Early Single-Center Experience of DaVinci® Single-Port (SP) Robotic Surgery in Colorectal Patients.

Background: DaVinci® single-port (SP) robotic surgery offers several benefits compared to traditional multiport laparoscopic or robotic surgeries. One of the main advantages is that it allows for a minimally invasive approach, resulting in a single, smaller incision and reduced trauma to the patient's body, leading to less postoperative pain, faster recovery, and reduced risk of complications. The cosmesis of a single port with minimal visible scarring is also an attractive aspect to the patients; however, many surgeons use an additional port for energy device, stapler use, and drain insertion. Pure single-port surgery with one incision is still rare. Here, we share our experience of our first 10 cases using the SP robotic platform in colorectal surgery. Methods: From May 2023 to December 2023, colorectal patients who underwent SP robotic surgery were analyzed. Placement of the incision was the umbilicus for eight patients, and right lower quadrant for two patients, through which ileostomy maturation was performed. Data on perioperative parameters and postoperative outcomes were analyzed, with a median follow-up of 4.6 months (range 0.6-7.4 months). Results: A total of 10 colorectal patients underwent DaVinci® single-port robotic colorectal surgery at our institution during this period. The patient demographic was four males (40%) and six females (60%) with a median age of 63.5 years (range 50-75 years). Median body mass index (BMI) was 22.89 kg/m2 (range 19.92-26.84 kg/m2). Nine patients were diagnosed with colorectal cancer, and one patient was diagnosed with a rectal gastrointestinal tumor. One patient underwent anterior resection and cholecystectomy simultaneously. Mean operation time was 222 min (range 142-316 min), and mean wound size was 3.25 cm (range 2.5-4.5 cm). Nine patients underwent surgery with single incision through which a single-port trocar was inserted, and one patient had one additional port for drain insertion. Mean hospital stay was 6 days (range 4-8 days) with one postoperative complication of bleeding requiring transfusion, but there was no readmission within 30 days. Conclusions: Overall, our experience with single-port robotic colorectal surgery has been promising. With only one patient with additional port for drain insertion, all nine patients underwent SP-robotic surgery with single incision for colon as well as rectal surgeries. Compared to an average postoperative length of stay of 6.5-8 days in laparoscopic colorectal surgeries reported in literature, SP-robotic surgery 33showed faster recovery of 6 days highlighting its benefits in patient recovery and satisfaction.

Human umbilical cord/placenta mesenchymal stem cell conditioned medium attenuates intestinal fibrosis in vivo and in vitro.

BACKGROUND: A significant unmet need in inflammatory bowel disease is the lack of anti-fibrotic agents targeting intestinal fibrosis. This study aimed to investigate the anti-fibrogenic properties and mechanisms of the conditioned medium (CM) from human umbilical cord/placenta-derived mesenchymal stem cells (UC/PL-MSC-CM) in a murine intestinal fibrosis model and human primary intestinal myofibroblasts (HIMFs). METHODS: UC/PL-MSC-CM was concentrated 15-fold using a 3 kDa cut-off filter. C57BL/6 mice aged 7 weeks old were randomly assigned to one of four groups: (1) control, (2) dextran sulfate sodium (DSS), (3) DSS + CM (late-phase treatment), and (4) DSS + CM (early-phase treatment). Chronic DSS colitis and intestinal fibrosis was induced by three cycles of DSS administration. One DSS cycle consisted of 7 days of oral DSS administration (1.75%, 2%, and 2.5% DSS), followed by 14 days of drinking water. UC/PL-MSC-CM was intraperitoneally administered in the late phase (from day 50, 10 times) or early phase (from day 29, 10 times) of DSS cycles. HIMFs were treated with TGF-ß1 and co-treated with UC/PL-MSC-CM (10% of culture media) in the cellular model. RESULTS: In the animal study, UC/PL-MSC-CM reduced submucosa/muscularis propria thickness and collagen deposition, which improved intestinal fibrosis in chronic DSS colitis. The UC/PL-MSC-CM significantly reduced the expressions of procollagen1A1 and α-smooth muscle actin, which DSS significantly elevated. The anti-fibrogenic effect was more apparent in the UC-MSC-CM or early-phase treatment model. The UC/PL-MSC-CM reduced procollagen1A1, fibronectin, and α-smooth muscle actin expression in HIMFs in the cellular model. The UC/PL-MSC-CM downregulated fibrogenesis by suppressing RhoA, MRTF-A, and SRF expression. CONCLUSIONS: Human UC/PL-MSC-CM inhibits TGF-ß1-induced fibrogenic activation in HIMFs by blocking the Rho/MRTF/SRF pathway and chronic DSS colitis-induced intestinal fibrosis. Thus, it may be regarded as a novel candidate for stem cell-based therapy of intestinal fibrosis.

Is cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still beneficial in patients diagnosed with colorectal peritoneal metastasis who underwent palliative chemotherapy?

BACKGROUND: With a 5-year overall survival of less than 5%, colorectal peritoneal metastasis (CPM) patients are often managed with palliative chemotherapy (CTx). In the past few decades, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been introduced as a possible curative treatment for highly selective CPM patients. We share our experience of CRS and HIPEC given the unique characteristics of the medical system and the benefit of CRS and HIPEC in palliative setting. METHODS: From April 2017 to October 2021, CPM patients who underwent CRS and HIPEC were analyzed. Patients were allocated into perioperative and palliative CTx arm based on the duration between initial diagnosis of CPM to undergoing CRS and HIPEC of 6 months. Data including perioperative parameters, postoperative outcomes, and survival were analyzed with a median follow-up of 28.5 months. RESULTS: Twenty-six CPM patients underwent CRS and HIPEC. Mean time from diagnosis of CPM to CRS and HIPEC was 5.5 months with 14 patients in the perioperative arm and 12 patients in the palliative arm. Perioperative group showed a longer RFS of 13.5 months compared to 8 months in the palliative group. Median overall survival of palliative group was 41.50 months, and 18 patients among all groups are alive at the time of this report. CONCLUSION: CRS and HIPEC could be a treatment option for a carefully selected CPM patients performed by experienced surgeons. Overall survival of 41.50 months in palliative group compared to 16.8 months from conventional systemic CTx supports CRS and HIPEC even in palliative patients.

Ultrasound-guided thread lifting for the prevention of parotid gland and diagnosing parotid duct complications.

BACKGROUND: Thread lifting is a common minimally invasive plastic surgery procedure. Parotid gland injury caused by thread lifting is a known complication; however, visual evidence of this complication is lacking. OBJECTIVES: This study aimed to present cases of parotid gland injury by thread lifting shown using ultrasound and to discuss the importance of ultrasound detection of the location of the parotid gland before thread insertion. METHODS: This study included eight patients diagnosed with parotid gland perforation and one with parotid duct injury due to threads from November 2020 to October 2022. RESULTS: Six patients showed tenderness and swelling, three were asymptomatic, and one with duct injury showed severe swelling and pain. Although the severity and duration of symptoms have differed, we confirmed the progress of improvement with conservative treatment and confirmed ultrasound findings progressed. CONCLUSIONS: Using ultrasound to detect the parotid gland's location before thread lifting might reduce the chance of parotid duct injury. Identifying immediate parotid duct or gland injury with ultrasound can help to act quickly for delayed pain or swelling and reduce the likelihood of additional complications.

A comparative study between open versus laparoscopic Hartmann reversal: A single-center experience and analysis.

ABSTRACT: As one of the most challenging procedures in colorectal surgery, Hartmann reversal (HR) carries a burden of morbidity and mortality. We report our experience and compare open and laparoscopic HR.Between December 2012 and January 2020, 30 patients who underwent Hartmann reversal were reviewed. All patients either received laparoscopic or open reversal.Of the 87 patients who underwent Hartmann operation (HO), 30 patients received HR (Laparoscopic Hartmann Reversal, [LHR], n = 20; Open Hartmann Reversal, Open Hartmann Reversal [OHR], n = 10). There were 15 males and 15 female patients. The mean operation time was 223.8 minutes (range 115-350 minutes) with mean blood loss of 252.5 mL (range 0-700 mL). There was no conversion from LHR to OHR, and there was no ileostomy formation. Mean time to flatus was 5.0 days (range 2-13 days). There were 15 early postoperative complications and 5 late postoperative complications, but only 1 case of grade 3A. No anastomosis leakage was reported.HR is an operation that can be performed safely in well-selected patients. Minimally invasive techniques, such as LHR, is an attractive option resulting in shorter operation time, less blood loss, less pain, and shorter hospital stay.

The multistep process of vaginal cancer arising from deep infiltrating endometriosis: a case report.

BACKGROUND: Malignant transformation of endometriosis in extraovarian sites remains rare. Furthermore, the process is not definitely understood. CASE PRESENTATION: Herein, we report the case of a 40-year-old premenopausal nulligravida woman who presented with vaginal bleeding and who was finally diagnosed with a vaginal cancer originating from endometriosis and with a synchronous endometrial cancer. A gynecologic examination revealed a multiple polypoid mass on the posterior vaginal fornix. Magnetic Resonance Imaging of the pelvis showed two masses abutting respectively on the anterior uterine wall, and in the rectovaginal septum. The patient underwent a total laparoscopic excision of the rectovaginal mass, radical hysterectomy and low anterior resection of the rectum. The lesions were diagnosed as endometriosis, endometriosis-associated complex hyperplasia and endometrioid cancer. Furthermore, a synchronous endometrioid endometrial cancer was reported. CONCLUSIONS: This case revealed the multistep process of malignant transformation of deep infiltrating endometriosis. The progression was individualized between implantation sites and in the same organ.

Colonic Perforation After Treatment With Nivolumab in Esophageal Cancer: A Case Report.

With the advent of checkpoint inhibitors, it has opened up opportunities for numerous cancer patients. However, as is the case with every treatment, complications need to be weighed. Gastrointestinal adverse effects, such as diarrhea and colitis are well-known complications for checkpoint inhibitors. In severe cases, colitis-induced colonic perforation may occur with an estimation of 1.0% to 1.5% in anti-CTLA-4 antibodies. However, only a handful of cases of such devastating complications have been reported in anti-PD-1 antibodies such as pembrolizumab and nivolumab. We here report a case of intestinal perforation in a patient treated with nivolumab.

Functional recovery by colon organoid transplantation in a mouse model of radiation proctitis.

Radiation proctitis is the collateral damage that occurs to healthy cells during radiation treatment of pelvic malignancies. Conservative treatment of radiation proctitis can mitigate inflammatory symptoms, but, to date, no therapeutic options are available for direct recovery of the damaged colonic epithelium. The present study assessed the ability of colon organoid-based regeneration to treat radiation proctitis. Radiation proctitis was induced in mice by irradiating their recta, followed by enema-based transplantation of mouse colon organoids. The transplanted colon organoids were found to successfully engraft onto the damaged rectal mucosa of the irradiated mice, reconstituting epithelial structure and integrity. Lgr5+ stem cells were shown to be pivotal to colon organoid mediated regeneration. Endoscopic examination showed the efficacy of localized transplantation of colon organoids with fibrin glue to irradiated sites. These findings provide useful insights into the use of colon organoid-based regenerative therapy for the treatment of radiation proctitis.

STING activation normalizes the intraperitoneal vascular-immune microenvironment and suppresses peritoneal carcinomatosis of colon cancer.

BACKGROUND: Peritoneal carcinomatosis is a fatal clinical presentation of colon cancer, characterized by unresponsiveness to conventional anticancer therapies, including immune checkpoint inhibitors. Here, we elucidated the immune-evasion mechanisms during the peritoneal carcinomatosis of colon cancer and developed a novel immunotherapy by activating the stimulator of interferon genes (STING) pathway. METHODS: We generated a syngeneic peritoneal carcinomatosis model of colon cancer. Mice were intraperitoneally treated with either STING agonist (MIW815, also known as ADU-S100) or PD-1 blockade or both. The tumor microenvironment was comprehensively analyzed using multiplexed immunofluorescence imaging, flow cytometry, and NanoString immune profiling. RESULTS: Intraperitoneal colon cancer cells induce a massive influx of immunosuppressive M2-like macrophages, upregulate immune checkpoints, and impair effector T cell functions during peritoneal dissemination; these collectively create a highly angiogenic and immunosuppressive milieu that is resistant to anti-PD-1 monotherapy. Intraperitoneal administration of a STING agonist suppressed aberrant angiogenesis, increased pericyte coverage, and normalized tumor vessels, thereby facilitating the infiltration of activated CD8+ T cells into peritoneal tumor nodules. Moreover, STING activation reprogramed tumor-associated macrophages toward the M1 phenotype. STING activation converted immunologically cold peritoneal tumors into T-cell-inflamed tumors in a type-I interferon-dependent manner. Lastly, the STING agonist synergistically cooperated with PD-1 and/or COX2 blockade to further suppress the peritoneal dissemination of colon cancer, resulting in complete eradication of tumor and ascites, and inducing durable antitumor immunity. CONCLUSIONS: STING activation can normalize the peritoneal vascular and immune microenvironment, providing a rationale for a novel combination therapeutic strategy for peritoneal carcinomatosis in colon cancer.

Easily Applicable Single-incision Laparoscopic Appendectomy Using Straightforward Instrumental Alignment and Conventional Laparoscopic Instruments.

BACKGROUND: Laparoscopic appendectomy is one of the most frequently performed operations. As such, single-incision laparoscopic appendectomy (SILA) is indicated as a feasible and safe procedure comparable to conventional laparoscopic appendectomy (CLA). However, novice surgeons face challenges in performing SILA, because the role of the surgeon's hands is reversed. We introduce an easily applicable technique of SILA by adapting the alignment of CLA. METHODS: A series of 61 consecutive patients underwent SILA between January 2019 and December 2019 by 4 surgeons at Bundang CHA Medical Center. Acute appendicitis was diagnosed preoperatively by abdomino-pelvis computed tomography or ultrasonography. During the operation, a 3-channel Glove port was used with conventional laparoscopic instruments. RESULTS: The study participants consisted of 32 males and 29 females, with a mean age of 26.8 years (range, 4 to 66 y). The mean body mass index was 20.79 kg/m2 (range, 11.89 to 27.04 kg/m2). The mean operation time was 37.5±17.0 minutes. There was only 1 case of conversion with 1 additional port. Eight patients (13.1%) experienced postoperative complications defined by Dindo-Clavien-Strasberg classification: grade 1 wound complication in 7 patients and grade 2 postoperative bowel obstruction in 1 patient. The mean postoperative hospital stay was 2.5±1.3 days. CONCLUSION: Alignment of the instruments during CLA was successfully implemented into a SILA. Our new, easily applicable SILA technique will decrease the learning curve for novice surgeons in performing single-incision laparoscopic surgery.

Oncolytic vaccinia virus reinvigorates peritoneal immunity and cooperates with immune checkpoint inhibitor to suppress peritoneal carcinomatosis in colon cancer.

BACKGROUND: Peritoneal carcinomatosis (PC) is a common and devastating manifestation of colon cancer and refractory to conventional anticancer therapeutics. During the peritoneal dissemination of colon cancer, peritoneal immunity is nullified by various mechanisms of immune evasion. Here, we employed the armed oncolytic vaccinia virus mJX-594 (JX) to rejuvenate the peritoneal antitumor immune responses in the treatment of PC. METHODS: PC model of MC38 colon cancer was generated and intraperitoneally treated with JX and/or anti-programmed cell death protein 1 (PD-1) antibody. The peritoneal tumor burden, vascular leakage, and malignant ascites formation were then assessed. Tumors and peritoneal lavage cells were analyzed by flow cytometry, multiplex tissue imaging, and a NanoString assay. RESULTS: JX treatment effectively suppressed peritoneal cancer progression and malignant ascites formation. It also restored the peritoneal anticancer immunity by activating peritoneal dendritic cells (DCs) and CD8+ T cells. Moreover, JX selectively infected and killed peritoneal colon cancer cells and promoted the intratumoral infiltration of DCs and CD8+ T cells into peritoneal tumor nodules. JX reinvigorates anticancer immunity by reprogramming immune-related transcriptional signatures within the tumor microenvironment. Notably, JX cooperates with immune checkpoint inhibitors (ICIs), anti-programmed death-1, anti-programmed death-ligand 1, and anti-lymphocyte-activation gene-3 to elicit a stronger anticancer immunity that eliminates peritoneal metastases and malignant ascites of colon cancer compared with JX or ICI alone. CONCLUSIONS: Intraperitoneal immunotherapy with JX restores peritoneal anticancer immunity and potentiates immune checkpoint blockade to suppress PC and malignant ascites in colon cancer.

A Two Cascaded Network Integrating Regional-based YOLO and 3D-CNN for Cerebral Microbleeds Detection.

Cerebral Microbleeds (CMBs) are small chronic brain hemorrhages, which have been considered as diagnostic indicators for different cerebrovascular diseases including stroke, dysfunction, dementia, and cognitive impairment. In this paper, we propose a fully automated two-stage integrated deep learning approach for efficient CMBs detection, which combines a regional-based You Only Look Once (YOLO) stage for potential CMBs candidate detection and three-dimensional convolutional neural networks (3D-CNN) stage for false positives reduction. Both stages are conducted using the 3D contextual information of microbleeds from the MR susceptibility-weighted imaging (SWI) and phase images. However, we average the adjacent slices of SWI and complement the phase images independently and utilize them as a two- channel input for the regional-based YOLO method. The results in the first stage show that the proposed regional-based YOLO efficiently detected the CMBs with an overall sensitivity of 93.62% and an average number of false positives per subject (FPavg) of 52.18 throughout the five-folds cross-validation. The 3D-CNN based second stage further improved the detection performance by reducing the FPavg to 1.42. The outcomes of this work might provide useful guidelines towards applying deep learning algorithms for automatic CMBs detection.

Association between Five Common Plasminogen Activator Inhibitor-1 (PAI-1) Gene Polymorphisms and Colorectal Cancer Susceptibility.

The plasminogen activator inhibitor-1 (PAI-1) is expressed in many cancer cell types and modulates cancer growth, invasion, and angiogenesis. The present study investigated the association between five PAI-1 gene polymorphisms and colorectal cancer (CRC) risk. Five PAI-1 polymorphisms (-844G > A [rs2227631], -675 4G > 5G [rs1799889], +43G > A [rs6092], +9785G > A [rs2227694], and +11053T > G [rs7242]) were genotyped using a polymerase chain reaction-restriction fragment length polymorphism assay in 459 CRC cases and 416 controls. Increased CRC risk was more frequently associated with PAI-1 -675 5G5G polymorphism than with 4G4G (adjusted odds ratio (AOR) = 1.556; 95% confidence interval (CI): 1.012-2.391; p = 0.04). In contrast, for the PAI-1 +11053 polymorphism, we found a lower risk of CRC with the GG genotype (AOR = 0.620; 95% CI: 0.413-0.932; p = 0.02) than with the TT genotype, as well as for recessive carriers (TT + TG vs. GG, AOR = 0.662; 95% CI: 0.469-0.933; p = 0.02). The +43AA genotype was associated with lower overall survival (OS) than the +43GG genotype. Our results suggest that the PAI-1 genotype plays a role in CRC risk. This is the first study to identify an association between five PAI-1 polymorphisms and CRC incidence worldwide.

Automated detection of cerebral microbleeds in MR images: A two-stage deep learning approach.

Cerebral Microbleeds (CMBs) are small chronic brain hemorrhages, which have been considered as diagnostic indicators for different cerebrovascular diseases including stroke, dysfunction, dementia, and cognitive impairment. However, automated detection and identification of CMBs in Magnetic Resonance (MR) images is a very challenging task due to their wide distribution throughout the brain, small sizes, and the high degree of visual similarity between CMBs and CMB mimics such as calcifications, irons, and veins. In this paper, we propose a fully automated two-stage integrated deep learning approach for efficient CMBs detection, which combines a regional-based You Only Look Once (YOLO) stage for potential CMBs candidate detection and three-dimensional convolutional neural networks (3D-CNN) stage for false positives reduction. Both stages are conducted using the 3D contextual information of microbleeds from the MR susceptibility-weighted imaging (SWI) and phase images. However, we average the adjacent slices of SWI and complement the phase images independently and utilize them as a two-channel input for the regional-based YOLO method. This enables YOLO to learn more reliable and representative hierarchal features and hence achieve better detection performance. The proposed work was independently trained and evaluated using high and low in-plane resolution data, which contained 72 subjects with 188 CMBs and 107 subjects with 572 CMBs, respectively. The results in the first stage show that the proposed regional-based YOLO efficiently detected the CMBs with an overall sensitivity of 93.62% and 78.85% and an average number of false positives per subject (FPavg) of 52.18 and 155.50 throughout the five-folds cross-validation for both the high and low in-plane resolution data, respectively. These findings outperformed results by previously utilized techniques such as 3D fast radial symmetry transform, producing fewer FPavg and lower computational cost. The 3D-CNN based second stage further improved the detection performance by reducing the FPavg to 1.42 and 1.89 for the high and low in-plane resolution data, respectively. The outcomes of this work might provide useful guidelines towards applying deep learning algorithms for automatic CMBs detection.

STING signaling is a potential immunotherapeutic target in colorectal cancer.

Background: Stimulator of Interferon Genes (STING) is an innate immune sensor for cytosolic DNA. STING signaling activation is indispensable for type I interferon response and the anti-cancer immune response by CD8+ T cells. The aim of this study was to characterize intratumoral STING expression pattern and its clinical implication in colorectal cancer (CRC). Methods: We analyzed STING and CD8 expression in 225 CRC patients who underwent surgical resection. Clinicopathological variables and survival outcomes were analyzed according to STING expression levels. Mice with syngeneic MC38 tumors were also treated with a STING agonist, and tumor microenvironments were analyzed using immunofluorescent staining and flow cytometry. Results: Distinct STING expression was observed in the CRC tumor specimens. Patients with higher STING expression had early stage cancer with increased intratumoral CD8+ T cell infiltration and less frequent lymphovascular invasion. Compared to CRC patients with lower STING expression, those with higher STING expression had longer overall and recurrence-free survival. Multivariate Cox regression model also revealed higher STING expression to be an independent prognostic factor for better overall survival. When MC38 colon tumors were treated with intratumoral injection of STING agonist, tumor growth was remarkably suppressed with increased intratumoral CD8+ T cell infiltration. Moreover, T-cell activation markers, ICOS and IFN-γ, were also upregulated in CD8+ T cells, indicating enhanced effector T cell function after STING treatment. Conclusion: We confirmed the distinct STING expression in CRC and demonstrated its independent prognostic value in survival outcomes. STING could be a potential therapeutic target that enhances anti-cancer immune response in CRC.

Umbilical cord/placenta-derived mesenchymal stem cells inhibit fibrogenic activation in human intestinal myofibroblasts via inhibition of myocardin-related transcription factor A.

BACKGROUND: The lack of anti-fibrotic agents targeting intestinal fibrosis is a large unmet need in inflammatory bowel diseases, including Crohn's disease and ulcerative colitis. Previous studies have found that perinatal tissue (umbilical cord, UC; placenta, PL)-derived mesenchymal stem cells (MSCs) reduce fibrosis in several organs. However, their effects on human intestinal fibrosis are poorly understood. This study investigated the anti-fibrogenic properties and mechanisms of MSCs derived from UC and PL (UC/PL-MSCs) on human primary intestinal myofibroblasts (HIMFs). METHODS: The HIMFs were treated with TGF-ß1 and co-cultured with UC/PL-MSCs. We used a small molecular inhibitor CCG-100602 to examine whether serum response factor (SRF) and its transcriptional cofactor myocardin-related transcription factor A (MRTF-A) are involved in TGF-ß1-induced fibrogenic activation in HIMFs. The anti-fibrogenic mechanism of UC/PL-MSCs on HIMFs was analyzed by detecting the expression of RhoA, MRTF-A, and SRF in HIMFs. RESULTS: UC/PL-MSCs reduced TGF-ß1-induced procollagen1A1, fibronectin, and α-smooth muscle actin expression in HIMFs. This anti-fibrogenic effect was more apparent in the UC-MSCs. TGF-ß1 stimulation increased the expressions of RhoA, MRTF-A, and SRF in the HIMFs. TGF-ß1 induced the synthesis of procollagen1A1, fibronectin, and α-smooth muscle actin through a MRTF-A/SRF-dependent mechanism. Co-culture with the UC/PL-MSCs downregulated fibrogenesis by inhibition of RhoA, MRTF-A, and SRF expression. CONCLUSIONS: UC/PL-MSCs suppress TGF-ß1-induced fibrogenic activation in HIMFs by blocking the Rho/MRTF/SRF pathway and could be considered as a novel candidate for stem cell-based therapy of intestinal fibrosis.

Inverted Meckel's diverticulum: Two case reports and a review of the literature.

Gastrointestinal surgeons seldom encounter inverted Meckel's diverticulum in their clinical practice. We describe two cases of inverted Meckel's diverticulum. If the patient has a disease-related complication such as intussusception, as with our first case, it can be easily detected. However, if the patient has subacute or chronic symptoms, as with our second case, the diagnosis might be delayed. Regardless of the disease-related complication, intussusception of inverted Meckel's diverticulum can be easily managed with laparoscopic single-port surgery.

C-Reactive Protein Level Predicts Survival Outcomes in Rectal Cancer Patients Undergoing Total Mesorectal Excision After Preoperative Chemoradiation Therapy.

BACKGROUND: Systemic inflammatory response, as measured by C-reactive protein (CRP), is associated with prognosis in various types of human malignancies. However, to the best of our knowledge, the clinical significance of CRP in patients with locally advanced rectal cancer that undergo preoperative chemoradiation has not been investigated in detail. This retrospective study validates CRP as a potential predictive marker for survival outcomes in rectal cancer patients. METHODS: In this study, we enrolled 125 patients that received total mesorectal excision after preoperative chemoradiation for rectal cancer between January 2003 and December 2010. We investigated the association between preoperative CRP and clinicopathological characteristics and assessed the prognostic value of CRP. RESULTS: The median follow-up was 41 months. Elevated CRP showed significant correlation with high histological grade (P = 0.009) and cancer recurrence (P = 0.027). The 5-year disease-free survival and cancer-specific survival were significantly lower in the elevated CRP group (P = 0.001). Moreover, CRP was the strongest predictive factor for cancer-specific survival in multivariate analysis (P = 0.001). In the subgroup analysis, elevated CRP was a significant prognostic factor in patients with node-positive disease (P = 0.025) and was associated with poorer tumor regression (TRG4-5; P = 0.011). CONCLUSIONS: The results of our study suggest that preoperative CRP level shows prognostic significance in rectal cancer patients that have undergone chemoradiation. Therefore, preoperative CRP may help clinicians to identify patients that need additional therapy to reduce systemic failure.

Predictive Nomogram for Recurrence of Stage I Colorectal Cancer After Curative Resection.

BACKGROUND: Patients with stage I colorectal cancer (CRC) have excellent prognosis after curative surgery. However, approximately 5% to 10% of patients experience recurrence and have a poor prognosis. Because the incidence of stage I CRC is increasing with active screening programs worldwide, a more accurate and easy-to-use predictive tool for recurrence is becoming more important. This study aimed to develop a predictive nomogram for recurrence in stage I CRC. PATIENTS AND METHODS: A total of 1538 patients who underwent curative surgery for stage I CRC were enrolled. Predictive factors for recurrence were determined by multivariate Cox regression model and were used to develop a predictive nomogram. This model was internally validated, and performance was evaluated through calibration plots. RESULTS: The cumulative recurrence rate at 5 years after surgery for stage I CRC was 5.3%. In multivariate Cox analysis, independent predictors of recurrence were tumor location at rectum, pT2 stage, and presence of lymphovascular invasion. The 5-year recurrence rate was significantly different depending on the number of risk factors (0.7% for 0, 5.8% for 1, and 9.7% for ≥ 2 risk factors). On this basis, a nomogram for recurrence-free survival was developed and internally validated. The concordance index of the nomogram was 0.71, and the performance was acceptable. CONCLUSION: We developed and internally validated a nomogram that can predict postoperative recurrence in stage I CRC patients. This nomogram may be used to more accurately stratify the risk of recurrence and to perform personalized postoperative surveillance in stage I CRC patients.

Single Center Experience With Hyperthermic Intraperitoneal Chemotherapy.

PURPOSE: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been proposed for controlling peritoneal seeding metastasis in some kinds of cancers, including those of colorectal origin, but their safety and oncological benefits are subjects of debate. We present our early experience with those procedures. METHODS: Data were retrospectively collected from all patients with peritoneal carcinomatosis (PC) and pseudomyxoma peritonei (PMP) treated using CRS and HIPEC at Yonsei Cancer Center between July 2014 and July 2015. Short-term outcomes and risk factors for postoperative complications were analyzed. RESULTS: Twenty-three patients with PC (n = 18) and PMP (n = 5) underwent CRS and HIPEC. Median follow-up and age were 2 months and 54 years, respectively. The median peritoneal carcinomatosis index score was 15, and CC0-1 was achieved in 78.3% of all patients. The median operation time and bleeding loss were 590 minutes and 570 mL, respectively. Grade-IIIa/grade-IIIb complications occurred in 4.3% (n = 1)/26.1% (n = 6) of the patients within 30 days postoperatively, and no 30-day mortalities were reported. Factors related to postoperative complications with CRS and HIPEC were number of organ resection (P = 0.013), longer operation time (P < 0.001), and amount of blood loss (P = 0.003). All patients treated with cetuximab for recurred colorectal cancer had grade-III postoperative complication. CONCLUSION: Our initial experience with CRS and HIPEC presented about 30% grade-III postoperative complications. Therefore, expert surgeons need to perform those procedures with great caution in selected patients who might benefit from it.