Chu-Hsin Chuang

Spigelian hernia: Mesh or not?

OBJECTIVE: The purpose of this study was to report our experience in management and clinical result of Spigelian hernia with preperitoneal mesh repair or without mesh repair. EXPERIMENTAL DESIGN: Retrospecitve analysis. SUBJECTS: the medical records of 11 cases of Spigelian hernia with surgical treatment were reviewed. The clinical characteristic, treatment and clinical result were evaluated. RESULTS: of the 11 cases that were evaluated, 7 patients underwent open repair of hernia without extra-peritoneal mesh (group A), the other 4 patients underwent open surgery with extra-peritoneal mesh (group B). There were no significant difference in age, gender, body mass index, underlying diseases, symptoms, duration of symptoms, features of hernia sac and method of approach. No recurrence was found in these two groups. The mean follow-up time was 8.5 +/- 3.2 (years) in group A and 6.7 +/- 2.1 (years) in group B. CONCLUSIONS: whether open repair of spigelian hernia with or without extra-peritoneal mesh gives the same and well result.

Management of Emphysematous Cholecystitis

Background: The purpose of this study was to report our experience in management of emphysematous cholecystitis. Patients and Methods: We reviewed the medical records of 11 cases (6 male, 5 female) over the last 5 years. The clinical characteristics, laboratory tests, imaging studies and treatments were recorded. Results: The average age was 72 years. Seven patients presented with right upper quadrant (RUQ) abdominal pain on admission. Nine patients had a history of diabetes mellitus (DM). Over half of the patients were pyrexial on admission. Nine patients had leukocytosis. The abdominal plain films (kidneys, ureters, bladder; KUB) were all reviewed. Only 3 patients were reported as being suspicious of gas bubbles in the RUQ. Sonography of abdomen were performed in 8 patients. Only 2 patients had suspicious of emphysematous cholecystitis. CT of abdomen was performed in 9 patients, including two patients reported as air in wall with pericholecystic fluid and air-fluid level in gallbladder. Six of 11 patients were treated by emergency cholecystectomy. One patient was treated conservatively by antibiotics and interval cholecystectomy 4 weeks later. Four patients were treated with percutaneous transhepatic gallbladder drainage followed by cholecystectomy and broadspectrum antibiotics. These 4 patients had uncomplicated postoperative recoveries. Conclusion: Percutaneous transhepatic gallbladder drainage followed by cholecystectomy and broad-spectrum antibiotics is an effective treatment of emphysematous cholecystitis.

Totally Implantable Access Ports: Approach via Femoral Vein

The purpose of this study was to report our results of totally implantable access ports (TIAP) approached via the femoral vein. Patients and Methods: Seven patients were enrolled. The mean age was 62 years. Four patients were male, and 3 patients were female. Six patients received TIAP via the right femoral vein and 1 patient via the left femoral vein. All patients underwent local anesthesia. The reason for femoral vein TIAP placement, mean operative time, follow-up time and complications were recorded. Results: The mean operative time was 37 ± 12 min, the mean follow-up time 13.5 ± 12.0 months. The causes for repeat TIAP or conversion to femoral vein access are as follows: In 2 cases repeat TIAP was associated with thrombus formation in the subclavian vein, 2 cases developed a superior vena cava syndrome (one was accompanied by chest wall invasion), 2 cases showed repeat catheter obstruction, and in 1 case infection and catheter obstruction was found. Five of the 7 patients had 2 TIAP before, 2 patients only 1 TIAP. All interventions remained free of complications. Conclusion: TIAP via conventional central venous access such as jugular, subclavian or brachial veins are simple. However, not all cases are suitable for these methods. We present an alternative method of central vein access: the approach via the femoral vein. This method is safe and simple, but the port site should be placed far away from the groin region to avoid infections.

Leukemoid reaction in pseudomembranous colitis

A 70-year-old man, was admitted to our hospital due to pneumonia. During the admission, he received medical treatment. He was discharged one week later and regular took oral antibiotics. Three weeks later, he presented with abdominal pain and diarrhea off and on for several days. Physical examination showed no particular finding. Laboratory test results showed leukocytosis (69.8 x 10/uL) with a neutrophil predominant differential cell counts. Abdominal plain film showed ileus. Computed tomography showed marked dilatation edematous wall thickening of ascending colon and cecum (Fig. 1). Colonoscopy showed yellowish plaques in ascending and transverse colon (Fig. 2). Stool assay study proved presence of Clostridium difficile. The leukocytosis resolved after treatment of metronidazole. Discussion

Inflammatory Pseudotumor of the Liver following Streptococcus bovis Liver Abscess and Occult Colonic Cancer

Background: Inflammatory pseudotumor of the liver is a rare disease. The lesions are classified as either benign proliferations or postinflammatory proliferations. Their etiology and pathogenesis are still unknown. The association between Streptococcus bovis septicemia or endocarditis and occult colonic cancer is well known. However, there are no previous cases reported of S. bovis hepatic abscess, occult colon cancer and inflammatory hepatic pseudotumor. Case Report: A 69-year-old man was admitted with 5 days of intermittent fever and general malaise. Abdominal ultrasonography showed a 5 × 5 cm hepatic abscess, and guided percutaneous drainage was done. S. bovis was cultured. A repeat ultrasound scan and a CT scan of the abdomen showed multiple focal lesions in the right lobe of liver. Panendoscopy showed active pyloric ulcer. Colonoscopy revealed a fungating tumor at the recto-sigmoid junction. Biopsies disclosed adenocarcinoma. A sigmoidectomy and wedge resection of liver segment 8 were done. Gross examination of the liver specimen showed a hard, fibrotic nodule. On microscopic examination it consisted of fibrous tissue infiltrated by chronic inflammatory cells. Six months after discharge, the patient suffered from mild epigastric pain. Panendoscopy showed a submucosal adenocarcinoma over the incisura angularis of the stomach. A radical subtotal gastrectomy was done, and no hepatic tumor was palpated. Conclusion: The cause of the liver abscess in our patient may be portal vein bacteremia developing from the ulcerated colon cancer. We hypothesize that repeated inflammation of the liver parenchyma by liver abscesses might be the cause of the inflammatory pseudotumor.

Hepatobiliary and pancreatic: Torsion of the gallbladder

A 54-year-old woman was admitted to hospital with a 24 hour history of upper abdominal pain. Previous episodes had occurred that had been attributed to biliary colic. On examination, she had marked upper abdominal tenderness and a positive Murphy’s sign. Various blood tests including a white cell count, liver enzymes and amylase were within the reference range. An upper abdominal ultrasound study showed a calculus in a distended gallbladder. The gallbladder wall was thickened to 6 mm when compared to a normal gallbladder wall of 3 mm or less. An abdominal computed tomography scan confirmed the presence of a calculus and, in addition, showed a somewhat enlarged gallbladder with pericholecystic fluid (Fig. 1). Laparotomy was performed and revealed torsion of the gallbladder associated with gangrene (Fig. 2). The gallbladder did not have a membranous attachment to the liver and there was an anticlockwise torsion involving the cystic duct and the neck of the gallbladder. The torsion was readily corrected and cholecystectomy was performed. The first report of torsion of the gallbladder has been attributed to Dr A Wendel in an article in the Annals of Surgery in 1898. The disorder appears to be uncommon although at least 400 cases have been reported in the medical literature. The disorder is more common in women than in men (ratio 3:1) and patients have a mean age of approximately 70 years. There are coexisting gallbladder stones in 20% of patients. Factors that predispose to torsion include a free-lying gallbladder without a membranous attachment to the liver or a gallbladder that is completely enveloped by peritoneum with a long mesenteric attachment to the liver. The former is more common and occurs in approximately 4% of the normal population. Under most circumstances, the gallbladder does not have sufficient mobility to twist as it is firmly attached to its fossa on the under-surface of the liver by an extension of the peritoneum. A preoperative diagnosis of torsion of the gallbladder is rare as the clinical features can mimic acute cholecystitis. The surgical outcome is usually satisfactory although mortality rates of >10% have been reported, particularly when surgery is delayed.

Adult Hirschsprung’s Disease: A Case Report

Background: Hirschsprung’s disease rarely occurs in adults. If it occurs, the symptoms and signs are usually milder than in children and manifest as chronic or intermittent constipation. Curative surgical intervention could be performed with good results. Case Report: We reported a 22-year-old male with complaints of abdominal fullness, pain and constipation for 1 month. Abdominal plain film and barium enema showed a dilatation of the whole colon. A laparotomy with total colectomy and ileostomy was done due to respiratory distress. Five months later, rectal mucosectomy and ileoanal anastomosis were performed, and the patient’s bowel movements returned to normal. Conclusion: Surgical intervention allows for curative treatment of Hirschsprung’s disease in adults as shown by the case presented here and by review of the literature.

An Endometrioma in Abdominal Wall without Previous Abdominal Surgery: Report of a Case

Extrapelvic endometriosis is defined as endometriotic lesions found elsewhere in the body, including the cervix, vagina, vulva, intestinal tract, urinary tract, abdominal wall, thoracic cage and lungs, extremities, and central nervous system. Endometriosis involving the abdominal wall is an unusual phenomenon that should be considered in the differential diagnosis of abdominal wall masses in women. We report herein a 40-year-old female who presented with a mass in the lower abdomen and painful sensation was associated with menstruation. The location of the endometrioma was the rectus muscle sheath. The mass was excised from the subcutaneous fat down to the anterior abdominal fascia. Histolopathology confirmed endometriosis. No recurrence was found after operation for 18 months.