Anal and perianal tuberculosis: a report of three cases in 10 years

From the computerized pathology record, three cases of anal and perianal tuberculosis were encountered in the Prince of Wales Hospital, Hong Kong during the last 10 years. The clinical history, examination findings and relevant investigations were reviewed retrospectively. Comparison was made with previous literature. Emphasis was put on the diversity of clinical presentations including acute perianal abscess, chronic anal ulcer and fistula in ano. It is concluded that a high index of suspicion is important to ensure an early diagnosis.

Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers

OBJECTIVE

To compare endoscopic adrenaline injection alone and adrenaline injection plus heat probe for the treatment of actively bleeding peptic ulcers.

DESIGN

Randomised prospective study of patients admitted with actively bleeding peptic ulcers.

SETTING

One university hospital.

SUBJECTS

276 patients with actively bleeding ulcers detected by endoscopy within 24 hours of admission: 136 patients were randomised to endoscopic adrenaline injection alone and 140 to adrenaline injection plus heat probe treatment.

MAIN OUTCOME MEASURES

Initial endoscopic haemostasis; clinical rebleeding; requirement for operation; requirement for blood transfusion; hospital stay, ulcer healing at four weeks; and mortality in hospital.

RESULTS

Initial haemostasis was achieved in 131/134 patients (98%) who received adrenaline injection alone and 135/136 patients (99%) who received additional heat probe treatment (P = 0.33). Outcome as measured by clinical rebleeding (12 v 5), requirement for emergency operation (14 v 8), blood transfusion (2 v 3 units), hospital stay (4 v 4 days), ulcer healing at four weeks (79.1% v 74%), and in hospital mortality (7 v 8) were not significantly different in the two groups. In the subgroup of patients with spurting haemorrhage 8/27 (29.6%; 14.5% to 50.3%) patients from the adrenaline injection alone group and 2/31 (6.5%; 1.1% to 22.9%) patients from the dual treatment group required operative intervention. The relative risk of this was lower in the dual treatment group (0.17; 0.03 to 0.87). Hospital stay was significantly shorter in the dual treatment group than the adrenaline injection alone group (4 v 6 days, P = 0.01).

CONCLUSION

The addition of heat probe treatment after endoscopic adrenaline injection confers an advantage in ulcers with spurting haemorrhage.

Comparison of two-dimensional vs three-dimensional camera systems in laparoscopic surgery

BACKGROUND

The lack of depth perception and spatial orientation in video vision are the drawbacks of laparoscopic surgery. The advent of a three-dimensional camera system enables surgeons to regain binocular vision and may be advantageous in complex laparoscopic procedures.

METHODS

We prospectively studied two groups of surgeons (with and without experiences in laparoscopic surgery) who performed a designated standardized laparoscopic task using a two-dimensional camera system (Olympus OTV-S4) vs a three-dimensional camera system (Baxter-V. Mueller VS7700) and compared their time performances.

RESULTS

The results suggested that only experience in laparoscopic surgery had significant effect on individual's performance. We could not demonstrate any superiority of the 3D system over the 2D system. However, two-thirds of the surgeons commented that the depth perception did improve.

CONCLUSIONS

With further refinement of the technology, the 3D system may improve its potential in laparoscopic surgery.

Use of a cotton tape tie in laparoscopic colorectal surgery

In this short article we describe the use of a cotton tape tie in laparoscopic colorectal surgery. This technique is useful in: (i) retraction and manipulation of the bowel; (ii) exteriorization of a bulky specimen; and (iii) occlusion of the rectal lumen to permit effective cytocidal rectal lavage.

Obturator hernia revisited: a review of 12 cases in 7 years

Twelve patients with obturator hernia seen over a 7-year period were reviewed retrospectively. All were elderly females presenting with small bowel obstruction. The median body weight was 35 kg. A significant proportion of patients (33%) came from homes for elderly people and were either bed-ridden or wheel chair-bound. All 12 patients were classified as high-risk-patients in pre-operative assessment. Only one patient (8.8%) had a history of previous abdominal operation. Clinical signs such as Howship-Romberg sign and palpable groin mass were absent in these patients. Contrast radiography was performed in three patients and was not helpful in the diagnosis. A correct pre-operative diagnosis was suspected in only one case. The medium treatment delay was 1.5 days and the gut resection rate was 75%. The overall mortality rate was high (25%). A high index of clinical suspicion is important in the diagnosis and obturator hernia should be suspected whenever an elderly thin female with no previous abdominal surgery developed small bowel obstruction. Early laparotomy is recommended in such patients.

A logical approach to hepatocellular carcinoma presenting with jaundice

OBJECTIVE

This prospective cohort study on patients with hepatocellular carcinoma (HCC) presenting with jaundice emphasized the importance of differentiating patients with hepatic insufficiency from patients with obstructive jaundice caused by tumor.

SUMMARY BACKGROUND DATA

There are little data in the medical literature on the management of patients with HCC presenting with jaundice. Experience has accumulated mainly from case reports and retrospective studies.

METHODS

Data were collected prospectively on 2095 patients with HCC seen over a 12-year period. All patients were investigated with blood tests, abdominal ultrasound, and chest radiography. Endoscopic retrograde cholangiopancreatography-percutaneous transhepatic cholangiography, computed tomography and hepatic angiography were carried out in selected patients.

RESULTS

Of the 530 patients who had clinically detectable jaundice, 481 had jaundice due to hepatic insufficiency and 49 patients had obstructive jaundice. Patients with hepatic insufficiency had extremely poor prognosis, and 90% of them died within 10 weeks of first presentation. "Curative" resection, however, was possible in 9 of 49 patients with obstructive jaundice, and histologic analysis showed resectional margin involvement by tumor in 1 patient. In addition, 35 patients were treated with biliary stents to relieve the obstructive jaundice. Supportive treatment only was given to five patients who were considered too terminally ill. The overall survival of patients with HCC with obstructive jaundice was similar to those patients who presented with no clinical detectable jaundice and was much better than those with jaundice due to hepatic insufficiency (log-rank test, p < 0.001).

CONCLUSIONS

The prognosis of patients with HCC who presented with jaundice due to hepatic insufficiency was dismal. It is important to identify the patients who had obstructive jaundice because with proper treatment, good palliation and occasional cure are possible.

Evaluation of artificial skin (Integra) in a rodent model

The biocompatibility of artificial skin (Integra) has been investigated in clean surgical wounds of 20 guinea-pigs. A rectangular 3 x 3 cm full-thickness skin defect with excision carried down to the panniculus carnosus was prepared on the dorsal area of the guinea-pig. A thin layer of silver sulfadiazine cream was applied and artificial skin was placed to cover the wound. At day 14, the uppermost silicone layer was removed. Good take of the artificial skin was observed in 18 of 20 animals. Microscopy showed good vascular ingrowth in 14 of the 18 animals. The remaining four animals showed necrotic tissue, absence of vascularization and haemorrhage in the wound bed. Two of the 20 wounds showed purulent discharge. In this animal model, clinical 'take' of the neodermis was achieved in 18/20 animals (90 per cent), while vascular ingrowth was observed in only 14/20 animals (70 per cent). These results suggested that artificial skin in clean surgical wound is readily biologically incorporated into surrounding viable tissue.

Clinical evaluation of the partition model for estimating radiation doses from yttrium-90 microspheres in the treatment of hepatic cancer

Radiation doses to the tumour and non-tumorous liver compartments from yttrium-90 microspheres in the treatment of hepatic cancer, as estimated by a partition model, have been verified by correlation with the actual doses measured with a beta probe at open surgery. The validity of the doses to the lungs, the tumour and non-tumorous liver compartment as estimated by the partition model was further evaluated in clinical settings. On the basis of the observation that one of three patients who received more than 30 Gy from a single treatment and one of two patients who received more than 50 Gy from multiple treatments developed radiation pneumonitis, it was deduced that an estimated lung dose < 30 Gy from a single treatment and a cumulative lung dose < 50 Gy from multiple treatments were probably the tolerance limits of the lungs. Three of five patients who received lung doses > 30 Gy as estimated by the partition model and were predicted to develop radiation pneumonitis, did so despite the use of partial hepatic embolization to reduce the degree of lung shunting. Furthermore, a higher radiological response rate and prolonged survival were found in the group of patients who received higher tumour doses, as estimated by the partition model, than in the group with lower estimated tumour doses. Thus the radiation doses estimated by the partition model can be used to predict (a) complication rate, (b) response rate and (c) duration of survival in the same manner as the actual radiation doses measured with a beta probe at open surgery. The partition model has made selective internal radiation therapy using 90Y microspheres safe and repeatable without laparotomy.

Hepatocellular carcinoma

Hepatocellular carcinoma is the most common cancer in males. Surgery is the only curative treatment, but is applicable in only 10-15% of patients. Systemic chemotherapy, transarterial embolization or chemo-embolization can only palliate. In the future, selective internal radiation may have a role in downstaging inoperable hepatoma to operable tumour.

Spontaneous internal herniation through the foramen of Winslow: a case report

A 41-year-old woman, who presented with acute onset of generalized peritonitis, was found to have a segment of strangulated small bowel incarcerated in the lesser peritoneal sac through the foramen of Winslow. The strangulated small bowel was reduced and resected. The predisposing factors for this condition as mentioned in the literature were not present in this case. In particular, the herniation was associated with a small foramen of Winslow and the presentation was one of rapidly developing peritonitis.

Laparoscopic ultrasonography during laparoscopic cholecystectomy

BACKGROUND

This study assessed the effectiveness of laparoscopic ultrasonography in demonstrating biliary anatomy, confirming suspected pathology, and detecting unsuspected pathology.

METHODS

Laparoscopic ultrasonography was performed on 48 patients (17 M:31 M) who underwent laparoscopic cholecystectomy. An Aloka 7.5-MHz linear laparoscopic ultrasound transducer was used for scanning.

RESULTS

Gallbladder stones were confirmed by laparoscopic ultrasonography in all patients and unsuspected pathology was found in five patients. Two patients were found to have common bile duct stones by laparoscopic ultrasonography and this was confirmed by laparoscopic cholangiography. Laparoscopic ultrasound was found to be helpful during dissection in four patients, particularly in a patient with Mirizzi syndrome. The entire common bile duct was visualized by laparoscopic ultrasonography in 40 patients but was poorly seen in eight patients. The mean time taken for the examination was 9 min (range 4-18 min).

CONCLUSION

Laparoscopic ultrasound is useful during laparoscopic cholecystectomy.

Is there a role for preoperative infusion or intraoperative cholangiography?

Background: There has been a resurgence of interest in recent years in preoperative infusion cholangiography (PIC). The role of routine PIC compared to routine intraoperative cholangiography (IOC) has not been clearly defined.

Study design: In our department between 1985 and 1991, 1,042 of 1,576 consecutive patients with biliary calculous disease had elective cholecystectomy: 694 patients were prospectively scheduled for PIC, and 348 patients were randomly allocated to IOC. The patients in the PIC and IOC groups were similar with regard to age, history of biliopancreatic complications, and laboratory findings. The cost of PIC in Sweden is nearly five times greater than the cost of IOC.

Results: Satisfactory opacification of the biliary system was obtained in 90.1 and 96.8 percent of patients who underwent PIC and IOC, respectively. Preoperative infusion cholangiography required support by IOC in 19.5 percent of patients. There were no statistically significant differences between the PIC and IOC groups with regard to the incidence (7 percent in both groups) of or positive predictive value (68 and 80 percent, respectively) for bile duct stones, rate of retained stones (6 and 20 percent, respectively), intraoperative (5.6 and 6.3 percent, respectively) or postoperative (13.3 and 15.9 percent, respectively) morbidity, or incidence of bile duct anomalies (0.9 and 0.3 percent, respectively). Median operative time was longer in .patients with (95 minutes) compared to those without (75 minutes) IOC (p<0.001). More postoperative complications occurred after bile duct exploration (26 of 75 patients) compared to cholecystectomy alone (114 of 917 patients, p<0.001). The 30-day mortality was zero. Minor bile duct injuries occurred in two patients (0.2 percent) at cholecystectomy, (one with and one without bile duct exploration). In no patient was the cholangiographic finding of a biliary anomaly crucial for the safe execution of cholecystectomy.

Conclusions: In our study, PIC and IOC were comparable, but routine use of either method did not promote the safety of cholecystectomy and thus their routine use is not warranted. The shorter operative time and preoperative identification of common bile duct (CBD) stones provided by PIC might favor this examination when applied selectively in patients with increased risk of having CBD stones. However, this potential advantage is offset by the need for PIC to be supported by IOC in approximately 20 percent of patients. Also, the cost of PIC is greater than the cost of IOC.

Pitfalls in the management of preauricular sinuses

A total of 159 operations for the excision of a preauricular sinus carried out in 117 patients over an 8-year period were reviewed. Previous excision, the use of a probe to delineate the sinus and operating under local anaesthesia all increased the chance of recurrence. The condition recurred more often in patients who developed post-operative wound sepsis than in those who healed primarily. Means of decreasing the recurrence rate include: (1) meticulous dissection of the sinus by an experienced head and neck surgeon under general anaesthesia; (2) the use of an extended preauricular incision; (3) clearance down to the temporalis fascia to ensure complete removal of all epithelial components; (4) avoidance of sinus rupture; and (5) closure of wound dead space.

High prevalence of Helicobacter pylori infection in duodenal ulcer perforations not caused by non-steroidal anti-inflammatory drugs

There has been controversy regarding the relationship between Helicobacter pylori and perforated peptic ulcer, which is known to have a high recurrence rate if only simple patch repair is performed. The aim of this study was to evaluate the association between H. pylori infection and intake of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with perforated duodenal ulcers. Of the 73 patients recruited over a 16-month period, 51 (70 per cent) had evidence of H. pylori infection by intraoperative gastroscopy and antral biopsies. The infection rate rose to 80 per cent if NSAID users were excluded. The H. pylori-infected group was significantly younger (mean 47.6 versus 62.5 years), with a male preponderance (49 of 51 versus 14 of 22 patients), and had significantly less NSAID consumption (three of 51 versus ten of 22) and more prolonged dyspepsia (40 of 51 versus ten of 22), compared with H. pylori-negative patients. H. pylori infection probably plays an important role in the causation of non-NSAID-induced duodenal ulcer perforation. Whether eradication of the bacteria can alleviate the strong ulcer diathesis in this subgroup of patients is unknown.

Hepatic haemangioendothelioma presenting with early heart failure in a newborn: treatment with hepatic artery embolization and interferon

We report our management of a newborn presenting in utero with congestive heart failure secondary to a giant hepatic haemangioendothelioma. Control of heart failure was achieved by transcatheter hepatic artery embolization, and rapid regression of the tumor was observed after a course of alpha 1 interferon. The combination of hepatic artery embolization and interferon may be a useful approach in the management of this rare, potentially fatal condition.

Mesh hernioplasty using a stapler

BACKGROUND

The recent development of laparoscopic hernioplasty has evoked extensive re-examination of the safety and effectiveness of using synthetic mesh materials in hernia surgery. We have investigated the efficacy of anterior stapling mesh repair in the treatment of inguinal hernia.

METHODS

From July 1993 to June 1994, a modified open mesh hernioplasty using staples for anchorage has been performed in 127 patients.

RESULTS

The mean age of patients was 61.4 +/- 13.0 years. Over 90% of them were operated on under local anaesthesia. The operation time ranged from 30 to 95 min with a median of 39 min. Only sixteen patients (12.6%) required postoperative parenteral analgesics and the median time for resuming daily activities was 7 days. Apart from two patients with reactionary haemorrhage, there was no other significant complication observed. Only one recurrence was encountered over the 26-month median follow-up period.

CONCLUSIONS

We conclude that the modified mesh hernia repair with a stapling device is a feasible, inexpensive and safe procedure that is well tolerated under local anaesthesia by most patients.

A prospective study on the use of water-soluble contrast follow-through radiology in the management of small bowel obstruction

BACKGROUND

The purpose of this prospective study was to determine the value of water-soluble contrast follow-through radiology in predicting the outcome in patients with small bowel obstruction.

METHODS

Patients with clinical and radiological evidence of small bowel obstruction were selected according to pre-set criteria. A water-soluble contrast follow-through examination using 76% urografin was carried out within 24 h of hospital admission. The result was interpreted as 'significant obstruction' if the contrast failed to reach the caecum in 4 h or if there was a clear cut-off in the gastrointestinal tract. The result was interpreted as 'insignificant obstruction' if the contrast reached the caecum within 4 h. The surgeon was blinded to the result of the contrast examination in the patient management, and the decision to operate was based entirely on conventional clinical grounds.

RESULTS

Fifty-one patients in an 18 month period underwent the contrast examinations. Thirty-four patients (67%) had previous abdominal operations. The results showed that significantly more patients who had 'significant obstruction' on contrast radiology required surgery to relieve the intestinal obstruction (17/19) than those who had "insignificant obstruction' (1/32; Fisher's exact test, P < 0.0001). This difference was found to be significant in both patient subgroups: patients with or without previous abdominal operation. There was no major morbidity or mortality related to the contrast radiology procedure.

CONCLUSIONS

Urografin follow-through examination is a safe procedure; using 4 h as the cut-off it is highly predictive of the outcome in small bowel obstruction in patients with or without previous abdominal operation.

Endoscopic drainage aborts endotoxaemia in acute cholangitis

Forty patients with acute calculous cholangitis had successful endoscopic drainage. Bile from nasobiliary drains and venous blood was collected at 0, 12, 24, 36 and 48 h after endoscopy. Endotoxin levels were measured by the chromogenic Limulus Amoebocyte Lysate assay. There was a significant reduction in both bile and serum endotoxin levels after endoscopic drainage (P < 0.001). Endotoxaemia occurred when bile endotoxin reached 10(3) EU/ml and rose exponentially beyond this threshold. Significant association was demonstrated between both bile and serum endotoxins to the clinical features of cholangitis (P < 0.05). No correlation was evident between serum endotoxin and the parameters of white cell count, serum bilirubin and alkaline phosphatase (r = 0.53, 0.00 and 0.00 respectively). Endoscopic drainage is effective in lowering bile and serum endotoxin levels and clinical signs and symptoms reliably predict endotoxaemia.

A randomized study comparing laparoscopic versus open repair of perforated peptic ulcer using suture or sutureless technique

OBJECTIVE

This study compares laparoscopic versus open repair and suture versus sutureless repair of perforated duodenal and juxtapyloric ulcers.

BACKGROUND DATA

The place of laparoscopic repair of perforated peptic ulcer followed by peritoneal toilet of the peritoneal cavity has been established. Whether repair of the perforated peptic ulcer by the laparoscopic approach is better than conventional open repair and whether sutured repair is better than sutureless repair are both undetermined.

METHODS

One hundred three patients were randomly allocated to laparoscopic suture repair, laparoscopic sutureless repair, open suture repair, and open sutureless repair.

RESULTS

Laparoscopic repair of perforated peptic ulcer (groups 1 and 2) took significantly longer than open repair (groups 3 and 4; 94.3 +/ 40.3 vs. 53.7 +/ 42.6 minutes: Student's test, p < 0.001), but the amount of analgesic required after laparoscopic repair was significantly less than in open surgery (median 1 dose vs. 3 doses) (Mann-Whitney U test, p = 0.03). There was no significant difference in the four groups of patients in terms of duration of nasogastric aspiration, duration of intravenous drip, total hospital stay, time to resume normal diet, visual analogue scale score for pain in the first 24 hours after surgery, morbidity, reoperation, and mortality rates.

CONCLUSIONS

Laparoscopic repair of perforated peptic ulcer is a viable option. Sutureless repair is as safe as suture repair and it takes less time to perform.