J Formos Med Assoc

Colonofiberscopic diagnosis of intestinal tuberculosis.

Hsiao TJ. Wong JM. Shieh MJ. Wu CH. Wang CY.
Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
The purpose of this study was to assess the predictive value of colonofiberscopy in the diagnosis of intestinal tuberculosis. The records of more than 14,000 colonofiberscopic examinations performed at the National Taiwan University Hospital from 1971 to 1995 were studied retrospectively. Colonofiberscopic diagnosis of intestinal tuberculosis required at least one of the following: circumferential ulcers, a single transverse axis ulcer with uneven base and elevated or nodular margin surrounded by nodular and hyperemic mucosa, or pseudopolyps. Sixty cases were diagnosed as intestinal tuberculosis based on these criteria, 29 of which were confirmed by histologic or bacteriologic findings or on the basis of clinical response to antituberculosis therapy. The positive predictive value of colonofiberscopy for intestinal tuberculosis was thus 43.3% (95% confidence interval 31-57%). Secondary intestinal tuberculosis with pulmonary tuberculosis accounted for 84% of cases. The most commonly involved area of the gastrointestinal tract was the ileocecal region, followed by the ascending colon and ileum. Based on our findings, colonofiberscopic examination with histopathologic and bacteriologic study of biopsy specimens is a powerful tool for the diagnosis of intestinal tuberculosis.

Preoperative concurrent chemotherapy and radiotherapy in rectal cancer patients.

Ch'ang HJ. Jian JJ. Cheng SH. Liu MC. Leu SY. Wang FM. Tsai SY. Tsao MH. Lin HH. Huang AT. Sung JL.
Department of Radiation Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
The management of rectal cancer has changed significantly in recent years. The key end-point is no longer survival but rather preservation of sphincter function with improved quality of life. Preoperative radiation can not only render a low-lying rectal tumor amenable to sphincter-preserving surgery but has also been reported to give better local control and lower toxicity than postoperative radiotherapy. From October 1991 through July 1996, 46 patients with local advanced or low-lying rectal cancer were treated with preoperative high-dose radiotherapy and concurrent chemotherapy. All patients underwent pelvic radiotherapy with 5,000 to 5,400 cGy in 25 to 27 fractions. Chemotherapy was given concomitantly and consisted of two courses of 5-fluorouracil (5-FU) at 1,000 mg/m2 for 4 days in week 1 and week 5 plus mitomycin C 10 mg/m2 single bolus on day 1 of week 1. In 30 patients, postoperative adjuvant chemotherapy with 5-FU and levamisole weekly was also given, for a total of 12 months. The most common acute toxicity was grade 1 to 2 diarrhea and tenesmus during radiation or soon afterward. Only five of the 46 patients experienced symptomatic grade 3 acute toxicity. Forty-two patients underwent subsequent surgery 6 to 8 weeks after concurrent chemoradiotherapy. Pathologic examination disclosed complete tumor regression in eight patients and microscopic residual disease in 13 patients after preoperative chemoradiation. Of the 42 patients who completed the intended treatments, only one had local recurrence. The sphincter was preserved in 21 of the 26 patients in whom the tumor was located within 5 cm above the anal verge. Twelve of the 16 evaluable patients had good to excellent sphincter function. The 2-year overall survival rate was 93% and the disease-free survival was 81%. Our findings indicate that preoperative concurrent chemoradiotherapy not only allows low-lying rectal tumors to be resected while preserving sphincter function but also results in good local control and acceptable toxicity.

Intermittent intussusception caused by colonic lipoma.

Chan KC. Lin NH. Lien HC. Chan SL. Yu SC.
Department of Diagnostic Radiology, Taiwan Provincial Taipei Hospital, Taiwan.
Colonic lipomas are rare, usually small, and occur most often in the right colon, particularly in the cecum. They are most common in elderly women. Intermittent episodes of intussusception are not uncommon in patients with colonic lipoma, but they are usually caused by larger pedunculated lipomas. We report a 43-year-old woman with a large colonic submucosal lipoma that induced intermittent colocolic intussusception. The patient presented with symptoms of peptic ulcer, including intractable upper abdominal pain, which did not resolve with treatment. Abdominal sonography showed typical findings of intussusception caused by a lipoma, but the manifestations on barium enema and computed tomography mimicked a malignant colonic tumor. The patient's abdominal pain disappeared after right hemicolectomy and the tumor was demonstrated to be a lipoma. The postoperative course was uneventful; there was no evidence of recurrence at follow-up 6 months later. Physicians should be aware that surrounding organs should also be evaluated in cases of chronic peptic ulcer with intractable upper abdominal pain.

Efficacy of a stress management program for patients with hepatocellular carcinoma receiving transcatheter arterial embolization.

Year 1998
Lin ML. Tsang YM. Hwang SL.
Department of Nursing, Taipei Medical College Hospital, Taiwan.
Transcatheter arterial embolization (TAE), a common treatment for patients with unresectable hepatocellular carcinoma (HCC), can provoke severe physical discomfort and psychologic stress. The purpose of this study was to investigate the effect of a combination of health education, muscle relaxation, and back massage on reducing physical and psychologic stress in HCC patients receiving TAE. A quasi-experimental design was used. Forty patients with HCC (30 men and 10 women) with a mean age of 57 +/- 12 years were recruited and randomly assigned to the control or experimental group. The effectiveness of the stress management program was evaluated using a knowledge questionnaire, a worry inventory, a state-trait anxiety inventory, and a physical distress scale. After completing the stress management program, the experimental group had a greater mean increase in knowledge score than the control group (5.1 vs 0.8, p < 0.0001) and a greater mean decrease in worry score (-8.2 vs 1.1, p < 0.0001). The mean decrease in the anxiety score in the experimental group was also significantly greater than in the control group before TAE (-5.8 vs 3.2, p < 0.001) and 2, 4, 6, and 7 days after TAE (-8.2 vs 7.1, p < 0.001; -8.7 vs 3.2, p < 0.001; -9.8 vs -2.1, p < 0.05; -11 vs -0.9, p < 0.05). The patients in the experimental group had a smaller mean increase in physical distress score than the control group at 2, 4, 6, and 7 days after TAE (34.7 vs 50.2, 20.9 vs 29.6, 10.6 vs 18.2, 3.9 vs 11.2, all p < 0.05). This stress management program effectively reduces the stress of HCC patients undergoing TAE.

Laparoscopic subtotal gastrectomy with lymphadenectomy in a patient with early gastric cancer.

Year 1998
Kuo WH. Lee WJ. Chen CN. Yuan RH. Yu SC.
Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
Laparoscopic surgery is rapidly gaining in popularity among general surgeons. It is not widely used to treat abdominal malignancies because of technical difficulties and the fear of peritoneal dissemination. We describe the use of laparoscopic surgery to treat early gastric cancer. A 66-year-old man was diagnosed with early gastric adenocarcinoma by endoscopic ultrasonography and biopsy. Subtotal gastrectomy along with removal of the perigastric (D1) and selective extraperigastric lymph nodes over the celiac trunk was accomplished laparoscopically, through five punctures and a minilaparotomy. The patient's convalescence was uneventful. Bowel sounds were heard on postoperative day 1. On postoperative day 3, he passed flatus. The patient was started on a clear liquid diet on postoperative day 5. There was neither leakage nor obstruction after oral intake. He was discharged on postoperative day 11. No local recurrence or distant metastasis was found during 16 months' follow-up. This is the first report of successful laparoscopic resection of early gastric cancer with lymph node dissection in Taiwan.

Factors affecting postoperative fecal soiling in Hirschsprungs disease.

Year 1998
Lu WT. Chen CC.
Department of Surgery, Taipei Municipal Women & Children's Hospital, Taiwan.
We retrospectively assessed the factors that may contribute to fecal soiling after surgery for Hirschsprung's disease. Fifty-eight patients underwent surgery for Hirschsprung's disease and returned for follow up. The patients were divided into two groups based on the presence or absence of fecal soiling. The postoperative period, level of bowel pulled through, stool frequency, stool character, presence or absence of anorectal surgical complications, and manometric findings of the two groups were compared. Forty-three patients (40 boys, 3 girls, mean age 9.5 yr) had soiling and 15 (10 boys, 5 girls, mean age 10.2 yr) did not. Patients with soiling had significantly higher rates of anorectal surgical complications (60% vs 7%), abnormal stool character (75% vs 7%), stool frequency greater than three times per day (63% vs 20%), absence of rectoanal inhibitory reflex (33% vs 2%), and narrow anorectal pressure gradient (60% vs 13%) than those without. The results of manometric study suggested that a damaged internal sphincter or irritable neorectum might have contributed to fecal soiling. In conclusion, although anorectal surgical complications might result in both irritable neorectum and damaged internal sphincter, their effect on the neorectum (significantly increased rate of high resting rectal pressure) seemed to outweigh that on the internal sphincter. A competent anal sphincter and a less irritable neorectum after operation may therefore lower the likelihood of fecal soiling.

Amebic liver abscess complicated with cardiac tamponade and mediastinal abscess.

Year 1998
Chao TH. Li YH. Tsai LM. Tsai WC. Teng JK. Lin LJ. Chen JH.
Department of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.
Amebic pericarditis is an extremely rare complication of liver abscess and an uncommon etiology of sterile pericardial effusion with cardiac tamponade. The association of mediastinal abscess in this clinical setting has not been reported in the literature. Herein, we describe a case of amebic liver abscess complicated with mediastinal abscess and amebic pericarditis with cardiac tamponade. A 44-year-old man was admitted to our hospital because of shortness of breath for the previous 2 days. Cardiac tamponade was diagnosed and emergency pericardiectomy was performed. Chocolate-like pus was found in the pericardial sac and mediastinal space during surgery. Abdominal computed tomography revealed an ill-defined hypodense lesion over the left lobe of the liver, suggesting a liver abscess. Amebic liver abscess and pericarditis were diagnosed on the basis of a high serum titer of amebic antibodies on hemagglutination test. The patient was treated with metronidazole for 2 weeks and discharged in good condition. This case should alert clinicians to the possibility of amebic pericarditis in patients with cardiac tamponade associated with chocolate-like sterile pus in the pericardium and mediastinum. To establish the diagnosis of amebic pericarditis, one should investigate the presence of a liver abscess, a high serum titer of amebic hemagglutination antibodies, and the presence of Entamoeba histolytica trophozoites in the pericardium or pericardial aspirate.

Radiographic and computed tomographic findings of gastric mucosa-associated lymphoid tissue lymphomas.

Year 1998
Peng SS. Tsang YM. Lin JT. Wang HH. Chiang IP. Hsu JC.
Department of Medical Imaging, Medical College and Hospital, National Taiwan University, Taipei.
The purpose of this retrospective study was to evaluate the detection of gastric mucosa-associated lymphoid tissue (MALT) lymphoma lesions by upper gastrointestinal (UGI) radiography and computed tomography (CT). Fifteen patients with endoscopic biopsy-proven MALT lymphoma were included. Fourteen of these patients underwent double-contrast UGI radiography and 14 were examined with CT of the upper abdomen; 13 underwent both procedures. UGI radiography identified 88% (30/34) of lesions detected by endoscopy, including 12 of 13 enlarged rugal folds and 15 of the 17 multinodular lesions, but failed to identify two of the three ulcerative lesions. UGI radiography identified the only submucosal lesion demonstrated by endoscopy, as well as one at the gastric antrum that had been missed by endoscopy. CT demonstrated nine of 30 endoscopically proven MALT lymphoma lesions, three with focal thickening of the gastric wall and six with a lobulated inner gastric wall. CT failed to demonstrate two fundal and 19 antral or gastric body lesions. Our findings suggest that the predominant UGI features of gastric MALT lymphoma are enlarged folds and multinodular lesions. Although UGI radiography does not reveal all MALT lymphoma lesions, it may find lesions that are not detected by endoscopy. Mucosal lesions of gastric MALT lymphoma are usually not detected by CT.

One-week proton pump inhibitor-based triple therapy eradicates residual Helicobacter pylori after failed dual therapy.

Year 1998
Sheu BS. Wu JJ. Yang HB. Huang AH. Lin XZ.
Department of Internal Medicine, National Cheng Kung University, Tainan, Taiwan.
The purposes of this study were to assess the efficacy of a 1-week proton pump inhibitor (PPI)-based triple therapy after failure of dual therapy in Helicobacter pylori eradication, and to compare the effectiveness of clarithromycin and metronidazole in this regimen. Between January 1996 and March 1997, 67 patients with persistent H. pylori infection after a 2-week course of dual therapy (amoxicillin plus omeprazole) were enrolled. They were randomly assigned to receive amoxicillin (1000 mg twice daily) and omeprazole (20 mg twice daily) plus either metronidazole (500 mg twice daily) or clarithromycin (250 mg twice daily). Endoscopy was performed in each patient to assess the status of H. pylori using the rapid urease test (CLOtest) and the histologic findings before dual therapy, after dual therapy, and after triple therapy. H. pylori isolates were tested for antibiotic resistance when triple therapy failed. The 1-week triple therapy was well tolerated in both groups with no adverse effects severe enough to cause withdrawal from the trial. Residual H. pylori was eradicated in 94% (33/35) of patients in the clarithromycin group and 84% (27/32) in the metronidazole group; the difference was not statistically significant. All seven patients in whom triple therapy failed were infected with metronidazole-resistant isolates and two also had clarithromycin-resistant isolates. This 1-week triple therapy is safe and effective in eradicating residual H. pylori after dual therapy failure. Failure of the rescue regimen is related to antimicrobial agent resistance. Because of the high metronidazole resistance rate in Taiwan, clarithromycin appears to be more promising than metronidazole for the control of H. pylori.

Successful resection of sigmoid colon cancer in a patient with factor XI deficiency.

Year 1998
Uen WC. Chou YH. Liu CC. Lin SM. Chen TJ.
Department of Hematology and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
A 42-year-old-women with sigmoid colon adenocarcinoma was found to have isolated prolonged activated partial thromboplastin time (aPTT 102.5 s, normal range 24-36 s) preoperatively. Her medical history included an episode of prolonged postdelivery uterine bleeding 16 years previously. A mixed aPTT test showed immediate correction of the prolonged aPTT, indicating a coagulation factor deficiency in the intrinsic pathway. Factor assays showed factor XI was below 1% of average normal value whereas factor VIII, IX and XII activities were normal. Family screening revealed one sister among the three siblings also had isolated prolonged aPTT. The patient was transfused with four units (5mL/kg) of fresh frozen plasma the day before surgery, then with two units during surgery. The operation was uneventful with no bleeding problems. The patient recovered smoothly and is currently undergoing adjuvant chemotherapy. This is the first formal report of a patient with factor XI deficiency undergoing major surgery in Taiwan. Careful monitoring of aPTT, with fresh frozen plasma transfusion, when needed, may safely overcome bleeding problems during surgery.