Hk Choi

Comparison of stenting with emergency surgery as palliative treatment for obstructing primary left-sided colorectal cancer

Self‐expanding metallic stents provide an alternative to surgery as definitive palliation in patients with obstructing colorectal cancer. This study aimed to compare the outcome of patients with obstruction due to primary left‐sided colorectal cancer treated by palliative stenting with outcome in patients who had undergone surgery.

Therapeutic Value of Gastrografin in Adhesive Small Bowel Obstruction After Unsuccessful Conservative Treatment: A Prospective Randomized Trial

ObjectiveTo assess the therapeutic value of Gastrografin in the management of adhesive small bowel obstruction after unsuccessful conservative treatment. Summary Background DataGastrografin is a hyperosmolar water-soluble contrast medium. Besides its predictive value for the need for surgery, there is probably a therapeutic role of this contrast medium in adhesive small bowel obstruction. MethodsPatients with clinical evidence of adhesive small bowel obstruction were given trial conservative treatment unless there was suspicion of strangulation. Those who responded in the initial 48 hours had conservative treatment continued. Patients showing no clinical and radiologic improvement in the initial 48 hours were randomized to undergo either Gastrografin meal and follow-through study or surgery. Contrast that appeared in the large bowel within 24 hours was regarded as a partial obstruction, and conservative treatment was continued. Patients in whom contrast failed to reach the large bowel within 24 hours were considered to have complete obstruction, and laparotomy was performed. For patients who had conservative treatment for more than 48 hours with or without Gastrografin, surgery was performed when there was no continuing improvement. ResultsOne hundred twenty-four patients with a total of 139 episodes of adhesive obstruction were included. Three patients underwent surgery soon after admission for suspected bowel strangulation. Strangulating obstruction was confirmed in two patients. One hundred one obstructive episodes showed improvement in the initial 48 hours and conservative treatment was continued. Only one patient required surgical treatment subsequently after conservative treatment for 6 days. Thirty-five patients showed no improvement within 48 hours. Nineteen patients were randomized to undergo Gastrografin meal and follow-through study and 16 patients to surgery. Gastrografin study revealed partial obstruction in 14 patients. Obstruction resolved subsequently in all of them after a mean of 41 hours. The other five patients underwent laparotomy because the contrast study showed complete obstruction. The use of Gastrografin significantly reduced the need for surgery by 74%. There was no complication that could be attributed to the use of Gastrografin. No strangulation of bowel occurred in either group. ConclusionsThe use of Gastrografin in adhesive small bowel obstruction is safe and reduces the need for surgery when conservative treatment fails.

Bowel Preparation for Colonoscopy: A Randomized Controlled Trial Comparing Polyethylene Glycol Solution, One Dose and Two Doses of Oral Sodium Phosphate Solution

OBJECTIVES To compare three bowel preparation regimens for colonoscopy in terms of the quality of preparation, the side effects and patient acceptance. METHODS A total of 299 patients who underwent colonoscopy were randomized to three bowel preparation regimens: polyethylene glycol solution (n = 106), or a single dose (n = 92) or two doses (n = 101) of sodium phosphate solution. The colonoscopists who recorded the quality of bowel preparation were blind to the preparation regimens. The discomforts associated with bowel preparation and patient acceptance of the preparation were also recorded. RESULTS Two doses of sodium phosphate solution achieved significantly better bowel preparation than polyethylene solution or a single dose of sodium phosphate solution (p < 0.05). Although two doses of sodium phosphate solution was associated with more dizziness and anal irritation, patients preferred preparation with sodium phosphate solution than with polyethylene glycol solution. Of the 69 patients in the sodium phosphate solution groups who had prior experience of bowel preparation using polyethylene glycol solution, 55 patients (80%) stated that they preferred sodium phosphate solution. CONCLUSION Two doses of sodium phosphate solution achieved better bowel preparation than polyethylene glycol solution and was more acceptable to patients. A single dose of sodium phosphate did not achieve similar bowel preparation to two doses of the solution.

A prospective randomized trial comparing the use of the flexible gastroscope versus the bronchoscope in the management of foreign body ingestion.

BACKGROUND Foreign body ingestion is a common clinical problem in Hong Kong. Some recent reports have proposed the use of flexible nasoendoscopy for foreign body retrieval. The present study is a prospective randomized trial on the use of the flexible gastroscope and bronchoscope in the management of foreign body ingestion. METHODS Two hundred sixteen patients older than 11 years were prospectively randomized to flexible endoscopic examination using either the gastroscope (108 patients) or the bronchoscope (108 patients). The duration of the procedure was noted. Patients were asked to assess their overall tolerance to the procedure on a scale of 1 (well tolerated) to 10 (unacceptable). RESULTS A foreign body was retrieved in 68 patients (31.5%). There was no difference between the two groups in the foreign body retrieval rate, type of foreign body retrieved, duration of procedure, and tolerance level. In the group managed with the bronchoscope, however, three patients required the additional use of the gastroscope for foreign body retrieval at (for one patient) or below (for two patients) the cricopharyngeus. The patients tolerance level was related only to the duration of procedure (rho = 0.386; p < 0.001). CONCLUSION The use of the flexible gastroscope is recommended because of its efficacy, safety, and tolerability.

Radiation stricture of rectosigmoid treated with self-expanding metallic stent.

Radiation stricture of the rectosigmoid with obstruction is a difficult clinical problem, and surgery is associated with high mortality and morbidity. We report a case involving radiation stricture of the rectosigmoid in an 80year-old woman who presented with acute colonic obstruction. A self-expanding metallic stent was successfully inserted, and the obstruction was relieved. The stent remained patent for 4 months without any complications until the patient died of sepsis resulting from pneumonia and bedsores. The literature on the use of a metallic stent to manage a benign colon condition was reviewed.

A prospective randomized trial comparing the use of omeprazole-based dual and triple therapy for eradication of helicobacter pylori

Background:Controversy surrounds the optimal composition, dosage, and duration of therapies for eradication of Helicobacter pylori. We prospectively compared omeprazole-based dual and triple therapies in the eradication of H. pylori in a randomized manner.Methods:Between June 1995 and March 1997, 1000 consecutive patients with acid-peptic disease associated with H. pylori infection (duodenal ulcer, 388 patients, gastric ulcer, 179 patients; duodenitis, 173 patients; gastritis, 260 patients) were prospectively recruited. They were randomized to either a 2-wk (OA) course of omeprazole 20 mg and amoxicillin 1 g, both given twice daily, or treatment for 1 wk (OCM) with omeprazole 20 mg once daily, clarithromycin 500 mg twice daily, and metronidazole 400 mg twice daily.Results:The age of these 1000 patients ranged from 16 to 90 yr, with a mean of 54.9 yr. Side effects occurred in 29.6% (95% confidence interval [CI] 25.6–33.8%) and 10.6% (95% CI 8.0–13.6%) of patients taking OCM and OA, respectively (p < 0.0001). Apart from taste disturbance, however, there were no significant differences in the incidences of side effects between the two groups. One patient in the OA group and four patients of the OCM group could not tolerate the medications, and therefore did not complete treatment (p= 0.37). Seven and 13 patients in the OA and OCM groups, respectively, refused a second endoscopy (p= 0.25). The remaining 975 patients underwent a second endoscopy. Positive endoscopic findings were significantly more common in the OA group (51/492; 10.4%; 95% CI 7.8–13.4%) than in the OCM group (25/483; 5.2%; 95% CI 3.4–7.5%) in the per-protocol (PP) analysis (p= 0.004). On intent-to-treat (ITT) analysis, the overall eradication rates in the OA and OCM groups were 73.6% (95% CI 69.5–77.4%) and 92% (95% CI 89.3–94.2%), respectively (p < 0.0001). On PP analysis, the corresponding rates were 74.8% (95% CI 70.7–78.6%) and 95.2% (95% CI 92.9–97.0%), respectively (p < 0.0001).Conclusions:A course of omeprazole, clarithromycin, and metronidazole for 1 wk is a safe, well-tolerated, efficacious, and cost-effective treatment for H. pylori infection.

The value of neck drain in esophageal surgery: a randomized trial.

The use of surgical drains in certain clean elective operations remains controversial. To evaluate the role of closed-suction drain for an esophageal anastomosis in the neck, we conducted a randomized, controlled study in 40 patients with esophageal carcinoma who underwent esophagectomy with an esophageal anastomosis in the neck, half of whom had a neck drain inserted at the end of operation. The median (range) duration of drainage was 46 hours (36 to 88 hours). The median (range) amount of drainage was 63 ml (15 to 210 ml). There was no incidence of haematoma or seroma formation in both the drained and non-drained groups. Anastomotic leakage did not occur in any patient. The benefits of closed suction neck drain could not be demonstrated. Routine use of neck drain for esophageal anastomosis in the neck is not necessary.

Randomized clinical trial of chewing gum after laparoscopic colorectal resection

Chewing gum may enhance intestinal motility after surgery. This trial studied whether chewing gum could lead to a further reduction in ileus in patients who had a laparoscopic colorectal resection and followed an enhanced recovery programme.

Hybrid single-incision and transanal total mesorectal excision for rectal cancer - the initial experience with 10 cases

Aim: The study aims to review surgical management of carotid body tumors (CBTs). Methods: All patients with CBTs underwent surgical resection during the period 1.1.1994 till 1.1.2014 in Queen Mary Hospital were retrospectively reviewed. Their presentation, operative details, postoperative complications as well as follow up information were reported. Results: 20 patients (4 males and 16 females) with 21 CBT operations were recorded. Median age was 36 (range 21–58). All except two CBTs presented as neck mass; one was incidental finding on CT scan and another presented as facial nerve palsy. 6 CBTs (28.6%) were Shamblin class I, 10 (47.6%) were class II and 5 (23.8%) were class III. Two operations required ICA resection and reconstruction to facilitate tumor removal. 4 resections were subtotal, while 17 achieved completion resection. Complications included 2 major strokes, 3 hoarseness of voice and 2 temporary Horner’s syndrome. Shamblin class predicted operative time, blood loss and whether complete resection accomplished (mean operative time 139 minutes, 279 minutes and 396 minutes, p = 0.04; mean blood loss 53 ml, 478 ml and 1500 ml, p < 0.001; complete resection in 6/6 (100%), 9/10 (90%) and 2/5 (40%) for class I, II and III respectively, p = 0.025), but could not predict complication (complications occurred in 2/6 (33%), 3/10 (30%) and 1/5 (20%) of class I, II and III respectively, p = 0.88). With 94 months median follow up, no tumor recurrence was found in all 16 patients whom complete resection achieved. Conclusion: Close proximity of the tumor to major carotid vessels and nerves incurred significant operative morbidities. Shamblin class would predict operative difficulty but not complication. P10

Comparison of outcomes following resection of right-sided and left-sided colon cancer

Book The Abstract Volume ISW 2009 will be available on-line at www.isw2009.org until December 2009 123 World J Surg (2009) 33:S1–S268 DOI 10.1007/s00268-009-0165-5