Wen-Sy Tsai

Effective Management of Posthemorrhoidectomy Secondary Hemorrhage Using Rectal Irrigation

AbstractPURPOSE: How to manage posthemorrhoidectomy secondary hemorrhage, a rare but serious complication, effectively remains controversial. This study evaluated the effectiveness of using rectal irrigation as an initial treatment for posthemorrhoidectomy secondary hemorrhage. METHODS: Among 4,880 patients on whom elective closed hemorrhoidectomy for symptomatic hemorrhoidal disease was performed, 45 (0.9 percent) developed posthemorrhoidectomy secondary hemorrhage. The 45 patients were divided into two groups based on the initial treatment in the stoma therapy room (n = 25) or in the operating room (n = 20). Patients in the stoma therapy room group were treated with rectal irrigation, whereas those in the operating room group were examined under anesthesia and the bleeding point (if any) was under-run using a suture. The two groups were then compared with respect to the cost-effectiveness of treatment, rehospitalization stay, and satisfaction with treatment. RESULTS: The two groups (stoma therapy room vs. operating room groups) were comparable with respect to the mean age of patients (44 vs. 38 years), interval of hemorrhage (9.4 vs. 7.8 days), and estimated amount of blood loss (560 vs. 520 ml). Bleeding effectively stopped in 22 (88 percent) patients in the stoma therapy room group but only in 12 (60 percent) patients in the operating room group (P = 0.010). The rehospitalization stay was three days in the stoma therapy room and 4.9 days in the operating room group (P = 0.016). In addition, the stoma therapy room group had a greater satisfaction rate than the operating room group did (80 vs. 10 percent, P < 0.001). Moreover, the average cost of treatment in the operating room group was six-fold higher than that in the stoma therapy room group. CONCLUSIONS: Our data suggest that rectal irrigation is an effective initial treatment for posthemorrhoidectomy secondary hemorrhage and offers a high rate of patient satisfaction with a reduced hospital cost.

Concurrent colonic mucosa-associated lymphoid tissue lymphoma and adenoma diagnosed after a positive fecal occult blood test: a case report

BackgroundColonic lymphoma is an uncommon presentation of extranodal lymphoma. Colonic mucosa-associated lymphoid tissue lymphoma is a different entity from gastric mucosa-associated lymphoid tissue lymphoma, and very rare. The presentation and management of colonic mucosa-associated lymphoid tissue are highly variable in the literature.Case presentationWe report the case of a 59-year-old Taiwanese man who underwent a colonoscopy after a positive test for fecal occult blood. His past history included hypertension and hyperthyroidism. The colonoscopy revealed an adenomatous polyp and mucosa-associated lymphoid tissue lymphoma. We successfully performed a polypectomy and endoscopic mucosal resection. The lymphoma was staged according to the Ann Arbor system modified by Musshoff as E-I. Our patient showed no lymphoma recurrence over a 3-year follow-up.ConclusionsEndoscopic mucosal resection for colonic mucosa-associated lymphoid tissue lymphoma without disseminated disease may be feasible. We successfully used colonoscopic treatment without adjuvant therapy to treat early-stage pathogen-free colonic mucosa-associated lymphoid tissue lymphoma.

Bone Marrow Stromal Antigen 2 Is a Novel Plasma Biomarker and Prognosticator for Colorectal Carcinoma: A Secretome-Based Verification Study

Background. The cancer cell secretome has been recognized as a valuable reservoir for identifying novel serum/plasma biomarkers for different cancers, including colorectal cancer (CRC). This study aimed to verify four CRC cell-secreted proteins (tumor-associated calcium signal transducer 2/trophoblast cell surface antigen 2 (TACSTD2/TROP2), tetraspanin-6 (TSPAN6), bone marrow stromal antigen 2 (BST2), and tumor necrosis factor receptor superfamily member 16 (NGFR)) as potential plasma CRC biomarkers. Methods. The study population comprises 152 CRC patients and 152 controls. Target protein levels in plasma and tissue samples were assessed by ELISA and immunohistochemistry, respectively. Results. Among the four candidate proteins examined by ELISA in a small sample set, only BST2 showed significantly elevated plasma levels in CRC patients versus controls. Immunohistochemical analysis revealed the overexpression of BST2 in CRC tissues, and higher BST2 expression levels correlated with poorer 5-year survival (46.47% versus 65.57%; p = 0.044). Further verification confirmed the elevated plasma BST2 levels in CRC patients (2.35 ± 0.13 ng/mL) versus controls (1.04 ± 0.03 ng/mL) (p < 0.01), with an area under the ROC curve (AUC) being 0.858 comparable to that of CEA (0.867). Conclusion. BST2, a membrane protein selectively detected in CRC cell secretome, may be a novel plasma biomarker and prognosticator for CRC.

Palliative Surgery for Colon Cancer with Unresectable Liver Metastasis

Objectives: For patients with unresectable synchronous liver metastasis, the treatment is complex and the advantages of palliative resection of the primary colon tumor have not been finally determined. Surgeons sometimes experience difficulty deciding to implement palliative primary colon cancer resection. The choice should depend on surgical risk, severity of symptoms and life expectancy. This study was designed to identify factors reducing survival post palliative surgery among patients with unresectable liver metastasis. Methods: A retrospective review of 212 colon cancer patients with unresectable liver metastases who received palliative surgery from 1995 to 2000 was conducted in this study. Clinical-pathological data were collected from medical records. Significance testing was performed using the Kaplan-Meier method to analyze survival difference and the Cox proportional hazard model for independent prognostic factor. Results: Altogether 183 patients received palliative resection of primary colon cancer and 29 patients received non-resection (bypass or diversion) surgery. Factors evaluated for survival were age, gender, comorbid heart disease, hemoglobin, albumin, bilirubin, tumor size, tumor cell differentiation, tumor resection, extent of liver metastasis, extent of systemic metastasis and chemotherapy. There were 15 postoperative deaths. The mean survival was 12.6 months for the palliative resection group and 4.7 months for the non-resection group. Patients with poor tumor differentiation, advanced liver metastases, multiple systemic metastases and absence of chemotherapy had significantly worse rates of survival. Conclusions: Palliative surgery for asymptomatic or minor symptomatic patients with poor tumor differentiation, advanced liver metastases or multiple systemic metastases is of limited survival benefit, unless the tumors are complicated with obstruction, perforation or bleeding. Postoperative chemotherapy is advocated after any type of palliative resection.

Volvulus of the Colon: Surgical Experience

Objective: Volvulus of the colon is a rare cause of intestinal obstruction that has had many types of management proposed over time. This study was designed to analyze results of various treatments through a review of patients with volvulus who were treated at our hospital. Methods: A total of 50 patients diagnosed with volvulus of the colon between 1982 and 2004 was collected, and each was assigned to one of four groups according to the mode of treatment. Results: Group 1 contained 10 patients who received colonoscopic decompression only; Group 2 contained 21 patients who underwent colonoscopic decompression followed by elective surgery; Group 3 contained 12 patients who received colonoscopic decompression followed by emergency surgery; and Group 4 contained 7 patients who underwent emergency surgery. Group 1 had no deaths, but the disease recurred in 7 of the 10 cases, requiring repeat colonoscopic decompression. Group 2, decompression followed by elective surgery, had one death and one patient who experienced significant morbidity (insufficiency of anastomosis requiring a diversion procedure). Group 3, decompression followed by emergency surgery, had three deaths and one patient with significant morbidity (with insufficiency of anastomosis requiring colostomy or ileostomy diversion). Finally, Group 4, initial emergency surgery, had three deaths and two patients with significant morbidity (colon obstruction and intra-abdominal abscess, each requiring an additional operative procedure for treatment). The overall mortality rate was 14% (7 of 50 patients). Conclusions: Colonoscopic decompression is the technique of choice for reducing volvulus of the colon if the patient has not yet developed peritonitis. However, decompression should be followed by definitive colectomy with anastomosis when the patient is medically fit to undergo surgery.