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Summary Background Although laparoscopic resection of colorectal carcinoma improves post-operative recovery, long-term survival and disease control are the determining factors for its application. We aimed to test the null hypothesis that there was no difference in survival after laparoscopic and open resection for rectosigmoid cancer. Methods From Sept 21, 1993, to Oct 21, 2002, 403 patients with rectosigmoid carcinoma were randomised to receive either laparoscopic assisted (n=203) or conventional open (n=200) resection of the tumour. Survival and disease-free interval were the main endpoints. Patients were last followed-up in March, 2003. Perioperative data were recorded and direct cost of operation estimated. Data were analysed by intention to treat. Findings The demographic data of the two groups were similar. After curative resection, the probabilities of survival at 5 years of the laparoscopic and open resection groups were 76·1% (SE 3·7%) and 72·9% (4·0%) respectively. The probabilities of being disease free at 5 years were 75·3% (3·7%) and 78·3% (3·7%), respectively. The operative time of the laparoscopic group was significantly longer, whereas postoperative recovery was significantly better than for the open resection group, but these benefits were at the expense of higher direct cost. The distal margin, the number of lymph nodes found in the resected specimen, overall morbidity and operative mortality did not differ between groups. Interpretation Laparoscopic resection of rectosigmoid carcinoma does not jeopardise survival and disease control of patients. The justification for adoption of laparoscopic technique would depend on the perceived value of its effectiveness in improving short-term post-operative outcomes.

Prosthetic mesh repair is currently the gold standard of treatment for incisional hernia. However, in the presence of bowel fistula or stoma, repair of incisional hernia is very difficult. The use of prosthetic mesh might be contraindicated in these situations. The present case report details the experience of using components separation or sliding myofascial flap technique to repair these complicated incisional hernias. All of the patients from the present report had their hernia repaired without using meshes and there was no recurrence. A review of published reports and discussion on applications of the components separation technique was also undertaken.

Objective: Per-rectal bleeding is a common reason of surgical referral. The average waiting time in a busy clinic could be months, which should preferably be shortened for potentially serious cases. With little information on referral letters, other methods for triage have to be searched for. Age and symptoms as triage methods were evaluated. Methods: Data from patients attending the United Christian Hospital specialist clinic for per-rectal bleeding were collected prospectively. The association between age and the prevalence of colorectal neoplasia was analysed. The most suitable cut-off age was determined by a receiving operating characteristic (ROC) curve. For symptoms, a questionnaire to check for high-risk features of per-rectal bleeding was designed. Non-medically trained volunteers were instructed to interview each patient before the surgical consultation. A positive result for the questionnaire is the presence of high-risk features. The surgeons were unaware of the questionnaires’ findings. The results were compared with the final diagnosis. Positive diagnoses were defined as either malignancy or significant polyps. The sensitivity and specificity of age and the questionnaire were computed. Results: A total of 194 patients were interviewed. Twenty patients declined colonoscopy and were excluded, leaving 174 for analysis. The ROC curve showed 60 years to be the most suitable age for triage. The sensitivity and specificity of age (≥ 60 years old) was 73.1% and 62.8%, respectively. The sensitivity and specificity of the questionnaire was 65.4% and 55.4%, respectively. The positive predictive value of age was 25.7%, which was increased to 33.6% with a positive questionnaire result. The negative predictive value of 93.0% by age alone was increased to 95.5% with a negative questionnaire result. Conclusion: Age is a very effective triage criterion. Using 60 years of age as a cut-off point screens out low-risk patients effectively. A preconsultation-structured interview designed to identify high-risk symptoms has little additional triage benefit. Chinese Abstract Figure Chinese Abstract. Figure Chinese Abstract. Figure Chinese Abstract. Figure Chinese Abstract. Figure Chinese Abstract.

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.

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 (

Aim: To evaluate the feasibility of handoscopic colectomy. Methods: A prospective nonrandomized study was initiated from January 2000 to September 2000 in United Christian Hospital recruiting patients indicated for colectomy. Results: 16 consecutive patients entered the study including 6 males and 10 females with an average age of 70.3 (ranged 46 to 84). Indications were 14 carcinomas, 1 caecal polyp and 1 caecal ulcer. There were 9 R hemicolectomies, 6 extended R hemicolectomies and 1 L hemicolectomy. One patient also had a cholecystectomy for gallstone. The average wound length was 6.5 cm. There was one conversion in a patient with carcinoma of hepatic flexure invading the liver in which a wedge resection of the liver was performed during laparotomy. The average operative time was 171.5 minutes (ranged 105–240) with an average blood loss of 163.2 mL (ranged 10–550). There was only 1 morbidity of urinary tract infection in the early post-op period with no mortality encountered. The average day of discharge was 8.2 (ranged 5–12). Within an average follow up of 16.9 weeks (ranged 4–36), there was no adverse outcome noticed except in a patient who was known to has liver metastasis preoperatively. Discussions: Handoscopic colectomy has comparable results over conventional technique. The handoscopic technique provides tactile sensation and allows blunt dissection of tissues that are not possible for the laparoscopic technique. Any bleeding can be effectively controlled by fingers accurately and rapidly before definitive haemostatic measures. The enlarged view provided by the laparoscope enhances meticulous dissection of the tissues that is important in apical lymphadenectomy. Furthermore, the hand port itself provides an excellent retractor for intestinal anastomosis and is an effective protector of the wound minimizing wound contamination.

Introduction: Haemorrhoidectomy is traditionally an in-patient procedure. With many benefits, day surgery arrangement is an attractive alternative. We explored the feasibility of day surgery haemorrhoidectomy in a case controlled design. Method: A single surgeon’s experience of day-surgery haemorrhoidectomy between 1 July 1999 and 31 March 2000 was compared with in-patient haemorrhoidectomy during the same period. The operations were performed in a government funded public hospital. Statistical tests were applied where appropriate. Results: There were 30 day-surgery and 15 in-patient haemorrhoidectomies. The groups were comparable in terms of age, gender, severity of haemorrhoids, method and duration of haemorrhoidectomy, blood loss, residual haemorrhoids, follow up duration and unplanned re-admission 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 hours), 1 for micturition syncope and 1 for acute urinary retention. There were 4 unplanned re-admissions after day-surgery: 1 for pain and 3 for secondary bleeding. All stopped spontaneously. All the 3 unplanned re-admissions after in-patient surgery were for secondary bleeding. All stopped spontaneously. Patient stay was significantly shorter with day-surgery (1 ± 1 day) than in-patient arrangement (4 ± 1.6 days). Conclusion: Day-surgery haemorrhoidectomy is feasible. The significantly shorter hospital stay implies savings in public medical expenses.

Aim: Anastomotic leakage following low anterior resection with total mesorectal excision carries a significant morbidity and mortality. Both loop ileostomy and loop transverse colostomy are common options of temporary faecal diversion to reduce the severity of anastomotic leakage. We use loop ileostomy routinely because of its ease of construction and closure, and low complication rate. Here, we reviewed our result of loop ileostomy. Methods: We reviewed the medical records of all patients who had temporary loop ileostomy constructed following low anterior resection with total mesorectal excision for CA rectum, from 1.1999 to 12.2003. Stoma related morbidity pre and post–closure of loop ileostomy were recorded. Results: Eighty-eight patients had loop ileostomy constructed and later closed from 1.1999 to 12.2003. Seventeen of them required small bowel resection during closure of the loop ileostomy. Three patients (3.4%) had skin excoriation and one patient (1.1%) had prolonged ileus after the construction of ileostomy (3.4%). After closure of ileostomy, two patients (2.2%) had wound infection and two patients (2.2%) had anastomotic leakage. Six patients (6.8%) developed intestinal obstruction later. Post-closure intestinal obstruction and anastomotic leakage were found to be associated with small bowel resection during the closure of ileostomy (P=0.042). Conclusion: Loop ileostomy and its closure are associated with low complication rates. We therefore continue to advocate the use of loop ileostomy as a temporary diversion procedure after total mesorectal excision.

Aim: Acutely thrombosed hemorrhoid is either treated conservatively or with emergency hemorrhoidectomy. The treatments have not been compared in a randomized controlled trial. We aim to investigate the relative effectiveness and safety of the two modes of treatment. Methods: We performed a randomized controlled trial at the United Christian Hospital. Patients with acutely thrombosed hemorrhoids were randomized to either conservative management or emergency hemorrhoidectomy. The primary outcome was the number of days to halve the visual analog pain score (VAS). Secondary outcomes included VAS on follow-up, early and late functional status, total analgesic requirment, days off work and complication rate. Results: Forty-six patients entered the trial between June 2000 and October 2001. Twenty-three were randomized to each group. Demographic variables were similar for both groups, so was VAS on admission. The number of days taken to halve the VAS was significantly shorter after emergency hemorrhoidectomy (2.5 vs 4.2 days, P=0.001). VAS at days 14, 21, 28 were similar between the groups. The functional status (mobilization and sitting, defecatory pain) at days 3, 6, 14, 21 and 28 were also similar. Analgesic requirements and days off work were similar. There was no complication after emergency hemorrhoidectomy. After resolution, nine patients (45%) of the conservative group required hemorrhoidectomy for persistent symptoms. Conclusion: Emergency hemorrhoidectomy relieves pain faster than conservative management. It is safe and has similar functional results as conservative management. Emergency hemorrhoidectomy is therefore the treatment of choice.