Early closure compared to late closure of temporary ileostomy in rectal cancer: a randomized controlled trial study.

BACKGROUND: A temporary loop ileostomy is one of the most common methods for the prevention of anastomotic leakage in rectal cancer patients who underwent low anterior resection. However, the optimal timing of loop ileostomy reversal remains unknown. The main objective of this study was to evaluate the debilitating complications caused by early closure of ileostomy in comparison with late closure in rectal cancer patients. DESIGN: A randomized, controlled, unblinded, and monocentric trial. METHODS: A total of 104 rectal cancer patients were randomly assigned to the case group of early closure of ileostomy (n = 50) and the control group of late closure of ileostomy (n = 54). This trial was undertaken in a single colorectal institution, a university-affiliated teaching hospital in Tehran, Iran. Randomization and allocation to the trial group were conducted by using variable block randomization based on quadruple numbers. The primary endpoint of this trial was determined by the complications of early ileostomy closure versus those of late closure in rectal cancer patients who had undergone low anterior resection. In early closure, loop ileostomy is reversed 2-3 weeks after the first two courses of adjuvant chemotherapy, while in late closure, the ileostomy is reversed 2-3 weeks after the last course of adjuvant chemotherapy. RESULTS: Follow-up of 1 year demonstrated a reduction in the risk of complications and an improved quality of life in patients with rectal cancer following low anterior resection and chemotherapy (neoadjuvant and adjuvant) in the case group but did not reach a significant difference (p = 0.555). In addition, there was no significant difference in perioperative outcomes, such as blood loss, operative time, readmission, and reoperation; also, no statistically significant differences were reported between the groups in patients' quality of life or LARS score. CONCLUSION: In summary, it seems that early closure of ileostomy is not better than late closure in improving patients' quality of life with rectal cancer following low anterior resection and chemotherapy (neoadjuvant and adjuvant); no statistical difference was observed for reduction of risk of ostomy complications. Thus, neither of these methods (early closure versus late closure) is superior to the other, and controversy still exists. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION: IRCT20201113049373N1.

Predicting rectal tumor response to neoadjuvant chemoradiotherapy using plasma levels of carcinoembryonic antigen (CEA): Results from a tertiary center in Iran.

Objectives: Nonsurgical treatment of colorectal cancer, the third most prevalent cancer worldwide, through chemoradiotherapy (CRT) has been suggested to induce complete remission. Carcinoembryonic antigen (CEA) has been used as a candidate marker to predict treatment response. In this study, we aimed to assess the applicability of plasma levels of CEAs in predicting the response to CRT, particularly complete pathological response. Methods: We designed a retrospective, cross-sectional study in which tumor stage and plasma levels of CEAs before and after neoadjuvant CRT were extracted from the medical records of patients with rectal tumors who underwent neoadjuvant chemoradiotherapy before surgery at Sina Hospital, Tehran, Iran from 2010 to 2015. Results: Pre-CRT plasma levels of CEA positively correlated with tumor stage, and chemoradiotherapy significantly decreased plasma levels of CEA. Whereas lower pre-CRT plasma levels of CEA and tumor stage were significantly associated with complete response to CRT, post-CRT plasma levels of CEA showed no association with complete response. In addition, in ROC curve analysis, a CEA cut-off value of 2.6 ng/mL predicted complete response to CRT (specificity = 82.6%, sensitivity = 40.5%). Conclusion: Although several factors other than plasma levels of CEA and tumor stage are important in determining the response to CRT, preliminary plasma levels of CEA and tumor stage can be used as factors for determining complete response to neoadjuvant chemoradiotherapy in rectal cancer.

Mesenchymal Stromal Cell Therapy Improves Refractory Perianal Fistula in Crohn's Disease: Case Series Clinical Interventional Study.

Objective: Perianal fistulas in Crohn's disease (CD) are the main challenges in inflammatory bowel diseases (IBDs). Some of the fistulas are refractory to any therapeutic strategy. The aim of this study was to evaluate the therapeutic effects of mesenchymal stromal cells (MSCs) as a novel promising modality for the treatment of fistulizing CD. Materials and Methods: This case series clinical interventional study was conducted from 2014 to 2017 at Shariati Hospital, an IBD referral center in Tehran, Iran. Refractory adult patients with CD who had draining perianal fistulas were enrolled in this study. All patients were examined by a colorectal surgeon and the fistula imaging studies were performed by pelvic magnetic resonance imaging (MRI). After autologous bone marrow (BM) aspiration and MSCs isolation, the cells were cultured and passaged under current good manufacturing practice (cGMP) conditions. Four intra-fistula injections of cells, each containing 40×106 MSCs suspended in fibrin glue, were administered by an expert surgeon every 4 weeks. Procedure safety, feasibility and closure of the perianal fistulas at week 24 were assessed. Clinical examination and MRI findings were considered as the primary end points. Results: In total, 5 patients (2 males and 3 females) were enrolled in this study. No adverse events were observed during the six-month follow-up in these patients. Both the Crohn's Disease Activity Index (CDAI) and Perianal Disease Activity Index (PDAI) scores decreased in all patients after cell injections and one patient achieved complete remission with closure of fistulas, discontinuation of fistula discharge, and closure of the external opening. Conclusion: Local injection of MSCs combined with fibrin glue is potentially a safe and effective therapeutic approach for complex perianal fistulas in patients with CD.

Prophylactic postoperative condom sheet placement: A randomized clinical trial to test a new concept.

OBJECTIVE: Postoperative urinary retention (POUR) is one of the most common complications after surgery with several risk factors. However, its precise etiology is not completely understood. So far, the effect of prophylactic condom sheet placement on the prevention of POUR has not been addressed. This study was designed to understand whether preventive condom sheet decreases the rate of POUR. MATERIALS AND METHODS: This randomized clinical trial was carried out in an educational hospital during 2018-2019. All male patients, who underwent anorectal surgery with spinal anesthesia, were included and randomly allocated into two groups (with and without postoperative condom sheet placement). RESULTS: A total of 172 patients were included in this study (86 patients per group). Twenty-three (13.4%) patients developed POUR. The incidence of POUR was 15.1% among patients with condom sheets and 11.6% in patients without condom sheets, which was not significantly different (P > 0.5). POUR development had a significant correlation with the use of morphine and history of hypertension in both univariate and multivariate analyses. CONCLUSION: Based on the present results, it seems that condom sheet placement did not effectively prevent POUR in patients; therefore, ambulation of patients after surgery is a more effective strategy for these patients.

Approach to Acute Abdominal Pain: Practical Algorithms.

CONTEXT: Acute abdominal pain is one of the most common complaints of patients admitted to emergency units. This study aimed to propose a new approach to abdominal pain by designing a more structured diagnostic workup for physicians. EVIDENCE ACQUISITION: A comprehensive review of relevant articles and algorithms presented in books and websites was conducted. Approaches which were relevant to the study concept, were selected. RESULTS: Seven algorithms were introduced with respect to the site of abdominal tenderness. The mainstay of these algorithms was differential diagnosis of the tenderness site. CONCLUSION: Based on the findings, the designed approach can prevent confusion among physicians and reduce requests for many unnecessary paraclinical tests, which delay the final diagnosis and impose unacceptable costs on patients and healthcare systems.

Functional and quality of life outcomes after ileal pouch-anal anastomosis in short versus long ileal J-pouch configuration in ulcerative colitis patients: a cohort study.

Advances in the pharmacological treatment of ulcerative colitis (UC) have enormously decreased the frequency of emergent surgeries. Ileal pouch-anal anastomosis (IPAA) is the procedure of choice in surgical treatment of refractive UC and J-pouch configuration is by far the most preferred pouch design by surgeons. Pouch configuration probably influences the outcomes of the surgery. In this study, we compared the impact of J-pouch size on the functional and quality of life (QoL) outcomes of patients. In this prospective cohort study, we recruited patients who underwent IPAA in two referral centers of our university with two different J-pouch sizes. Demographic data of patients were collected using the patients' medical files. To assess the QoL and bowel function status, SF-36 and Öresland scores were used to evaluate patients 6 and 12 months after the operation. Data analysis was performed with SPSS ver 21. 62 patients were evaluated in the study (31 subjects in each group). The mean age of patients was 40.85 ± 12.98. Thirty-nine patients (60.0%) were males and 23 (35.9%) were females. The mean of SF-36 and Öresland score was 84.30 ± 13.39 and 3.33 ± 2.45, respectively. The mean of SF-36 was significantly higher in patients with shorter J-pouch (P value 0.00). The mean of Öresland score was relatively lower in patients with shorter J-pouch but the difference was not statistically significant (P value 0.06). QoL was correlated with bowel functional outcomes and shorter length of the J-pouch. The only demographic parameter that was correlated with QoL was body mass index.

The rate and importance of Clostridium difficile in colorectal cancer patients.

AIM: The aim of this study was to analyze the Clostridium difficile and their toxins in cancerous tissues in comparison to their adjacent healthy tissues in patients with colorectal cancer (CRC) in Iran. BACKGROUND: Intestinal infection or colonization by microbial pathogens and their released metabolites may have a role in the exacerbation of CRC. METHODS: A total of 60 biopsy samples from 30 cancerous and 30 adjacent healthy tissues were collected from patients with CRC. Biopsies were homogenized and cultured in cycloserine cefoxitin fructose agar-agar medium to investigate the presence of C. difficile. DNA was extracted, PCR was performed on pure colonies for bacteria detection, and toxin genes were evaluated in each bacterium positive cases. Real-time PCR was performed on extracted DNA for quantitative comparison of Clostridium difficile in healthy and tumor tissues in CRC patients. RESULTS: Clostridium difficile was isolated from 18 of the cancerous tissue (60%) and 6 of their healthy adjacent tissue (20%) in the culture medium, but toxin genes were positive just in one sample in both groups. Real-time PCR showed the colonization in all samples. CONCLUSION: This study showed a higher prevalence of Clostridium difficile in cancerous lesions in comparison to healthy tissues. We suggest that the investigation of the rate of CD of colorectal cancer patients before surgery is critical for patients. Further studies with more samples size to study the importance of this bacterium and its toxins in the investigation of colorectal cancer patients survey is recommended.

Midgut volvulus is a rare cause of intestinal obstruction in adults: A case report.

INTRODUCTION: The incidence of midgut vovulus is rare in adults. However, a significant number of cases were seen in infant and children. PRESENTATION OF CASE: We report a case of a 34-year-old male who presented to the emergency room with persistent periumbilical abdominal pain without any other symptoms. Contrast-enhanced CT showed clearly the typical finding of midgut volvulus like whirlpool sign, corkscrew sign, and the superior mesenteric vein to the left of superior mesenteric artery. The patient was planned for Ladd's procedure and emergency laparotomy performed successfully with an uneventful postoperative recovery. DISCUSSION: Managing midgut volvulus is based on presentation. In symptomatic cases surgery is the treatment, but in asymptomatic cases, treatment is controversial. CONCLUSION: Although midgut volvulus is rare in adults, it should be considered as an intestinal obstruction.

The effect of intestinal microbiota metabolites on HT29 cell line using MTT method in patients with colorectal cancer.

AIM: The aim of this study was to evaluate the effect of intestinal microbiota metabolites in colorectal cancer patients on HT29 cell line using MTT assay. BACKGROUND: Colorectal cancer is one of the most common malignant tumors. Human guts harbor abundant microbes that adjust many aspects of the host physiology. Increasing studies suggest that gut microbiota play a significant role in the incidence and expansion of CRC, as a result of virulence factors, bacterial metabolites, or inflammatory pathways. METHODS: In this cross-sectional study, 60 biopsy samples including 30 cancerous and 30 adjacent healthy tissues were collected from patients with CRC during 2017. Biopsy samples were first cultured on Thioglycollate broth medium for 24hr after which the microbiota metabolites were filtered and stored at -20 C° for further evaluation. HT29 cells were treated by microbiota metabolites at different times (3, 6, 12, 18h) and its viability was assessed by MTT assay. RESULTS: The cells treated with microbiota metabolites showed increased viability and proliferation in time-dependent analysis by MTT assay, but there was not significant differences between the two groups. CONCLUSION: It seems that microbial metabolites are able to induce proliferation and increase cell viability and thus induce colorectal cancer.

Using 360-degree multi-source feedback to evaluate professionalism in surgery departments: An Iranian perspective.

BACKGROUND: Medical professionalism helps physicians adopt a proper and good healing action for the patients based on their particular circumstance. This study was conducted to assess professionalism in surgical residents, using a 360-degree evaluation technique in several teaching hospitals in Tehran, Iran. METHODS: This study was conducted on all the second and third year surgery residents from three university teaching hospitals in Tehran. Multi-source feedback questionnaire contained 10 questions on the residents' professional behavior and was completed by the faculty and staff members (nurses, operation room staff, and medical assistants) as well as other surgery residents, interns and patients to evaluate each resident. Response rates were used to determine feasibility for each of the respondent groups and the mean and standard deviation score for each question was computed to determine the viability of the items. Reliability was assessed using alpha Cronbach coefficient for each respondent group. The correlation between these scores and the residents' final and OSCE grade was also assessed. RESULTS: The internal consistency reliability for 360-degree rating was 0.889. There was no significant difference in the residents' score in different hospitals. While male residents obtained higher total score, there was no significant difference between them. The residents, however, obtained lower scores compared to the staff. The highest score was recorded for question 6, suggesting that the residents treated the patients regardless of their socioeconomic status. CONCLUSION: This study revealed a strong agreement between the results gathered from different respondents, confirming the reliability of the questionnaire and the respondents' unbiased response. It also revealed that the residents did well in the whole test, showing they were conscientious and learning to become medical professionals.

Measuring the rate of weight gain and the influential role of diet in patients undergoing elective laparoscopic cholecystectomy: a 6-month follow-up study.

Weight gain after cholecystectomy is one of the major surgical problems consistent with morbidities and long-term mortalities. Here, we aimed to study the impact of palliative cholecystectomy on weight gain and nutritional status of the patients before and in 1, 4 and 6 months after surgery. We performed a prospective survey on a cohort of 48 patients undergoing elective cholecystectomy. The nutritional status of the patients was collected by nutrition nurse and analysed by NutriBase software. There were 13 (16%) females and 35 (84%) males with the mean age of 51.8 ± 1.97. In 6 months after surgery, patients had higher values of BMI, daily energy expenditure, carbohydrate and lipid consumption and a decreased level of protein consumption. Weight gain after surgery was caused by an increase in fat consumption which resulted in the weight gain and worsening of lipid profile. Dietary consultation, shortly after surgery, would improve patient outcome after cholecystectomy.

Combined fascia and mesh closure of large incisional hernias.

BACKGROUND: Incisional hernias are common and recurrence after repair has been reported in up to 44% of patients. Large incisional hernias of the abdominal wall represent substantial defect of supportive tissues. METHODS: Twenty-nine patients with large incisional hernias underwent surgery from January 2003 through December 2005. Herein, we presented our experience in closure of large incisional hernias using a technique in which we combine a fascia with a prosthetic repair. The variables recorded were classified as patient-related (gender, age, obesity, cough, constipation, diabetes mellitus, glucocorticosteroid therapy, smoking habit, and abdominal surgical history) and operation-related factors (size of defect, recurrence, wound infection, hematoma, and duration of hospital stay). RESULTS: The repair was performed for 25 midline hernias and four large incisional hernias in the right subcostal region. Four patients were females and 25 were males with a mean age of 52 (range: 30 - 77) years. The mean size of fascial defect was 12.7x4.5 cm. The mean time of operation was three hours and 18 minutes. The mean hospital stay was six (range: four to ten) days. Two patients had recurrence during the follow-up period. The mean follow-up period was 16 (range: eight to 26) months. CONCLUSION: The combined three-layer fascia and mesh repair can be successfully used for large incisional hernias.