Frances K. Cheung

Prophylactic ilioinguinal neurectomy in open inguinal hernia repair: a double-blind randomized controlled trial.

Objective:We conducted a double-blinded randomized controlled trial to investigate the short- to mid-term neurosensory effect of prophylactic ilioinguinal neurectomy during Lichtenstein repair of inguinal hernia. Method:One hundred male patients between the age of 18 and 80 years with unilateral inguinal hernia undergoing Lichtenstein hernia repair were randomized to receive either prophylactic ilioinguinal neurectomy (group A) or ilioinguinal nerve preservation (group B) during operation. All operations were performed by surgeons specialized in hernia repair under local anesthesia or general anesthesia. The primary outcome was the incidence of chronic groin pain at 6 months. Secondary outcomes included incidence of groin numbness, postoperative sensory loss or change at the groin region, and quality of life measurement assessed by SF-36 questionnaire at 6 months. All follow-up and outcome measures were carried out by a designated occupational therapist at 1 and 6 months following surgery in a double-blinded manner. Results:The incidence of chronic groin pain at 6 months was significantly lower in group A than group B (8% vs. 28.6%; P = 0.008). No significant intergroup differences were found regarding the incidence of groin numbness, postoperative sensory loss or changes at the groin region, and quality of life measurement at 6 months after the operation. Conclusions:Prophylactic ilioinguinal neurectomy significantly decreases the incidence of chronic groin pain after Lichtenstein hernia repair without added morbidities. It should be considered as a routine surgical step during the operation.

Predicting Mortality in Patients With Bleeding Peptic Ulcers After Therapeutic Endoscopy

BACKGROUND & AIMS Despite advances in management of patients with bleeding peptic ulcers, mortality is still 10%. This study aimed to identify predictive factors and to develop a prediction model for mortality among patients with bleeding peptic ulcers. METHODS Consecutive patients with endoscopic stigmata of active bleeding, visible vessels, or adherent clots were recruited, and risk factors for mortality were identified in this deprivation cohort by using multiple stepwise logistic regression. A prediction model was then built on the basis of these factors and validated in the evaluation cohort. RESULTS From 1993 to 2003, 3220 patients with bleeding peptic ulcers were treated. Two hundred eighty-four of the patients developed rebleeding (8.8%); emergency surgery was performed on 47 of these patients, whereas others were managed with endoscopic retreatment. Two hundred twenty-nine of these sustained in-hospital death (7.1%). In patients older than 70 years, presence of comorbidity, more than 1 listed comorbidity, hematemesis on presentation, systolic blood pressure below 100 mm Hg, in-hospital bleeding, rebleeding, and need for surgery were significant predictors for mortality. Helicobacter pylori-related ulcers had lower risk of mortality. The receiver operating characteristic curve comparing the prediction of mortality with actual mortality showed an area under the curve of 0.842. From 2004 to 2006, data were collected prospectively from a second cohort of patients with bleeding peptic ulcers, and mortality was predicted by using the model developed. The receiver operating characteristic curve showed an area under the curve of 0.729. CONCLUSIONS Among patients with bleeding peptic ulcers after endoscopic hemostasis, advanced age, presence of listed comorbidity, multiple comorbidities, hypovolemic shock, in-hospital bleeding, rebleeding, and need for surgery successfully predicted in-hospital mortality.

Randomized Trial of Endoscopic Sphincterotomy With Balloon Dilation Versus Endoscopic Sphincterotomy Alone for Removal of Bile Duct Stones

BACKGROUND & AIMS Limited endoscopic sphincterotomy with large balloon dilation (ESBD) is an alternative to endoscopic sphincterotomy (ES) for removing bile duct stones, but it is not clear which procedure is most effective. We compared the 2 techniques in removal of bile duct stones. METHODS Between September 2005 and September 2011, 156 consecutive patients with suspected of having, or known to have, common bile duct stones were randomly assigned to groups that underwent ES or ESBD. Patients in the ESBD group underwent limited sphincterotomy (up to half of the sphincter) followed by balloon dilation to the size of the common bile duct or 15 mm, and patients in the ES group underwent complete sphincterotomy alone. Stones were then removed using standard techniques. The primary outcome was percentage of stones cleared, and secondary outcomes included procedural time, method of stone extraction, number of procedures required for stone clearance, morbidities and mortality within 30 days, and direct cost. RESULTS There was no significant difference between groups in percentage of stones cleared (ES vs ESBD: 88.5% vs 89.0%). More patients in the ES group (46.2%) than the ESBD group (28.8%) required mechanical lithotripsy (P = .028), particularly for stones ≥15 mm (90.9% vs 58.1%; P = .002). Morbidities developed in 10.3% of patients in the ES group and 6.8% of patients in the ESBD group (P = .46). The cost of the hospitalization was also significantly lower in the ESBD group (P = .034). CONCLUSIONS ESBD and ES clear bile stones with equal efficacy. However, ESBD reduces the need for mechanical lithotripsy and is less expensive; ClinicalTrials.gov number, NCT00164853.

BLUE RUBBER BLEB NEVUS SYNDROME: TREATMENT OF MULTIPLE GASTROINTESTINAL HEMANGIOMAS WITH ARGON PLASMA COAGULATOR

Blue rubber bleb nevus syndrome is a rare clinical entity characterized by the formation of multiple blue or purplish rubbery cavernous hemangiomas on the skin and other epithelial surfaces. Involvement of the gastrointestinal tract is common and often presents with crippling anemia as a result of chronic occult blood loss. While surgical extirpation is an option for symptomatic hemangiomas in the intestine, endoscopic therapy is more appealing for lesions found in the stomach and colon. Here we report the successful use of argon plasma coagulation in the management of an adult with multiple hemangiomas in her colon and terminal ileum.

Surgical Salvage of Bleeding Peptic Ulcers after Failed Therapeutic Endoscopy

Background: The approach to salvage surgery after failed endoscopic therapy for a bleeding peptic ulcer is controversial. We aimed to compare the outcomes of salvage surgery after failed endoscopic therapy for bleeding peptic ulcers over a 10-year period. Methods: Patients receiving salvage surgery for bleeding peptic ulcers were divided into 2 cohorts, the 1st from 1993 to 1998 and the 2nd from 1999 to 2004. The type of salvage surgery was defined as minimal if ulcer plication or an ulcerectomy was performed, and definitive if the patient received a vagotomy or gastrectomy. Results: One hundred and twenty-three patients received salvage surgery in the 1st cohort, while 42 patients received surgical hemostasis for the bleeding peptic ulcer in the 2nd cohort. Patients in the 2nd cohort consisted of a larger proportion of in-hospital bleeders (cohort 1: 12.2%, cohort 2: 42.9%; p < 0.005) and had a significantly higher proportion of comorbidities. A larger number of patients received minimal surgery in cohort 2 (cohort 1: 42.3%, cohort 2: 73.8%; p < 0.005). Conclusions: With advances in therapeutic endoscopy, patients who developed failed endoscopic hemostasis are likely to be poor surgical candidates with multiple comorbidities. The approach to salvage surgery has inclined towards minimal surgery to hasten surgical hemostasis among these fragile patients.

Endoscopic mucosal incision with an insulated-tip knife for intramucosal esophageal dissection: case report.

Lymphangioma of the oesophagus: a case report and a review of literature. Thorax 1994;49:1267-8. 22. Melcher GA, Ruedi T, Allemann J, Wust W. Das zystische Lymphangiom als seltene ursache des akuten abdomens [Cystic lymphangioma of the mesenterial root as a rare cause of acute abdomen]. Chirurg 1995; 66:229-31. 23. Young T, Ho AS, Tang HS, Hsu CT, Lee HS, Chac YC. Cystic lymphangioma of the transverse colon: report of a case and review of the literature. Abdom Imaging 1996;21:415-7. 24. Irani S, Fartab M. Gastrointestetinaler stromatumor: -ein chirurgischonkologisches sorgenkind [Gastrointestinal stroma tumor: a surgical oncology problem child?]. Chirurg 1999;70:259-64. 25. Sennon A, Gruwez JA, Lateur L, De Wever I. The importance of magnetic resonance imaging in the diagnosis and treatment of diffuse lymphangioma. Acta Chir Belg 1999;99:230-5. 26. Beham A. Lymphangioma. In: Fletcher Ch DM, Unni KK, Merten F, editors. World Health Organization, classification of tumors. Pathology and genetics of tumors of soft tissue and bone. Lyon (France): IARCPress; 2002. p. 162-3. 27. Takiffil, Calabria R, Yin L, Stabile BE. Mesenteric cysts and intraabdominal cystic lymphangiomas. Arch Surg 1985;120:1266-9. 28. Franquemont DW. Differentiation and risk assessment of gastrointestinal stromal tumors. Am J Clin Pathol 1995;103:41-7. 29. Canavese F, Cortese MG, Proietti L, Costantino S, Rosina M, Nangeroni M, et al. Bulky-pedunculated hemolymphangioma of the esophagus: rare case in a two-year-old girl. Eur J Pediatr Surg 1996;6: 170-2. 30. Kim KM, Choi KY, Lee A, Kim BK. Lymphangioma of large intestine: report often cases with endoscopic and pathologic correlation. Gastrointest Endosc 2000;52:255-9. 31. Tanabe S, Koizumi W, Mitomi H, Kitamura T, Tahara K, Ichikawa J, et al. Usefulness of EMR with an oblique aspiration mucosectomy device compared with strip biopsy in patients with superficial esophageal cancer. Gastrointest Endosc 2004;59:558-63. 32. Pross M, von Rahden BHA, Schubert D, Feulner H. Rendevousverfahren im bereich des osophagus. Chir Gastroenterol 2004;20:100-4. 33. Krakamp B, Freudenhammer Ch, Koehler L, Leidig P, Marx NI, Merkel F, et al. Granulosazelltumor-eine seltene tumoroese Oesophaguslaesion. Dtsch Med Wochensch 2000;125:1511-5.

Perigastric lymph node metastasis does not affect the survival of squamous cell carcinoma of the oesophagus treated with two‐field oesophagectomy

Aim:  There are some discrepancies as to the prognostic value of perigastric lymph node (LN) metastasis in the survival of squamous oesophageal carcinoma. The present study aimed to compare survival following standard oesophagectomy in the treatment of squamous oesophageal carcinoma with or without perigastric abdominal LN metastasis.