Cheng-Wen Hsiao

Hand-assisted laparoscopic colectomy vs open colectomy: a prospective randomized study

Background: We compared the perioperative parameters and outcomes achieved with hand-assisted laparoscopic colectomy (HALC) vs open colectomy (OC) for the management of benign and malignant colorectal disease, including cancer patients treated with curative intent. Methods: Sixty eligible patients were randomized to either HALC (n = 30) or OC (n = 30) treatment groups. We used Pearson’s chi-square and two-sample t-tests to compare the differences in demographics and perioperative parameters. Results: There were no significant differences in age, gender distribution, disease pattern, operative procedure, comorbidity, or history of abdominal surgery. The HALC patients had significantly shorter hospital stays and incision lengths, faster recovery of gastrointestinal function, less analgesic use and blood loss, and lower pain scores on postoperative days 1, 3, and 14. There were no significant differences in operative time, complications, or time to return to normal activity. Conclusion: Hand-assisted laparoscopic colectomy (HALC) is safe and produces better therapeutic results in terms of perioperative parameters than OC.

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.

Emergency stapled haemorrhoidectomy for haemorrhoidal crisis

Between January 2000 and December 2002, 30 consecutive patients with acute haemorrhoidal crisis were recruited. All patients gave written informed consent and were operated on by the same surgeon. Exclusion criteria included previous perianal surgery, other anorectal disorders, pregnancy and severe medical problems. All patients underwent stapled haemorrhoidectomy under local anaesthesia within 24 h of admission. Stapled haemorrhoidectomy was performed with the PPH TM set (Ethicon Endo-Surgery, Cincinnati, Ohio, USA), using the standard method reported by Longo1 (Fig. 1) modified by placing the purse-string suture closer to the dentate line (3 cm from anal margin) . Patients were instructed to complete a preoperative and postoperative subjective pain survey using a visual analogue scale ranging from 0 (no pain) to 10 (the worst pain ever experienced). Data were entered into a statistical database (SPSS version 12·0; SPSS, Chicago, Illinois, USA). Descriptive statistics were used for demographic data and operative outcomes. The χ2 method was used to test categorical variables. Trend analysis was performed to examine the progressive mean pain scores of the 30 patients. P < 0·050 was considered statistically significant.

Schwannoma of the rectum: report of a case and review of the literature.

Schwannoma is well-known as a benign tumor originating from the Schwann cells, which produce insulating myelin sheath to cover peripheral nerves. It could occur in any nerve region, typically in the extremities, spinal cord and central nervous system (1). In the literature, only few cases of rectal schwannoma have been reported (2-8). The surgical approaches, including abdominoperineal resection, transanal excision, perianal intersphincteric excision and transanal endoscopic resection were described for rectal schwannoma (2-8). In this report, we report one rare case of rectal schwannoma and review the published literatures. The surgical approaches and diagnosis are discussed.

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.

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.

Colonic neoplasm in a strangulated inguinal hernia

Inguinal hernia and colonic neoplasm are usual diseases. However, colonic neoplasm occurring in an inguinal hernia sac is rare. Pre-operation diagnosis and appropriate surgical intervention in these patients remain a technical challenge for surgeon. Clinicians must have a high index of suspicion for these cases and early management can ensure excellent prognosis. In this article, we report a case of colonic neoplasm presenting a strangulated inguinal hernia.

Primary non-Hodgkin's lymphoma of rectum presenting with rectal prolapse.

Involvement of the rectum by primary or secondary malignant lymphoma is uncommon in adults. Primary lymphoma of the rectum in children is an extremely rare occurrence. We describe a 12-year-old boy with a localized rectal tumor that presented with rectal prolapse and bleeding, mimicking a juvenile polyp. He underwent transrectal local wide excision of the tumor, and the pathologic condition proved to be non-Hodgkins lymphoma of diffuse large B-cell type. This case illustrates the importance of considering the possibility of a rectal malignancy manifesting as a rectal prolapse even in children and the surgical strategy used.