Sheng-Der Hsu

Midgut volvulus in an adult with congenital malrotation

Congenital midgut malrotation, a rare anatomic anomaly that can lead to duodenal or small-bowel obstruction, rarely is observed beyond the first year of life. Symptomatic patients present with either acute bowel obstruction and intestinal ischemia with a midgut or cecal volvulus or with chronic vague abdominal pain. Chronic symptoms often can make the diagnosis difficult. By using several modalities such as barium studies, computerized tomography, angiography, and emergency laparotomy, we diagnosed midgut volvulus and partial intestinal obstruction, which occur rarely in an adult with congenital midgut malrotation.

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.

Xanthogranulomatous panniculitis after spillage of gallstones during laparoscopic cholecystectomy mimics intra-abdominal malignancy.

Spillage of gallstones into the peritoneal cavity during laparoscopic cholecystectomy (LC) occurs frequently and may be associated with complications. Most of these complications present late after the original procedure, and many have clinical pictures that are not related to biliary etiology, which can confound and delay adequate management. Our patient presented with an intra-abdominal firm heterogeneous mass lesion. Imaging studies showed obvious abdominal wall invasion, and CA-125 level was elevated. Thus, malignancy could not be excluded. Final operative pathology revealed xanthogranulomatous inflammation. Complications of LC should be considered for patients with intra-abdominal abscess or mass lesion if there is a history of LC, regardless of time interval.

Lumbar Hernia: Clinical Analysis of Cases and Review of the Literature

Background: Lumbar hernias are relatively rare, and easily neglected. The aim of this retrospective study was to investigate the clinical manifestation, the accuracy rate of diagnosis, the treatment of the hernias, and the outcome of the surgical procedure. Patients and Methods: Fifteen cases of lumbar hernia were retrospectively enrolled in this study by clinical observation at Tri-Service General Hospital from January 1982 to December 2002. All patients were diagnosed clinically and confirmed operatively. Clinical manifestation, diagnosis, and treatment of the hernias as well as outcome of the surgical procedure were recorded. Results: The mean patient age was 63.4 years (range 48–81). Patients were divided into a primary acquired (spontaneous) hernia set (12 patients) and a secondary acquired (traumatic) hernia set (3 patients). Hernias occurred commonly in the superior lumbar triangle (9/15; 60%), followed by inferior lumbar triangle hernias (3/15; 20%) and diffused type hernias (3/15; 20%). Clinical manifestations were variable, with low back pain (7/15; 46.7%) and a protruding mass (9/15; 60%) being most common. Traumatic lumbar hernias (3/15; 20%) present with flank hematoma (3/3; 100%) and severe flank pain (2/3; 67%). Ten patients underwent primary repair, 3 patients primary repair with mesh due to the defect being too large, and 2 patients underwent laparoscopically assisted repair with mesh. Two patients experienced complications: incarcerated bowel in 1 patient of the spontaneous group, and mesenteric tears in 1 patient of the traumatic group. Fourteen of the 15 patients were treated successfully, and only 1 patient had recurrence at follow-up 1 year later. Conclusion: Accurate preoperative diagnosis of lumbar hernias is a challenge and should involve detailed radiological studies. Early operative repair is the treatment of choice.

Giant malignant mammary phyllodes tumor: report of a case and review of the literature.

To distinguish between a benign and malignant phyllodes tumor before surgery is difficult. Wide excision or mastectomy with adequate free margins is necessary in the case of a malignant phyllodes tumor. However, repairing the skin defect after removal of a giant malignant phyllodes tumor is a great challenge for the breast surgeon. Case Report: We report the case of a 45-year-old Taiwanese woman with a giant malignant phyllodes tumor measuring 30 × 25 × 22 cm. Prior to surgery, we carefully designed a flap to cover the skin defect, following standard mastectomy with at least 2 cm free margins. Postoperatively, the patient recovered well without any wound infection or flap necrosis. During follow-up at our outpatient department, there was no evidence of local relapse or distant metastasis. Conclusion: Giant malignant phyllodes tumors can be treated by total mastectomy with adequate free margins, using a flap technique to cover the skin defect.

Spontaneous Rupture of a Large Exogastric Hemangioma Complicated by Hemoperitoneum and Sepsis

Hemangiomas are benign congenital tumors of mature blood vessels and usually consist of dense masses of capillaries or larger blood vessels. Hemangioma of the stomach presenting with spontaneous rupture and sepsis is rare. We report a 22-year-old male who presented at the emergency room with sudden-onset epigastric pain, intractable nausea, and vomiting. Fever, tachycardia, leukocytosis and peritonitis were found on examination after admission. Computed tomography revealed a single, well-defined homogeneous lesion measuring approximately 6 x 8 x 9 cm in size over the left upper abdomen and hemoperitoneum. Laparotomy was performed because of intra-abdominal hemorrhage, peritonitis, and fever. During the operation, a dark red tumor was found on the greater curvature side of the stomach, accompanied by bleeding and hemoperitoneum. The tumor was removed and a wedge resection of the stomach and partial omentectomy were performed. Histopathologic examination of the excised tumor revealed mixed cavernous-capillary hemangioma with central necrosis. The postoperative course was uncomplicated. The pathogenesis of spontaneous rupture and sepsis in this case may have resulted from pedicle torsion accompanied by ischemia, central necrosis, rupture of hemangioma and subsequent peritonitis and sepsis.

Senior general surgery residents can be trained to perform focused assessment with sonography for trauma patients accurately

PurposesResearchers studying trauma have found that physicians are able to perform a focused assessment with sonography for trauma (FAST) with minimal training and achieve ideal accuracy. However, there are currently no consensus or standard guidelines regarding the performance of this assessment. The aim of our study was to clarify the value of FAST performed by well-qualified senior general surgery residents in cases of suspected blunt abdominal trauma, which presents an important diagnostic problem in emergency departments.MethodsThis was a retrospective study in the emergency department (ED) of our hospital performed from January 2011 to September 2013. Patients were included if they (1) had undergone a FAST examination performed by qualified residents and (2) had received subsequent formal radiographic or surgical evaluations. The results were compared against subsequent surgical findings or formal Department of Radiology reference standards.ResultsAmong the 438 patients enrolled, false-negative results were obtained in 8 and false-positive results in 5. Only one patient was missed and required laparotomy to repair a small intestine perforation. The sensitivity and specificity were 87 and 99%, respectively; the accuracy was 97%.ConclusionsSenior general surgery residents can be trained to perform accurate FAST examinations on trauma patients.

Risk of infertility following pelvic angiographic embolization in female patients with pelvic fractures: A nationwide population-based cohort study in Taiwan

Pelvic angiographic embolization is an effective procedure to provide haemostasis in patients with pelvic fractures. However, management with repeated follow-up radiographs may result in infertility. The study aimed to evaluate the risk of infertility following pelvic fracture treated with pelvic angiographic embolization in female patients. We used data from the National Health Insurance Research Database (NHIRD) provided by the Bureau of National Health Insurance of the Department of Health in Taiwan from the period of 1997–2010. A total of 36 and 18,029 patients were included in the case and control cohorts, respectively. The risk estimations for the case and control cohorts were compared using a Cox’s proportional hazards regression model. The significance level was set at <0.05. After adjusting for possible confounding factors, the incidence of infertility in the case cohort was nearly 30.7-fold higher than that in the control cohort (adjust hazard ratio [HR] = 30.7, 95% confidence interval [CI] = 10.643–70.109). Patients between 15–35 years of age had a much higher incidence of infertility in the case cohort than in the control cohort (adjusted HR = 49.9, 95% CI = 15.177–64.099). Taken together, pelvic fractures in female patients treated with arterioembolization for haemostasis might be associated with a higher risk of infertility in Taiwan. Physicians should be aware of the link and inform patients of this risk prior to arterioembolization.

The evolution of computed tomography from organ-selective to whole-body scanning in managing unconscious patients with multiple trauma: A retrospective cohort study.

Abstract We aimed to evaluate the benefit of whole-body computed tomography (WBCT) scanning for unconscious adult patients suffering from high-energy multiple trauma compared with the conventional stepwise approach of organ-selective CT. Totally, 144 unconscious patients with high-energy multiple trauma from single level I trauma center in North Taiwan were enrolled from January 2009 to December 2013. All patients were managed by a well-trained trauma team and were suitable for CT examination. The enrolled patients are all transferred directly from the scene of an accident, not from other medical institutions with a definitive diagnosis. The scanning regions of WBCT include head, neck, chest, abdomen, and pelvis. We analyzed differences between non-WBCT and WBCT groups, including gender, age, hospital stay, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, time in emergency department (ED), medical cost, and survival outcome. Fifty-five patients received the conventional approach for treating trauma, and 89 patients received immediate WBCT scanning after an initial examination. Patients’ time in ED was significantly shorter in the WBCT group in comparison with the non-WBCT group (158.62 ± 80.13 vs 216.56 ± 168.32 min, P = 0.02). After adjusting for all possible confounding factors, we also found that survival outcome of the WBCT group was better than that of the non-WBCT group (odds ratio: 0.21, 95% confidence interval: 0.06–0.75, P = 0.016). Early performing WBCT during initial trauma management is a better approach for treating unconscious patients with high-energy multiple trauma.