Risk Factors and Predictive Biomarkers for Anastomotic Leakage after Colorectal Cancer Surgery with the Double Stapling Technique.

Objectives: Anastomotic leakage (AL) is a serious complication associated with morbidity, mortality, and poor prognosis. This study aimed to identify the risk factors and predictive biomarkers for AL after colorectal surgery with double stapling technique (DST) anastomosis. Methods: We retrospectively analyzed 331 patients who underwent elective colorectal cancer surgery with DST anastomosis between April 2012 and July 2021. Patient-, tumor-, and surgery-related variables were examined using univariate and multivariate analyses to identify the risk factors for AL. Postoperative inflammatory biomarkers were also analyzed to identify the predictive factors for AL. Results: AL occurred in 28 (8.5%) patients. In multivariate analysis, male sex, a history of diabetes mellitus and high ligation of inferior mesenteric artery (IMA) were significant risk factors for AL. Serum C-reactive protein (CRP) levels on postoperative day (POD) 3 and 7 were significantly correlated with AL (OR; 95% CI, 1.134; 1.044-1.232, p = 0.003, and 1.154; 1.036-1.286, p = 0.009, respectively). The cut-off value of CRP on POD 3 was 10.91 mg/dL (sensitivity 0.714, specificity 0.835, positive predictive value [PPV] 0.290, and negative predictive value [NPV] 0.969). The cut-off value of CRP on POD 7 was 4.58 mg/dL (sensitivity 0.821, specificity 0.872, PPV 0.377, and NPV 0.981). Conclusions: Male sex, a history of diabetes mellitus and high ligation of IMA were risk factors for AL in colorectal cancer surgery with DST anastomosis. The predictive biomarkers for cases without AL were CRP levels on POD 3 and 7.

Short-term outcomes of patients undergoing endoscopic submucosal dissection for colorectal lesions.

Objectives: Endoscopic submucosal dissection (ESD) of colorectal lesions was invented in Japan, but postoperative management including hospital stay has not been reconsidered due to the Japanese insurance system. To explore appropriate postoperative management after colorectal ESD, we reviewed short-term outcomes after ESD in non-selected consecutive patients. Methods: Patients who underwent colorectal ESD from April 2013 to September 2020 in one institution were reviewed. The primary outcome measure was the occurrence of adverse events stratified by the Clavien-Dindo classification with five grades. A logistic regression model with the Firth procedure was applied to investigate predictors of severe (grade III or greater) adverse events. Results: A total of 330 patients (female 40%, male 60%; median 72 years; IQR 65-80 years) with colorectal lesions (median 30 mm, IQR 23-40 mm; colon 77%, rectum 23%; serrated lesion 4%, adenoma 47%, mucosal cancer 30%, invasive cancer 18%) was evaluated. The en bloc resection rate was 97%. The median dissection time was 58 min (IQR: 38-86). Intraprocedural perforation occurred in 3%, all successfully treated by endoscopic clipping. No delayed perforations occurred. Postprocedural bleeding occurred in 3% on days 1-10 (median day 2); all were controlled endoscopically. Severe adverse events included only delayed bleeding. In analyzing severe adverse events in a multivariate logistic regression model with the Firth procedure, antithrombotic agent use (p = 0.016) and rectal lesions (p = 0.0010) were both significant predictors. Conclusions: No serious adverse events occurred in this series. Four days of hospitalization may be too long for the majority of patients after ESD.

Rectal cancer eradication by proton beam therapy complicated by radiation proctitis: a case report.

A 74-year-old woman presented to her local physician with hematochezia. Colonoscopy showed a locally advanced 30 mm cancer adjacent to the anus. She refused abdominoperineal resection because of the necessity for a permanent stoma and decided to receive proton beam therapy (70.4 Gy equivalent) as an alternative treatment in another hospital. After proton beam therapy, the rectal cancer was eradicated at colonoscopy, and she was referred for surveillance. One year later, she developed frequent hematochezia. Colonoscopy revealed dilated vessels with oozing hemorrhage in the tumor scar. This was diagnosed as hemorrhagic radiation proctitis induced by proton beam therapy. Over 8 months, endoscopic hemostatic therapy was performed five times using argon plasma coagulation for refractory hemorrhagic disease. The patient's hemoglobin level dropped to as low as 4.5 g/dl requiring blood transfusion. Thereafter, the radiation proctitis gradually improved and there is no evidence of recurrent tumor for over 10 years. To the best of our knowledge, there are no previous reports of proton beam therapy eradication of locally advanced rectal cancer. Clinicians should be aware that radiation-induced proctitis with refractory hemorrhage could develop.

Prognostic factors of patients with left-sided obstructive colorectal cancer: post hoc analysis of a retrospective multicenter study by the Japan Colonic Stent Safe Procedure Research Group.

BACKGROUND: There are many reports on the choice of treatment for and prognosis of left-sided obstructive colorectal cancer; however, few studies have focused on the prognostic factors of left-sided obstructive colorectal cancer. Therefore, we analyzed the prognostic factors using a post hoc analysis of a retrospective multicenter study in Japan. METHODS: A total of 301 patients were enrolled in this study to investigate the prognostic factors for relapse-free survival. The relationships between sex, age, decompression for bridge to surgery, depth of invasion, lymph node metastasis, postoperative complications, adjuvant chemotherapy, carcinoembryonic antigen, carbohydrate antigen 19-9, neutrophil-to-lymphocyte ratio, and relapse-free survival were examined. RESULTS: No change in the decompression method, T3 cancer, negative postoperative complications (grades 0-1 of Clavien-Dindo classification), and adjuvant chemotherapy during Stage III indicated a significantly better prognosis in a Cox univariate analysis. Lymph node metastasis was not selected as a prognostic factor. Excluding patients with <12 harvested lymph nodes (possible stage migration), lymph node metastasis was determined as a prognostic factor. In a Cox multivariate analysis, change in the decompression method, depth of invasion, lymph node metastasis (excluding N0 cases with <12 harvested lymph nodes), and adjuvant chemotherapy were prognostic factors. CONCLUSIONS: Similar to those in nonobstructive colorectal cancer, depth of invasion and lymph node metastasis were prognostic factors in left-sided obstructive colorectal cancer, and patients with <12 dissected lymph nodes experienced stage migration. Stage migration may result in disadvantages, such as not being able to receive adjuvant chemotherapy.

Risk of Delayed Bleeding after Cold Snare Polypectomy in Patients with Antithrombotic Therapy.

BACKGROUND: Cold snare polypectomy is being increasingly adopted; however, there are few reports of cold snare polypectomy regarding antithrombotic therapy. AIMS: This study aimed to investigate the real-world safety of cold snare polypectomy during antithrombotic therapy. METHODS: We collected data from consecutive patients undergoing cold snare polypectomy in a single hospital between 2013 and 2017. Indications for cold snare polypectomy were any ≤ 10 mm polyp. The primary outcome was delayed bleeding. We compared rates of delayed bleeding between patients with and without antithrombotic therapy and analyzed risk factors for delayed bleeding using binary logistic regression model with firth procedure. RESULTS: In 2152 patients (mean age 67.6 years; male 1411), 4433 colorectal polyps (mean diameter 5.0 mm) underwent cold snare polypectomy. Clipping during the procedure was performed for 5.8%. Delayed bleeding occurred in 0.51% (11/2152) of patients and 0.25% (11/4433) of polyps, but no major delayed bleeding occurred. A total of 244 (11%) patients received antithrombotic therapy. Patients on antithrombotic therapy were older (p < 0.001), more likely male (p < 0.001) and had cold snare polypectomy in the proximal colon (p = 0.011). The rate of delayed bleeding was higher in patients on antithrombotic therapy (1.64% vs. non-antithrombotic therapy 0.37%, p = 0.009). Larger polyp size (> 5 mm), use of clips, and antithrombotic therapy were significant risk factors for delayed bleeding. There was no clear association between specific antithrombotic agents and delayed bleeding. CONCLUSIONS: Delayed bleeding after cold snare polypectomy was rare even in patients with antithrombotic therapy, and no major delayed bleeding occurred.

[The Evaluation of Neoadjuvant Chemotherapy for Locally Advanced Rectal Cancer].

We evaluated the efficacy of neoadjuvant chemotherapy(NAC)for 38 patients with locally advanced rectal cancer (LARC). We administered mFOLFOX6 in 15, FOLFIRI in 3, CAPOX in 10, IRIS in 1 and FOLFOXIRI in 9 patients. We also used bevacizumab in 31 and panitumumab in 7 patients. There were 27 male and 11 female patients, with a median age of 64 years, and location was RS 2, Ra 9, Rb 21, and P 6. Synchronous distant metastasis was recognized in 13 patients. Nine patients had suffered adverse event of Grade 3, however all patients could complete NAC. Clinical response was CR 3, PR 31, SD 4, response rate was 91.9%, and reduction rate was 43.3(range 18.8-100)%. Clinical response of distant metastasis was CR 3, PR 9 and SD 1. Laparoscopic surgery was performed in 29 patients. Postoperative complications of Grade 2 of Clavien- Dindo classification were recognized in 14 and Grade 3 in 4 patients. Three- and five-year overall survival rate of 25 patients without distant metastasis were 79.6% and 74.9%, respectively; and 13 with distant metastasis were 61.6% and 52.6%, respectively. The efficacy, safety and postoperative outcomes of NAC for LARC are favorable, and we think that NAC will be one of the treatments for LARC.

Recent trends in the prevalence and distribution of colonic diverticula in Japan evaluated using computed tomography colonography.

BACKGROUND: Computed tomography colonography (CTC) may be superior to colonoscopy and barium enema for detecting diverticula. However, few studies have used CTC to diagnose diverticula. AIM: To evaluate the current prevalence and distribution of colonic diverticula in Japan using CTC. METHODS: This study was conducted as part of the Japanese National Computed Tomographic Colonography Trial, which included 1181 participants from 14 hospitals in Japan. We analyzed the prevalence and distribution of colonic diverticula and their relationships with age and sex. The relationship between the diverticula and the length of the large intestine was also analyzed. RESULTS: Diverticulosis was present in 48.1% of the participants. The prevalence of diverticulosis was higher in the older participants (P < 0.001 for trend). The diverticula seen in younger participants were predominantly located in the right-sided colon. Older participants had a higher frequency of bilateral type (located in the right- and left-sided colon) diverticulosis (P < 0.001 for trend). The length of the large intestine with multiple diverticula in the sigmoid colon was significantly shorter in those without diverticula (P < 0.001). CONCLUSION: The prevalence of colonic diverticulosis in Japan is higher than that previously reported. The prevalence was higher, and the distribution tended to be bilateral in older participants.

Change in the neutrophil-to-lymphocyte ratio during chemotherapy may predict prognosis in patients with advanced or metastatic colorectal cancer.

The neutrophil-to-lymphocyte ratio (NLR) has been reported to be an independent prognostic factor of unresectable advanced or metastatic colorectal cancer (uCRC). However, few studies have documented changes in NLR during chemotherapy. The current study analyzed whether a change in NLR during chemotherapy in patients with uCRC could be used as a prognostic biomarker. The present retrospective study enrolled 71 patients who received first-line chemotherapy for uCRC between April 2012 and April 2019. The exclusion criteria were as follows: Acute infection or systemic inflammatory disease, duration of first-line chemotherapy <3 months, curative resection after chemotherapy and treatment with granulocyte-colony stimulating factor within 1 month. NLR, Lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), lactate dehydrogenase, alkaline phosphatase (ALP), albumin, carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were calculated before chemotherapy and at 3 months after chemotherapy. Among these laboratory data, NLR, PLR, ALP, CEA and CA19-9 levels were significantly decreased during chemotherapy. For Cox univariate analyses, these five data makers were divided into two groups: Decreased and increased (comparing before and at 3 months after chemotherapy). Only the change in NLR was significantly associated with overall survival (P=0.0002). Furthermore, the overall survival (P<0.0001) and progression-free survival (P=0.0041) of patients with decreased NLR was increased compared with patients with increased NLR. The change in NLR from pre-chemotherapy to 3 months following chemotherapy was determined to be a predictor of prognosis in patients with uCRC. The ability to predict prognosis at an early phase of chemotherapy may provide useful information for the selection of subsequent treatment and may improve the quality of patient life.

Diverticular hemorrhage of terminal ileum successfully treated by ultra-selective transcatheter arterial embolization using triaxial system: a case report.

Small intestinal hemorrhage due to diverticulum is a relatively rare condition among gastrointestinal hemorrhages. We report a case of diverticular hemorrhage of the terminal ileum that was successfully treated by ultra-selective transcatheter arterial embolization using a triaxial system. A 25-year-old man was referred to our hospital due to melena. Abdominal contrast-enhanced computed tomography demonstrated marked extravasation of contrast medium in a diverticulum of the terminal ileum. We immediately attempted transcatheter arterial embolization after onset of hemorrhagic hypovolemic shock. Angiogram of the superior mesenteric artery revealed apparent hemorrhage at the end of the ileocolic artery. We performed embolization with 2 platinum coils using a triaxial system via the vasa recta of the terminal ileum. This procedure stopped extravasation of contrast medium. Postoperative course was uneventful, and he was discharged four days postoperatively. The triaxial system may facilitate high diagnostic ability to accurately identify target arteries of the ileal diverticular hemorrhage.

Polyp detection algorithm can detect small polyps: Ex vivo reading test compared with endoscopists.

BACKGROUND AND STUDY AIMS: Small polyps are occasionally missed during colonoscopy. This study was conducted to validate the diagnostic performance of a polyp-detection algorithm to alert endoscopists to unrecognized lesions. METHODS: A computer-aided detection (CADe) algorithm was developed based on convolutional neural networks using training data from 1991 still colonoscopy images from 283 subjects with adenomatous polyps. The CADe algorithm was evaluated on a validation dataset including 50 short videos with 1-2 polyps (3.5 ± 1.5 mm, range 2-8 mm) and 50 videos without polyps. Two expert colonoscopists and two physicians in training separately read the same videos, blinded to the presence of polyps. The CADe algorithm was also evaluated using eight full videos with polyps and seven full videos without a polyp. RESULTS: The per-video sensitivity of CADe for polyp detection was 88% and the per-frame false-positive rate was 2.8%, with a confidence level of ≥30%. The per-video sensitivity of both experts was 88%, and the sensitivities of the two physicians in training were 84% and 76%. For each reader, the frames with missed polyps appearing on short videos were significantly less than the frames with detected polyps, but no trends were observed regarding polyp size, morphology or color. For full video readings, per-polyp sensitivity was 100% with a per-frame false-positive rate of 1.7%, and per-frame specificity of 98.3%. CONCLUSIONS: The sensitivity of CADe to detect small polyps was almost equivalent to experts and superior to physicians in training. A clinical trial using CADe is warranted.

Delayed hemorrhage after cold and hot snare resection of colorectal polyps: a multicenter randomized trial (interim analysis).

Background and study aims Delayed bleeding is believed to occur less frequently after cold snare polypectomy (CSP), but this has not been validated in clinical trials. This study aimed to compare rates of delayed bleeding after CSP and hot snare polypectomy (HSP). Patients and methods We conducted a multicenter, randomized controlled trial. Participants scheduled to undergo endoscopic resection of colorectal polyps ≤ 10 mm were enrolled and randomly assigned to CSP or HSP. Prophylactic clipping was performed at the endoscopists' discretion. The primary outcome was delayed bleeding rate. Secondary outcomes included immediate bleeding rate and clipping rate. Sample size calculation showed that 451 patients were required in each arm. Results At the end of the study period decided in advance, 308 participants were recruited and an interim analysis was performed. A total of 273 patients (mean age 62.2 ±â€Š8.8 years; 188 males) were analyzed, with 139 patients allocated to CSP and 134 to HSP. In total, 367 polyps were resected with CSP and 360 polyps with HSP. There were no significant differences in patient demographics or polyp characteristics. In per-patient-based analysis, delayed bleeding rates were 0.7 % after CSP and 0.7 % after HSP. Per-polyp analysis showed similar results (CSP: 0.3 % vs. HSP: 0.6 %). The immediate bleeding rate was significantly higher with CSP vs. HSP (54 % vs.14 %, P  < 0.0001), while clipping rates were 18 % and 19 %, respectively. Conclusion This interim analysis did not demonstrate that delayed bleeding after CSP is less frequent than after HSP. The delayed bleeding rate after HSP was lower than expected. Meeting presentations: Digestive Disease Week 2017.

A novel volume-reduced CT colonography regimen using hypertonic laxative (polyethylene glycol with ascorbic acid): randomized controlled trial.

OBJECTIVES: The aim of this study is to investigate the feasibility of bowel preparation using a hypertonic laxative (polyethylene glycol with ascorbic acid, PEG + Asc) for CT colonography (CTC) and to examine the volume limit of laxative. METHODS: In one institution, patients who met the indications for CTC were enrolled and randomly assigned to CTC with regimen A (800 ml PEG + Asc), B (600 ml PEG + Asc), or C (400 ml PEG + Asc). Sodium diatrizoate was given orally for fecal tagging. On the previous day, patients ate low-residue meals and took the assigned lavage solution after dinner. A reader blinded to the preparation graded residual stool/fluid and fecal tagging quality in six segments of the colorectum. The primary outcome was a proportion of colon segments without stool. One hundred twenty segments in 20 patients with each regimen were needed to show a non-inferiority margin of 15%, assuming 85% of no stool. RESULTS: A total of 360 segments in 60 patients were analyzed. There were 83% of segments with no stool in regimen A, 89% in regimen B, and 88% in regimen C. Using the delta method, the 95% confidence interval of the risk difference (6.7%) between regimens A and B was - 2.2% to 15.6%, and the risk difference (5.0%) between regimens A and C was - 4.1% to 14%, both within the non-inferiority margin. Residual fluid and fecal tagging quality were also within the non-inferiority margin. No adverse events occurred. CONCLUSIONS: A novel CTC regimen using hypertonic laxative demonstrated optimal colon cleansing effectiveness even with the lowest volume of laxative (UMIN000022851). KEY POINTS: • A novel CTC regimen using a hypertonic laxative is feasible. • The lowest volume of laxative provides excellent colon imaging. • However, the lowest volume of laxative did not improve patient acceptance.

[Curative Transanal Resection after Neoadjuvant Chemotherapy for Lower Rectal Cancer-A Case Report].

A 53-year-old woman was referred to our hospital with melena. Examinations revealed advanced rectal cancer involving the anal canal with invasion of the left-sided levator ani muscle. Neoadjuvant chemotherapy was administered to preserve anal function. A first course of capecitabine and oxaliplatin(CapeOX)plus bevacizumab was administered. CapeOX plus panitumumab was administered from the 2nd to the 8th courses after confirming the absence of RAS mutation. Endoscopy and computed tomography confirmed the disappearance of the tumor after completion of the chemotherapy. A biopsy of the scar tissue revealed no cancer cells. However, diffusion weighted-magnetic resonance imaging(MRI-DWI)revealed a suspected residual tumor. To determine the subsequent treatment, a transanal resection was performed. No carcinoma was identified in the specimen. Thus, additional surgical treatment and adjuvant chemotherapy were not administered. The patient was followed-up over 2.5 years post local resection and showed no recurrence.

[Two Cases of Advanced Colorectal Cancer Achieving Complete Response by FOLFOXIRI plus Bevacizumab-A Case Report].

We report 2 cases of advanced colorectal cancer achieving complete response by FOLFOXIRI plus bevacizumab. Case 1 was a 65-year-old male diagnosed with descending colon cancer with multiple liver metastases. Six courses of FOLFOXIRI plus bevacizumab were administered after laparoscopic-assisted left hemicolectomy. Ten partial hepatectomies and 1 radiofrequency ablation were performed as the liver metastases resolved. A pathological complete response was confirmed. Adjuvant chemotherapy was not administered, and recurrence-free survival was 21 months after hepatectomy. Case 2 was a 77-yearold male diagnosed with rectal cancer invading the pelvic wall and sacral foramen with bilateral lateral lymph node metastasis. Additionally, there was a cancer embolism in the right internal iliac vein. Six courses of FOLFOXIRI plus bevacizumab were administered, and the cancer tissue was absent on subsequent CT and MRI. The cancer was scarred by colonoscopy, and the biopsy showed no malignant cells. Six courses of FOLFIRI plus panitumumab were administered as second-line chemotherapy, and the patient survived without any recurrence after 12 months from initiation of chemotherapy.

Histological Comparison of Cold versus Hot Snare Resections of the Colorectal Mucosa.

BACKGROUND: Delayed postpolypectomy bleeding occurs more frequently after hot resection than after cold resection. OBJECTIVE: To elucidate the underlying mechanism, we performed a histological comparison of tissue after cold and hot snare resections. DESIGN: This is a prospective study, registered in the University Hospital Medical Information Network (UMIN000020104). SETTING: This study was conducted at Aizu Medical Center, Fukushima Medical University, Japan. PATIENTS: Fifteen patients scheduled to undergo resection of colorectal cancer were enrolled. INTERVENTION: On the day before surgery, 2 mucosal resections (hot and cold) of normal mucosa were performed on each patient using the same snare without saline injection. The difference was only the application of electrocautery or not. Resection sites were placed close to the cancer to be included in the surgical specimen. MAIN OUTCOME MEASURES: The primary outcome measure was the depth of destruction. Secondary outcome measures included the width of destruction, depth of the remaining submucosa, and number of vessels remaining at the resection sites. The number and diameter of vessels in undamaged submucosa were also evaluated. RESULTS: All cold resections were limited to the shallow submucosa, whereas 60% of hot resections advanced to the deep submucosa and 20% to the muscularis propria (p < 0.001). There was no significant difference in the width of destruction. The number of remaining large vessels after hot resections trended toward fewer (p = 0.15) with a decreased depth of remaining submucosa (p = 0.007). In the deep submucosa, the vessel diameter was larger (p < 0.001) and the number of large vessels was greater (p = 0.018). LIMITATIONS: Histological assessment was not blinded to the 2 reviewers. Normal mucosa was used instead of adenomatous tissue. CONCLUSIONS: Hot resection caused damage to deeper layers involving more large vessels. This may explain the mechanism for the reduced incidence of hemorrhage after cold snare polypectomy. See Video Abstract at http://links.lww.com/DCR/A631.

Colonoscopy in Patients Aged 85 Years or Older: An Observational Study.

OBJECTIVES: Colonoscopy is the first-line modality to examine the colon even in the very elderly but may have an increased risk of complications. This study aimed to evaluate the efficacy and safety of colonoscopy in the very elderly. METHODS: Patients ≥85y old, who underwent colonoscopy between September 2010 and August 2012 in two tertiary-care hospitals in Japan were enrolled. Main outcome measures were cecal intubation rate, detection rate of adenomas and cancers, treatment, adverse events, and long-term outcomes. RESULTS: A total of 207 colonoscopies were performed in 177 patients (females 72, males 105; maximum age 95 years). Of these, 202 attempted to reach the cecum, with success in 92%. Excluding patients with known colorectal neoplasms, invasive cancers were detected in 12%, including T1 lesions in 2% and T2 or deeper in 9%. No cancers were detected in patients referred for surveillance or mild abdominal symptoms. Cancers were found in 25% of patients with positive fecal immunochemical tests, 22% with altered bowel habits, 21% with anemia, and 18% with hematochezia. Treatment of 29 patients with cancer included surgery in 22, endoscopic resection in two and no treatment (due to comorbidities) in five. There were no complications. During 730 days (mean) of follow up, 27 patients died but only three died from recurrent colorectal cancer. CONCLUSIONS: Colonoscopy for patients aged ≥85 years is safe. A relatively high detection rate of cancers was found, and most were treatable and even curable. (UMIN000018575).

Topical lidocaine inhibits spasm during colonoscopy: a double-blind, randomized controlled trial (with video).

BACKGROUND AND STUDY AIMS: Topical peppermint oil prevents intestinal spasm, but can cause rebound spasm. Lidocaine hydrochloride, a local anesthetic, may work as an antispasmodic by blocking Na + channels. The aim of this study was to investigate the effect of topical lidocaine on the inhibition of colonic spasm during colonoscopy, compared with peppermint oil. PATIENTS AND METHODS: A randomized, controlled double-blind trial was conducted in an academic endoscopy unit. Patients requiring endoscopic resection were randomly allocated to colonoscopy with topical administration of lidocaine (n = 30) or peppermint oil (n = 30). Similar vials containing different solutions were randomly numbered. Allocation was made based on the vial number. The solution used and the vial number were not revealed during the study. Two endoscopists performed all procedures using midazolam, without anticholinergic agents. When a pre-selected lesion was identified, the solution in the assigned vial was dispersed and the bowel observed for 5 minutes. The primary endpoint was the duration of spasm inhibition, and a secondary endpoint was the occurrence of rebound spasm stronger than before dispersion. RESULTS: There were no significant differences in patient demographics. Spasm was inhibited in almost all patients in both groups, with a similar median duration (lidocaine 227 sec vs. peppermint 212.5 sec, P  = 0.508). In contrast, rebound spasm occurred less frequently in the lidocaine group (lidocaine 7 % vs. peppermint 47 %, P  = 0.001). There were no adverse events or symptoms associated with administration of the solutions. CONCLUSIONS: The inhibitory effect of lidocaine is not superior to peppermint oil. However, lidocaine significantly decreases the frequency of rebound spasms.

Pseudocirrhosis caused by regorafenib in an advanced rectal cancer patient with multiple liver metastases.

A 70-year-old man who was diagnosed with unresectable advanced rectal cancer with multiple liver metastases, received oxaliplatin-based treatment with bevacizumab as first-line chemotherapy and irinotecan-based treatment with bevacizumab as second-line chemotherapy for a total of 17 months. The patient was treated with regorafenib (160 mg/day for 3 weeks) as third-line chemotherapy. Following completion of one course of regorafenib treatment, the patient complained of abdominal distension. Computed tomography (CT) examination identified liver atrophy and massive ascites, while no such symptoms were observed prior to the regorafenib treatment. Blood testing revealed increases in the aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) levels. The patient was admitted to the Aizu Medical Center (Aizuwakamatsu, Japan). Approximately 2,000 ml of ascitic fluid were aspirated daily for 1 week by abdominal puncture. The patient was administered oral diuretics, including 20 mg/day of furosemide and 25 mg/day of spironolactone. Albumin was administered to correct the albumin deficit. The levels of AST, ALT and ALP were decreased from the peak value reported on admission and the patient was discharged from our hospital 16 days following treatment initiation. The CT examination after 1 month revealed that the volume of the liver had been restored and the ascites had disappeared. Furthermore, almost all the liver metastases were reduced in size. The carcinoembryonic antigen level, which was elevated prior to regorafenib treatment, also decreased to normal.

Ultrathin versus pediatric instruments for colonoscopy in older female patients: A randomized trial.

BACKGROUND AND AIM: Small-caliber endoscopes such as gastroscopes or pediatric colonoscopes are occasionally required to negotiate fixed or angulated colons. However, the use of a new ultrathin instrument (diameter 7.0 mm) narrower than other conventional colonoscopes has not been evaluated. The aim of the present study was to compare the use compare the use of an ultrathin colonoscope (UTC) with a pediatric colonoscope (PDC) for colonoscopy in older female patients. METHODS: A prospective, randomized, controlled trial was conducted in a single academic endoscopy unit. A total of 77 female patients aged ≥70 years undergoing unsedated colonoscopy were randomized to colonoscopy with a UTC (n = 39) or PDC (n = 38). Primary outcome measurement was the degree of pain using a numerical rating scale, and secondary outcomes were cecal intubation rate, ileal intubation rate, time to cecum and adenoma detection rate. RESULTS: There was a significant difference in reported pain using the numerical rating scale (median, UTC 1 vs PDC 4, P < 0.0001). Cecal intubation rates were 97.4% in UTC and 92.1% in PDC (P = 0.36), and ileal intubation rates were 82.0% and 89.4% (P = 0.76), respectively. However, median times to cecum were significantly longer using UTC compared with PDC (15.2 min vs 11.1 min, P = 0.022). Adenoma detection rates were 30.7% in UTC and 26.3% in PDC (P = 0.80). CONCLUSIONS: Colonoscopy using UTC was almost equivalent to that of PDC in older female patients, with significantly less pain compared with PDC. UTC may be an alternative to PDC for the difficult colon.

An evidence-based medicine approach to the laparoscopic treatment of colorectal cancer.

During the 1990s, laparoscopic resection was established as a treatment for gastrointestinal malignant tumors.　A number of randomized controlled trials comparing laparoscopic-assisted colorectal surgery with conventional open colorectal surgery for colon cancer have been conducted.　These trials have shown short-term benefits, and the vast majority demonstrated no significant difference in long-term outcomes.　Laparoscopic-assisted colorectal surgery is widely performed for the treatment of colon cancer, whereas laparoscopic-assisted colorectal surgery for rectal cancer is less commonly performed.　In recent years, there have been an increasing number of reports of laparoscopic-assisted colorectal surgery for rectal cancer, where improving short-term outcomes was shown, but no definitive effect on long-term survival has been shown to date.　Randomized controlled trials focusing on long-term survival are currently ongoing.