuitive, 3-D measurements can be more operator dependent. Few data are available on interobserver variability and intraobserver reproducibility. We aimed to assess the interobserver and intraobserver reliability using both planar and 3-D methods. Patients and Methods A total of 48 subarachnoid haemorrhage patients were recruited into the study. Results Aneurysm dimensions showed medium-to-large correlations among observers using the planar method, and large correlations for the 3-D method. The average Kendall's tau b coefficients among observers of aneurysm dimensions were significantly better for 3-D methods compared to the planar method. Excellent correlations in planar and 3-D aneurysm dimensions were found between repeated measurements (Kendall's tau b coefficients: 0.90–0.97; all P < 0.001). Conclusion High interobserver and intraobserver reliability was found for 3-D assessments of aneurysm dimensions in computed tomographic angiography (CTA) for aneurysmal subarachnoid haemorrhage. Thus, the 3-D method of aneurysm measurement can provide a reliable CTA assessment for cerebral aneurysm and data comparisons among different studies.

Abstract: Aim To compare the effectiveness of the pneumatic lithotripter and the combined lithotripter (pneumatic + ultrasonic) in percutaneous nephrolithotomy (PNL). Patients and Methods A total of 150 patients who underwent PNL between March 2009 and January 2011 were included in the study. In the first 49 cases, only the pneumatic lithotripter (group 1) was used, while in the next 101 patients, combined lithotripter (group 2) was used. Differences with regard to total clearance time, fluoroscopic screening time (FST), duration of hospital stay, duration of nephrostomy removal, haematocrit loss, blood transfusion rate and successful treatment rate were investigated between the two groups. Results The general characteristics of the patients were similar between the two groups. However, the mean stone size was statistically significantly higher in group 2. No statistically-significant difference was detected between the two groups in terms of hospital stay, nephrostomy removal days, successful treatment rate and blood transfusion rate, but compared to group 1 patients, total clearance time, FST and haematocrit loss were significantly less in group 2. Conclusion Although pneumatic and ultrasonic lithotripters are both sufficiently effective when used separately, the combined device was observed to positively influence total clearance time, FST and haematocrit loss significantly.

Abstract: Aim The aim of the present study was to investigate the diagnosis and treatment of spontaneous renal subcapsular effusion. Patients and Methods From May 2003 to December 2010, 14 patients with spontaneous renal subcapsular effusion were treated at our department. Subcapsular renal aspiration and drainage was performed in four patients, and effusion drainage and renal capsulotomy plus omentum wrapping was performed in 10 patients, among whom laparoscopic surgery was carried out in two cases. Results Fever was controlled within 3–5 days after aspiration or open surgical drainage plus omental wrapping. Renal subcapsular effusion disappeared after the second and third attempts of aspiration in three cases. In the other 11 cases, subcapsular effusion disappeared approximately 7–26 days after a single aspiration with continuous drainage or open surgical drainage plus omental wrapping (including two cases of laparoscopic surgery). No recurrence was observed during follow up (ranging from 6 months to 6 years). Conclusion Spontaneous renal subcapsular effusion is an inflammatory exudate of the renal parenchyma of undetermined aetiology. One of the possible causes is allergic disease of the renal vessels. Satisfactory therapeutic outcomes can be achieved by aspiration drainage or renal subcapsular effusion plus omental wrapping (including laparoscopic surgery), together with the administration of antibiotics and glucocorticoids.

Abstract: Abdominal lymphangiomas are extremely rare in the adult population. We report an unusual case of a cystic lymphangiomas arising from the hepatoduodenal ligament. A 45-year-old man was admitted to our hospital with discontinuous upper abdominal pain. The preoperative CT diagnosis was neurinoma. Exploratory laparotomy revealed a cystic mass originating from the hepatoduodenal ligament and then it was resected successfully. The pathological sections proved it to be lymphangioma. The patient remains well with no evidence of recurrence two years post resection.

Abstract: Aim In the present study, we discuss the surgical management, complications and clinical outcomes of patients with renal cell carcinoma (RCC) extending into the inferior vena cava (IVC), who were treated with surgical resection at a teaching hospital from 1997 to 2011. Patients and Methods Twelve patients diagnosed with RCC and IVC tumour thrombus underwent radical nephrectomy and IVC tumour thrombectomy during the study period. Results Of the 12 patients (male : female: 1:1), the mean age was 65 years (range: 48–82 years). All had good premorbid performance status and no distant metastasis at the time of operation. Employing the Mayo Clinic classification, the tumour thrombus extension was level I in four cases (33 per cent), level II in four cases (33 per cent), level III in two cases (17 per cent) and level IV in two cases (17 per cent). In one patient, the renal tumour extended into the right atrium and had a solitary right pulmonary artery tumour embolus, which subsequently underwent a simultaneous right pulmonary artery tumour embolectomy. In our series, the mean blood loss in levels I–IV tumour thrombus were 1050 mL, 2075 mL, 4152 mL and 11 500 mL, respectively. Complications occurred in three cases (25 per cent), and one (8.3 per cent) required re-laparotomy for haemostasis. There was no hospital mortality. The median follow up was 45.5 months (range: 6–125 months). Median disease-free and overall survivals were 29 and 76 months, respectively. Five-year disease-free and overall survivals were 35.5 per cent and 62.5 per cent, respectively. Conclusion Radical nephrectomy and IVC tumour thrombectomy remain a challenging procedure. With detailed perioperative planning and multidisciplinary efforts, surgical resection is the definitive treatment of choice for patients with RCC and IVC tumour thrombus. The perioperative and survival outcomes of the present series were comparable to contemporary series.

Abstract: Aim The aim of the present study was to evaluate the efficacy and safety of pancreatic enzymes on patients with chronic pancreatitis or pancreatic surgery. Patients and Methods The Cochrane Library, PUBMED and EMBASE review databases were searched up to December 2012. Randomized, controlled trials (RCT) that compared pancreatic enzymes with placebo in patients with chronic pancreatitis or pancreatic surgery were included. A method recommended by the Cochrane Collaboration was used to perform a meta-analysis of those RCT. Results Four RCT involving a total of 169 participants were included. The results showed that glutamine dipeptide has a positive effect in improving the coefficient of fat absorption (weighted mean difference [WMD] = 14.83, 95 per cent confidence interval (CI: 12.85, 15.95; P < 0.001) and coefficient of nitrogen absorption (WMD = 3.93, 95 per cent CI: 2.90, 4.93; P < 0.001), reducing stool consistency (WMD = −0.19, 95 per cent CI: −0.38, 0.01; P = 0.06), stool frequency (WMD = −0.80, 95 per cent CI: −0.91, −0.69; P < 0.001) and stool fat (WMD = −22.51, 95 per cent CI: −24.19, −20.83; P < 0.001). Treatment-emergent adverse events were similar in two groups (odds ratio = 1.10, 95 per cent CI: 0.52, 2.32; P = 0.81). However, the use of pancreatic enzymes had no effect on pain scores (WMD = −0.07, 95 per cent CI: −0.36, 0.23; P = 0.65). Conclusions Current best evidence demonstrates that pancreatic enzymes are effective and safe for exocrine pancreatic insufficiency due to chronic pancreatitis or pancreatic surgery. Further high-quality trials are required, and long-term effects and quality of life should be considered in future RCT with sufficient size and rigorous design.

Abstract: Aim Superior and inferior flaps beneath the platysmal layer have been used to open the midline raphe in thyroidectomy. Sometimes this flap dissection causes some serious complications, such as seroma and subcutaneous haematoma formation. Here, we described a new approach for flapless thyroidectomy. Patients and Methods A total of 289 patients who underwent thyroidectomy were eligible for the study. Group 1 was the control group. In group 2, a 5-mm wide tunnel from the thyroid cartilage superiorly to the sternal notch was inferiorly used to open the midline raphe. Patient demographics and complications were recorded and compared. Results Specimen volumes, skin incision lengths and operation times of the groups were 69.83 ± 37.72 mL and 71.17 ± 48.28 mL, 3.80 ± 0.89 cm and 3.96 ± 0.76 cm and 115.21 ± 26.73 min and 117.32 ± 27.25 min, respectively (P = 0.785, P = 0.196 and 0.875, respectively). Permanent recurrent laryngeal nerve palsy and permanent or temporary hypocalcaemia were similar (P = 0.137, P = 0.459 and P = 0.333). Seroma and subcutaneous haematoma were significantly higher in group 1 (P = 0.024). Conclusion This less traumatic approach is a technically feasible and an alternative to conventional flap dissection with any limitations.

Abstract: Pure squamous cell carcinoma of the breast is a rare form of metaplastic breast carcinomas. We report a case who presented with a breast abscess. Diagnosis was only made after wide local excision. The patient subsequently had a sentinel lymph node biopsy and is currently receiving radiation therapy. Squamous cell carcinoma of the breast is a rare tumour with limited evidence on its optimal treatment.

Abstract: The vacuum-assisted breast biopsy (VABB) system was first developed in 1995. It was initially designed as a diagnostic tool to obtain a sufficient amount of breast specimen to provide a more accurate diagnosis compared with conventional core biopsy. In 2002, the Food and Drug Administration approved the use of the VABB system for the therapeutic purpose of benign lesions, as could provide complete removal of lesions under real-time ultrasonic guidance. Many studies have evaluated the use of the VABB system, and the authors of those studies have concluded that using the VABB system in resecting breast fibroadenoma with a small incision is feasible and safe, and yields a high patient satisfaction rate of up to 97 per cent. It can be performed under local anaesthesia in outpatient settings. The complete removal of breast fibroadenoma using the VABB system was found to have only minimal complications. Lesions up to 2.5–3 cm can be completely removed with minimal or no scarring. The use of an 8-gauge needle is recommended for nodules > 1 cm in size. During the procedure, lesions must be removed as completely as possible to prevent growth, and extra samples should be obtained in different directions to ensure complete removal. Incomplete excision is attributed to the limitation of the use of the VABB system in the excision of benign breast lesions. Fine et al. reported that 97 per cent of women in their study demonstrated complete removal of the imaged mass immediately after biopsy. However, 27 per cent had a residual mass during a follow-up ultrasound 6 months later. They suggested several possibilities for this issue, which included the use of local anaesthesia, which might blur the operative field and contribute to a visual challenge when the mass became smaller during the procedure, bleeding during the procedure and that the mass was not completely removed and became enlarged over the ensuing months. Nevertheless, the rate of successful initial complete removal of a lesion varies widely, from 22 to 100 per cent, although most studies report rates of 75–100 per cent. Follow-up rates without recurrence are 62–98 per cent. These variations might be explained by the use of different gauge devices and different methods for assessing the completeness of removal, including clinical, radiological and histological assessments. The reported complication rate of this procedure ranges 0 to 9 per cent, with a mean of 2.5 cent. Haematoma is the most frequent post-procedure complication; others include subcutaneous bleeding, skin defects and pneumothorax. Most complications are of mild-to-moderate severity. Careful ultrasonic monitoring throughout the whole procedure is mandatory to avoid skin tear. Usually, subcutaneous bleeding can be controlled by direct compression, and crepe bandage for 24 h is recommended to diminish bruising. In conclusion, the vacuum assisted excision of breast lesions using the VABB system is a feasible and safe procedure. Careful real-time ultrasonic monitoring is mandatory to avoid complications.

Abstract: Endograft infection after emergency endovascular aortic repair (EVAR) procedure has received less attention than other complications, and usually occurs soon after endograft positioning. Consequently, clear guidelines for the prevention and treatment of endograft infection have yet to come. We report a case of an 85-year-old patient treated with an emergency EVAR procedure for a fissured abdominal aortic aneurysm, whose immediate follow up was complicated by a prolonged upper gastrointestinal occlusion. Six months, later he developed an endograft infection due to intestinal flora. After exclusion of all other possible causes, bacterial translocation from the bowel appeared the only plausible mechanism. This case highlights the importance of the gastrointestinal tract as a potential source of endograft infection, and suggests how a clinical condition representing potential reservoir of infection should be managed properly.