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   2017| November-December  | Volume 50 | Issue 6  
    Online since December 8, 2017

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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.
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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.
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Toxoplasmosis lymphadenitis of parotid gland concurrent with papillary thyroid carcinoma: A dilemma in differential diagnosis
Yu-Chen Hsu, Chien-Chin Chen, Chih-Hsuan Changchien
November-December 2017, 50(6):215-219
We report a case of toxoplasmosis lymphadenitis simulating a parotid mass concurrent with a papillary thyroid carcinoma. A 55-year-old male presented symptomless masses in the left lower neck and right preauricular region for 2 months. Physical examination revealed a 2 cm × 2-cm firm mass in the right parotid region and a 3-cm diameter soft mass in the left lobe of thyroid gland. Computed tomography confirmed a lobulated nodule, embedded in the right parotid gland, and; a left thyroid nodule, which resembled a papillary thyroid carcinoma. Fine-needle aspiration (FNA) of the left thyroid lobe suggested a papillary thyroid carcinoma. A radical thyroidectomy, central neck lymph node dissection, and right superficial parotidectomy were performed. Histopathological examination of the surgical specimen supported the diagnosis of a papillary carcinoma of the left thyroid lobe and toxoplasmosis lymphadenitis in the right parotid gland. Specific serum immunoglobulin tests suggested a current infection with Toxoplasma gondii. The patient was administered pyrimethamine and sulfadiazine for 4 weeks and underwent I-131 ablation for the functional thyroid remnants in the anterior neck. At a 16-month follow-up, the patient was clinically fit and recurrence free. This case highlights the importance of remaining clinically vigilant to differentiate an unusual metastatic carcinoma from inflammation of the parotid gland. A consideration of toxoplasmosis lymphadenitis by thorough history taking, appropriate serologic tests, and selective use of FNA may provide combined preoperative information for differential diagnosis of a parotid mass and help avoid an unnecessary surgical procedure.
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Pelvic fracture does not increase mortality in adult trauma patients: A propensity score analysis
Ching-Hua Hsieh, Chih-Che Lin, Shiun-Yuan Hsu, Hsiao-Yun Hsieh
November-December 2017, 50(6):200-208
Background: This study was designed to investigate the impact of pelvic fracture on the outcome of trauma patients. Methods: Detailed data of 512 and 20,159 adult patients with and without pelvic fracture, respectively, hospitalized between January 1, 2009, and December 31, 2015 were retrieved from the Trauma Registry System of a level I regional trauma center. Two-sided Fisher exact or Pearson Chi-square tests were used to compare categorical data. The unpaired Student t-test and Mann–Whitney U-test were used to analyze normally and nonnormally distributed continuous data, respectively. Propensity score matching was performed using NCSS software to evaluate the effect of pelvic fracture on mortality and expenditure. Results: Patients with pelvic fracture presented with a longer hospital stay, a higher likelihood of being admitted to the Intensive Care Unit, and a significantly higher incidence of mortality (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.3–3.5; P = 0.003) than those without pelvic fracture. However, the logistic regression analysis of 316 well-balanced pairs of patients with matched propensity scores (to eliminate the difference in sex, age, comorbidity, Glasgow coma scale, and injury severity score) showed that the association of pelvic fracture did not significantly influence mortality (OR 1.2, 95% CI 0.6–2.5; P = 0.581). Conclusions: This study revealed that the higher odds of mortality in patients with pelvic fracture can be attributed to a combination of multiple injuries to different body regions and risk factors of the patients.
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Multiple primary malignant neoplasms: Results from a 5-year retrospective analysis in a Metropolitan Hospital
Chih-Cheng Sun, Chi-Chang Chang
November-December 2017, 50(6):209-214
Background: The high effectiveness of cancer screening and therapies resulted in the increased diagnosis of multiple primary malignancies (MPMNs) in Taiwan. The aim of the present study was to investigate the clinical data of patients and to determine the frequency and clinical features of MPMNs. Methods: Between January 2010 and December 2014, a total of 2518 patients were screened and obtained retrospectively from the Tumor Registry Center of a metropolitan hospital. We quantified the clinical features and the most common cancer pairs of MPMNs using statistical and epidemiological indicators. Results: Two hundred and eleven patients with MPMNs were evaluated. The median age at initial cancer diagnosis was 63 years old (range 12–100 years). The median age of diagnosis of secondary cancer was 67 years old (range 35–95 years). The median time between initial and secondary cancer diagnoses was 5 months (range 0–57.1). The overall incidence of MPMNs was 8.38%, and the male: female ratio was 2.01:1. The most frequent types of cancer at secondary diagnosis were digestive (79 patients, 3.05%), breast (22 patients, 0.87%), liver (22 patients, 0.87%), head-neck (18 patients, 0.71%), and bladder cancer (14 patients, 0.56%). In women, the most frequent types of cancer at secondary diagnosis were digestive (25 cases, 2.21%), breast (22 cases, 1.95%), liver (11 cases, 0.97%), lung (8 cases, 0.71%), and gynecologic cancer (7 cases, 0.62%). In men, the most frequent types of cancer at secondary diagnosis were digestive (54 cases, 3.89%), head-neck (16 cases, 1.15%), liver (11 cases, 0.79%), bladder (10 cases, 0.72%), and prostate cancer (10 cases, 0.72%). The most common cancer pairs in males were digestive/digestive (22 cases, 1.59%), head-neck/head-neck (4 cases, 0.29%), lung/digestive (3 cases, 0.22%), and prostate/bladder (3 cases, 0.22%). In addition, tobacco smoking, alcohol consumption, and betel-chewing were observed to be important risk factors for the development of MPMNs. Conclusion: Indeed, the cancer registries can help us understand the disease better and use our resources to the best effect in prevention and treatment of MPMNs. In the present study, we discovered that patients with MPMNs tend to be older than those with a single primary malignant neoplasm. In conclusion, the clinical features and the most common cancer pairs of MPMNs are demonstrated in the present study. Based on these data, further analysis of the relationship between them is worthwhile.
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Pancreatoblastoma in a child
Aditya Pratap Singh, Ramendra Shukla, Ramesh Tanger, Arun Kumar Gupta
November-December 2017, 50(6):227-230
Pancreatoblastoma (PB) is a rare pancreatic tumor in children. Its biologic behavior is aggressive with frequent local invasion, recurrence, and metastasis, for which there has been no standard treatment regimen. Complete surgical resection has been considered for long-term survival of patients with PB. We present here a case of PB in a 3-year-old male child.
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Craniocervical junction spinal dural arteriovenous fistula presenting with progressive myelopathy and sudden deterioration
I-Cheng Lin, Hsiu-Ching Wu, Chieh-Hsin Wu, Wei-Chen Lin, Ann-Shung Lieu
November-December 2017, 50(6):223-226
Spinal dura arteriovenous fistula (SDAVF) is not an uncommon vascular malformation but is rare at craniocervical junction. The initial presentation is usually subarachnoid hemorrhage or cervical myelopathy caused by venous hypertension of the drainage vein. We report a male patient who has sudden onset of paraplegia, anesthesia of bilateral lower limbs, and urine retention. Cervical spinal cord edema and engorgement of posterior and anterior spinal veins were noted on magnetic resonance image study. Angiogram disclosed a SDAVF feeding by meningeal branch of the left vertebral artery and drainage inferiorly through posterior and anterior spinal vein. Complete obliteration of the fistula was achieved by transarterial embolization with n-butyl cyanoacrylate. The muscle power of lower limbs improved after the embolization. In previous studies, functional outcome is most correlated with pretreatment condition. Early diagnosis and treatment of the lesion will prevent permanent neurological deficit.
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Prophylactic antibiotics and percutaneous nephrolithotomy
Beuy Joob, Viroj Wiwanitkit
November-December 2017, 50(6):231-231
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