Laparoscopic abdominoperineal resection revisited: are there any health-related benefits? A comparative study.

BACKGROUND: Laparoscopic colectomy is associated with less overall morbidity and improved survival for patients with colonic cancers. There are unfortunately limited clinical reports on laparoscopic abdominoperineal resection. We therefore designed this study to compare laparoscopic abdominoperineal resection with conventional open surgery, with emphasis on health-related issues from the patients' perspective in order to justify its role in the management of low rectal or anal canal tumours. METHODS: We carried out a non-randomized, prospective comparative study on a cohort of patients who underwent either laparoscopic or open abdominoperineal resection between March 1994 and December 2003. Patient demographics, tumour characteristics, operative morbidity and mortality, as well as overall survival were considered. The standard endpoints of last follow-up date and deaths were used. Data was analyzed according to intention-to-treat principle. RESULTS: A total of 102 patients were recruited: 31 patients underwent conventional open abdominoperineal resection (OAPR) and 71 patients were treated laparoscopically. Patient demographics, median follow-up period, as well as tumour characteristics were similar between groups. The median operating time was similar among groups (145 min in laparoscopic group vs. 156 min in open group; p=0.62). Patients in the laparoscopic group had significantly less blood loss (p=0.01) and fewer requirements for blood transfusion (p=0.01). Despite similar overall morbidity, the laparoscopic group had a reduced incidence of abdominal wound infections (p=0.01) and chest infections (p=0.01). Overall survival was significantly better in the laparoscopic group (p=0.01). CONCLUSIONS: Laparoscopic abdominoperineal resection confers definite health-related benefits the over open approach in terms of reduced septic complications and fewer requirements for blood transfusion. It should be considered the procedure of choice for patients with low rectal or anal canal tumour in whom sphincter excision proved inevitable.

Improvement in colonoscopy performance with adjunctive magnetic endoscope imaging: a randomized controlled trial.

BACKGROUND AND STUDY AIM: Although magnetic endoscope imaging (MEI) has been reported to improve the performance of colonoscopy, so far only a few randomized controlled studies have been published supporting its adjunctive role. This randomized study was designed to evaluate the role of MEI on the overall performance of colonoscopy. PATIENTS AND METHODS: Patients admitted for elective colonoscopy were recruited. They were randomly allocated into two groups, either with an MEI view (study group) or without (control group). Examinations were performed by one of the two designated, trained endoscopists. The primary end point was intubation time. Other outcome measures included completion rate, pain score graded by patients, and ease of procedure as reflected by the number of attempts at straightening the scope, the number of times of hand pressure was applied abdominally, and the need to change the patient's position. Endoscopists were also asked to score the ease of procedure. Finally, in the MEI group, endoscopists were asked to comment on whether MEI helped to locate colonic lesions during endoscopy. RESULTS: In a 12-month period, 120 patients were recruited, with 60 patients in each group. The two groups were matched for age, gender distribution, and indications for colonoscopy. No complication occurred in either group. No significant difference was observed in the intubation time and colonoscopy completion rate. Other measures of ease of procedure and pain score were also similar. However, MEI was reported by endoscopists to be helpful in locating colonic lesions in 32 % of examinations with positive findings. CONCLUSION: For trained endoscopists, the device confers no benefit in terms of performance improvement. The only identified benefit is in locating lesions. Thus, while the routine use of MEI cannot be recommended, the device could be selectively offered to patients for follow-up examination after local treatment, or to patients with small colorectal tumors in whom laparoscopic surgery is planned.

Laparoscopic sphincter-preserving total mesorectal excision with colonic J-pouch reconstruction: five-year results.

OBJECTIVE: To prospectively evaluate the oncologic and functional outcomes of laparoscopic total mesorectal excision (TME) with colonic J-pouch reconstruction. BACKGROUND: TME is considered the established gold standard in rectal cancer surgery. However, data on laparoscopic sphincter-preserving TME are limited. METHODS: Patients with mid or low rectal cancer underwent laparoscopic TME with colonic J-pouch reconstruction by a single surgical team. Clinical and oncologic data were prospectively recorded and analyzed. RESULTS: From March 1999 to September 2004, 105 patients underwent laparoscopic TME with colonic J-pouch reconstruction. The mean operating time was 170.4 minutes and mean blood loss was 91.5 mL. The mean anastomotic distance from the anal verge was 3.9 cm. Conversion was required in 2 cases. The mean circumferential and distal margins were 17.1 mm and 3.4 cm, respectively. There was 1 case of microscopic circumferential margin involvement and 1 case of microscopic distal margin involvement. There was no 30-day mortality, and 6 patients underwent reoperation for major complications. There was no port-site metastasis. The mean follow-up time was 26.9 months (range, 1.3-65.6 months). The actuarial 5-year cancer-specific survival and local recurrence rates were 81.3% and 8.9%, respectively. Erectile dysfunction occurred in 13.6% of males, while 2 patients developed incomplete bladder denervation. Bowel function after ileostomy closure was satisfactory, with an average bowel motion of less than 3 times per day at 2 years after ileostomy closure. CONCLUSIONS: Laparoscopic TME with colonic J-pouch reconstruction is a safe procedure with reasonable operating time and does not appear to pose any threat to the oncologic and functional outcomes.

Minimally invasive surgery for rectal cancer.

The present scarcity of literature on laparoscopic rectal cancer surgery makes it premature to determine whether laparoscopic surgery should be the standard of care for rectal cancer. Notwithstanding that, the available evidence proves its safety and adequate oncological clearance. Moreover, current data do not suggest any detrimental effect on the postoperative and early oncological outcomes. On the contrary, there is level three evidence showing that laparoscopic technique results in less blood loss, shorter length of stay, and reduced abdominal wound disorders and pulmonary complications, albeit the overall morbidity remains similar to that of open surgery. Long-term survival outcomes remain largely unclear, however. Hence, it is high time that laparoscopic technique should be further evaluated, preferably by means of large-scale randomized trials, to define its exact role in the treatment of rectal cancer.

What are the needs of students? An experience from a district based health promoting schools project in Hong Kong.

A district based needs assessment as conducted over the past year to uderstand the health problems and the health education needs of the students in Tai Po district, Hong ong. 6879 primary one to primary six students from eighteen rimary schools, participating in a district based Health Promoting Schools Project in Hong Kong, were invited to complete a self-administrated questionnaire which was partly adapted from the Centre for Diseases and Control (CDC)'s Youth Risk Behaviour Surveillance Survey. The results presented a holistic picture of the health and needs of primary students with respect to their general health status, mental health, body weight and dietary behaviour, exercise, preventive health care, tobacco use, alcohol and other drug use, school environment and school health education. It provides baseline information for the project to prioritize the problems and strategically plan health promotion 'programmes with reference to the concept of Health Promoting Schools by the World Health Organization.

Laparoscopy and its current role in the management of colorectal disease.

OBJECTIVE: To evaluate the current place of laparoscopy in the management of colorectal disease. METHOD: A literature search was undertaken on Medline between the period 1991 and 2002. RESULTS: From the literature there is good evidence that the laparoscopic approach is associated with at least some short-term advantages. Improved cosmesis and better patient's satisfaction are also evident. Because of this laparoscopy has been widely employed in various benign conditions. Among others, laparoscopic stoma formation, laparoscopic resection for diverticular disease and Crohn's disease, laparoscopic rectopexy, as well as laparoscopic assisted reversal of Hartmann's procedure were commonly reported. As port site recurrence and oncological safety are of less concern, there have been increasing reports on laparoscopic resection for colorectal cancer. Although long-term follow up data is still limited, results of large prospective studies as well as various randomized trials show that recurrence and survival rates of the laparoscopic approach were at least comparable to open surgery. As experience and confidence accumulates, there are also increasing reports on technically demanding, laparoscopic sphincter-saving rectal excision. Articles on functional aspects following this type of resection also start to appear, which might be one of the future directions. CONCLUSION: The applicability of laparoscopy to colorectal disease continues to expand. Laparoscopic approach should be considered for patients with benign conditions. For colorectal cancer, results from randomized trials so far have been favourable. Hence, the authors suggest the utility of laparoscopy in potentially curable cancer can also be judiciously relaxed.

Prospective evaluation of laparoscopic total mesorectal excision with colonic J-pouch reconstruction for mid and low rectal cancers.

BACKGROUND: Results of laparoscopic sphincter-preserving total mesorectal excision and colonic J-pouch reconstruction are few. The aim of this study was to examine outcomes after this procedure. METHODS: Patients with mid or low rectal cancer underwent laparoscopic total mesorectal excision with construction of a colonic J pouch, performed by a single surgeon. The patients were evaluated prospectively. RESULTS: From March 1999 to January 2002, 44 patients underwent laparoscopic total mesorectal excision with colonic J-pouch reconstruction. There were 21 men and 23 women of median age 65.5 years. The median operating time was 180 min and median blood loss 80 ml. There was no conversion to an open procedure. The median distance of the anastomosis from the anal verge was 4 cm. No procedure-related death occurred. Four patients developed significant complications that required reoperation. With a median follow-up period of 15 months, no port-site recurrence was noted. Five patients developed distant metastases, and two had local recurrence in the pelvis. Bowel function was satisfactory at 6, 12 and 18 months after ileostomy closure. CONCLUSION: Laparoscopic total mesorectal excision with colonic J-pouch reconstruction is safe, with a reasonable operating time. Early results suggest satisfactory oncological control and functional outcomes.

Double-blind, randomized trial comparing Harmonic Scalpel hemorrhoidectomy, bipolar scissors hemorrhoidectomy, and scissors excision: ligation technique.

PURPOSE: The aim of this study was to compare the outcome of patients receiving hemorrhoidectomy using Harmonic Scalpel, bipolar scissors, and the conventional scissors excision-ligation technique. METHODS: Eighty-six patients with irreducible prolapsing piles were randomly assigned to receive 1) Milligan-Morgan hemorrhoidectomy using scissors excision-ligation technique or 2) bipolar scissors hemorrhoidectomy and Harmonic Scalpel hemorrhoidectomy. Neither the patient nor the independent assessor were aware of the technique used at operation. Patients were followed up at 4 and 12 weeks after operation. The measured outcomes included 1) operation time; 2) blood loss; 3) postoperative hospital stay; 4) pain score; 5) pain expectation score; 6) date of first bowel movement; 7) number of pethidine injections; 8) number of dologesic tablets taken; 9) time off work or normal activity; 10) wound healing; 11) satisfaction score; and 12) postoperative complications, including anal stenosis and fecal or flatus incontinence. RESULTS: There was no difference among the three groups in the operation time, hospital stay, pain expectation score, day of first bowel movement, number of dologesic tablets taken, time off work or normal activity, wound healing, and satisfaction score. The complication rate also did not differ in the three groups. Both Harmonic Scalpel hemorrhoidectomy and bipolar scissors hemorrhoidectomy were superior to Milligan-Morgan hemorrhoidectomy in terms of reduced blood loss. Harmonic Scalpel hemorrhoidectomy had the best pain score when compared with bipolar scissors hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy, and patients required significantly less pethidine injection after Harmonic Scalpel hemorrhoidectomy than after Milligan-Morgan hemorrhoidectomy. Although the time required to return to work or normal activity remained similar, patients after Harmonic Scalpel hemorrhoidectomy had the best satisfaction score among the three groups. CONCLUSION: The study shows that Harmonic Scalpel hemorrhoidectomy is as good as bipolar scissors hemorrhoidectomy in terms of reduced blood loss but is superior because it is associated with less postoperative pain and hence, better patient satisfaction. However, these observed benefits are small, and the time off work or normal activity remains similar.

Laparoscopic-assisted total mesorectal excision and colonic J pouch reconstruction in the treatment of rectal cancer.

BACKGROUND: Total mesorectal excision (TME) and colonic J pouch reconstruction has been widely practiced for mid- or low-rectal cancer. However, the laparoscopic version of TME has never been described. METHODS: Five patients suffering from newly diagnosed mid- to low-rectal cancer were seen between March and July 1999. These five patients were selected for laparoscopic TME and colonic J pouch reconstruction because preoperative investigations revealed resectable tumor without extrarectal disease. RESULTS: There were three men and two women with a mean age of 61 years. The average body weight was 69 kg (range, 57-80). None of the patients had had previous abdominal operations. In all five patients, the tumor was located within 9 cm from anal verge. The average size of the main incision was 5 cm. All patients had a covering ileostomy at the end of the procedure. The mean operating time was 208 min; average blood loss was 158 ml; and mean hospital stay was 10.6 days. Three patients had Dukes' B disease and two had Dukes' C disease. The resection margins (proximal, circumferential, and distal) were all clear. There were no deaths or major complications. Two patients suffered from transient urinary retention. After ileostomy closure, the median frequency of bowel motion was twice per day at 6-month follow-up. Neither incontinence nor nocturnal soiling was reported. CONCLUSION: To the best of our knowledge, this is the first published series of such an operation. With good patient selection, laparoscopic-assisted TME and colonic J pouch-anal anastomosis is safe and feasible.

The importance of three-dimensional brachytherapy treatment planning for nasopharyngeal carcinoma.

High dose rate (HDR) intracavitary brachytherapy is now more frequently incorporated into treatment programmes for patients with persistent and recurrent nasopharyngeal carcinoma (NPC). However, many centres still employ two-dimensional (2-D) image reconstruction for applicators with a three-dimensional (3-D) orientation. In this study, we introduced the use of a mobile modified Nucletron reconstruction box inside the brachytherapy suite for image reconstruction and quality assurance. Three-dimensional reconstruction of the applicators' configurations proved possible and the dose distributions generated by the 2-D and 3-D image reconstructions could be compared. Thirty-one applications were included in this part of the analysis. The results showed that, based on the 2-D planning method, the reference doses were under-prescribed by 1%-10% in all except one patient, whose dose was over-prescribed by 3%. The evaluated doses to the floor of the sphenoid, which was shown to be significant for subsequent local control, was shown to be underestimated by up to 19% or overestimated by 18%, with an average of 5.9% dose underestimation. With this system, the reliability of the anchoring techniques was verified by posttherapy radiographs. Any catheter displacement of more than 1 mm was counted as a failure. Nine of the 43 verified applications were classified as failures, although six of nine catheter displacements measured < or = 2.5 mm. We recommend the routine use of a modified reconstruction box for 3-D image reconstruction for dose calculation and prescription in the treatment of NPC with HDR intracavitary brachytherapy. Quality assurance programmes should be included as an integral part of any HDR treatment; their importance cannot be overemphasized.