Biomedical subjects
Publications and source records attributed to G B Ong.
A case of posttraumatic epidural hygroma is reported. This child presented with occipital injury. Slowly but progressively he developed bilateral Wallenberg's syndrome and retrocollis. Correct preoperative diagnosis was made with the aid of computerized tomography. The case is discussed with emphasis on the mechanism of formation of an epidural hygroma and its clinical presentation.
Assessment of the resectability of carcinoma of the oesophagus or cardia may be inaccurate. At exploration, 8 patients in whom resection was contemplated were found to have unresectable lesions. An intrathoracic oesophagogastric bypass was performed without further change of position. Five patients were discharged from hospital and survived between 3 and 20 months before they finally succumbed to metastases. Each of them was able to take an ordinary diet. The aims of palliation were achieved.
Primary intrahepatic stones are commonly found in association with recurrent pyogenic cholangitis. In 115 patients with this condition, the intrahepatic stones were removed by four different methods: common duct exploration (n = 74), transhepatic intubation (n = 10), hepatotomy (n = 5) and hepatic resection (n = 26). The choice of methods was guided by the location of stones and the condition of the bile ducts and the liver. These extraction procedures were combined with drainage procedures, i.e. sphincteroplasty and choledochojejunostomy, whenever the proper indications were present. The operative mortality was 4.3 per cent. Long term follow-up (median 7 years and 8 months) on 91 patients revealed that common duct exploration, transhepatic intubation and hepatotomy were associated with high incidences of recurrent symptoms requiring reoperation (23.6 per cent, 37.5 per cent and 75 per cent respectively). In most instances, failures were due to recurrent stone formation in the stenotic intrahepatic ducts. Hepatic resection had the lowest failure rate (4.2 per cent) and none of the patients had recurrent stones.
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Explore the source record for details and available documents.
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The survival of 103 patients operated on for advanced carcinoma of the stomach other than the cardia was assessed. The median duration of survival for patients subjected to palliative partial gastrectomy, total gastrectomy, gastrojejunostomy, and biopsy only was 24, 22, 11, and 10 weeks, respectively. All of these patients had definite residual tumor. In the 27 patients with preoperative signs of incurable tumor, the high operative mortality rate (19 percent), the low rate of resectability (26 percent), and the short duration of survival in the patients who had resection (median 11 weeks) combined lead to the conclusion that exploration for the possibility of resection is not worthwhile.
To evaluate the clinical significance of bacterial contamination in perforated duodenal ulcers, we prospectively studied septic complications in 184 consecutive patients. All patients received parenteral antibiotics (over 90 percent preoperatively) for at least 7 days. Thirteen infections developed in eight patients (4.3 percent). Peritoneal cultures, performed in 143 unselected patients, were positive in 33.6 percent of cases. Bacterial growth occurred more often and in heavier amounts in patients who underwent exploration late (after 48 hours) and those who had gross peritoneal soilage. Candida and gram-negative organisms predominated, but there was no correlation with pathogens that produced abscesses or wound infections. Old age and late exploration significantly increased the risk of infection. Neither peritoneal soiling nor a positive culture was likely to be clinically important when explorations was performed within 2 days of perforation. We treated perforated ulcers as clean-contaminated cases, and recommend that three doses of prophylactic antibiotics be begun preoperatively in all patients.
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Strains of Escherichia coli were isolated from laparotomy specimens from Chinese patients with recurrent pyogenic cholangitis in Hong Kong. A large variety of serotypes were found. Several sites were sampled in each patient. While only one serotype was normally isolated from one site, different sites often yielded different serotypes in the same patient. Generally the 'O' types found did not correspond to those found in the faeces of the Hong Kong Chinese population.
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Operative risk factors for patients with perforated duodenal ulcers were examined prospectively in 213 operated patients. Nine hospital deaths (4.2%) resulted from respiratory failure, sepsis, and bleeding. Forty-five complications developed in 27 patients (12.7%). Concurrent medical illness, preoperative shock, and longstanding perforations (more than 48 hours) were significant features that increased mortality. Old age, gross peritoneal soiling, and the length of the ulcer history did not affect mortality in the absence of risk factors. No death attributable to either sepsis or abscess formation occurred when surgery was performed within two days of perforation. Bacterial contamination may not signify clinical peritonitis during this period. We conclude that simple closure of perforated ulcers is a more prudent choice when any risk factor is present, but that definitive surgery in good-risk patients merits further evaluations.
The efficacy of cimetidine vs. surgery in the treatment of recurrent ulcers after definitive surgery for chronic duodenal ulcer was evaluated in two comparable groups (23 each) of patients. Cimetidine 1 g daily healed 79% and 91.6% of recurrent ulcers, as assessed endoscopically, after 6 and 12 weeks respectively. At the end of one year, maintenance treatment with cimetidine (400 mg nocte) prevented relapse in 89.5% of the healed ulcers, while surgery was successful in 94.4% (p greater than 0.1). The cimetidine group experienced significantly (p less than 0.05) less side effects than the surgical group, with respectively 10% and 50% of patients having Visick grade II and above. After one year of maintenance treatment, cimetidine was withdrawn, and ulcer recurred in 71.4% within six months. The relapse rates between the two groups were significantly different by life-table analysis (p less than 0.01). We conclude that cimetidine was as effective as surgery in preventing relapse of postsurgical recurrent ulcers and had fewer side effects, but indefinitely prolonged therapy appeared necessary.
Pelvic exenteration provided worthwhile palliation and achieved a cumulative five-year survival rate of 38.8% in 49 patients who had carcinoma of the lower colon or rectum infiltrating adjoining pelvic viscera. Survival and the disease-free period were not significantly different after total or posterior exenteration. The stage of disease was the major determinant of outcome: five-year survival rates averaged 51.8% and 28.8% for Stages II and III, respectively. Hospital mortality (26.9%) after total exenteration was chiefly due to technical mishaps, and the inclusion of many high-risk but symptomatic elderly patients. Complete clearance of locally advanced colorectal cancer by pelvic exenteration is indicated in fit patients, especially those with Stage II disease.
Sphincteroplasty was done via the extraperitoneal transduodenal approach in 42 patients. The indications were residual stones in 34 patients, stricture at Oddi's sphincter in seven patients, and relapsing pancreatitis in one patient. Seven patients suffered operative complications, with one death. Sphincteroplasty was successfully performed in all patients, and the residual stones were removed in 31. Thirty-three of the 36 patients followed up for a mean of seven years were asymptomatic. Extraperitoneal sphincteroplasty has a role in supplementing endoscopic papillotomy and percutaneous extraction through the T-tube tract in the treatment of patients with residual stones.
Three patients with mucoepidermoid carcinoma of the bile duct are described. In two patients the tumor arose from the common hepatic duct. Mucoepidermoid carcinoma of the extrahepatic bile duct has not been previously reported. The clinical features and pathologic behavior of this rare type of tumor are similar to the usual biliary adenocarcinoma. The coexistence of Clonorchis sinensis infestation and primary pyogenic cholangitis raises the possibility of an etiologic association.
A prospective, randomized, double-blind trial was conducted in 101 patients to evaluate the safety and benefits of immediate definitive surgery for perforated duodenal ulcers. These patients, who were judged by predefined criteria to be medically fit and to have perforations in chronic ulcers, were randomized to undergo simple closure (35 patients), truncal vagotomy and drainage (VD) (32 patients), or proximal gastric vagotomy with closure (PGV) (34 patients). Patients were followed with endoscopic assessment for up to 39 months. There was no mortality and only a few minor postoperative complications. At 39 months follow-up, the cumulative rates of recurrence were 63.3%, 11.8% and 3.8% after closure, VD, and PGV, respectively (p less than 0.001). With the exception of the one recurrence after PGV, all relapses were symptomatic, and eight of these 18 required reoperation. Relapse rates and Visick scores between VD and PGV were significantly different. Both safe as well as effective, immediate, nonresective, definitive operation is indicated for good-risk patients who have perforations in chronic duodenal ulcers.