Laparoscopic rectal cancer surgery: Where do we stand?

Large comparative studies and multiple prospective randomized control trials (RCTs) have reported equivalence in short and long-term outcomes between the open and laparoscopic approaches for the surgical treatment of colon cancer which has heralded widespread acceptance for laparoscopic resection of colon cancer. In contrast, laparoscopic total mesorectal excision (TME) for the treatment of rectal cancer has been welcomed with significantly less enthusiasm. While it is likely that patients with rectal cancer will experience the same benefits of early recovery and decreased postoperative pain from the laparoscopic approach, whether the same oncologic clearance, specifically an adequate TME can be obtained is of concern. The aim of the current study is to review the current level of evidence in the literature on laparoscopic rectal cancer surgery with regard to short-term and long-term oncologic outcomes. The data from 8 RCTs, 3 meta-analyses, and 2 Cochrane Database of Systematic Reviews was reviewed. Current data suggests that laparoscopic rectal cancer resection may benefit patients with reduced blood loss, earlier return of bowel function, and shorter hospital length of stay. Concerns that laparoscopic rectal cancer surgery compromises short-term oncologic outcomes including number of lymph nodes retrieved and circumferential resection margin and jeopardizes long-term oncologic outcomes has not conclusively been refuted by the available literature. Laparoscopic rectal cancer resection is feasible but whether or not it compromises short-term or long-term results still needs to be further studied.

Both stromal cell and colonocyte epidermal growth factor receptors control HCT116 colon cancer cell growth in tumor xenografts

Colon cancer growth requires growth-promoting interactions between malignant colonocytes and stromal cells. Epidermal growth factor receptors (EGFR) are expressed on colonocytes and many stromal cells. Furthermore, EGFR is required for efficient tumorigenesis in experimental colon cancer models. To dissect the cell-specific role of EGFR, we manipulated receptor function on stromal cells and cancer cells. To assess the role of stromal EGFR, HCT116 human colon cancer cells were implanted into immunodeficient mice expressing dominant negative (DN) Egfr(Velvet/+) or Egfr(+/+). To assess the role of cancer cell EGFR, HCT116 transfectants expressing inducible DN-Egfr were implanted into immunodeficient mice. To dissect EGFR signals in vitro, we examined colon cancer cells in monoculture or in cocultures with fibroblasts for EGFR transactivation and prostaglandin synthase 2 (PTGS2) induction. EGFR signals were determined by blotting, immunostaining and real-time PCR. Tumor xenografts in Egfr(Velvet/+) mice were significantly smaller than tumors in Egfr(+/+) mice, with decreased proliferation (Ki67) and increased apoptosis (cleaved caspase-3) in cancer cells and decreased stromal blood vessels. Mouse stromal transforming growth factor alpha (TGFA), amphiregulin (AREG), PTGS2 and Il1b and interleukin-1 receptor 1 (Il1r1) transcripts and cancer cell beta catenin (CTNNB1) and cyclin D1 (CCND1) were significantly lower in tumors obtained from Egfr(Velvet/+) mice. DN-EGFR HCT116 transfectants also formed significantly smaller tumors with reduced mouse Areg, Ptgs2, Il1b and Il1r1 transcripts. Coculture increased Caco-2 phospho-active ERBB (pERBB2), whereas DN-EGFR in Caco-2 cells suppressed fibroblast PTGS2 and prostaglandin E2 (PGE2). In monoculture, interleukin 1 beta (IL1B) transactivated EGFR in HCT116 cells. Stromal cell and colonocyte EGFRs are required for robust EGFR signals and efficient tumor growth, which involve EGFR-interleukin-1 crosstalk.

Antimesenteric functional end-to-end handsewn (Kono-S) anastomosis

INTRODUCTION

Anastomotic recurrence is a frequent event after bowel resection for Crohn's disease. To date, no anastomotic technique has been proven to be superior in reducing surgical recurrence rates in this setting. In this article, we describe our technique in performing a new antimesenteric functional end-to-end handsewn (Kono-S) anastomosis.

METHODS

The segment of bowel to be resected is identified and mobilized. The bowel is then divided transversely with a linear stapler-cutter device. The intervening mesentery is divided close to the bowel. The corners of the two stapled lines are sutured together, and the two stapled lines are approximated with interrupted sutures. An antimesenteric longitudinal enterotomy is performed on both sides, starting no more than 1 cm away from the staple line, to allow a transverse lumen of 7-8 cm. The openings are closed transversely in two layers.

RESULTS

From May 1, 2010 to July 31, 2011 we performed 46 Kono-S anastomoses. One patient had a contained anastomotic leak successfully treated conservatively. Currently, 18 patients (43 %) have undergone follow-up endoscopic surveillance with an average Rutgeert's score of 0.7 (0-3) at a mean of 6.8 months.

CONCLUSION

The Kono-S anastomosis is a safe anastomotic technique. Long-term studies are needed to confirm its efficacy in preventing surgical recurrence.

Totally laparoscopic total proctocolectomy: a safe alternative to open surgery in inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) patients have a high incidence of wound and overall postoperative complications. A totally laparoscopic approach could potentially reduce these risks. We adopted totally laparoscopic total proctocolectomy (TL-TPC) using the perineal wound for extraction as the procedure of choice in IBD patients who are not candidates for a restorative procedure. This study looks at the TL-TPC results and compares them with our open cohort.

METHODS

Prospectively collected data from 52 consecutive patients undergoing TL-TPC from 2002 to 2010 were compared to 31 contemporary patients undergoing open TPC.

RESULTS

Demographics and patient characteristics including body mass index were similar. Mean operative times were 340 ± 7 minutes for TL-TPC and 337 ± 9 minutes for open TPC (P = 0.91). Intraoperative blood loss was 228 ± 2 mL for TL-TPC and 484 ± 3 mL for open TPC (P < 0.001). Return of bowel function measured as an ileostomy output >100 mL per 8 hours occurred at 2.7 ± 2.8 days for TL-TPC versus 3.3 ± 1.8 days for open TPC (P = 0.025). The length of stay was 8.4 ± 5.0 days for TL-TPC versus 9.2 ± 3.2 days for open TPC (P = 0.05). The overall complication rate was 43% for TL-TPC versus 65% for open TPC (P = 0.07). Postoperative abdominal wound infections and parastomal hernias occurred in 23% and 10% of open TPC patients, respectively, versus zero (P = 0.001) and 6% (P = 0.67) for TL-TPC.

CONCLUSIONS

TL-TPC is therefore considered a safe alternative to open surgery for selected IBD patients not candidates for a restorative procedure.

Surgical treatment of ulcerative colitis in the biologic therapy era

Recently introduced in the treatment algorithms and guidelines for the treatment of ulcerative colitis, biological therapy is an effective treatment option for patients with an acute severe flare not responsive to conventional treatments and for patients with steroid dependent disease. The reduction in hospitalization and surgical intervention for patients affected by ulcerative colitis after the introduction of biologic treatment remains to be proven. Furthermore, these agents seem to be associated with increase in cost of treatment and risk for serious postoperative complications. Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice in ulcerative colitis patients. Surgery is traditionally recommended as salvage therapy when medical management fails, and, despite advances in medical therapy, colectomy rates remain unchanged between 20% and 30%. To overcome the reported increase in postoperative complications in patients on biologic therapies, several surgical strategies have been developed to maintain long-term pouch failure rate around 10%, as previously reported. Surgical staging along with the development of minimally invasive surgery are among the most promising advances in this field.

miR-143 and miR-145 are downregulated in ulcerative colitis: putative regulators of inflammation and protooncogenes

BACKGROUND

miR-143 and miR-145 are believed to function as colon cancer tumor suppressors, as they inhibit colon cancer cell growth and are downregulated in sporadic colonic tumors. We speculated that miR-143 and miR-145 might also be downregulated and contribute to malignant transformation of colonic epithelium in longstanding ulcerative colitis (UC).

METHODS

Biopsies were obtained 20 cm proximal to the anus from individuals with quiescent UC and from normal controls. RNA and proteins were extracted and measured. miR-143 and miR-145 were quantified by real-time polymerase chain reaction (PCR) and miR-145 was also assessed by in situ hybridization. Putative targets of these miRNAs, K-RAS, API5, MEK-2 (miR-143), and IRS-1 (miR-145) were determined by western blotting. To assess the effects of miR-143 and miR-145 on these predicted targets, HCT116 and HCA-7 colorectal cancer cells were transfected with miR-143 and miR-145 and expression levels of these proteins were measured.

RESULTS

In UC, miR-143 and miR-145 were significantly downregulated 8.3-fold (3.4-20.1) (P < 0.0001) and 4.3-fold (2.3-7.8) (P < 0.0001), respectively, compared to normal colon. In contrast, IRS-1, K-RAS, API5, and MEK-2 were upregulated in UC, consistent with their assignments as targets of these miRNAs. Furthermore, transfected miR-143 and miR-145 significantly downregulated these proteins in HCT116 or HCA-7 cells.

CONCLUSIONS

Compared to normal colonic mucosa, in chronic UC miR-143 and miR-145 were significantly downregulated and their predicted targets, IRS-1, K-RAS, API5, and MEK-2 were upregulated. We postulate that loss of these tumor suppressor miRNAs predispose to chronic inflammation and neoplastic progression in IBD.

Current laparoscopic management of inflammatory bowel disease

Since the introduction of laparoscopic surgery in the management of colorectal disease in the early '90s, minimally invasive techniques have gained popularity. While good quality studies have been published in the literature on laparoscopy for colorectal cancer, evidence supporting the use of minimally invasive surgery for inflammatory bowel disease is lacking. This patient population represents a challenge to the colorectal surgeon even in conventional open surgery and this has limited the widespread application of minimally invasive techniques especially in Crohn's disease. Laparoscopic ileocecal resection for Crohn's disease is the most performed minimally invasive procedure in the field of inflammatory bowel disease, with promising short-term outcomes but with still some concerns related to prolonged operative times and overall costs. For ulcerative colitis the magnitude of restorative procedures has also restricted the use of minimally invasive approaches to highly specialized tertiary referral centers. The benefits of performing restorative procedures laparoscopically for ulcerative colitis are less obvious based on the limited reports available in the literature with adequate follow-up for assessing long-term outcomes, and controversies still remains about the need for a staged approach in the era of biologic therapy. Nevertheless, surgeons are actively working in an effort to obviate to the current technical limitations of laparoscopy, and to further minimize surgical trauma. In this manuscript we will present the current evidence supporting the use of laparoscopy and minimally invasive techniques in inflammatory bowel disease and present the future direction of development and research.

Total abdominal colectomy for refractory ulcerative colitis. Surgical treatment in evolution

INTRODUCTION

Total abdominal colectomy is the procedure of choice for debilitated patients with acute, medical refractory ulcerative colitis in our practice. A laparoscopic approach has been previously shown to be safe and effective, and has become our preferred strategy. This study illustrates the laparoscopic evolution towards a truly minimally invasive approach comparing three phases of a single colorectal surgeon experience.

MATERIAL AND METHODS

In May 2010 single incision laparoscopy was introduced in our practice and has become our preferred approach. Ten consecutive ulcerative colitis patients were case matched and compared with 10 previous laparoscopic-assisted (Feb 2003-Jan 2007) and 10 hand-assisted (Feb 2006-Apr 2010) total abdominal colectomies. Patient, disease and surgery-related factors were analyzed and short-term outcomes were compared.

RESULTS

Given the study design, there were no differences in demographics, smoking history, disease duration and severity, nutritional and inflammatory parameters, and indication for surgery between groups. Single incision patients were more likely to have received immunosuppressive therapy within 30 days of the surgery (p = 0.016). In the single incision group we noticed significantly shorter duration of surgery (p < 0.001) and faster resumption of solid diet (p = 0.019) compared to the other groups. Other short-term outcomes did not differ between groups.

CONCLUSION

Single incision laparoscopy offers a safe alternative to other laparoscopic approaches. Despite the higher technical complexity, the duration of surgery is shorter with faster resumption of oral intake. Studies with larger sample size and longer follow-up will be required to confirm the benefits of this approach.

Laparoscopic treatment of Crohn's disease

The surgical and medical management of inflammatory bowel disease (IBD) has significantly evolved over the course of the last two decades. On the medical side, the introduction of biologic therapy has significantly changed the characteristics of the patients undergoing surgery for Crohn's disease (CD), while its impact on the need for surgical intervention and the surgical outcomes of these patients is still debated. On the surgical side, the introduction of and the growing experience with minimally invasive approaches to IBD have had a significant impact on outcomes and quality of life in this patient population. During the past three decades the evidence has been accumulating in favor of a minimally invasive approach to CD. Clearly, this is probably one of the most challenging diseases to treat laparoscopically for the colorectal surgeon, especially when the disease is located in the colon and involves multiple segments.

Acute appendicitis secondary to a granular cell tumor of the appendix in a 19-year-old male

INTRODUCTION

Granular cell tumors are rare, usually benign, neoplasms presenting as solitary small nodules in the skin or subcutaneous tissue. Involvement of the gastrointestinal tract is unusual, particularly of the appendix, and it is characterized by indolent, submucosal lesions usually diagnosed as an incidental finding.

CASE REPORT

We describe the rare case of acute appendicitis secondary to a granular cell tumor of the appendix in a 19-year-old male.

EGFR signals downregulate tumor suppressors miR-143 and miR-145 in Western diet-promoted murine colon cancer: role of G1 regulators

Epidermal growth factor receptors (EGFR) contribute to colonic tumorigenesis in experimental models of colon cancer. We previously showed that EGFR was also required for colonic tumor promotion by Western diet. The goal of this study was to identify EGFR-regulated microRNAs that contribute to diet-promoted colonic tumorigenesis. Murine colonic tumors from Egfr(wt) and hypomorphic Egfr(wa2) mice were screened using micro RNA (miRNA) arrays and miR-143 and miR-145 changes confirmed by Northern, real-time PCR, and in situ analysis. Rodent and human sporadic and ulcerative colitis (UC)-associated colon cancers were examined for miR-143 and miR-145. Effects of EGFR on miR-143 and miR-145 expression were assessed in murine and human colonic cells and their putative targets examined in vitro and in vivo. miR-143 and miR-145 were readily detected in normal colonocytes and comparable in Egfr(wt) and Egfr(wa2) mice. These miRNAs were downregulated in azoxymethane and inflammation-associated colonic tumors from Egfr(wt) mice but upregulated in Egfr(wa2) tumors. They were also reduced in human sporadic and UC colon cancers. EGFR signals suppressed miR-143 and miR-145 in human and murine colonic cells. Transfected miR-143 and miR-145 inhibited HCT116 cell growth in vitro and in vivo and downregulated G(1) regulators, K-Ras, MYC, CCND2, cdk6, and E2F3, putative or established targets of these miRNAs. miRNA targets Ras and MYC were increased in colonic tumors from Egfr(wt) but not Egfr(wa2) mice fed a Western diet. EGFR suppresses miR-143 and miR-145 in murine models of colon cancer. Furthermore, Western diet unmasks the tumor suppressor roles of these EGFR-regulated miRNAs.

Single incision ("scarless") laparoscopic total abdominal colectomy with end ileostomy for ulcerative colitis

INTRODUCTION

Total abdominal colectomy with ileal pouch-anal anastomosis is the intervention of choice for patients with medically uncontrolled ulcerative colitis. A three-stage approach is preferred in particularly debilitated patients. In this setting, laparoscopic surgery has shown to be safe, offering several advantages over the open approach. Single incision laparoscopic surgery is a new minimally invasive approach which represents a true scarless procedure for the first step of the restorative proctocolectomy. In this article, we describe our technique in performing the single-incision total abdominal colectomy.

METHODS

The single-access device is inserted through a circular incision made at the ileostomy site, which was marked preoperatively. The procedure is performed with conventional laparoscopic instruments through one 12-mm and three 5-mm trocars introduced in the single-access device gel platform. Good exposure of the operating field is obtained by changing the Trendelenburg position and the lateral tilting of the table. We start the operation by mobilizing the right colon, then proceeding clockwise to the rectosigmoid junction. The ileocolic pedicle is divided after the visualization of the right ureter and duodenum. The right colon is mobilized in the medial-to-lateral fashion. The hepatocolic ligament is taken down, and the transverse mesocolon and the greater omentum are divided to mobilize the transverse colon. Subsequently, the lateral attachments of descending colon are taken sharply, and the avascular line of Toldt is bluntly dissected. Under direct visualization of the left ureter, the inferior mesenteric vein and the branches of the sigmoid arteries are identified, dissected, and divided. After switching to a 5-mm laparoscope, the rectosigmoid junction is divided with an endoscopic stapler. The specimen is exteriorized, and the terminal ileum is divided extracorporeally. Finally, the ileostomy is matured in the standard Brooke fashion.

CONCLUSION

Between May and November 2010, we performed ten single-incision total abdominal colectomies, all completed successfully without complications or need of conversion, with a mean operative time of 139±24 min and an estimated blood loss of 100±120 ml. The postoperative course was unremarkable in all cases, with prompt return of bowel activity and short postoperative stay. In our experience, single-incision total abdominal colectomy has shown to be a safe alternative to standard laparoscopy in selected patients and appears to be a promising technique with the potential to improve short-term outcomes.

Role of radiation in intermediate-risk rectal cancer

The treatment of rectal cancer has greatly evolved during the last several decades as a result of the understanding of the pathways of cancer spread, natural history of the disease, stages prognosis and prognostic markers. The tendency is clearly to move toward a more personalized approach to these patients based on preoperative staging and response to therapy. Although in the past we have been adding more treatment modalities to surgery to the point that every stage II/III cancer was treated with neoadjuvant chemo and radiotherapy followed by radical surgery by total mesorectal excision with or without sphincter preservation and more chemotherapy to follow, more recently this algorithm has been under discussion and scrutiny. Two of the major topics of controversy are: the use of local excision or even a watch-and-wait approach after a clinical complete response and the need for radiotherapy in the intermediate risk group. In this manuscript we will present the historical perspective that has brought the treatment of rectal cancer to the current standard of care and present the evidence supporting further investigation in the intermediate risk group.

Chromosomal copy number alterations are associated with tumor response to chemoradiation in locally advanced rectal cancer

Rectal cancer response to chemoradiation (CRT) varies from no response to a pathologic complete response (pCR). Identifying predictive biomarkers of response would therefore be useful. We assessed whether chromosomal copy number alterations (CNAs) can assist in predicting pCR. Pretreatment tumor biopsies and paired normal surgical tissues from the proximal resection margin were collected from 95 rectal cancer patients treated with preoperative CRT and total mesorectal excision in a prospective Phase II study. Tumor and control DNA were extracted, and oligonucleotide array-based comparative genomic hybridization (aCGH) was used to identify CNAs, which were correlated with pCR. Ingenuity pathway analysis (IPA) was then used to identify functionally relevant genes in aberrant regions. Finally, a predictive model for pCR was built using support vector machine (SVM), and leave-one-out cross validation assessed the accuracy of aCGH. Chromosomal regions most commonly affected by gains were 20q11.21-q13.33, 13q11.32-23, 7p22.3-p22.2, and 8q23.3-q24.3, and losses were present at 18q11.32-q23, 17p13.3-q11.1, 10q23.1, and 4q32.1-q32.3. The 25 (26%) patients who achieved a pCR had significantly fewer high copy gains overall than non-pCR patients (P = 0.01). Loss of chromosomal region 15q11.1-q26.3 was significantly associated with non-pCR (P < 0.00002; Q-bound < 0.0391), while loss of 12p13.31 was significantly associated with pCR (P < 0.0003; Q-bound < 0.097). IPA identified eight genes in the imbalanced chromosomal regions that associated with tumor response. SVM identified 58 probes that predict pCR with 76% sensitivity, 97% specificity, and positive and negative predictive values of 91% and 92%. Our data indicate that chromosomal CNAs can help identify rectal cancer patients more likely to develop a pCR to CRT.

Minimally invasive pouch surgery for ulcerative colitis: is there a benefit in staging?

BACKGROUND

With the introduction of biologic agents, medical and surgical management of ulcerative colitis has been associated with significant morbidity. A staged surgical approach is advocated to obviate the risks of infectious complication and consequent poor pouch function.

OBJECTIVE

The aim of this study was to analyze the outcomes of our selective staged approaches in patients with ulcerative colitis who were undergoing laparoscopic pouch surgery.

DESIGN

Consecutive patients with ulcerative colitis referred for laparoscopic surgical treatment between 2002 and 2008 were included in the study. Data were prospectively collected. Patients were divided into 2 groups: a 3-stage group, initial laparoscopic abdominal colectomy followed by pouch surgery with a diverting loop ileostomy, and a 2-stage group, laparoscopic pouch surgery with a diverting loop ileostomy at the initial operation.

RESULTS

Of the 118 patients eligible for the study, 68 were in the 2-stage group and 50 were in the 3-stage group. Patients were more likely to have been receiving aggressive medical therapy in the 3-stage group than in the 2-stage group: 43% vs 16% (P = .01) receiving anti-tumor necrosis factor therapy and 96% vs 67% (P = .04) receiving systemic corticosteroids. Although overall complication rates were similar between groups (P = .4), infectious complications were higher in the 2-stage group (38.2% vs 21%, P < .05).

CONCLUSIONS

In our practice, we have selectively applied a 3-stage laparoscopic surgical approach to restorative proctocolectomy in patients with ulcerative colitis who are receiving aggressive medical therapy in an attempt to minimize perioperative complications. This strategy appears efficacious, and short-term outcomes compare favorably with those following a 2-stage approach.

Health related quality of life in inflammatory bowel disease: The impact of surgical therapy

Over the past 30 years, health related quality of life (HRQOL) has developed into a scientific index of subjective health status. Measurement of HRQOL is now clearly a mandatory component in evaluating interventions and management of medical and surgical diseases. In designing comprehensive and meaningful clinical studies particular attention ought to be made of measures of HRQOL. This is clearly very important in inflammatory bowel disease. Both ulcerative colitis (UC) and Crohn’s disease (CD) have a major impact on HRQOL. The chronic and unrelenting nature of these diseases, the often early age of onset, and the impact on social and sexual aspects of life significantly change patient’s perception, body image and quality of life. This manuscript is an overview of the available published data on HRQOL in UC and CD patients focusing on the impact of surgical therapy. While these two diseases may have some similarities in their management, clearly their impact on quality of life and the effects of are significantly different. Hence we are presenting the data separately.

Sprouty-2 controls c-Met expression and metastatic potential of colon cancer cells: sprouty/c-Met upregulation in human colonic adenocarcinomas

Sprouty negatively regulates receptor tyrosine kinase signals by inhibiting Ras/ERK pathways. Sprouty is down-regulated in breast, prostate and liver cancers and appears to function as a tumor suppressor. The role of Sprouty in colonic neoplasia, however, has not been investigated. Sprouty-2 protein and mRNA transcripts were significantly up-regulated in human colonic adenocarcinomas. Strikingly, the c-Met receptor was also upregulated in tumors with increased sprouty-2. To delineate a potential causal relationship between sprouty-2 and c-Met, K-ras mutant HCT-116 colon cancer cells were transduced with purified TAT-sprouty-2 protein or stably transfected with full-length human sprouty-2 gene. Sprouty-2 up-regulation significantly increased cell proliferation by accelerating cell cycle transition. Sprouty-2 transfectants demonstrated strong up-regulation of c-Met protein and mRNA transcripts and hepatocyte growth factor stimulated ERK and Akt phosphorylation and enhanced cell migration and invasion. In contrast, knockdown of c-Met by siRNA significantly decreased cell proliferation, migration and invasion in sprouty-2 transfectants. Further, knockdown of sprouty-2 by siRNA in parental HT-29 and LS-174T colon cancer cells also decreased cell invasion. Sprouty-2 transfectants formed significantly larger tumor xenografts and demonstrated increased proliferation and angiogenesis and suppressed apoptosis. Sprouty-2 tumors metastasized to liver from cecal orthotopic implants suggesting sprouty-2 might also enhance metastatic signals. Thus in colon cancer sprouty functions as an oncogene and its effects are mediated in part by c-Met up-regulation.

Laparoscopic colectomy for Crohn's colitis. A large prospective comparative study

INTRODUCTION

The purpose of this study was to compare short-term outcomes of laparoscopic (LC) vs open colectomy (OC) in patients with Crohn's colitis.

MATERIALS AND METHODS

We collected data on all patients undergoing colectomy for primary or recurrent Crohn's disease confined to the colon from July 2002 to August 2008. Patient and disease-specific characteristics and perioperative and short-term postoperative outcomes were prospectively collected and analyzed.

RESULTS

A total of 125 patients underwent colectomy during the study period, 55 (44%) LC. There were six conversions (10.9%). Median operative time was shorter in the LC group (212 min, interquartile range (IQR) 180-315 LC vs 286 min, IQR 231-387 OC, p = 0.032). Estimated blood loss was less for the LC group (100 ml, IQR 90-250 LC vs 250 ml, IQR 100-400 OC, p = 0.002). Earlier return of bowel function was noted in the LC group (3 days vs 4 days, OC). Length of post-op stay was shorter in the LC group (6 days, IQR 5-8 vs 8 days, IQR 6-10 OC, p = 0.001). There was one death in the OC group. Postoperative complications occurred in eight (14.5%) LC patients vs 16 (22.9%) OC. Disease recurrence rate was 16%, 10.9% LC and 20% OC, respectively.

CONCLUSIONS

Laparoscopic colectomy is a safe and effective technique in the hands of experienced surgeons. Benefits of laparoscopic colectomy in Crohn's disease include reduced operative blood loss, quicker return of bowel function, and shorter hospital length of stay.

Epidermal growth factor receptor is required for colonic tumor promotion by dietary fat in the azoxymethane/dextran sulfate sodium model: roles of transforming growth factor-{alpha} and PTGS2

PURPOSE

Colon cancer is a major cause of cancer deaths. Dietary factors contribute substantially to the risk of this malignancy. Western-style diets promote development of azoxymethane-induced colon cancer. Although we showed that epidermal growth factor receptors (EGFR) controlled azoxymethane tumorigenesis in standard fat conditions, the role of EGFR in tumor promotion by high dietary fat has not been examined.

EXPERIMENTAL DESIGN

A/J x C57BL6/J mice with wild-type Egfr (Egfr(wt)) or loss-of-function waved-2 Egfr (Egfr(wa2)) received azoxymethane followed by standard (5% fat) or western-style (20% fat) diet. As F(1) mice were resistant to azoxymethane, we treated mice with azoxymethane followed by one cycle of inflammation-inducing dextran sulfate sodium to induce tumorigenesis. Mice were sacrificed 12 weeks after dextran sulfate sodium. Tumors were graded for histology and assessed for EGFR ligands and proto-oncogenes by immunostaining, Western blotting, and real-time PCR.

RESULTS

Egfr(wt) mice gained significantly more weight and had exaggerated insulin resistance compared with Egfr(wa2) mice on high-fat diet. Dietary fat promoted tumor incidence (71.2% versus 36.7%; P < 0.05) and cancer incidence (43.9% versus 16.7%; P < 0.05) only in Egfr(wt) mice. The lipid-rich diet also significantly increased tumor and cancer multiplicity only in Egfr(wt) mice. In tumors, dietary fat and Egfr(wt) upregulated transforming growth factor-alpha, amphiregulin, CTNNB1, MYC, and CCND1, whereas PTGS2 was only increased in Egfr(wt) mice and further upregulated by dietary fat. Notably, dietary fat increased transforming growth factor-alpha in normal colon.

CONCLUSIONS

EGFR is required for dietary fat-induced weight gain and tumor promotion. EGFR-dependent increases in receptor ligands and PTGS2 likely drive diet-related tumor promotion.

Laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis: a comparative observational study on long-term functional results

PURPOSE

Long-term results after laparoscopic ileal pouch anal anastomosis (IPAA) have not been thoroughly evaluated. Our study prospectively compares short- and long-term outcomes of laparoscopic and open IPAA.

METHODS

Between October 2002 and November 2007, 73 laparoscopic and 106 open IPAA patients were enrolled. Patient- and disease-specific characteristics and short- and long-term outcomes were prospectively collected.

RESULTS

There were no differences in demographics, treatment, indication, duration of surgery, and diversion between groups. Laparoscopic patients had faster return of flatus (p = 0.008), faster assumption of a liquid diet (p < 0.001), and less blood loss (p = 0.026). While complications were similar, the incidence of incisional hernias was lower in the laparoscopic group (p = 0.011). Mean follow-up was 24.8 months. Average number of bowel movements was 6.8 +/- 2.8/day for laparoscopy and 6.3 +/- 1.7 for open (p = 0.058). Overall, 68.4% of patients were fully continent at 1 year, up to 83.7% long term without differences between groups. Other indicators of defecatory function and quality of life remain similar overtime.

CONCLUSIONS

Laparoscopic IPAA confers excellent functional results. Most patients are fully continent and have an average of six bowel movements/day. When present, minor incontinence improves over time. Laparoscopy mirrors the results of open IPAA and is a valuable alternative to open surgery.