Ting-Ming Huang

Adenosquamous Carcinoma of the Colon: A Case Report and Review of the Literature

Adenosquamous carcinomas are consisting of both glandular and squamous histologic components. Adenosquamous carcinoma of the colon is rare and has a worse prognosis than adenocarcinoma alone. We present and discuss a case of adenosquamous carcinoma of the proximal transverse colon with hepatic metastasis. A 35-year-old male patient was treated with a hemicolectomy and surgical resection of the hepatic adenosquamous carcinoma.

Laparoscopic Abdominoperineal Resection for Low Rectal Adenocarcinoma

Purpose. Laparoscopic abdominoperineal resection (LAPR) is an accepted alternative to open resection for treating patients with low rectal adenocarcinoma, but the long term results are seldom reported. The purpose of our study was to evaluate the long term outcome in low rectal adenocarcinoma patients treated with laparoscopic abdominoperineal resection. Methods. We reviewed our experience with 35 patients who underwent laparoscopic abdominoperineal resection for low rectal adenocarcinoma at Changhua Christian Hospital between 1999 and 2003, and another 31 low rectal adenocarcinoma patients who accepted open abdominoperineal resection during the same period of time was compared. The patients short term outcome, such as bowel function recovery time, duration of hospital stays and long term oncological result were recorded and analyzed. The option for conversion rate, laparoscopic operation time and complication were also discussed. Results. Of 66 total patients, 31 were in the open group and 35 were in the laparoscopic group; 4 (11%) of the latter were converted to open surgery. The overall complication rate in this study is 24.24% and there was no operative mortality in the study. No port-site metastasis was found in laparoscopic group, and no surgical wound metastasis was found in open group. No statistically significant difference in body weight, height, BMI, anesthesia score, pre-operative chemoradiotherapy, cancer stage, survival time, and mean operative time was found among the 3 groups. Blood loss for open surgery and completed laparoscopic resection were (mean±SD) 619±355.4 mL vs 325±292.7 mL(p=0.001). The time that bowel function resumed, time to ingestion of water, and time to resumption of solid foods between the open and laparoscopic groups were (mean ± SD) 2.5±0.6 vs 2±0.8 days (p=0.032), 2±0.8 vs 1.5±0.6 days (p=0.015), and 3.7±0.9 vs 3.2±0.9 days, respectively (p＜0.005). The over all survival rates at 5 years were 65.72% in open group and 69.40% in laparoscopic group (p=0.7723).There are four local recurrent (6.06%) in the study. Distal metastasis at 5 years follow-up was noted in 14 patients and located at liver, lung and adrenal gland. Conclusion. Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique for the treatment of patients with low rectal adenocarcinoma.

Laparoscopic Surgery and Incidence of Adhesion Ileus in Patients with Right-sided Colon Cancer

Purpose. Adhesions are an inevitable consequence of abdominal or pelvic surgery that may cause additional complications and increase hospital costs. A number of human and animal studies have shown that laparoscopic surgery is associated with a lower incidence of adhesion formation than open surgery. In this retrospective study, we compared the incidence of adhesion ileus between patients who underwent right hemicolectomy using laparoscopy and those who received open surgery. Materials and Methods. We retrospectively reviewed the medical and surgical records of all patients who underwent elective hemicolectomy for right-sided colon cancer between January 2005 and December 2011. Adhesion ileus was suspected in patients who presented to our emergency department or outpatient department with complaints of constipation for more than 48 hours together with intermittent, painful cramping, vomiting, or abdominal distension without flatus. For these patients, computed tomography (CT) imaging showed the presence of dilated bowel loops with a transitional zone over the adhesion site. Results. There were 281 patient who underwent elective right-sided hemicolectomy using open surgery (n=164) or laparoscopy (n=117) at our institution. The mean follow-up time was 66 months (median: 53 months, range, 24-96 months). Both the groups were comparable in terms of their age, gender, and American Society of Anesthesiologists (ASA) classification. There were no significant differences in the rates of re-admission for adhesion ileus (5.5% vs 3.4%, p=0.416) or surgery for adhesion (2.4% vs 0%, p=0.089) between the open and laparoscopic groups. Conclusions. In our 281-patient cohort, our results revealed that there was no significant difference in the incidence of post-surgical adhesion ileus between patients who underwent laparoscopic-assisted surgery and patients who received open surgery for right-sided colon cancer.

Low-Grade Appendiceal Mucinous Neoplasm: A Rare Cause of Acute Abdomen

Purpose. Low-grade appendiceal mucinous neoplasm (LAMN) is a rare type of appendiceal cancer. Patients with LAMN may initially present with acute abdominal pain. Despite the use of CT, ultrasound or colonoscopy, preoperative diagnosis is difficult. In this study, we retrospective analyze cases of LAMN diagnosed in the past 10 years in Chang-Hua Christian Hospital and review the associated literature.Materials and Methods. This study retrospectively analyzed 15 patients who underwent surgery and was histopathologically confirmed LAMN at Chang-Hua Christian Hospital between January 2000 to August 2011. Patient charts and data on patient demographics; clinical features; ultrasonography (US), colonoscopy and computed tomography (CT) findings; pathology reports; pre-operative diagnosis and operative method were reviewed.Results. The were 15 cases of LAMN at Chang-Hua Christian Hospital over the past ten years. In our review, there were eight (53.3%) female patients. The median age was 67 years (47-85 years), and the most common presentation was abdominal pain (93.3%). On US in six patients, findings were abdominal cystic mass and cyst wall calcification. The CT finding was well-encapsulated cystic mass in thirteen patients. Appendectomy was performed in ten patients. Right hemicolectomy was performed in five patients, and there was one patient found concomitant colon adenocarcinoma in the specimen.Conclusion. LAMN is difficult to diagnose before operation. The actual diagnosis is usually made intraoperatively or during histopathologic examination of the excised specimen. Although surgical treatment is straightforward, proper management of the incidentally found lesion requires understanding of the potential complications of widespread peritoneal disease. It should be kept in mind that LAMN may coexist with other neoplasms, and follow-up colonoscopy and pelvic examination is warranted for the high association with other colon and ovarian malignancies.

Laparoscopic Assisted Right Hemicolectomy-10 Years Experience in Chung-Hua Christian Hospital

Purpose. Laparoscopic surgery has became the current trend for colorectal cancer. Thus Chang-Hua Christian Hospital has gathered and analyzed data based on ten years of experience in laparoscopic assisted right hemicolectomy. Materials and Methods. This study retrospectively analyzed 89 patients who underwent laparoscopic assisted right hemicolectomy for colon cancer at Chang-Hua Christian Hospital between January 1999 to December 2008. During the same time period, 85 additional patients who underwent open right hemicolectomy were compared. Results. Patients who underwent laparoscopic resections require significantly longer operation time compared to the open methods (208 min vs. 162 min, p = 0.036) but suffered less blood loss (93 ml vs. 210 ml, p = 0.06). There were no significant differences in the number of lymph nodes harvested for cancer resections (Scopy: 24 vs. Open: 22). Comparing post-operative recovery time, the laparoscopic group had a shorter delay for first time post-operative bowel movement (2.41 days vs. 2.76 days, p = 0.027) and oral intake (1.66 days vs. 2.08 days, p = 0.019). Furthermore, the laparoscopic group spent fewer days in the hospital (7.33 days vs. 11.44 days, p = 0.131) and in addition had a lower complication rate compared with the open group (8.2% vs. 17.6%, p = 0.068). The convertion rate was 4.5% (4/89). Comparing the 5-year survival rate for all stages, both groups have a similar survival rate (Scopy: 67.9% vs. Open: 67.9%, p = 0.531). In stage I patients, there were no significant differences between both groups (Scopy: 87.5% vs. Open: 80.2%, p = 0.529). In stage II patients, there were also no significant differences between both groups (Scopy: 73.5% vs. Open: 67.5%, p = 0.404). The same result was noted in stage III patients (Scopy: 57.9% vs. Open: 61.7%, p = 0.663). Comparing the 5-year disease free survival rate for all stages, both groups have a similar survival rate (Scopy: 68.3% vs. Open: 65.8%, p = 0.405). In stage I patients, there were no significant differences between both groups (Scopy: 71.4% vs. Open: 80.2%, p = 0.502). In stage II patients, there were also no significant differences between both groups (Scopy: 74.5% vs. Open: 65.2%, p = 0.272). The same result was noted in stage III patients (Scopy: 55.6% vs. Open: 58.4%, p = 0.610). Local recurrent rate was 1.18% in scopy group and 3.53% in open group. Conclusion. Based on research and experience, laparoscopic assisted right hemicolectomy is a safe and feasible technique.

Preoperative Weekly 24-hour Infusion of High-dose 5-Fluorouracil and Leucovorin (HDFL) with Concurrent Radiation for T3, T4 Rectal Cancer on a Outpatient Basis

Background. Because of high local recurrent with traditional approaches for advanced rectal cancer, we investigated preoperative radiation-chemotherapy (5 -fluorouracil and leucovorin) for patients with T3, T4 rectal cancer. Methods. Twenty-eight outpatients (18men, 10women; median age 56.5years, range 28-74) with T3, T4 rectal adenocarcinoma received preoperative chemoradiation therapy (CCRT). The 24-hour infusions of 2600 mg/m^2 5-fluorouracil and 300 mg/m^2 leucovorin were given concurrently with radiation (5O4OcGy, 28 fractions over 5.5 weeks). Prior to curative total mesorectal excision (mean interval from CCRT, 5.7 weeks). Twelve cases received laparoscopic surgery, including one converted to an open procedure. Low anterior resection with J-pouch, transverse coloplasty pouch, or straight end-to-end anastomosis was done for two eight and nine patients, respectively. Results. Acute toxicity consisted of three patient with grade 3 diarrhea and one patient with neutropenic fever who discontinued chemotherapy (latter excluded from analysis). A total of 18 (62.96%) of 27 patients achieved tumor downstaging, and 8 (29.63%) had pathologic complete remission. Sphincter-preserving surgery was achieved in 6 (46.15%) of 13 low rectal cases. Surgical complication rate was 22.22%, including anastomosis dehiscence (n=2) and anastornosis stenosis (n=1). At 28.9 months median follow-up, the four-year overall survival and disease-free survival rates were 81.62% and 69.37% (mean overall survival time, 53.09 months). Five patients developed distal metastasis; two initially had local recurrence. Conclusions. Outpatient CCRT decreases hematologic toxicity while showing promise in improving outcomes such as pathologic remission and tumor downstaging, sphincter preservation, local recurrence/metastasis, and survival.

Leiomyosarcoma of the Sigmoid Mesocolon: Report of a Case

Although leiomyosarcoma arising primarily in the sigmoid mesocolon is rare, these sarcomas can be considered a special kind of retroperitoneal tumors. The clinical features are rarely obvious because of their location and lack of symptoms. Hence, they usually attain large sizes and may have metastases to distant sites at the time of diagnosis. Most authors agree on using computer tomography (CT) and nuclear magnetic resonance imaging (MIII) as diagnostic tools, but only histological examination can confirm the diagnosis, thus making a definitive pre-operative diagnosis difficult. We report the case of a 52-year-old female with low abdominal discomfort for 2 years, who mimicked having a large uterine myoma. During laparotomy, a tumor that was 13×7×6.5 cm in size was found on the sigmoid mesocolon. Curative resection was done, and the pathology confirmed a high-grade leiomyosarcoma. The post-operative survey revealed no evidence of distant metastasis.

Obstructed Small Cell Carcinoma of The Rectum : A Case Report and Literature Review

Small cell carcinoma of rectum is a rare entity and it is known for its aggressive progression and poor prognosis. We report a case of 71-year-old male patient who suffered from colon obstruction by a large small cell carcinoma of rectum. He was found to have bilateral hepatic metastases at the same time and received postoperative chemotherapy with various combinations. The patient died of sepsis ten months after operation.

Huge Outgrowing Perineal Leiomyoma

Outgrowing leiomyoma of the perineum is uncommon. We present an unusual case of a perineal leiomyoma larger than 10cm. A 19 year-old female visited our clinic with a complaint of perineal mass noted for 3 years. Physical examination revealed a huge mass with smooth border, arising from perineum. Colonoscopic examination reveled negative finding. Surgical resection of the tumor performed without postoperation complication. Pathology report was leiomyoma of rectum.