INTRODUCTION: Fluorescence imaging (FI) with indocyanine green (ICG) is increasingly implemented as an intraoperative navigation tool in hepatobiliary surgery to identify hepatic tumours. This is useful in minimally invasive hepatectomy, where gross inspection and palpation are limited. This study aimed to evaluate the feasibility, safety and optimal timing of using ICG for tumour localisation in patients undergoing hepatic resection. METHODS: From 2015 to 2018, a prospective multicentre study was conducted to evaluate feasibility and safety of ICG in tumour localisation following preoperative administration of ICG either on Day 0-3 or Day 4-7. RESULTS: Among 32 patients, a total of 46 lesions were resected: 23 were hepatocellular carcinomas (HCCs), 12 were colorectal liver metastases (CRLM) and 11 were benign lesions. ICG FI identified 38 (82.6%) lesions prior to resection. The majority of HCCs were homogeneous fluorescing lesions (56.6%), while CLRM were homogeneous (41.7%) or rim-enhancing (33.3%). The majority (75.0%) of the lesions not detected by ICG FI were in cirrhotic livers. Most (84.1%) of ICG-positive lesions detected were < 1 cm deep, and half of the lesions ≥ 1 cm in depth were not detected. In cirrhotic patients with malignant lesions, those given ICG on preoperative Day 0-3 and Day 4-7 had detection rates of 66.7% and 91.7%, respectively. There were no adverse events. CONCLUSION ICG FI is a safe and feasible method to assist tumour localisation in liver surgery. Different tumours appear to display characteristic fluorescent patterns. There may be no disadvantage of administering ICG closer to the operative date if it is more convenient, except in patients with liver cirrhosis.

Background/Aims: Serum fibrosis scores comprised of common laboratory tests have high utility to assess severity of liver fibrosis. We aimed to derive and validate a hepatocellular carcinoma (HCC) risk score based on serum fibrosis scores to predict HCC in treatment-naïve chronic hepatitis B (CHB) patients. Methods: Fifteen thousand one hundred eighty-seven treatment-naïve adult CHB patients were identified to form the training cohort in this retrospective study. Individual fibrosis score was included to construct a new HCC prediction score. The score was externally validated in an independent treatment-naïve Korean CHB cohort. Results: 180/15,187 patients (1.2%) in training cohort and 47/4,286 patients (1.1%) in validation cohort developed HCC during a mean follow-up of 52 and 50 months, respectively. The newly developed HCC risk score, Liang score, is composed of gender, age, hepatitis B virus DNA, fibrosis-4 (FIB-4) index, and ranges from 0 to 22. Area under the time-dependent receiver operating characteristic curve of Liang score was 0.79 (95% confidence interval, 0.70–0.89). A cutoff value of nine provided an extremely high negative predictive value of 99.9% and high sensitivity of 90.0% at 5 years in the validation cohort. Patients with Liang score ≤9 had HCC incidence <0.2% per year in both training and validation cohorts, in whom HCC surveillance might be exempted. Conclusion A novel HCC risk score, Liang score, based on FIB-4 index, is applicable and accurate to identify treatment-naïve CHB patients with very low risk of HCC to be exempted from HCC surveillance.

Background/Aims: Serum fibrosis scores comprised of common laboratory tests have high utility to assess severity of liver fibrosis. We aimed to derive and validate a hepatocellular carcinoma (HCC) risk score based on serum fibrosis scores to predict HCC in treatment-naïve chronic hepatitis B (CHB) patients. Methods: Fifteen thousand one hundred eighty-seven treatment-naïve adult CHB patients were identified to form the training cohort in this retrospective study. Individual fibrosis score was included to construct a new HCC prediction score. The score was externally validated in an independent treatment-naïve Korean CHB cohort. Results: 180/15,187 patients (1.2%) in training cohort and 47/4,286 patients (1.1%) in validation cohort developed HCC during a mean follow-up of 52 and 50 months, respectively. The newly developed HCC risk score, Liang score, is composed of gender, age, hepatitis B virus DNA, fibrosis-4 (FIB-4) index, and ranges from 0 to 22. Area under the time-dependent receiver operating characteristic curve of Liang score was 0.79 (95% confidence interval, 0.70–0.89). A cutoff value of nine provided an extremely high negative predictive value of 99.9% and high sensitivity of 90.0% at 5 years in the validation cohort. Patients with Liang score ≤9 had HCC incidence <0.2% per year in both training and validation cohorts, in whom HCC surveillance might be exempted. Conclusion A novel HCC risk score, Liang score, based on FIB-4 index, is applicable and accurate to identify treatment-naïve CHB patients with very low risk of HCC to be exempted from HCC surveillance.

INTRODUCTIONExperience with robot-assisted laparoscopic (RAL) hepatobiliary and pancreatic (HPB) surgery remains limited worldwide. In this study, we report our early experience with RAL HPB surgery in Singapore.

METHODSA retrospective review of the first 20 consecutive patients who underwent RAL HPB surgery at a single institution over a 34-month period from February 2013 to November 2015 was conducted. The 20 cases were performed by three principal surgeons, of which 17 (85.0%) were performed by a single surgeon.

RESULTSThe median age of patients was 56 (range 22-75) years and median tumour size was 4.0 (range 1.2-7.5) cm. The surgeries performed included left-sided pancreatectomies (n = 10), hepatectomies (n = 7), triple bypass with bile duct exploration for obstructing pancreatic head cancer with choledocholithiasis (n = 1), cholecystectomy for Mirizzi's syndrome (n = 1) and gastric resection for gastrointestinal stromal tumour (n = 1). The median operation time was 445 (range 80-825) minutes and median blood loss was 350 (range 0-1,200) mL. There was only 1 (5%) open conversion. There were 2 (10.0%) major morbidities (> Grade II on the Clavien-Dindo classification) and no 30-day/in-hospital mortalities. There was no reoperation for postoperative complications. The median postoperative stay was 5.5 (range 3-22) days.

CONCLUSIONOur initial experience confirms the feasibility and safety of RAL HPB surgery.

Adult ; Aged ; Bile Ducts ; surgery ; Cholecystectomy ; Female ; Hepatectomy ; Humans ; Laparoscopy ; Male ; Middle Aged ; Operative Time ; Pancreas ; surgery ; Pancreatectomy ; Postoperative Complications ; etiology ; Reoperation ; Retrospective Studies ; Robotic Surgical Procedures ; Singapore ; Young Adult

INTRODUCTIONWe aimed to analyse the changing trends, safety and outcomes associated with the adoption of laparoscopic liver resection (LLR) at a single centre.

METHODSA retrospective review of patients who underwent LLR from 2006 to 2014 at our institution was performed. To explore the evolution of LLR, the study was divided into three equal consecutive time periods (Period 1: 2006-2008, Period 2: 2009-2011, and Period 3: 2012-2014).

RESULTSAmong 195 patients who underwent LLR, 24 (12.3%) required open conversions, 68 (34.9%) had resection of tumours in the difficult posterosuperior segments and 12 (6.2%) underwent major (≥ 3 segments) hepatectomies. Median operation time was 210 (range 40-620) minutes and median postoperative stay was 4 (range 1-26) days. Major postoperative morbidity (> Grade II) occurred in 11 (5.6%) patients and 90-day/in-hospital mortality was 1 (0.5%). During the study, the number of LLRs performed showed an increasing trend (Period 1: n = 22; Period 2: n = 19; Period 3: n = 154). Other statistically significant trends were: (a) increase in malignant neoplasms resected; (b) increase in resections of difficult posterosuperior segments; (c) longer median operation time; and (d) decrease in open conversion rates.

CONCLUSIONOver the study period, the number of LLRs increased rapidly. LLR was increasingly performed for malignant neoplasms and lesions located in the difficult posterosuperior segments, resulting in longer operation times. However, open conversion rates decreased, and there was no change in postoperative morbidity and other perioperative outcomes.

INTRODUCTIONIn this study, we report our initial experience with robotic hepatectomy.

METHODSConsecutive patients who underwent robotic hepatectomy at Singapore General Hospital, Singapore, from February 2013 to February 2015 were enrolled in this study. The difficulty level of operations was graded using a novel scoring system for laparoscopic hepatectomies.

RESULTSDuring the two-year period, five consecutive robotic hepatectomies were performed (one left lateral sectionectomy, one non-anatomical segment II/III resection, one anatomical segment V resection with cholecystectomy, one extended right posterior sectionectomy and one non-anatomical segment V/VI resection). Two hepatectomies were performed for suspected hepatocellular carcinoma, two for solitary liver metastases and one for a large symptomatic haemangioma. The median age of the patients was 53 (range 38-66) years and the median tumour size was 2.5 (range 2.1-7.3) cm. The median total operation time was 340 (range 155-825) minutes and the median volume of blood loss was 300 (range 50-1,200) mL. There were no open conversions and no mortalities or major morbidities (> Clavien-Dindo Grade II). The difficulty level of the operations was graded as low in one case (Score 2), intermediate in three cases (Score 5, 6 and 6) and high in one case (Score 10). There was one minor morbidity, where the patient experienced Grade A bile leakage, which resolved spontaneously. The median length of postoperative hospital stay was 5 (range 4-7) days.

CONCLUSIONOur initial experience confirmed the feasibility and safety of robotic hepatectomy.

Adult ; Aged ; Carcinoma, Hepatocellular ; surgery ; Female ; Follow-Up Studies ; Hepatectomy ; methods ; Humans ; Laparoscopy ; methods ; Length of Stay ; Liver Neoplasms ; surgery ; Male ; Middle Aged ; Operative Time ; Prospective Studies ; Robotics ; Singapore

INTRODUCTIONThe use of laparoscopic distal pancreatectomy (LDP) has increased worldwide due to the reported advantages associated with this minimally invasive procedure. However, widespread adoption is hindered by its technical complexity. Robotic distal pancreatectomy (RDP) was introduced to overcome this limitation, but worldwide experience with RDP is still lacking. There is presently evidence that RDP is associated with decreased conversion rate and increased splenic preservation as compared to LDP.

METHODSWe conducted a prospective study on our initial experience with robotic spleen-saving, vessel-preserving distal pancreatectomy (SSVP-DP) between July 2013 and April 2014.

RESULTSThree consecutive patients underwent attempted robotic SSVP-DP. The indications were a 2.1-cm indeterminate cystic neoplasm, 4.5-cm solid pseudopapillary neoplasm and 1.2-cm pancreatic neuroendocrine tumour. For all three patients, the procedure was completed without conversion, and the spleen, with its main vessels, was successfully conserved. The median total operation time, blood loss and postoperative stay were 350 (range 300-540) minutes, 200 (range 50-300) mL and 7 (range 6-14) days, respectively. Two patients had minor Clavien-Dindo Grade I complications (one Grade A pancreatic fistula and one postoperative ileus). One patient had a Clavien-Dindo Grade IIIa complication (Grade B pancreatic fistula requiring percutaneous drainage). All patients were well at the time of reporting after at least six months of follow-up.

CONCLUSIONOur preliminary experience with robotic SSVP-DP confirmed the feasibility of the procedure.

Female ; Follow-Up Studies ; Humans ; Laparoscopy ; methods ; Male ; Middle Aged ; Organ Sparing Treatments ; Pancreatectomy ; methods ; Pancreatic Neoplasms ; surgery ; Patient Positioning ; Prospective Studies ; Robotic Surgical Procedures ; Singapore ; Spleen ; surgery ; Young Adult

INTRODUCTIONConventionally, patients who failed endoscopic removal of common bile duct stones (CBDS) by endoscopic retrograde cholangiopancreaticography (ERCP) would be treated with open cholecystectomy and common bile duct exploration. Laparoscopic common bile duct exploration (LCBDE) is an established option for treating CBDS. The aim of this paper was to look at the feasibility of LCBDE as a salvage procedure after failed endoscopic stone extraction (ESE). The secondary endpoint was to examine the short-term outcomes of our LCBDE series.

METHODSWe retrospectively reviewed a prospective database to study the feasibility of LCBDE as a salvage procedure for failed ERCP.

RESULTSSince its inception in 2006, 43 patients had undergone LCBDE at our centre. This was achieved via a transcystic approach in 25 patients and laparoscopic choledochotomy in 15 patients. There were three conversions. Of these 43 patients, 21 had a pre-operative attempt at ESE, but only six patients had their ducts cleared endoscopically. The 15 patients who failed ESE underwent LCBDE, of which 14 achieved successful stone clearance and one required open conversion. One patient developed a bile leak, which resolved spontaneously. The median length of stay (LOS) for these 15 patients was three days, while the median LOS for the whole cohort was two days.

CONCLUSIONLCBDE has been shown to be a safe and effective method for treating CBDS, with the added bonus of a short hospital stay. Where the expertise is available, LCBDE is a safe option as a salvage procedure for failed ESE.

Adult ; Aged ; Aged, 80 and over ; Cholangiopancreatography, Endoscopic Retrograde ; Choledocholithiasis ; diagnosis ; surgery ; Common Bile Duct ; surgery ; Feasibility Studies ; Female ; Follow-Up Studies ; Humans ; Laparoscopy ; methods ; Length of Stay ; Male ; Middle Aged ; Reoperation ; methods ; Retrospective Studies ; Salvage Therapy ; Treatment Failure

INTRODUCTIONLaparoscopic common bile duct exploration (CBDE) is becoming more popular in the management of choledocholithiasis due to improved laparoscopic expertise and advancement in endoscopic technology and equipment. This study aimed to evaluate the safety and short-term outcome of laparoscopic CBDE in a single institution over a 3-year period.

MATERIALS AND METHODSA retrospective review of the records of all patients who underwent laparoscopic CBDE in Tan Tock Seng Hospital between January 2006 and September 2008 was conducted.

RESULTSFifty consecutive patients, with a median age of 60 years (range, 27 to 85) underwent laparoscopic CBDE for choledocholithiasis during the study period. About half of our patients presented as an emergency with acute cholangitis (32.0%) accounting for the majority. A total of 22 (44.0%) patients underwent laparoscopic CBDE as their primary procedure while the remaining 28 (56.0%) were subjected to preoperative ERCP initially. Of the latter group, documented stone clearance was only documented in 5 (17.9%) patients. Laparoscopic CBDE via the transcystic route was performed in 27 (54.0%) patients while another 18 patients (36.0%) had laparoscopic choledochotomy and 1 patient (2.0%) had laparoscopic choledocho-duodenostomy. There were 4 (8.0%) conversions in our series. The median operative time for laparoscopic CBDE via the transcystic route and the laparoscopic choledochotomy were 170 (75-465) and 250 (160-415) minutes, respectively. For the 18 patients who underwent a laparoscopic choledochotomy, T-tube was inserted in 8 (44.4%) patients while an internal biliary stent was placed in 4 (22.2%) with the remaining 6 patients (33.3%) undergoing primary closure of the choledochotomy. The median length of hospital stay was 2 days (range, 1 to 15) with no associated mortality. The main complications (n = 4, 8.0%) included retained CBD stones and biliary leakage. These were treated successfully with postoperative endoscopic retrograde cholangiopancreatography (ERCP) with/without percutaneous drainage with no further surgery required.

CONCLUSIONLaparoscopic CBDE is a safe operation with good outcome in managing choledocholithasis. Its dividends include the numerous benefits of minimally invasive surgery. If possible, transcystic extraction is preferred to choledochotomy, as this obviates the need for biliary diversion. ERCP will still hold an important role in certain instances in the management of choledocholithiasis.

Adult ; Aged ; Aged, 80 and over ; Common Bile Duct ; surgery ; Female ; Gallstones ; diagnosis ; surgery ; Humans ; Laparoscopy ; methods ; Male ; Medical Audit ; Middle Aged ; Outcome Assessment (Health Care) ; Retrospective Studies ; Singapore

INTRODUCTIONThe revised Human Organ Transplant Act (HOTA) was implemented in Singapore in July 2004. We aim to evaluate expanding the potential donor pool for liver transplant in Singapore with the inclusion of marginal donors.

MATERIALS AND METHODSAll donor referrals between July 2004 and June 2007 were studied. All potential deceased liver donors were heart-beating. After being reviewed by the transplant coordinator, potential donors were assessed by a transplant hepatologist and a transplant surgeon for suitability of organ donation strictly based on the programme's donor assessment protocol. Reasons for rejection as potential donors were documented. The clinical characteristics of all donor referrals were retrospectively reviewed, and an independent decision was made as to whether liver retrieval in each rejected case might have been possible.

RESULTSAmong the 128 potential donor referrals, 20 donors (15.6%) underwent liver retrieval. Of the 20 livers retrieved, 16 were implanted and 4 were not implanted (3 unfit recipients, and 1 donor liver with 40% steatosis). Another 10 donor livers were assessed intraoperatively and were rejected because of varying levels of steatosis. Of these livers assessed, 5 donor livers had steatosis <40% and 5 had steatosis >40%. Of the remaining potential donors, 45 were deemed not possible because of prolonged hypotension (9), on-going or unresolved sepsis (13), high-risk behaviour (4), non-actualisation (8), or pre-existing medical conditions (11). Another 53 donors may potentially have been suitable donors but were rejected because of possible sepsis (13), no suitable recipients (12), transient hypotension (10), transient abnormal liver function test (6), history of alcohol ingestion (5), non-actualisation because of consent (4) and other reasons (3). Overall, it was deemed that 61 donors (47.7%) might potentially have been suitable liver donors.

CONCLUSIONSDespite new legislation (HOTA) in Singapore, the utilisation of cadaveric donor livers showed no increase in the last 3 years. By expanding our donor criteria to include marginal donors, we could potentially increase the availability of deceased donor livers to meet our waiting list demands.

Adult ; Female ; Humans ; Liver Transplantation ; Living Donors ; legislation & jurisprudence ; supply & distribution ; Male ; Middle Aged ; Referral and Consultation ; organization & administration ; Retrospective Studies ; Singapore ; Tissue and Organ Procurement ; legislation & jurisprudence ; Waiting Lists