Yu-Tang Chang

The importance of classification in sympathetic surgery and a proposed mechanism for compensatory hyperhidrosis: experience with 464 cases.

BackgroundCompensatory hyperhidrosis is the most troublesome side effect and the leading cause of regret with sympathetic surgery. A new classification is proposed to make the procedure more selective and to minimize the side effects and regret rate. Also, a proposed mechanism for compensatory hyperhidrosis is discussed.MethodsBetween January 2002 and July 2003, 464 patients with various sympathetic disorders underwent thoracoscopic sympathectomy/sympathicotomy (ETS) or sympathetic block by clipping (ESB) at various levels according to the authors’ classification. The surgery was performed on an outpatient basis. The rates of success, compensatory hyperhidrosis, and regret were recorded.ResultsAll the patients were followed up for 17 to 35 months. All excessive sweating was effectively stopped to varying degrees. The 25 patients with palmar hyperhidrosis who insisted on receiving ETS of T4 experienced no compensatory hyperhidrosis. Of the 54 patients with facial blushing who received ESB of T2, 23 experienced compensatory hyperhidrosis. Nine patients expressed regret and requested removal of the clips. Of the 33 patients with craniofacial hyperhidrosis who received ESB of T3, 9 experienced compensatory hyperhidrosis. Three expressed regret, and reverse procedures were performed. For 324 patients with palmar hyperhidrosis receiving ESB of T4, no compensatory hyperhidrosis was found. Only two expressed regret because of discomfort. No compensatory hyperhidrosis or regret was noted with 28 patients who received ESB of T5 for axillary sweating. There was no recurrence in the entire series.ConclusionsDifferent procedures are recommended for different sympathetic disorders according to the classification. The higher the level of sympathetic ganglion blockade, the higher is the regret rate. Therefore, for T2 and T3 ganglion, endoscopic thoracic sympathetic block by the clipping method is strongly recommended because of its reversibility.

Detection of KRAS Oncogene in Peripheral Blood as a Predictor of the Response to Cetuximab Plus Chemotherapy in Patients with Metastatic Colorectal Cancer

Purpose: Previously we developed membrane-arrays as a promising tool to detect circulating tumor cells (CTC) with KRAS oncogene in patients with malignancies. This study was conducted to determinate the predictive values of CTCs with KARS mutation by membrane-arrays for metastatic colorectal cancer patients treated with cetuximab plus chemotherapy. Experimental Design: Seventy-six metastatic colorectal cancer patients receiving cetuximab plus FOLFIRI or FOLFOX-4 chemotherapy were enrolled. KRAS mutation status in the peripheral blood of these patients was analyzed using membrane-arrays, and KRAS mutation status in tumors was analyzed by DNA sequencing. Results: Among 76 metastatic colorectal cancer patients, KRAS mutations in tumors and in peripheral blood were identified in 33 (43.4%) and 30 (39.5%) patients, respectively. The detection sensitivity, specificity, and accuracy of membrane-arrays for CTCs with KRAS oncogene were 84.4%, 95.3%, and 90.8%, respectively, and indeed a highly significant correlation to KRAS mutations in tumors (P < 0.0001) was observed. Forty-five (59.2%) patients responded to cetuximab plus chemotherapy, and 41 and 40 were wild-type KRAS in tumors and peripheral blood, respectively (both P < 0.0001). Patients with tumors that harbor wild-type KRAS are more likely to have a better progression-free survival and overall survival when treated with cetuximab plus chemotherapy (P < 0.0001). Likewise, patients with CTCs of wild-type KRAS in peripheral blood express a better progression-free survival and overall survival when treated with cetuximab plus chemotherapy (P < 0.0001). Conclusions: These findings provide evidence that detection of KRAS mutational status in CTCs, by gene expression array, has potential for clinical application in selecting metastatic colorectal cancer patients most likely to benefit from cetuximab therapy.

Treatment of Palmar Hyperhidrosis: T4 Level Compared With T3 and T2

Objective:The aim of this study was to compare the outcomes of 3 different levels of sympathectomy. Summary Background Data:Most surgeons still perform T2 or T2–3 sympathectomy for palmar hyperhidrosis, but both these treatments can cause severe side effects. Some recent articles have advocated T4 sympathectomy and obtained satisfactory results. Methods:Between January 2000 and August 2004, 234 records of patients treated for palmar hyperhidrosis were retrospectively reviewed. Of them, 86 patients were treated with endoscopic thoracic sympathectomy of T2 (ETS2), 78 patients with ETS3, and 70 patients with ETS4. Follow-up data were collected using a telephone questionnaire with a scoring system. Multiple linear regressions were used to model markers for degree of satisfaction and severity of compensatory sweating (CS), including descriptive data, level of sympathectomy, clinical outcomes, and postoperative complications. Results:Mean follow-up was 47.1 ± 17.2 months. All 3 levels of sympathectomy could have achieved comparable improvement of palmar hyperhidrosis (P = 0.162). However, 88.5% of the patients noticed CS. Patients with ETS4 presented the lowest incidence of CS (P = 0.030), had the least severity of CS (β = −1.537, P = 0.002), and felt the least palmar overdryness (P < 0.001). None expressed regret for the procedure in the ETS4 group (P = 0.022). Being obese did not increase the incidence of CS, but the severity of CS was directly related to body mass index (β = 0.917, P < 0.001). The patients would be more satisfied if the severity of CS was minimal (β = −0.185, P = 0.002). The degree of satisfaction may decrease with time (β = −0.025, P = 0.003) and was lower when their palms were overdry (β = −1.463, P < 0.001). Conclusions:Different from the current procedure of T2 or T3 sympathectomy for palmar hyperhidrosis, T4 sympathectomy would be a better and more effective procedure with minimal long-term complications.

A simple single-port laparoscopic-assisted technique for completely enclosing inguinal hernia in children.

Single-port endoscopic-assisted percutaneous extraperitoneal closure of inguinal hernia with variable devices is a novel technique in minimal-access surgery for pediatric inguinal hernias. However, a small peritoneal gap of the suture at the location of spermatic vessels and vas deferens may be left untouched, whereas some subcutaneous tissues, including nerves and muscles, may cause injury by their inclusion in the upper portion of the circuit suturing. The technique may fail to entirely enclose the hernia defect and has the potential to lead to higher incidence of hydrocele and hernia recurrence. The authors describe the modification of single-port endoscopic-assisted ligation with a homemade hooked injection needle, which is designed to cause hydrodissection to the preperitoneal space, tautly enclose the hernia defect without upper subcutaneous tissues and a lower peritoneal gap, and aid in the achievement of a near-zero recurrence rate.

Typhoid colonic perforation in childhood : A ten-year experience

BackgroundIntestinal perforation resulting from a complication of typhoid fever has always been of concern because of its high morbidity and mortality rates. Most perforations occur in the terminal ileum.MethodsBetween May 1995 and June 2005, 24 children with typhoid colonic perforations receiving operations were retrospectively reviewed. The patients were 5 months to 86 months of age (mean: 25.1 ± 17.5 months). Surgical management consisted of primary closure of the perforation with ileostomy (70.8%), wedge resection and simple closure (20.8%), and partial colectomy with colostomy (4.2%). For the 11 patients with solitary cecal perforation, 6 received simple closure with ileostomy (group I), and wedge resection and simple closure was performed in the remaining 5 patients (group C). After operation, total parenteral nutrition (TPN) was instituted in each patient.ResultsSolitary cecal perforation is the most common type (45.8%). The length of hospital stay (LOS) varied from 12 days to 73 days, and the mean duration was 24.5 ± 14.7 days. The LOS showed no significant difference with regard to the location and the number of perforations. No mortality was noted in the entire series, but 19 patients had one or more complications, which may have prolonged the LOS; anemia and wound infections were the two most common problems. Group C had the shorter LOS (16.4 ± 3.4 days, versus 40.2 ± 22.6 days for group I) and fewer complications (0.6 ± 0.5, versus 3.25 ± 1.7 for group I). Any readmission for secondary operation to restore intestinal continuity in group C was therefore avoided.ConclusionsTo understand thoroughly the clinical course of typhoid fever is important. The typically high rate of complications after intestinal perforation secondary to typhoid fever may be reduced if operation is undertaken earlier. Solitary cecal perforation can be managed safely with wedge resection and simple closure without bowel exterioration. Routine usage of TPN may reduce the mortality associated with complications resulting from typhoid perforations.

Early Video-Assisted Thoracic Surgery for Primary Spontaneous Hemopneumothorax

IntroductionPrimary spontaneous hemopneumothorax (PSHP) is a rare surgical emergency. The aim of this study was to compare the previous strategy of tube thoracostomy followed by thoracotomy when complications developed with early video-assisted thoracic surgery (VATS) for PSHP.MethodsBetween November 1989 and May 2005, a total of 24 consecutive patients with PSHP were retrospectively reviewed. Before January 2000, there were 13 patients who were subjected to the treatment strategy of initial tube thoracostomy and underwent operation if the condition deteriorated or later complications occurred (group T). Under this strategy, all of these patients later required operations. After January 2000, another 11 patients were treated with VATS as soon as their condition stabilized after tube thoracostomy and resuscitation (group V). The data for the two groups were compared: sex, age, involved side, initial heart rate (HR) and mean blood pressure (BP), initial hemoglobin (Hb), preoperative blood loss, operating time, amount of blood transfusion, period of chest tube drainage (POD), length of hospital stay (LOS), complications, and length of follow-up.ResultsThe sex, age, involved side, and the initial HR, BP, and Hb of the two groups were similar. The patients of group V had a significantly longer operating time [group V, 111 minutes (mean); group T, 85 minutes, P = 0.002]; less preoperative blood loss (group V, 946 ml; group T, 1687 ml, P = 0.003); less blood transfusion (group V, 465 ml; group T, 1044 ml, P = 0.002); shorter POD (group V, 4 days; group T, 7 days, P = 0.011); and shorter LOS (group V, 5 days; group T, 10 days, P = 0.002). No mortality or recurrence was noted in the entire series.ConclusionsOur study suggests that surgery should be undertaken for PSHP as soon as possible after the clinical condition has stabilized. Under this strategy, VATS is an acceptable approach. It allows a shorter hospital stay and is exempt from unnecessary blood transfusion. Later complications, such as empyema and impaired lung reexpansion, can also be avoided.

Is prophylactic treatment of contralateral blebs in patients with primary spontaneous pneumothorax indicated

OBJECTIVES More than 50% of patients with primary spontaneous pneumothorax have contralateral blebs/bullae, and about a quarter will develop a contralateral pneumothorax. The purpose of this prospective study was to determine the need for elective treatment of asymptomatic contralateral blebs/bullae in patients presenting with primary spontaneous pneumothorax. METHODS From May 2006 through June 2008, results from 35 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs receiving unilateral video-assisted thoracic surgery, 35 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery, and 16 patients with ipsilateral primary spontaneous pneumothorax receiving bilateral video-assisted thoracic surgery for positive contralateral blebs were collected. Their demographic and operating data were also recorded. RESULTS There was no significant difference in age, gender, smoking percentage, body mass index (kg/m(2)), blood loss, and postoperative pain among groups. There was longer operative time and length of stay in group receiving bilateral surgery. Within the follow-up period of 16.68 +/- 9.91 months (median, 17.50), no recurrence on either lung was found in the group operated on both sides, while contralateral occurrence was found in 17.14% of the group with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery within the period of 18.15 +/- 8.07 months (median, 21). CONCLUSION The study showed that the preemptive video-assisted thoracic surgery for the contralateral blebs/bullae effectively prevented the contralateral occurrence.

Pretreatment of Vitamin D3 Ameliorates Lung and Muscle Injury Induced by Reperfusion of Bilateral Femoral Vessels in a Rat Model

BACKGROUND Peripheral arterial occlusive disease (PAOD) is a challenge in peripheral vascular disease. Clinical observations show reperfusion of occluded vessels may cause compartment syndrome or remote organ injury. Less well known is the role of vitamin D3 in tissue injury; therefore, we attempted to determine whether vitamin D3 could alleviate local and remote organ injury induced by reperfusion of occluded vessels in animal models. METHODS Twenty-four male Sprague-Dawley rats were randomized into four groups: saline + sham, saline + I/R, vitamin D3 + sham, and vitamin D3 + I/R group. After pretreatment for 5 d, the animals designed to I/R injury were subjected to 3 h of ischemia induced by bilateral femoral arteries clamp, followed by reperfusion of the vessels for 3 h on d 6. Left lung and left anterior tibial muscle tissue were harvested for wet/dry weight ratio and histopathologic analysis. Blood was collected for analysis of urea nitrogen (BUN), creatinine (Cr), aspartate aminotransferase (AST), alanine aminotransferase (ALT), tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), ionized calcium levels, and heme oxygenase-1 (HO-1). RESULTS Compared with the saline + sham group, there was a significant increase in plasma IL-6 level in both saline + I/R and vitamin D3 + I/R groups and muscle, lung wet/dry weight ratio in the saline + I/R group (P < 0.05). Compared with the saline + I/R group, there was a significant decrease in plasma IL-6 level, muscle and lung wet/dry weight ratio in both vitamin D3 + sham and vitamin D3 + I/R groups, and leukocyte HO-1 expression in vitamin D3 + sham group (P < 0.05). Compared with the vitamin D3 + sham group, there was a significant increase in plasma IL-6 levels in the vitamin D3 + I/R group, and leukocyte HO-1 expression in vitamin D3 + sham group (P < 0.05). BUN, Cr, AST, ALT, TNF-α, ionized calcium levels did not differ significantly among the groups. CONCLUSIONS Pretreatment of vitamin D3 ameliorates the systemic IL-6 levels, lung and muscle injury induced by ischemia followed by reperfusion of bilateral occluded vessels in a rat model.

Preliminary experience of one-trocar laparoscopic herniorrhaphy in infants and children.

OBJECTIVE Laparoscopy is an alternative procedure for pediatric inguinal hernia, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports. The aim of this study was to evaluate the preliminary results of one-trocar laparoscopic herniorrhaphy in infants and children. METHODS Between April 2007 and March 2010, 216 infants and children treated were retrospectively reviewed. Under laparoscopic guidance, the hernia defect was closed extracorporeally by a nonabsorbable suture, which was introduced into the abdomen by an 18-gauge vascular access on one side of the hernia defect and withdrawn on the opposite side by a homemade hook-pin through a stab incision. Preperitoneal hydrodissection was performed during the procedure. Being a developing technique, multiple linear regressions were used to model markers for the operating time, including descriptive data, diameter of scope, operation findings, and the procedural volume. RESULTS A total of 308 procedures were successfully performed among 214 patients (99.1%) and the mean operating time was 42.9 ± 24.7 minutes (range: 9-255 minutes). Additional working instruments were necessary in 7 patients (3.3%). Only 2 (0.9%) recurrences were observed during this period. Male gender (β = 7.507, P = .001), prematurity (β = 10.051, P = .004), presence of incarcerated hernia (β = 12.188, P = .016), and both sides simultaneous operation (β = 7.057, P = .001) would increase the operating time, while being independent of age, weight, presence of sliding hernia, and diameter of scope. However, the operating time may decrease with procedural volume (β = -0.119, P < .001). CONCLUSIONS Without assistant working instrument, laparoscopy-assisted extracorporeal ligation of the hernia defect may be safely performed in most infants and children. The use of preperitoneal hydrodissection and extraperitoneal knot-tying could tautly enclose the hernia defect without peritoneal gaps and approach an accepted recurrence rate.

Spontaneous Perforation of Meckel's Diverticulum Without Peritonitis in a Newborn: Report of a Case

A case of a newborn male with a perforation of Meckels diverticulum is reported. The clinical course consisted of progressive abdominal distention and pneumoperitoneum that formed within 29 h after birth. The perforation of Meckels diverticulum was not associated with peritonitis because meconium did not contaminate the abdominal cavity. The histology of the diverticulum showed a nearly intact muscular layer but a focal muscular defect. Neither any inflammatory phenomena nor ectopic mucosa was found. A congenital focal muscular defect of the diverticulum and a sudden elevation of intraluminal pressure due to bowel movement after birth may thus be the pathogenesis of a spontaneous perforation. A search of the English literature did not reveal any similar case.