Crohn's disease in the Chinese population. An experience from Hong Kong

PURPOSE

Crohn's disease was extremely rare among Chinese. We reviewed all cases diagnosed as having Crohn's disease during a five-year period.

METHODS

A diagnosis of Crohn's disease was made only if all of the following criteria were fulfilled: 1) clinical symptom(s) and sign(s) compatible with chronic inflammatory bowel disease; 2) exclusion of intestinal infection by repeated stool cultures; 3) macroscopic features of small and/or large intestinal inflammation with skip lesion, stricture, and fistula formation; 4) histologic features of Crohn's disease, i.e., focal lymphoid aggregate, focal cryptitis, and granuloma formation; 5) clinical response to conventional therapy for inflammatory bowel disease.

RESULTS

Fifteen ethnic Chinese patients were diagnosed as having Crohn's disease in this period. All patients had colitis, whereas small intestine inflammation was documented in only 47 percent of patients. Extraintestinal manifestations were uncommon except for arthropathy: ankylosing spondylitis (2), sacroiliitis (1), juvenile rheumatoid arthritis (1), and colitic arthritis (1). The majority of our patients responded to medical therapy. Surgery was undertaken in 33 percent of patients.

CONCLUSION

Although there is a general increased incidence of Crohn's disease in the Western world, we too are beginning to see more cases in the Far East. Nevertheless, gastrointestinal infection with bacteria and/or parasites should still be carefully excluded in these countries.

Early results of laparoscopic intraperitoneal onlay mesh repair for inguinal hernia

Over a 15-month period, 39 patients (37 men) of mean age 52 years underwent laparoscopic inguinal hernia repair. Seven patients had bilateral hernia. Forty-six hernias (33 indirect, five direct, eight both direct and indirect) were repaired. A piece of polypropylene mesh measuring 8 x 10 cm was used to cover the direct and indirect spaces with an endoscopic multifeed hernia stapler. The mean operating time for unilateral and bilateral repair was 49 and 63 min respectively (range 25-90 min). One-third of patients required no postoperative analgesia and only seven had more than one injection of pethidine. The median postoperative stay was 1 (range 1-3) days. The mean period to resumption of daily activities was 7 (range 4-21) days. Three patients complained of paraesthesia of the lateral aspect of the thigh and one developed a hydrocele. Two recurrences were noted on follow-up at 3 months.

Two-team synchronous oesophagectomy

Between 1984 and 1992, 131 patients underwent two-team synchronous oesophagectomy for carcinoma. Some 95 per cent of tumours were successfully resected by this technique. In 5 per cent of patients the tumour was found to be irresectable at operation and gastric bypass was performed. The overall operative mortality rate was 8 per cent and the pulmonary complication rate 10 per cent. The actuarial survival rate was 55 per cent at 1 year, 22 per cent at 3 years and 16 per cent at 5 years. When compared with the traditional two-stage Lewis approach, two-team synchronous oesophagectomy was significantly faster (mean 222 versus 282 min), but was not significantly different with respect to blood loss, transfusion requirement, pulmonary complications or operative mortality rate. Patients undergoing two-team oesophagectomy had a significantly shorter hospital stay than those receiving the two-stage procedure (mean 16 versus 24 days).

Treatment of inoperable hepatocellular carcinoma with intrahepatic arterial yttrium-90 microspheres: a phase I and II study

Eighteen patients with inoperable hepatocellular carcinoma (HCC) were treated with intrahepatic arterial yttrium-90 microspheres. All these patients showed a lung shunting below 15% and a tumour-to-normal ratio higher than 2 as determined by diagnostic technetium-99m macroaggregated albumin (Tc-MAA) gamma scintigraphy. The treatment was given through an arterial port placed during laparotomy. The radiation doses to the liver and tumour were determined intraoperatively with a beta probe and liquid scintillation counting of multiple liver biopsies. The treatment was well tolerated without major complications. In all patients the tumour marker fell to a level which ranged from 41% to 0.2% of the pretreatment level. Tumour regression was found to be dose related. Progressive or static disease occurred in a higher proportion of patients whose tumours received < 120 Gy (P = 0.005). Survival was better in those whose tumours received > 120 Gy (median survival = 55.9 weeks) than those whose tumours received lower doses (median survival = 26.2 weeks). This difference is statistically significant with P = 0.005. We conclude that yttrium-90 microsphere therapy is safe and that tumour response is dose related. A tumour dose of > 120 Gy is recommended.

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.

Anti-proliferative activity of interferon-alpha on human squamous carcinoma of tongue cell lines

We evaluated the anti-tumour activity of human recombinant interferon-alpha (IFN-alpha) on two human squamous carcinoma of tongue cell lines (T2/CUHK and PWH-S1). The in vitro cytotoxicity was monitored by MTT assay. Continuous exposure to IFN-alpha alone at 500 IU/ml for 48 h produced inhibitory growth of 30% and 7% on T2/CUHK and PWH-S1 cell lines respectively. The ID50 of T2/CUHK cells was approximately 2500 IU/ml. PWH-S1 cells were resistant to treatment with interferon-alpha as 500 IU/ml IFN-alpha gave only 10% growth inhibition on PWH-S1 cells. IFN-alpha increased the anti-neoplastic activity of cisplatin and 5-FU against T2/CUHK cells, but the effect was less evident in PWH-S1 cells. Our findings support the further evaluation of IFN-alpha as a potent anti-proliferative cytokine therapy that may act synergistically with conventional chemotherapeutic agents for the treatment of squamous carcinoma of head and neck.

Laparoscopic rectopexy

Good results of rectopexy for complete rectal prolapse have been achieved using the transabdominal approach. With the introduction of the laparoscopic technique in cholecystectomy, many other abdominal procedures have been tried with the laparoscopic technique with varying degrees of success. The laparoscopic technique has opened up a new possibility of a minimally invasive approach to rectopexy. With the elimination of a major incision in laparoscopic rectopexy, the patients may benefit from less morbidity associated with a major abdominal wound. In this case report, laparoscopic rectal mobilization and rectopexy using Marlex mesh and a hernia stapler is reported.

A prospective randomized trial comparing R1 subtotal gastrectomy with R3 total gastrectomy for antral cancer

OBJECTIVE

The authors determined if more radical surgery with extended lymphadenectomy improves the results of gastrectomy in patients with adenocarcinoma of the gastric antrum.

SUMMARY BACKGROUND DATA

The overall survival in patients with gastric cancer is disappointing. Improved survival has been reported by Japanese authors. Whether this is because of a higher number of early gastric cancers in the Japanese series, different biologic behavior in Asians, or the adoption of radical surgery with lymphadenectomy remains unclear.

METHODS

R1 subtotal gastrectomy with omentectomy and R3 total gastrectomy (omentectomy, splenectomy, distal pancreatectomy, lymphatic clearance of the celiac axis, and skeletonization of vessels in the porta hepatis) were evaluated in a prospective, randomized comparison.

RESULTS

Fifty-five patients were randomized--25 to the R1 group and 30 to the R3 group. The two groups were comparable for age, sex, tumor size, TNM stage, and length of follow-up. The R3 group had a longer operating time (140 vs. 260 min; p < 0.05), a greater transfusion requirement (0 vs. 2 units, p < 0.05) and a longer hospital stay (8 vs. 16 days; p < 0.05) (medians; Mann-Whitney U test). The only postoperative death was in the R3 group and was caused by intra-abdominal sepsis. Fourteen patients in the R3 group developed left subphrenic abscesses. There were no major complications in the R1 group. Overall survival was significantly better in the R1 group (median survival estimated by Kaplan-Meier method, 1511 vs. 922 days, p < 0.05, log-rank test).

CONCLUSIONS

R3 total gastrectomy can be performed with a low mortality, but it has a high morbidity because of intra-abdominal sepsis. The data do not support the routine use of R3 total gastrectomy for treatment of patients with antral cancer.

Selective internal radiation therapy with intra-arterial iodine-131-Lipiodol in inoperable hepatocellular carcinoma

From August 1990 to June 1993, 26 patients with inoperable hepatocellular carcinoma were treated with intra-arterial iodine-131-Lipiodol (131I-L).

METHODS

Iodine-131-Lipiodol was given through either an implantable arterial port (9 patients) or during hepatic angiography (17 patients). All 26 patients had multiple lesions, 3 had involved resection margin after surgical resection and 1 had diffuse infiltrative lesions. The median size of the largest tumor among 22 patients with a measurable lesion was 4.5 cm (2-9.5 cm). The end points are tumor response in terms of tumor size, change in serum alpha-fetoprotein level, toxicity of treatment and overall survival.

RESULTS

Twenty-three patients received a single treatment of 1.11-2.22 GBq (30-60 mCi)131I-L. Three patients received 2.22-4.44 GBq (60-120 mCi)131I-L in three fractions. Considering both radiological regression and reduction in serum alpha-fetoprotein level as objective response criteria, the overall response rate was 52% (13 out of 25 patients with evaluable disease). Ten out of 15 patients who had raised alpha-fetoprotein levels had more than 50% reduction and 8 patients had more than 90% reduction in alpha-fetoprotein level. Since analysis, 19 patients have died and 7 remain alive, giving a minimum median survival of 6 mo (range 1.2-16.6 mo), with 4 surviving more than 1 yr calculated from the day of treatment. There was only one patient who had late deterioration of liver function compatible with radiation hepatitis. There was no bone marrow toxicity documented in any patients.

CONCLUSION

Treatment with intra-arterial 131I-L was well tolerated in patients with inoperable hepatocellular carcinoma and produced an objective response of 52% with median survival of 6 mo. A fractionated dose of 131I-L was feasible and the radiation dose could be escalated safely.

Preoperative ultrasound to predict technical difficulties and complications of laparoscopic cholecystectomy

Thirty-five patients with symptomatic gallbladder disease were prospectively evaluated by ultrasound the day before laparoscopic cholecystectomy. Diminished gallbladder function and wall thickening were significantly associated with increased technical difficulty of the operation (Student's t-test, P < 0.001). There was no association between gallbladder volume or number of calculi and operative difficulty. Dilated common bile ducts were detected by ultrasound in five patients (14%) and bile duct calculi in two patients (6%). Ultrasound findings can be used as predictors of potential operative difficulties when selecting patients for laparoscopic cholecystectomy. Ultrasound should be used as an initial screening investigation to detect common bile duct dilatation and calculi.

Cytoreductive surgery for hepatocellular carcinoma

A prospective study was conducted on 26 patients for cytoreductive surgery of inoperable hepatocellular carcinoma. These patients underwent cytoreduction with liver resection, cryosurgery, microwave tissue coagulation and/or absolute alcohol injection. In-hospital mortality was 7.7%. The symptomatic relief and quality of survival were excellent. The median survival of patients after cytoreduction was 10.0 months and the survival was much better than those of 26 patients matched by sex, age, tumour size, Child-Pugh grading and Karnofsky scores who received systemic chemotherapy during the same period of the study (log rank test, P = 0.0001). There was no statistical difference between the survival curves of those patients who received (19 patients) and those who did not receive (7 patients) additional treatment by chemotherapy or selective internal radiation therapy after cytoreduction. This suggests that the gained survival benefit could have been derived mainly from the cytoreductive surgery rather than the additional treatments.

Laparoscopic removal of inflamed or bulky tissue: preservation of the pneumoperitoneum

A technique is described for extraction of bulky tissue during laparoscopic surgery using a dedicated non-disposable instrument specifically designed for the purpose. The technique was used on seven patients with acute cholecystitis, three patients with big gallstones in elective cholecystectomy and two patients with acute appendicitis. The procedure took about 1 min in all patients. No patient suffered from complications related to the procedure.

Laparoscopic cholecystectomy for biliary pancreatitis

A prospective study was undertaken to assess the technical difficulty of early laparoscopic cholecystectomy for acute biliary pancreatitis. Patients underwent early endoscopic retrograde cholangiography (ERC) and laparoscopic cholecystectomy was performed after signs of clinical improvement. Five steps were assessed during surgery using a visual analogue score. These patients were compared with a control group undergoing elective surgery for chronic symptomatic gallstones. Of 24 patients aged 28-83 (median 60) years, eight had three or more positive signs according to Ranson's criteria. Twenty-three patients underwent successful ERC; seven had choledocholithiasis and were managed endoscopically. Laparoscopic cholecystectomy performed 3-24 (median 7) days after admission was successful in 21 of the 24 patients. The mean(s.d.) operative difficulty score was significantly increased in patients with acute biliary pancreatitis compared with that in the 40 controls (5.4(1.8) versus 3.6(1.4), P < 0.002), particularly for dissection of Calot's triangle (6.5(1.5) versus 3.0(1.6), P < 0.001). A dilated cystic duct was present in over 50 per cent of patients and in seven could not be safely closed with a clip; this finding was not predicted by ERC. Biliary pancreatitis is a further indication for laparoscopic cholecystectomy. Early surgery is safe but technical difficulty is increased. Cystic duct dilatation must be anticipated; an externally tied ligature in continuity is recommended.

Omitting side-holes in biliary stents does not improve drainage of the obstructed biliary system: a prospective randomized trial

Sludge, which occludes biliary stents, forms mainly around the side-holes of such stents. It has been reported that omitting the side-holes results in less sludge formation and theoretically improves drainage. To compare the clinical efficacy of biliary stents with and without side-holes, we randomized patients with malignant or benign strictures to receive 10FG polyethylene stents either with side-holes (SH) or without side-holes (NSH). The patients were seen at 4, 12, 20, and 28 weeks after stenting for symptom evaluation and serum liver enzyme and bilirubin assays. The stents were replaced only when clinical symptoms of cholangitis developed. Each group included 35 patients. The mean age of patients in the SH group was 68 years, and the ratio of men to women was 1:1.3. In the NSH group, the mean age of patients was 67 years, and the ratio of men to women was 1:1.4. Eight patients with SH stents and eight with NSH stents died before the stents were removed; two NSH stents migrated into the duodenum. During a mean follow-up period of 8.1 weeks (range, 1.1 to 28 weeks for the SH group and 0.6 to 28 weeks for the NSH group), 18 stents were found to be occluded in the SH group and 17 in the NSH group. The median time before total occlusion was 7.8 weeks (range, 2.6 to 28) for SH stents and 7.9 weeks (range, 0.6 to 28) for NSH stents (p > 0.1, NS). The occluded stents removed from these patients were freeze-dried and weighed to quantitate the sludge blocking the stent lumen.(ABSTRACT TRUNCATED AT 250 WORDS)

Transhepatic fenestration of liver cyst: a further application of laparoscopic surgery

Surgery is indicated for the treatment of highly symptomatic liver cysts in adult polycystic liver disease. Several options are available, including liver resection, but surgical morbidity in a benign condition may be unacceptable. The authors report the transhepatic fenestration of a liver cyst under laparoscopic guidance in a 47 year old Chinese male. There was an excellent clinical outcome and minimal morbidity. Laparoscopic treatment is both effective and minimally traumatic, which is appropriate for a condition that will inevitably progress.

Hepatitis B virus DNA in peripheral blood leukocytes. A comparison between hepatocellular carcinoma and other hepatitis B virus-related chronic liver diseases

BACKGROUND

Hepatitis B virus (HBV) DNA has been detected in the peripheral blood leukocytes (PBL) during acute and chronic HBV infection. Possible pathobiologic significance includes infectivity and altered immunity. There are few data relating PBL HBV-DNA with severity of the liver disease, in particular with hepatocellular carcinoma (HCC).

METHODS

HBV-DNA was detected by dot-spot hybridization technique in PBL separated from venous blood samples of 209 hepatitis B surface antigen-positive patients (28 healthy carriers and 95 chronic hepatitis, 29 cirrhotic, and 57 HCC patients). Serum HBV-DNA and hepatitis B e-antigen (HBeAg) were also measured.

RESULTS

Thirty percent of HCC patients were hepatitis e-antigen-positive compared to 50%, 84% (P < 0.0001), and 69% (P < 0.00001) of healthy carriers and chronic hepatitis and cirrhotic patients, respectively. Furthermore, only 11% of HCC patients had detectable serum HBV-DNA compared to 39% (P < 0.001), 58% (P < 0.001), and 31% (P < 0.05) of these respective patient groups. despite low viral replication among HCC patients, 58% had PBL HBV-DNA. Corresponding figures for healthy carriers and for chronic hepatitis and cirrhotic patients were 39%, 58%, and 56%. Fifty-two percent of HCC patients had positive PBL HBV-DNA in the absence of serum HBV-DNA, compared with 25% in healthy carriers (P < 0.05) and 22% in chronic hepatitis (P < 0.001) and 35% in cirrhotic patients (P = NS).

CONCLUSION

The high detection rate of PBL HBV-DNA among HCC patients may reflect certain pathogenetic processes of HBV infection and indicate a higher risk of development of HCC.

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.

Duodenal ulcer healing by eradication of Helicobacter pylori without anti-acid treatment: randomised controlled trial

Randomised trials have shown that duodenal ulcers treated by H2 blockers heal faster if Helicobacter pylori is eradicated concurrently. It remains unknown whether eradication of H pylori without suppression of acid-secretion, is sufficient to allow healing. 153 patients with H pylori infection and duodenal ulcer were randomised to receive either a 1-week course of bismuth subcitrate, tetracycline, and metronidazole (76), or omeprazole for 4 weeks with the same three-drug regimen for the first week (77). Endoscopy and antral biopsies were done at entry and 4 weeks after treatment. 132 patients were suitable for analysis. Duodenal ulcers healed in 60 (92%; 95% CI 86-100%) patients taking bismuth, tetracycline, and metronidazole compared with 63 (95%; 88-100%) taking omeprazole in addition to the three other drugs. H pylori was eradicated in 61 (94%; 88-100%) who received only three drugs compared with 66 (98%; 96-100%) who received omeprazole as well. Symptoms were reduced more effectively during the first week in patients who received omeprazole (p = 0.003). We conclude that a 1-week regimen of bismuth, tetracycline, and metronidazole for patients with H pylori and duodenal ulcer eradicates the organism and heals the ulcer in most patients. Concurrent administration of omeprazole reduces ulcer pain more rapidly but has no effect on ulcer healing.