Hsu-Kai Huang

Postoperative predictors of ipsilateral and contralateral recurrence in patients with primary spontaneous pneumothorax

BACKGROUND Preventive surgery for contralateral recurrence of primary spontaneous pneumothorax (PSP) remains controversial and few studies discussed both ipsilateral and contralateral recurrences simultaneously. Thus, we aimed to identify the predictors of ipsilateral and contralateral PSP recurrence and to review literatures on the association of blebs/bullae on HRCT with PSP recurrence. METHODS We retrospectively reviewed consecutive patients who were treated at our hospital for first recurrence of PSP between January 2001 and December 2005. RESULTS This study included 553 patients who were followed-up for a mean period of 124 months. Ipsilateral and contralateral recurrence of PSP developed in 19.35% and 15.19% of patients, respectively. In the Cox regression analysis, the only significant predictors were no video-assisted thoracoscopic surgery (VATS) bullectomy (OR: 16.629, P<0.001) for ipsilateral recurrence, and the presence of blebs/bullae on HRCT (OR: 3.215, P=0.024) and low BMI (<18.5 kg/m2) (OR: 1.560, P=0.045) for contralateral recurrence. CONCLUSIONS VATS bullectomy was a strong independent predictor for prevention of ipsilateral PSP recurrence. Patients with contralateral blebs or bullae on chest HRCT or those with low BMI may be candidates for preventive VATS bullectomy to avoid recurrences and possible complications.

The Role of Three-Dimensional Printing in the Nuss Procedure: Three-Dimensional Printed Model-Assisted Nuss Procedure

BACKGROUND The Nuss procedure is a minimally invasive surgery for pectus excavatum. Success of the Nuss procedure is dependent on a previously bent pectus bar that is shaped to the desired curvature of the chest wall. Traditionally, the size and curvature of the metallic pectus bar are determined by trial and error. Herein, we introduce a novel design method for the metallic pectus bar to optimize the bar curvature and outcome after the Nuss procedure. METHODS From August 2016 through March 2017, 10 consecutive patients with pectus excavatum underwent the three-dimensional (3D) printed model-assisted Nuss procedure. The computed tomography images were used to generate a 3D thorax model of pectus excavatum. The 3D models of personalized pectus bar curvature were completed by computer-aided design. Herein, we report the demographic data, treatment outcomes, and radiographic findings. RESULTS All patients with pectus excavatum received one pectus bar insertion. The mean age was 19.80 ± 4.73 years (range, 12 to 26). The mean preoperative Haller index was 3.48 ± 0.35 (range, 3.06 to 3.95). We advantageously utilized preoperative planning; the mean interval change of the Haller index was 20.71% ± 4.63%. With the benefit of 3D printed model simulation, the surgical duration was 59.8 ± 23.2 minutes (range, 32 to 107). No patient had adverse events after operation. CONCLUSIONS Our initial results revealed that the 3D printed model-assisted Nuss procedure reduces the surgical duration and facilitates an optimal morphological outcome.

A catastrophic cervical necrotizing fasciitis after tooth extraction.

This is a 56-year-old male patient who had a past history of type 2 diabetes with irregular control by medication for more than 10 years. He had the habits of cigarette smoking and betel nut chewing. He had a decayed tooth extraction by his dentist. One day later, the patient had severe pain and local swelling over the left cheek, and was dyspneic. Initially, he went to a regional hospital where esophagoscopy showed an erosive oropharynx. Subsequently, he was sent to our emergency department. On examination, erythema with a central eschar, marked swelling and local subcutaneous crepitation of neck were noted (Fig. 1a). The body temperature was 37.5 C, and there was an increased respiration rate. Urgent non-contrast enhanced computed tomography (CT) scanning showed a pneumomediastinum with air tracked downward from the pharynx to the paraaortic space (Fig. 1b), inflammatory changes, pleural effusion, bilateral empyema, and a left side pneumothorax (Fig. 1c). The patient was developed impending respiratory failure. We performed tracheal intubation assisted with a video-optical intubation stylet system due to the inflamed airway, and no chance of performing a surgical airway. An emergent surgery, a large area of debridement and drainage of the neck and mediastinum were performed by the surgeon. Necrotic soft tissue with a foul odor was removed during operation. The patient was admitted to the intensive care unit. The culture of the neck pus grew out Prevotella spp. The blood cultures showed two strains of bacteria: Serratia marcescens and Stenotrophomonas maltophilia. A broad-spectrum antibiotic with imipenem and cilastatin was administered. During admission, debridement was repeated several times. It was a complicated decayed tooth extraction. A video-assisted thoracic decortication was performed. The wound over the neck did not heal despite the surgical intervention and dressing changes. The sepsis worsened followed by multiple organ failure with acute respiratory distress syndrome. After 3 weeks of treatment, he erupted a massive blood loss from the neck wound, and expired despite resuscitation efforts. Cervical necrotizing fasciitis is a life-threatening illness, and is more likely with a preexisting diabetes mellitus, chronic alcoholism, intravenous drug abuse, immunocompromised status, and obesity. We report this case of cervical necrotizing fasciitis with deep neck space infection (DNSI) and subsequent descending necrotizing mediastinitis. Fatal complications ensued after a dental extraction. Diagnostic criteria for descending necrotizing mediastinitis are suggested by Estrera et al. [1], They are: (1) a clinical manifestation of severe oropharyngeal infection, (2) the radiologic features of mediastinitis on CT, (3) documentation of a necrotizing mediastinal infection at surgery or on postmortem examination, and (4) an established relationship between oropharyngeal infection and development & Wen-Yi Chiu hanrogyi@gmail.com

The beneficial application of preoperative 3D printing for surgical stabilization of rib fractures

Objectives The beneficial application of three-dimensional (3D) printing for surgical stabilization of rib fractures (SSRF) has never been proposed in the literature before. The aim of this study was to verify patients’ surgical outcomes when utilizing preoperative three-dimensional printing for SSRF. Methods We retrospectively reviewed the records of all consecutive patients who were treated at our hospital for SSRF from July 2015 to December 2017. The patients were divided into two groups according to whether or not 3D printing was utilized. Results Forty-eight patients who underwent SSRF at our hospital were enrolled. Of them, three patients underwent bilateral surgeries. The patients with application of preoperative 3D printing for SSRF had statistically significant associations with shorter operation time per fixed plate (p < 0.001), and a smaller incision length (p < 0.001). Conclusions We present an useful technique involving 3D printing for promoting SSRF significantly with shorter operation time and an appropriate incision length.

The role of the ground-glass opacity ratio in resected lung adenocarcinoma

OBJECTIVES The goal of this study was to investigate the role of the ground-glass opacity (GGO) ratio in lung adenocarcinoma in predicting surgical outcomes. METHODS Patients who underwent surgical resection for pulmonary adenocarcinoma between January 2004 and December 2013 were reviewed. The clinical data, imaging characteristics of nodules, surgical approaches and outcomes were analysed with a mean follow-up of 87 months. RESULTS Of 789 enrolled patients, 267 cases were categorized as having a GGO ratio ≥0.75; 522 cases were categorized as having a GGO ratio <0.75. The gender, tumour differentiation, epidermal growth factor receptor mutation, smoking habits, lymphovascular space invasion, tumour size, maximum standard uptake value and carcinoembryonic antigen levels were significantly different in the 2 groups. In the group with a GGO ratio ≥0.75, 63.3% of the patients underwent sublobar resection (18.8% with a GGO ratio < 0.75, P <0.001). These patients had fewer relapses (2.2% for GGO ratio ≥0.75, 26.8% for GGO ratio <0.75, P < 0.001) and a better 5-year survival rate (95.5% for GGO ratio ≥0.75, 77.4% for GGO ratio <0.75, P < 0.001). None of the patients with a GGO ratio ≥0.75 had lymph node involvement. The multivariable Cox regression analysis revealed that a GGO ratio <0.75 was an independent factor for postoperative relapse with a hazard ratio of 3.96. CONCLUSIONS A GGO ratio ≥0.75 provided a favourable prognostic prediction in patients with resected lung adenocarcinoma. Sublobar resection and lymph node sampling revealed a fair outcome regardless of tumour size. However, anatomical resection is still the standard approach for patients with tumours with a GGO ratio <0.75, size >2 cm.

The abbreviated burn severity index as a predictor of acute respiratory distress syndrome in young individuals with severe flammable starch-based powder burn

Here, we investigated whether the abbreviated burn severity index (ABSI) scoring system predicts acute respiratory distress syndrome (ARDS) in a retrospective analysis of a severe flammable starch-based powder burn population. Demographics, total body surface area (TBSA) burn, the presence of mouth and nose burn, ABSI, inhalation injury, and clinical outcomes for each patient were analysed for association with inpatient ARDS based on the Berlin definition. We treated 53 patients (64% male, 36% female) and observed no fatalities. The median age, TBSA burn, and the ABSI were 22.2±3.6, 42.2±21, and 7.8±2.8, respectively. Inhalation injury was present in 56.6% of the cases, and mouth and nose burn was present in 30.2%. ARDS was prevalent at 30%. The mean abbreviated burn severity index (ABSI) was 10.6±1.5 in the ARDS group and 6.6±2.3 in the non-ARDS (P<0.001) group. The mean TBSA burn percentage for ARDS and the non-ARDS groups were 61.4±13.9% and 34±18%, respectively (P<0.001). The area under the curve of the receiver operating characteristic curves for an ABSI≥9 was 0.905. Our results show that the ABSI is effective for predicting ARDS in young individuals with severe starch-based powder burn.

Adult-onset Langerhans cell histiocytosis of the sternum

Langerhans cell histiocytosis (LCH) is a rare disease with uncertain etiology that is more prevalent in children. LCH typically invades skeletal systems, but in rare cases, it has been reported in the ribs or sternum. Optimal treatment choices for single-site, skeletal LCH are still undefined. We report a case of adult-onset LCH of the sternum. The range of surrounding soft tissue invasion was confirmed by three-dimensional fusion and reconstruction of chest computed tomography and magnetic resonance images. Our patient was successfully treated by local surgical curettage and adjuvant radiation therapy. We concluded that postoperative adjuvant radiation therapy may be advantageous for single-site LCH of bones with soft tissue invasion.

Endoscopic diverticulotomy with a stapler can be an effective and safe treatment for Killian-Jamieson diverticulum

Killian-Jamieson diverticulum (KJD) is a rarely encountered esophageal diverticulum which attributes to several symptoms. Clinically, KJD should be differentiated from the most common type of esophageal herniation, i.e., Zenkers diverticulum (ZD). The two diverticula may present in a similar fashion, and treatments have evolved from transcervical to a minimally invasive endoscopic approach in recent years. We present a case of an 88-year-old male with symptomatic esophageal diverticulum. Barium swallow esophagogram and flexible esophagoscopy demonstrated a large KJD with food debris retention. Endoscopic diverticulotomy using a stapler was performed successfully without injury to the recurrent laryngeal nerve (RLN). A literature review and discussion concerning etiology, clinical presentations, and radiographic characteristics of KJD was conducted, and comparison between open and endoscopic method for esophageal diverticulum was also carried out.

Esophagogastric junction outflow obstruction-related functional chest pain treated using robotic-assisted thoracoscopic esophageal myotomy

Elevated relaxation pressure in combination with intact or weak peristalsis characterizes esophagogastric junction (EGJ) outflow obstruction. Symptoms of EGJ outflow obstruction include dysphagia and atypical chest pain. EGJ outflow obstruction can be diagnosed using high-resolution manometry (HRM), but there is a lack of consensus regarding treatment. We present a case report of a 43-year-old man with a history of headache and mitral valve disorder who suffered from intermittent atypical chest pain for 20 years. A diagnosis of EGJ outflow obstruction was made using esophageal HRM. Due to medication intolerance, robotic-assisted esophageal myotomy and Belsey-Mark IV fundoplication were performed. The symptoms went into complete remission and no motility disorders were detected on postoperative HRM. HRM is a useful diagnostic examination for EGJ outflow obstruction. The robotic systems-assisted long segment myotomy may potentially play an important role in the treatment of EGJ outflow obstruction-related functional chest pain.

Congenital Diaphragmatic Hernia with Spontaneous Gastric Rupture in Pregnancy

Background: Diaphragmatic hernias are rare in adults and extremely rare during pregnancy when diagnosis is difficult because of the nonspecific symptoms. However, delays in diagnosis can be fatal. Case Report: We report the successful repair of a Bochdalek hernia in a woman presenting with emesis and epigastric pain at 29 weeks of gestation. A diaphragmatic hernia complicated by rupture of the stomach was diagnosed by computed tomography. A cesarean section was performed, followed by surgical repair of the diaphragmatic defect and stomach perforation.