Scipedia: Documents published in 2017

Neonatal perforated Amyands hernia presenting as an enterocutaneous scrotal fistula

Scipedia content — Fri, 26 May 2017 12:27:48 +0200

Perforation of the vermiform appendix in a septic neonate with an Amyands hernia resulted in the formation of a scrotal enterocutaneous fistula. In conclusion from this exceptional complication, active parental awareness for any neonatal scrotal swelling is required, and an early operative policy for the neonatal inguinal hernia is significant.

Closure of tracheoesophageal fistula with prefabricated deltopectoral flap

Scipedia content — Fri, 26 May 2017 12:27:42 +0200

Tracheoesophageal fistula (TEF) is a serious complication associated with impaired quality of life. However, a successful TEF closure is difficult owing to the high incidence of recurrence. We utilized a prefabricated deltopectoral (DP) flap for closure of a TEF that occurred after an extended total thyroidectomy. Prefabrication of the inner soft tissue lining the DP flap with a split skin graft was performed prior to surgical closure of a TEF. Esophageal and tracheal mucosa were sutured to the split thickness side and full thickness side of the prefabricated DP flap, respectively. A successful closure of the fistula was achieved with this procedure. Prefabricated DP flap is a useful procedure for the surgical treatment of TEF.

Influence of hospital volume on outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity in Japan

Scipedia content — Fri, 26 May 2017 12:27:36 +0200

Little information is available on the relationship between hospital volume and the outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity. This study aimed to investigate the influence of hospital volume on patient outcomes of laparoscopic gastrectomy for gastric cancer in patients with comorbidity using a national administrative database. A total of 5941 comorbid patients treated with laparoscopic gastrectomy for gastric cancer were referred to 741 hospitals in Japan. We collected patients' data from the administrative database to compare laparoscopy-related complications, in-hospital mortality, length of stay (LOS), and medical costs during hospitalization in relation to hospital volume. Hospital volume was categorized into two groups: low (

Study of treatment results and early complications of tube drainage versus capitonnage after the unroofing and aspiration of hydatid cysts

Scipedia content — Fri, 26 May 2017 12:27:31 +0200

There is controversy concerning the management of the remaining cavity after the evacuation of a cyst in patients who have undergone surgical operation for liver hydatidosis. This study compares the results of capitonnage and tube drainage of the remaining cavity. In this retrospective study, participants were selected from two groups of patients with a liver hydatid cyst who underwent capitonnage or tube drainage from 2004 to 2012. The patients were followed for 6–24 months. The data of age, sex, involved liver lobe, size of the cyst, complications, drain duration, and hospital stay were analyzed. Participants included 155 patients consisting of 96 (61.94%) females and 59 (38.06%) males. Most cysts were in the right lobe, and the most common diameter of the cysts was greater than 10 cm. Capitonnage was performed on 90 (58.06%) patients and the tube drainage procedure was performed on the remaining 65 (41.94%) patients. In the tube drainage group and the capitonnage group, the operative times were 2.21 ± 0.65 hours and 2.53 ± 0.35 hours, respectively, the hospital stays were 5.695 ± 3.37 days and 4.43 ± 2.96 days, respectively, the drain duration was 9.2 ± 1.7 days and 2.1 ± 0.4 days, respectively, and the time to return to work was 14.7 ± 2.3 days and 8.3 ± 10.4 days, respectively. All variables were statistically significant, except for the operative time. Cavity infection and biliary fistula were identified in three patients and six patients, respectively, in the tube drainage group and identified in two patients and three patients, respectively, in the capitonnage group. This difference was not statistically significant. This study demonstrated that capitonnage versus the tube drainage method may result in a shorter hospital stay, decreased time to return to work, and low rate of morbidity and complications.

Most frequent location of the sentinel lymph nodes

Scipedia content — Fri, 26 May 2017 12:27:25 +0200

Inappropriate skin incisions can make sentinel lymph node dissection difficult. A knowledge of the most common locations of the hotspot in the axilla helps in planning the incision. This information also helps to locate the lymph node preoperatively by ultrasound. The aim of this prospective study was to determine the most common location of the sentinel lymph node in the axilla. From January 2006 to December 2010, 974 consecutive patients who underwent sentinel lymph node dissection guided by 99mTc–sulfur colloid were included and the position of the hotspot in the axilla was recorded prospectively. The location of the hottest spot on the skin of the axilla was categorized into seven areas divided by five landmarks. In 98.4% of our patients, the hotspot detected on the axilla skin before sentinel lymph node dissection was located in the area demarcated by the four landmarks of the hairline, a line tangential to and 2 cm below the center of the hairline, the lateral border of the pectoralis major muscle, and the mid-axillary line. The area between these four landmarks is the most frequent location of the sentinel lymph node identified using the radioisotope method. We suggest that this area should be carefully evaluated preoperatively by ultrasound for appropriate surgical planning. A skin incision in this area is also recommended when sentinel lymph node dissection is guided by blue dye.

Reiters syndrome postintravesical Bacillus Calmette–Guérin instillations

Scipedia content — Fri, 26 May 2017 12:27:20 +0200

Intravesical Bacillus Calmette–Guérin (BCG) has been a proven and effective immunotherapy treatment for superficial transitional cell carcinoma (TCC) of the bladder, especially for high-grade tumors and carcinoma in situ. Nevertheless, significant side effects are associated with BCG instillations, including fever, myalgia, malaise, dysuria, hematuria, and irritable lower urinary tract symptoms. We herein report the case of a patient who developed Reiters syndrome following intravesical BCG instillations. A 39-year-old Chinese man presented with a 3-week history of dysuria, suprapubic pain, and pain at the tip of the penis postmicturition. Initial investigations revealed that he had microhematuria, and an ultrasound with computed tomography scan of the abdomen showed a bladder mass. Transurethral resection of the bladder tumor was performed and the patient received a single dose of intravesical mitomycin postoperatively. Results of histopathological examination revealed high-grade bladder TCC (G3pT1), and the patient was managed with intravesical BCG for 2 weeks following the surgery. Four weekly cycles of BCG were administered uneventfully, however, before the fifth instillation, the patient complained of urethral discharge, bilateral conjunctivitis, and low back pain. Reiters syndrome was diagnosed as a rare but known complication of BCG instillation and the BCG immunotherapy was withheld. The patient was treated with nonsteroidal antiinflammatory drugs (for back pain) and eye ointment (for conjunctivitis) and his condition improved. This case report of Reiters syndrome should be highlighted as a rare but significant complication of BCG immunotherapy and urologists should have a high index of suspicion to diagnose this rare complication.

Laparoscopic management of symptomatic urachal remnants in adulthood

Scipedia content — Fri, 26 May 2017 12:27:15 +0200

The traditional surgical approach to the excision of persistent urachal remnants is a lower midline laparotomy or semicircular infraumbilical incision. The aim of this study is to report our experience with laparoscopic urachus excision as a minimally invasive diagnostic and surgical technique. This study was a prospective study involving patients who were diagnosed with persistent urachus and underwent laparoscopic excision. The morbidity, recovery, and outcomes of surgery were reviewed. Fourteen patients (8 men) with a mean age of 22.8 ± 6.42 years underwent laparoscopic excision. All patients presented with discharge from the umbilicus. Although four patients had no sonographic evidence of a patent urachus, a diagnostic laparoscopy detected a patent urachus that was excised laparoscopically. One patient required laparoscopic reoperation for persistent discharge, and one patient presented with bladder injury, which was repaired via a small Pfannenstiel incision without any morbidity. The mean operative time was 71.1 ± 0.28 minutes, and the mean duration of hospital stay was 1.3 ± 1.38 days. Pathological examination confirmed a benign urachal remnant in all cases. Laparoscopy is a useful alternative for the management of persistent or infected urachus, especially when its presence is clinically suspected despite the lack of sonographic evidence. The procedure is associated with low morbidity, although a small risk of bladder injury exists, particularly in cases of severe active inflammation. Recurrence is uncommon and was caused by inadequate excision of inflammatory tissue in our series that was easily managed laparoscopically.

Intramedullary schwannoma of conus medullaris with syringomyelia

Scipedia content — Fri, 26 May 2017 12:27:10 +0200

Intramedullary schwannomas of the spinal cord are rare tumors. They are most commonly observed in the cervical region, however, few have been described in the conus medullaris. The association of intramedullary schwannomas with syringomyelia is also rare. In this report, we present a case of intramedullary schwannoma of the conus medullaris with syringomyelia, which was treated surgically.

Fluorodeoxyglucose positron emission tomography/computed tomography findings in a patient with cerebellar mutism after operation in posterior fossa

Scipedia content — Fri, 26 May 2017 12:27:05 +0200

Cerebellar mutism is a transient period of speechlessness that evolves after posterior fossa surgery in children. Although direct cerebellar and brain stem injury and supratentorial dysfunction have been implicated in the mediation of mutism, the pathophysiological mechanisms involved in the evolution of this kind of mutism remain unclear. Magnetic resonance imaging revealed dentatothalamocortical tract injuries and single photon emission computed tomography showed cerebellar and cerebral hypoperfusion in patients with cerebellar mutism. However, findings with 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in this group of patients have not been documented previously. In this clinical case, we report a patient who experienced cerebellar mutism after undergoing a posterior fossa surgery. Right cerebellar and left frontal lobe hypometabolism was shown using FDG PET/CT. The FDG metabolism of both the cerebellum and the frontal lobe returned to normal levels after the resolution of the mutism symptoms.

Malignancy arising in a 41-year-old colonic interposition graft

Scipedia content — Fri, 26 May 2017 12:26:59 +0200

The colon can be used for esophageal reconstruction after an esophagectomy. The development of a malignancy in the colonic interposition graft is rare, with less than 15 cases reported in the literature. We present a case of a 60-year-old male with high-grade dysplasia of the colonic interposition graft used for reconstruction of the esophagus, which developed 41 years after the esophageal reconstruction. The long-term complication of the development of a malignancy must be considered when using the colon for reconstruction especially when the esophageal reconstruction is performed for a benign cause.

Vascular surgery research in the Gulf Cooperation Council countries

Scipedia content — Fri, 26 May 2017 12:26:54 +0200

To evaluate the quantity and quality of published vascular surgery research articles from the Gulf Cooperation Council (GCC) countries so as to identify areas for improvement. Descriptive study. Published MEDLINE articles on vascular surgery from the GCC countries (1960–2010). Critical analysis of the articles. A total of 146 articles were studied, majority of which were case series/case reports (55.5%), 33% of the articles were prospective. The first author was from a university in 67.1% of the articles. Only one randomized controlled trial was found. The median (range) impact factor of the journals was 1.16 (0.16–12.64). Kuwait had the highest number of publications/country, standardized/100, 000 inhabitants. There were 11 experimental studies, which were all from Kuwait. More statistically significant, experimental vascular surgery papers were published prior to 1993 (11/30 compared with 0/111 afterward, p

Surgically treated rectal cancer patients—Outcomes at a tertiary care cancer hospital in Pakistan

Scipedia content — Fri, 26 May 2017 12:26:47 +0200

The aim of this study was to analyze our experience with rectal cancer patients who underwent surgical excision at our institution. Data on 112 rectal cancer patients who underwent surgical resection with total mesorectal excision, from January 2005 to December 2008, were evaluated retrospectively. We achieved an initial complete remission rate of 74.1%. Overall, 92.8% of patients had a complete total mesorectal excision. The overall survival analysis for all patients showed a 1-year survival rate of 98%, a 3-year survival rate of 82%, and a 5-year survival rate of 70%. We report a 41.9% rate of postoperative complications. The 1-, 3-, and 5-year survival rates for females were 100%, 90%, and 72%, respectively and for males, they were 90%, 80%, and 68%, respectively. Differences in overall survival by sex were not statistically significant (p > 0.05). Those patients who were treated with only surgery had the best outcomes with survival being worse in those treated with surgery and adjuvant therapy. Neoadjuvant treatment followed by surgery led to better results. We conclude that we have been successful in achieving high rates of curative resection, complete remission, and overall survival. Neoadjuvant and adjuvant chemotherapy significantly impact rates of remission.

Laparoscopic bariatric surgery for the treatment of severe hypertriglyceridemia

Scipedia content — Fri, 26 May 2017 12:26:42 +0200

It is well established that severe hypertriglyceridemia can lead to pancreatitis. At present, medical treatment for patients with severe hypertriglyceridemia and repeat pancreatitis attacks is not adequate. The aim of this study was to assess the effectiveness of laparoscopic bariatric surgery in these patients. A review of 20 morbidly obese patients with severe hypertriglyceridemia (a triglyceride level of >1000 mg/dL) who received laparoscopic bariatric surgery was performed. The study population comprised 14 males and six females, with an average age of 35.0 years (range 24–52 years), and the mean body mass index was 38.2 kg/m2 (range 25–53 kg/m2). The preoperative mean plasma triglyceride level was 1782.7 mg/dL (range 1043–3884 mg/dL). Four patients had a history of hypertriglyceridemic pancreatitis and 13 patients had associated diabetes. Of the 20 patients, 17 (85%) received gastric bypass, whereas three (15%) received restrictive-type surgery. Laparoscopic access was used in all of the patients. Hypertriglyceridemia in morbidly obese patients was more commonly associated with male sex and a poorly controlled diabetic state. The mean weight reduction was 25.5% 1 year after surgery, with a marked improvement in diabetes management. As early as 1 month following surgery, the plasma mean triglyceride levels had decreased to 254 mg/dL (range 153–519 mg/dL), and this was further reduced to mean levels of 192 mg/dL (range 73–385 mg/dL) 1 year after surgery. One patient developed acute pancreatitis during the perioperative period, but none of the patients suffered an episode of pancreatitis in the follow-up period (from 6 months to 13 years). Bariatric surgery can be successfully used as a metabolic surgery in severe hypertriglyceridemia patients at risk of acute pancreatitis. However, control of triglyceride levels prior to bariatric surgery is indicated.

Laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-access platform and standard laparoscopic instruments: Technical considerations and surgical outcomes

Scipedia content — Fri, 26 May 2017 12:26:37 +0200

We previously reported our initial experience with laparoendoscopic single-site (LESS) retroperitoneal partial adrenalectomy using a custom-made single-port device and conventional straight laparoscopic instruments. Between December 2010 and February 2012, LESS retroperitoneal partial adrenalectomies were performed in 11 patients. Six patients had aldosterone-producing adenomas (APAs) and five patients had nonfunctioning tumors. A single-port access was created with an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) through an incision of 2–3 cm beneath the tip of the 12th rib. All procedures were performed with straight laparoscopic instruments. All LESS procedures were successfully completed without conversion to traditional laparoscopic conversion. The tumors ranged from 1 cm to 4.7 cm (mean, 2.3 cm). The operative time was 71–257 minutes (mean, 121 minutes). Most patients (n = 8) had minimal blood loss, the other three patients had a blood loss of 150 mL, 100 mL, and 100 mL. The mean hospital stay was 3 days (range, 1–6 days). There were no perioperative or postoperative complications. Pathological examinations revealed negative surgical margins in all specimens. All patients with Conns syndrome had an improvement in blood pressure and normalization of plasma renin activity and serum aldosterone levels, all patients were free of potassium supplementation. Our results clearly demonstrate that LESS retroperitoneal partial adrenalectomy can be performed safely and effectively using a custom-made single-access platform and standard laparoscopic instruments.

Laparoscopic adrenalectomy for adrenal tumors: A 21-year single-institution experience

Scipedia content — Fri, 26 May 2017 12:26:30 +0200

We have performed laparoscopic adrenalectomy including retroperitoneoscopic adrenalectomy via a single large port (RASLP) and conventional laparoscopic adrenalectomy (CLA) for adrenal tumors since 1992, and report our experience to date. The study population consisted of 134 patients who underwent laparoscopic adrenalectomy from 1992 to 2012. Fifty-eight patients (18 aldosterone-producing adenomas, 13 adenomas with Cushings syndrome, 1 adenoma with preclinical Cushings syndrome, and 26 nonfunctioning tumors) were treated using RASLP, and 76 patients (33 aldosterone-producing adenomas, 17 adenomas with Cushings syndrome, 6 adenomas with preclinical Cushings syndrome, 17 pheochromocytomas, and 3 nonfunctioning tumors) were treated using CLA. Complications were graded according to the modified Clavien system. The majority of RASLPs were performed during the 1990s, whereas all patients underwent CLA after 2000. The mean operation times (166 vs. 205 minutes, p

A propensity-matched comparison of perioperative complications and of chronic kidney disease between robot-assisted laparoscopic partial nephrectomy and radiofrequency ablative therapy

Scipedia content — Fri, 26 May 2017 12:26:24 +0200

The study presents a matched-pair analysis of robot-assisted laparoscopic partial nephrectomy (RALPN) versus radiofrequency ablation (RFA) to compare the perioperative incidence of complications and chronic kidney disease (CKD). All 46 RFA and 206 RALPN cases from June 2005 to December 2011 were retrospectively reviewed from the medical records and were matched 1:1 based on propensity scores by sex, tumor size, tumor laterality of kidney, tumor location within the kidney, and clinical T stage. Hilar vessel clamping was performed in all RALPN patients. The estimated glomerular filtration rate was used to define the CKD of

Open versus closed lateral internal anal sphincterotomy in the management of chronic anal fissures: A prospective randomized study

Scipedia content — Fri, 26 May 2017 12:26:19 +0200

Chronic anal fissure is a benign disorder that is associated with considerable discomfort. Surgical treatment in the form of lateral sphincterotomy has long been regarded as the gold standard of treatment. This study compared the open and closed techniques of lateral sphincterotomy in terms of their postoperative outcomes. A prospective, randomized comparative study was conducted between October 2010 and August 2012. A total of 136 patients were randomly assigned to each of two groups. Patients were followed up postoperatively for more than 1 year to assess any complications. The outcomes were compared among the two groups using the Chi-square test and Student t test. The mean age at presentation was 40.13 years. The male to female ratio was 1.47:1. The typical presentation was painful defecation. Fissures were most often located in the posterior midline and associated with a sentinel pile. Delayed postoperative healing was found in 4.4% of the group of patients undergoing open lateral sphincterotomy. The mean pain score and duration of hospital stay were lower with the closed technique. Closed lateral internal sphincterotomy is the treatment of choice for chronic fissures as it is effective, safe, less expensive, and associated with a lower rate of complications than the open sphincterotomy technique.

Experience and learning curve of retroperitoneal laparoscopic ureterolithotomy

Scipedia content — Fri, 26 May 2017 12:26:15 +0200

This study was conducted to evaluate clinical experience and learning curve associated with laparoscopic ureterolithotomy performed for upper ureteral stones. The medical data of 50 patients who had undergone retroperitoneal laparoscopic ureterolithotomy between June 2010 and March 2013 were retrospectively analyzed. To assess the learning curve, patients were divided into two groups: Group A (the first 25 cases) and Group B (the last 25 cases). In Group A, double J stents were placed in 17 patients, whereas in Group B 15 patients received double J stents. In Group A, three ports were placed in nine patients and four ports in 16 patients. In Group B, three ports were placed in 20 patients and five patients had four ports. The patients were compared according to demographics, operative time, stone size, complications, hospital stay, and transfusion. The mean age for Group A was 47.8 ± 14.13 (21–72) years and that for Group B was 44.2 ± 14.98 (22–78) years. Mean operative times were 106.4 ± 38 (55–210) minutes and 70.76 ± 30.4 (30–180) minutes for Groups A and B, respectively (p 0.05). In our study, as staff experience (in performing laparoscopic retroperitoneal ureterolithotomy) increased, operative time, length of hospital stay, and complication rates have correspondingly declined.

Refinement treatment of nasal bone fracture: A 6-year study of 329 patients

Scipedia content — Fri, 26 May 2017 12:26:09 +0200

The reliability of X-ray radiography for diagnosing nasal bone fractures (NBFs) remains controversial. Recent studies show that, for determining the orientation and location of the displaced/depressed fracture, nasal sonography is as accurate as facial computed tomography. This retrospective study compared conductor-assisted nasal sonography (CANS) to conventional diagnostic tools and reported subjective patient satisfaction and discomfort after closed reduction combined with tube technique. This retrospective study reports the results of 329 refinement treatments for nasal bone fracture (including 199 men and 130 women) performed from 2005 to 2011. All patients were assessed with CANS and completed a survey immediately prior to removing the packing. Questionnaires were adapted from the nasal obstruction symptom evaluation (NOSE) scale. The study found that CANS has a 97.2% rate of accuracy in diagnosing NBF. The visual analog scale scores of nasal obstruction, nasal congestion, sleep disturbance, trouble breathing, and inability to move air through the nose were analyzed. The experimental group scores were significantly different from the control group for all scores (p

Modified prepuce unfurling for buried penis: A report of 12 years of experience

Scipedia content — Fri, 26 May 2017 12:26:02 +0200

About 10 years ago, we started to correct buried penis using the technique of modified prepuce unfurling. We have made modifications in the years since our preliminary results were reported in 2002. One hundred and thirty-four patients received modified prepuce unfurling since 2000, with ages ranging from 2 months to 33 years. The surgical procedures included the removal of the narrowest part of the prepuce, dissection of the fibrotic tissue from the Bucks fascia, and unfurling the inner prepuce to cover the penis. Most patients had their procedures in day care service. No urinary catheter was needed. All patients were followed up for at least 2 months. Most patients had satisfactory results. All patients had the glans exposed after surgery, although one patient needed reoperation for prolonged edema and two patients had wound infections. Modified prepuce unfurling is a safe and effective method to correct buried penis.

Colorectal peritoneal carcinomatosis treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: The experience of a tertiary Asian center

Scipedia content — Fri, 26 May 2017 12:25:57 +0200

Compared with intravenous chemotherapy, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to improve survival in patients with recurrent colorectal disease confined to the peritoneum. We report our experience with CRS and HIPEC for colorectal cancer patients with peritoneal carcinomatosis, evaluating prognostic factors for disease-free survival (DFS), overall survival (OS), and perioperative morbidity and mortality. All patients who underwent CRS and HIPEC were included in our study. Clinical characteristics, operative data, and 30-day morbidity and mortality were collected and evaluated. Between January 2001 and December 2012, there were 35 consecutive patients who underwent CRS and HIPEC at our institution. Thirty-three patients (94%) had optimal cytoreduction. No 30-day mortality was reported, but 14 patients had postoperative complications. The median DFS was 9.4 months (95% confidence interval 5.5–18.7 months), and DFS at 1 year, 3 years, and 5 years were 43.8%, 22.3%, and 22.3%, respectively. The median OS was calculated to be 27.1 months (95% confidence interval 15.3–39.1), and the OS at 1 year, 3 years, and 5 years were 83.7%, 38.2%, and 19.1%, respectively. CRS and HIPEC can provide survival benefit, with reasonable morbidity and mortality for Asian patients with peritoneal carcinomatosis from colorectal cancer. Patient selection and perioperative management of the patients are key to the success of the procedure.

Robotic left hepatectomy with revision of hepaticojejunostomy

Scipedia content — Fri, 26 May 2017 12:25:50 +0200

Laparoscopic hepatectomy and hepaticojejunostomy remain a surgical challenge despite the recent advances in minimally invasive surgery. A robotic surgical system has been developed to overcome the inherent limitations of the traditional laparoscopic approach. However, techniques of robotic hepatectomy have not been well described, and a description of robotic major hepatectomy with bilioenteric anastomosis can be found only in two previous reports. Here, we report a 33-year-old man with a history of choledochocyst resection. The patient experienced repeat cholangitis with left hepatolithiasis during follow-up. Robotic left hepatectomy and revision of hepaticojejunostomy were performed smoothly. The patient recovered uneventfully and remained symptoms-free at a follow-up of 20 months. The robotic approach is beneficial in the fine dissection of the hepatic hilum and revision of hepaticojejunostomy in this particular patient.

Nonoperative management for perforated peptic ulcer: Who can benefit?

Scipedia content — Fri, 26 May 2017 12:25:45 +0200

Although nonoperative management for perforated peptic ulcer (PPU) has been used for several decades, the indication is still unclear. A clinicoradiological score was sought to predict who can benefit from it. A clinicoradiological protocol for the assessment of patients presenting with PPU was used. A logistic regression model was applied to identify determinant variables and construct a clinical score that would identify patients who can be successfully treated with nonoperative management. Of 241 consecutive patients with PPU, 107 successfully received nonoperative management, and 134 required surgery. In multivariable analysis, the following four variables correlated with surgery and were given one point each toward the clinical score: age ≥70 years, fluid collection detection by ultrasound, contrast extravasation detection by water-soluble contrast examination, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score ≥8. Eighty-five percent of patients with a score of 1 or less were successfully treated with nonoperative management, whereas 23 of 29 patients with a score of 3 or more required surgery. The area under the receiver operating characteristic curve was 0.804 (95% confidence interval = 0.717–0.891). By combining clinical, radiological parameters, and APACHE II score, the clinical score allowed early identification of PPU patients who can benefit from nonoperative management.

Primary right atrial angiosarcoma misdiagnosed as aortic intramural hematoma

Scipedia content — Fri, 26 May 2017 12:25:39 +0200

The overall incidence of cardiac tumor is very low, and malignant cardiac tumors account for only 25% of all cardiac tumors. Angiosarcomas are the most common type of malignant cardiac tumors, characterized by rapidly proliferating, extensively infiltrating anaplastic cells derived from blood vessels and lining irregular blood-filled spaces. We present a 26-year-old man with angiosarcoma involving the right atrium, which was misdiagnosed as aortic intramural hematoma by computed tomography, finally confirmed by transesophageal echocardiography during the operation.

Presentation of pericardial hydatid cyst as acute cardiac tamponade

Scipedia content — Fri, 26 May 2017 12:25:34 +0200

We report a case of a 47-year-old man with isolated pericardial hydatid cyst (without myocardial involvement) that presented as acute pericardial tamponade. After initial investigation and transthoracic echocardiography, emergent pericardial drainage was performed for downgrading the urgency of a definitive treatment for a hydatid cyst. A computed tomography examination after the pericardial drainage showed a pericardial cyst without heart muscle involvement, making the treatment possible through anterior thoracotomy and without performing cardiopulmonary bypass. Complete surgical removal of the cyst was performed. The postoperative course was uneventful. The patient received postoperative albendazole treatment. He remained asymptomatic and no recurrence was observed during a 1-year follow-up period.

Short- and long-term results of harmonic scalpel hemorrhoidectomy versus stapler hemorrhoidopexy in treatment of hemorrhoidal disease

Scipedia content — Fri, 26 May 2017 12:25:29 +0200

In this prospective randomized study, our aim is to compare the short- and long-term results of harmonic scalpel hemorrhoidectomy (HSH) and stapler hemorrhoidopexy (SH) methods in the surgical treatment of Grade III and Grade IV hemorrhoidal disease. Ninety-nine consecutive patients diagnosed with Grade III or Grade IV internal hemorrhoidal disease were included in the study. Patients were randomized to HSH (n = 48) or SH (n = 51) treatments. Data on patient demographic and clinical characteristics, operative details, postoperative pain score on a visual analog scale, additional analgesic requirement, postoperative short- and long-term complications, and recurrence of hemorrhoidal disease were also recorded. Patients were regularly followed for a total period of 24 (6–36) months. The patient demographic and clinical characteristics were similar in the two groups. The operative time was significantly shorter in the HSH group compared with the SH group. Overall pain scores were not significantly different between the groups, although severe pain was significantly more common in the HSH group. Recurrence was significantly lower in the HSH group compared with the SH group. HSH and SH are both safe and effective methods for surgical treatment of Grade III and Grade IV hemorrhoidal disease. In our study, the HSH method was determined to be safer, easier, and faster to perform, and associated with fewer long-term recurrences than the SH method.

Primary non-Hodgkins lymphoma of the common bile duct: A case report and literature review

Scipedia content — Fri, 26 May 2017 12:21:15 +0200

Hepatobiliary involvement by malignant lymphoma is usually a secondary manifestation of systemic disease, whereas primary non-Hodgkins lymphoma of the extrahepatic biliary ducts is an extremely rare entity. We describe the case of a 57-year-old man who presented with an acute onset of obstructive jaundice and severe itching. Abdominal ultrasonography and computed tomography revealed intrahepatic and common hepatic ducts dilatation. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed a mid-common bile duct stricture. The patient was presumed to have cholangiocarcinoma of the common bile duct, and an en bloc resection of the tumor with Roux-en-Y hepaticojejunostomy and porta-hepatis lymph nodes dissection was performed. Histopathology and immunohistochemistry revealed a large B cell non-Hodgkins lymphoma. The patient received six cycles of combination chemotherapy using cyclophosphamide, vincristine, prednisone, and rituximab (CVP-R) protocol, and after a 5-year follow-up he is still in complete remission. We also reviewed the cases published from 1982 to 2012, highlighting the challenges in reaching a correct preoperative diagnosis and the treatment modalities used in each case.

Infrahepatic inferior vena cava clamping in hepatectomy for tumors involving hepatocaval confluence

Scipedia content — Fri, 26 May 2017 12:21:10 +0200

Massive hemorrhage and the need for blood transfusion carry a high rate of morbidity and mortality after hepatectomy. The aim of this study was to evaluate the safety and potential benefit of infrahepatic inferior vena cava (IVC) clamping in hepatectomy for tumors involving hepatocaval confluence. We conducted a retrospective analysis of 113 consecutive patients who underwent hepatectomy with infrahepatic IVC clamping (n = 60, Group A) and without infrahepatic IVC clamping (n = 53, Group B) as the initial treatment for tumors involving hepatocaval confluence. In Group A, central venous pressure reduced from 7.6 ± 3.2 to 4.4 ± 2.7 cm H2O (p

Pseudolymphoma of the liver: Report of a case and review of the literature

Scipedia content — Fri, 26 May 2017 12:21:05 +0200

We report a case of pseudolymphoma of the liver in a 49-year-old woman without an underlying disease except for liver hemangioma. A 20-mm nodule was incidentally found in segment 2 of the liver by abdominal ultrasonography during a regular follow-up of the hepatic hemangioma. After a series of radiological examinations, a left lateral sectionectomy was performed because malignant hepatic tumor could not be excluded. The patient was discharged uneventfully 7 days after the operation. The pathology examination revealed a pseudolymphoma. No recurrence of the tumor was found 5½ years after the operation. To the best of our knowledge, only 46 cases of pseudolymphoma of the liver have been reported to date. A review of the literature showed that pseudolymphomas occur predominantly in females (89.4%), usually occur as a single tumor (80.4%), are no more than 20 mm in size (90.6%), and are frequently associated with either autoimmune disease or chronic liver disease. Because an accurate diagnosis is difficult to establish, vigilant follow-up is indicated, and surgical intervention is the choice of treatment once the suspiciousness of malignancy has been raised.

Maggot therapy for chronic ulcer: A retrospective cohort and a meta-analysis

Scipedia content — Fri, 26 May 2017 12:20:59 +0200

Maggot wound therapy (MWT) has been used in various wounds including diabetic foot ulcers, venous leg ulcers, pressure ulcers, and acute surgical wounds. However, the efficacy of MWT therapy has been controversial. We therefore conducted a cohort study and a meta-analysis to assess MWT effects. A retrospective cohort study was performed in diabetic foot ulcer (DFU) patients who were treated with MWT or conventional wound therapy (CWT) in Thailand. The Kaplan-Meier curve was applied to estimate the healing probability. A meta-analysis was performed to pool our study with four previous cohort studies identified from Medline and Scopus. The estimated incidence of wound healing was 5.7/100 (95% CI: 4.49, 7.32) patients-week, and the median time to healing was 14 weeks. The hazard ratio (HR) of wound healing was 7.87 times significantly higher in the MWT than the CWT (p

Left nutcracker syndrome and right ureteropelvic junction obstruction

Scipedia content — Fri, 26 May 2017 12:20:53 +0200

We report a rare case of left nutcracker syndrome and right ureteropelvic junction obstruction in a young woman who suffered flank pain and hematuria. The diagnosis was confirmed with the help of Doppler ultrasonography, retrograde pyelography, magnetic resonance angiography, and magnetic resonance urography. A surgery that involves left renal vein decompression and dismembered Anderson–Hynes pelvioplasty was performed. The patient was followed up for 23 months, and her symptoms were relieved.

Robotic single port cholecystectomy (R-LESS-C): Experience in 36 patients

Scipedia content — Fri, 26 May 2017 12:20:48 +0200

Laparoendoscopic single-site surgery (LESS) has emerged as a result of a search for “pain-less” and “scar-less” surgery. Laparoendoscopic single-site cholecystectomy (LESS-C) is probably the most common application in general surgery, although it harbors certain limitations. It was proposed that the da Vinci Single-Site (Si) robotic system may overcome some of the difficulties experienced during LESS, providing three dimensional views and the ability to work in a right-handed fashion. Thirty-six robotic single port cholecystectomies (R-LESS-C) performed with the da Vinci Si robotic system are evaluated in this paper R-LESS-C performed in 36 patients were reviewed. The data related to the perioperative period (i.e., anesthesia time, operation time, docking time, and console time) was recorded prospectively, whereas the hospitalization period, postoperative visual analogue scale (VAS) pain scores were collected retrospectively. A total number of 36 patients, with a mean age of 40.1 years (21–64 years), underwent R-LESS-C. There were five men and 31 women. The mean anesthesia and operation times were 79.3 minutes (45–130 minutes) and 61.8 minutes (34–110 minutes), respectively. The mean docking time was 9.8 minutes (4–30 minutes) and the mean console time was 24.9 minutes (7–60 minutes). The mean hospital stay was 1.05 days (1–2 days) and the mean pain score (VAS) was 3.6 (2–8) in the first 24 hours. Incisional hernia was recorded in one patient. R-LESS-C can be performed reliably with acceptable operative times and safety. The da Vinci Si robotic system may ease LESS-C. Two issues should be considered for routine use: expensive resources are needed and the incidence of incisional hernia may increase.

Retroperitoneal laparoscopic debridement and drainage of infected retroperitoneal necrosis in severe acute pancreatitis

Scipedia content — Fri, 26 May 2017 12:20:42 +0200

To explore the effect of retroperitoneal laparoscopic debridement and drainage on infected necrosis in severe acute pancreatitis. This retrospective study included 18 patients with severe acute pancreatitis (SAP) undergoing retroperitoneal laparoscopic debridement and drainage from May 2006 to April 2012 in our hospital. All patients had infected retroperitoneal necrosis and single or multiple peritoneal abscesses. Eleven patients transferred to our hospital were treated with the retroperitoneal laparoscopic debridement and drainage within 24–72 hours after admission. Conservative treatments were given to eight patients. Retroperitoneal laparoscopic debridement and drainage were applied 3–11 days after admission. All patients had infection of necrotic pancreas or peripancreatic tissues. Twelve patients had organ failure. Three patients underwent secondary surgery. Laparotomy with debridement and drainage were applied to one patient who had a huge lesser sac abscess 7 days after first surgery. The other two patients were given secondary retroperitoneal laparoscopic debridement and drainage. One case was complicated by retroperitoneal hemorrhage, four cases had pancreatic leakage, and no intestinal fistula was found. The patients' heart rate, respiration, temperature, and white blood cell count were significantly improved 48 hours after surgery compared with those prior to surgery (p

An unusual cause of acute abdomen—Gas-forming liver abscess due to Salmonella enteritidis

Scipedia content — Fri, 26 May 2017 12:20:36 +0200

Gas-forming pyogenic liver abscess (GFPLA) is considered to be a very severe form of PLA and carries a high mortality. Klebsiella pneumoniae is the most common pathogen responsible for the disease, whereas cases where Salmonella is cited as the cause are very uncommon. We report the first case of a 53-year-old lady suffering from GFPLA due to Salmonella, who was successfully treated with surgical drainage. To the best of our knowledge, this is the first case of GFPLA caused by Salmonella enteritidis to be reported in the English literature.

Discriminative features of thin-slice computed tomography for peripheral intrapulmonary lymph nodes

Scipedia content — Fri, 26 May 2017 12:20:31 +0200

The use of computed tomography (CT) scans has increased the opportunities to detect small nodular shadows in peripheral lung fields. Intrapulmonary lymph nodes (IPLNs) are sometimes identified among these nodular shadows, and a differential diagnosis is often difficult. However, few descriptions of the CT findings of IPLNs, with regard to their potential for the differential diagnosis of lung cancer, have been published. From 2006 through 2011, 606 patients underwent thoracic surgery for pulmonary nodules. Nine patients (1.5%) had pathologically diagnosed IPLNs. We retrospectively reviewed the clinicopathological features and thin-section CT findings of the patients with IPLNs. We also compared these IPLN patients with 17 patients having small-sized lung cancer. In six cases, the nodules were round, and linear density extending from the IPLNs was visualized in seven nodules. The nodules in IPLNs were located in the lower lobe, and the nodule borders were clearer than those of lung cancers. Six out of nine nodules were round, and linear densities were more easily visualized for the IPLNs. Medical specialists need to be familiar with the discriminative features of thin-slice CT for IPLNs not only to avoid performing unnecessary operations, but also to prevent the mis-staging of lung cancer.

Primary repair of tetralogy of Fallot in infants: Transatrial/transpulmonary or transventricular approach

Scipedia content — Fri, 26 May 2017 12:20:26 +0200

Right ventricular (RV) dysfunction is a significant cause of morbidity and mortality after surgical correction of tetralogy of Fallot (TOF). Transatrial/transpulmonary repair avoids a ventriculotomy (in contrast to the transventricular approach) in order to preserve the structure and function of the right ventricle. We performed a pilot prospective randomized controlled trial in infants with TOF undergoing primary repair. A pilot prospective controlled clinical trial was conducted in infants with TOF undergoing primary repair between January 2008 and December 2009. One hundred and six patients were recruited in the trial and divided into a transatrial–transpulmonary approach group (Group A, n = 53) and a transventricular approach group (Group B, n = 53), depending on the different surgical techniques used. Preoperative patient characteristics and procedure-related variables were similar. There were no deaths in Group A, while two patients died in Group B. There were significant differences in cardiopulmonary bypass time (95.02 ± 23.8 vs. 85.23 ± 22.63 minutes, p = 0.032), cross-clamp time (69.4 ± 10.36 vs. 61.17 ± 9.38 minutes, p = 0.035), inotropic support (1.63 ± 0.97 vs. 2.1 ± 1.09 days, p = 0.02), intubation time (26.62 ± 12.48 vs. 33.02 ± 17.55 hours, p = 0.033), duration of stay in the intensive care unit (ICU) (2.25 ± 1.28 vs. 2.85 ± 1.46 days, p = 0.026), and the incidence of arrhythmia [3 patients (5.7%) vs. 10 patients (18.9%), p = 0.038]. No significant differences in right/left ventricular pressure ratio and hospital stay were observed. Transatrial/transpulmonary repair of TOF is associated with excellent surgical results and immediately follow-up.

Comparison of superficial surgical site infection between delayed primary and primary wound closures in ruptured appendicitis

Scipedia content — Fri, 26 May 2017 12:20:22 +0200

Delayed primary (DPC) and primary (PC) wound closures have been applied in ruptured appendicitis, but results were controversial. This study aims at comparing the rate of superficial surgical site infection (SSI) in ruptured appendicitis between DPC and PC. A retrospective cohort of ruptured appendicitis was conducted between October 2006 and November 2009. Demographic, operative findings and postoperative infection data were retrieved. The superficial SSI rates between groups were compared using an exact test. An odds ratio of SSI was then estimated. One-hundred and twenty eight patients with ruptured appendicitis were eligible and their data were retrieved, 115 (90%) patients had received DPC and 13 (10%) patients had received PC. The SSI rate was much lower in PC patients than in DPC patients, i.e., 7.7% [95% confidence interval (CI): 0.02, 36.0] versus 27.8% (95% CI: 19.9, 37.0), respectively. There was an approximately 72% lower risk of SSI in the PC group than in the DPC group, but this did not reach statistical significance (p = 0.18). Our study suggested that PC does not increase risk of SSI in low SSI risk patients with ruptured appendicitis. DPC should not be routinely done.

Solitary benign fibrous mesothelioma of the peritoneum: A rare entity in a 2-year-old child

Scipedia content — Fri, 26 May 2017 12:20:16 +0200

Solitary benign fibrous mesothelioma (BFM) is uncommon and is termed as solitary fibrous mesothelioma or localized fibrous mesothelioma. Although the most common site for its development is the pleural region (65%), it has also been reported in the peritoneum. They are mostly seen in adults (average age: 54 years). Herein, we present a case of BFM in a 2-year-old male child, who presented to our hospital with abdominal pain and a lump in the abdomen. Differential diagnosis included solitary fibrous tumor, gastrointestinal stromal tumor, and benign fibrous lesions of mesentery. Establishing a preoperative diagnosis is difficult on the basis of clinical parameters or imaging studies and final diagnosis can only be assessed based on the results of histopathological and immunohistochemical examination.

Primary melanoma of the esophagus, a diagnostic challenge

Scipedia content — Fri, 26 May 2017 12:20:08 +0200

Primary melanoma of the esophagus is a rare condition. Its diagnosis can be challenging, as its presentation is similar to that of other esophageal malignancies, especially when melanin is not evidently expressed in the melanoma. We report a case of esophageal melanoma in a 59-year-old Chinese male, whose histological diagnosis was confirmed from the esophagectomy specimen.

Effects of albumin and synthetic polypeptide-coated oxygenators on IL-1, IL-2, IL-6, and IL-10 in open heart surgery

Scipedia content — Fri, 26 May 2017 12:18:05 +0200

In this study, we have tried to demonstrate the effects of coating style used in oxygenators on various hematologic and clinical parameters. Twenty-seven patients were included in the study, who had undergone operations because of elective coronary artery disease. Albumin-coated oxygenator was used in Group I. In Group II, a synthetic polypeptide-coated oxygenator was used. C1-inhib (complement), C3c, C4, interleukins (IL-1β, IL2, IL-6, IL-10), and tumor necrosis factor alpha (TNF-α) levels were examined at four different time intervals. Hemoglobin, hematocrit, leukocyte and platelet counts, drainage, and transfused blood volumes were analyzed. Albumin levels were significantly lower in Group I than those in Group II 5 minutes after the removal of the cross-clamp. Twenty-four hours after the surgery, Group I patients also had a significantly higher white blood cell count compared to Group II patients. TNF-α levels in Group I were always expressed in considerably higher amounts than those in Group II. IL-6 levels were significantly higher in Group I, but IL-10 levels were observed to be higher in Group II (p

Treatment of sternal wound infections after open-heart surgery

Scipedia content — Fri, 26 May 2017 12:17:59 +0200

The aim of this study was to investigate the proper treatment of infected median sternotomy wounds. A retrospective study was conducted to investigate the proper treatment of infected median sternotomy wounds on patients with sternal wound infections from January 2007 to July 2009. The characteristics of the sternal infections and the treatment outcomes were analysed. Ninety-seven patients with sternal wound infections were treated. A total of 32 patients acquired the infection within one month after open-heart surgery, 10 patients got the infection one to two months after the surgery, and 1 patient died two days after debridement. There were 54 patients who acquired the infection beyond two months post-surgery, while 1 patient died on the day before the operation. One patient received four cycles of wound debridement, 18 patients received two cycles and 78 patients only received one cycle. A total of 14 patients received a vacuum-assisted closure treatment. There were 73 patients who had surgery for repair of muscle flaps, 1 patient for breast tissue flap, 63 patients for pectoralis major muscle flap, and 9 patients with rectus abdominis muscle flap. There were 12 patients who received a transverse plate fixation of the sternum with titanium plating. A positive prognosis can be obtained by the algorithm treatment based on the onset and depth of the sternal infection.

Double peptic perforation: Report of a rare case

Scipedia content — Fri, 26 May 2017 12:17:55 +0200

Perforation peritonitis is the most common surgery performed in an emergency. Upper gastrointestinal tract perforation is more common than lower gastrointestinal perforation. Multiple peptic perforations in an individual are a relatively rare entity, with fewer than 10 cases reported in the literature. The factor that contributes the most for the occurrence of multiple peptic perforations is analgesic and steroid abuse. Herein, we report a rare case of double peptic perforation in a middle-aged man with history of analgesic use for 18 months.

Parathyroid carcinoma in tertiary hyperparathyroidism

Scipedia content — Fri, 26 May 2017 12:17:49 +0200

Parathyroid carcinoma is a rare disease of unknown etiology. This study presents a case of parathyroid carcinoma in a patient with tertiary hyperparathyroidism. Despite a successful kidney transplantation, the intact parathyroid hormone (iPTH) level of the patient was elevated consistently and could not be controlled by medical therapy. Due to the development of tertiary hyperparathyroidism with bone pain and osteoporosis, subtotal parathyroidectomy was performed 4 months after the kidney transplantation. Histological evaluation revealed that one of four parathyroid lesions was a parathyroid carcinoma, while the others were diffuse hyperplasia. Postoperative laboratory studies indicated a decreased level of iPTH. A positron emission tomography–computed tomography performed 6 months after the operation revealed no evidence of local recurrence or distant metastasis.

Treatment of thoracic wounds with adapted vacuum therapy

Scipedia content — Fri, 26 May 2017 12:17:44 +0200

This is a report of seven cases of infected thoracic wounds treated with an adapted low-cost vacuum therapy in the Thoracic Surgery Unit of Santa Marcelina Hospital. The vacuum system used was designed and adapted to our hospital due to financial limitations on the acquisition of commercial kits. The vacuum-assisted closure kit used in this study consisted of chlorhexidine sponges (which are usually used for antisepsis of the surgical team), a 16F nasogastric tube, and two sterile adhesive films (OPSITE) for surgical field reinforcement. The mean duration of vacuum therapy was 13.4 days (range, 10–20 days), with an average of three dressing changes (range, 1–5). After treatment with vacuum-assisted closure, three wounds (3/7) were closed with simple primary sutures, one of the lesions (1/7) was closed by muscle flap rotation, and three wounds (3/7) healed by second intention. This adapted vacuum therapy was safe and easy to apply in our institution, including its use in patients with thoracostomies.

Inflammatory myofibroblastic tumors of the duodenum

Scipedia content — Fri, 26 May 2017 12:17:37 +0200

Inflammatory myofibroblastic tumors (IMTs) are rare soft-tissue tumors that can occur at virtually any anatomical site. We report the case of a 58-year-old male with an IMT of the fourth part of the duodenum who presented with signs and symptoms of high intestinal obstruction and bilious vomiting. The patient underwent a surgical resection of the fourth part of the duodenum with end-to-end duodenojejunal anastomosis. The follow-up period of 6 months was uneventful with no evidence of recurrence. According to our knowledge, only six cases of duodenal IMTs have been reported in the literature thus far, and this is the first report of a duodenal IMT sited at the fourth part of the duodenum. The duodenum is among the rarest sites of IMTs. Signs and symptoms resulting from diagnostic imaging investigations are nonspecific and inadequate to obtain diagnosis accurately. In most cases, surgical treatment is considered a cure for IMTs. There is no evidence of deaths caused by duodenal IMT. IMT of the duodenum is a possible diagnosis in differential diagnosis of tumor-like lesions of the duodenum.

Endoscopic ultrasound-guided hepaticogastrostomy for advanced cholangiocarcinoma after failed stenting by endoscopic retrograde cholangiopancreatography

Scipedia content — Fri, 26 May 2017 12:17:31 +0200

Cholangiocarcinoma is common in Thailand. There are many palliative treatments available for patients with unresectable tumor, such as endoscopic retrograde cholangiopancreatography (ERCP) with stents, percutaneous transhepatic biliary drainage, or surgery. In cases in which ERCP has failed, we propose an alternative technique: the use of endoscopic ultrasound with fluoroscopy to perform hepaticogastrostomy for palliative drainage instead of percutaneous transhepatic biliary drainage. A case series study was conducted between December 2005 and December 2009 of 10 patients (4 male and 6 female, average age: 57 years) who presented with severe jaundice caused by advanced cholangiocarcinoma, who were treated with this procedure after failure to drain by ERCP. We used an electronic convex curved linear-array fluoroscopy-guided echoendoscope to drain the left dilated intrahepatic duct to the stomach by metallic wallstent. We performed the procedure with the first six patients under general anesthesia and with the other four under conscious sedation. Follow-up liver function tests were done, and clinical symptoms and survival times were recorded. Hepaticogastrostomy was unsuccessful on the first two patients (success rate = 8/10, 80%), and effective drainage was obtained in only seven patients. Average total bilirubin reduction was 14.96 mg/dL (58.75%) and 18.13 mg/dL (71.20%) after 2 weeks and 4 weeks, respectively, with good quality of life. One patient was not effectively drained because of malposition of the stent. There were two patients whose stent migrated into the stomach, one needed a second session with a second wallstent, and the other needed a double pigtail stent inside the second wallstent. Follow-up survival rates were 32–194 days (average: 123 days). Endoscopic-ultrasound-guided hepaticogastrostomy is safe and can be a good palliative option for advanced malignant biliary obstruction because it drains internally and is remote from the tumor site, promoting a long patency period of prosthesis and better quality of life.

Usefulness of breast-conserving surgery using the round block technique or modified round block technique in Japanese females

Scipedia content — Fri, 26 May 2017 12:17:25 +0200

The round block technique (RBT) is an oncoplastic technique in which only the perimamillary scars remain visible. We have performed RBT in cases that require resection of the breast tissue under the nipple–areola complex (NAC) and a modified round block technique (MRBT) in peripheral cases in which performing resection of the breast tissue under the NAC is unnecessary. We herein report the usefulness of these techniques. The study participants consisted of 18 patients who underwent breast-conserving surgery (BCS) using MRBT or RBT between July 2010 and July 2011. In the cases using RBT, de-epithelialization between the outer and inner incision lines was performed and the dermis was cut at the side of the tumor location. For MRBT cases, the dermis was cut in all parts of the inner and outer circles, and the skin between the inner and outer incision lines was resected. Cosmetic results were found to be excellent in three cases, good in eight cases, fair in five cases, and poor in two cases. In this study, the cosmetic results were unacceptable (fair and poor) in patients who underwent ≥25% resection or in whom the resected area was part of the lower portion of the breast. These techniques are useful for performing BCS in the upper portion of the breast. However, if the excision volume is >20% or excision of part of the lower portion of the breast is required, other procedures should be considered.

Goldilocks mastectomy for obese Japanese females with breast ptosis

Scipedia content — Fri, 26 May 2017 12:17:20 +0200

The Goldilocks mastectomy is a method that uses redundant mastectomy flap tissue alone to create a breast mound in female American patients with macromastia. Goldilocks mastectomy was performed for obese Japanese females with breast ptosis, and its indications were considered for Japanese female patients. This report presents the results of five patients who underwent Goldilocks mastectomy, including one with bilateral breast cancer. The average age of the patients was 72 years (range: 67–76 years). The body mass index (BMI) was more than 25 in all the cases. Four patients had invasive ductal carcinoma, and one patient had noninvasive ductal carcinoma of bilateral breasts. The cosmetic results were found to be good in two cases [a patient with bilateral breast cancer and a severely obese patient (BMI = 39)]. The cosmetic results in the other three cases were poor. Although the reconstructed breast size was small, this procedure resulted in better cosmetic results than what would be achieved with the usual method of mastectomy for Japanese patients with bilateral breast cancer and severely obese Japanese patients.

Composite pheochromocytoma with a malignant peripheral nerve sheath tumor: Case report and review of the literature

Scipedia content — Fri, 26 May 2017 12:17:15 +0200

Adrenal tumors with more than one cellular component are uncommon. Furthermore, an adrenal tumor composed of a pheochromocytoma and a malignant peripheral nerve sheath tumor is extremely rare. A composite pheochromocytoma with malignant peripheral nerve sheath tumor in a 42-year-old man is reported here. After adequate preoperative control, left adrenalectomy was performed simultaneously with resection of the ipsilateral kidney for spontaneous rupture of the left adrenal tumor. Pathological findings demonstrated pheochromocytoma and malignant peripheral nerve sheath tumor in a ruptured adrenal tumor. To date, there have been only four reported cases of composite pheochromocytoma with malignant peripheral nerve sheath tumor, so the present case is only the fifth case in the world. Despite the very poor prognosis of patients with pheochromocytoma and malignant peripheral nerve sheath tumors reported in the literature, the patient remains well without evidence of recurrence or new metastatic lesions at 36 months postoperatively.

Proximal direct endarterectomy combined with simultaneous distal endovascular therapy for chronic full-length occlusion of the superficial femoral artery in elderly patients

Scipedia content — Fri, 26 May 2017 12:17:09 +0200

The most proximal ostial site of the chronic occlusive superficial femoral artery is not suitable for ballooning or stenting because the deep femoral artery may be occluded by these procedures. Thus, the feasibility of performing an open endarterectomy for the occluded ostium of the superficial femoral arteries combined with an endovascular therapy for the remaining distal site was evaluated. Eleven critically ischemic limbs in 10 elderly patients with poor general health were enrolled. They had full-length occlusion of the superficial femoral artery involving its ostium. The ostial site was managed with an open endarterectomy followed by endovascular therapy for the remaining distal site. All procedures were successfully performed. All patients experienced pain relief, and the wounds healed. During the follow-up observation period (average: 23.9 ± 14.7 months), nine patients died. None of the patients, including those who had lost patency of the superficial femoral artery, received major amputation. Elderly patients, including those who were in terminal stage, were able to withstand the operation, and their postoperative quality of life was not compromised. Although the patency following the surgery was limited, sparing the deep femoral artery could either prevent or delay the recurrence of critical limb ischemia.

Mesenteric lipoblastoma presenting as a small intestinal volvulus in an infant: A case report and literature review

Scipedia content — Fri, 26 May 2017 12:17:04 +0200

A 1-year-old boy with no underlying disorder presented with non-bilious vomiting since 4 days before admission. He was referred to our hospital and was diagnosed with a small bowel obstruction due to an intraabdominal tumor. Laparotomy revealed an intestinal volvulus with a soft and lobulated tumor arising from the mesentery. The resected tumor with a small part of the small bowel was diagnosed as lipoblastoma histologically. From a literature review, mesenteric lipoblastoma with an intestinal volvulus showed different characteristics such as greater frequency of vomiting and less frequency of abdominal mass as clinical symptoms, and the size of the tumor was smaller than that of the tumor without the intestinal volvulus.

Medial pectoral pedicle is a reliable landmark for axillary lymph node dissection

Scipedia content — Fri, 26 May 2017 12:16:59 +0200

The anatomical orientation of structures in the axilla has not been well studied, although it is essential for a neat and safe dissection. The objective of this study was to determine the relations between neurovascular structures in the axilla as they were encountered during axillary lymph node dissection (ALND) for breast cancer. This was a prospective study of 29 consecutive ALNDs accompanying either mastectomy or wide local excision. The dissections were conducted in a stepwise manner and the orientation of the structures was determined as the dissections advanced from superficial to deeper planes. The medial pectoral pedicle was the most superficial neurovascular structure encountered during the dissections and was curled around the lateral border of the pectoralis minor muscle in most cases. The intercostobrachial nerve lay 1–2 cm behind and below, and the axillary vein was located 2–3 cm behind and above the pedicle. The long thoracic nerve was constantly found 2–3 cm behind the intercostobrachial nerve. The thoracodorsal nerve was always accompanied by a posterior tributary of the axillary vein. Relations between neurovascular structures in the axilla are predictable. The medial pectoral pedicle, which is consistently found and superficially located, could be used as a landmark for ALND.

Challenges in the management of massive intraorbital and hemifacial arteriovenous malformation as causing life-threatening epistaxis

Scipedia content — Fri, 26 May 2017 12:16:51 +0200

Arteriovenous malformations are congenital lesions that may evolve with time and manifest in a plethora of presentations. They can occur as torrential epistaxis when it extensively involves the facial region. Multi-imaging modalities are available to assist in characterizing the structure of the lesion as well as its location and extent. This complex disease requires a multidisciplinary team approach with preoperative embolization and surgery. We present a rare cause of life-threatening epistaxis in a gentleman with a longstanding orbital and hemifacial arteriovenous malformation and discuss the complexities involved in its management.

Lipomatous ganglioneuroma of the retroperitoneum

Scipedia content — Fri, 26 May 2017 12:16:46 +0200

Lipomatous ganglioneuroma (LG) is a rare variant of ganglioneuroma that is histologically characterized by a mature adipocytic component admixed with a conventional ganglioneuroma. We report the clinicopathological and immunohistochemical features of an LG in a 44-year-old Chinese male, additionally, we review the literature regarding this type of tumor. Magnetic resonance imaging revealed a left paravertebral soft-tissue mass at the T11–L3 levels. Grossly, the encapsulated neoplasm had a white to yellowish cut surface and rubbery consistency. Microscopic evaluation revealed an encapsulated lesion that consisted of areas of ganglioneuroma admixed with areas of mature fat. By immunohistochemistry, the ganglion cells were positive for chromogranin and synaptophysin, whereas the Schwann cells were positive for vimentin, S-100 protein, and glial fibrillary acidic protein (GFAP). This is the second known report of a retroperitoneal LG. The patient was well and without evidence of disease at 2 years' follow-up.

Single burr hole rigid endoscopic third ventriculostomy and endoscopic tumor biopsy: What is the safe displacement range for the foramen of Monro?

Scipedia content — Fri, 26 May 2017 12:16:39 +0200

To investigate the safe displacement range of the foramen of Monro (FM) during single burr hole rigid endoscopic third ventriculostomy (ETV) and endoscopic tumor biopsy (ETB). Eleven patients who received ETV/ETB for third ventricular and pineal region tumor were reviewed. The burr-hole location, the size, and the virtual displacement of FM were measured using neuronavigation software. Hydrocephalus was resolved, and no subsequent cerebrospinal fluid (CSF) shunting was required in all cases. Histological diagnosis was established in 11 patients. Ten cases received instrumental cognitive and memory assessment postoperatively. The results were within the normal range for eight cases. The mean burr-hole location was 1.7 cm anterior to coronal suture and 3 cm from the midline. The mean diameters of FM measured on the axial, coronal, sagittal, and views were 5.7, 7.8, and 5.6 mm, respectively. The mean virtual displacements of the FM were 1.9 ± 2.0 mm (range = 0–4.8) for ETV and 2.4 ± 2.1 mm (range = 0–5.5) for ETB. The maximum displacements were 4.8 mm anteriorly for ETV and 5.5 mm posteriorly for ETB. Single burr hole rigid ETV/ETB is likely to be safe within maximum FM displacements of 4.8 mm anterior for ETV and 5.5 mm posterior for ETB. Preoperative trajectory planning using neuronavigation software is recommended.

Comparison of transurethral plasmakinetic and transvesical prostatectomy in treatment of 100–149 mL benign prostatic hyperplasia

Scipedia content — Fri, 26 May 2017 12:16:34 +0200

To compare the safety and efficacy of transurethral plasmakinetic resection of the prostate (PKRP) versus transvesical prostatectomy (TVP) in the treatment of large-volume benign prostatic hyperplasia (LV-BPH) (100–149 mL). Ninety-nine BPH patients who had a prostate volume of 100–149 mL were divided into two groups to undergo PKRP or TVP. Preoperative clinical data were analyzed. Patients had follow-up appointments at 1 month, 3 months, 6 months, and 12 months postoperatively. Outcome measures included the International Prostate Symptom Score, quality of life score, maximum urinary flow rate, and postvoid residual urine volume. Adverse effects were also recorded. A total of 96 patients completed the 12-month follow-up. The operative time was longer, but intraoperative blood loss was lower in the PKRP group. Despite a higher percentage of patients requiring a blood transfusion, there was an obvious advantage in gland removal rate in the TVP group. The duration of postoperative catheterization, bladder irrigation, and hospital stay was significantly shorter in the PKRP group. Outcome measures were significantly improved in both groups 1 month postoperatively. The improvement in lower urinary tract symptoms was maintained throughout the 12 months after surgery. There were no significant differences in International Prostate Symptom Score, quality of life, maximum urinary flow rate, and postvoid residual urine volume between the two groups. PKRP has the advantage over TVP of being minimally invasive in the treatment of LV-BPH while achieving the same postoperative outcomes.

Comparison of the Nuss and sternal turnover procedures for primary repair of pectus excavatum

Scipedia content — Fri, 26 May 2017 12:16:30 +0200

Pectus excavatum (PE) is a common chest wall deformity. There are several surgical alternatives for the repair of PE. In our practice, the sternal turnover (STO) procedure had been performed for decades. In 2008, we started treating PE patients with the Nuss procedure. Our objective of this study is to compare these two procedures. A retrospective chart review was conducted on 50 patients undergoing pectus excavatum repairs from March 2005 to January 2013, including 20 patients with the STO procedure and 30 patients with the Nuss procedure. Patients were evaluated for type of repair performed, operating time, drainage after operation, length of postoperative stay, complications, and cosmetic results. The mean age of the STO group was 11.0 years and that of the Nuss group was 15.0 years (p = 0.353). The Nuss procedure had a much shorter mean operating time, a less mean drainage after operation, and a shorter mean time to drainage tube removal than those of the STO procedure. The rate of complication was 40.0% (8/20) in the STO group and 33.3% (10/30) in the Nuss group. Follow-up data indicated that 90% (18/20) of patients in the STO group and 96.7% (29/30) of patients in the Nuss group regarded the results as good or excellent (p = 0.965). Our data suggests that both the STO and Nuss procedures are equally safe and effective correction methods. However, less trauma, faster recovery, and better cosmetic results are the benefits of the Nuss procedure.

Antegrade repositioning of Memokath stent in malignant ureteroileal anastomotic stricture

Scipedia content — Fri, 26 May 2017 12:16:25 +0200

Ureteric strictures are common and can be due to benign or malignant causes. Various surgical treatments can be used from minimally invasive endoscopic retrograde JJ stent insertion, balloon dilatation, ureterolithotomy, to open surgical exploration and repair. Memokath 051 stent is a metallic stent designed for long-term ureteral stenting in the management of ureteral strictures. The insertion of this device is usually a straightforward procedure performed endoscopically in a retrograde fashion via cystoscopy. However, this procedure can be difficult in complicated scenarios when the bladder has been removed with neoureteral reimplantations or high-grade strictures. Here, we report a case of Memokath stent insertion complicated by placement difficulties in a lady with ileal conduit due to previous ovarian cancer complicated by vesicovaginal fistula, who presented with malignant stricture of the ureteroileal anastomosis. We describe a simple yet effective antegrade technique to precisely reposition the malpositioned Memokath stent, along with illustrations.

Laparoscopic transabdominal approach and its modified technique for incarcerated scrotal hernias

Scipedia content — Fri, 26 May 2017 12:16:19 +0200

Using laparoscopic methods for incarcerated scrotal hernias is controversial because of the perceived technical difficulties in treating such hernias. Herein, we present our experience with laparoscopic repair of such hernias. A retrospective review was undertaken to evaluate our experience with laparoscopic transabdominal approach and its modification for incarcerated hernias over a 3-year period. Two laparoscopic techniques were used for the repair of such hernias. The first technique, an exploratory laparoscopy, was performed to inspect the content of the hernia. This was followed by gentle retraction of the hernial content into the abdominal cavity and performing a standard transabdominal preperitoneal (TAPP) repair. If the hernia was not reducible, then a second technique involving a paramedian scrotal incision was performed. The sac was isolated, opened, and its contents were examined. If the bowel was encountered, it was reduced into the peritoneal cavity. However, if it was the omentum, it was excised. Following ligation of the scrotal sac and re-insufflation of the abdomen, a standard TAPP ensued. A total of 20 male patients with incarcerated scrotal hernia underwent laparoscopic TAPP repair (mean age: 48 years). Six had scrotal incision. Surgical site or mesh infection was not observed in any of the cases. Likewise, no recurrence after a mean follow-up of 22 months was encountered. Using the above modifications, we were able to perform laparoscopic repair of large incarcerated scrotal hernias, which previously would have been treated with an open procedure.

Chylous mesenteric cyst: A diagnostic dilemma

Scipedia content — Fri, 26 May 2017 12:16:13 +0200

A mesenteric cyst is defined as a cyst that is located in the mesentery of the gastrointestinal tract and may extend from the base of the mesentery into the retroperitoneum. A case report of a patient with mesenteric cyst is presented. In addition, a systematic review was performed of English language literature on chylous mesenteric cysts in adult humans. Of the 18 articles included in the review, there were 19 cases of chylous mesenteric cysts reported. Male to female ratio was 1.4:1 with a median age of 46 years. A preoperative diagnosis of mesenteric cyst was made in four patients based on computed tomography. All patients underwent surgery and there were no reports of recurrence on follow up. Chylous mesenteric cyst is a rare entity that needs to be recognized whenever a preliminary diagnosis of intra-abdominal cystic mass is made.

Differences in accuracy and underestimation rates for 14- versus 16-gauge core needle biopsies in ultrasound-detectable breast lesions

Scipedia content — Fri, 26 May 2017 12:16:08 +0200

Core needle biopsy (CNB) was widely used in the diagnosis of ultrasound-detectable breast lesions. We aimed at assessing the diagnostic performance differences between 14- and 16-gauge ultrasound-guided core biopsies. This retrospective study enrolled patients receiving CNB from January 2001 to December 2007. The results of 14- and 16-gauge breast CNBs were compared with pathology reports of open surgical biopsy (OSB). A total of 1024 paired CNB and OSB results were obtained from 1732 CNB procedures in 1630 patients.Those CNB results reached 92.9% sensitivity, 99.7% specificity, 5.96% underestimation, and 94.8% accuracy rates. There was no difference in sensitivity (p = 0.17) or specificity (p = 0.38) between 14- and 16-gauge needles. However, better overall accuracy (p = 0.02), less underestimation (p

Meningeal seeding from glioblastoma multiforme treated with radiotherapy and temozolomide

Scipedia content — Fri, 26 May 2017 12:16:02 +0200

Extracranial and meningeal seeding of glioblastoma multiforme is rare. We report herein a case of glioblastoma in a 41-year-old man who underwent surgical resection, concomitant chemoradiotherapy (CCRT) and seven courses of adjuvant chemotherapy with temozolomide. The patient then complained of intermittent severe lower back pain and gait disturbance. Imaging studies demonstrated that although the intracranial residual tumors were well-controlled by the treatment, meningeal seeding involving the brainstem and spinal cord was present. The patient died 2 months after the diagnosis of spinal seeding. This case illustrates the need for consideration of extracranial metastasis if a patient is symptomatic, even if the intracranial tumor appears responsive to treatment. We suggested that the prophylactic craniospinal irradiation may be considered in patients at high risk of meningeal seeding immediately after surgery.

Results of laparoscopic colorectal surgery from a national training center

Scipedia content — Fri, 26 May 2017 12:15:57 +0200

Trials have shown laparoscopic colorectal surgery to be safe. We aim to analyze the long-term results from a single national training center for laparoscopic surgery, especially in patients with high predicted mortality scores as well as in octogenarians. We also aim to explore the trend in the length of the learning curve among consultants and colorectal trainees, and determine whether or not laparoscopic colorectal surgery is amenable to surgical training. All patients between July 2003 and July 2011 having laparoscopic colorectal surgery were included in a prospectively maintained database and analyzed retrospectively. We collected operative data (operation time, conversion), postoperative 30-day morbidity/mortality, cancer survival (including local/distant recurrences), postoperative incisional/port site hernia rates, and rates of reoperation. A total of 508 patients (258 males and 250 females) were enrolled in the study. The mean age of patients was 65.5 years and median body mass index (BMI) 27 kg/m2, 70% of cases were malignant. Conversion rate was 15%, mean operation time was 175 minutes, and mean blood loss was 220 mL. The mean postoperative length of stay was 5.8 days, 30-day morbidity 23% (leak rate 1.38%), and 30-day mortality 1.57%. Operating time and conversion rates were significantly lower in right-sided resections compared to left-sided and rectal resections, and lymph node retrieval was significantly higher. Readmission and reoperation rates were 4.9% and 2.8%, respectively. The overall mean follow-up period was 1.8 years, rate of incisional/port site/parastomal hernia was 5.7% (n = 30), and readmission secondary to adhesions was 5% (P-Possum tool). No statistically significant increases were observed in conversion, morbidity, or mortality rates in these groups (p > 0.05), but length of stay was statistically longer—7 days for octogenarians and 8 days for patients with >5% predicted mortality (p

Light-chain amyloidosis presenting with rapidly progressive submucosal hemorrhage of the stomach

Scipedia content — Fri, 26 May 2017 12:15:52 +0200

The gastrointestinal tract is frequently in involved light-chain (AL) amyloidosis, but significant hemorrhagic complications are rare. A 71-year-old man presented to our hospital with dyspepsia and heartburn for 1 month. Gastroscopy revealed a large submucosal hematoma at the gastric fundus. Two days later, a follow-up gastroscopy indicated extensive expansion of the hematoma throughout the upper half of the stomach. The hematoma displayed ongoing expansion during the endoscopic examination, suggesting that rupture was imminent. Emergency total gastrectomy was performed, and amyloidosis was confirmed after examining the surgical specimen. Bone marrow examination revealed multiple myeloma, and serum immunoglobulin assay confirmed the diagnosis of myeloma-associated AL amyloidosis. At manuscript submission, the patient was doing well and was undergoing chemotherapy.

Adventitial cystic disease of the common femoral vein presenting as deep vein thrombosis

Scipedia content — Fri, 26 May 2017 12:15:46 +0200

Adventitial cystic disease of the common femoral vein is a rare condition. We herein report the case of a 50-year-old woman who presented with painless swelling in her left lower leg that resembled deep vein thrombosis. She underwent femoral exploration and excision of the cystic wall. The presentation, investigation, treatment, and pathology of this condition are discussed with a literature review.

Incretin levels 1 month after laparoscopic single anastomosis gastric bypass surgery in non-morbid obese type 2 diabetes patients

Scipedia content — Fri, 26 May 2017 12:15:40 +0200

Bariatric surgery is an efficient procedure for the remission of type 2 diabetes (T2DM) from morbid obesity. However, in Asian countries, the mean body mass index (BMI) of T2DM patients is about 25 kg/m2. Various data on patients undergoing gastric bypass surgery suggest that the control of T2DM after surgery occurs rapidly. We hypothesized that even in nonobese patients with T2DM, the levels of incretin and insulin changed along with the improvement of T2DM as a consequence of the gastric bypass. From March to December 2011, 12 nonobese patients (mean BMI, 26.2 kg/m2) with poorly-controlled [mean glycated hemoglobin (HbA1C), 9.5%] diabetes underwent gastric bypass surgery. Values related to diabetes, including incretin [gastric inhibitory peptide (GIP) and glucagon-like peptide-1 (GLP-1)] levels were measured before and 1 month after surgery. All values were measured in response to a 75 g oral glucose tolerance test (OGTT). On average, the BMI decreased by 2.1 ± 0.7 kg/m2. Mean HbA1C level decreased by 1.6 ± 2%. Oral glucose-stimulated insulin levels increased and GLP-1 levels also increased significantly. Oral glucose-stimulated GIP levels decreased sharply. Soon after gastric bypass in nonobese T2DM patients, control of T2DM is achieved. The incretin release after oral glucose is improved. This could be a consequence of changes of the enteroinsular axis, particularly in the incretins.

Carcinoid tumors of the lung: A report of 11 cases

Scipedia content — Fri, 26 May 2017 12:15:35 +0200

Carcinoid tumors of the lung are rare, and account for 1% of all primary tumors of the lung. This study was undertaken to investigate the histological characteristics and clinical behavior of carcinoid tumors of the lung. We have retrospectively reviewed the hospital records of 11 consecutive patients undergoing surgical treatment for carcinoid tumors of the lung between 1992 and 2007. Patients with carcinoid tumors accounted for 0.8% (11 of 1319) of the patients undergoing surgical treatment for nonsmall cell lung cancer. The group comprised six males and five females with a mean age at presentation of 58.6 years (range 27–78 years). All of the operations were lobectomies, including two sleeve lobectomies. Six patients had typical and five had atypical carcinoid tumors. Seven patients had stage IA disease, two had stage IB, one had stage IIA, and one had stage IIIA. Recurrent tumors developed in two of the five patients affected by atypical carcinoid tumors, but none of the six patients with typical carcinoid tumors. Overall, the 5-year survival rate of patients with both typical and atypical carcinoid tumors was 90.9%. Survival of carcinoid tumors was favorable. In this analysis, two patients with atypical carcinoid had postoperative recurrences. Recurrence was more common among patients with atypical carcinoid tumors.

Surgical treatment of catamenial pneumothorax: Report of three cases

Scipedia content — Fri, 26 May 2017 12:15:28 +0200

Catamenial pneumothorax (CP) is a rare entity of spontaneous, recurring pneumothorax in females. Although it has been known to be associated with thoracic endometriosis, varying clinical course and the lack of consistent intraoperative findings have led to conflicting etiological theories. We herein discuss the etiology, clinical course, and surgical treatment of three patients with CP. Three females (aged 40 years, 28 years, and 34 years) had recurrent right-sided spontaneous pneumothoraces that coincided with their menses. They had undergone video-assisted thoracoscopic surgery (VATS) previously. Blueberry spots in the right diaphragm were detected in all three cases. Two patients had recurrence, postoperatively. The other patient, who received luteinizing hormone-releasing hormone analog therapy for an abdominal endometriosis in the perioperative period and postoperative chemical pleurodesis to prevent recurrence, has been free of recurrence for 15 months, postoperatively. However, pelvic endometriosis was detected in this patient only. Therefore, CP should be suspected in ovulating females with spontaneous pneumothorax, even in the absence of any symptoms associated with pelvic endometriosis. In addition, while performing VATS, careful inspection of the diaphragmatic surface is important. In complicated cases, hormonal suppression therapy and chemical pleurodesis might also be helpful adjunct modalities.

Pseudoaneurysm after sutureless repair of left ventricular free wall rupture: Sequential magnetic resonance imaging demonstration

Scipedia content — Fri, 26 May 2017 12:15:23 +0200

Sutureless repair is an effective procedure for acute left ventricular free wall rupture, however, it may be complicated with a left ventricular pseudoaneurysm during the late postoperative period. We present a case of a large ventricular pseudoaneurysm that occurred after the sutureless repair of an inferior myocardial infarction with oozing left ventricular free wall rupture. The patient underwent aneurysmectomy successfully. Serial magnetic resonance imaging (MRI) indicated that the necrotic left ventricular wall, which was covered by Teflon felt, had ruptured and developed a pseudoaneurysm. Therefore, after simple gluing for a left ventricular free wall rupture, patients should undergo careful follow-up evaluation for potential pseudoaneurysm. Moreover, early detection by MRI and prompt surgical repair of the complication are important in patients with left ventricular free wall rupture.

Anastomotic stability and wound healing of colorectal anastomoses sealed and sutured with a collagen fleece in a rat peritonitis model

Scipedia content — Fri, 26 May 2017 12:15:15 +0200

Anastomotic insufficiency is associated with increased morbidity and mortality. A collagen fleece that supports anastomosis is effective for preventing anastomosis insufficiency. The objective of this study was to compare between the stability of sutured anastomoses and that of anastomoses sealed with a thrombin/fibrinogen-coated collagen fleece in a rat peritonitis model. In 72 male Wistar rats, peritonitis was induced with a specially prepared human fecal solution. Surgery at the rectosigmoid junction was performed 24–36 hours later. The different anastomotic techniques used were circular sutured anastomoses, semicircular sutured anastomosis and closure of the anterior wall with collagen patch, and complete closure with a collagen fleece. Bursting pressure, histology of anastomosis, mRNA expression of collagen types I and III, matrix metalloproteinase-13, and vascular endothelial growth factor (VEGF) were investigated after 24 hours, 72 hours, and 120 hours. All animals developed peritonitis of comparable severity. There were no differences in bursting pressures between the three suture techniques after 24 hours, 72 hours, or 120 hours. Anastomoses sealed with a collagen fleece appeared to be slightly less stable only at 24 hours, whereas they appeared to be more stable than semisutured or fully sutured anastomoses at 72 hours and 120 hours. Sealing with a collagen fleece was associated with an increase in granulation tissue, higher mRNA levels for collagen types I and III, and higher VEGF compared to sutured anastomoses. The use of a thrombin/fibrinogen-coated collagen fleece showed similar efficacy to conventional sutures in colorectal anastomoses in the presence of peritonitis inflammation, and may provide additional benefits due to an increase in mature granulation tissue.

Emphysematous pyelonephritis: An 8-year retrospective review across four acute hospitals

Scipedia content — Fri, 26 May 2017 12:15:10 +0200

To retrospectively review our experience of managing patients with emphysematous pyelonephritis (EPN). Case notes of patients with EPN were reviewed. The patients' demographic data, clinical presentation, investigation findings, treatment, and outcome were studied. Twelve patients were diagnosed with EPN. Majority (66.7%) of them had diabetes mellitus. All patients had been evaluated by computed tomography (CT). Using the classification proposed by Wan et al, five patients had type 1 EPN, whereas six, two, and four patients had Huang and Tseng CT class 2, 3a, and 3b EPN, respectively. Immediate nephrectomy was performed in six patients, whereas conservative treatment was adopted in the other six. In the nephrectomy group, one patient died of disseminated sepsis after a protracted course. Conservative treatment failed in three patients, who succumbed despite salvage nephrectomy in two of them. Analysis revealed that severe hyperglycemia and radiological CT class (both Wan and Huang systems) were significant predictors of mortality from EPN. Severe hyperglycemia and CT class of EPN are significant risk factors for death. CT is the investigation of choice for correct diagnosis of EPN. Additional intervention should be offered to EPN patients with Wan type 1 and Huang and Tseng class 3 CT features.

Vacuum-assisted closure therapy for salvaging a methicillin-resistant Staphylococcus aureus-infected prosthetic graft

Scipedia content — Fri, 26 May 2017 12:15:05 +0200

Infection of a vascular prosthesis after a bypass surgery is relatively rare. However, once developed, serious complications can occur, such as bleeding, sepsis, and organ ischemia, occasionally resulting in leg amputation or even death in some cases. The treatment of a vascular prosthesis infection involves the necessary removal of the infected graft, subsequently, an extra-anatomical bypass surgery is often considered. We herein report a case in which postoperative methicillin-resistant Staphylococcus aureus infection caused dehiscence of the femoral vessels and exposure of the graft vessel and anastomosed area. The infected tissue was surgically removed (debridement), and the patients condition was successfully treated by the application of a nonadherent dressing and vacuum-assisted closure therapy combined with the bridging technique.

Delayed small bowel perforation following blunt abdominal trauma: A case report and review of the literature

Scipedia content — Fri, 26 May 2017 12:15:00 +0200

We report a case of delayed presentation of a small bowel perforation following blunt abdominal trauma (BAT). An initial computed tomography (CT) scan revealed that the patient (a 32-year-old man) had a mesenteric hematoma, which was managed conservatively. Four weeks later, he returned to the hospital complaining of abdominal pain. A CT scan of the abdomen showed a thickened loop of the small bowel adjacent to the mesenteric hematoma at the level of the ileum. He was discharged home, but re-presented with acute abdomen 6 weeks post-trauma. An exploratory laparotomy was performed, which showed a perforated thickened loop of the ileum forming a phlegmon in the lower abdomen. In the English medical literature, only eight other reports of delayed post-traumatic presentation of ileal/jejunal perforation following BAT have been reported. We propose that post-traumatic intestinal perforation be considered in the differential diagnosis even in patients who experience a delayed small bowel perforation following BAT.

Mullerian inhibiting substance expression in papillary thyroid cancer

Scipedia content — Fri, 26 May 2017 12:14:55 +0200

To examine the expression of Mullerian inhibiting substance (MIS) in papillary thyroid cancer. The MIS expression was examined by studying the immunohistochemistry in deparafinized sections prepared from tissue blocks of patients who were diagnosed with papillary thyroid cancer, as given in the pathology archive records (n = 23). In all the cases studied, 50% (n = 10) showed strong staining and 50% showed moderate staining. The percentage of staining was found to be 94.2 ± 3.1% in strongly stained cases and 92.2 ± 2.1% in moderately stained cases. Normal thyroid tissues neighboring the tumor did not display any staining. The MIS expression can be used as a significant tool in differential diagnosis of papillary thyroid cancer and also to shed light on its etiopathogenesis.

Morbidity- and mortality-related prognostic factors of nontraumatic splenectomies

Scipedia content — Fri, 26 May 2017 12:14:50 +0200

Splenectomy is a common surgical procedure, but few reports focus on nontraumatic splenectomies. The aim of this study was to determine the predictors of morbidity and mortality of patients submitted to elective nontraumatic splenectomy. A descriptive cross-sectional study of 152 consecutive, nonselected, nontraumatic patients operated on by splenectomy between 1996 and 2010 was carried out. Clinical, laboratory, and surgical data, histological findings, perioperative mortality, and postoperative complications according to Clavien-Dindo classification, were recorded. Factors related to morbidity and mortality were analyzed. Of the 152 patients (89 male and 63 female, mean age 49.8 ± 17.8 years), 74 (48.7%) were operated on for malignant hematologic disorders, 44 for benign hematologic process, and 34 for other nonhematologic disorders. The spleen was enlarged in 95 patients (62.5%) and 78 patients (51.3%) had hypersplenism. The overall complications rate was 40.1%: Grades I and II in 27 cases (17.7%), and Grades III and IV in 23 patients (15.1%). Perioperative mortality was 7.2% (11 patients). In univariate analysis, significant negative predictors for morbidity were age (p = 0.004), anemia (p = 0.03), leukocytosis (p = 0.016), and blood transfusions (p

Gastric outlet obstruction secondary to paraesophageal herniation of gastric antrum after laparoscopic fundoplication

Scipedia content — Fri, 26 May 2017 12:14:44 +0200

The most common causes of acute gastric outlet obstruction (GOO) are duodenal and type 3 gastric ulcers. However, mechanical or functional causes may also lead to this pathology. Acute GOO is characterized by delayed gastric emptying, anorexia, or nausea accompanied by vomiting. Herein we report a 56-year-old man diagnosed with GOO secondary to paraesophageal hiatal herniation of gastric antrum after laparoscopic fundoplication. Because of the rarity of this disease, common gastrointestinal complaints may mislead the emergency physician to diagnose a nonsurgical gastrointestinal disease if a detailed history and physical examinations are not obtained.

Intraoperative retrograde ureteroscopy during laparoscopic ureteroureterostomy: Precise localization of the lesion

Scipedia content — Fri, 26 May 2017 12:14:39 +0200

In a case of upper ureteral stricture refractory to laser ureterotomy, laparoscopic ureteroureterostomy was performed for resection of the stricture and reanastomosis of the ureter. Precise localization of the stricture segment was achieved by retrograde ureteroscopy performed concurrently with laparoscopy, with minimal change in the patients position.

Transplantation of a 2-year-old deceased-donor liver to a 61-year-old male recipient

Scipedia content — Fri, 26 May 2017 12:14:35 +0200

The suitable size of a graft is a key element in the success of liver transplantation. A small-for-size liver graft is very likely to sustain a significant degree of injury as a result of ischemia, preservation, reperfusion, and rejection. Usually, small-for-size grafts are a concern in living-donor liver transplantation rather than in deceased-donor liver transplantation. Here, we describe the successful transplantation of a liver from a 2-year-old deceased donor to a 61-year-old male recipient who suffered from liver failure related to hepatitis B. No report of successful deceased-donor liver transplantation with discrepancies between donor and recipient age and size to such an extent has been found in the literature. Despite unusually large discrepancies, with effort in minimizing the ischemic time, revised surgical techniques, and strong regenerative power of the “young” graft, the old patients liver function gradually returned to normal. This again proves that the definition of a “suitable graft” evolves with time and experience.

Perpetuating proficiency in donor right hepatectomy for living donor liver transplantation

Scipedia content — Fri, 26 May 2017 12:14:27 +0200

Donor right hepatectomy (DRH) was developed by master liver surgeons and has been applied in many liver transplant centers as the mainstay for adult living donor liver transplantation. It is a major and complex surgical operation performed on living liver donors for the benefit of liver recipients. The donors deserve the lowest though inevitable morbidity and mortality. In this study, the surgical outcomes of DRH performed by newer surgeons at an established center were studied to assess the transferability of the techniques of this standardized procedure. We studied 450 consecutive DRHs performed by 11 surgeons. Three surgeons initiated and developed the transplant program and performed the first 200 DRHs (Era I). The role of chief surgeon in the following 250 DRHs (Era II) was gradually taken up by four newer surgeons with close guidance initially. Blood loss and operation time at the end of Era I versus the beginning of Era II were 251 vs. 341 mL and 391 vs. 497 minutes. The learning curve effect in Era I did not occur in Era II. The complication rates of the last 50 cases in Era I and Era II were 16% and 24%, respectively. Era I had one donor death whereas Era II had no donor death. At an established center, DRH can be carried out safely by newer surgeons with good outcomes.

Effects of OLV preconditioning and postconditioning on lung injury in thoracotomy

Scipedia content — Fri, 26 May 2017 12:14:22 +0200

To observe the effects of intermittent one-lung ventilation (OLV) before and after surgery on the inflammatory cytokines and biomarkers of oxidative stress in serum of lung cancer patients undergoing open thoracotomy. Between June 2011 to March 2012, 80 patients undergoing lobectomy were classified into four groups nonrandomly: Group A, control group, B, OLV preconditioning group, C, OLV postconditioning group, D, OLV preconditioning-combined-with-postconditioning group. Neutrophil granulocyte (PMN), interleukin 6 (IL-6), superoxide dismutase (SOD), and malondialdehyde (MDA) were assayed in plasma samples taken preoperatively (T1), intraoperatively (T2), and 2 hours postoperatively (T3). Comparison of T1 with T2 and T3 documented significant increase in MDA, PMN, and IL-6 levels and decrease in SOD in the control group (p

The admission systemic inflammatory response syndrome predicts outcome in patients undergoing emergency surgery

Scipedia content — Fri, 26 May 2017 12:14:16 +0200

To investigate the incidence of systemic inflammatory response syndrome (SIRS) on emergency department admission and the prognostic significance of SIRS in patients undergoing emergency surgery. This is a retrospective study of 889 adults who were admitted as emergency cases and were operated on within 24 hours of admission. Data on patient demography, clinical information including comorbidities, categories of surgery, American Society of Anesthesiologists physical status, SIRS score, postoperative outcomes including duration of mechanical ventilation, intensive care unit (ICU) and hospital lengths of stay, and mortality were collected. SIRS occurred in 43% of the patients and was associated with a significantly worse outcome in terms of duration of ventilator use (10.5 ± 15.4 vs. 3.5 ± 4.4 days, p

Vasovagal reflex emergency caused by Riedels thyroiditis: A case report and review of the literature

Scipedia content — Fri, 26 May 2017 12:14:10 +0200

Riedels thyroiditis is a rare type of chronic thyroiditis, associated with fibroinflammatory process and invasion into surrounding tissues, leading to compressive symptoms. A 45-year-old man had a left thyroid mass, presenting with hypotension and bradycardia many times. He was diagnosed with vasovagal reflex caused by cervical vessel compression due to a thyroid lesion. We performed the emergency operation, and most of the left thyroid was removed to relieve the compression on cervical vessels. The result of pathology proved to be Riedels thyroiditis. The vasovagal reflex did not occur any more during the 28-month follow up, except on the 3rd day after the surgery. Six months after the thyroidectomy, the patient was found to have retroperitoneal fibrosis, diagnosed by biopsy during a laparotomy for biliary disease. Riedels thyroiditis can lead to a vasovagal episode and might not be a primary thyroid disease but rather a manifestation of the systemic disorder, multifocal fibrosclerosis.

Comparison of topical isosorbide mononitrate, topical diltiazem, and their combination in the treatment of chronic anal fissure

Scipedia content — Fri, 26 May 2017 12:14:05 +0200

Chronic anal fissure is a painful condition that is associated with an increase in internal anal sphincter pressure. The main aim of this study is to evaluate the efficacy and adverse effects of topical isosorbide 5 mononitrate and topical diltiazem, when administered either as single agents or in combination, in the treatment of anal fissure. Patients with chronic anal fissure were enrolled in the study. They were randomized into three groups: Group A (0.2% isosorbide 5 mononitrate users), Group B (2% diltiazem users), and Group C (2%diltiazem + 0.2% isosorbide 5 mononitrate users). Pain was evaluated using a visual analog scale (VAS). Level of strain during defecation was graded on a 4-point scale. A total of 55 patients were enrolled in the study. The average ages of patients in Groups A, B, and C were 37.94 ± 16.19, 42.83 ± 13.21, 40 ± 13.58 years, respectively. After treatment, pain completely abated in 55.6% of patients in Group A, 27.8% (n = 5) in Group B, and 42.1% (n = 8) in Group C. The decreases in average VAS values prior to and after treatment in Groups A, B, and C were statistically significant (p values 0.0001, 0.001, and 0.0001, respectively). Average strain scores prior to and after treatment were 2.11/0.72 for Group A, 2.17/0.94 for Group B, and 1.95/0.47 for Group C. Strain during defecation prior to and after treatment in Groups A, B, and C was statistically significant (p values 0.001, 0.001, and 0.003, respectively). Topical diltiazem and a combination of nitrate and diltiazem can be used in the treatment of anal fissure. However, the agents are not significantly superior each other.

Evaluation of two hemorrhoidectomy techniques: Harmonic scalpel and Fergusons with electrocautery

Scipedia content — Fri, 26 May 2017 12:14:01 +0200

The prevalence of symptomatic hemorrhoidal disease is a common disease that usually needs surgery for treatment. Although conservative treatment is often enough for early stages, late stage disease usually needs surgical treatment. The most common and effective approaches used for conventional surgical treatment are harmonic scalpel (HS) and Fergusons with electrocautery hemorrhoidectomy (FEH). We aimed to use the HS device for hemorrhoidectomy in Grade III and Grade IV hemorrhoids and compare our results with FEH Enrolled into the study were 151 patients who were operated for symptomatic Grade III–IV hemorrhoids. Patients were randomized into FEH and HS groups. The present review focused on comparing HS hemorrhoidectomy versus FEH with regards to operating time, postoperative pain, duration of disease, number of issued analgesics, length of hospital stay, time to return to normal activity, and postoperative complications. The mean ages of patients who underwent HS and FEH were 34.1 ± 9.2 years and 33.7 ± 8.4 years, respectively. The average postoperative stay in the HS group was 1.0 ± 0.1 days and in the FEH group was 1.2 ± 0.4 (p = 0.001). The time of return to normal activity was less for the HS groups than for the FEH groups (10.6 ± 2.1 days vs. 16.0 ± 6.3 days, p = 0.001). The mean operating time of the HS and FEH groups was 16.8 ± 4.1 minutes and 25.5 ± 7.7 minutes, respectively (p = 0.001). The total analgesic doses for the HS group were 790 ± 206 mg, 619 ± 234 mg, and 30 ± 99 mg, and for the FEH group were 1096 ± 194 mg, 1000 ± 259 mg, and 40 ± 0 mg for postoperative Day 1, Day 7, and Day 28, respectively. There was no significant difference between the HS group and the FEH group in the terms of the number of excised hemorrhoid masses (2.0 ± 0.6 vs. 1.88 ± 0.6). HS hemorrhoidectomy is safe and effective, causes less blood loss and postoperative pain, and fewer complications compared to FEH.

Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure

Scipedia content — Fri, 26 May 2017 12:13:57 +0200

Anal fissure is a common benign condition. An anorectal problem is defined as a split in the anal canal mucosa that extends from the dentate line to the anal verge. Chronic anal fissure is defined by a history of symptoms present for more than 2 months' duration and with a triad of external skin tags, namely, a hypertrophied anal papilla, an ulcer with rolled edges, and a base exposing the internal sphincter. Because complications such as incontinence are associated with surgical treatment, chemical sphincterotomy is currently favored. The objective of this study is to compare the difference in outcome between open partial lateral anal sphincterotomy and application of topical 0.2% nitroglycerin ointment for the treatment of chronic anal fissure. This was a quasi-experimental study carried out between January 16, 2007 and January 15, 2008 in the Surgical Department of Jinnah Hospital, Lahore, Pakistan. Sixty consecutive cases with a clinical diagnosis of chronic anal fissure were recruited in the study. All recruited patients met the study inclusion criteria and were randomly assigned to one of the two groups. Group A was managed conservatively using topical 0.2% nitroglycerin ointment, whereas Group B underwent open partial lateral anal sphincterotomy. Both groups were followed up at 1 week, 2 weeks, 4 weeks, and 6 weeks after the treatment. All the patients complained of pain. A total of 43 (71.7%) patients had pain with constipation, whereas 31 (51.7%) patients had bleeding per rectum. Upon clinically examining the anal area, tenderness was elicited in all 60 (100%) patients. Group A included 30 (11 females and 19 males) cases treated with topical 0.2% nitroglycerin ointment and Group B included 30 (11 females and 19 males) cases who underwent open partial lateral anal sphincterotomy. In Group A, only 15 patients with fissures were successfully treated (50%). By contrast, 28 (93%) patients with fissures in Group B were successfully treated, and only two (7%) remained uncured. These two patients (6.6%) in Group B suffered from incontinence due to flatus and feces as a complication of the procedure. This quasi-experimental study demonstrates that open partial lateral internal sphincterotomy is superior to topical 0.2% nitroglycerin application in the treatment of chronic anal fissure, with good symptomatic relief, high rate of healing, fewer side effects, and a very low rate of early continence disturbances.

Upregulation of the proinflammatory cytokine-induced neutrophil chemoattractant-1 and monocyte chemoattractant protein-1 in rats' intestinal anastomotic wound healing—Does it matter?

Scipedia content — Fri, 26 May 2017 12:13:51 +0200

The proinflammatory cytokines and growth-promoting factor are essential components of the wound healing process. We hypothesized that under healthy conditions, faster healing of intestinal anastomotic wound is due to an early upregulation of proinflammatory cytokines, cytokine-induced neutrophil chemoattractant-1 (CINC-1) that is followed by a quicker upregulation of homeostatic chemokine, monocyte chemoattractant protein-1 (MCP-1) and late upregulation of transforming growth factor (TGF-β). We characterized the time course of CINC-1, MCP-1 and TGF-β release at four wounds (skin, muscle, small bowel, and colonic anastomosis) after surgery on 38 juvenile male Sprague Dawley rats. The tissue samples of each site were harvested at 0 (control), 1, 3, 5, 7 and 14 days postoperatively (n = 6–8/group) and analyzed by ELISA kits for CINC-1, MCP-1 and TGF-β. CINC-1 expression peaked earlier in muscle and colonic wounds when compared to skin and small bowel. MCP-1 levels were elevated early in skin and muscle wounds, but later expression of MCP-1 was shown in colonic wounds. TGF-β levels were unchanged in all wound sites. An earlier peak in CINC-1 levels and later expression of MCP-1 were seen in colonic wounds, but no significant increase in TGF-β levels was observed. These findings support the early healing process in intestinal anastomotic wounds.

Acute appendicitis: Diagnostic accuracy of Alvarado scoring system

Scipedia content — Fri, 26 May 2017 12:13:46 +0200

To evaluate the usefulness of the Alvarado scoring system in reducing the percentage of negative appendectomy in our unit. A cross-sectional study was conducted, comprising 110 patients, admitted to Surgical Unit I, Civil Hospital, Karachi, in 2011 with a preliminary diagnosis of acute appendicitis. Patients of both sexes and all age groups except younger than 10 years were included in the study and their Alvarado scores calculated, on the basis of which patients were divided into two groups: Group A (Alvarado score

Hyperparathyroid crisis: The timing of surgery

Scipedia content — Fri, 26 May 2017 12:09:06 +0200

Hyperparathyroid crisis is a rare, critical, and potentially fatal disease. The aim of this study was to classify different clinical courses of this disease, according to their preoperative medical responses and suggest the proper timing for surgery. Patients who had undergone parathyroidectomies for hyperparathyroid crisis, were enrolled between January 1, 1994 and January 31, 2009. Preoperative medical treatment and responses in terms of predisposing factors, preoperative localization, operative and pathological findings, postoperative outcome, and intervals from medicine to surgery, were retrospectively reviewed. A total of 11 patients, receiving more than 72 hours of medical treatment, were divided into three types by preoperative medical responses. These included: Type I (three patients were resistant to medicine with persistent serum Ca > 14 mg/mL and were eventually treated with emergency surgery, two died of postoperative respiratory and hepatic failure), Type II (six patients with abnormal serum Ca 14 mg/mL after 48 hours of medical treatment. All abnormal parathyroid glands were >1.8 cm in length and easily detectable using preoperative ultrasonography. Because the response to pharmaceutical treatment of hyperparathyroid crisis is unpredictable, relieving the patient’s dehydration is necessary first. Making a definite diagnosis and performing an early parathyroidectomy within 48 hours are then required, especially in patients exhibiting poor medical response.

Calcium content of different compositions of gallstones and pathogenesis of calcium carbonate gallstones

Scipedia content — Fri, 26 May 2017 12:09:00 +0200

Our aim was to investigate the calcium content of different gallstone compositions and the pathogenic mechanisms of calcium carbonate gallstones. Between August 2001 and July 2007, gallstones from 481 patients, including 68 calcium carbonate gallstones, were analyzed for total calcium content. Gallbladder bile samples from 33 cases and six controls were analyzed for pH, carbonate anion level, free-ionized calcium concentration and saturation index for calcium carbonate. Total calcium content averaged 75.6 %, 11.8 %, and 4.2 % for calcium carbonate, calcium bilirubinate and cholesterol gallstones. In 29.4 % of patients, chronic and/or intermittent cystic duct obstructions were caused by polypoid lesions in the neck region and 70.6 % were caused by stones. A total of 82 % of patients had chronic low-grade inflammation of the gallbladder wall and 18.0 % had acute inflammatory exacerbations. In the bile, we found the mean pH, mean carbonate anion, free-ionized calcium concentrations, and mean saturation index for calcium carbonate to be elevated in comparison to controls. From our study, we found chronic and/or intermittent cystic duct obstructions and low-grade GB wall inflammation lead to GB epithelium hydrogen secretion dysfunction. Increased calcium ion efflux into the GB lumen combined with increased carbonate anion presence increases SI_CaCO3 from 1 to 22.4. Thus, in an alkaline milieu with pH 7.8, calcium carbonate begins to aggregate and precipitate.

Computed tomography indices and criteria for the prediction of esophageal variceal bleeding in survivors of biliary atresia awaiting liver transplantation

Scipedia content — Fri, 26 May 2017 12:08:54 +0200

About 20% of biliary atresia (BA) survivors have attacks of esophageal variceal bleeding. We propose a method to evaluate the risk of esophageal variceal bleeding (EVB) using noninvasive indices by multislice computed tomography (CT). We reviewed 31 potential living-related liver recipients aged 99–5314 days (mean, 1474 days) who underwent CT examinations using a 64-slice multislice CT scanner. Of the 31 patients, 19 patients (Group A) with fecal occult blood had EVB on esophagogastroduodenoscopy, the rest belonged to Group B. Splenic diameters (mm) were divided by body heights (m) and platelet counts (1000/mm3) to produce standardized ratios of transverse splenic length/body height/platelet count (SLHPR). The transverse diameters of paraesophageal veins (PVs) and perigastric veins (PGVs) were measured adjacent to the lower thoracic esophagus and within the lesser sac, respectively. According to a receiver operating characteristic curve analysis, the SLHPRs (r = 0.833), transverse PV (r = 0.957), and PGV (r = 0.987) diameters were better predictors of EVB than demographic and laboratory variables. However, the transverse diameters of PGVs and PVs were the most accurate predictors of the EVB. For candidates awaiting liver transplantation, screening by noninvasive SLHPR and the transverse diameters of PGVs and PVs by CT may help to identify BA patients with a high risk of EVB.

A rare complication of Meckels diverticulum: A fistula between Meckels diverticulum and the appendix

Scipedia content — Fri, 26 May 2017 12:08:48 +0200

Meckel diverticulum is the most common congenital anomaly of the small intestine, occurring in about 2%–4% of the population. Meckel diverticulum results from incomplete closure of the omphalomesenteric duct. The presentation of symptomatic Meckel diverticulum includes gastrointestinal hemorrhage, intestinal obstruction, volvulus, intussusception, diverticulitis, and neoplasms. The development of fistula is an extremely rare complication. Previous literature has even shown an enterocolonic fistula, a vesicodiverticular fistula, ileorectal fistula, and fistula-in-ano. To the best of our knowledge, we present the first case of the fistula complicated between Meckel diverticulum and the appendix in a review of the English literature.

Waist circumference is an independent risk factor for prostatic hyperplasia in Taiwanese males

Scipedia content — Fri, 26 May 2017 12:08:43 +0200

Benign prostatic hyperplasia is a common disease affecting older males. As obesity becomes an increasing problem worldwide, its role in prostatic hypertrophy has been discussed recently. The purpose of this study is to evaluate the relationship between waist circumferences and prostatic hyperplasia in Taiwan. There were 539 men enrolled in the study who had health examinations at the Healthcare Center of Chang Gung Memorial Hospital, 53 were excluded because of history of conditions affecting prostatic volume. Their anthropometry was measured and serum prostate-specific antigen (PSA) levels as well as lipid profiles were analyzed. Prostate volume was measured by transrectal ultrasonography performed by experienced urologists. The mean prostate volume was 26.43 mL, whereas mean body mass index (BMI) was 25.27 kg/m2 and mean waist circumference (WC) was 90.81 cm. By age-adjusted logistic regression, PSA > 4 ng/mL, WC ≥ 90 cm, and BMI > 24 kg/m2 are associated with increased risk of developing prostatic hyperplasia, only WC ≥ 90 cm can be validated by multiple logistic regression. Further analysis of obesity patterns showed that abdominal overweight/obesity places patients at increased risk independently rather than high WC or high BMI alone. Study results showed that waist circumference ≥ 90 cm is an independent risk factor of prostatic hyperplasia in Taiwan. Men with abdominal overweight/obesity (WC ≥ 90 cm and BMI > 24 kg/m2) have a twofold risk of developing prostatic hyperplasia.

Use of the modified double-stapling technique with vertical division of the rectum during a sphincter-preserving operation for the treatment of a rectal tumor

Scipedia content — Fri, 26 May 2017 12:08:38 +0200

The modified double-stapling technique (DST) with vertical division of the rectum(IO-DST) has been reported as a feasible and safe procedure for performing low anastomosis during rectal cancer surgery. In this procedure, an endostapler was vertically used, instead of using a horizontally orientated linear stapler, when dividing the rectum. A previous study reported that this technique is useful for treating patients with a narrow pelvis and/or performing a very low anastomosis. The use of IO-DST anastomosis during anterior resection(AR) and low anterior resection was performed on 80 cases of rectal cancer between April 1998 and June 2004 at our institution. We reviewed those cases and evaluated the leakage rate. We found that leakage occurred in six cases (7.5%), however, leakage was not found in cases of AR or cases with a preserved left colic artery (LCA). The IO-DST technique is an adequate procedure for performing AR. The preservation of the LCA could be used to prevent leakage.

Delayed life-threatening upper gastrointestinal bleeding as a complication of laparoscopic adjustable gastric banding: Case report and review of the literature

Scipedia content — Fri, 26 May 2017 12:08:33 +0200

Morbid obesity is a common health problem worldwide. Laparoscopic adjustable gastric banding has been used extensively around the world for the treatment of morbid obesity. Life-threatening hemorrhage as a late complication of laparoscopic adjustable gastric banding is extremely rare. We report a case of massive upper gastrointestinal bleeding due to intragastric erosion of a gastric band 6 years postoperatively and review the English literature on this life-threatening rare condition. Initially, the patient was aggressively resuscitated and treated conservatively. After 1 year, the band was removed laparoscopically following an unsuccessful attempted removal by endoscopy. Clinicians who follow up patients with gastric banding should be aware of this condition. The early detection of erosion is important to avoid this serious complication.

Functional survival after acute care for severe head injury at a designated trauma center in Hong Kong

Scipedia content — Fri, 26 May 2017 12:08:28 +0200

Severe head injury is known to be a major cause of early mortalities and morbidities. Patients' long-term outcome after acute care, however, has not been widely studied. We aim to review the outcome of severely head-injured patients after discharge from acute care at a designated trauma center in Hong Kong. This is a retrospective study of prospectively collected data of patients admitted with severe head injuries between 2004 and 2008. Patients' functional status post-discharge was assessed using the Extended Glasgow Outcome Score (GOSE). Of a total of 1565 trauma patients, 116 had severe head injuries and 41 of them survived acute hospital care. Upon the last follow-up, 23 (56.1%) of the acute-care survivors had improvements in their GOSE, six (11.8%) experienced deteriorations, and 12 (23.5%) did not exhibit any change. The greatest improvement was observed in patients with GOSE of 5 and 6 upon discharge, but two of the 16 patients with GOSE 2 or 3 also had a good recovery. On logistic regression analysis, old age and prolonged acute hospital stay were found to be independent predictors of poor functional outcome after a mean follow-up duration of 42 months. Multidisciplinary neurorehabilitation service is an important component of comprehensive trauma care. Despite significant early mortalities, a proportion of severely head-injured patients who survive acute care may achieve good long-term functional recovery.

Treating thrombotic prosthetic arteriovenous access with cross-balloon occlusive thrombolysis and angioplasty

Scipedia content — Fri, 26 May 2017 12:08:22 +0200

Clot embolism remains a concern due to flushing of clot and thrombolytic agent centrally in the process of percutaneous pharmacomechanical thrombolysis (PMT) for a thrombosed prosthetic arteriovenous access (PAVA), which might be reduced by a modified technique. We retrospectively review this modified technique that uses two balloon-catheters in crisscross fashion and occludes both ends of PAVA during thrombolysis. Underlying stenotic lesions were dilated simultaneously with balloon angioplasty when needed. Among the 23 patients treated, 21 (91.3%), 10 (43.5%), and seven (30.4%) presented significant stenosis at the outflow, intragraft, and inflow segments of PAVA, respectively. The median duration of follow-up was 310.0 (range, 288.0–327.0) days. Anatomic success was achieved in 12 out of 23 (52.2%). Clinical success for successful dialysis was achieved in all patients. The median primary patency and secondary patency were 126.0 days (range, 7.0–316.0) days and 308.0 days (range, 84.0–327.0), respectively. We believe this method is safe and effective in dissolving PAVA thrombus as well as treating culprit stenosis. It may reduce concerns of flushing of clot and thrombolytic agent into the central circulation in the process of PMT.

Prediction of major postoperative complications and survival for locally advanced esophageal carcinoma patients

Scipedia content — Fri, 26 May 2017 12:08:17 +0200

Predicting the major complications after esophagectomy is important and may help in preselecting patients who are most likely to benefit from surgery, especially in locally advanced esophageal cancer patients who have poor prognosis. To identify the factors associated with the development of pneumonia and anastomotic leakage complications, and the survival characteristics in locally advanced esophageal cancer patients. A consecutive series of 232 locally advanced esophageal cancer patients (183 men and 49 women, median age 63 years) who underwent esophagectomy at Prince of Songkla University Hospital between 1998 and 2007 was analyzed. There were nine (3.8%) 30-day mortalities. Pneumonia occurred in 53 patients (22.8%) and anastomotic leakage in 37 patients (15.9%). Multivariate analyses showed that low body mass index was related to leakage (p = 0.015), while soft-diet dysphagia (p = 0.009), forced expiratory volume in 1 second

Laparoscopic versus open distal pancreatectomy: A meta-analysis

Scipedia content — Fri, 26 May 2017 12:08:10 +0200

Laparoscopic distal pancreatectomy (LDP) is a minimally invasive surgical technique. The aim of the present study was to evaluate the currently available literature and compare the short-term clinical outcomes of patients who underwent LDP for left-sided pancreatic pathology with patients who underwent traditional open surgery. A literature search was performed to identify and compare studies that reported the clinical outcomes of both LDP and open distal pancreatectomy (ODP). Pooled odds ratios (OR) and weighted mean differences (WMD) with 95% confidence intervals (95% CI) were calculated using either fixed-effects or random-effects models. Nineteen nonrandomized controlled studies were identified that matched the selection criteria and reported the clinical outcomes of 1935 patients, of whom 805 underwent LDP and 1130 underwent ODP. Compared with open surgery, reports on laparoscopic resection indicate potentially favorable outcomes in terms of operative blood loss (WMD: -273.11, 95% CI: -404.61 to -141.61), the requirement of a blood transfusion (OR: 0.28, 95% CI: 0.11–0.71), postoperative time until oral intake (WMD: -1.19, 95% CI: -1.87 to -0.50), time to first flatus (WMD: -1.03, 95% CI: -1.93 to -0.12), length of hospital stay (WMD: -3.87, 95% CI: -5.06 to -2.68), and overall morbidity (OR: 0.70, 95% CI: 0.56–0.87). There were no differences in terms of the extent of oncologic clearance and postoperative mortality. LDP results in a faster postoperative recovery and a comparable oncologic clearance in comparison with open surgery. Additional large trials are required to delineate the long-term clinical outcomes of patients diagnosed with malignant neoplasms who undergo either of these two surgeries.

Great saphenous vein aneurysm presenting as an inguinal hernia

Scipedia content — Fri, 26 May 2017 12:08:04 +0200

A primary aneurysm in the saphenous vein is very rare. This case study is based on a 55-year-old male patient who applied for general surgery with a complaint of swelling in his left inguinal area, after examinations led to a provisional diagnosis of inguinal hernia. It was decided that surgery was the best option due to the risk of thromboembolism, and pain caused by the condition itself. Confusion with inguinal hernia can affect prognosis. It increases the risk of thromboembolism as well as preventing the chance of early response.

Results of surgical resection for patients with thymoma according to World Health Organization histology and Masaoka staging

Scipedia content — Fri, 26 May 2017 12:07:59 +0200

Thymomas are relatively rare tumors. In this study, we investigated the clinical features of patients who underwent surgical resection for thymoma. This study clinicopathologically evaluated 54 consecutive patients who underwent a surgical resection of thymoma in our department between 1994 and 2006. A complete resection was performed in 52 patients, while two patients underwent an incomplete resection due to pleural dissemination. Combined resection with adjacent organs was performed for the lung (n = 6), pericardium (n = 5), and large vessels (brachiocephalic vein in three, superior vena cava in two). The concomitant autoimmune diseases were observed in 20 patients (37%), and they included myasthenia gravis in 17 patients, macroglobulinemia in one, pemphigus vulgaris in one, and stiff person syndrome in one patient. The histologic types of the World Health Organization classification diagnosed as type A in four patients, type AB in 14, type B1 in eight, type B2 in 15, and type B3 in 11. There were 27, 17, eight, and two patients with Masaoka stages I, II, III, and IV, respectively. Four patients died, and the causes of death included recurrence of thymoma in two, gastric carcinoma in one, and respiratory failure due to myasthenia gravis in one patient. The overall survival rate at 10 years was 94.6% in patients with stages I and II disease and 77.1% in patients with stages III and IV disease. Long-term survival can be expected not only for patients at early stages, as well as for patients with stages III and IV disease if surgical resection is completed macroscopically.