4) Laparoscopic repair of Perforated duodenal ulcer
I.L. Leong, T.Y. Lam, Manson Fok.
Department of surgery, Kiang Wu Hospital, Macau SAR, China

Background：Perforated duodenal ulcer is an abdominal surgical emergency. While open  omental patch is the treatment for this disease, laparoscopic repair is gaining acceptance as an acceptable therapeutic option.

Objective： To retrospectively compare the outcome of laparoscopic and open procedures for perforated duodenal ulcer.

Conclusion：Laparoscopic repair of duodenal perforation is an efficient and safe emergency therapy, it offers more advantages than open.

5) Endoscopic Retrograde Cholangiopancreatography (ERCP) in Kiang Wu Hospital

U. L. Lam, F. Z. Nie, S.Y. Zhu, W. Song, E. C. S. Lai

Department of Surgery, Kiang Wu Hospital, Macau SAR, PRC

OBJECTIVE: To evaluate the early experience in endoscopic retrograde cholangiopancreatography (ERCP) at our hospital.

RESULTS:  A total of 265 patients (male 158 / female 163 ; median age 69 (19-95)  had a total of 321 ERCPs, of which 69% therapeutic and 39% emergent ERCP was performed.  The commonest indication of ERCP was choledocholithiasis (n=167; 52%), among whom 83 presented with acute cholangitis, and 64 had pancreatitis, followed by medical jaundice (n=45; 14%), malignant obstruction (n=39; 12.1%), intrahepatic stones (n=23; 7.2%), benign stricture (n=6; 1.9%) and bile duct leak (n=2; 0.6%).  While the overall successful cannulation rate was 83 %; patients with biliary calculi (93%) had a higher success rate than those with malignant biliary obstruction (74.4%; p < 0.002).  Endoscopic sphincterotomy was conducted in 158 patients (49%) with a successful rate of 94%. Standard sphincterotome was used in the majority of cases (126 patients; 80%) but needle knife (32 patients; 20%) was used more frequently in recent years with increased participation of trainees.  Almost half of the patients (48%) underwent stone extraction. The overall ductal clearance rate of on the first attempt, second attempt and third attempt were 72%, 94% and 99%, respectively. Stent placement was used in 46 patients as a temporary drainage procedure to control fulminating biliary sepsis (11 patients) and incomplete ductal clearance pending follow-up endoscopy (35 patients), of which 35 pig-tial stents, 2 nasal-biliary drainage catheters and 9 straight stents were placed.  In terms of malignant obstruction, 14 straight stents, 7 pig-tail stents and 1 nasal-biliary catheter were used as temporary biliary drainage. Three self-expandable metallic stents (4.2%) were adopted as a palliative treatment in inoperable cases. Complications were noted in 17 patients (5.2%), namely post-ERCP pancreatitis (4%), bleeding (0.6%) and gastrointestinal perforation (0.6%) necessitating surgery in 2 patients (0.6 %). Three 30-day deaths (0.9%) from terminal malignancy was found. There was no procedure-related mortality.

6) Early Experience of Laparoscopic Cholecystectomy in Kiang Wu Hospital
K.K. Ho, F.Z. Nie, W. Sung ; ECS Lai
Department of Surgery, Kiang Wu Hospital, Macao SAR, PRC

Abstract
Objective: To evaluated the development of laparoscopic cholecystectomy in Kiang Wu hospital.
Method: Details of all patients for undergoing laparoscopic cholecystectomy in Kiang Wu hospital from January 2002 to December 2005 were reviewed retrospectively.

Result: A total of 381 patients (148 male; 233 female; mean age: 56.0 years (range, 16~93years)) were analyzed. Common duct stones were found in 71 patients (18.6%). The mean operation time was 98 min. The hospital stay after operation was 4.8 days. Conversions were noted in 27 cases (7.1%), including difficult anatomy, 19 patients (5.0%), bile duct injury, one patient (0.3%), bile leakage, three cases (0.8%), cystic artery bleeding, three cases (0.8%), and intolerance to pneumoperitoneum, one case (0.3%). Complications were noted in 11 patients (2.9 %): cardiopulmonary infection, two cases (0.5%), bile duct injury, two cases (0.5%), bile leakage, 5 cases (1.3%), wound infection, two cases (0.5%). There was no mortality. There were 80 cases (21%) acute cholecystitis and 301 cases (79%) chronic cholecystits were noted and either mean operation time (111.2 vs. 95.5 min; P=0.009) or conversion rate (17.5% vs. 4.6%; P<0.001) was higher in the acute group, the complication rate in acute group is higher (6.5% vs. 2.0%) but no significance (P=0.1). Average operation time in early (first 100 cases) was higher than the latter (last 100 cases) group (116.7 vs. 99.1; P=0.005). The conversion rate in early group was higher (12% vs. 2%; P=0.006), but no significance in complication rate (5% vs. 1%; P=0.212).
Conclusion: Laparoscopic cholecystectomy is a safe and feasible procedure in Kiang Wu hospital. The peri-operative outcome showed a steadfast improvement with increasing experience.

07) Transurethral Prostatectomy in High-risk Patients

H. F. Lao, K. W. Ho, L. G. Ng, W. Y. Cheung, T. I. Chan, Francis Lee, Richard K. Lo

Division of Urology, Department of Surgery, Kiang-Wu Hospital, Macau SAR, PRC

OBJECTIVE: To evaluate the local experience of transurethral prostatectomy (TURP) on the high-risk patients at Kiang Wu Hospital.

METHODS:  From January 2002 to December 2005, 298 patients undergoing TURP were retrospectively evaluated.  Of which 134 patients with either age  > 80 years old, with three or more co-morbidities, previous malignancy or ASA score > 3 were defined as high-risk patients (group 1), while the other 164 patients were low-risk patients (group 2). The patient profiles, indications, operation time, blood loss, postoperative irrigation time, complications and pathology of the 2 groups were compared.

RESULTS:  The mean age of patients operated was 74.7 years (48 to 96 years). In Group 1 and Group 2, the mean age was (80.5+7.1) years and (70+6.8) years.

The commonest indication of TURP was acute urinary retention (n=104; 39%), among whom (n=51; 17%) patients presented with hematuria.
Total PSA, prostate volume, pre-operation hematuria and pre-operation retention were similar in both groups. The following results of the two groups as well showed no difference, mean resected prostate weight (27+62) g vs (26+17) g (p=0.847); blood loss, (213+152) ml vs (267+181) ml (p=0.060); blood transfusion, (n=6, 4.6%) vs (n=4, 2.5%) (p=0.255); days of Foley indwelling, (4.6+2.0) days vs (4.4+1.4) days (p=0.297); days of bladder irrigation, (2.9+1.9) days vs (2.6+1.4) days (p=0.160). The mean operation time for the high-risk group and the low-risk group was (47+22) minutes and (56+29) minutes, respectively (p=0.03). Total fluid irrigation was (15380+7680) ml and (18950+10470) ml (p=0.01). Both operation time and total fluid irrigation were significantly shorter in group 1. The commonest postoperative complication was fever, which occurred (n=14, 10.5%) in group 1 and (n=16, 9.9%) in group 2. There were no significant differences between the two groups in other postoperative complications. The mortality rate had been low since we started using TURP for surgical management of our BPH patients. There were 2 deaths in group 1.

CONCLUSIONS:  With even shorter operation time and lesser amount of fluid irrigation , TURP is as safe and efficacious in the treatment for high-risk BPH patients as in the low-risk group.