Repairing large incisional hernia with abdominal wall reconstruction is a technically challenging problem for surgeons. We report our experience of large midline incisional hernia which was repaired successfully with components separation technique. A patient with incisional hernia, 35 x 20 cm in size, underwent operation following standard components separation technique. The aponeurosis of the external abdominal oblique muscle was longitudinally transected from the rectus sheath, and the external abdominal oblique muscle was separated from the internal abdominal oblique muscle. With further separation of the posterior rectus sheath from the rectus abdominis muscle, closure of the abdominal wall was attained without tension. The post-operative course was uneventful with minor wound seroma. The patient discharged safely, and no further complication in terms of recurrence and wound problem has occurred. Components separation technique could be a possible and effective treatment option for repair of large abdominal wall defect.
Abdominal Wall ; Hernia ; Hernia, Ventral ; Humans ; Muscles ; Rectus Abdominis ; Recurrence ; Seroma

Type 2 diabetes mellitus (T2DM) has become an epidemic. Compared to Western countries, Asian T2DM occurs in patients with a lower body mass index, due to central obesity and decreased pancreatic beta-cell function. The efficacy of surgical treatment such as sleeve gastrectomy, adjustable gastric banding, and gastric bypass in obese patients with T2DM has been demonstrated by numerous studies from Western countries. However, current evidence on surgical treatment for non-morbidly obese diabetic patients is lacking. Recently, several preliminary studies demonstrated the remission of hyperglycemia in non-obese T2DM patients by surgical bypass. One possible hypothesis is the foregut theory an inactivation of the anti-incretin system through the exclusion of the foregut from ingested food, and the other is the hindgut theory, in which rapid hindgut exposure prompts the delivery of undigested food to the terminal ileum and promotes the activation of incretin system such as glucagon-like peptide-1 The following teaching points and direction of future study are recommended: understanding the mechanism of diabetic remission through surgical procedure, defining the surgical indications for T2DM, predicting the possible complications and disadvantages of surgical treatment, and understanding the peculiarity of each surgical procedure. The remission of hyperglycemia in non-obese T2DM patients could possibly be achieved by surgical intervention. Although long-term follow-up data and verification of its exact mechanisms are required, early operative outcomes were satisfactory in terms of glycemic control and the safety of the procedure.
Asian Continental Ancestry Group ; Body Mass Index ; Diabetes Mellitus, Type 2 ; Gastrectomy ; Gastric Bypass ; Glucagon-Like Peptide 1 ; Humans ; Hyperglycemia ; Ileum ; Incretins ; Obesity, Abdominal

PURPOSE: We wanted to measure and compare the patient demographics and perioperative outcomes between patients with incarcerated and patients with non-incarcerated inguinal hernia. METHODS: We conducted a retrospective analysis of 945 patients who were scheduled for laparoscopic total extraperitoreal (TEP) repair of inguinal hernia from May 2002 to May 2010. There were 66 patients who had incarcerated hernia and 879 patients who had non-incarcerated hernia. RESULTS: The mean age was younger in the incarcerated hernia group than in the non-incarcerated hernia group (41.67 vs. 48.50 years, P < 0.01), and all the incarcerated inguinal hernias patients were male. Most of the incarcerated hernias (63 out of 66 cases, 95%) were indirect hernias. The mean hospital stay showed no difference between the two groups (1.03 vs. 0.93 days, P = 0.142) but the operation time was longer for the incarcerated group than that for the non-incarcerated group (33.36 vs. 24.59 minutes, P < 0.01). Postoperative swelling (including seroma) was more frequent in the incarcerated group (14 out of 66 cases, 21%, P < 0.01), but postoperative pain was similar in both groups (3.0 vs. 8.9%, P = 0.095). There was one recurrence in the non-incarcerated group, but this had no statistical significance. CONCLUSION: Laparoscopic TEP repair for the patients with chronic incarcerated inguinal hernias was safe and feasible. However, a well-designed study is needed to confirm if it is suitable for acute incarcerated inguinal hernias.
Demography ; Hernia ; Hernia, Inguinal ; Humans ; Length of Stay ; Male ; Pain, Postoperative ; Pyrazines ; Recurrence ; Retrospective Studies

Meckel's diverticulum is a common congenital anomaly in the small bowel. Most cases of Meckel's diverticulum are asymptomatic and are found incidentally. We herein report on a case of a 21-year-old male patient who complained of lower abdominal pain and febrile sensation with incidentally diagnosed gangrenous change of Meckel's diverticulum due to axial torsion itself. A 21-year-old man presented to our institution with acute lower abdominal pain. No accurate focus on abdominal pain such as appendicitis or diverticulitis was observed on abdominal ultrasonography and abdominal CT scan. However, the physical examination of the patient revealed the symptom of localized peritonitis with fever. Finally, laparoscopic exploration was performed to determine the cause of acute abdominal pain. During the operation, we found gangrenous change of Meckel's diverticulum with axial torsion itself and laparoscopic Meckel's diverticulectomy was performed. The patient made an uneventful recovery and was discharged on the 6th postoperative day.
Abdominal Pain ; Appendicitis ; Diverticulitis ; Fever ; Gangrene* ; Humans ; Laparoscopy ; Male ; Meckel Diverticulum* ; Peritonitis ; Physical Examination ; Sensation ; Tomography, X-Ray Computed ; Torsion Abnormality ; Ultrasonography ; Young Adult

Lack of awareness, the stigma of carrying a genetic mutation, and economic factors are barriers to acceptance of BRCA genetic testing or appropriate risk management. We aimed to investigate the influence of Angelina Jolie's announcement of her medical experience and also health insurance reimbursement for BRCA gene testing on practice patterns for hereditary breast and ovarian cancer (HBOC). A survey regarding changes in practice patterns for HBOC before and after the announcement was conducted online. The rate of BRCA gene testing was obtained from the National Health Insurance Review and Assessment Service database. From May to August 2016, 70 physicians responded to the survey. Genetic testing recommendations and prophylactic management were increased after the announcement. Risk-reducing salpingo-oophorectomy and contralateral prophylactic mastectomy was significantly increased in BRCA carriers with breast cancer. The BRCA testing rate increased annually. Health insurance and a celebrity announcement were associated with increased genetic testing.
Breast Neoplasms* ; Breast* ; Genetic Testing ; Insurance Coverage ; Insurance* ; Insurance, Health ; Insurance, Health, Reimbursement ; Mastectomy ; National Health Programs ; Ovarian Neoplasms ; Risk Management

Postoperative pyoderma gangrenosum (PPG) is rare, and its diagnosis is often delayed because of its wound infection-mimicking course. A 53-year-old breast cancer patient who underwent breast-conserving surgery of the right breast presented with fever, leukocytosis, C-reactive protein elevation, and redness of the right breast on postoperative day (POD) 3. The breast wound showed desquamation with painful ulcerative changes from POD 6, and fever was sustained under antibiotic administration. Wound irrigation was attempted; however, inflammatory skin damage progressed to involvement of the entire skin overlying the breast. With clinical suspicion of PPG, skin biopsy and systemic corticosteroid initiation were performed on POD 12. Wound damage progression ceased, and the systemic inflammation subsided. The patient underwent split-thickness skin grafting under intravenous corticosteroid administration, and the wound healed after 30 days. PPG is a rare clinical scenario. Early diagnosis is critical to avoid unnecessary treatment and aggravation of the surgical wound.

Postoperative pyoderma gangrenosum (PPG) is rare, and its diagnosis is often delayed because of its wound infection-mimicking course. A 53-year-old breast cancer patient who underwent breast-conserving surgery of the right breast presented with fever, leukocytosis, C-reactive protein elevation, and redness of the right breast on postoperative day (POD) 3. The breast wound showed desquamation with painful ulcerative changes from POD 6, and fever was sustained under antibiotic administration. Wound irrigation was attempted; however, inflammatory skin damage progressed to involvement of the entire skin overlying the breast. With clinical suspicion of PPG, skin biopsy and systemic corticosteroid initiation were performed on POD 12. Wound damage progression ceased, and the systemic inflammation subsided. The patient underwent split-thickness skin grafting under intravenous corticosteroid administration, and the wound healed after 30 days. PPG is a rare clinical scenario. Early diagnosis is critical to avoid unnecessary treatment and aggravation of the surgical wound.

Purpose: Totally implantable venous access ports (TIVAPs) can be used long-term for safe administration of intravenous drugs. TIVAP complications include catheter-related infections, venous thrombosis, extravasation, TIVAP migration, and pain. The relationship between the timing of the first chemotherapy administration after port implantation and complications is controversial. This study aimed to investigate the safety of immediate use of TIVAPs and the associated risk factors for complications. Methods: Between January 2016 and December 2018, 305 patients (median age, 53 years; 256 women) who underwent TIVAP placement at our institution were included. Chemotherapy was administered within 2 days of implantation. A retrospective analysis of patients’ clinical data was performed to investigate catheter days and complications of TIVAPs. Results: Overall, 305 patients were evaluated over 57,324 catheter days (median, 168 catheter days; interquartile range, 105). The median interval between placement and first use of TIVAPs was 0.98 days. The overall morbidity rate was 2.95%. Nine complications occurred in nine patients, including TIVAP-related infection (4), pain (2), port occlusion (1), thrombosis (1), and scar disunion (1), of which five required port removal (1.64%). The median number of catheter days before complications occurred was 61 (range, 10–457 days; interquartile range, 51). No complications occurred within 7 days of implantation. Body mass index was an independent risk factor for TIVAP-related complications in the Cox proportional hazards model (multivariable analysis: hazard ratio, 1.221; 95% confidence interval, 1.054–1.414; P = 0.008). Conclusion This study suggests the safe long-term use of TIVAPs following their immediate chemotherapy administration within 2 days of implantation.

Bariatric patients are at risk of diverse complications, such as bowel obstruction, internal hernia, and mesenteric thrombosis, which can result in massive small bowel resection with short bowel syndrome (SBS) as a consequence. In this study a case of an internal hernia after childbirth in a 36-year-old patient with a history of laparoscopic Roux-en-Y gastric bypass surgery is reported. An emergency laparotomy revealed an internal hernia in Petersen’s space with volvulus, causing extensive small bowel infarction and necrosis. SBS is a complicated multifaceted syndrome which requires a multidisciplinary approach, such as medical, nutritional, and pharmaceutical therapies, to optimize fluid and nutrient absorption over long-term monitoring and with revisions of the care plan. To reduce the morbidity and mortality associated with an internal hernia and volvulus, clinicians must be acutely aware of a potential SBS diagnosis and not delay surgical exploration, even if the vital signs, laboratory results, and imaging studies are normal.

Bariatric patients are at risk of diverse complications, such as bowel obstruction, internal hernia, and mesenteric thrombosis, which can result in massive small bowel resection with short bowel syndrome (SBS) as a consequence. In this study a case of an internal hernia after childbirth in a 36-year-old patient with a history of laparoscopic Roux-en-Y gastric bypass surgery is reported. An emergency laparotomy revealed an internal hernia in Petersen’s space with volvulus, causing extensive small bowel infarction and necrosis. SBS is a complicated multifaceted syndrome which requires a multidisciplinary approach, such as medical, nutritional, and pharmaceutical therapies, to optimize fluid and nutrient absorption over long-term monitoring and with revisions of the care plan. To reduce the morbidity and mortality associated with an internal hernia and volvulus, clinicians must be acutely aware of a potential SBS diagnosis and not delay surgical exploration, even if the vital signs, laboratory results, and imaging studies are normal.