Clinical relevance of intra-operative sentinel lymph node examination in breast cancer management

ABSTRACT
Hong Kong Med J 2007;13:8-11 | Number 1, February 2007
ORIGINAL ARTICLE
Clinical relevance of intra-operative sentinel lymph node examination in breast cancer management
KM Leung, KW Chan, GPS Yeoh, JKC Chan, PSY Cheung
Diagnostix Pathology Laboratories Ltd, Canossa Hospital, 1 Old Peak Road, Hong Kong
 
 
OBJECTIVES. To determine the sensitivity, accuracy, and clinical relevance of intra-operative examination of sentinel lymph nodes in breast cancer management.
 
DESIGN. Retrospective study.
 
SETTING. Private anatomical pathology practice.
 
PARTICIPANTS. Three hundred breast cancer patients who underwent axillary sentinel lymph node biopsies for intra-operative assessment between January 2004 and March 2006.
 
MAIN OUTCOME MEASURES. Correct identification of metastatic carcinoma in sentinel lymph nodes during intra-operative examination, sparing patient a second surgery.
 
RESULTS. The intra-operative diagnosis of sentinel lymph node biopsies from 300 consecutive patients were compared with the final pathological diagnoses. The final pathology results showed metastatic carcinoma in 74 patients, of whom 63 (85%) were correctly diagnosed during frozen section examination. There was no false-positive case (positive predictive value 100%). The sensitivity for detecting macro- and micro-metastases were 95% and 50%, respectively (P<0.01). The sensitivity for detecting metastases in T1 and T2/ above tumours were 72% and 90%, respectively (P<0.05).
 
CONCLUSIONS. Intra-operative examination is a reliable and sensitive method for the detection of sentinel lymph node metastasis. Eighty-five percent of the patients with metastatic disease were correctly diagnosed and spared a second operation for axillary dissection. The disadvantage of missing a positive lymph node is by far outweighed by the advantage of a single stage operation in case of a positive diagnosis. The benefit of intra-operative examination was slightly less in patients with smaller tumours.
 
Key words: Axilla; Breast neoplasms; Frozen sections; Lymph node excision
 
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Postoperative outcome in Chinese patients having primary total knee arthroplasty under general anaesthesia/intravenous patient-controlled analgesia compared to spinal-epidural anaesthesia/analgesia

ABSTRACT
Hong Kong Med J 2006;12:442-7 | Number 6, December 2006
ORIGINAL ARTICLE
Postoperative outcome in Chinese patients having primary total knee arthroplasty under general anaesthesia/intravenous patient-controlled analgesia compared to spinal-epidural anaesthesia/analgesia
CPW Chu, JCCM Yap, PP Chen, HH Hung
Department of Anaesthesia and Operating Services, Alice Ho Miu Ling Nethersole Hospital, 11 Chuen On Road, Tai Po, Hong Kong
 
 
OBJECTIVE. To compare postoperative outcomes in patients having primary total knee arthroplasty receiving general or regional anaesthesia.
 
DESIGN. Randomised prospective study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Patients having primary total knee replacement were randomised to either general anaesthesia followed by postoperative intravenous patient-controlled analgesia with morphine, or combined spinal-epidural anaesthesia followed by postoperative epidural infusion of bupivacaine 0.1% with fentanyl 2 micrograms/mL.
 
MAIN OUTCOME MEASURES. Visual analogue scale pain scores, perioperative blood loss, time to first meal and ambulation, and prevalence of postoperative complications.
 
RESULTS. Sixty consecutive patients were enrolled in this study. Postoperative median pain scores were consistently lower at 1 (P<0.0001), 6 (P=0.08), 12 (P=0.003), 24 (P=0.14), and 48 hours (P=0.007) in those given regional anaesthesia. Although there was a trend towards fewer complications in the latter group, there were no statistically significant differences between the two groups with respect to the incidence of postoperative blood loss, haemodynamic instability, pruritus, nausea, vomiting, urinary retention, or other surgical/medical complications. Postoperatively, patients given regional anaesthesia also resumed meals earlier (P<0.0001), and showed a trend towards earlier ambulation and hospital discharge.
 
CONCLUSION. Chinese patients undergoing total knee arthroplasty with regional anaesthesia/regionally delivered analgesia enjoyed better postoperative pain relief and resumed meals earlier than those receiving general anaesthesia/intravenous patient-controlled analgesia. The former also showed trends towards less adverse effects, postoperative complications, earlier ambulation, and earlier hospital discharge.
 
Key words: Analgesia, epidural; Analgesia, patient-controlled; Anesthesia, general; Anesthesia, local; Arthroplasty, replacement, knee
 
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Management of primary postpartum haemorrhage with arterial embolisation in Hong Kong public hospitals

ABSTRACT
Hong Kong Med J 2006;12:437-41 | Number 6, December 2006
ORIGINAL ARTICLE
Management of primary postpartum haemorrhage with arterial embolisation in Hong Kong public hospitals
SPY Yong, KB Cheung
Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Tuen Mun, Hong Kong
 
 
OBJECTIVE. To assess the utilisation, effectiveness, and safety of arterial (angiographic) embolisation for management of severe primary postpartum haemorrhage in Hong Kong public hospitals.
 
DESIGN. Retrospective study.
 
SETTING. All eight obstetrics and gynaecology units of the Hospital Authority in Hong Kong.
 
PATIENTS. Women who underwent arterial embolisation for primary postpartum haemorrhage from July 1999 to June 2004 inclusive.
 
MAIN OUTCOME MEASURES. Cause of primary postpartum haemorrhage, estimated blood loss, patient condition before embolisation, and the intervals between the diagnosis of postpartum haemorrhage and the procedure.
 
RESULTS. Primary postpartum haemorrhage occurred in 7200 (3.9%) cases of 183 700 deliveries; 90 (0.05%) underwent total hysterectomy, whilst 29 (0.016%) received angiographic embolisation. Arterial embolisation was 90% effective in treating medically uncontrollable primary postpartum haemorrhage, except in three patients who failed to respond and underwent a hysterectomy. All 29 patients survived, although due to severe haemorrhage one had a cardiac arrest, whilst another had transient right-leg claudication. Six patients developed mild fever.
 
CONCLUSIONS. In Hong Kong, arterial embolisation for severe primary postpartum haemorrhage is a safe and effective treatment modality but is underutilised. If first-line medical treatment fails and patients are haemodynamically stable, the procedure should be considered an alternative management option. A prompt decision and early resort to arterial embolisation are advisable so as to reduce the morbidity and avoid resorting to open surgery.
 
Key words: Embolization, therapeutic; Hemostatic techniques; Obstetric labor complications; Postpartum hemorrhage; Treatment outcome
 
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Practice of breastfeeding and factors that affect breastfeeding in Hong Kong

ABSTRACT
Hong Kong Med J 2006;12:432-6 | Number 6, December 2006
ORIGINAL ARTICLE
Practice of breastfeeding and factors that affect breastfeeding in Hong Kong
EYL Leung, KYA Au, SSW Cheng, SY Kok, HK Lui, WCW Wong
Department of Community and Family Medicine, School of Public Health, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
 
 
OBJECTIVES. To describe the patterns of and factors affecting breastfeeding and to find out any significant relationship between breastfeeding and health of the child.
 
DESIGN. Cohort study.
 
SETTING. Postnatal ward of the Prince of Wales Hospital.
 
PARTICIPANTS. A total of 243 infants born in 1998 to 2001 at the hospital. Each infant was followed up for 3 years. Home visits were carried out at 3, 15, 24, and 36 months of age by medical students from the Chinese University of Hong Kong. A questionnaire was completed at each visit. Independent sample t-tests and Pearson Chi squared tests were used.
 
RESULTS. Of the 243 subjects, 213 provided data on the method of infant feeding. There were 66.7% of mothers initiating breastfeeding, with a median duration of 1 month. Only 13.4% met the World Health Organization's recommendations on breastfeeding. Breastfeeding was found to have a statistically significant relationship with (i) the infant's birth order and (ii) the mother's and father's education level. During follow-up, 44.6% of the infants were hospitalised but there was no significant relationship between breastfeeding and number of hospitalisations.
 
CONCLUSIONS. The current breastfeeding rate in Hong Kong falls below expectations when compared with other developed nations. To raise this rate, more support is needed for families with parents having a lower education level or more than two children, as they are the least likely to breastfeed. This might be achieved by encouraging antenatal class attendance, counselling of husbands, and more support for breastfeeding from doctors.
 
Key words: Breast feeding; Infant, newborn; Infant nutrition
 
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Risk factors of long bone fracture in non-ambulatory cerebral palsy children

ABSTRACT
Hong Kong Med J 2006;12:426-31 | Number 6, December 2006
ORIGINAL ARTICLE
Risk factors of long bone fracture in non-ambulatory cerebral palsy children
CH Ko, PWT Tse, AKH Chan
Developmental Disabilities Unit, Department of Paediatrics and Adolescent Medicine, Caritas Medical Centre, 111 Wing Hong Street, Shamshuipo, Hong Kong
 
 
OBJECTIVES. To identify the risk factors for long bone fractures in non-ambulatory cerebral palsy children.
 
DESIGN. Case-control study.
 
SETTING. A residential rehabilitation centre in Hong Kong.
 
PATIENTS. The fracture group comprised 19 (13 male, 6 female) cerebral palsy children aged 4 years 5 months to 18 years 11 months (mean, 10 years; standard deviation, 3 years 9 months), who had their first long bone fracture during the period June 1992 to May 2001 inclusive. The control group was composed of 90 (46 male, 44 female) concomitant cerebral palsy residents aged 6 years 1 month to 16 years 11 months (mean, 9 years 11 months; standard deviation, 2 years 4 months) with no history of long bone fracture. Main outcome measures. Presence of features considered relevant to the risk of fracture, namely: anthropometry, feeding practice, orthopaedic surgery and duration of postoperative immobilisation, extremity contracture, anti-epileptic medications, and general health status in the 12 months prior to the fracture.
 
RESULTS. Of the 19 fracture episodes, 18 occurred in the femur and one in the tibia/fibula. Multivariate analysis revealed that weight for age Z scores (adjusted odds ratio=0.41, 95% confidence interval, 0.19-0.86) and recent postoperative immobilisation (weeks) [adjusted odds ratio=1.35, 95% confidence interval, 0.97-1.89] were independent predictors for fracture occurrence.
 
CONCLUSION. Early intervention targeting these risk factors may reduce the fracture risk in non-ambulatory cerebral palsy children.
 
Key words: Cerebral palsy; Fractures, bone; Immobilization
 
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A single-centre experience of 40 laparoscopic liver resections

ABSTRACT
Hong Kong Med J 2006;12:419-25 | Number 6, December 2006
ORIGINAL ARTICLE
A single-centre experience of 40 laparoscopic liver resections
CN Tang, KK Tsui, JPY Ha, GPY Yang, MKW Li
Department of Surgery, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong
 
 
OBJECTIVE. To review results of laparoscopic liver resections, particularly in those patients with hepatic malignancy and recurrent pyogenic cholangitis.
 
DESIGN. Retrospective analysis.
 
SETTING. Minimal access surgery training centre, Hong Kong.
 
PATIENTS. Patients with pathologies located at anterio-inferio-lateral segments (Couinaud segments 2, 3, 4b, 5, 6) for laparoscopic resection were recruited during the period 1998 to 2005. Patients were excluded from review if they had: pathologies at central locations and the superior and posterior segments (4a, 7, 8), large tumours (>5 cm in diameter), and those close to major vasculature or the liver hilum.
 
RESULTS. During the study period, we attempted 40 such laparoscopic liver resections, excluding marsupialisations and resections for simple liver cysts. There were 20 female and 20 male patients, with a mean age of 57 (standard deviation, 13; range, 29-81) years. All but one underwent a successful laparoscopic operation. Pathology included hepatocellular carcinoma (n=17), recurrent pyogenic cholangitis (n=14), colorectal liver metastasis (n=4), benign liver tumour (n=4), and intrahepatic cholangiocarcinoma (n=1). All except four were hand-assisted laparoscopic liver resections. The mean operating time was 169 (range, 60-290) minutes and mean blood loss amounted to 270 mL (range, 0-1000 mL). Complications occurred in eight (20%) patients, which included six wound infections, one postoperative bile leak, and two incisional hernias. There was no operative or hospital mortality. For hepatocellular carcinoma, clear resection (>10 mm) was achieved in all except five patients, and the 1-year and 2-year survival rates were 86% and 59% respectively. Favourable results were also obtained for resections in patients with recurrent pyogenic cholangitis; after a mean (standard deviation) follow-up of 29 (23) months, only one was readmitted (for cholangitis).
 
CONCLUSION. In appropriately selected patients, laparoscopic liver resection is feasible and safe, and achieves acceptable survival among individuals with hepatic malignancy and very favourable long-term outcomes in those with recurrent pyogenic cholangitis undergoing hand-assisted laparoscopic segmentectomy.
 
Key words: Carcinoma, hepatocellular; Cholangitis; Hepatectomy; Laparoscopy; Liver diseases
 
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Efficacy of multidisciplinary approach in treatment of constipation: a pilot study

ABSTRACT
Hong Kong Med J 2006;12:415-8 | Number 6, December 2006
ORIGINAL ARTICLE
Efficacy of multidisciplinary approach in treatment of constipation: a pilot study
PYY Lau, B Fung, WCS Meng, R Leung, AWC Yip, SP So, QSY Lee, D Chan
Department of Surgery, Kwong Wah Hospital, Hong Kong
 
 
OBJECTIVE. To evaluate a multidisciplinary Hong Kong treatment programme for patients with constipation.
 
DESIGN. Pilot study.
 
SETTING. A joint collaboration among the departments of surgery, physiotherapy, and dietetics in a regional hospital in Hong Kong.
 
PATIENTS. Thirty-one constipated patients with normal colonic transit and pelvic floor dyssynergia.
 
INTERVENTION. Multidisciplinary treatment including dietary modification, bowel habit adjustment, and physiotherapy.
 
MAIN OUTCOME MEASURES. Anorectal manometry, fibre intake, subjective improvement, bowel frequency, Bristol score, and straining time and effort.
 
RESULTS. Significant improvement was found in mean fibre intake, straining time and effort, but not in anal manometric results. A total of 78% of patients demonstrated more than 50% improvement in subjective symptoms, whereas 70% of the patients enjoyed objective improvement in pelvic floor dyssynergia documented by electromyography and anal pressure during a push effort.
 
CONCLUSION. The multidisciplinary rehabilitative programme for constipated patients significantly improved symptoms. Electromyography and anal pressure during a push effort are useful tools for objective assessment of the treatment effect.
 
Key words: Anal canal; Constipation; Digestive physiology; Rectum
 
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Surgical treatment of penile curvature

ABSTRACT
Hong Kong Med J 2006;12:410-4 | Number 6, December 2006
ORIGINAL ARTICLE
Surgical treatment of penile curvature
KL Ho, AWC Yip, LS Leung, IC Law
Department of Surgery, Kwong Wah Hospital, Yaumatei, Hong Kong
 
 
OBJECTIVE. To review long-term efficacy and complications of surgical treatment of penile curvature in a Chinese population.
 
DESIGN. Retrospective review.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. Patients who underwent surgical treatment of penile curvature between January 1997 and March 2005 inclusive.
 
INTERVENTION. Penile curvature corrective surgery.
 
MAIN OUTCOME MEASURES. Penile curvature recurrence, early and late complications.
 
RESULTS. Of 22 patients who underwent surgical treatment of penile curvatures, 19 had congenital and three had acquired diseases. The mean angle of deformity was 52.5 (range, 20-90) degrees. Ten patients had Nesbit procedures, ten had modified Nesbit procedures, and two underwent vein grafting. Twenty patients had residual or recurrent penile curvatures at a mean follow-up of 50.9 months. Fifteen patients had less than 30 degrees curvature and five had 30 to 60 degrees curvature. Early complications included wound infection (n=3), penile skin necrosis (n=1) treated by skin graft, and urethral injury (n=1). Three patients had erectile dysfunction; four complained of glans paraesthesia. Penile shortening (mean, 1.4 cm) and palpable knots were common late complications. A total of 19 patients were satisfied with the final outcomes.
 
CONCLUSIONS. Surgical treatment of penile curvature produces long-term patient satisfaction. Preoperative counselling on potential recurrence and common minor complications is crucial to produce favourable outcomes.
 
Key words: Penile diseases; Penile induration; Surgery
 
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Immuno-prophylaxis of babies borne to hepatitis B carrier mothers

ABSTRACT
Hong Kong Med J 2006;12:368-74 | Number 5, October 2006
ORIGINAL ARTICLE
Immuno-prophylaxis of babies borne to hepatitis B carrier mothers
K Tse, SLY Siu, KT Yip, SM Chan, TL Que, WYS Lui, PS Chan
Department of Paediatrics and Adolescent Medicine, Tuen Mun Hospital, Tsing Chung Koon Road, Tuen Mun, Hong Kong
 
 
OBJECTIVES. To examine the efficacy of current hepatitis B immuno-prophylaxis and estimate the prevalence of S-mutant infections among local newborn babies.
 
DESIGN. Prospective study.
 
SETTING. Regional hospital, Hong Kong.
 
PATIENTS. A total of 137 newborn babies delivered between the period of November 2000 and 30 June 2001 inclusive, whose mothers were chronic hepatitis B surface antigen carriers.
 
RESULTS. Of the 121 infants who were followed up for 12 months, three were found to be chronic hepatitis B virus carriers, giving a vertical transmission rate of 2.5%. One (0.8%) was suspected to be infected by the S-mutant. All the three hepatitis B virus carrier babies were born to mothers with hepatitis B e antigen, but none to the eight mothers suspected to have S-mutants. Of 119 (98.3%) infants who developed hepatitis B surface antibody upon follow-up at 12 months, 35 were found to have hepatitis B e antigen at birth. All were born to hepatitis B e antigen;ndash;positive mothers. Only three of the 35 babies were found to be hepatitis B virus carriers. Most babies lost the hepatitis B e antigen by 6 months of age; only the infected babies had the antigen persisting at 1 year of age. The non-infected infants' hepatitis B e antigen is likely transplacental.
 
CONCLUSIONS. Our hepatitis B virus prophylaxis programme was effective at preventing perinatal infection and the non-infected infants' hepatitis B e antigen was likely transplacental.
 
Key words: Hepatitis B e antigens; Hepatitis B surface antigens; Hepatitis B vaccines; Infant, newborn
 
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Uterine fibroid embolisation in Chinese women: medium-term results

ABSTRACT
Hong Kong Med J 2006;12:361-7 | Number 5, October 2006
ORIGINAL ARTICLE
Uterine fibroid embolisation in Chinese women: medium-term results
HLJ Mak, PCH Kwok, HHL Chau, MK Chan, SCH Chan, SCS Chan
Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong
 
 
OBJECTIVE. To evaluate the medium-term results of uterine fibroid embolisation in Chinese women with symptomatic uterine fibroids.
 
DESIGN. Prospective case series study.
 
SETTING. Gynaecology and Interventional Radiology units in a public hospital, Hong Kong.
 
PATIENTS. Patients with symptomatic fibroids who underwent uterine fibroid embolisation in Queen Elizabeth Hospital from October 1998 to June 2004.
 
RESULTS. Fifty women (mean age, 42.9 years, median follow-up period, 27.5 months) were recruited. Most (82%) had menorrhagia as the chief presenting symptom. Embolisation was successful in 49 (98%) women. Complications occurred in 12 (24%) patients, but were all self-limiting. Significant decrease in the median clinical uterine size (14 weeks vs 10 weeks) and median volume of the largest fibroid on magnetic resonance imaging (157.9 mL vs 45 mL) were observed during the first year. The reduction seemed to be maintained till the last follow-up. Menorrhagia improved in 34 (84%) patients, dysmenorrhoea in 28 (88%), pelvic pain in 18 (82%) and abdominal mass in 15 (83%). Poor response was found for urinary symptoms (29% improvement). Eight (16%) patients underwent hysterectomies after uterine fibroid embolisation. On logistic regression analysis, the only significant predictive factor for symptomatic improvement was fibroid volume reduction at 6 months (P=0.03).
 
CONCLUSION. Uterine fibroid embolisation is an effective uterine-preserving therapy in patients with symptomatic fibroids; overall symptomatic improvement was estimated as 80%. Uterine or fibroid size reduction correlated well with clinical outcome. The impact of uterine fibroid embolisation on young women wishing to conceive is yet to be determined.
 
Key words: Embolization, therapeutic; Leiomyoma; Magnetic resonance imaging; Uterus; Women
 
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