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Aim To achieve better outcomes, non-operative management (NOM) and damage control surgery (DCS) are now recommended for traumatic liver injury. This study aims to review the outcomes of patients suffering from liver trauma and to determine the factors affecting the outcomes, with emphasis on NOM and DCS. Patients and Methods This was a retrospective cohort study for liver trauma patients from a single centre. The outcomes were compared between two equal consecutive periods: period A (year 2001–2007) and period B (year 2008–2014). Results There were 116 patients with a mean age of 38.1 years and male predominance (61.2%). Around 57% of patients suffered from grade III or above liver injury. The mean Injury Severity Score (ISS) was 32.3. The 90-day mortality was 20.7%. In period B, the 90-day mortality was significantly lowered (6/56 vs. 18/60, P = 0.010) with less liver operation (13/56 vs. 26/60, P = 0.022) and more hepatic angiography+/−embolization (7/56 vs. 0/60, P = 0.005). The proportion of DCS was similar but more hepatectomies were performed in period B (4/13 vs. 0/26, P = 0.009). Multivariate analysis revealed ISS grade, age and sex were predictors for 90-day mortality. Conclusions A reduced mortality was seen in traumatic liver injury accomplished by increased NOM but not DCS.

Aim Studies comparing the efficacy of radiofrequency ablation (RFA) in terms of overall survival, disease-free survival and local recurrence in recurrent hepatocellular carcinoma (HCC) are limited. We carried out the present study to compare the survival of recurrent HCC after RFA with that of first-occurrence HCC. Patients and Methods A total of 170 patients with HCC smaller than 5 cm who received RFA in a tertiary academic hospital were recruited. Clinical data were prospectively collected, reviewed and compared between recurrent and first-occurrence HCC groups. Patients who received RFA for post-ablation recurrent HCC were excluded. Results There was no significant difference in the complication, incomplete ablation, recurrence and survival rates between the recurrent HCC and the first-occurrence HCC groups. The tumour size in the recurrent HCC group was significantly smaller than that in the first-occurrence group (1.8 vs 2.5 cm), and the recurrent HCC group had a significantly higher proportion of Child's A cirrhosis. Conclusions When detected and treated early, the overall survival of recurrent HCC treated RFA was comparable to that of first-occurrence HCC. The advantages of RFA, especially when percutaneous route is feasible, over hepatectomy should be extended to recurrent HCC in suitable cases.

Aim: To review the evidence in using inflow occlusion during liver resection. Other strategies to minimize the untoward effects of inflow occlusion will also be discussed. Methods: Randomized trials evaluating the use of inflow occlusion in hepatectomy and strategies to minimize its associated adverse effects were reviewed in this article. Recent experience showing comparable operative outcomes without the use of portal clamping was also described. Results: Results from randomized trials and meta-analyses were not conclusive on the benefits of routine inflow occlusion during liver resection. Intermittent inflow occlusion and ischaemic preconditioning had been found to be effective in reducing ischaemic–reperfusion injury to remnant liver. With refined operative techniques and better instruments, routine inflow occlusion in liver resection can now be safely avoided. Conclusion: Vascular inflow occlusion is an important armamentarium during liver resection, but it should not be used indiscriminately. With refined techniques and better instruments, hepatectomy can be performed safely without the need for routine inflow occlusion.

Aim: Patients suffering from xanthogranulomatous cholecystitis have variable clinical presentations. The present study aims to evaluate the clinical presentations of the disease and the various surgical treatment strategies in the management of patients suffering from xanthogranulomatous cholecystitis. Methods: This is a retrospective study in a university teaching hospital and a tertiary referral centre. The histopathological records of 5016 resected gallbladder specimens from January 1991 to June 2007 were reviewed and case notes of patients with a diagnosis of xanthogranulomatous cholecystitis were retrieved. Results: Eighty-six patients with xanthogranulomatous cholecystitis were identified. The spectrum of presentation was variable and a high proportion of patients had complicated pathology. Patients commonly presented with obstructive jaundice or acute cholecystitis. The proportion of patients with diabetes mellitus who presented with acute cholecystitis was higher than the local prevalence in this study. Conversion rate in laparoscopic cholecystectomy was also higher for patients with xanthogranulomatous cholecystitis. Conclusion: The clinical presentation of xanthogranulomatous cholecystitis is variable. The disease commonly presents as obstructive jaundice or acute cholecystitis but it may mimic carcinoma of the gallbladder. The disease carries a higher rate of conversion if laparoscopic cholecystectomy was attempted.

Objectives: Intrahepatic cholangiocarcinoma (ICC) is a rare tumor of the liver. The diagnosis and treatment of it are difficult. The present study reviewed the diagnostic pathways and operative results for ICC. Methods: A retrospective analysis was made of the clinical presentation, diagnostic pathways, and operative results of 20 patients with ICC who underwent hepatectomy from 1997 to 2004 in our institute. Results: The patients were predominantly female (female : male = 15:5), and ranged in age from 41 to 74 years (median 59.8). Abdominal pain was the main presenting symptom, and hepatomegaly was the commonest physical sign. Diagnosis relied mainly on ultrasound or computed tomography. Without biopsy, only two patients were correctly diagnosed with ICC before surgery. The median size of the tumor was 6 cm (range 1.6–12 cm). Major hepatectomy was carried out in 80% of patients. The operative mortality and morbidity were 15% and 40%, respectively. The median follow up was 18.3 months. Thirteen patients (65%) had recurrences at one or more sites, including, in decreasing frequency, the liver, abdominal lymph node, lung, bone, or skin. The median survival was 17.3 months and the 1-year, 3-year, and 5-year survival rates were 60%, 45%, and 10%, respectively. Conclusions: The poor survival of patients with ICC was mainly due to the delay in diagnosis and the aggressive nature of the disease. The diagnosis of ICC relies on a high index of suspicion as there is no reliable tumor marker and imaging results are usually inconclusive. Radical hepatectomy remains the only chance of cure for ICC. The role of lymph node dissection, liver transplantation, and adjunctive chemotherapy in the treatment of patients with ICC remains to be determined.

Foreign body in the rectum is not an uncommon condition encountered by general surgeons. Endoscopic retrieval can be attempted but may not always be successful. A small proportion of patients require an operation under general anaesthesia. There is no well-defined guideline for proper management of rectal foreign body. We report a rare case (a 10-inch rectal vibrator) in which colonoscopic retrieval failed and, subsequently, extraction under general anaesthesia was required. The literature was reviewed for an optimum method of removal.

A 27-year-old man and known hepatitis B carrier was incidentally found to have an 8-cm right lobe liver mass on computed tomography during evaluation of his recurrent pneumothorax. The α-fetoprotein was markedly elevated at 34834 ug/L. Dual-tracer positron emission tomography showed F-fluorodeoxyglucose (FDG)-avid and C-acetate non-avid liver mass (Fig. 1a). There were multiple hypermetabolic foci in portal, perigastric and left para-aortic lymph nodes and the mesentery (Fig. 1b). A clinical diagnosis of hepatocellular carcinoma with abdominal lymph node and peritoneal metastasis was made, and the patient was treated with a combination of sorafenib, capecitabine and oxaliplatin. After 6-month systemic treatment, follow-up computed tomography showed a size reduction of abdominal lymph nodes without the development of any new lesions. α-Fetoprotein decreased to 11243 ug/L. In view of his favourable response to systemic treatment and young age, he received right hepatectomy and excision of the mesenteric tumour and para-aortic lymph node. He had an uneventful recovery after operation. Pathology of the resected liver specimen showed a solitary moderately-differentiated hepatocellular carcinoma without any vascular invasion. Pathology of both the mesenteric mass and para-aortic lymph node revealed a plasma cell-rich lymphoproliferative lesion with multiple hyperplastic or involuted lymphoid follicles, which was most compatible with the plasma cell variant of Castleman’s disease. Subsequent work-up of this patient showed that he was HIV and HHV8 negative. He was regularly followed up by an oncologist with interval computed tomography for surveillance of recurrent liver cancer and monitoring of residual abdominal lymphadenopathy.