Identifying Patients With Cirrhosis Who Might Avoid Screening Endoscopy Based on Serum Albumin and Bilirubin and Platelet Counts

The presence of gastroesophageal varices is a major complication of portal hypertension associated with significant morbidity and mortality.¹ The Baveno VI criteria state that patients with liver stiffness measurement (LSM) <20 kPa by transient elastography (TE) and platelet count >150,000/μL can avoid screening endoscopy for high-risk varix (HRV).² However, because TE is not widely available, the Baveno VI criteria could not be applied in many clinical settings. As such, we aim to determine a concise clinical criterion as an alternative noninvasive tool to predict absence of HRV among patients with compensated cirrhosis to avoid screening esophagogastroduodenoscopy (EGD).

The influence of gender difference on the outcomes of infrainguinal bypass for critical limb ischaemia in Chinese patients

PURPOSE

to investigate the influence of gender difference on the outcomes of infrainguinal bypass operations performed in Chinese patients with critical limb ischaemia.

METHODS

we prospectively studied the results of 191 consecutive infrainguinal bypass operations (98 men, 93 women) for critical lower limb ischaemia in Chinese patients.

RESULTS

the women were older than men (median 75 vs 70 years, p=0.001) and cigarette smoking was commoner in men (83% vs 37% p<0.001). The calibre of run-off arteries at the level of distal anastomosis was smaller in women (median 2.5 mm vs 2.0 mm, p=0.03). The 30-day mortality was 3% (five men vs one woman, p=0.09) and early graft failure occurred in 19 patients (12 women vs seven men, p=0.28). At 3 months limb loss occurred in 16 (10 women vs six men, p=0.35) patients. Survival (38% vs 60% at 4 years, p=0.12) was similar in men and women. However, women suffered from poorer primary (33% vs 49% at 3 years, p=0.03) secondary graft patency rates (35% vs 64% at 3 years, p=0.02) than men. Limb survival rate in two groups (75% vs 85% at 4 years, p=0.18) was comparable.

CONCLUSION

following infrainguinal bypass for critical limb ischaemia, early results were similar in both gender groups. In the long-term, women patients suffered from significantly higher graft failure rate. However, their long-term survival and limb salvage rate remained comparable to those of men.

The impact of mastectomy, breast-conserving treatment and immediate breast reconstructions on the quality of life of Chinese women

BACKGROUND

The psychosocial impact of breast surgery has been extensively studied in the Western population. There is a relative paucity of comparable data in Oriental women who are increasingly affected by cancer of the breast. The present study investigates the effects that different types of breast surgery have on the quality of life of Chinese women.

METHODS

Forty-nine Chinese women with early breast cancer were interviewed at 6 months-2 years following their primary surgery (breast-conserving treatment (BCT, 17 patients), mastectomy (15 patients) and mastectomy with immediate breast reconstruction (17 patients)). Aspects of quality of life measured included general psychological well-being, body image, sexual functioning and social functioning.

RESULTS

Patients who received BCT had significantly better body image scores compared to mastectomy patients. They were less worried about their appearance, had more freedom in the choice of clothing, felt less upset by the change in their body and felt more accepted by their partners. The three groups did not differ significantly in the other aspects of quality of life measured.

CONCLUSIONS

Compared to mastectomy or mastectomy and immediate breast reconstruction, the most significant benefit of BCT is the preservation of a better body image.

Rabeprazole-based 3-day and 7-day triple therapy vs. omeprazole-based 7-day triple therapy for the treatment of Helicobacter pylori infection

BACKGROUND

Rabeprazole is a new proton pump inhibitor with more potent acid suppressive and anti-Helicobacter effects.

AIM

To compare two different regimens of rabeprazole-based triple therapy vs. 7-day omeprazole-based triple therapy for the eradication of Helicobacter pylori infection.

METHOD

Patients with proven H. pylori infection were randomized to receive: (i) 7-day rabeprazole, 10 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg, all twice daily; (ii) 3-day rabeprazole, 20 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg, all twice daily; or (iii) 7-day omeprazole, 20 mg, amoxicillin, 1000 mg, and clarithromycin, 500 mg, all twice daily. Endoscopy (CLO test, histology) was performed before randomization and 6 weeks after drug treatment.

RESULTS

One hundred and seventy-three patients were randomized. H. pylori eradication rates (intention-to-treat, n=173/per protocol, n=167) were 88%/91% for 7-day rabeprazole-based therapy, 72%/72% for 3-day rabeprazole-based therapy and 82%/89% for 7-day omeprazole-based therapy, respectively. The per protocol eradication rate was significantly better in the 7-day rabeprazole-based therapy and 7-day omeprazole-based therapy groups when compared to the 3-day rabeprazole-based therapy group (P=0.01 and P=0.04, respectively). Compliance was excellent and all three regimens were well tolerated.

CONCLUSIONS

The efficacy of seven-day rabeprazole-based triple therapy is similar to 7-day omeprazole-based triple therapy for the eradication of H. pylori infection.

Diagnostic accuracy of vacuum-assisted biopsy device for image-detected breast lesions

BACKGROUND

Non-palpable breast lesions present diagnostic difficulties. Ultrasound-guided fine-needle aspiration cytology (FNAC) is a common method used to obtain a diagnosis, but FNAC is frequently inconclusive or insufficiently accurate. Recently a vacuum-assisted biopsy device (Mammotome, Ethicon, Endo-surgery, USA) has been introduced. The diagnostic accuracy of this biopsy device was assessed for lesions that were visible on ultrasound.

METHODS

Fifty ultrasound-guided mammotome biopsies were performed. All were small breast lesions primarily detected by ultrasound. All received FNAC as initial assessment. Mammotome biopsy was performed whenever the breast lesion was considered indeterminate or if it was considered benign and there were associated risk factors such as a family history of breast cancer.

RESULTS

Of 50 mammotome biopsies 45 had benign histology. Three of 45 lesions were excised at the patients' request and were confirmed to be benign. The remaining 42 patients received an ultrasound follow up at 6 months. The lesion size remained static in 39 patients. In three patients the lesion size increased and they were excised and histology was benign. For the four malignancies diagnosed with mammotome biopsy, three patients received definitive treatment and one patient defaulted. There was one failed mammotome biopsy in the present series.

CONCLUSIONS

Mammotome biopsy is an acceptable diagnostic method for small breast lesions seen on ultrasound. It reduces the need for open biopsy without compromising diagnostic accuracy.

Spontaneous intramural hematoma of stomach

BACKGROUND

Intramural hematoma occurs uncommonly in the gastrointestinal tract and very rarely in the stomach. In case of a spontaneous gastric hematoma, the few previously reported patients all had certain predisposing factors. However, truly spontaneous intramural hematoma of the stomach without an identifiable cause has not been reported before.

METHOD

Emergency total gastrectomy was performed in a 49-year-old man with such pathology and the diagnosis was made postoperatively.

RESULTS

The patient required further laparotomy on day 10 for drainage and debridement of a subphrenic abscess. He recovered uneventfully from the second operation. After an extensive pathological search, no predisposing factors could be found. The patient remains in good health 18 months after the operations.

CONCLUSION

Spontaneous intramural gastric hematoma is extremely rare. But even rarer is when predisposing conditions or lesions are absent.

Experience of neoadjuvant chemotherapy for breast cancer at a public hospital: retrospective study

OBJECTIVE

To review local experience of neoadjuvant chemotherapy in breast cancer.

DESIGN

Retrospective study.

SETTING

Public hospital, Hong Kong.

PATIENTS

Seventeen patients who presented from August 1988 through April 1997 with locally advanced breast cancer, which was treated with neoadjuvant chemotherapy.

RESULTS

The clinical response rate was 71% and two of the 12 patients who responded to chemotherapy achieved complete remission. Three patients had their tumours downstaged sufficiently to allow them to undergo breast conservation surgery after neoadjuvant chemotherapy. None of these three patients has so far had a local recurrence of disease.

CONCLUSION

Neoadjuvant chemotherapy can achieve a high objective response rate in patients with locally advanced breast cancer and thus enables breast conservation surgery to be performed on patients who are initially not suitable for this procedure.

Surgical treatment of recalcitrant radiation-induced gastric erosions

BACKGROUND

Uncontrolled bleeding as a result of radiation gastritis in patients who have pharyngo-laryngo-esophagectomy and gastric pull-up is seldom reported. Surgical resection in the management of this condition has rarely been described.

METHOD

A 66-year-old man with hypopharyngeal cancer was treated by pharyngo-laryngo-esophagectomy and gastric transposition. He received postoperative radiotherapy and had recurrent hemorrhagic gastritis, necessitating surgical resection. The manubrium was resected to access the mediastinal part of the gastric conduit. The diseased part of the gastric conduit was removed and a free jejunal graft was interposed to replace the resected stomach.

RESULTS

Manubrial resection offered adequate access to the stomach transposed in the mediastinum, and the life-threatening bleeding gastritis was successfully controlled by surgical resection.

CONCLUSION

Surgical resection of the radiation-damaged transposed stomach through a manubrial resection approach can safely be performed. Free jejunal graft is the choice of reconstruction of the circumferential defect.

Case report: two cases of biliary papillomatosis with unusual associations

Papillomatosis arising from the biliary tree is a well recognized but rare entity. We encountered two patients with this condition. However, one of them had associated hepatocellular carcinoma and cirrhosis and the other had concomitant recurrent pyogenic cholangitis. To our knowledge, these associations have not been reported before. We, therefore, present these clinical problems and highlight the added difficulty in the management of these patients.

Arterial lesions in severe lower limb ischaemia: a prospective study of 100 consecutive ischaemic limbs in a Hong Kong Chinese population

BACKGROUND

The pattern and distribution of arterial lesions in a local Chinese population were studied to assess the feasibility of reconstruction and the possibility of avoiding major amputation of ischaemic limbs.

METHOD

Between March 1995 and August 1997, 90 consecutive patients with 100 severely ischaemic lower limbs and their arteriograms were analysed. There were 48 female and 42 male patients with a mean age of 72 years. All the patients were in fair general health, did not have foot pulses and were willing to undergo major arterial reconstruction. Ten patients had bilateral limb ischaemia and 94 of the ischaemic limbs were affected by rest pain with or without ulcer and/or gangrene. The remaining six patients had debilitating claudication. These lesions were classified into low-grade (less than 50% stenosis), high-grade (50-90% stenosis) and critical (> 90% stenosis to occlusion).

RESULTS

Critically stenotic or occlusive lesions were present in 16% of aorto-iliac segments; 76% of femoropopliteal arteries; and 82% of trifurcation and infrapopliteal segments. In at least 27 patients one of the two main foot arteries was also severely diseased. The present analysis suggested that 79 of these ischaemic limbs had reconstructable lesions. Sixteen were not suitable for intervention and in five patients the reconstructability was uncertain radiologically.

CONCLUSION

Contrary to local belief, the majority of patients in the Chinese community with severe lower limb ischaemia without foot pulses would have technically reconstructable arterial lesions and could benefit from a revascularization procedure.

Pancreatic tuberculosis: case reports and review of the literature

Tuberculosis affecting the pancreas is rare. Its occurrence may pose a diagnostic problem in differentiating it from carcinoma of the pancreas. Two cases of tuberculosis affecting the pancreas are reported, illustrating the value of fine needle aspiration in such a situation. The response of the disease to antituberculous drugs was slow, but sure.

Arterial reconstruction for lower limb ischaemia in Hong Kong Chinese

BACKGROUND

Lower limb ischaemia due to peripheral arterial disease is uncommon in Chinese people, and few arterial bypass operations have been performed. The management of a consecutive series of patients who were admitted to our department with severe lower limb ischaemis between March 1990 and October 1996 is reported here.

METHODS

A total of 91 primary arterial bypass operations were performed for 83 patients (eight patients had bilateral, or two procedures). Of these, 84 operations were for foot salvage and seven operations were for debilitating claudication. There were 80 infra-inguinal bypasses, 10 of which required additional femoro-femoral crossover grafts to improve in-flow. The remaining 11 bypass procedures were performed for aorto-iliac occlusion, which included aortobifemoral bypass (5), axillobifemoral bypass (3) and cross-femoral bypass (3) grafts. There were 46 male and 37 female patients, with a median age of 70 years (36-94).

RESULTS

Six patients died (6.6%) postoperatively, all of whom were in the foot salvage group. The overall cumulative foot salvage rate and graft patency was 84 and 56%, respectively, at 5 years.

CONCLUSIONS

These results justified the use of the same aggressive approach that was adopted in Western countries for the treatment of peripheral arterial disease, which seemed to be an emerging problem in Hong Kong.

Single-layer continuous anastomosis in gastrointestinal surgery: a prospective audit

BACKGROUND

Single-layer intestinal anastomoses have been constructed conventionally using an interrupted suture technique. It is however, increasingly popular to perform such anastomosis using a continuous suture.

METHODS

One hundred and eighty consecutive patients with 254 continuous single-layer anastomoses performed over a 4 year period were included in the study. Sixty-one patients underwent oesophagectomy, oesophageal bypass or gastrectomy, 32 underwent biliary bypass, hepatic, biliary or pancreatic resection and 88 had colorectal operations. The median age was 67 years.

RESULTS

There were 254 anastomoses of which four leaked (1.6%). Fifteen patients (8.3%) died in hospital.

CONCLUSION

These results show that the single-layer continuous suture technique is safe in gastrointestinal anastomoses.

Comparison of prophylactic ampicillin/sulbactam with gentamicin and metronidazole in elective colorectal surgery: a randomized clinical study

A randomized control clinical study was conducted to compare the effectiveness of prophylactic ampicillin/sulbactam in preventing wound infection after elective colorectal surgery with a combination of gentamicin and metronidazole. Over a 2-year period, 143 patients were recruited, but 15 patients were subsequently excluded due to the use of additional antibiotics for the treatment of pulmonary or urinary infection or early postoperative death without wound infection. Of the 128 evaluable patients, six of the 63 patients (9.5%) in the ampicillin/sulbactam group and seven of the 65 patients (10.7%) in the gentamicin and metronidazole group developed wound infection. We conclude that prophylactic ampicillin/sulbactam is effective in reducing the risk of wound infection following colorectal surgery.

Pneumogastrogram in the diagnosis of perforated peptic ulcer

Early diagnosis and surgical intervention is important in the management of peptic ulcer perforation. This study looks at the value of a pneumogastrogram in the diagnosis of patients suspected of having a perforated peptic ulcer. One hundred and twenty-nine patients were studied. Pneumogastrogram increased the diagnostic yield of pneumoperitoneum from 66% following plain erect X-ray examination to 91%. The procedure was free of complications.

Obturator hernia: a continuing diagnostic challenge

BACKGROUND

The rare obturator hernia has a high incidence of potentially lethal complications. This report reviews this condition and stresses the dangers of unrecognized obturator hernia.

METHODS

Thirteen patients with 14 obturator hernias were seen during a 5-year period. All the patients were emaciated and elderly, and 12 were women. They all had clinical features of small bowel obstruction. The classic Howship-Romberg sign was present in only three patients. The diagnosis was made before surgery in five patients.

RESULTS

All hernial sacs contained small bowel. Ileum were present in 11 instances. Richter-type hernia was present in 10 cases. Bowel resection for gangrenous loop was required in seven instances. Apart from associated poor medical conditions, delay in presentation and operation also contributed to the high morbidity and mortality rates. Five patients (38.5%) had postoperative complications, and two patients (15.4%) died of chest infections.

CONCLUSIONS

The need for awareness of the condition is stressed and the diagnosis of obturator hernia should be strongly suspected in a thin, elderly woman who has small bowel obstruction and no previous abdominal surgery.

Mirizzi syndrome with cholecystocholedochal fistula: preoperative diagnosis and management

Gallstone obstruction of the cystic duct with resulting repeated attacks of inflammation and pressure necrosis leads to the formation of cholecystocholedochal fistulas (Mirizzi syndrome type II). Obstructive jaundice and cholangitis are the common presentations of the condition. These fistulas are often not recognized before operation and constitute a high risk of damage to the common duct during a formal cholecystectomy. A high index of suspicion is required to diagnose the condition. We report five patients with cholecystocholedochal fistulas diagnosed by endoscopic retrograde cholangiography that delineated the fistula and the obstructing stone. The plan of management was formulated before surgery, and persistent attempt to dissect the Calot's triangle was avoided. In three patients the common duct defect was closed with the use of a gallbladder flap. Hepaticojejunostomy was required for the two difficult cases with large common duct defects and inflamed tissue.

Plea for selective operative cholangiography

A prospective study was carried out to evaluate the use of routine operative cholangiography in 382 patients undergoing elective cholecystectomy. Operative cholangiography was performed in 356 patients. In each patient, the presence or absence of clinical and operative indications for common duct exploration was correlated with the result of the operative cholangiography. In 114 patients (32%) there were one or more indications for exploration and only 34 patients showed positive cholangiographic findings and were explored. Ductal stones were found in 25 patients and nine patients had negative explorations. In the remaining 242 patients who had no indication for common duct exploration, normal cholangiogram was obtained in 234 patients and eight had false positive cholangiograms and were explored unnecessarily. No unsuspected common duct stones were detected in the whole series. Based on these results, a plea is made for selective operative cholangiography.

Mesenteric hernias through defects of the mesosigmoid

Internal herniation through defects in the gastrointestinal mesentery is extremely rare. Two patients with small bowel herniation involving the sigmoid mesocolon are reported. The condition has a high incidence of strangulation, with rapid onset of gangrene of the bowel. The mortality is high and the role of early surgical intervention is stressed.

A new semiquantitative culture method for early detection of surgical incisional wound infection

A semiquantitative culture technique for early detection of surgical wound infection was done by rolling a segment of a plastic intravenous catheter across a blood agar plate after insertion into the most inflamed part of the wound on postoperative day 3. Patients were monitored daily for purulent discharge until healing. Of the 53 wounds studied, 44 (83%) had no growth or low-density superficial colonization on the blood agar (generally less than 15 colony-forming units and within the upper 1.5 cm of the catheter). None of these 44 wounds was subsequently infected; therefore, these colonies represented colonization. Of the 9 wounds (17%) that yielded greater than 15 colony-forming units and a diffuse subcutaneous pattern (colonies below the upper 1.5 cm of the catheter), all developed purulent discharge with a positive culture of the same organisms found by semiquantitative culture. This result differed significantly (P less than .01) from the 44 wounds without subsequent infection. This semiquantitative technique has the potential to distinguish infection from colonization and may be useful in diagnosing surgical wound infection.

Incidence and significance of pneumoperitoneum after inguinal herniorrhaphy

Previous studies have shown pneumoperitoneum either to be extremely rare or to not occur after inguinal herniorrhaphy, and that its presence signifies a serious intra-abdominal complication. A prospective study has been carried out to consider the incidence and significance of pneumoperitoneum after herniorrhaphy for indirect inguinal hernias. In a 1-year period, 100 patients were studied. Pneumoperitoneum was detected in six patients. In five patients, the amount of free gas was minimal and was reabsorbed after 48 h. The pneumoperitoneum was large and of increasing amount in one patient. Faecal fistula developed 7 days after operation due to an injury from the hernial repair to the sigmoid colon. The result of this study suggested that detectable pneumoperitoneum of small amount may be present after inguinal herniorrhaphy and, if it persists for longer than 48 h, the presence of a perforated viscus should be considered.