Volume 21, Issue S1 pp. 3-6
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First published: 13 September 2017

FP1: Implementation of evidence-based practice for chronic subdural haematoma: Reduction of recurrence with placement of subdural drain after burr-hole drainage

DYC Chan, DTM Chan, GKC Wong and WS Poon

Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong

Background and Aim: Chronic subdural haematoma (CSDH) treated with burr-hole drainage has a risk of recurrence requiring re-operation. A considerable proportion of surgeons remained concern with the potential complications of bleeding or infection. The aim of the present study is to evaluate the compliance of the use of subdural drain and the impact on recurrence and complications.

Method: The study design was a 6-year longitudinal study. Ethic approval was obtained. Data of consecutive patients with burr-hole drainage performed for CSDH at a University Hospital (Prince of Wales Hospital, Hong Kong) during a six-year period from January 2008 to December 2013 were prospectively collected and retrospectively analysed. Primary outcome was the rate of implementation of subdural drain after burr hole drainage. Secondary outcomes including rate of symptomatic recurrence requiring re-operation within six months, incidence of bleeding or infection.

Results: A total of 557 patients were identified. Usage of subdural drain significantly increased from 5.9% in 2008 to 81.4% in 2013 (Odds Ratio=0.0143, 95%CI 0.0046-0.0441; p<0.001). The Pearson correlation coefficient was 0.952, with was a strong positive correlation. The recurrence rate was 4.96% (13/262) with drain placement versus 11.2% (33/295) with no drain (Odds Ratio=0.443, 95%CI 0.229-0.861; p=0.0163). Local wound infection, subdural empyema, acute subdural haematoma and other complications had no significant difference.

Conclusion: Implementation of best-evidence practice with the use of subdural drain for CSDH in a university hospital in Hong Kong was successful with high compliance rate. This practice had significantly reduced recurrence with no significant increase in complications.

FP2: Prognostic value of preoperative Alpha-fetoprotein (AFP) level in patients receiving curative hepatectomy - An analysis of 1182 patients in Hong Kong

MY Chan, WH She, SHY Tsang, WC Dai and TT Cheung

Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The University of Hong Kong, Hong Kong SAR

Aim: Alpha-fetoprotein (AFP) as a prognostic indicator in patients with hepatocellular carcinoma (HCC) has been proposed in recent studies. This analysis aims to evaluate the prognostic value of preoperative AFP level.

Methods: This retrospective study reviewed the data of all patients who underwent initial liver resection for HCC at Queen Mary Hospital from 1999 to 2013. Patients with palliative resection, positive resection margin or distant metastasis were excluded from the study. Survival of patients with AFP level of <20, 20-400 and >400 ng/mL were compared with Kaplan-Meier analysis. Subgroup analysis was performed according to tumour stage and size. The optimal cutoff value was determined by discriminant analysis.

Results: 1182 patients were included. Best overall and disease free survival was observed in patients with AFP level <20 ng/mL. Progressively worse outcomes were seen for patients with increasing level of AFP. The median overall survival were 132.9, 77.2 and 38.4 months for patients with AFP <20, 20-400 and >400 ng/mL respectively (p<0.001). The median disease free survival for these three groups were 55.6, 25 and 8.4 months respectively (p<0.001). With subgroup analysis according to tumour stage and size, such difference was still observed and remained statistically significant. Optimal cutoff value by discriminant analysis was 12918.3 ng/mL for overall survival and 9733.3 ng/mL for disease free survival.

Conclusion: This study demonstrates that despite tumour stage and size, high level of AFP is associated with poorer overall and disease free survival. It may be worthwhile to consider incorporating AFP level to current staging systems.

FP3: A randomized controlled clinical trial to assess the impact of enhanced geraitric input on elderly patients undergoing colorectal cancer surgery

MF Ho,1 DLK Dai,2 JFY Lee,1 B Ma,2 WW Leung,3 SSM Ng1,3 and TWC Mak1,3

1Division of Colorectal Surgery, Department of Surgery, Prince of Wales Hospital, Shatin, Hong Kong SAR, China

2Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong SAR, China

3Division of Colorectal Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China

Aim: To evaluate the impact of enhanced geriatric input on elderly (age >70yrs) colorectal cancer patients undergoing curative treatment.

Method: Consecutive elderly patients (>70 yrs) with histologically proven colorectal cancer and confirmed fit for elective curative resection were randomized to either conventional surgical care or enhanced geriatric input. Primary endpoint is length of hospital stay while secondary endpoints are morbidity, Mini-Mental State Examination(MMSE) and mortality. Assuming a two-sided type I error of 0.05 and an estimated power of 80% and 10% dropout rate, 74 patients in total will be required.

Results: Both groups were homogenous with respect to age, ASA, site of pathology and tumour stage. Minimally invasive surgery (laparoscopic or robotic) was performed on 83.8% of patients in both groups.The median length of stay was statistically significantly shorter in the intervention group when compared to control (7.1 +/- 4.0 days vs 14.0 +/- 10.9 days, p<0.0001)Postoperative complication was significantly lower in the intervention group (16.2% vs 54.1%, p<0.001). The MMSE before discharge in intervention group is better but it was not significant. There was no mortality in such group of patients.

Conclusion: Enhanced geriatric input on elderly patients undergoing curative colorectal cancer surgery could shorten hospital stay and may reduce complications. Study was registered in www.clinicaltrial.gov: NCT02352688

FP4: Wireless ambulatory urodynamic study: A child-friendly way of studying bladder dysfunction

JWS Hung, KLY Chung, FSD Yam, YCL Leung, CSW Liu, PMY Tang, NSY Chao, MWY Leung, KKW Liu

Aim: Urodynamic studies remained to have an essential role in evaluation in paediatric patients with lower urinary tract symptoms, be it due to neurogenic or non-neurogenic causes. However traditional urodynamic studies may not be child friendly and since 2013 we have introduced wireless, ambulatory form of the study. We undertake a baseline audit of our paediatric urodynamic service within an 8 years period and to determine its indications, outcome and complications.

Method

A retrospective review of all urodynamic studies performed between August 2011 to April 2017 was done. Demographics including age, gender, indications were collected. Urodynamic parameters including type of catheter used, presence of detrusor over-activity, compliance, end-fill pressure, maximum voiding pressure, residual volume and bladder emptying efficiency were collected. Complications from either catheter insertion or urodynamic study itself were documented.

Results: Sixty-seven studies were done between the study period in 55 patients (16 female and 39 males). Wireless ambulatory studies were done in 58 studies since 2013. Median age at study was 2.1 years (range 0.1 to 17 years). Indications include spina bifida (61%, n= 41 studies), bilateral high-grade vesicoureteric reflux (18%, n= 12), dysfunctional voiding (15%, n=10) and valve bladder (6%, n=4). Suprapubic catheters were used in 61 studies and 5 studies used transurethral catheter. Median age of patient in this group is 15 years (range 14-18years). Abnormal study was noted in 79.1%(53 studies). The most common abnormal finding was detrusor overactivity (60%). No complications resulted from suprapubic catheter insertion or urodynamic studies itself.

Conclusion: Ambulatory urodynamic studies using our unit’s protocol remains safe and child-friendly with minimal complications and high patients and parent’s satisfaction.

FP5: Evaluating the optimal ablation duration of adrenal radiofrequency ablation using a porcine model

SYW Liu,1 AWH Chan,2 THW Chiu,1 TK Tam,3 X Lo,3 CM Chu4 and EKW Ng1

1Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, Chinese University of Hong Kong

2Department of Anatomical & Cellular Pathology, Prince of Wales Hospital, Faculty of Medicine, Chinese University of Hong Kong

3Department of Surgery, North District Hospital

4Diagnostic Radiology & Organ Imaging Department, Prince of Wales Hospital, Faculty of Medicine, Chinese University of Hong Kong

Introduction: Radiofrequency ablation (RFA) is an emerging local ablative treatment for hormone-producing adrenal adenomas. Our group had previously confirmed the safety and efficacy of RFA in treating primary aldosteronism.[1-3] While a 12-minute ablation cycle was implemented in our RFA protocol, many investigators adopted a shorter variable duration of 6–10 minutes because adrenocortical cells were believed to be highly heat sensitive. This study aims to determine the shortest duration of RFA required for complete adrenocortical cell ablation using a porcine model.

Methods: This was an animal study on 12 adrenal glands of six anesthetized swine. After exposure of the adrenal gland by laparotomy, a single-type Cool-tipTM RFA needle with 1-2cm tip exposure was inserted along the long axis of the adrenal. Uninterrupted ablation cycles of 1, 2, 3, 6, 9 and 12 minutes were applied and each duration was tested for twice. The ablated adrenal glands were then harvested for histological analysis under hematoxylin-eosin staining. The extents of thermal damage and cellular shrinkage were measured. Complete thermal ablation was defined as >50% cellular shrinkage within the ablation zone.

Results: All 12 RFA procedures were successfully completed without macroscopic damage of the adjacent viscera. The mean maximal ablation temperatures of the 1, 2, 3, 6, 9, and 12-minute cycles were 40°C, 60°C, 62°C, 60°C, 53°C and 52°C respectively. Cellular damage by thermal ablation was evident in the ablation zones of all tested cycles. For the extent of cellular shrinkage, it was 1% in 1-minute cycle, 5% in 2-minute cycle, 9.5% in 3-minute cycle, 15% in 6-minute cycle, 35% in 9-minute cycle, and 55% in 12-minute cycle. Complete thermal ablation was only achieved in the 12-minute ablation cycle.

Conclusion: To ablate adrenocortical cells, an uninterrupted RFA cycle of at least 12 minutes was required to achieve complete thermal ablation. A 12-minute ablation cycle should therefore be recommended as the standard adrenal RFA protocol.

References
  1. SY Liu, EK Ng, PS Lee, SK Wong, PW Chiu, WL Mui, WY So, FC Chow. Radiofrequency ablation for benign aldosterone-producing adenoma: a scarless technique to an old disease. Ann Surg 2010; 252(6): 1058–1064.
  2. SY Liu, CM Chu, TK Tsui, SK Wong, AP Kong, PW Chiu, FC Chow, EK Ng. CT-guided radiofrequency ablation for aldosterone-producing adenoma in primary aldosteronism: long-term results and recurrence rate. Radiology 2016; 281(2): 625–634.
  3. SY Liu, CM Chu, AP Kong, SK Wong, PW Chiu, FC Chow, EK Ng. Laparoscopic adrenalectomy versus radiofrequency ablation for aldosterone-producing adenoma: a comparative analysis. Br J Surg 2016; 103(11): 1476–1486.

FP6: How to choose the correct ureteroscope during URSL: flexible versus rigid ureteroscopy? A retrospective study

CH Tam, CF Tsang, CKW Wong, TCT Lai, BSH Ho, ATL Ng, WK Ma, JHL Tsu and MK Yiu

Division of Urology, Department of Surgery, Queen Mary Hospital, Hong Kong

Aim and Objectives: The aim of this study was to evaluate the outcome of ureteroscopic lithotripsy by rigid (R-URS) and flexible ureteroscopy (F-URS) and identify the potential factors that predicts failure of R-URS.

Methods: Operative records for URSL between January 2012 to December 2016 were reviewed retrospectively. Forty patients who failed URSL by means of R-URS requiring F-URS were identified. Patient demographics, stone characteristics and procedural outcome were extracted and compared with patients who had successful URSL using R-URS.

Results: Patients requiring F-URS had larger stone size of 11.5mm compared with R-URS of 8.3mm (p=0.005). 95% of the stones in F-URS were upper ureteric stones compared to 23% in R-URS. Multivariate analysis isolated stone location and presence of hydronephrosis as independent predictive factors for failure of R-URS. The F-URS group had lower stone free rate (68%, 95%; p=0.002) and longer mean operative time (79.6 minutes, 36.0 minutes; p<0.0001) compared with R-URS. There was no statistical difference in complication rates.

Conclusion: Patients with upper ureteric stone and hydronephrosis at diagnosis were more predisposed to URSL failure by R-URS. They may benefit from lithotripsy using F-URS.

FP7: Can we predict which patient presenting with benign prostate hyperplasia will eventually need surgical treatment? A retrospective cohort analysis at a single institution in Hong Kong

TF Wong, W Lam, CF Tsang, CT Lai, B Ho, ATL Ng, WK Ma and JHL Tsu

Division of Urology, Department of Surgery, Queen Mary Hospital, University of Hong Kong

Aim: To identify predictive factors in patients with lower urinary tract symptoms (LUTS) secondary to benign prostate hyperplasia (BPH) who would eventually require surgical treatment at a single institution.

Methods: A retrospective analysis was carried out in patients who presented to our outpatient clinic with LUTS secondary to BPH between July 2008 to June 2009. Data was collected through the hospital Clinical Management System. Inclusion criteria: patients with at least 5 years of follow-up data available. Exclusion criteria: patients who had history of acute urinary retention (AUR), previous urethral treatment or prostate surgery. Patient demographics, International Prostate Symptom Score (IPSS), Quality of life score (QOL), Qmax at uroflowmetry, post-void residual volume (PVR) serum creatinine and prostate-specific antigen (PSA) levels were recorded and analyzed. A logistic regression multivariate analysis was used to study significance of variables.

Results: 227 patients were eligible for the study. The median follow up was 63 months. 22 (9.7%) patients eventually required surgical treatment, of whom 15 (6.6%) patients were due to the development of AUR. Patients who required surgery had a higher baseline PVR (OR, 1.005; CI, 1.001-1.008; p = 0.008). There was no statistically significant difference in age, Qmax, IPSS, QoL, PSA and creatinine between patients who required surgery when compared with those who did not. Elevated PSA (above or equal to 4) was the only independent risk factor able to predict patients who developed AUR (OR 3.39; CI, 1.11-10.36; p = 0.032).

Conclusion: This study demonstrated that PVR is an independent predictor in BPH patients who would eventually require surgical treatment. Patients with an elevated PSA level carry a higher risk of developing AUR.

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