Hurng-Sheng Wu

Prevalence and risk factors of gallstone disease in an adult population of Taiwan: an epidemiological survey

Background and Aims:  The aim of this study was to determine the prevalence and risk factors of gallstone disease (GSD) in an adult population of Taiwan through a population‐based screening study.

Comparison of robot-assisted laparoscopic adrenalectomy with traditional laparoscopic adrenalectomy - 1 year follow-up

BackgroundLaparoscopic adrenalectomy offers distinct benefits to patients and has now become the gold standard for the removal of adrenal lesions. Nonetheless, the procedure poses a challenge for surgeons in regards to the maneuverability of instruments, the two-dimensional operating field and the counterintuitive movements. This study reports our experience using the Zeus robotic surgical system in laparoscopic adrenalectomy compared with traditional laparoscopic adrenalectomy.Patients and MethodsFrom January 2003 to February 2005, a total of 12 patients were prospectively enrolled to receive robot-assisted laparoscopic adrenalectomy (RALA) or traditional laparoscopic adrenalectomy (TLA). The time necessary for robotic setup and operation was recorded, as well as complications, technical problems, postoperative hospital stay, morbidity, and mortality.ResultsFive RALA procedures and seven TLA were successfully completed. There was no significant difference between the groups in terms of age, body mass index, and tumor size. Resection times were longer in the RALA group (168.0 ± 30.7 min vs. 131.4 ± 29.0 min, p = 0.05). There were no perioperative complications. There was neither postoperative mortality nor morbidity at the time of discharge and during one year follow-up.ConclusionsRALA is as safe and technically feasible as TLA, It provides a real benefit for the surgeon with the three dimensional view, a comfortable sitting position, the elimination of the surgeon’s tremor, and increased degrees of freedom of the operative instruments compared with TLA. However, patient outcomes and operative costs should be evaluated further.

Reappraisal of percutaneous transhepatic cholangioscopic lithotomy for primary hepatolithiasis

BackgroundA review of the literature pertaining to percutaneous transhepatic cholangioscopic lithotomy (PTCSL) showed that more than 50% of reported patients had undergone earlier biliary surgery.MethodsA retrospective study investigated 74 patients undergoing initial PTCSL for hepatolithiasis who had undergone no prior biliary surgery or manipulation. The patients were followed for 1 to 23 years after PTCSL for effective evaluation of the procedure outcome.ResultsComplete clearance of hepatolithiasis was achieved for 61 (82%) patients. The incomplete clearance rate was higher for patients with intrahepatic duct stricture (11/37 [30%] vs 2/37 [5%]; p < 0.05), although it showed no relation to the actual lobar distribution of hepatolithiasis (left: 7/41 [17%] vs right: 2/11 [18%] vs bilateral: 4/22 [18%]; p < 0.05). The recurrence rate for hepatolithiasis also was higher for patients with intrahepatic duct stricture (18/26 [69%] vs 13/35 [37%]; p < 0.05), but the recurrence rate showed no relation to the lobar distribution of hepatolithiasis (left: 18/34 [53%] vs right: 4/9 [44%] vs bilateral: 9/18 [50%] p > 0.05) or the presence of gallbladder stones (5/12 [42%] vs 26/49 [53%]; p > 0.05). Patients showing the coexistence of retained or recurrent hepatolithiasis demonstrated a higher incidence of recurrent cholangitis (57% [13/23] vs 14% [7/51]; p < 0.01) or cholangiocarcinoma (17% [4/23]) vs 0% [0/51]; p < 0.01).ConclusionsThe findings show that PTCSL is effective for treating primary hepatolithiasis, and that complete stone clearance is mandatory to diminish the sequelae of hepatolithiasis. Intrahepatic duct stricture was the main factor contributing to incomplete clearance and stone recurrence.

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.

F18-fluorodeoxyglucose positron emission tomography in detecting metastatic papillary thyroid carcinoma with elevated human serum thyroglobulin levels but negative I-131 whole body scan.

Papillary carcinomas are the most common thyroid malignancies. They invade the regional lymphatics and metastasize frequently to local lymph nodes in the neck. Distant metastasis, generally to the lungs, is also common. Methods. The aim of this study is to evaluate the effectiveness of F18‐fluorodeoxyglucose (FDG) positron emission tomography (PET) to detect metastatic lesions in patients with papillary thyroid carcinomas (PTC) after nearly total thyroidectomy and I‐131 treatments who present with elevated human serum thyroglobulin (hTg) levels but negative I‐131 whole body scan (WBS). Twenty patients with PTC who underwent nearly total thyroidectomy and radioiodine treatments were included in this study. Results. All of the 20 patients had negative I‐131 WBS results and elevated hTg levels (hTg ≥ 2.0 µIU/mL) under thyroid‐stimulating hormone (TSH) stimulation (TSH ≥ 30 µIU/mL). Conclusions. FDG‐PET was performed to detect metastatic lesions. F18‐fluorodeoxyglucose‐PET could detect hypermetabolic lesions in 17 patients but failed to demonstrate miliary pulmonary metastases in two patients. No definite lesion was found in FDG‐PET, x‐ray chest computed tomography (CT) and other imaging studies of the remaining one patient. This study showed that FDG‐PET is a useful tool in detecting metastatic lesions in PTC with elevated hTg but negative I‐131 WBS. However, miliary lung metastases may be missed in FDG‐PET. In this circumstance, chest CT should be included in the follow‐up protocol.

To predict response chemotherapy using technetium-99m tetrofosmin chest images in patients with untreated small cell lung cancer and compare with p-glycoprotein, multidrug resistance related protein-1, and lung resistance-related protein expression

Our preliminary studies found technetium-99m tetrofosmin (Tc- TF) chest imaging was related to Pgp or MRP1 expression and successfully predict chemotherapy response and in SCLC in human. However, there was no published literature to study relationship of Tc-TF chest images and LRP expression in SCLC patients. Therefore, the aim of this study was to investigate the relationships among Tc- TF accumulation in untreated small cell lung cancer (SCLC), the expression of P-glycoprotein (Pgp), multidrug resistance related protein-1 (MRP1), and lung resistance-related protein (LRP), as well as the response to chemotherapy in patients with untreated SCLC. Thirty patients with SCLC were studied with chest images 15 to 30 minutes after intravenous injection of Tc-TF before chemotherapeutic induction. Tumor-to-background (T/B) ratios were obtained on the static and plantar Tc-TF chest images. The response to chemotherapy was evaluated upon completion of chemotherapy by clinical and radiological methods. These patients were separated into 15 patients with good response and 15 patients with poor response. No significant differences of prognostic factors (Karnofsky performance status, tumor size, or tumor stage) were found between the patients with good and poor responses. Immunohistochemical analyses were performed on multiple nonconsecutive sections of biopsy specimens to detect Pgp, MRP1, and LRP expression. The difference in T/B ratios on the Tc-TF chest images of the patients with good versus poor response was significant. The differences in T/B ratios of the patients with positive versus negative Pgp expression and with positive versus negative MRP1 expression were significant. The difference in T/B ratios of the patients with positive versus negative LRP expression was not significant. We concluded that Tc-TF chest images could accurately predict chemotherapy response of patients with SCLC. In addition, The Tc-TF tumor uptake was related to Pgp or MRP1 but not LPR expression in SCLC.

Metoclopramide decreases emesis but increases sedation in tramadol patient-controlled analgesia

PurposeTo evaluate the clinical benefits and disadvantages of adding metoclopramide to tramadol for patient-controlled analgesia (PCA).,MethodsForty adult patients, undergoing elective arthroplasties, were recruited into this prospective, randomized, double-blind study. During general anesthesia all patients received 2.5 mg·kg−1 of tramadol as a loading dose at the beginning of wound closure. In the postanesthesia care unit (PACU) patients were randomly allocated to receive PCA containing either 20 mg tramadol + 1 mg metoclopramide per millilitre (n = 20, Group T+M) or tramadol 20 mg per millilitre (n = 20, Group T). The PCA setup was 1 mL/bolus with a lockout interval of five minutes. A blinded investigator assessed the vital signs, visual analogue scale, and severity of postoperative nausea and/or vomiting in the PACU. The PCA demand and delivery, overall satisfaction rate and adverse effects were recorded in the PACU and on postoperative days one and two.ResultsNausea/vomiting scores were more severe (1.7 ± 1.0 vs 0.2 ± 0.5, 2.3 ± 1.2 vs 0.6 ± 0.6, 1.9 ± 0.9 vs 0.2 ± 0.5, at 12 hr, 18 hr, 24 hr, respectively,P < 0.05) and more frequent (7/20 vs 1/20, 5/20 vs 0/20 for nausea and vomiting respectively,P < 0.05) on postoperative day one in Group T compared to Group T+M. However, the incidence of sedation was higher in Group T+ M (7/20 vs 1/20,P < 0.05).ConclusionsThe incidence and severity of nausea/vomiting decreased if metoclopramide was added to tramadol for PCA. An increased incidence of sedation was noticed with this drug combination.RésuméObjectifÉvaluer les avantages et les inconvénients cliniques de l’ajout de métoclopramide au tramadol pour l’analgésie auto-contrôlée (AAC).MéthodeQuarante adultes devant subir une arthroplastie non urgente ont participé à l’étude prospective, randomisée et à double insu. Pendant l’anesthésie générale, tous les patients ont reçu 2,5 mg·kg−1 de tramadol comme dose d’attaque au début de la fermeture de la plaie. Une fois à la salle de réveil (SDR), les patients ont été répartis de façon aléatoire et ont reçu une AAC contenant soit 20 mg de tramadol + 1 mg de métoclopramide par millilitre (n = 20, Groupe T+M), soit 20 mg de tramadol par millilitre (n = 20, Groupe T). L’AAC comportait des bolus de 1 mL et des périodes réfractaires de cinq minutes. Un chercheur impartial a évalué les signes vitaux, les scores de l’échelle visuelle analogique et la sévérité des nausées et des vomissements postopératoires. La demande et la disponibilité d’AAC, le taux de satisfaction générale et les effets indésirables ont été notés à la salle de réveil et les premier et deuxième jours postopératoires.RésultatsLes nausées et les vomissements ont été plus sévères (1,7 ± 1,0 vs 0,2 ± 0,5, 2,3 ± 1,2 vs 0,6 ± 0,6, 1,9 ± 0,9vs 0,2 ± 0,5, à 12 h, 18 h et 24 h, respectivement, P < 0,05) et plus fréquents (7/20 vs 1/20, 5/20 vs 0/20 pour les nausées et les vomissements, P < 0,05), du premier jour chez les patients du groupe T comparé au groupe T+M. Cependant, l’incidence de la sédation a été plus élevée chez ceux du groupe T+M (7/20 vs 1/20, P < 0,05).ConclusionL’incidence et la sévérité des nausées et des vomissements diminuent si du métoclopramide est ajouté au tramadol pour l’AAC. Une incidence accrue de sédation a été notée avec cette combinaison de médicaments.

Simulation of pneumoperitoneum for laparoscopic surgery planning

Laparoscopic surgery planning is usually realized on a preoperative image that does not correspond to the operating room conditions. Indeed, the patient undergoes gas insufflation (pneumoperitoneum) to allow instrument manipulation inside the abdomen. This insufflation moves the skin and the viscera so that their positions do no longer correspond to the preoperative image, reducing the benefit of surgical planning, more particularly for the trocar positioning step. A simulation of the pneumoperitoneum influence would thus improve the realism and the quality of the surgical planning. We present in this paper a method to simulate the movement of skin and viscera due to the pneumoperitoneum. Our method requires a segmented preoperative 3D medical image associated to realistic biomechanical parameters only. The simulation is performed using the SOFA simulation engine. The results were evaluated using computed tomography [CT] images of two pigs, before and after pneumoperitoneum. Results show that our method provides a very realistic estimation of skin, viscera and artery positions with an average error within 1 cm.

Tramadol 2.5 mg·kg−1 appears to be the optimal intraoperative loading dose before patient-controlled analgesia

PurposeWe previously established that a 5 mg·kg−1 intraoperative dose can reduce the nausea/vomiting associated with tramadol patient-controlled analgesia (PCA). This study was conducted to identify the most appropriate initial dose to improve the quality of tramadol PCA.MethodsDuring general anesthesia, 60 patients undergoing knee arthroplasty were randomly allocated to receive 1.25 mg·kg−1 (Group I), 2.5 mg·kg−1 (Group II), 3.75 mg·kg−1 (Group III), or 5 mg·kg−1 (Group IV) tramadol. The emergence condition was recorded. The titration of additional tramadol 20 mg + metoclopramide 1 mg doses by PCA every five minutes was performed in the postanesthesia care unit (PACU) until the visual analogue scale (VAS) score was ≤ 3. An investigator blinded to study group recorded the VAS and side effects every ten minutes.ResultsIn the PACU, significantly more tramadol (8.4 ± 3.1vs 4.3 ± 2.1, 2.5 ± 1.8, and 0.4 ± 0.3,P < 0.05), and a higher incidence (15/15vs 5/15, 3/15, and 2/15,P < 0.05) of PCA use was observed in Group I compared to Groups II–IV. VAS was significantly higher in Group I than in Groups II–IV at zero and ten minutes (P < 0.05). Unexpected delayed emergence anesthesia (> 30 min) was observed in Group III (n = 1) and in Group IV (n = 2). Sedation was more important in Groups III and IV than in Groups I and II (P < 0.05).ConclusionWhen considering efficacy and side-effect profile, 2.5 mg·kg−1 of tramadol is the optimal intraoperative dose of this drug to provide effective postoperative analgesia with minimal sedation.RésuméObjectifIl a été antérieurement établi qu’une dose peropératoire de 5 mg·kg−1 pouvait réduire les nausées et vomissements associés à l’analgésie auto-contrôlée (AAC). La présente étude voulait préciser la dose initiale la plus appropriée à une meilleure qualité de l’AAC au tramadol.MéthodePendant l’anesthésie générale, 60 patients subissant une arthroplastie du genou ont été répartis au hasard et ont reçu 1,25 mg·kg−1 (Groupe I), 2,5 mg·kg−1 (Groupe II), 3,75 mg·kg−1 (Groupe III) ou 5 mg·kg−1 (Groupe IV) de tramadol. Les conditions du réveil ont été notées. Le titrage de doses supplémentaires de 20 mg de tramadol + 1 mg de métoclopramide administrées par AAC toutes les cinq minutes a été réalisé à la salle de réveil (SDR) jusqu’à l’obtention d’un score ≤ 3 à l’échelle visuelle analogique (EVA). Un expérimentateur impartial a enregistré les scores de l’EVA et les effets secondaires toutes les dix minutes.RésultatsÀ la SDR, une quantité significativement plus importante de tramadol (8,4 ± 3,1 vs 4,3 ± 2,1, 2,5 ± 1,8 et 0,4 ± 0,3, P < 0,05) et une incidence plus élevée (15/15 vs 5/15, 3/15 et 2/15, P < 0,05) d’utilisation d’AAC ont été observées dans le Groupe I, comparé aux Groupes II–IV. Les scores à l’EVA ont été significativement plus élevés dans le Groupe I que dans les Groupes II–IV à zéro et dix minutes (P < 0,05). Un délai imprévu du retour à la conscience (> 30 min) a été observé chez les patients du Groupe III (n = 1) et du Groupe IV (n = 2). La sédation a été plus importante dans les Groupes III et IV que dans les Groupes I et II (P < 0,05).ConclusionSi on considère l’efficacité et les effets secondaires, on peut affirmer que 2,5 mg·kg−1 de tramadol constitue la dose peropératoire optimale permettant de fournir une analgésie postopératoire efficace et une sédation minimale.

Perirectal Oncologic Gateway to Retroperitoneal Endoscopic Single-Site Surgery (PROGRESSS): a feasibility study for a new NOTES approach in a swine model.

Introduction. A transanal, posterior, retrorectal approach has been demonstrated as a feasible natural orifice transluminal endoscopic surgery (NOTES) total mesorectal excision (TME) procedure. The aim was to assess the feasibility of a transrectal approach with a completely retroperitoneal mobilization of the left colon and mesenteric vessels in an acute porcine model. Materials and methods. Eight pigs were used. A purse-string suture was made 3 cm above the anal sphincter. Next, the retroperitoneal, perirectal space was entered with an endoscope through a single (or twin) anterior lateral, transrectal viscerotomy. A retroperitoneal tunnel was created using pneumodissection or endoscopically guided dissection to the inferior mesenteric artery (IMA). The IMA was skeletonized and lymph nodes retrieved using the IsisScope or other instruments. The IMA was divided with the Ligasure, clips, or ligature performed with the IsisScope. The rectum was dissected transanally in the “Holy” plane. After achieving mobilization using a completely retroperitoneal approach, the peritoneal attachments were then divided and the rectosigmoid specimen exteriorized through the anus. An explorative laparoscopy was then performed to evaluate the quality of the mobilization. Results. The procedure was successfully completed and the IMA correctly identified and ligated in all cases. In all but one case, no further mobilization was possible, even by a laparoscopic approach. Conclusions. Perirectal oncologic gateway to retroperitoneal endoscopic single-site surgery for left-sided colonic resections using both flexible and rigid surgical endoscopic platforms was feasible and reproducible in an acute porcine model. This technique might represent a step toward pure NOTES left-sided colorectal procedures.