Value of Additional Ultrasound Examination in Patients with Equivocal Computed Tomography Findings of Acute Appendicitis: Comparison with Computed Tomography Reassessment.

OBJECTIVES: The objective of this study was to find the diagnostic values of additional ultrasound (US) in patients with equivocal computed tomography (CT) findings of acute appendicitis, compared to CT reassessment. MATERIALS AND METHODS: Patients with equivocal CT findings of acute appendicitis (n = 115), who underwent the US, were included in the study. Two abdominal radiologists reviewed CT scans independently. They analyzed CT findings and made a diagnosis of acute appendicitis. The patients were categorized into positive and negative appendicitis based on the previous US reports. The diagnostic performance, interobserver agreement of CT findings, and appendicitis likelihood were calculated. RESULTS: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of US (100%, 92.1%, 79.5%, and 100%, respectively) were higher than those of CT reassessment (reviewer 1: 51.9%, 87.5%, 56.1%, and 85.6%; reviewer 2: 66.7%, 85.2%, 58.1%, and 89.3%, respectively). In the coexistent inflammation group, the sensitivity, specificity, PPV, and NPV of US (reviewer 1: 100%, 98%, 91.5%, and 100%; reviewer 2: 100%, 98%, 87.7%, and 100%, respectively) were higher than those of CT reassessment (reviewer 1: 27.3%, 94.1%, 49.9%, and 85.8%; reviewer 2: 14.3%, 98.0%, 50.5%, and 88.9%, respectively). CONCLUSION: In patients with equivocal CT findings of acute appendicitis, US shows better diagnostic performance than CT reassessment, and helps differentiate with periappendicitis.

Sonographic Findings of Malignant Appendix Tumors in Seven Cases.

We report the sonographic features of confirmed malignant appendiceal tumors in seven cases. The histologic diagnoses of these tumors were mucinous cystadenocarcinoma (n = 2), colonic type adenocarcinoma (n = 4), and signet-ring cell carcinoma (n = 1). The 2 mucinous cystadenocarcinomas showed mucocele type, which had markedly enlarged inner luminal diameters (mean, 23 mm; range, 15-31 mm) and thick, irregular walls (mean wall thickness, 5.5 mm; range, 5-6 mm). In contrast, the 5 nonmucinous carcinomas (4 adenocarcinomas and 1 signet-ring cell carcinoma) showed nonmucocele type, which had relatively small inner luminal diameters (mean ± standard deviation [SD], 6.6 ± 4.5 mm; range, 2-15 mm) and prominent wall thickening (mean wall thickness ± SD, 6.2 ± 2.3 mm; range, 3-10 mm). Of the 5 nonmucinous tumors, only one had a discernible mass, three had thick irregular walls, two had loss of the wall layer pattern, and four had submucosal hypoechogenicity. Regardless of the histologic type, five of the seven malignant appendiceal tumors showed a severe periappendiceal fat infiltration or periappendiceal abscess, suggestive of perforation. Although the sonographic findings of the malignant appendiceal tumors were nonspecific, some of the sonographic features seen in these seven cases may help radiologists consider the possibility of underlying malignant appendiceal tumors.

Initial experience of transanal total mesorectal excision with rigid or flexible transanal platforms in cadavers.

BACKGROUND: Transanal total mesorectal excision (taTME) is expected to provide benefits in the removal of the complete mesorectum for low rectal lesions, and several clinical studies regarding this technique have been reported. However, a transanal platform has not yet been standardized, and diverse transanal endoluminal surgery access devices have been used, based on individual surgeon preferences. In the present study, we performed laparoscopy-assisted taTME in cadavers and compared the characteristics of four different platforms. METHODS: Between January 2013 and April 2015, laparoscopy-assisted taTME was performed on six fresh cadavers. Flexible [SILS™ Port (Covidien), GelPOINT(®) Path Transanal Access Platform (Applied Medical)] and rigid [TEO(®) (Karl Storz Endoskope), TEM (Richard Wolf)] transanal access platforms were used on three cadavers each. RESULTS: All cadavers were male, with a mean age of 69.2 (range 57-86) years. The mean operation time was 146.3 (range 140-155) min with flexible platforms and 206.7 (range 150-260) min with rigid platforms. The mean specimen length was 23 (range 18-26) cm. Complete or nearly complete mesorectal specimens were obtained in all cases, except for one case using the TEM platform. Flexible platforms (SILS and GelPOINT) provided a short set-up time, relatively atraumatic retraction, and easy application of familiar laparoscopic instruments; a narrow operative field was its limitation. The rigid platforms (TEO and TEM) enabled larger and more stable operative fields and space than did the SILS platform, but they were limited by a narrow view, prolonged set-up time, rigidity, and long channels relative to the short distance from the anus to the rectal closure site. CONCLUSION: In this preliminary study, laparoscopy-assisted taTME was a feasible and safe procedure using both rigid and soft platforms, despite some limitations of each platform.

Interleukin 10 level in the peritoneal cavity is a prognostic marker for peritoneal recurrence of T4 colorectal cancer.

Peritoneal recurrence (PR) is a major relapse pattern of colorectal cancer (CRC). We investigated whether peritoneal immune cytokines can predict PR. Cytokine concentrations of peritoneal fluid from CRC patients were measured. Patients were grouped according to peritoneal cancer burden (PCB): no tumor cells (≤ pT3), microscopic tumor cells (pT4), or gross tumors (M1c). Cytokine concentrations were compared among the three groups and the associations of those in pT4 patients with and without postoperative PR were assessed. Of the ten cytokines assayed, IL6, IL10, and TGFB1 increased with progression of PCB. Among these, IL10 was a marker of PR in pT4 (N = 61) patients based on ROC curve (p = 0.004). The IL10 cut-off value (14 pg/mL) divided patients into groups with a low (7%, 2 of 29 patients) or high (45%, 16 of 32 patients) 5-year PR (p < 0.001). Multivariable analysis identified high IL10 levels as the independent risk factor for PR. Separation of patients into training and test sets to evaluate the performance of IL10 cut-off model validated this cytokine as a risk factor for PR. Peritoneal IL10 is a prognostic marker of PR in pT4 CRC. Further research is necessary to identify immune response of intraperitoneal CRC growth.

CT Scan Findings Can Predict the Safety of Delayed Appendectomy for Acute Appendicitis.

BACKGROUND: The relationship between duration of in-hospital waiting time and outcomes from appendectomy in patients with suspected appendicitis remains equivocal. The aim of this study was to investigate the influence of in-hospital waiting time on perforation rates and clinical outcomes in patients with suspected appendicitis who underwent appendectomy. METHODS: A retrospective review of 5956 patients who underwent appendectomy at a single institution from January 2008 to December 2016 was performed. Patients were separated into two groups based on the duration from hospital arrival to surgery: patients with an in-hospital waiting time ≤ 12 h (no-delay group; n = 5287) and those with an in-hospital waiting time > 12 h (delayed group; n = 669). One-to-one propensity score matching (n = 421 per group) was performed to compare perforation rates and postoperative outcomes between the groups. RESULTS: After propensity score matching, an in-hospital waiting time > 12 h was not associated with increased rates of perforation and significant complications, such as wound infection and abscess. However, in the matched cohorts and in the patients whose initial CT scans suggested perforated appendicitis, the delayed group had a higher risk of developing postoperative ileus (OR 9.18, 95% CI 1.16-72.74, p = 0.021; OR 2.17, 95% CI 1.03-4.59, p = 0.048, respectively) and longer postoperative length of hospital stay (87.38 vs. 79.07 h, p = 0.008; 161.61 vs. 130.87 h, p < 0.001, respectively) than the no-delay group. CONCLUSIONS: Our results indicate that a > 12-h in-hospital waiting time to surgery for appendicitis presents very little risk to the patient. However, the surgeon needs to carefully weigh the "safety" of a delay to surgery for appendicitis in patients whose initial CT scans suggested perforated appendicitis.

Predictive factors and outcomes of negative appendectomy.

BACKGROUND: The aim of this study was to assess predictive factors for negative appendectomy and to evaluate the outcomes of negative appendectomy. METHODS: A retrospective chart review of 4,878 patients who underwent appendectomy at our institution from January 2008 to December 2014 was performed. RESULTS: Younger age (≤15 years), normal white blood cell count, appendix diameter of less than 6 mm on computed tomography (CT), and CT grade less than 3 were found to be independent predictive factors for negative appendectomy. When complications were investigated according to the results of pathologic diagnosis, negative appendectomy had more complications than appendectomy for nonperforated appendicitis, and this was statistically significant. CONCLUSIONS: When CT findings are equivocal, in deciding to operate for acute appendicitis, additional ultrasonography can be performed. Furthermore, if the patient is younger than 15 years and the white blood cell count is normal, it is recommended to monitor changes in symptoms a little longer rather than operating hastily.

Appendectomy: Should it Be Performed So Quickly?

Controversy surrounds appendectomy timings and their effects on postoperative outcomes. This study evaluated the influence of hospital delays on perforation rates and complications in patients with acute appendicitis. From January 2008 to December 2013, the cases of 4148 consecutive patients who had undergone appendectomies for suspected appendicitis were reviewed. The patients' demographic data, times from symptom onset to hospital arrival (prehospital delay), times from hospital arrival to surgery (hospital delay), histological findings, and postoperative outcomes were documented. Perforation rates and complications were assessed at each time interval between symptom onset and surgery. Perforation rates and complications increased with longer prehospital delays, but no correlations were evident between hospital delays and perforation rates or between hospital delays and complications. Although delaying appendectomies for >18 hours had no statistically significant impact on perforation rates (25.3 vs 19.4%, P = 0.133), it caused more complications (8.7 vs 3.8%, P = 0.023) compared with cases delayed for 12 to 18 hours. Multivariate analyses determined that hospital delays were not associated with increased risks of perforation, complications, wound infections, or intra-abdominal abscesses. However, a >18-hour hospital delay was associated with a significantly increased risk of postoperative ileus (odds ratio = 2.94, 95% confidence interval = 1.17-7.41, P = 0.022). Hospital delays were not associated with significantly increased risks of perforation and complications. However, patients with perforated appendicitis had higher risks of developing postoperative ileus if hospital delays were >18 hours. Therefore, hospital delays of ≤18 hours are safe, but caution is required if delays are >18 hours.

Prolonged operative time in laparoscopic appendectomy: Predictive factors and outcomes.

INTRODUCTION: To our knowledge, this study is the first to identify the predictive factors and outcomes of prolonged operative time associated with laparoscopic appendectomy. We aimed to identify preoperative factors that influence operation time and to determine how operative time affects laparoscopic appendectomy outcomes. METHODS: The medical records of 3049 patients who had undergone laparoscopic appendectomy between January 2008 and December 2014 were retrospectively reviewed. Prolonged operative time was defined in the top 10% according to distribution (>90 min). A multivariate regression model was generated to assess potential predictive factors and outcomes of prolonged operative time. RESULTS: In laparoscopic appendectomy for non-perforated appendicitis, independent factors that predict a prolonged operative time as identified through multivariate analysis were elevated C-reactive protein levels, symptom duration of more than 3 days, and computed tomography findings indicating an appendiceal diameter of more than 10 mm. In laparoscopic appendectomy for perforated appendicitis, overweight, elevated C-reactive protein, symptom duration of more than 3 days, and computed tomography findings of abscess were independent predictive factors for prolonged operative time. Prolonged surgery increases the risk of complications, prolonged hospital stay, and readmission. CONCLUSIONS: Overweight, elevated C-reactive protein, symptom duration of more than 3 days, appendiceal diameter of more than 10 mm, and abscess were independent predictive factors of prolonged operative time. Furthermore, prolonged operative time was associated with adverse postoperative outcomes after laparoscopic appendectomy.

Erratum: Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study.

[This corrects the article on p. 138 in vol. 31, PMID: 26361615.].

Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study.

PURPOSE: This study prospectively investigated the effects of biofeedback therapy on objective anorectal function and subjective bowel function in patients after sphincter-saving surgery for rectal cancer. METHODS: Sixteen patients who underwent an ileostomy were randomized into two groups, one receiving conservative management with the Kegel maneuver and the other receiving active biofeedback before ileostomy closure. Among them, 12 patients (mean age, 57.5 years; range, 38 to 69 years; 6 patients in each group) completed the study. Conservative management included lifestyle modifications, Kegel exercises, and medication. Patients were evaluated at baseline and at 1, 3, 6, and 12 months after ileostomy closure by using anal manometry, modified Wexner Incontinence Scores (WISs), and fecal incontinence quality of life (FI-QoL) scores. RESULTS: Before the ileostomy closure, the groups did not differ in baseline clinical characteristics or resting manometric parameters. After 12 months of follow-up, the biofeedback group demonstrated a statistically significant improvement in the mean maximum squeezing pressure (from 146.3 to 178.9, P = 0.002). However, no beneficial effect on the WIS was noted for biofeedback compared to conservative management alone. Overall, the FI-QoL scores were increased significantly in both groups after ileostomy closure (P = 0.006), but did not differ significantly between the two groups. CONCLUSION: Although the biofeedback therapy group demonstrated a statistically significant improvement in the maximum squeezing pressure, significant improvements in the WISs and the FI-QoL scores over time were noted in both groups. The study was terminated early because no therapeutic benefit of biofeedback had been demonstrated.

Rectourethral fistula: systemic review of and experiences with various surgical treatment methods.

PURPOSE: A rectourethral fistula (RUF) is an uncommon complication resulting from surgery, radiation or trauma. Although various surgical procedures for the treatment of an RUF have been described, none has gained acceptance as the procedure of choice. The aim of this study was to review our experience with surgical management of RUF. METHODS: The outcomes of 6 male patients (mean age, 51 years) with an RUF who were operated on by a single surgeon between May 2005 and July 2012 were assessed. RESULTS: The causes of the RUF were iatrogenic in four cases (two after radiation therapy for rectal cancer, one after brachytherapy for prostate cancer, and one after surgery for a bladder stone) and traumatic in two cases. Fecal diversion was the initial treatment in five patients. In one patient, fecal diversion was performed simultaneously with definitive repair. Four patients underwent staged repair after a mean of 12 months. Rectal advancement flaps were done for simple, small fistula (n = 2), and flap interpositions (gracilis muscle flap, n = 2; omental flap, n = 1) were done for complex or recurrent fistulae. Urinary strictures and incontinence were observed in patients after gracilis muscle flap interposition, but they were resolved with simple treatments. The mean follow-up period was 28 months, and closure of the fistula was achieved in all five patients (100%) who underwent definitive repairs. The fistula persisted in one patient who refused further definitive surgery after receiving only a fecal diversion. CONCLUSION: Depending on the severity and the recurrence status of RUF, a relatively simple rectal advancement flap repair or a more complex gracilis muscle or omental flap interposition can be used to achieve closure of the fistula.

Individualized Cutoff Value of the Preoperative Carcinoembryonic Antigen Level is Necessary for Optimal Use as a Prognostic Marker.

PURPOSE: Carcinoembryonic antigen (CEA) is an important prognostic marker in colorectal cancer (CRC). However, in some stages, it does not work. We performed this study to find a way in which preoperative CEA could be used as a constant prognostic marker in harmony with the TNM staging system. METHODS: Preoperative CEA levels and recurrences in CRC were surveyed. The distribution of CEA levels and the recurrences in each TNM stage of CRC were analyzed. An optimal cutoff value for each TNM stage was calculated and tested for validity as a prognostic marker within the TNM staging system. RESULTS: The conventional cutoff value of CEA (5 ng/mL) was an independent prognostic factor on the whole. However, when evaluated in subgroups, it was not a prognostic factor in stage I or stage III of N2. A subgroup analysis according to TNM stage revealed different CEA distributions and recurrence rates corresponding to different CEA ranges. The mean CEA levels were higher in advanced stages. In addition, the recurrence rates of corresponding CEA ranges were higher in advanced stages. Optimal cutoff values from the receiver operating characteristic curves were 7.4, 5.5, and 4.5 ng/mL for TNM stage I, II, and III, respectively. Those for N0, N1, and N2 stages were 5.5, 4.8, and 3.5 ng/mL, respectively. The 5-year disease-free survivals were significantly different according to these cutoff values for each TNM and N stage. The multivariate analysis confirmed the new cutoff values to be more efficient in discriminating the prognosis in the subgroups of the TNM stages. CONCLUSION: Individualized cutoff values of the preoperative CEA level are a more practical prognostic marker following and in harmony with the TNM staging system.

Analysis of risk factors for the development of incisional and parastomal hernias in patients after colorectal surgery.

PURPOSE: The purpose of this study was to evaluate the overall rate and risk factors for the development of an incisional hernia and a parastomal hernia after colorectal surgery. METHODS: The study cohort consisted of 795 consecutive patients who underwent open colorectal surgery between 2005 and 2007 by a single surgeon. A retrospective analysis of prospectively collected data was performed. RESULTS: The overall incidence of incisional hernias was 2% (14/690). This study revealed that the cumulative incidences of incisional hernia were 1% at 12 months and 3% after 36 months. Eighty-six percent of all incisional hernias developed within 3 years after a colectomy. The overall rate of parastomal hernias in patients with a stoma was 6.7% (7/105). The incidence of parastomal hernias was significantly higher in the colostomy group than in the ileostomy group (11.9% vs. 0%; P = 0.007). Obesity, abdominal aortic aneurysm, American Society of Anesthesiologists score, serum albumin level, emergency surgery and postoperative ileus did not influence the incidence of incisional or parastomal hernias. However, the multivariate analysis revealed that female gender and wound infection were significant risk factors for the development of incisional hernias female: P = 0.009, wound infection: P = 0.041). There were no significant factors related to the development of parastomal hernias. CONCLUSION: Our results indicate that most incisional hernias develop within 3 years after a colectomy. Female gender and wound infection were risk factors for the development of an incisional hernia after colorectal surgery. In contrast, no significant factors were found to be associated with the development of a parastomal hernia.