High-dose omeprazole infusion compared with scheduled second-look endoscopy for prevention of peptic ulcer rebleeding: a randomized controlled trial.

BACKGROUND AND STUDY AIM: Previous studies have shown that both scheduled second-look endoscopy and high-dose continuous omeprazole infusion are effective in preventing peptic ulcer rebleeding. The aim of this noninferiority trial was to compare the efficacy of these two strategies for the prevention of rebleeding following primary endoscopic hemostasis. PATIENTS AND METHODS: Consecutive patients who received endoscopic treatment for bleeding peptic ulcers (actively bleeding, with nonbleeding visible vessels) were randomized to two treatment groups following hemostasis. One group (second-look endoscopy group) received the proton pump inhibitor (PPI) omeprazole as an intravenous bolus every 12 hours for 72 hours and a second endoscopy within 16 - 24 hours with retreatment for persistent stigmata of bleeding. The other group (PPI infusion group) received continuous high-dose omeprazole infusion for 72 hours. Patients who developed rebleeding underwent surgery if repeat endoscopic therapy failed. The primary outcome was the rebleeding rate within 30 days after initial hemostasis. The margin for noninferiority was set at 5 %. RESULTS: A total of 153 patients were randomized to the PPI infusion group and 152 to the second-look endoscopy group. Rebleeding occurred within 30 days in 10 patients (6.5 %) in the PPI infusion group and in 12 patients (7.9 %) in the second-look endoscopy group (P = 0.646). Surgery was required for rebleeding in six patients from the PPI infusion group and three patients in the second-look endoscopy group (P = 0.32). Intensive care unit stay, transfusion requirements, and mortality were not different between the groups. Patients in the second-look endoscopy group were discharged 1 day earlier than those in the PPI infusion group (P < 0.001). CONCLUSIONS: After endoscopic hemostasis, high-dose PPI infusion was not inferior to second-look endoscopy with bolus PPI in preventing peptic ulcer rebleeding. TRIAL REGISTRATION: ClinicalTrials.gov (NCT: 00164931).

Complication rates of central compartment dissection in papillary thyroid cancer.

BACKGROUND: The benefits of central compartment dissection (CCD) in papillary thyroid carcinoma (PTC) are still debatable and should be weighed against its potential risks. We aim to compare the complication rates in total thyroidectomy with and without CCD for patients with PTC. METHODS: This is a retrospective study on prospectively collected data from our cancer registry over a 15-year period. Patients with pathologically proven PTC treated with total thyroidectomy alone or with CCD were included. CCD was performed at the operating surgeon's discretion. A total of 105 patients were included and divided into two groups for analysis: group A - total thyroidectomy alone (51 patients, 49%) and group B - total thyroidectomy with CCD (54 patients, 51%). The operative complications between the two groups were then evaluated. RESULTS: Overall, 6.9% and 0.98% patients had transient and permanent recurrent laryngeal nerve palsies, respectively. About 19.0% and 2.9% patients had transient and permanent hypoparathyroidism, respectively and 27.6% patients had parathyroid glands found to be included in the resected specimen. Complication rates in terms of transient or permanent recurrent laryngeal nerve palsy or hypoparathyroidism did not differ significantly between groups A and B. Within group B, 41 patients had unilateral CCD and 12 had bilateral CCD. Transient hypoparathyroidism was more frequent in bilateral CCD (50% versus 12.2%, P = 0.01). CONCLUSIONS: Total thyroidectomy with prophylactic unilateral CCD is a safe procedure for PTC without added complication rates compared with total thyroidectomy alone. It is recommended for patients with PTC and clinically negative neck lymph nodes.

Parotidectomy under local anesthesia--report of 7 cases.

OBJECTIVE: Parotidectomy is usually carried out under general anesthesia. We reported our early experience of performing parotidectomy under local anesthesia. STUDY DESIGN: Case series reviewed. SETTING: Head and neck services of a regional hospital. PATIENTS, INTERVENTION, AND RESULTS: Seven patients underwent parotidectomy under local anesthesia. The indications were high risk for general anesthesia due to co-morbidity in 2 patients and personal preference for the rest. The operations were performed by retrograde facial nerve dissection after superficial cervical plexus block and incision wound infiltration with local anesthetics. There was no conversion to general anesthesia. Six operations were carried out in the setting of ambulatory procedure and were discharged on the same day. Transient mild facial paresis occurred in 2 patients. CONCLUSION: Parotidectomy under local anesthesia can be conducted successfully and avoid the adverse effect of general anesthesia.

Prediction of simultaneous esophageal lesions in head and neck squamous cell carcinoma: a multivariate analysis.

OBJECTIVE: To evaluate the frequency of concomitant esophageal lesions detected by esophagoscopy in squamous cell carcinoma (SCC) in the head and neck (HNSCC) and to identify the risk factors. DESIGN: Retrospective medical record analysis. SETTING: Regional hospital. PATIENTS: From March 2000 to March 2006, 118 patients with HNSCC had undergone esophagoscopy as part of the disease workup. Three patients had double head and neck primary tumors. Sixty-five patients also underwent chromoendoscopy with Lugol's iodine solution. MAIN OUTCOME MEASURES: The incidence of simultaneous esophageal cancer diagnosed on esophagoscopy. Additional esophageal lesions of clinical significance discovered during chromoendoscopy were also evaluated. RESULTS: Clinically important esophageal lesions were found in 12 patients (10%)-9 carcinomas and 3 dysplastic lesions. Chromoendoscopy was useful in 5 of these 12 cases, detecting 3 dysplastic lesions not visualized by ordinary esophagogastroduodenoscopy and additional lesions in 2 patients with esophageal carcinoma. Of the patients in whom isolated oral cavity SCC was considered, the incidence of synchronous esophageal lesions was only 1.5%. Sex (P = .02), younger age (P = .04), alcohol drinking (P = .047), and tumor sites (P = .002) were significant predictors of synchronous esophageal lesions on univariate analysis. On multivariate analysis, only tumor site remained a significant risk factor (P = .009). CONCLUSIONS: Clinically important esophageal lesions rarely coexists with oral cavity SCC, for which the benefit of routine esophagogastroduodenoscopy is questionable. Chromoendoscopy enhances the identification of early but clinically important esophageal abnormalities if esophagoscopy is performed for SCC in the larynx, hypopharynx, and oropharynx.

Submandibular sialoadenectomy with local anesthesia in the era of minimally invasive surgery.

OBJECTIVE: To assess the feasibility and advantages of submandibular sialoadenectomy under local anesthesia. STUDY DESIGN: Retrospective clinical study. SUBJECTS AND METHODS: Twenty patients with benign submandibular masses underwent submandibular sialoadenectomy. The procedure was carried out under local anesthesia (LA) in 12 patients and general anesthesia (GA) in 8 patients. The patient and tumor characteristics, as well as treatment outcome or complications, were compared between the two groups. RESULTS: There was no conversion from LA to GA. Nine patients in the LA group could be discharged as day-case surgery versus none in the GA group, P = 0.001. The postoperative hospital stay was also much shorter in the LA group: 0.4 day vs 2.0 days, P < 0.001. Postoperative vomiting occurred in only two of the eight patients of the GA group. Complication rate was similar. CONCLUSION: Submandibular sialoadenectomy under local anesthesia is feasible. It can shorten the hospital stay and facilitate day-case surgery.

Ranula successfully treated by botulinum toxin type A: report of 3 cases.

The conventional treatment of ranula is surgical procedure. We report an innovative method for ranula by using botulinum toxin type A on 3 patients. All 3 cases of ranula resolved after this minimally invasive therapy. The treatment complication was minimal.

Improvement of anemia after parathyroidectomy in Chinese patients with renal failure undergoing long-term dialysis.

HYPOTHESIS: Most patients undergoing long-term dialysis are anemic because of underproduction of erythropoietin and its inhibition by high parathyroid hormone levels due to secondary hyperparathyroidism. Renal anemia can be improved by parathyroidectomy. DESIGN: Retrospective cohort study. SETTING: Regional hospital. PATIENTS: Twenty-three Chinese patients without a previous functioning renal transplant underwent parathyroidectomy for severe secondary hyperparathyroidism in a 3-year period. INTERVENTION: Total parathyroidectomy with or without parathyroid autograft at the forearm. MAIN OUTCOME MEASURES: The preoperative and 6-month postoperative hematological and biochemical variables were compared for any differences by means of a paired t test. RESULTS: The mean +/- SD follow-up duration was 17.7 +/- 8.1 (range, 6-34) months. Three patients (13%) developed persistent or recurrent hyperparathyroidism and 2 patients (9%) were biochemically hypoparathyroid. The other 18 patients (78%) were euparathyroid. Surgical morbidity was minimal; only 1 patient had complications, consisting of a postoperative fever of unknown origin that resolved with conservative treatment. The mean +/- SD hemoglobin level (8.6 +/- 2.1 vs 9.4 +/- 2.1 g/dL) but not the mean platelet level was significantly (P = .04) increased 6 months postoperatively. Likewise, the following other mean +/- SD biochemical values improved after surgery: parathyroid hormone (2235 +/- 500 vs 151 +/- 312 pg/mL; P<.001), alkaline phosphatase (645 +/- 349 vs 123 +/- 82 U/L; P<.001), calcium (10.8 +/- 4.0 vs 9.3 +/- 1.0 mg/dL; P<.001), phosphate (1.93 +/- 0.73 vs 1.50 +/- 0.51 mmol/L; P = .02), and albumin (3.5 +/- 0.5 vs 3.8 +/- 0.6 g/dL; P = .006). CONCLUSIONS: Parathyroidectomy is highly effective to control secondary hyperparathyroidism with an exceedingly low complication rate. The hemoglobin level was significantly elevated 6 months postoperatively. The long-term effect warrants future trials.

Reconstruction with submental flap for aggressive orofacial cancer.

BACKGROUND: The submental flap was described for head and neck reconstruction more than a decade ago. Its application is confined mainly to nonmalignant diseases or low-grade malignancies, as the submental flap resides in the level I lymphatic drainage region of the neck. The authors report the use of the submental flap for soft-tissue reconstruction in a selected group of patients with aggressive orofacial cancer. METHODS: From March of 2003 to September of 2005, 10 patients (nine with intraoral squamous cell carcinoma and one with facial angiosarcoma) underwent submental flap reconstruction after surgical extirpation of aggressive orofacial malignancies. The indications were severe comorbidity, old age, the presence of another incurable cancer, and/or the patient's skepticism about undergoing a free flap operation. RESULTS: Of the surviving patients, the median follow-up was 21 months (range, 2 to 37 months). There were no cases of total flap failure, but partial necrosis occurred in two cases. Three patients experienced tumor recurrence, but only one case might have been related to use of the submental flap. Postoperative oral function, in terms of swallowing and speech, was well preserved; conventional dentures were fabricated for four patients. CONCLUSIONS: In selected patients with aggressive orofacial cancer, the submental flap is an expedient alternative to free tissue transfer for reconstruction. Nonetheless, indiscriminate use might compromise the oncological outcome, so it cannot be regarded as a standard method of treatment.

Sensation recovery improved by great auricular nerve preservation in parotidectomy: a prospective double-blind study.

BACKGROUND: The great auricular nerve (GAN) is frequently sacrificed during parotidectomy and causes sensory disturbance of the auricle. Our study is to investigate whether GAN preservation can improve the sensory recovery. METHODS: Patients undergoing superficial or total conservative parotidectomy for benign tumours were recruited consecutively from November 1998 to September 2001. Different sensory methods (light touch, two-point discrimination and sharp pain) of the auricle were evaluated by a designated physiotherapist preoperatively as well as at 1, 3, 6 and 12 months postoperatively. The patients and the physiotherapist were blinded to the integrity of the GAN. Long-term subjective assessment was also carried out beyond 2 years postoperatively. RESULTS: A total of 21 patients were recruited for the study. GAN were preserved in 10 patients. The mean follow up was 16 months (12-42 months). There was no difference in sex distribution, type of operation and pathology of parotid tumour between the two groups. No postoperative mortality occurred and postoperative morbidity did not differ between the two groups. Patients with GAN preserved had significantly better light touch and sharp pain recovery at 1 year postoperatively. Subjective assessment of sensory dysfunction also favoured GAN preservation. CONCLUSION: Great auricular nerve preservation minimizes the postoperative sensory disturbance and should be considered whenever tumour clearance is not compromised.

Diagnostic challenges of tuberculosis peritonitis in patients with and without end-stage renal failure.

BACKGROUND: Information about diagnostic features of tuberculosis (TB) peritonitis among patients with end-stage renal failure (ESRF), compared with those without ESRF, is limited. Here, we review our experience with TB peritonitis in patients with and without ESRF over a period of 11 years, with special reference to the clinical features of and diagnostic tools for TB peritonitis. METHODS: The records of all patients with TB peritonitis who were seen at United Christian Hospital (Hong Kong) from 1996 through 2006 were reviewed. The diagnosis of TB peritonitis was based on (1) detection of mycobacteria on smear and/or Mycobacterium tuberculosis on culture of ascitic fluid and/or peritoneal biopsy specimens and/or (2) demonstration of caseating granulomata on histological assessment of peritoneal biopsy specimens. RESULTS: During the study period, 52 patients (19 without ESRF and 33 with ESRF) had TB peritonitis. Patients with ESRF tended to have more-acute onset of symptoms and neutrophil-predominant peritoneal fluid, which mimicked bacterial peritonitis. Diagnosis was made earlier among patients without ESRF than among those with ESRF. Laparotomy or laparoscopy was the initial diagnostic tool for 12 patients (63%) without ESRF, whereas mycobacterial culture was the diagnostic method for 18 patients (55%) with ESRF. CONCLUSIONS: TB peritonitis has nonspecific and protean manifestations. It should be considered in the context of culture-negative peritonitis and in the context of culture-positive peritonitis that fails to respond to appropriate antibiotics. Laparoscopy with biopsy should be considered at an early stage when TB peritonitis is suspected.

Contralateral neck recurrence of squamous cell carcinoma of oral cavity and oropharynx.

PURPOSE: Contralateral neck failure after therapy for squamous cell carcinoma of the oral cavity and oropharynx has rarely been studied in detail. We aimed to examine the pattern and outcome of contralateral neck relapse and possible predictive clinicopathologic factors. PATIENTS AND METHODS: Seventy-three patients undergoing surgery for cancer of oral cavity/oropharynx with curative intent were recruited from the hospital head and neck cancer registry. The age, gender, tumor site, primary tumor laterality, TNM status, clinical N status, pathologic T status, ipsilateral pathologic N status, tumor stage, status of residual disease, histopathologic differentiation, postoperative radiotherapy, local relapse, distant relapse, extracapsular spread of lymph node metastasis and neck dissection were evaluated for association with contralateral neck relapse. RESULTS: Seven patients developed ipsilateral, 5 patients developed contralateral, and 3 patients developed bilateral neck recurrence after therapy. Only 1 patient with contralateral or bilateral neck relapse survived after salvage therapy. Ipsilateral positive nodal status was the only significant clinicopathologic parameter associated with contralateral neck relapse, which occurred rather commonly in well-lateralized tumors. CONCLUSION: Contralateral and ipsilateral neck relapses are similar in occurrence. Pathologic positive nodal status is associated with a higher incidence of contralateral neck relapse. Aggressive and comprehensive adjuvant radiotherapy to the neck plus close surveillance in the first 2 years postoperatively might curtail the frequency and mortality due to contralateral neck failure.

Endoscopic hemostasis for bleeding gastric stromal tumors by application of hemoclip.

In the past, numerous reports have advocated primary surgical resection as a treatment of choice for bleeding gastric stromal tumors (GIST). There were scarce reports on primary hemostasis with endoscopic therapy. We encountered two patients who presented to our unit with acute bleeding from gastric fundal stromal tumor, in whom we were able to achieved successful endoscopic hemostasis with hemoclip therapy. We describe the management of these cases and reviewed the current management strategies in bleeding gastric stromal tumor.