Prevalence of obstetric anal sphincter injury following vaginal delivery in primiparous women: a retrospective analysis.

INTRODUCTION: Obstetric anal sphincter injuries (OASIS) may be underdetected in primiparous women. This study evaluated the prevalence of OASIS in primiparous women after normal vaginal delivery or instrumental delivery using endoanal ultrasound (US) during postnatal follow-up. METHODS: This study retrospectively analysed endoanal US data collected during postnatal follow-up (6-12 months after vaginal delivery) at a tertiary hospital in Hong Kong. Offline analysis to determine the prevalence of OASIS was performed by two researchers who were blinded to the clinical diagnosis. Symptoms of faecal and flatal incontinence were assessed with the Pelvic Floor Distress Inventory. RESULTS: Of 542 women included in the study, 205 had normal vaginal delivery and 337 had instrumental delivery. The prevalence of OASIS detected by endoanal US was 7.8% (95% confidence interval [CI]=4.1%-11.5%) in the normal vaginal delivery group and 5.6% (95% CI=3.1%-8.1%) in the instrumental delivery group. Overall, 82.9% of women with OASIS on endoanal US did not show clinical signs of OASIS. Birth weight was significantly higher in the OASIS group (P=0.012). At 6 to 12 months after delivery, 5.5% of women reported faecal incontinence and 17.9% reported flatal incontinence, but OASIS was not associated with these symptoms. CONCLUSIONS: Additional training for midwives and doctors may improve OASIS detection.

Laparoscopic-assisted resection of rectosigmoid carcinoma. Immediate and medium-term results.

BACKGROUND: The technique of laparoscopic-assisted resection of colorectal carcinoma has been established. However, whether such a procedure is beneficial to patients is uncertain. OBJECTIVE: To review the immediate and medium-term results of laparoscopic-assisted resection in patients with rectosigmoid carcinoma. PATIENTS AND INTERVENTIONS: We attempted laparoscopic-assisted sigmoid colectomy or anterior resection in 50 patients with rectosigmoid carcinoma (ie, the study group). The results were compared with those of 50 matched patients who underwent conventional open resection in the immediate prelaparoscopic era (ie, the control group). RESULTS: The median follow-up times for the study and control groups were 32.8 and 39.1 months, respectively. The operating time was significantly longer (P < .001, Student t test), while the analgesic requirement was significantly less (P < .001, Mann-Whitney U test) and the duration of hospitalization was significantly shorter (P = .001, Mann-Whitney U test), in the study group than in the control group. The oncological clearance (ie, the number of lymph nodes removed and the distal resection margin), the complication rate, the disease-free rate, and the survival rate were comparable in the 2 groups. CONCLUSION: The immediate and medium-term results of laparoscopic-assisted resection of rectosigmoid carcinoma are promising.

Endoscopic management of submandibular sialolithiasis.

BACKGROUND: Transoral removal and sialoadenectomy are the two main modalities of treatment for submandibular stones. However, missed ductal stones are not uncommon, and there is a risk of lingual or hypoglossal nerve injury. We attempted to avoid these complications by using an endoscopic technique. METHODS: The case notes of the patients who had undergone endoscopic removal of submandibular stones were studied retrospectively. The procedure was performed under general anesthesia. The submandibular orifice was incised by carbon dioxide laser, and a 3.1-mm rigid scope was inserted under direct vision with normal saline irrigation after dilatation. The stones were either broken down by laser or removed with a Dormia basket or forceps. RESULTS: A total of 13 patients underwent the procedure. The duration of median follow-up was 15 months. In 11 patients, the stones were identified and removed. No stone was found in two patients (15.4%). There were no false negatives, since no stones were discovered subsequently in these two patients. One, two, three, and four stones were present inside the ducts in seven patients (54.6%), one patient (7.7%), two patients (15.4%), and one patient (7.7%), respectively. The symptoms subsided completely in 11 patients within 4 weeks after the procedure. Persistent swelling occurred in two patients. In one of them, no residual stone was revealed by CT scan. The other patient had a large calculus that was only partially fragmented by laser lithotripsy at the initial operation. No lingual nerve or hypoglossal nerve injury was detected in any patient. CONCLUSION: Sialoendoscopy is a safe and efficacious treatment for submandibular ductal stones. It reduces the incidence of missed stones, and nerve injury, as well as the need for sialoadenectomy.

Laparoscopic-assisted abdominoperineal resection for low rectal adenocarcinoma.

BACKGROUND: Laparoscopic-assisted resection for colorectal lesions is feasible, but most reported series are heterogeneous and noncomparative. The aim of this study was to investigate whether laparoscopic-assisted resection was better than open abdominoperineal resection for low rectal adenocarcinoma. METHODS: Twenty-five (study group) of 59 consecutive patients who were considered suitable were selected for laparoscopic-assisted abdominoperineal resection based on the availability of informed consent, laparoscopic instruments, and experienced surgeons. The results in these patients were compared with the other 34 patients operated on by the open method (control group). RESULTS: The median follow-up times for the study and control groups were 30.1 and 28.3 months, respectively. The operation time was significantly longer (t-test, p < 0.001), while operative blood loss (Mann-Whitney U test, p = 0.02), postoperative analgesic requirement (Mann-Whitney U test, p = 0.02), time to resume normal diet (Mann-Whitney U test, p = 0.04), and total hospital stay (Mann-Whitney U test, p = 0.02) were significantly less in the study than in the control group. The oncological clearance, complication rate, disease-free interval, and survival were comparable in the two groups. CONCLUSIONS: Laparoscopic-assisted abdominoperineal resection allowed earlier postoperative recovery, with equal oncological clearance, morbidity, mortality, disease-free interval, and survival.

Feasibility case-controlled study of day-case haemorrhoidectomy.

INTRODUCTION: Haemorrhoidectomy is traditionally an inpatient procedure. With many benefits, the day-surgery arrangement is an attractive alternative. The feasibility of day-surgery haemorrhoidectomy was explored and the hospital days were calculated in a case controlled design. METHODS: A single surgeon's experience of day-surgery haemorrhoidectomy between 1 July 1999 and 31 March 2000 was compared with inpatient haemorrhoidectomy during the same period. The operations were performed at United Christian Hospital Department of Surgery, Hong Kong (a government-funded public hospital). Statistical tests were applied where appropriate. RESULTS: There were 30 day-surgery and 15 inpatient haemorrhoidectomies. The groups were comparable in terms of age, gender, severity of haemorrhoids, method and duration of haemorrhoidectomy, blood loss, residual haemorrhoids, duration of follow up and unplanned readmission rate. Significantly more day-patients received general than spinal anaesthesia. Twenty-six of 30 (87%) patients were successfully discharged after day surgery. Two were admitted for transient fever (< 24 h), one for micturition syncope and one for acute urinary retention. There were four unplanned readmissions after day surgery: one for pain and three for secondary bleeding. All stopped spontaneously. All three unplanned readmissions after inpatient surgery were for secondary bleeding. All stopped spontaneously. Patient stay was significantly shorter for day surgery (1 +/- 1 day) than for the inpatient arrangement (4 +/- 1.6 days). CONCLUSION: Day-surgery haemorrhoidectomy is feasible. The significantly shorter hospital stay implies savings in public medical expenses.

Conservative approach is feasible in the management of acute diverticulitis of the right colon.

BACKGROUND: Acute diverticulitis of the caecum and ascending colon is uncommon. Controversies abound as regards the optimal surgical treatment, ranging from appendectomy, diverticulectomy to right hemicolectomy. The aim of the present paper was to review treatment strategy followed by a critical appraisal. METHODS: The case notes of 30 patients with acute diverticulitis of the right colon who were treated at the United Christian Hospital, Hong Kong from 1992 to 1998 were systematically reviewed. The data were subjected to statistical analysis. RESULTS: The median age was 34 years, with a male:female ratio of 1:1.15. All patients presented with acute right lower abdominal pain and localized rebound tenderness. All were diagnosed preoperatively as having appendicitis. The mean duration of symptoms was 2 days (range: 1-6 days). Two treatment groups were identified. Group A (n = 16; 53%) received appendicectomy alone, while group B (n = 14; 47%) underwent diverticulectomy in addition to appendicectomy, including one patient with perforated diverticulitis. Overall, there was no procedure-related morbidity or mortality. Both groups received a similar duration of broad-spectrum antibiotics. All the patients were interviewed by phone after operation to detect any recurrence of symptoms, with a median follow-up interval of 34 months (range: 11-78 months). There was no recurrence of symptoms in group A, which received appendicectomy and antibiotics. The only difference was operative time. CONCLUSION: For non-perforated diverticulitis of the right colon, appendicectomy and intravenous antibiotics without diverticulectomy is the preferred treatment strategy.

Lymphoepithelioma-like carcinoma of oral cavity: report of three cases and literature review.

Lymphoepithelioma-like carcinoma is a rare tumour in the oral cavity and is characterized histologically by non-keratinizing, undifferentiated squamous cell carcinoma with lymphocytic infiltration. Three consecutive cases of intraoral lymphoepithelioma-like carcinoma are reported. A review of the literature reveals a similar biological behaviour to that of nasopharyngeal lymphoepithelioma: a high incidence of cervical nodal spread and remarkable radiosensitivity. Chemotherapy should be considered when nodal or distant metastases are present. The association of the Epstein-Barr virus with this tumour remains unclear but our experience suggests a positive correlation in Chinese individuals.

Incidence and predictive value of congenital hypertrophy of retinal pigment epithelium in Chinese familial adenomatous polyposis patients.

OBJECTIVE: To investigate the incidence and predictive value of congenital hypertrophy of retinal pigment epithelium (CHRPE) in the Chinese familial adenomatous polyposis (FAP) patients. METHODS: Eleven FAP patients and 28 at risk relatives from 7 families were examined for CHRPE lesions. RESULTS: CHRPE was present in all 11 FAP patients. Nine CHRPE lesions were found in 9 of the 28 at risk relatives. There were great intra and inter-familial variations of the CHRPE lesions. Two at risk relatives were diagnosed to have FAP only after our screening and subsequent proctosigmoidoscopy. Nine at risk relatives were put under high surveillance because of the presence of CHRPE. CONCLUSION: The incidence of CHRPE in the FAP patients in our study is 100%. Eye examination for CHRPE for FAP patients and their at risk relatives is of very high value. A central FAP registry is thus recommended.

Laparoscopic intracavitary drainage of subphrenic abscess.

Percutaneous drainage is now the preferred initial treatment of subphrenic abscess. The result is best for simple, unilocular abscesses but less so for complex ones. Failure of drainage can lead to high morbidity and mortality. We describe a case in which a large multiloculated subphrenic abscess was successfully drained laparoscopically without contaminating the general peritoneal cavity.

Radially expanding trocar: a less painful alternative for laparoscopic surgery.

BACKGROUND AND PURPOSE: One advantage of minimal-access surgery is that it produces less pain. A radially expanding trocar has been claimed to reduce pain further. We aimed to evaluate this claim. PATIENTS AND METHODS: This was a randomized controlled single-blind clinical trial. Fifty-four patients who underwent laparoscopic cholecystectomy at the Department of Surgery, United Christian Hospital, Hong Kong, between July 1997 and September 1998 were randomized into either the study group or the control group. The radially expanding 10-mm trocar was used for the epigastric port in the study group. The conventional 10-mm metal trocar was used similarly in the control group. The operation was otherwise performed with a standardized technique. Another conventional 10-mm metal trocar was used for the subumbilical port for all patients. Pain was measured using a visual analog scale. Pain scores for the epigastric port and subumbilical port were documented for 3 days after the surgery. RESULTS: There was no difference in age, sex, diagnoses, operating time, or conversion rate. There was consistently no difference in the pain experienced in the subumbilical wound, whereas pain at the epigastric wound was consistently less with the radially expanding trocar (p < 0.05). CONCLUSION: The radially expanding trocar produces less early postoperative pain than the conventional metal trocar.

Use of botulinum toxin type A in a case of persistent parotid sialocele.

Sialocele is an uncommon complication of parotidectomy. Most cases resolve after conservative therapy consisting of repeated aspiration and pressure dressing. The condition is, however, occasionally resistant to such therapy. We report on a 52-year-old Chinese man who had a 10-year history of right parotid swelling. Following fine-needle aspiration cytology, Warthin's tumour was diagnosed, but after elective parotidectomy, a swelling developed and parotid sialocele was diagnosed. Botulinum toxin type A was given after the sialocele had persisted for almost 3 weeks after surgery, and after conservative management had been tried; the sialocele disappeared after two doses of treatment. Botulinum toxin therapy was thus an effective method of treating persistent sialocele.

Outcomes and complications of thyroid surgery: retrospective study.

OBJECTIVE: To study the outcome and complications of thyroid surgery. DESIGN: Retrospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: Three hundred and twelve patients (266 women and 46 men) underwent thyroid surgery between January 1994 and December 1999. MAIN OUTCOME MEASURES: Complications of thyroidectomy for various thyroid diseases according to surgical technique used. RESULTS: Capsular dissection gradually became a more popular surgical technique: 33% and 58% in the first and second halves of the study period respectively (P<0.001). The overall rate of permanent vocal cord palsy was 2%. Near-total thyroidectomy became the preferred surgical treatment for toxic goitre over the study period. The incidence of recurrent hyperthyroidism was reduced from 21% to 7% (P>0.1, not significant). The incidence of hypoparathyroidism was approximately 30% after thyroidectomy for cancer. CONCLUSION: Capsular dissection is increasingly utilised in thyroid surgery. Low complication rates can be achieved after thyroidectomy for benign diseases. Hypoparathyroidism, however, is a relatively common complication after surgery for thyroid cancer.

Use of fine-needle aspiration cytology and frozen section examination in diagnosis of thyroid nodules.

BACKGROUND: With the advent of fine-needle aspiration cytology (FNAC), the role of frozen section (FS) in the management of non-toxic thyroid nodules has become uncertain. METHODS: During the period from January 1993 to December 1995, a total of 84 patients have undergone operative treatment for non-toxic thyroid nodules at the United Christian Hospital, Kowloon. The medical records of these patients were studied retrospectively. RESULTS: In the benign group, the diagnostic accuracy of FNAC was 94% and that of FS was 91%. If FNAC reported malignancy, the diagnostic accuracy was 70%. If FS reported malignancy, the report was accurate in 100%. Among the 43 cases reported as benign on FNAC, FS did not alter the surgical management in any case. In 10 cases reported as suspicious on FNAC, FS altered the surgical treatment in one (10%). However, among the 10 cases reported as malignant on FNAC, FS subsequently altered the surgical management in five cases (50%). In three cases of malignancy on FNAC, both FS and the final histopathology report showed benign disease. Hence, FS avoided overtreatment in three patients. CONCLUSION: Frozen section is indicated if pre-operative FNAC of the thyroid nodules suggests malignancy, in order to determine the extent of the operation and to avoid overtreatment of benign disease. However, FS can be omitted if FNAC is reported as benign or suspicious.

Devine exclusion for unresectable carcinoma of the stomach.

Between July 1986 and July 1988, Devine exclusion was performed in 20 patients with unresectable carcinoma of the gastric antrum. All 20 patients presented with repeated vomiting. On endoscopy, 16 patients had complete gastric outlet obstruction while the remainder manifested significant gastric outlet stenosis. There was no hospital mortality. All except two patients could take an oral diet after surgery until their demise. Devine exclusion is safe and effective in relieving gastric outlet obstruction and is not associated with prolonged delay in return of gastric emptying.

Laparoscopic removal of inflamed or bulky tissue: preservation of the pneumoperitoneum.

A technique is described for extraction of bulky tissue during laparoscopic surgery using a dedicated non-disposable instrument specifically designed for the purpose. The technique was used on seven patients with acute cholecystitis, three patients with big gallstones in elective cholecystectomy and two patients with acute appendicitis. The procedure took about 1 min in all patients. No patient suffered from complications related to the procedure.

Laparoscopic rectopexy.

Good results of rectopexy for complete rectal prolapse have been achieved using the transabdominal approach. With the introduction of the laparoscopic technique in cholecystectomy, many other abdominal procedures have been tried with the laparoscopic technique with varying degrees of success. The laparoscopic technique has opened up a new possibility of a minimally invasive approach to rectopexy. With the elimination of a major incision in laparoscopic rectopexy, the patients may benefit from less morbidity associated with a major abdominal wound. In this case report, laparoscopic rectal mobilization and rectopexy using Marlex mesh and a hernia stapler is reported.

Anal and perianal tuberculosis: a report of three cases in 10 years.

From the computerized pathology record, three cases of anal and perianal tuberculosis were encountered in the Prince of Wales Hospital, Hong Kong during the last 10 years. The clinical history, examination findings and relevant investigations were reviewed retrospectively. Comparison was made with previous literature. Emphasis was put on the diversity of clinical presentations including acute perianal abscess, chronic anal ulcer and fistula in ano. It is concluded that a high index of suspicion is important to ensure an early diagnosis.

Use of a cotton tape tie in laparoscopic colorectal surgery.

In this short article we describe the use of a cotton tape tie in laparoscopic colorectal surgery. This technique is useful in: (i) retraction and manipulation of the bowel; (ii) exteriorization of a bulky specimen; and (iii) occlusion of the rectal lumen to permit effective cytocidal rectal lavage.