Robotic versus laparoscopic hepatectomy: application of the difficulty scoring system.

BACKGROUND: The development of robotic system may help to relieve the difficulties encountered during laparoscopic hepatectomy. A difficulty scoring system (DSS) was developed to assess the difficulty of various laparoscopic liver resection procedures. The aim of this study is to explore if the DSS is applicable in robotic hepatectomy and to compare the outcomes of robotic hepatectomy and laparoscopic hepatectomy among different difficulty levels. METHODS: Clinical data from all consecutive patients who underwent robotic and conventional laparoscopic hepatectomy at the Prince of Wales Hospital, Hong Kong, were prospectively collected and reviewed. The difficulty level of operations was graded using the DSS. Perioperative outcomes of robotic and conventional laparoscopic hepatectomy were compared at each difficulty level. RESULTS: A total of 107 and 94 patients underwent robotic and laparoscopic hepatectomy during the study period, respectively. Among them, 16 and 2 patients were operated for recurrent pyogenic cholangitis, respectively, and were excluded because no mark for tumour location can be assigned. For robotic hepatectomy, a higher DSS was significantly correlated with higher minor complication rate (p = 0.001), more intraoperative blood loss (p = 0.002), longer operation time (p < 0.001) and longer post-operative hospital stay (p < 0.001). The mean DSS scores of robotic and laparoscopic hepatectomy were 4.5 and 3.6, respectively. (p = 0.004). For cases with low (DSS 1-3) and intermediate (DSS 4-6) difficulty level, there was no significant difference in operative blood loss, operation time and overall complications rate. Only 2 cases (2.2%) with high difficulty level were operated with laparoscopic approach while 20% of patients operated with robotic approach had DSS > 6. CONCLUSIONS: DSS significantly correlated with surgical outcomes in patient who underwent robotic hepatectomy. Perioperative outcomes following robotic and conventional laparoscopic hepatectomy were similar in cases with low and intermediate difficulty. However, robotic system allowed minimally invasive approach in cases with higher difficulty level.

Enhanced recovery after surgery for liver resection.

INTRODUCTION: Enhanced recovery after surgery (ERAS) reduces postoperative length of hospital stay and patient stress response to liver surgery. The aim of the present study was to evaluate the efficacy and feasibility of an ERAS programme for liver resection. METHODS: A multidisciplinary ERAS protocol was implemented for both open and laparoscopic liver resection in a tertiary hospital in Hong Kong. The clinical outcomes of patients who underwent liver resection and underwent the ERAS perioperative programme were compared with those who received a conventional perioperative programme between September 2015 and July 2016. Propensity score matching analysis was used to minimise background differences. RESULTS: A total of 20 patients who underwent liver resection were recruited to the ERAS programme. Their clinical outcomes were compared with another 20 patients who received hepatectomy under a conventional perioperative programme after propensity score matching. The ERAS programme was associated with a significantly shorter length of hospital stay (P=0.033) without an increase in complication rates in patients who underwent open liver resection. There was no such significant association in patients who underwent laparoscopic liver resection. No patients required readmission in this cohort. CONCLUSIONS: The ERAS perioperative programme for liver resection is safe and feasible. It significantly shortened the hospital stay after open liver resection but not after laparoscopic liver resection.

Reduction of operative mortality after implementation of Surgical Outcomes Monitoring and Improvement Programme by Hong Kong Hospital Authority.

INTRODUCTION: Since 2008, the Hong Kong Hospital Authority has implemented a Surgical Outcomes Monitoring and Improvement Programme (SOMIP) at 17 public hospitals with surgical departments. This study aimed to assess the change in operative mortality rate after implementation of SOMIP. METHODS: The SOMIP included all Hospital Authority patients undergoing major/ultra-major procedures in general surgery, urology, plastic surgery, and paediatric surgery. Patients undergoing liver or renal transplantation or who had multiple trauma or massive bowel ischaemia were excluded. In SOMIP, data retrieval from the Hospital Authority patient database was performed by six full-time nurse reviewers following a set of precise data definitions. A total of 230 variables were collected for each patient, on demographics, preoperative and operative variables, laboratory test results, and postoperative complications up to 30 days after surgery. In this study, we used SOMIP cumulative 5-year data to generate risk-adjusted 30-day mortality models by hierarchical logistic regression for both emergency and elective operations. The models expressed overall performance as an annual observed-to-expected mortality ratio. RESULTS: From 2009/2010 to 2015/2016, the overall crude mortality rate decreased from 10.8% to 5.6% for emergency procedures and from 0.9% to 0.4% for elective procedures. From 2011/2012 to 2015/2016, the risk-adjusted observed-to-expected mortality ratios showed a significant downward trend for both emergency and elective operations: from 1.126 to 0.796 and from 1.150 to 0.859, respectively (Mann- Kendall statistic = -0.8; P<0.05 for both). CONCLUSION: The Hospital Authority's overall crude mortality rates and risk-adjusted observed-to-expected mortality ratios for emergency and elective operations significantly declined after SOMIP was implemented.

Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review.

BACKGROUND: The aim of this study was to evaluate and compare transanal haemorrhoidal dearterialisation (THD) and stapled haemorrhoidopexy [also called procedure for prolapsed haemorrhoids (PPH)] in the management of haemorrhoidal disease, in terms of short-term outcomes and efficacy. METHODS: Patients presenting with symptomatic haemorrhoids were treated with THD. Patient demographics, pre-operative data, post-operative pain scores, complications, recurrence, and patient satisfaction scores were evaluated and recorded. Patients with acute thrombosed haemorrhoids, external haemorrhoids only, or other concomitant anal diseases were excluded. These data were compared with the historical data of PPH. RESULTS: Forty consecutive patients underwent THD from February 2012 to July 2013 and were compared to 37 patients who underwent PPH taken from a medical records database. There were no significant differences in terms of demographic data, type of anaesthesia, operative time, and blood loss. Length of hospital stay, time to first post-operative bowel movement, and complications were similar between the two groups. The median pain score after THD and PPH was 1.71 and 5.00, respectively, on a scale of 0-10 (10 = worst possible pain) (p = 0.000). There was a significant improvement in bleeding and prolapse scores after THD. THD patients had an earlier return to normal daily activities (3.13 vs. 6.78 days, p = 0.001) when compared with the PPH group. Upon follow-up, patients in both groups had similar satisfaction scores, and complication and recurrence rates. CONCLUSIONS: Both THD and PPH appear to be safe procedures for haemorrhoidal disease, and they appear to have similar short-term outcomes. In particular, THD seems to be associated with a lower pain score than PPH, an earlier return to normal daily activities, and similar rates of complication and recurrence.

Randomized clinical trial of open hepatectomy with or without intermittent Pringle manoeuvre.

BACKGROUND: The intermittent Pringle manoeuvre (IPM) is commonly applied during liver resection. Few randomized trials have addressed its effectiveness in reducing blood loss and the results have been conflicting. The present study investigated the hypothesis that IPM could reduce blood loss during liver resection by 50 per cent. METHODS: Between May 2008 and April 2011, patients who underwent elective open hepatectomy were randomized into an IPM or no Pringle manoeuvre (NPM) group and stratified according to the presence or absence of cirrhosis. Data on demographics, type of hepatectomy, operative blood loss, duration of operation, mortality, morbidity and postoperative liver function were recorded and analysed. The primary endpoint was operative blood loss. RESULTS: There were 63 patients in each group. Median (range) operative blood loss was 370 (50-3600) ml in the IPM group versus 335 (40-3160) ml in the NPM group (P = 1·000). There were no differences in blood loss in different phases of the operation, blood loss per area of liver transected or blood transfusion rate, nor in total duration of operation or liver transection time. Postoperative serum alanine aminotransferase levels were higher in the IPM group (P < 0·001). There were more postoperative complications in the IPM group (41 versus 24 per cent; P = 0·036). CONCLUSION: The IPM did not reduce blood loss, but was associated with raised levels of postoperative liver parenchymal enzymes and more complications. REGISTRATION NUMBER: NCT00730743 (http://www.clinicaltrials.gov).

Surgical ablation of hepatocellular carcinoma with 2.45-GHz microwave: a critical appraisal of treatment outcomes.

OBJECTIVE: To evaluate the efficacy and safety of a new generation of 2.45-GHz microwave to ablate hepatocellular carcinoma by surgical approach. DESIGN; Case series with prospective follow-up. SETTING: A university teaching hospital in Hong Kong. PATIENTS: From March 2009 to January 2011, 26 consecutive patients (19 men and 7 women) with a median age of 63 (range, 49-79) years with hepatocellular carcinoma were recruited. Five (19%) of the patients had recurrent hepatocellular carcinoma after previous treatment. INTERVENTION: Microwave ablation for hepatocellular carcinomas (one tumour, n=24; two tumours, n=2) using a laparoscopic (n=16) or open approach (n=10). MAIN OUTCOME MEASURES: Operative mortality and morbidity, rate of incomplete ablation, recurrence rate, and survival rate. RESULTS: The median tumour diameter was 3.8 cm (range, 2.0-6.0 cm). Complications occurred in five (19%) of the patients; only one was ablation-related, and there was no operative mortality. One (4%) of the patients experienced incomplete ablation. Recurrent tumours were noted in 11 (42%) of the patients (5 were local, 2 were remote, and 4 were multifocal) after a median follow-up of 14 (range, 4-26) months. The failure rate for local disease control was 23%, and was 14% if patients with recurrent hepatocellular carcinoma were excluded. All but one patient survived until the time of censorship. The mean survival was 25 (standard deviation, 1) months. CONCLUSION: This new-generation microwave technique is safe and effective for local ablation of hepatocellular carcinoma. It is a valuable treatment option for patients who are not candidates for hepatectomy.

Utility of a preoperative assessment clinic in a tertiary care hospital.

OBJECTIVES: To assess the utilisation rate of a preoperative assessment clinic and its impact on length of stay and discharge destinations. DESIGN: Retrospective case series with internal comparisons. SETTING: A tertiary hospital in Hong Kong. PATIENTS: All medical records of elective surgical admissions to a hospital in Hong Kong from April to June 2008 were retrieved. Medical records of patients who did not attend the preoperative assessment clinic were further reviewed by surgeons to assess if the patients could have been referred to the clinic. MAIN OUTCOME MEASURES: Total length of stay, preoperative and postoperative length of stay, and the discharge destinations of the patients attending and not attending the clinic were compared. RESULTS. In all, 640 patients underwent elective operations, of whom 22 (3%) patients were seen in the preoperative assessment clinic. In patients who had a major operation, the mean (standard deviation) total length of stays for clinic attenders and non-attenders were: 5.2 (3.6) versus 13.2 (18.8) days (P<0.001). The respective figures for preoperative and postoperative length of stay were: 1.3 (2.3) versus 4.5 (8.9) days (P=0.001), and 3.9 (2.9) versus 8.7 (14.5) days (P<0.001). For patients who had an intermediate operation, the respective mean (standard deviation) length of hospital stays were 2.4 (2.0) versus 7.3 (13.9) days (P=0.002) and the figures for postoperative length of stays were 1.3 (0.5) versus 4.5 (9.3) days (P=0.001). Surgeons had classified 108 (17%) of the cases as possible preoperative assessment clinic users. Among the latter, 71 (66%) had no special reason to stay in the hospital. The discharge destination was not associated with the use of preoperative assessment clinic for patients having major (Chi squared=0.18, P=0.912) or intermediate (Chi squared=0.34, P=0.468) operations. CONCLUSION: Successful implementation of preoperative assessment clinic service requires close collaboration between surgeons, anaesthetists, clinicians, and also the re-engineering of health service delivery.

Single-incision laparoscopic cholecystectomy: from four wounds to one.

OBJECTIVE: To review the initial results and surgical outcomes of single-incision laparoscopic cholecystectomy. DESIGN: Prospective case series. SETTING: A university teaching hospital and a regional hospital in Hong Kong. PATIENTS: All patients undergoing single-incision laparoscopic cholecystectomy from August 2009 to March 2011. RESULTS: Fifty patients underwent single-incision laparoscopic cholecystectomy during the study period. The indications for surgery included symptomatic gallstones (n=43) and gallbladder polyps (n=7). The mean operating time was 78 (standard deviation, 24) minutes. Forty-five of the patients successfully underwent single-incision laparoscopic cholecystectomy, giving a success rate of 90%. In the remaining five patients, additional working ports were constructed to obtain better exposure and dissection around Calot's triangle. On comparing the results of the initial 25 cases to the subsequent 25 cases, in the latter group the operating time was significantly shorter (86 vs 71 minutes; P=0.02), and the success rate was higher (80% vs 100%; P=0.05). During the median follow-up period of 6.8 months, four patients had complications, which included: postoperative urinary retention (n=2), one each with a haematoma and an incisional hernia. No patient endured bile duct injury, postoperative bile leakage, or haemorrhage in our series. CONCLUSION: Single-incision laparoscopic cholecystectomy is feasible and safe for treatment of uncomplicated gallbladder diseases. There was a reduction in the operating time and increase in success rate with accumulation of experience. Nevertheless, surgeons should be cautious about the potential risks of this new technique.

A community-acquired methicillin-resistant Staphylococcus aureus liver abscess.

Liver abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus are rarely reported. We report such a case in a 25-year-old man who presented with an intermittent fever. He had a history of prolonged antibiotic use for acne and skin abscesses. The liver abscess was successfully treated with percutaneous drainage and a prolonged course of linezolid. To our knowledge, this is the first reported case of a community-acquired methicillin-resistant Staphylococcus aureus liver abscess in Hong Kong, demonstrating the increasing threat posed by this multidrug-resistant organism. This case also suggests that a different epidemiology and route of infection may apply to community-acquired methicillin-resistant Staphylococcus aureus liver abscesses in contrast to the more common pyogenic liver abscesses.

Dilated common bile ducts mimicking choledochal cysts in ketamine abusers.

Substance abuse is a major health and social problem among Hong Kong youth and ketamine is the drug most commonly abused. Ketamine abuse is associated with a series of side-effects that include hallucination, nausea, vomiting, elevation of blood pressure, and urinary bladder dysfunction. Here we report three cases of ketamine abuse in which the abusers presented with recurrent epigastric pain and dilated common bile ducts that mimicked choledochal cysts on imaging. The dilated biliary tree may occur more frequently than was once assumed.

Radiofrequency ablation for 110 malignant liver tumours: preliminary results on percutaneous and surgical approaches.

BACKGROUND: Radiofrequency ablation (RFA) has been widely applied for the treatment of hepatocellular carcinoma and liver metastases. The reported mortality and morbidity rates are low. The aim of this study is to evaluate the safety and efficacy of RFA, and compare the results performed percutaneously versus surgically. PATIENTS AND METHODS: From 2003 to 2006, 79 patients with hepatic malignancies (59 hepatocellular carcinoma, 20 liver metastases) with a total of 110 lesions underwent RFA in our centre. Postablation assessment by CT scan was performed in all patients at 1-, 3- and 6-month intervals. Post-procedural complications, recurrence and survival were analysed. RESULTS: The patients' mean age was 60.0 years. In 46.8% of cases, we used a percutaneous approach; in 53.2% of cases, a surgical approach (8.9% laparoscopic; 44.3% open) was used if percutaneous approach was not feasible. The mean tumour size was 2.4 cm. Within the surgical group, 69% of patients received concomitant operative procedures such as cholecystectomy and hepatectomy. No treatment-related mortality was observed. Immediate complications occurred in five patients (6.3%), including gastric serosal burn (n = 1), ground pad superficial skin burn (n = 1), intra-abdominal bleeding (n = 2) and pleural effusion (n = 1). All patients except one attended subsequent follow-up, with a mean period of 16 months. Ablation was considered complete in 82.3% of patients (percutaneous approach 81.1%, surgical approach 83.3%, p = 0.72). Intrahepatic recurrence was observed in 52.3%, the majority of them located away from the RFA site. Extrahepatic recurrences were observed in 16.9% (percutaneous approach 16.7%, surgical approach 17.1%, p = 0.76). The overall one- and two-year survival rate was 93.7% and 74.4% respectively, and no statistically significant difference was observed between the two approaches. CONCLUSION: RFA is a safe and effective procedure for treating patients with malignant liver tumours. No difference in short term outcomes was observed between percutaneous and surgical approaches. A more prolonged follow-up study is required to assess longer-term outcomes.

Fine-needle aspiration cytology of thyroid nodules--how well are we doing?

OBJECTIVES: To review the accuracy of fine-needle aspiration cytology in diagnosing non-toxic thyroid nodules and determine what factors are predictive of malignancy in patients with indeterminate cytology results. DESIGN: Retrospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: Patients with non-toxic thyroid nodules undergoing thyroidectomy from December 1999 to December 2003. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive value of fine-needle aspiration cytology, predictive factors for malignancy in patients with indeterminate fine-needle aspiration cytology results. RESULTS: The sensitivity, specificity, positive predictive value, and negative predictive value of fine-needle aspiration cytology were 54%, 100%, 100%, and 75% respectively. For the 92 patients with fine-needle aspiration cytology reported as 'indeterminate for malignancy', aspiration cytology subgroup (P=0.005) and age (P=0.001) were significant risk factors for diagnosing malignancy. CONCLUSIONS: Fine-needle aspiration cytology has high positive predictive value for thyroid cancer, enabling us to 'rule-in' malignant lesions with confidence. Among those with indeterminate fine-needle aspiration cytology, atypical cell lesions and age greater than 40 years conferred increased risk of malignancy.

Laparoscopic versus open hepatectomy for liver tumours: a case control study.

OBJECTIVE: To evaluate the benefits of laparoscopic versus open resection of liver tumours. DESIGN: Case control study. SETTING: Tertiary teaching hospital, Hong Kong. PATIENTS: Data from 25 patients who underwent laparoscopic resections for liver tumours from 2003 to 2006 were compared to a retrospective series of 25 patients who underwent open hepatectomy in a pair-matched design. MAIN OUTCOME MEASURES: Duration of operation, operative morbidity and mortality, blood loss, tumour resection margin, analgesics usage, days to return to an oral diet, duration of postoperative hospital stay, and survival of patients with malignancy. RESULTS: The demographic data and the tumour characteristics were comparable in the two patient groups, as were mortality (0% in both groups) and morbidity rates (4% in both groups). Two (8%) of the patients having laparoscopic resections were converted to open surgery. There was no statistically significant difference between the two groups in terms of operating time or resection margins. However, the laparoscopically treated patients experienced significantly less blood loss (median, 100 vs 250 mL), had shorter hospital stays (median, 4 vs 7 days), were prescribed less analgesia (median morphine dosage, 0.16 vs 0.83 mg per kg body weight), and resumed oral diet earlier (median, 1 vs 2 days). For patients with malignant tumours, there was no significant difference between the two groups in terms of actuarial and disease-free survival. CONCLUSION: Compared to open hepatectomy, in selected patients laparoscopic liver resection delivers the benefits of decreased blood loss, shorter hospital stay, lesser requirement for analgesics, and an earlier return to an oral diet, without evidence of compromised oncological clearance.

Is regular follow-up scan for giant liver haemangioma necessary?

OBJECTIVES: To review the reliability of radiological diagnosis and need of regular scans for giant liver haemangioma, in terms of long-term outcome and management options. DESIGN: Retrospective study. SETTING: Division of Hepato-biliary and Pancreatic Surgery, Prince of Wales Hospital, Hong Kong. PATIENTS: Patients with giant liver haemangioma noted on initial imaging from February 1996 to July 2006. MAIN OUTCOME MEASURES: Patient demographics, clinical assessments, management, and outcomes. RESULTS: There were 42 female and 22 male patients with a median age of 49 (range, 27-84) years with a suspected haemangioma. The median maximal diameter of the lesions was 5.5 cm (range, 4.0-20.3 cm). They were first detected by ultrasonography (n=45), contrast-enhanced computed tomographic scan (n=18), or magnetic resonance imaging (n=1). Besides regular follow-up scans, 22 patients were investigated further to confirm the diagnosis/exclude malignancy. Finally, 63 patients had a haemangioma and one had a hepatocellular carcinoma. Regarding the patients with haemangiomas, two were operated on for relief of pain and the rest were managed conservatively. The median duration of follow-up was 34 months. Most (54%) of the patients were asymptomatic, but in 17% the haemangioma enlarged to exceed its original size by more than 20%. There were no haemangioma-associated complications. CONCLUSIONS: Majority of patients having giant liver haemangioma are asymptomatic and do not suffer complications. If the diagnosis is uncertain, selective further investigations may be necessary. Lesions with a confirmed diagnosis tend to remain static in size; performing regular scans for asymptomatic giant liver haemangiomas may not be necessary.

Characteristics, management process, and outcome of patients suffering in-hospital cardiopulmonary arrests in a teaching hospital in Hong Kong.

OBJECTIVES: To examine the demographics, process indicators of adult in-hospital cardiopulmonary arrest resuscitation, and outcomes in a teaching hospital in Hong Kong. DESIGN: Retrospective study. SETTING: A university-affiliated tertiary referral hospital with 997 acute adult beds in Hong Kong. PATIENTS: Those who suffered a cardiopulmonary resuscitation event, as documented in retrieved records of all in-patients during the inclusive period January 2002 to December 2005. RESULTS: There were 531 resuscitation events; the mean (standard deviation) age of the corresponding patients was 70.7 (15.4) years. Most (83%) occurred in non-monitored areas and most (97%) were cardiopulmonary arrests. The predominant initial rhythm was asystole (52%); only 8% of patients had ventricular tachycardia/fibrillation. All the resuscitations were initiated by on-site first responders. The median times from collapse to arrival of the resuscitation team, to defibrillation, to administration of adrenaline, and to intubation were: 5 (interquartile range, 2-6) minutes, 5 (1-7) minutes, 5 (3-10) minutes, and 9 (5-13) minutes, respectively. The overall hospital survival (discharge) rate was 5%. The survival rate was higher among patients in monitored areas (9 vs 4%, P=0.046), among patients with isolated respiratory arrests (61 vs 3%, P<0.001), primary ventricular tachycardia/fibrillation arrests (13 vs 4%, P<0.001), shorter interval times from collapse to medication (1.5 vs 5 min, P=0.013), and longer interval times to intubation (12 vs 8 min, P=0.013). CONCLUSION: Hospital survival after in-hospital cardiopulmonary arrests was poor. Possible strategies to improve survival include shorten time interval to defibrillation, and provision of more monitored beds.

Circulating human leucine-rich α-2-glycoprotein 1 mRNA and protein levels to detect acute appendicitis in patients with acute abdominal pain.

BACKGROUND: Elevated levels of circulating plasma and urine leucine-rich-2-glycoprotein-1 (LRG1) protein has been found in patients with acute appendicitis (AA) and may be useful for diagnosis. This study aimed to investigate whether combined tests including circulating LRG1 mRNA levels improve the early diagnosis of AA. METHODS: Between December 2011 and October 2012, a prospective study was conducted on patients aged 18years or older presenting to the ED with acute abdominal pain (<7days of symptom onset). Levels of whole blood LRG1 mRNA and plasma LRG1 protein taken from these patients within 24h of arrival (mean 12.4h) were analyzed. The primary outcome was AA. RESULTS: Eighty-four patients (40 (47.6%) with AA and 44 (52.4%) without AA; mean age 35years; 41.6% males) were recruited. Median whole blood LRG1 mRNA and plasma LRG1 levels were higher in AA patients than in non-AA. Of 40 AA patients, 13 (32.5%) were diagnosed as complicated AA. In ROC analysis of LRG1 mRNA (normalized to GAPDH), LRG1 protein and Alvarado score for discriminating AA and non-AA, the areas under the curve (AUC) were 0.723, 0.742 and 0.805 respectively. The AUC of combination of normalized LRG1 mRNA, LRG1 protein and Alvarado score was 0.845. CONCLUSION: A combination of modified whole blood LRG1 mRNA levels, plasma LRG1 protein and Alvarado score at the ED may be useful to diagnose simple and complicated AA from other causes of abdominal pain.

Antiviral therapy improves post-hepatectomy survival in patients with hepatitis B virus-related hepatocellular carcinoma: a prospective-retrospective study.

BACKGROUND: The effect of antiviral therapy on the post-hepatectomy long-term survival in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) remains uncertain. AIM: To evaluate the effect of antiviral therapy on post-hepatectomy survival and recurrence in patients with HBV-related HCC. METHODS: This was a prospective-retrospective study of a total of 404 patients who underwent hepatectomy for HBV-related HCC in a tertiary academic hospital. Data on patient and tumour characteristics, tumour recurrence, treatment for recurrence and survival were compared between antiviral and no antiviral groups. RESULTS: Patient's and tumour characteristics were comparable between the two groups, except a higher proportion of patients with cirrhosis in the antiviral group. With a mean follow-up time of 52.4 months, antiviral group had a better 5-year overall survival (66.7% vs. 56.0%, P = 0.001) while there was no significant difference in the 5-year disease-free survival (44.7% vs. 38.1%, P = 0.166). Use of antiviral therapy was associated with better liver function reserve at the time of recurrence and a greater proportion of patients could receive curative treatment for recurrence (38.5% vs. 24.3%, P = 0.041). There was no significant different in the hazard ratios of patients who started antiviral therapy before or after operation (P = 0.054). CONCLUSIONS: Use of antiviral therapy improves the long-term post-hepatectomy survival in patients with HBV-related HCC. With a better liver function reserve at the time of recurrence, a greater proportion of patients in antiviral group could receive curative treatment for recurrence.

Coloduodenal fistula: a rare complication of right-sided diverticulitis.

Coloduodenal fistula is an uncommon disease entity. It can be caused by either a malignant or benign disease. We report the fifth case of coloduodenal fistula secondary to colonic diverticulosis. Our patient, a 60-year-old man, presented with severe diarrhoea and recurrent severe hypokalaemia. A partial colectomy with en bloc excision of the fistula was performed, and the duodenal defect was closed primarily. A literature review was carried out on the aetiology, presentation, diagnosis and management of coloduodenal fistula.