Totally laparoscopic versus open gastrectomy for advanced gastric cancer: a matched retrospective cohort study.

INTRODUCTION: Laparoscopic gastrectomy revolutionised the management of gastric cancer, yet its oncologic equivalency and safety in treating advanced gastric cancer (especially that in smaller centres) has remained controversial because of the extensive lymphadenectomy and learning curve involved. This study aimed to compare outcomes following laparoscopic versus open gastrectomy for advanced gastric cancer at a regional institution in Hong Kong. METHODS: Fifty-four patients who underwent laparoscopic gastrectomy from January 2009 to March 2017 were compared with 167 patients who underwent open gastrectomy during the same period. All had clinical T2 to T4 lesions and underwent curative-intent surgery. The two groups were matched for age, sex, American Society of Anaesthesiologists class, tumour location, morphology, and clinical stage. The endpoints were perioperative and long-term outcomes including survival and recurrence. RESULTS: All patients had advanced gastric adenocarcinoma and received D2 lymph node dissection. No between-group differences were demonstrated in overall complications, unplanned readmission or reoperation within 30 days, 30-day mortality, margin clearance, rate of adjuvant therapy, or overall survival. The laparoscopic approach was associated with less blood loss (150 vs 275 mL, P=0.018), shorter operating time (321 vs 365 min, P=0.003), shorter postoperative length of stay (9 vs 11 days, P=0.011), fewer minor complications (13% vs 40%, P<0.001), retrieval of more lymph nodes (37 vs 26, P<0.001), and less disease recurrence (9% vs 28%, P=0.005). CONCLUSION: Laparoscopic gastrectomy offers a safe and effective therapeutic option and is superior in terms of operative morbidity and potentially superior in terms of oncological outcomes compared with open surgery for advanced, surgically resectable gastric cancer, even in a small regional surgical department.

Epidemiological features and spatio-temporal clusters of hand-foot-mouth disease at town level in Fuyang, Anhui Province, China (2008-2013).

Hand-foot-mouth disease (HFMD) is a frequently occurring epidemic and has been an important cause of childhood mortality in China. Given the disease's significant impact nationwide, the epidemiological characteristics and spatio-temporal clusters in Fuyang from 2008 to 2013 were analysed in this study. The disease exhibits strong seasonality with a rising incidence. Of the reported HFMD cases, 63·7% were male and 95·2% were preschool children living at home. The onset of HFMD is age-dependent and exhibits a 12-month periodicity, with 12-, 24- and 36-month-old children being the most frequently affected groups. Across the first 60 months of life, children born in April [relative risk (RR) 8·18], May (RR 9·79) and June (RR 8·21) exhibited an elevated infection risk of HFMD relative to January-born children; the relative risk compared with the reference (January-born) group was highest for children aged 24 months born in May (RR 34·85). Of laboratory-confirmed cases, enterovirus 71 (EV71), coxsackie A16 (Cox A16) and other enteroviruses accounted for 60·1%, 7·1% and 32·8%, respectively. Spatio-temporal analysis identified one most likely cluster and several secondary clusters each year. The centre of the most likely cluster was found in different regions in Fuyang. Implications of our findings for current and future public health interventions are discussed.

Donation frequency and its association with demographic characteristics--a 1-year observational study.

OBJECTIVE: The aim of this study is to enhance the understanding of frequent blood donors' characteristics and devise strategies to achieve an optimal blood inventory. BACKGROUND: Apart from donor recruitment and retention, an effective way to increase blood supply is to increase the donation frequency among donors. Understanding the characteristics of frequent donors will be helpful to impact their future donation pattern, which would in turn achieve a stable and adequate blood inventory to meet the changing demands of the society. METHODS AND MATERIALS: Demographic information of blood donors for each donation in Hong Kong (HK) was routinely collected and stored in the database of Hong Kong Red Cross Blood Transfusion Service. Logistic regression models (by gender group) with interaction effects were constructed to analyse the differences in the likelihood of being frequent donors and the associations with their demographic characteristics. RESULTS: A total of 158,666 blood donors in 2010 gave 227,634 donations during the study. In general, male donors were more likely to be frequent donors. Logistic regression models further identified the characteristics of frequent donors in HK: older, blood type Rh D-ve and repeat donors, although their extent of impact was different for different gender group. CONCLUSION: To achieve an optimal blood inventory to meet the challenge of ageing in the society, donors who donate less often should be targeted to increase their donation frequency. More efforts in promotion should be made to recruit those non-donors to join the blood donation pool and motivate 'targeted' existing donors in the population to participate blood donation more regularly.

Laparoscopic sphincter-preserving total mesorectal excision: 10-year report.

AIM: Total mesorectal excision (TME) is currently the gold standard for resection of mid or low rectal cancer and is associated with a low local recurrence rate. However, few studies have reported the long-term oncological outcome following use of a laparoscopic approach. The aim of this study was to evaluate the long-term oncological outcome after laparoscopic sphincter-preserving TME with a median follow up of about 4 years. METHOD: Patients with mid or low rectal cancer who underwent laparoscopic sphincter-preserving TME with curative intent between March 1999 and March 2009 were prospectively recruited for analysis. RESULTS: During the 10-year study period, 177 patients underwent laparoscopic sphincter-preserving TME with curative intent for rectal cancer. Conversion was required in two (1%) patients. There was no operative mortality. At a median follow-up period of 49 months, local recurrence had occurred in nine (5.1%) patients. The overall metastatic recurrence rate after curative resection was 22%. The overall 5-year survival and 5-year disease-free survival in the present study were 74% and 71%, respectively. CONCLUSION: The results of this study show that laparoscopic sphincter-preserving TME is safe with long-term oncological outcomes comparable to those of open surgery.

Obstructive complications of laparoscopically created defunctioning ileostomy.

PURPOSE: The use of defunctioning ileostomy is a common practice to reduce the septic complications after anastomotic leakage in colorectal surgery. In open surgery, the fashioning of ileostomy is a straightforward procedure. However, in the laparoscopic approach, this can be a difficult task and obstructive complications can occur postoperatively. METHODS: A retrospective review was undertaken for all patients who underwent laparoscopic colorectal resection and defunctioning loop ileostomy over a 15-year period. RESULTS: In this period, 161 patients underwent laparoscopic colorectal surgery with defunctioning ileostomy. Eight patients developed obstructive complications in the early postoperative period requiring surgical intervention (5 percent). All patients presented with intestinal obstruction from the fourth to the sixth postoperative day. The median time to reoperation was 9.5 days (range, 5 to 19). The causes of obstructive complications were twisting of the ileostomy (n = 3), adhesive kinking proximal to the ileostomy (n = 3), tight fascia (n = 1), and both tight fascia and twisting of ileostomy (n = 1). Six patients underwent laparotomy for diagnosis and refashioning of ileostomy. The seventh patient had endoscopic decompression of small bowel and refashioning of ileostomy. The last patient was successfully managed with combined endoscopic and laparoscopic approach. CONCLUSIONS: Various pitfalls can occur in laparoscopically created defunctioning ileostomy. Measures can be taken to minimize these technical errors. Various surgical reinterventions can be attempted to determine the cause. With combined uses of enteroscope and laparoscope, a laparotomy can be avoided.

Stapled technique for acute thrombosed hemorrhoids: a randomized, controlled trial with long-term results.

PURPOSE: This study was designed to compare stapled vs. conventional hemorrhoidectomy for patients with acute thrombosed hemorrhoids. METHODS: Forty-one patients with acute thrombosed hemorrhoids were randomized into: 1) stapled hemorrhoidectomy (PPH group; n = 21), and 2) open hemorrhoidectomy (open group; n = 20). Emergency surgery was performed with perioperative data and complications were recorded. Patients were followed up by independent assessors to evaluate pain, recurrence, continence function, and satisfaction at regular intervals. RESULTS: The median follow-up for the PPH group and open group were 59 and 56 weeks, respectively. There was no significant difference in terms of the hospital stay, complication rate, and continence function; however, the mean pain intensity in the first postoperative week was significantly less in the PPH group (4.1 vs. 5.7, P = 0.02). Patients in the PPH group recovered significantly faster in terms of the time to become analgesic-free (4 vs. 8.5 days, P < 0.01), time to become pain-free (9 vs. 20.5 days, P = 0.01), resumption of work (7 vs. 12.5 days, P = 0.01), and time for complete wound healing (2 vs. 4 weeks, P < 0.01). On long-term follow-up, significantly fewer patients in the PPH group complained of recurrent symptoms (0 vs. 5, P = 0.02). The overall symptom improvement and patients' satisfaction were significantly better in the PPH group (90 vs. 80 percent, P = 0.03 and +3 vs. +2, P < 0.01 respectively). CONCLUSIONS: Stapled hemorrhoidectomy is safe and effective for acute thrombosed hemorrhoids. Similar to elective stapled procedure, emergency stapled excision has greater short-term benefits compared with conventional excision: diminished pain, faster recovery, and earlier return to work. Long-term results and satisfaction were excellent.

Non-operative management of small cell carcinoma of esophagus.

Primary small cell carcinoma of the esophagus (SmCC) is an uncommon aggressive tumor characterized by early systemic dissemination and poor prognosis, regardless of the methods of treatment. The optimal treatment strategy remains uncertain. A retrospective study was conducted to review the results of non-operative treatment for patients with limited and metastatic esophageal SmCC. Between 1993 and 2003, 10 patients were diagnosed to have primary esophageal SmCC in our institution. Six of them had disseminated diseases, whereas the other four had limited disease upon diagnosis. All patients were managed non-operatively by either chemotherapy and/or radiotherapy. The overall median survival was 8 months (range, 2-62 months). The survival was 4-62 months for patients with limited disease, whereas it was 2-10 months for patients with disseminated disease at initial diagnosis. In summary, the current study demonstrated satisfactory palliation could be achieved with chemo-radiation for patients with limited disease; however, the ultimate role of primary chemo-radiation for esophageal SmCC must await results from randomized trials.

Endo-Lap OR: an innovative "minimally invasive operating room" design.

BACKGROUND: A newly constructed Endoscopic-Laparoscopic operating room (Endo-Lap OR) started to operate in our department in January 2005. A prospective study was conducted to evaluate its feasibility, efficacy, and safety, as well as the staff's satisfaction. PATIENTS AND METHODS: From January 2005 to September 2005, all patients undergoing operation in this Endo-Lap OR were included in the study. The patient's diagnosis, types of operating procedures, incidents of operating failure (either due to the hardware or the software of Endo-Lap OR) that led to a delay in the patient's transfer or that extended the total operating time were recorded. In addition, questionnaires regarding staff satisfaction with the new operating room were distributed to nurses, anesthetists, and surgeons. RESULTS: A total of 640 cases were included in the study period, 245 cases of open surgery, 282 cases of laparoscopic surgery, 82 cases of endoscopic surgery, 17 cases of video-assisted thoracoscopic surgery, and 14 cases of combined endoscopic-laparoscopic surgery. There were no reported incidents of operating failure related to hardware or software problems. The overall staff satisfaction was excellent. CONCLUSIONS: The integration of endoscopic and laparoscopic surgery into this newly constructed Endo-Lap OR is feasible and safe. The running of the operating room was smooth and it received a high level of acceptance and satisfaction from different staff members.

Immediate preoperative laparoscopic staging for squamous cell carcinoma of the esophagus.

BACKGROUND: Conventional preoperative staging for esophageal carcinoma could be inaccurate. Laparoscopy has been applied for the staging of various upper gastrointestinal malignancies. It can identify peritoneal and liver deposits not shown by imaging, and could reduce the number of nontherapeutic laparotomies. This study aimed to evaluate the efficacy of laparoscopic staging for the management of squamous cell carcinoma involving the mid and distal esophagus. METHODS: A retrospective review was performed for all patients with esophageal cancer evaluated for surgical resection from January 1998 to January 2004. Laparoscopy was performed for all the patients with mid and distal esophageal cancer immediately before open gastric mobilization. The efficacy of laparoscopy for the management of squamous cell carcinoma of the esophagus was evaluated. RESULTS: Among the 63 patients with potentially resectable disease shown on conventional imaging, 54 (84%) underwent esophagectomy with curative intent after laparoscopic staging. Seven patients (11%) underwent laparoscopy alone because of abdominal metastases (n = 5) or other medical conditions (n = 2) that precluded esophagectomy. Two patients (3%) had exploratory right thoracotomy without esophagectomy despite normal laparoscopic findings. The sensitivity and specificity of laparoscopic staging were 100% in this series of patients (100% sensitivity and specificity means no false-positives or -negatives). CONCLUSION: Laparoscopic staging is valuable for the management of patients with mid and distal squamous cell carcinoma of the esophagus. Patients with metastatic disease and those with prohibitive surgical risk can thus avoid unnecessary laparotomy and be offered other treatment methods.

Acute gastric volvulus: an unusual cause of gastric outlet obstruction.

Gastric outlet obstruction initiated by acute gastric volvulus is rare but potentially fatal. An unusual case of intrathoracic acute gastric volvulus complicated by distal stomach and transverse colon herniation into retrocardial space is reported. Prompt clinical diagnosis was followed by emergency laparoscopic de-rotation and gastropexy.

Non-operative management of endoscopic iatrogenic haemobilia: case report and review of literature.

Haemobilia denotes an abnormal communication between a vessel of the splanchnic circulation and the biliary system. Patients typically presents with the triad of abdominal pain, upper gastrointestinal haemorrhage, and jaundice. Common causes for haemobilia are iatrogenic causes secondary to hepatobiliary system instrumentation and trauma. Management of patients with haemodynamic significant haemobilia is aimed at stopping bleeding, maintaining continuous flow of biliary system, and cure of the underlying aetiology. Iatrogenic haemobilia after ERCP polyethylene biliary endoprosthesis placement is extremely uncommon. Herein we present a case of iatrogenic haemobilia triggered by biliary endoprosthesis placement and was successfully managed by non-operative treatment. The management algorithm for a rational approach to haemobilia is discussed.

Hospitalisation for gastroenteritis in Western Australia.

AIMS: To document gastroenteritis hospitalisations of the 1995-96 cohort of infants born in Western Australia to mid-2002, and to assess factors associated with their hospitalisations and readmissions. METHODS: Retrospective analysis of the State's hospitalisation data, Midwives' Notification of Births data, the Australian Bureau of Statistics mortality data and clinical and demographic information. RESULTS: Aboriginal infants were hospitalised for gastroenteritis eight times more frequently than their non-Aboriginal peers, and were readmitted more frequently and sooner for diarrhoeal illnesses than the other group. They also stayed in hospital for twice as long and many Aboriginal patients were hospitalised on numerous occasions. Hospitalisation rates were higher in remote areas and were significantly associated with co-morbidities such as undernutrition, anaemia, co-existing infections, and intestinal carbohydrate intolerance. CONCLUSIONS: Gastroenteritis is very prevalent in Australian Aboriginal infants and children and is a major cause of their hospitalisation in Western Australia. It is often associated with undernutrition, anaemia, intestinal parasitic infestations, other infections, intestinal carbohydrate intolerance, and, in some instances, with low birth weight. This is often due to unhygienic living conditions and behaviours and presents major challenges to public health, health promotion, and clinical personnel, particularly paediatric services. Childhood diarrhoeal diseases occur commonly in other indigenous groups but have not received the attention that they deserve.

Factors affecting length of hospitalization of infants and children for recurrent gastroenteritis in Western Australia.

AIM: Aboriginal infants in Western Australia (WA) have much higher rates of hospitalization for gastroenteritis than do their non-Aboriginal peers. The aim of this 7-y retrospective study was to investigate the factors affecting the duration of hospitalizations due to recurrent gastroenteritis in WA. METHODS: All infants born in WA in 1995 and 1996 who had indexed gastroenteritis admissions during their first year of life (n = 1009) were followed until 31 May 2002. Linked hospitalization and birth records were retrieved to derive the outcome measures, associated co-morbidities and other demographic variables. A proportional hazards frailty model was then used to determine factors influencing discharge from hospital for the study cohort. RESULTS: Aboriginal patients were readmitted to hospital more frequently and stayed in hospital more than twice as long as non-Aborigines. Factors that slowed the rate of discharge from hospital included Indigenous status and the presence of coexisting conditions such as dehydration, sugar intolerance, failure to thrive and iron-deficiency anaemia. CONCLUSION: Gastrointestinal infections are common illnesses in infants and children, particularly for those who live in overcrowded and unhygienic conditions. Coexisting morbidities including undernutrition, nutrient deficiencies, other infections and gastrointestinal carbohydrate intolerance contribute to prolonged and recurrent hospitalization. Multifaceted clinical, disease prevention and health/hygiene promotion are needed to lessen the burden of these infections.

Factors influencing hospitalisation of infants for recurrent gastroenteritis in Western Australia.

OBJECTIVE: To determine factors affecting length of hospitalisation of infants for recurrent gastroenteritis using linked data records from the Western Australia heath information system. METHODS: A seven-year retrospective cohort study was undertaken on all infants born in Western Australia in 1995 who were admitted for gastroenteritis during their first year of life (n = 519). Linked hospitalisation records were retrieved to derive the outcome measure and other demographic variables for the cohort. Unlike previous studies that focused mainly on a single episode of gastroenteritis, the durations of successive hospitalisations were analysed using a proportional hazards model with correlated frailty to determine the prognostic factors influencing recurrent gastroenteritis. RESULTS: Older children experienced a shorter stay with an increased discharge rate of 1.9% for each month increase in admission age. An additional co-morbidity recorded in the hospital discharge summary slowed the adjusted discharge rate by 46.5%. Aboriginal infants were readmitted to hospital more frequently, and had an adjusted hazard ratio of 0.253, implying a much higher risk of prolonged hospitalisation compared to non-Aborigines. CONCLUSIONS: The use of linked hospitalisation records has the advantage of providing access to hospital-based population information in the context of medical informatics. The analysis of linked data has enabled the assessment of prognostic factors influencing length of hospitalisations for recurrent gastroenteritis with high statistical power.

Determinants of maternity length of stay: a Gamma mixture risk-adjusted model.

With obstetrical delivery being the most frequent cause for hospital admissions, it is important to determine health- and patient-related characteristics affecting maternity length of stay (LOS). Although the average inpatient LOS has decreased steadily over the years, the issue of the appropriate LOS after delivery is complex and hotly debated, especially since the introduction of the mandatory minimum-stay legislation in the USA. The purpose of this paper is to identity factors associated with maternity LOS and to model variations in LOS. A Gamma mixture risk-adjusted model is proposed in order to analyze heterogeneity of maternity LOS within obstetrical Diagnosis Related Groups (DRGs). The determination of pertinent factors would benefit hospital administrators and clinicians to manage LOS and expenditures efficiently.

Zero-inflated Poisson regression with random effects to evaluate an occupational injury prevention programme.

This study presents a zero-inflated Poisson regression model with random effects to evaluate a manual handling injury prevention strategy trialled within the cleaning services department of a 600 bed public hospital between 1992 and 1995. The hospital had been experiencing high annual rates of compensable injuries of which over 60 per cent were attributed to manual handling. The strategy employed Workplace Risk Assessment Teams (WRATS) that utilized a workplace risk identification, assessment and control approach to manual handling injury hazard reduction. The WRATS programme was an intervention trial, covering the 1988-1995 financial years. In the course of compiling injury counts, it was found that the data exhibited an excess of zeros, in the context that the majority of cleaners did not suffer any injuries. This phenomenon is typical of data encountered in the occupational health discipline. We propose a zero-inflated random effects Poisson regression model to analyse such longitudinal count data with extra zeros. The WRATS intervention and other concomitant information on individual cleaners are considered as fixed effects in the model. The results provide statistical evidence showing the value of the WRATS programme. In addition, the methods can be applied to assess the effectiveness of intervention trials on populations at high risk of manual handling injury or indeed of injury from other hazards.

Determining the effects of patient casemix on length of hospital stay: a proportional hazards frailty model approach.

OBJECTIVES: To identify factors associated with hospital length of stay (LOS) and to model variations in LOS within Diagnosis Related Groups (DRGs). METHODS: A proportional hazards frailty modelling approach is proposed that accounts for patient transfers and the inherent correlation of patients clustered within hospitals. The investigation is based on patient discharge data extracted for a group of obstetrical DRGs. RESULTS: Application of the frailty approach has highlighted several significant factors after adjustment for patient casemix and random hospital effects. In particular, patients admitted for childbirth with private medical insurance coverage have higher risk of prolonged hospitalization compared to public patients. CONCLUSIONS: The determination of pertinent factors provides important information to hospital management and clinicians in assessing the risk of prolonged hospitalization. The analysis also enables the comparison of inter-hospital variations across adjacent DRGs.

Long-term survivor mixture model with random effects: application to a multi-centre clinical trial of carcinoma.

A mixture model incorporating long-term survivors has been adopted in the field of biostatistics where some individuals may never experience the failure event under study. The surviving fractions may be considered as cured. In most applications, the survival times are assumed to be independent. However, when the survival data are obtained from a multi-centre clinical trial, it is conceived that the environmental conditions and facilities shared within clinic affects the proportion cured as well as the failure risk for the uncured individuals. It necessitates a long-term survivor mixture model with random effects. In this paper, the long-term survivor mixture model is extended for the analysis of multivariate failure time data using the generalized linear mixed model (GLMM) approach. The proposed model is applied to analyse a numerical data set from a multi-centre clinical trial of carcinoma as an illustration. Some simulation experiments are performed to assess the applicability of the model based on the average biases of the estimates formed.