Surgical morbidity and mortality in obturator hernia: a 10-year retrospective risk factor evaluation.

UNLABELLED: Obturator hernia is a rare condition occurring predominantly in elderly, thin, female patients and causes significant morbidity and mortality. Due to obscure presenting symptoms and signs, diagnosis and management are often delayed. While previous studies have attributed the high mortality to the delay in diagnosis, current literature remains controversial about this issue. The aim of this study was to identify peri-operative risk factors associated with mortality in patients with obturator hernia at our hospital. METHODS: We retrospectively reviewed our series of 20 consecutive patients who underwent surgical repair of 21 obturator herniae and examined their clinical characteristics and post-operative outcomes. RESULTS: Overall mortality rate was 47.6 %. Survivors did not differ from non-survivors in terms of basic demographics and operative parameters (operative time, blood loss and the need for intestinal resection). The use of computed tomography for pre-operative diagnosis was associated with reduced need for bowel resection, but did not result in shorter time to operation or improved morbidity and mortality. Our series demonstrated that early timing of surgery alone did not improve operative outcome. The absence of bowel motion and a high serum urea level at the time of operation were independent factors for mortality. CONCLUSIONS: Obturator hernia remains a highly lethal surgical emergency. Adequate peri-operative resuscitation may be the key to further improvement in surgical outcomes.

Early outcome after emergency gastrectomy for complicated peptic ulcer disease.

OBJECTIVE. To analyse outcomes of patients who underwent emergency gastrectomy for complicated peptic ulcer disease. DESIGN. Prognostic study on a historical cohort. SETTING. A regional hospital in Hong Kong. PATIENTS. Patients who underwent emergency gastrectomy from 2000 to 2009 in our hospital. MAIN OUTCOME MEASURES. Primary outcome measures were in-hospital mortality and the predictors of such deaths. Secondary outcome measures were 7-day mortality, 30-day mortality, and morbidities. RESULTS. In all, 112 patients had emergency gastrectomies performed for complicated peptic ulcer disease during the study period. In-hospital mortality was 30%. In the univariate analysis, old age, duodenal ulcer, failed primary surgery, gastrojejunostomy anastomosis for reconstruction, hand-sewn technique for duodenal stump closure, use of a sump drain, low haemoglobin level, preoperative blood transfusion, prolonged prothrombin time, and high creatinine or bilirubin levels were associated with an increased risk of in-hospital mortality. In the multivariate analysis, failed primary surgery, old age, and high creatinine level turned out to be independent risk factors. CONCLUSIONS. Emergency gastrectomy should be considered seriously as the primary treatment option in appropriately selected elderly patients, instead of salvage procedures to repair a perforation or control bleeding by plication.

Colorectal cancer surgery of octogenarians in Hong Kong: who will survive?

OBJECTIVE. To assess the accuracy of the Association of Coloproctology of Great Britain and Ireland scoring system in predicting the 30-day mortality after surgery for colorectal cancer in Hong Kong elderly (aged 80 years or more) patients. DESIGN. Early mortality outcome audit in a historical cohort. SETTING. Queen Elizabeth Hospital, Hong Kong. PATIENTS. All Chinese patients (aged 80 years or more) who underwent elective or emergency surgery for colorectal cancer in the Department of Surgery between January 2005 and December 2009. MAIN OUTCOME MEASURES. Receiver operating characteristic curve analyses were used to estimate the predictive ability of the score. RESULTS. In all, 180 patients with colorectal cancer were included in this review. The overall 30-day and hospital mortality rates were 29/180 (16%) and 31/180 (17%), respectively. The Association of Coloproctology of Great Britain and Ireland score was significantly higher among patients who died within 30 days (4.2 vs 3.1, P=0.0001), and was the only independent predictor for 30-day mortality by logistic regression (P=0.009; odds ratio=2.555; 95% confidence interval, 1.277-4.932). The mean score of this study population was 3.22 (median, 3.10), giving a predicted 30-day mortality rate of 16.0 to 17.4%, which corresponded with an observed 30-day mortality of 16.1% encountered in this study. The score had a significantly larger area under the curve for the 30-day mortality rates (odds ratio=0.811; 95% confidence interval, 0.722-0.849) as compared to the American Society of Anesthesiologists score (0.664; 0.589-0.735) [P=0.0001]. CONCLUSION. The Association of Coloproctology of Great Britain and Ireland scoring system can accurately predict the 30-day mortality rate of elderly Hong Kong Chinese patients (aged 80 years or more) operated on for colorectal cancer.

Clinical significance of CDX2-positive circulating tumour cells in colorectal cancer patients.

BACKGROUND: Our recent work has shown the feasibility of using a refined immunomagnetic enrichment (IE) assay to detect cytokeratin 20-positive circulating tumour cells (CK20 pCTCs) in colorectal cancer (CRC) patients. We attempted to improve the sensitivity for CRC by detecting another intestinal-type differentiation marker, CDX2 pCTCs, using the same methodology. METHODS: CDX2 pCTCs were detected in patients with CRC, colorectal adenoma (CAD), benign colorectal diseases (BCD), other common cancers (OCC) and normal subjects (NS). Statistical analysis was used to correlate CDX2 pCTCs to the clinicohistopathological factors, recurrence, metastasis and survival after follow-up for 42 months in CRC patients. RESULTS: CDX2 pCTCs were detected in 81% CRC patients (73 out of 90, median number=21.5 CTCs), 7.5% CAD patients (3 out of 40), 0% patients with BCD (0 out of 90), 2.5% patients with OCC (2 out of 80) and 0% NS (0 out of 40). Furthermore, statistical analysis showed that CDX2 pCTC numbers were associated with tumour- node-metastasis stage and lymph node status. Using the median CDX2 pCTC numbers as the cutoff points, stratified groups of CRC patients had significant differences in their recurrence and survival. CONCLUSIONS: This study showed that the refined IE assay can detect CDX2 pCTCs with high sensitivity and that CDX2 pCTCs can generate clinically important information for CRC patients.

A novel de novo BRCA1 mutation in a Chinese woman with early onset breast cancer.

Germline mutations in the two breast cancer susceptibility genes, BRCA1 and BRCA2 account for a significant portion of hereditary breast/ovarian cancer. De novo mutations such as multiple exon deletion are rarely occurred in BRCA1 and BRCA2. During our mutation screening for BRCA1/2 genes to Chinese women with risk factors for hereditary breast/ovarian cancer, we identified a novel germline mutation, consisting of a deletion from exons 1 to 12 in BRCA1 gene, in a patient diagnosed with early onset triple negative breast cancer with no family history of cancer. None of her parents carried the mutation and molecular analysis showed that this novel de novo germline mutation resulted in down-regulation of BRCA1 gene expression.

If not appendicitis, then what else can it be? A retrospective review of 1492 appendectomies.

OBJECTIVE: To audit the appendectomies at our institute, and summarise atypical pathological results with a discussion of appropriate management. DESIGN. Retrospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: All patients who underwent appendectomy for presumed acute appendicitis from June 2003 to June 2008 were recruited. Incidental appendectomy was excluded. Patient demographics, pathological findings, and surgical outcomes were analysed. RESULTS. The overall negative appendectomy rate was 18.2%. Female patients of reproductive age (11-50 years) conferred an independent risk for a higher negative appendectomy rate than other females (28.7% vs 11.5%; P<0.001). The overall perforation rate was 22.5%; the extremes of age (<11 or >70 years) conferred an independent risk of perforated appendicitis (25.2% vs 16.3%; P=0.002). Preoperative imaging was not associated with a lower negative appendectomy rate or rate for perforated appendicitis (P=0.205 and 0.218, respectively). Multivariate analysis suggested that a preoperative white cell count of less than 13.5 x 10(9) /L was an independent predictor of negative appendectomy (P<0.001); the body temperature and pulse rate of the patients with perforated appendicitis were higher than in those without perforation (P=0.004 and 0.003, respectively). Only 4.0% of the appendectomy specimens contained other appendiceal pathologies. Appendiceal diverticulitis was the most common inflammatory pathology, contributing to 2.7% of all appendectomies, followed by granulomatous appendicitis. In this series there were eight carcinoid tumours, three adenocarcinomas, two mucinous cystadenomas; tubular adenoma, metastatic deposition, mucinous cystadenocarcinoma and pseudomyxoma peritonei each occurred in one patient only. CONCLUSIONS: A more focused utilisation of preoperative imaging in females of reproductive age and patients at the extremes of age is suggested. Long-term follow-up should be offered to patients with granulomatous appendicitis and neoplastic appendiceal diseases.

A Chinese version of the Sleep Apnea Quality of Life Index was evaluated for reliability, validity, and responsiveness.

OBJECTIVE: Obstructive sleep apnea (OSA) is a common disorder in many ethnic populations. Patients with OSA have impaired health-related quality of life (HRQOL). No sleep apnea-specific HRQOL measure has been validated in Chinese patients. STUDY DESIGN AND SETTING: A cross-sectional sample of 106 Chinese OSA patients and a longitudinal sample of 51 patients in Hong Kong completed a Chinese (Cantonese) version of SAQLI for assessment of its acceptability, scaling assumptions, reliability, validity, and responsiveness. RESULTS: The instrument was understood and seen as relevant by 97% of subjects. Internal consistency, test-retest reliability, item-scale convergent validity and discriminatory validity, and construct validity were good to excellent. Construct validity was confirmed by significant correlations with SF-36 subscale scores. However, factor analysis showed that only items of daily functioning and symptom domains all loaded on the hypothesized scales. Longitudinal data showed that SAQLI was more responsive than SF-36 to changes after treatment. CONCLUSION: Hence, this version of SAQLI was an acceptable, psychometrically valid, and responsive HRQOL measure for evaluating impact of illness and treatment effectiveness in Chinese OSA patients.

An optimised protocol for the extraction of non-viral mRNA from human plasma frozen for three years.

AIMS: To detect non-viral mRNA in human plasma that has been frozen for three years using a new protocol. METHODS: Plasma from 15 patients with colorectal cancer and 10 normal subjects was separated and frozen with Trizol at -80 degrees C for three years. As a control measure, plasma from 10 of the 15 patients was separated using the same protocol but no Trizol during storage. After three years, all samples were extracted using Trizol and RNeasy before the reverse transcriptase polymerase chain reaction was performed to detect non-viral beta catenin mRNA. In addition, extraction of three plasma samples by Trizol or RNeasy independently was carried out for comparison. RESULTS: beta Catenin mRNA was detected in all 15 patient plasma samples and only one of the 10 normal subjects. In contrast, no beta catenin mRNA was found in the control and patient samples that were independently extracted by Trizol and RNeasy kit. CONCLUSIONS: This new protocol is a reliable method for extracting non-viral mRNA from the plasma of patients with cancer after longterm storage for three years. Extractions using Trizol and RNeasy kits independently could not isolate mRNA with sufficient quantity and quality for detection.

Percutaneous transhepatic choledochoscopic removal of intrahepatic stones.

BACKGROUND: Treatment of hepatolithiasis is complex and difficult. With the advent of biliary endoscopy and radiological intervention, percutaneous choledochoscopic removal of intrahepatic stones has become a well established procedure. METHODS: Seventy-nine patients with intrahepatic stones that were removed by percutaneous transhepatic choledochoscopy (PTCS) between 1993 and 2001 were studied retrospectively. The results of the procedure and the long-term outcome of these patients were analysed. RESULTS: The success rate of choledochoscopic removal of intrahepatic stones was 76.8 per cent. Complications occurred in 17 patients (21.5 per cent). Removal of stones predominantly on the right side was difficult using this method. Cholangitis occurred in about one third of patients within 3-5 years after PTCS. For patients with a stricture, cholangitis recurred gradually over the years of follow-up. CONCLUSION: Intrahepatic stricture was the major determinant for the recurrence of stones or symptoms. Hepatic resection should be offered to these patients if the disease is localized in one liver segment or lobe. In other cases, percutaneous choledochoscopy and stricture dilatation is a useful solution, and may reduce further damage to the liver.

Coronavirus as a possible cause of severe acute respiratory syndrome.

BACKGROUND: An outbreak of severe acute respiratory syndrome (SARS) has been reported in Hong Kong. We investigated the viral cause and clinical presentation among 50 patients. METHODS: We analysed case notes and microbiological findings for 50 patients with SARS, representing more than five separate epidemiologically linked transmission clusters. We defined the clinical presentation and risk factors associated with severe disease and investigated the causal agents by chest radiography and laboratory testing of nasopharyngeal aspirates and sera samples. We compared the laboratory findings with those submitted for microbiological investigation of other diseases from patients whose identity was masked. FINDINGS: Patients' age ranged from 23 to 74 years. Fever, chills, myalgia, and cough were the most frequent complaints. When compared with chest radiographic changes, respiratory symptoms and auscultatory findings were disproportionally mild. Patients who were household contacts of other infected people and had older age, lymphopenia, and liver dysfunction were associated with severe disease. A virus belonging to the family Coronaviridae was isolated from two patients. By use of serological and reverse-transcriptase PCR specific for this virus, 45 of 50 patients with SARS, but no controls, had evidence of infection with this virus. INTERPRETATION: A coronavirus was isolated from patients with SARS that might be the primary agent associated with this disease. Serological and molecular tests specific for the virus permitted a definitive laboratory diagnosis to be made and allowed further investigation to define whether other cofactors play a part in disease progression.

Surgical treatment of parastomal hernia complicating sigmoid colostomies.

PURPOSE: Parastomal hernia is a common late complication of colostomy. Surgical approach to the repair of parastomal hernia is controversial. Results of surgical treatment are disappointing. The aim of this study was to assess the outcome of surgical treatment of parastomal hernia. METHOD: This article reports a retrospective review of those patients who had undergone a surgical treatment of parastomal hernia complicating sigmoid colostomy. The indications, surgical procedures, complications, and outcome were carefully studied. RESULTS: There were 43 surgical treatments of parastomal hernia. Sixteen underwent simple local repair; 25 stomas were relocated, and 2 were locally repaired with mesh. Overall recurrence was 18 of 40 (45 percent). Recurrences for fascial repair and stoma relocation were 6 of 13 (46 percent) and 10 of 25 (40 percent), respectively. Stoma relocation could be accomplished without formal laparotomy in 19 of 25 cases. Incisional hernia occurred in only 2 of these 25 relocations. CONCLUSION: Fascial repair alone can be performed for symptomatic small hernias because of its advantage of minimal morbidity. Stoma relocation without formal laparotomy can be advocated for larger hernias. A combination of local resite together with mesh reinforcement may be the alternative for further improvement of results.

Use of non-invasive positive-pressure ventilation for acute respiratory failure: prospective study.

OBJECTIVE: To study the effectiveness and safety of non-invasive positive-pressure ventilation in the management of acute respiratory failure. DESIGN: Prospective study. SETTING: Regional public hospital, Hong Kong. PATIENTS: One hundred and eighty-nine haemodynamically stable adult Chinese patients with acute respiratory failure (119 men and 70 women; mean age, 71.2 years [range, 18-92 years]) who were treated with non-invasive positive-pressure ventilation as the primary mode of ventilatory assistance from 1 January 1996 to 31 December 1998. MAIN OUTCOME MEASURES: Arterial blood gas measurements, respiratory rate, airway pressures used, use of endotracheal intubation, and standardised mortality ratio. RESULTS: Fifty-two patients had hypoxaemic respiratory failure (group I); 97 had hypercapnic respiratory failure (group II); and 40 had either type with advanced co-morbidities and were not planned to receive endotracheal intubation (group III). For groups I and II, the overall mean duration of non-invasive positive-pressure ventilation was 56.2 hours. Improvements in gas exchange were seen in approximately 71% of these patients, endotracheal intubation was not needed for 82%, and the standardised mortality ratio was 0.86. The hospital survival rate was approximately 93% in non-intubated patients and 41% in intubated patients. Predictors of success were reduction in respiratory rate within 6 hours (P<0.005), and (for hypercapnic respiratory failure) increased pH and reduced arterial carbon dioxide tension within 24 hours (P<0.005). Patients with pneumonia had significantly higher failure rates (P<0.05). Group III patients were older, had higher Acute Physiology and Chronic Health Evaluation II scores, and required longer ventilatory support, but their gas exchange response rate was 68%. The only complication of treatment was minor facial skin abrasions. CONCLUSION: Non-invasive positive-pressure ventilation is effective in treating haemodynamically stable patients with acute respiratory failure and causes few and minor complications.

Lung and heart-lung transplantation in Hong Kong.

OBJECTIVE: To review the donor and recipient selection criteria, surgical techniques, perioperative and post-operative management, and complications of lung/heart-lung transplantation. DATA SOURCES: Medline and non-Medline search of the relevant English literature, local data, and personal experience. STUDY SELECTION: Studies containing supporting evidence were selected. DATA EXTRACTION: Data were extracted and analysed independently by the authors. DATA SYNTHESIS: Lung/heart-lung transplantations are considered only for patients who have progressively disabling and end-stage disease. Numerous investigations of the recipient and rigorous matching between the donor and recipient are required. Factors such as maintaining the donor's haemodynamic stability, graft preservation, effective perioperative immunosuppression, and careful postoperative monitoring are key to a successful transplantation. Follow-up should include the home-monitoring of body weight, temperature, and spirometry, as well as regular chest X-rays, pulmonary function tests, and blood tests. So far, two double and two single lung transplantations, and one heart-lung transplantation have been performed in Hong Kong. CONCLUSION: Lung transplantation is an invaluable treatment modality for patients with end-stage lung disease.

Audit of laparoscopic cholecystectomy in a single center.

A continuous audit is required to ensure laparoscopic cholecystectomy (LC) is performed safely in the surgical community in general. A retrospective review of all LC done in a single center was performed. A total of 1,244 LC were attempted. The conversion rate was 12.4%, the complication rate 3.5%, and the bile duct injury rate 0.4%. Forty percent of bile duct injury occurred after conversion. A decreasing trend of complication rate was seen in the early part of the series, then the rate steadied at about 2.5-3%. A higher threshold of conversion may not increase the bile duct injury rate. However, good laparoscopic technique and adequate experience are prerequisites to safe LC.

The investigation and management of thyroid nodules--a retrospective review of 183 cases.

The management of the patient with a thyroid nodule remains a clinical challenge because of its risk of malignancy. This is a retrospective audit of 183 patients undergoing thyroidectomy for thyroid nodules at the Queen Elizabeth Hospital, Hong Kong, in 1994. The history, physical examination and investigations done were charted and analysed against the final histopathology of the specimens. Age, sex, symptom duration and nodularity were not associated with malignancy statistically, whereas a nodule hard in consistency was shown to be associated with malignancy (P < 0.05). The sensitivity and specificity of ultrasonography, radionuclide scan and fine-needle aspiration cytology (FNAC) were 71% and 57%, 50% and 43%, and 93% and 60%, respectively. Hence, history and physical examination are unreliable for detecting malignant thyroid nodules and FNAC is mandatory. FNAC is superior to ultrasonography or radionuclide scan for evaluating thyroid nodules and should be used as the initial investigation.

Postoperative choledochoscopic removal of intrahepatic stones via a T tube tract.

BACKGROUND: The management of primary intrahepatic stones is extremely difficult. During operation it is often difficult to remove all the stones. The postoperative T tube tract provides an invaluable access to the intrahepatic system. METHODS: This paper reports a retrospective review of postoperative choledochoscopic removal of intrahepatic stones in a series of 44 patients. Special emphasis is placed on the result of the procedure and on the long-term outcome of patients. RESULTS: Overall, the procedure was successful in 22 of the 44 patients. Presence of strictures was associated significantly with failure rate (P = 0.002). There were complications in five patients; most subsided with conservative management. However, there was one procedure-related death in the series. Some 28 patients were followed for 16-115 months. The long-term outcome was significantly related to the success rate of choledochoscopic stone removal (P = 0.03). CONCLUSION: All intrahepatic stones should be removed. T tube choledochoscopy is the preferred method for treating retained intrahepatic stones. This should be supplemented with other modalities of treatment, such as endoscopic and radiological approaches, especially in patients with strictures.

Acute appendicitis---a recent audit of an old problem.

We conducted a retrospective review of all patients who had an appendicectomy performed at the Queen Elizabeth Hospital, Hong Kong, from January 1993 through December 1994. The diagnostic accuracy for true appendicitis was 74%. Nine per cent of patients had other pathologies, which also needed exploration. The diagnostic accuracy in female patients was 66%, compared with 82% for male patients (P<0.0001). Female patients aged between 15 to 40 years were diagnosed accurately 62% of the time, which has significantly lower than the rate for other female patients (P=0.016). the overall morbidity and mortality rates were 9.2% and 3%, respectively. Complicated appendicitis had a higher morbidity rate of 21%, compared with 9% for uncomplicated appendicitis (P<0.0001). Results for patients who were operated on the day of admission were compared with those who were operated on the day after admission. No significant difference in diagnostic accuracy (P=0.46), percentage of complicated appendicitis (P=0.7), and morbidity rate (P=0.8) was found.

Complications of an abdominal stoma: an analysis of 322 stomas.

This paper reports a series of 316 patients with 322 stomas, of which 156 were end-sigmoid colostomies (48.5%) and 123 urological ileal conduits (38.2%). An overall complication rate of 66.8% was detected, with parastomal herniation rate, stenotic rate, and prolapse rate of 31.1, 10.2 and 6.8%, respectively. Complications were detected much later in a urological stoma than in a colostomy. Patients bearing an abdominal stoma should be followed up stringently. The creation of an abdominal stoma should not be regarded as a minor surgical procedure. Certain stomas, such as loop transverse colostomy, should be avoided whenever possible.

Eight cases of Legionnaires' disease.

Eight patients with Legionnaires' disease were seen at one hospital in the summer of 1979. They presented in the same 12-day period with an illness of rapid onset characterized by fever, chills, malaise, profuse sweating and neurologic symptoms. Neutrophilia, a high erythrocyte sedimentation rate, proteinuria, hypoalbuminemia, hyponatremia, hypochloremia and abnormal liver enzyme levels in the serum were usually noted. The roentgenographic findings in the lungs ranged from segmental interstitial infiltration to panlobar pneumonia. Seven patients responded to erythromycin treatment, though one died suddenly, presumably of unrelated cardiac disease. The other patient died of a combination of renal and respiratory failure, with pulmonary edema.