Long-term prognosis of ulcerative colitis and its temporal changes between 1986 and 2015 in a population-based cohort in the Songpa-Kangdong district of Seoul, Korea.

OBJECTIVE: No population-based study has evaluated the natural course of UC over three decades in non-Caucasians. We aimed to assess the long-term natural course of Korean patients with UC in a population-based cohort. DESIGN: This Korean population-based, Songpa-Kangdong IBD cohort included all patients (n=1013) newly diagnosed with UC during 1986-2015. Disease outcomes and their predictors were evaluated. RESULTS: During the median follow-up of 105 months, the overall use of systemic corticosteroids, thiopurines and antitumour necrosis factor (anti-TNF) agents was 40.8%, 13.9% and 6.5%, respectively. Over time, the cumulative risk of commencing corticosteroids decreased, whereas that of commencing thiopurines and anti-TNF agents increased. During follow-up, 28.7% of 778 patients with proctitis or left-sided colitis at diagnosis experienced proximal disease extension. A total of 28 patients (2.8%) underwent colectomy, demonstrating cumulative risks of colectomy at 1, 5, 10, 20 and 30 years after diagnosis of 1.0%, 1.9%, 2.2%, 5.1% and 6.4%, respectively. Multivariate Cox regression analysis revealed that extensive colitis at diagnosis (HR 8.249, 95% CI 2.394 to 28.430), ever use of corticosteroids (HR 6.437, 95% CI 1.440 to 28.773) and diagnosis in the anti-TNF era (HR 0.224, 95% CI 0.057 to 0.886) were independent predictors of colectomy. The standardised mortality ratio in patients with UC was 0.725 (95% CI 0.508 to 1.004). CONCLUSION: Korean patients with UC may have a better clinical course than Western patients, as indicated by a lower colectomy rate. The overall colectomy rate has continued to decrease over the past three decades.

Clinicopathological Outcomes in Patients With Locally Advanced Rectal Cancer Undergoing Preoperative Short-Versus Long-course Chemoradiotherapy With Delayed Surgery.

BACKGROUND/AIM: We aimed to compare the clinicopathological outcomes in patients with locally advanced rectal cancer after short- or long-course concurrent chemoradiotherapy (CCRT) followed by delayed surgery. PATIENTS AND METHODS: The records of 94 patients with cT3-4N0-2M0 rectal cancer who received CCRT between 2010 and 2017 were reviewed. Short-course radiotherapy (RT) was delivered with a median total dose of 25 Gy in five fractions (n=27), and long-course RT was delivered with a median total dose of 50.4 Gy in 28 fractions (n=67). The following concurrent chemotherapy regimens were administered: 5-fluorouracil plus leucovorin in 58 and capecitabine in 24; in 12 cases agents were unknown. The median interval between CCRT and surgery was 8 weeks. Adjuvant chemotherapy was administered after surgery in 80 patients (5-fluorouracil plus leucovorin, n=54; capecitabine, n=9; other, n=14; and unknown, n=3). Propensity-score matching analysis was conducted. RESULTS: The median follow-up duration was 4.3 years. There were no statistically significant differences between the short- and long-course RT groups in sphincter preservation (85.2% vs. 92.5%, p=0.478), pathological complete remission (18.5% vs. 14.9%, p=0.905), downstaging (44.4% vs. 26.9%, p=0.159), and negative circumferential resection margin (92.6% vs. 89.6%, p=0.947) rates. No differences were found in survival outcomes between the short- and long-course groups at 3 years (overall survival: 91.8% vs. 88.1%, p=0.790; disease-free survival, 75.2% vs. 72.5%, p=0.420; locoregional relapse-free survival, 90.5% vs. 98.4%, p=0.180; and distant metastasis-free survival, 79.6% vs. 73.5%, p=0.490). Similar results were observed after PSM. CONCLUSION: Clinically, short-course CCRT may be a feasible alternative to long-course CCRT in patients with locally advanced rectal cancer.

Clinical Features and Long-Term Outcomes of Paediatric-Onset Inflammatory Bowel Disease in a Population-Based Cohort in the Songpa-Kangdong District of Seoul, Korea.

BACKGROUND AND AIMS: The long-term outcomes of paediatric-onset inflammatory bowel disease [pIBD] in non-Caucasian populations are unknown. We therefore evaluated and compared the clinical features and long-term outcomes of pIBD with those of adult-onset IBD [aIBD] using a population-based cohort in the Songpa-Kangdong district of Seoul, Korea. METHODS: Clinical characteristics and prognoses were compared between the two groups: pIBD [defined as <18 years of age at diagnosis] and aIBD [18-59 years of age at diagnosis]. RESULTS: We identified 131 patients with pIBD (48 ulcerative colitis [UC], 83 Crohn's disease [CD]) and 1192 patients with aIBD [866 UC, 326 CD] during 1986-2015. Extensive colitis at diagnosis was more prevalent in pUC than in aUC [45.8% vs 22.3%, p < 0.001], and the overall exposure to corticosteroids, thiopurines and anti-tumour necrosis factor agents was higher in pUC than in aUC [p < 0.001]. The cumulative risk of colectomy was higher in pUC than in aUC during a median follow-up of 125.0 and 112.1 months, respectively [8.9% vs 1.8% at 10 years after diagnosis, p = 0.030]. Ileocolonic location and inflammatory behaviour at diagnosis were more common in pCD than in aCD; however, patients with pCD and aCD did not differ regarding treatment or disease course during a median follow-up of 137.2 and 120.9 months, respectively. CONCLUSION: Our study showed clear differences between pIBD and aIBD, especially in UC. pUC presents with more extensive diseases and may have a more severe disease course, as suggested by an earlier time to administering medications and performing colectomy.

Changes in the Long-term Prognosis of Crohn's Disease between 1986 and 2015: The Population-Based Songpa-Kangdong Inflammatory Bowel Disease Cohort Study.

BACKGROUND/AIMS: The long-term course of Crohn's disease (CD) has never been evaluated in non-Caucasian population-based cohorts. The aim of the present study was to evaluate the longterm prognosis of Korean CD patients in the well-defined population-based Songpa-Kangdong inflammatory bowel disease cohort. METHODS: Outcomes of disease and their predictors were evaluated for 418 patients diagnosed with CD between 1986 and 2015. RESULTS: During a median of 123 months, systemic corticosteroids, thiopurines, and anti-tumor necrosis factor (TNF) agents were administered to 58.6%, 81.3%, and 37.1% of patients, respectively. Over time, the cumulative probability of starting corticosteroids significantly decreased (p=0.001), whereas that of starting thiopurines and anti-TNFs significantly increased (both p<0.001). The cumulative probability of behavioral progression was 54.5% at 20 years, and it significantly decreased during the anti-TNF era. Intestinal resection was required for 113 patients (27.0%). The cumulative probabilities of intestinal resection at 1, 5, 10, 20, and 25 years after CD diagnosis were 12.7%, 16.5%, 23.8%, 45.1%, and 51.2%, respectively. Multivariable Cox regression analysis identified stricturing behavior at diagnosis (adjusted hazard ratio [aHR], 2.70; 95% confidence interval [CI], 1.55 to 4.71), penetrating behavior at diagnosis (aHR, 11.15; 95% CI, 6.91 to 17.97), and diagnosis of CD during the anti-TNF era (aHR, 0.51; 95% CI, 0.35 to 0.76) as independently associated with intestinal resection. The standardized mortality ratio among CD patients was 1.36 (95% CI, 0.59 to 2.68). CONCLUSIONS: The long-term prognosis of Korean patients with CD is at least as good as that of Western CD patients, as indicated by the low intestinal resection rate. Moreover, behavioral progression and intestinal resection rates have decreased over the past 3 decades.

Clinical Characteristics and Long-term Prognosis of Elderly-Onset Ulcerative Colitis in a Population-Based Cohort in the Songpa-Kangdong District of Seoul, Korea.

Background/Aims: We aimed to evaluate the clinical characteristics and long-term prognosis of elderly-onset ulcerative colitis (EOUC) in Korean patients over a 30-year period using a wellestablished population-based cohort in the Songpa-Kangdong district of Seoul, Korea. Methods: Clinical characteristics and prognosis were compared between two groups: EOUC, defined as UC diagnosed in individuals aged ≥60 years and non-EOUC (N-EOUC), defined as UC diagnosed in individuals aged 18 to 59 years. Results: We identified 99 patients with EOUC (10.3%) and 866 patients with N-EOUC (89.7%) between 1986 and 2015. During the median follow-up of 104.5 months, the overall exposure to medications was comparable between patients with EOUC and N-EOUC (p=0.091 for corticosteroids, p=0.794 for thiopurines, and p=0.095 for anti-tumor necrosis factor agents). The cumulative risks of disease outcomes were also comparable between patients with EOUC and N-EOUC (22.4% vs 30.4% for proximal disease extension [p=0.351], 11.9% vs 18.1% for hospitalization [p=0.240], and 2.3% vs 1.8% for colectomy [p=0.977]) at 10 years after diagnosis. Multivariate Cox regression analysis revealed that corticosteroid use at diagnosis was an independent predictor of proximal disease extension (hazard ratio [HR], 6.216; 95% confidence interval [CI], 1.314 to 28.826) and hospitalization (HR, 11.241; 95% CI, 3.027 to 41.742) in patients with EOUC. Conclusions: In this population-based study from Korea, the pattern of medication use seemed comparable between the EOUC and N-EOUC groups. Moreover, patients with EOUC and those with N-EOUC have a similar disease course in terms of proximal disease extension, hospitalization, and colectomy.

International consensus on natural orifice specimen extraction surgery (NOSES) for gastric cancer (2019).

At present, natural orifice specimen extraction surgery (NOSES) has attracted more and more attention worldwide, because of its great advantages including minimal cutaneous trauma and post-operative pain, fast post-operative recovery, short hospital stay, and positive psychological impact. However, NOSES for the treatment of gastric cancer (GC) is still in its infancy, and there is great potential to improve its theoretical system and clinical practice. Especially, several key points including oncological outcomes, bacteriological concerns, indication selection, and standardized surgical procedures are raised with this innovative technique. Therefore, it is necessary to achieve an international consensus to regulate the implementation of GC-NOSES, which is of great significance for healthy and orderly development of NOSES worldwide.

A 30-year Trend Analysis in the Epidemiology of Inflammatory Bowel Disease in the Songpa-Kangdong District of Seoul, Korea in 1986-2015.

BACKGROUND AND AIMS: Although the incidence of inflammatory bowel disease [IBD] is increasing in Asia, data on long-term epidemiological trends are limited. We performed a 30-year longitudinal study to investigate temporal trends in the epidemiology of Crohn's disease [CD] and ulcerative colitis [UC] in Seoul, Korea. METHODS: This population-based study included 1431 IBD patients [418 CD, 1013 UC] diagnosed between 1986 and 2015 in the Songpa-Kangdong district of Seoul, Korea. Temporal trends in incidence, prevalence, and disease phenotype at diagnosis were analysed. RESULTS: The adjusted mean annual incidence rates of CD and UC per 100 000 inhabitants increased from 0.06 (95% confidence interval [CI], 0.05-0.07) and 0.29 [95% CI, 0.27-0.31], respectively, in 1986-1990 to 2.44 [95% CI, 2.38-2.50] and 5.82 [95% CI, 5.73-5.92], respectively, in 2011-2015. Average annual percentage change in IBD incidence was 12.3% in 1986-1995, 12.3% in 1996-2005, and 3.3% in 2006-2015. The male-to-female ratio of the adjusted incidence rate was 3.3:1 for CD and 1.2:1 for UC. Perianal fistula/abscess was present in 43.3% of patients before or at CD diagnosis. At diagnosis, 54.3% of UC patients presented only with proctitis. The adjusted prevalence rate in 2015 was 31.59/100 000 [95% CI, 31.10-32.07] for CD and 76.66/100 000 [95% CI, 75.91-77.42] for UC. CONCLUSIONS: The incidence and prevalence of IBD in Korea have continued to increase over the past three decades. Korean patients have distinct demographic and phenotypic characteristics, including a male predominance and high frequency of perianal fistula/abscess in CD and high proportion of proctitis in UC.

Preoperative short- vs. long-course chemoradiotherapy with delayed surgery for locally advanced rectal cancer.

PURPOSE: To compare the clinical outcomes between short-course chemoradiotherapy (CRT) and long-course CRT with delayed surgery in locally advanced rectal cancer patients. RESULTS: From 2010 to 2015, 19 patients were treated with short-course CRT and 53 patients were treated with LCRT. The sphincter-saving rate (89.5% vs. 94.3%, short-course CRT vs. long-course CRT), pathologic complete remission (21.1% vs. 13.2%), downstaging (47.4% vs. 26.4%), and treatment complications including anastomotic site leakage, bowel adhesion, and hematologic toxicity associated with short-course CRT were not significantly different from those associated with long-course CRT. 2-year overall survival was 90.0% and 91.2% (p = 0.448), respectively. METHODS AND MATERIALS: 72 patients with stage cT3-4N0-2M0 rectal cancer participated in a multicenter study. Short-course CRT treatment was as follows: a total of 25 Gy of radiotherapy was delivered in 5 equal doses with intensity modulated radiation therapy. Chemotherapy was consisted of Leucovorin 400 mg/m2 administered by bolus injection on day 1 and 5-Fluouracil 1200 mg/m2 given by continuous infusion on days 1 and 2. An additional three cycles of chemotherapy were administered before the surgery. Long-course CRT treatment was as follows: a total of 50.4 Gy of radiotherapy was delivered in 28 equal doses. Chemotherapy consisted of a bolus injection of 5-Fluouracil + Leucovorin during the first and last week of radiotherapy. Surgery was performed 6-8 weeks after completion of radiotherapy in both groups. CONCLUSIONS: Preoperative short-course CRT is an effective and safe modality. It is clinically comparable to long-course CRT in locally advanced rectal cancer.

Comparison of skin incisions used for open lateral internal sphincterotomies--radial versus circumferential incisions: a retrospective cohort study.

INTRODUCTION: Lateral internal sphincterotomy (LIS) is a safe and effective surgical treatment, commonly used in patients with chronic anal fissures (CAFs). Although LIS is a simple surgical technique, it may cause several complications. Open LIS is usually performed through an incision made in the intersphincteric groove; radial or circumferential incisions, used according to the surgeon's preference. However, differences in clinical outcomes and wound healing, based on type of skin incision, are unclear. We investigated incision site wound healing and other clinical outcomes, after open LIS, according to the type of skin incision employed. METHODS: We retrospectively reviewed the data of the electronic medical records of 602 patients who underwent open LIS for CAFs between March 2005 and February 2010 at Yang Hospital, Seoul, Korea. RESULTS: Of the 602 patients, 298 patients received radial incisions and 304 received circumferential incisions. Circumferential incisions of the anus reduced the wound healing time compared to radial incisions (19.1 vs. 24.0 days, p < 0.001). There were no significant differences between the groups in wound complications such as perianal abscess, fistula, or cellulitis. Clinical outcomes including recurrence, persistence of fissures, and continence problems were also similar between the groups. CONCLUSIONS: Our study shows that circumferential skin incisions, during LIS, are associated with shorter healing times than radial incisions.

The use of a staged drainage seton for the treatment of anal fistulae or fistulous abscesses.

PURPOSE: The aim of this retrospective study was to evaluate the rate of recurrence and incontinence after the treatment of fistulae or fistulous abscesses by using the staged drainage seton method. METHODS: According to the condition, a drainage seton alone or a drainage seton combined with internal opening (IO) closure and relocation of the seton was used. After a period of time, the seton was changed with 3-0 nylon; then, after another period of time, the authors terminated the treatment by removing the 3-0 nylon. Telephone interviews were used for follow-up. The following were evaluated: the relationship between the type of fistula and recurrence; the relationship between the type of fistula and the period of treatment; the relationship between the recurrence and presence of abscess; the relationship between IO closure and recurrence; the relationship between the period of seton change and recurrence; reported continence for flatus, liquid stool, and solid stool. RESULTS: The recurrence rate of fistulae or suppuration was 6.5%, but for cases of horseshoe extension, the recurrence rate was 57.1%. The rate of recurrence was related to the type of fistula (P = 0.001). Incontinence developed in 3.8% of the cases. No statistically significant relationship was found between the rate of recurrence and the presence of an abscess or between the closure of the IO and the period of seton change or removal. CONCLUSION: In the treatment of anal fistulae or fistulous abscesses, the use of a staged drainage seton can reduce the rate of recurrence and incontinence.

Is There Any Relationship between the Chronicity of Chronic Anal Fissure and Endothelin-1?

PURPOSE: Many kinds of substances are produced on vascular endothelial activation. The aim of this study is to confirm an increase in Endothelin-1 (ET-1), the most potent vasoconstrictor, which is produced by endothelial activation, in patients with chronic anal fissure and to infer the relationship between ET-1 and anal fissure chronicity. METHODS: The study groups are divided into three different groups with 30 subjects each. Group 1 is comprised of healthy volunteers, group 2 of chronic anal fissure patients, and Group 3 of patients with higher than 3rd degree hemorrhoids. Blood samples were taken to measure the ET-1 levels in subject's serum and to compare the results with those for the control groups. RESULTS: Among the 90 subjects, 38 were male, and 52 were female. The average age was 36.8. The average ET-1 level marked 1.47 ± 0.78 pg/mL for male subjects and 1.16 ± 0.47 pg/mL for female subjects (P = 0.02). The average ET-1 level in the patient groups is as follow: 1.21 ± 0.44 pg/mL in group 1, 1.46 ± 0.83 pg/mL in group 2, and 1.20 ± 0.56 pg/mL in group 3 (P = 0.14). CONCLUSION: Group 2, the chronic anal fissure patient group, showed a higher ET-1 level than groups 1 and 3, the control group and the hemorrhoid patient group, but this difference had no statistical significance.

Risk factors for anastomotic leakage after laparoscopic rectal resection.

PURPOSE: The anastomotic leakage rate after rectal resection has been reported to be approximately 2.5-21 percent, but most results were associated with open surgery. The aim of this study was to identify risk factors and their relationship to the experience of the surgeon for anastomotic leakage after laparoscopic rectal resection. METHODS: Between March 2003 and December 2008, 156 patients underwent a laparoscopic rectal resection without a diverting ileostomy. The patients' characteristics, the details of treatment, the intraoperative results, and the postoperative results were recorded prospectively. Univariate and multivariate analyses were applied to identify risk factors for anastomotic leakage. RESULTS: The majority of operations were performed for malignant disease (n = 150; 96.2%), and 96 patients (61.5%) were males. Conversion to open surgery occurred in 1 case (0.6%). The anastomotic leak rate was 10.3% (16/156), and there were no mortalities. In the univariate analysis, tumor location, anastomotic level, intraoperative events, and operation time were associated with increased anastomotic leakage rate. In the multivariate analysis, anastomotic level (odds ratio [OR], 6.855; 95% confidence interval [CI], 1.271 to 36.964) and operation time (OR, 8.115; 95% CI, 1.982 to 33.222) were significantly associated with anastomotic leakage. CONCLUSION: The important risk factors for anastomotic leakage after laparoscopic rectal resection without a diverting ileostomy were low anastomosis and long operation time. An additional procedure, such as diverting stoma, may reduce the anastomotic leakage if it is selectively applied in cases with these risk factors.