Heng-Tat Leong

Predictive Factors of Long Hospital Stay After Laparoscopic Cholecystectomy

OBJECTIVEnLaparoscopic 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.nnnMETHODSnA 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.nnnRESULTSnOf 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.nnnCONCLUSIONnWith 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.

Safety of Nurse-administered Propofol Sedation Using PCA Pump for Outpatient Colonoscopy in Chinese Patients: A Pilot Study

BACKGROUNDnTo determine the safety and effectiveness of nurse-administered propofol sedation using patient-controlled analgesia (PCA) pump in outpatient colonoscopy in a Chinese population.nnnMETHODSnFrom 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.nnnRESULTSnThe 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.nnnCONCLUSIONnNurse-administered propofol sedation using PCA pump is safe and effective in sedation and pain control in outpatient colonoscopy in a healthy Chinese population.

Go-kart injuries of the abdominal cavity

Go‐karting is one of the famous sporting activities in Hong Kong and southern China. Go‐karting is easily accessible to the general public and almost everyone can enjoy the excitement of the sport. Although karting has always been claimed to be safe, the risks and injuries of this fun sport should not be overlooked. From May 2001 to February 2004, we observed three serious intra‐abdominal injuries with go karts in the North District Hospital of Hong Kong. The injuries included hemoperitoneum caused by omental vessel tear, peritonitis caused by perforation of duodenojejunal flexure and peritonitis caused by perforation in the duodenum associated with liver laceration. A high index of clinical suspicion is essential in encountering such cases, as potential life‐threatening complications can occur.

In-situ medical simulation for pre-implementation testing of clinical service in a regional hospital in Hong Kong

The implementation of a new clinical service is associated with anxiety and challenges that may prevent smooth and safe execution of the service. Unexpected issues may not be apparent until the actual clinical service commences. We present a novel approach to test the new clinical setting before actual implementation of our endovascular aortic repair service. In-situ simulation at the new clinical location would enable identification of potential process and system issues prior to implementation of the service. After preliminary planning, a simulation test utilising a case scenario with actual simulation of the entire care process was carried out to identify any logistic, equipment, settings or clinical workflow issues, and to trial a contingency plan for a surgical complication. All patient care including anaesthetic, surgical, and nursing procedures and processes were simulated and tested. Overall, 17 vital process and system issues were identified during the simulation as potential clinical concerns. They included difficult patient positioning, draping pattern, unsatisfactory equipment setup, inadequate critical surgical instruments, blood products logistics, and inadequate nursing support during crisis. In-situ simulation provides an innovative method to identify critical deficiencies and unexpected issues before implementation of a new clinical service. Life-threatening and serious practical issues can be identified and corrected before formal service commences. This article describes our experience with the use of simulation in pre-implementation testing of a clinical process or service. We found the method useful and would recommend it to others.

Intravenous lignocaine infusion facilitates acute rehabilitation after laparoscopic colectomy in the Chinese patients.

INTRODUCTIONnIntravenous infusion of lignocaine has emerged in recent years as a feasible, cost-effective, and safe method to provide postoperative analgesia. There is, however, no literature about this perioperative pain control modality in Chinese patients. This study aimed to determine whether perioperative intravenous lignocaine safely reduces postoperative pain, shortens postoperative ileus, and reduces the length of hospital stay in laparoscopic colorectal surgery.nnnMETHODSnBetween September 2012 and May 2015, 16 patients who underwent elective laparoscopic resection of colorectal cancer and received a 1% lignocaine infusion for 24 hours postoperatively were studied. After surgery, categorical pain scores were obtained immediately, followed by hourly pain scores at rest. Pain scores at rest and with mobilisation, and patient satisfaction score were documented on postoperative day 1. Return of bowel function was measured by time of first flatus and bowel opening. The patients rehabilitation was assessed by time taken to tolerate diet, full mobilisation, and length of hospital stay.nnnRESULTSnThe median (interquartile range) self-reported pain scores at 2 hours and 6 hours after surgery were 1.5 (0-4) and 2 (0-3), respectively. The median pain scores at rest and mobilisation on postoperative day 1 were 1 (0-2.5) and 2 (2.5-5), respectively, with a median satisfaction score of 7.5 (7-9). The median times to first flatus and first bowel opening were 21 (18-35) hours and 3 (1-3) days, respectively. No patient had postoperative ileus. The median times to tolerating diet and mobilisation were 1 (1-1) day and 2 (2-3) days, respectively. The median postoperative stay was 6 (5-8) days.nnnCONCLUSIONSnIntravenous lignocaine is a safe and effective postoperative analgesic in a Chinese population. It enhances the rehabilitation process for patients following laparoscopic resection of colorectal cancer.

Magnetic resonance cholangiogram patterns and clinical profiles of ketamine-related cholangiopathy in drug users

BACKGROUND & AIMSnRecreational ketamine use has emerged as an important health and social issue worldwide. Although ketamine is associated with biliary tract damage, the clinical and radiological profiles of ketamine-related cholangiopathy have not been well described.nnnMETHODSnChinese individuals who had used ketamine recreationally at least twice per month for six months in the previous two years via a territory-wide community network of charitable organizations tackling substance abuse were recruited. Magnetic resonance cholangiography (MRC) was performed, and the findings were interpreted independently by two radiologists, with the findings analysed in association with clinical characteristics.nnnRESULTSnAmong the 343 ketamine users referred, 257 (74.9%) were recruited. The mean age and ketamine exposure duration were 28.7 (±5.8) and 10.5 (±3.7) years, respectively. A total of 159 (61.9%) had biliary tract anomalies on MRC, categorized as diffuse extrahepatic dilatation (nu202f=u202f73), fusiform extrahepatic dilatation (nu202f=u202f64), and intrahepatic ductal changes (nu202f=u202f22) with no extrahepatic involvement. Serum alkaline phosphatase (ALP) level (odds ratio [OR] 1.007; 95% CI 1.002-1.102), lack of concomitant recreational drug use (OR 1.99; 95% CI 1.11-3.58), and prior emergency attendance for urinary symptoms (OR 1.95; 95% CI 1.03-3.70) had high predictive values for biliary anomalies on MRC. Among sole ketamine users, ALP level had an AUC of 0.800 in predicting biliary anomalies, with an optimal level of ≥113u202fU/L having a positive predictive value of 85.4%. Cholangiographic anomalies were reversible after ketamine abstinence, whereas decompensated cirrhosis and death were possible after prolonged exposure.nnnCONCLUSIONSnWe have identified distinctive MRC patterns in a large cohort of ketamine users. ALP level and lack of concomitant drug use predicted biliary anomalies, which were reversible after abstinence. The study findings may aid public health efforts in combating the growing epidemic of ketamine abuse.nnnLAY SUMMARYnRecreational inhalation of ketamine is currently an important substance abuse issue worldwide, and can result in anomalies of the biliary system as demonstrated by magnetic resonance imaging. Although prolonged exposure may lead to further clinical deterioration, such biliary system anomalies might be reversible after ketamine abstinence. Clinical trial number: NCT02165488.

Pneumomediastinum: Can we tell prognosis upon presentation?

Pneumomediastinum is an uncommon condition with differential diagnoses of very different prognosis. The aim of the present study was to retrospectively review patients who presented with pneumomediastinum, and to look for salient features on presentation to establish the difference between benign spontaneous pneumomediastinum (SPM) and oesophageal perforation (Boerhaaves syndrome) on presentation.

Metastatic renal cell carcinoma presenting with thyroid nodule and Addisonian crisis: Tumour-to-tumour metastasis

Metastasis to the thyroid gland is uncommon. More infrequent is metastasis occurring within a primary thyroid carcinoma. We report a rare case presenting as an enlarging primary thyroid tumour, harbouring metastatic renal cell carcinoma within. The primary thyroid tumour was only identified after thyroidectomy. The pathology of metastatic disease into a thyroid neoplasm is demonstrated with a brief review of the literature.

Appendicitis in abdominal wall hernia: Case series and literature review

Appendicitis in hernia is a rare disease entity. It usually presents with symptoms and signs of incarcerated hernia, and accurate preoperative diagnosis is difficult. Management includes appendicectomy and hernia repair. Different approaches of appendicectomy have been proposed, including transherniotomy, transabdominal and laparoscopic routes. In this case series, three cases of appendicitis inside different types of abdominal wall hernias, namely incisional, inguinal and Spigelian, are described. A literature review was also performed. Scientific evidence is lacking, and the optimal management remains to be defined.

Protocol-driven self-expanding metallic stenting for malignant large-bowel obstruction in a district hospital

The acute management of non‐perforated malignant large‐bowel obstruction (MLBO) now includes self‐expanding metallic stenting (SEMS) as one of the possible options. Whether it can be the standard treatment of MLBO, however, remained controversial.