Formosan Journal of Surgery (Formos J Surg)

Determinant factors of mortality in terminally ill patients with do-not-resuscitate orders Chao-Hui Su, Shih-Chiang Hung, Wan-I Chen, Li-Hui Yang, Chi-Wei Lee, Ching-Hua Hsieh Formosan Journal of Surgery 2018 51(6):213-218 Background: This study aimed to profile the clinical pictures and identify the risk factors of mortality among terminally ill patients who visited the emergency department (ED) and had signed do-not-resuscitate (DNR) consents. Methods: This prospective study employed purposeful sampling of 200 adult, nontrauma, terminally ill patients who visited the ED and signed a DNR consent between July 1, 2011, and March 31, 2012. Physiological variables were compared between fatal and survival patients using Student's t-tests after assessing the normality of the data distribution. Results: The Cox proportional regression analysis revealed that patients taking antiarrhythmic drugs and vasopressor had a 47.6-fold and 2.8-fold higher mortality, respectively, compared to nonusers and those who had a respiratory rate ≥28 breaths/min showed a 2.8-fold increase in their risk of death compared to those with a respiratory rate <28 breaths/min. Conclusions: Among terminally ill patients who had signed a DNR consent at the ED, significantly higher hazard ratios of mortality were observed in patients who were on antiarrhythmic drugs or vasopressor, had respiratory rates ≥28 breaths/min, had been intubated, and had serum potassium levels ≥ 4.5 mEq/L.

Acute pancreatitis and primary hyperparathyroidism: Effect of parathyroidectomy Riju Ramachandran, Gopalakrishnan C Nair, Misha J C Babu, Pradeep Jacob Formosan Journal of Surgery 2018 51(6):219-222 Background: The association between primary hyperparathyroidism (PHPT) and acute pancreatitis (AP) is well known. However, the causal association is disputed. Aims: The present cohort study of PHPT patients was done: (1) to assess the prevalence of AP and (2) to assess the effect of successful parathyroidectomy in preventing further recurrence. Materials and Methods: Case records of patients admitted with AP during the study period were reviewed. Diagnosis of PHPT among this group was based on serum level of corrected calcium and parathyroid hormone. Review of records of patients who were successfully operated for PHPT was done. Records of patients treated with confirmed diagnosis of AP during the study period were reviewed. Variables used for analysis were serum levels of calcium (adjusted to serum albumin), phosphate, intact parathyroid hormone, 25-OH-Vitamin D, alkaline phosphatase, and estimated glomerular filtration rate (eGFR). For continuous/numerical variables with two groups, Mann–Whitney U-test was applied. Multivariate regression analysis was done if the univariate analysis showed significance (P < 0.05). Results: There were 13 (7.5%) patients with confirmed diagnosis of AP and serum calcium level significantly elevated in this group. There was a linear association of serum calcium with AP. Successful parathyroidectomy prevented further episodes in 11 (84.6%) of patients. There was 2% prevalence of PHPT among 558 patients with AP. Conclusions: Hypercalcemia in PHPT patients was significantly associated with AP and early parathyroidectomy prevented further recurrence.

Prospective randomized control study comparing gauze-based with foam-based negative pressure wound therapy for the stage 4 pressure injuries Chiun-Sheng Chen, Chao-Chin Yu Formosan Journal of Surgery 2018 51(6):223-227 Background: Negative pressure wound therapy (NPWT) has been used to accelerate the formation of granulation tissue and to promote wound closure in the treatment of difficult-to-heal wounds. This study compared the effectiveness between gauze- and foam-based NPWT for stage 4 pressure injuries. Materials and Methods: A total of 38 patients with 48 wounds of stage 4 pressure injuries were recruited and randomly divided into gauze-based and foam-based groups. After initial debridement therapy, gauze-based and foam-based fillers were used, and clinical observations were recorded when dressings were changed, twice a week for 3 weeks. The system was connected to a 1-bottle water-seal chest drainage system and standard wall suction at 125 mmHg negative pressure. The percentages of wound area reduction (PWAR), the scores of Pressure Ulcer Scale for Healing (PUSH) tool and the scores of Bates-Jensen wound assessment tool (BWAT) were used to evaluate wound healing activity. Results: Both groups showed significant changing trends in the wound assessments of PWAR, PUSH, and BWAT during follow-up. However, the area of healing at each clinical observation was consistently greater in the foam group than in the gauze group during the follow-up period, while the PUSH score was consistently greater in the gauze group than that in the foam group. The declining trends of BWAT were alike in both groups. Conclusion: Gauze-based therapy is noninferior to foam-based therapy with respect to PWAR, PUSH, and BWAT for stage 4 pressure injuries.

Statistical relevance of mean hematoma density and it's internal architecture: Potential clinical application in chronic subdural hematomas Tzu-Yung Chen, Sue-Ting Chang, Muh-Shi Lin Formosan Journal of Surgery 2018 51(6):228-233 Background: The postoperative recurrence rate of chronic subdural hematomas (CSDHs) ranges from 9% to 20%, which is a serious concern for neurosurgeons. Both qualitative and quantitative assessment methods have been developed to identify the mechanisms involved in postoperative recurrence. These methods include Nakaguchi's clinical classification scheme and the quantification of mean hematoma density (MHD). This is the first study to examine the correlations between the quantification of MHD and Nakaguchi's clinical classification of patients with CSDHs. Materials and Methods: This study investigated 35 consecutive cases of CSDH between July 2010 and July 2013. In accordance with Nakaguchi's clinical classification, CSDH cases were separated into four groups: homogenous, laminar, separated, and trabecular. In addition, we quantified the area of the hematoma according to MHD using a computer-based image analysis of preoperative brain computed tomography scans. Results: The mean age of patients was 72.2 ± 8.05 years (range: 55–86). Mean MHD values were as follows: trabecular (12.45 ± 0.72 HU), homogenous (14.46 ± 4.51 HU), laminar (25.99 ± 0.93 HU), and separated (36.32 ± 3.04 HU). Differences in MHD were statistically significant for all CSDH types (P < 0.001, ANOVA with Student–Newman–Keuls post hoc test), and we observed a significant linear relationship between MHD and the priority order of clinical CSDH types determined according to postoperative recurrence (Spearman's rank correlation coefficient = 0.842, P < 0.001). Conclusions: This study provides statistical evidence that MHD is significantly correlated with Nakaguchi's clinical classification of CSDH. The applications of MHD quantification and hematoma's internal architecture helped to gain better understanding of possible mechanisms underlying CSDH recurrence.

Hemorrhage glioblastoma mimicks a dural-based meningioma Tse-Fu Wen, Lin-Hsue Yang, Che-Kuang Lin Formosan Journal of Surgery 2018 51(6):234-237 The so-called “dural tail sign” (DTS) is a thickening of the dura that is most often seen adjacent to a meningioma. Although the DTS is highly specific for meningioma, it has been observed in numerous other intracranial lesions. The origin of the DTS is an issue of debate. Some authors have described it as a tumor extension, while others have considered it as a proliferation of connective tissue, hypervascularity, and vascular dilatation within the dura and adjacent to cranial masses. Here, we reported a rare case of glioblastoma multiforme (GBM) with image findings of a DTS. A 74-year-old female was taken to our hospital due to the sudden onset of mental status change and right-side hemiparesis. Brain magnetic resonance imaging (MRI) with contrast enhancement showed an intracranial mass with heterogeneous enhancement in the left temporal lobe which was consistent with the DTS. A left frontotemporal craniotomy was performed, and grossly total tumor removal was achieved. The final pathology reported was GBM. Although it is rare, GBM may also on occasion be associated with a DTS. The histopathological examination for DTS in GBM is limited. Currently, excision of the dural tail in GBM is suggested.

Chemical colitis in posterior mediastinum colonic conduit Chen-Ming Mai, Chia-Ying Li Formosan Journal of Surgery 2018 51(6):238-240 For patients with severe corrosive injury of the esophagus and stomach, the colon is considered a well-functional and durable esophageal substitute. We report a Chinese male suffered from chemical colitis of the colon conduit located in the posterior mediastinum after drinking strong liquor. To the best of our knowledge, this is the first case reported in the literature. After conservative and supportive therapy with antibiotics and oral fasting, he recovered from chemical conduit colitis completely.

Open fracture of tibia mid-shaft associated with the contralateral leg acute compartment syndrome without fracture Tsung-Mu Wu, Chi-Rung Chung, Po-Chang Huang, Chung-Da Wu Formosan Journal of Surgery 2018 51(6):241-244 The acute extremity compartment syndrome is caused by increased compartment volume or restriction of compartment size. There are 23% of all compartment syndrome is caused by isolated soft-tissue injury especially in crushing injury. We report a 30-year-old male with the initial diagnosis of the right tibia open fracture, Gustilo Type II, due to a motor-vehicle accident. Besides the right leg condition, he was continually suffered from left leg pain, where the X-ray revealed no apparent fracture since the collision. The physical examination showed no skin lesion and deformity; however, numbness and tightness were noted, toe stretching pain+, Pedis Dorsalis Artery+, Posterior Tibialis Artery+. Doppler showed the presence of PDA and PTA blood flow. Nine hours after the injury, pain and numbness of his left leg and foot still persisted and also pale and pulseless developed. Doppler for his left leg was done again and showed the negative result of PTA and PDA. Emergent bilateral side fasciotomy for his left leg was arranged, and the cardiovascular department was consulted for intraoperative angiography. The fasciotomy wound was cared with sterilized saline wet dressing for 3 days. Medial fasciotomy was closed with delayed primary method, and the lateral sides were treated with split-thickness skin graft. Acute compartment syndrome is diagnosed by the interpretation of a collection of clinical signs and symptoms. In a patient with a swollen limb, in the absence of a fracture and for whom, there is a suspicion of an acute compartment syndrome, methods, technology, and application for the early detection of acute compartment syndrome is important and also provides promising opportunities for the clinicians to perform early interventions.

Occult medullary breast carcinoma in a male Devesh Sanjeev Ballal, Gabriel Rodrigues Formosan Journal of Surgery 2018 51(6):245-248 Occult breast cancer (OBC) or breast cancer presenting without an evident primary tumor is a rare presentation and can lead to a diagnostic dilemma. Further, the treatment of OBC is a subject of much controversy. We present a 47-year-old male who had been admitted with a fungating lesion in his axilla. As clinical examination was unremarkable, a punch biopsy from the lesion revealed a medullary carcinoma of breast. The purpose of this report is to highlight this unusual presentation of carcinoma breast and the treatment dilemma that it poses, especially in men, where breast cancer is seldom considered a diagnostic possibility in the setting of occult primary cancer. This is the first-ever case report of medullary carcinoma presenting as OBC in a male. ORIGINAL ARTICLES   Determinant factors of mortality in terminally ill patients with do-not-resuscitate orders  p. 213 Chao-Hui Su, Shih-Chiang Hung, Wan-I Chen, Li-Hui Yang, Chi-Wei Lee, Ching-Hua Hsieh DOI:10.4103/fjs.fjs_1_18   Background: This study aimed to profile the clinical pictures and identify the risk factors of mortality among terminally ill patients who visited the emergency department (ED) and had signed do-not-resuscitate (DNR) consents. Methods: This prospective study employed purposeful sampling of 200 adult, nontrauma, terminally ill patients who visited the ED and signed a DNR consent between July 1, 2011, and March 31, 2012. Physiological variables were compared between fatal and survival patients using Student's t-tests after assessing the normality of the data distribution. Results: The Cox proportional regression analysis revealed that patients taking antiarrhythmic drugs and vasopressor had a 47.6-fold and 2.8-fold higher mortality, respectively, compared to nonusers and those who had a respiratory rate ≥28 breaths/min showed a 2.8-fold increase in their risk of death compared to those with a respiratory rate <28 breaths/min. Conclusions: Among terminally ill patients who had signed a DNR consent at the ED, significantly higher hazard ratios of mortality were observed in patients who were on antiarrhythmic drugs or vasopressor, had respiratory rates ≥28 breaths/min, had been intubated, and had serum potassium levels ≥ 4.5 mEq/L. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Acute pancreatitis and primary hyperparathyroidism: Effect of parathyroidectomy p. 219 Riju Ramachandran, Gopalakrishnan C Nair, Misha J C Babu, Pradeep Jacob DOI:10.4103/fjs.fjs_158_17   Background: The association between primary hyperparathyroidism (PHPT) and acute pancreatitis (AP) is well known. However, the causal association is disputed. Aims: The present cohort study of PHPT patients was done: (1) to assess the prevalence of AP and (2) to assess the effect of successful parathyroidectomy in preventing further recurrence. Materials and Methods: Case records of patients admitted with AP during the study period were reviewed. Diagnosis of PHPT among this group was based on serum level of corrected calcium and parathyroid hormone. Review of records of patients who were successfully operated for PHPT was done. Records of patients treated with confirmed diagnosis of AP during the study period were reviewed. Variables used for analysis were serum levels of calcium (adjusted to serum albumin), phosphate, intact parathyroid hormone, 25-OH-Vitamin D, alkaline phosphatase, and estimated glomerular filtration rate (eGFR). For continuous/numerical variables with two groups, Mann–Whitney U-test was applied. Multivariate regression analysis was done if the univariate analysis showed significance (P < 0.05). Results: There were 13 (7.5%) patients with confirmed diagnosis of AP and serum calcium level significantly elevated in this group. There was a linear association of serum calcium with AP. Successful parathyroidectomy prevented further episodes in 11 (84.6%) of patients. There was 2% prevalence of PHPT among 558 patients with AP. Conclusions:Hypercalcemia in PHPT patients was significantly associated with AP and early parathyroidectomy prevented further recurrence. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Prospective randomized control study comparing gauze-based with foam-based negative pressure wound therapy for the stage 4 pressure injuries p. 223 Chiun-Sheng Chen, Chao-Chin Yu DOI:10.4103/fjs.fjs_176_17   Background: Negative pressure wound therapy (NPWT) has been used to accelerate the formation of granulation tissue and to promote wound closure in the treatment of difficult-to-heal wounds. This study compared the effectiveness between gauze- and foam-based NPWT for stage 4 pressure injuries. Materials and Methods: A total of 38 patients with 48 wounds of stage 4 pressure injuries were recruited and randomly divided into gauze-based and foam-based groups. After initial debridement therapy, gauze-based and foam-based fillers were used, and clinical observations were recorded when dressings were changed, twice a week for 3 weeks. The system was connected to a 1-bottle water-seal chest drainage system and standard wall suction at 125 mmHg negative pressure. The percentages of wound area reduction (PWAR), the scores of Pressure Ulcer Scale for Healing (PUSH) tool and the scores of Bates-Jensen wound assessment tool (BWAT) were used to evaluate wound healing activity. Results: Both groups showed significant changing trends in the wound assessments of PWAR, PUSH, and BWAT during follow-up. However, the area of healing at each clinical observation was consistently greater in the foam group than in the gauze group during the follow-up period, while the PUSH score was consistently greater in the gauze group than that in the foam group. The declining trends of BWAT were alike in both groups. Conclusion: Gauze-based therapy is noninferior to foam-based therapy with respect to PWAR, PUSH, and BWAT for stage 4 pressure injuries. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Statistical relevance of mean hematoma density and it's internal architecture: Potential clinical application in chronic subdural hematomas p. 228 Tzu-Yung Chen, Sue-Ting Chang, Muh-Shi Lin DOI:10.4103/fjs.fjs_155_17   Background: The postoperative recurrence rate of chronic subdural hematomas (CSDHs) ranges from 9% to 20%, which is a serious concern for neurosurgeons. Both qualitative and quantitative assessment methods have been developed to identify the mechanisms involved in postoperative recurrence. These methods include Nakaguchi's clinical classification scheme and the quantification of mean hematoma density (MHD). This is the first study to examine the correlations between the quantification of MHD and Nakaguchi's clinical classification of patients with CSDHs. Materials and Methods: This study investigated 35 consecutive cases of CSDH between July 2010 and July 2013. In accordance with Nakaguchi's clinical classification, CSDH cases were separated into four groups: homogenous, laminar, separated, and trabecular. In addition, we quantified the area of the hematoma according to MHD using a computer-based image analysis of preoperative brain computed tomography scans. Results: The mean age of patients was 72.2 ± 8.05 years (range: 55–86). Mean MHD values were as follows: trabecular (12.45 ± 0.72 HU), homogenous (14.46 ± 4.51 HU), laminar (25.99 ± 0.93 HU), and separated (36.32 ± 3.04 HU). Differences in MHD were statistically significant for all CSDH types (P < 0.001, ANOVA with Student–Newman–Keuls post hoc test), and we observed a significant linear relationship between MHD and the priority order of clinical CSDH types determined according to postoperative recurrence (Spearman's rank correlation coefficient = 0.842, P < 0.001). Conclusions: This study provides statistical evidence that MHD is significantly correlated with Nakaguchi's clinical classification of CSDH. The applications of MHD quantification and hematoma's internal architecture helped to gain better understanding of possible mechanisms underlying CSDH recurrence. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta CASE REPORTS Hemorrhage glioblastoma mimicks a dural-based meningioma p. 234 Tse-Fu Wen, Lin-Hsue Yang, Che-Kuang Lin DOI:10.4103/fjs.fjs_23_18   The so-called “dural tail sign” (DTS) is a thickening of the dura that is most often seen adjacent to a meningioma. Although the DTS is highly specific for meningioma, it has been observed in numerous other intracranial lesions. The origin of the DTS is an issue of debate. Some authors have described it as a tumor extension, while others have considered it as a proliferation of connective tissue, hypervascularity, and vascular dilatation within the dura and adjacent to cranial masses. Here, we reported a rare case of glioblastoma multiforme (GBM) with image findings of a DTS. A 74-year-old female was taken to our hospital due to the sudden onset of mental status change and right-side hemiparesis. Brain magnetic resonance imaging (MRI) with contrast enhancement showed an intracranial mass with heterogeneous enhancement in the left temporal lobe which was consistent with the DTS. A left frontotemporal craniotomy was performed, and grossly total tumor removal was achieved. The final pathology reported was GBM. Although it is rare, GBM may also on occasion be associated with a DTS. The histopathological examination for DTS in GBM is limited. Currently, excision of the dural tail in GBM is suggested. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Chemical colitis in posterior mediastinum colonic conduit p. 238 Chen-Ming Mai, Chia-Ying Li DOI:10.4103/fjs.fjs_43_18   For patients with severe corrosive injury of the esophagus and stomach, the colon is considered a well-functional and durable esophageal substitute. We report a Chinese male suffered from chemical colitis of the colon conduit located in the posterior mediastinum after drinking strong liquor. To the best of our knowledge, this is the first case reported in the literature. After conservative and supportive therapy with antibiotics and oral fasting, he recovered from chemical conduit colitis completely. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Open fracture of tibia mid-shaft associated with the contralateral leg acute compartment syndrome without fracture p. 241 Tsung-Mu Wu, Chi-Rung Chung, Po-Chang Huang, Chung-Da Wu DOI:10.4103/fjs.fjs_22_18   The acute extremity compartment syndrome is caused by increased compartment volume or restriction of compartment size. There are 23% of all compartment syndrome is caused by isolated soft-tissue injury especially in crushing injury. We report a 30-year-old male with the initial diagnosis of the right tibia open fracture, Gustilo Type II, due to a motor-vehicle accident. Besides the right leg condition, he was continually suffered from left leg pain, where the X-ray revealed no apparent fracture since the collision. The physical examination showed no skin lesion and deformity; however, numbness and tightness were noted, toe stretching pain+, Pedis Dorsalis Artery+, Posterior Tibialis Artery+. Doppler showed the presence of PDA and PTA blood flow. Nine hours after the injury, pain and numbness of his left leg and foot still persisted and also pale and pulseless developed. Doppler for his left leg was done again and showed the negative result of PTA and PDA. Emergent bilateral side fasciotomy for his left leg was arranged, and the cardiovascular department was consulted for intraoperative angiography. The fasciotomy wound was cared with sterilized saline wet dressing for 3 days. Medial fasciotomy was closed with delayed primary method, and the lateral sides were treated with split-thickness skin graft. Acute compartment syndrome is diagnosed by the interpretation of a collection of clinical signs and symptoms. In a patient with a swollen limb, in the absence of a fracture and for whom, there is a suspicion of an acute compartment syndrome, methods, technology, and application for the early detection of acute compartment syndrome is important and also provides promising opportunities for the clinicians to perform early interventions. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Occult medullary breast carcinoma in a male p. 245 Devesh Sanjeev Ballal, Gabriel Rodrigues DOI:10.4103/fjs.fjs_48_18   Occult breast cancer (OBC) or breast cancer presenting without an evident primary tumor is a rare presentation and can lead to a diagnostic dilemma. Further, the treatment of OBC is a subject of much controversy. We present a 47-year-old male who had been admitted with a fungating lesion in his axilla. As clinical examination was unremarkable, a punch biopsy from the lesion revealed a medullary carcinoma of breast. The purpose of this report is to highlight this unusual presentation of carcinoma breast and the treatment dilemma that it poses, especially in men, where breast cancer is seldom considered a diagnostic possibility in the setting of occult primary cancer. This is the first-ever case report of medullary carcinoma presenting as OBC in a male. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta