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   2017| July-August  | Volume 50 | Issue 4  
    Online since July 19, 2017

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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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Procalcitonin levels to predict bacterial infection in Surgical Intensive Care Unit patients
Jin You Jhan, Yen Ta Huang, Cian Huei Shih, Jhen Da Yang, Yi Tsen Lin, Shin-Jie Lin, Hsiao Hui Yang, Lee Ying Soo, Guan Jin Ho
July-August 2017, 50(4):135-141
Background: Infection-induced inflammatory response might be aggravated by surgery insults. The clinical presentation of Surgical Intensive Care Unit (SICU) patients might be different from medical critically ill patients. Purpose: To evaluate the diagnostic and prognostic values of procalcitonin (PCT) to predict bacterial infection in SICU patients. Methods: We retrospectively analyzed the 2-year (2013 and 2014) records of 342 adult SICU cases with suspected bacterial infection in SICU of Hualien Tzu Chi Hospital. The past histories, the first infection-related parameters when SICU admission, culture results, infection-related laboratory examinations, and outcomes were collected. Results: Median of PCT level in patients with negative and any positive culture was 0.84 (interquartile range [IQR] 0.18–6.21) and 2.27 (IQR 0.54–9.93) ng/ml, respectively. Infection from blood, urine, and skin/soft tissue elicited significantly higher PCT levels. PCT in receiver operating characteristic (ROC) curve demonstrated the most accurate to predict bacterial infection (area under the ROC curve [AUC]: 0.61; 95% confidence interval [CI]: 0.54–0.63) and bacteremia (AUC: 0.73; 95% CI: 0.66–0.80) compared to white blood cell count, ratio of neutrophils, and neutrophil-to-lymphocyte count ratio (NLCR). Significantly higher PCT levels (4.12 ng/ml, 1.12–19.99; median, IQR) were observed in mortality cases. Higher PCT levels were significantly accompanied with higher NLCR, as well as higher incidence of leukopenia and bandemia. Using Kaplan–Meier analysis, significantly higher intrahospital mortality was observed in cases with above the cutoff PCT levels of 0.5 and 2 ng/ml cases, respectively. Conclusion: PCT is a relatively more useful tool to predict bacterial and particularly bloodstream infection compared to other infection-related parameters in routinely clinical practice. Initial PCT levels may be a prognostic factor of SICU patients with bacterial infection.
  3,619 366 -
Living donor hepatectomy in female donors with ongoing menstruation: Safety and ethical issues
Horng-Ren Yang, Ashok Thorat, Kin-Shing Poon, Chun-Chieh Yeh, Yi-Ying Chiang, Te-Hung Chen, Shih-Chao Hsu, Long-Bin Jeng
July-August 2017, 50(4):119-124
Purpose: The purpose of this study was to study the safety of the major hepatectomy in female donors with ongoing menstruation in situations where the recipient needs urgent liver transplantation and its impact on menstrual bleeding and subsequent menstrual cycles. Materials and Methods: Fifty-eight female donors that underwent adult-to-adult living donor liver transplantation were enrolled in this study and were categorized into two groups. Group A comprised 49 female donors with normal physiological state and Group B comprised nine female donors with ongoing menstruation during the surgery. All the donors in the cohort underwent right hepatectomy including the middle hepatic vein without any blood transfusion in perioperative period. Results: Preoperative international normalized ratio (INR) in Group A and B was 1.05 ± 0.08 and 1.07 ± 0.08, respectively, while INR at postoperative day 7 in Group A donors was 1.72 ± 0.22 while in Group B donors, it was 1.75 ± 0.26. Perioperative hemoglobin drop in Group A and B was statistically insignificant (1.59 ± 0.83 g% vs 1.68 ± 1.51 g%, P = 0.78). The menstrual blood loss in both the groups was statistically comparable. Conclusions: Our study shows safety of right lobe living donation in female donors with ongoing menstruation with no increased risk of intraoperative excessive bleeding and postoperative physiological impact on their general health.
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Correlation between lumbar lordosis and the treatment of chronic low back pain with pulsed radiofrequency applied to the L2 dorsal root ganglion
Hsien-Ta Hsu, Shang-Jen Chang, Kuo-Feng Huang, Po-An Tai, Tin-Chou Li, Chun-Jen Huang
July-August 2017, 50(4):125-130
Background: Percutaneous pulsed radiofrequency (PRF) applied to the L2 dorsal root ganglion (DRG) is an alternative procedure for treating patients with chronic discogenic pain. It is assumed that afferent nerve fibers innervating the degenerated disc and facet joint might travel in the same pathway and finally enter into the L2 DRG. Blocking the L2 DRG with PRF might alleviate discogenic pain and facet joint pain concurrently. Purpose: The purpose of this study was to investigate the correlation between different types of lumbar lordosis (LL) and the treatment of chronic low back pain with PRF applied to the L2 DRG. Materials and Methods: Between 2008 and 2013, 84 patients (29 men and 55 women) were enrolled. Their mean age was 56.03 ± 9.04 years. All patients suffered from low back pain for more than 6 months that worsened on prolonged sitting or standing and did not improve with at least 3 months of conservative treatment. LL was classified into four types based on Roussouly's classification. The L2 DRG was blocked with 2-Hz PRF waves lasting for 120 s at 45 V with the temperature of the electrode tip not above 42°C. The functional outcomes were assessed pre- and post-operatively using a visual analog scale (VAS) and the Oswestry Disability Index (ODI). Results: Twenty-four patients were Type 1 LL, 26 were Type 2 LL, 21 were Type 3 LL, and 13 were Type 4 LL. The mean age of patients with each type of LL was type 1 (56.63 ± 12.09 years), Type 2 (55.39 ± 11.05 years), Type 3 (55.86 ± 11.40 years), and Type 4 (56.54 ± 12.73 years). There were similar improvements in the VAS and ODI scores for all LL types. Two patients experienced cerebrospinal fluid leakage when the needle was moved toward the L2 DRG, but neither patient experienced a neurological deficit. Conclusion: PRF applied to the L2 DRG is an alternative procedure for treating patients with chronic low back pain, regardless of which type of LL the patients have. Chronic low back pain, including discogenic pain and facet joint pain, may be treated by PRF applied to the L2 DRG.
  2,890 213 -
Severe rhabdomyolysis after head and neck surgery
Man-Ling Kao, Ta-Lun Kao
July-August 2017, 50(4):153-157
Rhabdomyolysis constitutes a severe medical emergency that requires immediate recognition and prompt treatment to prevent serious consequences. There are a variety of causes, but rhabdomyolysis after head and neck surgery is very rare. Here, we present a patient who underwent right parotidectomy and complicated with acute kidney injury secondary to severe postoperative rhabdomyolysis. Physicians require special attention for the high-risk patients to avoid severe complications.
  2,505 189 -
Segmental dilatation of the ileum
Tune-Yie Shih
July-August 2017, 50(4):150-152
A 2-year-old boy was sent to the emergency department with the chief problem of abdominal pain for 1 day. He was just discharged from the pediatric ward with the diagnosis of mycoplasmal pneumonia and paralytic ileus. After initial examinations and radiographic investigations, midgut volvulus was impressed. An emergency laparotomy was performed. Segmental dilatation of the ileum with volvulus was found. The operative procedure was resection of the dilated ileal segment with anastomosis. The postoperative recovery was uneventful. The unique abnormality of gastrointestinal tract – segmental dilatation of the ileum, is described in details and the literature is reviewed.
  2,493 194 -
Cranial migration of ventriculoperitoneal shunt
Praveen Mathur, Rahul Gupta, Sunil Mehra, Pragya Chaturvedi, Pradeep Kumar Gupta, Ramendra Shukla
July-August 2017, 50(4):142-144
We report a rare case of an 11-month male infant with cranial migration of ventriculoperitoneal (VP) shunt assembly. The shunt chamber was lying inside the ventricles. At the time of shunt revision, outsized burr hole and wide dural opening were observed. The ventricular migrated chamber of VP shunt was first retrieved from the ventricle followed by the removal of whole shunt assembly. A new VP shunt was placed on the other side with the chamber firmly anchored to the pericranium. The diagnosis was timely done and prevented complete shunt migration into the ventricles. We attribute factors such as outsized burr hole, wide dural opening, and poor anchoring of the straight connector of shunt chamber to periosteum because of poor tissue preservation (redo operation). Repeated flushing of the shunt chamber by cranial direction pressing on it by the mother might be a contributing factor for loosening of anchor sutures and cranial migration. Patients undergoing VP shunt procedure must be under regular follow-up for early recognition of this potential complication. Cranial migration of VP shunt is usually not a fatal complication.
  2,414 208 -
A rare etiology of Fournier's gangrene: Pubic tubercle fracture complicated with hematoma and acute osteomyelitis
Chien-Liang Fang
July-August 2017, 50(4):145-149
The etiologies of Fournier's gangrene are well described into four groups: anorectal, genitourinary, dermatologic, and idiopathic. Here, we present the case of a hematoma and acute osteomyelitis (related to a closed fracture of the pubis), which progressed to Fournier's gangrene 1 month after trauma. A 68-year-old woman was admitted to our emergency department because she had sustained a left side pubic bone fracture from a fall. On her first admission to our emergency department, conservative treatment had been prescribed; however, she was readmitted to our emergency department due to septic shock, local swelling, and pus discharge from the pubis and the left labium majus. A whole abdomen computed tomography scan revealed fluid accumulation in the left suprapubic and perineum region in addition to acute osteomyelitis of the pubis. Acute osteomyelitis-related Fournier's gangrene and sepsis were suspected; hence, she underwent urgent fasciotomy and sequestrectomy. After three rounds of sequestrectomies, partial wound reconstruction with local flap and 24-day hospitalization, she was discharged from our hospital with continuing wound care management. Conservative treatment of closed stable fractures of the pelvic bone along with bed rest is suggested by most orthopedists. However, surgical drainage of hematoma is necessary due to the poor hematoma absorption owing to pelvic fracture. The patient subsequently contracted acute osteomyelitis, a secondary infection associated with the etiology of Fournier's gangrene, particularly in the case of patients with diabetes mellitus. We concluded that this was a rare etiology of Fournier's gangrene and examined the complications of pelvic bone fracture in this context.
  2,312 196 -