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   Table of Contents - Current issue
March-April 2022
Volume 55 | Issue 2
Page Nos. 39-74

Online since Monday, April 25, 2022

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Traumatic blunt aortic injury: experience in one hospital p. 39
Che-Hui Yeh, Jiun-Yi Li
Background: Traumatic blunt aortic injury (TBAI) is a rare event with an incidence rate of approximately 2.6 patients per year at a medical center. However, high rates of early mortality render it the second leading cause of mortality among traumatic injuries. The optimal management and long-term outcomes after intervention therapy remain unclear. We reviewed TBAI cases in our hospital and discussed the surgical strategy. Materials and Methods: We retrospectively analyzed ten patients diagnosed with TBAI between 2006 and 2019 in our Health insurance database. We used the grading system of the Society of Vascular Surgery. Patients who were classified as Grade 1 or 2 injuries received nonoperative treatment. Patients who were classified as Grade 3 or 4 injuries underwent surgical intervention. Follow-up computed tomography angiography was arranged within 1 year of discharge. Results: Two and seven patients presented with Grade 2 and 3 aortic injuries, respectively. One patient incidentally found chronic Type B aortic dissection after trauma. For one early case, open aortic replacement was performed. Four (including one brain dead) patients received nonoperative treatment. Five patients underwent percutaneous thoracic endovascular aortic repair. Nine patients survived after treatment. Three of the five patients who underwent endovascular repair developed postoperative complications, including endoleak and paraplegia. Two patients who underwent nonoperative treatment showed complete resolution within 2 months. Conclusion: In selected cases with Grade 2 injury, nonoperative treatment may be appropriate and complete resolution of intramural hematoma may occur.
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The absence of urinary diversion in radical cystectomy avoids early complications in hemodialysis patients p. 44
Yun-Ta Yang, Jui-Ming Liu, Cheng-Feng Lin, Kuan-Lin Liu, Cheng-Chia Lin, Chun-Te Wu
Background: Patients with end-stage renal disease who receive dialysis are considered a high-risk group for perioperative complications following anesthesia and surgery. However, for patients with anuria who will undergo radical cystectomy (RC), a urinary diversion is unnecessary. This study aimed to identify a safe surgical strategy by comparing oncologic outcomes and early complication rates in dialysis and nondialysis patients after RC. Materials and Methods: This study included 85 patients with primary urothelial cell carcinoma of the bladder who underwent RC at the Chang Gung Memorial Hospital, Keelung, Taiwan. Twenty-eight of these patients underwent regular hemodialysis. Overall survival and recurrence-free survival were compared to evaluate the oncologic outcomes. Complications at 3 months were graded using the Clavien–Dindo classification. Results: The overall survival and recurrence-free survival differences between dialysis and nondialysis patients were not significant (P = 0.686; P = 0.528). The degree of muscle-invasive disease was an independent factor affecting overall survival. The overall complication rates in the dialysis and nondialysis groups were 36% and 84%, respectively (P < 0.001). The major complication (Grades III–V) was 16% in the dialysis group and 28% in the nondialysis group (P = 0.241). The most common early complications were urinary tract infection and bowel kinetics change, and both were significantly lower in the dialysis group. A lower re-admission rate was also observed in the dialysis group. Conclusion: Lower rates of early complications and acceptable survival outcomes were observed in dialysis patients. Surgery can be conducted more aggressively, with confidence in suitable cases.
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Pelvic splenosis in a patient with a 20-year history of splenectomy p. 52
Wei-Lun Huang, Chun-Ting Chu
Pelvic splenosis, also called ectopic pelvic spleen, is a rarely reported clinical condition. Pelvic splenosis refers to autotransplantation of splenic tissue resulting from seeding into the pelvic space that typically occurs after trauma. This report presents the case of a 39-year-old male with a rectal lesion. After a laparoscopic low anterior resection of rectosigmoid colon with colorectal anastomosis, the lesion was resected and diagnosed as an ectopic pelvic spleen. Pelvic splenosis requires no treatment in most cases. Surgery is considered only if it is accompanied with acute complications. When the diagnosis remains unclear, further biopsy or laparoscopy is recommended. If pelvic splenosis is confirmed, careful follow-up is beneficial. Finally, pelvic splenosis should be considered in the differential diagnosis of pelvic masses in patients with a history of splenectomy.
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Robotic pancreaticoduodenectomy in a patient with situs inversus totalis and variant celiacomesenteric trunk p. 56
Bor-Shiuan Shyr, Bor-Uei Shyr, Shih-Chin Chen, Yi-Ming Shyr, Shin-E Wang
Situs inversus totalis (SIT) is a rare congenital anomaly characterized by right–left reversal of visceral organs and dextrocardia; the use of robotic pancreaticoduodenectomy (RPD) may be challenging in these patients. A male patient presented with jaundice; imaging studies revealed a bile duct tumor and SIT with variant celiacomesenteric trunk and multiple vascular anomalies. RPD was carried out cautiously and successfully. The trocar port design mirrored that of a normal patient. Pathological examination revealed extrahepatic bile duct adenocarcinoma, classified as pT3N1M0, stage IIB. The patient recovered uneventfully. Although difficult, RPD is technically feasible in an SIT patient with cholangiocarcinoma.
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Nonischemic priapism treated with selective arterial embolization p. 60
Ting-Jui Hsu, Bang-Ping Jiann, Cheng-Hsun Hsueh
Nonischemic priapism is a rare, painless, and nonurgent type of priapism which is usually related to a history of perineal trauma. It can be distinguished from ischemic priapism by history taking and oxygenated, nonacidotic blood in cavernous blood gas analysis. The diagnosis is further confirmed by elevated cavernosal artery blood flow under color Doppler ultrasound. This article reviews the diagnosis and intervention of two cases with nonischemic priapism. The patients received selective arterial embolization with either microcoil or Gelfoam. Both of them were satisfied with their erectile function 1 week after embolization. Our practice reflects that selective arterial embolization is a safe and effective treatment for patients with nonischemic priapism.
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Sacrococcygeal teratoma Type IV presenting as anal canal duplication: Lessons learned p. 64
Rahul Gupta, Girish Saini, Arun Gupta
We present an extremely rare association of anal canal duplication with sacrococcygeal teratoma Altman's Type IV. A 3-year-old female child presented with anal discharge, itching, and vague perineal pain. On examination, a small second opening of 5 mm in size and 2.5 cm in length was located just posterior to the normal anus at 6 'o'clock position. The lumen ended blindly without connection to the normal anorectum. Ultrasound and radiological investigations were normal. During excision of the duplicated tract, it was seen arising from a presacral mass which was completely excised along with coccygectomy. Biopsy was confirmed mature teratoma and anal canal duplication.
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Colonic perforation due to advanced prostate cancer in prostate-specific antigen era p. 67
Manoj Kumar, Reva Shankar Sahu, Ruchi Sinha, Rajeev Nayan Priyadarshi
Prostate cancer presentation with perforation peritonitis due to rectal infiltration is quite rare. We report a 53-year-old man who presented with rectal growth resulting in bowel obstruction and transverse colon perforation, for which emergent exploration was performed. Postoperative evaluation with imaging, serum tumor markers, and histopathological examination including immunohistochemistry revealed it to be prostate cancer infiltrating to surrounding structures including the rectum. It is rare to observe such advanced cases in the era of serum prostate-specific antigen screening, but a high index of suspicion is necessary for adequate diagnosis and treatment, eventually benefitting the patient.
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Case report of delayed metastasis from thyroid micropapillary carcinoma to the deltoid muscle in a patient with thyroglobulin elevated negative iodine scintigraphy (TENIS) p. 70
Riju Ramachandran, Anoop Vasudevan Pillai, Sanju Samuel
Differentiated thyroid cancers are common but distant metastasis to the muscles is rare. We present a case of 64-year-old male who underwent thyroidectomy for a suspicious thyroid lesion. His histopathology was reported as widely invasive follicular carcinoma of the thyroid with a focus of micropapillary carcinoma (MPC). He underwent radioiodine ablation. On follow-up, he had a serial increase in thyroglobulin but a whole-body radioiodine scan failed to detect any lesion. An 18-fluorodeoxyglucose positron emission tomography (PET)-computed tomography scan picked up a lesion in the left deltoid muscle. An intraoperative ultrasound localization was done and the nonpalpable lesion was successfully removed surgically. The deltoid lesion was a delayed metastasis of a thyroid MPC. A rising thyroglobulin level in a patient with negative iodine scintigraphy warrants further evaluation with PET since rare distant metastasis may be present. A surgeon performing intraoperative ultrasound is useful in effectively identifying and removing occult lesions with small incisions.
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