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   Table of Contents - Current issue
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May-June 2018
Volume 51 | Issue 3
Page Nos. 91-131

Online since Thursday, June 21, 2018

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ORIGINAL ARTICLES  

Lessening hepatic injury in cholestatic liver by optimal dietary docosahexaenoic acid supplementation in rats p. 91
Guan-Yeu Diau, Shih-Ming Kuo, Chieh-Wen Lin
DOI:10.4103/fjs.fjs_148_17  
Background: Dietary adjuvant management for the cholestatic liver disease before/after surgery is an important clinical issue. This study investigated the possibility for the dietary supplementation of docosahexaenoic acid (DHA) to treat cholestasis liver through the bile duct ligation (BDL) rat model. Materials and Methods: Thirty-six male Wistar rats were divided into four groups (N: no BDL; BL, 1P, 5P: received BDL) and consumed either a regular diet (N, BL) or of DHA-enriched diet (1P: at 1% and 5P: at 5% weight percentage) for 4 weeks. The liver fatty acids (FAs) profiles, serum aspartate transaminase (AST), alanine aminotransferase (ALT), total bilirubin, alkaline phosphatase, interleukin-2 (IL-2), interferon γ (INF-γ), and pathological examination with H and E, Masson, CD56 (natural killer cell), CD68 (macrophage) were examined. Results: The DHA dietary supplement increased liver DHA after BDL. Liver DHA N 8.09 ± 0.60% and BL 8.41 ± 0.55% were the lowest than the supplemented groups 1P 12.57 ± 1.16%, 5P 18.36 ± 2.00% (P = 0.000). However, liver arachidonic acid (20:4n-6) 1P 23.13 ± 2.19% was the highest than N 18.86 ± 4.31%, BL 17.13 ± 3.07%, 5P 18.78 ± 1.76% (P = 0.001). The serum AST (U/L) in N 147.4 ± 28.2 and 1P 155.9 ± 35.1 were lower than B 317.1 ± 195.8, 5P 326.9 ± 141. 8 (P = 0.006). The serum alkaline phosphatase (U/L) showed the same trend N 49.8 ± 5.4, 1P 67.6 ± 21.1 were lower than the BL 172.2 ± 108.1, 5P 171.1 ± 149.1 (P = 0.017). Pathological examination with H and E, Masson revealed the fibrosis was prominent in BL, 5P. However, there were no significant differences in serum ALT, total bilirubin, IL-2, INF-γ, and immunohistochemical stain for the CD56, CD68. Conclusions: The results suggested that optimal dietary supplementing of DHA (1P) had less destruction and liver enzymes released after the BDL. However, higher enriched DHA (5P) could not benefit from this dietary treatment. The body weight did not increase even with this enriched high FAs diet after BDL for 4 weeks.
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Hypotensive effect of labetalol and dexmedetomidine blood loss and surgical conditions in functional endoscopic sinus surgery: A double-blind randomized clinical trial p. 98
Aliakbar Eghbal, Hesameddin Modir, Esmail Moshiri, Mohammad Khalili, Farzad Zamani Barsari, Abolfazl Mohammadbeigi
DOI:10.4103/fjs.fjs_131_17  
Background: Excessive bleeding occurs from mucosal edges during functional endoscopic sinus surgery (FESS). This could decrease the visibility of the surgeon and increase the risk incidence of complications. The current study aimed to evaluate the effect of labetalol and dexmedetomidine on intraoperative blood loss and surgical conditions in ESS. Methods: A double-blind randomized clinical trial was conducted on 100 candidates for FESS that randomly were assigned by block randomization method in two groups including labetalol or dexmedetomidine. Heart rate (HR), mean arterial blood pressure, and the percent of arterial oxygen saturation were measured after induction and during the hypotension. These items were recorded till the end of the surgery. A blinded surgeon was assessed the bleeding of operation field. Data were analyzed using t-test, Chi-square, and analysis of variance for repeated measures. Results: The mean time of surgery was not statistically significant between two groups (104.65 ± 7.38 vs. 105.12 ± 7.33). The mean of HR was higher in dexmedetomidine group in all times after induction (P < 0.001) and a significant decreasing trend observed in the mean of HR for labetalol while the HR in dexmedetomidine group was increasing. The extubation and recovery time in dexmedetomidine group was higher than labetalol group (P < 0.001). Moreover, the operation field without bleeding or with low bleeding was higher in labetalol group, and the labetalol could be controlled the bleeding better than the dexmedetomidine. Conclusion: Bleeding score, extubation, and recovery time in labetalol group was lower than dexmedetomidine group. Moreover, patients in labetalol group have had higher recovery score and lower bleeding. Therefore, labetalol could reduce the bleeding during FESS and improved the visualization of the operation field and was superior to dexmedetomidine in concern to lower bleeding and extubation and recovery time.
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Thoracoscopic repair of esophageal atresia: Comparison with open approach Highly accessed article p. 105
Chun-Hui Lin, Yih-Cherng Duh, Yu-Wei Fu, Yao-Jen Hsu, Chin-Hung Wei
DOI:10.4103/fjs.fjs_145_17  
Background: The aim of the present study is to evaluate our initial experiences of thoracoscopic repair (TR) for esophageal atresia with/without trachoesophageal fistula (EA/TEF) and also to compare the results with open repair (OR). Subjects and Methods: Patients with EA/TEF who received surgeries in our institution between July 2009 and June 2015 were included in the study. The medical records were retrospectively reviewed. Patients are divided into two groups as follows: TR and OR. Parameters collected includes demographics, operation time, conversion, time to oral feeding, length of hospital stay, complications, and growth status. Statistical Analysis Used: Wilcoxon rank sum test, Chi-square, and Fisher's exact test. Results: A total of 21 patients with EA/TEF, 19 with type C and 2 with type A, were enrolled. There were 9 and 12 patients in TR and OR groups, respectively. There was no significant difference in demographics between both groups. Median operation time was significantly longer in TR (197.5 vs. 115 min, P < 0.01). The operations were converted in the initial three patients. In the following six patients, only one patient with pure EA required conversion. Median time to oral feeding was significantly longer in TR (12 vs. 7 days, P = 0.04). Anastomotic leakage occurred in three and one patients, respectively (33.3% vs. 8.3%, P = 0.27). Esophageal dilatation was required in 3 (33.3%) and 4 (33.3%) patients for esophageal stenosis in TR and OR groups, respectively (P = 0.999). Fundoplication was required in 2 (22.2%) and 3 (25%) patients of TR and OR groups, respectively (P = 1.00). Recurrent TEF developed in one patient (11.1%) of TR. The bodyweight fell behind 3 percentiles of the growth curve in 6 (66.7%) and 6 (50%) patients (P = 0.660). Conclusions: TR for EA/TEF is feasible. The initial experiences revealed longer operation time and higher complication rate compared to OR.
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Association between laboratory markers and oncological outcomes in patients with osteosarcoma – A review of osteosarcoma treatment in Indonesia p. 111
Achmad Fauzi Kamal, Rangga Ardianto Prasetyo
DOI:10.4103/fjs.fjs_140_17  
Background: Treatment of osteosarcoma requires multi-disciplinary team work and a rigorous follow-up schedule to achieve best oncological and functional outcomes. However, standard treatment and routine image study may not be available for all Indonesian patients because of complex geographic reason in Indonesian archipelago. Therefore, we aimed to review treatment outcome of osteosarcoma in Indonesia and validate potential laboratory markers associated with oncological outcomes. Materials and Methods: From January 2015 to August 2016, we retrospectively reviewed 57 patients with osteosarcoma who had received treatment in Dr. Cipto Mangunkusumo Hospital (RSCM), Jakarta, Indonesia. Association between laboratory markers including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), lactate dehydrogenase (LDH), alkaline phosphatase (ALP) and oncological outcomes including mortality and distant metastasis have been validated. Results: Our results showed that a combination of neoadjuvant chemotherapy, tumor resection and adjuvant chemotherapy would lead to the best oncological and functional outcome. ESR, CRP LDH and ALP level decreased after surgery and chemotherapy. Lower level of ESR and CRP were not associated with less distant metastasis and less mortality. On the other hand, the elevated LDH was correlated with higher mortality (P < 0.01), whereas elevated ALP was also correlated with a higher risk of distal metastasis (P = 0.044). Conclusions: Patients who had been properly treated with neoadjuvant chemotherapy, tumor resection and adjuvant chemotherapy had the best oncological and functional outcomes. LDH and ALP might be useful laboratory markers to predict oncological outcome.
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CASE REPORTS Top

Adult-onset neurocutaneous melanosis with Dandy–Walker malformation p. 118
Ting-Wei Chang, Po-Chuan Hsieh, Zhuo-Hao Liu, Po-Hsun Tu
DOI:10.4103/fjs.fjs_108_17  
Neurocutaneous melanosis (NCM) is characterized by diffuse or focal proliferation of melanin-producing cells over the skin or leptomeninges. Even without malignant transformation, the prognosis is poor after symptomatic progression of NCM, resulting from either mass effect in central nervous system or hydrocephalus. We reported a 26-year-old female patient with rapid deterioration after the onset of NCM. Despite no solid tumor formation, elevated cerebrospinal fluid protein content, which complicated shunting procedure, associated with hydrocephalus played the key role in clinical deterioration. Adult onset of NCM with Dandy–Walker malformation was never reported in our literature review. Diagnosis and treatment for such disease entity are discussed.
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Jejunostomy tube-induced intussusception p. 122
Arvind Krishnamurthy
DOI:10.4103/fjs.fjs_126_17  
Intussusception involves the telescoping of a segment of bowel into an adjacent segment. It is the leading cause of intestinal obstruction in the pediatric age group; however, it is relatively rare and accounts for just about 1% of the cases of small bowel obstruction in adults. Jejunostomy tube-induced intussusception is an extraordinarily rare complication of feeding jejunostomy tube placement, the exact mechanism of which is not definitively known. The diagnosis of jejunostomy tube-induced intussusception is not easy as it generally does not interfere with the enteral feeding. Computed tomography (CT) scan is widely considered to be the imaging modality of choice in the diagnostic evaluation of adult intussusception. The finding of a heterogeneous sausage-shaped soft-tissue mass consisting of an outer intussuscipiens and central intussusceptum is virtually pathognomonic of intussusception. Surgery is the mainstay of management in an adult with intussusception. Nonoperative treatment strategies including radiologic reductions aided by hydrostatic/contrast/air enemas, which have mainly been attempted in the pediatric age group, have shown unpredictable results and are not recommended in adults. We present an unusual cause of jejunostomy tube-induced intussusception following a salvage laryngopharyngoesophagectomy and gastric pull-up in a patient with a postchemoradiation residue of a locally advanced carcinoma of the postcricoid region. A high degree of suspicion among clinicians and timely imaging with a CT scan are prerequisites for diagnosing intussusception in patients who complain of persistent gastrointestinal symptoms, especially with a jejunostomy tube in situ.
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Primary cervical spine melanoma p. 125
Chih-Ming Hu, Cheng-Neng Chen, Kuo-Hua Hung, Ming-Shiang Yang, Kuan-Ju Lai
DOI:10.4103/fjs.fjs_77_17  
Primary spinal melanoma is too rare to have any systemic statistical data on the epidemiology of this disease. We report a 58-year-old woman presented with spastic gait for 10 days, preceded by chronic pain at her left anterior chest that progressively spread to her neck, left shoulder, and arm in half a year. Cervical magnetic resonance imaging (MRI) displayed a well-enhancing focal intraspinal extramedullary tumor at C6/7 level. After surgical resection of the tumor and thorough studies to exclude extraspinal melanoma, the primary spinal melanoma is diagnosed. Postoperative MRI did not disclose any evidence of recurrence at 4 and 21 months later. We present the clinical, radiological, and pathological features of a patient with a primary cervical extramedullary spinal melanoma.
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Emphysematous gastritis after radical subtotal gastrectomy for advanced gastric cancer p. 129
Jou-Chien Liao, Chung-Wei Lin
DOI:10.4103/fjs.fjs_86_17  
Emphysematous gastritis is a rare but severe disease characterized by air within the gastric wall. It is commonly caused by a bacterial infection and carries a remarkably high mortality rate (50%–60%). The most common predisposing factors include ingestion of corrosive substances, alcohol abuse, and recent abdominal surgery. Diagnosis of emphysematous gastritis is difficult and relies on computed tomography (CT) scan because of the nonspecific clinical presentation of abdominal pain with systemic toxicity. In this report, we present a case of a 78-year-old male with gastric adenocarcinoma who underwent laparoscopic radical subtotal gastrectomy. After the operation, he complained of severe abdominal pain and fever. Subsequently, the patient developed acute respiratory distress syndrome and septic shock. A CT scan performed on postoperative day 17 revealed extensive intramural gas in the stomach. The patient was diagnosed with emphysematous gastritis and received conservative treatment.
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