Kin-Wah Chu

Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision.

BACKGROUND This study aims to analyze the risk factors for anastomotic leakage after low anterior resection with the technique of total mesorectal excision (TME). METHODS From September 1993 to November 1998, 196 patients with rectal cancer from 3 to 12 cm from the anal verge were treated with low anterior resection with TME. The data were entered in a prospective manner, and the factors that might affect anastomotic leakage were analyzed. RESULTS The mean level of anastomosis was 3.6 cm from the anal verge (range 1 to 5 cm). The leakage rate was 10.2%. Female gender (P = 0.01; 95% confidence interval [CI] 1.3 to 14.3; odds ratio 4.3) and presence of a diversion stoma (P = 0.01; 95% CI 1.4 to 14.2; odds ratio 4.5) were independent significant factors for lower anastomotic leakage. The absence of a stoma was associated with significantly increased leakage in male (P = 0.001) but not in female (P = 0.51) patients. CONCLUSIONS With low anastomosis after low anterior resection with TME, diversion stoma construction should be performed routinely in men. In women, the need for diversion can be more selective.

Thoracoscopic esophagectomy for esophageal cancer

BACKGROUND Minimal access surgery is an alternative to open surgery in esophageal surgery. Its role in cancer resection is controversial. METHODS Thoracoscopic esophageal resection was attempted in 22 patients who had increased operative risk. Postoperative outcomes of these patients were compared with the outcomes of 63 patients who underwent open thoracotomy resection during the same period. RESULTS Thoracoscopy was completed in 18 patients. Conversion to thoracotomy was necessary because of locally advanced tumor in three patients, and a bypass procedure was performed in another patient because of poor ventilation during thoracoscopy and the finding of metastatic disease. The median thoracoscopy time was 110 minutes (range, 55 to 165 minutes). The total operating times were 240 minutes (range, 165 to 360 minutes) and 250 minutes (range, 190 to 420 minutes) for thoracoscopy and thoracotomy, respectively, p = 0.5. Blood loss was significantly less than that of open resection; medians were 450 ml (range, 200 to 800 ml) and 700 ml (range, 300 to 2500 ml) for thoracoscopy and thoracotomy, respectively, p < 0.01. The median number of lymph nodes removed at thoracoscopy was 7 (range, 2 to 13) compared with 13 (range, 5 to 34) in the thoracotomy group. Bronchopneumonia affected 17% of both groups of patients. Only one patient who was converted to open thoracotomy died. Port site recurrence developed in one patient. Overall survival rates were not significantly different. CONCLUSIONS Thoracoscopic esophageal resection was a feasible option. Clear advantages over open thoracotomy were not demonstrated, although patients who were selected for thoracoscopy had worse performance status. This technique deserves further investigation in dedicated centers.

Prospective Evaluation of Selective Defunctioning Stoma for Low Anterior Resection with Total Mesorectal Excision

Abstract. Low anterior resection with total mesorectal excision for rectal carcinoma is associated with a high anastomotic leakage rate, and the effectiveness of a defunctioning stoma in preventing anastomotic leakage remains controversial. In this study a policy of selective defunctioning stoma for stapled colorectal anastomosis after low anterior resection with total mesorectal excision in 148 consecutive patients was evaluated prospectively. A defunctioning stoma was performed in 61 patients (41%) considered at high risk of anastomotic leakage. Clinical leakage occurred in 2 patients (3.3%) with a stoma and 11 patients (12.6%) without a stoma (p= 0.047). Among those without a stoma, the leakage rate among male patients (20.9%) was significantly higher than that for female patients (4.5%) (p= 0.022). Leakage subsided with conservative treatment in the two patients with a stoma, but seven patients without a stoma developed peritonitis requiring laparotomy. No deaths resulted from leakage, and there was one hospital death (0.6%) in the whole group. Median hospital stay was similar with and without a stoma (13.0 vs. 12.0 days) (p= 0.290). Closure of the stoma was associated with no mortality, a morbidity rate of 8.7%, and a median hospital stay of 6.0 days. In conclusion, a defunctioning stoma is effective in preventing clinical anastomotic leakage after low anterior resection with total mesorectal excision. The relatively high incidence of leakage in the low risk group indicates the difficulty of predicting anastomotic leakage and hence the need for more liberal use of a defunctioning stoma especially in male patients.

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.

Esophagectomy for carcinoma of the esophagus in the elderly : Results of current surgical management

OBJECTIVE This study aims to evaluate the risk of esophagectomy in the elderly compared with younger patients and to determine whether results of esophagectomy in the elderly have improved in recent years. SUMMARY BACKGROUND DATA An increased life expectancy has led to more elderly patients presenting with carcinoma of the esophagus in recent years. Esophagectomy for carcinoma of the esophagus is associated with significant morbidity and mortality, and advanced age is often considered a relative contraindication to esophagectomy despite advances in modern surgical practice. METHODS The perioperative outcome and long-term survival of 167 elderly patients (70 years or more) with esophagectomy for carcinoma of the esophagus were compared with findings in 570 younger patients with esophagectomy in the period 1982 to 1996. Changes in perioperative outcome and survival between 1982 to 1989 and 1990 to 1996 were separately analyzed. RESULTS The resection rate in the elderly was 48% (167/345), lower than the 65% (570/874) resection rate in younger patients (p < 0.001). There were significantly more preoperative risk factors and postoperative medical complications in the elderly, but no significant differences were observed in surgical complications. The 30-day mortality rate was higher in the elderly (7.2%) than in younger patients (3.0%) (p = 0.02), but the hospital mortality rate was not significantly different in the elderly (18.0%) and younger age groups (14.4%) (p = 0.27). The long-term survival after curative resection in elderly patients was worse than younger patients (p = 0.01). However, when deaths from unrelated medical conditions were excluded from analysis, survival was similar between the two age groups (p = 0.23). A comparison of data for the periods 1982 to 1989 and 1990 to 1996 revealed that the resection rate had increased from 44% to 54% in the elderly, with significantly fewer postoperative complications and lower 30-day and hospital mortality rates. Long-term survival has also improved, although this has not reached a statistically significant level. CONCLUSIONS With current surgical management, esophagectomy for carcinoma of the esophagus can be carried out with acceptable risk in the elderly, but intensive perioperative support is required. The improved results of esophagectomy in the elderly in recent years are attributed to increased experience and better perioperative management. Long-term survival was similar to that of younger patients, excluding deaths caused by unrelated medical conditions.

Negative findings at appendectomy

A prospective study was conducted on 107 patients with negative findings at appendectomy. The operation was unnecessary in 94 of the patients. A cause for the symptoms could be found in 43 patients, 32 during operation and 11 later by investigation or by a second operation. Diagnosis remained unclear in 64 patients. There are many diseases that mimic acute appendicitis, and based on the disease entities encountered in this series, the surgeon must examine the abdominal organs carefully if the appendix is normal. The financial loss of negative appendectomy was substantial in our study, and the total early and late complication rate was 14 percent. Patients with negative appendectomy should be regularly followed up to 1 year, since 9.3 percent of patients had a diagnosis made later by investigation, and 12.1 percent had moderate to severe pain on follow-up. Possible means to cut down the negative appendectomy rate without increasing the perforation rate have been suggested herein for further evaluation.

Resection of Local Recurrence of Rectal Cancer: Results

Abstract. Locally recurrent rectal cancer is a difficult clinical problem, and surgical resection can be done only in selected patients. The aims of this study were to evaluate the results of resecting the local recurrence of rectal cancer and to analyze factors that might predict curative re-resection and those that affect survival. Forty-seven patients who underwent resection for locally recurrent rectal cancer formed the basis of the study. Twenty-four were curative in nature, and the others were palliative. There was no operative mortality, and the complication rate was 38%. The median survival of the whole group was 16.5 months. The ability to perform curative resection was found to be the only independent factor associated with improved survival. Female gender is a significant factor associated with curative resection of local recurrence. In patients with curative reresection, local control is up to 87%. It was concluded that resection of local recurrent rectal cancer can achieve good local control and can improve survival in selected patients. The ability to perform curative resection is associated with survival benefit, and female gender is associated with the increased possibility of carrying out curative resection.

Triple rubber band ligation for hemorrhoids: prospective, randomized trial of use of local anesthetic injection.

PURPOSE: Rubber band ligation is a common office procedure for hemorrhoids. Triple rubber band ligation in a single session has been shown to be a safe and economical way of treating hemorrhoids. However, postligation discomfort after triple rubber band ligation is not uncommon. The aim of this study was to evaluate the effectiveness of local anesthetic injection to the banded hemorrhoidal tissue in reducing postligation discomfort. METHODS: Patients attending an outpatient clinic for symptomatic hemorrhoids suitable for triple rubber band ligation were randomly assigned to two groups. In the treatment group rubber band ligation was performed at three columns of hemorrhoids, and 1 to 2 ml of 2 percent lignocaine was injected into the banded hemorrhoidal tissue. In the control group triple rubber band ligation was performed in a similar manner, but local anesthetic was not given. Patients were followed up by telephone at the second week and in the clinic after six weeks. RESULTS: From April to August 1996, 101 patients entered the trial and were treated with triple rubber band ligation. Sixty-two patients were randomly assigned to the local anesthetic injection group and 39 to the control group. Overall good to excellent results occurred in 89 percent of patients, and there was no difference between the two groups. Postligation pain occurred in 26 and 20 percent of patients in the treatment and control groups, respectively (P>0.05). Postligation tenesmus occurred in 32 and 41 percent of patients in the treatment and control groups, respectively (P>0.05). No patients suffered from septic complications or bleeding that required transfusion. CONCLUSION: Triple rubber band ligation in a single session is a safe, economical, and effective way of treating symptomatic hemorrhoids. Postligation pain and tenesmus occurred in 24 and 37 percent, respectively. Discomfort was usually tolerable. Local anesthetic injection to the banded hemorrhoidal tissue did not help to reduce postligation discomfort.

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.

Inflammatory cecal masses in patients presenting with appendicitis.

Abstract. An unexpected inflammatory cecal mass of uncertain etiology encountered during surgery for presumed appendicitis poses a dilemma to the surgeon when deciding the appropriate operative management. A retrospective study was performed to review the pathology and surgical management of this condition. Among 3224 patients who had emergency surgery for a diagnosis of acute appendicitis between January 1990 and December 1997, a group of 52 patients (1.6%) underwent either ileocecal resection or right hemicolectomy for an inflammatory cecal mass of uncertain etiology. The final pathologic diagnosis was cecal diverticulitis in 26 patients (50%), appendiceal phlegmon or abscess in 21 patients (40%), cecal carcinoma in 3 patients (6%), tuberculosis in 1 patient (2%) and schistosomiasis in another patient (2%). Altogether 34 patients underwent ileocecal resection, and 18 patients underwent right hemicolectomy, including the 3 patients with cecal carcinoma. Ileocecal resection was associated with a shorter mean operative time (144 vs. 201 minutes; p < 0.001), a lower morbidity rate (3% vs. 22%; p= 0.043), and a shortened mean postoperative hospital stay (6.8 vs. 11.2 days; p= 0.011) than right hemicolectomy. There was no mortality in either group. In conclusion, most inflammatory cecal masses are due to benign pathologies and could be managed safely and sufficiently with ileocecal resection. Careful intraoperative assessment including examination of the resected specimen is essential to exclude malignancy, which would require right hemicolectomy.