1. Case presentation 2012.04.11 Supervisor : 黃允中醫師 Presenter : PGY 紀乃宇

3. Patient Profiles  Name: 蘇林 O 香  Gender: Female  Age: 83 years old  Admission date: 2012-03-09 GYN. Ward than transfered to Proto. Ward  Chart number: 10549827  Occupation : Nil

4. Chief Complaint  Lower abdomen pain for 1 day

5. Present Illness  This 83 year-old woman had past history of duodenum ulceration (Gr.LA 2) diagnosed on 2008/07/30  She suffered from dysuria, frequency for 3 days with progressive low abdomen pain (pain score 8). No fever, chillness and gross hematuria. 活動狀態：無法行走. T/P/R: 37.6 ℃ / 103 bpm/ 18. BP: 156 / 90 mmHG

6. Physical Examination  Consciousness ： clear  Appearance ： acute ill- looking  Vital signs ： BP ： 156/90 mmHg, BT :37.6 ℃, HR ： 103/min, RR :18 /min  Head ： no deformity  Eyes ： isocoric conjunctiva ： mild pale  sclera ： anicteric  ENT ： no injected throat or enlarged tonsil  Neck ： supple  Chest ： symmetric expansion,  Breathing sound bilateral clear  Heart ： regular heart beat no murmur  Abdomen ： tenderness over lower abdomen, muscle gaurding, no shifting dullness, liver and spleen : impalable bowel sounds ： hypoactive  Back: no Knocking pain  Extremity ： freely movable No edema  RDE: no palpable mass

7. CBC/DC on 3/09 at ED

8. Urine routine on 3/09 at ED

9. 3/09 KUB 3/09 Chest plain-film

10. Bedside abdominal echo at ED  Liver: no visible mass  GB: no distension, no stone  Kidney: no hydronephrosis

11. Tentative diagnosis 1. Septicemia, infection source ? 2. Ileus  Arranged abdominal CT for follow up

12. Past History  Duodenum ulceration (Gr.LA 2) diagnosed on 2008/07/30  Denied other systemic history

13. Personal history  Smoking: (-)  Alcohol consumption: (-)  Current drug history: (-)  Allergy history: (-)

14. Family History  Family history of Type 2 diabetes mellitus (-)  Family history of hypertension: (-)  Family history of coronary artery disease: (-)  Family history of cerebrovascular accident: (-)

15. Transverse view without contrast

16. Transverse view with contrast

18. Coronal view

19. Consultation at ED  Due to pelvic abscess was found, Gyn Dr. 黃嵩 杉 was consulted.  Suggested admission and surgical intervention

20. Surgical Date : 2012-03-10 –1  Laparotomy and lysis of adhesion on 3/10  OPERATION FINDING: 1. Uterus:atrophic 2. Ovaries:adhesion 3. Tubes:adhesion 4. Pelvis ＆ abdominal cavity:adhesion with abscess 5. Complication in performance and other finding: abscess from colon  Consulted proctologic Dr. 黃允中 at table.

21. Surgical Date : 2012-03-10 –2  Pre-op diagnosis: Pelvic abscess,cause?  Operative finding: 1.Phlegmone formation over meso-colon of sigmoid colon with purulent abscess formation over right aspect of pelvis, causing erosion of right ovary was noted. A palpable mass, about 3*4*3cm in size over upper rectum was found incidentally.

22. Operation  Hartmann's procedure + Peri-toneal lavage + Right oophorectomy

25. Pathological report ---- Tuboovarian abscess  Diagnosis Adnexa, right, adnexectomy ---- Tuboovarian abscess  Gross Finding The specimen submitted consists of several tissue fragments measuring up to 4 x 2.5 x 1 cm in size, fixed in formalin. Grossly, they are whitish and soft tissue fragments. Representative sections are taken and labeled as: A1-A2  Microscopic Finding The sections of the right adnexa show a picture of tuboovarian abscess, composed of acute inflammatory cell infiltration, hemorrhage and abscess formation.

26. Pathological report Rectal tumor-- Gross Finding  A rectosigmoid, measuring 18 cm in length and 5.5 cm in circumference. A fugnating tumor, measuring 3.3 x 2.8 x 1.6 cm. Two diverticula measuring up to 1 x 1 cm in size are found in the colon. No polyps were found.

27. Microscopic Finding: 1. Tumor type: Adenocarcinoma, NOS 2. Histological grade: Moderately differentiated 3. Lymphovascular invasion: Absent 4. Perineural invasion: Absent 5. Tumor extension: To muscularis propria 6. Proximal and distal surgical margins: Free of tumor cells 7. Circumferential margin: Free of tumor cells 8. Lymph nodes, perirectal and pericolic ( 0 /16 ): Reactive hyperplasia 9. Polyps (away from tumor): Absent 10. Perforated diverticulitis is found in the remaining colon. 11. AJCC stage: pT2 N0

28. Final diagnosis 1. Adenocarcinoma over upper rectum, ( pT2N0MO stage:I ) s/p Hartmann's procedure 2. Diverticulitis over sigmoid colon with perforation and abscess formation over right aspect of pelvis, causing erosion of right ovary, s/p Peritoneal lavage + Right oophorectomy  Discharged on 3/20 with stable condition

29. OPD follow-up  2012/03/21 S:No specific complaints  2012/04/05 S:No specific complaints after operation. P: scheduled closure of colostomy on 101-06-10

30. Discussion 醫療品質與醫學倫理

31. However...... Pelvic abscess and A three cm upper rectal tumor…….

32. Management and complications of tuboovarian abscess Uptodate Literature review current through: 2012/02. This topic last updated: 2012/02/15.

33. SUMMARY AND RECOMMENDATIONS Rupture of a TOA occurs in approximately 15 percent of cases. Women suspected of having a ruptured TOA or who present with signs of sepsis require immediate surgical exploration. Laparotomy appears to be the best route in these emergent cases.

34. We suggest treatment with antibiotic therapy alone for women who meet the following criteria: hemodynamically stable with no signs of a ruptured TOA; abscess <9 cm in diameter; adequate response to antibiotic therapy; and premenopausal (Grade 2C). Treatment with antibiotics alone is also reasonable in women with an abscess that is ≥9 cm who meet these criteria and are aware of the decreased efficacy of this approach in their clinical situation.Grade 2C

35. The rates of concurrent gynecologic malignancy appear to be much higher among postmenopausal women with TOA. For postmenopausal women with a presumed TOA, we suggest surgical diagnosis and/or treatment rather than treatment solely with antibiotics or a minimally invasive drainage procedure (Grade 2C).Grade 2C

36. For women who show no improvement on antibiotic therapy alone, but are not worsening, we suggest a minimally invasive abscess drainage procedure (Grade 2C). For those on antibiotic therapy who are clinically worsening, we suggest surgical treatment (Grade 2C). Antibiotic therapy should be maintained in combination with these additional interventions.Grade 2C

37. 大腸直腸癌診療方法之提議 第一期 ( T1-2 N0 M0 ) ， T1 直腸癌可作經肛門 或由後方局部切除及術後放射線治療；或低前 位切除 ( low anterior resection, LAR ) ；或病人 因不適合開刀而作放射線治療。 For patients with non-metastatic invasive upper and mid-rectal cancers, low anterior resection (LAR) is the standard surgical approach. Surgical treatment of rectal cancer, 2012/02 Uptodate

38. Hartmann’s procedure This operation is often carried out as an emergency if there has been a perforation of the bowel, especially if you have diverticular disease, colorectal cancer or had a trauma to the bowel.

39. Computed Tomography Accuracy of CT Colonography for Detection of Large Adenomas and Cancers N ENGL J MED 2008; 359:1207 1217September 18, 2008September 18, 2008

41. When Use a Bowel Preparation? Flexsigmoidoscopy and colonoscopy Elective colorectal surgeries Emergency colorectal surgeries?

42. Why a Clean Bowel Is So Important? Better visualization for endoscopic examination- faster, more accurate, and comfort Decrease infection rate Improve “ease of bowel handling” Allows for intraoperative colonoscopy Safer anastomosis Lowers the rate of stoma creation Lowers wound infection rate

43. Ovarian metastases The prevalence: 1)At the time of diagnosis: –colonic cancer: 1.1 percent (34 of 3172) –rectal cancer: 0.6 per cent (8 of 1394) (P = 0.105). 2)After radical resection of stage I-III of colorectal cancer during follow-up : –colonic cancer: 1.1 per cent (22 of 1971) –rectal cancer: 0.1 per cent (1 of 881) with (P = 0.006).  Ovarian metastases from colorectal cancer are uncommon. Epidemiology and prognosis of ovarian metastases in colorectal cancer. Br J Surg. 2010;97(11):1704.

44. And more...... Right oophorectomy was not permitted by the patient or her family member before the procedure 哎呀，忘記說了 ……

45. Justice Bemjamin Cardozo(1914) 每一個心智健全之成年人都有權利決定其 身體要接受何種之處置。

46. 知情同意的法律意義 具侵襲性的檢查和治療是一種侵害行為，若未 取得病人同意，將被視為違法行為。醫師為病 人施行侵襲性檢查或治療，除了必須是業務上 正當行為外，也因為病人同意在先，而阻卻了 違法性 。 病人係在具體個別的診療行為和侵襲範圍內同 意，病人一旦同意，則在特定診療行為範圍內 的侵襲程度及其可能伴隨的危險性，病人均有 忍受的義務 。 但超越同意範圍的醫療行為，則 不具法律效力 。

47. 知情同意的法律意義 法律規定： – 對手術同意的規定：醫療法第 63 條 – 對侵入性檢查或治療同意的規定：醫 療法第 64 條 – 對施行人體實驗同意的規定：醫療法 第 79 條 – 同意書只能證明已經針對擬進行的醫 療程序或檢查做過討論，並不能取代 告知及同意過程 。

50. CRC- features More in middle-aged group –> 50 year-old Left-side dominant –Change of stool character –Early detection Right-side disease –Young-aged group, familial –Advanced disease