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   Table of Contents - Current issue
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September-October 2017
Volume 50 | Issue 5
Page Nos. 158-194

Online since Monday, October 9, 2017

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ORIGINAL ARTICLES  

Common bile duct exploration for elderly patients with choledocholithiasis: Is laparoscopic method better? p. 158
Yi-Feng Lin, Yu-Feng Tian, Yih-Huei Uen
DOI:10.4103/fjs.fjs_97_17  
Background: Choledocholithiasis is the most common cause of acute cholangitis which resulted in potentially life-threatening infection. The prevalence of common bile duct (CBD) stone increases with age.[1] Common bile duct exploration (CBDE) is one of the treatments. However, there are a few studies about this procedure in the elderly patients. Hence, we discover the outcomes of CBDE in elderly patients ≥70 years). The methods of CBDE, including open and laparoscopic (LC) method were also compared. Material and Method: From January 2009 to December 2014, the elderly patients with proven choledocholithiasis who underwent CBDE were included. The deremographical information, surgical outcome and postoperative complication were all recorded and evaluated. Result: There were 97 patients in open method group (Group A) and 21 patients in LC method group (Group B). The mean age was 76.9 years (70–93 years). The demographics and comorbidity in both groups were similar. The mean length of stay after operation for Group A was 11.2 ± 9.0 days and Group B was 5.67 ± 2.29 days (P < 0.0001). The complication rate was similar in both groups (Group A, 22.6%; Group B, 4.76%; P = 0.07). The overall complication and mortality rate was 19.5% and 0.8%, respectively. The clearance of CBD stone was 95.9% in Group A and 95.2% in Group B (P = 1.00). Conclusion: CBDE can be performed safely in the elderly with accepted morbidity and mortality, and the stone clearance is also reliable. The LCBDE approach is safe in these elderly and has benefit for shortening the hospital stay.
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Shah-Waardenburg syndrome p. 163
Rahul Gupta, Dinesh Kumar Barolia, Ramesh Tanger, Lila Dhar Agrawal, Arun Kumar Gupta, Ram Babu Goyal
DOI:10.4103/fjs.fjs_30_17  
Introduction: Shah-Waardenburg syndrome (SWS) is WS associated with Hirschsprung's disease. It is very rare with <80 cases reported in the literature. Aim: The aim of this study was to describe our experience with SWS. Methods: The records of patients admitted to our tertiary care pediatric surgical institute between 2011 and 2015 were retrospectively reviewed. All patients with histopathological diagnosis of Hirschsprung's disease were studied. SWS was identified as per the diagnostic criteria proposed by the Waardenburg consortium. Results: There were 202 patients diagnosed with Hirschsprung's disease during 5 years. We identified three male patients fulfilling the diagnostic criteria for WS (white forelock with the involvement of eyebrows and eyelashes, pigmentary disturbances of the iris, and broad high nasal root). All presented in the neonatal period with clinical and radiological features of small bowel obstruction. Family history (sibling) of SWS was seen in one of the neonates. Exploration revealed distended jejunal and ileal loops in all of them; colon contracted and unused (microcolon). Multiple seromuscular biopsies were performed from colon in all 3 neonates. Initial ileostomy was performed in case 2 and case 3. In case 1, the right transverse colostomy was done primarily as total colonic aganglionosis (TCA) was not expected (absence of transition zone in the early neonatal period) and also frozen section facilities were not available. It was followed by ileostomy (second surgery) about 15 cm proximal to the ileocecal junction as colostomy was not functioning adequately. The histopathology of gut biopsies revealed aganglionosis in the entire colon, confirming the diagnosis of TCA in all the cases. Out of three patients in our study, two neonates died in the postoperative period, while third case succumbed due to severe episodes of ileostomy diarrhea. Conclusion: A patient of WS presenting with neonatal intestinal obstruction or constipation since birth should be evaluated on the lines of SWS . Patients with SWS have a higher incidence of TCA or long-segment Hirschsprung's disease. In SWS when transition zone is not clear, an ileostomy would be preferable in view of nonavailability of frozen section.
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A retrospective comparison of two-, three-, and four-port laparoscopic cholecystectomies p. 169
Heng Hui Lien, Chi Cheng Huang, Ching Shui Huang
DOI:10.4103/fjs.fjs_128_17  
Purpose: A total of 1276 laparoscopic cholecystectomies (LCs) using two-, three-, and four-port methods were analyzed to evaluate the feasibility and effectiveness of two and three-port LCs in management for acute or elective gallstone disease when compared with four-port LC. Materials and Methods: A between-group comparison was performed on the difference of operation time, postsurgery admission days, postsurgery daily pain score between acute or elective surgery or different procedures. Results: Proportion of four-port LC was significant high in acute then in elective surgery (93.3% vs. 79.0%; P = 0.001). In elective surgeries, difference among mean operative time of two-, three-, and four-port LC (36.76, 34.72, and 27.32 min, respectively) was statistically significant (P = 0.001). Three-port LC showed a significant lowest mean pain score (1.887; 1 to 10 point pain score) on the first-day post-LC.(P = 0.04) Difference on the mean post-LC hospitalization of two-, three-, and four-port LCs (2.158, 2.141 and 2.412 days, respectively) were significant in elective (P = 0.001) while not significant in acute surgery (two-, three-, and four-port LCs: 2.75, 2.778, and 3.097 days, respectively; P = 0.237). Conclusions: Four-port LC was the procedure of choice in acute surgery. The operative time was the shortest for four and longest for two-port LC. Three-port LC could be adopted using strategic selection (elective surgery) and conversion (with adding port) as safety guard for the benefits of less wound pain, decreased post-LC admission days.
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Contralateral breast lesions detected by breast MRI study - An analysis of 735 Taiwanese women with primary operable breast cancer p. 175
Hung-Wen Lai, Wan-Yu Hung, Chih-Wei Lee, Hwa-Koon Wu, Shou-Tung Chen, Dar-Ren Chen, Chih-Jung Chen, Shou-Jen Kuo
DOI:10.4103/fjs.fjs_69_17  
Purpose: Women with unilateral breast cancer are at an increased risk for the development of contralateral breast cancers. In this study, we evaluated the incidence and pathology of contralateral breast cancer detection by preoperative magnetic resonance imaging (MRI) in Taiwanese women with primary operable breast cancer. Methods: A retrospective review of patients who received preoperative breast MRI and underwent operation for breast cancer at single institution between January 2011 and December 2013 was conducted. The incidence, pathology, and management methods of MRI-detected contralateral breast lesions were reported and analyzed. Results: A total of 735 patients enrolled in the current study, and 70 patients (9.5%) were found to have contralateral breast lesions detected by preoperative MRI. Among these 70 patients, 44 (62.9%) received surgical intervention for the MRI-detected contralateral occult lesions. Malignancy was detected in the final pathologic specimen in 21 (47.7%) patients, and benign lesions found in 23 (52.3%) patients. Among these 21 MRI-detected occult contralateral breast cancers, there were 7 (33.3%) invasive ductal carcinoma, 1 (4.8%) mucinous carcinoma, and 13 (61.9%) ductal carcinoma in situ. Compared with the pathology of the 735 primary operable breast cancers, MRI-detected contralateral breast cancer was associated with higher in situ carcinoma (61.9% vs. 15.9%, P < 0.01). The positive predictive value of MRI was 37.7%, eight of 28 MRI Breast Image Reporting and Data System(BI RADS)-4 cases had a pathological malignancy; nine of 17 MRI BI RADS-5 cases had a pathological malignancy. Conclusion: In women with known unilateral breast cancer, 2.9% of patients were diagnosed to have synchronous contralateral breast cancer when combined with preoperative breast MRI evaluation. Adequate biopsy or surgical strategy should be discussed in patients whose preoperative breast MRI showed contralateral occult lesions with suspicious for malignancy.
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CASE REPORTS Top

Direct intraoperative measurement of residual pressure gradient after resection of discrete subaortic stenosis p. 181
Jiunn-Miin Lin, Shye-Jao Wu
DOI:10.4103/fjs.fjs_63_17  
Transesophageal echocardiography (TEE) plays an important role for congenital cardiac surgery, such as measurement of residual shunt, residual regurgitation, residual pressure gradient (PG), and so on. For discrete subaortic stenosis, it could be a simple and effective option to check residual PG by direct intraoperative periaortic retrograde left ventricular catheterization if infantile TEE is not available.
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Ductal carcinoma in situ in a 35-year-old male presenting with ipslateral gynecomastia p. 183
Chih-Jen Huang, Jenn-Perng Chen, Hsin-Ju Lin, Hsien-Pin Sun
DOI:10.4103/fjs.fjs_1_17  
Concomitant ductal carcinoma in situ (DCIS) and ipslateral gynecomastia (GM) are very rarely reported in male <40. We report an unusual case of a 35-year-old male, with no familial history of breast cancer, presented with unilateral GM, diffuse type. After subcutaneous mastectomy for his unilateral GM, a 0.7 cm × 0.3 cm DCIS lesion was incidentally found without clinical symptom. About 14%–43% of patients with DCIS have the potential of evolving into an invasive tumor in the subsequent 10–20 years. Our case emphasizes the rare incidence of DCIS in male breast and the presence of concurrent GM can frequently result in misdiagnosis. In patients with rapid growth in breast tissue should be cautious of cancer in young men with GM.
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Robot-assisted laparoscopic partial cystectomy for urinary bladder paraganglioma p. 186
Shu-Chi Wang, Ren-Ching Wang, Kun-Yuan Chiu
DOI:10.4103/fjs.fjs_64_17  
Pheochromocytoma is a rare neuroendocrine tumor that occurs in the urinary bladder. We reported a 56-year-old male patient with a history of bradycardia, dizziness, and hypertension provoked by micturition for 5 years. Magnetic resonance imaging discovered a 3.1 cm urinary bladder tumor over the right dome. High urinary catecholamines' level was also found. Robot-assisted laparoscopic partial cystectomy was performed smoothly without perioperative complications.
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Myxoinflammatory fibroblastic sarcoma of the chest wall p. 189
Yang-Fan Liu, Wun-Ke Chen, Yu-Peng Liu, Pei-Wen Huang
DOI:10.4103/fjs.fjs_65_17  
This study presents the case of an 87-year-old male who developed a huge tumor at the chest wall that limited the range of motion of the upper limb. We performed a wide excision of the tumor with chest wall reconstruction. The tumor exhibited lobulated pattern with myxoid fluid and fibrous tissue, which was accumulated by a thin capsule. The final diagnosis was myxoinflammatory fibroblastic sarcoma (MIFS), a kind of uncommon low-grade malignant tumor that extremely develops rarely in the chest wall. At this moment, we review the epidemiology, histopathologic characteristics, similar cases, and the current treatment for MIFS.
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ERRATA Top

Erratum: Procalcitonin levels to predict bacterial infection in surgical intensive care unit patients p. 192

DOI:10.4103/fjs.fjs_130_17  
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Erratum: Intractable constipation in an adult with megarectosigmoid following repair of low-type anorectal malformation p. 193

DOI:10.4103/fjs.fjs_144_17  
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Erratum: Prognostic factors for radial nerve palsy associated with humeral shaft fracture p. 194

DOI:10.4103/fjs.fjs_150_17  
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