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There was rapid growth of telehealth practice during the COVID-19 outbreak in 2020. In surgery, there were beneficial effects in terms of saving time and avoiding physical contact between healthcare professionals and patients when using telehealth in the delivery of perioperative care. As telehealth is gaining momentum, the evolving ethical and medico-legal challenges arising from this alternative mode of doctor-patient interaction cannot be underestimated. With reference to the "Ethical Guidelines on Practice of Telemedicine" issued by the Medical Council of Hong Kong and some published court and disciplinary cases from other common law jurisdictions, this article discusses relevant ethical and medico-legal issues in telehealth practice with emphasis on the following areas: duty of care; communication and contingency; patient-centred care and informed consent; limitations and standard of care; keeping medical records, privacy, and confidentiality; and cross-territory practice. Whilst existing ethical and legal obligations of practicing medicine are not changed when telehealth is used as opposed to in-person care, telehealth practitioners are advised to familiarize themselves with the ethical guidelines, to keep abreast of the medico-legal developments in this area, and to observe the licensure requirements and regulatory regimes of both the jurisdiction where they practice and where their patients are located.

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Mediation is a voluntary process whereby a neutral and impartial third party-t-he mediator--is present to facilitate communication and negotiation between the disputing parties so that amicable settlements can be agreed. Being confidential and non-adversarial in nature, the mediation process and skills are particularly applicable in clinical practice to facilitate challenging communications following adverse events, to assist bioethical decision making and to resolve disputes. Mediation is also a more effective and efficient means of dispute resolution in medical malpractice claims when compared with civil litigation. Health care mediation teams should be set up at individual facilities to provide education and consultation services to frontline staff and patients. At a community level, the Government, the mediation community, and the health care professionals should join forces to promote mediation as a means to settle medical malpractice claims outside of the courtroom.

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BACKGROUND: The variable-stiffness colonoscope incorporates different degrees of stiffness of the insertion tube, which can be adjusted during the examination. Whether its use can lead to reduced procedure-related pain and sedative use is unknown. OBJECTIVE: Our purpose was to compare the use of 3 types of colonoscope with different shaft stiffnesses in relation to procedure-related pain and sedative consumption. DESIGN: Prospective randomized trial. SETTING: Endoscopy unit of a university-affiliated hospital. PATIENTS: Consecutive patients undergoing ambulatory colonoscopy. INTERVENTIONS: Random assignment was made of patients into 3 groups to receive colonoscopic examinations by one of the 3 types of colonoscope: conventional standard adult size, 1.3-m; 1.6-m; and the new variable-stiffness adult size, full-length (1.6-m) colonoscope. A mixture of propofol and afentanil, delivered by a patient-controlled syringe pump, was used for sedation in all groups. MAIN OUTCOME MEASURES: Outcome measures included dose of patient-controlled sedation consumed, pain score, cecal intubation rate, cecal intubation time, requirement of abdominal pressure and change of patients' positions during colonoscopy, and endoscopists and patients' satisfaction scores according to a visual analog scale. RESULTS: A total of 335 patients were randomized. Patients in group 3 used significantly less propofol (in milligrams per kilograms, mean [SD]) compared with the other 2 groups (group 1: 1.00 [0.75], group 2: 0.93 [0.62], and group 3: 0.75 [0.65]; P = .02; 1-way analysis of variance). The mean (SD) pain score was also lower in group 3. LIMITATIONS: The endoscopists were not blinded. CONCLUSION: The use of the new variable-stiffness adult-size colonoscope significantly reduced procedure-related pain and doses of sedative medications during colonoscopy.

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We report a rare case of transomental small-bowel herniation in a 91-year-old lady who presented with central abdominal pain and mild distension. Urgent abdominal computed tomography (CT) showed a segment of dilated ileum with features suggestive of strangulation. Emergency exploration revealed a segment of congested small-bowel loop herniated through a defect over the greater omentum. Reduction of the bowel loops and division of the omental defect was performed without the need for bowel resection. The patient made an uneventful recovery. We discuss the value of CT scan and highlight the importance of recognizing this rare cause of small-bowel obstruction.

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BACKGROUND AND AIMS: The role of Kupffer cells in obstructive jaundice (OJ) has not been fully understood. The aims of the present study were to measure superoxide and nitric oxide (NO) production by Kupffer cells in experimental OJ in rats and to investigate the response to internal and external biliary drainage. METHODS: Eighty male Sprague-Dawley rats were assigned to four groups: sham operation, OJ, and internal and external biliary drainage. Kupffer cells were isolated on day 7 in the sham operation and OJ group, and on day 7 after drainage procedures. Cells were cultured with or without lipopolysaccharide (LPS). Superoxide production was quantified in cultured Kupffer cells at 2 h and 48 h, respectively, after cell isolation using the superoxide dismutase inhibitable ferricytochrome c reduction method. Nitrite production in cell culture supernatants was measured 48 h later using Greiss reagents. RESULTS: Without LPS stimulation, Kupffer cells produced comparable superoxide and nitrite in each group (P > 0.05). With LPS stimulation, Kupffer cells in the OJ group produced significantly higher superoxide anions than the other groups (P = 0.006). Nitrite production was significantly increased in the OJ group and external biliary drainage group compared to rats in the sham operation and internal drainage groups (P < 0.01). CONCLUSIONS: Kupffer cells from rats with OJ produce great amounts of endotoxin-mediated oxidants. Both internal and external biliary drainage can decrease the elevated superoxide production. Internal drainage is superior to external drainage for reversing the distortional capacity of NO production by Kupffer cells.

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BACKGROUND: A prospective randomized trial was conducted to compare the safety, effectiveness, and patient acceptance of patient-controlled sedation and intravenous sedation for colonoscopy in a group of elderly patients undergoing outpatient colonoscopy. METHODS: One hundred patients over 65 years of age were recruited and randomized to patient-controlled sedation (n = 50) or intravenous sedation (n = 50) groups by means of computer-generated numbers. In the patient-controlled sedation group, a mixture of propofol and alfentanil was delivered by means of a patient-controlled pump; each bolus delivered 4.8 mg propofol and 12 microg alfentanil. No loading dose was used and the lockout time was set at zero. In the intravenous sedation group, fixed doses of diazemuls (0.1 mg/kg) and meperidine (0.5 mg/kg) were given with further increases in dosages administered at the discretion of the endoscopist. Outcome measures assessed included cardiopulmonary complications, recovery time, pain score, and satisfaction score. RESULTS: The mean (SD) age of patients in the patient-controlled sedation and intravenous sedation groups were, respectively, 72.4 years (5.3) and 73.5 years (6.1). The mean dose of propofol consumed in the patient-controlled sedation group was 0.79 (0.46) mg/kg. The mean doses of diazemuls and meperidine consumed in intravenous sedation group were, respectively, 5.8 (1.3) mg and 30.1 (6.8) mg. Hypotension occurred in 2 (4%) patients in the patient-controlled sedation group and 14 (28%) in the intravenous sedation group (p < 0.01). Oxygen desaturation was recorded for 4 patients (8%) in the intravenous sedation group. The median (interquartile range [IQR]) recovery time was significantly shorter in the patient-controlled sedation group compared with the intravenous sedation group (respectively, 0 minutes [IQR 0-5] vs. 5 minutes [IQR 5-10]; p < 0.01). There were no statistically significant differences between groups for pain and satisfaction scores. CONCLUSIONS: Patient-controlled sedation appears to be safer than intravenous sedation, with comparable effectiveness and acceptance, in elderly patients undergoing elective outpatient colonoscopy.

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BACKGROUND AND PURPOSE: Two-port laparoscopic cholecystectomy has been reported to be safe and feasible with a higher patient satisfaction score. However, it was technically difficult even in expert hands because of the small operating field. We have modified the operating telescope to achieve a wide field of view. PATIENTS AND METHODS: Since September 2000, 14 patients have been enrolled for two-port laparoscopic cholecystectomy. The male to female ratio was 5:9. The median age was 54.5 years (interquartile range [IQR] 45-67.75 years). RESULTS: The median operative time was 53 minutes (IQR 38-61 minutes). Two patients required one additional 5-mm port or a traction suture because of dense adhesions. There was no conversion to open surgery. The median postoperative hospital stay was 2 days (IQR 1-2.25 days). The median oral postoperative analgesia requirement was 1 dose (IQR 0-3 doses). There were no major or minor complications, and there were no deaths. CONCLUSION: The modified two-port technique greatly facilitates two-port laparoscopic cholecystectomy and improves the clinical outcome.

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BACKGROUND: Endoscopic drainage has replaced emergent surgery for biliary decompression in patients with acute cholangitis. The aim of this study was to prospectively compare the efficacy of the nasobiliary catheter and indwelling stent as temporary measures for biliary decompression in acute suppurative cholangitis caused by bile duct stones. METHODS: Over a 60-month period, 79 patients with acute cholangitis who required emergent endoscopic drainage were recruited. Indications for urgent drainage included any one of the following: temperature greater than 39 degrees C, septic shock with systolic blood pressure less than 90 mm Hg, increasing abdominal pain, and impaired level of consciousness. Patients who had previously undergone sphincterotomy or had coexisting intrahepatic duct stones were excluded. After successful bile duct cannulation, patients were randomized to receive either a nasobiliary catheter or indwelling stent without sphincterotomy for biliary decompression. Outcome measures included procedure time, complications, clinical response, and patient discomfort (scored with a 10-cm, unscaled visual analog score). RESULTS: Of the 79 patients, 5 were excluded because of previous sphincterotomy and intrahepatic duct stones, 40 were randomized to receive a nasobiliary catheter (NBC group), and 34 to receive indwelling stent (stent group). Demographic data were similar between the groups. All procedures were successful in the NBC group; there was one failure in the stent group. The mean (SD) procedure time was similar (NBC group 14.0 [9.3] minutes vs. stent group 11.4 [7.2] min). There were 2 ERCP-related complications in the NBC group. Four patients pulled out the nasobiliary catheter and one catheter became kinked. One stent occluded. There was a significantly lower mean (SD) patient discomfort score on day 1 after the procedure in the stent group (stent group 1.8 [2.6] vs. NBC group 3.9 [2.7]; p = 0.02 t test). The overall mortality rate was 6.8% (2.5% NBC group vs. 12% stent group). CONCLUSION: Endoscopic biliary decompression by nasobiliary catheter or indwelling stent was equally effective for patients with acute suppurative cholangitis caused by bile duct stones. The indwelling stent was associated with less postprocedure discomfort and avoided the potential problem of inadvertent removal of the nasobiliary catheter.

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BACKGROUND: A prospective randomized controlled trial was performed to test the hypotheses that music decreases the dose of sedative medication required for colonoscopy and that the combination of music and patient-controlled sedation improves patient acceptance of colonoscopy. METHODS: One hundred sixty-five patients scheduled to undergo elective colonoscopy were randomized to receive 1 of 3 different modes of sedation: Group 1, a combination of music and patient-controlled sedation with a mixture of propofol and alfentanil; Group 2, patient-controlled sedation alone; Group 3, music alone with diazemuls and meperidine administered intravenously if requested by the patient. Each bolus of patient-controlled sedation delivered 4.8 mg propofol and 12 microg alfentenil. Music was provided by means of a portable compact disc machine with headphones. Outcome measures assessed immediately after colonoscopy and 24 hours later included dose of patient-controlled sedation used, complications, recovery time, pain score, satisfaction score, and willingness to repeat the procedure with the same mode of sedation. RESULTS: The mean (SD) dose of propofol used in Group 1 was significantly less than Group 2 (0.84 mg/kg [0.69 mg/kg] vs. 1.15 mg/kg [0.83 mg/kg]; p = 0.02, t test). The mean (SD) satisfaction score was higher in Group 1 (7.8 [2.1]) compared with Group 2 (6.8 [2.3]) and Group 3 (7.4 [2.3]) (p = 0.05, 1-way analysis of variance). The majority of patients in Group 1 were willing to repeat the same mode of sedation when queried immediately after colonoscopy (87%) and 24 hours later (75%), which was significantly different from the corresponding results in the other 2 groups; p = 0.04 and p < 0.01 respectively, chi-square test. CONCLUSIONS: Music can decrease the dose of sedative medication required for colonoscopy. The combination of music and patient-controlled sedation was the best-accepted mode of sedation among 3 groups.

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