Late result of sphincteroplasty in the treatment of primary cholangitis

Sphincteroplasty is one of the surgical procedures used in the treatment of primary cholangitis. We performed this operation on 342 patients over a 13-year period, with an operative mortality of 4.7%. Postoperative examination of 271 patients (average follow-up, seven years four months) showed that a good result was achieved in 226 patients, a fair result in 23 patients, and a poor result in 22 patients. Analysis of the reoperations in 17 patients showed that stone reformation is the most common finding, followed by sphincteroplasty stricture, liver abscess, and empyema of the gallbladder. When performed with proper indications in the management of primary cholangitis, sphincteroplasty is a safe procedure, and the majority of patients can expect good results.

Coexisting congenital primary superior vena caval aneurysm and rheumatic mitral stenosis

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Leakage of lymph through scrotal skin

We report a case of scrotal dermal chylorrhea associated with chyluria. This is an uncommon complication of chyluria and the only case recorded in our series of 206 patients. Lymphograms showed the presence of abnormal reflux from the inguinal lymphatics into the scrotum.

The surgical management of anorectal malignant melanoma

The biological vagaries of anal malignant melanoma are illustrated by four cases in Chinese patients. All four died within five years. Their poor prognosis emphasizes the value of preoperative studies to detect clinically occult metastases and obviate futile radical surgery. Many patients already have disseminated disease at the time of diagnosis, and local excision of the tumour provides acceptable palliation. For localized disease, abdominoperineal resection prevents local recurrence and removes the mesenteric nodes which are frequently involved. Palpable inguinal nodes necessitate therapeutic groin dissection, but we perform elective resection only when affected nodes are found at laparotomy. Pelvic lymphadenectomy should be performed in conjunction with abdominoperineal resection. The efficacy of chemotherapy for anorectal melanoma remains uncertain.

Carcinoma of the gallbladder

A retrospective study of 100 proved cases of primary carcinoma of the gallbladder admitted to the University Surgical Unit, University of Hong Kong, over a 20-year period was undertaken. The female to male ratio was 1.4 to 1. The peak incidence was in the seventh decade for the females and the sixth decade for the males. Preoperative diagnosis was made in 10 patients. "Curative" cholecystectomy was performed in 20 patients with a 5-year survival rate of 10 per cent. Palliative procedures were performed in 44 patients with a median survival of 8 weeks, which was not significantly different from that in the 30 patients who were not operated upon or had laparotomy and biopsy only. Radical resection was carried out in 6 patients, all of whom died in hospital. Gallstones were found in only 26 patients. The gallbladders of 3 patients had associated benign tumours, one of which had malignant transformation at multiple sites. One patient had chronic typhoid infection. The incidence of clonorchis infestation and primary pyogenic cholangitis in these 100 patients was not different from that of our general hospital population.

Pulmonary coin lesions: a ten-year review of 239 cases

The results of a study of 239 resected solitary pulmonary nodules are presented; 66.5% of the resected nodules were malignant, and there were three patients with malignant coin lesions who were under 30 years of age. These findings confirm the generally accepted fact that most solitary pulmonary nodules must be resected if the presence of cancer is to be excluded. Transbronchial biopsy under biplane fluoroscopic guidance through a flexible bronchoscope may provide an effective alternative to early thoracotomy in the future, so that malignant nodules can be diagnosed before operation and patients with benign lesions are spared a thoracotomy.

Total parenteral nutrition versus gastrostomy in the preoperative preparation of patients with carcinoma of the oesophagus

Gastrostomy feeding has been a well established form of nutritional support for patients presenting with total dysphagia for carcinoma of the oesophagus. More recently, total parenteral nutrition has proved to be efficient and safe, offering an alternative to gastrostomy feeding. Twenty-four patients were randomly selected into two groups to compare the efficacy of total parenteral nutrition and gastrostomy feeding with respect to nitrogen balance and weight gain. Total parenteral nutrition was found to be superior to gastrostomy feeding in achieving an earlier positive nitrogen balance and greater weight gain during a 4-week period. However, gastrostomy feeding is still preferred as it is cheap, simple and safe, and allows patients to be active, mobile and self dependent. Total parenteral nutrition is reserved for those patients in whom an earlier operation is advisable.

Oesophageal microbial flora in carcinoma of the oesophagus

In 79 patients, with carcinoma of the oesophagus, oesophageal aspirates obtained at oesophagoscopy were cultured for aerobic and anaerobic organisms in an attempt to identify the microbial flora. The aspirate culture was correlated with the pathogens isolated when infective complications developed after operation. Bacteroides were isolated from the oesophagus in 39.2% of patients, streptococcus in 10.1% and coliform organisms in 7.6%. No growth was obtained in 35.4% patients. Forty-one patients underwent oesophageal resection. Six of these had the complication of empyema thoracis in the postoperative period. Two patients had identical organisms isolated from the oesophagus and the empyema. B. melaninogenicus was cultured from the pleural fluid in two patients whose oesophageal aspirate culture yielded no growth. Six patients developed wound infection, all with anastomotic cutaneous fistula. There was no demonstrable relationship between the organisms isolated from two sources. Prophylactic antibiotic administration should be directed against the bacteroides, since it is the most common organism isolated from within the oesophagus.

Bilateral ureteric obstruction secondary to metastatic carcinoma of the oesophagus

Ureteric involvement by metastatic tumour from squamous cell carcinoma of the oesophagus has not yet been described, and we report here a case of this condition.

Splenectomy in children in Hong Kong

A review of the hospital course of 82 splenectomies in children performed in the past 15 years has been carried out. Three indications have been identified: therapeutic, diagnostic, and traumatic. Thalassemia was identified as the commonest indication. Comparisons of the spleens removed showed that those from thalassaemia patients were the biggest, while those removed for idiopathic thrombocytopenic purpura (ITP), lymphoma staging, and trauma, were small. Twenty-eight per cent of patients had accessory spleens. Intrathoracic complications were frequent in the traumatic cases, whereas wound complications were commoner after splenectomies carried out for haematological reasons. No gallstones were detected. The platelet response to the various indications was studied and compared. There were two postoperative deaths.

Operative cholangiography: evaluation of its routine use in 569 cholecystectomies

From 1974 till 1979, 569 cholecystectomies with routine operative cholangiography were performed in the university surgical unit, Kwong Wah Hospital, Hong Kong, for non-malignant disease of the gallbladder. Gallstones were present in 522 cases. Acalculous cholecystitis occurred in 47 cases. At least one of the clinical or operative indications to explore the common bile duct was present in 312 of the patients. However, in this group of patients in whom routine operative cholangiography was done, exploration of the common bile duct was performed in only 147, thus avoiding unnecessary exploration of the duct in 165 cases (52.8%). In the remaining 257 patients in whom there was no indication to explore the common bile duct, operative cholangiography revealed unexpected stones in the common bile duct in 14 (5.5%). After choledochotomy, post exploratory operative T-tube cholangiography was performed to rule out overlooked stones, which were present in six cases (6/161, i.e., 3.7%). Postoperative T-tube cholangiography performed on the 12th to the 14th postoperative day showed retained stones in 17 cases, giving an incidence of known retained stones of 11% (17/161) of cholecystectomies with exploration of the common bile ducts, or 3% (17/569) in the whole series of cholecystectomies.

Alcohol tolerance and gastric emptying after replacement of the oesophagus with the stomach

Alcohol tolerance and gastric emptying were studied in ten patients before and three months after oesophagectomy and gastric replacement. There was no change in alcohol tolerance, but gastric emptying was accelerated. It is postulated that intestinal absorption may be impaired at three months after operation.

Identification of two subgroups of familial early-onset duodenal ulcers

Pentagastrin-stimulated maximal acid output and postprandial integrated gastrin response (sigma gastrin) were measured in 170 consecutive patients with duodenal ulcers. Within both acid normosecretor and hypersecretor groups, patients with positive family history of ulcer dyspepsia had significantly higher mean maximal acid output than did those without such history. In early-onset (symptoms before age 30) but not late-onset (symptoms after age 30) patients, mean sigma gastrin was significantly greater in those with positive than in those with negative family histories, and in normosecretors than in hypersecretors. Among early-onset patients, family-history-positive normosecretors had a significantly positive correlation between maximal acid output and sigma gastrin, whereas family-history-positive hypersecretors had a significantly negative correlation between these variables. Thus, two subgroups of familial ulcers were identified among early-onset patients. A drive mainly on the G cells may be present in the former group, whereas a drive mainly on the parietal cells may be present in the latter.

Pharyngocutaneous fistula complicating total laryngectomy

A series of 124 total laryngectomies for carcinoma is reviewed. The postoperative morbidity is discussed, and pharyngocutaneous fistula was found to occur in 30 patients. Its management is reviewed, and consideration is given to its relation to preoperative irradiation. This was found to increase its incidence and adversely affect the prospects of successful closure.

Early intracardiac repair of large ventricular septal defects with conventional cardiopulmonary bypass and moderate hypothermia

With the use of conventional cardiopulmonary bypass and moderate hypothermia, primary intracardiac repair of large ventricular septal defects was performed in 30 children below the age of two years. All babies were falling to thrive and suffered from cardiac failure resistant to medical therapy, or had evidence of early pulmonary vascular disease. Two patients died after the operation, giving an operative mortality of 6.7%. Twenty-eight survivors have been followed for periods of one month to two and a half years. All are thriving and have normal or mildly enlarged hearts on their chest skiagrams. Primary intracardiac repair of large ventricular septal defects can be performed in infants and small children with a low operative risk when the standard cardiopulmonary bypass technique is being used.

Surgical treatment of carcinoma of the hypopharynx and cervical oesophagus

From 1964 to 1979 a total of 1,702 patients with carcinoma of the oesophagus were admitted into the University Department of Surgery, Queen Mary Hospital, Hong Kong. Among these the tumour was situated at the hypopharynx in 112 cases and at the cervical oesophagus in 36 cases. The treatment of choice for resectable tumours of these sites was pharyngo-laryngo-oesophagectomy (81 cases). Reconstruction with pharyngo-gastric anastomosis was preferred (76 cases). Other methods of reconstruction were indicated only when the stomach had been resected previously. Although the hospital mortality after pharyngo-laryngo-oesophagectomy was 31% this was the only means by which a long term survival could be achieved. Occasionally even when the trachea was infiltrated by tumour, salvage could be attempted by including the posterior wall of the trachea in the resection and repairing with an in-turned delto-pectoral flap. Although the actuarial survival of patients after pharyngo-laryngo-oesophagectomy was only 9%, all the patients who survived the operation were relieved of their distressing symptom of dysphagia.

Relationship of postprandial serum gastrin response to sex, body weight, blood group status, familial dyspepsia, duration, and age of onset of ulcer symptoms in duodenal ulcer

Integrated postprandial serum gastrin levels were studied in a prospective series of 144 Chinese patients with duodenal ulcer in relation to sex, total body weight, age of onset and duration of ulcer symptoms, blood group status, and positivity for familial dyspepsia. Postprandial gastrin was unrelated to sex, total body weight, duration of symptoms, and blood group status. Patients whose onset age was in the first two decades (early onset group) had significantly higher postprandial gastrin than those with onset age in the 4th and 6th decades (P less than 0.01). This was found to be associated with the presence in the early onset group (n = 35) of a high proportion of patients with positive family history of ulcer dyspepsia (n = 24), in whom postprandial gastrin was significantly higher than those without such history (P less than 0.01). These results suggest that early onset patients who are positive for family history of ulcer dyspepsia segregate to form one subgroup of duodenal ulcer. They also offer a clue that familial hypergastrinaemia may be one marker for familial duodenal ulcer.