De-Chuan Chan

The mechanisms of failure of totally implantable central venous access system: analysis of 73 cases with fracture of catheter.

BACKGROUND Totally implantable access ports are often used for the administration of chemotherapy or prolonged intravenous infusions in patients with cancer. The technique has been well described. However, some complications would happen. The pinch-off-syndrome is one of these complications. We report another presentation of pinch-off-syndrome and how to prevent. METHODS From January 2005 to December 2007, 73 patients of catheter fracture were collected. The duration of Port-A implantation ranged from January 2003 to October 2007. During this period, 3358 port-catheters were implanted. There were three brands of Port-A implanted included 46% BardPort (Bard, Salt Lake City, UT, USA), 42% A Port (Arrow international, Reading, PA, USA) and 12% PORT-A CATH (Deltec, St. Paul, MN, USA). RESULTS The most common clinical presentation was difficulty in injection in 32 cases (43.8%). The incidence of brand C was far lower than brand A and B. The most common site of fracture was at the proximal part (anastomosis between injection port and catheter) in 68 cases (93.2%). The incidence of fracture of Port-A was 6 in 738 (0.81%) in cut-down method; 67 in 2620 (2.56%) in percutaneous subclavian method. Most of the cases (34%) were no more than six months. CONCLUSION The most frequent location of fracture Port-A was in proximal part - anastomosis between injection port and catheter. The cause of easily fracture may be associated with pinch-off-syndrome and design of Port-A. This kind of fracture could be prevented by cut-down method and fixed one stitch in proximal part.

Superselective transarterial chemoembolization vs hepatic resection for resectable early-stage hepatocellular carcinoma in patients with Child-Pugh class a liver function

PURPOSE In contrast to hepatic resection (HR) for resectable early-stage HCC, the efficacy of transarterial chemoembolization (TACE) is controversial. This study is designed to compare the long-term outcome of TACE using superselective technique with hepatic resection for the treating resectable early-stage HCC and Child-Pugh class A liver function. METHODS In total, 185 consecutive patients with resectable early-stage HCC and Child-Pugh class A liver function were included: 73 patients received superselective TACE (group I) and 112 patients underwent HR (group II). We evaluated the therapy-related recurrence and long-term outcome and in both groups. The risk factors of recurrence and mortality were assessed by Coxs model. RESULTS The mean survival time of group 1 patient was similar to that of group 2 patient (40.8±19.8 vs 46.7±24.6 months respectively, p=0.91). The 1-, 3-, and 5-year overall survival rates after TACE (group I)and HR (group II) were 91%, 66%, and 52% and 93%, 71%, and 57%, respectively (p=0.239). The 1-, 3-, and 5-year recurrence-free survival rates in groups 1 and 2 were 68%, 28%, and 17% and 78%, 55%, and 35%, respectively (p<0.0001). Serum albumin, tumour size, tumour number and recurrence interval were independent risk factors for mortality. Serum albumin level, tumour size, tumour number, and treatment modality of TACE or HR could predict HCC recurrence. CONCLUSION TACE is an efficient and safe treatment for resectable early-stage HCC with overall survival rates similar to that of HR. Thus, TACE is indicated in selected patients with resectable early-stage HCC.

Extended O6-methylguanine methyltransferase promoter hypermethylation following n-butylidenephthalide combined with 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) on inhibition of human hepatocellular carcinoma cell growth.

Epigenetic alteration of DNA methylation plays an important role in the regulation of gene expression associated with chemosensitivity of human hepatocellular (HCC) carcinoma cells. With the aim of improving the chemotherapeutic efficacy for HCC, the effect of the naturally occurring compound n-butylidenephthalide (BP), which is isolated from a chloroform extract of Angelica sinensis, was investigated. In both HepG2 and J5 HCC cell lines, a synergistic antiproliferative effect was observed when a low dosage of BP was combined with the chemotherapeutic drug 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU). BCNU is an alkylating agent, and it prompts us to examine one of DNA repair genes, O(6)-methylguanine methyltransferase (MGMT). It was evident from methylation-specific polymerase chain reaction (PCR) analysis that BP/BCNU combined treatment caused a time- and concentration-dependent enhancement of MGMT promoter methylation. Overexpression of MGMT could abolish BP-induced growth inhibition in the J5 tumor cell line as measured by colony formation assay. When BP was combined with BCNU and administered, it showed significant antitumor effects in both HepG2 and J5 xenograft tumors as compared with the use of only one of these drugs. The BCNU-induced apoptosis and inhibited MGMT protein expression in HCC cells, both in vitro and in vivo, resulting from the combination treatment of BP and BCNU suggest a potential clinical use of this compound for improving the prognosis for HCCs.

Ectopic pancreas presenting as ampulla of vater tumor

Ectopic pancreas is relatively rare and is defined as pancreatic tissue that is situated abnormally, has no contact with the normal pancreas, and has its own ductal system and blood supply. It is usually an incidental finding in clinical practice. Most patients with an ectopic pancreas are asymptomatic, and, if present, symptoms are nonspecific and depend on the site of the lesion and the different complications encountered. Heterotopic pancreatic tissue has been found in several abdominal and intrathoracic locations, most frequently in the stomach (25%-60%) or the duodenum (25%-35%). Herein, we report a patient presenting with symptoms of ampullary tumor with obstructive jaundice, but the imaging study did not suggest the possibility of ectopic pancreas preoperatively.

Role of Nasogastric Tube Insertion after Gastrectomy

Nasogastric decompression has been routinely used in most abdominal operations to prevent the consequences of postoperative ileus. Most surgeons traditionally continue to use nasogastric decompression, believing that its use facilitates better surgical field and reduces complications such as nausea, vomiting, aspiration, and anastomotic leakage caused by postoperative ileus. The aim of the study was to evaluate whether gastric cancer surgery could be performed safely without nasogastric decompression. Patients and Methods: We enrolled 151 patients who had been surgically treated for gastric adenocarcinoma at the Tri-Service General Hospital from January 2005 to December 2005. The mean age was 55.4 years (range 25-72 years). 76 patients (Group A) were randomized into the intubated group and the other 75 patients (Group B) were randomized into the tubeless group. All patients received epidural pain control. Postoperative complications, preoperative serum albumin levels, mean time to first orally feeding, passage of stools, hospital stay and cost of hospitalization were recorded. Results: Between the two groups, there were no significant differences in preoperative clinical characteristics, age, stage and operative parameters. The complication rate, length of hospital stay, and time to pass flatus were not different in the two groups. Only the postoperative complication rate in those patients of Group A with low serum albumin level was significantly lower than that of patients without nasogastric tube. Conclusion: There were no significant differences with respect to improvement of postoperative complications when comparing gastric cancer patients who underwent gastrectomy with or without nasogastric tube insertion.

Predictors of the outcomes of acute-on-chronic hepatitis B liver failure

AIM To identify the risk factors in predicting the outcome of acute-on-chronic hepatitis B liver failure patients. METHODS We retrospectively divided 113 patients with acute-on-chronic liver failure-hepatitis B virus (ACLF-HBV) and without concurrent hepatitis C or D virus infection and hepatocellular carcinoma into two groups according to their outcomes after anti-HBV therapy. Their demographic, clinical, and biochemical data on the day of diagnosis and after the first week of treatment were analyzed using the Mann-Whitney U test, Fishers exact test, and a multiple logistic regression analysis. RESULTS The study included 113 patients (87 men and 26 women) with a mean age of 49.84 years. Fifty-two patients survived, and 61 patients died. Liver failure (85.2%), sepsis (34.4%), and multiple organ failure (39.3%) were the main causes of death. Multivariate analyses showed that Acute Physiology and Chronic Health Evaluation (APACHE) II scores ≥ 12 [odds ratio (OR) = 7.160, 95% CI: 2.834-18.092, P < 0.001] and positive blood culture (OR = 13.520, 95% CI: 2.740-66.721, P = 0.001) on the day of diagnosis and model for end-stage liver disease (MELD) scores ≥ 28 (OR = 8.182, 95% CI: 1.884-35.527, P = 0.005) after the first week of treatment were independent predictors of mortality. CONCLUSION APACHE II scores on the day of diagnosis and MELD scores after the first week of anti-HBV therapy are feasible predictors of outcome in ACLF-HBV patients.

Gum Chewing in Patients with Subtotal Gastrectomy

The purpose of this study was to report the efficacy of gum chewing (GC) in gastric cancer patients who underwent D2 subtotal gastrectomy. Patients and Methods: 26 patients were enrolled in this study. 13 patients received GC after D2 subtotal gastrectomy (group A) and 13 did not (group B). All patients had received epidural pain control. The mean times to first bowel movement, orally feeding, passage of stools, and hospital discharge as well as cost of hospitalization were recorded. Results: Between the two groups, there were no significant differences with respect to preoperative clinical characteristics, stage and operative parameters. The times to first flatus and passage of stools and the hospital stay were shorter in group A. Also the cost of hospitalization was lower in group A, but there were no significant differences. Conclusion: Although GC is a safe, non-expansive and physiologic method, this study suggests that there is no significant improvement of postoperative bowel motility of gastric cancer patients who underwent D2 gastrectomy. This implies that the cephalic-vagal reflex plays a major role in sham feeding.

Primary Malignant Mesothelioma of the Greater Omentum: Report of a Case

We report a rare case of primary malignant mesothelioma of the greater omentum. To our knowledge, only one other such case has been described in the English literature. The patient was a 61-year-old Taiwanese woman without any history of exposure to asbestos, who presented with lower back pain. Abdominal sonography and computed tomography showed a 12 × 9 × 9-cm3 mass occupying the lower abdomen. Laparotomy revealed a tumor in the greater omentum, invading the posterior wall of the uterus, without diffuse mesenteric thickening or multiple small nodules in the peritoneum. We performed en bloc resection of the mass, which involved omentectomy, hysterectomy, and bilateral salpingo-oophorectomy. Microscopically, the tumor cells were arranged in a tubulopapillary pattern lined by a single layer of uniform, cuboidal cells. A pattern of sclerotic stroma with irregular glandular elements was also recognized. Immunohistochemically, the tumor cells showed strong positivity for calretinin. The final pathologic diagnosis was malignant mesothelioma. The patient did not receive chemotherapy or radiotherapy, and has remained in good health without any evidence of recurrence for almost 3 years since her operation.

Malignant Perivascular Epithelioid Cell Tumor of the Mesentery: A Case Report and Literature Review

Background: Perivascular epithelioid cell tumors (PEComas) are very rare mesenchymal neoplasms, and have been found in various organs such as the liver, kidney, falciform ligament, uterus, uterine cervix, and both the small and large bowel. However, only 3 cases of mesenteric PEComa have been described in the literature so far. The treatment and prognosis of malignant mesenteric PEComas are discussed. Case Report: We report the case of a 59-year-old man diagnosed with PEComa. He underwent segmental resection of the jejunum and tumor resection. Malignant mesenteric PEComa was confirmed on the basis of clinicopathological features. Tumor resection was followed by concurrent chemoradiotherapy. Conclusion: Besides surgery, no effective treatment for malignant PEComa has been established thus far because of the rarity of this tumor. Here, we report our experience of treating a malignant mesenteric PEComa using surgery and subsequent adjuvant therapy, which effectively controlled disease progression and prevented local recurrence.

Rare rectal mucocele mimic tumor following hemorrhoidectomy in an adult patient

Mucoceles are commonly associated with the appendix and cranial sinuses. Rectal mucoceles are rare. There are case reports of rectal mucoceles following Hartmann’s procedure, and secon dary to high anal sphincter tone following spinal trauma (1,2). Mucoceles have developed in defunctioned colon after pull-through surgery due to stenosis and retraction of the colonic stump (3,4). Scarring of the mucus fistula, or failure to create a mucus fistula are other described contributing factors. We report a case of small rectal mucoceles following hemorrhoidectomy which caused scarring and stricture of the anal canal.