Chang-Chieh Wu

NECROTIZING FASCIITIS DUE TO ACUTE PERFORATED APPENDICITIS: CASE REPORT

Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis is often hindered due to various presentations that differ from the typical signs of appendicitis, especially the position of the appendix. A delay in treatment increases the likelihood of complications such as perforation, which is associated with an increase in morbidity and mortality rates. We herein present the case of a 76-year-old woman presenting with necrotizing fasciitis of the abdominal wall and right flank regions due to a perforated appendix. Such complication is extremely rare but life-threatening. It may be confused with cellulitis, causing a delay in aggressive treatment. This case represents an unusual complication of a common disease. Also, acute appendicitis or intra-abdominal pathologies should be taken into consideration in determining the cause of necrotizing fasciitis presenting over abdominal, flank, or perineal regions.

H-rev107 regulates prostaglandin D2 synthase-mediated suppression of cellular invasion in testicular cancer cells

BackgroundH-rev107 is a member of the HREV107 type II tumor suppressor gene family which includes H-REV107, RIG1, and HRASLS. H-REV107 has been shown to express at high levels in differentiated tissues of post-meiotic testicular germ cells. Prostaglandin D2 (PGD2) is conjectured to induce SRY-related high-mobility group box 9 (SOX9) expression and subsequent Sertoli cell differentiation. To date, the function of H-rev107 in differentiated testicular cells has not been well defined.ResultsIn the study, we found that H-rev107 was co-localized with prostaglandin D2 synthase (PTGDS) and enhanced the activity of PTGDS, resulting in increase of PGD2 production in testis cells. Furthermore, when H-rev107 was expressed in human NT2/D1 testicular cancer cells, cell migration and invasion were inhibited. Also, silencing of PTGDS would reduce H-rev107-mediated increase in PGD2, cAMP, and SOX9. Silencing of PTGDS or SOX9 also alleviated H-rev107-mediated suppression of cell migration and invasion.ConclusionsThese results revealed that H-rev107, through PTGDS, suppressed cell migration and invasion. Our data suggest that the PGD2-cAMP-SOX9 signal pathway might play an important role in H-rev107-mediated cancer cell invasion in testes.

Rare rectal mucocele mimic tumor following hemorrhoidectomy in an adult patient

Mucoceles are commonly associated with the appendix and cranial sinuses. Rectal mucoceles are rare. There are case reports of rectal mucoceles following Hartmann’s procedure, and secon dary to high anal sphincter tone following spinal trauma (1,2). Mucoceles have developed in defunctioned colon after pull-through surgery due to stenosis and retraction of the colonic stump (3,4). Scarring of the mucus fistula, or failure to create a mucus fistula are other described contributing factors. We report a case of small rectal mucoceles following hemorrhoidectomy which caused scarring and stricture of the anal canal.

Phospholipase A/Acyltransferase enzyme activity of H-rev107 inhibits the H-RAS signaling pathway

BackgroundH-rev107, also called HRASLS3 or PLA2G16, is a member of the HREV107 type II tumor suppressor gene family. Previous studies showed that H-rev107 exhibits phospholipase A/acyltransferase (PLA/AT) activity and downregulates H-RAS expression. However, the mode of action and the site of inhibition of H-RAS by H-rev107 are still unknown.ResultsOur results indicate that H-rev107 was co-precipitated with H-RAS and downregulated the levels of activated RAS (RAS-GTP) and ELK1-mediated transactivation in epidermal growth factor-stimulated and H-RAS-cotransfected HtTA cervical cancer cells. Furthermore, an acyl-biotin exchange assay demonstrated that H-rev107 reduced H-RAS palmitoylation. H-rev107 has been shown to be a PLA/AT that is involved in phospholipid metabolism. Treating cells with the PLA/AT inhibitor arachidonyl trifluoromethyl ketone (AACOCF3) or methyl arachidonyl fluorophosphate (MAFP) alleviated H-rev107-induced downregulation of the levels of acylated H-RAS. AACOCF3 and MAFP also increased activated RAS and ELK1-mediated transactivation in H-rev107-expressing HtTA cells following their treatment with epidermal growth factor. In contrast, treating cells with the acyl-protein thioesterase inhibitor palmostatin B enhanced H-rev107-mediated downregulation of acylated H-RAS in H-rev107-expressing cells. Palmostatin B had no effect on H-rev107-induced suppression of RAS-GTP levels or ELK1-mediated transactivation. These results suggest that H-rev107 decreases H-RAS activity through its PLA/AT activity to modulate H-RAS acylation.ConclusionsWe made the novel observation that H-rev107 decrease in the steady state levels of H-RAS palmitoylation through the phospholipase A/acyltransferase activity. H-rev107 is likely to suppress activation of the RAS signaling pathway by reducing the levels of palmitoylated H-RAS, which decreases the levels of GTP-bound H-RAS and also the activation of downstream molecules. Our study further suggests that the PLA/AT activity of H-rev107 may play an important role in H-rev107-mediated RAS suppression.

The Use of Table Fixation Staples to Control Massive Presacral Hemorrhage : A Successful Alternative Treatment. Report of a Case

Management of presacral hemorrhage has always been a challenge for surgeons because such bleeding can rapidly destabilize a patient during pelvic surgery. Conventional hemostatic measures are often effective for arresting this type of hemorrhage, however, sometimes conventional measures make the problem worse. A number of alternative hemostatic techniques have been proposed. This case report describes a successful tamponade of presacral hemorrhage with a titanium table fixation staple and a cancellous bone graft fixed to the sacrum. The bleeding was stopped immediately and the patient recovered uneventfully. We think this is an effective alternative method for controlling massive hemorrhage from a large hole in presacral fascia.

Modified Longo’s stapled hemorrhoidopexy with additional traction sutures for the treatment of residual prolapsed piles

PurposeResidual prolapsed piles is a problem after the stapled hemorrhoidopexy, especially in large third- or fourth-degree hemorrhoids. We have developed a method using additional traction sutures along with modified Longo’s procedure to manage this problem.Materials and methodsFrom January 2005 to October 2005, 30 consecutive patients with symptomatic third- or fourth-degree hemorrhoids who underwent the modified Longo’s stapled hemorrhoidopexy with additional traction sutures in a single institution were collected. The demographics, postoperative pain score, surgical features, outcomes, and early and late complications were recorded. All patients were followed for a mean duration of 8.8 (range, 4–15) months.ResultsThirty patients (17 males) with a mean age of 45 (range, 27–63) years were identified. The mean postoperative pain score on the morning of the first postoperative day was 2.8 (range, 1–4). The mean duration of operation was 30.7 (range, 25–37) min. The mean duration of hospital stay was 2 (range, 1–3) days. The mean days for patients to resume normal work was 6.7 (range, 4–9) days. No other procedure-related complications occurred in all patients. There was no early complication except for fecal urgency found in one patient during the first postoperative days. Regarding the late complications, no residual prolapsed piles, persistent anal pain, incontinence, anal stenosis, or recurrent symptoms were found.ConclusionsOur preliminary experiences indicated that this modified procedures truly contributed to reduce the residual internal hemorrhoids and maintained the benefits of stapled hemorrhoidopexy. Randomized trial and long-term follow-up warrant to determine possible surgical and functional outcome.

A modified Ferguson hemorrhoidectomy for circumferential prolapsed hemorrhoids with skin tags.

PurposeWe describe a modification of the Ferguson hemorrhoidectomy for circumferential prolapsed hemorrhoids. This details the operative procedure and compares the results of other radical methods in patients with circumferential hemorrhoidal disease.MethodsA total of 738 patients (mean age, 43 (range, 19–83) years) were treated with our modified Ferguson method under sedative analgesia between 1989 and 2004: 576 patients had Grade III and 162 patients had Grade IV hemorrhoids, and 131 patients also had a partial lateral internal sphincterotomy to correct anal hypertonia.ResultsPostoperative bleeding occurred in 16 patients, 3 of whom required surgical hemostasis. Fecal impaction occurred in 11 patients and wound complications in 6 patients. Thirty-two patients needed bladder catheterization because of acute urinary retention. The median follow-up was 13.2 months in our outpatient department. One patient developed mild gas incontinence, five developed anal stenosis, and three had an anal fissure. Only three patients had recurrent skin tags, which did not affect their quality of life.ConclusionsOur modified Ferguson method represents a good choice for radical treatment of circumferential prolapsed hemorrhoids because it is easy to perform, has few complications, and provides satisfying results.

Rare complication following screening colonoscopy: Ischemic colitis

Ischemic colitis is the most common form of gastrointestinal ischemia, accounting for more than 50 percent of cases. The risk factors for ischemic colitis are numerous. To confirm the diagnosis, colonoscopy is the gold standard. However, some case reports have indicated the procedure itself may be a risk factor for ischemic colitis. Because of the rarity of this condition, the definite mechanism responsible for colonoscopy-induced ischemic colitis is debated. We report on a man with no risk factors for ischemic colitis who underwent screening colonoscopy. Before the procedure, the patient was advised to drink sodium phosphate (45 mL Fleet Phospho-soda; C.B. Fleet Company, Inc., Lynchburg, VA, USA) in 500 mL of a soft drink twice. During the procedure, a dry, wan mucosa was observed in the descending colon (Fig. 1A). Mild periumbilical pain and repeated bloody diarrhea developed several hours later. Abdominal computed tomography with contrast showed edematous wall thickening from the rectum to the transverse colon but no evidence of fluid accumulation in the peritoneal cavity (Fig. 2). Ischemic colitis was diagnosed by emergency colonoscopy (Fig. 1B). The patient received conservative treatment with fluids, peripheral parenteral nutrition, and i.v. antibiotics. The patient recovered fully 7 days after admission. In 1990, Wheeldon and Grundman first described a patient with systemic lupus erythematosus (SLE) who developed the complication of ischemic colitis after colonoscopy. Since then, only a few cases have been reported. We consider that intravascular volume depletion was the most probable predisposing factor. Moreover, our patient underwent the procedure without anesthesia. Abdominal discomfort and anxiety may cause contraction of blood vessels, which can lead to ischemic colitis. We observed the wan, dry mucosa during the screening colonoscopy. This may suggest ongoing ischemic changes in the colon mucosa. When observing this sign during the procedure, immediate hydration may prevent the progression to ischemic colitis.

Postoperatively parastomal infection following emergent stoma creation for colorectal obstruction: the possible risk factors

BackgroundThe aim of the present study was to discuss the possible risk factors related to the parastomal infection after the patients received emergent stoma creation in colorectal obstruction that was caused by adenocarcinoma, diverticulitis, or a variety of other miscellaneous causes.Patients and methodsA total of 360 patients with colorectal obstruction underwent emergent stoma creation, including diversion and Hartmann’s procedure between January 1996 and January 2005. We analyze the patients’ records to document the possible risk factors associated with parastomal infection. Patients’ demographics, indication for ostomy, ostomy type/location, and risk factors were recorded. Logistic regression was used to calculate adjusted odds ratios. A p value of less than 0.05 was considered significant.ResultsTwenty patients (5.6%) with emergent stoma creation had parastomal infection. Descending colostomy had the highest incidence (6.7%) of parastomal infection, followed by transverse colostomy (6.1%) and ileostomy (3.2%). Significant predictors of parastomal infection as presented with odds ratios and 95% confidence intervals include obstruction period, obesity, operative time, serum albumin, and serum C-reactive protein (CRP). Parastomal infection is also highly associated with abdominal surgical wound infection.ConclusionWe concluded that risk factors for parastomal infection include obstruction period, obesity, operative time, serum albumin, and serum CRP. Furthermore, the abdominal surgical wound infection predispose to parastomal infection. Therefore, prolonged and specific antibiotics for results of culture should be used for patients with the above risk factors to prevent parastomal infection.

Adjuvant chemotherapy with tegafur/uracil for more than 1 year improves disease-free survival for low-risk Stage II colon cancer

Background It is uncertain whether adjuvant chemotherapy (CMT) improves survival in patients with low‐risk Stage II colon cancer. We aimed to determine the disease‐free survival (DFS) and 5‐year overall survival (OS) of low‐risk Stage II colon cancer patients treated with adjuvant tegafur/uracil (UFUR). Methods From January 2004 to December 2011, the follow‐up status of 278 low‐risk Stage II colon cancer patients who underwent surgery in a single medical center was retrospectively analyzed. These patients were divided into three groups based on whether they received adjuvant CMT with UFUR, adjuvant CMT with 5‐fluorouracil, or surgery alone. DFS and 5‐year OS curves were calculated using Kaplan–Meier survival analysis and Cox proportional hazards regression. Results In the study population, including 278 low‐risk Stage II colon cancer patients with a mean age of 68.28 ± 13.01 years, 132 (47.5%) received adjuvant CMT with UFUR, 49 (17.6%) received adjuvant CMT with 5‐fluorouracil, and 97 (34.9%) underwent radical surgery alone. At 5 years, the adjusted DFS and OS of low‐risk Stage II colon cancer patients were 85.5% and 81.8%, respectively, in the surgery alone group and 97.9% and 96.2%, respectively, in the surgery plus UFUR > 12 months group (p = 0.004 and p = 0.098, respectively). In multivariate analysis, CMT with UFUR for more than 12 months increased DFS over surgery alone. There was no statistical difference in the 5‐year OS. Conclusion Adjuvant CMT treatment of low‐risk Stage II colon cancer patients with UFUR for more than 12 months following surgery improves DFS over surgery alone.