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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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: The aim of this study was to investigate the usability of immature granulocyte count (IGC), immature granulocyte percentage (IG%), and IGC to neutrophil ratio (IGC/N ratio), a new inflammatory marker, in both diagnosing acute appendicitis (AA) and differentiation of simple and complicated appendicitis (SA and CA). Materials and Methods: This study was conducted on 262 adult patients who underwent appendectomy. The patients were histopathologically divided into positive and negative appendectomy groups. The patients in the AA group were also divided into SA and CA subgroups. The demographic and laboratory data of the patients were compared. Results: The mean values of white blood cell count, neutrophil-to-lymphocyte ratio, IGC, IG%, IGC/N, and C-reactive protein (CRP) are the parameters that can be used both to diagnose AA and to differentiate CA from SA. In our study, the ability of IGC to predict AA was found to be greater than that of other parameters. For IGC, the area under the receiver operating characteristic curve (AUC) was 0.784, the sensitivity was 98.3% and the specificity was 80%. CRP and IGC/N ratio had the highest specificity predictive values in differentiating CA from SA. For IGC/N, the AUC was 0.702, the sensitivity was 63.9%, and the specificity was 72.3%. Conclusion: IGC is a reliable inflammatory marker in the diagnosis of AA but immature granulocytes and derivatives (IGC, IG%, and IGC/N) cannot be used for predicting CA because of low sensitivity and specificity.

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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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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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Fecaloma is a rare complication of chronic constipation with fecal impaction, which usually is underestimated. The megacolon would be noted as a result of that the harden stool commonly obstructs the rectum and sigmoid colon. So far, numerous cases about obstructive uropathy caused by fecaloma have been reported. We present the case of a 63-year-old female with a history of hemorrhagic stroke, who experienced acute bilateral hydronephrosis and fecaloma. She was successfully treated by colonoscopy irrigation and manual manipulation. In this literature, we focus on the association with the change of bowel movement after brain injury and remind neurosurgeons the clinical care about bowel program.

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Background: Virtual reality laparoscopic simulators were introduced to provide an optimal and safe learning environment for surgical trainees. The simulators had been validated and proven to be beneficial. Materials and Methods: The aim of this study is to assess the performance of the local surgical trainees using a validated simulator and help in the development of a training program using the simulator. Prospective repeated measures study in a single center using a validated virtual reality simulator was performed. Years 1 and 2 local postgraduate surgical trainees with limited laparoscopic cholecystectomy experience were included in the study. The trainees underwent a proposed training module, and the simulator evaluated each performance. Comparison was made between the performance before and after the training module. Results: Nine surgical trainees (eight males, median age: 33 years old) with a median of 5 years of surgical experience after graduation were included in the study. The time to complete each basic laparoscopic skill improved between 26.5% and 64.3% (P < 0.05) while the time taken to complete each of the cholecystectomy procedural task improved between 43.2% and 73.8% (P < 0.05). The time taken to complete a full cholecystectomy procedure improved from 873s to 512s (P = 0.008), and the efficiency of cauterization improved by 15.3% (P = 0.008). Analysis of the various learning curve showed the improvement plateaued between the third and tenth sessions. Conclusion: Virtual reality laparoscopic training should be implemented as part of training as it improves certain skill sets.

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Background: In this study, we aimed to identify the association between chronic periodontal disease (CPD) and erectile dysfunction (ED) in a large young population. Patients and Methods: Totally 2191 male participants aged 18–28 years attended the Army Training Center in Taiwan between August 2012 and May 2013. All 1932 included participants filled in the International Index of Erectile Function-5 (IIEF-5) questionnaire and received a comprehensive dental examination to classify whether CPD. Results: There was a statistically significant correlation between the presence of ED and CPD (P < 0.001). Multivariate logistic regression analysis indicated that men with CPD were 1.6 (95% confidence interval = 1.280–2.009, P < 0.001) times more likely to have ED than men without CPD after adjusting confounders. Conclusion: This study demonstrates a link between ED and CPD, and it may be attributed to a combination of psychogenic and organic etiologies, such as systemic inflammation, oxidative stress, and endothelial dysfunction. This study highlights the significance of oral health, which may take a role in sexual function, even in young males. In clinical practice, more comprehensive management strategies to address participants with ED and CPD need to be investigated.

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Background: Hyperbaric oxygen (HBO) therapy is an adjuvant treatment in patients with burns. However, evidence regarding the effectiveness of the HBO therapy for the improvement of patient's satisfaction has seldom been discussed; thus, we share our experience in this topic. Aim and Objectives: This study aimed to evaluate the improvement of burn patients' satisfaction after adjuvant HBO therapy. Materials and Methods: This was a retrospective case–control study involving 35 burn patients admitted to our hospital without a history of chronic pain and burn treatments from 2012 to 2015. Group I consisted of 18 burn patients who received HBO therapy to manage burns. The HBO therapy was administered in the hyperbaric chamber and received 60 min of 100% oxygen at a therapeutic pressure at 50 feet for 20 sessions. Group II consisted of 17 burn patients without a history of HBO therapy. Age, gender, total body surface area (TBSA), scar progression, improvement of visual analogue scale score, satisfaction improvement, and infection rate were documented and analyzed. Results: The mean age of Group I (37.0 ± 9.2) was significantly lower than that of Group II (49.4 ± 17.4) (P = 0.015). The mean improvement pain score in Group I (4.7 ± 1.1) was significantly higher than that of Group II (3.6 ± 0.9) (P = 0.004). The mean satisfaction improvement of Group I (3.4 ± 0.5) was significantly higher than that of Group II (2.9 ± 0.6) (P = 0.009). No significant difference was observed between gender, TBSA, debridement times, skin graft times, skin graft surface, infection rate, length of hospital stay, and progression of scar score in both groups, but there was a positive correlation between HBO therapy and the progression of scar score, so does the infection rate. There is no significant interaction between the two factors (HBO and age) on the improvement of pain score and improvement of satisfaction. Conclusion: Evaluation of the results obtained in the study suggests that the HBO therapy has a significant improvement in the pain relieve and satisfaction improvement after control of age factor in patients with thermal burns.

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Background: Acute traumatic wounds are a common and distressing event for patients presenting to plastic surgery clinics. There are no definitive conclusions regarding the benefits of collagen-based wound care products toward the application on full-thickness wounds compared to traditional ointment or gauze care. In this clinical trial, we aimed to define the potential benefits of collagen-based dressings on healing through the comparison of collagen-based composite dressings with antibiotic ointment dressings. Methods: This was a randomized two-tailed controlled clinical trial. The acute full-thickness wounds underwent wound cleansing, debridement, and were secured with different dressings in both experimental and control groups. The wounds were subsequently photographed weekly, and the wound areas were calculated using ImageJ software to evaluate wound healing rate. Results: The results demonstrate that the collagen-based triple layer composite dressings which consisted of silver sheet, collagen sponge, and foam films promoted better epithelialization and healing than antibiotic ointment treatment. Collagen supplementation improved wound healing and epithelialization by providing a dry environment during the late stage of wound healing. Conclusion: We demonstrated that the collagen-based triple layer wound dressing could potentially increase the healing rate when used for traumatic full-thickness wound care compared to the conventional antibiotic ointment dressing, providing a new prospective in the future applications of wound care.

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Introduction: Pediatric surgeons dealt with cases of omphalomesenteric duct remnants, which presented with various symptomatic patterns. Meckel's diverticulum was the most common remnant in this study, which presented with different signs and symptoms. The aim is to study the various remnants of omphalomesenteric duct with their presenting symptoms and to introduce a new variant of patent vitellointestinal duct (PVID) and describe how to treat these variants of omphalomesenteric duct. Materials and Methods: This is a retrospective study conducted in 132 neonates and children (102 male and 30 female), who were operated at our institute and containing persistent omphalomesenteric duct and its derivatives. This study was conducted from January 2017 to June 2018 at our institute. This study analyzed the presenting sign and symptoms of various remnants of omphalomesenteric duct. The study analysis was based on the following parameters – age, sex, sign, symptom, investigation, operative finding, and postoperative complications. Results: In this study, male-to-female ratio was 3.4:1. Meckel's band obstruction was the most common presentation (n = 48, 36.36%), while umbilical cyst (n = 1, 0.75%) and umbilical sinus were least commonly present (n = 1, 0.75%) in all remnants of omphalomesenteric duct. We found a new variant of PVID, which presented with an intact omphalomesenteric duct, but the umbilical end was obliterated. This variant had not been included or reported in literature. Conclusion: Omphalomesenteric duct remnants are presenting with various sign and symptoms, like intestinal obstruction, umbilical discharge, umbilical swelling, pain abdomen etc. A new variant of PVID is named end- obliterated PVID reported here, may present with features of intestinal obstruction.

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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.

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Paragangliomas are rare neuroendocrine tumors also known to occur in the head-and-neck regions and generally involve the carotid body or vagal region. Till date, only a single study has reported the occurrence of paragangliomas involving both the carotid body and vagal region. The present study, to the best of our knowledge, is the second study in the world which reported the multiple paragangliomas involving the carotid body and vagal region. The patient in the present case study was a 45-year-old male with a single swelling in the left upper part of the neck. In the preoperative clinical examination, the swelling was identified as carotid body tumor, and the patient was then planned for surgery. The intra-operative findings revealed that it involved both the vagal and carotid body and was subsequently operated successfully. Postoperatively, the swelling was described as bilateral carotid paragangliomas with left vagal paraganglioma.

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Arteriovenous fistula of the filum terminale (AVFFT) is an uncommon disease. We reported a case of this rare condition and we used intraoperative angiography to identify the completeness of fistula obliteration. A 53-year-old man presented with a history of low back pain and radiating pain of bilateral legs for 2 months. Lumbar spine magnetic resonance imaging revealed edema of conus medullaris at the T10–L1 level; engorged vein was also identified from L1 to L4. Digital subtraction angiography confirmed the diagnosis of AVFFT. Clipping of fistula was successfully performed, and complete obliteration was confirmed by intraoperative angiography. Magnetic resonance imaging follow-up showed no edema postoperatively. The patient's symptoms/signs improved tremendously. Both radiological and clinical outcomes were good after complete occlusion of the fistula was done. Hence, we suggested intraoperative angiography in hybrid OR as a useful tool to identify the fistulous point and confirm complete occlusion the fistula.

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Background: Robotic nipple-sparing mastectomy (R-NSM), which uses the da Vinci surgical platform (Intuitive Surgical, Sunnyvale, CA, USA), could perform NSM and immediate breast reconstruction through small and inconspicuous extramammary axillary incision. Its application in the management of early breast cancer or risk-reducing mastectomy had been reported in some series and a growing number of R-NSM were performed worldwide. The authors would like to present a single-center experience of R-NSM as well as review of the current literature.Materials and Methods: The medical records of patients who underwent R-NSM for breast cancer during the period from March 2017 to July 2018 were retrieved from a prospectively collected database. A review of case series of R-NSM in the current literature were also performed through the PubMed database to determine the effectiveness and oncologic safety of R-NSM.Results: A total of 37 breast cancer patients who received 46 R-NSM procedures were included in the study. Thirty-nine cases (84.8%) were performed for therapeutic purpose. No R-NSM procedure was converted to conventional or endoscopic mastectomy. One (2.6%, 1/39) R-NSM procedure was found to have positive margin involvement. The rate of total nipple-areolar complex (NAC) necrosis was 0%, and no implant loss or local recurrence was observed during a mean follow-up of 10.9 ± 8.2 months. In the joint collective analysis and review of the current literature, a total of 138 R-NSM procedures were available for analysis, and 59 of them were for therapeutic indications. The overall conversion rate was 2.2% (3/138), total NAC necrosis rate was 0%, implant loss rate was 0.8% (1/128), and margin involved rate was 1.7% (1/59). No local recurrence case was reported.Conclusion: From our preliminary experience and review of the current literature, R-NSM is a feasible and safe alternative for NSM in the management of breast cancer. The long-term oncological outcomes, however, will only be determined with longer follow-up.

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Introduction: Application of preperitoneal mesh method in the treatment of inguinal hernia can be regarded as one of the successful methods in this regard. However, the impact of mesh fixation or nonfixation on the recurrence of hernia and the incidence of its complications have not been thoroughly investigated.The present study aimed at comparing the effect of mesh fixation and nonfixation on transabdominal preperitoneal (TAPP) laparoscopy for inguinal hernia repair. Materials and Methods: In this study, eighty patients with inguinal hernia underwent TAPP laparoscopy with mesh fixation (n = 41) and nonfixation (n = 39). Mesh was fixed using a suture in Group A and nonfixed in Group B. Then, the duration of operation, length of in-hospital stay, complications and recurrence of hernia, and pain severity 1 day after the surgery, during discharge, at the 1^st and 2^nd weeks, and at 1 and 6 months after the surgery were compared between the two groups. Results: The length of in-hospital stay and return to work in Group B was statistically significantly lower than that of Group A (P < 0.05). Neuralgia and urinary retention were statistically significantly higher in Group A as compared with Group B (P < 0.05). There were no and 5.1% hernial recurrence in Group A and Group B, respectively (P > 0.05). The level of pain was generally higher in Group A and was statistically significant 1 and 2 weeks after the surgery (P < 0.05). Conclusion: Mesh nonfixation causes less postoperative complications and pain in patients undergoing TAPP repair; however, in long-term follow-up, the level of chronic pain following the application of mesh fixation and non-fixation methods is not different.

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Background: This study was designed to investigate the impact of alcohol intoxication on injury severity and outcomes of adult patients who experienced different modes of trauma. Materials and Methods: This retrospective study collected data of hospitalized patients who experienced trauma at age ≥20 years between January 1, 2009 and December 21, 2015, from the Trauma Registry System of a Level I trauma center. Patients were categorized into two groups according to their blood alcohol concentrations (BACs): alcohol intoxication (BAC of ≥50 mg/dL at the time of arrival to the emergency room) and nonalcohol intoxication (BAC of <50 mg/dL). The Abbreviated Injury Scale (AIS) score of each injured body region, Injury Severity Score, length of stay (LOS) in the hospital, and in-hospital mortality of these trauma patients according to different modes of trauma were compared between patients with or without alcohol intoxication. Results: Among 20,513 patients included in this study, 1206 had alcohol intoxication and 19,307 did not. Patients with alcohol intoxication were predominantly males and younger than those without alcohol intoxication. Among patients who had a motorcycle accident, bicycle accident, fall accident, and hit by/against an object, AIS of ≥3 head/neck injuries more commonly occurred in patients with alcohol intoxication than in those without. In addition, compared to those without alcohol intoxication, patients with alcohol intoxication who experienced motorcycle accidents and hit by/against an object had longer hospital LOS, whereas those who experienced motor vehicle and motorcycle accidents had significantly higher mortality rates. Conclusions: This study revealed that alcohol intoxication had impacted the injury severity and outcomes in adult patients who experienced different modes of trauma.

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Background: The SpineJack, a third-generation percutaneous augmentation system, is designed to be left in the vertebral body to maintain the recovery of body height following treatment for vertebral compression fractures (VCFs). This study retrospectively compared SpineJack implantation with traditional percutaneous vertebroplasty (PVP) in terms of anatomic restoration in patients with single-level VCFs. Materials and Methods: Between January 2015 and December 2017, 74 patients with single-level VCFs underwent SpineJack implantations or PVP. The degree of pain relief was measured by a Visual Analog Scale score, and the vertebral kyphotic angle, Cobb's angle, the vertebral body height, and the vertebral body compression ratio (VBCR) were recorded preoperatively as well as immediately, 1 month, 3 months, and 1 year after surgery to evaluate anatomical restoration. Results: There were 42 patients in the SpineJack group and 32 patients in the PVP group. No significant difference in pain relief was observed between the two groups. The SpineJack group had better kyphotic angle (6.67° ± 4.38° vs. 9.86° ± 6.73°,P < 0.01) and Cobb's angle (12.28° ± 10.13° vs. 18.03° ± 9.66°,P < 0.01) corrections than the PVP group. The postoperative VBCR was also higher in the SpineJack group than in the PVP group (78.21% ± 19% vs. 67.05% ± 18.85%, P = 0.02). The complication rates did not differ between the groups. Conclusion: SpineJack implantation achieved better kyphosis correction and vertebral body height restoration than PVP. SpineJack implantation is safe and may not increase the risk of subsequent VCFs.

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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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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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Background: Treatment of osteosarcoma requires multi-disciplinary team work and a rigorous follow-up schedule to achieve best oncological and functional outcomes. However, standard treatment and routine image study may not be available for all Indonesian patients because of complex geographic reason in Indonesian archipelago. Therefore, we aimed to review treatment outcome of osteosarcoma in Indonesia and validate potential laboratory markers associated with oncological outcomes. Materials and Methods: From January 2015 to August 2016, we retrospectively reviewed 57 patients with osteosarcoma who had received treatment in Dr. Cipto Mangunkusumo Hospital (RSCM), Jakarta, Indonesia. Association between laboratory markers including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), lactate dehydrogenase (LDH), alkaline phosphatase (ALP) and oncological outcomes including mortality and distant metastasis have been validated. Results: Our results showed that a combination of neoadjuvant chemotherapy, tumor resection and adjuvant chemotherapy would lead to the best oncological and functional outcome. ESR, CRP LDH and ALP level decreased after surgery and chemotherapy. Lower level of ESR and CRP were not associated with less distant metastasis and less mortality. On the other hand, the elevated LDH was correlated with higher mortality (P < 0.01), whereas elevated ALP was also correlated with a higher risk of distal metastasis (P = 0.044). Conclusions: Patients who had been properly treated with neoadjuvant chemotherapy, tumor resection and adjuvant chemotherapy had the best oncological and functional outcomes. LDH and ALP might be useful laboratory markers to predict oncological outcome.

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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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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: Finding optimal treatment for skin wounds, especially using natural substances, has been of main focus in skin care and cosmetics. Aloe vera has been historically used in wound care, and chitosan, which is obtained from crustaceans, has a variety of biomedical applications. Accordingly, it seems that a mixture of aloe/chitosan may provide added benefits in wound healing. Aims: The aim of the present study was to evaluate the effects of a mixture of aloe/chitosan gel in comparison to each component alone, on the healing of excisional full-thickness wounds in rats. Materials and Methods: Round full-thickness wounds were made on the back of animal necks. Five experimental groups received either no treatment (Group 1) or daily topical treatments with 1% carboxymethyl cellulose (CMC) (Group 2), aloe (Group 3), chitosan (Group 4), or mixed aloe/chitosan gels (Group 5) for 14 days. Wound areas on days 3, 7, and 14 and histopathologic parameters on day 14 were measured for analysis. Results: Means of wound areas showed a significant decreasing pattern in all groups through days 3–14 (P < 0.001). The topical treatment of wounds with aloe/chitosan significantly reduced wound areas compared to nontreated (P = 0.019) or 1% CMC-treated (P = 0.021) wounds. Histopathologic analysis revealed more reepithelialization, fibroblasts, collagen fibers and less polymorphonuclear leukocytes, new vessels, and granulation tissue in wounds treated with aloe/chitosan in comparison to controls (P < 0.05). Conclusions: Aloe/chitosan-treated wounds showed convincing healing profiles affirming the benefits of using natural bioactive substances in wound healing, especially in combination therapy.

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