Preliminary study of rat liver transplantation from non‐heart‐beating donors

Objective : The aim of this study was to investigate the tolerance of warm ischaemia of liver grafts from non‐heart‐beating donors (NHBD). Livers harvested from NHBD would greatly expand the donor pool for transplantation. However, sensitivity of the donor liver to warm ischaemia is a major obstacle to the successful use of livers from NHBD and the limit of non‐heart‐beating time in the donor remains unclear. Materials and Methods : Rat orthotopic liver transplantation was performed in 5 groups (groups 1–5) with non‐heart‐beating time in the donor ranging from zero to 15, 30, 45 and 60 min. The cardiac‐arrest time was counted from clamping the base of the donor’s heart to the beginning of cold flushing the liver. Graft pathological changes, hepatic function and the recipients’ survival rates in each group were compared. Results : With a stepwise increase of the non‐heart‐beating time from zero to 15, 30, 45 and 60 min in donors, the recipient 1‐week survival rates from groups 1–5 were 100%, 75%, 62.5%, 25% and 0%, respectively. The stepwise increase of non‐heart‐beating time significantly reduced recipient survival rates after 30 min. The recipients in groups 1–4 could survive more than 60 days. Conclusions : The liver is less sensitive to warm ischaemia than was formerly believed. Rat liver can be used for transplantation after cardiac arrest for up to 45 min with a chance of survival.      

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.      

Retained intra‐aortic balloon pump catheter causing acute ischaemic limb: Report of two cases

Intra‐aortic balloon pump (IABP) catheter is used widely in the management of left heart failure. Its complications are well described; however, retained IABP catheter is an extremely rare but serious complication, which is seldom described. Fewer than 20 cases have been reported. Two cases of entrapment of IABP catheter which resulted in acute limb ischaemia requiring surgical intervention for its removal are reported. Its prevention and management are also discussed.      

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.      

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.      

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.      

Irreducible inguinal hernia: To reduce or not to reduce?

A case of irreducible inguinal hernia is reported. Successful reduction of the hernia resulted in delayed perforation of the sigmoid colon and faecal peritonitis. The question of whether one should attempt reducing an irreducible inguinal hernia is discussed.      

Clinical outcome of patients with initial diagnosis of acute self‐limiting colitis of unknown aetiology

Objective : To investigate the clinical course and outcome of patients whose initial histological features were compatible with acute self‐limiting colitis (ASLC) of unknown aetiology. Materials and Methods : We performed a computer search of our pathology registry for non‐specific inflammation of the colon and rectum for the years 1997–98. The histology reports and clinical notes were reviewed in detail. Results : Thirty‐three suitable patients were identified (17 males) with a median age of 48 years (22–87 years). The commonest presenting symptoms were rectal bleeding and diarrhoea. The passage of mucus and abdominal pain were also commonly found symptoms. Physical examination was usually normal, although abdominal tenderness was occasionally elicited. Systemic upset was unusual. Three patients had complications at presentation: severe bleeding (n = 1), intestinal obstruction (probably unrelated, n = 1), sigmoid colon cancer (probably unrelated, n = 1). Of 30 patients who were observed only, 10 patients’ symptoms resolved and 8 patients improved symptomatically, one worsened and one had not returned for reassessment. Ten subsequently needed medical treatment. Together with the other 3, a total of 13 patients received medication at some stage in their disease and 3 patients eventually required long‐term therapy. Two patients developed ulcerative colitis after 7.5 and 12 years, respectively. Conclusion : Patients with initial histological features of ASLC usually follow a self‐limiting clinical course and an initial period of observation is justified. Progression to a more protracted disease course occurs in one‐third and the diagnosis of ASLC should be revised. Salicylates and steroids are useful in refractory cases. Less than 6% progressed to chronic inflammatory bowel disease.      

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.      

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.      

Brachial plexus injury occurring during breast surgery

A case of brachial plexus injury occurring during axillary dissection as part of breast conservative surgery for breast cancer is reported. The mechanisms, diagnosis and management of such injury are discussed. Proper positioning of the patient is the key to preventing brachial plexus injury.      

Axillofemoral bypass for limb salvage

Objective : To evaluate the early and long‐term outcomes of axillofemoral bypass performed at a tertiary referral vascular centre over a 17‐year period. Methods : From 1982 to 1998, 30 patients underwent axillofemoral bypass at the University of Hong Kong Medical Centre. A retrospective analysis of all these records was undertaken. Data on demographic features and results of surgical intervention were reviewed. Early outcomes were analyzed with respect to morbidity, mortality and improvement of clinical category (according to the Reporting Standards of the Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery). Long‐term outcomes were documented with respect to graft patency, patient survival and limb loss rates. Results : Clinical success was achieved in 22 patients (73%) after operation. The postoperative morbidity and mortality rates were 30% and 20%, respectively. The primary patency of axillofemoral bypass was 62%, 51% and 45% at 1, 2 and 3 years, respectively. Limb loss rate was 23% at 3 years. The cumulative survival rate of the study population was 67%, 57% and 57% at 1, 2 and 3 years, respectively. Conclusions : Axillofemoral bypass is a valuable limb‐salvaging surgical option for revascularization of lower limbs in high‐risk patients with aorto‐iliac occlusive disease.      

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.      

Clinical experience of needle‐laparoscopic cholecystectomy

Forty‐eight cholecystectomy cases were successfully treated at Luohu hospital by needle laparoscopy. The patients were aged 22–69 years and included 36 cases of gallstones, 9 cases of gallbladder polyps, and 3 cases of gallbladder polyps with gallstones. All patients recovered and left hospital 1–3 days postoperatively (average 2.6 ± 0.6 days). There were minimal complications from the surgery and patients recovered quickly. Because the needle laparoscope is more difficult to use than the standard laparoscope, both surgeon and assistant must practise its use, first on cholecystitis cases with minor inflammation, especially in those patients whose gallbladder walls are thinner than 3 mm on ultrasound. Generally, the needle laparoscope is used for inserting titanium clips when the gallbladder is removed. The operation can best be performed by surgeons experienced in laparoscopic cholecystectomy using the standard laparoscope.      

Laparoscopic cholecystectomy in an adult with situs inversus

Situs inversus totalis is a rare anatomical entity. We present a case in a young patient with situs inversis totalis and cholelithiasis, who underwent an uncomplicated laparoscopic cholecystectomy, despite the reversed anatomical relationships. The approach used was a ‘left‐right reversal’ of the conventional four‐port technique. The patient’s postoperative recovery was uneventful.      

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.      

Impact of antenatal diagnosis on perinatal management of omphalocele and gastroschisis

Omphalocele and gastroschisis are rare congenital abnormalities that always present as challenging problems to clinicians. Antenatal diagnosis provides important information for evaluation of prognosis and planning of management of these conditions. In this article, current application of antenatal diagnosis and perinatal management of omphalocele and gastroschisis are reviewed.      

Metachronous multiple non‐anastomotic aneurysms in a bifurcated double velour knitted Dacron graft

A case of metachronous non‐anastomotic aneurysms in a bifurcated double velour knitted Dacron aorto‐bifemoral graft is reported. The cause of non‐anastomotic graft aneurysms is most likely due to a basic structural failure in the graft, as a result of defects in fabrication, Dacron fibre deterioration or a combination of both. Local excision of the graft defect with interposition graft replacement is an accepted treatment for local graft failure. However, as fabrication defects and Dacron fibre deterioration are both factors affecting the whole graft, it is not surprising to find multiple aneurysms in the same graft synchronously or metachronously. Thus, a total graft replacement should be the treatment of choice for graft failure.      

Does appendix position affect the clinical outcome of acute appendicitis?

Objective: To elucidate if the course of acute appendicitis is influenced by the variable positions of the appendix. The appendix positions were divided into two groups: (i) the anterior group, which included the anterior, the pelvic and the paracaecal positions; and (ii) the posterior group, which included the retrocaecal and retroileal positions. Method: The hospital records of 161 patients who underwent appendectomy for acute appendicitis from January 2000 to June 2001 at Prince of Wales Hospital were reviewed retrospectively. Results: Clinicians’ delay in reaching the diagnosis was longer in the posterior group (9.9 h vs 5.8 h; P=0.043). However, complicated appendicitis (gangrenous changes, perforation or abscess formation) was not associated with the appendix location (P = 0.078). The median operating time for laparoscopic appendectomies lasted longer in the posterior group (77.5 min vs 60 min; P = 0.02). These patients also had a longer hospital stay (6 days vs 4 days; P = 0.049). No difference was observed among patients who underwent open surgery. Conclusion: Appendices in the ‘hidden’ position did not translate into a higher incidence of complicated appendicitis or postoperative complications except for the slightly longer hospital stay in patients treated by laparoscopy. Therefore, we concluded that the location of appendices does not affect the clinical course of appendicitis in the locality studied.      

Diagnostic difficulties in the differentiation of pancreatic pseudocyst and cystic pancreatic neoplasm

Cystic tumours of the pancreas are rare and may be difficult to differentiate from pseudocysts, especially when the lesion is discovered after abdominal trauma. The case of a 48‐year‐old woman who developed a cystic lesion of the pancreas 4 months after blunt abdominal trauma is reported. Whilst the lesion had diagnostic features consistent with pseudocyst, the final diagnosis of benign mucinous cystadenoma was established only after radical resection 27 months later. The possible role of trauma in its aetiology is discussed.