Removal of a self-knotted feeding jejunostomy tube in a patient with tongue base cancer.

The knotting of an intragastric tube is a rare complication, and knotting of a feeding jejunostomy tube is rarer, and the removal or replacement of the tube is difficult. There are many reports on the removal of intragastric knotted tubes, but these methods cannot be applied for the removal of knotted feeding jejunostomy tubes, which do not have a natural orifice as large as the mouth to facilitate the introduction of instruments to correct the complication or remove the knotted tube. This is a stressful situation and doctors have to adopt strategies to resolve this problem safely and effectively in the absence of strong evidence-based knowledge. The author presents the case of a patient with tongue base cancer with a nasogastric feeding jejunostomy tube that knotted during the therapeutic course and describes a simple method to remove the knotted tube using Kelly clamps without additional invasive surgery. A literature review to elucidate methods for the removal of a self-knotted nasogastric tube, especially that occurring in feeding jejunostomy, is also reported.

Intestinal regeneration by a novel surgical procedure.

BACKGROUND: Treatment of short bowel syndrome is problematical. Small bowel tissue engineering has achieved modest results in animal studies. The aim of this study was to investigate intestinal regeneration in a novel surgical model. METHODS: Roux-en-Y bypass procedures were performed on 40 Wistar rats weighing 250-350 g. Animals were killed at 1, 2, 3, 4, 8, 12 and 24 weeks after implantation with a 3-cm silicone tube. The spatio temporal relationship of intestinal regeneration was analysed using three-dimensional multislice computed tomography, and examination of sequential morphological changes on gross or histological findings and measurement of missing intestinal tissue (growth defects). RESULTS: Progressive intestinal regeneration on a silicone tube was identifiable in 35 animals. Most adhesions were initially localized on the tube but spread to a distal site 4 weeks after implantation. Growth defects decreased with time, with a marked reduction in the first 4 weeks and a gradual reduction to week 24 after implantation. Luminal patency shown radiologically as well as sequential histological findings, such as mucosal lining, matrix remodelling and muscular regeneration, suggested that regeneration of intestinal tissue took place, not merely scar contraction. CONCLUSION: Non-invasive as well as histomorphological assessment followed intestinal regeneration over time in this model, which provides scope for further studies.

Recurrent gastric adenocarcinoma presenting as acute appendicitis: a case report.

We report a case of acute appendicitis due to recurrent metastatic gastric adenocarcinoma involving only appendix, without the evidence of abdominal carcinomatosis 2 years after initial diagnosis of the primary gastric lesion. This case, in contrast to other previously reported cases that carried a dismal prognosis, had survived without tumour recurrent for more than 1 year after appendectomy, while this report was made.

Video-assisted laparoscopic procedures in peritoneal dialysis.

BACKGROUND: Although laparoscopy is commonly adopted for the diagnosis and management of various medical or surgical problems, its use for patients with peritoneal dialysis has seldom been addressed. This retrospective study analyzes the indications and clinical effects of this procedure. METHODS: A retrospective chart was drawn up and a videotape review performed for 18 laparoscopic procedures involving 198 patients receiving peritoneal dialysis on a long-term basis at our dialysis unit from May 1992 to June 2002. The clinical and demographic parameters in this study included gender, age, underlying renal diseases, duration of peritoneal dialysis before laparoscopy, indications of laparoscopic intervention, laparoscopic findings, time of operation, laparoscopic procedures, postoperative complications, mortality, and catheter results. RESULTS: A total of 18 laparoscopic procedures were performed in 17 uremia patients, with indications including catheter malfunction in five cases, preimplantation evaluation of peritoneal space in three cases, evaluation of the etiology underlying intractable peritonitis in nine cases, and verification of the cause for dialysate leakage in one case. Four (80%) of the five catheter malfunctions were successfully corrected, including one case of catheter migration and three cases of omental wrapping, whereas correction failed in the remaining case because of severe bowel adhesion. New catheter placement after adhesiolysis was successful in all three cases of preimplantation peritoneal evaluation (100%). Of the nine patients whose peritonitis episodes were evaluated, two were found to have secondary peritonitis, two had fungal peritonitis; one had tuberculous peritonitis and four had bacterial peritonitis. In the case of persistent exit-site dialysate leakage, laparoscopy showed a penetrating injury of the abdominal wall, raising a strong suspicion of iatrogenic injury during the tunneling maneuvers in initial catheter placement. Two conversions to laparotomy were performed: one to repair the penetrating injury and the other to save the life of a patient threatened by severe fungal peritonitis with abdominal cocoon formation. The laparoscopic procedures lasted 20 to 150 min (average, 50 min). Despite one instance of postoperative hydrocele, there was no operative mortality. CONCLUSIONS: The analytical results of this study demonstrate that the current video-assisted laparoscopic technique is an effective means for managing several problems related to peritoneal dialysis such as catheter malfunction, preimplantation evaluation, location of the source of the dialysate leak, and assessment of the causes for peritonitis. Thus, this technique should always be considered when the these problems arise.

Correction of a migrated Tenckhoff peritoneal dialysis catheter using a Lunderquist guidewire: report of two cases.

Two chronic ambulatory peritoneal dialysis (CAPD) patients who experienced from ultrafiltration failure resulting from malposition of a Tenckhoff catheter were treated. Conservative management such as changing body position, saline infusion, and enemas had been tried, but had failed. To avoid surgical intervention, we attempted to correct the malposition using a 120-cm-long Lunderquist guidewire (Nycomed, NY) with a 15-cm-long soft and flexible tip at its distal end. Under fluoroscopy, we successfully repositioned these two migrated Tenckhoff catheters using a Lunderquist guidewire. To the best of our knowledge, this is the first report of using a Lunderquist guidewire to correct a malfunctioning Tenckhoff catheter in CAPD patients. The Lunderquist guide wire has the advantages of being relatively non-invasive and easily used and it provides a reduced morbidity rate. Moreover, using this guidewire allows the Tenckhoff catheter to produce torque and whiplash, buckling, sweeping and rotating maneuvers that can help to correct malposition of the catheter and redirect the catheter to its ideal position. We therefore suggest that patients who receive surgical revision for a malfunctioning Tenckhoff catheter have at least one attempt at correction using this safe and easy procedure before surgery.

Discovery of encysted Paragonimus westermani eggs in the omentum of an asymptomatic elderly woman.

We report a case of asymptomatic chronic infiltrate of the omentum by eggs of Paragonimus westermani in an elderly woman who had immigrated to Taiwan from mainland China 46 years ago. The patient had a habit of eating raw freshwater crabs from the lakes of eastern China during her period of residence in that country. She stopped eating raw crabs after coming to Taiwan 20 years ago. During surgery for a peptic ulcer complicated by severe bleeding in 1995, her omentum was found to contain many small nodules approximately 2 x 2 x 1.5 cm in size. Biopsy of the nodules revealed eggs of P. westermani embedded in necrotic debris surrounded by capsules. A sputum examination result was negative and a chest radiograph was normal. The majority of the nodules in the omentum were removed during the surgery and praziquantel was given. At the present time, the patient remains asymptomatic.

An alternative approach of choledocholithotomy via laparoscopic choledochotomy.

OBJECTIVE: To evaluate the safety and feasibility of laparoscopic choledocholithotomy via choledochotomy for the treatment of choledocholithiasis. DESIGN: A prospective series of 1332 consecutive patients who underwent laparoscopic cholecystectomies, with a mean follow-up of 21.2 months. SETTING: University-affiliated referral center. PATIENTS: Forty-three patients (3%) with documented common bile duct stones from January 1991 to February 1995. INTERVENTIONS: Laparoscopic choledocholithotomy with choledochotomy and T tube drainage were performed in 40 patients. Postoperative endoscopic sphincterotomy after laparoscopic cholecystectomy was performed in three patients. MAIN OUTCOME MEASURES: Documented removal of common bile duct stones and procedure-related complications. RESULTS: Laparoscopic choledocholithotomy via choledochotomy was successful in 35 (88%) of 40 patients in whom this procedure was attempted. The mean (+/- SD) operation time was 191.3 +/- 75.4 minutes, and the mean (+/- SD) length of postoperative stay was 10.4 +/- 2.7 days. Seven complications (18%) were recorded, including three major complications (8%) and two retained stones (5%). CONCLUSIONS: Laparoscopic choledocholithotomy via choledochotomy can be performed safely, without increasing the morbidity rate as compared with that of open choledocholithotomy. Thus, some of the advantages of minimally invasive surgery are preserved.

Breast cancer and pregnancy.

BACKGROUND: Breast cancer developing during pregnancy or lactation is such an infrequent problem that, when it occurs, physicians are confronted with ethical and therapeutic challenges. Moreover, there are very few references to compare or discuss breast cancer in pregnant women in Taiwan. We hope that data from this review will add to our understanding of such difficult problem as well as help improve the treatment of our patients. METHODS: Between 1979 and 1988 the charts of 21 women, who were pregnant or postpartum within one year of the breast cancer diagnosis, were analyzed retrospectively. All of the patients were followed until Dec. 1990. Patients with pregnancy-associated breast cancer were compared with nonpregnant women (199 cases) of similar age who were treated at the same hospital and during the same period. RESULTS: We found no statistical differences in the overall 5-year survival rate between pregnant (57.1%) and nonpregnant (69.6%) groups. It is noteworthy that the time lag was significantly longer in the pregnant group than in the nonpregnant group. A stage-by-stage comparison showed equivalent survival rates between pregnant and nonpregnant patients. The pregnant patients at stage II had a somewhat lower survival rate; however, there was no statistical significance. CONCLUSIONS: The rule of cancer treatment, "early diagnosis followed by aggressive management," is still a key principle to improve the treatment in pregnant women with breast cancer.

Comparison of aged and young adult patients with cholelithiasis: a prospective controlled study.

BACKGROUND: Surgical operations for gallstones are associated with increased perioperative mortality in the elderly. The presence of pre-existing cardiovascular disease and acute cholangitis might be the cause as found in the literature. METHODS: From August 1989 to December 1990, twenty-nine patients (Age > or = 70 years) with cholelithiasis undergoing biliary surgery in Veterans General Hospital-Taipei were collected as experimental group. Twenty-nine patients from 62 patients (Age < or = 50 years) with cholelithiasis were selected as control group. The basic data, symptomatology, blood biochemistry, peri-operative complications, mortality and gallstone compositions were analyzed and compared between both groups. RESULTS: There was a higher male to female ratio (4.8:1) in the aged group. Aged patients had higher incidence of common bile duct stone (11/29 versus 3/29, P < 0.025), while young adult patients had higher incidence of intrahepatic stone (1/29 versus 10/29, P < 0.05). The perioperative morbidity and mortality was higher in the aged group (37.9% and 3.4%) as compared with the young age group (3.4% and 0%, P < 0.005). CONCLUSIONS: Aged cholelithiatic patients were associated with male preponderance, more common bile duct stones, higher perioperative morbidity and mortality, as compared with the young adult cholelithiatic patients.

Risk factors linked to tumor recurrence of human hepatocellular carcinoma after hepatic resection.

A total of 238 patients who received curative hepatic resections during the last 10 yr were observed to search for the risk factors linked to early tumor recurrence of human hepatocellular carcinoma after hepatectomy. The results revealed that tumor size, tumor appearance and DNA ploidy were the factors in predicting tumor recurrence after resection for hepatocellular carcinoma. Patients with a tumor size less than or equal to 5 cm or a tumor appearance of the solitary type had better disease-free survival than did those with a tumor size greater than 5 cm or a tumor appearance of multiple/daughter nodule types (p < 0.05). Although patients with pattern III (aneuploid with > or = 2 G0/G1 peaks) hepatoma had fewer statistically significant differences (p = 0.19) than did those with pattern I (diploid) or pattern II (aneuploid with single G0/G1 peak) tumors in predicting tumor recurrence, they did have poorer results in terms of the overall survival rate (p < 0.05). We conclude that patients with hepatocellular carcinoma having the aforementioned risk factors should be observed closely.