Yuk-hoi Lam

Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers.

Background and Methods After endoscopic treatment to control bleeding of peptic ulcers, bleeding recurs in 15 to 20 percent of patients. In a prospective, randomized study, we compared endoscopic retreatment with surgery after initial endoscopy. Over a 40-month period, 1169 of 3473 adults who were admitted to our hospital with bleeding peptic ulcers underwent endoscopy to reestablish hemostasis. Of 100 patients with recurrent bleeding, 7 patients with cancer and 1 patient with cardiac arrest were excluded from the study; 48 patients were randomly assigned to undergo immediate endoscopic retreatment and 44 were assigned to undergo surgery. The type of operation used was left to the surgeon. Bleeding was considered to have recurred in the event of any one of the following: vomiting of fresh blood, hypotension and melena, or a requirement for more than four units of blood in the 72-hour period after endoscopic treatment. Results Of the 48 patients who were assigned to endoscopic retreatment, 35 had long-term...

Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial.

OBJECTIVE In this randomized trial, the authors sought to determine whether eradication of Helicobacter pylori could reduce the risk of ulcer recurrence after simple closure of perforated duodenal ulcer. BACKGROUND DATA Immediate acid-reduction surgery has been strongly advocated for perforated duodenal ulcers because of the high incidence of ulcer relapse after simple patch repair. Although H. pylori eradication is now the standard treatment of uncomplicated and bleeding peptic ulcers, its role in perforation remains controversial. Recently a high prevalence of H. pylori infection has been reported in patients with perforations of duodenal ulcer. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair and hence obviates the need for an immediate definitive operation. METHODS Of 129 patients with perforated duodenal ulcers, 104 (81%) were shown to be infected by H. pylori. Ninety-nine H. pylori-positive patients were randomized to receive either a course of quadruple anti-helicobacter therapy or a 4-week course of omeprazole alone. Follow-up endoscopy was performed 8 weeks, 16 weeks (if the ulcer did not heal at 8 weeks), and 1 year after hospital discharge for surveillance of ulcer healing and determination of H. pylori status. The endpoints were initial ulcer healing and ulcer relapse rate after 1 year. RESULTS Fifty-one patients were assigned to the anti-Helicobacter therapy and 48 to omeprazole alone. Nine patients did not undergo the first follow-up endoscopy. Of the 90 patients who did undergo follow-up endoscopy, 43 of the 44 patients in the anti-Helicobacter group and 8 of the 46 in the omeprazole alone group had H. pylori eradicated; initial ulcer healing rates were similar in the two groups (82% vs. 87%). After 1 year, ulcer relapse was significantly less common in patients treated with anti-Helicobacter therapy than in those who received omeprazole alone (4.8% vs. 38.1%). CONCLUSIONS Eradication of H. pylori prevents ulcer recurrence in patients with H. pylori-associated perforated duodenal ulcers. Immediate acid-reduction surgery in the presence of generalized peritonitis is unnecessary.

Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: A prospective randomized trial

BACKGROUND Endoscopic drainage has replaced emergent surgery for biliary decompression in patients with acute cholangitis. The aim of this study was to prospectively compare the efficacy of the nasobiliary catheter and indwelling stent as temporary measures for biliary decompression in acute suppurative cholangitis caused by bile duct stones. METHODS Over a 60-month period, 79 patients with acute cholangitis who required emergent endoscopic drainage were recruited. Indications for urgent drainage included any one of the following: temperature greater than 39 degrees C, septic shock with systolic blood pressure less than 90 mm Hg, increasing abdominal pain, and impaired level of consciousness. Patients who had previously undergone sphincterotomy or had coexisting intrahepatic duct stones were excluded. After successful bile duct cannulation, patients were randomized to receive either a nasobiliary catheter or indwelling stent without sphincterotomy for biliary decompression. Outcome measures included procedure time, complications, clinical response, and patient discomfort (scored with a 10-cm, unscaled visual analog score). RESULTS Of the 79 patients, 5 were excluded because of previous sphincterotomy and intrahepatic duct stones, 40 were randomized to receive a nasobiliary catheter (NBC group), and 34 to receive indwelling stent (stent group). Demographic data were similar between the groups. All procedures were successful in the NBC group; there was one failure in the stent group. The mean (SD) procedure time was similar (NBC group 14.0 [9.3] minutes vs. stent group 11.4 [7.2] min). There were 2 ERCP-related complications in the NBC group. Four patients pulled out the nasobiliary catheter and one catheter became kinked. One stent occluded. There was a significantly lower mean (SD) patient discomfort score on day 1 after the procedure in the stent group (stent group 1.8 [2.6] vs. NBC group 3.9 [2.7]; p = 0.02 t test). The overall mortality rate was 6.8% (2.5% NBC group vs. 12% stent group). CONCLUSION Endoscopic biliary decompression by nasobiliary catheter or indwelling stent was equally effective for patients with acute suppurative cholangitis caused by bile duct stones. The indwelling stent was associated with less postprocedure discomfort and avoided the potential problem of inadvertent removal of the nasobiliary catheter.

A Randomized Comparison of Acute Phase Response and Endotoxemia in Patients with Perforated Peptic Ulcers Receiving Laparoscopic or Open Patch Repair

BACKGROUND In patients with peritonitis from perforated peptic ulcers, we compared acute stress responses, endotoxemia, and bacteremia following laparoscopic or open surgery. PATIENTS AND METHODS Consecutive patients with peritonitis from perforated peptic ulcers were randomized to receive laparoscopic sutured or open omental repair. Undiluted peritoneal fluid was obtained at surgery for quantitative bacterial and endotoxin (Limulus Amoebocyte Lysate) assay. Serial blood samples were taken at 0, 30, 60, 90, 120, and 180 minutes, and at 12, 24, 48, 72, and 120 hours for determinations of quantitative bacterial and endotoxin assays, interleukin-6 (IL-6), C-reactive protein (CRP), and cortisol. RESULTS Twenty-two patients were randomized: laparoscopy group (n = 12), open repair group (n = 10). Conversions were required in 3 patients assigned to laparoscopy, leaving 9 patients for analysis. The two groups were comparable in their demographic data, median duration of perforation (13.5 hours versus 10 hours), severity of peritoneal contamination as indicated by viable bacterial count (5.9 x 102 versus 1.5 x 10(2) colony forming unit/mL) and endotoxin concentration in peritoneal fluid (27.2 versus 24.6 EU/mL). No significant endotoxemia or bacteremia was detected in these patients. Median interleukin-6 was highest at 0 hour (1520 versus 962 pg/mL) and fell rapidly following surgery. C-reactive protein peaked at 24 hours and plateaued thereafter. Cortisol was highest intraoperatively and fell thereafter. No difference was noted between the two treatment groups with respect to these inflammatory markers (IL-6 P = 0.19, CRP P = 0.14, cortisol P = 0.56, multivariate analysis of variance). CONCLUSION Endotoxemia and bacteremia are insignificant in most patients with perforated peptic ulcers. In patients with perforated peptic ulcers, laparoscopic patch repair does not reduce acute stress responses when compared with open surgery.

Endoscopic balloon dilation for benign gastric outlet obstruction with or without Helicobacter pylori infection

BACKGROUND Endoscopic balloon dilation has been used to treat patients with gastric outlet obstruction caused by peptic stricture. This study assessed the role of endoscopic balloon dilation in patients with gastric outlet obstruction with or without Helicobacter pylori infection. METHODS Consecutive patients seen between January 1996 and September 2001 with benign gastric outlet obstruction (defined as stenosis preventing the passage of a 9-mm diameter endoscope, vomiting, succussion splash, and recent weight loss) were prospectively studied. Exclusion criteria were the following: refusal to undergo dilation, and gastric outlet obstruction because of malignancy. At endoscopy, antral biopsy specimens were obtained for histopathologic evaluation and for a rapid urease test for Helicobacter pylori infection. Patients then underwent dilation with through-the-scope balloons. After balloon dilation, patients with Helicobacter pylori infection were treated to eradicate the infection. RESULTS Fifty-one patients (33 men, 18 women; median age 65 years; IQR 44-79 years) were studied; 33 consented to endoscopic balloon dilation. Symptom resolution occurred in 25 patients (14 Helicobacter pylori positive, 11 Helicobacter pylori negative). During a median follow-up of 24 months (IQR 16-40 months), 3 of 14 patients in the Helicobacter pylori positive group and 6 of 11 in the Helicobacter pylori negative group developed further ulcer complications (p=0.039). CONCLUSIONS After endoscopic dilation for gastric outlet obstruction, eradication of Helicobacter pylori infection is associated with fewer ulcer complications.

OPTIMUM DURATION OF PROPHYLACTIC ANTIBIOTICS IN ACUTE NON‐PERFORATED APPENDICITIS

Background:  The effect of extended prophylactic antibiotic therapy on postoperative infective complications such as wound infection and intra‐abdominal abscess for non‐perforated appendicitis is poorly defined.

Percutaneous cholecystostomy and endoscopic cholecystolithotripsy in the management of acute cholecystitis

AbstractBackground: Percutaneous cholecystostomy is a valuable alternative temporary measure for acute cholecystitis in elderly patients with severe underlying cardiopulmonary disease, but the subsequent management of gallbladder calculi is still controversial. Methods: Eleven patients treated with percutaneous endoscopic cholecystolithotripsy after percutaneous cholecystostomy were evaluated retrospectively. Results: All patients showed clinical improvement after percutaneous cholecystostomy. Tract dilation succeeded in 9 patients. Complete stone clearance was achieved in seven patients over one to four sessions (average, two sessions). Stone extraction could not be completed in two patients because gallbladder access was lost in one patient, and the other refused further procedure. There were three complications, with two biliary fistulas and one major bile leakage leading to emergency cholecystectomy. The duration of the entire procedure ranged from 30 to 126 days (mean, 58 days). During the follow-up (mean 17.2 months), one patient had recurrent cholangitis and the others remained asymptomatic. Conclusions: Percutaneous cholecystolithotripsy after percutaneous cholecystostomy is a safe alternative in the management of high-risk elderly patients with acute cholecystitis.

Early clinical outcomes after subfascial endoscopic perforator surgery (SEPS) and saphenous vein surgery in chronic venous insufficiency

Background: Subfascial endoscopic perforator surgery (SEPS) has recently become popular as a minimally invasive way to treat chronic venous insufficiency (CVI) of the lower extremities. We report the early clinical outcomes of SEPS and saphenous vein surgery in a prospective series of Chinese patients who presented with severe CVI. Methods: All patients referred to our hospital for the management of severe CVI (class IV disease or above) after January 1998 underwent SEPS using an ultrasonic scalpel in conjuction with saphenous vein surgery. All patients were followed up prospectively to assess ulcer healing, ulcer recurrence, and symptoms after SEPS. Clinical outcome was evaluated by the scoring system suggested by the Consensus Committee of the American Venous Forum on Chronic Venous Disease. Results: Over a 24-month period, we performed 36 SEPS on 31 patients. Nineteen lower extremities (53%) had active or healing ulcers. Sapheno-femoral ligation was also performed in 33 limbs (92%). Four limbs (11%) developed superficial wound infection, and two (6%) had saphenous nerve dysesthesia. The mean clinical score and disability score decreased from 8.42 to 3.42 and 1.45 to 0.31 respectively, after a median follow-up of 14 months (range, 6-22) (p < 0.005). Eleven ulcers (58%) healed within 6 weeks after surgery. At 1-year follow-up, ulcer recurrence was found in two legs (11%). Conclusion: SEPS is safe and feasible. Early clinical results have shown a promising outcome in patients with severe chronic venous insufficiency.

Subfascial endoscopic perforator vein surgery (SEPS) using the ultrasonic scalpel

Subfascial endoscopic perforator vein surgery (SEPS) was recently introduced as a minimally invasive method to ligate incompetent perforating veins in patients with severe chronic venous insufficiency of the lower extremities. Herein we describe a technique in which we used a 5-mm ultrasonic scalpel for the transection of perforating veins in 16 SEPS performed in 14 patients. The use of the ultrasonic scalpel allowed for the precise coagulation and transection of the perforator vein with hemostasis, while avoiding the use of metal clips. Our initial results showed that the technique was feasible with minimal morbidity. We recommend the use of the ultrasonic scalpel as an alternative tool to transect perforating veins in SEPS.

Case report: Laser-assisted removal of a foreign body impacted in the esophagus

We reported the use of Holmium‐YAG laser in the management of a foreign body impacted in the esophagus.