Hung Lau

Irradiation-induced extracranial carotid stenosis in patients with head and neck malignancies

BACKGROUNDnCarotid stenosis is a recognized complication of external irradiation to the head and neck for malignancy. This study aim to investigate the pattern and prevalence of radiation induced carotid disease, and to identify risk factors associated with significant stenosis.nnnMETHODSnIn a comparative cross-sectional study, carotid arteries color flow duplex scan was performed on 240 patients who had received external irradiation to the head and neck area, with a mean interval of 72 months from radiotherapy. They consisted of 181 men and 59 women, with a mean age of 59 years. Fifteen patients had a history of cerebrovascular symptoms.nnnRESULTSnInternal carotid artery (ICA) stenosis of 70% or greater was detected in 29 arteries in 24 patients. Common carotid artery (CCA) disease of > or =70% was present in 13 arteries in 12 patients. Overall 28 patients had significant ICA/ CCA disease (11.7%). Patients with nasopharyngeal and laryngeal carcinoma had more cerebrovascular symptoms, and more frequent CCA stenosis. Significant ICA/CCA stenosis was associated with age, smoking, coronary heart disease, stroke, no head and neck surgery, time interval from radiotherapy, and the site of primary tumor. On logistic regression analysis age (>60 years), cerebrovascular symptoms, interval from irradiation (>5 years), and nasopharynx and larynx cancer were found to be independent significant (P<0.05) predictors of 70% or greater ICA/CCA stenosis.nnnCONCLUSIONSnPatients who had received radiotherapy to the head and neck have a high risk of developing significant carotid stenosis. Routine duplex ultrasound screening in these patients is indicated.

Management of postoperative urinary retention: a randomized trial of in−out versus overnight catheterization

Background: u2003There has been no consensus on the best catheterization strategy for the management of postoperative urinary retention. A prospective randomized trial was undertaken to establish the best practice guidelines for the management of postoperative urinary retention. The authors also evaluated the contemporary incidence of urinary retention following different categories of general surgery and examined risk factors associated with its occurrence.

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.

Screening for asymptomatic carotid stenosis in patients with peripheral vascular disease: a prospective study and risk factor analysis.

Screening for asymptomatic carotid artery stenosis using color flow duplex scan was performed on 186 Chinese patients with peripheral vascular disease. They consist of 121 male and 65 females, with a mean age of 70.6 years. A carotid bruit was present in 43 (23.1%) of the patients. Internal carotid artery stenosis of 70% or greater was detected in 46 patients (24.7%) including six total occlusions. Another 79 patients (42.5%) had internal carotid artery stenosis in the 30-69% range. Significant internal carotid artery stenosis was associated with age, male sex, the quantity and duration of smoking and a carotid bruit, and inversely with cholesterol, triglyceride and VLDL. Age, the number of cigarettes consumed per day, and carotid bruit were independent significant predictors of > or =70% internal carotid artery stenosis on logistic regression analysis. The degree of internal carotid artery stenosis is more severe in patients with a carotid bruit, and correlated positively with age (P<0.01), the number of cigarettes smoked (P = 0.04), and the duration of smoking (P = 0.03). Multiple linear regression analysis showed that only the age of the patient bears a significant relationship with the degree of internal carotid artery stenosis (P<0.01). There was no relationship between the degree of lower limb ischemia with carotid stenosis. The prevalence of > or =70% internal carotid artery stenosis in a high risk population with peripheral vascular disease was 24.7%. Routine duplex screening is worthwhile in this group of patients, particularly in male, elderly smokers.

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.

Epidemiology of atherosclerotic peripheral arterial occlusive disease in Hong Kong.

p < 0.001), age (p < 0.001), nonsmoking (p < 0.001), diabetes (p < 0.005), a low hemoglobin/hematocrit (p < 0.001), a high white blood cell count (p < 0.001), and high levels of fibrinogen (p < 0.01) and cholesterol (p < 0.05). An increasing incidence of PAD was noted in Hong Kong. Most of the patients present late with advanced ischemia. It is possible that this disease pattern represents only a fraction of the true incidence of PAD in the territory.

Intraoperative Endovascular Angioplasty and Stenting of Iliac Artery: An Adjunct to Femoro–Popliteal Bypass

BACKGROUNDnWith the rapid development of endovascular techniques, the management strategy of patients with multilevel atherosclerotic arterial occlusive disease is also evolving. Iliac artery stenting is a means whereby multiple bypass operations can be avoided in such patients. The early results of preoperative iliac artery stenting seem promising but the role of intraoperative iliac artery angioplasty and stenting is less clear.nnnSTUDY DESIGNnThis study was undertaken to evaluate our early results of a combined endovascular and operative approach to patients with multilevel atherosclerotic arterial occlusive disease. Between June 1995 and March 1997, primary intraoperative iliac artery balloon angioplasty and stent placement were performed on 13 affected limbs of 12 patients undergoing an infrainguinal bypass operation. Indications for operation, patient demographics, and risk factors were noted. The outcome of surgery and the patency rates of bypass graft and stent were also recorded.nnnRESULTSnThe initial technical success of primary iliac artery angioplasty and stenting was 93%. An improvement of the ankle-brachial index by a mean value of 0.38 was attained after operation (p < 0.001). Clinical success, based on the criteria suggested by the Society for Vascular Surgery/International Society for Cardiovascular Surgery, was achieved in all patients. There was no operative or hospital mortality. Postoperative morbidity rate was 8% (n = 1). The cumulative 1-year patency rates of iliac stent and infra-inguinal bypass grafts were 100% and 85%, respectively. The limb loss rate was 7%.nnnCONCLUSIONSnThe technique of intraoperative angioplasty and stenting can be easily mastered by an experienced and skilled vascular surgeon, using a portable C-arm fluoroscopic unit, in the operation theater. A combined endovascular and operative approach optimizes the therapeutic option to this selected group of patients.

Endoscopic totally extraperitoneal inguinal hernioplasty for recurrence after open repair.

Background: u2003Whether endoscopic totally extraperitoneal inguinal hernioplasty (TEP) for recurrent inguinal hernia is as safe and efficacious as that for primary inguinal hernia has rarely been examined. The objective of the present study was to compare the early and late outcomes of TEP for primary and recurrent inguinal hernia. The clinical pattern of recurrence after previous open repair of inguinal hernia was also examined.

Long‐term prognosis of femoropopliteal bypass: An analysis of 349 consecutive revascularizations

Background: Femoropopliteal bypass is the commonest procedure for lower limb revascularization. The aim of the present study was to determine the long‐term outcomes of femoropopliteal bypass and evaluate the prognostic significance of various clinical factors on the long‐term results.

A comparative outcome analysis of bilateral versus unilateral endoscopic extraperitoneal inguinal hernioplastics.

BACKGROUNDnBilateral inguinal hernia is an accepted indication for endoscopic totally extraperitoneal inguinal hernioplasty (TEP), but few studies have proved that the outcomes of bilateral TEP are as good as those of unilateral TEP. The objective of the present study was to compare the clinical outcomes of patients who underwent unilateral TEP with those of patients who underwent bilateral TEP.nnnPATIENTS AND METHODSnFrom June 1999 to May 2002, 103 patients underwent simultaneous bilateral TEP. The clinical data and outcomes of these patients were compared with those of an agematched cohort of patients who underwent unilateral TEP during the same period.nnnRESULTSnThe demographic features and hernia types were similar for the two groups. The incidence of direct inguinal hernia was significantly higher in the patients with bilateral inguinal hernia. The mean operative time for unilateral TEP was 65 minutes, and for bilateral TEP it was 97 minutes. The mean pain score at rest was significantly lower in the bilateral group than in the unilateral group on postoperative days 2 and 3. Pain scores at rest and during coughing from the day of operation to day 6 were otherwise comparable for the two groups. Comparisons of postoperative morbidity, length of hospital stay, and time to resumption of normal outdoor activities showed no significant differences between the two groups.nnnCONCLUSIONSnThe postoperative recovery and morbidity of patients who underwent bilateral TEP were equivalent to those who underwent unilateral TEP. Simultaneous bilateral TEP is safe and advantageous in patients with from bilateral inguinal hernias.