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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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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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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Radial nerve palsy commonly associated with humeral shaft fracture, at the time of injury (primary), after manipulation (secondary), or late onset (not related to injury or manipulation). For the latter, there are still few documented cases regarding late-onset radial nerve palsy. In this case report, we present a case of late-onset radial nerve palsy associated with humeral shaft fracture treated with coaptation splint, which became evident 5 weeks after treatment. Surgical exploration revealed that the radial nerve had become stretched and encapsulated in callus and fibrous tissue. Neurolysis was performed with subsequent recovery of the radial nerve 12 weeks after the surgery.

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Extraskeletal osteosarcoma is extremely rare in human beings, in contrast with liposarcoma, one of the most common types of soft-tissue sarcoma. Lung extraskeletal osteosarcoma was only published in a few case reports, with even less associated with soft-tissue liposarcoma. Within those few reports, no case has mentioned the coexistence of liposarcoma and lung extraskeletal osteosarcoma in the same patient. Herein, we present a very rare case of a patient who suffered a right middle lobe lung extraskeletal osteosarcoma for 20 months, following a complete left chest wall pleomorphic liposarcoma adjuvant therapy. Pleomorphic lipoblast with atypical mitosis was found in previous histology slides; however, typical osteoid was found in the right middle lobe pleura. Unfortunately, although adjuvant chemotherapy with high-dose radiotherapy was arranged immediately, the patient still died in 4 months. According to the literature review, chemotherapy and radiotherapy could induce gene mutation and subsequent transformation of cancer types or mix two cancer types. Since the two tumors can grow rapidly in a short period, the possibilities of cancer recurrence or formation of double primary cancers should not be neglected.

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Liver abscess caused by foreign-body penetration of the alimentary tract is rare. Preoperative diagnosis is difficult as patients are often unaware of the foreign-body ingestion and the unusual characteristic is often being paucisymptomatic until secondary complications occur. We report a patient with fishbone-related liver abscess. Preoperative demonstration of a hyperdense, linear lesion was performed by computed tomography. He was treated successfully after removal of the foreign body and drainage of the abscess.

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Background: A presacral tumor (PT) is a rare, congenital abnormality. PTs may present similarly to Hirschsprung disease (HD) in early infancy. Through this case report, we share our experiences regarding patients with a PT mimicking HD. Materials and Methods: The medical records of patients with a PT at our hospital were retrospectively reviewed. The parameters investigated included age, sex, presentation, imaging findings, operation procedures, pathology, and bowel and bladder function outcomes. Results: Three patients who were aged 38, 15, and 1.5 years at the latest follow-up were identified. All patients were initially diagnosed with HD; of these patients, one had concomitant anal stenosis. The patients individually received abdominal Duhamel, abdominal Soave, and transanal Soave procedures. PTs were incidentally found after pull-through through a laparotomy in two patients and imaged in one patient. All patients had sacral bone defects that were evident on plain radiographs. The PTs in two cases were separately excised through laparotomy and the posterior approach. Postoperative bowel dysfunction was noted in all patients and was treated with permanent colostomy and regular enemas and laxatives. Two of the three patients developed neuropathic bladders and subsequent upper urinary tract injury. Sexual dysfunction was noted in the adult patient. Conclusions: PTs may mimic HD, delaying their diagnosis. Sacral dysgenesis evident on plain radiographs is the key to early detection. Long-term surveillance is imperative.

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A 55-year-old male patient received an anoplasty at infancy for low-type anorectal malformation, and intractable constipation was observed since. The patient presented with colitis at the emergency department. Computed tomography revealed feces with a megarectosigmoid of diameter 18 cm. Hirschsprung disease was suspected on the basis of the imaging findings. Therefore, a rectal biopsy was performed, which indicated the presence of normal ganglion cells. Bowel management was implemented with one large-volume enema to empty the huge rectal pouch daily. The patient was free of constipation and had an improved nutritional status with appropriate weight gain in 3 months. A laparoscopic Swenson pull-through was performed. The hospital course was uneventful. Enemas, loperamide, and water-soluble fibers were required for frequent soiling because of postoperative hypermotile colon. The treatments were weaned off gradually. At the latest follow-up (2 years postoperatively), the patient had regular voluntary bowel movements with complete bowel control.

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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.

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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.

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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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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.

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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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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.

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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.

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Background: The postoperative recurrence rate of chronic subdural hematomas (CSDHs) ranges from 9% to 20%, which is a serious concern for neurosurgeons. Both qualitative and quantitative assessment methods have been developed to identify the mechanisms involved in postoperative recurrence. These methods include Nakaguchi's clinical classification scheme and the quantification of mean hematoma density (MHD). This is the first study to examine the correlations between the quantification of MHD and Nakaguchi's clinical classification of patients with CSDHs. Materials and Methods: This study investigated 35 consecutive cases of CSDH between July 2010 and July 2013. In accordance with Nakaguchi's clinical classification, CSDH cases were separated into four groups: homogenous, laminar, separated, and trabecular. In addition, we quantified the area of the hematoma according to MHD using a computer-based image analysis of preoperative brain computed tomography scans. Results: The mean age of patients was 72.2 ± 8.05 years (range: 55–86). Mean MHD values were as follows: trabecular (12.45 ± 0.72 HU), homogenous (14.46 ± 4.51 HU), laminar (25.99 ± 0.93 HU), and separated (36.32 ± 3.04 HU). Differences in MHD were statistically significant for all CSDH types (P < 0.001, ANOVA with Student–Newman–Keuls post hoc test), and we observed a significant linear relationship between MHD and the priority order of clinical CSDH types determined according to postoperative recurrence (Spearman's rank correlation coefficient = 0.842, P < 0.001). Conclusions: This study provides statistical evidence that MHD is significantly correlated with Nakaguchi's clinical classification of CSDH. The applications of MHD quantification and hematoma's internal architecture helped to gain better understanding of possible mechanisms underlying CSDH recurrence.

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Background: Tailgut cysts are rare congenital lesions that are generally located in the retrorectal regions. We performed a cases series in Taiwan to compare with others. Materials and Methods: The demographics, clinical presentation, surgical management, pathological features, and long-term outcome of 14 patients of tailgut cysts diagnosed at Taipei Veterans General Hospital from 1989 to 2018 were reviewed. Results: In this series, 11 patients (78.6%) were female with the mean age of 46.7 (18–75) years. The majority of cases (83.3%) were symptomatic with variable manifestations. All patients received radiological examination and/or endoscopy. One case underwent biopsy before the therapy. Surgical methods included Kraske, transanal, abdominal, and combined approaches. Tailgut cysts were benign in ten patients (71.4%) and malignancy included mixed adenoneuroendocrine carcinoma, carcinoid tumor, and borderline mucinous tumor. No long-term adverse effect was reported. There was no recurrence of benign tailgut cysts during the median follow-up of 3 years. Conclusion: Tailgut cysts are uncommon and diagnosed predominantly in the middle-aged female. They can present with variable clinical manifestations, and diagnosis relies on image study. A routine preoperative biopsy is not indicated as it can be uninformative or false negative. Complete surgical excision is recommended even in asymptomatic cases for definite diagnosis and the possibility of malignant transformation. A variety of surgical approaches can achieve complete surgical removal and avoid recurrence if being planned ahead by image carefully.

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Background: This study aims to compare the prophylactic effects of dexamethasone, ketamine, and dexmedetomidine versus normal saline on intra- and postoperative nausea and vomiting (PONV) associated with cesarean section (CS) under spinal anesthesia. Materials and Methods: A double-blind prospective clinical trial was performed on 140 patients scheduled for elective CS and was assigned randomly to four groups. The first group received 20 cc normal saline; the second group received dexamethasone at a dose of 0.1 mg/kg; the third group received ketamine at a dose of 0.5 mg/kg; and the fourth group received IV dexmedetomidine (1 μg/kg). Nausea and vomiting score was measured by visual analog scale and sedation levels by Ramsay sedation scale (RSS). Results: There was a significant difference among the four groups in PONV scores immediately after and 1, 2, 3, and 4 h following administration of the drug (P = 0.001). Nausea and vomiting score was the lowest in the dexmedetomidine group. Significant differences were observed in Ramsey score at the 10^th–110^th min following administration, and the dexmedetomidine group had a higher RSS than the other groups. The incidence of metoclopramide intervention in three experimental groups is comparable. Heart rate (HR) and mean blood pressure show decreasing trend following spinal anesthesia in dexmedetomidine group. Conclusion: The tested groups (dexamethasone, dexmedetomidine, and ketamine) all present a lower incidence of nausea and vomiting than the placebo group. In addition, dexmedetomidine provides the best efficacies in the reduction of nausea and vomiting but is more liable in lowering blood pressure and HRs. We recommend that dexmedetomidine is the drug of choice in decreasing nausea and vomiting for patients undergoing CS with spinal anesthesia.

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Background: The last few years have seen the emergence of minimally invasive mediastinal parathyroidectomy. Here, we report our single-center experience with this procedure. Materials and Methods: Between December 2002 and September 2017, we performed minimally invasive mediastinal parathyroidectomy in 12 patients with primary (n = 4) or secondary (n = 8) hyperparathyroidism (median age: 54.5 years; interquartile range: 50.5 − 62.75 years). The following variables were retrospectively collected from clinical records: demographic characteristics, results of imaging studies, surgical approach, complications, and final pathological diagnosis. Results: Technetium-99 m sestamibi examinations were performed for preoperative localization of the ectopic parathyroid glands in 11 patients (91.67%). All cases successfully underwent minimally invasive mediastinal parathyroidectomy, without the necessity to convert to open surgery. The most commonly used minimally invasive approach was video-assisted thoracoscopic surgery (n = 10; 83.33%) followed by mediastinoscopy (n = 2; 16.67%). The anatomical locations of the ectopic glands were as follows: intrathymic in six patients (50%), within the aortopulmonary window in 1 patient (8%), and in other intrathoracic sites in five patients (42%). Parathyroid adenomas and parathyroid hyperplasias were diagnosed in 5 (42%) and seven patients (58%), respectively. There were no perioperative deaths, and the median length of hospital stay was 5.5 days. Conclusion: Minimally invasive removal of mediastinal ectopic parathyroid glands is safe and feasible if their anatomical position is accurately determined. Surgical approaches depend on gland location and the surgeon's preference.

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Background: Geriatric trauma demands attention in aging societies. The trauma hospitalization rate gradually increases in elderly populations because they are more vulnerable to accidental injuries. High trauma admission rates among elderly groups led to further research about injury patterns and outcomes. We hope to understand more about the demographic patterns and mortality rate of geriatric trauma. Methods: Information about all injured in-hospital patients ≥64 years was retrieved from a claims dataset from 2007 to 2008 from the Bureau of National Health Insurance in Taiwan. Statistical analyses were conducted on the population-based dataset to discover the incidence, mortality rate, percentage of chronic illness, and associations among variables such as age group, gender, injury mechanism, injury severity, and mortality. Results: A total of 134,024 patients (28.2% of total inpatients' admissions) ≥64 years were admitted in 2007 and 2008; 45.0% were male patients, and 43.9% were rural residents. These resulted in 4120 deaths. Nearly 40.0% of patients had at least one chronic illness. Diabetes mellitus was the most common comorbidity (20.2%). Injury was most commonly caused by falls on the same level, followed by motorcycle accidents. A higher mortality rate was observed in the subgroup with higher injury severity scores. Logistic regression showed that the mortality rate was significantly higher in subgroups comprising patients aged 75–84 and >84 years, with higher Charlson index, and with mechanisms such as pedestrians hit by vehicles or falls from height. Conclusion: High trauma hospitalization rates among elderly people can be reduced. Choosing a target population for injury prevention policy is required to reduce the geriatric trauma hospitalization rate. A regionalized trauma system providing the elderly population with optimal trauma care is mandatory.

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Background: Lactate is a widely used biomarker for patients with conditions such as infection or trauma. The value of lactate level in risk stratification is rarely investigated for patients admitted to the surgical Intensive Care Unit (ICU), regardless of diagnosis. Purposes: This study examines whether arterial lactate levels at the approximate time of admission can predict short-term mortality in all unscheduled surgical ICU patients. Materials and Methods: A retrospective cohort study of all unscheduled surgical ICU admissions from July 2010 to June 2013 was conducted. Patients were stratified into low (<2.0 mmol/L), intermediate (2.0–3.9 mmol/L), and high (≥4.0 mmol/L) lactate groups according to initial lactate measurements. The primary endpoint was 28-day mortality. Results: Of 1404 eligible admissions, 163 (11.6%) of them died within 28 days. Admission lactate levels were significantly higher in nonsurvivors than in survivors (P < 0.001). Multiple regression analysis showed that both intermediate and high lactate levels were independent risk factors for mortality. Patients with a high lactate level had an odds ratio (OR) of 1.81 (95% confidence interval [CI] 1.12–2.91; P = 0.015) relative to patients with a low lactate level. Patients with an intermediate lactate level had an OR of 1.73 (95% CI 1.07–2.79; P = 0.025) relative to patients with a low lactate level. Other independent predictors of mortality included Acute Physiology and Chronic Health Evaluation II score, existence of malignancy, and thrombocytopenia. Conclusion: An admission arterial lactate level of 2.0 mmol/L or higher at the time of ICU admission can be used to identify high-risk surgical patients.

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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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Background: The aim of this study was to evaluate practicable predictors of 5-year disease-free survival (DFS) and impact of 5-fluorouracil (5-FU)-based adjuvant chemotherapy in stage IIa and IIb colon cancer. Materials and Methods: A total of 1474 patients with stage II colon cancer were enrolled in study. The independent predictors of 5-year DFS and the benefits of adjuvant chemotherapy were analyzed for patients with stage IIa (n = 771) and IIb (n = 703). Results: The incidences of pretreatment anemia, hypoalbuminemia, emergent surgery, and lymphovascular invasion (LVI) corresponded significantly to an advanced T-stage in patients with stage II colon cancer. Although the incidence of surgical morbidity was not different between stage IIa and IIb, stage II patients with hypoalbuminemia had a higher incidence of surgical morbidity than did those with normal serum albumin (17.2% vs. 9.6%, P < 0.001). The co-independent survival predictors in patients with stage IIa and IIb colon cancer were carcinoembryonic antigen (CEA < 5 ng/mL, P = 0.007 and 0.043), serum albumin (≥3.5 g/dL, P < 0.001 and P = 0.025), and nonsurgical morbidity (P < 0.001, both). Suboptimal lymph node harvest (<12 examined nodes, P < 0.001) and no adjuvant chemotherapy (P = 0.008) were poor prognostic factors only in stage IIb colon cancer. LVI showed a trend to worse DFS (P = 0.059). A survival benefit from adjuvant chemotherapy analyzed in four subgroups stratified by stage IIa and IIb, with or without the present prognostic factors, was only observed in patients with stage IIb colon cancer with hypoalbuminemia, abnormal CEA, suboptimal lymph node harvest, and postoperative morbidity. Conclusion: Different predictors of DFS were observed in stage IIa and IIb colon cancer; adjuvant chemotherapy could provide a survival benefit for patients with stage IIb colon cancer who have one of the four factors that were studied in our hospital-based analysis.

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Background: Although thoracic endovascular aneurysm repair (TEVAR) has been widely used as the first choice of emergency surgical procedure for ruptured descending thoracic aortic aneurysms (rDTAAs), the risk factors of adverse outcome have less been investigated. Purpose: To investigate the outcomes of patients undergoing TEVAR for rDTAA and to identified risk factors of worse prognoses. Materials and Methods: The surgical outcome of TEVAR for rDTAA in National Cheng Kung University Hospital was retrospectively analyzed. From February 2008 to December 2016, 27 patients were included, after excluding patients with traumatic aortic injury, infected aneurysm, esophageal malignancy-related aortoesophageal fistula or those in association with aortic dissection. Results: There were 5 (18.5%) 30-day mortalities, including 3 (11.1%) intraoperative deaths. Seven additional patients died during follow-up and the estimated survival rate at 1 year and 3 years was 61.3 ± 9.7% and 50.5 ± 10.6%, respectively. Among these patients with late mortality, five patients presented with hematemesis or hemoptysis preoperatively. Aortoesophageal fistula was confirmed in three patients by esophagogastroduodenoscopy presenting with hematemesis. These patients underwent subsequent open debridement along with esophagectomy after TEVAR and remained alive during follow-up. On the other hand, those with possible occult aortic fistulations that were not detected by endoscopic examinations and not surgically managed had worse late outcomes (P = 0.058). Conclusions: For patients with rDTAA having hematemesis or hemoptysis as part of the initial presentations, careful survey for possible aorta-related fistulation is important. Although definite diagnosis of fistulation might be difficult, surgical exploration for hematoma evacuation, adequate debridement, and repair of intraoperative identified fistulation should be advocated.

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Background: Autologous fat graft is a well established technique for soft tissue augmentation and the most significant drawback remains the unpredictability of the absorption rate and the possible repeating fat harvest procedures. In our basic study, we found evidence to support that fat cryopreservation is a practical method of storing fat tissue and several anecdotal clinical experiences suggest its clinical efficacy. Methods: Thirty two patients who received autologous cryopreserved fat grafts for facial deficiencies were retrospectively reviewed. Autologous cryopreserved fat grafts were transplanted for “touch up” or augmentation of other soft tissue deficiencies at least three months after fresh fat grafting, The patients' satisfaction was evaluated by a study-specific questionnaire. Results: 84 autologous fresh fat graft and 178 autologous cryopreserved fat graft procedures for the face were performed in 32 patients. There was no infection, skin retraction, fibrosis or necrosis identified except one patient complained of lump formation in the left upper lid (1/178, 0.6%). The self-assessment questionaaire revealed no statistical difference of effectiveness rating between the fresh and cryopreserved fat grafting results (mean± standard deviation: 8.64±1.09 vs 8.73±0.985; P > 0.05) but there was significant statistical difference of convenience rating between the fresh and cryopreserved fat grafting (mean± standard deviation: 2.68±1.07 vs 8.41±1.05; P < 0.05). Of the twenty-two patients who returned the questionnaire, all reported willing to have the treatment in the future (9.73±0.456) and all said that they would like to recommend this treatment to their friends (9.82±0.395). Conclusions: Autologous cryopreserved fat graft is a safe, simple, and convenient technique to restore facial soft tissue defects with acceptable patient satisfaction rate. Clinical Question/Level of Evidence: Therapeutic, IV.

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