Tzong-Bor Sun

Treatment of Venomous Snakebites in Eastern Taiwan

Background: The incidence of snakebites decreased gradually in recent years due to change of the socioeconomic environment in Taiwan. However, venomous snakebites still can cause severe morbidity and even death occasionally. Aim and Objectives: This report described treatment and result of poisonous snakebites in Eastern Taiwan. We hope to improve management and decrease complications. Materials and Methods: The medical records of the patients admitted to the Buddhist Tzu Chi General Hospital due to venomous snakebites from Jan 2000 to Sep 2004 were retrospectively reviewed. The patients demographic data, species of causative snake, manifestations of envenomation, treatment and clinical course were collected and analyzed. Results: There were 93 cases of snakebites collected. Most of the snakebites (27%) occurred in the fourth decade of age. The species of snakebites included: Taiwan habu bites (29%), Taiwan bamboo viper bites (16%), cobra bites (7.5%) and unknown bites (34%). The most common locations of the bite were in the upper extremity (60%). 24 patients (25.8%) required surgical intervention, including fasciotomy which was performed in 17 patients (18.3%). The average lengths of hospital stay in non-operated group and operated group were 4.2 days and 18.8 days respectively. Acute renal failure developed in three patients, and one of them required temporary hemodialysis. There was only one death in this series. Conclusion: Surgical intervention is indicated in a particular group of patients and different treatment algorithms should be developed according to snake species to decrease the morbidity of venomous snakebites.

Surgical Reconstruction for Buccal Cancer in Eastern Taiwan

Objective: To clarify and promote the outcome of surgical reconstruction for buccal cancer in eastern Taiwan. Patients and Methods: Eighty patients with buccal cancer had surgery at Buddhist Tzu-Chi General Hospital between December 1989 and August 1997. Charts of them were reviewed retrospectively. Data such as case number, sex, race, betel nut exposure, method of reconstruction, histology and outcome were collected and analyzed. Results: There were 70 male and 10 female patients, 77 of them (96%) had the habit of betel nut chewing. There were only seven aboriginal patients. The ratio between aboriginal and non-aboriginal patients was quite different from the local racial distribution between these ethnic groups in eastern Taiwan. The stages according to the American Joint Committee on Cancer(AJCC) staging ere stage I, 12 (15%); stage II, 22 (28%); stage III, 16 (20%); and stage IV, 30 (37%). Among 54 patients who had surgery more than 2 years, t patients were lost to follow-up. For this group of patients whose minimal follow-up was 2 years ( n=49), the two-year-survival rate for early buccal cancer (stage I and II) was 75.0%, and for advanced disease (stage III and IV) it was 48.3%. Eighty-four reconstruction procedures were undertaken. There were 44 free flaps, 25 pedicle flaps and 15 split-thickness skin grafts. Forty-four percent of patients with local flap reconstructions and 57% of patients with free flap reconstructions had problems of drooling. Eighty-nine percent of patients with local flap reconstructions and 76% of patients with free flap reconstructions had a comprehensible speech. Conclusions: Betel nut chewing did correlate with the development of buccal cancer. Early detection and early surgical resection followed by reconstruction gives the best results in treatment for buccal cancer. Due to improvements in reconstruction techniques, more radical resection procedures could be done.

Outcome after Below-knee Amputation in Patients of Diabetic Foot

Diabetes mellitus is the most common underlying cause of leg amputation. Lower leg amputation in diabetic patients is associated with significant morbidity, mortality and disability. From January 1991 to November 1996, there were 61 patients of diabetic foot received below-knee amputations at Buddhist Tzu-Chi General Hospital. Nine died during the pen-operative period, 13 patients received stumps revision due to failure of wound healing (23.6%), and 7 patients received below-knee amputations on another leg. (12.7%) During the period of follow-up, 23 patients died and mean life expectancy after amputation is 24.1 months. Prevention of amputation is an important goal of treatment in diabetic ptients. A multidisciplinary foot-care team is necessary to retard the disease progress. Combined effort by patients and health professionals may reduce the risk for amputation and thus decrease the manpower and economic cost that accompany limb loss in diabetic patients.

Mucosa-related Lymphoid Tissue Lymphoma of the Parotid Gland-Case Report and Literature Review

Background:Mucosa-related lymphoid tissue (MALT) lymphomas are rare low-grade B-cell lymphomas, mostly arising from the gastrointestinal tract. MALT lymphomas arising from the parotid gland are very rare.Aim and objective:We report the rare condition of mucosa-related lymphoid tissue lymphoma arising from the parotid gland and discuss their treatment and outcome.Material and Methods:A 77-year-old man presents with a 10-month history of a slow growing painless tumor at his right periauricular area. It measured 4 x 3 cm in size. There were another two palpable tumors at lower pole of the parotid gland, with the largest one measuring 1.7cm. After excisional biopsy of the minor tumors at the lower pole. The pathology confirmed MALT lymphoma. Superficial parotidectomy with concurrent radiation therapy was done.Results:There was no evidence of local recurrence and distant metastasis on the 11 months follow-up.Conclusion:Mucosa-associated lymphoid tissue lymphoma is rarely arising from the parotid gland. Diagnosis of the disease is very difficult and should be suspected if a patient has significant risk factors. Conservative superficial parotidectomy is recommended both for diagnosis and treatment. Radiation therapy is recommended for limited stages of the disease with systemic chemotherapy advised for advanced stage. Prognosis is favorable with careful post-treatment follow-up.

Radionecrosis of Soft Tissue: Surgical Treatment and Reconstruction

Background: Radiation therapy has been used increasingly in treating certain malignancies or often as a standard treatment combination in head and neck cancer. However, radiation related wounds can at times be devastating and troublesome. Aim and Objectives: In this paper, we reviewed retrospectively our experience in treating these types of wounds. We reviewed their surgical management and the different methods of reconstruction. Materials and Methods: A total of 6 patients were included in the study. All wounds were located at the head and neck region and associated with previous cancer treatment. Radiotherapy is an inclusion criteria. Medical records were retrospectively reviewed. All the clinical details including pre-reconstructive treatment and reconstructive methods were analyzed. Results: All patients received surgical debridement. Post-debridement wound care included both open type and occlusive type (V.A.C.®). Reconstructive methods followed the reconstructive ladder and all patients received flap coverage, whether as a pedicled flap or as a free flap. One patient received free tissue transfer and the rest received pedicled flap for wound coverage. Two patients received pectoralis major musculocutaneous flap (PMMF) and three patients received deltopectoral fasciocutaneous flap (DPFF). All patients recovered well without complications. Conclusion: Radiation injury to the soft tissue is a prolong progressive continuous process of injury which is hard to heal with ordinal procedure. When the radiation dosage was over 6000 cGy the possibility of wound necrosis and ulceration would be seen more often. The incidence might be underestimated due to poor recognition and identification among these patients. Most of the patients with minor necrosis can be treated with conservative methods and hyperbaric oxygen therapy . But those with extensive areas of necrosis with exposure of underlying major vessels or vital structures need to undergo serial debridements until a suitable wound bed without infection is obtained prior to reconstruction. The pedicled flap shown in our series seemed to be an alternative second choice for reconstruction for it does not require microsurgery and has a shorter operative time when compared to free flap transfer.

Anatomical Analysis of the Vascular Distribution in the Pectoralis Major Myocutaneous Flap Using Latex Injection

Background:Although the free flap has become the first choice in recent head and neck reconstruction, the pectoralis major (PM) myocutaneous flap still plays an important role, especially in salvage operations. However, unstable blood circulation of skin paddle with a higher partial necrosis rate has previously been reported.Aim and Objectives:In this current study, we tried to clarify the blood supply of the pectoralis major myocutaneous flap and to determine whether it can be harvested as a pedicled perforator flap.Materials and Methods:The 6 sides of 3 fresh frozen cadavers were examined in this study. The pectoral branch of the thoracoacromial artery was dissected out and injected with colored latex. In the first step, the pectoralis major muscle was elevated from the thoracic cage and the characteristics of the encountered muscular perforators were recorded. Following that, the skin flap was separated from the underlying muscle and the cutaneous perforating branches were also documented.Results:The circulation of the pectoralis major muscle has two main territories. It receives blood supply from pectoral branch of the thoracoacromial artery in the cranial portion and from multiple perforating intercostal branches in the caudal portion. These two territories are linked by choke vessels mainly at the level of fourth costal cartilage. The perfusion of the distal flap is maintained by muscle body containing these choke vessels. However, the number of perforating branches to the skin paddle is much smaller than that to the pectoralis major muscle and their locations vary individually, so the perfusion of the skin is unreliable in the absence of these perforators.Conclusion:The blood circulation of the skin paddle of the pectoralis major myocutaneous flap is unstable because of variation in the number and location of perforating vessels present and also the relative paucity of the cutaneous perforating branches. When designing a skin island, especially a small one, great efforts must be made to include either the third perforating branch of the internal mammary artery or the major intercostal perforating branches to improve blood flow. Hand-held Doppler may be helpful in localization of these vessels. (J Taiwan Soc of Plast Surg 2011; 20: 266~273)

Free Flap Reconstruction for Diabetic Foot Lesions

Background: Diabetic foot lesions are often complicated by angiopathy and neuropathy. If a deep ulcer or osteomyelitis is present, there is often exposure of the underlying bone or tendon after aggressive debridement. Owing to recent advancements in microsurgery, such lesions can now be managed successfully with free flap reconstruction. Aim and Objectives: This study was aimed to evaluate the outcome of diabetic foot salvage using free flap reconstruction. Materials and Methods: Between January 2003 and June 2009, patients with diabetic foot and managed with free flap reconstruction in Buddhist Tzu-Chi General Hospital were reviewed. The flap types, success rate and complication rate were analyzed. Results: Forty-six patients (28 males and 18 females) with diabetic foot were reconstructed with a total of 48 free flaps. The mean age was 52.4 years (range from 27 to 79). The different kinds of free flaps that were used were: 25 vastus lateralis flaps, 10 anterolateral thigh flaps, 8 radial forearm flaps, 2 rectus abdominis flaps, 1 rectus femoris flap, 1 gracilis flap and 1 lateral leg flap. The complication rate was 41.7%. This included: total flap loss (1), partial flap loss (2), wound infection (9), loss of split thickness skin graft (4), venous thrombosis (2), hematoma (1) and pedicle bleeding (1). The infection rate was higher in the free muscle flap group (25%) than in the myocutaneous flap group (0%) or the fasciocutaneous flap group (11.8%). There were no perioperative mortalities. The mean follow-up was 15.0 months (range from 1 to 59). The limb salvage rate was 97.8%. Conclusion: In selected cases, diabetic foot lesions can be managed successfully with free flap reconstruction. There is a good outcome with an acceptable complication rate.

Tissue Expansion in Children

Background: Tissue expansion has allowed plastic surgeons to achieve both functional and aesthetic reconstructive goals with tissues of similar color, thickness, and texture. It has become a major modality in reconstruction and has gained widespread application in the past 30 years. Tissue expansion is particularly applicable in the pediatric population as it is well tolerated during their daily activities. Aim and Objective: Clinical application of tissue expansion for reconstruction in the pediatric population at Tzu-Chi hospital was reviewed and the results are delineated. Materials and Methods: A retrospective study was performed from July 1995 to August 2009. There were 12 patients who had undergone 20 surgical procedures. A total of 32 tissue expanders were placed. There were 8 males and 4 females, with their ages ranging from 10 months to 16 years old. The indications for tissue expansion were burn scar contracture in 4 patients, burn scar alopecia in 2 patients, a pair of xipho-omphalopagus conjoined twins for separation, 1 patient with lymphedema receiving scrotal area reconstruction, 1 patient with widely excised malignant hemangioendothelioma, 1 patient with traumatic scar alopecia and 1 patient with residual arterio-venous malformation. The numbers and location of tissue expanders implanted were; 16 in the chest, 6 in the scalp, 7 in the thigh, 2 in the forearm and 1 in the neck. The complication rates and the clinical results were analyzed to evaluate the outcome of tissue expansion in this group of patients. Results: All patients tolerated the expansion procedure well either on an outpatient or inpatient basis. Tissue expander extrusion that necessitated removal occurred 3 times. One case developed wound infection. Debridement was carried out, the expander was removed and the expansion procedure was postponed. A total of 4 tissue expanders were removed. Two episodes of partial skin necrosis at the wound edge occurred in one patient. The wound was debrided and primary wound closure was done. The expansion course continued smoothly once the wound had healed completely. The overall complication rate was 18.75%. Eleven out of 12 children ultimately achieved fair to good results. Conclusion: Tissue expansion in the pediatric population has a similar complication rate when compared to adults. Children tolerate the procedure well and the tissue expander can well withstand the childs daily activities. With proper patient selection, thorough perioperative planning and meticulous technique, tissue expansion provides healthy tissues for surgeons to achieve a good reconstructive result with minimal donor site morbidity in children.

Malignant Melanoma: 10 Years Retrospective Study of Buddhist Tzu-chi General Hospital

Background: Retrospective review of melanoma in east Taiwan Aim and Objectives: To determine the characteristics and clinical outcome of patients with malignant melanoma in east Taiwan and survey the subtype of melanoma and survival between surgery and non-surgery group Materials and Methods: Thirty-six patients at Buddhist Tzu-Chi Hospital between May 1995 and April 2004 were included into study for clinical features and outcomes. Results: Of the 36 cases, there were 30 cases (84%) of acral lentiginous melanoma (ALM), one (2.7%) of nodular melanoma (NM), one (2.7%) of superficial spreading melanoma (SSM) and 4 cases (11.1%) of noncutaneous melanoma. Twenty-eight patients received surgery with or without lymph node dissection. Eight patients (male: female=7:1) took conservative treatment. Wide excision with therapeutic lymph node dissection was performed on 4 patients. Other sixteen patients received prophylatic LND after definite surgery. Theres no significant difference in survival between surgery and surgery combined with lymph node dissection. The 5-year survival rates of patients with stageⅡ, Ⅲ, and Ⅳ, disease were 54%, 12.5%, & 0% respectively. The mean survival of the 36 cases was 2.56 years (0.024-12 years). Overall 5-year survival rate was 14% (5/36). All of these 5 patients received surgical excisions. There is significant difference between surgery and non-surgery group. Conclusion: Malignant melanoma is a highly lethal disease. Most of our patient possessed advanced stage at diagnosis and this account for poor 5-year survival in this series. Although uncommon in Taiwan, we strongly emphasize that more education for both general publics and physicians will promote early tumor detection and treatment, providing a better prognosis.

Computed Tomographic Angiography for Diagnosis of Peripheral Arterial Injury

The use of the computed tomographic (CT) angiography for the peripheral vascular injury can contribute to a proper investigative process and an accurate diagnosis. The procedure of choice for the definite diagnosis is usually the conventional angiography. The CT angiography has the advantages of clear view of related soft-tissue and bony injuries and available on an emergency basis. Between 2001 and 2002, we reported 6 patients of peripheral arterial injuries diagnosed and followed up according to the reconstructed images of the three-dimensional spiral CT angiography. The age ranged from 24 to 78 years old. The injury involved two radial arteries, two femoral arteries, one superficial temporal artery and one brachial artery. The etiologies included two stabbing injuries, three crush injuries and one iatrogenic origin. The arterial injuries were explored and repaired in four patients. After two-year follow-up, all patients recovered uneventfully without any complications. Early diagnosis and appropriate treatment are favorable to avoid complications of the limb ischemia following the vascular injury. The CT angiography offers a good choice for the accurate diagnosis of the peripheral arterial injury.