Preservation of superior rectal artery in laparoscopically assisted subtotal colectomy with ileorectal anastomosis for slow transit constipation

BACKGROUND

Slow transit constipation (STC) has traditionally been considered as a functional disorder. However, evidence is accumulating that suggests that most of the motility alterations in STC might be of a neuropathic etiology. If the patient does not meet the diagnosis of pelvic outlet obstruction and poorly response to conservative treatment, surgical intervention with subtotal colectomy may be effective. The most unwanted complication of the procedure is anastomotic leakage, however, preservation of the superior rectal artery (SRA) may reduce its incidence.

AIM

To evaluate the preservation of the SRA in laparoscopically assisted subtotal colectomy with ileorectal anastomosis in STC patients.

METHODS

This was a single-center retrospective observational study. STC was diagnosed after a series of examinations which included a colonic transit test, anal manometry, a balloon expulsion test, and a barium enema. Eligible patients underwent laparoscopically assisted total colectomy with ileorectal anastomosis and were examined between January 2016 and January 2018. The operation time, blood loss, time to first flatus, length of hospital days, and incidence of minor or major complications were recorded.

RESULTS

A total of 32 patients (mean age, 42.6 years) who had received laparoscopic assisted subtotal colectomy with ileorectal artery anastomosis and preservation of the SRA. All patients were diagnosed with STC after a series of examinations. The mean operative time was 151 min and the mean blood loss was 119 mL. The mean day of first time to flatus was 3.0 d, and the mean hospital stay was 10.6 d. There were no any patients conversions to laparotomy. Post-operative minor complications including 1 wound infection and 1 case of ileus. There was no surgical mortality. No anastomosis leakage was noted in any of the patients.

CONCLUSION

Laparoscopically assisted subtotal colectomy with ileorectal anastomosis and preservation of the SRA can significantly improve bowel function with careful patient selection. Sparing the SRA may protect against anastomosis leakage.

Hypermethylation of SHISA3 DNA as a blood-based biomarker for colorectal cancer

In Taiwan, colorectal cancer (CRC) is the second most common cancer and the cancer with the third highest mortality rate. This may be because of the difficulty of detecting the disease in the early stages, as well as the fact that colonoscopy, a typical method used in screening for CRC, causes discomfort to the recipient and is prone to technical interference. For the earlier detection of CRC, finding an easier screening method with a simpler collection procedure is essential. Thus, in the present study, plasma samples from patients with CRC were analyzed to determine the extent of methylation in SHISA3 DNA. Studies have suggested that SHISA3, a newly identified tumor suppressor, can regulate tumor growth, and that the inactivation of its DNA can be traced to epigenomic alterations in CRC. Another study reported the presence of hypermethylated SHISA3 DNA in CRC biopsy specimens. In the present study, the plasma of 30 patients with CRC and nine healthy controls was collected and analyzed for the concentration of cell-free DNA through bisulfite sequencing. The methylation rates were determined. Our results have shown that an increasing amount of cell-free DNA in the group of CRC patient's plasma compared to the healthy group. Moreover, patients with later stages of CRC had higher concentrations of cell-free DNA. Notably, the methylation rate of SHISA3 was higher in the plasma of the CRC group than in that of the healthy group. The results indicated that the presence of tumor cells does not reduce the degree of SHISA3 DNA in the peripheral blood of patients with CRC. In other words, the hypermethylation of SHISA3, which inactivates the gene, is a potential cause of tumorigenesis. Furthermore, the methylation rate of SHISA3 DNA was higher in the plasma of patients with stage II CRC than in that of those with stage I CRC. In conclusion, the combination of conventional testing and screening for SHISA3 hypermethylation in plasma could improve the rate at which CRC is detected.

Anaesthesia mumps after laparoscopic right hemicolectomy under general anaesthesia: A case report

INTRODUCTION

Anaesthesia mumps is an extremely rare postoperative complication that occurs following various surgical procedures after general anaesthesia. We aimed to contribute to the growing knowledge of potential clinical presentations, outcomes, and possible causes.

PRESENTATION OF CASE

A 93-year-old man experienced acute swelling of a unilateral parotid gland 1 day after laparoscopic right hemicolectomy under general anaesthesia. The symptoms he presented with were acute, non-tender swelling in the left preauricular and submandibular triangle with well-marginated, circular swelling of the buccal mucosa. Amylase level was within the normal range. Computed tomography showed left preauricular soft tissue swelling and enlargement and an enhanced left parotid gland exhibiting inflammation. The swelling subsided after 3 days of conservative treatment.

DISCUSSION

Anaesthesia mumps have been associated with a variety of surgeries, including colorectal surgery, and is a rare complication after the induction of general anaesthesia. Despite the few cases presenting with airway obstruction, the outcome for swelling of the parotid or submandibular gland is generally good.

CONCLUSION

Early awareness of anaesthesia mumps and close evaluation lead to a fair prognosis for scar presentation.

Risk of Colorectal Cancer in Patients With Attention-Deficit Hyperactivity Disorder: A Nationwide, Population-Based Cohort Study

Background: The association between attention-deficit hypersensitivity disorder (ADHD) and the risk of developing colorectal cancer (CRC) is, as yet, to be investigated, and thus, we have conducted this nationwide, cohort study to examine the association in patients from Taiwan. Methods: In this study, 798 individuals with newly diagnosed ADHD and 2,394 (1:3) age-, gender-, and index year- matched controls without ADHD were enrolled, between 2000 and 2013, from the Longitudinal Health Insurance Database, a subset of the National Health Insurance Research Database in Taiwan. The cumulative incidence of CRC was assessed in each cohort by the Kaplan-Meier method. The multivariate Cox proportional hazards model was used to estimate the crude, and the adjusted hazards ratios (HRs) with 95% confidence intervals (CIs), was conducted to estimate the association between ADHD and CRC. Results: The Kaplan-Meier analysis revealed that the cumulative incidence of CRC was significantly higher in patients with ADHD than in those without it (log rank test, p < 0.001). After adjustments for age, gender, comorbidities, and other covariates, the ADHD group was associated with an increased risk of CRC in comparison to the non-ADHD group (adjusted HR = 3.458, 95% CI = 1.640-7.293, p < 0.001). In addition, the usage of methylphenidate was not associated with the risk of developing CRC in patients with ADHD. Conclusion: This retrospective cohort study depicts the evidence that ADHD was associated with the increased risk of CRC. Further studies are needed to confirm the association and the underlying mechanisms.

Two-Person Colonoscopy as a Training Approach to Non-sedation Colonoscopy

BACKGROUND

Reported learning curves of colonoscopy vary from 94 to 275 cases and focus on one-person colonoscopy. Our aim was to evaluate the learning curve of two-person non-sedation colonoscopy for trainees in a single tertiary care hospital.

PATIENTS AND METHODS

We conducted a retrospective study in 1264 patients who underwent diagnostic or screening colonoscopies in a single institution from August 2012 to January 2013. Most of the patients (1174/1264) did not receive sedation during the procedure. All procedures were performed under two-person control. Two third-year residents who received previous colonoscopic training via a plastic model were the trainees.

RESULTS

In comparison to the performance of 5 staff members, the colonoscopic outcomes showed no significant differences in the completion rates (77.2% vs. 79.8%, P = .382), average polyp numbers (.9 ± 1.7 vs. 1.0 ± 1.8, P = .453), polyp detection rates (43.5% vs. 46.3%, P = .434), or intubation lengths (96.4 ± 29.3 vs. 96.3 ± 26.7 cm, P = .939). The total procedure times for the 2 groups were 17.2 ± 10.6 minutes (trainees) and 12.9 ± 7.8 minutes (staff) (P < .001).

CONCLUSION

Trainees achieved acceptable outcomes over an 81-97 case learning curve under a two-person non-sedation colonoscopy technique, an approach with potential as a transition to single-operator colonoscopy.

Risk of colorectal cancer in patients with alcoholism: A nationwide, population-based nested case-control study

BACKGROUND

Colorectal cancer (CRC) is regarded as a multifactorial disease and shares many risk factors with alcoholism. However, the association between alcoholism and CRC remains controversial.

OBJECTIVES

In this study, we aimed to evaluate the association between alcoholism and risk of CRC.

METHODS

We performed a large-scale, population-based nested case-control study using the Longitudinal Health Insurance Database 2013, derived from Taiwan's National Health Insurance Research Database, and collected data from 2000 to 2013. There were 49,095 diagnosed cases of CRC defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification. Each case was matched with three controls by sex, age, index date of CRC, and annual medical visits; a total of 147,285 controls were identified. Multiple risk factors of CRC in alcoholism cases were investigated using unconditional multiple logistic regression analysis.

RESULTS

Among 49,095 cases of CRC, alcoholism was associated with a significantly higher risk of CRC (adjusted odds ratio (OR), 1.631; 95% CI, 1.565-1.699) in multivariate logistic regression, after adjusting other CRC risk factors, and in stratified analysis with multivariate logistic regression. In addition, there was a time-dependent relationship between alcoholism duration and CRC risk in >1 year, > 2 years, >5 years, and > 11 years groups (adjusted ORs, 1.875, 2.050, 2.662 and 2.670; 95% CI, 1.788-1.967, 1.948-2.158, 2.498-2.835, and 2.511-2.989 respectively).

CONCLUSION

An association between alcoholism and risk of CRC was found in this study. Furthermore, patients with longer alcoholism history showed higher likelihood of developing CRC, which indicates a time-dependent relationship between alcoholism exposure and CRC. Further research on colorectal tumorigenesis is needed.

Novel methylation gene panel in adjacent normal tissues predicts poor prognosis of colorectal cancer in Taiwan

BACKGROUND

It is evident that current clinical criteria are suboptimal to accurately estimate patient prognosis. Studies have identified epigenetic aberrant changes as novel prognostic factors for colorectal cancer (CRC).

AIM

To estimate whether a methylation gene panel in different clinical stages can reflect a different prognosis.

METHODS

We enrolled 120 CRC patients from Tri-Service General Hospital in Taiwan and used the candidate gene approach to select six genes involved in carcinogenesis pathways. Patients were divided into two groups based on the methylation status of the six evaluated genes, namely, the < 3 aberrancy group and ≥ 3 aberrancy group. Various tumor stages were divided into two subgroups (local and advanced stages) on the basis of the pathological type of the following tissues: Tumor and adjacent normal tissues (matched normal). We assessed DNA methylation in tumors and adjacent normal tissues from CRC patients and analyzed the association between DNA methylation with different cancer stages and the prognostic outcome including time to progression (TTP) and overall survival.

RESULTS

We observed a significantly increasing trend of hazard ratio as the number of hypermethylated genes increased both in normal tissue and tumor tissue. The 5-year TTP survival curves showed a significant difference between the ≥ 3 aberrancy group and the < 3 aberrancy group. Compared with the < 3 aberrancy group, a significantly shorter TTP was observed in the ≥ 3 aberrancy group. We further analyzed the interaction between CRC prognosis and different cancer stages (local and advanced) according to the methylation status of the selected genes in both types of tissues. There was a significantly shorter 5-year TTP for tumors at advanced stages with the promoter methylation status of selected genes than for those with local stages. We found an interaction between cancer stages and the promoter methylation status of selected genes in both types of tissues.

CONCLUSION

Our data provide a significant association between the methylation markers in normal tissues with advanced stage and prognosis of CRC. We recommend using these novel markers to assist in clinical decision-making.

Multiple gene promoter methylation and clinical stage in adjacent normal tissues: Effect on prognosis of colorectal cancer in Taiwan

This study provide an insight that the panel genes methylation status in different clinical stage tended to reflect a different prognosis even in matched normal tissues, to clinical recommendation. We enrolled 153 colorectal cancer patients from a medical center in Taiwan and used the candidate gene approach to select five genes involved in carcinogenesis pathways. We analyzed the relationship between DNA methylation with different cancer stages and the prognostic outcome. There were significant trends of increasing risk of 5-year time to progression and event-free survival of subjects with raising number of hypermethylation genes both in normal tissue and tumor tissue. The group with two or more genes with aberrant methylation in the advanced cancer stages (Me/advanced) had lower 5-year event-free survival among patients with colorectal cancer in either normal or tumor tissue. The adjusted hazard ratios in the group with two or more genes with aberrant methylation with advanced cancer stages (Me/advanced) were 8.04 (95% CI, 2.80–23.1; P for trend <0.01) and 8.01 (95% CI, 1.92–33.4; P for trend <0.01) in normal and tumor tissue, respectively. DNA methylation status was significantly associated with poor prognosis outcome. This finding in the matched normal tissues of colorectal cancer patients could be an alternative source of prognostic markers to assist clinical decision making.

Association between atopic dermatitis and colorectal cancer risk: A nationwide cohort study

The role of atopic dermatitis (AD) in the development of colorectal cancer (CRC) has been a matter of scientific debate with mixed results. We conducted a nationwide cohort study to assess the association between AD and risk of CRC. Drawing on Taiwan's National Health Insurance Research Database, 46,703 patients with AD (the AD cohort) and 186,812 sex, age, and index year-matched patients without AD (the non-AD cohort) were identified in the period between 2000 and 2008. Follow-up time was calculated from the date of entry in the cohort until the occurrence of a first CRC diagnosis, death, or the end of the observation period (December 31, 2013), whichever occurred first. Hazards ratios (HRs) and accompanying 95% confidence intervals (CIs) derived from the Fine-Gray competing risk model were used to estimate the association between AD and CRC risk. After multivariable adjustment, AD was associated with an increased risk of CRC (adjusted HR, 1.26; 95% CI, 1.14-1.40). Of note, a significant positive association between AD and CRC risk was evident in both men and women and in all age groups. In summary, this population-based cohort study revealed that AD was associated with an increased risk of CRC in an Asian population. It will be of interest for cohort studies with prediagnostic specimens to evaluate the potential relationship between AD and CRC using biomarkers for allergy status.

Cancer-Derived Succinate Promotes Macrophage Polarization and Cancer Metastasis via Succinate Receptor

Macrophages form a major cell population in the tumor microenvironment. They can be activated and polarized into tumor-associated macrophages (TAM) by the tumor-derived soluble molecules to promote tumor progression and metastasis. Here, we used comparative metabolomics coupled with biochemical and animal studies to show that cancer cells release succinate into their microenvironment and activate succinate receptor (SUCNR1) signaling to polarize macrophages into TAM. Furthermore, the results from in vitro and in vivo studies revealed that succinate promotes not only cancer cell migration and invasion but also cancer metastasis. These effects are mediated by SUCNR1-triggered PI3K-hypoxia-inducible factor 1α (HIF-1α) axis. Compared with healthy subjects and tumor-free lung tissues, serum succinate levels and lung cancer SUCNR1 expression were elevated in lung cancer patients, suggesting an important clinical relevance. Collectively, our findings indicate that the secreted tumor-derived succinate belongs to a novel class of cancer progression factors, controlling TAM polarization and promoting tumorigenic signaling.

Rare Huge Tubular Papillary Adenoma on the Buttock Demonstrated by Magnetic Resonance Imaging (MRI)

Patient: Male, 35

Final Diagnosis: Tubular papillary adenoma of the buttock

Symptoms: Firm • redness • pain • swelling of the fixed perianal mass

Medication: —

Clinical Procedure: Excision biopsy

Specialty: Surgery

Factors affecting local regrowth after watch and wait for patients with a clinical complete response following chemoradiotherapy in rectal cancer (InterCoRe consortium): an individual participant data meta-analysis

BACKGROUND

In patients with rectal cancer who achieve clinical complete response after neoadjuvant chemoradiotherapy, watch and wait is a novel management strategy with potential to avoid major surgery. Study-level meta-analyses have reported wide variation in the proportion of patients with local regrowth. We did an individual participant data meta-analysis to investigate factors affecting occurrence of local regrowth.

METHODS

We updated search results of a recent systematic review by searching MEDLINE and Embase from Jan 1, 2016, to May 5, 2017, and used expert knowledge to identify published studies reporting on local regrowth in patients with rectal cancer managed by watch and wait after clinical complete response to neoadjuvant chemoradiotherapy. We restricted studies to those that defined clinical complete response using criteria equivalent to São Paulo benchmarks (ie, absence of residual ulceration, stenosis, or mass within the rectum on clinical and endoscopic examination). The primary outcome was 2-year cumulative incidence of local regrowth, estimated with a two-stage random-effects individual participant data meta-analysis. We assessed the effects of clinical and treatment factors using Cox frailty models, expressed as hazard ratios (HRs). From these models, we derived percentage differences in mean θ as an approximation of the effect of measured covariates on between-centre heterogeneity. This study is registered with PROSPERO, number CRD42017070934.

FINDINGS

We obtained individual participant data from 11 studies, including 602 patients enrolled between March 11, 1990, and Feb 13, 2017, with a median follow-up of 37·6 months (IQR 25·0-58·7). Ten of the 11 datasets were judged to be at low risk of bias. 2-year cumulative incidence of local regrowth was 21·4% (random-effects 95% CI 15·3-27·6), with high levels of between-study heterogeneity (I²=61%). We noted wide between-centre variation in patient, tumour, and treatment characteristics. We found some evidence that increasing cT stage was associated with increased risk of local regrowth (random-effects HR per cT stage 1·40, 95% CI 1·00-1·94; p_trend=0·048). In a subgroup of 459 patients managed after 2008 (when pretreatment staging by MRI became standard), 2-year cumulative incidence of local regrowth was 19% (95% CI 13-28) for stage cT1 and cT2 tumours, 31% (26-37) for cT3, and 37% (21-60) for cT4 (random-effects HR per cT stage 1·50, random-effects 95% CI 1·03-2·17; p_trend=0·0330). We estimated that measured factors contributed 4·8-45·3% of observed between-centre heterogeneity.

INTERPRETATION

In patients with rectal cancer and clinical complete response after chemoradiotherapy managed by watch and wait, we found some evidence that increasing cT stage predicts for local regrowth. These data will inform clinician-patient decision making in this setting. Research is needed to determine other predictors of a sustained clinical complete response.

FUNDING

None.

Risk of colorectal cancer in patients with periodontal disease severity: a nationwide, population-based cohort study

BACKGROUND

Periodontal disease (PD) and colorectal cancer (CRC) were associated with chronic inflammation. This retrospective cohort study examined the association between PD severity and CRC in a large-scale, population-based Chinese cohort.

METHODS

A total of approximately 106,487 individuals with newly diagnosed PD and 106,487 age-matched and sex-matched patients without PD from 2000 to 2002 were identified from Taiwan's National Health Insurance Research Database (NHIRD).

RESULTS

The Kaplan-Meier analysis revealed that the cumulative incidence of CRC was significantly higher in patients with PD than in those without PD (log-rank test, P < 0.001). After adjustment for age, sex, and comorbidities, patients with PD were associated with a significantly higher risk of CRC compared with those without PD (adjusted HR = 1.64, 95% CI = 1.50-1.80). Further, the risk of CRC appeared to increase with increasing frequency of PD medical visits [adjusted HR (95% CI) was 1.78 (1.58-2.02) and 1.53 (1.35-1.74) for annual visits > 10 and < 4, respectively].

CONCLUSION

Based on our study, PD severity was associated with an increase in the risk of CRC. Further mechanistic research is needed.

NKX6.1 hypermethylation predicts the outcome of stage II colorectal cancer patients undergoing chemotherapy

Colorectal cancer (CRC) is a common malignancy worldwide. CRC patients in the same stage often present with dramatically different clinical scenarios. Thus, robust prognostic biomarkers are urgently needed to guide therapies and improve treatment outcomes. The NKX6.1 gene has been identified as a hypermethylation marker in cervical cancer, functioning as a metastasis suppressor by regulating epithelial-mesenchymal transition. Here, we investigated whether hypermethylation of NKX6.1 might be a prognostic biomarker for CRC. By analyzing the methylation and expression of NKX6.1 in CRC tissues and CRC cell lines. We quantitatively examined the NKX6.1 methylation levels in 151 pairs of CRC tissues by using methylation-specific polymerase chain reaction analysis and found that NKX6.1 was hypermethylated in 35 of 151 CRC tissues (23%). NKX6.1 gene expression was inversely correlated with the DNA methylation level in CRC cell lines in vitro. Then, we analyzed the association of NKX6.1 methylation with clinical characteristics of these CRC patients. Our data demonstrated that patients with NKX6.1 methylation presented poorer 5-year overall survival (P = 0.0167) and disease-free survival (P = 0.0083) than patients without NKX6.1 methylation after receiving adjuvant chemotherapy. Most importantly, these data revealed that stage II CRC patients with NKX6.1 methylation had poorer 5-year disease-free survival (P = 0.0322) than patients without NKX6.1 methylation after adjuvant chemotherapy. Our results demonstrate that methylation of NKX6.1 is a novel prognostic biomarker in CRC and that it may be used as a predictor of the response to chemotherapy.

A Modified Bowel Preparation Regimen for Colonoscopy Providing the Patients' Satisfaction and Convenience

Background

A complete cleansing of the bowel is a critical factor that impacts the diagnostic accuracy of colonoscopies. However, the common bowel preparation regimen of two 45 mL doses of sodium phosphate (2×NaP) often leads to uncomfortable symptoms and subsequently lower patient adherence. To improve patient adherence and satisfaction, we proposed a modified regimen composed of two sennoside tablets and one bottle of NaP (S+NaP) and we then evaluated bowel preparation quality and patient satisfaction.

Material/Methods

A total of 531 patients who underwent colonoscopies at the outpatient coloproctology clinic from January 2016 to December 2016 were retrospectively reviewed. Eligible patients were divided into two groups: S+NaP group (n=93) and 2×NaP group (n=60). We compared bowel preparation quality, adenoma detection rate (ADR), self-reported patient satisfaction scores, and adverse events among the two groups.

Results

Regarding high bowel preparation quality, our results showed that there was no significant difference among the two groups (p=0.775), as well as no significant differences in ADRs (p=0.187). However, a lower proportion of nausea was found in the S+NaP group compared to the 2×NaP group (24.7% versus 41.7%, respectively, p=0.028). In addition, patients in the S+NaP group were more likely to be very satisfied with the regimen compared with patients in the 2×NaP group (odds ratio: 5.58; 95% confidence interval: 2.36–13.213, p<0.001).

Conclusions

Our modified bowel preparation regimen, S+NaP, yielded significantly higher patient satisfaction with less nausea while maintaining similar bowel preparation quality.

Oral tegafur-uracil as metronomic therapy following intravenous FOLFOX for stage III colon cancer

The purpose of this study was to estimate the impact of metronomic therapy with oral tegafur-uracil (UFUR) following an intravenous FOLFOX regimen as surgical adjuvant chemotherapy on the overall survival (OS) and disease-free survival (DFS) of stage III colon cancer patients. From the retrospective database of patients who underwent a surgical resection for colorectal cancer at the Tri-Service General Hospital from October 2008 through December 2014, stage III colon carcinomas treated with radical R0 resection were reviewed. One hundred thirty two patients were treated with a FOLFOX regimen (comparison group), and 113 patients were treated with the same regimen followed by additional oral UFUR (UFUR group). The clinical characteristics and mean age of the comparison and UFUR groups were similar. Furthermore, for all study patients, DFS was not significantly different between the two groups. However, 5-year OS rates were 86.8% and 68.5% in the UFUR and comparison groups, respectively (p = 0.0107). Adding UFUR to a FOLFOX regimen was found to significantly improve the OS in patients with stage III colon cancer. UFUR as a maintenance therapy following FOLFOX regimen as an alternative therapeutic option for the treatment of stage III colon cancer patients.

Adjuvant chemotherapy with tegafur/uracil for more than 1 year improves disease-free survival for low-risk Stage II colon cancer

BACKGROUND

It is uncertain whether adjuvant chemotherapy (CMT) improves survival in patients with low-risk Stage II colon cancer. We aimed to determine the disease-free survival (DFS) and 5-year overall survival (OS) of low-risk Stage II colon cancer patients treated with adjuvant tegafur/uracil (UFUR).

METHODS

From January 2004 to December 2011, the follow-up status of 278 low-risk Stage II colon cancer patients who underwent surgery in a single medical center was retrospectively analyzed. These patients were divided into three groups based on whether they received adjuvant CMT with UFUR, adjuvant CMT with 5-fluorouracil, or surgery alone. DFS and 5-year OS curves were calculated using Kaplan-Meier survival analysis and Cox proportional hazards regression.

RESULTS

In the study population, including 278 low-risk Stage II colon cancer patients with a mean age of 68.28 ± 13.01 years, 132 (47.5%) received adjuvant CMT with UFUR, 49 (17.6%) received adjuvant CMT with 5-fluorouracil, and 97 (34.9%) underwent radical surgery alone. At 5 years, the adjusted DFS and OS of low-risk Stage II colon cancer patients were 85.5% and 81.8%, respectively, in the surgery alone group and 97.9% and 96.2%, respectively, in the surgery plus UFUR > 12 months group (p = 0.004 and p = 0.098, respectively). In multivariate analysis, CMT with UFUR for more than 12 months increased DFS over surgery alone. There was no statistical difference in the 5-year OS.

CONCLUSION

Adjuvant CMT treatment of low-risk Stage II colon cancer patients with UFUR for more than 12 months following surgery improves DFS over surgery alone.

Is preoperative bowel preparation necessary for gynecological oncology surgery?

OBJECTIVE

We investigated the necessity of preoperative bowel preparation for gynecological oncology surgery.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients who underwent gynecological oncology surgery with simultaneous colon or rectal resection between April 2005 and September 2014 at the Tri-Service General Hospital, Taipei, Taiwan. Patients were divided into two groups based on whether preoperative mechanical bowel preparation (MBP) was performed. Patient characteristics, including duration of antibiotic treatment, surgical procedures, and occurrence of surgical and nonsurgical complications, were compared.

RESULTS

We enrolled 124 patients who underwent gynecological oncology surgery with simultaneous colon or rectal resection, of whom 76 received MBP and 48 did not receive mechanical bowel preparation. On comparison between the two groups, no significant differences were noted in the assessed patient characteristics, including mean age (p = 0.61), Federation of Gynecology and Obstetrics stage (p = 0.9), American Society of Anesthesiologists grade (p = 0.9), body mass index (p = 0.8), and residual tumor size (p = 0.86). Furthermore, duration of antibiotic treatment (p = 0.97), surgical procedures (p = 0.99), and total hospital days (p = 0.75), were not different between groups. The risk of surgical (p = 0.78) or nonsurgical (p = 1.0) complications was not significantly higher in the non-MBP group than in the MBP group.

CONCLUSION

MBP provides no significant benefit during gynecological oncology surgery. Thus, preoperative MBP is not essential before gynecological oncology surgery and can be omitted.

Rectal cancer with complete clinical response after neoadjuvant chemoradiotherapy, surgery, or "watch and wait"

PURPOSE

The purpose of this study was to compare the outcomes of patients treated with chemoradiotherapy with a complete clinical response followed by either a "watch and wait" strategy or a total mesorectal excision.

METHODS

This was an observational retrospective study from a single institute. Patients with locally advanced rectal cancer following chemoradiotherapy with a complete clinical response from January 1, 2007 to December 31, 2014 were included.

RESULTS

The study population consisted of 18 patients who opted for a "watch and wait" policy and 26 patients who underwent radical surgery after achieving a complete clinical response. Patients had no documented treatment complications under the watch and wait policy, while 13 patients who underwent radical surgery experienced significant morbidity. There were two local recurrences in the watch and wait group; both were treated with salvage resection and had no associated mortality. In the radical surgery group, 1 patient showed an incomplete pathologic response (ypT0N1), and the remaining 25 patients showed complete pathologic responses; 1 had a distant recurrence, which was managed non-operatively, and 2 patients died of unrelated causes. The 5-year overall survival rate and median disease-free survival time were 100% and 69.78 months in the watch and wait group and 92.30% and 89.04 months in the radical surgery group.

CONCLUSIONS

A watch and wait policy avoids the morbidity associated with radical surgery and preserves oncologic outcomes in our retrospective study from a single institute. It could be considered a therapeutic option in patients with locally advanced rectal cancer following chemoradiotherapy with a complete clinical response.

Computed tomographic-guided percutaneous radiofrequency ablation with hydrodissection of hepatic malignancies in the subcapsular location: Evaluation of safety and technical efficacy

BACKGROUND

Image-guided percutaneous radiofrequency ablation (RFA) has been the most commonly used modality in the treatment of nonresectable hepatic malignancies. However, tumors in the subcapsular location are still technically challenging. This study was undertaken to evaluate the feasibility, safety, and efficacy of computed tomographic-guided percutaneous RFA with hydrodissection for hepatic malignancies in the subcapsular location.

METHODS

A total of 103 patients with 253 hepatic lesions were treated with computed tomographic-guided percutaneous RFA. Computed tomographic-guided percutaneous RFA with hydrodissection was performed in 15 patients with 15 hepatic nodules. All tumors located in the hepatic subcapsular location were considered difficult to treat on planning sonography. Hydrodissection was performed with 5% dextrose in water or saline solution in displacing adjacent structures ≥ 10 mm away from the liver capsule. Two RFA systems with multitined expandable electrodes or straight internally cooled single electrodes were used for treatment of hepatic malignancies. The feasibility, safety, and efficacy of this technique were analyzed on follow-up contrast-enhanced computed tomography or magnetic resonance imaging.

RESULTS

Hydrodissection was successfully achieved in 15 (100%) patients, displacing the adjacent structures ≥ 10 mm that were originally < 10 mm away from the liver capsule with administration of a mean of 376 mL of dextrose in water or saline solution. The average distance between an adjacent structure and the liver capsule after hydrodissection was 1.50 ± 0.40 cm and 0.11 ± 0.15 cm prior to hydrodissection, which was statistically significant (p < 0.001). No complication related to hydrodissection occurred during the follow-up period. The primary technical success rate of percutaneous RFA for tumor was 100% (15/15) at 1-month follow-up imaging. There were three minor complications (20%, 3/15) related to the RFA procedure.

CONCLUSION

Computed tomographic-guided percutaneous RFA with hydrodissection is a feasible, safe, and effective technique in the treatment of hepatic malignancies in the subcapsular location.

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/m(2) 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.

Removal of a Giant Rectosigmoid Phytobezoar without Laparotomy

Bezoars are the uncommon result of ingestion of indigestible or poorly digestible substances. Phytobezoars are the most common bezoars in children. Small bowel obstruction, especially of the terminal ileum, is the most common complication. Colonic obstruction is rare. Most reviewed intestinal phytobezoars with obstruction necessitate laparotomy with enterotomy. Here, we report a rare case of giant rectosigmoid phytobezoar with near-total colonic obstruction. Successfully, removal of this bezoar by an alternative way of fragmentation with colonoscopy, not conventional enterotomy is needed. The patient recovered well and then discharged without any morbidity 2 days later.

Association between colonic diverticular disease and colorectal cancer: a nationwide population-based study

BACKGROUND & AIMS

We investigated whether a diagnosis of colonic diverticular disease is associated with an increased risk for subsequent development of colorectal cancer (CRC) in a nationwide population-based retrospective study.

METHODS

We identified 41,359 individuals diagnosed with colonic diverticular disease as inpatients from 2000 through 2009 from the Taiwan National Health Insurance Research Database (study cohort) and collected data for 165,436 randomly selected additional subjects, matched by sex, age, and baseline year (comparison cohort). Data were collected until individuals developed CRC or withdrew from the National Health Insurance system, or until December 31, 2010. Cumulative incidences and hazard ratios (HRs) of CRC development were determined. To assess for ascertainment bias, we conducted an analysis excluding the first 12 months of follow-up evaluation.

RESULTS

The risk of CRC was significantly higher in the study cohort than in the comparison cohort (HR adjusted for age, sex, and comorbidities, 4.54; 95% confidence interval, 4.19-4.91; P < .0001). In a sensitivity analysis, we excluded the first 12 months of follow-up evaluation after a diagnosis of colonic diverticular disease; subsequent incidence rates for CRC in the study and comparison cohorts were 15.13 and 15.74 per 10,000 person-years, respectively (adjusted HR, 0.96; 95% confidence interval, 0.83-1.11).

CONCLUSIONS

Colonic diverticular disease is not associated with an increased risk of subsequent CRC after the first year of diagnosis of colonic diverticular disease. An increased risk was observed in the first year, possibly owing to misclassification and screening effects.

Association between irritable bowel syndrome and colorectal cancer: a nationwide population-based study

OBJECTIVES

To determine whether irritable bowel syndrome (IBS) is associated with an increased risk for the subsequent colorectal cancer (CRC).

METHODS

We identified 91,746 patients who were diagnosed with IBS between 2000 and 2010 from the Taiwan National Health Insurance Research Database (NHIRD) as the study cohort, and randomly extracted the data of 183,492 patients matched by sex, age, and baseline year for the comparison cohort. The follow-up period was terminated after CRC development, withdrawal from the national health insurance (NHI) system, or at the end of 2010. Cumulative incidences and hazard ratios (HRs) of CRC development were determined.

RESULTS

During the first 2years of follow-up, the subsequent CRC incidence rates in the IBS and comparison cohorts were 37.3 and 5.61 per 10,000person-years, respectively (adjusted HR, 6.72; 95% CI, 5.70-7.92; p<.0001). Thereafter, the risk did not differ significantly between the 2 cohorts (adjusted HR, 1.08; 95% CI, 0.93-1.26); the participants in the IBS cohort commonly underwent more colonoscopies/sigmoidoscopies than did the non-IBS cohort.

CONCLUSIONS

IBS was not associated with the long-term development of CRC in Taiwan. The increased risk of CRC in the first 2years may have occurred because some CRC patients were initially misclassified as IBS patients.

Iatrogenic colonic perforation by colonoscopy: a fatal complication for patients with a high anesthetic risk

PURPOSE

Colonoscopy is currently a standard and widespread technique used in screening for colorectal cancer. Iatrogenic colonic perforation during colonoscopy is an unfortunate complication that can induce significant morbidity and even death. Here, we reviewed the clinical results of iatrogenic colonoscopic perforation in our hospital.

METHODS

This was a retrospective review of 35,186 colonoscopies performed in the Tri-Service General Hospital, Taipei, Taiwan from January 1998 to December 2007. Patient demographic data, indications, comorbidities, operative history, perforation site, time of diagnosis, management, complications, hospital stay, and outcomes were recorded.

RESULTS

In this 10-year period, 23 cases of iatrogenic colonic perforation were recorded (0.065%) affecting 11 men and 12 women. The mean age was 71.2 years. There were 13 patients in American Society of Anesthesiology (ASA) classifications 1 or 2 (low anesthetic risk, group A), and ten patients in ASA classes 3 or 4 (high anesthetic risk, group B). The mean hospital stay was 12 days in group A versus 23.5 days in group B (P = 0.002). Moreover, four patients in group B died (17%; P = 0.024).

CONCLUSION

Colonoscopy-related perforation can progress to peritonitis and sepsis, resulting in serious morbidity or death. High-anesthetic risk patients with colonic perforation have a longer hospital stay and a poor prognosis. Hence, patients need to be informed of the complications of colonoscopy, and clinicians must be cautioned about the potential problems for patients with a high-anesthetic risk when performing the procedure.

Efficacy and safety of transnasal butorphanol for pain relief after anal surgery

AIM: To compare the analgesic properties and efficacy of transnasal butorphanol with intramuscular meperidine after anal surgery.

METHODS: Sixty patients who underwent fistulectomy were enrolled in the study from January 2006 to December 2007. They were randomly divided into transnasal butorphanol (n = 30) or intramuscular meperidine (n = 30) treatment groups. Assessment of postoperative pain was made using a visual analogue scale (VAS). The VAS score was recorded 6 h after the completion of surgery, before receiving the first dose of analgesic, 60 min after analgesia and the next morning. Any adverse clinical effects such as somnolence, dizziness, nausea or vomiting were recorded. Satisfaction with narcotic efficacy, desire to use the particular analgesic in the future and any complaints were recorded by patients using questionnaires before being discharged.

RESULTS: Forty-two men and eighteen women were included in the study. There were no significant differences in VAS scores between the groups within 24 h. Length of hospital stay and the incidence of adverse effects between the groups were similar. In addition, most patients were satisfied with butorphanol nasal spray and wished to receive this analgesic in the future, if needed.

CONCLUSION: Butorphanol nasal spray is effective for the relief of pain after fistulectomy. However, it offered patients more convenient usage and would be suitable for outpatients.

Comparison of clinical effects between warm water spray and sitz bath in post-hemorrhoidectomy period

BACKGROUND

Warm water sitz bath is advised for a variety of anorectal disorders. However, preparation of the sitz bath is sometimes difficult for patients. As an alternative to the sitz bath, we have adapted a water spray method. A randomized, controlled study was conducted to determine if the water spray method has similar effects to the sitz bath in the post-hemorrhoidectomy period and it is easy to carry out.

METHODS

A total of 120 patients were randomly assigned to water spray or sitz bath groups. All patients received analgesics and a fiber-rich diet after hemorrhoidectomy. Clinical parameters including pain, irritation (burning or itching sensations), hygiene, convenience, and overall satisfaction were evaluated by a visual analog scale to assess treatment outcome in both groups.

RESULTS

There was no obvious difference in age, gender distribution, body mass index, or duration of disease between groups. There were no significant difference in scores for postoperative pain (p = 0.23), irritation (p = 0.48), or hygiene (p = 0.725) between groups. However, the water spray group reported significantly greater convenience (p < 0.05) and higher overall satisfaction (p < 0.05) compared with the sitz bath group. At the end of the 4-week postoperative follow-up period, 90% of patients in the watery spray group and 93% of patients in the sitz bath group showed complete wound healing. There were no significant differences in postoperative complications between groups.

CONCLUSION

Our results demonstrate that the water spray method could provide a safe and reliable alternative to the sitz bath for post-hemorrhoidectomy care. Furthermore, the water spray method could be used instead of the sitz bath as a more convenient and satisfactory form of treatment.

Primary non-Hodgkin's lymphoma of rectum presenting with rectal prolapse

Involvement of the rectum by primary or secondary malignant lymphoma is uncommon in adults. Primary lymphoma of the rectum in children is an extremely rare occurrence. We describe a 12-year-old boy with a localized rectal tumor that presented with rectal prolapse and bleeding, mimicking a juvenile polyp. He underwent transrectal local wide excision of the tumor, and the pathologic condition proved to be non-Hodgkin's lymphoma of diffuse large B-cell type. This case illustrates the importance of considering the possibility of a rectal malignancy manifesting as a rectal prolapse even in children and the surgical strategy used.

Colonic diverticular bleeding with comorbid diseases may need elective colectomy

BACKGROUND

Colonic diverticular bleeding can usually be managed with conservative treatment. However, in a selected group of patients under conditions of recurrent, persistent bleeding influencing quality of life or causing life-threatening shock, it should be managed with surgery. This is a retrospective study to clarify the risk factors relating to colectomy for colonic diverticular bleeding.

METHODS

Between 1997 and 2005, a retrospective chart review of 73 patients with colonic diverticular bleeding was undertaken. Univariate and multivariate logistic regression analyses were performed to identify the relevant risk factors correlating to colectomy.

RESULTS

The mean age of the 73 patients was 70 years (range, 22-90 years). Most colonic diverticular bleeding could be managed with conservative treatment (n = 63, 86.3%), and urgent colectomy was performed in ten patients (13.7%). The bleeding site could not be well identified in six of those ten patients and so underwent total abdominal colectomy with ileorectal anastomosis, and the other four underwent right hemicolectomy after a diagnosis of right-sided colon diverticula with bleeding. There were two deaths in the surgical group and one death in the nonsurgical group. The overall mortality rate in the series was 4.11% and 20% among patients undergoing urgent colectomy. Multiple logistic regression analysis showed that the presence of comorbidities and daily maximum blood transfusion requirement were risk factors for urgent colectomy for colonic diverticular bleeding.

CONCLUSION

Preoperative comorbid diseases may increase operative risk in urgent surgery, and the outcome is poor. To avoid high mortality and morbidity relating to the urgent colectomy, we suggest that patients of colonic diverticular bleeding with comorbid diseases, especially subgroups of patients with diabetes and gouty arthritis, may need early elective colectomy.

The use of table fixation staples to control massive presacral hemorrhage: a successful alternative treatment. Report of a case

Management of presacral hemorrhage has always been a challenge for surgeons because such bleeding can rapidly destabilize a patient during pelvic surgery. Conventional hemostatic measures are often effective for arresting this type of hemorrhage, however, sometimes conventional measures make the problem worse. A number of alternative hemostatic techniques have been proposed. This case report describes a successful tamponade of presacral hemorrhage with a titanium table fixation staple and a cancellous bone graft fixed to the sacrum. The bleeding was stopped immediately and the patient recovered uneventfully. We think this is an effective alternative method for controlling massive hemorrhage from a large hole in presacral fascia.

Postoperatively parastomal infection following emergent stoma creation for colorectal obstruction: the possible risk factors

BACKGROUND

The aim of the present study was to discuss the possible risk factors related to the parastomal infection after the patients received emergent stoma creation in colorectal obstruction that was caused by adenocarcinoma, diverticulitis, or a variety of other miscellaneous causes.

PATIENTS AND METHODS

A total of 360 patients with colorectal obstruction underwent emergent stoma creation, including diversion and Hartmann's procedure between January 1996 and January 2005. We analyze the patients' records to document the possible risk factors associated with parastomal infection. Patients' demographics, indication for ostomy, ostomy type/location, and risk factors were recorded. Logistic regression was used to calculate adjusted odds ratios. A p value of less than 0.05 was considered significant.

RESULTS

Twenty patients (5.6%) with emergent stoma creation had parastomal infection. Descending colostomy had the highest incidence (6.7%) of parastomal infection, followed by transverse colostomy (6.1%) and ileostomy (3.2%). Significant predictors of parastomal infection as presented with odds ratios and 95% confidence intervals include obstruction period, obesity, operative time, serum albumin, and serum C-reactive protein (CRP). Parastomal infection is also highly associated with abdominal surgical wound infection.

CONCLUSION

We concluded that risk factors for parastomal infection include obstruction period, obesity, operative time, serum albumin, and serum CRP. Furthermore, the abdominal surgical wound infection predispose to parastomal infection. Therefore, prolonged and specific antibiotics for results of culture should be used for patients with the above risk factors to prevent parastomal infection.

Massive lower gastrointestinal hemorrhage caused by a large extraluminal leiomyoma of the colon: report of a case

The occurrence of leiomyoma of the colon is uncommon. Most of these lesions are clinically silent and are found incidentally during laparotomy or endoscopic procedures for unrelated conditions. Symptomatic leiomyomas of the colon are encountered less frequently, with only sporadic reports in the literatures. We describe a heretofore unreported case of a large extraluminal leiomyoma of the sigmoid colon presenting as massive lower gastrointestinal hemorrhage. Because it was extraluminal in position, it was difficult to make an accurate diagnosis endoscopically and the condition was easily misdiagnosed as angiodysplasia of the colon until CT scan results were seen. Although rare and benign in nature, leiomyoma of the colon may cause life-threatening complications that require emergency surgery and should be included in the differential diagnosis of lower gastrointestinal hemorrhage.

Clinical entity and treatment strategies for adult intussusceptions: 20 years' experience

PURPOSE

Intestinal intussusception in adults is rare and the optimal management of this problem remains controversial. The purpose of this study was to determine the causes of intussusceptions in adults and to assess their treatment.

METHODS

A retrospective review of patients older than aged 18 years who were diagnosed with intestinal intussusception at Tri-Service General Hospital between July 1984 and July 2004 was conducted.

RESULTS

During the 20-year period, there were 292 patients with intussusception, 24 (8.2 percent) of which were adults. Abdominal pain was the most common presenting complaint (79.2 percent). The diagnosis of adult intussusception was made preoperatively in 18 cases (75 percent) and intraoperatively in 6 cases (25 percent). Of the 24 patients, 20 (83.3 percent) had a defined lesion; 11 (55 percent) lesions were benign and 9 (45 percent) were malignant. In eight patients (33.3 percent), the intussusception was reduced; perforation occurred in one patient (12.5 percent). Segmental resections were performed on 14 patients (58.3 percent), right hemicolectomies on 6 patients (25 percent), laparoscopic low anterior resection on 1 patient (4.2 percent), appendectomy on 1 patient (4.2 percent), and diverticulectomy on 1 patient (4.2 percent). Intraoperative colonoscopy was performed on three patients (12.5 percent) before reduction (lipomas were noted in 2 of the patients (66.7 percent) with limited resection of the ileum and preservation of the antireflux ileocecal valve. There was one perioperative mortality (4.2 percent) and seven postoperative morbidities (29.2 percent).

CONCLUSIONS

Adult intussusception is an unusual and challenging condition and is a preoperative diagnostic problem. We discuss our 20 years of experience in treatment strategies for dealing with such unusual problems.

Intrapelvic migration with long-term retention of a rectal thermometer: a case report

Rectal perforation is a serious complication of manipulation of the anus and rectum, with catheters and thermometers. Such procedures should be performed with caution. We report a case of a 19-year-old male with retention of an intrapelvic foreign body, a mercury thermometer, which after perforating the rectum migrated into the pelvis and remained there without any symptoms for the next 7 years. A mercury thermometer, broken into 2 fragments, retained in the pelvis was noted accidentally by pelvic roentgenogram examination. An extrinsic thermometer tip over the upper rectal region was palpable by digital rectal examination. On physical examination, no infections or signs of peritonitis were observed. There were no significant abnormal findings by flexible colonoscopy. Computed tomography revealed a foreign body retained in the pelvis. Blood mercury level and a 24-hour urinary measurement of mercury were within normal limits. The patient refused any further treatment since he did not have any discomfort. The patient was in good condition and had not had surgery in the preceding 7 years.

Neutrophils in acidotic haemodialysed patients have lower intracellular pH and inflamed state

BACKGROUND

The effect of intracellular pH (pHi) on neutrophils has not been clearly defined.

METHODS

We used pre-dialysis neutrophils from three groups of haemodialysis (HD) patients having different levels of pre-dialysis plasma bicarbonate concentrations (PHCO3) and pH values (pre-dialysis PHCO3 of groups A, B and C were consistently<or=21, 21-26 and>or=26 mmol/l [mEq/l], respectively) and neutrophils from age- and sex-matched healthy controls to determine pHi, apoptosis, phagocytosis and oxidative burst reactions in vivo. We also studied, in group A, the effect of metabolic acidosis correction on neutrophil function. Furthermore, we investigated the effect of intracellular acidification on neutrophil functioning in vitro.

RESULTS

Neutrophils from the HD patients in group A exhibited significantly lower pHi than those in groups B and C. In addition, group A neutrophils had significantly delayed apoptosis, enhanced phagocytosis and increased oxidative burst reactions compared with those in groups B and C. These alterations in neutrophil function in group A were reduced by correcting metabolic acidosis over a period of 1 month. Moreover, our in vitro studies demonstrated that the pHi of neutrophils is positively correlated with apoptosis and inversely correlated with phagocytosis and oxidative burst reactions.

CONCLUSION

HD patients having low PHCO3 exhibited low neutrophil pHi. This intracellular acidification may contribute to the delayed apoptosis, enhanced phagocytosis and increased oxidative burst reactions observed in these neutrophils compared with neutrophils having normal or higher pHi.