Introduction: Hypoglycemia, a frequent and potentially life-threatening consequence of anti-diabetic therapy, remains a major barrier to optimal glycemic control. Effective inpatient management depends on frontline staff knowledge and preparedness; thus, knowledge gaps may compromise patient safety. This audit evaluated staff knowledge of hypoglycemia management in a district hospital in Malaysia to identify areas for improvement. Methodology: A cross-sectional audit was conducted among healthcare staff in a district hospital. A structured, modified questionnaire based on the Malaysian MEMS Inpatient Glycemic Guidelines was used. The 10-item questionnaire assessed definition, initial and subsequent management, reassessment, escalation, and documentation, yielding scores from 0 to 10. Descriptive statistics were used for analysis. Conclusion Despite high overall knowledge, critical gaps remain in reassessment, drug-related risks, and stepwise management, warranting targeted education, protocol reinforcement, and re-audit to enhance patient safety.
Hospitals, District ; Hypoglycemia

Objective: Bariatric surgery effectively treats non-alcoholic fatty liver disease (NAFLD). The glutamate-serine-glycine (GSG) index has emerged as a non-invasive diagnostic marker for NAFLD, but its ability to monitor treatment response remains unclear. This study investigates the GSG index's ability to monitor NAFLD's response to bariatric surgery. Methodology: Ten NAFLD participants were studied at baseline and 6 months post-bariatric surgery. Blood samples were collected for serum biomarkers and metabolomic profiling. Hepatic steatosis [proton density fat fraction (PDFF)] and fibroinflammation (cT1) were quantified with multiparametric magnetic resonance imaging (mpMRI), and hepatic stiffness with magnetic resonance elastography (MRE). Amino acids and acylcarnitines were measured with mass spectrometry. Statistical analyses included paired Student’s t-test, Wilcoxon-signed rank test, and Pearson’s correlation. Results: Eight participants provided complete data. At baseline, all had hepatic steatosis (BMI 39.3 ± 5.6 kg/m2, PDFF ≥ 5%). Post-surgery reductions in PDFF (from 12.4 ± 6.7% to 6.2 ± 2.8%, p = 0.013) and cT1 (from 823.3 ± 85.4ms to 757.5 ± 41.6ms, p = 0.039) were significant, along with the GSG index (from 0.272 ± 0.03 to 0.157 ± 0.05, p = 0.001). Conclusion The GSG index can potentially be developed as a marker for monitoring the response of patients with NAFLD to bariatric surgery.
Non-alcoholic Fatty Liver Disease ; Amino Acids ; Metabolomics

PURPOSE: The laparoscopic cholecystectomy has increasingly been accepted as the procedure of choice for treatment of symptomatic gall stones and chronic cholecystitis. However, its role and its timing in the management of patients with acute cholecystitis remain controversial. This retrospective study was undertaken to compare on early laparoscopic cholecystectomy with a delay one for patients with acute cholecystitis. METHODS: Between January 1995 and June 1999, 15 patients were operated on within 72 hours of symptom onset. Those patients were classified as the early laparoscopic cholecystectomy group. The 18 patients who underwent a delayed laparoscopic cholecystectomy after a percutaneous transhepatic cholecystostomy (PTCS) and conservative management were classified as the delayed laparoscopic cholecystectomy group. RESULTS: No significant differences were seen in the conversion rate (1 case in the delayed group), the operation time (early group 107.3 min., delayed group 118.6 min.), postoperative complications (early group 20.0%, delayed group 16.7%), and the postoperative hospital stay (early group 4.7 days, delayed group 7.1 days). The early group had significantly more frequent operation modifications and decreased total hospital stays than the delayed group: 86.7% and 7.0 days, for the early group and 44.4% and 22.8 days for the delayed group. CONCLUSION: Early laparoscopic cholecystectomy for acute cholecystitis did not increase the operation time, the morbidity, or the conversion rate. Although this study was not a randomized study and the sample size was small, an early laparoscopic cholecystectomy seems to be safe and feasible for patients with acute cholecystitis, having the benefit of a decreased total hospital stay.
Cholecystectomy, Laparoscopic* ; Cholecystitis ; Cholecystitis, Acute* ; Cholecystostomy ; Gallstones ; Humans ; Length of Stay ; Postoperative Complications ; Retrospective Studies ; Sample Size

BACKGROUND: Cystic neoplasms of the pancreas are rare tumor with malignant potential. Preoperative differentiation of a benign versus malignant tumor is unreliable and routine testing for this purpose is questionable. Therefore an aggressive resectional approach for cystic tumor of the pancreas was a recent trend and anticipate good prognosis. METHODS: This is a retrospective analysis of 23 patients with cystic neoplasm of the pancreas between Jun.1990 and Dec.1999. Data include patient demographics, presenting symptom, operative procedure, pathologic diagnosis, perioperative morbidity and mortality, survival follow-up data. RESULTS: The mean age of patients was 33.48 years and twenty one patients were women. There were 3 serous cystadenoma, 4 mucinous cystadenoma, 2 mucinous cystadenocarcinoma, 13 SPEN, 1 ductal ectasia. Major symptoms were abdominal pain(39.1%), palpable mass(30.4%), incidental(21.7%), melena( 4.3%), hematemesis(4.3%). Tumor site were 6 head(26.1%), 3 body(13.4%), 14 tail(60.9%). Main investigations were ultrasonography and CT. Other investigation were ERCP, MRCP, cytology. Operative procedure were 12 distal pancreatectomy and splenectomy, 4 PPPD, 2 mass enucleation, 2 distal pancreatectomy, 1 PD, 1 subtotal pancreatectomy, 1 cystojejunostomy. An accurate preoperative diagnosis of tumor type was proposed 65% pancreatic cystic tumor. Mean follow-up was 27 months(range 0.8 months to 90 months). Of these 23 patients, 20 patients were alive without recurrence during mean follow-up. One patient was died due to postoperative sepsis. Two patients was dead of unrelated cause. CONCLUSION: An aggressive resectional approach for cystic tumor of the pancreas is recommend in cystic tumor of the pancreas, if medically fit to tolerate surgery.
Cholangiopancreatography, Endoscopic Retrograde ; Cystadenocarcinoma, Mucinous ; Cystadenoma, Mucinous ; Cystadenoma, Serous ; Demography ; Diagnosis ; Dilatation, Pathologic ; Female ; Follow-Up Studies ; Humans ; Mortality ; Pancreas* ; Pancreatectomy ; Pancreatic Cyst ; Prognosis ; Recurrence ; Retrospective Studies ; Sepsis ; Splenectomy ; Surgical Procedures, Operative ; Ultrasonography

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the treatment of choice for patients with symptomatic gallbladder (GB) stones. About 10% of patients with symptomatic GB stones may have common duct (CD) stones at the same time. For patients with symptomatic GB stones and suspected CD stones, an endoscopic retrograde cholangiopancreaticography (ERCP) should be performed. The preferred approach to these patients is an ERCP, an endoscopic sphincterotomy (EST), and removal of the CD stones, followed by a LC. The aims of this study were to test the safety and to evaluate the efficacy of the endoscopic and laparoscopic procedure in patients with symptomatic GB stones associated with CD stones. MATERIAL AND METHODS: A retrospective review was conducted on 522 patients who had been treated surgically for GB stones with or without CD stones between Jul. 1994 and Jun 1997. Among them, an ERCP followed by a LC was performed in 57 (67.1%) of the 85 patients who had CD stones, a LC in 377, an open cholecystectomy in 60, and an open cholecystectomy and CD exploration in 28. RESULTS: There were significant differences in operation times, hospital stays, and postoperative complications between the group with an EST followed by a LC and the group with an open cholecystectomy and CD exploration, but no significant differences between the LC group and the group with an EST followed by a LC. CONCLUSIONS: An EST followed by a LC is a good and safe treatment mordality for patients with symptomatic GB stones associated with CD stones.
Cholangiopancreatography, Endoscopic Retrograde ; Cholecystectomy ; Cholecystectomy, Laparoscopic* ; Choledocholithiasis* ; Gallbladder ; Humans ; Length of Stay ; Postoperative Complications ; Retrospective Studies ; Sphincterotomy, Endoscopic*

BACKGROUND: Hepatolithiasis is rarely associated with a cholangiocarcinoma and the etiologic relationship between them has not been proved. Hepatolithiasis is a risk factor for cholangiocarcinoma. Accurate preoperative diagnosis remains low, and the survival outcome is still dismal, despite improvements in imaging studies. METHODS: Eighteen cases of intrahepatic cholangiocarcinomas among the 522 cases undergoing treatments from Jan. 1984 to May 1998 for hepatolithiasis at the Department of Surgery, Kyung Hee University Hospital were reviewed. RESULTS: The patients had a significantly long duration of symptoms, a high incidence of previous biliary surgery, and a lower rate of preoperative diagnosis. The eighteen cases accounted for 3.4% of the hepatolithiasis cases and 8.5% of the cholangiocarcinomas. There were 17 women and 1 man, and the most prevalent age group was in the 5th and the 6th decades. HBsAg was positive in one case who had chronic hepatitis, 3 patients had clonorchiasis, and 2 patients had liver cirrhosis. CEA and CA19-9 were elevated in 42.9% (3/7) and 27.3% (3/11) of the patients. Various imaging studies, including ultrasonography, CT, choangiography, angiography, and ERCP were performed for diagnosis. The malignant lesions could not be detected preoperatively in 9 patients, and the presence of a coexisting malignant tumor was confirmed by frozen section or by permanent tissue pathology. The operative methods were as follows; a lobectomy in 4 patients, a segmentectomy in 4 patients, and a CBD resection for palliation or explo-laparotomy only in 4 patients because of multiple hepatic metastases. During the operation, the exact location of the stones and the gross pathology of the tumor were recorded in each case. The left side was more prevalent than the right. The mean survival was 15 months for resection group and 9 months for non resection group. CONCLUSIONS: The lower survival rates may be attributed to delayed diagnosis, lower diagnostic accuracy, and relatively fewer curative resections in the patients with stone-containing cholangiocarcinomas. Hepatolithiasis is one of the risk factors of a cholangiocarcinoma. During the diagnostic and operative procedures, we should not overlook a cholangiocarcinoma which can coexist with hepatolithiasis, and we should examine tumor markers, the results of imaging studies and tissue examinations, and the operative findings.
Angiography ; Biomarkers, Tumor ; Cholangiocarcinoma* ; Cholangiopancreatography, Endoscopic Retrograde ; Clonorchiasis ; Delayed Diagnosis ; Diagnosis ; Female ; Frozen Sections ; Hepatitis B Surface Antigens ; Hepatitis, Chronic ; Humans ; Incidence ; Liver Cirrhosis ; Mastectomy, Segmental ; Neoplasm Metastasis ; Pathology ; Risk Factors ; Surgical Procedures, Operative ; Survival Rate ; Ultrasonography

This study was conducted to investigate the risk factors for postoperative mortality and morbidity in 322 consecutive hepatic resections. The indications for the hepatic resection were 178 intrahepatic stones, 81 hepatocellular carcinomas, 21 cholangiocarcinomas, 16 benign liver tumors, 12 metastatic liver cancers, 7 liver abscesses, and 7 other diseases. The overall in-hospital mortality and morbidity rates were 0.9% and 39.4%, respectively. Various postoperative complications developed, including 60 wound infections (18.6%), 49 pulmonary complications (15.2%), 19 bile leakages (5.9%), 13 intraabdominal abscesses (4.0%), 13 ascites (4.0%), 4 bleedings (1.2%), 3 hepatic failures (0.9%), 3 cholangitis (0.9%) and 28 other complications (8.7%). Among the risk factors, perioperative transfusion was significantly associated with more frequent wound infections (p=0.004), pulmonary complications(p=0.008), and bile leakages (p=0.039). Coexisting hepatitis was related to increased pulmonary complication rate (p=0.0223) and ascites formation (p=0.0157). Diabetes, was associated with increased wound infection rate (p=0.0433), and preexisting heart disease was associated with higher pulmonary complication rate (p= 0.0213). However, age, presence of liver cirrhosis, extent of resection, operative time, pulmonary disease or combined bowel surgery had no influence on the outcome. In conclusion, minimizing perioperative blood loss and transfusion is essential to reduce postoperative complications in hepatectomy.
Abscess ; Ascites ; Bile ; Carcinoma, Hepatocellular ; Cholangiocarcinoma ; Cholangitis ; Heart Diseases ; Hepatectomy ; Hepatitis ; Hospital Mortality ; Liver ; Liver Abscess ; Liver Cirrhosis ; Liver Neoplasms ; Lung Diseases ; Mortality ; Operative Time ; Postoperative Complications ; Risk Factors* ; Wound Infection

To assess the clinico-pathological characteristics of patients with multiple primary colorectal cancer, 458 patients who underwent curative surgery and being followed-up at our institution between Jan. 1987 and Dec. 1993 were evaluated in this study. The median follow-up period was 42 months. Synchronous cancer was defined as distinct lesions separated by a distance of greater than 4cm with the invasion of the tumor below the muscularis mucosa at the time of diagnosis or within 6 months after initial treatment, and metachronous cancer was defined as the development of colon cancers more than 6 months after the initial treatment without evidence of the recurrence or metastases from primary tumor. There were 29 cases of multiple primary colorectal cancer(6.3%). Eighteen cases(3.9%) of them were synchronous, 11 cases(2.4%) were metachronous cancers. Seven cases(1.5%) were related to 5 hereditary non-polyposis colorectal cancer(HNPCC) families. During the follow-up period, 11 patients(2.4%) developed cancers in other organs. Adenomatous polyps were identified 14 cases of 29 patients with multiple primary colorectal cancers(48.3%), compared to 43 cases(10%) in 429 patients with solitary colorectal cancer(p<0.01). After initial curative surgery, there were 8 recurrences in 29 patients with multiple primary colorectal cancers(23.6%), compared to 100 recurrences in 429 patients with solitary primary colorectal cancer(23.3%)(p>0.05). In aspect of family history, there was close-relationship with this regarding in the group of multiple primary colorectal cancers. However, authors were unable to make analysis this regarding in the group of solitary primaries because of lack of the information. Conclusively, authors guess the frequent association of the adenomatous polyps in multiple primary colorectal cancers as the evidence of the adenoma-carcinoma sequence. In addition, authors emphasized the importance of the total colonoscopic examinations in pre-and post-operation in order to make diagnosis of the multiple primary colorectal cancers and paying attention as to the family history of colorectal cancer patients because we have good therapeutic results after operation of early stage in synchronous cancers and co-existent adenomatous polyps.
Adenomatous Polyps ; Colonic Neoplasms ; Colorectal Neoplasms* ; Diagnosis ; Follow-Up Studies ; Humans ; Mucous Membrane ; Neoplasm Metastasis ; Recurrence

Transcatheter hepatic arterial embolization (THAE) is one of the treatment modalities that can be applied to hepatocellular carcinomas (HCC) and metastatic tumors of the liver. Complications such as cholecystitis and gallbladder necrosis, are common with THAE, but liver and peripheral bile duct necrosis are rare, and intrahepatic stones with main bile duct necrosis have never been reported. To prevent intrahepatic spread during operative manupulation and to decrease the vascularity and size of the tumor, we performed a THAE on a huge-sized HCC five times before performing the hepatectomy. We succesfully undertook a right lobectomy after the THAE with lipiodol, gelform, and adriamycin. However, severe bile duct stricture and intrahepatic stones were confirmed during the operation.
Bile Ducts* ; Bile* ; Carcinoma, Hepatocellular ; Cholecystitis ; Constriction, Pathologic* ; Doxorubicin ; Ethiodized Oil ; Gallbladder ; Hepatectomy ; Liver ; Necrosis

The aim of this study was to establish whether the pylorus-preserving pancreatico-duodenectomy (PPPD) is a safe, but radical, procedure in the treatment of malignant periampullary lesions, without increased morbidity and mortality rates, compared with the standard Whipple's procedure (PD). From 1993 to 1996, a PD (N = 25) or a PPPD(N = 15) was performed on 40 patients. Postoperative mortality rates were 2% after the PD and 0% after the PPPD. The mean operation time and blood loss in the PPPD group were 465 minutes and 840ml, respectively, and in the PD group were 444 minutes and 1080ml, respectively, both statistically insignificant. During follow-up, no differences were found in the postoperative complications, the recurrence of disease, and survival rates according to operation type, lymph node metastasis, or pancreas invasion. No differences were found the numbers of days of gastric drainage, liquid diet, and regular diet, but a delayed gastric emptying time was found in the PPPD group(40% of the patients after PPPD vs 12% after PD). Tumor-containing duodenal or gastric resection margins were not found in either group of patients. The hospital stay was the same for both groups (38 days after PPPD, 37 days after PD). The mean duration of follow-up was 23 months. Weight gain fter operation during follow-up was relatively more favorable after a PPPD. In conclusion, a PPPD is a safe, but radical, procedure and can be an alternative choice, without compromising curability. to a PD in the treatment periampullary cancer. No difference in either the morbidity or the mortality rates existed between the two procedures. Further investigation will be needed to understand the delayed gastric emptying time in the PPPD group, but during 3 months, of follow-up weight gain was better in the PPPD group.
Diet ; Drainage ; Follow-Up Studies ; Gastric Emptying ; Humans ; Length of Stay ; Lymph Nodes ; Mortality ; Neoplasm Metastasis ; Pancreas ; Pancreaticoduodenectomy* ; Postoperative Complications ; Recurrence ; Survival Rate ; Weight Gain