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Objective: The purpose of our study was to measure the radiation dose from ECG-gated CT coronary angiography in children and to estimate the cancer risk associated with the radiation dose., Materials and Methods: Organ doses were measured with a 5-year-old pediatric phantom and thermoluminescent dosimeters on a 64-MDCT scanner. Four retrospectively ECG-gated CT coronary angiography protocols with four simulated heart rates and the corresponding pitches were studied. The lifetime attributable risk of cancer incidence was estimated for children in the United States and Hong Kong according to the National Academies Biologic Effects of Ionizing Radiation VII report., Results: The effective doses were 16.45, 12.17, 11.97, and 11.81 mSv for the four protocols, respectively. The corresponding lifetime attributable risks estimated for 5-year-old U.S. boys and girls were 0.14%-0.20% and 0.43%-0.60%, respectively, and for 5-year-old Hong Kong boys and girls were 0.22%-0.33% and 0.61%-0.85%. In relation to the total cancer incidence (baseline cancer incidence plus lifetime attributable risk), lifetime attributable risk from radiation exposure contributed up to 0.99% and 3.51% for Hong Kong boys and girls and up to 0.46% and 1.57% for U.S. boys and girls., Conclusion: Our results suggest that radiation dose and cancer risk of CT coronary angiography to pediatric patients are not negligible, more so in Hong Kong children than in U.S. children. Therefore, these examinations should be well justified clinically.

Background: Although laparoscopic resection of colorectal carcinoma improves post-operative recovery, long-term survival and disease control are the determining factors for its application. We aimed to test the null hypothesis that there was no difference in survival after laparoscopic and open resection for rectosigmoid cancer., Methods: From Sept 21, 1993, to Oct 21, 2002, 403 patients with rectosigmoid carcinoma were randomised to receive either laparoscopic assisted (n=203) or conventional open (n=200) resection of the tumour. Survival and disease-free interval were the main endpoints. Patients were last followed-up in March, 2003. Perioperative data were recorded and direct cost of operation estimated. Data were analysed by intention to treat., Findings: The demographic data of the two groups were similar. After curative resection, the probabilities of survival at 5 years of the laparoscopic and open resection groups were 76.1% (SE 3.7%) and 72.9% (4.0%) respectively. The probabilities of being disease free at 5 years were 75.3% (3.7%) and 78.3% (3.7%), respectively. The operative time of the laparoscopic group was significantly longer, whereas postoperative recovery was significantly better than for the open resection group, but these benefits were at the expense of higher direct cost. The distal margin, the number of lymph nodes found in the resected specimen, overall morbidity and operative mortality did not differ between groups., Interpretation: Laparoscopic resection of rectosigmoid carcinoma does not jeopardise survival and disease control of patients. The justification for adoption of laparoscopic technique would depend on the perceived value of its effectiveness in improving short-term post-operative outcomes.

Background: Occult lymph node (LN) metastasis is common in papillary thyroid carcinoma. Sentinel lymph node (SLN) biopsy has been proven to be successful and accurate to predict the nodal status in melanoma and breast cancer. We investigate the use of SLN in papillary thyroid carcinoma., Methods: Patients of previously untreated papillary thyroid carcinoma, diagnosed preoperatively by fine-needle cytology without any palpable cervical LN are prospectively studied. Blue dye injection was utilized for the SLN biopsy followed by central compartment lymphadenectomy. The histopathological results of the SLN and lymphadenectomy specimens were compared., Results: Fifteen consecutive patients underwent surgery including SLN biopsy for papillary thyroid carcinoma. Occult nodal metastases were identified in 10 patients (67%). The other five cases had no nodal metastasis. SLN were found in 10 cases. One, two and three SLN were present in three, three and four patients, respectively. SLN were located in the central compartment in eight cases. The SLN were found in the lateral compartment in one case. In the remaining one case, the SLN were found in both the central and lateral compartments. Of the group with found SLN, false negative occurred in one case. The overall accuracy of the SLN in predicting the nodal status was 90%. The sensitivity, specificity, positive predictive value and negative predictive value were 88%, 100%, 100% and 67%, respectively. No complications were directly related to SLN biopsy., Conclusion: Occult nodal spread is frequently encountered in papillary thyroid carcinoma. SLN biopsy is safe and feasible in papillary thyroid cancer, however further studies are necessary to improve the diagnostic accuracy prior to routine clinical use.

Background: The aim of this study was to determine the predictive risk factors for complications resulting from foreign body ingestion., Methods: A consecutive series of 1338 patients with suspected foreign body ingestion presenting from 1996 to 2000 were studied retrospectively. The potential risk factors for complications after foreign body ingestion were analysed by multivariate logistic regression and included concurrent medical illness, age, duration and types of symptoms, types of foreign body ingested, positive cervical radiographic findings and the level of foreign body impaction., Results: Fish bone (62.7 per cent) was the commonest type of foreign body ingested. Most of the objects were impacted at or above the cricopharyngeus, the commonest site being the valleculae (31.4 per cent). Multivariate analysis showed that presentation delayed for more than 2 days (P < 0.001), positive cervical radiographic findings (P < 0.001) and foreign body impacted at the cricopharyngeus (P = 0.009) or upper oesophagus (P = 0.005) were significant independent risk factors associated with the development of complications after foreign body ingestion., Conclusion: In patients with a foreign body seen on plain cervical radiography, presentation delayed for more than 2 days after ingestion, and foreign body impacted at the level of the cricopharyngeus or oesophagus there is a high degree of correlation with the occurrence of complications. Awareness should be raised when these risk factors are present., (Copyright 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Aim: Recurrent bleeding after initial haemostasis is an important factor that directly relates to the outcome in the management of peptic ulcer bleeding. Conflicting reports have been published concerning the effectiveness of scheduled second therapeutic endoscopy on ulcer rebleeding. We investigate the use of scheduled second endoscopy with appropriate therapy on peptic ulcer rebleeding., Methods: From August 1999 to January 2001, we prospectively randomised patients who had endoscopically confirmed bleeding peptic ulcer with stigmata of acute bleeding, visible vessel, or adherent clot into two groups. Endoscopic therapy was standardised to initial epinephrine injection and subsequent heater probe application. The study group (n = 100) received scheduled second endoscopy 16-24 hours after initial haemostasis, and further therapy was applied if endoscopic stigmata persisted, as above. The control group (n = 94) were observed closely. Those patients that developed rebleeding in either group underwent operation if further endoscopic therapy failed. Outcome measures included ulcer rebleeding, transfusion, duration of stay, and mortality., Results: After initial endoscopic haemostasis, 194 eligible patients were randomised into two groups. Thirteen patients in the control group developed recurrent bleeding within 30 days while five patients in the study group sustained recurrent bleeding (p = 0.0314) (relative risks 0.33, 95% confidence interval 0.1-0.96). The number of patients that required surgery for recurrent bleeding was six in the control group and one in the study group (p = 0.05). There was no difference in duration of hospital stay, transfusion, or mortality between the two groups., Conclusions: A scheduled repeat endoscopy with appropriate therapy 16-24 hours after initial endoscopic haemostasis reduces the number of cases of recurrent bleeding.

Sialocele is an uncommon complication of parotidectomy. Most cases resolve after conservative therapy consisting of repeated aspiration and pressure dressing. The condition is, however, occasionally resistant to such therapy. We report on a 52-year-old Chinese man who had a 10-year history of right parotid swelling. Following fine-needle aspiration cytology, Warthin's tumour was diagnosed, but after elective parotidectomy, a swelling developed and parotid sialocele was diagnosed. Botulinum toxin type A was given after the sialocele had persisted for almost 3 weeks after surgery, and after conservative management had been tried; the sialocele disappeared after two doses of treatment. Botulinum toxin therapy was thus an effective method of treating persistent sialocele.

Background: Transoral removal and sialoadenectomy are the two main modalities of treatment for submandibular stones. However, missed ductal stones are not uncommon, and there is a risk of lingual or hypoglossal nerve injury. We attempted to avoid these complications by using an endoscopic technique., Methods: The case notes of the patients who had undergone endoscopic removal of submandibular stones were studied retrospectively. The procedure was performed under general anesthesia. The submandibular orifice was incised by carbon dioxide laser, and a 3.1-mm rigid scope was inserted under direct vision with normal saline irrigation after dilatation. The stones were either broken down by laser or removed with a Dormia basket or forceps., Results: A total of 13 patients underwent the procedure. The duration of median follow-up was 15 months. In 11 patients, the stones were identified and removed. No stone was found in two patients (15.4%). There were no false negatives, since no stones were discovered subsequently in these two patients. One, two, three, and four stones were present inside the ducts in seven patients (54.6%), one patient (7.7%), two patients (15.4%), and one patient (7.7%), respectively. The symptoms subsided completely in 11 patients within 4 weeks after the procedure. Persistent swelling occurred in two patients. In one of them, no residual stone was revealed by CT scan. The other patient had a large calculus that was only partially fragmented by laser lithotripsy at the initial operation. No lingual nerve or hypoglossal nerve injury was detected in any patient., Conclusion: Sialoendoscopy is a safe and efficacious treatment for submandibular ductal stones. It reduces the incidence of missed stones, and nerve injury, as well as the need for sialoadenectomy.

Objective: The number of hours worked by specialty trainees has come under scrutiny recently. One approach aimed at decreasing the number of consecutive hours worked is the night shift call system (NSCS). This study aimed to determine the advantages and disadvantages of an NSCS compared with those of the conventional overnight call system (ONCS)., Subjects and Methods: Sixteen basic surgical trainees (BSTs) from our unit participated in this prospective, self-controlled trial. During April 2000, the conventional 1-in-4 ONCS with a post-call half-day off was instituted. From May to June 2000, each BST rotated to work 1 week of night duty (20.00-08.00) and 7 weeks of daytime duty. A battery of neuropsychological tests were administered to the group after call during the study period., Results: On average the numbers of consecutive hours worked during the NSCS and ONCS periods were 12 and 28 hours, respectively. There was no difference in numbers of errors committed and no difference in discrepancy between diagnoses made on admission and discharge. Two of the simple neuropsychological tests (memory scanning and addition tests) showed a significant fall-off in performance during the ONCS period (P < 0.05). Most specialists preferred the ONCS, while the majority of the BSTs preferred the NSCS (P < 0.05). This was because without extra manpower, the overall workloads of senior staff were increased., Conclusions: The NSCS is 1 way of reducing work hours, and was associated with significantly less impaired cognition on the part of our BSTs. It is only feasible if extra relieving staff are available to cover daytime duties.

Background and Aims: Fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), and colonoscopy are the most commonly recommended screening tests for colorectal cancer. The aim of this study was to compare the accuracy and safety of these 3 screening procedures in a general population of ethnic Chinese., Methods: Asymptomatic adults older than 50 years were recruited from the general public through health exhibitions. All enrolled subjects were offered FOBT and full colonoscopy under sedation. Advanced colonic lesions (defined as adenoma > or = 10 mm, villous adenoma, adenoma with moderate or severe dysplasia, or invasive cancer) were recorded. Lesions at the distal 40 cm in the left colon and rectum were taken as findings of FS., Results: A total of 505 subjects (56% women; mean age +/- SD, 56.5 +/- 5.4 years) were enrolled, and 476 (94.3%) had a complete colonoscopy. Advanced colonic neoplasms were documented in 63 subjects (12.5%), of which 45 had lesions in the distal colon and 26 in the proximal colon. Among the 385 subjects with a normal distal colon, 14 (3.6%) had advanced lesions in the proximal colon that would be missed by FS alone. The sensitivity and specificity of FOBT for advanced colonic lesions were 14.3% and 79.2% and the sensitivity and specificity of FS were 77.8% and 83.9%, respectively. Combining FOBT with FS would not significantly improve the results of FS alone. Among these 505 subjects who underwent colonoscopy and 148 who underwent polypectomy, there was no perforation and only one occurrence of postpolypectomy bleeding recorded., Conclusions: Colonoscopy is a safe and accurate method for the screening of colorectal neoplasms in Chinese subjects.

Background: The present study was undertaken to evaluate the efficacy of acupuncture anaesthesia in inguinal hernia repair., Methods: Twelve patients with non-recurrent inguinal hernia had Lichtenstein mesh repair under acupuncture anaesthesia. Selected acupuncture loci were stimulated with fine needles connected to low frequency current. Supplementary local anaesthetic was given when required., Results: Four (33%) patients reported satisfactory analgesic effect throughout the operation without need for additional medication, eight (67%) patients experienced mild discomfort during the operation requiring 1-4 mL of 1% lignocaine injection. Blood pressure and heart rate were stable during the procedure. All patients were able to sit up and resume their diet immediately post-operatively. All but one patient were discharged on day one after the procedure, with no early or late complications reported. Most patients were satisfied with the analgesic effect of acupuncture anaesthesia., Conclusions: Acupuncture anaesthesia is a feasible anaesthetic option. It reduces the amount of local anaesthetic required, and thus the associated potential complications. It is effective in pain relief and inhibiting gastrointestinal upset. Postoperative recovery was rapid and complication free.

Purpose: Controversies abound regarding the optimal surgical management in noncomplicated diverticulitis of the right colon, ranging from a conservative approach to diverticulectomy to right hemicolectomy. One of the arguments for resection is to exclude carcinoma. However, there is significant morbidity associated with resection. We aim to introduce on-table cecoscopy as a tool to improve the diagnosis of acute diverticulitis of the right colon, exclude carcinoma, and reduce the rate of resection., Methods: From October 1999 to June 2000, five patients presented to our unit with suspected acute appendicitis. Intraoperatively, we found a colonic inflammatory mass at either the cecum or the ascending colon. The cecum and ascending colon were mobilized, and bowel clamps were applied to the ascending colon and ileum. A bronchoscope (Olympus(R) BF-P200) was introduced through the appendix stump. To achieve a good endoscopic view, a limited volume of air was introduced through the working channel., Results: After on-table cecoscopy, all the patients were diagnosed as having acute nonperforated diverticulitis of the right colon. They received appendicectomy, and the diverticulitis was managed conservatively. They were treated with a course of cephalosporin and metronidazole. We performed colonoscopy four weeks later and confirmed that none of them had carcinoma of the colon., Conclusions: On-table cecoscopy is a new, safe, and effective means of diagnosing acute diverticulitis of the right colon. We can confidently exclude carcinoma and reduce the amount of colonic resection in patients with noncomplicated diverticulitis of the right colon.

Lymphoepithelioma-like carcinoma is a rare tumour in the oral cavity and is characterized histologically by non-keratinizing, undifferentiated squamous cell carcinoma with lymphocytic infiltration. Three consecutive cases of intraoral lymphoepithelioma-like carcinoma are reported. A review of the literature reveals a similar biological behaviour to that of nasopharyngeal lymphoepithelioma: a high incidence of cervical nodal spread and remarkable radiosensitivity. Chemotherapy should be considered when nodal or distant metastases are present. The association of the Epstein-Barr virus with this tumour remains unclear but our experience suggests a positive correlation in Chinese individuals.

Introduction: Haemorrhoidectomy is traditionally an inpatient procedure. With many benefits, the day-surgery arrangement is an attractive alternative. The feasibility of day-surgery haemorrhoidectomy was explored and the hospital days were calculated in a case controlled design., Methods: A single surgeon's experience of day-surgery haemorrhoidectomy between 1 July 1999 and 31 March 2000 was compared with inpatient haemorrhoidectomy during the same period. The operations were performed at United Christian Hospital Department of Surgery, Hong Kong (a government-funded public hospital). Statistical tests were applied where appropriate., Results: There were 30 day-surgery and 15 inpatient haemorrhoidectomies. The groups were comparable in terms of age, gender, severity of haemorrhoids, method and duration of haemorrhoidectomy, blood loss, residual haemorrhoids, duration of follow up and unplanned readmission rate. Significantly more day-patients received general than spinal anaesthesia. Twenty-six of 30 (87%) patients were successfully discharged after day surgery. Two were admitted for transient fever (< 24 h), one for micturition syncope and one for acute urinary retention. There were four unplanned readmissions after day surgery: one for pain and three for secondary bleeding. All stopped spontaneously. All three unplanned readmissions after inpatient surgery were for secondary bleeding. All stopped spontaneously. Patient stay was significantly shorter for day surgery (1 +/- 1 day) than for the inpatient arrangement (4 +/- 1.6 days)., Conclusion: Day-surgery haemorrhoidectomy is feasible. The significantly shorter hospital stay implies savings in public medical expenses.

Background: Acute diverticulitis of the caecum and ascending colon is uncommon. Controversies abound as regards the optimal surgical treatment, ranging from appendectomy, diverticulectomy to right hemicolectomy. The aim of the present paper was to review treatment strategy followed by a critical appraisal., Methods: The case notes of 30 patients with acute diverticulitis of the right colon who were treated at the United Christian Hospital, Hong Kong from 1992 to 1998 were systematically reviewed. The data were subjected to statistical analysis., Results: The median age was 34 years, with a male:female ratio of 1:1.15. All patients presented with acute right lower abdominal pain and localized rebound tenderness. All were diagnosed preoperatively as having appendicitis. The mean duration of symptoms was 2 days (range: 1-6 days). Two treatment groups were identified. Group A (n = 16; 53%) received appendicectomy alone, while group B (n = 14; 47%) underwent diverticulectomy in addition to appendicectomy, including one patient with perforated diverticulitis. Overall, there was no procedure-related morbidity or mortality. Both groups received a similar duration of broad-spectrum antibiotics. All the patients were interviewed by phone after operation to detect any recurrence of symptoms, with a median follow-up interval of 34 months (range: 11-78 months). There was no recurrence of symptoms in group A, which received appendicectomy and antibiotics. The only difference was operative time., Conclusion: For non-perforated diverticulitis of the right colon, appendicectomy and intravenous antibiotics without diverticulectomy is the preferred treatment strategy.

Objective: To study the outcome and complications of thyroid surgery., Design: Retrospective study., Setting: Regional hospital, Hong Kong., Patients: Three hundred and twelve patients (266 women and 46 men) underwent thyroid surgery between January 1994 and December 1999., Main Outcome Measures: Complications of thyroidectomy for various thyroid diseases according to surgical technique used., Results: Capsular dissection gradually became a more popular surgical technique: 33% and 58% in the first and second halves of the study period respectively (P<0.001). The overall rate of permanent vocal cord palsy was 2%. Near-total thyroidectomy became the preferred surgical treatment for toxic goitre over the study period. The incidence of recurrent hyperthyroidism was reduced from 21% to 7% (P>0.1, not significant). The incidence of hypoparathyroidism was approximately 30% after thyroidectomy for cancer., Conclusion: Capsular dissection is increasingly utilised in thyroid surgery. Low complication rates can be achieved after thyroidectomy for benign diseases. Hypoparathyroidism, however, is a relatively common complication after surgery for thyroid cancer.

A facial depressed deformity subsequent to superficial parotidectomy is unsightly. Although a facelift incision can improve the cosmetic outcome by concealing the scar, the hollow contour around the angle of the mandible remains conspicuous. We have attempted to mitigate this problem by transposition of the sternomastoid muscle. Transposition of the sternomastoid muscle to cover the parotid bed after superficial parotidectomy for benign tumour was performed in eight consecutive patients. The histopathology and postoperative results, including complications and patient satisfaction, were analysed. The depressed deformity was considerably alleviated in all eight patients. All patients except one, who had a wound infection, were satisfied with the cosmetic outcome postoperatively. The extra operative time required for sternomastoid-muscle transposition was only 10 min. There was no morbidity related to this additional procedure. By combining this simple method with a facelift incision, an appealing cosmetic outcome can be achieved after superficial parotidectomy., (Copyright 2001 The British Association of Plastic Surgeons.)

Background and Purpose: One advantage of minimal-access surgery is that it produces less pain. A radially expanding trocar has been claimed to reduce pain further. We aimed to evaluate this claim., Patients and Methods: This was a randomized controlled single-blind clinical trial. Fifty-four patients who underwent laparoscopic cholecystectomy at the Department of Surgery, United Christian Hospital, Hong Kong, between July 1997 and September 1998 were randomized into either the study group or the control group. The radially expanding 10-mm trocar was used for the epigastric port in the study group. The conventional 10-mm metal trocar was used similarly in the control group. The operation was otherwise performed with a standardized technique. Another conventional 10-mm metal trocar was used for the subumbilical port for all patients. Pain was measured using a visual analog scale. Pain scores for the epigastric port and subumbilical port were documented for 3 days after the surgery., Results: There was no difference in age, sex, diagnoses, operating time, or conversion rate. There was consistently no difference in the pain experienced in the subumbilical wound, whereas pain at the epigastric wound was consistently less with the radially expanding trocar (p < 0.05)., Conclusion: The radially expanding trocar produces less early postoperative pain than the conventional metal trocar.

Background: Laparoscopic-assisted resection for colorectal lesions is feasible, but most reported series are heterogeneous and noncomparative. The aim of this study was to investigate whether laparoscopic-assisted resection was better than open abdominoperineal resection for low rectal adenocarcinoma., Methods: Twenty-five (study group) of 59 consecutive patients who were considered suitable were selected for laparoscopic-assisted abdominoperineal resection based on the availability of informed consent, laparoscopic instruments, and experienced surgeons. The results in these patients were compared with the other 34 patients operated on by the open method (control group)., Results: The median follow-up times for the study and control groups were 30.1 and 28.3 months, respectively. The operation time was significantly longer (t-test, p < 0.001), while operative blood loss (Mann-Whitney U test, p = 0.02), postoperative analgesic requirement (Mann-Whitney U test, p = 0.02), time to resume normal diet (Mann-Whitney U test, p = 0.04), and total hospital stay (Mann-Whitney U test, p = 0.02) were significantly less in the study than in the control group. The oncological clearance, complication rate, disease-free interval, and survival were comparable in the two groups., Conclusions: Laparoscopic-assisted abdominoperineal resection allowed earlier postoperative recovery, with equal oncological clearance, morbidity, mortality, disease-free interval, and survival.

Background: With the advent of fine-needle aspiration cytology (FNAC), the role of frozen section (FS) in the management of non-toxic thyroid nodules has become uncertain., Methods: During the period from January 1993 to December 1995, a total of 84 patients have undergone operative treatment for non-toxic thyroid nodules at the United Christian Hospital, Kowloon. The medical records of these patients were studied retrospectively., Results: In the benign group, the diagnostic accuracy of FNAC was 94% and that of FS was 91%. If FNAC reported malignancy, the diagnostic accuracy was 70%. If FS reported malignancy, the report was accurate in 100%. Among the 43 cases reported as benign on FNAC, FS did not alter the surgical management in any case. In 10 cases reported as suspicious on FNAC, FS altered the surgical treatment in one (10%). However, among the 10 cases reported as malignant on FNAC, FS subsequently altered the surgical management in five cases (50%). In three cases of malignancy on FNAC, both FS and the final histopathology report showed benign disease. Hence, FS avoided overtreatment in three patients., Conclusion: Frozen section is indicated if pre-operative FNAC of the thyroid nodules suggests malignancy, in order to determine the extent of the operation and to avoid overtreatment of benign disease. However, FS can be omitted if FNAC is reported as benign or suspicious.

Purpose: Our aim was to test the hypothesis that laparoscopic-assisted resection for colorectal cancer has an immunologic advantage over traditional open surgery., Methods: Sixteen patients with colorectal cancer were randomized to undergo laparoscopic-assisted resection or open surgery. Basic patient data were recorded, and serum interleukin-6 levels, relative proportions of lymphocytes, and human leukocyte antigen-DR expression on monocytes were determined at specific time intervals., Results: Operating time was longer for laparoscopic-assisted resection (P=0.02), but analgesic requirements were less (P=0.04). All patients exhibited the following: interleukin-6 levels increased to a maximum at 4 hours and returned to preoperative levels within 48 hours. This response appeared greater for open resection (mean peak level, 313 vs. 173 pg/ml; P=0.25). Relative granulocytosis (P < 0.001) was seen within 48 hours, which was offset by a decrease in percentage of lymphocytes (P < 0.001). Changes in lymphocyte subfractions were most significant seven days postsurgery: natural killer cells decreased (P=0.003); T cells increased (P=0.008), with elevation in the CD4/CD8 ratio (P=0.003). B cells were largely unchanged at all time periods. Human leukocyte antigen-DR expression on monocytes was significantly less at 48 hours postsurgery (P < 0.001). All changes were reversed within three weeks of surgery. There were no differences when comparing laparoscopic-assisted resection with open surgery., Conclusions: Both laparoscopic-assisted resection and open surgery affect the immune response. It would appear that laparoscopic-assisted resection does not have an immunologic advantage over open surgery in patients with colorectal cancer.

Background: It is important to establish the precise location of a colorectal lesion preoperatively. We used a model based on colorectal cancer to assess the efficacy of colonoscopy in locating these lesions., Methods: We retrospectively analyzed all consecutive new colorectal cancer cases at the Department of Surgery, United Christian Hospital, Hong Kong, in 1995., Results: Of the 123 cases reviewed by us, 84 cases satisfied the analysis criteria. The overall accuracy was 81%. It was especially high in the rectosigmoid region (93%) and descending colon (100%). The overall predictive power was 83%. It was especially high in the right-sided colon (100%) and the rectosigmoid region (93%)., Conclusions: We conclude that colonoscopy is an accurate means for locating lesions in the upper rectum and sigmoid colon. It is also very predictive of lesions in the upper rectum, sigmoid colon, and right-sided colon.

Background: The aim of this prospective randomized study was to define the optimum management between early and delayed laparoscopic cholecystectomy for patients with acute cholecystitis., Methods: Patients were randomized to receive either early laparoscopic cholecystectomy within 24 h of randomization or initial conservative treatment followed by delayed laparoscopic cholecystectomy 6-8 weeks later., Results: There were 53 patients in the early group and 51 in the delayed group. There was no significant difference in conversion rate (early 21 per cent versus delayed 24 per cent), postoperative analgesic requirement (1 versus 2 doses) and postoperative complications. However, the early group had significantly longer operating time (122.8 versus 106.6 min, P = 0.04) and shorter total hospital stay (7.6 versus 11.6 days, P < 0.001)., Conclusion: Early laparoscopic cholecystectomy is safe and feasible for acute cholecystitis with the additional benefit of shorter total hospital stay. Apart from a shorter operating time, treating patients with delayed laparoscopic cholecystectomy does not offer additional benefit.

Objective: To investigate the incidence and predictive value of congenital hypertrophy of retinal pigment epithelium (CHRPE) in the Chinese familial adenomatous polyposis (FAP) patients., Methods: Eleven FAP patients and 28 at risk relatives from 7 families were examined for CHRPE lesions., Results: CHRPE was present in all 11 FAP patients. Nine CHRPE lesions were found in 9 of the 28 at risk relatives. There were great intra and inter-familial variations of the CHRPE lesions. Two at risk relatives were diagnosed to have FAP only after our screening and subsequent proctosigmoidoscopy. Nine at risk relatives were put under high surveillance because of the presence of CHRPE., Conclusion: The incidence of CHRPE in the FAP patients in our study is 100%. Eye examination for CHRPE for FAP patients and their at risk relatives is of very high value. A central FAP registry is thus recommended.

Percutaneous drainage is now the preferred initial treatment of subphrenic abscess. The result is best for simple, unilocular abscesses but less so for complex ones. Failure of drainage can lead to high morbidity and mortality. We describe a case in which a large multiloculated subphrenic abscess was successfully drained laparoscopically without contaminating the general peritoneal cavity.

We report on five male patients with sigmoid volvulus treated by laparoscopy-assisted sigmoid colectomy. Intraoperative colonic irrigation was used in two patients prior to resection and primary anastomosis. An intracorporeal technique of bowel anastomosis was used that allowed smaller skin incisions as compared with the extracorporeal technique. All five patients recovered uneventfully, and most were discharged within 1 week after the operation. There was no recurrence at the conclusion of the follow-up. Laparoscopy-assisted sigmoid colectomy may prove to be the procedure of choice in patients with sigmoid volvulus.

Background: The technique of laparoscopic-assisted resection of colorectal carcinoma has been established. However, whether such a procedure is beneficial to patients is uncertain., Objective: To review the immediate and medium-term results of laparoscopic-assisted resection in patients with rectosigmoid carcinoma., Patients and Interventions: We attempted laparoscopic-assisted sigmoid colectomy or anterior resection in 50 patients with rectosigmoid carcinoma (ie, the study group). The results were compared with those of 50 matched patients who underwent conventional open resection in the immediate prelaparoscopic era (ie, the control group)., Results: The median follow-up times for the study and control groups were 32.8 and 39.1 months, respectively. The operating time was significantly longer (P < .001, Student t test), while the analgesic requirement was significantly less (P < .001, Mann-Whitney U test) and the duration of hospitalization was significantly shorter (P = .001, Mann-Whitney U test), in the study group than in the control group. The oncological clearance (ie, the number of lymph nodes removed and the distal resection margin), the complication rate, the disease-free rate, and the survival rate were comparable in the 2 groups., Conclusion: The immediate and medium-term results of laparoscopic-assisted resection of rectosigmoid carcinoma are promising.

From the computerized pathology record, three cases of anal and perianal tuberculosis were encountered in the Prince of Wales Hospital, Hong Kong during the last 10 years. The clinical history, examination findings and relevant investigations were reviewed retrospectively. Comparison was made with previous literature. Emphasis was put on the diversity of clinical presentations including acute perianal abscess, chronic anal ulcer and fistula in ano. It is concluded that a high index of suspicion is important to ensure an early diagnosis.

In this short article we describe the use of a cotton tape tie in laparoscopic colorectal surgery. This technique is useful in: (i) retraction and manipulation of the bowel; (ii) exteriorization of a bulky specimen; and (iii) occlusion of the rectal lumen to permit effective cytocidal rectal lavage.

Background: One-week bismuth triple therapy has been established to be highly effective in curing H. pylori infection, but patient compliance has been the major factor of success in therapy. For patients hospitalized for ulcer bleeding, an effective regimen that can completed before discharge will ensure full compliance., Aim: To compare 2-day versus 1-wk bismuth triple therapy plus omeprazole in curing H. pylori infection and bleeding peptic ulcers., Methods: 100 patients with non-actively bleeding duodenal (DU) or gastric ulcers (GU) and confirmed H. pylori infection were randomized to receive either bismuth subcitrate 120 mg, tetracycline 500 mg, and metronidazole 400 mg four times daily for 1 wk (OBTM-7) or bismuth subcitrate 240 mg, tetracycline 500 mg, and metronidazole 400 mg four times daily for 2 days (OBTM-2). Both groups of patients also received omeprazole 20 mg twice daily for the first week. In the OBTM-2 group, the anti-Helicobacter therapy was finished during hospitalization. Endoscopy was repeated 5 wk after randomization to monitor ulcer healing and determine H. pylori status. Side effects related to the anti-Helicobacter therapy was graded as follows: A, mild discomfort, which did not affect daily activity; B, moderate discomfort affecting daily activity; and C, severe discomfort and patients discontinued therapy., Results: Forty-six patients in the OBTM-2 group and 50 in the OBTM-7 group returned for follow-up endoscopy. With an intention-to-treat analysis, ulcer healing was achieved in 44 of 46 patients (95.7%) in the OBTM-2 group versus 49 of 50 (98%) in the OBTM-7 group, p = 0.61. H. pylori eradication was successful in 35 of 46 patients (76.1%) in the OBTM-2 and in all 50 patients (100%) in the OBTM-7 group, p = 0.00024. There was no difference in the severity of side effects experienced by the patients in the OBTM-2 group than in the OBTM-7 group (19 vs 32%, p = 0.16). None of the patients had rebled during the period of follow-up., Conclusion: Despite similar efficacy in ulcer healing, the 2-day quadruple therapy is less effective than the 1-wk regimen in curing H. pylori infection.

We investigated the optimal position of the laparoscope in relationship to the working ports. The optical angle (theta), defined as the angle formed by the line of action (determined by the working ports) and the line of vision (determined by the laparoscope), was varied by 30 degrees intervals from 0 degree to 180 degrees to the left and to the right. We also studied the time taken to accomplish a standardized task of tying a square knot with each optical angle in a laparoscopic simulator setting. The optimal position is at the optical angle of 0 degree. The optimal range of the optical angle is 60 degrees to the left and 60 degrees to the right of the optimal position of 0 degree.

The distal resection margin measured in situ at operation, on the fresh specimen and on the fixed specimen was analysed prospectively in 55 consecutive patients undergoing anterior resection for carcinoma of the rectum. There was obvious contraction in length from the operative margin to the specimen margin and to the fixed margin. As measured by contraction coefficients, contraction was greater in more proximal tumours than in distal ones. Eight of 55 patients had microscopic intramural spread in the fixed distal margin and the maximum spread was 12 mm. Taking contraction of the fixed margin into account, the extrapolated microscopic spread in the operative margin ranged from 0 to 47 mm.

Objective: The authors described their experience with laparoscopic-assisted colorectal resection for colorectal carcinoma, both curative and palliative, with emphasis on patient selection. The techniques of the operations were described., Summary Background Data: Laparoscopic colorectal procedures for treatment of benign lesions have been shown to be less painful and to enhance early postoperative recovery. However, use of laparoscopic procedures for treatment of colorectal cancer are controversial. The authors have used laparoscopic techniques for curative and palliative resections of colorectal carcinoma with satisfactory early results., Methods: One hundred patients with colorectal carcinoma were selected over a 30-month period for laparoscopic-assisted colorectal resection. For 17 patients, laparoscopy revealed bulky tumor or locally advanced disease, and open surgery was performed. For 83 patients, laparoscopic-assisted colon and rectal resections were attempted. Procedural data and postoperative results were entered prospectively. The median follow-up period was 15.2 months (range, 2.5-32.7 months)., Results: Fourteen of 83 patients eventually required conversion to open surgery. The median operative time was 180 minutes. The patients could return to a normal diet in a median of 4 days. The median number of doses of analgesics required was two, and the median hospital stay was 6 days. The morbidity rate was 12%, and there was no deaths attributable to the procedure. There were four distant recurrences and one pelvic recurrence., Conclusions: Laparoscopic-assisted colorectal resection for selected patients is feasible, and early postoperative results are encouraging. This procedure does not appear to be associated with an excessive recurrence rate, and long-term follow-up is necessary for late survival figures.

Good results of rectopexy for complete rectal prolapse have been achieved using the transabdominal approach. With the introduction of the laparoscopic technique in cholecystectomy, many other abdominal procedures have been tried with the laparoscopic technique with varying degrees of success. The laparoscopic technique has opened up a new possibility of a minimally invasive approach to rectopexy. With the elimination of a major incision in laparoscopic rectopexy, the patients may benefit from less morbidity associated with a major abdominal wound. In this case report, laparoscopic rectal mobilization and rectopexy using Marlex mesh and a hernia stapler is reported.

A technique is described for extraction of bulky tissue during laparoscopic surgery using a dedicated non-disposable instrument specifically designed for the purpose. The technique was used on seven patients with acute cholecystitis, three patients with big gallstones in elective cholecystectomy and two patients with acute appendicitis. The procedure took about 1 min in all patients. No patient suffered from complications related to the procedure.

In a prospective randomised controlled trial, amoxycillin plus clavulanic acid was compared to a combination of cefotaxime and metronidazole as prophylactic antibiotics in 164 patients who underwent elective colorectal resectional surgery. Wound infection occurred in 15 patients (9.1%) and deep surgical infection in 4 (2.4%). Seven cases of wound infection and 2 cases of deep infection occurred in the amoxycillin plus clavulanic acid arm, while 8 cases of wound infection and 2 cases of deep infection occurred in the cefotaxime plus metronidazole arm. Eighty-eight percent of infections occurred in patients who had low anterior resection or abdominoperineal resection of the rectum. Both the amoxycillin plus clavulanic acid and the combination of cefotaxime and metronidazole offer the same degree of protection against post-operative infection. The use of amoxycillin plus clavulanic acid as antibiotic prophylaxis is recommended because of its easier use and cheaper cost.

Between July 1986 and July 1988, Devine exclusion was performed in 20 patients with unresectable carcinoma of the gastric antrum. All 20 patients presented with repeated vomiting. On endoscopy, 16 patients had complete gastric outlet obstruction while the remainder manifested significant gastric outlet stenosis. There was no hospital mortality. All except two patients could take an oral diet after surgery until their demise. Devine exclusion is safe and effective in relieving gastric outlet obstruction and is not associated with prolonged delay in return of gastric emptying.