α-Synuclein in the colon and premotor markers of Parkinson disease in neurologically normal subjects.

Extranigral non-motor signs precede the first motor manifestations of Parkinson's disease by many years in some patients. The presence of α-synuclein deposition within colon tissues in patients with Parkinson's disease can aid in identifying early neuropathological changes prior to disease onset. In the present study, we evaluated the roles of non-motor symptoms and signs and imaging biomarkers of nigral neuronal changes and α-synuclein accumulation in the colon. Twelve subjects undergoing colectomy for primary colon cancer were recruited for this study. Immunohistochemical staining for α-synuclein in normal and phosphorylated forms was performed in normally appearing colonic tissue. We evaluated 16 candidate premotor risk factors in this study cohort. Among them, ten subjects showed positive immunostaining with normal- and phosphorylated-α-synuclein. An accumulation of premotor markers in each subject was accompanied with positive normal- and phosphorylated-α-synuclein immunostaining, ranging from 2 to 7 markers per subject, whereas the absence of Lewy bodies in the colon was associated with relative low numbers of premotor signs. A principal component analysis and a cluster analysis of these premotor markers suggest that urinary symptoms were commonly clustered with deposition of peripheral phosphorylated-α-synuclein. Among other premotor marker, color vision abnormalities were related to non-smoking. This mathematical approach confirmed the clustering of premotor markers in preclinical stage of Parkinson's disease. This is the first report showing that α-synuclein in the colon and other premotor markers are related to each other in neurologically normal subjects.

Comparison of Long-Term Outcomes Between Emergency Surgery and Bridge to Surgery for Malignant Obstruction in Right-Sided Colon Cancer: A Multicenter Retrospective Study.

BACKGROUND: Malignant obstruction in right-sided colon (MORC) has traditionally been treated by emergency resection with primary anastomosis. The aim of this study was to evaluate short-term postoperative and long-term oncologic outcomes according to the surgical approach adopted for MORC. METHODS: A total of 1785 patients who underwent curative surgery for stage II or III colon cancer in seven hospitals were reviewed retrospectively. Seventy-four of 1785 patients had MORC. We compared the postoperative outcome and long-term oncologic outcome between the emergency surgery (ES) group (49 patients) and the bridge to surgery (BS) group (25 patients) for 74 patients with MORC. RESULTS: There were no differences in the length of the distal and proximal resection margin (p = 0.820 and p = 0.620) or the number of metastatic lymph nodes (p = 0.221). There were no differences in flatus passage (p = 0.242), start of diet (p = 0.336), hospital stay (p = 0.444), or postoperative morbidity (p = 0.762). The 5-year overall survival rates were 73.2 % in the ES group and 90.7 % in the BS group (p = 0.172). Moreover, the 5-year disease-free survival rates were 71.9 % in the ES group and 76.2 % in the BS group (p = 0.929). CONCLUSIONS: On the basis of the above results, the postoperative course of the ES group was similar to that of the BS group. In addition, the long-term oncologic outcome of the BS group was similar or slightly better than that of the ES group. BS after colonic stent may be an alternative option for MORC.

Stromal expression of miR-21 in T3-4a colorectal cancer is an independent predictor of early tumor relapse.

BACKGROUND: MicroRNA-21 (miR-21) is an oncogenic microRNA that regulates the expression of multiple cancer-related target genes. miR-21 has been associated with progression of some types of cancer. Metastasis-associated protein1 expression and loss of E-cadherin expression are correlated with cancer progression and metastasis in many cancer types. In advanced colorectal cancer, the clinical significance of miR-21 expression remains unclear. We aimed to investigate the impact of miR-21 expression in advanced colorectal cancer and its correlation with target proteins associated with colorectal cancer progression. METHODS: From 2004 to 2007, 277 consecutive patients with T3-4a colorectal cancer treated with R0 surgical resection were included. Patients with neoadjuvant therapy and distant metastasis at presentation were excluded. The expression of miR-21 was investigated by in situ hybridization. Immunohistochemistry was used to detect E-cadherin and metastasis-associated protein1 expression. RESULTS: High stromal expression of miR-21 was found in 76 of 277 (27.4%) colorectal cancer samples and was correlated with low E-cadherin expression (P = 0.019) and high metastasis-associated protein1 expression (P = 0.004). T3-4a colorectal cancer patients with high miR-21 expression had significantly shorter recurrence-free survival than those with low miR-21 expression. When analyzing colon and rectal cancer separately, high expression of miR-21 was an independent prognostic factor of unfavorable recurrence-free survival in T3-4a colon cancer patients (P = 0.038, HR = 2.45; 95% CI = 1.05-5.72) but not in T3-4a rectal cancer patients. In a sub-classification analysis, high miR-21 expression was associated with shorter recurrence-free survival in the stage II cancer (P = 0.001) but not in the stage III subgroup (P = 0.267). CONCLUSIONS: Stromal miR-21 expression is related to the expression of E-cadherin and metastasis-associated protein1 in colorectal cancer. Stage II colorectal cancer patients with high levels of miR-21 are at higher risk for tumor recurrence and should be considered for more intensive treatment.

Syndecan-1 expression is associated with tumor size and EGFR expression in colorectal carcinoma: a clinicopathological study of 230 cases.

BACKGROUND: Syndecan-1 (SDC1) is reported to modulate several key processes of tumorigenesis and has variable expression in many cancers. To date, the cause of altered expression has not been elucidated. In this study, we compared SDC1 expression with various clinicopathological parameters and molecular markers to evaluate its clinical significance in colorectal carcinoma. METHODS: We screened for SDC1 expression using immunohistochemistry in 230 surgical specimens of primary colorectal carcinoma from patients consecutively treated between 2008 and 2011 at Seoul St. Mary's Hospital, The Catholic University of Korea. The relationship between SDC1 expression and various clinicopathological parameters and molecular markers was analyzed. RESULTS: The tumors were principally located in the left colon (71.3%) and rectum (33.5%). There were 216 (93.9%) adenocarcinomas, 10 (4.3%) mucinous adenocarcinomas, and 4 other tumors. Most of the carcinomas were pT3 (68.3%) and pT4 (22.2%). There was regional lymph node metastasis in 140 patients. SDC1 expression was identified in the cancer cells of 212 (96.8%) colon cancer cases. Of the SDC1-positive cases, 131 showed predominantly membranous immunopositivity, and 81 showed a predominantly cytoplasmic staining pattern. Mixed membranous and cytoplasmic staining was observed in 154 cases. In 93 cases, stromal SDC1 reactivity was noted. Epithelial SDC1 immunopositivity was significantly associated with tumor size (p=0.016) and epidermal growth factor receptor expression (p=0.006). However, it was not significantly correlated with lymph node metastasis, distant metastasis, lymphatic or vascular invasion, or KRAS mutation. In addition, stromal SDC1 immunopositivity was significantly associated with the male sex (p=0.018). CONCLUSIONS: The expression profile of SDC1 may be of clinical value in colorectal cancer and may help in identifying aggressive forms of colorectal carcinoma. Further studies are needed in order to better understand the role of SDC1 in the progression and invasiveness of colorectal carcinoma.

Prognostic utility of adequate nutritional support in critically ill surgical patients as revealed by the modified nutrition risk in critically ill score.

BACKGROUND: The modified Nutrition Risk in the Critically Ill (mNUTRIC) score was developed to identify patients most likely to benefit from nutritional therapies and to stratify or select subjects for clinical trials. However, the validity of the score and the association between that score and the prognosis of patients in surgical intensive care units (SICUs) remain unclear. This study explored whether the score was a useful prognostic indicator for SICU patients, and whether survival could be improved via nutritional interventions based on mNUTRIC status. METHODS: This retrospective observational study enrolled 123 patients admitted to our SICU for critical care from January 2018 to December 2019. Among these, mNUTRIC medical data were available for 116. In-hospital mortality rates were compared based on both mNUTRIC status and the adequacy of nutritional supplementation. RESULTS: mNUTRIC-high status (5 points or more) was apparent in 16 â€‹% of all critically ill surgical patients. In-hospital mortality was significantly higher in those with mNUTRIC-high scores (42.1 â€‹% vs. 15.5 â€‹%, P â€‹= â€‹0.023). Both groups exhibited less mortality when nutrition was adequate vs. inadequate (5.0 â€‹% vs. 40.9 â€‹% and 26.7 â€‹% vs. 100 â€‹%, respectively). In multivariate analysis, mNUTRIC-high scores and inadequate nutritional support were significant risk factors for in-hospital mortality (hazard ratios 7.336 and 13.636, P â€‹= â€‹0.027 and 0.002, respectively). CONCLUSION: In critically ill surgical patients, those identified as nutritionally high-risk using the mNUTRIC classification had poor in-hospital survival. Moreover, patients who received adequate nutritional support had a better prognosis than those who did not.

Plastic Wound Protector vs Surgical Gauze for Surgical Site Infection Reduction in Open GI Surgery: A Randomized Clinical Trial.

Importance: Surgical site infections (SSIs) are prevalent hospital-acquired infections with significant patient impacts and global health care burdens. The World Health Organization recommends using wound protector devices in abdominal surgery as a preventive measure to lower the risk of SSIs despite limited evidence. Objective: To examine the efficacy of a dual-ring, plastic wound protector in lowering the SSI rate in open gastrointestinal (GI) surgery irrespective of intra-abdominal contamination levels. Design, Setting, and Participants: This multicenter, patient-blinded, parallel-arm randomized clinical trial was conducted from August 2017 to October 2022 at 13 hospitals in an academic setting. Patients undergoing open abdominal bowel surgery (eg, for bowel perforation) were eligible for inclusion. Intervention: Patients were randomized 1:1 to a dual-ring, plastic wound protector to protect the incision site of the abdominal wall (experimental group) or a conventional surgical gauze (control group). Main Outcomes and Measures: The primary end point was the rate of SSI within 30 days of open GI surgery. Results: A total of 458 patients were randomized; after 1 was excluded from the control group, 457 were included in the intention-to-treat analysis (mean [SD] age, 58.4 [12.1] years; 256 [56.0%] male; 341 [74.6%] with a clean-contaminated wound): 229 in the wound protector group and 228 in the surgical gauze group. The overall SSI rate in the intention-to-treat analysis was 15.7% (72 of 458 patients). The SSI rate for the wound protector was 10.9% (25 of 229 patients) compared with 20.5% (47 of 229 patients) with surgical gauze. The wound protector significantly reduced the risk of SSI, with a relative risk reduction (RRR) of 46.81% (95% CI, 16.64%-66.06%). The wound protector significantly decreased the SSI rate for clean-contaminated wounds (RRR, 43.75%; 95% CI, 3.75%-67.13%), particularly for superficial SSIs (RRR, 42.50%; 95% CI, 7.16%-64.39%). Length of hospital stay was similar in both groups (mean [SD], 15.2 [10.5] vs 15.3 [10.2] days), as were the overall postoperative complication rates (20.1% vs 18.8%). Conclusions and Relevance: This randomized clinical trial found a significant reduction in SSI rates when a plastic wound protector was used during open GI surgery compared with surgical gaze, supporting the World Health Organization recommendation for use of wound protector devices in abdominal surgery. Trial Registration: ClinicalTrials.gov Identifier: NCT03170843.

Initial experience of a surgical fellow in laparoscopic colorectal cancer surgery under training protocol and supervision: comparison of short-term results for 70 early cases (under supervision) and 73 late cases (without supervision).

PURPOSE: Laparoscopic colorectal surgery is a technically challenging procedure for beginners, such as surgical fellows. The purpose of this study was to assess the safety, feasibility, and short-term surgical outcomes of laparoscopic colorectal cancer surgery by a single surgical fellow. METHODS: The study analyzed the data from 143 consecutive patients who underwent laparoscopic colorectal resection by a single surgical fellow between August 2009 and October 2010. The patients were divided into two groups: the early group-the first 70 patients (under supervision of experienced surgeon), and the late group-the last 73 patients (without supervision). The short-term surgical results were compared between two groups. RESULTS: The operations were 24 right colon resections, two transverse colectomies, six left colectomies, 36 anterior resections, 57 low anterior resections, 12 intersphincteric resections, two abdominoperineal resections, three Hartmann's operations, and 1 total colectomy. The mean operating time, mean amounts of blood loss, and conversion rate were similar between the two groups. The morbidity rate, anastomosis leak rate, and mortality rate within 30 days of surgery did not differ significantly. The mean number of lymph nodes was larger in the late group (23.8 vs. 31.7, P = 0.017). In terms of low anterior resection, the mean number of endo-linear staplers used was smaller in the late group (2.46 ± 0.81 vs. 1.97 ± 0.83, P = 0.028). The anastomosis leakage rate in rectal cancer surgery was not significantly different between the two groups. CONCLUSIONS: This study demonstrates that laparoscopic colorectal resections can be independently performed safely after a period of supervision and training by an experienced surgeon.

Prognostic significance of S100A4 mRNA and protein expression in colorectal cancer.

BACKGROUND AND OBJECTIVES: The calcium-binding protein S100A4 promotes tumor progression and metastasis. We investigated the expression of S100A4 in colorectal cancer and its clinicopathologic significance in colorectal cancer. METHODS: A total of 526 colorectal cancer patients were examined for S100A4 protein by immunohistochemistry using tissue microarrays. S100A4 mRNA was subsequently investigated by in situ hybridization. RESULTS: S100A4 protein was expressed in various cell types including tumor cells, but S100A4 mRNA was only expressed in tumor cells. Cytoplasmic expression of S100A4 protein was seen in 127 (24.1%) of 526 tumors and significantly correlated with older age, depth of invasion, lymph node metastasis, and worse overall survival. Nuclear expression of S100A4 protein was observed in 136 (25.9%) tumors and significantly related to the depth of invasion, perineural invasion, and worse overall survival. However, there was no correlation between S100A4 mRNA expression and clinicopathological parameters. Upon multivariate analysis nuclear expression of S100A4 protein was found to be an independent prognostic factor of poor survival. CONCLUSIONS: Expression of S100A4 protein in colorectal cancers may indicate tumor progression and lymph node metastasis and can be useful for prediction of overall survival of patients with colorectal cancers.

Concurrent ascending colon adenocarcinoma and ileocecal tuberculosis: A case report.

RATIONALE: Few cases have been reported of the coexistence of tuberculosis and adenocarcinoma of the large bowel. We report a rare case of concurrent ascending colon adenocarcinoma and ileocecal tuberculosis, which were nearly indistinguishable from one another. PATIENT CONCERNS: A 59-year-old man visited our clinic with dizziness and anorexia. DIAGNOSIS: Computed tomography revealed a mass in the ascending colon with ill-defined nodules in the liver. A colon biopsy showed adenocarcinoma with multinucleated giant cells. The liver nodules were confirmed to be metastatic adenocarcinomas. INTERVENTIONS: Ant tuberculosis medications were administered prior to surgery. Two weeks later, a laparoscopic right hemicolectomy and radiofrequency ablation of the liver were performed. OUTCOMES: The final pathology confirmed adenocarcinoma with chronic granulomatous inflammation and giant cells. LESSONS: In this patient, the cancer was in an advanced stage and had no history of tuberculosis infection. Thus, in this case, the malignancy seemed to create the proper environment for either reactivation of a latent tuberculosis infection or, less likely, for the acquisition of a primary mycobacterial infection. In conclusion, clinicians should be aware of the possibility of concurrent colon adenocarcinoma and intestinal tuberculosis.

Clinical features of abdominal actinomycosis: a 15-year experience of a single institute.

This study was designed to evaluate the clinical features of abdominal actinomycosis and to assess its therapeutic outcome. We reviewed patients with abdominal actinomycosis in Seoul St. Mary hospital, between January 1994 and January 2010. Twenty-three patients (5 male and 18 female, mean age, 47.8 yr; range, 6-75 yr), with abdominal actinomycosis were included. Emergency surgery was performed in 50% due to symptoms of peritonitis. The common presentation on preoperative computerized tomography was a mass with abscess, mimicking malignancy. The mean tumor size was 7.0 cm (range, 2.5-10.5). In all patients, actinomycotic masses were surgically removed. Mean duration of hospital stay was 17.8 days (range, 5-49). Long term oral antibiotic treatment (mean 4.2 months; range, 0.5-7.0 months) were administered to all patients. All patients were free of recurrence after a median follow up of 30.0 months (mean 35.5 ± 14.8 months, range, 10.0-70.0 months); recurrence was not seen in any patient. In conclusion, abdominal actinomycosis should be included as a differential diagnosis when an unusual abdominal mass or abscess presents on abdominal CT. Assertive removal of necrotic tissue with surgical drainage and long term antibiotic treatment provide a good prognosis in patients with actinomycosis.

Short- and long-term outcomes of laparoscopic segmental left colectomy for splenic flexure colon cancer: comparison with propensity score matching.

PURPOSE: Splenic flexure colon cancer (SFCC) is a rare disease that accounts for 2%-8% of colorectal cancers, and the extent of surgery and resection is still debatable. There have also been few studies on the safety and feasibility of laparoscopic surgery for SFCC. The purpose of this study is to evaluate outcomes and prognoses of surgery for SFCC. METHODS: We included patients with stage 1 to 3 who had undergone laparoscopic surgery for distal transverse-to-sigmoid colon cancer at 2 hospitals from March 2004 to December 2016 and collected data by retrospective design. We defined SFCC as being cancer between distal transverse and proximal descending colon. The short- and long-term outcomes of the anterior resection (AR) group (those patients who had undergone laparoscopic AR for mid and distal descending to sigmoid colon cancer) and the left colon resection (LR) group (those who had undergone laparoscopic segmental left colectomy for SFCC) were compared using propensity score matching. RESULTS: The median follow-up period was 60 months. The numbers of subjects in the AR and the LR groups were 948 and 118. After 2:1 propensity score matching, 236 vs. 118 patients were selected. There was no significant difference in 5-year disease-free survival (80.7% vs. 78.6%, P = 0.607), and both the 5-year overall survival (89.2% vs. 88.2%, P = 0.563) as well as short-term outcomes showed no statistical difference in most of the variables. CONCLUSION: Laparoscopic segmental left colectomy can be one option among the standard procedures for SFCC.

Addition of V-Stage to Conventional TNM Staging to Create the TNVM Staging System for Accurate Prediction of Prognosis in Colon Cancer: A Multi-Institutional Retrospective Cohort Study.

We evaluated the prognostic impact of vascular invasion (VI) compared with nodal (N) stage and developed a new staging system including VI in colon cancer. Patients who underwent curative resection with stage II-III colon cancer were assigned to VI and non-VI groups; the latter was subclassified as N0, N1, and N2; a new TNVM staging was devised by adding the V-stage. Among the 2243 study participants, the VI group independently showed worse oncological outcomes than the N1 group (disease-free survival (DFS), hazard-ratio (HR) 1.704, 1.267-2.291; overall survival (OS), HR 2.301, 1.582-3.348). The 5-year DFS in the VI group was 63.4% [N1b (74.6%), p = 0.003; N2a (69.7%), p = 0.126; and N2b (56.8%), p = 0.276], and the 5-year OS was 76.6% [N1b (84.9%), p = 0.004; N2a (83.0%), p = 0.047; and N2b (76.1%), p = 0.906]. Thus, we considered VI as N2a in TNVM staging; 78 patients (3.5%) underwent upstaging. The 5-year OS rates of stage IIB and IIC increased from 88.6% and 65.9% in TNM staging to 90.5% and 85.7% in TNVM staging, respectively. In stage II-III colon cancer, VI had a similar prognostic impact as the N2 stage without VI. The incorporation of the V-stage into the conventional TNM staging facilitates better prediction of prognosis.

Guidelines for accreditation of endoscopy units: quality measures from the Korean Society of Coloproctology.

PURPOSE: Colonoscopy is an effective method of screening for colorectal cancer (CRC), and it can prevent CRC by detection and removal of precancerous lesions. The most important considerations when performing colonoscopy screening are the safety and satisfaction of the patient and the diagnostic accuracy. Accordingly, the Korean Society of Coloproctology (KSCP) herein proposes an optimal level of standard performance to be used in endoscopy units and by individual colonoscopists for screening colonoscopy. These guidelines establish specific criteria for assessment of safety and quality in screening colonoscopy. METHODS: The Colonoscopy Committee of the KSCP commissioned this Position Statement. Expert gastrointestinal surgeons representing the KSCP reviewed the published evidence to identify acceptable quality indicators and indicators that lacked sufficient evidence. RESULTS: The KSCP recommends an optimal standard list for quality control of screening colonoscopy in the following 6 categories: training and competency of the colonoscopist, procedural quality, facilities and equipment, performance indicators and auditable outcomes, disinfection of equipment, and sedation and recovery of the patient. CONCLUSION: The KSCP recommends that endoscopy units performing CRC screening evaluate 6 key performance measures during daily practice.

Which prognostic factors are important for long-term outcomes in symptomatic obstructive colon cancer? A multi-institutional retrospective cohort study.

Purpose: The prognostic factors in obstructive colon cancer have not been clearly identified. We aimed to identify the prognostic factor to establish optimal treatment strategy in obstructive colon cancer. Methods: Patients who underwent surgery for primary colon cancer in stages II and III with symptomatic obstruction from 2004 to 2010 in six hospitals were retrospectively collected. Clinicopathological and surgical outcomes were compared between stent insertion and emergent surgery group. Multiple regression analysis and survival curve analysis were used to identify the prognostic factors in symptomatic obstructive colon cancer. Results: Among 210 patients, 168 patients (80.0%) underwent stent insertion followed by surgery and 42 patients (20.0%) underwent emergent surgery. Laparoscopic approach (55.4% vs. 23.8%, p < 0.001) and adequate lymph node (LN) harvest (≥12) (93.5% vs. 69.0%, p < 0.001) were significantly higher in stent insertion group. In multiple regression analysis, emergent surgery (hazard ratio [HR], 2.153; 95% confidence interval [CI], 1.031-4.495), vascular invasion (HR, 6.257; 95% CI, 2.784-14.061), and omitting adjuvant chemotherapy (HR, 3.107; 95% CI, 1.394-6.925) were independent poor prognostic factors in 5-year overall survival, and N stage (N1 HR, 3.095; 95% CI, 1.316-7.284; N2 HR, 4.156; 95% CI, 1.671-10.333) was the only poor prognostic factor in 5-year disease-free survival. Conclusion: In symptomatic obstructive colon cancer, emergent surgery, N stage, vascular invasion, and omission of adjuvant chemotherapy were independent poor prognostic factors. Stent insertion is suggested as the initial treatment for symptomatic obstructive colon cancer, and adjuvant chemotherapy is recommended, especially when vascular invasion or LN metastasis is confirmed.

Expression of protease activated receptor-2 in human colorectal cancer and its association with tumor progression.

PURPOSE: Protease activated receptor-2 has been reported to promote the proliferation of colorectal cancer cells. The aim of this study was to investigate the relationship of protease activated receptor-2 expression to clinicopathologic factors to clarify its role in tumor progression and patient survival in human colorectal cancer. METHODS: Immunohistochemical staining with anti-protease activated receptor-2 antibody was carried out and evaluated on samples from 295 patients with colorectal cancer obtained during surgical treatment at Kangnam St. Mary's Hospital, Seoul, Republic of Korea. Medical records were reviewed and relationships between immunostaining and clinicopathologic findings were evaluated. RESULTS: Positive staining for protease activated receptor-2 was observed in samples from 100 patients (33.9%). Expression of protease activated receptor-2 was significantly associated with depth of tumor invasion (P = .013), liver metastasis (P = .008), TNM stage (P = .009), and tumor location (P = .011). However, protease activated receptor-2 expression did not significantly correlate with overall survival of patients and was not a significant negative prognostic factor for survival in univariate or multivariate analyses. CONCLUSIONS: The expression of protease activated receptor-2 is related to tumor invasion and metastasis in human colorectal cancer. However, further studies are needed to clarify the role of protease activated receptor-2 in the prognosis of patients with colorectal cancer.

Single-port transumbilical laparoscopic appendectomy: 43 consecutive cases.

BACKGROUND: In this modern era of minimally invasive surgery, cosmesis and early recovery are strongly emphasized. To reduce abdominal trauma and improve cosmesis, surgeons have adopted a single-port laparoscopic appendectomy for patients with acute appendicitis. METHODS: From August to December 2008, 43 cases of appendectomy were managed using the single-port transumbilical laparoscopic technique. A multichannel single port was created using a surgical glove (no. 6), three trocars, one-three-way catheter, and a wound retractor (Alexis). An umbilical incision (1.5-2.0 cm) was made transumbilically or infraumbilically. The intraabdominal procedures were almost identical to those for conventional laparoscopic appendectomy. The methods for mesenteric dissection and appendiceal stump ligation were identical. Despite slight discomforts with retraction and visualization, the procedure was nevertheless possible. A resected appendix was put into a finger of the single-port glove. RESULTS: The 43 study cases included 23 men and 20 women with a mean age of 31 years (range, 9-65 years) and a mean body mass index (BMI) of 22.3 kg/m(2) (range 15-29.7 kg/m(2)). The mean operative time was 61.3 min (range 24-120 min). Drainage was used in two cases with perforated appendicitis. Bowel movement returned at a mean of 1.2 days, and oral feeding was resumed on postoperative day 1.2. The pathology showed negative inflammation in 4 cases (9.3%), suppurative appendicitis in 29 cases (67.4%), gangrenous appendicitis in 8 cases (18.6%), and perforated appendicitis in 2 cases. Only one patient required readmission due to pericecal inflammation and pain, and another patient needed a percutaneous drainage of fluid collection. Three minor umbilical wound complications were controlled conservatively. CONCLUSIONS: Single-port appendectomy may require a longer operative time than laparoscopic appendectomy, but it is a feasible technique with good cosmetic results. It could be one of the alternative methods for treating acute appendicitis.

Effectiveness of stent placement for palliative treatment in malignant colorectal obstruction and predictive factors for stent occlusion.

BACKGROUND: Self-expandable metallic stent (SEMS) for malignant colorectal obstruction is widely used in palliative treatment and as an alternative to surgery. The aims of this study are to evaluate the effectiveness of stent placement for palliative treatment and to identify the predictive factors associated with stent occlusion. METHODS: A retrospective analysis was performed in 55 patients who had undergone placement of an uncovered SEMS from February 2004 to April 2007 for palliative treatment of malignant colorectal obstruction with metastatic or locally advanced cancer that was surgically unresectable. We analyzed the technical and clinical outcomes of stent placement, complications related to the procedure, stent patency rate, and predictive factors associated with stent occlusion. RESULTS: The causes of colorectal obstruction before stent placement were primary colorectal cancer in 42 patients and noncolorectal extrinsic cancer in 13 patients. The initial technical success rate was 98.2%, and the clinical success rate was 94.4%. Complications occurred in 17 patients (30.9%). These included stent occlusion (n = 8), migration (n = 6), bowel perforation (n = 1), stent distortion (n = 1), and fistula formation (n = 1). The mean and median stent patency periods were 184 days [95% confidence interval (CI), 137-230 days] and 141 days (95% CI, 69-213 days), respectively. The degree of expansion 48 h after stent placement was significantly better in the nonocclusion group than in the stent occlusion group. In the multivariate Cox proportional hazard model, insufficient stent expansion (<70%) 48 h after stent placement was significantly associated with an increase in stent occlusion during the follow-up period (odds ratio, 12.55; p = 0.002). CONCLUSIONS: Uncovered SEMS placement is an effective palliative treatment for malignant colorectal obstruction. The degree of stent expansion 48 h after stent placement is significantly associated with the maintenance of stent patency and is a predictive factor for stent occlusion.

Nasal tip plasty using three-dimensional printed polycaprolactone (Smart Ball®).

BACKGROUND: Rhinoplasty is one of the most commonly performed cosmetic surgery procedures. Most Asians desire elevation of their relatively flat nasal dorsum and tip to make them appear more prominent. This study introduces a simple method of nasal tip plasty using three-dimensional (3D)-printed polycaprolactone (PCL) (Smart Ball®), which provides the required length and volume for this purpose and enables the creation of a nasal tip of the desired shape in a safe and simple manner. METHODS: Between September 2014 and May 2017, 22 patients participated in a survey to assess postoperative satisfaction levels. Additionally, three plastic surgeons compared patients' pre- and 1-year postoperative photographs to evaluate the results. All patients underwent 2- to 4-year postoperative follow-up. RESULTS: Levels of subjective satisfaction among patients were 3.59, 3.50, 3.82, 3.73, 3.55, and 3.82 for each of the 6 categories evaluated, with a mean of 3.67/4 points, indicating high satisfaction levels. The mean plastic surgeon-reported score for the 22 patients was 4.47/5 points, which also indicates highly successful outcomes. Postoperative nasal tip rotation and tip projection were ideal in most patients. CONCLUSION: Our novel method using 3D-printed PCL (Smart Ball®) provides the optimal length and volume required for nasal tip plasty and enables the creation of a nasal tip of the desired shape, in a safe and simple manner. An advantage of our method is that it retains the original nasal structure in contrast to structural changes observed with the use of conventional methods.

The optimal time interval between the placement of self-expandable metallic stent and elective surgery in patients with obstructive colon cancer.

A bridge to surgery (BTS) after a colonic stent for obstructive colon cancer has not been accepted as a standard treatment strategy. Also, there is no consensus regarding the optimal time interval for BTS. We aimed to identify the optimal timing for BTS after stent placement to decrease the oncologic risk. We retrospectively collected data of 174 patients who underwent BTS after stent placement for stage II or III obstructive colon cancer from five hospitals. We divided the patients into three groups based on the time interval for BTS after stent placement: within 7 days (Group 1), from 8 to 14 days (Group 2), and after 14 days (Group 3). The primary outcome was to compare the oncologic outcomes including overall survival (OS), disease-free survival (DFS), and recurrence rate (RR) among the three groups. Groups 1, 2, and 3 involved 75, 56, and 43 patients, respectively. Postoperative morbidity rates were 17.3%, 10.8%, and 9.3% in Groups 1, 2, and 3, respectively (P = 0.337). RRs were 16.0%, 35.7%, and 30.2% in Groups 1, 2, and 3, respectively (P = 0.029). In multivariate analysis, the time interval for BTS was an independent risk factor for DFS (P < 0.001; HR, 14.463; 95% CI, 1.458-3.255) and OS (P = 0.027; HR, 4.917; 95% CI, 1.071-3.059). In conclusion, the perioperative short-term outcome was not affected by the time interval of BTS. However, elective surgery within 7 days after colonic stent might be suggested to balance the short-term benefits and long-term oncologic risks.

Circular pOlyethylene drape in preVEntion of suRgical site infection (COVER trial): study protocol for a randomised controlled trial.

INTRODUCTION: Surgical site infection (SSI) after abdominal surgery remains a significant cause of morbidity and is associated with an increased socioeconomic burden and a reduced quality of life. Circular wound protectors have been expected to reduce the risk of SSI, but previous studies reported conflicting results on their protective effects. The purpose of this study was to evaluate the efficacy of circular wound protectors in reducing SSI in open abdominal surgery. METHODS AND ANALYSIS: The circular pOlyethylen drape in preVEntion of suRgical site infection (COVER) trial investigates whether the application of a dual-ring circular plastic wound protector reduces the rate of SSI in patients undergoing elective or emergent open abdominal surgery related to the gastrointestinal tract, regardless of the type of wound classified by the Centers for Disease Control. The COVER trial is a multicentre, randomised controlled clinical trial with two parallel arms-one using a dual-ring wound protector with circular polyethylene drape and the other using conventional surgical dressing gauze. The primary outcome will measure the rate of SSI within 30 days after surgery in two groups. Statistical analysis of the primary end point will be based on the intention-to-treat population. The sample size was determined to achieve a study power of 80% with 95% two-sided confidence limits. Considering a dropout rate of up to 5%, a total of 458 patients, 229 patients in each group, will be enrolled in this study. ETHICS AND DISSEMINATION: The trial protocol and informed consent document have been reviewed and approved by the institutional review board at each participating centre. Written informed consent will be obtained from each study participant. The clinical outcomes of this trial will be submitted to an international peer-reviewed journal and presented at international conferences. TRIAL REGISTRATION NUMBER: NCT03170843.