RhoB expression associated with chemotherapy response and prognosis in colorectal cancer

PURPOSE

To examine the role of RhoB expression in relation to chemotherapy response, clinical outcomes and associated signaling pathways in colorectal cancer patients.

MATERIALS AND METHODS

The study included 5 colon cancer cell lines, zebrafish embryos and 260 colorectal cancer patients treated with 5-fluorouracil (5-FU) and oxaliplatin (OXL). The methods consisted of CRISPR/Cas9, reactive oxygen species (ROS), caspase-3 activity, autophagy flux, in-silico RNA sequencing and immunohistochemistry. Gene expression analysis and pathway analysis were conducted using RNA-seq data.

RESULTS

All cancer lines tested, including SW480, SW480-KO13 (RhoB knockout), SW480-KO55 (RhoB knockout), HCT116 and HCT116-OE (RhoB overexpressed), exhibited cytotoxicity to 5-FU and OXL. RhoB knockout cell lines demonstrated significantly reduced migration compared to the control cell lines. Furthermore, RhoB played a role in caspase-3-dependent apoptosis, regulation of ROS production and autophagic flux. The mRNA sequencing data indicated lower expression levels of oncogenes in RhoB knockout cell lines. The zebrafish model bearing SW480-KO showed a light trend toward tumor regression. RhoB expression by immunohistochemistry in patients was increased from normal mucosa to tumor samples. In patients who received chemotherapy, high RhoB expression was related to worse survival compared to low RhoB expression. Furthermore, the molecular docking analysis revealed that OXL had a higher binding affinity for RhoB than 5-FU, with a binding affinity of -7.8 kcal/mol and HADDOCK predicted molecular interactions between RhoB and caspase 3 protein. Gene-set enrichment analysis supported these findings, showing that enrichment of DNA damage response pathway and p53 signaling in RhoB overexpression treatment group, while the RhoB knockout treatment group exhibited enrichment in the negative regulation pathway of cell migration.

CONCLUSION

RhoB was negatively associated with chemotherapy response and survival in colorectal cancers. Therefore, RhoB inhibition may enhance chemotherapeutic responses and patient survival.

CD45RA+CD62L- ILCs in human tissues represent a quiescent local reservoir for the generation of differentiated ILCs

Innate lymphoid cells (ILCs) are highly plastic and predominantly mucosal tissue-resident cells that contribute to both homeostasis and inflammation depending on the microenvironment. The discovery of naïve-like ILCs suggests an ILC differentiation process that is akin to naïve T cell differentiation. Delineating the mechanisms that underlie ILC differentiation in tissues is crucial for understanding ILC biology in health and disease. Here, we showed that tonsillar ILCs expressing CD45RA lacked proliferative activity, indicative of cellular quiescence. CD62L distinguished two subsets of CD45RA⁺ ILCs. CD45RA⁺CD62L⁺ ILCs (CD62L⁺ ILCs) resembled circulating naïve ILCs because they lacked the transcriptional, metabolic, epigenetic, and cytokine production signatures of differentiated ILCs. CD45RA⁺CD62L^- ILCs (CD62L^- ILCs) were epigenetically similar to CD62L⁺ ILCs but showed a transcriptional, metabolic, and cytokine production signature that was more akin to differentiated ILCs. CD62L⁺ and CD62L^- ILCs contained uni- and multipotent precursors of ILC1s/NK cells and ILC3s. Differentiation of CD62L⁺ and CD62L^- ILCs led to metabolic reprogramming including up-regulation of genes associated with glycolysis, which was needed for their effector functions after differentiation. CD62L^- ILCs with preferential differentiation capacity toward IL-22-producing ILC3s accumulated in the inflamed mucosa of patients with inflammatory bowel disease. These data suggested distinct differentiation potential of CD62L⁺ and CD62L^- ILCs between tissue microenvironments and identified that manipulation of these cells is a possible approach to restore tissue-immune homeostasis.

Antagonism of Adherent Invasive E. coli LF82 With Human α-defensin 5 in the Follicle-associated Epithelium of Patients With Ileal Crohn's Disease

BACKGROUND

The first visible signs of Crohn's disease (CD) are microscopic erosions over the follicle-associated epithelium (FAE). The aim of the study was to investigate the effects of human α-defensin 5 (HD5) on adherent-invasive Escherichia coli LF82 translocation and HD5 secretion after LF82 exposure in an in vitro model of human FAE and in human FAE ex vivo.

METHODS

An in vitro FAE-model was set up by the coculture of Raji B cells and Caco-2-cl1 cells. Ileal FAE from patients with CD and controls were mounted in Ussing chambers. The effect of HD5 on LF82 translocation was studied by LF82 exposure to the cells or tissues with or without incubation with HD5. The HD5 secretion was measured in human FAE exposed to LF82 or Salmonella typhimurium. The HD5 levels were evaluated by immunofluorescence, immunoblotting, and ELISA.

RESULTS

There was an increased LF82 translocation across the FAE-model compared with Caco-2-cl1 (P < 0.05). Incubation of cell/tissues with HD5 before LF82 exposure reduced bacterial passage in both models. Human FAE showed increased LF82 translocation in CD compared with controls and attenuated passage after incubation with sublethal HD5 in both CD and controls (P < 0.05). LF82 exposure resulted in a lower HD5 secretion in CD FAE compared with controls (P < 0.05), whereas Salmonella exposure caused equal secretion on CD and controls. There were significantly lower HD5 levels in CD tissues compared with controls.

CONCLUSIONS

Sublethal HD5 reduces the ability of LF82 to translocate through FAE. The HD5 is secreted less in CD in response to LF82, despite a normal response to Salmonella. This further implicates the integrated role of antimicrobial factors and barrier function in CD pathogenesis.

Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis

BACKGROUND

The standard of care for acute uncomplicated diverticulitis today is antibiotic treatment, although there are no controlled studies supporting this management. The aim was to investigate the need for antibiotic treatment in acute uncomplicated diverticulitis, with the endpoint of recovery without complications after 12 months of follow-up.

METHODS

This multicentre randomized trial involving ten surgical departments in Sweden and one in Iceland recruited 623 patients with computed tomography-verified acute uncomplicated left-sided diverticulitis. Patients were randomized to treatment with (314 patients) or without (309 patients) antibiotics.

RESULTS

Age, sex, body mass index, co-morbidities, body temperature, white blood cell count and C-reactive protein level on admission were similar in the two groups. Complications such as perforation or abscess formation were found in six patients (1·9 per cent) who received no antibiotics and in three (1·0 per cent) who were treated with antibiotics (P = 0·302). The median hospital stay was 3 days in both groups. Recurrent diverticulitis necessitating readmission to hospital at the 1-year follow-up was similar in the two groups (16 per cent, P = 0·881).

CONCLUSION

Antibiotic treatment for acute uncomplicated diverticulitis neither accelerates recovery nor prevents complications or recurrence. It should be reserved for the treatment of complicated diverticulitis.

Appendectomy versus Antibiotic Treatment in Acute Appendicitis. A Prospective Multicenter Randomized Controlled Trial

BACKGROUND

Appendectomy has been the treatment for acute appendicitis for over 120 years. Antibiotic treatment has occasionally been used in small uncontrolled studies, instead of operation, but this alternative has never before been tried in a multicenter randomized trial.

PATIENTS AND METHODS

Male patients, 18-50 years of age, admitted to six different hospitals in Sweden between 1996 and 1999 were enrolled in the study. No women were enrolled by decision of the local ethics committee. If appendectomy was planned, patients were asked to participate, and those who agreed were randomized either to surgery or to antibiotic therapy. Patients randomized to surgery were operated on with open surgery or laparoscopically. Those randomized to antibiotic therapy were treated intravenously for 2 days, followed by oral treatment for 10 days. If symptoms did not resolve within 24 hours, an appendectomy was performed. Participants were monitored at the end of 1 week, 6 weeks, and 1 year.

RESULTS

During the study period 252 men participated, 124 in the surgery group and 128 in the antibiotic group. The frequency of appendicitis was 97% in the surgery group and 5% had a perforated appendix. The complication rate was 14% in the surgery group. In the antibiotic group 86% improved without surgery; 18 patients were operated on within 24 hours, and the diagnosis of acute appendicitis was confirmed in all but one patient, and he was suffering from terminal ileitis. There were seven patients (5%) with a perforated appendix in this group. The rate of recurrence of symptoms of appendicitis among the 111 patients treated with antibiotics was 14% during the 1-year follow-up.

CONCLUSIONS

Acute non-perforated appendicitis can be treated successfully with antibiotics. However, there is a risk of recurrence in cases of acute appendicitis, and this risk should be compared with the risk of complications after appendectomy.

Prospective evaluation of 6895 groin hernia repairs in women

Background

Although 8 per cent of groin hernia repairs are performed in women, there is little published literature relating specifically to women. This study compared differences in outcome between women and men after groin hernia repair.

Methods

Data collected prospectively in the Swedish Hernia Register between 1992 and 2003 were analysed, including 6895 groin hernia repairs in women and 83 753 in men.

Results

A higher proportion of emergency operations was carried out in women (16·9 per cent) than men (5·0 per cent), leading to bowel resection in 16·6 and 5·6 per cent respectively. During reoperation femoral hernias were found in 41·6 per cent of the women who were diagnosed with a direct or indirect inguinal hernia at the primary operation. The corresponding proportion for men was 4·6 per cent. The hernia repair was not classified as a standard operation (e.g. Shouldice, Lichtenstein, Plug/Mesh, TAPP/TEP) in 38·2 per cent of women and 11·2 per cent of men. Women had a significantly higher risk of reoperation for recurrence than men, and techniques associated with the lowest risk for reoperation in men had the highest risk in women.

Conclusion

A greater proportion of women than men require emergency groin hernia repair, with consequently higher rates of bowel resection, complications and death. Surgical techniques developed for use in men may put women at unnecessary risk.

Choice of anesthesia and risk of reoperation for recurrence in groin hernia repair

OBJECTIVE

To analyze the relative risk of reoperation for recurrence using 3 anesthetic alternatives, general anesthesia (GA), regional (spinal-, epidural-) anesthesia (RA), and local anesthesia (LA), and to study time trends for various anesthetic and operative methods, as well as other risk factors regarding reoperation for recurrence.

BACKGROUND

The method of anesthesia used for hernia repair is generally assumed not to affect the long-term outcome. The few studies on the topic have rendered conflicting results.

METHODS

Data from the Swedish Hernia Register was used. Relative risk was first estimated using univariate analysis for assumed risk variables and then selecting variables with the highest or lowest univariate risk for multivariate analysis.

RESULTS

From 1992 through 2001, 59,823 hernia repairs were recorded. Despite the fact that univariate analysis showed a somewhat lower risk for reoperation in the LA group, the multivariate analysis showed that LA was associated with a significantly increased risk for reoperation in primary but not in recurrent hernia repair. The Lichtenstein technique carried a significantly lower reoperation risk than any other method of operation.

CONCLUSIONS

LA was associated with a higher risk of reoperation for recurrence after primary hernia repair. The use of mesh techniques has increased considerably, and among these the Lichtenstein repair was associated with a significantly lower risk for reoperation than any other repair.

Influence of suture material and surgical technique on risk of reoperation after non-mesh open hernia repair

BACKGROUND

Although mesh techniques are used with increasing frequency, sutured repair still has a place in groin hernia surgery. Studies relating suture material to recurrence rate have yielded conflicting results. The aim of the present study was to analyse the influence of suture material and sutured non-mesh technique on the risk of reoperation in open groin hernia repair using data from the Swedish Hernia Register.

METHODS

The relative risk of reoperation after sutured repair using non-absorbable, late absorbable and early absorbable sutures was compared in multivariate analyses, taking into account known confounding factors.

RESULTS

Between 1992 and 2000, 46,745 hernia repairs were recorded in the Swedish Hernia Register. Of these, 18,057 repairs were performed with open non-mesh methods and were included in the analysis. Using non-absorbable suture as reference, the relative risk of reoperation after repair with early absorbable suture and late absorbable suture was 1.50 (95 per cent confidence interval (c.i.) 1.22 to 1.83) and 1.03 (95 per cent c.i. 0.83 to 1.28) respectively. Using the Shouldice repair as reference, other sutured repairs were associated with a significantly higher relative risk of reoperation (1.22, 95 per cent c.i. 1.03 to 1.44).

CONCLUSION

A non-absorbable or a late absorbable suture is recommended for open non-mesh groin hernia repair. The Shouldice technique was found to be superior to other open methods.

Recurrence and pain three years after groin hernia repair. Validation of postal questionnaire and selective physical examination as a method of follow-up

OBJECTIVES

To evaluate recurrence rate and chronic groin pain three years after hernia repair and to validate a postal questionnaire with selective physical examination as a method of follow-up.

DESIGN

Prospective cohort study.

SETTING

County hospital, Sweden.

PATIENTS

Prospective data were retrieved from the Swedish Hernia Register for patients aged 15-80 years at the time of groin hernia repair, operated on during 1994.

INTERVENTIONS

Three years after operation patients were mailed a three-item questionnaire and invited to have a physical examination. Those examined answered a detailed questionnaire about pain and functional impairment. When appropriate an extended physical examination was undertaken to find out the probable cause of the pain.

MAIN OUTCOME MEASURES

Recurrence, pain, and functional impairment.

RESULTS

272 hernias were repaired in 264 patients. 24 patients had died and 16 had a recurrence before the follow-up examination. After a median observation time of 44 months, 218 patients with 223 repairs (96%) were examined. Depending on the definition of recurrence and completeness of physical examination (selective or all patients) the recurrence rate varied between 10% (25/239) and 15% (35/239) including recurrences diagnosed before follow-up. 40 patients (18%) reported groin pain at follow-up, which was considered to be caused by a previous hernia repair in 34 (15%), 12 of whom (5%) had moderate or severe pain. Postoperative complications were associated with an increased risk of chronic pain, whereas type of hernia and use of mesh had no influence.

CONCLUSIONS

The incidence of recurrence and chronic pain after hernia repair requires continuous audit in non-specialised units. Participation in a register and follow-up by a three-item questionnaire and selective physical examination provides a solid basis for quality control.

Reoperation after recurrent groin hernia repair

OBJECTIVE

To analyze reoperation rates for recurrent and primary groin hernia repair documented in the Swedish Hernia Register from 1996 to 1998, and to study variables associated with increased or decreased relative risks for reoperation after recurrent hernia.

METHODS

Data were retrieved for all groin hernia repairs prospectively recorded in the Swedish Hernia register from 1996 to 1998. Actuarial analysis adjusted for patients' death was used for calculating the cumulative incidence of reoperation. Relative risk for reoperation was estimated using the Cox proportional hazards model.

RESULTS

From 1996 to 1998, 17,985 groin hernia operations were recorded in the Swedish Hernia Register, 15% for recurrent hernia and 85% for primary hernia. At 24 months the risk for having had a reoperation was 4.6% after recurrent hernia repair and 1.7% after primary hernia repair. The relative risk for reoperation was significantly lower for laparoscopic methods and for anterior tension-free repair than for other techniques. Postoperative complications and direct hernia were associated with an increased relative risk for reoperation. Day-case surgery and local infiltration anesthesia were used less frequently for recurrent hernia than for primary hernia.

CONCLUSIONS

Recurrent groin hernia still constitutes a significant quantitative problem for the surgical community. This study supports the use of mesh by laparoscopy or anterior tension-free repair for recurrent hernia operations.

Closed vs. open hemorrhoidectomy--is there any difference?

PURPOSE

The aim of this study was to compare closed (Ferguson) hemorrhoidectomy to open (Milligan-Morgan) hemorrhoidectomy regarding postoperative conditions, complications, and long-term results.

METHOD

This was a randomized study of 77 patients with second-degree or third-degree hemorrhoids suitable for hemorrhoidectomy. In 39 patients the Milligan-Morgan procedure was used, and in 38 patients the Ferguson procedure was used. Details of operations, postoperative complications, and length of postoperative stay were recorded. Pain was assessed from a visual analog scale and by registration of postoperative analgesic medication. Follow-up was done at three weeks, six weeks, and by visit or telephone interview after at least a year.

RESULTS

No statistically significant differences were found between the two methods regarding complications, pain, or postoperative stay. There were four reoperations for bleeding, all after Milligan-Morgan operations. At follow-up after three weeks 86 percent of the Ferguson patients had completely healed wounds, and none had signs of infection. Of the Milligan-Morgan patients, only 18 percent had completely healed wounds, and symptoms of delayed wound healing were significantly more frequent. One patient had a superficial wound infection. After one year more than 10 percent in each group had recurrent hemorrhoids with symptoms.

CONCLUSION

Both methods are fairly efficient treatment for hemorrhoids, without serious drawbacks. The closed method has no advantage in postoperative pain reduction, but wounds heal faster, and the risk of wound dehiscence seems exaggerated.

Hernia registers and specialization

Registration of hernia surgery is useful in the demonstration of outcome quality provided reoperation is linked to the primary procedure. Prerequisites for a hernia register are discussed based on Swedish experience. Evidence indicates that register participation reduces reoperation rate and increases costeffectiveness. Monitoring of outcome quality is important for both specialized and nonspecialized hernia surgeons. Registers of the type discussed may assist general surgeons in their efforts to achieve levels defined by experts.

Methods of repair and risk for reoperation in Swedish hernia surgery from 1992 to 1996

BACKGROUND

Difficulties in obtaining and analysing outcome measures in hernia surgery may be an obstacle to necessary progress in non-specialized hospitals. Against this background a voluntary register was initiated in 1992 with the aim of describing and evaluating hernia surgery in participating units.

METHODS

Prospective registration of all hernia operations carried out in participating hospitals was undertaken using identification codes specific for each individual. Repair technique, complications, day surgery, type of anaesthesia, and reoperation for recurrence were recorded. Actuarial analysis was used to determine the cumulative incidence of reoperation. Relative risk for reoperation was estimated by the Cox proportional hazards model.

RESULTS

The number of participating hospitals and registered operations increased from eight and 1689 respectively in 1992 to 21 and 4056 in 1996. The use of mesh increased from 7 per cent of all operations in 1992 to 51 per cent in 1996. The proportion of operations done for recurrent hernia remained constant at 16-17 per cent throughout the 5-year study period. For all 12542 herniorrhaphies registered, the cumulative incidence of reoperation at 2 years was 3 (95 per cent confidence interval 3-4) per cent. Postoperative complications, recurrent hernia, direct hernia and absorbable suture were associated with increased risk of reoperation for recurrence. An increased incidence of reoperation, although not statistically significant, was noted for conventional open repairs (Bassini, McVay, Marcy and others) versus the Shouldice technique.

CONCLUSION

In this prospective audit an increasing use of mesh was observed for open and laparoscopic surgery, especially for bilateral and recurrent hernia operations. Reoperation rates decreased significantly between 1992 and 1995.

Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies

OBJECTIVE

Analysis of reoperation and recurrence rates three years after repair of groin hernias.

DESIGN

Prospective audit by questionnaire and selective follow-up.

SETTING

Eight Swedish hospitals.

SUBJECTS

All groin hernia operations done during 1992 on patients between the ages of 15 and 80 years.

MAIN OUTCOME MEASURES

Postoperative complications, reoperation for recurrence, and recurrence.

RESULTS

During 1992, 1565 hernia operations were done. The postoperative complication rate was 8% (125/1565). At 36 months postoperatively 108 recurrences had already been reoperated on, six patients with recurrences were on the waiting list for reoperation and a further 36 recurrences had been detected at follow-up. The interhospital variation in recurrence rate ranged from 3% to 20%. Postoperative complications, recurrent hernia, direct hernia and hospital catchment area over 100000 inhabitants were all factors associated with an increased relative risk of recurrence.

CONCLUSIONS

The recurrence rate exceeded the reoperation rate for recurrence by almost 40% which should be taken into account if the reoperation rate is used as the endpoint after repairs of groin hernia. An audit scheme, based on prospective recording, reoperation rate, and (periodic) calculation of the recurrence rate may be used to identify risk factors for recurrence and areas in need of improvement.

Hernia surgery in a defined population: a prospective three year audit

OBJECTIVE

To establish a register of inguinal hernia surgery that allows audit and analyses of data from several centres.

DESIGN

Prospective recording of data on a common protocol.

SETTING

Eight Swedish hospitals.

SUBJECTS

All groin hernia operations done for patients over 15 years old from January 1992 to December 1994.

MAIN OUTCOME MEASURES

Methods of repair, postoperative complications including mortality, day surgery rate, and reoperations for recurrence.

RESULTS

During the three years studied 4879 hernia operations were undertaken in 4474 patients. Postoperative mortality within 30 days of operation for emergency and elective hernia repairs was 3.5% and 0.07%, respectively. Of all herniorrhaphies 798 (16%) were done for recurrences, 142 of these after operations between 1992 and 1994. At 24 months 4% of all operations had been redone because of recurrences with highly significant variations among hospitals ranging from 1.5% to 6.7%. Postoperative complications within 30 days after operation, direct hernia, recurrent hernia, and the use of absorbable sutures were associated with an increased risk of reoperation.

CONCLUSIONS

A quality register recorded voluntarily can identify significant interhospital differences in outcome as well as variables associated with an increased risk of reoperation, thereby raising quality awareness and facilitating the process of improvement.