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Blue-light cystoscopy and narrow-band imaging in bladder cancer management
Zhijiang Zang, Qinghui Wu, Edmund Chiong
September-October 2019, 52(5):155-160
Despite the high resolution of modern imaging technology including computed tomography and magnetic resonance imaging, cystoscopy remains the gold standard method for detecting bladder cancer. Cystoscopy is conventionally conducted with white light visualization, and the pitfalls of white light cystoscopy are well-recognized. Novel technologies to enhance visualization of bladder lesion have emerged during the past 20 years. Among them, blue-light cystoscopy (BLC) and narrow-band imaging (NBI) are the most promising and well-studied. Many clinical trials have suggested the benefit of these two technologies. In this review, we aim to summarize the data, evidence, and current role of BLC and NBI in clinical practice.
  12,940 411 1
Chronic neuropathic pain following inguinal hernia repair
Toufik Berri
July-August 2019, 52(4):111-121
Since recurrence rates have been considerably reduced with mesh repairs, chronic pain has recently become the main concern after inguinal hernia repair (IHR), with significant impact on patient satisfaction, societal cost, and quality of life. Some 31% of all patients with persistent postsurgical pain develop neuropathic pain (NP) after IHR seeing that the inguinal nerves that cross the surgical field can directly or indirectly be damaged. Because of the multiplicity of the risk factors and the complexity of the pathophysiological mechanisms, substantial attention has been devoted to the multidisciplinary approaches and to the preventive measures. More clinical trials are needed to improve the level of evidence of the use of pharmacological, surgical, and interventional procedures in both prevention and treatment of chronic NP following IHR. In this article, the current objectives are to review the incidence, risk factors, pathogenesis, diagnosis, prevention, and treatment of chronic NP after IHR.
  12,541 576 -
Inhibitory effect of methamphetamine on intracavernous pressure in rats
Tao-An Chang, Bang-Ping Jiann
March-April 2018, 51(2):63-68
Background: There is a paucity of animal study investigating the effect of methamphetamine (METH) on penile erection in spite of its worldwide population. Aim: We investigated the changes of intracavernous pressure (ICP) elicited by cavernous nerve stimulation after a single and repeated dosing of METH in male rats. Methods: Rats were randomly assigned to five treated groups and one control group with each group having 3 rats. Rats in treated group 1, 2, and 3 received a single dose intravenous injection with 0.1, 1.0, and 10.0 μg/kg METH, respectively. Rats in treated group 4 and 5 received an intraperitoneal injection with 1.0 and 5.0 mg/kg METH four times daily for two weeks, respectively. ICP was measured during penile erection elicited by cavernous nerve stimulation. Expression of neural nitric oxide synthase (nNOS) was measured in the cavernous nerve and muscle after single and repeated dosing. Main Outcome Measures: The primary outcome measure was the ΔICP/mean arterial pressure (MAP) and the secondary was the expression of nNOS in the tissue. Results: The ΔICP/MAP increased slightly in group 1 rats and decreased substantially in group 2 and 3 rats compared with the baseline. A single dose of METH within the range of 0.1 to 10.0 μg/kg exhibited an inhibitory effect of ICP (%). The ΔICP/MAP significantly decreased in group 4 and 5 rats after repeated dosing of METH, compared with that in group 3. The expression of nNOS significantly increased in the cavernous muscle after single and repeated dosing of METH compared with the control. Conclusions: The preliminary results suggested that a single dose of METH exhibits an inhibitory effect on ICP and repeated dosing of METH exerted a greater inhibition than a single dosing. However, these results need further study.
  9,799 360 -
Long-term follow-up for patients with colonic perforation due to colonoscopy: From clinical and medicolegal viewpoints
Tzu-Chun Chen, Ji-Shiang Hung, Been-Ren Lin, John Huang, Jin-Tung Liang
November-December 2017, 50(6):195-199
Background: This retrospective study analyzes the clinicopathologic features and medicolegal debates on this complication. Methods: There were 29 records of colonic perforations, whose charts were retrospectively reviewed. Results: A total of 26 perforations occurred as a result of diagnostic colonoscopy, and three occurred after therapeutic colonoscopy. Eight perforations were diagnosed immediately during the procedure, based on the revelation of intraperitoneal organs with bleeding of bowel wall on the colonoscopic monitor. Twenty patients were diagnosed as a hollow-organ perforation within 12 h after the completion of colonoscopy, whereas one perforation was found more than 24 h after colonoscopy. Abdominal pain and distention are the most common symptoms. All the patients underwent emergency surgery. One patient had wound infection, and two patients had leakage of the repair site. One patient aged 80 died of pulmonary septic complication. Our hospital paid all additional expenses which were not covered by the National Health Insurance Bureau for all patients, ranging from 500.0 to 1500.0 US dollars (mean ± standard deviation, 549.0 ± 145.0 US dollars). Four patients (13.8%) asked for further compensation of the complication and one litigated. Conclusions: Iatrogenic colonic perforation due to endoscopy is potentially lethal, especially for aged patients. Some patients and their family viewed the perforation as malpractice and asked for compensations. Usually, the primary repair of the perforation site is safe, and long-term follow-up reveals no sequelae after adequate treatment.
  9,424 494 1
Ulnar nerve injury due to lateral traction device during shoulder arthroscopy: Was it avoidable?
Vivek Pandey, Sandesh Madi, Kiran Acharya
November-December 2017, 50(6):220-222
Most of the nerve injuries reported during shoulder arthroscopy in a beach chair, or lateral position is related to inappropriate patient positioning or excess traction. The lateral decubitus position is more vulnerable for traction-related neuropraxia. The present case serves as an important lesson from an avoidable situation of “having a one track mind” of the surgical team during the arthroscopic repair of shoulder instability performed in the lateral decubitus position. The operating surgeon must supervise the appropriate positioning of the patient on operation table and adequate padding of vulnerable bony points before beginning of shoulder arthroscopy to prevent any position-related nerve injuries. This is probably the first case to illustrate an unusual cause of ulnar nerve compression particularly related to the use of an additional traction device in the arthroscopic repair of shoulder instability performed in lateral decubitus position, which has not been previously defined.
  7,857 375 -
Eighty percent partial splenic embolization is a safe and effective procedure in management of cirrhotic hypersplenism
Bor-Gang Wu, Andy Shau-Bin Chou, Guan-Jin Ho, Ming-Che Lee
May-June 2017, 50(3):101-106
Background: Partial splenic embolization (PSE) has been proposed in patients with cirrhotic hypersplenism in cases when thrombocytopenia causes clinical manifestations or if there are contraindications to subsequent therapeutic procedures. We provide a retrospective review of the safety and favorable treatment results of 80% splenic embolization in patients with cirrhotic hypersplenism in our institute. Methods: Thirteen consecutive patients with cirrhotic hypersplenism were included in a 4-year study period. The indications for PSE were as follows: percutaneous treatment of hepatocellular carcinoma (HCC) (n = 3), transarterial chemoembolization plus hepatic arterial infusion chemotherapy for HCC (n = 2), preparation for major surgery (n = 5), and severe purpura (n = 3). PSE was performed with up to 80% reduction of splenic blood flow by radiological intervention. A tight protocol of prophylactic antibiotics was introduced. Patient demographics, procedure-related complication, and efficacy of PSE were analyzed. Results: The mean follow-up time was 26.1 ± 12.3 months. All the patients tolerated the procedure. The minor complication of postembolization syndromes such as fever and abdominal pain occurred in 38.5% and 61.5% of patients, respectively. Only a major complication of transient ascites needs diuretic therapy occurred in two patients. Pre-PSE platelet count was 35,077 ± 11,049/mm3, and it significantly increased 1 week after PSE, with a mean increase of platelet count to 384% of pre-PSE level (P < 0.001). The effect of PSE sustained to maintain the platelet count significantly at a mean level of 112,636 ± 33,341/mm3, 114,571 ± 30,696/mm3, and 118,000 ± 31,035/mm3 at 12, 24, and 36 months, respectively. Conclusion: Our series demonstrated that 80% PSE is a safe and effective method to treat patients with cirrhotic hypersplenism. It could not only increase the platelet count within a short period of time but also maintain it at an acceptable level for a long duration. Under a tight protocol of prophylactic antibiotic and delicate technique of PSE, there was no any septic complication developed in our series.
  7,158 557 3
Prognostic factors for radial nerve palsy associated with humeral shaft fracture
Yen-Yi Hoa, Lee-Wei Chen, Kao-Chang Yang, Kuei Chang Hsu, Wen-Chung Liu, Cheng-Ta Lin
January-February 2017, 50(1):1-9
Background: Radial nerve palsy (RNP) associated with humeral shaft fracture is a common injury pattern in trauma patients. The management of RNP associated with humeral fractures in high-energy trauma is controversial and poses a challenge to surgeons treating it. Purpose: Based on a review of our experience over the past 15 years, we determined the prognostic factors of radial nerve recovery after humeral fractures, evaluated the diagnostic role of nerve conduction studies and electromyography (EMG), and compared the outcomes of different treatment strategies. Materials and Methods: The data of 26 patients having RNP associated with humeral shaft fractures over a 15-year period were collected for a retrospective review. For statistical analysis, the patients were divided into groups on the basis of their recovery from RNP and the treatment strategies used. Results: The incidence of RNP associated with humeral fractures was 2.05%. In total, 91.3% of patients with primary RNP in this series experienced high-energy trauma. Spontaneous recovery was observed in 9 of 26 patients (34.6%). Radial nerve lesions were found in 7 of 8 patients with high-energy trauma. The severity of humeral shaft fractures was found to be a significant prognostic factor for spontaneous recovery from RNP. The rate of spontaneous recovery was significantly higher in the AO Foundation and Orthopaedic Trauma Association Type A humeral shaft fractures (P = 0.028) and lower in Type C fractures (P = 0.055). The median time to detect initial radial nerve recovery using EMG was 34 and 75 days after injury (P = 0.033). In high-energy trauma, tendon transfers were associated with more predictable outcomes than nerve reconstruction (favorable functional recovery: 100% for tendon transfers vs. 25% for nerve reconstruction, P = 0.007). Moreover, tendon transfers were associated with a shorter overall treatment duration (median treatment duration: 190 days for tendon transfers vs. 422 days for nerve reconstruction, P = 0.007). Conclusion: The prognosis of RNP associated with humeral shaft fractures in high-energy trauma is less favorable, with a low rate of spontaneous recovery. EMG is helpful for the early detection of initial nerve recovery. The outcomes of tendon transfers in high-energy trauma are predictable and the treatment duration is shorter. First-intention tendon transfer is a reasonable treatment strategy in patients with difficult nerve exploration, lower requirement for functional recovery, and lower compliance with treatment.
  6,632 632 1
Experience in traumatic small bowel perforation management
Ping-Tze Chen, Hong-Ming Chao
January-February 2018, 51(1):32-37
Small bowel perforations due to blunt abdominal injury are rare. In this study, we compiled five cases of traumatic small bowel perforation and then analyzed a number of the prognostic factors. Elapsed time to surgery was identified as the most important prognostic factor, due to the risk of peritonitis. Laparoscopy surgery appears to be a safe, effective procedure in cases where the diagnosis is uncomplicated by other major problems, such as lacerations to the liver or spleen.
  6,179 391 -
Isolated tuberculous epididymitis
Shao-Ming Chen
March-April 2017, 50(2):74-76
Isolated tuberculous epididymitis (ITE) is an uncommon disease that is often incorrectly diagnosed as the more common epididymo-orchitis. ITE is usually treated using long-term general parenteral or oral antibiotics. The nonspecific nature of laboratory tests for ITE renders its diagnosis challenging. Here, we report the case of a 65-year-old male patient who presented with a 6-month history of the left scrotal swelling. He was initially treated with general oral antibiotics but without any noticeable improvement. On the basis of his symptoms and signs, laboratory test and imaging results, and biopsy, we finally made a diagnosis of ITE. After receiving appropriate treatment, the patient was cured completely without the need of surgical intervention.
  5,912 413 3
Callus formation in bone fractures combined with brain injury in rat
Yu-Ping Chen, Hsin-Chin Shih
March-April 2017, 50(2):57-62
Objective: The objective of this study was to determine the speed of bony union and the serum levels of biomarkers in the setting of bone fractures combined with brain injury. Materials and Methods: In this study, Sprague–Dawley rats were randomized into four groups: sham, brain injury, bone fracture, and bone fracture plus brain injury groups. The serum levels of biochemical markers, namely, nerve growth factor (NGF), Wnt-3a, Dickkopf-related protein-1, receptor-activator of NF-κB ligand, and adrenocorticotropic hormone (ACTH), were measured on the days 1, 3, 7, and 14 following injury. Bony union was evaluated using radiographs every week for 6 weeks. Results: Compared with the brain injury group and bone fracture group, the radiographs of the bone fracture plus brain injury group revealed enhanced callus formations in week 2. From week 3, the callus formation did not differ significantly among the groups. The serum levels of the biomarkers varied at different time points. The serum levels of NGF on days 1 and 3, Wnt-3a on days 3 and 14, and ACTH on days 1, 3, and 7 were significantly higher in the bone fracture plus brain injury group than in the bone fracture group. Conclusions: Brain injury increases callus formation in simultaneous bone fracture. Considering the time point, early NGF, Wnt-3a, and ACTH elevation might be associated with early callus formation enhancement. The results indicate that these brain injury-induced biomarkers might play crucial role in accelerating bone healing.
  5,832 451 1
Chloroquine induces lysosomal membrane permeability-mediated cell death in bladder cancer cells
Hung-En Chen, Ji-Fan Lin, Yi-Chia Lin, Shen-I Wen, Shan-Che Yang, Te-Fu Tsai, Kuang-Yu Chou, I-Sheng Thomas Hwang
July-August 2018, 51(4):133-141
Background: Chloroquine (CQ) is recognized as a potent adjuvant when combined with other chemotherapies to treat cancers. However, the effects of a single treatment of CQ on bladder cancer (BC) cells have not been investigated. Methods: The growth and viability of CQ-treated BC cells were examined. The lysosomal morphology was detected using LysoTracker. The induction of lysosomal membrane permeability (LMP) was detected by acridine orange (AO) translocation, and cathepsin B and D release. The expression of the bid, caspase-3, and cytosolic cytochrome C (Cyto. C) in CQ-treated cells was detected by the Western blot. The pepstatin A and E64d were used to attenuate CQ-induced LMP. Results: A single dose of CQ treatment induced BC cell death, and attenuated by pepstatin A and E64d. The diminishing of fluorescent in CQ-treated cells stained with LysoTracker, suggesting that CQ targets lysosomal functions. This was further supported by increased AO translocation and the releasing of CatB and CatD into the cytosol. The increased level of cleavage bid and cytosolic Cyto. C indicated mitochondrial outer membrane permeabilization and subsequently leading to apoptosis induction judged by the increased level of activated caspase 3. Conclusion: CQ-induced LMP that enhances apoptosis and ultimately leading to BC cell death. The study results demonstrated for the first time that single CQ treatment against BC cells by inducing LMP and subsequent mitochondria membrane permeability that trigger apoptosis, making it a potential treatment for BC therapy in the future.
  5,619 561 1
Long-term surgical outcome of median nerve injuries
Mohammadreza Emamhadi, Hamid Behzadnia, Sasan Andalib
May-June 2019, 52(3):71-75
Background: Median nerve integrity is a prerequisite of normal hand function. The median nerve is a frequently injured nerve, and recent evidence indicates that nerve surgery may produce acceptable outcomes. The present study provides a framework of long-term surgical outcomes of median nerve injuries and specifies independent predictors of motor and sensory recovery. Materials and Methods: In the retrospective study, patients with median nerve injuries undergoing the nerve surgery were reviewed. Mechanism of injury, level of injury (arm, elbow/forearm, and wrist), type of injury and lesion, type of surgical repair, and the time interval from injury to surgery were assessed. The long-term follow-up of motor recovery, sensory recovery, and quality of life was done. Results: A total of 106 cases with median nerve injuries undergoing nerve surgery were included in this study. Most injuries were at wrist level with a higher frequency of sharp and not in continuity lesions. There was a significant association between the three outcomes (motor recovery, sensory recovery, and quality of life) and smoking, addiction, type of injury, type of lesion, and type of nerve repair. There was a significant correlation between quality of life and muscle force recovery and between quality of life and sensory recovery. Muscle force recovery was significantly correlated with sensory recovery. Conclusions: The findings of the present study suggest that male and young subjects, lesions in continuity, and injuries treated without grafting may show better surgical outcomes.
  5,602 359 1
Traumatic scrotal anal fistula
Shao-Ming Chen
May-June 2017, 50(3):107-109
Scrotal wounds are most often related to infection or allergy and are generally identified in urology clinics. Topical medications, which are generally applied initially to the wound, can assist with spontaneous healing without any sequelae. However, further workup is sometimes required if the wound does not heal properly. Herein, we present two cases which were finally diagnosed as traumatic scrotal anal fistulae, for which surgical excision was clearly indicated.
  5,438 322 -
Geriatric nutritional risk index in screening malnutrition among young adult and elderly trauma patients
Yueh-Wei Liu, Ching-Hua Tsai, Sheng-En Chou, Wei-Ti Su, Chi Li, Shiun-Yuan Hsu, Ching-Hua Hsieh
September-October 2021, 54(5):183-190
Background: The geriatric nutritional risk index (GNRI) calculated as 1.489 × albumin (g/dL) +41.7× (current body weight/ideal body weight) is useful in identifying high-risk for malnutrition in elderly patients with subacute or chronic diseases. Given that trauma patients have sustained injuries in an acute condition, this study is designed to explore the association between GNRI on admission and outcomes in elderly and young adult patients with trauma. Materials and Methods: From January 01, 2009, to December 31, 2019, a total of 1772 elderly and 2194 young adult trauma patients were categorized into four nutritional risk groups according to GNRI: high-risk group (GNRI <82), moderate-risk group (GNRI 82 to <92), low-risk group (GNRI 92–98), and no-risk group (GNRI >98). Propensity score-matched patient cohorts were created in different nutritional risk groups against the no-risk group to minimize the confounding effects of sex, age, pre-existing comorbidities, Glasgow Coma Scale score, and Injury Severity Score on outcome measurements. Primary outcome was in-hospital mortality, and secondary outcome was the length of hospital stay. Results: Young adult patients with trauma were comparable in pattern of mortality outcomes and hospital stays to that in elderly patients. Analysis of the selected propensity score-matched patient cohorts revealed that both elderly and young adult patients in the high-risk group had significantly higher odds of mortality (elderly, odds ratio [OR], 6.5; 95% confidence interval [CI], 3.00-14.03; P < 0.009; young adult, OR, 2.7; 95% CI, 1.45-5.11; P = 0.001) and longer hospital stay (elderly, 21.5 days vs. 12.4 days, respectively, P < 0.001; young adults, 22.5 days vs. 14.1 days, respectively, P < 0.001) than those of the no-risk group. Conclusion: This study demonstrated that the GNRI could serve as a useful screening method to identify high-risk malnutrition in acutely injured trauma patients, including not only the elderly trauma patients but also the young adult trauma patients.
  5,623 126 1
Hyperbaric oxygen therapy for hemorrhagic radiation cystitis
Kung-Hung Lin, Hui-Chieh Lee, Wen-Shyan Huang, Po-Wei Huang, Seng-Chung Ke, Man-Gang Lee
March-April 2017, 50(2):52-56
Background: Radiation cystitis with macroscopic hematuria is a frustrating clinical problem for urologists. Since 1985, hyperbaric oxygen therapy (HBOT) has been applied as a treatment for radiation cystitis with macroscopic hematuria; numerous studies have shown that this treatment has favorable results. Purpose: The purpose of this study was to elucidate the HBOT affected the clinical outcomes and treatment of hemorrhagic radiation cystitis (HRC). Methods: Between November 1989 and June 2014, 42 patients (39 women and three men) with HRC were treated with hyperbaric oxygen at a pressure of 2.5 atmospheres absolute, breathing 100% O2for 120 min in a multiplace hyperbaric chamber. Results: After an average of 38 hyperbaric oxygen sessions, macroscopic hematuria was completely halted in 35 patients (83.3%) and markedly decreased in three patients (7.1%). A comparison of cystoscopic findings before and after HBOT showed significant decreases in both hemorrhagic sites and telangiectasis of the bladder mucosa. The mean follow-up was 20.7 months (range: 3–49 months). No cases exhibited evidence of barotrauma or oxygen toxicity. One patient underwent a urodynamic study both before and after HBOT, with several changes in bladder function observed after HBOT: urine peak flow increased from 12.8 mL/s before HBOT to 15.0 mL/s after HBOT and urine mean flow increased from 6.5 mL/s to 8.9 mL/s. Urine voiding time decreased from 40.0 s to 28.0 s, urine flow time from 39.0 s to 28.0 s, time to peak flow from 15.0 s to 8.0 s, and voided volume from 251 mL to 248 mL. Conclusion: The results of this study suggest that early application of HBOT is a safe and effective treatment method for HRC. Whether HBOT is beneficial to urinary bladder function requires further study with a larger patient cohort enrolled.
  5,082 460 1
Abdominoscrotal hydrocele: A rare cause of a cystic abdominal mass in children
Gurmeet Singh, Anand Pandey, Ajay Verma, Archika Gupta
March-April 2018, 51(2):88-90
Abdominoscrotal hydrocele (ASH) is a rare cause of cystic abdominal and scrotal mass in children. A timely diagnosis is important because appropriate surgical treatment is important. We encountered a patient who presented with scrotal swelling and later turned out to be a patient of ASH. The case is being presented with review of relevant literature.
  5,000 304 -
Kimura's disease
Manish Swarnkar, Anand Agrawal
January-February 2018, 51(1):26-28
Kimura's disease (KD) is a benign chronic inflammatory disorder attributed to an immune-mediated hypersensitivity which often presents as a tumor-like swelling in the head and neck region with or without lymphadenopathy, associated with hypereosinophilia and elevated serum immunoglobulin E. Most cases have been described predominantly in Chinese and Japanese people. KD has been confused with angiolymphoid hyperplasia with eosinophilia, from which it probably should be distinguished as a separate entity. The course is usually benign except for the potential cosmetic disfigurement. The diagnosis may be suggested by a fine-needle aspirate but is established by a biopsy. A case of KD in a 42-year-old male with recurrent left submandibular swelling is presented together with a brief review of the literature.
  4,939 339 -
A randomized clinical trial comparing a collagen-based composite dressing versus topical antibiotic ointment on healing full-thickness skin wounds to promote epithelialization
Hsin-Chung Tsai, Hui-Ching Shu, Li-Chuan Huang, Chuan-Mu Chen
March-April 2019, 52(2):52-56
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.
  4,776 457 3
Distal pancreatectomy and celiac axis resection for pancreatic body carcinoma involving celiac artery
Shih-Chun Chang, Yu-Yin Liu, Tse-Ching Chen, Cheng-Huei Tseng, Ta-Sen Yeh
January-February 2017, 50(1):28-31
Pancreatic body or tail cancer with invasion to major vessels, including the common hepatic artery and the celiac artery, was previously considered to be unresectable. However, an increasing number of surgeons have aggressively adopted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR) in this scenario to attempt curative resection, thus improving long-term survival. In this paper, we present the case of a 45-year-old man with pancreatic body cancer invading the celiac axis who underwent DP-CAR with negative margins (R0) and subsequently exhibited an uneventful postoperative course. We also reviewed literature, which unequivocally demonstrates a comparable oncological outcome between pancreatic body or tail cancer with and without celiac artery resection. To the best of our knowledge, our study is the first documented case in which DP-CAR was successfully performed in Taiwan.
  4,743 410 -
The use of perforator flaps for the reconstruction of sacral defects: Ten-year experience
Hao-Yu Chiao, Shun-Cheng Chang, Chang-Yi Chou, Yuan-Sheng Tzeng, Shyi-Gen Chen, Chin-Ta Lin
July-August 2018, 51(4):142-147
Background: Despite advances in reconstruction techniques, sacral defects continue to challenge surgeons. The perforator flap preserves the entire contralateral side as a future flap donor site and the gluteal muscle itself on the ipsilateral side to minimize donor-site morbidity. Materials and Methods: Between April 2003 and March 2013, data obtained from 60 patients with sacral defects reconstructed with perforator flaps were retrospectively analyzed. Results: We analyzed the sacral defects reconstructed with three different perforator flaps into the following groups: group 1, 30 patients with superior gluteal artery perforator flaps, (average flap size was 83.8 cm2); Group 2, 19 patients with parasacral perforator flaps (average flap size was 94.2 cm2); and Group 3, 11 patients with inferior gluteal artery perforator flaps (average flap size was 85.8 cm2). The overall flap survival rate was 93.3% (56/60). Conclusion: Perforator flaps are a reliable option for soft-tissue defect reconstruction as they provide a sufficient amount of tissue to cover large sacral defects. We recommend perforator flaps as a viable alternative in the management of sacral defects that cannot be reconstructed with primary closure or local fasciocutaneous flaps.
  4,658 432 -
Shah-Waardenburg syndrome
Rahul Gupta, Dinesh Kumar Barolia, Ramesh Tanger, Lila Dhar Agrawal, Arun Kumar Gupta, Ram Babu Goyal
September-October 2017, 50(5):163-168
Introduction: Shah-Waardenburg syndrome (SWS) is WS associated with Hirschsprung's disease. It is very rare with <80 cases reported in the literature. Aim: The aim of this study was to describe our experience with SWS. Methods: The records of patients admitted to our tertiary care pediatric surgical institute between 2011 and 2015 were retrospectively reviewed. All patients with histopathological diagnosis of Hirschsprung's disease were studied. SWS was identified as per the diagnostic criteria proposed by the Waardenburg consortium. Results: There were 202 patients diagnosed with Hirschsprung's disease during 5 years. We identified three male patients fulfilling the diagnostic criteria for WS (white forelock with the involvement of eyebrows and eyelashes, pigmentary disturbances of the iris, and broad high nasal root). All presented in the neonatal period with clinical and radiological features of small bowel obstruction. Family history (sibling) of SWS was seen in one of the neonates. Exploration revealed distended jejunal and ileal loops in all of them; colon contracted and unused (microcolon). Multiple seromuscular biopsies were performed from colon in all 3 neonates. Initial ileostomy was performed in case 2 and case 3. In case 1, the right transverse colostomy was done primarily as total colonic aganglionosis (TCA) was not expected (absence of transition zone in the early neonatal period) and also frozen section facilities were not available. It was followed by ileostomy (second surgery) about 15 cm proximal to the ileocecal junction as colostomy was not functioning adequately. The histopathology of gut biopsies revealed aganglionosis in the entire colon, confirming the diagnosis of TCA in all the cases. Out of three patients in our study, two neonates died in the postoperative period, while third case succumbed due to severe episodes of ileostomy diarrhea. Conclusion: A patient of WS presenting with neonatal intestinal obstruction or constipation since birth should be evaluated on the lines of SWS . Patients with SWS have a higher incidence of TCA or long-segment Hirschsprung's disease. In SWS when transition zone is not clear, an ileostomy would be preferable in view of nonavailability of frozen section.
  4,618 386 2
Association between laboratory markers and oncological outcomes in patients with osteosarcoma – A review of osteosarcoma treatment in Indonesia
Achmad Fauzi Kamal, Rangga Ardianto Prasetyo
May-June 2018, 51(3):111-117
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.
  4,587 389 2
Management of tailgut cysts in a single institute in Taiwan
Yu-Zu Lin, Wen-Yih Liang, Hung-Hsin Lin, Chun-Chi Lin, Jeng-Kai Jiang, Sheng-Chieh Huang
January-February 2019, 52(1):11-16
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.
  4,628 347 2
Laparoscopic-assisted peritoneal dialysis catheter insertion with two 5-mm ports: Complications and outcomes of 30 cases
Kung-Ning Hu, Kun-Hung Shen, Chih-Chiang Chien, Chien-Liang Liu
July-August 2017, 50(4):131-134
Introduction: End-stage renal disease has high prevalence in Taiwan, and peritoneal dialysis (PD) is one of the effective treatments. Although the open catheter placement method is more popular, the laparoscopic method is proven to be superior. We present our initial experience with laparoscopic PD catheter insertion. Materials and Methods: We set one 5-mm trocar over the periumbilicus with another assisting 5-mm trocar in a region about 3 cm lateral to the umbilicus. Abdominal exploration using laparoscopy is performed, and enterolysis is also performed if needed. The PD catheter is inserted through the assisted trocar deep into the Douglas pouch under vision. Finally, we check the final condition under laparoscopy and close the wound. Results: A total of thirty patients (median age 56.5 years old, 15 women) underwent this procedure. No intraoperative complications were noted, and the mean operation time was 32 min. Two postoperative complications were found (2/30, 6.7%). Delayed bleeding was noted due to abdominal wall vessel injury while setting the trocar. The vessel was sutured under laparoscopy, which stopped the bleeding. The other complication was tube dysfunction due to omentum wrapping. Laparoscopic revision of the tube was performed. All the complications could be resolved, and the PD was continued. The mid-term tube function at follow-up (at least 16 months) was acceptable in all cases. Conclusions: Laparoscopic-assisted PD catheter insertion is a feasible procedure that can reduce wound pain with acceptable PD function.
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Prophylatic efficacy of dexamethasone, ketamine and dexmedetomidine against intra- and postoperative nausea and vomiting under spinal anesthesia
Hesameddin Modir, Esmail Moshiri, Alireza Kamali, Maryam Shokrpour, Nilufar Shams
January-February 2019, 52(1):17-23
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 10th–110th 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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