Chou-Fu Wei

Systematic analysis of missed extremity fractures in emergency radiology

Purpose: To systematically analyze fractures in the extremities that were missed in the initial radiological report, primarily on plain radiographs, in the emergency department (ED). Material and Methods: From January 2003 to June 2004, 2407 new patients were confirmed to have fractures in the extremities in the ED. A total of 3081 fractures were confirmed. In the initial radiological reports, 115 fractures in 108 patients were missed. One musculoskeletal radiologist and one emergency radiologist independently carried out a second review of these images. The easily missed fracture sites were recorded. The possible reasons for misinterpretation were determined by consensus. Results: The most frequent location for missed fractures, expressed as a percentage of all fractures in the same location, was the foot (7.6%), followed by the knee (6.3%), elbow (6.0%), hand (5.4%), wrist (4.1%), hip (3.9%), ankle (2.8%), and shoulder (1.9%). The average percentage for all missed fractures was 3.7%. On the second review, 70% of the initially missed fractures were identified. Analysis of the possible reasons for missed fractures showed the most common reason was subtlety of the fracture. Conclusion: The overall percentage of missed fractures in the extremities was 3.7%. Only 33% of the initially missed fractures were attributed to radiographically imperceptible lesions. Adequate training for physicians and radiologists in the ED may reduce the rate of missed fractures.

Esophageal Atresia with Tracheoesophageal Fistula: Ten Years of Experience in an Institute

Background: Esophageal atresia (EA), tracheoesophageal fistula (TEF), or both is a complicated problem. The purpose of this study was to evaluate the outcomes and postoperative complications in patients with EA/TEF who were admitted to our hospital. Methods: In total, 15 patients were enrolled from 1994 to 2003, including 8 males and 7 females. Patient demographics, associated anomalies, and outcomes were analyzed. Results: The most common variant was EA with a distal TEF (type C), which occurred in 12 patients (80%). The latter had associated congenital anomalies, and cardiac anomalies were the most frequent, occurring in 8 patients (53.3%). Of the 6 cases who had life‐threatening anomalies, 4 (66.7%) died, and of the 9 cases who had no life‐threatening anomalies, 2 (22.2%) died. Tracheomalacia and/or stenosis were diagnosed in 8 patients (66.7%) postoperatively. Though 3 of the 4 cases who suffered from dying spell received intratracheal stent implantation, 2 cases still died. Conclusion: The survival rate of the patients with EA/TEF is influenced mainly by associated life‐threatening anomalies. TMS combined with a history of dying spell may be the major fatal complication.

Domino liver graft from a patient with homozygous familial hypercholesterolemia.

Liu C, Niu D‐M, Loong C‐C, Hsia C‐Y, Tsou M‐Y, Tsai H‐L, Wei C. Domino liver graft from a patient with homozygous familial hypercholesterolemia.
Pediatr Transplantation 2010: 14:E30–E33.

Venoplasty of hepatic venous outflow with a venous patch in domino liver transplantation.

The domino donor (DD) was a 16-year-old boy with homozygous familial hypercholesterolemia. He received a whole liver graft from a 9-year-old deceased donor. We designed the hepatic outflow to be reconstructed by side-to-side cavocaval anastomosis for the first liver transplantation, so the DD hepatectomy was performed with preservation of the inferior vena cava (IVC) and the stumps of 3 hepatic veins were preserved as long as possible.

Surgical treatment of chylothorax caused by cardiothoracic surgery in children

Four pediatric cases of chylothorax after cardiothoracic surgery, which were managed surgically, are reviewed retrospectively. All patients underwent right thoracotomy and mass ligation of the right thoracic duct without detecting the true site of leakage. Although 1 patient died from heart failure the day after operation, the other 3 recovered quickly without sequelae. Based on our limited experience, we suggest that right thoracotomy with mass ligation of the right thoracic duct can successfully cure chylothorax on either side, particularly if identification of the site of leakage is considered too risky because of severe adhesion from previous cardiothoracic surgery.

Prepubertal testicular germ cell tumors: 25-year experience in Taipei Veterans General Hospital.

Background: Due to the rarity of testicular tumors in the prepubertal population, adequate information about their biological course is difficult to document well in a single institution. The purpose of this study was to focus on prepubertal males in an attempt to evaluate clinical features and optimal management among various testicular germ cell tumors with long‐term follow‐up. Methods: We retrospectively reviewed the records of children younger than 12 years of age with primary testicular germ cell tumors between February 1981 and December 2005 at Taipei Veterans General Hospital. Thirty‐four children were diagnosed with adequate clinical and pathologic data. The stage of the disease was determined according to the staging system used by the Childrens Oncology Group. Mean follow‐up time was 139 months (range, 2–283 months). Results: All of the 34 prepubertal patients were diagnosed initially with a painless scrotal mass. The mean age of the patients at diagnosis ranged from 6 months to 84 months (mean, 20.5 months). All patients underwent radical orchiectomy as an initial treatment. Twenty‐nine (85.3%) patients had yolk sac tumors, and 5 (14.7%) had mature teratomas. Of the 29 patients with yolk sac tumor, 26 (89.7%) were diagnosed as stage I, 1 (3.4%) as stage III, and 2 (7.0%) as stage IV. Five (19.2%) of the 26 stage I yolk sac tumors progressed to metastasis after radical orchiectomy, and all of these 5 patients later received chemotherapy. One patient initially with stage III yolk sac tumor and 2 patients with stage IV yolk sac tumor were also treated with chemotherapy. Eventually, 1 patient with stage IV yolk sac tumor died due to tumor pro‐gression; the remaining 28 patients with yolk sac tumor all survived without tumor relapse after appropriate treatment. In the 5 patients with teratomas, there was no tumor relapse after radical orchiectomy with a mean follow‐up time of 139.1 months. The 5‐year survival rates for yolk sac tumor and teratomas were 96.5% and 100%, respectively. Conclusion: The most common prepubertal malignant testicular tumor is yolk sac tumor, and the most common benign testicular tumor is teratoma. Children with testicular germ cell tumors have excellent long‐term survival rates after appropriate treatment.

Renal Cell Carcinoma in Children and Young Adults

Renal cell carcinoma (RCC) is a relatively uncommon tumor in childhood. Its biologic behavior and prognostic factors have rarely been documented. We report treatment and survival of 4 children (aged 8, 9, 11, and 14 years) who had RCC, along with a review of the literature to analyze the frequency of major symptoms, clinical stage, and prognostic factors based on 130 published cases of RCC in individuals younger than 20 years of age. Two of our cases had renal tumors detected by ultrasound screening, and all 4 cases were followed for a considerable length of time and were alive and free of disease after treatment. An analysis of these 130 published cases of pediatric RCC showed tumor staging and cell type to be the factors that affected patient survival. Tumors composed of granular cells or mixed cells, or at advanced stages, had a poor prognosis. Age, sex, tumor size, symptom duration, and cellular pattern were not related to patient prognosis. Children older than 10 years of age, who have an abdominal mass, flank pain, and/or hematuria should alert clinicians to consider the possibility of RCC. The importance of early diagnosis of renal tumors, using ultrasound as a tool of screening, is emphasized, since surgical treatment leads to a favorable prognosis only in the early stage of RCC.

Surgical outcomes of total colonic aganglionosis in children: A 26-year experience in a single institute

Background: There is a lack of consensus regarding the treatment of total colonic aganglionosis (TCA) with respect to perioperative morbidity, mortality, complications, and functional outcomes. The aim of this study was to review the results of surgical TCA treatment over a 26‐year period and characterize the outcomes. Methods: We retrospectively reviewed the clinical characteristics, surgical courses, and outcomes of TCA patients who underwent definitive pull‐through operations from 1986 to 2012. Follow‐up data were collected by chart reviews and telephone interviews using a standardized questionnaire. Results: We identified nine infants with TCA (8.6%) from among 105 infants with Hirschsprungs disease treated during the 26‐year period. Neither sex predominated (male/female ratio = 4:5). All infants underwent laparotomies and simultaneous enterostomies. All patients eventually underwent modified Duhamel pull‐through procedures at a mean age of 179 days (range, 47–352 days). Two infants died of complications after surgery including heart failure and sepsis. The remaining infants recovered smoothly with antilaxative medications, and all but one was weaned off these medications. Although the surviving patients did not catch up on growth, they and their families were satisfied with the surgical results. Conclusion: Infants with TCA had satisfactory outcomes after the modified Duhamel pull‐through operation. Based on our experience, we suggest that the pull‐through operation could be performed earlier, even when there are loose stools from the enterostomy.

Duct‐to‐duct biliary reconstruction in selected cases in pediatric living‐donor left‐lobe liver transplantation

Abstract:  The feasibility of D‐D biliary reconstruction in pediatric LDLT using left‐lobe graft has been discussed in few reports. The use of a trans‐anastomotic biliary tube seemed to be the favorable method to avoid the complications according to these reports. We had performed left‐lobe LDLT for seven pediatric cases and D‐D was done originally. Three cases were converted to R‐Y hepaticojejunostomy due to radical resection of hepatoduodenal ligament (n = 1) and severe kinking of D‐D (n = 2). Four cases received D‐D using 6‐0 PDS interrupted sutures without external stent tube. One D‐D case died of intra‐cerebral hemorrhage 10 days after operation with a functioning graft. There was one biliary leakage in a D‐D patient who required PTCD stent for 4 months without any sequale. From our limited experience, D‐D biliary reconstruction without external stent tube in left‐lobe LDLT is feasible in certain pediatric cases having normal extra‐hepatic bile ducts. In smaller recipient with larger graft, the use of a trans‐anastomotic biliary tube can prevent anastomotic kinking although we suggest R‐Y biliary reconstruction is better for this condition.

Retrograde Arterial Flush of the Liver Graft in Living Donor Liver Transplantation

ABSTRACT  Formal hepatic arterial flush to preserve the liver graft in living donor liver transplantation (LDLT) is not recommended by most transplant centers because direct cannulation may injure the intima of the hepatic artery. The authors describe a method of retrograde arterial flush of the liver graft without arterial cannulation by hepatic venous outflow occlusion (HVOO) in LDLT. First, we proved no backflow of the hepatic artery without HVOO by portal flush to pig livers. Then we used HVOO on 15 LDLT cases (Group HVOO). The results were compared with those of 24 counterpart LDLT cases (Group non-HVOO) without hepatic artery flush. The two-week posttransplantational liver functions were not different between two groups except that the day-three and day-seven serum bilirubin levels were lower in Group HVOO (day-three total bilirubin: 4.99 ± 4.04 mg/dl versus 7.65 ± 4.33 mg/dl, p =.016; day-seven total bilirubin: 5.06 ± 5.02 mg/dl versus 9.57 ± 6.09, p =.005). The rates of vascular complications, six-month graft survival, and biliary anastomotic stricture in Group HVOO were 0, 93.3, and 13.3% respectively, which were not different from those of Group non-HVOO. In summary, to avoid intima injury, the retrograde arterial flush of liver graft by HVOO is safe in LDLT. The short-term results showed the effect of decreasing early functional cholestasis but the long-term benefits need further evaluation, especially with regards to biliary anastomotic complications.