Tsai-Yu Lee

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.

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.

Colonic manifestation of mantle cell lymphoma with multiple lymphomatous polyposis

Dear Editor: Mantle cell lymphoma (MCL) is an aggressive B cell neoplasm of smallto medium-sized lymphocytes with overexpression of cyclin D1 caused by translocation (11;14), and it has tropism for the gastrointestinal tract identifiable as multiple lymphomatous polyposis (MLP) and mass lesions through the gastrointestinal tract. Lymphomatous polyposis of colon is a rare disease, and it is very important to precisely establish the histological type of lymphoma as the prognosis and treatment is quite different. Herein, we presented a case of mantle cell lymphoma with colonic manifestation of MLP and polypoid mass protruding through the appendiceal orifice. A 64-year-old male had history of peptic ulcer disease status post-subtotal gastrectomy with Billroth II anastomosis. He suffered from bowel habit change and general malaise since 3 months ago. Passage of bloody stool and right lower quadrant abdominal pain were noted in recent days. Physical examinations showed bloody stool and rectal polypoid lesions. Laboratory findings were unremarkable, except a hemoglobin level of 9.8 g/dl. Colonoscopic findings showed multiple polyps under 1-cm diameter on whole course of colon and polypoid mass of the ileocecal valve. Persistent gastrointestinal bleeding and an appendiceal orifice polypoid protuberance with suspicious tumor obstruction prompted colectomy. Wide spread lymph node enlargements over the mesentery was found during the surgery. Pathology revealed small-sized cleaved follicular lymphoid cells, with highly specific marker of cyclin D1 confirmed the diagnosis of mantle cell lymphoma. He received adjuvant systemic chemotherapy after the surgery and was uneventful. MCL is a distinct clinicopathologic entity of nonHodgkin B cell characterized by a monotonous proliferation of small to medium-sized lymphocytes with co-expression of CD5, CD20, and specific marker of cyclin D1, an aggressive and incurable clinical course and frequent t(11;14)(q13;q32) translocation. Extranodal involvement of the gastrointestinal tract occurs in about 20% of cases, and the most frequent finding is MLP. The term MLP was coined by Cornes to describe polypoid mucosal involvement of a long segment of the gastrointestinal tract by lymphoma and subsequently was found to represent involvement of the gastrointestinal tract by MCL. Macroscopic appearance of MCL in gastrointestinal tract is variable: from tumoral mass, ulcer, mucosal thickness to multiple polypoid lesions. In MLP, the colon is involved in the majority of cases, followed by the small intestine. The ileocecum is frequently the original focus of MCL involvement and remains the primary site of disease. Despite having tropism for the ileocecum, appendiceal MCL has rarely been documented as a mass lesion thickening the entire mucosal aspect. Our example was pan-appendiceal and herniated through the orifice as a polypoid protrusion notable on endoscopic examination. It rendered the surgery of resection because of synchronous adenocarcinoma and MCL of the colon being documented in a few case reports. Lymphomas of the colon occurred <0.4% of colonic neoplasms. Colonic lymphomas usually present as a Int J Colorectal Dis (2009) 24:729–730 DOI 10.1007/s00384-009-0649-7

Laparoscopically Assisted Reversal of Hartmann's Procedure for Perforated Diverticulitis

The aim of this study was to retrospectively review the clinical outcomes of laparoscopically assisted and open surgical reversal of Hartmanns procedure (HR). We reviewed all patients undergoing l...

Short-term Outcome of ＂Watch and Wait＂ for Rectal Cancer with Clinical Complete Response after Neoadjuvant Chemoradiotherapy

Purpose. ＂Watch andWait＂ policy would be the option of treatment for locally advanced rectal cancer following chemoradiotherapy with clinical complete response The short-term outcome for ＂Watch andWait＂ has not been well established. The purpose of this work was to assess the shortterm outcome of non-operative strategies. Methods. This is an observational retrospective study of one institute. All of the patients with locally advanced rectal cancer following chemoradiotherapy with clinical complete response from January 1, 2007 to December 31, 2013 were included. Results. The study population consisted of 18 patients. 14 patients underwent transanal wide excision of primary lesion 8-12 weeks later after chemoradiotherapy, and the remaining 4 patients were left for only observation. Two local recurrences occurred in those undergoing transanal wide excision and were successfully treated by another transanal wide excision. Average disease-free period was 69.78 months, and 5 year-overall survival rate was 100%. CEA were within normal range in 3 years follow-up. Conclusions. ＂Watch andWait＂ policy offers good results in terms of survival and recurrence rates, and the policy could be be considered a therapeutic option in patients with locally advanced rectal cancer follwing chemoradiation therapy with complete clinical response.

The outcome of 5-fluorouracil chemotherapy after the completion of neoadjuvant chemoradiotherapy, administered until 2 weeks before rectal cancer resection

Background In most institutions, locally advanced rectal cancer is treated with neoadjuvant chemoradiotherapy followed by surgery 6–8 weeks later, allowing time for tumor response and recovery from chemoradiotherapy‐related toxicities. In our hospital, we continuously administer chemotherapy after the completion of chemoradiotherapy, until 2 weeks before surgery for most patients. Methods This was a retrospective study. Patients received a diagnosis of adenocarcinoma of the rectum at our hospital between January 2003 and December 2008 and received neoadjuvant chemoradiotherapy and curative surgery. Chemoradiotherapy consisted of continuous infusion of 225 mg/m2 5‐fluorouracil, 5 days per week. Radiation therapy was delivered at 1.8 Gy per day, 5 days per week for 5–6 weeks (median radiation dose, 50.4 Gy). Chemotherapy was continued until 2 weeks before surgery, and surgery was performed 6–8 weeks after completion of chemoradiotherapy. Results The study included 119 patients (median age, 61 years; range, 24–84 years). Twenty‐nine patients (24.4%) had a complete response and 65 (54.6%) had a partial response. Over a median follow‐up duration of 52 months, 10 patients experienced local recurrence and 18 had distant metastasis. The 5‐year overall and disease‐free survival rates were 80.6% and 72.9%, respectively. Grade 3–4 toxicity only occurred in 14 patients (11.8%). Conclusion Continued chemotherapy with 5‐fluorouracil after completing neoadjuvant chemoradiotherapy until 2 weeks before surgery for locally advanced rectal cancer results in a good pathological control rate, with low toxicity. Patients who achieved a complete pathological response had a better long‐term oncological outcome than those who did not.

Colorectal Cancer in Patients under the Age of 40: Tri-Service General Hospital Experience

Background. In Taiwan, colorectal cancer is the first common cancer and is the third most common cause of cancer related death. In recent years, patients with colorectal cancer became younger. The purpose of this study was to analyse the patients under the age of 40 years suffering colorectal cancer. Material and Methods. We conducted a retrospective study in Tri-Service General Hospital. From January 2007 to December 2011, patients under the age of 40 years with colorectal cancer were included. Patient demographics, tumor type, tumor stage, tumor differentiation, tumor location, treatment and mean survival time were analysed. Results. Totally 52 patients, including 34 males and 18 females had colorectal cancer under the age of 40 years. The most common symptom was anal bleeding. Except 4 patients with carcinoid, all of the other patients had adenocarcinoma. Thirty-six patients had stage III/IV at diagnosis. Twenty-eight patients with adenocarcinoma had moderate differentiation. Twenty-three patients suffered from rectal cancer. Mean survival time of adenocarcinoma of colo-rectum was 4.1 ± 0.6 years in stage III patients, and 1.8 ± 0.5 years in stage IV patients. Conclusion. All patients with suspicious symptoms of colorectal cancer merit undergoing large bowel evaluation.

Liver cirrhosis is a risk factor of repeat acute hemorrhagic rectal ulcer in intensive care unit patients

Background: Acute hemorrhagic rectal ulcer (AHRU) can be found in patients with severe comorbid illness, who are bedridden for a long time. Per anal suturing is a quick and feasible treatment. However, recurrent bleeding occurs frequently after suture ligation of a bleeder and can be life-threatening. However, the risk factor for recurrent bleeding is not well known. Our study tries to clarify the risk factor of repeat AHRU in Intensive Care Unit (ICU) patients. Materials and Methods: From January 2004 to December 2009, the medical records of 32 patients, who were admitted to the ICU of the Tri-Service General Hospital, a tertiary referral center in Taiwan, and who underwent per anal suturing of acute hemorrhagic rectal ulcer were retrospectively reviewed. Results: Of the 96 patients who received emergency treatment for acute massive hematochezia, 32 patients were diagnosed with AHRU. Eight (25%) patients had recurrent bleeding following suture ligation of AHRU and underwent a reoperation; no patient had recurrent bleeding after the second operation. The duration from the first hematochezia attack to surgery ( P = 0.04), liver cirrhosis ( P = 0.002), and coagulopathy ( P = 0.01) were the risk factors of recurrent bleeding after suture ligation of a bleeder. Multivariate logistic regression analysis indicated that liver cirrhosis (OR = 37.77, P = 0.014) was an independent risk factor for recurrent bleeding. Conclusion: AHRU could be a major cause of acute massive hematochezia in patients with severe illness. Our data showed that per anal suturing could quickly and effectively control bleeding. We found that liver cirrhosis was an independent risk factor for recurrent bleeding. Therefore, treatment of a liver cirrhosis patient with AHUR should be more aggressive, such as, early detection and proper suture ligation.

Outcomes of Neoadjuvant Chemoradiation Therapy for Locally Advanced Rectal Cancer: The Effect of Preoperative Chemoradiotherapy Followed by Additional Chemotherapy on Advanced Rectal Cancer

Background. In most cases of locally advanced rectal cancer, neoadjuvant chemoradiation therapy (CCRT) reduces tumor size and results in histopathologic downstaging. This results in improved long-term oncologic outcomes. Pathologic complete remission ranges from 8% to 19%, depending on the regimen and dose of chemotherapy and/or radiotherapy.Patients and Methods. We retrospectively reviewed the medical records of patients diagnosed with rectal adenocarcinoma who were receiving neoadjuvant CCRT and curative surgery in our hospital from January 2005 to December 2008. The regimen of neoadjuvant CCRT included a high weekly dose of 5-fluorouracil (5-FU) (2000 mg/m^2 5-FU for 24 hours plus 500 mg/m^2 leucovorin intravenously for 2 hours), concurrent with radiotherapy at a total dose of 4500 cGy. Chemotherapy was continued until 2 weeks before surgery, and patient underwent surgery within 6 to 8 weeks of completing CCRT.Result. In total, 61 patients, including 31 males and 30 females with an average age of 67.6 years were examined. Most patients had a good response to neoadjuvant CCRT and experienced tumor downstaging. Only 15 patients did not experience a change in disease stage after neoadjuvant CCRT. The non-responding group had a significantly lower curative resection rate (R0 resection rate) (p=0.04) and higher local recurrence rate (p=0.03) than the responding group.Conclusion. Neoadjuvant CCRT for locally advanced rectal cancer can result in tumor downstaging and shrinkage. The regimen, dosage, and duration of chemotherapy were variable. Our results demonstrate that the administration of chemotherapy until 2 weeks before curative surgery was safe, however, the effect on the pathological complete response rate requires additional study.