I-Feng Sun

A review of intraoperative airway management for midface facial bone fracture patients.

In craniofacial trauma patients, oral route endotracheal intubation may thwart the accuracy of dental occlusion and nasotracheal intubation carries the risk of intracranial invasion in skull base fracture cases.Between November 2005 and June 2006, patients receiving facial bone fracture operations at Kaohsiung Medical University Hospital were enrolled in this study. Intraoperatively, the endotracheal tube was pushed to either the retromolar space or the missing tooth space and secured by two 4.0 silk stitches. Then, surgeons could perform the usual procedure to explore the fracture sites, check the occlusion and correct the deviated nose without limitation. Also, for better understanding the time needed for various intubation techniques, a time-measuring study was performed.Ninety-one patients were treated by this method. Most of them were satisfied with the result of occlusion and nasal contour. Only 2 patients received second surgery to correct nasal deformity. One hundred seventeen anesthesia procedures were checked. In average, an experienced anesthesiologist could successfully intubate a patient in less than 105 seconds. The advantages and reported complications of different intubation methods were discussed.This retromolar position and tooth fixation technique allowed surgeons to correct the dental occlusion and nasal deformity simultaneously. It has served well for zygoma fracture, maxilla fracture, and Le Fort II fracture patients. It is worthy of consideration in management of middle face trauma patients involving occlusion change and nasal deviation.

Experiences of Interprofessional Implementation of a Healthcare Matrix

The Taiwan Joint Commission on Hospital Accreditation endorsed the Institute of Medicine (IOM) dimensions of health care quality as safe, timely, effective, efficient, equitable, and patient‐centered. The Taiwan Association of Medical Education has also adopted the Accreditation Council for Graduate Medical Education (ACGME) outcome project and core competencies for Taiwan physicians in training. These schemes focus on patient care, medical knowledge and skills, interpersonal and communication skills, professionalism, system‐based practice and practice‐based learning and improvement. Bingham (2004) described a Healthcare Matrix that links to the ACGME Core Competencies and the IOM Dimensions of Quality as a tool to improve health care. The matrix provides a blueprint to help residents learn the core competencies in patient care, and to help the faculty to link mastery of the competencies with improvements in quality of care. However, the “six‐by‐six” framework was too complicated to fill in. Furthermore, the translation of the IOM aims and ACGME core competencies into the Chinese language seemed incoherent and difficult to remember. We simplified the matrix by merging some columns of the original Healthcare Matrix, and reduced the 6 × 6 form into a 4 × 5 framework. The matrix was applied in case conferences, mortality and morbidity conferences, combined meetings and nursing quality assurance meetings in different departments. This format organizes the presentation and discussion, highlighting strengths or deficiencies in key aspects of patient care. With interprofessional collaboration, the matrix has been used in the departments of Plastic Surgery, and Nursing and Performance Management in our hospital. The achievements are encouraging. The Taiwan Edition Healthcare Matrix is worthy of consideration, having been used in a Mandarin‐speaking region of Asia.

Forehead osteoma excision by endoscopic approach.

Six cases of frontal osteoma had been operated with assistance of endoscopic surgery. Patient age ranged from 34 to 59 years. The diameter of the masses varies from 8 to 14 mm. The access incision was hidden behind the frontal hairline and the dissection plane went in the subperiosteal layer. The injury of the nerve branch and vessel can be easily avoided and endorsed by manipulating the endoscope. The average length of the procedure was 59.5 minutes. There is no complication such as scalp sensation impairment or hematoma over the forehead or scalp area. The elimination of the forehead osteoma can be executed at the forehead area scarlessly by the assistance of the endoscopic-assisted surgery.

Continuous Arteriovenous Hemodialysis and Continuous Venovenous Hemofiltration in Burn Patients with Acute Renal Failure

Acute renal failure (ARF) is a very common condition that may occur in patients with major burn injuries. The majority of burn patients with ARF have a high mortality rate, ranging from 73% to 100%. There are several ways to treat ARF in burn patients, including peritoneal dialysis (PD), intermittent hemodialysis, and continuous renal replacement therapy (CRRT). CRRT is generally used in patients in whom intermittent hemodialysis has failed to control hypovolemia, as well as in patients who cannot tolerate intermittent hemodialysis. Additionally, PD is not suitable for patients with burns within the abdominal area. For these reasons, most patients with unstable hemodynamic conditions receive CRRT. In this study (conducted in our burn unit between 1997 and 2004), six burn patients received CRRT: three received continuous arteriovenous hemodialysis (CAVHD) and the other three received continuous venovenous hemofiltration (CVVH). The patients were all males, with a mean age of 49.8 years (range, 27–80 years), and a mean burnt surface area of 65.1% (range, 30–95%). Four patients died due to multiple organ failure, and two patients recovered from severe ARF. CRRT has been proven safe and useful for burn patients with ARF. According to this study, we conclude that CVVH is an appropriate tool for treating ARF, with a lower incidence of vascular complications than CAVHD.

Management of the primary varicose veins with venous ulceration with assistance of endoscopic surgery

Two hundred sixty-two cases of primary varicose veins in which the lesions extended to the areas of the lower third of the leg and/or the ankle were treated with the assistance of endoscopic surgery. The conditions of varicose veins were classified by the reporting standards in venous disease. The number of cases in lesions of C2, C4, C5, and C6 were 60, 156, 31, and 15, respectively. They were also classified into 4 clinicoanatomic types according to varicositic changes in normal veins. The number of cases in types I, II, III, and IV were 57, 88, 42, and 75, respectively. The incidence of skin changes resulting from varicosity were 100%, 90.5%, 53%, and 50% in types I, II, III, and IV, respectively. The incidence of skin changes in this series was 77.6%. About one fourth of the cases having skin changes progressed to C5 and/or C6 lesions. Early and radical treatment of varicose veins could prevent the occurrence of skin changes and subsequently avoid the incidence of C5 and/or C6 lesions. The mean number of incisions in each limb was 2.9. With good illumination and magnified monitor view, the varicose veins and incompetent perforating veins were radically excised, but the normal veins were preserved. Forty-six cases of C5 and C6 lesions were followed up at least 1 year postoperatively. Four cases were lost from follow-up. In all cases except 1, there has been no recurrence. The conditions of skin changes improved subsequently. The recurrent rate of ulceration was 2.4%. In treatment of primary varicose veins with or without ulceration, surgery with assistance of endoscopic surgery achieved a low recurrence of ulcerations and minimal operative scarring.

Aeromonas Hydrophila Septicemia in Acute Hand Injury: A Case Report

Aeromonas hydrophila is an uncommon and frequently overlooked cause of skin and soft‐tissue infection. Rapid onset of cellulitis and bullae formation in the setting of soft‐tissue trauma in connection with exposure to fresh water should alert the clinician to the possibility of infection by this organism. We report a case of severe necrotizing fasciitis due to A. hydrophila infection involving the hand and arm, complicated by septicemia within 30 hours of injury. In addition to appropriate antibiotic therapy and general supportive care, treatment involves early surgical exploration for compartment decompression and aggressive debridement of all necrotic tissue followed by skin grafting for delayed wound closure. There was good functional outcome after more than 1 year of follow‐up. Early awareness of A. hydrophila infection, as well as of infection by Vibrio, is necessary in preventing crippling deformities of the hand in post‐traumatic wound infection with a history of exposure to fresh water.

Reconstruction of the Post Cardiac Surgery Deep Sternal Wound Infection-a Review of 10 Years KMUH Experience

Background:Its rare to see major infection of sternal wound after median sternotomy in cardiac surgery which yet may seriously affect the post-operation course including the morbidity, hospital stay, cost, and mortality. Various management strategies have been reported for the sternal wound care including debridement plus rewiring, open wound care, continuous irrigation, Redon tube closed irrigation, open packing then delayed closure, topical negative pressure dressing, and flaps reconstruction. All recent studies share one common principle, that is, adequate debridement of the infected tissue and covering of the defect with well-vascularized tissue.Aim and Objectives:Here we present our treatment strategy for the deep sternal wound infection (DSWI) involving the sternal bone or mediastinal space at Kaohsiung Medical University Hospital in the past ten years.Materials and Methods:From September 2001 to September 2011, 1732 sternotomies were performed at Kaohsiung Medical University Hospital. We identified 41 patients who had suffered from deep sternal wound infection and were referred to plastic department for further treatment.Result:Total 41 patients adopted the surgical reconstruction in our hospital. All patients accepted the extensive debridement and topical negative pressure therapy first. Eight (19.50/0) of them received delay closure. Twenty-one (51.2%) patients with the defect limited to the upper and middle third of the sternum received the pectoralis major muscle (PM) advance flap reconstruction. Seven (17.1%) patients with the defect limited to the lower third of sternum received the rectus abdominis musde (RAM) flap (3), PM turnover flap (2), and PM plus RAM bi-pedicle flap (2) reconstruction. The rest five (12.2%) patients with the defect, involving whole sternum, received the PM plus RAM bi-pedicle flap (3) and Omentum flap (2) reconstruction.One patient got partial wound dehiscence post PM plus RAM bi-pedicle flap due to Mycobacterium tuberculosis infection. The dehiscent lesion got stable and healed after systemic and local anti-tuberculous treatment. Among all the 41 patients, four patients expired during their hospital stay. Three of them who had received the debridement, topical negative pressure dressing, and delay wound closure died of heart failure, and one case with PM advance flap died of sepsis, mediastinitis related.Conclusion:Adequate debridement, local infection control, and wound repair with well vascularized tissue are the keys to successful reconstruction. We prefer to use the PM flap to treat the DSWI. The PM flap is versatile, and 68.3% of the patient with DSWI in KMU hospital were treated with PM based flap including PM advance or turnover flap and PM plus RAM flap. However, the flap design should depend on the patients status individually.

Management of the Infected Sternotomy Wound

Background: Sternal osteomyelitis is a potentially life-threatening complication after cardiac surgery. The infection can spread into the mediastinum, involving the prosthetic valve, grafts, and suture lines. It may be the cause of postoperative morbidity and mortality. Aim and Objectives: Topical negative pressure (TNP) dressing, muscle flap and hyperbaric oxygen therapy (HBO) have been proved to be effective for sternal wound healing. We want to take advantages of these methods to improve the results of intractable sternal wound infection. Materials and methods: From January 2005 to January 2008, 12 patients with sternal wound infection were treated at Kaohsiung Medical University Chung-Ho Memorial Hospital. All wounds received extensive debridement, irrigation, and TNP dressing. Seven patients received pectoralis major (PM) muscle flap coverage. Three patients accepted rectus abdominis myocutaneous (RAM) flaps coverage. Four patients received HBO therapy. Results: These patients received 1-3 times debridement before flap reconstruction or wound healed. Two patients did not receive any muscle flap for reconstruction after HBO management. After management, the infections were controlled and the wounds healed. There was no recurrence of sternal osteomyelitis during the follow-up periods. Conclusions: (1) The TNP dressing can apply several advantages to make the wound bed suitable for reconstruction. (2) According to the anatomic site of wound, we can choose proper muscle flap for sternal wall reconstruction. (3) The HBO therapy can be an alternative and inexpensive method for the difficult sternal wound infection patient.

Radical Surgical Treatment of Recurrent Ingrown Toenail

The treatment of paronychia has usually resulted in high recurrence rates. The impingement of ingrown toenail into the lateral nail fold irritating and inducing inflammatory change of local tissue seems to be the major pathophysiology of paronychia. Traditionally, partial resection of the involved nail bed without change of the convexity of the lateral nail groove is always followed by recurrent paronychia. In our series, besides the removal of the impinged nail spur and electro-destruction of the involved germinal matrix, we reshaped the curvature of the lateral nail fold by crescent wedge resection of the edge tissue. We used this modified radical procedure on a total of sixteen patients to treat 19 lesions of recurrent paronychia, which resulted in a high cure rate.

Management of Primary Varicose Veins with the Assistance of Endoscopic Surgery: Its Role in the Treatment of Venous Ulceration

Purpose: Primary varicose veins have been treated using endoscopic surgery and achieved an encouraging result, with very low incidence of recurrence. In this study, the result of endoscope-assisted operation for primary varicose veins with venous ulceration was evaluated. Materials and Methods: From February 1997 to December 2006, 103 legs in 91 patients of primary varicose veins with skin ulceration (C5 and/or C6 lesions) were treated with the assistance of endoscopic surgery. The mean age of these patients at the time of operation was 58.1 (range 28-87) years. The numbers of C5 and C6 lesions were 55 and 48 respectively. A total of 97 legs in 87 patients received complete follow-up. The follow-up period ranged from 2 to 104 months. The results for the rate of ulcer healing and recurrence were analyzed with the Kaplan-Meier survival analysis. Results: Among the 97 legs receiving complete follow-up, initial ulcer healing was achieved in 95 legs (97.9%), including 50 legs in the C5 group and 45 legs in the C6 group. The mean time for ulcer healing was 11.3 and 15.2 weeks in C5 and C6 groups respectively. The total number of recurrences was 5 and the mean time of recurrence was 35.8 months. The 5-year ulcer recurrence rate was 7.3%. Only two legs in two patients did not heal completely after the operation in this series. This study revealed that there were always clustered varicose veins with variable incompetent perforating vessels running immediately beneath the ulcerated skin and/or at the base of the ulcer. To achieve a complete and non-recurrent ulcer healing, radical excision of these varicose veins was mandatory. Conclusion: In the treatment of primary varicose veins with ulceration, surgery with assistance of the endoscope achieved an excellent ulcer healing rate with low recurrence of ulcerations. Besides, with the advantages of the endoscope providing a magnified monitoring view with good illumination, the relationship between varicose veins and the venous ulcer was also established. This is a good alternative for the treatment of venous ulceration.