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Eighty percent partial splenic embolization is a safe and effective procedure in management of cirrhotic hypersplenism
Bor-Gang Wu, Andy Shau-Bin Chou, Guan-Jin Ho, Ming-Che Lee
May-June 2017, 50(3):101-106
Background: Partial splenic embolization (PSE) has been proposed in patients with cirrhotic hypersplenism in cases when thrombocytopenia causes clinical manifestations or if there are contraindications to subsequent therapeutic procedures. We provide a retrospective review of the safety and favorable treatment results of 80% splenic embolization in patients with cirrhotic hypersplenism in our institute. Methods: Thirteen consecutive patients with cirrhotic hypersplenism were included in a 4-year study period. The indications for PSE were as follows: percutaneous treatment of hepatocellular carcinoma (HCC) (n = 3), transarterial chemoembolization plus hepatic arterial infusion chemotherapy for HCC (n = 2), preparation for major surgery (n = 5), and severe purpura (n = 3). PSE was performed with up to 80% reduction of splenic blood flow by radiological intervention. A tight protocol of prophylactic antibiotics was introduced. Patient demographics, procedure-related complication, and efficacy of PSE were analyzed. Results: The mean follow-up time was 26.1 ± 12.3 months. All the patients tolerated the procedure. The minor complication of postembolization syndromes such as fever and abdominal pain occurred in 38.5% and 61.5% of patients, respectively. Only a major complication of transient ascites needs diuretic therapy occurred in two patients. Pre-PSE platelet count was 35,077 ± 11,049/mm3, and it significantly increased 1 week after PSE, with a mean increase of platelet count to 384% of pre-PSE level (P < 0.001). The effect of PSE sustained to maintain the platelet count significantly at a mean level of 112,636 ± 33,341/mm3, 114,571 ± 30,696/mm3, and 118,000 ± 31,035/mm3 at 12, 24, and 36 months, respectively. Conclusion: Our series demonstrated that 80% PSE is a safe and effective method to treat patients with cirrhotic hypersplenism. It could not only increase the platelet count within a short period of time but also maintain it at an acceptable level for a long duration. Under a tight protocol of prophylactic antibiotic and delicate technique of PSE, there was no any septic complication developed in our series.
  1,885 160 -
Prognostic factors for radial nerve palsy associated with humeral shaft fracture
Yen-Yi Hoa, Lee-Wei Chen, Kao-Chang Yang, Kuei Chang Hsu, Wen-Chung Liu, Cheng-Ta Lin
January-February 2017, 50(1):1-9
Background: Radial nerve palsy (RNP) associated with humeral shaft fracture is a common injury pattern in trauma patients. The management of RNP associated with humeral fractures in high-energy trauma is controversial and poses a challenge to surgeons treating it. Purpose: Based on a review of our experience over the past 15 years, we determined the prognostic factors of radial nerve recovery after humeral fractures, evaluated the diagnostic role of nerve conduction studies and electromyography (EMG), and compared the outcomes of different treatment strategies. Materials and Methods: The data of 26 patients having RNP associated with humeral shaft fractures over a 15-year period were collected for a retrospective review. For statistical analysis, the patients were divided into groups on the basis of their recovery from RNP and the treatment strategies used. Results: The incidence of RNP associated with humeral fractures was 2.05%. In total, 91.3% of patients with primary RNP in this series experienced high-energy trauma. Spontaneous recovery was observed in 9 of 26 patients (34.6%). Radial nerve lesions were found in 7 of 8 patients with high-energy trauma. The severity of humeral shaft fractures was found to be a significant prognostic factor for spontaneous recovery from RNP. The rate of spontaneous recovery was significantly higher in the AO Foundation and Orthopaedic Trauma Association Type A humeral shaft fractures (P = 0.028) and lower in Type C fractures (P = 0.055). The median time to detect initial radial nerve recovery using EMG was 34 and 75 days after injury (P = 0.033). In high-energy trauma, tendon transfers were associated with more predictable outcomes than nerve reconstruction (favorable functional recovery: 100% for tendon transfers vs. 25% for nerve reconstruction, P = 0.007). Moreover, tendon transfers were associated with a shorter overall treatment duration (median treatment duration: 190 days for tendon transfers vs. 422 days for nerve reconstruction, P = 0.007). Conclusion: The prognosis of RNP associated with humeral shaft fractures in high-energy trauma is less favorable, with a low rate of spontaneous recovery. EMG is helpful for the early detection of initial nerve recovery. The outcomes of tendon transfers in high-energy trauma are predictable and the treatment duration is shorter. First-intention tendon transfer is a reasonable treatment strategy in patients with difficult nerve exploration, lower requirement for functional recovery, and lower compliance with treatment.
  1,711 180 1
Inhibitory effect of methamphetamine on intracavernous pressure in rats
Tao-An Chang, Bang-Ping Jiann
March-April 2018, 51(2):63-68
Background: There is a paucity of animal study investigating the effect of methamphetamine (METH) on penile erection in spite of its worldwide population. Aim: We investigated the changes of intracavernous pressure (ICP) elicited by cavernous nerve stimulation after a single and repeated dosing of METH in male rats. Methods: Rats were randomly assigned to five treated groups and one control group with each group having 3 rats. Rats in treated group 1, 2, and 3 received a single dose intravenous injection with 0.1, 1.0, and 10.0 μg/kg METH, respectively. Rats in treated group 4 and 5 received an intraperitoneal injection with 1.0 and 5.0 mg/kg METH four times daily for two weeks, respectively. ICP was measured during penile erection elicited by cavernous nerve stimulation. Expression of neural nitric oxide synthase (nNOS) was measured in the cavernous nerve and muscle after single and repeated dosing. Main Outcome Measures: The primary outcome measure was the ΔICP/mean arterial pressure (MAP) and the secondary was the expression of nNOS in the tissue. Results: The ΔICP/MAP increased slightly in group 1 rats and decreased substantially in group 2 and 3 rats compared with the baseline. A single dose of METH within the range of 0.1 to 10.0 μg/kg exhibited an inhibitory effect of ICP (%). The ΔICP/MAP significantly decreased in group 4 and 5 rats after repeated dosing of METH, compared with that in group 3. The expression of nNOS significantly increased in the cavernous muscle after single and repeated dosing of METH compared with the control. Conclusions: The preliminary results suggested that a single dose of METH exhibits an inhibitory effect on ICP and repeated dosing of METH exerted a greater inhibition than a single dosing. However, these results need further study.
  1,701 90 -
Long-term follow-up for patients with colonic perforation due to colonoscopy: From clinical and medicolegal viewpoints
Tzu-Chun Chen, Ji-Shiang Hung, Been-Ren Lin, John Huang, Jin-Tung Liang
November-December 2017, 50(6):195-199
Background: This retrospective study analyzes the clinicopathologic features and medicolegal debates on this complication. Methods: There were 29 records of colonic perforations, whose charts were retrospectively reviewed. Results: A total of 26 perforations occurred as a result of diagnostic colonoscopy, and three occurred after therapeutic colonoscopy. Eight perforations were diagnosed immediately during the procedure, based on the revelation of intraperitoneal organs with bleeding of bowel wall on the colonoscopic monitor. Twenty patients were diagnosed as a hollow-organ perforation within 12 h after the completion of colonoscopy, whereas one perforation was found more than 24 h after colonoscopy. Abdominal pain and distention are the most common symptoms. All the patients underwent emergency surgery. One patient had wound infection, and two patients had leakage of the repair site. One patient aged 80 died of pulmonary septic complication. Our hospital paid all additional expenses which were not covered by the National Health Insurance Bureau for all patients, ranging from 500.0 to 1500.0 US dollars (mean ± standard deviation, 549.0 ± 145.0 US dollars). Four patients (13.8%) asked for further compensation of the complication and one litigated. Conclusions: Iatrogenic colonic perforation due to endoscopy is potentially lethal, especially for aged patients. Some patients and their family viewed the perforation as malpractice and asked for compensations. Usually, the primary repair of the perforation site is safe, and long-term follow-up reveals no sequelae after adequate treatment.
  1,548 128 -
Hyperbaric oxygen therapy for hemorrhagic radiation cystitis
Kung-Hung Lin, Hui-Chieh Lee, Wen-Shyan Huang, Po-Wei Huang, Seng-Chung Ke, Man-Gang Lee
March-April 2017, 50(2):52-56
Background: Radiation cystitis with macroscopic hematuria is a frustrating clinical problem for urologists. Since 1985, hyperbaric oxygen therapy (HBOT) has been applied as a treatment for radiation cystitis with macroscopic hematuria; numerous studies have shown that this treatment has favorable results. Purpose: The purpose of this study was to elucidate the HBOT affected the clinical outcomes and treatment of hemorrhagic radiation cystitis (HRC). Methods: Between November 1989 and June 2014, 42 patients (39 women and three men) with HRC were treated with hyperbaric oxygen at a pressure of 2.5 atmospheres absolute, breathing 100% O2for 120 min in a multiplace hyperbaric chamber. Results: After an average of 38 hyperbaric oxygen sessions, macroscopic hematuria was completely halted in 35 patients (83.3%) and markedly decreased in three patients (7.1%). A comparison of cystoscopic findings before and after HBOT showed significant decreases in both hemorrhagic sites and telangiectasis of the bladder mucosa. The mean follow-up was 20.7 months (range: 3–49 months). No cases exhibited evidence of barotrauma or oxygen toxicity. One patient underwent a urodynamic study both before and after HBOT, with several changes in bladder function observed after HBOT: urine peak flow increased from 12.8 mL/s before HBOT to 15.0 mL/s after HBOT and urine mean flow increased from 6.5 mL/s to 8.9 mL/s. Urine voiding time decreased from 40.0 s to 28.0 s, urine flow time from 39.0 s to 28.0 s, time to peak flow from 15.0 s to 8.0 s, and voided volume from 251 mL to 248 mL. Conclusion: The results of this study suggest that early application of HBOT is a safe and effective treatment method for HRC. Whether HBOT is beneficial to urinary bladder function requires further study with a larger patient cohort enrolled.
  1,429 181 -
Distal pancreatectomy and celiac axis resection for pancreatic body carcinoma involving celiac artery
Shih-Chun Chang, Yu-Yin Liu, Tse-Ching Chen, Cheng-Huei Tseng, Ta-Sen Yeh
January-February 2017, 50(1):28-31
Pancreatic body or tail cancer with invasion to major vessels, including the common hepatic artery and the celiac artery, was previously considered to be unresectable. However, an increasing number of surgeons have aggressively adopted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR) in this scenario to attempt curative resection, thus improving long-term survival. In this paper, we present the case of a 45-year-old man with pancreatic body cancer invading the celiac axis who underwent DP-CAR with negative margins (R0) and subsequently exhibited an uneventful postoperative course. We also reviewed literature, which unequivocally demonstrates a comparable oncological outcome between pancreatic body or tail cancer with and without celiac artery resection. To the best of our knowledge, our study is the first documented case in which DP-CAR was successfully performed in Taiwan.
  1,423 123 -
Isolated tuberculous epididymitis
Shao-Ming Chen
March-April 2017, 50(2):74-76
Isolated tuberculous epididymitis (ITE) is an uncommon disease that is often incorrectly diagnosed as the more common epididymo-orchitis. ITE is usually treated using long-term general parenteral or oral antibiotics. The nonspecific nature of laboratory tests for ITE renders its diagnosis challenging. Here, we report the case of a 65-year-old male patient who presented with a 6-month history of the left scrotal swelling. He was initially treated with general oral antibiotics but without any noticeable improvement. On the basis of his symptoms and signs, laboratory test and imaging results, and biopsy, we finally made a diagnosis of ITE. After receiving appropriate treatment, the patient was cured completely without the need of surgical intervention.
  1,419 108 -
Direct intraoperative measurement of residual pressure gradient after resection of discrete subaortic stenosis
Jiunn-Miin Lin, Shye-Jao Wu
September-October 2017, 50(5):181-182
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.
  1,370 68 -
Callus formation in bone fractures combined with brain injury in rat
Yu-Ping Chen, Hsin-Chin Shih
March-April 2017, 50(2):57-62
Objective: The objective of this study was to determine the speed of bony union and the serum levels of biomarkers in the setting of bone fractures combined with brain injury. Materials and Methods: In this study, Sprague–Dawley rats were randomized into four groups: sham, brain injury, bone fracture, and bone fracture plus brain injury groups. The serum levels of biochemical markers, namely, nerve growth factor (NGF), Wnt-3a, Dickkopf-related protein-1, receptor-activator of NF-κB ligand, and adrenocorticotropic hormone (ACTH), were measured on the days 1, 3, 7, and 14 following injury. Bony union was evaluated using radiographs every week for 6 weeks. Results: Compared with the brain injury group and bone fracture group, the radiographs of the bone fracture plus brain injury group revealed enhanced callus formations in week 2. From week 3, the callus formation did not differ significantly among the groups. The serum levels of the biomarkers varied at different time points. The serum levels of NGF on days 1 and 3, Wnt-3a on days 3 and 14, and ACTH on days 1, 3, and 7 were significantly higher in the bone fracture plus brain injury group than in the bone fracture group. Conclusions: Brain injury increases callus formation in simultaneous bone fracture. Considering the time point, early NGF, Wnt-3a, and ACTH elevation might be associated with early callus formation enhancement. The results indicate that these brain injury-induced biomarkers might play crucial role in accelerating bone healing.
  1,303 98 -
Invasive lobular carcinoma of breast with synchronous colon metastasis
Zhu-Jun Loh, Kuo-Ting Lee, Wei-Pang Chung, Wen-Chung Chen, Hsueh-Li Kuo, Po-Jun Chen, Hsi-Huei Lu, Hui-Ping Hsu
March-April 2017, 50(2):69-73
Secondary colon malignancy is rare and has a nonspecific presentation. Breast cancer is the second most common malignancy that metastasizes to the gastrointestinal (GI) tract. Here, we present the case of a 54-year-old woman diagnosed with breast cancer and synchronous colon metastasis through a positive result obtained from stool occult blood screening. Colonoscopy revealed a subepithelial tumor of the colon. Biopsy revealed metastatic cancer with positive cytokeratin and GATA-binding protein 3 staining, as well as negative caudal-type homeobox 2 staining. A palpable right breast mass with nipple retraction was found, and invasive lobular carcinoma (ILC) was diagnosed. Multiple bone, left adrenal gland, para-aortic lymph node, and contralateral breast metastases were detected. Multimodality treatment involving systemic chemotherapy, hormone therapy, and modified radical mastectomy was applied. In our clinical experience, colon metastasis from breast cancer is rare and usually mimics primary colon cancer. High-alert speculation and aggressive biopsy for patients with abnormal GI bleeding are indicated for diagnosis. Patients with colon metastasis from ILC of the breast have a poor prognosis. Therefore, multimodality treatments should be applied to improve their prognosis.
  1,236 102 -
Treatment strategies for locally advanced rectal cancer with synchronous resectable liver metastasis
Youn Young Park, Nam Kyu Kim
January-February 2018, 51(1):1-8
Approximately one-third of patients with colorectal cancer are estimated to be diagnosed with synchronous liver metastasis (LM). The only method to get cured is to achieve curative resection for both primary and LM. When it comes to locally advanced rectal cancer with synchronous LM, determination of the treatment strategy for each individual is a quite complex procedure, because it demands sophisticated consideration for both local and systemic control. Timing for the application of systemic chemotherapy (CTx), determination of a chemotherapeutic agent, radiation dose and fractions, and sequencing of preoperative treatment and surgeries are all essential components for establishing optimal treatment strategies for the patients with this disease. In this article, treatment strategies proposed in the literature will be reviewed in the light of oncologic outcomes and treatment toxicity with their possible advantages and disadvantages. Owing to a lack of concrete evidences for the best strategy, this article can guide authors to a better way of determining more tailored treatment for each individual.
  1,139 189 -
Ulnar nerve injury due to lateral traction device during shoulder arthroscopy: Was it avoidable?
Vivek Pandey, Sandesh Madi, Kiran Acharya
November-December 2017, 50(6):220-222
Most of the nerve injuries reported during shoulder arthroscopy in a beach chair, or lateral position is related to inappropriate patient positioning or excess traction. The lateral decubitus position is more vulnerable for traction-related neuropraxia. The present case serves as an important lesson from an avoidable situation of “having a one track mind” of the surgical team during the arthroscopic repair of shoulder instability performed in the lateral decubitus position. The operating surgeon must supervise the appropriate positioning of the patient on operation table and adequate padding of vulnerable bony points before beginning of shoulder arthroscopy to prevent any position-related nerve injuries. This is probably the first case to illustrate an unusual cause of ulnar nerve compression particularly related to the use of an additional traction device in the arthroscopic repair of shoulder instability performed in lateral decubitus position, which has not been previously defined.
  1,220 79 -
Clinical experience of double primary gastric cancer and hepatocellular carcinoma
Po-Da Chen, Chiung-Nien Chen, Rey-Heng Hu, Hong-Shiee Lai
January-February 2017, 50(1):10-15
Background: With improvements in the prognosis of gastric cancer, the clinical importance of treating patients with both gastric cancer and hepatocellular carcinoma (HCC) is increasing because of the high prevalence of HCC in Taiwan. Patients and Methods: We reviewed the medical records of 5468 patients who received a diagnosis of primary gastric cancer at National Taiwan University Hospital between 1980 and 2010. Of these, we identified 18 patients with HCC. Results: Regarding the double cancer cases, six patients received a diagnosis of synchronous cancers, six patients received a diagnosis of HCC during follow-up for gastric cancer, and six patients had undergone HCC treatment before receiving a gastric cancer diagnosis. All the patients who received an HCC diagnosis after gastric cancer underwent curative therapy, except for one patient who had a large hepatic tumor. By contrast, of the patients who received an HCC diagnosis first, only one received an early gastric cancer diagnosis, and the remaining patients received an advanced gastric cancer diagnosis. Despite the presence of double cancers, surgical mortality did not occur in the patients who underwent curative-intended treatment. Conclusion: The study results suggest the necessity of closely following up patients with gastric cancer or HCC for the early diagnosis and treatment of the other malignancy. Aggressive treatments including surgery and radiofrequency ablation are safe and can prolong survival in some patients.
  1,113 146 -
A noninvasive method for preoperative localization of breast microcalcifications
Wei-Hsin Chen, Dah-Cherng Yeh
January-February 2018, 51(1):38-40
Wire localization of breast microcalcifications before surgical biopsy has been used for a long time. However, it causes patient's psychical trauma before operation with more cost of money and time as well. We design a noninvasive method using the concept of trigonometric function for preoperative localization. It can yield potential for cost-savings, increased efficacy in operating room and radiology scheduling, and patient comfort and convenience. Our method is simple and its failure rate is low.
  1,160 71 -
Procalcitonin levels to predict bacterial infection in Surgical Intensive Care Unit patients
Jin You Jhan, Yen Ta Huang, Cian Huei Shih, Jhen Da Yang, Yi Tsen Lin, Shin-Jie Lin, Hsiao Hui Yang, Lee Ying Soo, Guan Jin Ho
July-August 2017, 50(4):135-141
Background: Infection-induced inflammatory response might be aggravated by surgery insults. The clinical presentation of Surgical Intensive Care Unit (SICU) patients might be different from medical critically ill patients. Purpose: To evaluate the diagnostic and prognostic values of procalcitonin (PCT) to predict bacterial infection in SICU patients. Methods: We retrospectively analyzed the 2-year (2013 and 2014) records of 342 adult SICU cases with suspected bacterial infection in SICU of Hualien Tzu Chi Hospital. The past histories, the first infection-related parameters when SICU admission, culture results, infection-related laboratory examinations, and outcomes were collected. Results: Median of PCT level in patients with negative and any positive culture was 0.84 (interquartile range [IQR] 0.18–6.21) and 2.27 (IQR 0.54–9.93) ng/ml, respectively. Infection from blood, urine, and skin/soft tissue elicited significantly higher PCT levels. PCT in receiver operating characteristic (ROC) curve demonstrated the most accurate to predict bacterial infection (area under the ROC curve [AUC]: 0.61; 95% confidence interval [CI]: 0.54–0.63) and bacteremia (AUC: 0.73; 95% CI: 0.66–0.80) compared to white blood cell count, ratio of neutrophils, and neutrophil-to-lymphocyte count ratio (NLCR). Significantly higher PCT levels (4.12 ng/ml, 1.12–19.99; median, IQR) were observed in mortality cases. Higher PCT levels were significantly accompanied with higher NLCR, as well as higher incidence of leukopenia and bandemia. Using Kaplan–Meier analysis, significantly higher intrahospital mortality was observed in cases with above the cutoff PCT levels of 0.5 and 2 ng/ml cases, respectively. Conclusion: PCT is a relatively more useful tool to predict bacterial and particularly bloodstream infection compared to other infection-related parameters in routinely clinical practice. Initial PCT levels may be a prognostic factor of SICU patients with bacterial infection.
  1,064 142 -
Bilateral primary inguinal hernia repair in Taiwanese adults: A nationwide database analysis
Jian-Han Chen, Jin-Chia Wu, Wen-Yao Yin, Cheng-Hung Lee
May-June 2017, 50(3):89-96
Objective: The objective of this study was to identify the long-term rates of and treatment options for recurrence of bilateral primary inguinal hernias following various hernia repair methods, namely, open inguinal hernia repair (OIHR) without mesh, OIHR with mesh (OIHR-M), and laparoscopic inguinal hernia repair (LIHR). Materials and Methods: Data in this retrospective study were retrieved from the Taiwan's National Health Insurance Research Database. All adult patients who underwent primary bilateral inguinal hernia repair were selected from this database using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes. Results: From 2000 to 2010, 13,636 adult patients underwent elective bilateral inguinal hernia repair, with a median follow-up of 63.95 months. The risk of recurrence was significantly lower in the LIHR group than in the OIHR group (hazard ratio [HR] =0.691,P = 0.003) and was similar to that in the OIHR-M group (HR = 1.187,P = 0.184). The median recurrence-free period was 28.93 months. After recurrence, 52.6% of patients underwent repair at the same hospital, and 35.5% of patients were operated on by the same surgeons. The LIHR group had a significantly shorter median recurrent period than did the other groups (OIHR, OIHR-M, and LIHR: 33.83, 23.33, 16.56 months, respectively;P < 0.001). Moreover, recurrence occurred in a significantly higher proportion of patients who were treated by the same surgeon (OIHR vs. OIHR-M vs. LIHR = 31.8% vs. 40.1% vs. 48.6%,P < 0.001). Conclusions: In this large cohort study, the recurrence risk was significantly lower in the LIHR group than in the OIHR group and was similar to that in the OIHR-M group, for primary bilateral hernia repair. In addition, the LIHR group experienced similar mortality as the other groups but lower readmission rates. Moreover, the proportion of LIHR patients treated by the same doctor was significantly higher than that of traditional hernia repair patients. In short, LIHR is a reliable procedure and may offer an improved surgical experience for bilateral primary inguinal hernia repair.
  1,065 105 1
Experience in traumatic small bowel perforation management
Ping-Tze Chen, Hong-Ming Chao
January-February 2018, 51(1):32-37
Small bowel perforations due to blunt abdominal injury are rare. In this study, we compiled five cases of traumatic small bowel perforation and then analyzed a number of the prognostic factors. Elapsed time to surgery was identified as the most important prognostic factor, due to the risk of peritonitis. Laparoscopy surgery appears to be a safe, effective procedure in cases where the diagnosis is uncomplicated by other major problems, such as lacerations to the liver or spleen.
  1,061 87 -
Laparoscopic-assisted peritoneal dialysis catheter insertion with two 5-mm ports: Complications and outcomes of 30 cases
Kung-Ning Hu, Kun-Hung Shen, Chih-Chiang Chien, Chien-Liang Liu
July-August 2017, 50(4):131-134
Introduction: End-stage renal disease has high prevalence in Taiwan, and peritoneal dialysis (PD) is one of the effective treatments. Although the open catheter placement method is more popular, the laparoscopic method is proven to be superior. We present our initial experience with laparoscopic PD catheter insertion. Materials and Methods: We set one 5-mm trocar over the periumbilicus with another assisting 5-mm trocar in a region about 3 cm lateral to the umbilicus. Abdominal exploration using laparoscopy is performed, and enterolysis is also performed if needed. The PD catheter is inserted through the assisted trocar deep into the Douglas pouch under vision. Finally, we check the final condition under laparoscopy and close the wound. Results: A total of thirty patients (median age 56.5 years old, 15 women) underwent this procedure. No intraoperative complications were noted, and the mean operation time was 32 min. Two postoperative complications were found (2/30, 6.7%). Delayed bleeding was noted due to abdominal wall vessel injury while setting the trocar. The vessel was sutured under laparoscopy, which stopped the bleeding. The other complication was tube dysfunction due to omentum wrapping. Laparoscopic revision of the tube was performed. All the complications could be resolved, and the PD was continued. The mid-term tube function at follow-up (at least 16 months) was acceptable in all cases. Conclusions: Laparoscopic-assisted PD catheter insertion is a feasible procedure that can reduce wound pain with acceptable PD function.
  1,035 78 -
Shah-Waardenburg syndrome
Rahul Gupta, Dinesh Kumar Barolia, Ramesh Tanger, Lila Dhar Agrawal, Arun Kumar Gupta, Ram Babu Goyal
September-October 2017, 50(5):163-168
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.
  1,004 97 1
Thoracoscopic repair of esophageal atresia: Comparison with open approach
Chun-Hui Lin, Yih-Cherng Duh, Yu-Wei Fu, Yao-Jen Hsu, Chin-Hung Wei
May-June 2018, 51(3):105-110
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.
  945 120 -
Can mechanical bowel preparation with oral antibiotics reduce surgical site infection and anastomotic leakage rates following elective colorectal resections?
Wen-Chun Sun, Hsi-Hsien Hsu, Hao-Che Liu, Chien-Kuo Liu
January-February 2018, 51(1):21-25
Background: Surgical site infection(SSI) and anastomotic leakage are major causes of morbidity after colorectal resections. Mechanical bowel preparation (MBP) combined with oral antibiotics (OAs) was considered to reduce SSI and anastomotic leakage. Purpose: This study analyzed the influence of oral antibiotic use together with MBP on SSI, anastomotic leakage rate and length of hospital stays in patients with elective colorectal surgery. Materials and Methods: From January 2013 to December 2015, 321 patients who underwent elective colorectal resections with complete bowel preparation were included in the study. All patients received MBP. Patients in group A did not receive OAs, whereas patients in group B received OAs. Exclusion criteria were emergent operation, colonoscopy, colostomy or closure of colostomy and received preoperative chemoradiotherapy. The outcome measured was SSI, anastomotic leakage and prophylactic colostomy. Results: Of 321 patients, group A (n =122) and group B (n =199), both groups had similar age, gender, localization and stage of the disease, underlying disease, prophylactic stomy and operation time. Patients receiving OAs with MBP didn't demonstrated a lower rate of SSI and lower leakage rate after multivariate logistic analysis. Conclusions: OAs with MBP prior to elective colorectal resection was no better than MBP only on reducing SSI and anastomotic leakage rates. And OAs will increase patients uncomfortable and GI function side effect. Therefore, MBP alone might be enough colon prepare and higher compliance for the patients.
  895 122 -
Unusual presentation of a late complication in a polyacrylamide gel-injected breast
Hui-Ling Peng, Yi-Ho Cheng, Yu-Hsien Lin, Chun-Hung Ko
March-April 2017, 50(2):77-80
Implant migration is a known complication of hydrophilic polyacrylamide gel (PAAG) mammoplasty. We report the case of a female patient with an undisclosed history of bilateral breast augmentation with PAAG injections 10 years ago. The patient presented with abdominal pain and rapid gel migration into the abdominal and pelvic walls after sneezing. Computed tomography and sonography were performed, but the results were inconclusive. The diagnosis of PAAG migration was not made until the patient complained of progressive shrinkage of her right breast and disclosed the history of PAAG mammoplasty. A subsequent magnetic resonance imaging study confirmed the diagnosis. Gel migration was successfully treated using endoscopic lavage and breast debridement. Familiarity with the radiological features of PAAG migration and a thorough examination of the patient's history are mandatory for the accurate diagnosis of this complication.
  904 93 1
Natural orifice specimen extraction with single-stapling anastomosis for distal colon resection: Feasibility and outcomes
Yu-Chun Huang, Sheng-Chi Chang, Hua-Che Chiang, Tao-Wei Ke, Hwei-Ming Wang, William Tzu-Liang Chen
January-February 2017, 50(1):16-20
Background: The double-stapling technique (DST) and triple-stapling technique used in laparoscopic anterior resection are considered risk factors of leakage or anastomotic leakage. A high anastomotic leakage rate could be avoided by the single-stapling technique (SST). Purposes: This study analyzed the feasibility, as well as the operative and immediate postoperative outcomes of natural orifice specimen extraction (NOSE) with single-stapled anastomosis. Materials and Methods: We retrospectively analyzed the data of 82 patients from China Medical University Hospital who underwent elective surgery from January 2012 to April 2015 for benign or malignant lesions that were between 10 and 40 cm from the anal verge, ≤5 cm in diameter on radiological examination, and in stage T1-T3/Nx/M0. All patients were monitored according to the enhanced recovery after surgery protocol. Results: NOSE with SST was feasible and showed intraoperative complication and morbidity rates of 2% and 7.3%, respectively. No patients needed conversion to open surgery. The rate of conversion to NOSE with DST was 6.1%. Moreover, the anastomotic leakage rate was 2.4%. Total hospital stay required was 4.8 ± 3.4 days. The first postoperative bowel movement observed was at 1.2 ± 0.5 days. Conclusions: Although SST is technically challenging, NOSE with SST is as feasible and as NOSE with DST.
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Traumatic scrotal anal fistula
Shao-Ming Chen
May-June 2017, 50(3):107-109
Scrotal wounds are most often related to infection or allergy and are generally identified in urology clinics. Topical medications, which are generally applied initially to the wound, can assist with spontaneous healing without any sequelae. However, further workup is sometimes required if the wound does not heal properly. Herein, we present two cases which were finally diagnosed as traumatic scrotal anal fistulae, for which surgical excision was clearly indicated.
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Cytomegalovirus infection in a kidney transplantation patient presented with skin lesion
Shun-Kai Chang, Yeong-Chin Jou, Show-Hwa Tong, Yen-Fen Lin, Yu-Ling Kuo, Jia-Fang Wu
May-June 2017, 50(3):114-116
Cytomegalovirus (CMV) infection commonly occurs after major organ transplantation. It mostly presents gastrointestinal tract symptoms in clinical manifestation. Dermatologic lesion as a main presenting feature for posttransplantation CMV is very rare. Here, we report a case of CMV infection predominated by skin ulcers in genitalia and perianal area in a 59-year-old female who received renal transplantation 3 months ago. She had initially been treated with both oral and topical antibiotics for suspicious bacterial or fungus infection without response. Subsequent serological study proved positive CMV infection. After treatment of ganciclovir and valganciclovir for 2 weeks, respectively, the skin ulcers healed gradually. This case report suggests that CMV-induced skin infection should be concerned in the diagnosis of poor healing skin ulcers in patients received organ transplantation.
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