Management of a Pelvic Abscess and Abdominal Fistula after Palliative Total Pelvic Exenteration with Intraoperative Radiotherapy in Recurrent Rectal Cancer Without NPWT: A Case Report.

ABSTRACT: A 59-year-old man with recurrent rectal cancer and type 2 diabetes mellitus underwent palliative total pelvic exenteration and intraoperative radiotherapy. After surgery, he experienced a pelvic abscess and abdominal-perineal fistula. Profuse exudate contaminated the midline abdominal incision through the abdominal-perineal fistula and delayed healing. Because of a residual tumor and the high cost, negative-pressure wound therapy was not performed. After 76 days of local treatment that involved removing necrotic tissue, controlling inflammation with an antimicrobial silver dressing, absorbing and draining exudate with a hypertonic saline dressing, promoting granulation and preventing infection with a silver alginate dressing, and promoting re-epithelialization with recombinant human epidermal growth factor gel, the abdominal wound and abdominal-perineal fistula healed successfully.

High KCNQ1OT1 expression might independently predict shorter survival of colon adenocarcinoma.

AIM: To explore the expression profile of KCNQ1OT1 and its prognostic value in colon and rectal adenocarcinoma (COAD and READ) separately. PATIENTS & METHODS: clinicopathological, genomic and survival data from The Cancer Genome Atlas and GSE39582 were obtained for a secondary analysis. RESULTS: KCNQ1OT1 was significantly up-regulated in both COAD and READ compared with adjacent normal tissues. However, its up-regulation was only independently associated with shorter overall survival (hazard ratio: 2.02; 95% CI: 1.18-3.46; p = 0.01) and recurrence-free survival (hazard ratio: 2.79, 95% CI: 1.54-5.07; p < 0.01) in COAD, but not in READ. CONCLUSION: KCNQ1OT1 up-regulation might serve as a valuable independent prognostic indicator of shorter overall survival and recurrence-free survival of COAD, but not READ.

Comparable outcomes of the consistent use versus switched use of anti- tumor necrosis factor agents in postoperative recurrent Crohn's disease following ileocolonic resection.

PURPOSE: There are no published data or guidelines on whether the same anti-tumor-necrosis factor (TNF) agents used preoperatively or different anti-TNF agents are preferable to treat postoperative recurrence. Our aim was to compare the efficacy of the consistent vs. switched anti-TNF approaches in patients with recurrent Crohn's disease (CD) after their inception ileocolonic resection (ICR). METHODS: Patients with CD receiving anti-TNF agents before the inception ICR who were treated for clinical recurrence with the same or different anti-TNF agents after surgical resection were included in the study. The outcome of the study was the need for the subsequent resection of ileocolonic anastomosis (ICA) as calculated with survival curves. RESULTS: Eighty-five patients were included in the study. The mean age of the whole cohort at the inception ICR was 35.1 ± 13.5 years. The whole cohort consisted 42 (49.4 %) in the consistent group and 43 (50.6 %) in the switched group. No significant differences were observed in demographic and clinical variables between the two groups. During the median follow-up of 1.5 (interquartile range, 0.8-3.1) years, seven (16.7 %) patients in the consistent group and eight (18.6 %) in the switched group required the repeat resection of ICA. Similar results were found in terms of the subsequent resection of ICA-free survival (hazard ratio = 1.36, 95 % confidence interval 0.49-3.76, P = 0.54) between the consistent and switched groups. CONCLUSIONS: The adherence to the same anti-TNF agent appeared to be as effective as the switching approach to different anti-TNF agent in treating postoperative recurrent CD after the inception ICR.

K-Ras mutation and prognosis of colorectal cancer: a meta-analysis.

BACKGROUND/AIMS: Colorectal cancer (CRC) is one of the most common malignant tumors worldwide. Kirsten ras (K-ras) gene is considered to participate in the progression from adenoma to carcinoma of colorectal neoplasms. The correlation between K-ras mutation and the prognosis of CRC is sill controversial. This study aimed at quantitatively summarizing the evidence for such a relationship. METHODOLOGY: The literature search was based on Pub Med. Population-based and hospital-based case-control studies concerning K-ras mutation and prognosis were eligible for analysis. RESULTS: 13 literatures were included in the meta-analysis, with 1 multicenter study and 12 case control studies. Totally, 3771 patients were enrolled in the analysis, 1202 of which had K-ras mutation. There were significant difference between the survival of patients with normal and mutated K-ras gene, but no statistic differences were found between either Condon 12 or Condon 13 mutations and prognosis. CONCLUSION: Current available evidences demonstrated the K-ras mutation is a predictive molecular mark of colorectal cancer patients' survivals, further studies are needed to investigate the race difference and the relationship between certain K-ras mutation and prognosis.

Neoadjuvant Immunotherapy With Ipilimumab Plus Nivolumab in Mismatch Repair Deficient/Microsatellite Instability-High Colorectal Cancer: A Preliminary Report of Case Series.

BACKGROUND: Although ipilimumab plus nivolumab have significantly improved the survival of metastatic colorectal cancer (CRC) with mismatch repair deficient (dMMR) /microsatellite instability-high (MSI-H), the data on neoadjuvant setting is limited. PATIENTS AND METHODS: We enrolled 11 patients with advanced dMMR/MSI-H CRC. 10 patients were locally advanced and 1 was metastatic. Ten patients were treated with 1 dose of ipilimumab (1 mg/kg) and 2 doses of nivolumab (3 mg/kg), and 1 patient was treated with 1 dose of ipilimumab (1 mg/kg) and 2 doses of nivolumab (3 mg/kg) with 2 cycles. All the patients underwent surgery after immunotherapy. The aim of the study was to evaluate the safety and short-term efficacy of this strategy. RESULTS: Pathologic responses were observed in 11/11 (100%) dMMR/MSI-H tumors, with 9/11 (81.8%) achieving complete responses. Among these 9 cases with complete responses, 1 achieved a radiological noncomplete response after treatment with 1 dose of ipilimumab (1 mg/kg) and 2 doses of nivolumab (3 mg/kg), so another cycle of treatment with 1 dose of ipilimumab (1 mg/kg) and 2 doses of nivolumab (3 mg/kg) was administered, followed by surgery. The postoperative pathological evaluation was a complete response. Seven patients (63.6%) developed grade I/II adverse events. No patients developed grade III/IV adverse events or postoperative complications. CONCLUSION: Neoadjuvant immunotherapy with ipilimumab plus nivolumab induced tumor regression with a major clinical and pathological response in advanced dMMR/MSI-H CRC. Notably, patients do not achieve a complete response to neoadjuvant immunotherapy, additional neoadjuvant immunotherapy may offer benefits. Further research is needed to assess the long-term efficacy of this strategy.

A case of unexpected peripherally inserted central catheter removal from a colorectal cancer patient with cetuximab-induced skin toxicity and contact dermatitis at the peripherally inserted central catheter insertion site: Should we recommend the patient to choose subcutaneous port preferentially?

INTRODUCTION: Obtaining central venous access is one of the most commonly performed procedures in cancer patients. However, there are very limited data to guide clinicians when selecting a device for metastatic colorectal cancer patients who received cetuximab. CASE DESCRIPTION: A 54-year-old male patient with metastatic colorectal cancer treated with cetuximab plus FOLFIRI used peripherally inserted central catheter as intravenous pathway. After eight cycles, the patient suffered cetuximab-induced grade 2 skin toxicity and grade 3 contact dermatitis at the peripherally inserted central catheter insertion site. Finally, he removed the peripherally inserted central catheter and accepted subcutaneous port instead for 2 years without implantation cutaneous complication. CONCLUSIONS: We suggest that metastatic colorectal cancer patients treated with cetuximab should be recommended to choose subcutaneous port preferentially to avoid potential risk of unexpected peripherally inserted central catheter removal due to cetuximab-induced skin toxicity or contact dermatitis. Further clinical practices and researches are needed for more profound evidences for better practical suggestions.

Postoperative excessive gain in visceral adipose tissue as well as body mass index are associated with adverse outcomes of an ileal pouch.

BACKGROUND: There are no published studies on the impact of visceral adipose tissue (VAT) change on outcomes of restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The aim of this historic cohort study was to evaluate the impact of excessive VAT gain on the outcomes of inflammatory bowel disease (IBD) patients with IPAA. METHODS: We evaluated all eligible patients with at least two sequential CT scans after pouch construction from our prospectively maintained Pouchitis Registry between 2002 and 2014. The visceral fat area (VFA) was measured on CT images. The study group comprised patients with a significant VAT gain (> 15%), and the control group was those without. The adverse outcomes of the pouch were defined as the new development of chronic pouch inflammation (chronic pouchitis, chronic cuffitis or Crohn's disease of the pouch), anastomotic sinus and the combination of above (the composite adverse outcome) or pouch failure, after the inception CT. RESULTS: Of 1564 patients in the Registry, 59 (3.8%) with at least 2 CT scans after pouch surgery were included. Twenty-nine patients (49.2%) were in the study group, and 30 (50.8%) were in the control group. The median duration from the inception to the latest CT was 552 (range: 31-2598) days for the entire cohort. We compared the frequency of new chronic pouch inflammation (13.8% vs 3.3%, P = 0.195), new pouch sinus (10.3% vs 0%, P = 0.112), composite adverse pouch outcome (24.1% vs 3.3%, P = 0.026) or pouch failure (10.3% vs 6.7%, P = 0.671) between the two groups. Kaplan-Meier plot for time-to-pouch failure between the pouch patients with or without excessive body mass index (BMI) gain (> 10%) showed statistical difference (P = 0.011). Limited stepwise multivariate analysis showed that excessive VAT gain (odds ratio = 12.608, 95% confidence interval: 1.190-133.538, P = 0.035) was an independent risk factor for the adverse pouch comes. CONCLUSIONS: In this cohort of ileal pouch patients, excessive VAT gain as well as gain in BMI after pouch construction was found to be associated with poor long-term outcomes.

Perioperative Blood Transfusion and Postoperative Outcome in Patients with Crohn's Disease Undergoing Primary Ileocolonic Resection in the "Biological Era".

BACKGROUND: Perioperative blood transfusion has been shown to be associated with inflammatory response and immunosuppression. Patients receiving blood transfusion may have an increased risk for developing postoperative morbidities. The impact of blood transfusion on the postoperative recurrence of Crohn's disease (CD) has been controversial. The aim of this study was to assess the effect of blood transfusion on postoperative outcomes in CD in the current biological era. METHODS: This historical cohort study involved data collection and analysis of CD patients who underwent the index ileocolonic resection in our institution between 2000 and 2012. Postoperative complications were compared between the transfused and nontransfused patients. The effects of perioperative blood transfusion on postoperative complications and disease recurrence were analyzed with both univariate and multivariate analyses. RESULTS: A total of 318 patients were included in the study, and 52 of them (16.5 %) received perioperative blood transfusion. Blood transfusion was found to be associated with an increased risk of postoperative infectious and noninfectious complications both in univariate (P < 0.001 for each) and multivariable analyses (infectious complications: odds ratio [OR] = 8.73, 95 % confidence interval [CI] 2.85-26.78, P < 0.001; noninfectious complications: OR = 3.64, 95 % CI 1.30-10.18; P = 0.014). In addition, the Cox regression model indicated that blood transfusion was associated with both surgical (hazard ratio [HR] = 3.43, 95 % CI 1.92-6.13; P < 0.001) and endoscopic (HR = 2.08, 95 % CI 1.38-3.14; P < 0.001) CD recurrence following the index surgery. CONCLUSION: Adverse outcomes after perioperative blood transfusion for the primary ileocolonic resection for CD resemble findings in surgery for other diseases. The presumed immunosuppressive effect of blood transfusion did not confer any protective effect on disease recurrence.

Presence of Granulomas in Mesenteric Lymph Nodes Is Associated with Postoperative Recurrence in Crohn's Disease.

BACKGROUND: The association between the presence of granulomas in the mesenteric lymph node (MLN) and postoperative recurrent Crohn's disease (CD) is unknown. Our aim was to assess the predictive value of the presence of granulomas in MLN as well as in bowel wall for postoperative recurrence of CD. METHODS: Patients with CD who underwent the index ileocolonic resection between 2004 and 2012 were included. Surgical pathology reports were reviewed for the presence and location of granulomas. The status of MLN granulomas was confirmed by re-review of surgical pathology specimen from randomly sampled patients by an expert pathologist. Both univariable and multivariable analyses were performed to assess the risk factors associated with postoperative recurrent CD. RESULTS: A total of 194 patients were included. Granulomas were detected in the MLN in 23 patients (11.9%), and in the intestinal wall in 57 (29.4%). On Kaplan-Meier curve, the presence of granulomas in MLN was found to be a risk factor for postoperative endoscopic recurrence (P = 0.015) as well as surgical recurrence (P = 0.035). In contrast, granulomas in the bowel wall, which was not found to be associated with neither endoscopic recurrence (P = 0.94) or surgical recurrence (P = 0.56). On Cox proportional hazards regression analysis, the presence of MLN granulomas was independently associated with an increased risk for both postoperative endoscopic recurrence (hazard ratio [HR] = 1.91; 95% confidence interval [CI], 1.06-3.45; P = 0.031) and surgical recurrence (HR = 3.43; 95% CI, 1.18-9.99; P = 0.023). CONCLUSIONS: The presence of granulomas in MLN but not in intestine per se was found to be an independent risk factor for recurrence in CD patients undergoing ileocolonic resection.

Long-term survival outcomes of laparoscopic versus open gastrectomy for gastric cancer: a systematic review and meta-analysis.

Many meta-analyses have confirmed the technical feasibility and favorable short-term surgical outcomes of laparoscopic gastrectomy (LG) for gastric cancer patients, but the long-term survival outcome of LG remains controversial compared with open gastrectomy (OG). This study aimed to compare the 5-year overall survival (OS), recurrence, and gastric cancer-related death of LG with OG among gastric cancer patients. PubMed was searched to February 2014. The resectable gastric cancer patients who underwent curative LG or OG were eligible. The studies that compared 5-year OS, recurrence, or gastric cancer-related death in the LG and OG groups were included. A meta-analysis, meta-regression, sensitivity analysis, subgroup analysis, and stage-specific analysis were performed to estimate the survival outcome between the two groups and identify the potential confounders. Quality assessment was based on a tailored comparability scoring system. Twenty-three studies with 7336 patients were included. The score of comparability between two groups and the extent of lymphadenectomy were two independent confounders. Based on the well-balanced studies, the 5-year OS (OR = 1.07, 95% CI 0.90-1.28, P = 0.45), recurrence (OR = 0.83, 95% CI 0.68-1.02, P = 0.08), and gastric cancer-related death (OR = 0.86, 95% CI 0.65-1.13, P = 0.28) rates were comparable in LG and OG. Several subsets such as the publication year, study region, sample size, gastrectomy pattern, extent of lymphadenectomy, number of nodes harvested, and proportion of T1-2 or N0-1 did not influence the estimates, if they were well balanced. Particularly, the stage-specific estimates obtained comparable results between the two groups. Randomized controlled trials comparing LG with OG remain sparse to assess their long-term survival outcomes. The major contributions of this systematic review compared with other meta-analyses are a comprehensive collection of available long-term survival outcomes within a much larger number of observations and a more precise consideration of confounders. Current knowledge indicates that the long-term survival outcome of laparoscopic gastric cancer surgery is comparable to that of open surgery among early or advanced stage gastric cancer patients, and LG is acceptable with regard to oncologic safety.

Can K-ras gene mutation be utilized as prognostic biomarker for colorectal cancer patients receiving chemotherapy? A meta-analysis and systematic review.

INTRODUCTION: K-ras gene mutations were common in colorectal patients, but their relationship with prognosis was unclear. OBJECTIVE: Verify prognostic differences between patient with and without mutant K-ras genes by reviewing the published evidence. METHOD: Systematic reviews and data bases were searched for cohort/case-control studies of prognosis of colorectal cancer patients with detected K-ras mutations versus those without mutant K-ras genes, both of whom received chemotherapy. Number of patients, regimens of chemotherapy, and short-term or long-term survival rate (disease-free or overall) were extracted. Quality of studies was also evaluated. PRINCIPAL FINDINGS: 7 studies of comparisons with a control group were identified. No association between K-ras gene status with neither short-term disease free-survival (OR=1.01, 95% CI, 0.73-1.38, P=0.97) nor overall survival (OR=1.06, 95% CI, 0.82-1.36, P=0.66) in CRC patients who received chemotherapy was indicated. Comparison of long-term survival between two groups also indicated no significant difference after heterogeneity was eliminated (OR=1.09, 95% CI, 0.85-1.40, P=0.49). CONCLUSIONS: K-ras gene mutations may not be a prognostic index for colorectal cancer patients who received chemotherapy.

A-kinase anchoring proteins 10 expression in relation to 2073A/G polymorphism and tumor progression in patients with colorectal cancer.

The cAMP/PKA signalling events regulated by A-kinase anchoring proteins 10 (AKAP10) is involved in tumorigenesis. Previous study showed that AKAP10 polymorphism (2073 A/G, I646V) was associated with colorectal cancer risk. However, there was no literature reporting the role of AKAP10 in the pathogenesis of colorectal cancer. The aim of the study was to investigate the clinicopathologic significance of A-kinase anchoring proteins 10 (AKAP 10) expression and the relationship with its polymorphism in colorectal cancer. The expression of AKAP10 was determined by immunohistochemical staining (IHC) and western blot assay on colorectal cancer (n = 176), adenoma (n = 87) and distant normal mucosa (n = 72). 176 patients with colorectal cancer were genotyped for AKAP10 2073A/G polymorphism by TaqMan RT-PCR. We found that the positive expression rate of AKAP10 in colorectal cancer (59 %) was significantly higher than those in adenoma (39 %) and distant normal mucosa (42 %) (P = 0.004). There was no significant difference between adenoma and distant normal mucosa (P = 0.741). Positive AKAP10 staining was correlated with deeper tumor invasion (P < 0.001), lymph nodes metastasis (P = 0.022), advanced tumor stage (P < 0.001) and poorly differentiated degree (P = 0.003). Compared with AA genotype (52 %), positive expression of AKAP10 was significantly increased in colorectal cancer patients with the variant (AG+GG) genotypes (68 %, P = 0.033). It was concluded that AKAP10 may play an important role in the development and progression of colorectal cancer.

Laparoendoscopic single-site versus traditional laparoscopic surgery in patients with cholecystectomy: a meta-analysis.

OBJECTIVES: To evaluate the primary outcomes of traditional laparoscopic cholecystectomy (TLC) compared with laparoendoscopic single-site cholecystectomy (LESSC). SUBJECTS AND METHODS: Randomized controlled trials (RCTs) comparing TLC with LESSC were included by a systematic literature research. The inclusion and extraction of the data were completed by two authors independently. Meta-analysis was performed using Review Manager version 5.1.4 software. The clinical outcomes were evaluated by odds ratio (OR) and standard mean difference (SMD) according to the different types of data. Sensitivity and heterogeneity analyses were used to account for rationality of pooling data and sources of heterogeneity. RESULTS: Seven RCTs involving 611 patients met the predefined inclusion criteria. The cosmetic score of the LESSC group was significantly higher at 1 week (SMD = 0.48; 95% confidence intervals [CI] 0.24, 0.73; P = .0001), 2 weeks (SMD = 0.87; 95% CI 0.61, 1.13; P < .00001), and 1 month (SMD = 0.88; 95% CI 0.62, 1.44; P<.00001) postoperatively. However, LESSC showed a lesser physical quality of life (PQOL) score at 3 days (SMD = -0.28; 95% CI -0.52, -0.44; P = .02), 1 week (SMD = -0.31; 95% CI -0.55, 0.06; P = .01), and 2 weeks (SMD = -0.30; 95% CI -0.55, -0.05; P = .02) postoperatively. There was no significant difference between the two groups in operating time, perioperative complication, intraoperative blood loss, postoperative hospital stay, Visual Analog Scale pain score, and PQOL on 1 day, 5 days, and 1 month postoperatively. CONCLUSION: LESSC is associated with a higher cosmetic score and a lesser short-term PQOL score compared with TLC.

Duodenal intussusception due to a giant neuroendocrine carcinoma in a patient with Peutz-Jeghers syndrome: case report and systematic review.

Duodenal intussusception is a rare entity. To date, only a few cases have been reported in the literature. In this report, a case of duodenal intussusception due to an unusual tumor was presented and the clinical features of this entity were discussed. A 42-year-old man with Peutz-Jeghers syndrome presented with epigastric pain, vomiting, and severe anemia. Computed tomography scan revealed synchronous duodenojejunal and jejunojejunal intussusceptions. An emergency laparotomy revealed a polypoid mass originating from the lateral wall of the descending duodenum with intussusception of the distal duodenum. Histological examination demonstrated a poorly differentiated neuroendocrine carcinoma with muscularis infiltration, vascular invasion, and a Ki-67 index of 20%. A comprehensive literature search revealed 44 English reports that provided adequate descriptions of an additional 47 such cases. Clinical presentation was usually chronic and nonspecific. Diagnostic modalities included ultrasonography, upper gastrointestinal series, computed tomography, and endoscopy. Five patients were due to a non-neoplastic lesion; however, the other 43 patients were secondary to a tumor, benign in 35 cases and malignant in eight cases. Only one patient was treated by endoscopic polypectomy, whereas the remaining underwent open surgeries. Duodenal intussusception is a challenging condition due to its rarity and nonspecific presentation. It should be considered in the differential diagnosis of gastric outlet obstruction, upper gastrointestinal bleeding, pancreatitis, and obstructive jaundice.

Chaiqin Chengqi Decoction decreases IL-6 levels in patients with acute pancreatitis.

OBJECTIVE: In this paper, we investigated the effect of the traditional Chinese medicine Chaiqin Chengqi Decoction (CQCQD) on serum cytokines in acute pancreatitis (AP) patients. METHODS: Peripheral blood samples from 107 AP patients were collected within the first 48 h of AP onset and on the 10th day of CQCQD treatment. Control samples were collected from 20 healthy individuals. Serum proinflammatory cytokines tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6), and anti-inflammatory cytokines IL-10 and IL-1ß receptor antagonist (IL-1ra) were examined using the Luminex 100 system. RESULTS: Within the first 48 h of AP onset, IL-6 and IL-1ra levels in severe AP (SAP) patients were significantly higher than those in mild AP (MAP) patients, but IL-10 levels in SAP patients were significantly lower than those in MAP patients. Proinflammatory cytokine IL-6 was significantly decreased after CQCQD treatment (P<0.05), especially in SAP patients (n=25 of 36, P<0.05). The hospitalization time of SAP patients was shortened significantly when serum IL-6 decreased after CQCQD treatment (P<0.05). CONCLUSIONS: CQCQD decreased proinflammatory cytokine IL-6 levels in AP patients.