275 ENT and Plastic Surgery Senior House Officers/house Officers Access to Patient Clinic Letters - Closed Loop Audit

Aim

To evaluate whether senior house officers (SHOs) and house officers (HOs) on plastic surgery and ENT: 1. have received training to access healthcare records and 2. feel confident with accessing healthcare records when needed.

Method

Retrospective audit. Questionnaires were sent to ENT and plastic surgery SHOs and HOs. After the first cycle of audit, the induction that ENT and plastic surgery SHOs and HOs receive at the start of rotation was changed to incorporate training for accessing healthcare records and a second audit cycle was completed. The audit gold standard were local trust guidelines, and the target benchmark was 100%.

Results

First audit cycle showed 0% of SHOs and HOs on plastic surgery and ENT were trained to access healthcare records at induction and 25% felt confident with accessing healthcare records when needed after their induction. After the changes to induction were implemented, the second audit cycle showed that 80% of SHOs and HOs were trained to access healthcare at induction and 100% of SHOs and HOs felt confident with accessing healthcare records when needed after their induction.

Conclusions

Induction at the start of a rotation is essential for junior doctors to be equipped with the knowledge required to deliver their clinical duties effectively. It is important to listen to feedback and improve this induction process. Further cycles of audit are required to assess if this change has been sustainable.

1136 Cochlear Implant Outcomes in Patients with Otosclerosis: A Systematic Review

Introduction

In otosclerosis, spongiotic bone replaces normal bone in the ossicular chain. Focal deposits may also be found within the cochlea leading to sensorineural hearing loss refractory to conventional treatment. Cochlear implantation can play an important role in the management of otosclerosis in these patients. Our study objective is to establish hearing outcomes following cochlear implantation in patients with otosclerosis.

Method

Systematic review and narrative synthesis. Databases searched: Medline, PubMed, Embase, Web of Science, Cochrane Collection and ClinicalTrials.gov. No limits placed on language or year of publication. Review conducted in accordance with the PRISMA statement.

Results

Searches identified 68 studies meeting the inclusion criteria and reporting outcomes in a minimum of 481 patients with at least 516 implants. The methodological quality of included studies was modest, predominantly consisting of case reports and non-controlled case series with small numbers of patients. Significant heterogeneity existed in terms of outcomes and methods of reporting, which precluded a meta-analysis. Access to good rehabilitation support is essential to achieving the good hearing outcomes and Patient Reported Outcome Measures that can be expected by 12 months post-implantation in most cases. There was significant association between the radiological severity of otosclerosis and an increase in surgical and post-operative complications. Post-operative facial nerve stimulation can occur and may require deactivation of electrodes and subsequent hearing detriment.

Conclusions

Hearing outcomes are typically good, but patients should be counselled on associated surgical complications which may compromise hearing. Modern diagnostic techniques may help to identify potentially difficult cases to aid operative planning and patient counselling.

1309 Cochlear Implantation in Patients with Usher Syndrome: A Systematic Review of The Literature

Introduction

Usher syndrome is a common cause of deaf-blindness characterised by progressive visual loss with congenital (types 1 and 2) or adult-onset (type 3) sensorineural hearing loss. Cochlear implantation is one of few effective options to enable patient access to useful sound. Auditory rehabilitation after cochlear implantation may be limited by deterioration of retinal function. Our objective was to evaluate the auditory outcomes of cochlear implantation in patients with Usher syndrome.

Method

Systematic review of Medline via PubMed, Ovid EMBASE, Web of Science, CENTRAL and clinicaltrials.gov was performed up to 30/03/2020, conducted in accordance with the PRISMA statement. Patient demographics, comorbidity, details of cochlear implantation, auditory and quality of life (QOL) outcomes were extracted and summarised. CRD 42020185102.

Results

32 studies reported over 215 cochlear implants in 186 patients with Usher syndrome, comprising subtypes 1 (56 patients), 2 (9 patients), 3 (23 patients), and not specified (98 patients). Where reported, cochlear implantation improved sound detection, speech perception, speech intelligibility, and patient-reported quality of life in the majority of patients with Usher syndrome.

Conclusions

Outcomes of cochlear implantation were comparable to those of patients without multiple sensory handicap. As clinical practice has evolved to emphasise early, bilateral implantation and access to oral education it is likely that these reported outcomes may underestimate contemporary implant outcomes among young children with Usher syndrome. To avoid multisensory deficits incurred by poor cochlear implant outcomes secondary to late implantation with Usher syndrome-related progressive visual loss, early implantation is crucial in the prelingually deaf Usher group.

454 Impact Of COVID-19 Pandemic on Elective Theatre Productivity in Otolaryngology

Aim

COVID-19 has had a significant impact on otolaryngology surgery. There are new requirements to prepare patients for theatre however the impact on theatre productivity is unknown. This study aims to evaluate the impact of COVID-19 on elective theatre productivity.

Method

We conducted a retrospective evaluation of elective otolaryngology theatre lists. Ten consecutive theatre lists beginning on the final week of November 2019 and November 2020 were analysed. Dedicated emergency operation lists were excluded.

Results

There were fewer operating lists per working day in 2020 (0.9) compared to 2019 (2.0) and a higher percentage of operations cancelled (2020: 15.4%, 2019: 8.6%). Theatre lists finished significantly earlier in 2020 than in 2019 (2020 median: 97.5 minutes, 2019 median: 15.5 minutes; p = 0.00018). The percentage of theatre lists finishing over 60 minutes early was substantially greater than the national average of 23% (2020: 75%, 2019: 30%). The median pre-list delay was higher in 2020 than 2019 (2019: 20.5 minutes, 2020: 31.5 minutes; p = 0.14) whilst the median total delay was higher in 2019 compared to 2020 (2019: 20.5 minutes, 2020: 18 minutes; p = 0.21). Both results were not statistically significant. The commonest reason for delay in 2020 were COVID-19 related reasons such as awaiting test results, in 2019 the commonest reason was patient not being ready for theatre such as consent not completed.

Conclusions

COVID-19 has had a significant impact on theatre productivity and is currently the commonest cause of theatre list delay. The early theatre finishing time suggest that improvements can be made to improve theatre productivity.

1160 LEARN (Urological Teaching in British Medical Schools Nationally): A Multicentre Cross-Sectional Study

Introduction

Urology is a common rotation for UK Foundation Year (FY) doctors, and accounts for >25% of acute surgical referrals. In 2012, the British Association of Urological Surgeons (BAUS) produced ‘An Undergraduate Syllabus for Urology’, advising on common clinical areas of urology to be covered during medical school. However, its national uptake remains unknown. LEARN aims to assess undergraduate urology teaching across UK medical schools.

Method

LEARN is the largest ever multicentre cross-sectional study of undergraduate urology teaching. Year 2-5 medical students and FY1 doctors were invited to complete a survey between 3rd October-20th December 2020. The primary objective is to compare current undergraduate urology teaching against the BAUS syllabus. Secondary objectives investigate the type and quantity of teaching provided, the reported performance rate of GMC mandated urological procedures, and the proportion of those considering urology as a career.

Results

A total of 7,611/8,346 (91.2%) responses from 39 medical schools that met the inclusion criteria were analysed. 16.5% of responses were newly appointed FY1 doctors. In their undergraduate training, the most commonly taught topics were urinary tract infection, acute kidney injury and haematuria; the least taught topics were male urinary incontinence, male infertility and erectile dysfunction. 90.6% and 86.3% had reported performing catheterisation as undergraduates on male and female patients respectively, and 16.9% had considered a career in urology.

Conclusion

LEARN provides the largest evaluation of any undergraduate specialty teaching. It has identified areas to improve teaching, to equip the future workforce with the competencies to manage urological pathology, irrespective of future career choice.

P73 LEARN: uroLogical tEAching in bRitish medical schools Nationally - a national retrospective multi-centre audit of urology teaching across British medical schools

Introduction

Urological conditions account for approximately 25% of acute surgical referrals and 10-15% of general practitioner appointments. In 2012, the British Association of Urological Surgeons (BAUS) produced ‘An Undergraduate Syllabus for Urology’, advising on common clinical areas of urology that must be covered during undergraduate medical training. However, its uptake nationally remains unknown. This project aims to assess undergraduate urology teaching across UK medical schools.

Methods

A targeted advertising drive using social media, medical school societies, websites and newsletters was performed over 4 weeks. Collaborators are responsible for recruiting survey respondents (year 2 medical students to foundation year 1 (FY1) doctors). Survey respondents will complete a REDCap survey retrospectively assessing their urology teaching to date. The primary objective is to compare current urology teaching in medical schools across the United Kingdom with the BAUS undergraduate syllabus.

Results

Currently, 522 collaborators have registered from 36 medical schools nationally. Of these collaborators, 6.32% (33/522) are FY1s and 93.68% (489/522) are medical students. Each collaborator will be responsible for recruiting at least 15 survey respondents to be eligible for PubMed-indexed collaborator authorship.

Conclusion

LEARN has recruited successfully to date, with all collaborators from the medical student and FY1 cohort. With the role of collaborators to further recruit survey respondents, LEARN will provide the most representative and thorough evaluation of UK undergraduate urological teaching to date. It will provide evidence to support changes in the medical school curriculum, and allow re-evaluation of the current national undergraduate BAUS syllabus.

P57 Global recruitment for the RESECT study (transurethral REsection and Single-instillation intravesical chemotherapy Evaluation in bladder Cancer Treatment) - an international observational cohort study aiming to improve the quality of surgery for non-muscle invasive bladder cancer

Introduction

Non-muscle invasive bladder cancer (NMIBC) is one of the most expensive cancers to treat, driven by high recurrence rates and disease progression. Mortality rates in the UK for all bladder cancers have remained relatively stable over the past decade. NMIBC can be curatively treated with transurethral resection of the bladder tumour (TURBT). Despite international evidence-based guidelines on the TURBT procedure and postoperative single instillation of mitomycin-C, TURBT quality continues to vary widely. RESECT will be the first ever international study of TURBT surgery evaluating the achievement of TURBT quality indicators globally and assessing if audit and performance feedback can improve surgical outcomes.

Methods

RESECT is a prospective, multicentre international observational cohort study. Collaborators at each site will collect data using REDCap about local TURBT practice, early recurrence rates and the experience of local TURBT surgeons. The primary outcome is the rate of achievement of key TURBT quality indicators. Advertisement for the study launched in 2020.

Results

As of October 1st, 2020, 524 collaborators have registered to participate. Collaborators represent 334 centres from 54 countries, with the highest number of centres from the United Kingdom (133), Spain (17), and India (16). 50.8% are trainees, 30.3% consultants, and 17.2% medical students. Based on current registrations, patient recruitment will far exceed initial projections and considerably improve statistical power.

Conclusion

RESECT has attracted many collaborators internationally from consultants and trainees at all stages. RESECT has significant potential to positively impact TURBT practice, health economics and ultimately improve outcomes for patients with NMIBC globally.

Evaluation of Leponex (Clozapine) in Schizophrenia with Acute Symptomatology

Thirty-three in-patients, diagnosed as suffering from schizophrenia with acute symptomatology, were involved in a double-blind cross-over trial comparing Leponex (clozapine) with placebo. Leponex was found to be effective, particularly in the control of paranoid manifestations and excited and aggressive behaviour, with rapid onset of action. The drug should however be used with some caution at this stage because of its hypotensive effects, which led to collapse in 13% of cases in the initial stages of treatment. This side-effect could be avoided by starting on low dosage.

Using positive youth development constructs to design a money management curriculum for junior secondary school students in Hong Kong

This paper aims to discuss the relationships between the selected positive youth development constructs and the enhancement of Hong Kong junior secondary school students' money management skills, values, and attitudes. Various issues of money management of adolescents are reviewed. These issues include the need for money management programs for adolescents, the content and coverage of an appropriate money management program, and its relationships with the selected positive youth development constructs. The curriculum units for secondary 3 students are taken as examples to illustrate the design of the program. It is believed that promoting cognitive competence, self-efficacy, and spirituality could be an effective way to enhance students' money management skills, values, and attitudes, thus preparing them better for facing the finance-related issues in life.

Outcome after partial hepatectomy for hepatocellular cancer within the Milan criteria

BACKGROUND

There is a trend to offer liver transplantation to patients with hepatocellular carcinoma (HCC) with tumour status within the Milan criteria but with preserved liver function. This study aimed to evaluate the outcome of such patients following partial hepatectomy as primary treatment.

METHODS

A retrospective analysis was performed on all adult patients with HCC and tumour status within the Milan criteria undergoing partial hepatectomy at a single centre from 1995 to 2008. Their outcomes were compared with those of similar patients having right-lobe living donor liver transplantation (LDLT) as primary treatment.

RESULTS

A total of 408 patients with HCC were enrolled. Some 384 patients with a solitary tumour 5 cm or less in diameter had a better 5-year survival rate than 24 patients with oligonodular tumours (2-3 nodules, each 3 cm or less in size) (70·7 versus 46 per cent; P = 0·025). Multivariable analysis identified younger age (65 years or less), lack of postoperative complications, negative resection margin, absent microvascular invasion and non-cirrhotic liver as predictors of favourable overall survival. The 5-year survival rate of 287 younger patients with chronic liver disease and R0 hepatectomy was 72·8 per cent, comparable to that of 81 per cent in 50 similar patients treated by LDLT (P = 0·093).

CONCLUSION

Partial hepatectomy for patients with HCC and tumour status within the Milan criteria achieved a satisfactory 5-year survival rate, particularly in younger patients with solitary tumours and R0 hepatectomy. Patients with oligonodular tumours have a worse survival and might benefit from liver transplantation.

Women with placenta praevia and antepartum haemorrhage have a worse outcome than those who do not bleed before delivery

We set out to assess the maternal and neonatal outcomes of women with placenta praevia and antepartum haemorrhage (APH) between 1991 and 1997, compared with woman with a diagnosed placenta praevia who did not bleed. The demographic data, maternal and perinatal outcomes of 159 women with antepartum haemorrhage were compared with 93 women without antepartum haemorrhage in a retrospective study. Women with antepartum haemorrhage had the diagnosis of placenta praevia confirmed at an earlier gestation. More women with antepartum haemorrhage received antenatal steroids and tocolytic agents, and had emergency caesarean sections. The majority of women with bleeding had an emergency caesarean section for antepartum haemorrhage and more delivered early because of fetal distress. There were more preterm deliveries in women with antepartum haemorrhage. The mean birth weight was 2.69 kg in the women with antepartum haemorrhage and 3.06 kg in those without. More infants in the bleeding group had a low Apgar score at the first minute, respiratory distress syndrome, and admission to special baby care and neonatal intensive care unit. It is concluded that there is an increased risk of premature delivery in women with antepartum haemorrhage and placenta praevia. Aggressive management, tocolysis and cervical cerclage should be explored further to improve the perinatal outcome. Women without antepartum haemorrhage can be managed on an outpatient basis.

Effects of cognitive-behavioural therapy on anxiety for children with high-functioning autistic spectrum disorders

INTRODUCTION

Children with autistic spectrum disorders (ASD) often exhibit one or more comorbid disorders, including anxiety, disruptive behaviour, mental retardation, and depression. Various studies have documented the effectiveness of cognitive-behavioural therapy (CBT) in treating children with anxiety. Although studies have indicated a high prevalence of anxiety in individuals with ASD, there is a lack of systematic studies substantiating the effectiveness of cognitive-behavioural interventions among children with high-functioning autism.

METHODS

This pilot study investigated the effects of a 16-session CBT programme on six high-functioning children diagnosed with ASD (mean age 11.50 years, standard deviation 0.84 years). These children were diagnosed with ASD or Asperger's syndrome by the DSM-IV criteria. Measures on levels of child's anxiety, parental and teacher stress were administered at pre- and post-treatment.

RESULTS

Children showed lower levels of anxiety at post-treatment. Parents and teachers also reported lower levels of stress following the CBT programme.

CONCLUSION

Findings from the present study provided some evidence of the effects of CBT for high-functioning autistic children in reducing anxiety, parental and teacher stress. Interpretation of the findings, recommendations for future research and implications of the present study are presented.

The impact of psychological abuse by an intimate partner on the mental health of pregnant women

Objective

The objective of this first population-based study in Hong Kong was to assess the impact of psychological abuse by an intimate partner on the mental health of pregnant women.

Design

Survey.

Setting

Antenatal clinics in seven public hospitals in Hong Kong.

Population

Three thousand two hundred and forty-five pregnant women.

Methods

The Abuse Assessment Screen (AAS) and demographic questionnaires were administered face-to-face at 32–36 weeks of gestation. At 1 week postpartum, the AAS, Edinburgh Postnatal Depression Scale and SF-12 Health Survey were administered by telephone.

Main outcome measures

Intimate partner violence, postnatal depression and health-related quality of life.

Results

Two hundred and ninety six (9.1%) of the participants reported abuse by an intimate partner in the past year. Of those abused, 216 (73%) reported psychological abuse only and 80 (27%) reported physical and/or sexual abuse. Forty six (57.5%) in the physical and/or sexual abuse group also reported psychological abuse. Women in the psychological abuse only group had a higher risk of postnatal depression compared with nonabused women (adjusted OR: 1.84, 95% CI: 1.12–3.02). They were also at a higher risk of thinking about harming themselves (adjusted OR: 3.50, 95% CI: 1.49–8.20) and had significantly poorer mental health-related quality of life (P < 0.001). The higher risks of postnatal depression and thinking of harming themselves were not observed in the physical and/or sexual abuse group although significantly poorer mental health-related quality of life (P < 0.001) was observed.

Conclusions

Psychological abuse by an intimate partner against pregnant women has a negative impact on their mental health postdelivery. Furthermore, psychological abuse in the absence of physical and/or sexual abuse can have a detrimental effect on the mental health of abused women. The findings underscore the importance of screening pregnant women for abuse by an intimate partner and the need for developing, implementing and evaluating interventions to address psychological abuse.

Please cite this paper as: Tiwari A, Chan K, Fong D, Leung W, Brownridge D, Lam H, Wong B, Lam C, Chau F, Chan A, Cheung K, Ho P. The impact of psychological abuse by an intimate partner on the mental health of pregnant women. BJOG 2008;115:377–384.

Improved operative and survival outcomes of surgical treatment for hilar cholangiocarcinoma

BACKGROUND

The aim of the present study was to assess whether an aggressive surgical approach in the management of patients with hilar cholangiocarcinoma was associated with improved operative and survival outcomes.

METHODS

Eighty-two patients with hilar cholangiocarcinoma treated between 1989 and 1998 (period 1), and 60 patients treated between 1999 and 2004 (period 2), were evaluated. Modifications to management in period 2 primarily included percutaneous biliary drainage instead of endoscopic drainage for relief of obstructive jaundice, preoperative right portal vein embolization before right-sided hepatectomy, routine total caudate lobectomy and radical lymphadenectomy during surgical resection of the tumour.

RESULTS

The surgical resection rate was significantly higher in period 2 than in period 1 (45 versus 16 per cent; P < 0.001). All patients in period 2 underwent major hepatectomy with concomitant caudate lobectomy. The operative morbidity and hospital mortality rates decreased significantly in period 2 compared with period 1, with significantly better survival outcomes. In multivariate analysis, resection of the tumour in period 2 and operative blood loss of 1.5 litres or less were the significant independent factors associated with improved survival.

CONCLUSION

An aggressive surgical approach was associated with improved operative and survival outcomes for patients with hilar cholangiocarcinoma.

Efficacy and safety of radiofrequency ablation for perivascular hepatocellular carcinoma without hepatic inflow occlusion

BACKGROUND

The role of radiofrequency ablation (RFA) for perivascular (up to 5 mm from the major intrahepatic portal vein or hepatic vein branches) hepatocellular carcinoma (HCC) is unclear because of possible incomplete tumour ablation and potential vascular damage. This study aimed to evaluate the safety and efficacy of RFA for perivascular HCC without hepatic inflow occlusion.

METHODS

Between May 2001 and November 2003, RFA using an internally cooled electrode was performed on 52 patients with perivascular HCC (group 1) through open (n = 39), percutaneous (n = 9), laparoscopic (n = 2) and thoracoscopic (n = 2) approaches. Hepatic inflow occlusion was not applied during the ablation procedure. The perioperative and postoperative outcomes were compared with those of 90 patients with non-perivascular HCC (group 2) treated by RFA during the same period.

RESULTS

The morbidity rate was similar between groups 1 and 2 (25 versus 28 per cent; P = 0.844). One patient in group 1 (2 per cent) and two in group 2 (2 per cent) had developed thrombosis of major intrahepatic blood vessels on follow-up computed tomography scan. There were no significant differences between groups 1 and 2 in mortality rate (2 versus 0 per cent; P = 0.366), complete ablation rate for small HCC (92 versus 98 per cent; P = 0.197), local recurrence rate (11 versus 9 per cent; P = 0.762) and overall survival (1-year: 86 versus 87 per cent; 2-year: 75 versus 75 per cent; P = 0.741).

CONCLUSION

RFA without hepatic inflow occlusion is a safe and effective treatment for perivascular HCC.

Evaluation of outcome of laparoscopic colorectal resection with POSSUM, Portsmouth POSSUM and colorectal POSSUM

BACKGROUND

This study evaluated the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM), Portsmouth (P) POSSUM and colorectal (CR) POSSUM in laparoscopic colorectal resection.

METHODS

Observed mortality and morbidity rates in 400 patients who underwent laparoscopic colorectal resection were compared with those predicted by POSSUM, P-POSSUM and CR-POSSUM.

RESULTS

Observed mortality and morbidity rates were 0.5 and 19.0 per cent respectively. Mortality rates predicted by POSSUM, P-POSSUM and CR-POSSUM were 10.8, 4.0 and 5.6 per cent respectively, and the morbidity rate predicted by POSSUM was 43.0 per cent. The predicted and observed mortality and morbidity rates showed significant lack of fit. The conversion rate to open surgery was 11.5 per cent. The mortality rate for patients having conversion was 2 per cent and was not significantly different to that predicted by P-POSSUM (4 per cent; P = 0.493) or CR-POSSUM (5 per cent; P = 0.370). In this group, the observed and POSSUM-predicted morbidity rates were also similar (43 versus 48 per cent respectively; P = 0.104).

CONCLUSION

POSSUM, P-POSSUM and CR-POSSUM overestimated mortality and morbidity in patients who underwent laparoscopic colorectal resection. However, the mortality rate in patients who required conversion fitted the models of P-POSSUM and CR-POSSUM, and the morbidity rate was comparable to that predicted by POSSUM.

Clinico-biochemical prediction of biliary cause of acute pancreatitis in the era of endoscopic ultrasonography

BACKGROUND

Occult biliary stones escape detection on conventional investigations, and clinico-biochemical systems proposed for predicting biliary pancreatitis has low predictive values.

AIM

To evaluate the accuracy of clinico-biochemical parameters for prediction of biliary pancreatitis in patients undergoing endoscopic ultrasonography.

METHODS

Early endoscopic ultrasonography was performed on 139 patients presenting with acute pancreatitis within 24 h of admission. The aetiologies of all patients were determined after complete evaluations, and clinico-biochemical characteristics of patients with a biliary cause (biliary group) and non-biliary causes (non-biliary group) were compared.

RESULTS

Biliary pancreatitis was diagnosed in 107 patients and 32 patients had non-biliary causes. The biliary group belonged to a significantly older age group, had a female predominance, significantly more derangement of liver function and a higher incidence of severe attack of acute pancreatitis. On multivariate analysis, female sex, age >58 years and serum alanine aminotransferase >150 U/L were independent predictive factors for biliary cause of acute pancreatitis. Using these three factors for prediction of biliary cause, the sensitivity was 93% and overall accuracy was 85%.

CONCLUSION

Clinico-biochemical prediction for biliary cause of acute pancreatitis improves in the era of endoscopic ultrasonography with a higher sensitivity and overall accuracy. In centres where endoscopic ultrasonography is inaccessible or local expertise is unavailable, clinico-biochemical prediction of biliary cause of acute pancreatitis may provide a useful alternative in the initial management of this group of patients.

Pseudo-renal failure following total abdominal hysterectomy

Intraperitoneal urinary bladder perforation should be in the differential diagnosis of acute oliguric renal failure soon after gynecological surgery. We present a case of reversible acute pseudo-renal failure after total abdominal hysterectomy for uterine fibroid. Biochemical features of uremia occur as a result of intraperitoneal extravasation of urine, which is in turn reabsorbed through the peritoneum. Early recognition and surgical repair, as opposed to dialysis therapy, are warranted in such clinical setting. Nephrologists, who are often the first to encounter those patients with presumably acute renal failure, should be aware of this condition. Prompt recovery of the serum biochemistry is to be expected, in contradistinction to genuine renal failure or kidney insults.

Laparoscopic surgery for common surgical emergencies: a population-based study

BACKGROUND

Despite being controversial in the past, many reports on the safe use of laparoscopic surgery in emergency settings have been published. The aim of this study was to investigate the diffusion of laparoscopic surgery in three common surgical emergency operations, namely, appendectomy, cholecystectomy, and simple repair of perforated peptic ulcer (PPU), in a stable population.

METHODS

This was a retrospective analysis of the central database of the Hospital Authority (HA) in Hong Kong. Data for patients managed in 14 HA hospitals from 1998 to 2002 were studied. The operation record and discharge record of each patient were also investigated to verify the data.

RESULTS

A total of 12,708 patients underwent appendectomy, 2631 patients underwent cholecystectomy, and 2260 patients had simple repair of PPU performed. During the study period, 37.2% of appendectomies, 46.5% of cholecystectomies, and 23.1% of simple repairs of PPU were performed laparoscopically. More than a two-fold increase in the proportion of laparoscopic surgery was observed in each of these three operations. By the end of 2002, the percentage of laparoscopic surgery had increased to 53.5% for appendectomies, 61.3% for cholecystectomies, and 32.9% for simple repairs of PPU. Significantly lower hospital mortality rates and shorter postoperative hospital stay were consistenty observed in patients with laparoscopic surgery of the three emergencies. A wide variation in the use of laparoscopic surgery, ranging from 3.7% to 73.1%, was observed among the 14 HA hospitals. However, there was no correlation in the use of laparoscopic surgery with the volume of operation performed in each hospital (p = 0.933).

CONCLUSION

A high diffusion rate on the use of laparoscopic surgery for common surgical emergency was observed in Hong Kong. However, there was also a wide variation in the diffusion rate among the 14 HA hospitals. Efforts to reduce hospital variation for the better dissemination of safe laparoscopic technique may be warranted.

The relationship between hypertension and anxiety or depression in Hong Kong Chinese

BACKGROUND

Psychosocial stress can be the cause or the consequence of hypertension.

OBJECTIVE

To study the association between hypertension and anxiety or depression in adults from Hong Kong, China.

SUBJECTS AND METHODS

Patients with diagnosed hypertension (n=197) were recruited to complete the Hospital Anxiety and Depression Scale (HADS) questionnaire. The control group comprised 182 normotensive subjects recruited using random telephone numbers.

RESULTS

The score in the anxiety subscale (HADS-A) of the HADS correlated with age (r= -0.23, P<0.001) and sex (r=0.11, P=0.042), and was found to be higher in women. The score in the depression subscale (HADS-D) correlated with age (r=0.17, P=0.003) and hypertension (r=0.12, P=0.039), but not with sex (r=0.02, P=0.68). When the control subjects were matched for sex and age with the subjects with hypertension, the mean HADS-A score was 5.51+/-0.41 in 113 hypertensive subjects and 4.38+/-0.39 in 113 normotensive subjects (P=0.047). The mean HADS-D score was 5.56+/-0.39 in the hypertensive and 4.76+/-0.32 in the normotensive subjects (P=0.11). Multiple regression analysis using data from both groups indicated that the HADS-A score was related to the HADS-D score (beta=0.49, P<0.001), age (beta= -0.25, P<0.001) and sex (beta=0.12, P=0.01) (R(2)=0.28), whereas the HADS-D score was related to the HADS-A score (beta=0.48, P<0.001), age (beta=0.30, P<0.001), positive smoking status (beta=0.13, P=0.004) and lack of exercise habit (beta=0.12, P=0.008) (R(2)=0.31). Hypertension was related to waist circumference, history of parental hypertension and age (R(2)=0.38, P<0.001). Anxiety and depression scores were rejected as independent variables.

CONCLUSIONS

Hypertension was associated with anxiety but not depression; however, age, history of parental hypertension and central obesity appeared to have a stronger association with hypertension in adults from Hong Kong.

Delayed portal vein thrombosis after experimental radiofrequency ablation near the main portal vein

BACKGROUND

Portal venous blood flow may protect adjacent tumour cells from thermal destruction with radiofrequency ablation (RFA). This study aimed to investigate the local effect of RFA on the main portal vein branch, and the completeness of cellular ablation in its vicinity, with or without a Pringle manoeuvre using a porcine model.

METHODS

This was an in vivo study on 23 domestic pigs. RFA using a cooled-tip electrode was performed 5 mm from the left main portal vein branch under ultrasonographic guidance for 12 min with (n = 10) or without (n = 10) a Pringle manoeuvre. Ten pigs were killed 4 h after the procedure to study the early effects of RFA and ten others were killed 1 week later to determine any delayed effect. As a control, sham operations with a Pringle manoeuvre for 12 min were performed on three pigs. The flow velocity changes of portal vein and hepatic artery were measured using Doppler ultrasonography, and the completeness of cellular ablation around the portal vein was assessed qualitatively by histochemical staining and quantitatively by measuring intracellular levels of adenosine 5'-triphosphate (ATP).

RESULTS

In the absence of the Pringle manoeuvre, there was no significant change in mean(s.d.) portal vein flow velocity before RFA (20.0(3.5) cm/s) and at 4 h (18.5(2.5) cm/s) (P = 0.210) and 1 week (19.5(2.2) cm/s) (P = 0.500) after the procedure. Gross and histological examination of the portal vein branches showed no damage without the Pringle manoeuvre. In all pigs that underwent RFA with a Pringle manoeuvre, the portal vein was occluded 1 week after the operation; histological examination of the affected portal vein showed severe thermal injury and associated venous thrombosis. The local effect of RFA on the hepatic artery was similar. With intact portal blood flow during RFA, complete ablation of liver tissue around the pedicle was demonstrated by histochemical staining and measurement of the intracellular ATP concentration.

CONCLUSION

RFA was safe when applied close to the main portal vein branch without a Pringle manoeuvre, with complete cellular destruction. Use of the Pringle manoeuvre resulted in delayed portal vein and hepatic artery thrombosis and injury to the hepatic artery and bile duct.

Prevalence and characteristics of familial hepatocellular carcinoma caused by chronic hepatitis B infection in Hong Kong

BACKGROUND

Hepatitis B virus infection is an important aetiological factor for hepatocellular carcinoma. Clusters of hepatocellular carcinoma have been observed in families infected with hepatitis B virus.

AIM

To investigate the prevalence and characteristics of hepatocellular carcinoma associated with familial hepatitis B virus in Hong Kong.

METHODS

Hepatitis B virus patients were screened for familial hepatocellular carcinoma using a standardized questionnaire. The clinical features of patients with familial hepatocellular carcinoma were compared with those of 118 patients with sporadic hepatocellular carcinoma attending the clinic during the same period.

RESULTS

A total of 5080 patients were interviewed. Validation of the questionnaire indicated that the reliability was high. There were 22 families with familial hepatocellular carcinoma, giving a prevalence of 4.3 families/1000 hepatitis B virus carriers. The mean age of onset was 48.5 +/- 13 years in familial hepatocellular carcinoma and 62 +/- 11 years in sporadic hepatocellular carcinoma (P = 0.005). The ages of onset were 59 +/- 11, 40 +/- 10 and 18 +/- 4 years in the first, second and third generations, respectively (P < 0.0001), suggesting an anticipation phenomenon. Familial hepatocellular carcinoma patients were more likely to present with pain (70% vs. 10%, P < 0.0001), but not on routine screening (14% vs. 52%, P < 0.0001), than sporadic hepatocellular carcinoma patients.

CONCLUSION

The prevalence of familial hepatocellular carcinoma is significant in Hong Kong. These patients show specific clinical features when compared with patients with sporadic hepatocellular carcinoma.

SIADH associated with ovarian immature teratoma: a case report

Immature teratoma in association with SIADH is rare. A 17-year-old patient presented with a pelvic mass and serum sodium concentration of 121 mmol/l. Subsequent investigation confirmed SIADH and grade 2 ovarian immature teratoma. No other causes of SIADH were found apart from the immature teratoma. There was no further recurrence of SIADH after the curative surgery and chemotherapy. We postulate that immature teratoma consists of neurohypophyseal structures which account for the ADH release.

Cholestatic jaundice caused by sequential carbimazole and propylthiouracil treatment for thyrotoxicosis

A 36-year-old Chinese man presented to the Queen Mary Hospital in August 1999 with a 2-week history of jaundice due to propylthiouracil treatment for thyrotoxicosis. He had previously received carbimazole but had developed an urticarial skin rash after 2 weeks of treatment. The patient developed liver failure and fulminant pneumonitis shortly after hospital admission. Despite receiving treatment with broad-spectrum antibiotics and intravenous immunoglobulin, he died 11 days after the onset of the respiratory symptoms. Postmortem examination using electron microscopy showed typical glycogen bodies within the cytoplasm of the hepatocytes, which corresponded to eosinophilic cytoplasmic inclusion bodies visible under light microscopy. Immunohistochemical studies of the inclusion bodies were positive for carcinoembryonic antigen and albumin, and negative for fibrinogen, complement protein C3, immunoglobulins G, M, and A, alpha-fetoprotein, and alpha-1-antitrypsin. This is the first report of a patient who received two sequential antithyroid drugs and developed predominate cholestasis with unique histological features. Extreme caution should be taken when a patient develops allergy to one type of antithyroid drug, because cross-reactivity may develop to the other type.

Radiofrequency ablation as a salvage procedure for ruptured hepatocellular carcinoma

Spontaneous rupture of hepatocellular carcinoma is a distinct presentation causing acute abdomen. Different treatment approaches have been advocated including emergency hepatectomy, initial hemostasis by hepatic artery ligation or transarterial embolization and second-stage hepatectomy. Unrecognized ruptured hepatocellular carcinoma during laparotomy is often encountered in countries where the incidence of hepatocellular carcinoma is low. Radiofrequency ablation is a new localized thermal ablative technique for the treatment of unresectable hepatic tumors including hepatocellular carcinoma. We report a case where radiofrequency ablation was used as a salvage procedure for ruptured hepatocellular carcinoma during emergency laparotomy.

Risk factors for preterm delivery in women with placenta praevia and antepartum haemorrhage: retrospective study

OBJECTIVE

To identify risk factors for preterm delivery in women with placenta praevia and antepartum haemorrhage.

DESIGN

Retrospective study.

SETTING

Regional obstetric unit, Hong Kong.

SUBJECTS AND METHODS

Women delivered at Princess Margaret Hospital between 1 January 1990 and 31 December 1997. Possible risk factors for preterm delivery among women with placenta praevia and antepartum haemorrhage including onset, pattern, and severity of vaginal bleeding; presence of uterine contractions on admission; and type of placenta were assessed.

RESULTS

Three risk factors for preterm delivery were identified from univariate analysis. These included second trimester vaginal bleeding (odds ratio=4.19; 95% confidence interval, 1.29-13.66), the presence of uterine contractions on admission (odds ratio=4.00; 95% confidence interval, 1.57-10.19), and a haemoglobin decrease of more than 20 g/L (odds ratio=3.00; 95% confidence interval, 1.00-9.04). Using the logistic regression model, second trimester vaginal bleeding and the presence of uterine contractions were found to be independent risk factors for delivery before 36 weeks.

CONCLUSION

Preterm delivery is increased in women with placenta praevia and antepartum haemorrhage who have second trimester vaginal bleeding or the presence of uterine contractions. This high-risk group may benefit from close in-patient monitoring and more aggressive management.

Biliary complications during liver resection

Biliary complications after hepatectomy may lead to sepsis, liver failure, and death. Measures to detect biliary injury after liver transection may reduce such morbidity. The aim of this study was to investigate the trend of biliary complications after hepatectomy during the last 10 years and assess the efficacy of intraoperative measures (methylene blue test, cholangiography, fibrin glue application) for reducing postoperative biliary complications. This is a retrospective study of 616 consecutive patients who underwent hepatectomy in our institution from January 1989 to September 1998. The study period was divided into the first 5 years and the second 5 years for comparison. The hospital mortality rate was 6%. It was significantly reduced during the second 5-year period (3.3% vs. 10.6%; p = 0.0002). The postoperative biliary leakage rate was 5.5% and was also reduced during the second 5-year period (3.5% vs. 9.8%; p = 0.004). Postresection methylene blue tests were performed more frequently during the second 5-year period than the first (63% vs. 28%; p = 0.0001). The postoperative biliary leakage rate was reduced by the methylene blue test (3.6% vs. 7.3%; p < 0.05) but not by application of fibrin glue (7.2% vs. 4.2%) or postresection cholangiography. However, among the 60 patients with a positive methylene blue test, postoperative biliary leakage still occurred in 10% of them after the leakage sites were sutured. In conclusion, the biliary complication rate is decreasing. Only the postresection methylene blue test, but not postresection cholangiography or application of fibrin glue, helps to reduce the postoperative biliary leakage rate.

Detection of choledocholithiasis by EUS in acute pancreatitis: a prospective evaluation in 100 consecutive patients

BACKGROUND

ERCP is the standard for detection of choledocholithiasis in patients with acute biliary pancreatitis, and, if performed early, ERCP decreases morbidity. However, there are procedure-related complications. The aim of the present prospective study was to evaluate the ability of EUS to detect choledocholithiasis in patients presenting with acute pancreatitis.

METHODS

The study group comprised 100 consecutive patients who presented with acute pancreatitis. EUS, and immediately thereafter, ERCP were performed by separate blinded examiners within 24 hours of admission. The diagnostic accuracy of EUS in identifying gallbladder stones was compared with that of transcutaneous US. The diagnostic accuracy of EUS in detecting choledocholithiasis was then compared with that of US and ERCP based on the results of endoscopic instrumentation of the bile duct after sphincterotomy.

RESULTS

EUS was more sensitive than US in detecting gallbladder stones (100% vs. 84%, p < 0.005). The sensitivities of ERCP and EUS for choledocholithiasis were both 97%, and the overall accuracies were 96% and 98%, respectively, with no significant difference. EUS detected the absence of choledocholithiasis in 65 of 66 patients (specificity = 98%). Endosonographic examination was successful in all patients, whereas ERCP was unsuccessful in 5 patients (p > 0.05). Post-endoscopic sphincterotomy bleeding developed in 4 patients; there was no EUS-related morbidity (p > 0.05).

CONCLUSION

EUS is more sensitive than US in detecting biliary stones in patients with acute pancreatitis. It is as accurate as ERCP in detecting choledocholithiasis. EUS can be used to select patients with acute pancreatitis who require therapeutic ERCP, thus avoiding diagnostic ERCP and its associated potential for complications in the majority of patients.

Management of spontaneous rupture of hepatocellular carcinoma: single-center experience

PURPOSE

To report the management of patients with spontaneous rupture of hepatocellular carcinoma (HCC) in a single center over a 10-year period and to evaluate a two-stage therapeutic approach.

PATIENTS AND METHODS

A retrospective study was performed on all 1,716 patients with HCC who presented from 1989 to 1998. The two-stage therapeutic approach to manage ruptured HCC consisted of initial management by conservative method, hemostasis by transarterial embolization (TAE) or surgical means, followed by second-stage hepatic resection or transarterial oily chemoembolization (TOCE). Results of definitive treatment were compared with patients with no history of rupture during the same study period.

RESULTS

During the study period, 154 patients (9%) had spontaneous HCC rupture. Initial intervention to control bleeding included TAE in 42 patients, surgical hemostasis in 35 patients, and conservative management only in 53 patients. The 30-day mortality rate was 38%. Independent factors on presentation affecting 30-day mortality were shock on admission, hemoglobin, serum total bilirubin, and known diagnosis of inoperable tumor. After initial stabilization and clinical evaluation, 33 patients underwent hepatic resection and 30 patients received TOCE. Median survival of the hepatectomy patients was 25.7 months; that of the TOCE patients was 9.7 months. Compared with patients with no rupture, survival after hepatectomy (25.7 months v 49.2 months, P =.003) was inferior but still substantially long, whereas survival after TOCE was comparable (9.7 months v 8.7 months, P =.904).

CONCLUSION

Early mortality of spontaneous rupture of HCC was dependent on prerupture disease state, liver function, and severity of bleeding. Although it was a catastrophic presentation, prolonged survival could be achieved in selected patients with second-stage hepatic resection or TOCE.

Improving survival results after resection of hepatocellular carcinoma: a prospective study of 377 patients over 10 years

OBJECTIVE

To investigate whether the survival results after resection of hepatocellular carcinoma (HCC) have improved within the past decade by an analysis of a prospective cohort of patients over a 10-year period.

SUMMARY BACKGROUND DATA

The surgical death rate after resection of HCC has greatly improved in recent years, but the long-term prognosis remains unsatisfactory. It remains unknown whether the survival results after resection of HCC have improved within the past decade.

METHODS

The clinicopathologic and follow-up data of 377 patients who underwent curative resection of HCC between January 1989 and January 1999 were prospectively collected. These patients were categorized according to two time periods: before 1994 (group 1, n = 136) and after 1994 (group 2, n = 241). The two groups were compared for clinicopathologic data and survival results. The prognostic factors for disease-free survival were further analyzed to identify the factors that might have led to improved survival outcomes.

RESULTS

The overall and disease-free survival results were significantly better in group 2 compared with group 1. Patients in group 2 had significantly higher proportions of subclinical presentation, small tumors, and tumors of early pTNM stage. There were also significantly lower frequencies of histologic margin involvement, less intraoperative blood loss, and a lower transfusion rate in group 2. By multivariate analysis, early pTNM stage, subclinical HCC, and no perioperative transfusion were independent favorable prognostic factors for disease-free survival.

CONCLUSIONS

Significant improvement of overall and disease-free survival results after resection of HCC has been achieved within the past decade as a result of advances in the diagnosis and surgical management of HCC. Earlier diagnosis of HCC by better imaging modalities, increased detection of subclinical HCC by screening of high-risk patients, and a reduced perioperative transfusion rate were identified as the major contributory factors for the improved outcomes.

Soluble E-cadherin is a valid prognostic marker in gastric carcinoma

BACKGROUND

Gastric cancer remains a major cause of cancer mortality globally but no good prognostic tumour marker is available. Soluble fragment of E-cadherin protein has been reported to increase in the sera of patients with cancer and recently was found to be elevated in 67% of patients with gastric cancer.

AIMS

To investigate if serum soluble E-cadherin is a valid prognostic marker in gastric cancer.

METHODS

Concentrations of soluble E-cadherin from 116 patients with histologically confirmed gastric adenocarcinoma and 40 healthy subjects were measured using an immunoenzymometric method with a commercially available sandwich ELISA kit based on monoclonal antibodies.

RESULTS

The logarithm of the means of soluble E-cadherin concentration was significantly higher in patients with gastric cancers (mean 3.85 (SD 0.28)) than in healthy subjects (3.71 (0.18)) (p=0.001), and in palliative/conservatively treated cancers (3.91 (0.35)) than in operable cancers (3.78 (0.19)) (p=0.015). The logarithm of the concentrations correlated with tumour size (p=0.032) and carcinoembryonic antigen concentrations (p=0.001). The cut off value calculated from discriminant analysis on operability and inoperability/palliative treatment was 7025 ng/ml. Soluble E-cadherin concentrations higher than this cut off value predicted tumour (T4) depth invasion (p=0.020, confidence interval (CI) 1.008-1.668) and palliative/conservative treatment (p=0.023, CI 1.038-2.514). In contrast, the relative risks for lymph node (N2) metastasis, distant metastasis, and stage III/IV disease were 1.41, 1.33, and 1.55 respectively, despite not reaching statistical significance.

CONCLUSION

Serum soluble E-cadherin is a potential valid prognostic marker for gastric cancer. A high concentration predicts palliative/conservative treatment and T4 invasion.

A dinoflagellate mutant with higher frequency of multiple fission

The dinoflagellate Crypthecodinium cohnii Biecheler propagates by both binary and multiple fission. By a newly developed mutagenesis protocol based on using ethyl methanesulfonate and a cell size screening method, a cell cycle mutant, mf2, was isolated with giant cells which predominantly divide by multiple fission. The average cell size of the mutant mf2 is larger than the control C. cohnii. Cell cycle synchronization experiments suggest that mutant mf2, when compared with the control strain, has a prolonged G1 phase with a corresponding delay of the G2 + M phase.

Management of gallstone cholangitis in the era of laparoscopic cholecystectomy

HYPOTHESIS

The combined endoscopic and laparoscopic approach is safe and effective in managing gallstone cholangitis in the era of laparoscopic cholecystectomy (LC).

DESIGN

Retrospective case series.

SETTING

University teaching hospital.

PATIENTS

One hundred eighty-four consecutive patients with gallstone cholangitis treated between January 1995 and December 1998.

INTERVENTIONS

The main treatments were endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) followed by interval LC. Open or laparoscopic common bile duct exploration (OCBDE or LCBDE) was used when ERCP or ES failed.

MAIN OUTCOME MEASURES

Success of various interventions, morbidity and mortality, and long-term incidence of recurrent biliary symptoms.

RESULTS

Endoscopic retrograde cholangiopancreatography was successful in 175 patients (95%), with bile duct stones found in 147 (84%). Endoscopic stone clearance by ES was achieved in 132 patients (90%). Morbidity rate after ERCP or ES was 4.0% (n = 7), and overall mortality rate from cholangitis was 1.6% (n = 3). After bile duct stone clearance, 82 patients underwent LC with a conversion rate of 9.8% (n = 8) and a morbidity rate of 3.6% (n = 3). Eighteen patients underwent OCBDE with a morbidity rate of 33% (n = 6), and 3 underwent LCBDE with 1 conversion and no morbidity. There was no operative mortality. Seventy-eight patients were managed conservatively after endoscopic clearance of bile duct stones. Follow-up data were available in 101 patients with cholecystectomy and 73 patients with gallbladder in situ. During a median follow-up of 24 months, recurrent biliary symptoms occurred in 5.9% (n = 6) and 25% (n = 18), respectively (P =.001). In both groups, the most common recurrent symptom was cholangitis (n = 5 and n = 14, respectively). Gallbladder in situ (risk ratio, 4.16; 95% confidence interval, 1.39-12.50; P =.01) and small-size papillotomy (risk ratio, 2.94; 95% confidence interval, 1. 07-8.10; P =.04) were significant risk factors for recurrent biliary symptoms.

CONCLUSIONS

Endoscopic sphincterotomy for biliary drainage and stone removal, followed by interval LC, is a safe and effective approach for managing gallstone cholangitis. Patients with gallbladder left in situ after ES have an increased risk of recurrent biliary symptoms. Laparoscopic cholecystectomy should be recommended after endoscopic management of cholangitis except in patients with prohibitive surgical risk.33333333333333333333333

Determining resectability for hepatocellular carcinoma: the role of laparoscopy and laparoscopic ultrasonography

We reviewed our experience with preoperative determination of resectability in patients with hepatocel-lular carcinoma (HCC) over the last 10 years, and evaluated the role of laparoscopy with laparoscopic ultrasonography (USG) since we instituted this technique in June 1994. From January 1989 to December 1998, 500 of 1741 patients with HCC (28.7%) were considered suitable for hepatic resection after preoperative assessment. Significantly more contrast-enhanced computed tomography (CT) scans and fewer percutaneous USGs or hepatic arteriograms were performed in the 299 patients managed since June 1994 (group 2) than in the 201 patients managed before then (group 1). One hundred and ninety-eight patients in group 2 (66%) underwent laparoscopy with laparoscopic USG. Unresectable disease was found in 41 patients in group 1 (20.4%) (all at laparotomy), and in 68 patients in group 2 (22.7%) (16 at laparotomy without laparoscopic examination, 31 at laparoscopic examination alone, and 21 at laparotomy after an inconclusive laparoscopic examination) (P = 0.5). The most common features of unresectable disease were the presence of bilobar intrahepatic metastases and an inadequate liver remnant with cirrhosis. The adoption of the laparoscopic examination after June 1994 improved the overall resection rate at laparotomy in group 2 from 77.3% to 86. 2%, which was better than that in group 1 (79.6%, P = 0.057). For patients with unresectable disease, the operation time and hospital stay were significantly shorter in group 2. The postoperative morbidity and mortality rates were 9.8% and 4.9%, respectively, in group 1, and 5.9% and 2.9% in group 2. There was no operative morbidity in the 31 patients who had unresectable disease detected by the laparoscopic examination alone. Laparoscopy with laparoscopic USG avoids unnecessary laparotomy, and has a definite role in determining resectability in patients with HCC.

Pharmacokinetics of ciprofloxacin in the human eye: a clinical study and population pharmacokinetic analysis

Ciprofloxacin, a fluoroquinolone antibiotic active against a wide variety of bacteria, is one of a few antibiotics which enters the human eye after oral administration. However, little is known about its pharmacokinetics in the human eye. One or two oral doses of 750 mg of ciprofloxacin (at a 12-h interval) were administered to 48 patients at various times prior to ocular surgery. Clotted blood, aqueous, and vitreous were collected at surgery, and the concentrations of ciprofloxacin were assayed by high-performance liquid chromatography. Our data were combined with those of others, and a population pharmacokinetic analysis was conducted. The concentrations of ciprofloxacin in both aqueous and vitreous were lower than those in serum and peaked at a later time. The pharmacokinetics of ciprofloxacin in aqueous and vitreous were fitted to a compartmental model in which the antibiotic was transferred into and out of the two compartments (aqueous and vitreous) by first-order processes. Population pharmacokinetic software, P-Pharm, was used to calculate the mean half-lives of the loss of ciprofloxacin from aqueous and vitreous, which were 3.5 and 5.3 h, respectively. At steady state, the mean ratios of then concentrations in aqueous and vitreous to the concentrations in serum were 23 and 17%, respectively. After the administration of one or two doses of 750 mg of ciprofloxacin, the concentrations in both aqueous and vitreous in a number of patients were lower than the MICs at which 90% of isolates are inhibited (0.5 mg/liter) for common intraocular bacterial pathogens. Simulations of concentrations in the eye after the administration of higher doses (1,500 mg of ciprofloxacin as a single dose, two doses of 750 mg 2 h apart, and 750 mg every 6 h) indicated that in approximately 20% of patients the concentrations would still be below 0.5 mg/liter. Although oral ciprofloxacin may be a beneficial adjunctive therapy, the use of oral ciprofloxacin alone may not be adequate for perioperative prophylaxis or for treatment of bacterial endophthalmitis.

Major hepatectomy for hepatocellular carcinoma in patients with an unsatisfactory indocyanine green clearance test

BACKGROUND

Liver failure is the commonest cause of postoperative death in patients with hepatocellular carcinoma (HCC). With the improvement in operative technique and perioperative care, the limit of hepatic functional reserve may be lowered. The aim of this study was to evaluate the postoperative morbidity, mortality and survival rates in patients with an indocyanine green (ICG) retention value higher than 14 per cent, after major hepatectomy for HCC.

METHODS

From January 1994 to December 1997, 117 patients underwent major hepatectomy for HCC; 92 patients had preoperative ICG retention at 15 min lower than 14 per cent (median 8.3 (range 1.6-13.8) per cent), while 25 patients had ICG retention greater than 14 per cent (17.4 (range 14.3-35.3) per cent). Data were collected prospectively and analysed retrospectively.

RESULTS

The two groups of patients were similar in terms of age, sex ratio, preoperative platelet count, liver biochemistry, Child-Pugh status and operative procedures performed, but the prothrombin time was significantly longer in the high ICG group. The operative blood loss (1.5 litres), the amount of blood transfused and the number of patients requiring blood transfusion were similar. The postoperative complication rate (41 versus 40 per cent), duration of hospital stay (12 versus 13 days), hospital mortality rate (1 versus 4 per cent) and median survival time (47 versus 45 months) were not significantly different.

CONCLUSION

With meticulous surgical technique to decrease intraoperative blood loss and good perioperative care, selected patients with limited hepatic functional reserve can achieve a good immediate postoperative result and a survival rate similar to that of patients with good hepatic functional reserve.

Carcinoma of the colon with synchronous hepatic metastasis in a cirrhotic liver harboring a hepatocellular carcinoma

Tumor metastasis to a cirrhotic liver is rare. It has been suggested that colorectal cancer does not metastasize to the cirrhotic liver. We reported a 65 year-old man, a known carrier of hepatitis B surface antigen, diagnosed to have hepatocellular carcinoma with routine screening. A partial hepatectomy with resection of segments VI and VII was performed. The hepatectomy specimen revealed a 4.5 cm diameter HCC in a cirrhotic liver. Incidentally, 0.8 cm diameter ulcer at the descending colon. Histological examination of the left hemicolectomy specimen showed a moderately differentiated adenocarcinoma.

Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths

OBJECTIVE

The authors report on the surgical techniques and protocol for perioperative care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hepatectomy results are analyzed with the aim of further reducing the postoperative morbidity rate.

SUMMARY BACKGROUND DATA

In recent years, hepatectomy has been performed with a mortality rate of <10% in patients with HCC, but a zero hospital mortality rate in a large patient series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC have evolved yearly into a final standardized protocol that reduced the hospital mortality rate from 28% in 1989 to 0% in 1996 and 1997.

METHODS

Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion, and ischemic injury to the liver remnant in hepatectomy. Postoperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutritional support that consisted of branched-chain amino acid-enriched solution, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed each year to assess the influence of the evolving surgical techniques and perioperative care on outcome.

RESULTS

Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and chronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectively. There were no significant changes in the patient characteristics throughout the 9-year period, but there were significant reductions in intraoperative blood loss and blood transfusion requirements. From 1994 to 1997, the median blood transfusion requirement was 0 ml, and 64% of the patients did not require a blood transfusion. The postoperative morbidity rate remained the same throughout the study period. Complications in the patients operated on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, biliary leakage, and hepatic coma, were absent. By univariate analysis, the volume of blood loss, volume of blood transfusions, and operation time were correlated positively with postoperative morbidity rates in 1996 and 1997. Stepwise logistic regression analysis revealed that the operation time was the only parameter that correlated significantly with the postoperative morbidity rate.

CONCLUSION

With appropriate surgical techniques and perioperative management to preserve function of the liver remnant, hepatectomy for HCC can be performed without hospital deaths. To improve surgical outcome further, strategies to reduce the operation time are being investigated.

Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths

OBJECTIVE

The authors report on the surgical techniques and protocol for perioperative care that have yielded a zero hospital mortality rate in 110 consecutive patients undergoing hepatectomy for hepatocellular carcinoma (HCC). The hepatectomy results are analyzed with the aim of further reducing the postoperative morbidity rate.

SUMMARY BACKGROUND DATA

In recent years, hepatectomy has been performed with a mortality rate of <10% in patients with HCC, but a zero hospital mortality rate in a large patient series has never been reported. At Queen Mary Hospital, Hong Kong, the surgical techniques and perioperative management in hepatectomy for HCC have evolved yearly into a final standardized protocol that reduced the hospital mortality rate from 28% in 1989 to 0% in 1996 and 1997.

METHODS

Surgical techniques were designed to reduce intraoperative blood loss, blood transfusion, and ischemic injury to the liver remnant in hepatectomy. Postoperative care was focused on preservation and promotion of liver function by providing adequate tissue oxygenation and immediate postoperative nutritional support that consisted of branched-chain amino acid-enriched solution, low-dose dextrose, medium-chain triglycerides, and phosphate. The pre-, intra-, and postoperative data were collected prospectively and analyzed each year to assess the influence of the evolving surgical techniques and perioperative care on outcome.

RESULTS

Of 330 patients undergoing hepatectomy for HCC, underlying cirrhosis and chronic hepatitis were present in 161 (49%) and 108 (33%) patients, respectively. There were no significant changes in the patient characteristics throughout the 9-year period, but there were significant reductions in intraoperative blood loss and blood transfusion requirements. From 1994 to 1997, the median blood transfusion requirement was 0 ml, and 64% of the patients did not require a blood transfusion. The postoperative morbidity rate remained the same throughout the study period. Complications in the patients operated on during 1996 and 1997 were primarily wound infections; the potentially fatal complications seen in the early years, such as subphrenic sepsis, biliary leakage, and hepatic coma, were absent. By univariate analysis, the volume of blood loss, volume of blood transfusions, and operation time were correlated positively with postoperative morbidity rates in 1996 and 1997. Stepwise logistic regression analysis revealed that the operation time was the only parameter that correlated significantly with the postoperative morbidity rate.

CONCLUSION

With appropriate surgical techniques and perioperative management to preserve function of the liver remnant, hepatectomy for HCC can be performed without hospital deaths. To improve surgical outcome further, strategies to reduce the operation time are being investigated.

Prolonged survival in selected patients following surgical resection for pulmonary metastasis from hepatocellular carcinoma

BACKGROUND

Pulmonary metastasis is the commonest site of extrahepatic spread from hepatocellular carcinoma (HCC). The aim of the present study was to evaluate the efficacy of surgical management in patients with solitary pulmonary metastases from HCC.

METHODS

This was a retrospective study of patients with HCC admitted for hepatectomy from July 1972 to June 1995. The records of patients who had a pulmonary resection for histologically proven pulmonary recurrence after curative hepatectomy were selected for analysis.

RESULTS

In the study interval, 380 patients with HCC underwent hepatectomy. Some 48 patients (12.6 per cent) developed pulmonary metastases documented pathologically or radiologically. Nine (seven men and two women) were suitable for curative pulmonary resection. The median disease-free survival between hepatectomy and appearance of the lung metastasis was 21 months. The median survival after pulmonary resection was 42 months, and the 1-, 2- and 5-year survival rates were 100, 78 and 67 per cent respectively.

CONCLUSION

Pulmonary resection for metastases from HCC resulted in long-term survival in these highly selected patients.

Hemoperitoneum caused by spontaneous rupture of a true splenic cyst

A 34 year-old man presented with hemoperitoneum from a spontaneously ruptured spleen. At laparotomy, a 5-cm diameter splenic cyst was found to be ruptured. Histological examination confirmed the diagnosis of a true splenic cyst of the mesothelial type. Spontaneous rupture with hemoperitoneum is a rare but potentially lethal complication of a true splenic cyst.

Prolonged survival in selected patients following surgical resection for pulmonary metastasis from hepatocellular carcinoma

BACKGROUND

Pulmonary metastasis is the commonest site of extrahepatic spread from hepatocellular carcinoma (HCC). The aim of the present study was to evaluate the efficacy of surgical management in patients with solitary pulmonary metastases from HCC.

METHODS

This was a retrospective study of patients with HCC admitted for hepatectomy from July 1972 to June 1995. The records of patients who had a pulmonary resection for histologically proven pulmonary recurrence after curative hepatectomy were selected for analysis.

RESULTS

In the study interval, 380 patients with HCC underwent hepatectomy. Some 48 patients (12.6 per cent) developed pulmonary metastases documented pathologically or radiologically. Nine (seven men and two women) were suitable for curative pulmonary resection. The median disease-free survival between hepatectomy and appearance of the lung metastasis was 21 months. The median survival after pulmonary resection was 42 months, and the 1-, 2- and 5-year survival rates were 100, 78 and 67 per cent respectively.

CONCLUSION

Pulmonary resection for metastases from HCC resulted in long-term survival in these highly selected patients.

Hepatic cryosurgery for recurrent hepatocellular carcinoma after hepatectomy: a preliminary report

BACKGROUND AND OBJECTIVES

The treatment of choice for recurrent hepatocellular carcinoma (HCC) is repeated resection. However, only a small percentage of patients are suitable for further hepatic resection. The aim of this study was to evaluate the surgical risk and operative outcome of hepatic cryosurgery in patients with recurrent HCC.

METHODS

A retrospective analysis of patients with recurrent HCC after previous curative hepatectomy treated with cryosurgery. Four patients with recurrent HCC not suitable for further resection were enrolled for cryosurgery, their clinical parameters, the operative details and outcome were studied.

RESULTS

No intraoperative or postoperative complications were noted. The duration of operation ranged from 3-5.2 hr and the operative blood loss from 173-1,300 ml. All patients are still alive with survival after cryosurgery ranging from 12-23 mo (25-63 mo after the hepatic resection). Three patients showed evidence of recurrent disease and one patient was disease free.

CONCLUSIONS

Hepatic cryosurgery is a safe therapy for patients with unresectable recurrent HCC.

Hepatic cryosurgery for recurrent hepatocellular carcinoma after hepatectomy: a preliminary report

BACKGROUND AND OBJECTIVES

The treatment of choice for recurrent hepatocellular carcinoma (HCC) is repeated resection. However, only a small percentage of patients are suitable for further hepatic resection. The aim of this study was to evaluate the surgical risk and operative outcome of hepatic cryosurgery in patients with recurrent HCC.

METHODS

A retrospective analysis of patients with recurrent HCC after previous curative hepatectomy treated with cryosurgery. Four patients with recurrent HCC not suitable for further resection were enrolled for cryosurgery, their clinical parameters, the operative details and outcome were studied.

RESULTS

No intraoperative or postoperative complications were noted. The duration of operation ranged from 3-5.2 hr and the operative blood loss from 173-1,300 ml. All patients are still alive with survival after cryosurgery ranging from 12-23 mo (25-63 mo after the hepatic resection). Three patients showed evidence of recurrent disease and one patient was disease free.

CONCLUSIONS

Hepatic cryosurgery is a safe therapy for patients with unresectable recurrent HCC.

Hepatic cryosurgery for recurrent hepatocellular carcinoma after hepatectomy: a preliminary report

BACKGROUND AND OBJECTIVES

The treatment of choice for recurrent hepatocellular carcinoma (HCC) is repeated resection. However, only a small percentage of patients are suitable for further hepatic resection. The aim of this study was to evaluate the surgical risk and operative outcome of hepatic cryosurgery in patients with recurrent HCC.

METHODS

A retrospective analysis of patients with recurrent HCC after previous curative hepatectomy treated with cryosurgery. Four patients with recurrent HCC not suitable for further resection were enrolled for cryosurgery, their clinical parameters, the operative details and outcome were studied.

RESULTS

No intraoperative or postoperative complications were noted. The duration of operation ranged from 3-5.2 hr and the operative blood loss from 173-1,300 ml. All patients are still alive with survival after cryosurgery ranging from 12-23 mo (25-63 mo after the hepatic resection). Three patients showed evidence of recurrent disease and one patient was disease free.

CONCLUSIONS

Hepatic cryosurgery is a safe therapy for patients with unresectable recurrent HCC.

Thermal characteristics of a hepatic cryolesion formed in vitro by a 3-mm implantable cryoprobe

The objective of the investigation was to characterize the hepatic cryolesion formed with an implantable needle (3 x 100 mm) cryoprobe. This was used to produce cryolesions in isolated porcine liver tissue equilibrated to 37 degrees C in a water bath. The shape, size, and temperature zones within the cryolesion and the effect of single versus repeated freeze-thaw cycles on cryolesion size were studied. The final shape of the cryolesion at 15-20 min freezing was cylindrical and its distal hemispherical end extended 8 mm beyond the tip of the cryoprobe. The rate of increase in maximum diameter was logarithmic and decreased from 4.7 mm/min during the first 5 min to 0.4 mm/min during the fourth 5-min period of freezing. By contrast, the rate of increase in volume was linear and ranged from 9.6 to 7.9 ml/min during the corresponding periods. The volume of the hepatic cryolesion after 20 min of continuous freezing was significantly greater than that of the cryolesion formed with 20 min of cumulative freezing interrupted by a 5-min spontaneous thaw. The ultimate temperatures reached and the cooling rates varied in different zones within the cryolesion depending on distances away from and alongside the cryoprobe. Diameter measurements taken in isolation do not reflect the actual growth rate of the cryolesion. Volume measurements define more accurately the amount of tissue frozen and left in situ. Prolonged freezing beyond 20 min did not increase the diameter of the cryolesion. A single continuous freeze produces a larger cryolesion than two freeze-thaw cycles of the same freezing duration.