Jeng-Kae Jiang

Rectal perforation: a life-threatening complication of stapled hemorrhoidectomy: report of a case.

Stapled hemorrhoidectomy is considered to be safe and carries advantages. We describe a patient with rectal perforation and fecal peritonitis after stapled hemorrhoidectomy. We suggest that it should be performed by experienced colorectal surgeons who are familiar with the technique and aware of possible complications.

Effect of Transcutaneous Electrical Nerve Stimulation for Pain Relief on Patients Undergoing Hemorrhoidectomy: Prospective, Randomized, Controlled Trial

PURPOSE: Posthemorrhoidectomy pain control remains a challenging problem. Transcutaneous electrical nerve stimulation is known to be effective in the treatment of many diseases. Our aim was to investigate the effect of transcutaneous electrical nerve stimulation on pain relief in patients undergoing hemorrhoidectomy. METHODS: Sixty patients with symptomatic hemorrhoids were randomly allocated into two groups, the acupoint group (n=30) and the nonpoint control group (n=30). Transcutaneous electrical nerve stimulation was applied to those patients who received hemorrhoidectomy, and patient-controlled analgesia was achieved by injection of morphine through ambulatory infusion pumps. The dependent measures in this study were pain score from 0 (no pain) to 10 (agonizing pain), analgesic doses administrated through patient-controlled analgesia, and postoperative complications. RESULTS: The subjective pain scores evaluated 8, 12, 16, and 24 hours after hemorrhoidectomy in the control group and the acupoint group were 5.9±0.5 and 4.1±0.5, 5.7±0.5 and 3.5±0.4, 4.1±0.4 and 2.3±0.3, and 3.2±0.4 and 1.9±0.2, respectively (two-way analysis of variance;P<0.05). There was a significant difference between treatment groups in morphine use, with 11.6±2.2 mg in the control group and 6.2±1.3 mg in the acupoint group (P<0.05). The acupoint group tended to have less postoperative acute urinary retention (Fishers exact probability test;P=0.145) and less need for analgesics than the control group (P=0.112, Fishers exact test). CONCLUSION: Transcutaneous electrical nerve stimulation is effective for pain relief in patients receiving hemorrhoidectomy. Its efficacy and safety could assist outpatient pain management after hemorrhoidectomy.

Large Bowel Tuberculosis and Possible Influencing Factors for Surgical Prognosis: 30 Years’ Experience

Abstract. The incidence of tuberculosis is rising in the United States. Similarly, the incidence of pulmonary tuberculosis in Taiwan is increasing, but that of large bowel tuberculosis in this region has not been reported. The purpose of this study was to investigate the changing disease pattern and to determine some possible surgical prognostic factors for large bowel tuberculosis. Seventy cases of large bowel tuberculosis treated at our institute during the period 1965–1995 were reviewed and analyzed. A steady decline in the case number of large bowel tuberculosis were noted from 1975, but there seems to be a slight increase in cases since 1990. The average age of these patients was 65.1 years, and none had human immunodeficiency virus infection. The ileocecum is the most common region of involvement. Of these 70 patients, 59 had not been definitively diagnosed until surgery. Active pulmonary tuberculosis was found in 18 patients (25.7%). The incidence of postoperative pulmonary complications was higher in patients with active pulmonary tuberculosis or disseminating large bowel tuberculosis. Postoperative abdominal complications, including intestinal obstruction, abdominal cutaneous fistula, and wound infection, were seen in 13 patients, none of whom had active pulmonary tuberculosis. Although the incidence of tuberculosis has been reduced for years, it is now rising. Physicians should bear in mind the possibility of large bowel tuberculosis in patients with intestinal obstruction without specific origin. Postoperative respiratory care is important for patients with pulmonary tuberculosis, with either active or disseminating lesions.

Clinical Analysis and Surgical Results of Primary Colorectal Sarcoma

Purpose. Colorectal sarcomas are rare and their treatment remains controversial. This study describes the clinical features of colorectal sarcoma. Methods. Data were obtained from a retrospective database of all colorectal malignancies at Taipei Veterans General Hospital. From 1998-2008, 873 sarcoma cases and 5594 colorectal malignant tumors were diagnosed. Eleven patients with colorectal sarcoma were identified. Results. The 11 patients (five males, six females, mean age of 61.7 years) presented primary tumors in the rectum (n=7) and colon (n=4). Surgical intervention in 10 patients (one patient was initially diagnosed with lung metastasis and did not undergo surgical intervention) was uneventful. The mean tumor size was 9.6 cm (range, 4-30 cm). Histological findings were leiomyosarcoma in seven cases and sarcomatoid carcinoma, liposarcoma, synovial sarcoma and embryonal rhabdomyosarcoma each in one case. Five of the seven leiomyosarcoma patients (71.4%) developed recurrences during the follow-up period. Recurrence sites included local recurrence (n=2) and liver metastasis (n=3). The overall and disease-free survival periods of the leiomyosarcoma patients were 52.8 months and 44.7 months, respectively. Conclusions. In our experience, sarcoma is a rare tumor in colorectal neoplasm and leiomyosarcoma is the most common histological type. Despite radical surgical intervention and no lymph node metastasis at time of treatment, leiomyosarcoma has a high recurrence rate. The absences of a reliable tumor marker and useful adjuvant chemotherapy make close image follow-up mandatory in the disease management.

The Clinicopathologic Features and Outcome of Patients with Gastrointestinal Stromal Tumors in Colorectal Region

Background: Gastrointestinal stromal tumor (GIST), originated from c-kit mutation, is a rare tumor in colorectal region. This study was to describe the clinicopathologic features and outcome of patients with colorectal GIST.Methods: We prospectively recorded the clinical data of colorectal tumors receiving operations in Taipei-Veterans General Hospital since 1997. The patients with the diagnosis of GIST were reviewed for the clinical courses and pathological results. The diagnosis of GIST was confirmed by positive staining of CD117 in immunohistochemistry.Results: From Dec. 1997 to Oct. 2008, 19 of the 4205 patients (0.44%) were diagnosed to have GIST. The mean age was 61.3 ± 16.2 year-old (range: 23-81 year-old). Fourteen (74%) were male. Fourteen (74%) tumors located at rectum. The mean diameter of tumor was 4.0 ± 3.3 cm. The largest size of the tumor was 13 × 7 × 6 cm. Eleven tumors showed high grade mitosis. Fifteen patients received radical resection. Nine patients received imatinib treatment for high grade mitosis, large tumor size (＞ 5 cm in diameter) and intraabdominal seeding. The average follow-up period was 40.2 ± 29.8 months (range: 3-111 months). Eleven patients had high mitosis (≧ 5/50 HPF), 7 of them had recurrent disease in 56 months (median = 29.9 ± 21.7 months). For patients with low mitosis tumor, survival rate was 87.5%, better than those with high mitosis (54.6%). High risk patients had higher risk of tumor recurrence (66.7%).Conclusion: Patients with GIST who had large tumor size (tumor size ＞ 5 cm, recurrent rate 100%) or high mitosis (mitosis ≧ 5/50 HPF, recurrent rate 63.5%) in pathological analysis had higher incidence of tumor recurrence, even after radical surgical resection.

Long Term Outcome of Local Excision for T1-2 Rectal Cancer

Purpose. Local excision is an alternative method of treatment for middle to low rectal cancer due to low morbidity and good functional result. We reviewed the experience with local excision of early rectal cancer to evaluate the long term result. Patients & Methods. Between January 1982 and December 2004, patients with T1-2 adenocarcinoma of the middle to lower rectum (below 10 cm from anal verge) treated by local excision were reviewed. The pathology of specimen was reviewed. Seventy-six patients were assessed and 44 were T1 and 32 were T2 cancers. Eleven patients received adjuvant radiation therapy. Data analysis included clinical characteristics and pathological features. The tumor recurrence was identified as local, distant or both. 59 patients (77%) were followed until death or more than five years and 51 patients (67%) were followed until death or more than ten years. The outcomes were defined as five-year and ten-year cumulative data of tumor recurrence rate, cancer-specific and disease-free survival rates. Results. The ten-year local and overall recurrence rate were 9.1% and 15.9% for T1 lesion and 12.5% and 21.9% for T2 lesion. The five-year and ten-year cancer-specific survival rates of T1 lesion were 97.2% and 92.1% and of T2 lesion were 83.9% and 76.3%. On multivariate analysis, the significant prognostic factors of cancer-specific survival rate were T stage (p=0.038) and angio-vascular invasion (p＜0.001). The only significant factor of disease-free survival rate was angio-vascular invasion (p＜0.001). Of the eight patients who had isolated local recurrence, five patients received salvage surgery and the disease-free survival rate was 60% with mean follow up of 77 months. Conclusion. Local excision for middle to lower T1 rectal cancer is acceptable with good long-term result but is not considered in T2 lesion due to unsatisfied cancer-specific survival rate. The pathological feature of angio-vascular invasion seems to be the prognostic factor of diseasefree and cancer-specific survival.

Prognosis of Resecting Local Recurrence for the Cases with Synchronous Distant Metastasis of Rectal Cancer

目的 近年來，研究顯示手術治療對於有直腸癌併局部復發的病人有較好的存活率。而此研究目的在探討直腸癌局部復發並遠端轉移病人接受局部切除之預後。方法 自1999 至2013 年間，自台北榮民總醫院資料庫中回溯性地找出30 名診斷有直腸癌合併局部復發和遠端轉移的病人。我們收集並分析所有的預後因子，如病人基本資料、腫瘤特性、治療方法、復發特質及遠端轉移型態等。結果 在30 名病人中，依據對於局部復發的治療可分成手術切除組 (SR) 及非手術治療組 (NST)。開刀的適應症包括腸阻塞、腫瘤出血、輸尿管侵犯併感染等。在SR 組中，只有3 名病人達到顯微鏡下邊緣無腫瘤侵犯 (R0 切除)。整體來說，平均復發時間是18.9個月。兩組病人在年齡、性別、初始腫瘤期別、腫瘤細胞型態、治療方法、復發位置、及遠端轉移之治療皆沒有統計上差別。然而，採取局部切除的病人的存活時間在統計上並無顯著差別 (p 值 = 0.829)；而是否有肝臟轉移反倒是唯一有達到統計上顯著差異的預後因子 (p 值 = 0.009)。結論 對於有直腸癌合併有局部復發及遠端轉移病人而言，只採取局部手術切除並無法改善存活時間。在本研究中，是否有肝臟轉是最重要的預後因子。

Impact of Pre-Operative Chemoradiotherapy on cT3N0M0 Middle and Low Rectal Cancer

Purpose. To evaluate the oncological benefit of neoadjuvant concurrent Chemo-RadioTherapy (CCRT) for cT3N0M0 rectal cancer.Materials and Method. Between July 2000, and December 2004, 103 patients of middle and low rectal cancer with primary cT3N0M0 were enrolled. Of them, 37 patients were staged by magnetic resonance imaging (MRI), and 66 by computed tomography (CT); 80 patients did not receive pre-operative concurrent Chemo-RadioTherapy (CCRT) and 23 did. Radical resections were performed as the protocol. The oncological results including survival, local and distant metastasis rates were analyzed.Results. For the concurrent Chemo-RadioTherapy (CCRT) group, the complete response rate was 34.8% and the down staging rate was 73.9%. There was no significant difference in survival analysis between the two groups (OS: 91.3% vs. 82.1%; DFS: 86.4% vs. 79.5%; CSS: 91.3% vs. 91.0%), neither in local (10% vs. 4.3%) nor distant control (23.8% vs. 17.4%).Conclusion. Pre-operative concurrent Chemo-RadioTherapy (CCRT) might not provide better local control or survival benefit for cT3N0M0 middle and low rectal cancer.

Nerve Conduction Velocity Study is Effective in Objectively Assessing Oxaliplatin-induced Peripheral Neuropathy

Oxaliplatin is effective in the treatment of metastatic colorectal cancer patients; however, severe neurotoxicity developed frequently. To assess the efficacy of nerve conduction velocity (NCV) study in objectively assessing oxaliplatin-induced peripheral neuropathy, a pilot study was performed. A total of 28 patients with metastatic colorectal cancer treated at Taipei Veterans General Hospital were enrolled. Oxaliplatin (85 mg/m^2, day 1 and 15), plus weekly bolus 5-fluorouracil (5-FU; 500 mg/m^2) and folinic acid (FA; 20 mg/m^2) on day 1, 8, and 15 were given every 28 days as first-line treatment. Chemotherapy-associated neurological toxicity and electrophysiological alterations, especially NCV, were assessed. Twenty patients showed a remarkably reduced NCV and the remainders were NCV-normal. After 6 cycles of treatments, a significant correlation was identified in NCV abnormalities and the severity of neurological symptoms (P=0.01), including 16 patients with a reduced NCV accompanied by severe (grade 3 or 4) neuropathy, and 6 patients with a normal NCV without developing severe neurological symptoms. However, there remained 2 patients with a normal NCV who developed severe (grade 3 or 4) neuropathies, and 4 patients who showed a remarkably reduced NCV without or with only mild neurological symptoms. We conclude that nerve conduction studies correlate well with the severity of neurological symptoms and may serve as a useful tool in objectively assessing the severity of oxaliplatin-induced peripheral neuropathy. The addition of a detailed electrophysiological examination to a precise physical examination may be effective in objectively assessing oxaliplatin-induced neuropathy.

Is Single Stool Occult Blood Test or Serum CEA Level Valuable in Health Check Up

Purpose. Stool occult blood tests and serum CEA level examinations are widely used at health check-up of detecting colorectal lesions. The aim of this study is to evaluate the effectiveness of using single stool occult blood tests or serum CEA levels in routine health check up. Methods. We examined 1404 patients who came for health check up at Veterans General Hospital, Taipei, Taiwan from April 2004 to May 2005. They were all underwent single stool occult blood test, serum CEA level and complete colonoscopy during the check up. Results. There were patients with colorectal cancers in 9 (0.6%), polyps in 268 (19.1%) (Significant polyps in 95), diverticulum in 86 (6.1%) and other lesions in 9 (0.6%). Positive stool occult blood tests were noted in 97 patients (6.9%). The sensitivity, specificity, false positive rate and false negative rate of stool occult blood test to detect significant colorectal neoplasm were 14.4%, 93.1%, 6.9% and 85.6% respectively. There were 39 (2.8%) patients showed elevated serum CEA level with the cut-off value of 6.0 ng/mL. The sensitivity, specificity, false positive rate and false negative rate of elevated CEA level to detect colorectal tumor was 15.4%, 92.8%, 7.2% and 84.6% respectively. The distributions of colorectal cancers and polyps were 26.5% proximal and 73.5% distal to the descending colon. Among the patients with colorectal cancers, only one who came for health check-up was completely free of gastrointestinal symptoms. Conclusions. Single stool occult blood test and serum CEA level were failed to effectiveness in health check up due to very low sensitivity and unacceptable high false-negative rates, the routine fibro-sigmoidoscopic examination of 60cm in check up was not enough for complete detection of colorectal cancer and polyp because there were still one fourth lesions distributed proximal to the upper limit of flexible sigmoidoscopic examinations. The most effective ways to detect colorectal lesions were complete colonoscopy and the awareness of the early symptoms of the cancer. Complete colonoscopy should be recommended in patients asking for health checkup.