Francis Lee

Randomized Clinical Trial of Postoperative Subfascial Infusion with Bupivacaine following Ambulatory Open Mesh Repair of Inguinal Hernia

Background: Wound pain remains the commonest problem after ambulatory open repair of inguinal hernia. Postoperative subfascial infusion of the wound with bupivacaine extends local analgesia at home and may achieve superior analgesia compared with oral analgesics alone. The objective of the present trial was to evaluate the efficacy of postoperative subfascial infusion of the wound with 0.5% bupicavaine at 2 ml per hour for 48 h after operation. Methods: Forty-four patients who underwent ambulatory open tension-free mesh hernioplasties were randomized to two arms of treatment. The pump group had an infusion pump containing 100 ml 0.5% bupivacaine being placed between the external oblique aponeurosis and the Prolene mesh, whereas the nonpump group was treated with oral analgesics alone. Assuming that an observed difference of 2.0 existed between the mean pain scores of the two groups, the estimated sample size would be at least 20 patients in each group. Results: Postoperative pain scores at rest and on coughing were significantly lower in the pump group than in the nonpump group on days 0 and 1 after surgery (p < 0.01). Before being discharged, none of the pump group patients requested analgesics, but 6 patients of the nonpump group required analgesic supplement (p = 0.025). Ten patients (50%) of the pump group experienced no pain during the period of bupivacaine infusion. Recovery variables, including time taken to resume ambulation and micturition, were comparable between the two groups. The pump and nonpump group patients returned to their normal activities after a median of 3 and 4 days, respectively (p = 0.217). The postoperative morbidity rates of the two groups were similar. Conclusion: Postoperative subfascial infusion of the wound with 0.5% bupivacaine achieved superior analgesia compared with oral analgesics alone. Portable infusion pump is a safe technique to continue local analgesia at home after ambulatory open repair of inguinal hernia. The drawbacks of the ON-Q Pain Management System included its high cost and frequent seepage of blood-stained anesthetic fluid into the wound dressing.

Laparoscopic resection of an appendiceal mucocele.

A 78-year-old man was incidentally discovered to have an asymptomatic right lower quadrant abdominal mass during physical examination for influenza. CT scan of the abdomen revealed a cystic sausage-shaped lesion arising from the cecum. Diagnostic laparoscopy revealed an appendiceal mucocele. There was no ascites or metastatic peritoneal nodules. Laparoscopic excision of the unruptured appendiceal mucocele was achieved. Histopathologic examination of the mucocele showed epithelial dysplasia, a feature diagnostic of a mucinous cystadenoma. The patient was discharged on postoperative day one and recovered uneventfully. No analgesic was required after surgery. The patient remained well and symptom-free during the follow-up period. The laparoscopic approach allows diagnostic laparoscopy and appendectomy to be performed, and confers the advantages of minimal-access surgery, including the avoidance of a large incision, a better cosmetic outcome, and a short convalescent period.

Outpatient Laparoscopic Cholecystectomy in Hong Kong Chinese – An Outcome Analysis

BACKGROUND Laparoscopic cholecystectomy (LC) is now the procedure of choice for symptomatic gallbladder disease. Although many recent studies, mostly from abroad, report that it can be performed safely in the outpatient setting, the experience of outpatient LC in Hong Kong is still limited. This retrospective study evaluated the feasibility, safety and patient acceptance of outpatient LC in Hong Kong Chinese patients. PATIENTS AND METHODS The data of 73 consecutive patients who had undergone outpatient LC between February 2000 and October 2002 in the Day Surgery Centre of Tung Wah Hospital were prospectively collected and reviewed. The selection criteria for patients undergoing outpatient LC included American Society of Anesthesiologists risk classification I or II, age less than 70 years, and the availability of a competent adult to accompany the patient home and look after them for 24 hours. No effort was made to exclude complicated cases. After assessment by the operating surgeon, patients were discharged from the Day Surgery Centre in the afternoon when their clinical condition satisfied pre-defined discharge criteria. All patients were followed up in the Day Surgery Centre in the first and fourth postoperative weeks. RESULTS The same-day discharge rate was 88% and the conversion rate was 4%. Six patients (8.2%) with uneventful LC required hospitalization after the procedure. There was no major complication and no unplanned admission. Two patients had port site wound infection requiring hospital admission at the first follow-up. Patient satisfaction was high, pain acceptance was good, and analgesic consumption was minimal. Mild fat intolerance was common in patients postoperatively (> 50%), but this had almost all resolved by postoperative week four. All patients were able to resume their usual daily activities within 2 weeks after surgery. CONCLUSIONS LC is a safe and feasible outpatient procedure in Hong Kong, with high levels of patient satisfaction. A prospective study with a larger patient population is warranted to verify whether it should be recommended as treatment for gallstone disease in selected patients in future.

Teens of the Night: The Young Night Drifters in Hong Kong

This article describes a recent study on young night drifters in Hong Kong, which is currently an alarming youth problem in the territory. The social background, subculture, and problems faced by these young people are introduced. Employing an environmental perspective, the causes of their night-drifting behavior are suggested. In addition, the identified service needs of, and proposed services for, these young people are also presented. It is believed that this study has implications for youth policy makers and service providers in countries that have encountered similar problems.

Prospective randomized trial of pre-emptive analgesics following ambulatory inguinal hernia repair: Intravenous ketorolac versus diclofenac suppository

Background : A pre-emptive non-steroidal anti-inflammatory drug is routinely given to patients undergoing ambulatory inguinal hernia repair. The present prospective randomized trial was undertaken to compare the efficacy of intravenous ketorolac and rectal diclofenac for ambulatory inguinal hernia repairs. Methods : Between June 1999 and February 2001, a total of 108 patients who underwent ambulatory inguinal hernia repairs under general anaesthesia were recruited. Patients were randomized to receive either intravenous ketorolac 30 mg immediately prior to induction of general anaesthesia ( n = 54) or rectal diclofenac 50 mg after signing consent at the Day Surgery Centre ( n = 54). Results : The demographic features, hernia types, anaesthetic time, dosage of anaesthetic medication and operative details of the two groups were comparable. There was no significant difference in total amount of analgesic consumption and linear analogue pain scores after operation. With regard to recovery variables, the respective times taken to regain ambulation and micturition were similar in both groups. Conclusion : Diclofenac suppository 50 mg and intravenous ketorolac 30 mg provided equivalent postoperative analgesia following ambulatory inguinal hernia repair under general anaesthesia. Diclofenac suppository is an economical alternative to intravenous ketorolac. In the interests of cost containment rectal diclofenac could be considered the non-steroidal anti-inflammatory drug of choice for pre-emptive analgesia.

Clinical factors influencing return to work after ambulatory inguinal herniorrhaphy in Hong Kong

Ambulatory inguinal hernia repair is the commonest day case general surgery operation. The present study was conducted to evaluate factors influencing the contemporary pattern of convalescence following ambulatory inguinal hernia repair in Hong Kong. A total of 271 consecutive ambulatory inguinal hernia repairs were performed at a day surgery centre from December 1995 to December 1998. The convalescent period prior to resuming work was analysed by multi-variate analysis with respect to significant clinical variables. A sick leave of 3 weeks was adequate for most patients following uncomplicated ambulatory inguinal hernia repairs. Factors associated with early return to work included age </=50 years, indirect inguinal hernia and sedentary occupation. Occupation was the only independent factor affecting the duration of time off work on multi-variate analysis.

Patient satisfaction after ambulatory inguinal hernia repair in Hong Kong.

Ambulatory surgery was introduced to Asia in the 1990s. Acceptance of ambulatory surgery by oriental patients remains largely unknown. A telephone survey was conducted to evaluate the level of patient satisfaction following ambulatory inguinal hernia repair. A total of 157 patients (61%) completed the telephone survey. More than 90% of the respondents expressed satisfaction with regard to the pre-operative, operative and post-operative service. The majority of the respondents (>80%) preferred to undergo day surgery again in case of hernia recurrence. Our findings prove that ambulatory surgery has a high level of acceptance in Chinese patients and supports the expansion of a day surgery service in Hong Kong.

Adopting a restorative approach to young offenders in Hong Kong: a public survey

With declining faith in the retributive and rehabilitative models of the criminal justice system, the restorative justice (RJ) model has become increasingly favored. Most countries that practice RJ do so for juvenile offenders, and most of these are western countries. It is believed that the illegal acts of most juvenile offenders are committed impulsively. Hong Kong, as an international Asian city that is predominantly Chinese, may want to follow the global trend in adopting some types of RJ practice to deal with juvenile offenders. As public sanction/endorsement is one of the crucial criteria for the implementation of RJ, this article presents the findings of a telephone survey in Hong Kong to explore public support for the idea. It was found that the general public is in favor of the idea of RJ even though their knowledge of the local juvenile justice system is typically inadequate. Some preliminary recommendations are offered.

Teens of the night.

Young people hanging around in groups in public places has become a problem in Hong Kong, particularly in regard to harassing people, the use of drugs, and promiscuous behaviour. This exploratory study, based on research by six social workers, included semi-participant observation of 16 groups and 60 individual interviews. The data collected deals with the subculture of night drifting teens, the causes of their behavior, and targets their particular service needs. Recommendations are provided on appropriate service programmes so as to help these young people towards a healthy and pro-social pattern of life. NIGHT DRIFTING SPOTS Three popular spots where night drifting teens gather were selected as the locations for the present investigation. These spots were: 1. Hong Kong Cultural Centre in Tsimshatsui East; 2. Macdonalds Restaurant in Sai Yeung Choi Street South and Mongkok Road Playground in Mongkok; 1 Tel: (852) 28592288/(852) 2857-8569; Fax: (852) 2858-7604; email: fwllee@hkucc.hku.hk VOL. 10, NO. 3, 1998 227

Service needs of young new arrivals from Mainland China to Hong Kong

After the reunification of Hong Kong with China, in July 1997, there has been an exodus of thousands of arrivals, coming to and settling in Hong Kong from Mainland China. A majority of these arrivals are young people, who come to Hong Kong for the purpose of family reunion. These newly arrived young people have encountered considerable adjustment problems, such as language, schooling, employment, family life, leisure, social relationship, psychological well-being, and support network. More and more natural groups of newly arrived young people are spotted, loitering in communities where most new arrivals settle. Through a qualitative study, which employed in-depth individual interviews with 10 newly arrived young people, the problems they encountered, in the process of adjustment to the Hong Kong society, and their welfare service needs were explored. Based on the findings, relevant policies and services are recommended so that their integration into the Hong Kong society can be facilitated.