Distilled water peritoneal lavage in patients with rupture hepatocellular carcinoma.

BACKGROUND/AIMS: Intra-peritoneal lavage is well known and used in intra-peritoneal malignancy However, the clinical role for patients with rupture of HCC has not yet been established. The aim of this study was to evaluate the clinical value of intraoperative peritoneal lavage for patients with rupture of HCC. METHODOLOGY: A retrospective study of operative findings, other factors, and outcome was performed in 66 patients with rupture of HCC who underwent distilled water peritoneal lavage (DWPL) during hepatectomy. RESULTS: There was a trend towards a higher intra-peritoneal, extra-hepatic recurrence rate in patients without DWPL. Patients who underwent DWPL had a significantly better 5-year disease-free survival rate than control group, 11.5±4.6 months and 30.2±8.4 months (p=0.018), respectively, and better overall survival rate, 21.7±6.2 months, than control group, 57.3±11.2 months (p=0.001). CONCLUSIONS: DWPL during liver resection retards tumor recurrence and improves the intraoperative survival rate in patients with spontaneously ruptured HCC.

Effect of multidisciplinary team care on the risk of recurrence in breast cancer patients: A national matched cohort study.

BACKGROUND: Cancer has been the leading cause of death in the past decade in Taiwan, with breast cancer being the most common type of cancer in females. Very few studies looked at the risk of recurrence in patients who received multidisciplinary team (MDT) care. We analyzed the influence of MDT on the risk of recurrence and death in breast cancer patients. METHOD: In this retrospective study, we included newly diagnosed patients from 2004 to 2010. The study included 9,266 breast cancer patients who were enrolled in MDT care and 9,266 patients who were not. The study used log-rank test to analyze patients' characteristics, hospital characteristics, cancer staging, and treatment methods to compare the recurrence rates in MDT care and non-MDT care participants. We used Cox proportional hazards model to examine the effect of MDT and associated factors on the risk of recurrence and mortality of breast cancer patients. RESULTS: Relative risk of recurrence was lower for patients who received MDT care than for patients who did not (HR, 0.84; 95%CI: 0.70-0.99) after matching. The mortality risk for breast cancer patients with relapse was 8.48 times (95%CI: 7.53-9.54) than that for patients without relapse. CONCLUSIONS: The relative risk of recurrence and death was significantly lower for breast cancer patients who received MDT care than for those who did not. We suggest that MDT care be implanted in the National Health Policy settings of breast cancer patients.

Knot formation in the feeding jejunostomy tube: a case report and review of the literature.

Jejunostomy feeding tubes provide surgeons with an excellent method for providing nutritional support, but there are several complications associated with a tube jejunostomy, including complications resulting from placement of the tube, mechanical problems related to the location or function and development of focally thickened small-bowel folds. A 76-year old man who presented with multiple medical diseases was admitted to our hospital due to aspiration pneumonia with acute respiratory failure and septic shock. He underwent exploratory laparotomy with feeding jejunostomy using a 14-French nasogastric tube for nutritional support. However, occlusion of the feeding tube was found 30 d after operation, and a rare complication of knot formation in the tube occurred after a new tube was replaced. On the following day, the tube was removed and replaced with a similar tube, which was placed into the jejunum for only 15 cm. The patient's feedings were maintained smoothly for two months. Knot formation in the feeding tube seems to be very rare. To our knowledge, this is the third case in the literature review. Its incidence is probably related to the length of the tube inserted into the lumen.

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.

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.

Diverticulosis of the jejunum with intestinal obstruction: A case report.

A diagnosis of intestinal diverticulosis is difficult to make pre-operatively because the clinical symptoms are usually non-specific. We report the case of a 70-year-old man who had suffered from three episodes of intestinal obstruction in 1 year. He experienced dull pain and a sensation of fullness over the whole abdomen. The symptoms did not improve after conservative treatment. The presumptive diagnosis was intestinal obstruction, and an exploratory laparotomy found diverticulosis of the proximal jejunum, with an adhesion band formed from the base of one diverticulum. Strangulation of a segment of the jejunum resulted from the internal herniation caused by the band. The band was removed and the proximal jejunum segmentally resected. His postoperative course was uneventful.

Preventing prolonged post-operative ileus in gastric cancer patients undergoing gastrectomy and intra-peritoneal chemotherapy.

AIM: To assess the efficacy of metoclopramide (Met) for prevention of prolonged post-operative ileus in advanced gastric cancer patients undergoing D2 gastrectomy and intra-peritoneal chemotherapy (IPC). METHODS: Thirty-two advanced gastric cancer patients undergoing D2 gastrectomy and IPC were allocated to two groups. Sixteen patients received Met immediately after operation (group A), and 16 did not (group B). Another 16 patients who underwent D2 gastrectomy without IPC were enrolled as the control group (group C). All patients had received epidural pain control. The primary endpoints were time to first post-operative flatus and time until oral feeding with a soft diet without discomfort. Secondary endpoints were early complications during hospitalization. RESULTS: Gender, the type of resection, operating time, blood loss, tumor status and amount of narcotics were comparable in the three groups. However, the group C patients were older than those in groups A and B (67.5+/-17.7 vs 56.8+/-13.2, 57.5+/-11.7 years, P = 0.048). First bowel flatus occurred after 4.35+/-0.93 d in group A, 4.94+/-1.37 d in group B, and 4.71+/-1.22 d in group C (P>0.05). Oral feeding of a soft diet was tolerated 7.21+/-1.92 d after operation in group A, 10.15+/-2.17 d in group B, and 7.53+/-1.35 d in group C (groups A and C vs group B, P<0.05). There was no significant difference in respect to the first flatus among the three groups. However, the time of tolerating oral intake with soft food in groups A and C patients was significantly shorter than that in group B patients. Levels of C-reactive protein (CRP) were significantly lower in group C and there was a more prominent and prolonged response in CRP level in patients undergoing IPC. The incidence of post-operative complications was similar in the three groups except for prolonged post-operative ileus. There was no increased risk of anastomotic leakage in patients receiving Met. CONCLUSION: The results suggest that a combination of intravenous Met and epidural pain control may be required to achieve a considerable decrease in time to resumption of oral soft diet in advanced gastric cancer patients who underwent gastrectomy and IPC. Furthermore, the administration of Met did not increase anastomotic leakage. Met has a role in the prevention of prolonged post-operative ileus.

Superselective transarterial chemoembolization vs hepatic resection for resectable early-stage hepatocellular carcinoma in patients with Child-Pugh class a liver function.

PURPOSE: In contrast to hepatic resection (HR) for resectable early-stage HCC, the efficacy of transarterial chemoembolization (TACE) is controversial. This study is designed to compare the long-term outcome of TACE using superselective technique with hepatic resection for the treating resectable early-stage HCC and Child-Pugh class A liver function. METHODS: In total, 185 consecutive patients with resectable early-stage HCC and Child-Pugh class A liver function were included: 73 patients received superselective TACE (group I) and 112 patients underwent HR (group II). We evaluated the therapy-related recurrence and long-term outcome and in both groups. The risk factors of recurrence and mortality were assessed by Cox's model. RESULTS: The mean survival time of group 1 patient was similar to that of group 2 patient (40.8±19.8 vs 46.7±24.6 months respectively, p=0.91). The 1-, 3-, and 5-year overall survival rates after TACE (group I)and HR (group II) were 91%, 66%, and 52% and 93%, 71%, and 57%, respectively (p=0.239). The 1-, 3-, and 5-year recurrence-free survival rates in groups 1 and 2 were 68%, 28%, and 17% and 78%, 55%, and 35%, respectively (p<0.0001). Serum albumin, tumour size, tumour number and recurrence interval were independent risk factors for mortality. Serum albumin level, tumour size, tumour number, and treatment modality of TACE or HR could predict HCC recurrence. CONCLUSION: TACE is an efficient and safe treatment for resectable early-stage HCC with overall survival rates similar to that of HR. Thus, TACE is indicated in selected patients with resectable early-stage HCC.

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.

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.

Aggressive hepatic resection for patients with pyogenic liver abscess and APACHE II score > or =15.

BACKGROUND: Most liver abscesses resolve after antimicrobial therapy or percutaneous tube drainage (PD). The aim of this study was to evaluate the results of hepatic resection (HR) for patients with pyogenic liver abscesses and an Acute Physiology and Chronic Health Evaluation II (APACHE II) score > or =15. METHODS: We compared the clinical outcomes of 81 patients with APACHE II scores > or =15 undergoing PD and/or HR. RESULTS: The failure rate (3 of 65) and double-treatment rate (32 of 65) in the PD group were significantly higher than in the HR group (3 of 35 vs 0 of 35; P = .0002). The mortality rate in the PD group was significantly higher than the other 2 groups (14 of 46 vs 2 of 19 and 1 of 16; P = .038). The length of hospital stay was significantly shorter and antibiotic use less in the HR group than in the PD group (P < .05). CONCLUSIONS: Aggressive HR for patients with liver abscesses and APACHE II scores > or =15 produced better clinical outcomes.

Trigger arrhythmia to confirm the position of totally implantable access ports (TIAP).

BACKGROUND: Totally implantable access ports (TIAP) with cutdown method has few complications, but needs assessment of fluoroscopic system. METHODS: We present a method to confirm the position of TIAP catheter without fluoroscopic assessment. We use the cutdown method and trigger arrhythmia while introducing the TIAP catheter. RESULTS: This method was applied in 54 patients and no complications were found. CONCLUSIONS: Checking the position by triggering arrhythmia while performing TIAP with cephalic vein cutdown in case of C-arm was not available is simple and safe.

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

BACKGROUND: 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 x 25 x 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.

Peritoneal lavage with distilled water during liver resection in patients with spontaneously ruptured hepatocellular carcinomas.

Spontaneously rupture of hepatocellular carcinoma is a life threatening and worse prognosis. Not only the lower rate of resection and hemodynamic unstable, but also the hepatic failure and recurrence. Distilled water irrigation had been applied in several cancer surgeries including colon, stomach, breast, ovary, and bladder; thus had good results in lowering the tumor spreading. We applied distilled water peritoneal lavage after liver resection in patients with spontaneous rupture of hepatocellular carcinoma to define the influence of prognosis. Thirteen patients with spontaneous ruptured hepatocellular carcinoma underwent distilled water peritoneal lavage after curative liver resection (Group A). Nineteen patients with spontaneous ruptured hepatocellular carcinoma did not undergo distilled water peritoneal lavage after curative liver resection (Group B). There were 11 patients of tumor recurrence in Group B; 2 in Group A. The mean disease-free time of Group B was 2.05 +/- 0.74 years; for Group A it was 3.59 +/- 0.60 (P = 0.045). Peritoneal lavage in this series resulted in significantly better survival time for the patients in Group A (P = 0.0158). That implies distilled water peritoneal lavage during liver resection would retard the tumor recurrence and further improve the survival rate in patients with spontaneously ruptured hepatocellular carcinoma.