Review of experience over four decades in the management of carotid body tumours

Objective: To review the experience of the management of carotid body tumours in a major vascular centre in mainland China. Patients and methods: This was a retrospective review of 52 cases of carotid body tumour. There were 24 male and 28 female patients with an age range of 18–67 years; and 23 right‐sided, 24 left‐sided and five bilateral lesions. The modality of preoperative imaging was as follows: duplex scan and computed tomography in 40 cases, magnetic resonance imaging in 10 cases, carotid artery angiogram in 32 cases with selective embolization of the feeding vessel in 19. Operative treatment was carried out for 55 lesions and was summarized as follows: simple tumour excision for 44 lesions and en bloc tumour excision together with carotid bifurcation for 11 lesions; ICA reconstruction with interposition graft in three cases; and external to ICA anastomosis in two cases. Results: There were no operative mortalities. Postoperative complications included two ischaemic strokes, one case of vagus nerve damage and one case of hypoglossal nerve damage. Conclusion: Carotid body tumour is a rare neoplasm. Its special anatomical position imposes great difficulty during surgery. Adequate preoperative preparation and embolization of feeding arteries could reduce operative blood loss, improve tumour excision and preserve the ICA flow.      

Paediatric brain tumour,a 10‐year local experience (1992–2001)

Objective: To report our local experience on incidence and outcomes of different paediatric brain tumour. Methods: A detailed data search was carried out from our operative records and histopathology database. A total of 48 paediatric patients bearing 49 brain tumours (one patient had two tumours) within the period between 1992 and 2001 was retrieved. The discharge summary, out‐patient follow‐up record was examined for each patient. The data was grouped according to different pathology type. Results: The results were mainly concentrating over several selected pathologies: (i) low‐grade glioma; (ii) high‐grade glioma; (iii) germ cell tumour; (iv) medulloblastoma; and (v) craniopharyngioma. Conclusions: The most prevalent pathology in our experience is low‐grade astrocytoma, followed by germ cell cell tumour and medulloblatoma. The highest mortality rate is high‐grade glioma.      

Surgical treatment of thyrotoxicosis: a local institution's perspective

Objective: The most optimal form of thyroidectomy for thyrotoxicosis is controversial. Geographical factor, possibly due to the difference in iodine intake, can profoundly influence the therapy outcomes. The results of different forms of thyroidectomy in a local hospital for thyrotoxicosis is presented. Their pros and cons were evaluated. Methods: From January 1995 to December 2001, 69 patients with toxic goitres treated surgically were retrospectively studied. The factors potentially affecting the postoperative thyroid function were also analysed. Results: The mean follow‐up duration was 22.6 ± 17.2 months. The incidence of permanent vocal cord palsy and hypoparathyroidism were 0 and 2.9%, respectively. Remission, hypothyroidism, and recurrent hyperthyroidism occurred in 39, 52.5 and 8.5% respectively, of patients who have undergone either subtotal thyrodiectomy or Dunhill procedure (hemithyroidectomy plus contralateral subtotal lobectomy). Only the size of the remnant was found to be a significant factor of postoperative hypothyroidism (P = 0.048). Conclusion: Subtotal thyroidectomy or Dunhill procedure are efficacious in treating thyrotoxicosis with acceptable incidence of operative complications and recurrent hyperthyroidism. A significant portion of patients were rendered euthyroid without the need of thyroxine replacement.      

Pseudomyxoma peritonei: Role of cytoreduction and intraperitoneal chemotherapy

In the past, pseudomyxoma peritonei was considered as an incurable disease and often no active treatment was given. With the advent of cytoreductive surgery, including peritonectomy procedures and intraperitoneal chemotherapy, long‐term survival of these patients is actually possible. A 61‐year‐old patient with adenocarcinoma of the appendix who presented with a clinical picture of pseudomyxoma peritonei is described in the present report. The patient achieved independent activity of daily living and improved quality of life after aggressive surgical approach and intraperitoneal chemotherapy.      

Laparoscopic cholecystectomy in haemodialysis patients

Objective : To study the effect and safety of laparoscopic cholecystectomy in haemodialysis patients. Method : From May 1994 to December 1998, the clinical progress of nine haemodialysis patients who underwent laparoscopic cholecystectomy were reviewed. Results : Eight patients recovered very well from surgery, while one patient had a mild complication of a collection of seroma represented by ultrasound in the gallbladder region. Conclusions : Perioperative management is important when performing laparoscopic cholecystectomy in patients on haemodialysis. Those patients on well‐managed haemodialysis will tolerate laparoscopic cholecystectomy.      

Adoption of laparoscopic technique for radical prostatectomy in a district hospital in Hong Kong

Objective: To investigate the feasibility of adopting laparoscopic radical prostatectomy in treating organ‐confined adenocarcinoma of the prostate in a low volume urology centre. Methodology: We applied the technique to 21 patients with early prostate cancer from March 2002 to July 2003. Modifications of the technique were described. Methods to shorten the learning time were discussed. Results: Operative time and blood loss improved after the first 10 cases and were averaged at 260 min and 650 mL, respectively, in the last 10 cases. Two patients required re‐operation for complications. A total of 14.7% of specimens showed positive surgical margin. Only one of the 15 patients needed to wear a pad for incontinence. Two of the eight patients regained the ability to have an erection after attempts of nerve sparing. A longer follow‐up was required for the evaluation of oncological control. Conclusion: Adoption of the technique was feasible for an Asian centre with a caseload of approximately 20 cases per year.      

Free air or colon?

Background: Subphrenic abscess can present with respiratory symptoms with minimal or no abdominal signs. The air/fluid level seen on chest X‐ray can be misinterpreted as that within a loop of intestine (Chilaiditi's sign) thus leading to delayed diagnosis. Methods: Case report. Results: An 83‐year‐old female presented with respiratory symptoms. Chest X‐ray showed an air/fluid level under the right hemi‐diaphragm. This was initially interpreted as Chilaiditi's sign. The subphrenic abscess was confirmed by a computed tomography scan. At laparotomy, the abscess was communicating with a perforation in the fundus of the gall bladder. In addition, there was a fistula connecting the neck of the gall bladder and the second part of the duodenum. The abscess was drained and the fistula tract disconnected. Post‐operatively the patient had an uneventful recovery. Conclusion: Patients with subphrenic abscess can present with symptoms mimicking a respiratory infection. The air/fluid level seen on chest X‐ray can be misinterpreted as Chilaiditi's sign. Most subphrenic abscesses occur secondarily to an underlying pathology within the gastrointestinal tract. A thorough search for an underlying intra‐abdominal pathology must be made.      

Heart valve surgery in the modern era: Towards zero operative mortality in the developing area

Objective: Despite modern technology, heart valve replacement still carries significant operative mortality, ranging from 2 to 10% in most cardiac centres. Methodology: From December 1999 to January 2003, more than 150 heart valve operations on mitral valve (MV)/aortic valve (AV) or double valve replacement (DVR) were performed at the cooperative heart institutes with no operative mortality (defined as either in‐hospital or postoperative 30‐day death). The present study analyses the data of the 109 patients among this group who were operated on by a single surgeon (the author). Results: There were 49 male and 60 female patients with an average age of 41.6 ± 1.2 years old (range: 7–69 years). All patients had a certain degree of heart failure and most had cardiothoracic ratio increased, with the largest being 99%. The operations performed were: MV replacement (41); AV replacement (21; five patients had concomitant repair of rupture of the aneurysm of sinus of Valsalva); double valve replacement/intervention (46); MV repair ± annuloplasty ring (3); concomitant coronary artery bypass grafting (5) and tricuspid valve annuloplasty (2). There were no operative deaths. The prostheses used were: St. Jude (86); Sorin (10); Monostrut (24) and China Langzhou (29). One patient died of bleeding and infectious complications 5 months after the operation. Conclusions: We conclude that in the modern era, valve replacement can have superior results even in a developing area. The commonly used prostheses have similar results. Particular attention should be paid to proper preoperative preparation, operative details, and postoperative care.      

Creation of a subcutaneous tunnel in antesternal oesophageal replacement with the aid of a rigid sigmoidoscope

A technique to create a subcutaneous tunnel in antesternal oesophageal replacement using a rigid sigmoidoscope is reported.      

Single centre experience of chronic rejection in liver transplantation

Objective : To review the Australian National Liver Transplantation Unit’s (ANLTU) experience with chronic rejection (CR) in liver transplantation (LTx) in order to establish a better management strategy. Materials and Methods : Clinical records and prospective data on the ANLTU database were reviewed. Statistical analysis was performed on microcomputer. Results : Between January 1986 and June 1997, 17 patients (6.4%) (9 male, 8 female) were diagnosed with CR at a median 0.83 years (0.21–6.33 years) after LTx. Prior to the diagnosis of CR, all had a background of increasingly cholestatic liver function tests. The total number of prior acute rejection episodes was 42 (mean 2.5, range 1–5) with 18 episodes (42%) being steroid resistant. Other co-morbid factors included: cytomegalovirus infection 10 (58%); low levels of immunosuppression 7 (41%); and biliary complications 6 (35%). Mortality was high at 14 (82%). Conclusions : The outcome is poor in adults with CR, with or without re-Tx. Efforts should be made to avoid septic complications that require lowering the dosage of immunosuppression. Early diagnosis and prompt treatment of acute rejection are recommended. In cases of early CR, conversion to FK506 regimen is worthwhile.      

Upper mini-sternotomy for aortic valve operations

Objective : To review our experience in using an upper mini-sternotomy approach to aortic valve surgery. Materials and methods : Nineteen consecutive non-selected patients (15 males, mean age 66 years) underwent isolated aortic valve replacement using an upper mini-sternotomy approach. Twelve patients had isolated aortic valve stenosis, four patients had isolated aortic valve incompetence and three patients had mixed aortic valve disease. Results : In all cases, an excellent view of the aortic valve was obtained, aortic valve replacement was performed and no intra-operative difficulties were encountered. Mean aortic cross-clamp time was 83 min and mean cardiopulmonary bypass perfusion time was 97 min. All patients except two were extubated in the operating theatre and there were no major postoperative complications. Mean hospital stay was 4 days. There were no late complications. Conclusions : Aortic valve surgery can be performed, in the conventional manner and using standard surgical instruments, through an upper mini-sternotomy with no alteration to cardiopulmonary bypass or myocardial protection routines.      

Laparoscopic appendectomy in young female patients: Should we remove the normal-looking appendix?

Objective : This study evaluated whether a significant reduction in unnecessary appendectomies is possible by performing diagnostic laparoscopy before appendectomy in female patients of child-bearing age, leaving behind the normal-looking appendix. Materials and methods : Sixty-one consecutive female patients between the ages of 15 and 45 years with clinical diagnosis of acute appendicitis were studied prospectively. Diagnostic laparoscopy was performed to detect whether the appendix was inflamed. The appendix was then removed and the result of laparoscopic diagnosis was matched with histological diagnosis. Results : Ten out of the 42 laparoscopically diagnosed appendicitis cases had normal appendices on histological examination. Six out of the 19 laparoscopically diagnosed normal appendices had histological evidence of appendicitis. The sensitivity of laparoscopy was 84% and the specificity was 56.5%. Conclusions : Discrepancies existed between laparoscopic appearance and histological examination in acute appendicitis. The appendices of all those with clinically suspected appendicitis should be removed and sent for histological confirmation.      

Laparoscopic urology development in Hong Kong

Objectives: The application of laparoscopy in urology is increasing in Hong Kong. In the present paper the development of laparoscopic urology in Hong Kong is portrayed. The variety of laparoscopic urological operation that have been developed is defined, as well as interesting features associated with its development. Methods: A search on presentation/publications on laparoscopic urological topics by local authors were carried out on the electronic database supplemented by a manual hand search from January 1991 to November 2002. Results: A total of 68 presentations were identified covering a variety of urological topics including some of the most complex reconstructive procedures. The first report was in 1994. The three most presented topics were on paediatric urology, adrenalectomy and nephrectomy. Up to 45% of the reports were contributed by or collaborated with another specialty. Conclusions: Laparoscopic urology had a good foundation and able to keep pace with the world development. Cross specialty collaboration and interaction is an important feature in its development.      

Choriocarcinoma: An unusual cause of gangrene of the bowel

Secondary involvement of the small intestine by choriocarcinoma is uncommon. Such cases usually present as a polyp or necrotic mass within the wall of the bowel. The clinical manifestations include abdominal pain and/or haematemesis. In this report, we present a rare case of gangrene of the small bowel caused by choriocarcinomatous embolization of mesenteric vessels.      

Annual Scientific Meeting of The College of Surgeons of Hong Kong: A 5‐year audit

Objective : To examine the quality of surgical research in Hong Kong by auditing the results of abstracts submitted for annual scientific meetings held by The College of Surgeons of Hong Kong. Materials and Methods : From 1993 to 1998, all abstracts submitted for the meetings were evaluated and classified according to the hierarchy of evidence. The institutions of the presenting authors were recorded. Ovid MEDLINE search was then conducted to determine whether the abstracts were subsequently published in an indexed medical journal. Results : In total, 165 abstracts were submitted for the meeting in a 5‐year period. Randomized controlled trials constituted 12% of this research. Participation from community surgeons showed an encouraging trend from 17% in 1993 to 63% in 1998. In the first 4 years, 38% of abstracts were of publishable quality. More than half of the prospective randomized controlled trials were selected for presentation and subsequently published. Those abstracts selected for presentation have a higher chance of being published subsequently (P < 0.03). Conclusions : The randomized controlled trial remains a powerful research tool but is scarce in Hong Kong surgical research.      

Intracerebral haematoma: Operative versus non‐operative

Background: Spontaneous supratentorial intracerebral haemorrhage (ICH) accounts for 10–30% of all strokes resulting in a high mortality and major morbidity. Although guidelines for medical treatment and surgical intervention for ICH are available, selection of patients for surgery in this group of patients is controversial and varies greatly throughout the world. Objective: In the current study, we aimed to review our selection criteria for treatment and their management results. Methods: We had prospectively collected the data of patients admitted to our centre with spontaneous supratentorial ICH in a 2‐year period (January 2001–December 2002). We divided the patients into three main groups according to the anatomical site: putaminal, subcortical and deep basal ganglia. Surgical treatment was limited to patients aged below 65 years, with a clot size between 30 and 100 mL, and motor scores of normal flexion to localizing to pain. Results: One hundred and twenty‐four patients were recruited in the current study. Thirty‐four patients managed by early surgery had an 18% mortality, 29% were independent and 53% dependent at 6 months. Early surgery for subcortical haematoma carried the best prognosis (42% achieved independence), whereas deep basal ganglia haematoma carried the worst prognosis (none achieved independence). Conclusions: Although this prospective audit was not intended to be a case–control study, data from the present study support early surgery for patients with putaminal and subcortical haematomas with a clot size larger than 50 mL. For smaller haematomas less than 30 mL, conservative management is associated with a superior clinical outcome.      

Evaluation of Hyphecan (1‐4,2‐acetamide‐deoxy‐B‐D‐glucan polymer) on wound healing in a rodent model

Objective: To evaluate the effect of an artificial skin Hyphecan (1‐4,2‐acetamide‐deoxy‐B ‐D ‐glucan polymer) on wound healing in a rodent model. Materials and Method: The prospective study was conducted at a basic science laboratory at a tertiary teaching hospital. Two 4 cm × 4 cm full‐thickness wounds were created on the dorsal surface of 10 Spraque–Dawley rats and covered with Hyphecan and Kaltostat, respectively. Wounds were examined and measured on days 4, 10, 21 and 28, and would continue after day 28 until healed up completely. Punch biopsies (3 mm) were taken on days 4, 10 and 28 for histological examination of the response of healing and repair. Results: Despite the fact that the wound healing rate was similar for both groups on days 4, 10, 21 and 28, the average healing time for the Hyphecan group (29.1 ± 1.7 days) was significantly shorter statistically (P = 0.03) than the Kaltostat group (30.7 ± 2.8 days). Conversely, the marked healing response elicited by Hyphecan on day 4 persisted on days 10 and 28 in contrast to Kaltostat, which had only a mild degree of healing response on days 10 and 28. The study suggests that wounds treated by Hyphecan heal faster than Kaltostat. Conclusion: The findings provide basic scientific evidence supporting the clinical use of Hyphecan in different wounds and might also reduce the cost of wound management as Hyphecan is cheaper than Kaltostat and requires a shorter treatment time.      

Impact of programmed second endoscopy with appropriate re‐treatment on peptic ulcer re‐bleeding: A systematic review

Objectives: The aim of the present systematic review is to critically appraise the current evidence from published medical trials on the role of programmed second endoscopy with appropriate therapy on peptic ulcer re‐bleeding. Methods: A systematic review of five prospective randomized controlled trials comparing the effect of programmed second endoscopy against conservative management on peptic ulcer re‐bleeding was carried out. Results: From the meta‐analysis of the combined results from the five trials on the effect of programmed second endoscopy in ulcer bleeding, we found that a programmed second endoscopy with appropriate therapy reduced the number of recurrent bleeding significantly (Peto odds ratio = 1.97, Mantel Haenszel‐Peto P < 0.01). The number of patients needed for treatment with a programmed second endoscopy in order to prevent one recurrent bleeding ranged from four to 11. Conclusion: Programmed second endoscopy with appropriate therapy reduced the number of recurrent bleeding significantly in patients with bleeding peptic ulcers. Individual trials also showed a possible benefit in reduction of the number of surgical interventions.      

Water soluble contrast follow‐through in the management of adhesive small bowel obstruction: A prospective randomized trial

Objective: Postoperative adhesive intestinal obstruction is the most common cause of small bowel obstructions in adults. The use of water‐soluble contrast follow‐through has been shown to be safe with a high predictive value for surgery. This study aims to evaluate the impact of contrast follow‐through on clinical outcomes of patients with adhesive small bowel obstructions. Methods: From July 1994 to June 1998, 150 patients were recruited into the study and randomized into two groups. One group (n = 75) received water‐soluble contrast follow‐through within 24 h of admission, whereas the control group (n = 75) did not. Both groups were put on conservative management and the outcomes measured included operative rate, postoperative morbidities, length of hospital stay and mortality. Results: The operative rate of both groups was similar (33.3 vs 38.7%, P = 0.496). The preoperative observation period (42 vs 65 h. P = 0.014) and the total median hospital stay (5 vs 7 days, P = 0.025) of the contrast group were significantly shorter than those of the control group. No significant difference could be found between the two groups in terms of postoperative morbidities and mortalities. Conclusions: In managing patients suspected to have adhesive small bowel obstruction, water‐soluble contrast follow‐through expedites the decision process for surgical intervention, which translates into a shorter hospital stay.      

Thromboprophylaxis in laparoscopic abdominal surgery

Background: Since the introduction of laparoscopic cholecystectomy, there has been a great concern regarding the increased risk of thromboembolism following laparoscopic surgery. However, in the absence of clear guidelines, the use of thromboprophylaxis in laparoscopic abdominal surgery is controversial. Methods: The evidence for and against routine and selective thromboprophylaxis in patients undergoing laparoscopic abdominal procedures was reviewed based mainly on published British and Danish surveys, together with the author's own survey. An attempt was made to come up with a generally‐accepted protocol for thromboprophylaxis in laparoscopic surgery. Results: Less thromboembolic events were encountered by laparoscopic surgeons who adopt routine thromboprophylaxis. More thromboembolic events following laparoscopic abdominal surgery were encountered by surgeons adopting selective thromboprophylaxis policy. Conclusion: Routine thromboprophylaxis seems to be more effective in protection against thromboembolism. However, this warrants further confirmation by prospective randomized trials.