Hospital Authority audit of the outcome of endoscopic resection of superficial upper gastro-intestinal lesions in Hong Kong

OBJECTIVES

To review the short-term outcome of endoscopic resection of superficial upper gastro-intestinal lesions in Hong Kong.

DESIGN

Historical cohort study.

SETTING

All Hospital Authority hospitals in Hong Kong.

PATIENTS

This was a multicentre retrospective study of all patients who underwent endoscopic resection of superficial upper gastro-intestinal lesions between January 2010 and June 2013 in all government-funded hospitals in Hong Kong.

MAIN OUTCOME MEASURES

Indication of the procedures, peri-procedural and procedural parameters, oncological outcomes, morbidity, and mortality.

RESULTS

During the study period, 187 lesions in 168 patients were resected. Endoscopic mucosal resection was performed in 34 (18.2%) lesions and endoscopic submucosal dissection in 153 (81.8%) lesions. The mean size of the lesions was 2.6 (standard deviation, 1.8) cm. The 30-day morbidity rate was 14.4%, and perforations and severe bleeding occurred in 4.3% and 3.2% of the patients, respectively. Among patients who had dysplasia or carcinoma, R0 resection was achieved in 78% and the piecemeal resection rate was 11.8%. Lateral margin involvement was 14% and vertical margin involvement was 8%. Local recurrence occurred in 9% of patients and 15% had residual disease. The 2-year overall survival rate and disease-specific survival rate was 90.6% and 100%, respectively.

CONCLUSION

Endoscopic mucosal resection and endoscopic submucosal dissection were introduced in low-to-moderate-volume hospitals with acceptable morbidity rates. The short-term survival was excellent. However, other oncological outcomes were higher than those observed in high-volume centres and more secondary procedures were required.

Adenocarcinoma of the duodenum

Adenocarcinoma of the duodenum is an exceedingly rare disorder. Its vague and non-specific symptoms often lead clinicians and patients to suspect other more benign differential diagnoses. Improved endoscopy and radiology have enabled more of these cases to be unearthed. Definitive surgery is the only means of potential cure, with the prognosis being significantly better for node-negative patients. We present a case of a 52-year-old man who underwent a Whipple's operation for this uncommon disease and a literature review of the subject.

Total intravenous anesthesia using propofol and ketamine for ambulatory gynecologic laparoscopy

Laparoscopy under total intravenous anesthesia (TIVA) with spontaneous respiration is a commonly encountered procedure in ambulatory gynecologic surgery. The purpose of this study was to evaluate the efficacy of TIVA using propofol and ketamine, compared with endotracheal inhalational general anesthesia (EIGA) for ambulatory gynecologic laparoscopy. Fifty-eight female patients, aged 17-48 years, were randomly allocated into two groups. Group 1 (TIVA) (n = 28) received propofol at the induction of anesthesia followed by propofol infusion for maintenance. Intravenous ketamine 0.5 mg/kg was administered before operation for anesthetic effect. Natural airway and spontaneous breathing were then maintained in patients. Group 2 (n = 30) received EIGA with isoflurane under controlled ventilation. We found that the two groups demonstrated similar trend characters of pH and PaCO2 during operation and in recovery room. The incidence of postoperative vomiting was higher in group 2 than in group 1 (30% vs. 7%; p < 0.05). The incidence of intraoperative arrhythmia was higher in group 2 than in group 1 (40% vs. 3%; p < 0.001). Furthermore, the incidence of sore throat was higher in group 2 than in group 1 (47% vs. 7%; p < 0.001). We conclude that TIVA with spontaneous respiration is suitable for ambulatory gynecologic laparoscopy.

Reliability of a facebow transfer procedure

The three-dimensional orientation of a maxillary cast mounting from a simulated-kinematic facebow transfer was evaluated in multiple trials among three operators on a single subject. The anterior and posterior anatomic facial reference points were marked on the subject. Each operator performed a separate series of trials to reset the anterior facebow component, the two posterior facebow components, and a control series with no resetting of any facebow components relative to the subject. The x, y, and z coordinates of three reference points on the maxillary cast were determined with a machinist microscope relative to a fixed reference after each facebow transfer. A range of differences between mountings of the maxillary cast were found between trials with all three methods used. These mounting errors were due to setting of the instrument and would be expected in routine clinical use of this instrument.