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Papers by edgar sy

Research paper thumbnail of Hirschsprung's disease, a rare precipitating factor in neonatal perforated Meckel's diverticulum

Journal of Pediatric Surgery, Jul 1, 2006

Perforation of Meckel's diverticulum (MD) during the neonatal period may occur in the presence of... more Perforation of Meckel's diverticulum (MD) during the neonatal period may occur in the presence of distal colon obstruction. Herein, we describe a unique case of a 2-day-old infant that presented with pneumoperitoneum, in which a perforated MD was induced by distal intestinal obstruction secondary to total colonic aganglionosis. In the setting of neonatal perforated MD found intraoperatively, the determination of the possible precipitating etiology is necessary. The clinical history of delayed passage of meconium is emphasized, and either a rectal or colon biopsy is recommended intraoperatively to avoid overlooking the associated presence of Hirschsprung's disease.

Research paper thumbnail of Superior mesentery artery syndrome in post-spinal cord injury masquerading as peptic ulcer disease

Research paper thumbnail of Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy

PubMed, Oct 1, 2004

Background and purpose: Pylorus-preserving pancreaticoduodenectomy is associated with a high inci... more Background and purpose: Pylorus-preserving pancreaticoduodenectomy is associated with a high incidence of delayed gastric emptying. The aim of this study was to determine the incidence and risk factors for delayed gastric emptying after this procedure. Methods: This retrospective study included 63 consecutive patients who received pylorus-preserving pancreaticoduodenectomy from July 1993 to December 2002. The patients were divided into 2 groups based on the presence of delayed gastric emptying. Preoperative indices, postoperative morbidity, nasogastric intubation, and hospital stay were compared. The risk factors for delayed gastric emptying were analyzed. Results: The postoperative incidence of delayed gastric emptying was 44% (28/63 patients). Multivariate analysis revealed that no preoperative biliary drainage, no cholestatic change in the liver and blood loss > 400 mL were significant risk factors for delayed gastric emptying. Conclusions: Pylorus-preserving pancreaticoduodenectomy is a safe procedure with a high incidence of delayed gastric emptying. Delicate surgical dissection to decrease blood loss and the extent of perigastric inflammation may be the key factor to prevent delayed gastric emptying.

Research paper thumbnail of Immature intrinsic nerve innervations of pyloric muscle in idiopathic hypertrophic pyloric stenosis

PubMed, Jul 1, 2004

Background and purpose: Various etiologies have been suggested to be responsible for the developm... more Background and purpose: Various etiologies have been suggested to be responsible for the development of idiopathic hypertrophic pyloric stenosis (IHPS) in the newborn. The purpose of this study was to determine the maturity of intrinsic nerves and nitrergic neurons in the pyloric muscle in IHPS. Methods: Full thickness pyloric muscle specimens were obtained from 6 infants with IHPS with age ranging from 27 to 95 (mean 58) days old and subjected to immunohistochemical and double chemiluminescence staining for protein gene product 9.5 (PGP9.5) and neuronal nitric oxide synthase (nNOS). Results: The results showed absence of myenteric plexus between the circular and longitudinal muscle layers in 2 patients, decrease in 1 patient, normal myenteric plexus in 1 patient, and absence of nNOS-containing neurons in 4 patients. All 6 patients had expression of markers for supporting nerve cells and myogenesis in the pyloric smooth muscle. Conclusions: These results suggest that absence or immaturity of intrinsic nerve and nNOS-containing neurons in the pyloric muscle is the cause of IHPS. The demonstrated lack of innervation or delayed innervation may be the responsible mechanism for the development of IHPS, but further study is needed to elucidate the pathogenesis.

Research paper thumbnail of A Simple Method of Intracorporeal “W-shaped” Liver Retraction Technique for Minimally Invasive Gastric Cancer Surgery

Surgical laparoscopy, endoscopy & percutaneous techniques, Jun 1, 2019

Background: Minimally invasive gastric cancer surgery requires an extended liver retraction in or... more Background: Minimally invasive gastric cancer surgery requires an extended liver retraction in order to provide optimal operative view, working space for lymph node dissection, and esophageojejunal reconstruction. Ideally, it should avoid reposition of the retractor, additional skin incision or puncture, and liver parenchyma injury. Herein, we introduced an intracorporeal W-shaped liver retraction technique (W-LRT) for minimally invasive gastric cancer surgery without an additional incision or abodminal puncture. Methods: Between October 2013 and October 2016, the W-LRT was applied in 80 patients undergoing minimally invasive gastric cancer surgery. The W-LRT was performed using one 75 cm 3-0 monocryl suture with its end fixed to one hemoclip. The perioperative outcome was recorded. Results: The W-LRT was applied in 80 gastric cancer patients using either laparoscopic approach (N = 69) or robotic approach (N = 11). The mean age was 62.7 ± 14 years and the mean body mass index (BMI) was 24.1 ± 3.6 kg/m 2. The time required for W-LRT was 5.6 ± 5.2 minutes in laparoscopic approach and 6.2 ± 4.7 minutes in robotic approach. This technique was successfully applied in all procedures and no other technique or additional instrument was required. Major complications developed in 7 patients (8.8%), classified as greater than Clavien-Dindo classification II; however, there was neither any intraoperative nor postoperative major complication related to W-LRT. The length of hospital stay was 9.1 ± 4.4 days. Conclusions: In laparoscopic or robotic gastric cancer surgery, the W-LRT can provide excellent operative view during lymph node dissection and reconstruction of esophagojejunostomy and eliminate an additional skin incision or abdominal puncture.

Research paper thumbnail of Acute Mesenteric Venous Occlusion in Patients with Warfarin: Warfarin Therapy May Complicate the Diagnosis of Intestinal Vascular Complications

Formosan Journal of Surgery, 2005

Many intra-abdominal complications are associated with the usage of warfarin, including hematoma ... more Many intra-abdominal complications are associated with the usage of warfarin, including hematoma or hemorrhage within the gastrointestinal tract; however, acute mesenteric venous occlusion is a rare condition with an indolent course. Due to its nonspecific clinical presentation and laboratory results, it presents a great challenge for diagnosis. In this report, five patients on long-term anticoagulant therapy developed acute abdomen with small bowel dilatation initially. Acute mesenteric venous occlusion with focal small bowel wall thickening was suspected with computed tomography, and later shown by laparotomy. Associated pathology included mesenteric hematoma and intramural hemorrhage. Though the anticoagulant was still given to prevent thromboembolic events, the postoperative course was uneventful. Patients on long-term anticoagulant therapy may present a complex diagnosis of gastrointestinal vascular disease, so a high index of suspicion is important for early diagnosis and prom...

Research paper thumbnail of Hirschsprung's disease, a rare precipitating factor in neonatal perforated Meckel's diverticulum

Journal of Pediatric Surgery, 2006

Perforation of Meckel's diverticulum (MD) during the neonatal period may occur in the presence of... more Perforation of Meckel's diverticulum (MD) during the neonatal period may occur in the presence of distal colon obstruction. Herein, we describe a unique case of a 2-day-old infant that presented with pneumoperitoneum, in which a perforated MD was induced by distal intestinal obstruction secondary to total colonic aganglionosis. In the setting of neonatal perforated MD found intraoperatively, the determination of the possible precipitating etiology is necessary. The clinical history of delayed passage of meconium is emphasized, and either a rectal or colon biopsy is recommended intraoperatively to avoid overlooking the associated presence of Hirschsprung's disease.

Research paper thumbnail of Obscure gastrointestinal bleeding due to Meckel’s diverticulum: unusual capsule endoscopic finding as polyp-like lesion

Research paper thumbnail of Immature intrinsic nerve innervations of pyloric muscle in idiopathic hypertrophic pyloric stenosis

Journal of the Formosan Medical Association = Taiwan yi zhi, 2004

BACKGROUND AND PURPOSE Various etiologies have been suggested to be responsible for the developme... more BACKGROUND AND PURPOSE Various etiologies have been suggested to be responsible for the development of idiopathic hypertrophic pyloric stenosis (IHPS) in the newborn. The purpose of this study was to determine the maturity of intrinsic nerves and nitrergic neurons in the pyloric muscle in IHPS. METHODS Full thickness pyloric muscle specimens were obtained from 6 infants with IHPS with age ranging from 27 to 95 (mean 58) days old and subjected to immunohistochemical and double chemiluminescence staining for protein gene product 9.5 (PGP9.5) and neuronal nitric oxide synthase (nNOS). RESULTS The results showed absence of myenteric plexus between the circular and longitudinal muscle layers in 2 patients, decrease in 1 patient, normal myenteric plexus in 1 patient, and absence of nNOS-containing neurons in 4 patients. All 6 patients had expression of markers for supporting nerve cells and myogenesis in the pyloric smooth muscle. CONCLUSIONS These results suggest that absence or immaturi...

Research paper thumbnail of Pneumatic colon injury following high pressure blow gun dust cleaner spray to the perineum

International Journal of Surgery Case Reports, 2015

INTRODUCTION: A pneumatic tool or air tool such as blow gun dust cleaner is a tool driven by comp... more INTRODUCTION: A pneumatic tool or air tool such as blow gun dust cleaner is a tool driven by compressed air and spraying of the perineum can insufflate the colon due to its high pressure and high flow rate. PRESENTATION OF CASE: We present a case of 4 year old boy who developed sudden onset of tense abdominal distention and developed peritonitis. Patient's family initially denied a history of trauma. Radiologic examination showed pneumoperitoneum and colon dilatation. Exploratory laparotomy revealed a tension pneumoperitoneum, bloody ascitic fluid, multiple site of ecchymosis and serosal tear of the colon and a minute perforation of transverse colon. Postoperative reinvestigation revealed that the patient's perineum was sprayed, using blow gun dust cleaner. DISCUSSION: Air from pneumatic tools produces column of air at pressure of 3.5-8.8 kg/cm 2 and pressure greater than the resting anal pressure of 0.109 kg/cm 2 force air to enter the colon when the perineum is sprayed. Different degree of colon injury results when airflow is greater than 1.46 L/m, and/or intraluminal pressure greater than 0.109 kg/cm 2. In most children, initial anxiety to tell the truth result in difficulty to obtain good history. CONCLUSION: Spraying of the perianal with excessive pneumatic force of greater than the resting anal pressure and high air flow rate causes multiple site colon injury and tension pneumoperitoneum due to colon perforation. Parent should be caution in children playing with high pressure pneumatic tool, and the importance of history is emphases for early correct diagnosis.

Research paper thumbnail of IS-024 Meckel diverticulum : Surgical management based on the timing of diagnosis and pathology(International Session VI,Better Life for Sick Children, Better Future for Pediatric Surgery,the 45th Annual Meeting of Japanese Society of Pediatric Surgeons)

Journal of the Japanese Society of Pediatric Surgeons, 2008

Research paper thumbnail of Laparoscopic Splenic Vessels and Spleen Preservation Distal Pancreatectomy Via Inferior-Posterior Splenic Vein Approach

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2020

Background: Preservation of splenic vessels can minimize the risks of splenic infarction and gast... more Background: Preservation of splenic vessels can minimize the risks of splenic infarction and gastric varices in laparoscopic spleen preserving distal pancreatectomy. A well-established procedure would provide high splenic vessels and spleen preservation rate. This study evaluated the outcomes and depending factors of laparoscopic splenic vessels and spleen preservation distal pancreatectomy (LsvspDP) via inferior-posterior splenic vein approach. Materials and Methods: This retrospective study enrolled patients who underwent LsvspDP via inferior-posterior splenic vein approach in National Cheng-Kung University Hospital from February 2009 to June 2019. The clinic-pathologic data were collected and analyzed. The primary outcome of this study was the learning curve based on the cumulative sum analysis. The secondary outcomes were to evaluate the critical factors for the failure of splenic vessels and spleen preservation. Results: During the study period, a total of 64 patients received LsvspDP attempt. Splenic vessels were successfully preserved in 49 patients and the overall spleen preservation rate was 76.6%. According to cumulative sum analysis, the learning curve of LsvspDP was the 33rd case and several plateaus were observed during the learning curve phase. Old age (P=0.001), tail location (P=0.038), and large tumor (P=0.01) were independent risk factors of failed splenic vessels preservation, whereas the cut-off point of tumor size for prediction of spleen preservation was 5.4 cm. The complication rates were 7.8%, 7.8%, and 12.5% for Clavien grade I, II, and III, respectively, and 0% for Clavien grade IV or V. The rate of postoperative pancreatic fistula-grade B was 14.8%, among which the tail location was lower than the nontail location (0% vs. 24.3%; P=0.008). The mean value of operative time, blood loss, and hospital stay were 198±67 minutes, 139±242 mL, and 8.5±5.6 days, respectively. Conclusions: In LsvspDP, the inferior-posterior splenic vein approach resulted in high splenic vessels and spleen preservation rate. Thirty-three patients were required to overcome the learning curve. Old age, tail location, and large tumor size were independent factors for the failure of splenic vessels preservation, whereas the cut-off value for tumor size was 5.4 cm to predict splenic vessels preservation.

Research paper thumbnail of Burkitt's lymphoma presenting as ovarian mass and ileocecal intussusception in an adult

Formosan Journal of Surgery, 2018

Burkitt's lymphoma (BL) is usually diagnosed in children and young adults. Adults with Burkit... more Burkitt's lymphoma (BL) is usually diagnosed in children and young adults. Adults with Burkitt's lymphoma, particularly those with advanced stage disease, present with poorer prognosis compared to children and very rarely as multiorgan tumors. Involvement of the gastrointestinal (GI) tract presents with GI tract symptoms and can cause intussusception. Herein, we report a 42-year-old, chronic schizophrenic woman, presenting with lower GI bleeding secondary to intussusception, and the radiologic study revealed multiple site organs involvement including terminal ileum, cecum, and bilateral ovaries. She underwent optimal cytoreduction procedure, bilateral salpingo-oophorectomy and radical right hemicolectomy with ileocolostomy, and adjuvant multiagents chemotherapy postoperatively with the regimen of CODOX-M/IVAC for four courses without radiologic evidence of tumor recurrence after a 6-year follow-up.

Research paper thumbnail of Vitelline fistula associated with omphalocele: Diagnostic dilemma?

International Journal of Surgery Case Reports, 2018

INTRODUCTION: Combination vitelline fistula (VF) and omphalocele at birth is a rare congenital an... more INTRODUCTION: Combination vitelline fistula (VF) and omphalocele at birth is a rare congenital anomaly as a result disturbance in organogenesis with failure of normal return of intestines into the abdominal cavity and failed obliteration of the vitelline duct. CASE PRESENTATION: A newborn presented with omphalocele sac with visible intestine, stoma like lesion with prolapsing mucosa just lateral to the umbilical cord and passage of meconium stool. Operative surgery was confirmed an intact omphalocele sac and vitelline fistula. Fistulectomy, using wedge resection of the small bowel and primary closure abdominal wall defect. DISCUSSION: In our review of literature, VF associated with omphalocele had not been reported. Combination of anomaly maybe misleading, however, can be easily diagnosed the location of VF opening on the omphalocele sac, which is adjacent to the umbilical cord and luminal passage of meconium stool after birth. A fistulogram may be the best initial diagnostic imaging approach for identifying and confirmation of a fistula tract. CONCLUSION: VF associated with omphalocele is rare. Post-natal diagnosis is easily by gross appearance stoma like lesion, which is located just lateral of the umbilical cord, an intact omphalocele sac and postnatal meconium stool passage.

Research paper thumbnail of Effects of duodenal–jejunal bypass surgery in ameliorating nonalcoholic steatohepatitis in diet-induced obese rats

Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 2019

Background: Duodenal-jejunal bypass (DJB) is an important component of many types of current bari... more Background: Duodenal-jejunal bypass (DJB) is an important component of many types of current bariatric surgery including Roux-en-Y gastric bypass, mini-gastric bypass, biliopancreatic diversion, duodenal switch, and DJB plus sleeve gastrectomy. Surgery is often observed to ameliorate nonalcoholic steatohepatitis (NASH), but without a clearly delineated mechanism. In this study, we investigated the effects of DJB in diet-induced obese rats with NASH. Materials and methods: Male Wistar rats were divided into four groups and fed the following diets over 6 months: A) normal chow (NC group, n=6); B) methionine-choline-deficient (MCD)-high-fat (HF) diet (HF group, n=6); C) MCD-HF diet for 3 months followed by DJB and MCD-HF diet for subsequent 3 months (DJB group, n=6); and D) MCD-HF diet for 3 months followed by treatment with pioglitazone (PGZ) with MCD-HF diet for subsequent 3 months (PGZ group, n=6). Body weight, glucose tolerance, the homeostatic model assessment-insulin resistance index, and lipid profiles were compared. Liver and visceral adipose tissue histology, inflammatory marker and hepatic stellate cell (HSC) activity, and hepatocyte autophagy were assessed. Results: Compared with the HF group, the DJB group showed improved body weight, insulin sensitivity, lipid metabolism, and steatosis severity. The DJB group exhibited a significantly lower nonalcoholic fatty liver disease activity score than the HF and PGZ group (P<0.001 and P=0.003, respectively). Furthermore, DJB significantly reduced fat mass and adipocyte size. These effects were also observed in the PGZ group. Therefore, we speculated that the improvements induced by DJB are closely related to an alteration in insulin sensitivity. Moreover, DJB reduced HSC activity and TNF-α expression and enhanced hepatocyte autophagy. Conclusion: DJB improves NASH through several mechanisms, particularly by altering insulin sensitivity, inflammatory responses, HSC activity, and hepatocyte autophagy.

Research paper thumbnail of Metaplastic breast carcinoma with multiple muscle metastasis: a case report

Medicine, 2015

Metaplastic breast carcinoma (MBC) is a rare type of breast carcinoma. Recurrence presenting as c... more Metaplastic breast carcinoma (MBC) is a rare type of breast carcinoma. Recurrence presenting as chest wall invasion is common but rarely as metastasis to distal skeletal muscle in which most patients present with a painful mass. Herein, we report a rare case of 65-year-old woman, with MBC and recurrence presenting as distal multiple muscle metastasis. The patient received surgical excision for symptomatic relief. Unfortunately, she died 12 months postoperatively due to disease progression with multiple lung metastasis.In addition to radiotherapy and chemotherapy, surgical excision is an alternative option in selected patients such as those with painful, isolated, and easily approachable mass.

Research paper thumbnail of Predictors for resectability and survival in locally advanced pancreatic cancer after gemcitabine-based neoadjuvant therapy

BMC surgery, 2014

To evaluate the predictors for resectability and survival of patients with locally advanced pancr... more To evaluate the predictors for resectability and survival of patients with locally advanced pancreatic cancer (LAPC) treated with gemcitabine-based neoadjuvant therapy (GBNAT). Between May 2003 and Dec 2009, 41 tissue-proved LAPC were treated with GBNAT. The location of pancreatic cancer in the head, body and tail was 17, 18 and 6 patients respectively. The treatment response was evaluated by RECIST criteria. Surgical exploration was based on the response and the clear plan between tumor and celiac artery/superior mesentery artery. Kaplan-Meier analysis and Cox Model were used to calculate the resectability and survival rates. Finally, 25 patients received chemotherapy (CT) and 16 patients received concurrent chemoradiation therapy (CRT). The response rate was 51% (21 patients), 2 CR (1 in CT and 1 in CRT) and 19 PR (10 in CT and 9 in CRT). 20 patients (48.8%) were assessed as surgically resectable, in which 17 (41.5%) underwent successful resection with a 17.6% positive-margin rate...

Research paper thumbnail of Chronic Hemosuccus Pancreaticus: A Rare Complication of Pancreatic Microcystic Adenoma Successfully Treated with Whipple's Procedure

Research paper thumbnail of Reduction of intrinsic inhibitory enteric neurons in the antropyloric area in PPPD patients with delayed gastric emptying

Hepato-gastroenterology

Intrinsic inhibitory enteric neurons are considered to play an important role in the regulation o... more Intrinsic inhibitory enteric neurons are considered to play an important role in the regulation of antropyloroduodenum coordination for gastric emptying. This study is designed to investigate the change of enteric neurons in the pylorus and antrum muscle in PPPD patients who have delayed gastric emptying. Muscle strips of the pylorus and antrum from 6 normal and 2 PPPD patients with delayed gastric emptying were used for contraction study, immunohistochemical staining for enteric neurons, and western blotting for expression of neuropeptides. Under the stimulation of carbachol, the contraction profile of the muscle strip from patients who had PPPD was different from those of the normal strips: muscle power of the ED50 of the pylorus/antrum were 1270mg/1400mg in normal strips, 400mg/1000mg in case 1, and 50mg/500mg in case 2. The frequency of muscle contraction was 3 times per minute in the normal strips, but 2.5 and 2 times per minutes in case 1 and case 2. From immunohistochemical s...

Research paper thumbnail of The significance of CD44 expression in gastrointestinal neuroendocrine tumors

Hepato-gastroenterology

Expression of CD44 and its isoforms has been demonstrated to be a prognostic marker in many neopl... more Expression of CD44 and its isoforms has been demonstrated to be a prognostic marker in many neoplasms. Gastrointestinal neuroendocrine tumor is a slow-growing neoplasm, whose behavior is determined by site of occurrence, size or specific histologic growth pattern. In this study, the feasibility of using CD44 as a prognostic marker in gastrointestinal neuroendocrine tumor is evaluated. Representative paraffin-embedded sections of gastrointestinal neuroendocrine tumor from 22 patients were studied by immunohistochemical staining using monoclonal antibodies against CD44, Ki-67, and p53 retrospectively. The correlation between these markers and clinical behavior of the tumors was analyzed. Positive expression of CD44 was observed in 15 cases (68%) of gastrointestinal neuroendocrine tumor. Expression of CD44 showed significant inverse correlation with lymph node status (P=0.049), distant metastasis (p<0.001) and mortality (p=0.002). Neither p53 nor Ki-67 correlated with lymph node sta...

Research paper thumbnail of Hirschsprung's disease, a rare precipitating factor in neonatal perforated Meckel's diverticulum

Journal of Pediatric Surgery, Jul 1, 2006

Perforation of Meckel's diverticulum (MD) during the neonatal period may occur in the presence of... more Perforation of Meckel's diverticulum (MD) during the neonatal period may occur in the presence of distal colon obstruction. Herein, we describe a unique case of a 2-day-old infant that presented with pneumoperitoneum, in which a perforated MD was induced by distal intestinal obstruction secondary to total colonic aganglionosis. In the setting of neonatal perforated MD found intraoperatively, the determination of the possible precipitating etiology is necessary. The clinical history of delayed passage of meconium is emphasized, and either a rectal or colon biopsy is recommended intraoperatively to avoid overlooking the associated presence of Hirschsprung's disease.

Research paper thumbnail of Superior mesentery artery syndrome in post-spinal cord injury masquerading as peptic ulcer disease

Research paper thumbnail of Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy

PubMed, Oct 1, 2004

Background and purpose: Pylorus-preserving pancreaticoduodenectomy is associated with a high inci... more Background and purpose: Pylorus-preserving pancreaticoduodenectomy is associated with a high incidence of delayed gastric emptying. The aim of this study was to determine the incidence and risk factors for delayed gastric emptying after this procedure. Methods: This retrospective study included 63 consecutive patients who received pylorus-preserving pancreaticoduodenectomy from July 1993 to December 2002. The patients were divided into 2 groups based on the presence of delayed gastric emptying. Preoperative indices, postoperative morbidity, nasogastric intubation, and hospital stay were compared. The risk factors for delayed gastric emptying were analyzed. Results: The postoperative incidence of delayed gastric emptying was 44% (28/63 patients). Multivariate analysis revealed that no preoperative biliary drainage, no cholestatic change in the liver and blood loss > 400 mL were significant risk factors for delayed gastric emptying. Conclusions: Pylorus-preserving pancreaticoduodenectomy is a safe procedure with a high incidence of delayed gastric emptying. Delicate surgical dissection to decrease blood loss and the extent of perigastric inflammation may be the key factor to prevent delayed gastric emptying.

Research paper thumbnail of Immature intrinsic nerve innervations of pyloric muscle in idiopathic hypertrophic pyloric stenosis

PubMed, Jul 1, 2004

Background and purpose: Various etiologies have been suggested to be responsible for the developm... more Background and purpose: Various etiologies have been suggested to be responsible for the development of idiopathic hypertrophic pyloric stenosis (IHPS) in the newborn. The purpose of this study was to determine the maturity of intrinsic nerves and nitrergic neurons in the pyloric muscle in IHPS. Methods: Full thickness pyloric muscle specimens were obtained from 6 infants with IHPS with age ranging from 27 to 95 (mean 58) days old and subjected to immunohistochemical and double chemiluminescence staining for protein gene product 9.5 (PGP9.5) and neuronal nitric oxide synthase (nNOS). Results: The results showed absence of myenteric plexus between the circular and longitudinal muscle layers in 2 patients, decrease in 1 patient, normal myenteric plexus in 1 patient, and absence of nNOS-containing neurons in 4 patients. All 6 patients had expression of markers for supporting nerve cells and myogenesis in the pyloric smooth muscle. Conclusions: These results suggest that absence or immaturity of intrinsic nerve and nNOS-containing neurons in the pyloric muscle is the cause of IHPS. The demonstrated lack of innervation or delayed innervation may be the responsible mechanism for the development of IHPS, but further study is needed to elucidate the pathogenesis.

Research paper thumbnail of A Simple Method of Intracorporeal “W-shaped” Liver Retraction Technique for Minimally Invasive Gastric Cancer Surgery

Surgical laparoscopy, endoscopy & percutaneous techniques, Jun 1, 2019

Background: Minimally invasive gastric cancer surgery requires an extended liver retraction in or... more Background: Minimally invasive gastric cancer surgery requires an extended liver retraction in order to provide optimal operative view, working space for lymph node dissection, and esophageojejunal reconstruction. Ideally, it should avoid reposition of the retractor, additional skin incision or puncture, and liver parenchyma injury. Herein, we introduced an intracorporeal W-shaped liver retraction technique (W-LRT) for minimally invasive gastric cancer surgery without an additional incision or abodminal puncture. Methods: Between October 2013 and October 2016, the W-LRT was applied in 80 patients undergoing minimally invasive gastric cancer surgery. The W-LRT was performed using one 75 cm 3-0 monocryl suture with its end fixed to one hemoclip. The perioperative outcome was recorded. Results: The W-LRT was applied in 80 gastric cancer patients using either laparoscopic approach (N = 69) or robotic approach (N = 11). The mean age was 62.7 ± 14 years and the mean body mass index (BMI) was 24.1 ± 3.6 kg/m 2. The time required for W-LRT was 5.6 ± 5.2 minutes in laparoscopic approach and 6.2 ± 4.7 minutes in robotic approach. This technique was successfully applied in all procedures and no other technique or additional instrument was required. Major complications developed in 7 patients (8.8%), classified as greater than Clavien-Dindo classification II; however, there was neither any intraoperative nor postoperative major complication related to W-LRT. The length of hospital stay was 9.1 ± 4.4 days. Conclusions: In laparoscopic or robotic gastric cancer surgery, the W-LRT can provide excellent operative view during lymph node dissection and reconstruction of esophagojejunostomy and eliminate an additional skin incision or abdominal puncture.

Research paper thumbnail of Acute Mesenteric Venous Occlusion in Patients with Warfarin: Warfarin Therapy May Complicate the Diagnosis of Intestinal Vascular Complications

Formosan Journal of Surgery, 2005

Many intra-abdominal complications are associated with the usage of warfarin, including hematoma ... more Many intra-abdominal complications are associated with the usage of warfarin, including hematoma or hemorrhage within the gastrointestinal tract; however, acute mesenteric venous occlusion is a rare condition with an indolent course. Due to its nonspecific clinical presentation and laboratory results, it presents a great challenge for diagnosis. In this report, five patients on long-term anticoagulant therapy developed acute abdomen with small bowel dilatation initially. Acute mesenteric venous occlusion with focal small bowel wall thickening was suspected with computed tomography, and later shown by laparotomy. Associated pathology included mesenteric hematoma and intramural hemorrhage. Though the anticoagulant was still given to prevent thromboembolic events, the postoperative course was uneventful. Patients on long-term anticoagulant therapy may present a complex diagnosis of gastrointestinal vascular disease, so a high index of suspicion is important for early diagnosis and prom...

Research paper thumbnail of Hirschsprung's disease, a rare precipitating factor in neonatal perforated Meckel's diverticulum

Journal of Pediatric Surgery, 2006

Perforation of Meckel's diverticulum (MD) during the neonatal period may occur in the presence of... more Perforation of Meckel's diverticulum (MD) during the neonatal period may occur in the presence of distal colon obstruction. Herein, we describe a unique case of a 2-day-old infant that presented with pneumoperitoneum, in which a perforated MD was induced by distal intestinal obstruction secondary to total colonic aganglionosis. In the setting of neonatal perforated MD found intraoperatively, the determination of the possible precipitating etiology is necessary. The clinical history of delayed passage of meconium is emphasized, and either a rectal or colon biopsy is recommended intraoperatively to avoid overlooking the associated presence of Hirschsprung's disease.

Research paper thumbnail of Obscure gastrointestinal bleeding due to Meckel’s diverticulum: unusual capsule endoscopic finding as polyp-like lesion

Research paper thumbnail of Immature intrinsic nerve innervations of pyloric muscle in idiopathic hypertrophic pyloric stenosis

Journal of the Formosan Medical Association = Taiwan yi zhi, 2004

BACKGROUND AND PURPOSE Various etiologies have been suggested to be responsible for the developme... more BACKGROUND AND PURPOSE Various etiologies have been suggested to be responsible for the development of idiopathic hypertrophic pyloric stenosis (IHPS) in the newborn. The purpose of this study was to determine the maturity of intrinsic nerves and nitrergic neurons in the pyloric muscle in IHPS. METHODS Full thickness pyloric muscle specimens were obtained from 6 infants with IHPS with age ranging from 27 to 95 (mean 58) days old and subjected to immunohistochemical and double chemiluminescence staining for protein gene product 9.5 (PGP9.5) and neuronal nitric oxide synthase (nNOS). RESULTS The results showed absence of myenteric plexus between the circular and longitudinal muscle layers in 2 patients, decrease in 1 patient, normal myenteric plexus in 1 patient, and absence of nNOS-containing neurons in 4 patients. All 6 patients had expression of markers for supporting nerve cells and myogenesis in the pyloric smooth muscle. CONCLUSIONS These results suggest that absence or immaturi...

Research paper thumbnail of Pneumatic colon injury following high pressure blow gun dust cleaner spray to the perineum

International Journal of Surgery Case Reports, 2015

INTRODUCTION: A pneumatic tool or air tool such as blow gun dust cleaner is a tool driven by comp... more INTRODUCTION: A pneumatic tool or air tool such as blow gun dust cleaner is a tool driven by compressed air and spraying of the perineum can insufflate the colon due to its high pressure and high flow rate. PRESENTATION OF CASE: We present a case of 4 year old boy who developed sudden onset of tense abdominal distention and developed peritonitis. Patient's family initially denied a history of trauma. Radiologic examination showed pneumoperitoneum and colon dilatation. Exploratory laparotomy revealed a tension pneumoperitoneum, bloody ascitic fluid, multiple site of ecchymosis and serosal tear of the colon and a minute perforation of transverse colon. Postoperative reinvestigation revealed that the patient's perineum was sprayed, using blow gun dust cleaner. DISCUSSION: Air from pneumatic tools produces column of air at pressure of 3.5-8.8 kg/cm 2 and pressure greater than the resting anal pressure of 0.109 kg/cm 2 force air to enter the colon when the perineum is sprayed. Different degree of colon injury results when airflow is greater than 1.46 L/m, and/or intraluminal pressure greater than 0.109 kg/cm 2. In most children, initial anxiety to tell the truth result in difficulty to obtain good history. CONCLUSION: Spraying of the perianal with excessive pneumatic force of greater than the resting anal pressure and high air flow rate causes multiple site colon injury and tension pneumoperitoneum due to colon perforation. Parent should be caution in children playing with high pressure pneumatic tool, and the importance of history is emphases for early correct diagnosis.

Research paper thumbnail of IS-024 Meckel diverticulum : Surgical management based on the timing of diagnosis and pathology(International Session VI,Better Life for Sick Children, Better Future for Pediatric Surgery,the 45th Annual Meeting of Japanese Society of Pediatric Surgeons)

Journal of the Japanese Society of Pediatric Surgeons, 2008

Research paper thumbnail of Laparoscopic Splenic Vessels and Spleen Preservation Distal Pancreatectomy Via Inferior-Posterior Splenic Vein Approach

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2020

Background: Preservation of splenic vessels can minimize the risks of splenic infarction and gast... more Background: Preservation of splenic vessels can minimize the risks of splenic infarction and gastric varices in laparoscopic spleen preserving distal pancreatectomy. A well-established procedure would provide high splenic vessels and spleen preservation rate. This study evaluated the outcomes and depending factors of laparoscopic splenic vessels and spleen preservation distal pancreatectomy (LsvspDP) via inferior-posterior splenic vein approach. Materials and Methods: This retrospective study enrolled patients who underwent LsvspDP via inferior-posterior splenic vein approach in National Cheng-Kung University Hospital from February 2009 to June 2019. The clinic-pathologic data were collected and analyzed. The primary outcome of this study was the learning curve based on the cumulative sum analysis. The secondary outcomes were to evaluate the critical factors for the failure of splenic vessels and spleen preservation. Results: During the study period, a total of 64 patients received LsvspDP attempt. Splenic vessels were successfully preserved in 49 patients and the overall spleen preservation rate was 76.6%. According to cumulative sum analysis, the learning curve of LsvspDP was the 33rd case and several plateaus were observed during the learning curve phase. Old age (P=0.001), tail location (P=0.038), and large tumor (P=0.01) were independent risk factors of failed splenic vessels preservation, whereas the cut-off point of tumor size for prediction of spleen preservation was 5.4 cm. The complication rates were 7.8%, 7.8%, and 12.5% for Clavien grade I, II, and III, respectively, and 0% for Clavien grade IV or V. The rate of postoperative pancreatic fistula-grade B was 14.8%, among which the tail location was lower than the nontail location (0% vs. 24.3%; P=0.008). The mean value of operative time, blood loss, and hospital stay were 198±67 minutes, 139±242 mL, and 8.5±5.6 days, respectively. Conclusions: In LsvspDP, the inferior-posterior splenic vein approach resulted in high splenic vessels and spleen preservation rate. Thirty-three patients were required to overcome the learning curve. Old age, tail location, and large tumor size were independent factors for the failure of splenic vessels preservation, whereas the cut-off value for tumor size was 5.4 cm to predict splenic vessels preservation.

Research paper thumbnail of Burkitt's lymphoma presenting as ovarian mass and ileocecal intussusception in an adult

Formosan Journal of Surgery, 2018

Burkitt's lymphoma (BL) is usually diagnosed in children and young adults. Adults with Burkit... more Burkitt's lymphoma (BL) is usually diagnosed in children and young adults. Adults with Burkitt's lymphoma, particularly those with advanced stage disease, present with poorer prognosis compared to children and very rarely as multiorgan tumors. Involvement of the gastrointestinal (GI) tract presents with GI tract symptoms and can cause intussusception. Herein, we report a 42-year-old, chronic schizophrenic woman, presenting with lower GI bleeding secondary to intussusception, and the radiologic study revealed multiple site organs involvement including terminal ileum, cecum, and bilateral ovaries. She underwent optimal cytoreduction procedure, bilateral salpingo-oophorectomy and radical right hemicolectomy with ileocolostomy, and adjuvant multiagents chemotherapy postoperatively with the regimen of CODOX-M/IVAC for four courses without radiologic evidence of tumor recurrence after a 6-year follow-up.

Research paper thumbnail of Vitelline fistula associated with omphalocele: Diagnostic dilemma?

International Journal of Surgery Case Reports, 2018

INTRODUCTION: Combination vitelline fistula (VF) and omphalocele at birth is a rare congenital an... more INTRODUCTION: Combination vitelline fistula (VF) and omphalocele at birth is a rare congenital anomaly as a result disturbance in organogenesis with failure of normal return of intestines into the abdominal cavity and failed obliteration of the vitelline duct. CASE PRESENTATION: A newborn presented with omphalocele sac with visible intestine, stoma like lesion with prolapsing mucosa just lateral to the umbilical cord and passage of meconium stool. Operative surgery was confirmed an intact omphalocele sac and vitelline fistula. Fistulectomy, using wedge resection of the small bowel and primary closure abdominal wall defect. DISCUSSION: In our review of literature, VF associated with omphalocele had not been reported. Combination of anomaly maybe misleading, however, can be easily diagnosed the location of VF opening on the omphalocele sac, which is adjacent to the umbilical cord and luminal passage of meconium stool after birth. A fistulogram may be the best initial diagnostic imaging approach for identifying and confirmation of a fistula tract. CONCLUSION: VF associated with omphalocele is rare. Post-natal diagnosis is easily by gross appearance stoma like lesion, which is located just lateral of the umbilical cord, an intact omphalocele sac and postnatal meconium stool passage.

Research paper thumbnail of Effects of duodenal–jejunal bypass surgery in ameliorating nonalcoholic steatohepatitis in diet-induced obese rats

Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 2019

Background: Duodenal-jejunal bypass (DJB) is an important component of many types of current bari... more Background: Duodenal-jejunal bypass (DJB) is an important component of many types of current bariatric surgery including Roux-en-Y gastric bypass, mini-gastric bypass, biliopancreatic diversion, duodenal switch, and DJB plus sleeve gastrectomy. Surgery is often observed to ameliorate nonalcoholic steatohepatitis (NASH), but without a clearly delineated mechanism. In this study, we investigated the effects of DJB in diet-induced obese rats with NASH. Materials and methods: Male Wistar rats were divided into four groups and fed the following diets over 6 months: A) normal chow (NC group, n=6); B) methionine-choline-deficient (MCD)-high-fat (HF) diet (HF group, n=6); C) MCD-HF diet for 3 months followed by DJB and MCD-HF diet for subsequent 3 months (DJB group, n=6); and D) MCD-HF diet for 3 months followed by treatment with pioglitazone (PGZ) with MCD-HF diet for subsequent 3 months (PGZ group, n=6). Body weight, glucose tolerance, the homeostatic model assessment-insulin resistance index, and lipid profiles were compared. Liver and visceral adipose tissue histology, inflammatory marker and hepatic stellate cell (HSC) activity, and hepatocyte autophagy were assessed. Results: Compared with the HF group, the DJB group showed improved body weight, insulin sensitivity, lipid metabolism, and steatosis severity. The DJB group exhibited a significantly lower nonalcoholic fatty liver disease activity score than the HF and PGZ group (P<0.001 and P=0.003, respectively). Furthermore, DJB significantly reduced fat mass and adipocyte size. These effects were also observed in the PGZ group. Therefore, we speculated that the improvements induced by DJB are closely related to an alteration in insulin sensitivity. Moreover, DJB reduced HSC activity and TNF-α expression and enhanced hepatocyte autophagy. Conclusion: DJB improves NASH through several mechanisms, particularly by altering insulin sensitivity, inflammatory responses, HSC activity, and hepatocyte autophagy.

Research paper thumbnail of Metaplastic breast carcinoma with multiple muscle metastasis: a case report

Medicine, 2015

Metaplastic breast carcinoma (MBC) is a rare type of breast carcinoma. Recurrence presenting as c... more Metaplastic breast carcinoma (MBC) is a rare type of breast carcinoma. Recurrence presenting as chest wall invasion is common but rarely as metastasis to distal skeletal muscle in which most patients present with a painful mass. Herein, we report a rare case of 65-year-old woman, with MBC and recurrence presenting as distal multiple muscle metastasis. The patient received surgical excision for symptomatic relief. Unfortunately, she died 12 months postoperatively due to disease progression with multiple lung metastasis.In addition to radiotherapy and chemotherapy, surgical excision is an alternative option in selected patients such as those with painful, isolated, and easily approachable mass.

Research paper thumbnail of Predictors for resectability and survival in locally advanced pancreatic cancer after gemcitabine-based neoadjuvant therapy

BMC surgery, 2014

To evaluate the predictors for resectability and survival of patients with locally advanced pancr... more To evaluate the predictors for resectability and survival of patients with locally advanced pancreatic cancer (LAPC) treated with gemcitabine-based neoadjuvant therapy (GBNAT). Between May 2003 and Dec 2009, 41 tissue-proved LAPC were treated with GBNAT. The location of pancreatic cancer in the head, body and tail was 17, 18 and 6 patients respectively. The treatment response was evaluated by RECIST criteria. Surgical exploration was based on the response and the clear plan between tumor and celiac artery/superior mesentery artery. Kaplan-Meier analysis and Cox Model were used to calculate the resectability and survival rates. Finally, 25 patients received chemotherapy (CT) and 16 patients received concurrent chemoradiation therapy (CRT). The response rate was 51% (21 patients), 2 CR (1 in CT and 1 in CRT) and 19 PR (10 in CT and 9 in CRT). 20 patients (48.8%) were assessed as surgically resectable, in which 17 (41.5%) underwent successful resection with a 17.6% positive-margin rate...

Research paper thumbnail of Chronic Hemosuccus Pancreaticus: A Rare Complication of Pancreatic Microcystic Adenoma Successfully Treated with Whipple's Procedure

Research paper thumbnail of Reduction of intrinsic inhibitory enteric neurons in the antropyloric area in PPPD patients with delayed gastric emptying

Hepato-gastroenterology

Intrinsic inhibitory enteric neurons are considered to play an important role in the regulation o... more Intrinsic inhibitory enteric neurons are considered to play an important role in the regulation of antropyloroduodenum coordination for gastric emptying. This study is designed to investigate the change of enteric neurons in the pylorus and antrum muscle in PPPD patients who have delayed gastric emptying. Muscle strips of the pylorus and antrum from 6 normal and 2 PPPD patients with delayed gastric emptying were used for contraction study, immunohistochemical staining for enteric neurons, and western blotting for expression of neuropeptides. Under the stimulation of carbachol, the contraction profile of the muscle strip from patients who had PPPD was different from those of the normal strips: muscle power of the ED50 of the pylorus/antrum were 1270mg/1400mg in normal strips, 400mg/1000mg in case 1, and 50mg/500mg in case 2. The frequency of muscle contraction was 3 times per minute in the normal strips, but 2.5 and 2 times per minutes in case 1 and case 2. From immunohistochemical s...

Research paper thumbnail of The significance of CD44 expression in gastrointestinal neuroendocrine tumors

Hepato-gastroenterology

Expression of CD44 and its isoforms has been demonstrated to be a prognostic marker in many neopl... more Expression of CD44 and its isoforms has been demonstrated to be a prognostic marker in many neoplasms. Gastrointestinal neuroendocrine tumor is a slow-growing neoplasm, whose behavior is determined by site of occurrence, size or specific histologic growth pattern. In this study, the feasibility of using CD44 as a prognostic marker in gastrointestinal neuroendocrine tumor is evaluated. Representative paraffin-embedded sections of gastrointestinal neuroendocrine tumor from 22 patients were studied by immunohistochemical staining using monoclonal antibodies against CD44, Ki-67, and p53 retrospectively. The correlation between these markers and clinical behavior of the tumors was analyzed. Positive expression of CD44 was observed in 15 cases (68%) of gastrointestinal neuroendocrine tumor. Expression of CD44 showed significant inverse correlation with lymph node status (P=0.049), distant metastasis (p<0.001) and mortality (p=0.002). Neither p53 nor Ki-67 correlated with lymph node sta...