Effects of Deficits in the Neuromuscular and Mechanical Properties of the Quadriceps and Hamstrings on Single-Leg Hop Performance and Dynamic Knee Stability in Patients After Anterior Cruciate Ligament Reconstruction

Background:

Understanding the role of neuromuscular and mechanical muscle properties in knee functional performance and dynamic knee stability after anterior cruciate ligament reconstruction (ACLR) may help in the development of more focused rehabilitation programs.

Purpose:

To compare the involved and uninvolved limbs of patients after ACLR in terms of muscle strength, passive muscle stiffness, muscle activation of the quadriceps and hamstrings, hop performance, and dynamic knee stability and to investigate the association of neuromuscular and mechanical muscle properties with hop performance and dynamic knee stability.

Study Design:

Cross-sectional study; Level of evidence, 3.

Method:

The authors studied the quadriceps and hamstring muscles in 30 male patients (mean ± SD age, 25.4 ± 4.1 years) who had undergone unilateral ACLR. Muscle strength was measured using isokinetic testing at 60 and 180 deg/s. Passive muscle stiffness was quantified using ultrasound shear wave elastography. Muscle activation was evaluated via electromyographic (EMG) activity. Hop performance was evaluated via a single-leg hop test, and dynamic knee stability was evaluated via 3-dimensional knee movements during the landing phase of the hop test.

Results:

Compared with the uninvolved limb, the involved limb exhibited decreased peak torque and shear modulus in both the quadriceps and hamstrings as well as delayed activity onset in the quadriceps (P < .05 for all). The involved limb also exhibited a shorter hop distance and decreased peak knee flexion angle during landing (P < .05 for both). Decreased peak quadriceps torque at 180 deg/s, the shear modulus of the semitendinosus, and the reactive EMG activity amplitude of the semimembranosus were all associated with shorter hop distance (R² = 0.565; P < .001). Decreased quadriceps peak torque at 60 deg/s and shear modulus of the vastus medialis were both associated with smaller peak knee flexion angle (R² = 0.319; P < .001).

Conclusion:

In addition to muscle strength deficits, deficits in passive muscle stiffness and muscle activation of the quadriceps and hamstrings were important contributors to poor single-leg hop performance and dynamic knee stability during landing. Further investigations should include a rehabilitation program that normalizes muscle stiffness and activation patterns during landing, thus improving knee functional performance and dynamic knee stability.

Effects of Whole-Body Vibration Therapy on Quadriceps Function in Patients With Anterior Cruciate Ligament Reconstruction: A Systematic Review

CONTEXT

Quadriceps dysfunction is common for patients after anterior cruciate ligament reconstruction (ACLR). Whole-body vibration (WBV) could effectively treat quadriceps dysfunction.

OBJECTIVE

To summarize WBV protocols for patients with ACLR and to evaluate the effects of WBV on quadriceps function.

DATA SOURCES

PubMed, CINAHL, SportDiscus, Web of Science, Medline, and Embase were searched from inception to January 2020.

STUDY SELECTION

Randomized controlled trials recruiting patients with ACLR, using WBV as intervention, and reporting at least 1 of the following outcomes, strength, rate of torque development (RTD), and voluntary activation ratio of quadriceps, were included.

STUDY DESIGN

Systematic review.

EVIDENCE LEVEL

Level 3.

METHODS

This systematic review was reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality of evidence was determined by PEDro criteria and GRADE system. Participant characteristics, interventions, and the relevant results of the included studies were extracted and synthesized in a narrative way.

RESULTS

In total, 8 studies were included. Of these, 2 studies had serious risk of bias. Five of 8 studies implemented a series of WBV program ranging from 2 to 10 weeks in duration, while the other 3 studies implemented a single session of WBV. Eight WBV protocols were reported. The reported outcomes consisted of quadriceps strength, RTD, and central activation ratio. WBV protocols were heterogeneous. Low quality of evidence supported that exclusive conventional rehabilitation was more effective than exclusive WBV therapy in increasing quadriceps strength. Low quality of evidence supported that WBV combined with conventional rehabilitation was more beneficial in increasing quadriceps strength when compared with conventional rehabilitation alone. Very low quality of evidence supported the efficacy of a single session of WBV on quadriceps function.

CONCLUSIONS

There is no standardized WBV protocol for patients with ACLR, and the effectiveness of WBV in rehabilitation on quadriceps function remains inconclusive.

Decreased passive muscle stiffness of vastus medialis is associated with poorer quadriceps strength and knee function after anterior cruciate ligament reconstruction

BACKGROUND

Muscle deficits of the quadriceps and hamstrings are common after anterior cruciate ligament reconstruction, and increase the risk of knee reinjury. Muscle stiffness is an important factor for dynamic joint stability. However, the changes in quadriceps and hamstring muscle stiffness and its influence after anterior cruciate ligament reconstruction remain unclear.

METHOD

Twenty-five male subjects with anterior cruciate ligament reconstruction and twenty-one matched healthy subjects participated in this study. The passive muscle stiffness of the quadriceps and hamstrings was assessed by shear modulus using ultrasound shear wave elastography. The isokinetic muscle strengths of the quadriceps and hamstrings were tested. Knee function was evaluated by the International Knee Documentation Committee and Lysholm score. Muscle stiffness was compared between limbs via non-parametric tests. Correlation analysis was used to detect the relationship between muscle stiffness, isokinetic muscle strength and knee functional scores.

FINDINGS

The involved limb exhibited significantly decreased shear modulus in the vastus medialis compared to the dominant limbs(z = -3.585;P = 0.001;ES = 1.13) and non-dominant limbs(z = -3.551;P = 0.002;ES = 1.24) of healthy controls. The shear modulus of ST was also significantly lower in the involved limb when compared with the contralateral limbs(z = -3.996;P < 0.001;ES = 1.33), dominant limbs(z = -4.477;P < 0.001;ES = 1.65) and non-dominant limbs(z = -4.234;P = 0.001;ES = 1.43) of healthy controls. The shear modulus of the vastus medialis was associated with quadriceps peak torque at 60°/s(r = 0.470; p < 0.001) and knee functional score(r = 0.459; p = 0.021).

INTERPRETATION

The passive muscle stiffness of the vastus medialis decreased after anterior cruciate ligament reconstruction, which is associated with poorer quadriceps strength and knee function. The effect of modulation of muscle stiffness on improving knee function warrants future investigation.

Is Pre-operative Quadriceps Strength a Predictive Factor for the Outcomes of Anterior Cruciate Ligament Reconstructions

Persistent quadriceps weakness prevents patients from returning to sports after ACL reconstruction. Pre-operative quadriceps strength was indicated as an important factor for the outcomes of ACL reconstruction. However, the existing evidence is controversial. Therefore, this systematic review was conducted to summarize and evaluate the relationship between pre-operative quadriceps strength and the outcomes following ACL reconstruction, and to summarize the predictive value of pre-operative quadriceps strength for satisfactory post-operative outcomes. Pubmed, WOS, Embase, CINAHL and SportDiscus were searched to identify eligible studies according to PRISMA guidelines. Relevant data was extracted regarding quadriceps strength assessment methods, pre-operative quadriceps strength, participants treatment protocols, post-operative outcomes, follow-up time points and the relevant results of each individual study. Twelve cohort studies (Coleman methodology score: 62±10.4; from 44-78) with 1773 participants included. Follow-up period ranged from 3 months to 2 years. Moderate evidence supports the positive association between pre-operative quadriceps strength and post-operative quadriceps strength; weak evidence supports the positive association between pre-operative quadriceps strength and post-operative functional outcomes. By now, there is no consensus on the predictive value of pre-operative quadriceps strength for achieving satisfactory quadriceps strength after ACLR. To conclude, pre-operative quadriceps strength should be taken into consideration when predict patient recovery of ACLR.

The effect of psychological factors on pain, function and quality of life in patients with rotator cuff tendinopathy: A systematic review

BACKGROUND

Psychological factors may affect the pain level, shoulder function and quality of life in patients with rotator cuff tendinopathy.

OBJECTIVE

To systematically review the prevalence of psychological factors reported in patients with rotator cuff tendinopathy; and to determine the association between psychological factors and pain, function and quality of life in patients with rotator cuff tendinopathy.

STUDY DESIGN

Systematic review METHODS: Pubmed, Embase, CINAHL and Web of Science were systematically searched from inception to June 2019. Studies that investigated patients with signs and symptoms suggestive of rotator cuff tendinopathy, and reported psychological variables and patient-reported outcome measures including pain, shoulder function or disability and quality of life.

RESULTS

A total of 14 studies were included. Our results showed that 22.8%-26.2% of patients with rotator cuff tendinopathy reported depression; 23% reported anxiety; and 70.2%-89% of patients reported sleep disturbance or insomnia. Overall, nine psychological factors were identified to be associated with pain, function and quality of life in patients with rotator cuff tendinopathy. Low-to-moderate quality of evidence suggests that various psychological factors are associated with pain, function and quality of life in patients with rotator cuff tendinopathy CONCLUSION: This review identified various psychological factors may affect the pain level, shoulder function and quality of life in patients with rotator cuff tendinopathy, and the causal relationship warrants future high-quality prospective studies.

Risk factors for rotator cuff tendinopathy: A systematic review and meta-analysis

OBJECTIVES

To conduct a systematic review and meta-analysis to identify risk and associated factors for symptomatic rotator cuff tendinopathy.

DATA SOURCES

PubMed, CINAHL and Scopus were searched from inception to June 2017.

STUDY SELECTION

Participants presented with signs and symptoms suggestive of rotator cuff tendinopathy/tendinosis/tendinitis, shoulder impingement syndrome, or subacromial bursitis diagnosed by clinical tests and/or conventional imaging.

DATA EXTRACTION

Screening, quality assessment and data extraction were carried out by 2 reviewers.

DATA SYNTHESIS

Sixteen studies were included in this review. Overall, 22 factors were identified and 5 factors were explored using meta-analysis. Pooled analyses provided strong evidence that age above 50 years (odds ratio (OR)?=?3.31, 95% confidence interval (95% CI)?=?2.304.76, I2?=?0%, p<0.001) and diabetes (OR?=?2.24, 95% CI?=?1.373.65, I2?=?0%, p?=?0.001) were associated with increased risk of rotator cuff tendinopathy. In addition, moderate evidence showed that work with the shoulder above 90° was associated with increased risk of rotator cuff tendinopathy (OR?=?2.41, 95% CI?=?1.314.45, I2=?83%, p?=?0.005).

CONCLUSION

Age above 50 years, diabetes and overhead activities were associated with increased risk of rotator cuff tendinopathy.

Joint recommendations on management of anaemia in patients with gastrointestinal bleeding in Hong Kong

The demand for blood products continues to grow in an unsustainable manner in Hong Kong. While anaemia associated with gastrointestinal bleeding (GIB) is the leading indication for transfusion, there is no local recommendation regarding best practices for transfusion. We aimed to provide evidence-based recommendations regarding management of anaemia in patients with acute and chronic GIB. We reviewed all original papers, meta-analyses, systematic reviews, or guidelines that were available in PubMed. For acute GIB, a restrictive transfusion strategy, targeting a haemoglobin threshold of 7 to 8 g/dL, should be adopted because overtransfusion is associated with significantly higher all-cause mortality and re-bleeding. A liberal transfusion strategy should only be considered in patients with co-existing symptomatic coronary artery disease, targeting a haemoglobin threshold of 9 to 10 g/dL. When acute GIB settles, patients should be prescribed iron supplements if iron deficiency is present. For chronic GIB, iron stores should be replenished aggressively via iron supplementation before consideration of blood transfusion, except in patients with symptoms of severe anaemia. Oral iron replacement is the preferred first-line therapy, while intravenous iron is indicated for patients with inflammatory bowel disease, poor response or poor tolerability to oral iron, and in whom a rapid correction of iron deficit is preferred. Intravenous iron is underutilised and the risk of anaphylactic reaction to current preparations is extremely low. These recommendations are provided to local clinicians to facilitate judicious and appropriate use of red cell products and iron replacement therapy in patients with GIB.

In-situ medical simulation for pre-implementation testing of clinical service in a regional hospital in Hong Kong

The implementation of a new clinical service is associated with anxiety and challenges that may prevent smooth and safe execution of the service. Unexpected issues may not be apparent until the actual clinical service commences. We present a novel approach to test the new clinical setting before actual implementation of our endovascular aortic repair service. In-situ simulation at the new clinical location would enable identification of potential process and system issues prior to implementation of the service. After preliminary planning, a simulation test utilising a case scenario with actual simulation of the entire care process was carried out to identify any logistic, equipment, settings or clinical workflow issues, and to trial a contingency plan for a surgical complication. All patient care including anaesthetic, surgical, and nursing procedures and processes were simulated and tested. Overall, 17 vital process and system issues were identified during the simulation as potential clinical concerns. They included difficult patient positioning, draping pattern, unsatisfactory equipment setup, inadequate critical surgical instruments, blood products logistics, and inadequate nursing support during crisis. In-situ simulation provides an innovative method to identify critical deficiencies and unexpected issues before implementation of a new clinical service. Life-threatening and serious practical issues can be identified and corrected before formal service commences. This article describes our experience with the use of simulation in pre-implementation testing of a clinical process or service. We found the method useful and would recommend it to others.

Tendon vascularity in overhead athletes with subacromial pain syndrome and its correlation with the resting subacromial space

BACKGROUND

Supraspinatus tendinopathy is one of the common causes of subacromial pain syndrome (SAPS) in overhead athletes. Changes in tendon vascularity have been reported in painful tendons; however, the prevalence and distribution have not been investigated in young overhead athletes.

METHODS

We conducted a cross-sectional study of 47 overhead athletes (male, 31; female, 16) aged 18 to 36 years with SAPS for >3 months. A sonographer graded the severity of the tendinopathy and area of vascularization. Ultrasound imaging was used to measure supraspinatus tendon thickness, vascularity, and resting subacromial space. A self-written program was used to semiquantify the intensity of vascularity, expressed as the vascular index.

RESULTS

The majority (87.2%) of the participants had signs of tendinopathy in the supraspinatus tendon, and 40 (85.1%) of the tendinopathic tendons had vascularity. The majority (66.0%) of the vascularized subjects presented with minimal increase in vascularity, and 19.1% had moderate to severe vascularization. Most (79.2%) of the vascularization was observed in the pericortical region. The vascular index was negatively correlated with the resting subacromial space in male athletes with a reduced subacromial space (ρ = -0.63; P = .038).

CONCLUSION

Of overhead athletes with SAPS, 87.2% had supraspinatus tendinopathy with minimal to moderate vascularization, with the majority of vascularization occurring in the pericortical region. In male athletes with a reduced subacromial space, greater vascularity in the supraspinatus tendon was associated with a smaller resting subacromial space.

Intravenous lignocaine infusion facilitates acute rehabilitation after laparoscopic colectomy in the Chinese patients

INTRODUCTION

Intravenous infusion of lignocaine has emerged in recent years as a feasible, cost-effective, and safe method to provide postoperative analgesia. There is, however, no literature about this perioperative pain control modality in Chinese patients. This study aimed to determine whether perioperative intravenous lignocaine safely reduces postoperative pain, shortens postoperative ileus, and reduces the length of hospital stay in laparoscopic colorectal surgery.

METHODS

Between September 2012 and May 2015, 16 patients who underwent elective laparoscopic resection of colorectal cancer and received a 1% lignocaine infusion for 24 hours postoperatively were studied. After surgery, categorical pain scores were obtained immediately, followed by hourly pain scores at rest. Pain scores at rest and with mobilisation, and patient satisfaction score were documented on postoperative day 1. Return of bowel function was measured by time of first flatus and bowel opening. The patient's rehabilitation was assessed by time taken to tolerate diet, full mobilisation, and length of hospital stay.

RESULTS

The median (interquartile range) self-reported pain scores at 2 hours and 6 hours after surgery were 1.5 (0-4) and 2 (0-3), respectively. The median pain scores at rest and mobilisation on postoperative day 1 were 1 (0-2.5) and 2 (2.5-5), respectively, with a median satisfaction score of 7.5 (7-9). The median times to first flatus and first bowel opening were 21 (18-35) hours and 3 (1-3) days, respectively. No patient had postoperative ileus. The median times to tolerating diet and mobilisation were 1 (1-1) day and 2 (2-3) days, respectively. The median postoperative stay was 6 (5-8) days.

CONCLUSIONS

Intravenous lignocaine is a safe and effective postoperative analgesic in a Chinese population. It enhances the rehabilitation process for patients following laparoscopic resection of colorectal cancer.

Colorectal endoscopic submucosal dissection at a low-volume centre: tips and tricks, and learning curve in a district hospital in Hong Kong

INTRODUCTION

Colorectal endoscopic submucosal dissection is not a widely adopted procedure due to its technical difficulties. This study aimed to share the experience in setting up this novel procedure and to report the learning curve for such a procedure at a low-volume district hospital in Hong Kong.

METHODS

This case series comprised 71 colorectal endoscopic submucosal dissections that were performed by a single endoscopist without experience in gastric or colorectal endoscopic submucosal dissection. Lesion characteristics, procedure time per unit area of tumour, en-bloc resection rate, R0 resection rate, complications, and length of stay were recorded prospectively. Results were compared for two consecutive periods to study the learning curve.

RESULTS

Overall, 41 (57.7%) tumours were located in the right colon, 21 (29.6%) in the left colon, and nine (12.7%) in the rectum. The median tumour area was 4 cm(2) (range, 0.25-16 cm(2)). The median operating time was 105 (range, 47-342) minutes. The median procedure time per unit area of tumour was 24.9 min/cm(2). There was one instance of intra-operative bleeding that required conversion to laparoscopic colectomy. There was no postoperative haemorrhage. The overall perforation rate was 15.5%, in which one required conversion to laparoscopic colectomy. The overall morbidity rate was 16.9% and there was no mortality. The median hospital stay was 1 day (range, 0-11 days). The overall en-bloc resection rate and R0 resection rate was 81.2% and 58.0%, respectively. Comparison of the two study periods revealed that procedure time per unit area of tumour decreased significantly from 31.5 min/cm(2) to 21.5 min/cm(2) (P=0.032). The en-bloc resection rate improved from 78.8% to 83.3% (P=0.15). The R0 resection rate improved significantly from 39.4% to 75.0% (P<0.01).

CONCLUSION

Untutored colorectal endoscopic submucosal dissection is feasible with acceptable clinical outcomes at a low-volume district hospital in Hong Kong.

Reduction of the subacromial space in athletes with and without rotator cuff tendinopathy and its association with the strength of scapular muscles

OBJECTIVES

To compare the reduction of subacromial space (SAS) during arm abduction between overhead athletes with and without rotator cuff (RC) tendinopathy, and to explore the relationship between the strength of scapular muscles with the SAS.

DESIGN

Cross-sectional study.

METHODS

Sixty-six athletes (33 healthy and 33 with RC tendinopathy, mean age=22.3 years) participated in the study. Ultrasound measurement of the SAS with arm at 0°, 30° and 60° of shoulder abduction were taken, and the maximal isometric force in upper, middle and lower trapezius, and serratus anterior with manual muscle tests (MMT) were assessed using a handheld dynamometer. The change in SAS during arm abduction from 0° to 30° (SAS_0°-30°), 30° to 60° (SAS_30°-60°) and 0° to 60° (SAS_0°-60°) was compared between groups. Differences in force produced with scapular muscles MMT between groups and relationships with reduction in SAS were explored.

RESULTS

We found more reduction of the SAS during SAS_0°-30° in athletes with RC tendinopathy (0.44±1.22mm) than healthy athletes (-0.06±1.41mm) (p=0.045). Athletes with RC tendinopathy demonstrated significant decrease in all scapular muscles MMT strength when compared to their healthy counterparts (p<0.05). In healthy athletes, a lower middle and lower trapezius MMT strength were moderately associated with a greater reduction in SAS during 0° to 30° (r=-0.445, p=0.016 and r=-0.423, p=0.022, respectively) and 0° to 60° of shoulder abduction (r=-0.415, p=0.018 and r=-0.504, p=0.003, respectively).

CONCLUSIONS

Athletes with RC tendinopathy demonstrated more reduction in the SAS during early arm abduction. Decreased strength of middle and lower trapezius was related to reduction of the SAS.

Nurse-administered propofol-alfentanil sedation using a patient-controlled analgesia pump compared with opioid-benzodiazepine sedation for outpatient colonoscopy

BACKGROUND AND STUDY AIM

Nurse-administered propofol sedation (NAPS) and patient-controlled sedation using patient-controlled analgesia (PCA) pumps are gaining increasing popularity for gastrointestinal endoscopy. We compared the safety and efficacy of NAPS using PCA pumps with diazemuls-pethidine sedation (DPS) for outpatient colonoscopy.

PATIENTS AND METHODS

In a prospective randomized controlled trial patients underwent outpatient colonoscopy with sedation by either NAPS or DPS. For NAPS, following intravenous loading of 0.8 mg/kg propofol, mixtures of 14.3 mg propofol and 35 microgram alfentanil were titrated by nurses using a PCA pump. For DPS, 0.1 mg/kg diazemuls and 0.5 mg/kg pethidine were given as intravenous bolus; further titration was administered as half doses at the endoscopist's discretion. Adequacy of sedation was measured by the Observer's Scale for Sedation and Alertness (OSSA) score (range 1-5).

RESULTS

Between July 2005 and June 2006, 88 patients were randomly allocated to NAPS and 90 to DPS. The groups were comparable for baseline characteristics and procedure time. With NAPS, levels of sedation both during colonoscopic intubation and at reaching the cecum were significantly deeper than with DPS (OSSA 3 vs. 5, P < 0.0001). There were no significant differences in cardiopulmonary complication rates, pain scores, satisfaction scores, and patients' willingness to repeat colonoscopy with the same sedation. Drugs cost for NAPS was higher than for DPS (Hong Kong dollars [HKD] 98.34 vs. 5.01).

CONCLUSION

Despite higher costs, nurse-administered propofol-alfentanil sedation using a PCA pump can provide deeper conscious sedation, comparable satisfaction, and similar complication risks compared with conventional opioid-benzodiazepine sedation.

Scan-directed unilateral neck exploration for primary hyperparathyroidism: eight-year results from a regional hospital

OBJECTIVE

To determine the results of scan-directed unilateral neck exploration for primary hyperparathyroidism.

DESIGN

Retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Patients who underwent parathyroid surgery for primary hyperparathyroidism between January 2000 and December 2007 were included.

MAIN OUTCOME MEASURES

The demographic, imaging, biochemical, and pathological data, as well as surgical outcomes were analysed according to the treatment received.

RESULTS

A total of 78 patients were included in this study; 65 underwent unilateral neck exploration with image guidance by ultrasonography or technetium Tc99m sestamibi scan. The scan sensitivity for localising the side of the lesion was 66% for ultrasound scans, 71% for technetium Tc99m sestamibi scans, and 85% for both scans used in combination. Pathological analysis showed that 95% (74/78) of the patients had a single parathyroid adenoma, two had hyperplasia of four glands, one had a double adenoma, and one a parathyroid carcinoma. Among the patients undergoing scan-directed unilateral neck exploration, one defaulted follow-up, while the remaining 64 patients achieved normal calcium levels at a median follow-up of 6 months.

CONCLUSION

Scan-directed unilateral neck exploration is a safe alternative form of treatment for patients with primary hyperparathyroidism, with a cure rate similar to conventional therapy.

Fine-needle aspiration cytology of thyroid nodules--how well are we doing?

OBJECTIVES

To review the accuracy of fine-needle aspiration cytology in diagnosing non-toxic thyroid nodules and determine what factors are predictive of malignancy in patients with indeterminate cytology results.

DESIGN

Retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Patients with non-toxic thyroid nodules undergoing thyroidectomy from December 1999 to December 2003.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive value of fine-needle aspiration cytology, predictive factors for malignancy in patients with indeterminate fine-needle aspiration cytology results.

RESULTS

The sensitivity, specificity, positive predictive value, and negative predictive value of fine-needle aspiration cytology were 54%, 100%, 100%, and 75% respectively. For the 92 patients with fine-needle aspiration cytology reported as 'indeterminate for malignancy', aspiration cytology subgroup (P=0.005) and age (P=0.001) were significant risk factors for diagnosing malignancy.

CONCLUSIONS

Fine-needle aspiration cytology has high positive predictive value for thyroid cancer, enabling us to 'rule-in' malignant lesions with confidence. Among those with indeterminate fine-needle aspiration cytology, atypical cell lesions and age greater than 40 years conferred increased risk of malignancy.

Multicenter prospective randomized trial comparing standard esophagectomy with chemoradiotherapy for treatment of squamous esophageal cancer: early results from the Chinese University Research Group for Esophageal Cancer (CURE)

We conducted a prospective randomized trial to compare the efficacy and survival outcome by chemoradiation with that by esophagectomy as a curative treatment. From July 2000 to December 2004, 80 patients with potentially resectable squamous cell carcinoma of the mid or lower thoracic esophagus were randomized to esophagectomy or chemoradiotherapy. A two- or three-stage esophagectomy with two-field dissection was performed. Patients treated with chemoradiotherapy received continuous 5-fluorouracil infusion (200 mg/m2/day) from day 1 to 42 and cisplatin (60 mg/m2) on days 1 and 22. The tumor and regional lymphatics were concomitantly irradiated to a total of 50-60 Gy. Tumor response was assessed by endoscopy, endoscopic ultrasonography, and computed tomography scan. Salvage esophagectomy was performed for incomplete response or recurrence. Forty-four patients received standard esophagectomy, whereas 36 were treated with chemoradiotherapy. Median follow-up was 16.9 months. The operative mortality was 6.8%. The incidence of postoperative complications was 38.6%. No difference in the early cumulative survival was found between the two groups (RR = 0.89; 95% confidence interval, 0.37-2.17; log-rank test P = 0.45). There was no difference in the disease-free survival. Patients treated with surgery had a slightly higher proportion of recurrence in the mediastinum, whereas those treated with chemoradiation sustained a higher proportion of recurrence in the cervical or abdominal regions. Standard esophagectomy or chemoradiotherapy offered similar early clinical outcome and survival for patients with squamous cell carcinoma of the esophagus. The challenge lies in the detection of residue disease after chemoradiotherapy.

A fatal case of hepatic failure possibly induced by nitrosofenfluramine: a case report

A 42-year-old female developed fulminant hepatic failure after having ingested an undetermined quantity of a herbal product over a period of approximately four months prior to the onset of her illness. Clinically, the cause of liver failure was assessed to be drug-induced and she eventually underwent total hepatectomy, with porto-caval shunting, in anticipation of a living-unrelated liver transplant. Unfortunately, her condition deteriorated and she died less than 48 hours post-operatively, approximately three weeks post-admission. An autopsy showed that the subject was deeply jaundiced and severely obese (BMI: 47.1 kg m(-2)), with evidence of diffuse haemorrhage, including the presence of 1.35 l of blood in the peritoneal cavity. The liver had been removed and was later recovered as a formalin-fixed specimen which was markedly contracted, comprising multiple micronodules interspersed with extensive areas of dense fibrotic tissue. Histologically, there was massive necrosis of the hepatic parenchyma, such that the residual hepatocytes were disposed as nodules displaying variable cellular regeneration and ballooning degeneration, attended by florid ductal proliferation and mixed inflammatory infiltrates. Infective, autoimmune, metabolic, vascular, neoplastic and most other natural causes of massive hepatocellular necrosis were effectively excluded. Analysis of the post-mortem blood samples yielded fluconazole, metronidazole, frusemide, lignocaine and tramadol, (therapeutic agents administered to the patient during her last illness). Subsequent analysis of the residual capsules revealed that they were adulterated by fenfluramine, N-nitrosofenfluramine (1.3-1.6 mg per capsule), nicotinamide (13.3-15.6 mg per capsule) and thyroid extract. None of the herbal ingredients is currently known to be hepatotoxic and much the same applies to fenfluramine, nicotinamide (except when taken in mega-doses) and thyroid extract. However, as nitrosamines are known to be variably hepatotoxic, it would be reasonable to surmise that, in the absence of a more plausible cause of liver damage, N-nitrosofenfluramine was the likely cause of massive hepatocellular necrosis in this instance.

Malignant rhabdoid tumour of the oesophagus: a case report

Malignant extrarenal rhabdoid tumour (MERT) of the gastrointestinal tract is rarely reported in the literature. This report describes the clinical and pathological features of a malignant rhabdoid tumour of the oesophagus in a Chinese man. Ivor-Lewis oesophagectomy had been performed. The tumour behaved aggressively and the patient died from disseminated malignancy one year later. This is only the second case report of a malignant rhabdoid tumour affecting the oesophagus.

Laparoscopic repair of morgagni's hernia with percutaneous placement of suture

Simultaneous laparoscopic repair of Morgagni's hernia and laparoscopic cholecystectomy in a 59-year-old lady is described. In contrast to most previous reported series, in which repairs were fashioned with direct intracorporeal suturing, stapling, or mesh placement, an alternative technique of suture placement with a percutaneously inserted needle was applied. The procedure was smooth, and there was no evidence of recurrent hernia 9 months after the operation.

Diagnosis and current management of gastrojejunocolic fistula

Gastrojejunocolic fistula is a late complication of gastroenterostomy and is associated with inadequate gastric resection and incomplete vagotomy. In the past, attempted primary repair had high mortality and staged operations were normally performed. We present two cases of gastrojejunocolic fistula and discuss the modern management of this condition. In both cases, improved nutritional support allowed successful one-stage surgical repair to be performed.

Outpatient laparoscopic cholecystectomy in Hong Kong: patient acceptance

The authors performed a prospective evaluation of 60 Hong Kong Chinese patients with symptomatic gallstones and gallbladder polyps undergoing outpatient laparoscopic cholecystectomy in a regional hospital in Hong Kong from March 1996 to May 1998 to determine the feasibility, satisfaction, and acceptance of this procedure among Chinese patients. Patients with American Society of Anesthesiologists grade I and II gallstones or polyps were selected. Exclusion criteria included 1) history of upper abdominal operations, attacks of acute cholecystitis, cholangitis, or pancreatitis; 2) abnormal liver function; and 3) ultrasonographic evidence of contracted gallbladder, thickened gallbladder wall, dilated common bile duct, or common bile duct stones. Patients discharged at 5:00 PM on the day of cholecystectomy were defined as having undergone outpatient procedure. Patients were asked about procedure acceptance, rated on a scale of 1 to 10 (best), using a standardized questionnaire 4 weeks after operation. The study included 21 men and 39 women with mean age of 40.5 years (range, 27-59). There were no conversions to open procedures in the series. There were 6 (10%) unanticipated postoperative hospital admissions; all patients were discharged on the first postoperative day. Another patient was readmitted 3 days after operation because of a common bile duct stone. Overall patient acceptance of outpatient laparoscopic cholecystectomy was good, with a mean score of 8.6 of 10. Thirteen patients (22%) expressed dissatisfaction with being discharged earlier than they had expected, and 9 (15%) would have preferred inpatient care. Forty-eight patients (80%) resumed full daily activities by the first postoperative day; the remaining 12 did so by the end of the first week. Among the 44 working patients, only 4 (9%) resumed full duty within the first postoperative week; 29 (66%) did so by the second week and the remaining 11 (25%) returned to work after the third week. By selecting appropriate subjects, outpatient laparoscopic cholecystectomy is feasible and highly accepted among Hong Kong Chinese patients. Approximately one quarter of the patients preferred a longer postoperative stay or inpatient care.

Emergency laparoscopic orchidectomy for torsion of intra-abdominal testis: a case report

Torsion of an intraabdominal testis is a rare cause of acute abdominal pain. With a history of undescended testis, it is difficult to establish the diagnosis and to exclude other emergency abdominal conditions without a laparotomy. The following case report illustrates the usefulness of laparoscopy as a diagnostic as well as a therapeutic tool in such a condition.

Laparoscopic gastropexy for chronic gastric volvulus

Gastric volvulus is an infrequently encountered clinical entity characterized by abnormal rotation of the stomach around an axis made by its two fixed portions, the cardia and pylorus. Surgical treatment by anterior gastropexy is usually indicated for chronic gastric volvulus to prevent complications and treat the underlying pathology. We report a patient with chronic gastric volvulus who was treated with laparoscopic anterior and diaphragmatic gastropexy. Laparoscopy not only identifies underlying predisposing conditions but also allows effective fixation for gastric volvulus. Laparoscopic approach minimizes the access trauma and is superior for benign upper gastrointestinal lesions.

How useful is colonoscopy in locating colorectal lesions?

BACKGROUND

It is important to establish the precise location of a colorectal lesion preoperatively. We used a model based on colorectal cancer to assess the efficacy of colonoscopy in locating these lesions.

METHODS

We retrospectively analyzed all consecutive new colorectal cancer cases at the Department of Surgery, United Christian Hospital, Hong Kong, in 1995.

RESULTS

Of the 123 cases reviewed by us, 84 cases satisfied the analysis criteria. The overall accuracy was 81%. It was especially high in the rectosigmoid region (93%) and descending colon (100%). The overall predictive power was 83%. It was especially high in the right-sided colon (100%) and the rectosigmoid region (93%).

CONCLUSIONS

We conclude that colonoscopy is an accurate means for locating lesions in the upper rectum and sigmoid colon. It is also very predictive of lesions in the upper rectum, sigmoid colon, and right-sided colon.

Laparoscopic intracavitary drainage of subphrenic abscess

Percutaneous drainage is now the preferred initial treatment of subphrenic abscess. The result is best for simple, unilocular abscesses but less so for complex ones. Failure of drainage can lead to high morbidity and mortality. We describe a case in which a large multiloculated subphrenic abscess was successfully drained laparoscopically without contaminating the general peritoneal cavity.

Single stitch laparoscopic omental patch repair of perforated peptic ulcer

The standard treatment for perforated peptic ulcers in most institutions is omental patch repair and lavage. A laparoscopic approach is attractive because of the simplicity of the procedure. Most of the previously described laparoscopic methods required multiple working ports and multiple stitches. We employed three operating ports and applied a single stitch to close small peptic ulcer perforations. Prospective evaluations of the initial 33 cases of laparoscopic patch repair have confirmed its safety. There were five conversions, two for large perforations (> 10 mm), two for perforated gastric ulcers and the remaining one was converted because of bleeding. One patient early in the series with a 10-mm perforation suffered from radiological leakage after repair, which required secondary intervention. The mean operating time was 50 min. Patients, on average, require one dose of intramuscular pethidine (1 mg/kg body weight) for pain relief. The mean hospital stay was 6 days and 97% of them returned to their daily activities within 10 days of the operation. There was no mortality.

Laparoscopic resection of bleeding gastric polyps

Gastric polyps account for a small proportion of gastric neoplasms. Many of them presented with acute or chronic bleeding. Endoscopic polypectomy is the preferred treatment modality. However, endoscopic polypectomy is often incomplete and impossible for large polyps. Large and intramural polyps require laparotomy and excision. From June to October 1995, four patients with bleeding gastric polyps received laparoscopic resection in our unit. All were women, aged 40-78, with polyps 2-6 cm in diameter. One patient underwent emergency surgery for active bleeding. The others received elective operations. Operating time ranged from 90 to 120 min. There was no perioperative morbidity or mortality. Full diet was resumed by the 4th postoperative day. The average postoperative hospital stay was 5. 3 days (4-7). Laparoscopic resection of gastric polyp is a preferable treatment option when endoscopic treatment fails.

Epinephrine or epinephrine plus alcohol for injection of bleeding ulcers: a prospective randomized trial

BACKGROUND

Rebleeding following epinephrine injection of bleeding peptic ulcers occurs in 10% to 20% of all cases. The addition of a sclerosant has the theoretical advantage of inducing vessel thrombosis and permanent hemostasis.

METHODS

A prospective randomized controlled trial was conducted to compare injections with epinephrine alone or epinephrine plus absolute alcohol in patients with actively bleeding ulcers at endoscopy. Repeat endoscopy was performed 24 hours later; treatment was repeated in the presence of endoscopic signs of rebleeding. Surgery was performed when arterial bleeding could not be controlled endoscopically, clinical rebleeding with hematemesis or shock occurred, or the transfusion total exceeded 8 units.

RESULTS

One hundred sixty patients were enrolled (epinephrine alone, 81; epinephrine and absolute alcohol, 79). They were matched in age, sex, location of ulcers, hemoglobin on admission, shock, and severity of bleeding. Initial hemostasis was comparable: 79 of 81 with epinephrine alone (97.5%) versus 75 of 79 with epinephrine and absolute alcohol (94.9%). No difference was observed between the two with respect to either rebleeding (9 vs 6), need for emergency operation (12 vs 9), transfusion requirement (median, three units vs two units), hospital stay (median, 5 days vs 4 days), mortality (4 vs 7) and ulcer healing at 4 weeks (50 vs 46).

CONCLUSIONS

The additional injection of absolute alcohol after endoscopic epinephrine injection confers no advantage.

Gasless laparoscopic excision of bleeding gastric polyp

A case of bleeding gastric polyp in an elderly woman with compromised respiratory function was treated successfully as an emergency by the gasless laparoscopic technique after endoscopic means failed to control the bleeding. The application of laparoscopic mechanical stapling devices allows rapid gastrotomy and resection, with simultaneous hemostasis that is beneficial in acute bleeding condition. The use of gasless laparoscopy also allows continuous suction to be applied for identification of the bleeding pathology and it also reduces the risk of pneumoperitoneum in patients with poor cardiorespiratory reserve. The operative approach and technique are fully discussed.

Perforation after endoscopic injection sclerotherapy for bleeding gastric varices

Bleeding from gastric varices is an uncommon condition for which hemostatic control is difficult and ill defined. Most clinicians tend to achieve hemostasis by endoscopic treatment because of the prevailing poor general condition of these patients. A case of fundal perforation following excessive injection sclerotherapy is reported and possible mechanism discussed.

Palliation of malignant oesophageal obstruction by endoscopic alcohol injection

Thirty six-patients with inoperable cancers of the oesophagus or gastric tumour in the cardia were treated by endoscopic alcohol injection. After dilatation using Savary dilators, absolute alcohol was injected in 0.5-1 ml aliquots into protuberant parts using a sclerotherapy needle. The mean volume per session was 7.8 ml. The mean dysphagia score improved from 2.7 before treatment to 1.4 after treatment (p < 0.001). Complications included mediastinitis in one patient and tracheo-oesophageal fistulas in two patients. The mean duration of palliation before the development of recurrent dysphagia was 35 days. The mean survival was 82 days. Endoscopic alcohol injection is effective in relieving malignant dysphagia. This inexpensive and easily available technique merits comparative studies with more established forms of therapy, such as laser photocoagulation.

Adding a sclerosant to endoscopic epinephrine injection in actively bleeding ulcers: a randomized trial

We compared the efficacy of epinephrine injection and epinephrine injection followed by sodium tetradecyl sulfate in controlling active ulcer bleeding. Out of 2814 patients who underwent endoscopy for gastrointestinal bleeding, 200 patients with actively bleeding ulcers seen at the time of endoscopy were randomized to receive epinephrine injection alone (99 patients) or epinephrine injection followed by 3% sodium tetradecyl sulfate (101 patients). After the procedure the patients were transferred to the surgical gastroenterology ward and were treated by surgeons who were unaware of the mode of treatment. The patients underwent routine endoscopy 24 hours later, and epinephrine injection was repeated if active bleeding was seen again. Emergency surgery was performed for the following: (1) arterial spurting not controlled endoscopically, (2) failure of the blood pressure or pulse to stabilize after 4 units of blood, (3) total transfusion of more than 8 units of blood, or (4) rebleeding as defined by hematemesis with pulse greater than 100 beats/min or blood pressure less than 100 mm Hg after stabilization. The two groups were comparable in age, sex, site of ulcer, and severity of bleeding. Initial hemostasis was obtained at the time of endoscopy in 94% of the epinephrine group and 97% of the epinephrine plus sodium tetradecyl sulfate group. No difference in outcome was seen in the two groups as measured by emergency surgery requirement, blood transfusion, hospital stay, and hospital mortality. Endoscopic epinephrine injection is effective in controlling active ulcer bleeding. The additional injection of sodium tetradecyl sulfate confers no additional advantage.

Proximal gastric vagotomy and anterior seromyotomy with posterior truncal vagotomy assessed by the endoscopic congo red test

The completeness of vagotomy following proximal gastric vagotomy or anterior seromyotomy with posterior truncal vagotomy was assessed prospectively in 48 patients using the intraoperative congo red test. Pentagastrin (6 micrograms/kg) was given subcutaneously before the assessment. An endoscope was passed into the stomach and 180 ml congo red solution washed over the gastric mucosa. Continuing acid production was indicated by the appearance of a black colour (pH < 3) 2 min after introduction of the dye. A grading system was adopted where grades I and II showed little black discoloration and grades III and IV showed increasing areas of discoloration indicating that further denervation was required. All 20 patients undergoing anterior seromyotomy with posterior vagotomy were classified as grade I. Fifteen of an initial 23 patients receiving proximal gastric vagotomy were grade III or IV. Following division of either the right gastroepiploic nerve or the posterior vagal trunk, 22 patients improved to grade I (16) or II (six). In the subsequent five proximal vagotomies, modification of the dissection produced grade I results. Anterior seromyotomy with posterior truncal vagotomy gave consistently complete vagotomy. The congo red test highlighted major differences in the adequacy of vagotomy achieved using various dissection techniques during proximal gastric vagotomy. The test is a useful, reproducible and simple intraoperative method for assessing the completeness of denervation.

Conventional versus laparoscopic surgery for acute appendicitis

A total of 155 consecutive patients with suspected acute appendicitis were studied to compare laparoscopic and conventional operations. Patients were not randomized: laparoscopy was performed when a suitably trained surgeon and laparoscopic instruments were available. Laparoscopic appendicectomy was attempted in 51 patients and was successful in 46 (90 per cent); all conversions to open operation were because of marked inflammatory adhesions around the appendix. There were no intraoperative complications. Reintroduction of normal diet and discharge from hospital occurred earlier after laparoscopic than open surgery (P < 0.05). The requirement for analgesia after successful laparoscopic surgery was less than that after conventional appendicectomy, but the difference was not significant. The incidence of wound infection was reduced after the laparoscopic procedure (P = 0.06). It is concluded that laparoscopic appendicectomy is practical and may have advantages over conventional operation, although a randomized study is necessary.

Phytobezoar: an uncommon cause of small bowel obstruction

Phytobezoars are an unusual cause of small bowel obstruction. We report 13 patients presenting with 16 episodes of small bowel obstruction from phytobezoars. Eleven patients had previously undergone surgery for peptic ulceration (eight truncal vagotomy and pyloroplasty). A history of ingestion of persimmon fruit was common and the majority of cases presented in the autumn when this fruit is in season. One phytobezoar causing obstruction at the third part of the duodenum was removed by endoscopic fragmentation, while an episode of jejunal obstruction was precipitated by endoscopic fragmentation of a gastric bezoar. Twelve patients underwent surgery for obstruction on 15 occasions, with milking of the phytobezoar to the caecum performed in ten, enterotomy and removal in four and resection in one patient. Associated gastric phytobezoars were found in two cases and multiple small bowel bezoars in two other cases. These were removed to prevent recurrent obstruction. Phytobezoar should be considered preoperatively as a cause of obstruction in patients with previous ulcer surgery. Wherever possible milking of a phytobezoar to the caecum should be performed. Careful assessment for other phytobezoars should be made. Prevention of phytobezoars is dependent upon dietary counselling of patients by surgeons after gastric resection or vagotomy and drainage for peptic ulcer.

Mechanical lithotripsy of large common bile duct stones using a basket

Experience with the Olympus basket mechanical lithotriptor (BML-1Q) in crushing large common bile duct stones before their endoscopic removal is reported. From January 1988 to January 1990, 68 patients with common duct stones too large to be extracted by Dormia baskets or balloon catheters after sphincterotomy were treated with the BML system. The largest stones in each patient ranged from 1.0 to 4.9 cm in diameter. Fifty-seven patients required one session of lithotripsy, ten patients two sessions and one patient three sessions; 26 patients required further endoscopic extraction of stone fragments after successful lithotripsy. The stones were successfully crushed by the BML system and the ducts cleared in 55 patients (81 per cent). In 13 patients mechanical lithotripsy failed because the stones could not be engaged in the lithotriptor basket. In one patient the stone was crushed with the Soehendra lithotriptor, six patients were successfully managed by electrohydraulic lithotripsy through a 'mother and baby' endoscope, indwelling stents were inserted in four patients and two patients underwent surgery.