Outcome of neoadjuvant chemoradiation in MRI staged locally advanced rectal cancer: Retrospective analysis of 123 Chinese patients.

BACKGROUND: For advanced rectal cancer with involved or threatened mesorectal fascia (MRF), current standard is pre-operative long course chemoradiotherapy (PLCRT) with either capecitabine or 5-fluorouracil (5-FU). However, few Chinese data on its clinical outcome are available, especially for those with pelvic MRI staging. METHODS: Between Jan-2009 and Oct-2014, 123 consecutive patients with biopsy proven adenocarcinoma of rectum, all with pelvic MRI staging, selected for PLCRT after multi-disciplinary team discussion were recruited. Their clinical records were retrospectively reviewed. RESULTS: Median follow-up was 1392 days (range: 48-2886) MRI defined poor risk factors as follows: MRF threatened or involved ≤1 mm 61.8% (n = 76), cT4 13.8% (n = 17), cN2 26.8% (n = 33) and low-lying tumor (≤5 cm from anal verge) 24.4% (n = 30). Five year OS and DFS were 63.9% and 68.3% respectively. Among 112 patients who received TME, 108 (96.4%) had microscopic clear resection (R0). Twelve and 32 individuals had pathological complete response and ypT0-2N0, respectively. Five local recurrences (4.5%) were detected. The incidence of grade 3 or above acute and late radiotherapy toxicity was 8.1% and 12.2% respectively. After multivariate adjustment, positive circumferential resection margin (CRM) status on pathology report was found to be significant factor for worse OS and DFS. CONCLUSION: The clinical outcomes of PLCRT in our institution are comparable with those in western literature. Our MRI staging lends support to the validity of data. CRM status is the most significant prognostic factor in OS and DFS, after multivariate adjustment.

Outcomes and predictors of mortality and stoma formation in surgical management of colonoscopic perforations: a multicenter review.

OBJECTIVES: To perform a retrospective review of all patients with colonoscopic perforations managed in hospitals within the Eastern New Territories region of Hong Kong and to determine the predictors of mortality and stoma formation in patients with colonoscopic perforations. DESIGN: Retrospective computer-based review. SETTING: Multicenter (1 university teaching hospital and 2 district hospitals). METHODS: We reviewed the outcomes of patients with colonoscopic perforations surgically managed between January 1, 1998, and December 31, 2005. Predictors of mortality and stoma formation were identified with multivariable analysis. MAIN OUTCOME MEASURES: Mortality and stoma rates and their predictors. RESULTS: A total of 37,971 colonoscopies were performed during the study period, and 43 colonoscopic perforations were identified. The overall perforation rate was 0.113% and represented a decreasing trend. There was no significant difference in the perforation rate between gastroenterologists (0.148%) and surgeons (0.091%) (P = .15). Perforations that occurred during diagnostic colonoscopies were significantly larger than those that occurred during therapeutic colonoscopies (P = .04), and the patients presented earlier (P = .02). Surgical intervention was performed in 39 patients. The overall morbidity and mortality rate was 48.7% and 25.6%, respectively. The stoma rate was 38.5%. The predictors of stoma formation include moderate to severe peritoneal contamination and the presence of malignant colonic neoplasms (P = .01 and P = .008, respectively). The predictors of mortality include American Society of Anesthesiologists class 3 or higher and antiplatelet therapy (P = .009 and P = .001, respectively). CONCLUSIONS: Colonoscopic perforations were in a decreasing trend. Patients with predictors of mortality should not be treated conservatively. Other options of large bowel investigations should be considered in high-risk patients when the potential diagnostic yield is low.

Abdominal drain causing early small bowel obstruction after laparoscopic colectomy.

We report a rare drain-related complication leading to small bowel obstruction after laparoscopic colectomy. An 82-year-old man developed small bowel obstruction on the second day after laparoscopic anterior resection. Emergency relaparoscopy found herniation of the small bowel mesentery into the side holes of the silicon intraabdominal drain, which led to a 90-degree acute turn of the small bowel and mechanical obstruction. The herniation was reduced, and the drain was removed laparoscopically.

Recurrence pattern of fistula-in-ano in a Chinese population.

BACKGROUND AND AIMS: Fistula-in-ano is a common colorectal complaint. Despite of the advancement in preoperative imaging and surgical techniques, recurrence is not uncommon in this disease entity. We aimed to determine the recurrence pattern and predictors of FIA in Chinese population. SETTING: single regional hospital serving a 300,000 population. DESIGN AND PARTICIPANTS: A systematic retrospective review of inpatient and follow up records and operation records in patients with diagnosis of fistula-in-ano (ICD code - 565.1) from January 2001 to December 2004 was performed. INTERVENTION: Surgery for fistula-in-ano. RESULTS: 135 out of 137 Chinese patients received anal fistula operations. 14 patients (10.4%) had high type anal fistulas and 27 patients (20%) had perianal sinus. The most common operation was combined fistulotomy-fistulectomy (78 patients, 57.8%). 18 patients (13.3%) had recurrence with a median time to recurrence of 7.5 months. Six factors including: 1) positive history of perianal abscess, 2) previous perianal operation, 3) complex fistula, 4) perianal sinus, 5) absence of an internal opening, 6) surgical procedure of sinus tract excision were significantly associated with recurrence in univariate analysis. Sinus tract excision was the only independent factor to predict recurrence in logistic regression (p=0.002, 95%CI=1.29-3.27). CONCLUSION: Fistula-in-ano carried a significant risk of recurrence in perianal sinus with sinus tract excision performed. No difference was found between Chinese and Caucasian in recurrence pattern of fistula-in-ano.

Safety of nurse-administered propofol sedation using PCA pump for outpatient colonoscopy in Chinese patients: a pilot study.

BACKGROUND: To determine the safety and effectiveness of nurse-administered propofol sedation using patient-controlled analgesia (PCA) pump in outpatient colonoscopy in a Chinese population. METHODS: From April to June 2005, 50 consecutive ASA class I or II patients aged 18-65 undergoing outpatient colonoscopy in an endoscopy centre of a regional hospital were prospectively recruited in this study. After a loading dose of 40-60 mg intravenous propofol, a mixture containing 14.3 mg propofol and 35 microg alfentanil were delivered via a patient-controlled syringe pump as bolus dose by an endoscopy nurse under the supervision of an endoscopist during the procedure. Lockout time was set to be zero. We aimed to achieve conscious sedation, with an Observers Scale for Sedation and Alertness (OSSA) score of 3. The primary outcome measure was complications from sedation, which included hypotension, bradycardia and desaturation. Other outcome measures included onset time, patients pain score, endoscopists and nurses satisfaction on the level of sedation, patients satisfaction regarding the procedure (measured by 10 cm visual analogue scale), and their willingness to repeat the procedure. RESULTS: The mean lowest systolic blood pressure and mean arterial pressure (MAP) were 103.2 +/- 12.4 mmHg and 78.3 +/- 11.0 mmHg, respectively. The mean percentage drop in MAP was 15.7 +/- 11.9%. Six patients (12.2%) developed transient hypotension. Three patients (6.1%) had bradycardia. There was no episode of desaturation. The median onset time to reach OSSA score of 3 was 1 minute (range, 0.5-20.5). The OSSA score of 3 could be maintained throughout the procedure. The mean loading dose of propofol was 48.9 +/- 6.7 mg. The mean total dosages of propofol and alfentanil given were 124.2 +/- 38.1 mg and 184.3 +/- 93.7 mug, respectively. Endoscopists, endoscopy nurses and patients were highly satisfied with the sedation. The median pain score was 1 (range, 0-10; 0 = no pain, 10 = very painful), and the mean recovery time was 2.8 +/- 2.8 minutes. Most patients (93.9%) were willing to repeat the procedure. CONCLUSION: Nurse-administered propofol sedation using PCA pump is safe and effective in sedation and pain control in outpatient colonoscopy in a healthy Chinese population.

Predictive factors of long hospital stay after laparoscopic cholecystectomy.

OBJECTIVE: Laparoscopic cholecystectomy (LC) is the most common minimally invasive surgery in Hong Kong. However, ambulatory LC is not a common practice in Hong Kong. This study aims to identify the causes of long hospital stay after elective LC and to delineate a guideline for ambulatory LC. METHODS: A retrospective analysis of 278 patients who underwent successful elective LC in a single unit between 1 January 2002 and 31 December 2003 was performed. They were divided into two groups: LS group had a long hospital stay (>24 hours after operation) and SS group had a short hospital stay. A total of 18 variables, including five patient variables, nine operative variables and four postoperative variables, were identified for univariate analysis. Significant pre- and postoperative factors were included in the multivariate analysis to identify independent predictive factors for long hospital stay. RESULTS: Of the 278 patients, 118 (44.2%) could be discharged within 24 hours, while 149 (55.8%) had long hospital stay. Nine significant factors were identified in the univariate analysis; three independent factors were found to predict long hospital stay in the multivariate analysis. Patients with age more than 60 years had double risk of long hospital stay. Patients who could not tolerate diet within 8 hours or took more than two tablets of oral analgesia (dologesics) had a four- and threefold increase in risk of long hospital stay, respectively. CONCLUSION: With careful patient selection, optimal postoperative pain control and early resumption of diet with better management of postoperative nausea and vomiting, ambulatory LC was feasible and safe.

Use of a variable-stiffness colonoscope decreases the dose of patient-controlled sedation during colonoscopy: a randomized comparison of 3 colonoscopes.

BACKGROUND: The variable-stiffness colonoscope incorporates different degrees of stiffness of the insertion tube, which can be adjusted during the examination. Whether its use can lead to reduced procedure-related pain and sedative use is unknown. OBJECTIVE: Our purpose was to compare the use of 3 types of colonoscope with different shaft stiffnesses in relation to procedure-related pain and sedative consumption. DESIGN: Prospective randomized trial. SETTING: Endoscopy unit of a university-affiliated hospital. PATIENTS: Consecutive patients undergoing ambulatory colonoscopy. INTERVENTIONS: Random assignment was made of patients into 3 groups to receive colonoscopic examinations by one of the 3 types of colonoscope: conventional standard adult size, 1.3-m; 1.6-m; and the new variable-stiffness adult size, full-length (1.6-m) colonoscope. A mixture of propofol and afentanil, delivered by a patient-controlled syringe pump, was used for sedation in all groups. MAIN OUTCOME MEASURES: Outcome measures included dose of patient-controlled sedation consumed, pain score, cecal intubation rate, cecal intubation time, requirement of abdominal pressure and change of patients' positions during colonoscopy, and endoscopists and patients' satisfaction scores according to a visual analog scale. RESULTS: A total of 335 patients were randomized. Patients in group 3 used significantly less propofol (in milligrams per kilograms, mean [SD]) compared with the other 2 groups (group 1: 1.00 [0.75], group 2: 0.93 [0.62], and group 3: 0.75 [0.65]; P = .02; 1-way analysis of variance). The mean (SD) pain score was also lower in group 3. LIMITATIONS: The endoscopists were not blinded. CONCLUSION: The use of the new variable-stiffness adult-size colonoscope significantly reduced procedure-related pain and doses of sedative medications during colonoscopy.

Operative cholangiography in two-port needlescopic cholecystectomy.

We report the use of operative cholangiography in two-port needlescopic (minilaparoscopic) cholecystectomy. A prospective series of 11 patients underwent two-port needlescopic cholecystectomy with operative cholangiography. In ten cases, operative cholangiography was successfully performed. There were no conversions. No additional ports were required. No related complications were noted. Two cases positive for common bile duct stones were identified. The median operative time was 92.5 minutes. Operative cholangiography in two-port needlescopic cholecystectomy is safe and feasible.

Premedication with intravenous ketorolac trometamol (Toradol) in colonoscopy: a randomized controlled trial.

OBJECTIVE: We conducted a prospective double-blinded placebo-controlled randomized trial to investigate the effect of ketorolac trometamol (KT) administered intravenously as premedication in colonoscopy. METHODS: One hundred and forty patients undergoing colonoscopy were randomized to receive either 60 mg of KT (KT group (KTG), n=70) or placebo (normal saline group (NSG), n=70) intravenously as premedication 30 min prior to procedure. Patient-controlled sedation (PCS) was used as the mode of sedation. Outcome measures included patient self-assessed pain score in a 10-cm unscaled visual analog scale (VAS), endoscopist assessment of patient pain score in VAS, patient's willingness to repeat colonoscopy, administered and demanded doses of PCS, patient satisfaction score in VAS, and hemodynamic changes during and after the procedure. RESULTS: The mean patient self-assessed pain score (SD) during procedure was significantly lower in KTG than NSG: 5.08 (2.74) vs 6.62 (2.45); p=0.001. The mean endoscopist assessment of patient pain score (SD) was significantly lower in KTG than NSG as well: 3.99 (2.80) vs 5.28 (2.71); p=0.006. More patients in KTG were willing to repeat procedure as compared with NSG (80.0%vs 57.1%; p=0.004). No significant difference was found in the administered and demanded doses of PCS, mean satisfactory scores and hemodynamic changes in both groups. No serious complication related to intravenous (IV) KT was noted. CONCLUSIONS: Premedication with IV KT (Toradol) improves pain control during colonoscopy with no associated serious complications.

Patient-controlled sedation versus intravenous sedation for colonoscopy in elderly patients: a prospective randomized controlled trial.

BACKGROUND: A prospective randomized trial was conducted to compare the safety, effectiveness, and patient acceptance of patient-controlled sedation and intravenous sedation for colonoscopy in a group of elderly patients undergoing outpatient colonoscopy. METHODS: One hundred patients over 65 years of age were recruited and randomized to patient-controlled sedation (n = 50) or intravenous sedation (n = 50) groups by means of computer-generated numbers. In the patient-controlled sedation group, a mixture of propofol and alfentanil was delivered by means of a patient-controlled pump; each bolus delivered 4.8 mg propofol and 12 microg alfentanil. No loading dose was used and the lockout time was set at zero. In the intravenous sedation group, fixed doses of diazemuls (0.1 mg/kg) and meperidine (0.5 mg/kg) were given with further increases in dosages administered at the discretion of the endoscopist. Outcome measures assessed included cardiopulmonary complications, recovery time, pain score, and satisfaction score. RESULTS: The mean (SD) age of patients in the patient-controlled sedation and intravenous sedation groups were, respectively, 72.4 years (5.3) and 73.5 years (6.1). The mean dose of propofol consumed in the patient-controlled sedation group was 0.79 (0.46) mg/kg. The mean doses of diazemuls and meperidine consumed in intravenous sedation group were, respectively, 5.8 (1.3) mg and 30.1 (6.8) mg. Hypotension occurred in 2 (4%) patients in the patient-controlled sedation group and 14 (28%) in the intravenous sedation group (p < 0.01). Oxygen desaturation was recorded for 4 patients (8%) in the intravenous sedation group. The median (interquartile range [IQR]) recovery time was significantly shorter in the patient-controlled sedation group compared with the intravenous sedation group (respectively, 0 minutes [IQR 0-5] vs. 5 minutes [IQR 5-10]; p < 0.01). There were no statistically significant differences between groups for pain and satisfaction scores. CONCLUSIONS: Patient-controlled sedation appears to be safer than intravenous sedation, with comparable effectiveness and acceptance, in elderly patients undergoing elective outpatient colonoscopy.

Two-port laparoscopic cholecystectomy: initial results of a modified technique.

BACKGROUND AND PURPOSE: Two-port laparoscopic cholecystectomy has been reported to be safe and feasible with a higher patient satisfaction score. However, it was technically difficult even in expert hands because of the small operating field. We have modified the operating telescope to achieve a wide field of view. PATIENTS AND METHODS: Since September 2000, 14 patients have been enrolled for two-port laparoscopic cholecystectomy. The male to female ratio was 5:9. The median age was 54.5 years (interquartile range [IQR] 45-67.75 years). RESULTS: The median operative time was 53 minutes (IQR 38-61 minutes). Two patients required one additional 5-mm port or a traction suture because of dense adhesions. There was no conversion to open surgery. The median postoperative hospital stay was 2 days (IQR 1-2.25 days). The median oral postoperative analgesia requirement was 1 dose (IQR 0-3 doses). There were no major or minor complications, and there were no deaths. CONCLUSION: The modified two-port technique greatly facilitates two-port laparoscopic cholecystectomy and improves the clinical outcome.

Relaxation music decreases the dose of patient-controlled sedation during colonoscopy: a prospective randomized controlled trial.

BACKGROUND: A prospective randomized controlled trial was performed to test the hypotheses that music decreases the dose of sedative medication required for colonoscopy and that the combination of music and patient-controlled sedation improves patient acceptance of colonoscopy. METHODS: One hundred sixty-five patients scheduled to undergo elective colonoscopy were randomized to receive 1 of 3 different modes of sedation: Group 1, a combination of music and patient-controlled sedation with a mixture of propofol and alfentanil; Group 2, patient-controlled sedation alone; Group 3, music alone with diazemuls and meperidine administered intravenously if requested by the patient. Each bolus of patient-controlled sedation delivered 4.8 mg propofol and 12 microg alfentenil. Music was provided by means of a portable compact disc machine with headphones. Outcome measures assessed immediately after colonoscopy and 24 hours later included dose of patient-controlled sedation used, complications, recovery time, pain score, satisfaction score, and willingness to repeat the procedure with the same mode of sedation. RESULTS: The mean (SD) dose of propofol used in Group 1 was significantly less than Group 2 (0.84 mg/kg [0.69 mg/kg] vs. 1.15 mg/kg [0.83 mg/kg]; p = 0.02, t test). The mean (SD) satisfaction score was higher in Group 1 (7.8 [2.1]) compared with Group 2 (6.8 [2.3]) and Group 3 (7.4 [2.3]) (p = 0.05, 1-way analysis of variance). The majority of patients in Group 1 were willing to repeat the same mode of sedation when queried immediately after colonoscopy (87%) and 24 hours later (75%), which was significantly different from the corresponding results in the other 2 groups; p = 0.04 and p < 0.01 respectively, chi-square test. CONCLUSIONS: Music can decrease the dose of sedative medication required for colonoscopy. The combination of music and patient-controlled sedation was the best-accepted mode of sedation among 3 groups.