Danny W.H. Lee

Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers.

Background and Methods After endoscopic treatment to control bleeding of peptic ulcers, bleeding recurs in 15 to 20 percent of patients. In a prospective, randomized study, we compared endoscopic retreatment with surgery after initial endoscopy. Over a 40-month period, 1169 of 3473 adults who were admitted to our hospital with bleeding peptic ulcers underwent endoscopy to reestablish hemostasis. Of 100 patients with recurrent bleeding, 7 patients with cancer and 1 patient with cardiac arrest were excluded from the study; 48 patients were randomly assigned to undergo immediate endoscopic retreatment and 44 were assigned to undergo surgery. The type of operation used was left to the surgeon. Bleeding was considered to have recurred in the event of any one of the following: vomiting of fresh blood, hypotension and melena, or a requirement for more than four units of blood in the 72-hour period after endoscopic treatment. Results Of the 48 patients who were assigned to endoscopic retreatment, 35 had long-term...

Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial.

OBJECTIVE In this randomized trial, the authors sought to determine whether eradication of Helicobacter pylori could reduce the risk of ulcer recurrence after simple closure of perforated duodenal ulcer. BACKGROUND DATA Immediate acid-reduction surgery has been strongly advocated for perforated duodenal ulcers because of the high incidence of ulcer relapse after simple patch repair. Although H. pylori eradication is now the standard treatment of uncomplicated and bleeding peptic ulcers, its role in perforation remains controversial. Recently a high prevalence of H. pylori infection has been reported in patients with perforations of duodenal ulcer. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair and hence obviates the need for an immediate definitive operation. METHODS Of 129 patients with perforated duodenal ulcers, 104 (81%) were shown to be infected by H. pylori. Ninety-nine H. pylori-positive patients were randomized to receive either a course of quadruple anti-helicobacter therapy or a 4-week course of omeprazole alone. Follow-up endoscopy was performed 8 weeks, 16 weeks (if the ulcer did not heal at 8 weeks), and 1 year after hospital discharge for surveillance of ulcer healing and determination of H. pylori status. The endpoints were initial ulcer healing and ulcer relapse rate after 1 year. RESULTS Fifty-one patients were assigned to the anti-Helicobacter therapy and 48 to omeprazole alone. Nine patients did not undergo the first follow-up endoscopy. Of the 90 patients who did undergo follow-up endoscopy, 43 of the 44 patients in the anti-Helicobacter group and 8 of the 46 in the omeprazole alone group had H. pylori eradicated; initial ulcer healing rates were similar in the two groups (82% vs. 87%). After 1 year, ulcer relapse was significantly less common in patients treated with anti-Helicobacter therapy than in those who received omeprazole alone (4.8% vs. 38.1%). CONCLUSIONS Eradication of H. pylori prevents ulcer recurrence in patients with H. pylori-associated perforated duodenal ulcers. Immediate acid-reduction surgery in the presence of generalized peritonitis is unnecessary.

Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: A prospective randomized trial

BACKGROUND Endoscopic drainage has replaced emergent surgery for biliary decompression in patients with acute cholangitis. The aim of this study was to prospectively compare the efficacy of the nasobiliary catheter and indwelling stent as temporary measures for biliary decompression in acute suppurative cholangitis caused by bile duct stones. METHODS Over a 60-month period, 79 patients with acute cholangitis who required emergent endoscopic drainage were recruited. Indications for urgent drainage included any one of the following: temperature greater than 39 degrees C, septic shock with systolic blood pressure less than 90 mm Hg, increasing abdominal pain, and impaired level of consciousness. Patients who had previously undergone sphincterotomy or had coexisting intrahepatic duct stones were excluded. After successful bile duct cannulation, patients were randomized to receive either a nasobiliary catheter or indwelling stent without sphincterotomy for biliary decompression. Outcome measures included procedure time, complications, clinical response, and patient discomfort (scored with a 10-cm, unscaled visual analog score). RESULTS Of the 79 patients, 5 were excluded because of previous sphincterotomy and intrahepatic duct stones, 40 were randomized to receive a nasobiliary catheter (NBC group), and 34 to receive indwelling stent (stent group). Demographic data were similar between the groups. All procedures were successful in the NBC group; there was one failure in the stent group. The mean (SD) procedure time was similar (NBC group 14.0 [9.3] minutes vs. stent group 11.4 [7.2] min). There were 2 ERCP-related complications in the NBC group. Four patients pulled out the nasobiliary catheter and one catheter became kinked. One stent occluded. There was a significantly lower mean (SD) patient discomfort score on day 1 after the procedure in the stent group (stent group 1.8 [2.6] vs. NBC group 3.9 [2.7]; p = 0.02 t test). The overall mortality rate was 6.8% (2.5% NBC group vs. 12% stent group). CONCLUSION Endoscopic biliary decompression by nasobiliary catheter or indwelling stent was equally effective for patients with acute suppurative cholangitis caused by bile duct stones. The indwelling stent was associated with less postprocedure discomfort and avoided the potential problem of inadvertent removal of the nasobiliary catheter.

A Randomized Comparison of Acute Phase Response and Endotoxemia in Patients with Perforated Peptic Ulcers Receiving Laparoscopic or Open Patch Repair

BACKGROUND In patients with peritonitis from perforated peptic ulcers, we compared acute stress responses, endotoxemia, and bacteremia following laparoscopic or open surgery. PATIENTS AND METHODS Consecutive patients with peritonitis from perforated peptic ulcers were randomized to receive laparoscopic sutured or open omental repair. Undiluted peritoneal fluid was obtained at surgery for quantitative bacterial and endotoxin (Limulus Amoebocyte Lysate) assay. Serial blood samples were taken at 0, 30, 60, 90, 120, and 180 minutes, and at 12, 24, 48, 72, and 120 hours for determinations of quantitative bacterial and endotoxin assays, interleukin-6 (IL-6), C-reactive protein (CRP), and cortisol. RESULTS Twenty-two patients were randomized: laparoscopy group (n = 12), open repair group (n = 10). Conversions were required in 3 patients assigned to laparoscopy, leaving 9 patients for analysis. The two groups were comparable in their demographic data, median duration of perforation (13.5 hours versus 10 hours), severity of peritoneal contamination as indicated by viable bacterial count (5.9 x 102 versus 1.5 x 10(2) colony forming unit/mL) and endotoxin concentration in peritoneal fluid (27.2 versus 24.6 EU/mL). No significant endotoxemia or bacteremia was detected in these patients. Median interleukin-6 was highest at 0 hour (1520 versus 962 pg/mL) and fell rapidly following surgery. C-reactive protein peaked at 24 hours and plateaued thereafter. Cortisol was highest intraoperatively and fell thereafter. No difference was noted between the two treatment groups with respect to these inflammatory markers (IL-6 P = 0.19, CRP P = 0.14, cortisol P = 0.56, multivariate analysis of variance). CONCLUSION Endotoxemia and bacteremia are insignificant in most patients with perforated peptic ulcers. In patients with perforated peptic ulcers, laparoscopic patch repair does not reduce acute stress responses when compared with open surgery.

Small-bowel Intestinal Obstruction Caused by an Unusual Internal Hernia

We report a rare case of transomental small-bowel herniation in a 91-year-old lady who presented with central abdominal pain and mild distension. Urgent abdominal computed tomography (CT) showed a segment of dilated ileum with features suggestive of strangulation. Emergency exploration revealed a segment of congested small-bowel loop herniated through a defect over the greater omentum. Reduction of the bowel loops and division of the omental defect was performed without the need for bowel resection. The patient made an uneventful recovery. We discuss the value of CT scan and highlight the importance of recognizing this rare cause of small-bowel obstruction.

Superoxide and nitric oxide production by Kupffer cells in rats with obstructive jaundice: effect of internal and external drainage.

Background and Aims:  The role of Kupffer cells in obstructive jaundice (OJ) has not been fully understood. The aims of the present study were to measure superoxide and nitric oxide (NO) production by Kupffer cells in experimental OJ in rats and to investigate the response to internal and external biliary drainage.

Is it always the trainees’ fault?

The following is the fictional scene of a mortality and morbidity meeting where a higher surgical trainee was presenting a mortality case: A 30-year-old gentleman attended the casualty because of abdominal colic of increasing severity for 4 h after lunch. He had always been healthy, except for a history of open appendectomy at age 15, and had occasional abdominal colics, which normally resolved spontaneously. After a few hours of waiting in casualty, assessments and X-rays, he was admitted to the surgical ward with a diagnosis of suspected intestinal obstruction (IO). An injection of 50 mg tramadol was given before he was transferred to the ward. When the patient arrived to the ward at approximately 1 a.m., he was still in pain, but the intern and the first-call resident (the higher surgical trainee) were engaged in a difficult case of incarcerated inguinal hernia where a segment of the small bowel was completely gangrene in an obese patient with a body mass index of 35. The ward nurse asked if the higher surgical trainee could go out and assess the newlyadmitted patient; the answer was obviously ‘no’. Knowing that the patient’s vital signs were quite stable, but not knowing a shot of analgesic had already been given before arriving to the surgical ward, the higher surgical trainee prescribed an injection of 50 mg tramadol, hoping that would buy some time and continuing with the difficult case in front of him. At approximately 5 a.m., the difficult case of hernia repair and small bowel resection was finished. The higher surgical trainee and the intern went to the ward and they were shocked to find the patient admitted for suspected IO was in fact having a generalized peritonitis. His pulse had gone up from 96 /min at 1 a.m. to 145 /min. Blood pressure had dropped to 105/55. Noticing that a foley catheter was not inserted, he quickly inserted one and found that, at most, there was 30 mL of urine in the past 4 h. Knowing that the patient was having generalized peritonitis and deteriorating, the higher surgical trainee initiated all the correct management steps, including resuscitation, consulting the intensive care unit, booking operating room and paging his second call to come. On emergency laparotomy at 7 a.m., the patient was found to have a perforated sigmoid colon and faecal peritonitis. The intraabdominal adhesion was very bad, and the segment of sigmoid colon was found twisting around the adhesion. A Hartmann’s procedure was finished in approximately 1 hour. The patient unfortunately did not improve afterwards, despite intensive care supports and high dose inotropes. All major systems were failing and the patient eventually died on day 3 after the laparotomy. While the mortality and morbidity meeting is a good arena for surgeons to reflect and improve their practices and prevent future recurrence, little emphasis will usually be placed on the discussion on the potential medicolegal risks, especially from the trainee’s point of view. In this case, the surgical trainee has two queries in his mind, but nonetheless did not raise any of them at the meeting: Will the court lower the standard of care expected of him when adjudicating this potential negligence case because he is still in training? And, how much or to what extent a trainee like him, as an employee of the Hospital Authority (HA), is responsible for the delay of treatment or the death of the patient in terms of legal proceedings and damages? In order to establish a civil claim of clinical negligence, the claimant (patient) has the burden to prove the defendant doctor has acted below the standard of care in the case. In assessing the standard of care, the court has long used the objective criteria of ‘what a reasonable professional would have acted in the circumstances – the Bolam test’. In order to avoid legal uncertainty, the court would not consider the trainee’s experience or the level of training when assessing what the standard of care at issue is. Put simply, when a trainee is acting in a particular capacity or post, such as an on-call surgeon looking after emergency patients, the court would only examine what a reasonable specialist surgeon (not a reasonable trainee) would have done in the situation. Despite the apparently harsh approach, the court has accepted that the trainee’s liability could be discharged when he seeks assistance from a more experienced colleague. Thus, it remains the sole responsibility of the trainee to stay vigilant in their work and to call for appropriate assistance from seniors when needed. After all, it is an important part of the surgical training to ‘learn the limit of oneself’ and to ‘know when to seek help’. Needless to say, the training unit (or hospital) has the irrefutable responsibility to set up a robust system to support on-call trainee residents.

7077 Through-the-scope stent (ttss) for obstructive non-esophageal gastrointestinal tumors.

Background: Endoscopic stenting for duodenal or colorectal obstruction is often more difficult due to the excessive looping of the deployment system inside the dilated stomach or tortuous axis in rectosigmoid colon. Throughthe-scope stent has the advantage of putting the stent via the working channel of the endoscope. We reported our results on through-the-scopestent (TTSS) in palliating obstructive non-esophageal gastrointestinal tumors. Materials and Methods: From Sept 98 to Aug 99, 10 patients (6 male: 4 female, mean age 64, range 35-88) received TTSS for relieving gastrointestinal obstruction. The procedure was performed under intravenous sedation and fluoroscopy. Enteral Wallstents (Schnieder, US Stent Division, USA) with a diameter of 20 or 22mm and 60 or 90mm length were used and delivered over a guidewire through the flexible endoscope with an operating channel of at least 3.7mm. Results: All stents were successfully deployed. The locations of the obstruction were: recto-sigmoid: in 3; descending colon: in 1; antral-pyloric in 3 and duodenum: in 3. All colonic stents relieved the bowel obstruction. Of these 4 colonic stents, one patient required second endoscopy to remove the stent because of persistent tenesmus and bleeding, and one patient received curative surgery for the tumor 2 weeks after stenting. For gastric outlet obstruction, the mean dysphagia score improved from 3.5 to 2 (p=0.02) after stenting. The mean survival and symptom free period was 7.25 weeks (range 0.5 to 16 weeks). One patient required another endoscopy to stop bleeding from tumor overgrowth. Conclusion: TTSS is safe and feasible. It offered a minimal invasive way to palliate obstruction in non-esophageal tumors.

Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers

BACKGROUND AND METHODS After endoscopic treatment to control bleeding of peptic ulcers, bleeding recurs in 15 to 20 percent of patients. In a prospective, randomized study, we compared endoscopic retreatment with surgery after initial endoscopy. Over a 40-month period, 1169 of 3473 adults who were admitted to our hospital with bleeding peptic ulcers underwent endoscopy to reestablish hemostasis. Of 100 patients with recurrent bleeding, 7 patients with cancer and 1 patient with cardiac arrest were excluded from the study; 48 patients were randomly assigned to undergo immediate endoscopic retreatment and 44 were assigned to undergo surgery. The type of operation used was left to the surgeon. Bleeding was considered to have recurred in the event of any one of the following: vomiting of fresh blood, hypotension and melena, or a requirement for more than four units of blood in the 72-hour period after endoscopic treatment. RESULTS Of the 48 patients who were assigned to endoscopic retreatment, 35 had long-term control of bleeding. Thirteen underwent salvage surgery, 11 because retreatment failed and 2 because of perforations resulting from thermocoagulation. Five patients in the endoscopy group died within 30 days, as compared with eight patients in the surgery group (P=0.37). Seven patients in the endoscopy group (including 6 who underwent salvage surgery) had complications, as compared with 16 in the surgery group (P=0.03). The duration of hospitalization, the need for hospitalization in the intensive care unit and the resultant duration of that stay, and the number of blood transfusions were similar in the two groups. In multivariate analysis, hypotension at randomization (P=0.01) and an ulcer size of at least 2 cm (P=0.03) were independent factors predictive of the failure of endoscopic retreatment. CONCLUSIONS In patients with peptic ulcers and recurrent bleeding after initial endoscopic control of bleeding, endoscopic retreatment reduces the need for surgery without increasing the risk of death and is associated with fewer complications than is surgery.