Stapled hemorrhoidopexy is a safe and effective procedure for Grade III hemorrhoidal disease. Patients derive greater short-term benefits of reduced pain, shorter length of stay, and earlier resumption to work. Long-term follow-up is necessary to determine whether these initial results are lasting.

Laparoscopic abdominoperineal resection confers definite health-related benefits the over open approach in terms of reduced septic complications and fewer requirements for blood transfusion. It should be considered the procedure of choice for patients with low rectal or anal canal tumour in whom sphincter excision proved inevitable.

Management of patients presenting with bowel obstruction secondary to oburator hernia is difficult due to the rarity of the condition. Herein, two patients with incarcerated obturator hernia are presented, and the role of diagnostic laparoscopy in their management is discussed. A new surgical approach, transabdominal repair with dual mesh, is described.

Objective: Stapled haemorrhoidectomy is a new modality in the surgical treatment of haemorrhoidal disease and rectal mucosal prolapse. This paper aims at reporting the initial experience in a local institution. Method: From July 2000 to March 2001, a total of 17 patients underwent stapled haemorrhoidectomy, including 16 patients with third‐degree haemorrhoids and one patient with rectal mucosal prolapse. With the aid of a specially designed assessment form, data were collected during the inpatient period and at 4 weeks, 8 weeks and 12 weeks after the operation. Results: The median operation time was 18 min (range 5–45 min) with a median blood loss of 10 mL (range 0–100 mL). Only three patients required pethidine injection during the postoperative period; other patients could be managed with simple oral analgesic. Thirteen patients (76%) could be discharged on the second day after the operation (range 1–7 patients), and the median time off work was 9 days (range 1–21 days). Complications encountered were minor, and symptom control and functional outcome appeared superior to excisional haemorrhoidectomy. Conclusion: Stapled haemorrhoidectomy is safe. The improved postoperative pain and the reduced time off work are evident; however, long‐term outcomes still need further evaluation. Chinese Abstract Chinese Abstract

Elderly patients have a high incidence of co-existing medical disorders, especially cardiovascular disease, and postoperative death. Effective pre-operative assessment and treatment of comorbidities may improve postoperative outcomes [1,2]. We investigated pre-operative assessment, identification and subsequent referral of elderly patients at high operative risk. MethodsRecords of all patients >80 years of age undergoing hemiarthroplasty were reviewed over a three-month period. Patients were defined as high operative risk if they were of ASA physical status ‡3 with evidence of cardiac comorbidity (except controlled hypertension), as evidenced by a positive cardiac history, findings on examination, medication history, ECG, chest X-ray and abnormal cardiac enzymes. The number of patients referred for anaesthetic and/or medical pre-operative assessment or intervention and the accuracy of the initial surgical clerking with regard to factors indicative of cardiac comorbidity was recorded. ResultsTwenty-nine casenotes were reviewed. The mean (median [range]) age was 88 (88 [80-96)] years. Fourteen were ASA 2, 11 were ASA 3 and four were ASA 4. Mean (median [range]) time to operation was 5 (3 [1-17]) days. Thirteen (45%) patients were identified as being of high operative risk by the assessors and five (38%) of these were referred for pre-operative advice or intervention. Of the eight not referred, evidence of their being at high risk was not documented in four (50%). In total, 83% of patients showed evidence of cardiovascular comorbidity (excluding controlled essential hypertension) and nine (38%) of these were not identified as having such findings at the initial surgical clerking. The investigators discovered 91 factors in the history, investigation or examination of all patients that could constitute evidence of cardiac comorbidity. In contrast, only 29 (32%) such factors were identified in the initial surgical clerking. DiscussionWe did not determine whether the low detection rate of cardiac comorbidity in the initial surgical clerking was due to inadequate clerking technique, poor record keeping or unavailability of a collateral history in confused patients. Irrespective of the cause, inadequate surgical pre-operative assessment of these patients may have led to a lower recognition of potential anaesthetic risks and referral for assessment. We believe that more robust mechanisms of pre-operative medical assessment and screening, and subsequent interdisciplinary referral systems, need to be established in this group of patients who are at high operative risk.