Chi-Chuan Yeh

MINI-LAPAROTOMY IMPLANTATION OF PERITONEAL DIALYSIS CATHETERS: OUTCOME AND RESCUE

♦ Background: Continuous ambulatory peritoneal dialysis is one of the main treatments for end-stage renal disease. To correct mechanical outflow obstruction after open surgical methods of catheter insertion, laparoscopic techniques are widely employed. ♦ Methods: Between January 2001 and December 2006, 228 open Tenckhoff catheter implantations were carried out by mini-laparotomy in 218 patients at our medical center. The procedures were all performed by an experienced surgeon, and the postoperative care, patient education, and long-term follow-up were all conducted by the same peritoneal dialysis team. ♦ Results: Infection of the exit site or tunnel was the most common complication (27/228, 11.8%), followed by peritonitis (18/228, 7.9%) and refractory mechanical catheter obstruction (9/228, 3.9%). The main causes of catheter removal were successful renal transplantation (21/228, 9.2%), peritonitis (18/228, 7.9%), and infection of the exit site or tunnel (7/228, 3.1%). In the 9 cases of refractory mechanical catheter obstruction, laparoscopic surgery was performed to identify the pathology and to rescue the catheter at the same time. Omental wrapping was the major cause (8/9) of catheter obstruction, with blood clot in the lumen and tube migration occurring in the remaining case (1/9). Partial omentectomy was performed in 5 patients to prevent recurrent obstruction. Neither technique failure nor operation-related complications were noted in our laparoscopic rescue group. For 20 of the 25 patients with refractory infection of the exit site or tunnel, the salvage technique of partial re-plantation was performed, with an 85% (17/20) technique survival rate. ♦ Conclusions: With an experienced surgeon and a good postoperative care team, open paramedian placement is a simple, safe, and effective method for Tenckhoff catheter insertion, with a low complication rate. Laparoscopic surgery is effective as rescue for mechanical obstruction, and partial re-plantation is effective as salvage for exit-site or tunnel infection.

Robot‐assisted renal transplantation in the retroperitoneum

Minimally invasive surgery for renal transplantation is still under development. We employed the robotic surgical system to perform renal transplantation with a minimally invasive wound. The operation was performed with a Gibson incision and two working ports. The space for the transplantation was created by retroperitoneal dissection with the robot lifting the abdominal wall. Vascular reconstruction was performed with two robotic needle drivers. We successfully performed robot‐assisted renal transplantation in five female and five male patients with an average wound length of 7.7 ± 1.04 cm. Nine of the renal allografts functioned immediately, but one with prolonged warm ischemia during the live donor nephrectomy had delayed function. The average creatinine level and estimated glomerular filtration rate at discharge were 1.31 ± 0.31 mg/dl and 58.2 ± 8.1 ml/min, respectively. All the transplants are currently functioning at 6.9 ± 3.9 months after operations. In conclusion, with robot assistance, minimal invasive renal transplantation can be performed successfully in the retroperitoneum.

De novo malignancy is associated with renal transplant tourism

Despite the objections to transplant tourism raised by the transplant community, many patients continue travel to other countries to receive commercial transplants. To evaluate some long-term complications, we reviewed medical records of 215 Taiwanese patients (touring group) who received commercial cadaveric renal transplants in China and compared them with those of 321 transplant recipients receiving domestic cadaveric renal transplants (domestic group) over the same 20-year period. Ten years after transplant, the graft and patient survival rates of the touring group were 55 and 81.5%, respectively, compared with 60 and 89.3%, respectively, of the domestic group. The difference between the two groups was not statistically significant. The 10-year cumulative cancer incidence of the touring group (21.5%) was significantly higher than that of the domestic group (6.8%). Univariate and multivariate stepwise regression analyses (excluding time on immunosuppression, an uncontrollable factor) indicated that transplant tourism was associated with significantly higher cancer incidence. Older age at transplantation was associated with a significantly increased cancer risk; however, the risk of de novo malignancy significantly decreased with longer graft survival. Thus, renal transplant tourism may be associated with a higher risk of post-transplant malignancy, especially in patients of older age at transplantation.

Hand-assisted versus total laparoscopic live donor nephrectomy: comparison and technique evolution at a single center in Taiwan

Lai I‐R, Yang C‐Y, Yeh C‐C, Tsai M‐K, Lee P‐H. Hand‐assisted versus total laparoscopic live donor nephrectomy: comparison and technique evolution at a single center in Taiwan.
Clin Transplant 2009 DOI: 10.1111/j.1399‐0012.2009.01173.x.
© 2009 John Wiley & Sons A/S.

Survival After Pancreaticoduodenectomy for Ampullary Cancer is not Affected by Age

BackgroundAlthough pancreaticoduodenectomy (PD) provides the best chance of survival for elderly patients with ampullary carcinoma, it is associated with considerable surgical risk. The aim of the present study was to compare the benefits and risks of pancreaticoduodenectomy as a treatment of ampullary carcinoma between young and elderly patients.Patients and methodsWe retrospectively reviewed the medical records of 171 consecutive patients treated at our hospital. Comparison of the biological aggressiveness of ampullary cancer between old and younger patients was also performed by immunohistochemical study of several prognostic biological markers, including MUC1, MUC2, CK17, and CDX2.ResultsFor patients in whom ampullary carcinoma was presumed resectable preoperatively, actuarial survival was significantly poorer in 55 elderly patients because 9 of them did not have PD (the other 46 had PD) than in 101 younger patients (all had PD). Multivariate analysis indicated that PD was the only independent prognostic factor; age was not. There were no significant differences in MUC1, CK17, MUC2, and CDX2 immunohistochemical staining of ampullary carcinomas between elderly and young patients. In spite of increased co-morbidities, PD could be performed as safely in elderly patients as in young patients. After PD, the actuarial survivalwas similar between old and young patients.ConclusionsOur data support the conclusion that ampullary cancers in elderly patients should be treated as aggressively as in younger patients.

Emotional Learning and Identity Development in Medicine: A Cross-Cultural Qualitative Study Comparing Taiwanese and Dutch Medical Undergraduates

Purpose Current knowledge about the interplay between emotions and professional identity formation is limited and largely based on research in Western settings. This study aimed to broaden understandings of professional identity formation cross-culturally. Method In fall 2014, the authors purposively sampled 22 clinical students from Taiwan and the Netherlands and asked them to keep audio diaries, narrating emotional experiences during clerkships using three prompts: What happened? What did you feel/think/do? How does this interplay with your development as a doctor? Dutch audio diaries were supplemented with follow-up interviews. The authors analyzed participants’ narratives using a critical discourse analysis informed by Figured Worlds theory and Bakhtin’s concept of dialogism, according to which people’s spoken words create identities in imagined future worlds. Results Participants talked vividly, but differently, about their experiences. Dutch participants’ emotions related to individual achievement and competence. Taiwanese participants’ rich, emotional language reflected on becoming both a good person and a good doctor. These discourses constructed doctors’ and patients’ autonomy in culturally specific ways. The Dutch construct centered on “hands-on” participation, which developed the identity of a technically skilled doctor, but did not address patients’ self-determination. The Taiwanese construct located physicians’ autonomy within moral values more than practical proficiency, and gave patients agency to influence doctor–patient relationships. Conclusions Participants’ cultural constructs of physician and patient autonomy led them to construct different professional identities within different imagined worlds. The contrasting discourses show how medical students learn about different meanings of becoming doctors in culturally specific contexts.

B cells and immunoglobulin in ABO-incompatible renal transplant patients receiving rituximab and double filtration plasmapheresis

BACKGROUND/PURPOSE The effect of rituximab on B cell and immunoglobulin production after therapeutic apheresis has not been studied in ABO-incompatible renal transplant patients. METHODS Twenty consecutive ABO-incompatible renal transplant patients receiving rituximab induction and double filtration plasmapheresis were enrolled; one case was excluded because of repeated plasmapheresis and immunoglobulin therapy (Incompatible group). The B cell count of the Incompatible group was compared to another group of 18 ABO-compatible renal transplant patients who were operated on during the same period (Compatible group). In the Incompatible group, the total IgM, IgG, and IgG1-4 subclasses after transplantation were compared to those before desensitization. Tacrolimus, mycophenolate mofetil, and steroids were used for both groups. RESULTS The B cell count of the Incompatible group was significantly lower than the Compatible group post-transplant from Month 1 to Month 11 only. The B cell count of the Compatible group also decreased for the first 6 months, suggesting that maintenance immunosuppressive agents suppress B cells. Total IgG and IgM levels after transplantation were significantly lower than before desensitization during the 24-month follow-up period. The post-transplant IgG3 level was significantly lower than before desensitization for only 3 months. CONCLUSION With the aid of tacrolimus and mycophenolate mofetil, rituximab resulted in sustained suppression of B cell count and total IgG and IgM. Among the IgG subclasses, IgG3 was less sensitive to rituximab.

Gasless laparoscopy-assisted versus open resection of small bowel lesions.

BACKGROUND We had developed an innovative method of minimally invasive surgery using gasless laparoscopy in resection of the small bowel lesion. This study aimed at evaluating the feasibility and efficacy of this procedure by comparison with traditional open small bowel surgery. METHODS A wedge or segmental resection of the small bowel for removal of the lesion was performed in 25 patients at National Taiwan University Hospital from September 2006 to January 2009. Thirteen patients underwent gasless laparoscopy-assisted surgery (GLAS), and 12 patients underwent open surgery. The perioperative characteristics and clinical results between the two groups were compared. RESULTS The demographics, clinical data, lesion size, and operative time were comparable between the GLAS and open surgery groups, but the wound length and blood loss were significantly less in the GLAS group (P < 0.001 and P = 0.021, respectively). The time to first postoperative flatus and first oral intake were significantly less in the GLAS group (P = 0.007 and 0.036, respectively). No major complication occurred in either group. No tumor recurrence was found after a median follow-up period of 14 months (range = 1-30) in the GLAS group. CONCLUSIONS GLAS for resection of the small bowel may be a feasible and safe procedure for the small bowel lesions. It has the advantages of better cosmetic outcome, less blood loss, and earlier recovery of bowel movement.

Modified Paul-Mikulicz Ileostomy in a Swine Model of Isolated Small Bowel Transplantation

BACKGROUND Intestinal transplantation (ITx) is a life-saving procedure for patients with intestinal failure. The poorer outcome of ITx than of other organ transplantation, however, warrants more clinical and basic research on ITx. Herein, we developed a modified Paul-Mikulicz ileostomy procedure in a swine model of ITx, and investigated its feasibility for obtaining intestinal samples of both the graft and the recipient. MATERIALS AND METHODS We performed ITx in 10 pairs of piglets, each weighing 15-20 kg. Procurement included an isolated segment of the small bowel, constituting a model of a living, related donor surgery. The recipient procedures included end-to-end anastomosis of vascular stumps, a proximal jejuno-jejunal anastomosis, and a distal modified Paul-Mikulicz ileostomy. The procedure differed from the classic Paul-Mikulicz ileostomy in that a common channel was created in a side-to-side fashion. RESULTS Vascular thrombosis occurred in three pigs, resulting in immediate loss of the graft. All other pigs underwent ITx successfully and survived for at least 1 wk (7-180 d). No pig experienced anastomotic leaks, ileus, or stoma-related complications. Moreover, this technique enabled us to obtain tissue samples of both the graft and the native ileum without disturbing the natural bowel conduit. CONCLUSIONS The modified Paul-Mikulicz ileostomy was feasible in a swine model of ITx. It facilitated the collection of intestinal samples of both the graft and the recipient.

Dynamic tracking of anatomical object for a steerable endoscope

The performance of MIS is usually limited by restricted view field and awkward tool manipulation. An intelligent auto-tracking steerable endoscope has been proposed to solve the restricted view field issue. We design a flexible tip for an endoscope, which was actuated by cable-driven method. The flexible tip can rotate in all direction dynamically to keep the target within the view filed during the tools operating on the anatomy. The kinematic model to describe the view filed of the steerable endoscope is derived and experimental verification on auto-tracking of the target object has been performed.