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Hungry bone syndrome is characterized by prolonged and severe hypocalcemia following parathyroidectomy. Previously, we reported that preoperative alkaline phosphatase is a major factor predicting prolonged hospital stay. Nonetheless, some patients with low alkaline phosphatase levels presented with hungry bone syndrome, suggesting that additional factors may play a role. From September 2010 to December 2017, consecutive dialysis patients who underwent parathyroidectomy for secondary hyperparathyroidism were analyzed. Length of hospital stay was used as a surrogate marker for postoperative bone hunger. A total of 260 patients were included in the study. The median postoperative hospital stay was 3 days, and 69 (27%) patients had a stay longer than 3 days. Multivariate logistic regression analysis revealed that alkaline phosphatase (odds ratio [OR] = 1.005), osteocalcin (OR = 1.001), and subtotal parathyroidectomy (OR = 0.061) were associated with prolonged hospital stay. Multivariate linear regression analysis indicated that age (β = − 0.170), alkaline phosphatase (β = 0.430), and osteocalcin (β = 0.166) were correlated with the length of stay. After surgery, the median osteocalcin level increased from 264 to 478 ng/mL (P

Colorectal cancer (CRC) guidelines recommend adjuvant chemotherapy according to the level of lymph node metastasis. Let-7a-5p is a microRNA, which inhibits migration, invasion, as well as the epithelial-mesenchymal transition by targeting HMGA2. The aim of this study was to investigate the role of let-7a-5p in the clinical impact of CRC. In this study, one hundred and ninety-two CRC patients were enrolled. The expression of let-7a-5p and HMGA2 in serum and tumour tissues were analysed by real-time PCR and immunohistochemistry. Kaplan-Meier analysis was used to analyse primary outcomes, including the survival and tumour recurrence. The expression of let-7a-5p in tumour tissues was significantly negative correlated with the tumour size, stage and lymph node metastasis in CRC patients (p = 0.024 for tumour size, p

Background/objectives Surgery offers the potential to relieve symptoms for patients with cancer at the end of life (EOL) but at significant physiological and economic costs. However, the characteristics and correlates of surgery in last month of life (EOL surgery) of patients with cancer have not been comprehensively explored. This population-based study characterized EOL surgery use and identified its correlates. Methods This retrospective cohort study examined administrative data among 339,546 Taiwanese cancer decedents, 2001 to 2010. We classified procedures according to their likely intent. Results Approximately 1 in 10 (11.44%, range: 11.08%-11.86%) patients underwent EOL surgery with an increasing utilization over time. The intention for EOL surgery was primarily palliative, followed by cancer-directed, nonmalignancy-directed, and diagnostic. EOL surgery for palliative intent increased whereas other intents decreased significantly over time. EOL surgery was more likely among those who were male, younger, and married; not diagnosed with hepatic-pancreatic or lung cancers; had no comorbidity or documented metastatic codes; and survived less than 1 year from diagnosis. The likelihood of EOL surgery use was higher for patients who received care in a teaching hospital with more acute care hospital beds and higher EOL care intensity. Conclusions Rates of EOL surgery are lower in Taiwan than those reported in the United States. The increasing use of EOL surgery in Taiwan is primarily for palliative intent. Appropriateness of EOL surgery should be carefully evaluated to avoid underutilizing potentially beneficial, palliative-intent surgery and overutilizing cancer-directed and other surgical procedures, especially for physicians working in hospitals with abundant health care resources and a tendency to treat at-risk patients with cancer aggressively.

The current guidelines recommend that potassium iodide be given in the immediate preoperative period for patients with Graves' disease who are undergoing thyroidectomy. Nonetheless, the evidence behind this recommendation is tenuous. The purpose of this study is to clarify the benefits of preoperative iodine administration from published comparative studies.We searched PubMed, Embase, Cochrane, and CINAHL from 1980 to June 2018.Studies were included that compared preoperative iodine administration and no premedication before thyroidectomy. For the meta-analysis, studies were pooled with the random-effects model.A total of 510 patients were divided into the iodine (n = 223) and control (n = 287) groups from 9 selected studies. Preoperative iodine administration was significantly associated with decreased thyroid vascularity and intraoperative blood loss. Significant heterogeneity was present among studies. We found no significant difference in thyroid volume or operative time. Furthermore, the meta-analysis showed no difference in the risk of postoperative complications, including vocal cord palsy, hypoparathyroidism/hypocalcemia, and hemorrhage or hematoma after thyroidectomy.Preoperative iodine administration decreases thyroid vascularity and intraoperative blood loss. Nonetheless, it does not translate to more clinically meaningful differences in terms of operative time and postoperative complications.

Background Gastric bypass surgery is the recommended treatment for severely obese patients. However, postoperative symptomatic gastrointestinal (GI) episodes are common complaints. Objectives To determine if administration of probiotics improves symptomatic GI episodes after gastric bypass surgery. Setting Hospital-based bariatric center. Methods This double-blind, randomized trial was conducted between March 2010 and September 2010 with 60 patients who underwent gastric bypass for severe obesity and experienced postoperative symptomatic GI episodes. Patients were randomly assigned to the probiotics group A (n = 20; 1 g Clostridium butyricum MIYAIRI twice daily); probiotics group B (n = 20; Bifidobacterium longum BB536 twice daily); or digestive enzymes group (n = 20; Aczym, containing 100 mg takadiastase N, 20 mg cellulase AP, 50 mg lipase MY, and 100 mg pancreatin, twice daily). Quality of life was measured using the modified Gastrointestinal Quality of Life Index (mGIQLI) before and after the 2-week intervention. Results Preintervention patient characteristics and mGIQLI scores were similar among the 3 groups. After the 2-week intervention, the mean mGIQLI score improved from 57.4 to 63.9 points in the entire sample and also within each group for 7 items specifically for 7: excessive passage of gas, foul smell of flatulence, belching, heartburn, abdominal noises, abdominal bloating, and abdominal pain. Conclusions Administration of probiotics or digestive enzymes may improve symptomatic GI episodes after gastric bypass surgeries and improve quality of life, at least initially.

Prophylactic dexamethasone has been shown to reduce postoperative pain, nausea, and vomiting in patients undergoing thyroidectomy. However, its effects on postoperative voice outcomes remain uncertain. A systematic review and meta-analysis of the literature was conducted. Cochrane database, MEDLINE, EMBASE, and CINAHL were thoroughly searched. Studies that compared intravenous dexamethasone administration with no dexamethasone in patients undergoing thyroidectomy were included. Main outcome measure was the difference in postoperative voice assessment between groups. Standardized mean difference (SMD) and 95 % confidence intervals (CIs) were estimated using fixed and random effects models. Four studies with a total of 313 patients met inclusion criteria. Significant heterogeneity of study results was noted. Using random effects models, pooled data showed no difference in subjective voice quality between groups preoperatively (SMD, 0.29; 95 % CI −0.37 to 0.96; P = 0.39), 24 h after thyroidectomy (SMD, −1.02; 95 % CI −2.36 to 0.31; P = 0.13), or at 48 h (SMD, −0.05; 95 % CI −0.30 to 0.21; P = 0.72). A sensitivity analysis excluding one observational study yielded similar results. There are insufficient data for definite conclusions to be drawn regarding the effectiveness of a single perioperative administration of dexamethasone to reduce short-term voice disturbances after thyroidectomy. Further prospective trials using objective voice analysis are warranted to evaluate the efficacy of dexamethasone.

SummaryBackground/IntroductionDialysis modalities may influence parathyroid hormone (PTH) levels and renal osteodystrophy patterns. To date, no study has compared the effects of dialysis modality on surgical patients with renal hyperparathyroidism.Purpose/AimThis study evaluated the influence of different dialysis modalities on perioperative features among patients undergoing parathyroidectomy.MethodsOverall, 386 patients who underwent initial parathyroidectomy for renal hyperparathyroidism were recruited. Biochemical data and relevant symptoms were compared between hemodialysis and peritoneal dialysis patients.ResultsCompared with the hemodialysis patients, the 40 (10%) peritoneal dialysis patients were younger (p = 0.002) and had a shorter duration of dialysis (p

Background Systemic inflammation has been implicated in complications and heightened mortality of patients with secondary hyperparathyroidism. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are widely available surrogate markers of inflammation. This study sought to delineate the changes in NLR and PLR after parathyroidectomy. Methods A total of 213 patients undergoing initial parathyroidectomy from 2010 to 2015 for secondary hyperparathyroidism were identified from a prospectively maintained clinical database. Among 183 patients free of persistent or recurrent disease, follow-up NLR and PLR were available for analysis in 85 patients. Results In the whole study population, the baseline NLR was positively correlated with male sex, total white blood cell count, height, serum phosphorus, and calcium–phosphorus product levels. The baseline PLR was positively correlated with platelet count, serum phosphorus, and calcium–phosphorus product levels and negatively associated with patient age. Postoperative parathyroid hormone levels were positively correlated with NLR and PLR at follow-up. For patients who had successful parathyroidectomy, there was a decrease in NLR (P = 0.0006), PLR (P = 0.0003), and platelet count (P = 0.033), whereas hemoglobin significantly increased (P = 0.0002) after surgery. Those with persistent or recurrent hyperparathyroidism had no change in NLR, PLR, hemoglobin, total white blood cell, or platelet count. Conclusions Successful parathyroidectomy is associated with a decrease in NLR and PLR. The modulatory effects of parathyroidectomy on systemic inflammation may partially explain the benefits of surgery in secondary hyperparathyroidism.

Objective Phyllodes tumors are composed of a benign epithelial component and a cellular spindle cell stroma that form a leaf-like structure. The purpose of this study was to define changes in patient characteristics, histopathologic parameters, and the outcome during two periods: before and after the introduction of core needle biopsy for preoperative diagnosis. Methods Records were reviewed of 170 patients with phyllodes tumors who were managed surgically. Patients treated from 1997 to 2004 (n = 101) were compared with patients treated from 2006 to 2013 (n = 69). Results The analysis of the two treatment periods revealed that the tumor size at diagnosis increased from 4.6 cm during the earlier period to 7.0 cm during the recent period (p

BACKGROUND Continuous ambulatory peritoneal dialysis (CAPD) is a treatment for patients with end-stage renal disease (ESRD). Peritoneal dialysis catheters are usually placed using a small laparotomy. This traditional technique is usually safe if well executed, but it cannot be safely performed if the patient has had a previous abdominal operation. A minimally invasive procedure may progress safely by laparoscopic intervention. However, dysfunction of the catheter during a laparoscopic intervention is a common complication related to CAPD. This usually involves intra-abdominal migration of the catheter, even with one intra-abdominal fixation. In an effort to increase catheter survival, we tested a modified laparoscopic technique with two intra-abdominal fixations of a Tenckhoff catheter. MATERIALS AND METHODS Forty-one consecutive ESRD patients (mean age, 53.4 y; range, 31 to 84 y) underwent modified laparoscopic Tenckhoff catheter implantation with 2 intra-abdominal fixations between September 2009 and January 2013. The same perioperative protocol and surgical technique were used in all patients. Another 49 ESRD patients who had received laparoscopic Tenckhoff catheter implantation with 1 intra-abdominal fixation performed by the same surgeon were retrospectively recruited for comparison. RESULTS The modified laparoscopic procedure with two intra-abdominal fixations of a Tenckhoff catheter was successfully performed in all patients. The mean operating time was 24.3 minutes (range, 15 to 37 min). The mean blood loss was 5.6 mL (range, 5 to 20 mL). Catheter survival was 100% until February 2013. No major perioperative complications were found. A Kaplan-Meier Survival Analysis found no significant difference between the 2 groups in sex, age, operative time, or blood loss. The catheter survival rate was significantly higher in the patients with two intra-abdominal fixations. Most patients were satisfied with the functional results of the Tenckhoff catheter. CONCLUSIONS The laparoscopic 2-site fixation technique is an effective and safe procedure but long-term follow-up and more cases are necessary.

Somatic BRAF mutation is frequently observed in papillary thyroid carcinoma (PTC). Recent evidence suggests that PTCs are heterogeneous tumors containing a subclonal or oligoclonal occurrence of BRAF mutation. Conflicting results have been reported concerning the prognostic significance of the mutant allele frequency. Our present aim was to investigate the association between the percentage of BRAF c.1799T > A (p.Val600Glu) alleles and clinicopathological parameters in PTC. Genomic DNA was extracted from fresh-frozen specimens obtained from 50 PTC patients undergoing total thyroidectomy. The BRAF mutation status was determined by Sanger sequencing. The percentage of mutant BRAF alleles was quantified by mass spectrometric genotyping, pyrosequencing, and competitive allele-specific TaqMan PCR (castPCR). Positive rate of BRAF mutation was 72 % by Sanger sequencing, 82 % by mass spectrometric genotying, and 84 % by pyrosequencing or castPCR. The average percentage of mutant BRAF alleles was 22.5, 31, and 30.7 %, respectively. There was a good correlation among three quantification methods (Spearman’s rho = 0.87–0.97; p

Summary Background Single-incision laparoscopic surgery (SILS) has emerged recently, and this procedure minimizes surgical trauma. Laparoscopic Roux-en-Y gastric bypass is one of the most effective bariatric surgeries. From five to seven small skin incisions are usually required to perform this procedure. In regard to the single-incision laparoscopic surgery procedure, we developed a modified single-laparoscopic technique (2-site incision technique) to perform a Roux-en-Y gastric bypass. Our method and the associated learning curve will be presented here. Methods Three hundred consecutive patients with a mean age of 31.7 years (range, 19–52 years) underwent a two-site incision laparoscopic Roux-en-Y gastric bypass (TILRYGB) between February 2009 and December 2010. The mean body mass index of the patients was 40.5 kg/m2 (range, 30.1–59.9 kg/m2) preoperatively. The same perioperative protocol and surgical technique were used in all patients. These 300 patients were equally divided into three groups in sequence. The pre- and postoperative data were collected and compared. Results The TILRYGB procedure was performed successfully in all patients. The mean operative time of the groups in sequence was 170.9 minutes, 157.3 minutes, and 149.0 minutes. No perioperative major complications occurred. Minor complications occurred in these three groups in five, three, and zero cases. These minor complications included gastrointestinal bleeding and ileus, all of which resolved with conservative treatment. The mean hospital stay in sequence was 4.1 days, 3.8 days, and 3.5 days. Conclusion TILRYGB is a safe, feasible, and reproducible bariatric procedure; once the learning curve is overcome, it can provide better postoperative results than other surgical procedures.

The parathyroidectomy assessment of symptoms (PAS) score was designed initially for primary hyperparathyroidism to provide a specific symptom assessment and was validated later in secondary and tertiary hyperparathyroidism. The aim of our study was to evaluate changes in the PAS scores and quality of life before and after parathyroidectomy for secondary hyperparathyroidism.This prospective study included 49 consecutive patients who underwent parathyroidectomy for secondary hyperparathyroidism. The PAS and Short Form (SF)-36 questionnaires were completed before parathyroidectomy and at 12 months postoperatively.All 13 symptoms included in the PAS score improved significantly. The mean ± standard deviation PAS score decreased from 545 ± 263 to 284 ± 201 (P.0001) after parathyroidectomy. Quality of life was enhanced in both physical (40.3 ± 17.1 to 59.0 ± 14.9; P.0001) and mental (47.6 ± 17.1 to 63.7 ± 13.0; P.0001) components. The PAS score was inversely correlated with the SF-36 global score preoperatively and postoperatively (r(2) = 0.48 and 0.25; P.001). The change in PAS score also correlated with the change in SF-36 global score (r(2) = 0.29; P.001). Multiple linear regression analysis showed that preoperative PAS score and bone mineral density T-score were predictors of the decrease in PAS score. Preoperative SF-36 global score and intact parathyroid hormone levels were predictors of the increment in SF-36 score.The symptom burden of secondary hyperparathyroidism has a negative impact on a patient's quality of life. Parathyroidectomy is associated with a marked improvement in symptoms and quality of life.

Background and Objectives Inflammation has been implicated in the initiation and progression of thyroid cancer. Neutrophil-to-lymphocyte ratio (NLR) is a simple index of systemic inflammatory response, and has been shown to be a prognostic indicator in some types of cancer. The aim of this study was to examine the relationship between NLR and clinicopathological features in patients with differentiated thyroid cancer. Methods Total white blood cell and differential counts of 159 patients with differentiated thyroid cancer were compared to those of 318 age- and sex-matched controls undergoing thyroidectomy for benign thyroid nodules. Clinicopathological variables, stratified by NLR tertiles, were analyzed. Results There was no difference in NLR between patients having benign and malignant thyroid nodules (P = 0.293). Cancer patients in the higher NLR tertile had significantly larger tumor size (P = 0.004). Higher NLR was observed in patients with high American Thyroid Association (ATA) risk of recurrence. Conclusions High preoperative NLR was associated with increased tumor size and high ATA risk of recurrence in patients with differentiated thyroid cancer. J. Surg. Oncol. 2013;107:493–497. © 2012 Wiley Periodicals, Inc.

Background Laparoscopic liver resection has become a feasible and safe procedure for liver tumor, but it requires experienced surgeons in the case of hepatobiliary and laparoscopic surgeries. More minimally invasive laparoscopic techniques of liver surgery are developed. We here report our experience of using a marionette technique for 3-port laparoscopic liver resection. Methods Between June 2009 and December 2010, 7 patients underwent 3-port laparoscopic liver resection with the use of marionette technique. Five patients had hepatocellular carcinoma. Two patients with prior abdominal operations for colon cancer had colorectal liver metastasis. The procedure of marionette technique was performed as below: after insertion of the 3 trocars, a 2-0 nylon straight needle line was inserted through the abdominal wall, and using the needle holder, it was allowed to traverse the liver edge twice. Then, the straight needle line was forced out of the abdominal wall and clamped using mosquito for traction. Another straight needle line was similarly created at the opposite side of the liver edge. Results None of the patients had to be converted to open surgery. The mean operative time was 96.7 ± 63.2 minutes (range, 45 to 195 min), and the mean volume of blood loss was 45.6 ± 27.9 mL (range, 30 to 100 mL). The mean pain score recorded on the visual analog scale was 2.7 ± 0.8. The mean hospital stay was 5.6 ± 1.7 days (range, 4 to 9 d). Currently, all the 7 patients are alive, and the tumors have not recurred (Supplementary Digital Content video 1 http://links.lww.com/SLE/A67). Conclusions Our experience demonstrated that the simple marionette technique procedure could help surgeons ease laparoscopic liver resection and achieve better postoperative results.

Summary Background The accurate evaluation of muscle mass by a non–invasive and easy method is the first step to help prevent falling events in elderly people. Methods To develop greater predictive accuracy and precision in the measurement of body composition in lower limbs by bioelectrical impedance analysis (BIA), the Back Propagation Artificial Neural Network (BP–ANN) was used to calculate predictive results and was compared with data from dual–energy X–ray absorptiometry (DXA) in 22 male and 16 female elderly people in Taiwan. Fat–free mass (FFM), tissue weight, and fat mass (FM) of the lower limbs were directly measured by DXA, and the BIA values (Z) of left side hand to right side foot in the standing position were measured by BIA. The parameters of height, weight, age, gender and BIA values were combined to create the BP–ANN mathematical model, which was developed to predict the FFM and FM in lower limbs in elderly. Result A relatively lower correlation coefficient ( r 2 ) of 0.964 and standard deviation (2SD) of 0.01 ± 3.64% were obtained for the prediction of FFM and FM by BIA with the BP–ANN mathematical model, whereas the linear regression analyzing model had an r 2 value of 0.845 and 2SD of 0.12 ± 7.68%, respectively. The performance of the BP–ANN mathematical model at BIA measurement was superior to that of the current linear regression model. Conclusion In summary, the greater predictive accuracy and precision made the application of BIA with the BP–ANN mathematical model more feasible for the clinical measurement of FM and FFM in the lower limbs of elderly people.

Biliary tract complications remain the Achilles’ heel of liver transplantation, with an incidence of 10% to 30% in cadaveric liver transplantation and a higher incidence of 4% to 60% in living donor liver transplantation LDLT). The major issues are bile leakage and biliary stricture at the anastomotic site. There are various treatment methods for biliary tract complications, including endoscopic, radiologic, and surgical management. For biliary stricture, endoscopic retrograde cholangiography (ERC) guided balloon dilation or stenting and percutaneous transhepatic cholangiography (PTC) guided balloon dilation or stenting are applied as primary treatments. Surgical revision is considered when endoscopic and radiologic approaches fail. Chan and Fan stated various methods of percutaneous transhepatic dilation and stenting and hepaticojejunostomy have to be performed with the utmost care to avoid vessel injury. The diffiult issues in redo surgery of biliary reconstruction for DLT recipients are severe adhesion, confused portal riad, and afraid of hepatic vessels injury. Percutaneous ranshepatic choledocal drainage (PTCD) catheter or akes dilator-guided biliary exploration have been reorted in management of bile duct injury. But dense adhesions can make it difficult for surgeons to palpate and identify the biliary tract. Here, we present a novel choledochoscopic light-guided procedure via previous PTCD hole for exploration of biliary system in surgical intervention for redo surgery of hepaticojejunostomy or duct-to-duct hepaticocholedochostomy.

Epidemiologic studies have shown that obesity is associated with an increased risk of thyroid cancer. Leptin, an adipocyte-derived cytokine, can act as a growth factor on certain normal and transformed cells. Aberrant expression of leptin or leptin receptor has been detected in some types of cancer. The aim of this study is to determine immunohistochemical expression of leptin and leptin receptor in papillary thyroid cancer to investigate the relationship between their expression and clinicopathologic features.The expression of leptin and leptin receptor was assessed in 49 primary neoplasms and 15 lymph node metastases using a semiquantitative immunohistochemical staining method.Leptin and leptin receptor were expressed in 37% and 51% of papillary thyroid cancer, respectively. They were not expressed in normal follicles. In the primary neoplasms and the metastatic nodes, expression of leptin correlated closely with leptin receptor (P.001 for the primary neoplasms and P = .017 for nodal metastases). Expression of either protein was associated with greater neoplasm size (leptin expression, 32.0 +/- 10.7 vs 20.5 +/- 8.4 mm; P = .001; leptin receptor expression, 27.9 +/- 11.5 vs 21.4 +/- 9.0 mm; P = .032). Coexpression of leptin and leptin receptor in primary neoplasms had greater incidence of lymph node metastasis (P = .038).Expression of leptin and/or leptin receptor in papillary thyroid cancer is associated with neoplasm aggressiveness, including tumor size and lymph node metastasis.

SUMMARY Background: The success of peritoneal dialysis (PD) in elderly patients has been reported to be either slightly inferior or equivalent to that of younger patients. The purpose of this study was to evaluate the outcome and suitability of PD in older individuals. Methods: Between January 2005 and December 2007, 67 patients with end-stage renal disease who underwent a surgical PD catheter insertion procedure were enrolled in this study. Complications related to PD catheters, hospital stay, morbidity, mortality, and catheter survival were assessed. Analysis of catheter survival was performed using the Kaplan-Meier method. Results: Fifteen elderly patients (65 years and older) undergoing PD catheter placement had similar complication rates (p = 0.568) and catheter survival (log rank test, p = 0.805) to those of the younger group. The postoperative stay was longer in elderly patients (24 vs. 18 days; p = 0.049). Conclusion: Our results indicate that PD is a feasible and safe option for elderly patients with end-stage renal disease. [International Journal of Gerontology 2009; 3(3): 143–148]

The likelihood of thyroid cancer is similar in patients with one or more nodules, but tumor characteristics of thyroid cancer in glands with multinodular goiter are unclear. This study consisted of 100 consecutive patients (ages 15–81 years; 84 women), who underwent thyroidectomy for papillary or follicular thyroid carcinoma between 2005 and 2006. Patient demographics, diagnostic tests, operations, and pathological findings were reviewed. In a univariate analysis, cancer diagnosed within multinodular goiter was different from solitary cancer nodule in age of diagnosis (48 vs 40 years, p = 0.002), tumor size (1.42 vs 2.20 cm, p = 0.024), and the presence of cervical lymph node metastases (p = 0.035). There was no difference in gender, extrathyroidal invasion, multifocality, and types of operation. Only age (odds ratio, 1.056) and tumor size (odds ratio, 0.730) revealed independent correlation in multivariate analysis. Thyroid cancer in glands with multiple nodules is associated with older age at diagnosis and smaller tumor size.

Laparoscopic cholecystectomy in elderly patients has been linked to higher complication rates and longer lengths of stay. The purpose of this study was to identify risk factors associated with prolonged postoperative hospitalization in elderly patients undergoing laparoscopic cholecystectomy.The records of 287 patients aged 65 years or older, who underwent successful laparoscopic cholecystectomy between January 2001 and July 2006, were retrospectively reviewed. Clinical data was abstracted from the chart and compared between patients with a shorter or longer postoperative stay.The median postoperative hospital stay was three days (interquartile range 3-5). Forty-eight patients had complications, with an overall morbidity of 16% and mortality of 0.7%. The only independent predictor of prolonged postoperative stay was the occurrence of any major complication [odds ratio, 3.144; 95% confidence interval (CI), 1.882-5.251]. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and underlying chronic obstructive pulmonary disease were independently associated with major complications.A major complication is the most important cause of prolonged hospital stay after laparoscopic cholecystectomy in the elderly. No specific comorbidity has direct impact on the duration of hospitalization, but pulmonary disease is associated with increased risk of major complications.

SUMMARY The geriatric population is growing in number and complexity in modern surgical practice. This challenging group presents differences in physiology and outcomes that make a more comprehensive and multidisciplinary approach necessary. This review emphasizes the meticulous assessment and preparation in all facets before surgery, including a thorough examination, nutrition evaluation and intervention, and preoperative optimization of pulmonary function and cardiovascular hemodynamics. This article highlights the importance of age-related pharmacokinetic and pharmacodynamic considerations, effective pain control, as well as prevention and treatment of hypothermia, fluid and electrolyte imbalance, and postoperative delirium. The vulnerable elderly patient with multiple medical problems and functional impairment is best served by a surgeon with a particular interest and working knowledge of the changes associated with aging and the physiology of surgery and anesthesia. [International Journal of Gerontology 2007; 1(2): 89–97]

Objectives Intravenous lidocaine infusion has been shown to reduce postoperative pain among patients undergoing abdominal surgery. This study aimed to evaluate the effects of perioperative lidocaine administration in breast surgery. Methods A meta-analysis of randomized controlled trials comparing lidocaine infusion vs. placebo/routine treatment was performed. Standardized mean difference (SMD) or risk ratio (RR) with 95% confidence intervals (CIs) was calculated from pooled data. Random-effects models were used, and heterogeneity was assessed. Results A total of 4 reports (3 primary studies and 1 extension) with 84 patients randomized to the lidocaine group and 83 patients randomized to the control group were included. There was no difference in pain scores at rest or during activity between the 2 groups from postoperative 2 hours to 3 days. At postoperative 72 hours, the lidocaine group had fewer analgesics consumed (SMD, −0.479; 95% CI, −0.914 to −0.043; P = 0.031). Chronic pain was assessed 3 to 6 months after breast surgery in 51 patients of the lidocaine group and 46 patients of the control group. Patients in the lidocaine group had significantly lower risk for the development of chronic pain (RR, 0.332; 95% CI, 0.141 to 0.781; P = 0.012). Conclusion The results indicate no significant benefits of intravenous lidocaine infusion in terms of acute postoperative pain. Although lidocaine seems to attenuate the risk of chronic pain after breast surgery, there is insufficient evidence to conclude that lidocaine infusion is of proved benefit because the results were based on a limited number of small trials.

Phyllodes tumors of the breast are uncommon, and it is difficult to predict biologic behavior based on clinicopathologic features. Despite the wealth of data on the factors to predict recurrence, little is known about the impact of treatment refinements. This study seeks to define changes in patient characteristics, histopathologic parameters, and outcome between the two periods before and after the care of patients with breast diseases was centralized to a breast specialty.The records of 182 patients with phyllodes tumors managed surgically were reviewed. Patients treated from 1985 to 1996 (n=81) were compared with those seen from 1997 to 2004 (n=101).The analysis of the two treatment periods revealed that there was a decrease in tumor size at diagnosis, from 7.7 cm during the earlier period to 4.6 cm during the recent period (P=0.003). The patients undergoing breast-conserving surgery were significantly increased during the recent period. In contrast, pathologic features and local recurrence rates remained unchanged during the study period. Multivariate analysis revealed that positive surgical margin was the only independent predictor of recurrence, with an increased hazard of 8.0. Overall, upgrading to the next grade was observed in 16% of recurrences.Breast-conserving surgery with clear margins is the current treatment of choice for phyllodes tumors, but this strategy does not further reduce local recurrence effectively. Optimal management continues to be a challenge.

Introduction Conventional rigid endoscope requires a bundle of optic fibers for illumination and a set of camera for viewing body cavity. The design is bulky in the hand-held part and the laterally positioned optic fibers may hinder manipulation of instruments, especially in single port surgery. We designed a simplified unit to replace conventional endoscope. Materials and methods We used an independent front image sensor along with six light emitting diode crystals. A wireless module working in 2.4 GHz and its antenna were integrated into the hand-help part. Two 800 mA batteries were used for power supply. The study was tested in two 35 kg pigs. Some simple thoracoscopic and laparoscopic operations were simulated to test the reliability and surgeon's acceptability. Results Signal Noise ratio can be controlled well in the setting of the operative room. Signal transmission was influenced significantly when covered by damped gauze or drape. The best quality of wireless transmission is through line-of-sight. Dropping frame is less than 1 frame per second in 99% time period during the test. Conclusion Wireless modules in the design of rigid endoscope may be a plausible option with good acceptability.

Aluminum overload and accumulation in tissues may lead to skeletal, hematological, and neurological toxicity. The aim of this study was to assess the effects of serum aluminum levels on presentations, postoperative recovery, and symptom improvement in patients undergoing parathyroidectomy for secondary hyperparathyroidism. From 2008 to 2013, all patients with end-stage renal disease undergoing initial parathyroidectomy were included in the study. Serum aluminum level was measured preoperatively and/or within 1 week after surgery. Preoperative and postoperative biochemical profile and symptoms were compared between the low and high aluminum groups. A total of 176 patients were included in the study. Of these, 38 (22 %) patients had serum aluminum levels higher than 20 μg/L. A higher percentage of patients in the high aluminum group were on peritoneal dialysis than in the low aluminum group (24 vs. 4 %, p = 0.001). Both groups had similar bone mineral density and changes in biochemical profiles. The preoperative parathyroidectomy assessment of symptoms (PAS) score was not associated with serum aluminum levels (p = 0.349), whereas the postoperative PAS score showed positive association (p = 0.005). There was a negative association between serum aluminum levels and the improvement of total PAS scores (p = 0.001). The high aluminum group had more residual symptoms in three aspects: bone pain (p = 0.038), difficulty getting out of a chair or car (p = 0.045), and pruritus (p = 0.041). A high serum aluminum level was associated with reduced symptom improvement in patients undergoing parathyroidectomy for secondary hyperparathyroidism.

Objectives: Although phytobezoars are a rare cause of gastrointestinal obstruction, they are most commonly found in patients with previous gastric surgery. It is well known that predisposing factors of phytobezoar formation are ingestion of fruits containing soluble tannin, presence of dilute hydrochloric acid in the stomach, and gastric stasis or delayed emptying. We investigated whether intake of acid-suppressing drugs that neutralize gastric acidity or inhibit gastric acid secretion to constitute a hypo-acidic condition, increases the risk of phytobezoar formation. Materials and methods: Between September 1992 and October 2008, 32 patients (24 male and 8 female) with gastrointestinal phytobezoars were diagnosed either surgically or endoscopically at the Tri-Service General Hospital, Taipei, Republic of China. The data were collected from hospital records and analyzed retrospectively. Results: Eighteen (56.25%) of all patients had previous gastric surgery and 6 (42.9%) of the 14 patients who had not undergone surgery had diabetes mellitus. The majority of admissions were during winter and spring (between October and March) (P < 0.01) and none of the patients had taken acid-suppressing drugs during the 6 months before detection of gastrointestinal phytobezoars. Conclusions: In our study, intake of acid-suppressing drugs did not increase the risk of phytobezoar formation in patients with normal gastric motility. Moreover, we believe that the major factor in phytobezoar formation is gastric stasis or delayed emptying, which sufficiently prolongs the retention period of materials in the stomach, while dilute hydrochloric acid is a minor factor.

Peritoneal dialysis (PD)-related peritonitis is the most common complication and the leading cause of technique failure for patients on PD therapy. The aim of this study was to review the episodes and outcomes of PD-related peritonitis, with special reference to the effects of age and diabetes status.The study comprised 204 consecutive peritonitis episodes between January 2001 and June 2011 from our registry database. Factors associated with treatment failure and mortality were analyzed with multi-variable logistic regression modeling.The overall peritonitis rate was one episode per 65 patient-months or 0.187 episodes/patient-year. Older patients had lower probability of remaining free of peritonitis (log rank, p0.001). Elderly patients and diabetic subjects had a higher risk of peritonitis-related dropout. Age (odds ratio [OR], 1.37; p=0.041), diabetes mellitus (OR, 3.64; p=0.005), and gram-negative peritonitis (OR, 3.55; p=0.011) were independent determinants of catheter removal. Age (OR, 1.93; p=0.026) and diabetes (OR, 5.98; p=0.015) were the only predictors of death from peritonitis.Old age and diabetes mellitus are two major risk factors for adverse outcomes of PD-related peritonitis. Although they are not contraindications to PD, our results suggest that these patients need meticulous care when peritonitis occurs.

Background: Conventionally, laparoscopic surgery was performed in the setting of artificial pneumoperitoneum. Some devices were developed allowing surgeons to perform gasless laparoscopic surgery by way of lifting methods. The application of lifting methods was quite limited because the created space was narrow. In the study, we attempted to design an intra-abdominal stenting device in order to create an acceptable operative space. Methods: The device was designed to be composed of two key components using multiple segments of stainless steel stick with several joints and an expanding controller. The device was placed into the peritoneal cavity through an umbilical incision followed by expansion of the stent. The procedure was tested in two experimental pigs to simulate the condition of laparoscopic surgery. Results: The device was tested for the plausibility and feasibility during the preparation stage of laparoscopic surgery and compared its efficacy to that of pneumoperitoneum using carbon dioxide (CO 2 ). The results showed that the device was an acceptable alternative to conventional pneumoperitoneum. Conclusions: The intra-abdominal stenting device is an acceptable alternative to conventional pneumoperitoneum. The study confirmed its feasibility and plausibility.

Preoperative detection of vocal cord palsy is important in thyroid and parathyroid surgery. However, routine fiberoptic laryngoscopy may bring patients unnecessary discomfort. The aim of this study was to determine the feasibility of using surgeon-performed ultrasonography (US) as a screening tool for preoperative assessment of vocal cord movement.In the first phase, patients had both laryngoscopic and US examination before surgery. In the second phase, patients had US evaluation first. Those with abnormal vocal cord movement on US, with invisible cord movement, or presenting with significant vocal symptoms underwent laryngeal examination.In all, 93 (82 %) of 114 patients had successful US evaluation of vocal cord movement during the first phase. Two of them had vocal cord paralysis. In the second phase, vocal cord movement could be evaluated by US in 349 (84 %) of 415 patients. Four patients with abnormal movement were confirmed to have vocal cord palsy by laryngoscopy. None of 46 symptomatic patients with normal movement on US had vocal cord palsy. One other patient whose cord movement could not be seen by US had vocal cord palsy on laryngoscopic examination.Surgeon-performed US appears to be a relatively accurate method for assessing vocal cord movement in the preoperative setting. It can be used to select patients to undergo laryngoscopic examination before thyroidectomy and parathyroidectomy.

Mondor's disease, superficial thrombophlebitis of the anterolateral chest wall, is a rare cause of breast pain. This disease often presents as a cordlike lesion with tenderness in the lateral breast. It is usually a benign and self-limiting process and only symptomatic control is needed. However, a small proportion of cases (2.4% to 12%) are associated with breast cancer. Breast sonography is a useful tool in the diagnosis of this disease, with the advantages of convenience and good resolution in young Asian females. We present a 24-year-old postpartum woman with a painful cord-like structure in the left lateral breast. This lesion resolved in 2 weeks after conservative treatment. The sonographic features of Mondor's disease in this patient are illustrated and the association with breast cancer is emphasized.

Protracted hypocalcemia is the most common complication after parathyroidectomy for secondary hyperparathyroidism. Several parameters have been identified to predict the degree of postoperative hypocalcemia. The purpose of this study was to determine whether there were any factors associated with prolonged hospitalization in these patients. A total of 81 consecutive patients with end-stage renal disease and advanced secondary hyperparathyroidism who underwent parathyroidectomy between January 2004 and December 2006 were studied. The postoperative calcium infusion protocol and discharge criteria were standardized. Clinical variables were compared between patients with a shorter or longer postoperative stay. The mean postoperative hospital stay was 5.6 days. Preoperative alkaline phosphatase levels were significantly higher in patients with a longer stay (p = 0.035). In a linear regression model, the postoperative length of stay was moderately but significantly correlated with preoperative alkaline phosphatase levels (R 2 = 0.254; p

Background: Castleman disease is a rare lymphoproliferative disease of low malignant potential occurring in two forms, unicentric and multicentric. Surgery, chemotherapy, immunotherapy and radiation therapy have all been used to manage the disease. In this study, we evaluate whether the site of the lesions, that is, superficial or deep, influences the surgical outcome. Methods: We retrospectively reviewed the records of 20 patients operated on for Castleman disease from 1994 to 2003, of whom 11 patients had superficial disease and 9 had deep lesions. The end-points of this study were survival and recurrence. Results: Of the 20 patients, 19 had unicentric (cervical in 8, mediastinal in 5, retroperitoneal in 2, axillary in 2, hepatic in 1, and mesenteric in 1) and 1 had multicentric Castleman disease. Among 19 patients who had complete resection (18 with unicentric and 1 with multicentric disease), there has been no evidence of recurrence. Conclusion: Whether Castleman disease is superficial or deep has no effect on surgical outcome as long as resection is complete.

A number of studies have investigated the effects of surgery on symptoms and quality of life in patients with hyperparathyroidism. However, the results are inconsistent. We conducted this meta-analysis to quantitatively assess changes in quality of life among patients with asymptomatic primary hyperparathyroidism. Different databases were searched for randomized controlled trials comparing surgery with surveillance. Quality of life was measured by the Short Form-36 general health survey. The pooled random-effects estimates of standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated. Three trials involving 294 participants were included. At 1 year, patients undergoing parathyroidectomy had significantly better physical role functioning (SMD, 0.31; 95% CI 0.04–0.57; P = 0.02) and emotional role functioning (SMD, 0.29; 95% CI 0.02–0.55; P = 0.03). At 2 years, the surgery group had significantly better emotional role functioning (SMD, 0.35; 95% CI 0.02–0.67; P = 0.04) than the surveillance group. Furthermore, compared with baseline, emotional role functioning improved after surgery (SMD, 0.31; 95% CI 0.02–0.60; P = 0.04), whereas emotional role functioning tended to get worse in patients assigned to medical surveillance (SMD, −0.27; 95% CI −0.55 to 0.02; P = 0.07). Although Short Form-36 is a generic instrument, our results suggest that parathyroidectomy may be associated with better quality of life, especially in the emotional aspects of well-being.

Background and Objectives Phyllodes tumors (PTs) are uncommon biphasic breast tumors that usually occur in adult females. They are composed of a benign epithelial component and a cellular, spindle cell stroma forming a leaf-like structure. No one morphologic finding is reliable in predicting the clinical behavior of the tumor. The purpose of this study was to explore the clinicopathologic factors associated with outcome and metastasis. Methods We retrospectively reviewed the records of 172 patients seen at Mackay Memorial Hospital from January 1985 to December 2003. Clinical data analyzed included age, presenting symptoms and signs, tumor size, location, type of surgery, time to recurrence, and metastasis. The clinicopathologic factors associated with outcome and metastasis were analyzed statistically using the chi-square test with Yate correction. Results The mean follow-up was 71 months (range 7–237). The mean age was 37 years (range 11–73). The majority of tumors were found in the upper outer quadrant (46.0%), with an equal propensity to occur in either breast (48.8% vs. 50.0%). The pathologic diagnoses included 131 benign, 12 borderline, and 29 malignant lesions. Nineteen patients (11%) had a recurrence and three (1.7%) had metastases. The initial diagnosis of all 19 recurrent tumors were benign. Age, surgical approach, mitotic activity, and surgical margin were significantly correlated with recurrence (P = 0.029, 0.020, 0.048, and 0.00018, respectively). Stromal cellularity, stromal overgrowth, stromal atypia, mitotic activity, tumor margin, and heterologous stromal elements were significantly correlated with metastases (P = 0.032, 0.00008, 0.000002, 0.004, 0.005, and 0.046, respectively). Mammography and breast echo were not reliable for differentiating PTs from fibroadenomas (6.9% vs. 37.9% and 3.3% vs. 45%, respectively). Frozen section was of limited value (41.6%). The role of adjuvant radiotherapy and chemotherapy remains to be defined. Local excision, wide excision, or mastectomy with negative surgical margins yielded high local control rates (88.7%, 88.2%, and 100%, respectively), but local excision was associated with a relatively high percentage of positive surgical margins (18.3%). A total of 42 modified radical mastectomies were performed. The reasons for these procedures included a diagnosis of malignancy on frozen section or because the tumors were so large, they were assumed to be carcinomas. No axillary lymph node metastases were found. Fifteen patients in our series had tumors with infiltrating tumor margin, severe stromal overgrowth, atypia, and cellularity. All three patients with metastases (3/15) were in this group. Presence of metastases was significantly correlated with this group (P = 0.0000038). Conclusions Wide excision with a clear margin may be the preferable initial therapy, even for malignant PTs. Routine axillary lymph node dissection is not recommended. Patients have tumors with infiltrating tumor margin, severe stromal overgrowth, atypia, and cellularity are at high risk for metastases. J. Surg. Oncol. 2005;91:185–194. © 2005 Wiley-Liss, Inc.

AIM: To determine whether routine nasogastric (NG) decompression benefitted patients undergoing radical gastric surgery. METHODS: Between January 1998 and December 2008, 519 patients who underwent distal gastrectomy for gastric cancer were retrospectively divided into 2 time-period cohorts; those treated with Billroth II (BII) reconstruction in the first 6 years and those with Roux-en-Y (RY) reconstruction in the last 5 years. In the latter group, the patients were further divided into 2 subgroups; with and without nasogastric decompression. RESULTS: Postoperatively, there were no significant differences in the number of anastomotic leaks between the 3 groups. In the tubeless RY group, time to semi-liquid diet was significantly shorter than in the other 2 groups (4.4 d ± 1.4 d vs 7.2 d ± 1.3 d and 5.9 d ± 1.2 d, P = 0.005). The length of postoperative stay was significantly increased in patients with BII reconstruction compared with patients with RY reconstruction with/without NG decompression (15.4 d ± 4.3 d in BIIgroup vs 12.6 d ± 3.1 d in decompressed RY and 11.4 d ± 3.4 d in the tubeless RY group, P = 0.035). The postoperative pneumonia rate was lowest in the tubeless group and highest in the BII group (1.4% vs 4.6%, P = 0.01). Severe sore throat was noted in 59 (20.7%) members of the BII group, 18 (17.4%) members of the decompressed RY group and 6 (4.2%) members of the tubeless RY group. Fewer patients in the tubeless group complained of severe sore throat (P = 0.001). CONCLUSION: This study provides support for abandoning routine NG decompression in patients undergoing subtotal gastrectomy with Roux-en-Y gastrojejunostomy.

To investigate the clinical characteristics of a coexisting sharp ductal angulation (90 degrees) with biliary stricture and to evaluate the difficulties it imposes in the management of retained or recurrent hepatolithiasis.Case-controlled study.A referral center.Eighteen consecutive patients having right-sided hepatolithiasis and a coexisting sharp ductal angulation associated with biliary stricture (group 1) were compared with 84 patients matched with sex, age, and conditions of hepatolithiasis and intrahepatic biliary stricture(s) but no sharp angulated duct (group 2).Postoperative cholangioscopic management (electrohydraulic lithotripsy or other lithotripsy, lithotomy, balloon dilation, biopsy, etc, via T-tube tract or percutaneous transhepatic route).Sessions of manipulations, incidence of complications associated with interventions or disease, and mortality were compared.Patients of group 1 needed more sessions of postoperative manipulation of stones and strictures (13.7 +/- 4.2 vs 8.0 +/- 2.3; P.001). During management, there was a significantly increased vulnerability of severe and/or recurrent cholangitis (66.7% vs 9.5%; P.001), septic shock (77.8% vs 11.9%; P.001), liver abscess (55.6% vs 7.1%; P.001), or massive hemobilia (33.3% vs 7.4%) in group 1 than in group 2. Their risks of coexisting secondary biliary cirrhosis (55.6% vs 9.5%; P.001) and/or cholangiocarcinoma (16.6% vs 2.4%; P.04) and mortality (27.8% vs 4.8%; P.01) were also significantly higher in group 1.Our results suggest that the coexisting sharp ductal angulation with biliary strictures in right-sided hepatolithiasis is a distinct difficult clinical entity in the field of biliary tract calculi.

Background Complete resection seemed to be curative in patients with Castleman disease of any location but the disease is likely to be reactive in its pathogenesis. The relation between Epstein-Barr virus and Castleman disease has not been elucidated. We tried to define the role of Epstein-Barr virus in the pathogenesis of Castleman disease. Methods 20 cases of Castleman disease were retrospectively reviewed from 1993 to 2006. At least 2 to 4 representative sections of formalin-fixed, paraffin-embedded specimens from each patient were obtained to examine the presence of EBV and its localization by hematoxylin-eosin stain, immunohistochemistry, polymerase chain reaction and In-situ hybridization Results Hyaline-vascular type was diagnosed in 18 cases, plasma cell type in 1 and mixed type in 1 case. All of them were positive for Epstein-Barr virus confirmed by PCR. For tumors that EBER(Epstein-Barr early region) signals mainly localized in the germinal centers have increased vascularity than cases with EBER detected in inter-follicular areas. Conclusion There is a strong association between Castleman disease and Epstein-Barr virus. EBV may have a potential role in angiogenesis of Castleman disease. For smaller lesion with high activity of angiogenesis but not amenable for curative resection, anti-angiogenesis medications may have a potential role to control the disease.

Summary Postoperative ileus is among the most common complications after surgery. Aging is associated with an increased colonic transit time, and anesthetic disturbance to colonic motility is often aggravated in the elderly. Postoperative ileus increases morbidity, prolongs the length of hospital stay, and constitutes a significant economic burden on the healthcare system. Multimodal enhanced recovery protocols, or fast-track surgeries, have been developed to improve postoperative recovery. Patient education, avoidance of perioperative fluid overload, selective use of nasogastric decompression, early ambulation, adopting a minimally invasive approach, early initiation of clear fluids, and gum chewing are all possible measures to reduce postoperative ileus. Thoracic epidural anesthesia is a well-established technique to hasten recovery, whereas insufficient data are available to ascertain the safety and efficacy of opioid-sparing analgesia in the elderly. The evidence is clear that traditional prokinetic medications are not helpful in the treatment or prevention of postoperative ileus. Early results suggest that alvimopan is a promising agent to reverse opioid-induced ileus. Since postoperative ileus is a multifactorial condition, a concerted effort is therefore necessary to prevent or decrease the duration of postoperative ileus using multimodal strategies.