Outlet Obstruction of Temporary Loop Diverting Ileostomy.

Stoma formation is commonly performed in operations to treat carcinoma, inflammatory bowel disease (IBD) and familial adenomatous polyposis (FAP). In this study, we report several cases of stomal outlet obstruction and investigate the clinical features of cases of outlet obstruction in patients who underwent diverting loop ileostomy. Sixty-one patients with IBD, FAP or rectal cancer who required diverting loop ileostomy were identified for inclusion in this study. We defined outlet obstruction as a small bowel obstruction at the opening of the ileostomy following surgery. All cases of outlet obstruction were diagnosed by computed tomography. In the univariate analysis the type of diagnosis, type of operation, age, and white blood cell count were the factors significantly associated with outlet obstruction following ileostomy, and outlet obstruction was considered to have a connection with restorative proctocolectomy. In conclusion, we found that adhesion and twisting of the ileostomy were the causes of outlet obstruction. For temporary diversion, simple rotation of the ileostomy should be recommended, especially in restorative proctocolectomy. Additional study is required to explore other risk factors of outlet obstruction.

C-reactive protein level as a possible predictor for early postoperative ileus following elective surgery for colorectal cancer.

BACKGROUND/AIMS: Inflammatory reactions are par- tially responsible for postoperative ileus (POI). Serum C-reactive protein (CRP) is an acknowledged marker of inflammation. In this study the CRP response with respect to POI in elective colorectal surgery was exam- ined to define the role of serum CRP as an early predic- tor of POI. METHODOLOGY: Three hundred eighty-three patients who underwent elective colorectal resection were identified for inclusion in this study. We defined early POI as that occurring within 30 days following the surgery. Thirty-five patients with POI were com- pared to a subgroup of 348 patients with an unevent- ful postoperative course, and the correlation between postoperative serum CRP levels and POI in colorectal surgery was investigated. RESULTS: In the univariate analysis, length of operation, surgical blood loss, and serum CRP were factors significantly associated with POI following colorectal surgery; however, these fac- tors lost their significance on multivariate analysis. CONCLUSION: Our results suggest that an increase in CRP levels alone is not a predictor for POI following surgery for colorectal surgery. Although inflammatory responses are known to contribute to the ileus, ad- ditional study is required to identify risk factors that would be more useful for prediction of POI.

The association of VEGF-C expression with tumor lymphatic vessel density and lymph node metastasis in patients with gastric cancer and gastrointestinal stromal tumor.

BACKGROUND/AIMS: Although tumors metastasize to lymph nodes via the lymphatics, the importance of vascular endothelial growth factor-C (VEGF-C) expression in mediating the process has not been well elucidated. We investigated the correlation between VEGF-C expression and lymphatic vessel density (LVD) and node metastasis in cases with gastric cancer and gastrointestinal stromal tumor (GIST). METHODOLOGY: Immunohistochemistry, VEGF-C expression and LVD were performed in 41 patients with gastric cancer invading the muscularis propria and 19 patients with GIST. The clinicopathological features of these cases were compared. RESULTS: In gastric cancer, VEGF-C expression was significantly associated with tumor LVD and lymph node metastasis. In GIST, none of these patients had lymph node metastasis and VEGF-C expression was not detected. The LVD was significantly higher in the cases with gastric cancer than in those with GIST. In gastric cancer, LVD was increased more in patients with positive lymph nodes than in those with negative lymph nodes. CONCLUSIONS: These results indicate that the expression of VEGF-C is associated with tumor LVD and lymph node metastasis, suggesting that VEGF-C plays a critical role in node metastasis via lymphangiogenesis. The clinical observation that GIST rarely metastasizes to the lymph nodes may depend on the lack of VEGF-C expression.

Synchronous colorectal liver metastasis in patients without node metastasis: possibility of localized liver metastasis.

BACKGROUND/AIMS: The liver is the most common distant site of metastasis from colorectal cancer and is often the only organ affected. We hypothesized that whether distant disease is localized in the liver or is a more systemic disease, may be important in the prognosis of patients with synchronous liver metastasis. The purpose of this study was to investigate the possibility of localized liver metastasis in cases with colorectal synchronous liver metastasis and without lymph node involvement. METHODOLOGY: Three hundred and twenty-five consecutive patients who underwent colorectal resection were identified for inclusion in this study, of which 24 cases with synchronous liver metastasis were detected. Of these, 11 who underwent curative simultaneous surgical resection of primary tumor and liver metastases were analyzed in this study. The clinical and pathological features of these cases were reviewed. RESULTS: Of the 11 patients with synchronous liver metastasis from colorectal cancer, 4 had disease recurrence, but none of those without regional node involvement had disease recurrence. In the multivariate analysis, only regional node metastases were significantly associated with disease recurrence. Recurrence-free interval by Kaplan-Meier curves differed significantly among patients with positive regional nodes. CONCLUSIONS: Our results imply that synchronous liver metastasis without regional lymph node metastasis is localized disease.

Serum albumin is superior to prealbumin for predicting short-term recurrence in patients with operable colorectal cancer.

The relationship between preoperative prealbumin and cancer survival has not been fully elucidated. The purpose of this study was to examine the relationship between preoperative nutritional conditions, including prealbumin and albumin concentrations, and the risk of recurrence in cases with operable colorectal carcinoma. One hundred fifty-eight patients who underwent elective colorectal resection were analyzed in this study. Of the eligible cases, 56 (35.4%) had decreased serum prealbumin and 15 (9.5%) had decreased serum albumin preoperatively. Among 158 cases in this study, 18 (11.4%) had disease recurrence. In the univariate analysis, the depth of tumor invasion, lymph node metastasis, lymphovascular invasion, serum albumin, prealbumin, and carcinoembryonic antigen were the factors significantly associated with disease recurrence. Multivariate analysis demonstrated that only serum albumin was a predictor of the recurrence; however, serum prealbumin lost its significance on multivariate analysis. Time to tumor recurrence by Kaplan-Meier curves significantly differed among patients with low serum albumin and prealbumin level. Our results suggest that prealbumin and albumin may be sensitive indicators of the risk of recurrent disease; however, low serum albumin levels are more useful than prealbumin in predicting short-term disease recurrence in operable colorectal cancer.

Serum albumin and prealbumin do not predict recurrence in patients with breast cancer.

BACKGROUND: We have previously reported that prealbumin and albumin may be sensitive indicators of the risk of recurrent disease in colorectal cancer; however, the relationship between preoperative prealbumin and cancer survival has not been fully-elucidated. The purpose of this study was to examine the relationship between preoperative nutritional conditions, including prealbumin and albumin concentrations, and the risk of recurrence in cases with breast cancer. PATIENTS AND METHODS: One hundred and fifty-seven patients who underwent breast surgery were analyzed in this study. The detection limit of the prealbumin assay was 22 mg/dl; patients were divided in analytical groups of <22 mg/dl and ≥22 mg/dl. The detection limit of the albumin assay was 4.0 g/dl; patients were divided in analytical groups of <4.0 g/dl and ≥4.0 g/dl. The clinical features of these cases were reviewed according to prealbumin and albumin levels, and statistical analysis was performed. RESULTS: Among 157 cases in this study, five (3.2%) had disease recurrence. Out of the eligible cases, 38 (24.2%) had decreased serum prealbumin and 19 (12.1%) had decreased serum albumin preoperatively. No statistically significant association of the preoperative prealbumin level was found with the clinicopathological variables. The only statistically significant association found for preoperative albumin level was age; age was higher in patients with low albumin levels. In short, we were unable to establish a connection between preoperative prealbumin or albumin and various clinical features, including recurrence, lymph node metastasis and tumor size. CONCLUSION: Prealbumin and albumin may be sensitive indicators of disturbances in protein metabolism, and reflect inflammation activity and malnutrition. However, our results suggest that evaluation of serum prealbumin and albumin are not useful for predicting disease aggressiveness or recurrence in breast cancer.

Arteriovenous malformation detected by small bowel endoscopy.

Gastrointestinal bleeding that originates in the small intestine is often difficult to diagnose. When successful diagnosis reveals a lesion that can be localized preoperatively, the laparoscopic approach is an appropriate and beneficial treatment modality for small bowel resection. A 69-year-old man presented with a 6-month history of gastrointestinal bleeding and symptomatic transfusion-dependent anemia. Upper and lower endoscopy were normal. Double-balloon endoscopy established the source of the bleeding as a 0.5-cm polypoid mass appearing as a submucosal tumor with redness and pulsation in the lower ileum, suggesting a vascular lesion. Laparoscopic small bowel resection was successful in removing the mass in the ileum. Histological evaluation of the mass revealed an arteriovenous malformation. Preoperative small bowel endoscopy can be useful for diagnosing the cause and localization of arteriovenous malformation in the small intestine.

Benefit of oral feeding as early as one day after elective surgery for colorectal cancer: oral feeding on first versus second postoperative day.

The optimal timing of early oral intake after surgery has not been fully established. The objective of this study was to compare early oral intake at postoperative day 1 after resection of colorectal cancer with that of day 2 to identify the optimal timing for resumption of oral intake in such patients. Consecutive patients with colorectal cancer who underwent elective colorectal resection were separated into two groups. Sixty-two patients began a liquid diet on the first postoperative day (POD1 group) and 58 patients began on POD2 (POD2 group) and advanced to a regular diet within the next 24 hours as tolerated. As for gastrointestinal recovery, the first passage of flatus was experienced, on average, on postoperative day 3.1 ± 1.0 in the POD2 group and on day 2.3 ± 0.7 in the POD1 group. The first defecation was also significantly earlier in patients in the POD1 group than those in the POD2 group (POD 3.2 ± 1.2 versus 4.2 ± 1.4, respectively). No statistical difference was found between the two groups in terms of postoperative complications. Our results suggest that very early feeding on POD1 after colorectal resection is safe and feasible and that induced a quicker recovery of postoperative gastrointestinal movement in patients.

Vascular invasion, but not lymphatic invasion, of the primary tumor is a strong prognostic factor in patients with colorectal cancer.

BACKGROUND: We previously showed that the presence of vascular invasion, but not lymphatic invasion, was a strong prognostic factor for breast cancer. Lymphatic invasion may represent mainly the selective affinity of cancer cells for lymph nodes. The present study was undertaken to evaluate the presence of vascular invasion that may reflect systemic disease as a predictor of disease recurrence in colorectal cancer, separate from lymphatic invasion of the primary tumor. PATIENTS AND METHODS: We retrospectively evaluated the cases of 177 consecutive patients with primary colorectal cancer who underwent colorectal resection. We examined the relationship between recurrence and the prognostic significance of clinicopathological factors, particularly lymphatic and vascular invasion. RESULTS: The presence of vascular invasion (v) was significant, while that of lymphatic invasion (ly) was not significant in univariate analysis. The presence of vascular invasion was an independent prognostic factor in multivariate analysis. Among the 60 patients in the ly-/v- group, one (1.7%) had disease recurrence, and among the 33 patients in the ly+/v- group, one (3.0%) had disease recurrence. On the other hand, among the 71 patients in the ly+/v+ group, 16 patients (22.5%) suffered recurrence, and among the 13 patients in the ly-/v+ group, four (30.8%) suffered recurrence. It is interesting to note that despite the presence of lymphatic invasion, the group without vascular invasion (ly+/v-) had a few patients with distant metastases, a result which is similar to that of the ly-/v- group. CONCLUSION: The presence of vascular invasion, but not lymphatic invasion, could be an indicator of high biological aggressiveness and may be a strong prognostic factor for colorectal cancer.

Effect of long interval between hyperthermochemoradiation therapy and surgery for rectal cancer on apoptosis, proliferation and tumor response.

Neoadjuvant chemoradiotherapy is commonly used to improve the local control and resectability of locally advanced rectal cancer, with surgery performed after an interval of a number of weeks. We have been conducting a clinical trial of preoperative chemoradiotherapy in combination with regional hyperthermia (hyperthermo-chemoradiation therapy; HCRT) for locally advanced rectal cancer. In the current study we assessed the effect of a longer (>10 weeks) interval after neoadjuvant HCRT on pathological response, oncological outcome and especially on apoptosis, proliferation and p53 expression in patients with rectal cancer. Forty-eight patients with proven rectal adenocarcinoma who underwent HCRT followed by surgery were identified for inclusion in this study. Patients were divided into two groups according to the interval between HCRT and surgery, ≤ 10 weeks (short-interval group) and >10 weeks (long-interval group). Patients in the long-interval group had a significantly higher rate of pathological complete response (pCR) (43.5% vs. 16.0%) than patients of the short-interval group. Patients of the long-interval group had a significantly higher rate of down-staging of T-stage (78.3% vs. 36.0%) and relatively higher rate of that of N-stage (52.2% vs. 36.0%) than patients of the short-interval group. Furthermore, apoptosis in the long-interval group was relatively higher compared to that of the short-interval group, without a significant difference in the Ki-67 proliferative index and expression of p53 in the primary tumor. In conclusion, we demonstrated that a longer interval after HCRT (>10 weeks) seemed to result in a better chance of a pCR, a result confirmed by the trends in tumor response markers, including apoptosis, proliferation and p53 expression.