Surgery

ORIGINAL ARTICLES
	Surgical treatment of noncaustic benign esophageal stenosis	p. 1
	Ming-Ho Wu, Han-Yun Wu DOI:10.4103/fjs.fjs_19_18   Background: Noncaustic benign esophageal stenosis is an uncommon esophageal disorder. We report herein our surgical results for this type of esophageal stenosis. Materials and Methods: A retrospective review of 30 patients presenting with noncaustic benign esophageal stenosis between June 2009 and February 2018 was conducted. Patient demographics, preoperative diagnoses, treatment strategies, surgical procedures, and the postoperative course of treatment were investigated. Results: No hospital death occurred. Four (13.3%) patients had operative complications, namely, one incident of a duodenal bleeding ulcer, one incident of respiratory failure, and two incidents of wound infections. One patient with primary achalasia required a second myotomy 5 months after initial surgery. All other patients resumed a regular diet after surgery. Conclusion: Delayed diagnosis and treatment of noncaustic benign esophageal stenosis are common. The surgical approach depends on the location and nature of the esophageal disease. Quality of life of patients can be enhanced through careful surgery.
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	Minimally invasive removal of mediastinal ectopic parathyroid glands: A single-center experience	p. 6
	Pin-Li Chou, Yin-Kai Chao, Yun-Hen Liu DOI:10.4103/fjs.fjs_33_18   Background: The last few years have seen the emergence of minimally invasive mediastinal parathyroidectomy. Here, we report our single-center experience with this procedure. Materials and Methods: Between December 2002 and September 2017, we performed minimally invasive mediastinal parathyroidectomy in 12 patients with primary (n = 4) or secondary (n = 8) hyperparathyroidism (median age: 54.5 years; interquartile range: 50.5 − 62.75 years). The following variables were retrospectively collected from clinical records: demographic characteristics, results of imaging studies, surgical approach, complications, and final pathological diagnosis.Results: Technetium-99 m sestamibi examinations were performed for preoperative localization of the ectopic parathyroid glands in 11 patients (91.67%). All cases successfully underwent minimally invasive mediastinal parathyroidectomy, without the necessity to convert to open surgery. The most commonly used minimally invasive approach was video-assisted thoracoscopic surgery (n = 10; 83.33%) followed by mediastinoscopy (n = 2; 16.67%). The anatomical locations of the ectopic glands were as follows: intrathymic in six patients (50%), within the aortopulmonary window in 1 patient (8%), and in other intrathoracic sites in five patients (42%). Parathyroid adenomas and parathyroid hyperplasias were diagnosed in 5 (42%) and seven patients (58%), respectively. There were no perioperative deaths, and the median length of hospital stay was 5.5 days.Conclusion: Minimally invasive removal of mediastinal ectopic parathyroid glands is safe and feasible if their anatomical position is accurately determined. Surgical approaches depend on gland location and the surgeon's preference.
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	Management of tailgut cysts in a single institute in Taiwan	p. 11
	Yu-Zu Lin, Wen-Yih Liang, Hung-Hsin Lin, Chun-Chi Lin, Jeng-Kai Jiang, Sheng-Chieh Huang DOI:10.4103/fjs.fjs_61_18   Background: Tailgut cysts are rare congenital lesions that are generally located in the retrorectal regions. We performed a cases series in Taiwan to compare with others. Materials and Methods: The demographics, clinical presentation, surgical management, pathological features, and long-term outcome of 14 patients of tailgut cysts diagnosed at Taipei Veterans General Hospital from 1989 to 2018 were reviewed. Results: In this series, 11 patients (78.6%) were female with the mean age of 46.7 (18–75) years. The majority of cases (83.3%) were symptomatic with variable manifestations. All patients received radiological examination and/or endoscopy. One case underwent biopsy before the therapy. Surgical methods included Kraske, transanal, abdominal, and combined approaches. Tailgut cysts were benign in ten patients (71.4%) and malignancy included mixed adenoneuroendocrine carcinoma, carcinoid tumor, and borderline mucinous tumor. No long-term adverse effect was reported. There was no recurrence of benign tailgut cysts during the median follow-up of 3 years.Conclusion: Tailgut cysts are uncommon and diagnosed predominantly in the middle-aged female. They can present with variable clinical manifestations, and diagnosis relies on image study. A routine preoperative biopsy is not indicated as it can be uninformative or false negative. Complete surgical excision is recommended even in asymptomatic cases for definite diagnosis and the possibility of malignant transformation. A variety of surgical approaches can achieve complete surgical removal and avoid recurrence if being planned ahead by image carefully.
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	Prophylatic efficacy of dexamethasone, ketamine and dexmedetomidine against intra- and postoperative nausea and vomiting under spinal anesthesia	p. 17
	Hesameddin Modir, Esmail Moshiri, Alireza Kamali, Maryam Shokrpour, Nilufar Shams DOI:10.4103/fjs.fjs_37_18   Background: This study aims to compare the prophylactic effects of dexamethasone, ketamine, and dexmedetomidine versus normal saline on intra- and postoperative nausea and vomiting (PONV) associated with cesarean section (CS) under spinal anesthesia. Materials and Methods: A double-blind prospective clinical trial was performed on 140 patients scheduled for elective CS and was assigned randomly to four groups. The first group received 20 cc normal saline; the second group received dexamethasone at a dose of 0.1 mg/kg; the third group received ketamine at a dose of 0.5 mg/kg; and the fourth group received IV dexmedetomidine (1 μg/kg). Nausea and vomiting score was measured by visual analog scale and sedation levels by Ramsay sedation scale (RSS). Results: There was a significant difference among the four groups in PONV scores immediately after and 1, 2, 3, and 4 h following administration of the drug (P = 0.001). Nausea and vomiting score was the lowest in the dexmedetomidine group. Significant differences were observed in Ramsey score at the 10th–110th min following administration, and the dexmedetomidine group had a higher RSS than the other groups. The incidence of metoclopramide intervention in three experimental groups is comparable. Heart rate (HR) and mean blood pressure show decreasing trend following spinal anesthesia in dexmedetomidine group. Conclusion: The tested groups (dexamethasone, dexmedetomidine, and ketamine) all present a lower incidence of nausea and vomiting than the placebo group. In addition, dexmedetomidine provides the best efficacies in the reduction of nausea and vomiting but is more liable in lowering blood pressure and HRs. We recommend that dexmedetomidine is the drug of choice in decreasing nausea and vomiting for patients undergoing CS with spinal anesthesia.
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CASE REPORTS
	Neglected giant dermatofibrosarcoma protuberans	p. 24
	Gautam Prakash, Manojit Midya, Pankaj Sharma, Rakesh K Jain DOI:10.4103/fjs.fjs_57_18   Dermatofibrosarcoma protuberans (DFSP) is a rare, slow growing, intermediate to low grade malignant soft tissue neoplasm originating from the dermal layer of the skin. Scalp DFSP is even a rarer entity occurring at less than 1% of all DFSP. We recently encountered a massive DFSP on the scalp which presented to us in the emergency settings with acute bleeding. This was successfully managed by wide local excision of the tumour. This case is remarkable due to the large size of tumour on the rather rare site on the scalp presenting unusually as acute bleeding and its successful management with wide local excision as a life saving procedure.
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	Metastatic lung neuroendocrine carcinoma presenting as a breast lump	p. 28
	Tai-Chien Huang, Wan-Yi Kang, Shu-Yi Tsao, Yu-Lin Chang DOI:10.4103/fjs.fjs_55_18   This case is a 78-year-old woman with hypertension, diabetes mellitus, cardiovascular disease, valvular heart failure and hepatitis C. She presented to outpatient department for her right breast lump. The pathology of the core biopsy under breast sonography showed carcinoma with neuroendocrine features. Its immunohistochemical study showed negative for estrogen receptor (ER), progesterone Receptor (PR), HER2/neu and GATA-3, and positive for chromogranin A, synaptophysin, and TTF-1. A staging workup was then performed. The computed tomography (CT) of chest and abdomen revealed another mass in the left lung. CT-guided biopsy was done for the lung mass. According to the results of immunostains, a primary lung large cell neuroendocrine carcinoma (LCNEC) with breast metastasis was diagnosed. The patient received chemotherapy with etoposide and carboplatin for 6 cycles. The CT performed 3 and 5 months later showed that the response of the tumors was stable.
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	Primary small gut lymphoma presenting as an incarcerated inguinal hernia in an adult	p. 33
	Prosanta Kumar Bhattacharjee, Amitabha Sarkar, Somnath Biswas, Tanvi Goel DOI:10.4103/fjs.fjs_70_18   A 73-year-male presented with features of subacute small gut obstruction of 10 days duration. He also complained of a painless, slowly enlarging swelling in the right groin, which was first noticed 10 years ago. There was a history of weight loss, anorexia, and asthenia but no history of fever, respiratory, or urinary symptoms. He was a smoker and was on medication for hypertension and type 2 diabetes mellitus. The general health of the patient was poor. He appeared pale and dehydrated. No lymphadenopathy was evident on the general survey. The abdomen was distended, tense with hyperactive bowel sounds. Examination of the groin and genitalia revealed right inguinal hernia and an irreducible, firm, solid, nontender, 6 cm × 5 cm scrotal mass separate from the right testis. Digital rectal examination revealed no abnormality. Contrast-enhanced computed tomography of the abdomen showed dilated gut loops, right inguinal hernia, and a gut related endophytic soft-tissue mass in the scrotum. Exploration after resuscitation revealed a firm, endoluminal soft-tissue mass arising from the apex of the herniated loop of the small gut which was obliterating its lumen. The tumor-bearing segment of the gut was resected through a groin incision. We then performed a laparotomy to bring out the ends of the bowel loops as double barrel ileostomy. The hernial defect was then repaired. Postoperative recovery was uneventful. Histopathology of the excised specimen suggested the possibility of Non-Hodgkin's lymphoma of small gut. Immunohistochemistry confirmed it to be low-grade follicular B-cell NHL.
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SHORT COMMUNICATIONS
	Low-tidal-volume ventilation for recipients of lung transplant: Ready for clinical use?	p. 37
	Manijeh Yousefi Moghadam DOI:10.4103/fjs.fjs_35_18
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