Comparing Surgical Site Infection Rate Between Primary Closure and Rhomboid Flap After Stoma Reversal.

BACKGROUND: Primary closure (PC) is a common wound closure procedure after stoma reversal and is associated with a high rate of surgical site infection (SSI). This study introduced a new method of skin closure, a rhomboid flap (RF), for skin closure after stoma reversal and compared the SSI rate between the 2 techniques. METHODS: This is a single-center retrospective study. Patients who underwent colostomy or ileostomy closure performed using either rotation flap (n = 33) or PC (n = 121) techniques for skin closure after stoma reversal between April 2019 and July 2022 were enrolled in this study. Medical records were retrospectively reviewed to obtain data. Both groups were followed up postoperatively at 1 month for wound infection. Wound infection within 30 days after surgery was indicated by the presence of purulent discharge, erythema, local heat, or positive culture for bacteria. RESULTS: In the PC group, the infection rate was 25.6% (n = 121) compared with 12.1% (n = 33) in the RF group (P = 0.158). Among the patients who underwent colostomy reversal, the infection rate of the RF group was significantly lower compared with that of the PC group (11.1% vs 36.9%, P = 0.045). Among the patients who underwent ileostomy reversal, no significant differences in the infection rates between the groups were found (13.3% vs 12.5%, P = 1.000). CONCLUSIONS: Although the RF technique requires slightly longer operative time for flap design in practice than the linear closure method, the technique can significantly reduce the SSI rate after colostomy reversal through the dissection of the surrounding inflammatory tissues and obliteration of the dead space. Additional studies are required to evaluate this technique, compare it with other existing methods, and explore long-term complications.

Efficacy and Safety of a Parenteral Nutrition Program for Patients with RAS Wild-Type Metastatic Colorectal Cancer Administered First-Line Cetuximab Plus Chemotherapy: A Propensity Score Matching Study.

Malnutrition is a common problem in patients with metastatic colorectal cancer (mCRC) receiving targeted therapy plus chemotherapy, resulting in severe toxicity and decreased survival rates. This retrospective study employing propensity score matching (PSM) examined the efficacy and safety of a supplemental home parenteral nutrition (HPN) program for patients with RAS wild-type mCRC receiving cetuximab plus chemotherapy. This retrospective nationwide registry study included data from 14 medical centers/hospitals across Taiwan, and the data period ranged from November 2016 to December 2020. Patients with RAS wild-type mCRC receiving cetuximab plus chemotherapy as their first-line therapy were included and divided into HPN and non-HPN program groups. HPN was initiated based on patient-specific factors, such as baseline nutritional status, treatment-related toxicities, and comorbidities. Clinical outcomes were evaluated using response to therapy, duration of response (DoR), progression-free survival (PFS), and overall survival (OS). This study recruited 758 patients, of whom 110 and 648 were included in the HPN and non-HPN program groups, respectively. After 1:3 PSM, the data of 109 and 327 patients from the HPN and non-HPN program groups were analyzed, respectively. The HPN program group had a higher metastasectomy rate (33.9% vs. 20.2%, p = 0.005), and longer duration of treatment and DoR than the non-HPN program group (13.6 vs. 10.3 and 13.6 vs. 9.9 months, p = 0.001 and < 0.001, respectively). The HPN program group tended to have a longer median PFS (18.2 vs. 13.9 months, p = 0.102). Moreover, we noted a significant improvement in the median OS in the same group (53.4 vs. 34.6 months, p = 0.002). Supplemental HPN programs may be recommended for select patients with mCRC receiving targeted therapy plus chemotherapy to improve oncological outcomes.

Survival benefit of metastasectomy in first-line cetuximab therapy in patients with RAS wild-type metastatic colorectal cancer: a nationwide registry.

This multicenter study aimed to explore the survival benefit of metastasectomy by first-line cetuximab-based chemotherapy in real-world patients with RAS wild-type metastatic colorectal cancer (mCRC). The primary endpoints were overall survival (OS) and progression-free survival (PFS). The secondary endpoints included objective response rate (ORR), disease control rate (DCR), and metastasectomy rate. The exploratory endpoint was the optimal treatment cycle for better OS and PFS. Receiver operating characteristic curve with the area under curve (AUC) was used to identify the optimal cut-off cycle for survival outcomes. A total of 758 mCRC patients were enrolled in this study, with a median OS of 35.1 months, median PFS of 14.6 months, and metastasectomy rate of 21.4%. Left-sided mCRC had a significantly higher DCR (88.9% vs. 73.1%, P<0.001) and better OS (36.4 vs. 19.6 months, P<0.001). There were no significant differences in PFS and metastasectomy rate between left-sided and right-sided mCRC. However, mCRC patients who underwent metastasectomy over the course of treatment had better OS (54.9 vs. 28.6 months, P<0.001) and PFS (21.0 vs. 13.1 months, P<0.001) than those who did not. Notably, right-sided mCRC who benefited from first-line cetuximab-based chemotherapy to underwent metastasectomy also had favorable outcomes, on a par with left-sided mCRC. The optimal treatment cycle was 14 cycles (AUC: 0.779, P<0.001). Patients who received ≥14 cycles had higher metastasectomy rates (27.5% vs. 13.5%, P<0.001), favorable OS (42.6 vs. 23.4 months, P<0.001) and PFS (18.1 vs. 8.6 months, P<0.001), and, importantly, had comparable adverse events compared with patients who received <14 cycles of treatment. Patients who underwent metastasectomy after or during first-line cetuximab therapy have an improved OS in both left-sided and right-sided mCRC. Furthermore, patients receive ≥14 cycles of treatment whenever possible to achieve a higher likelihood of metastasectomy was associated with favorable survival outcomes.

Development and validation of a deep learning-based algorithm for colonoscopy quality assessment.

BACKGROUND: Quality indicators should be assessed and monitored to improve colonoscopy quality in clinical practice. Endoscopists must enter relevant information in the endoscopy reporting system to facilitate data collection, which may be inaccurate. The current study aimed to develop a full deep learning-based algorithm to identify and analyze intra-procedural colonoscopy quality indicators based on endoscopy images obtained during the procedure. METHODS: A deep learning system for classifying colonoscopy images for quality assurance purposes was developed and its performance was assessed with an independent dataset. The system was utilized to analyze captured images and results were compared with those of real-world reports. RESULTS: In total, 10,417 images from the hospital endoscopy database and 3157 from Hyper-Kvasir open dataset were utilized to develop the quality assurance algorithm. The overall accuracy of the algorithm was 96.72% and that of the independent test dataset was 94.71%. Moreover, 761 real-world reports and colonoscopy images were analyzed. The accuracy of electronic reports about cecal intubation rate was 99.34% and that of the algorithm was 98.95%. The agreement rate for the assessment of polypectomy rates using the electronic reports and the algorithm was 0.87 (95% confidence interval 0.83-0.90). A good correlation was found between the withdrawal time calculated using the algorithm and that entered by the physician (correlation coefficient r = 0.959, p < 0.0001). CONCLUSION: We proposed a novel deep learning-based algorithm that used colonoscopy images for quality assurance purposes. This model can be used to automatically assess intra-procedural colonoscopy quality indicators in clinical practice.

Inter-segmental coordination amplitude and variability differences during gait in patients with Ehlers-Danlos syndrome and healthy adults.

BACKGROUND: There is limited research examining gait and inter-segmental coordination in patients with Ehlers-Danlos syndrome. The objective was to compare lower extremity inter-segmental coordination amplitude and variability during gait between patients with Ehlers-Danlos syndrome and healthy adults. METHODS: This cross-sectional study included participants with Ehlers-Danlos syndrome (n = 13) and healthy adults (n = 14). Gait data were acquired using a motion capture system and force plates. Participants ambulated at self-selected speeds for five trials. Inter-segmental coordination was quantified using continuous relative phase, which examined the dynamic interaction between the thigh-shank and shank-foot paired segments (i.e. phase space relation). A 2-way mixed analysis of variance examined the effects of groups (Ehlers-Danlos and healthy) and gait phases (stance and swing phase) on inter-segmental coordination amplitude and between-trial variability. Effect sizes were calculated using Cohen's d. FINDINGS: The Ehlers-Danlos group had greater inter-segmental coordination variability compared to the healthy group for foot-shank and shank-thigh segment pairs in the sagittal plane over stance and swing phases (P = 0.04; small to large effect sizes). The Ehlers-Danlos group also had greater variability in the frontal plane at the foot-shank segment pair during stance phase (P = 0.03; large effect). There were no differences in inter-segmental coordination amplitude between groups (P = 0.06 to 0.85). INTERPRETATION: Patients with Ehlers-Danlos syndrome have more variability between gait trials in lower limb motor coordination than healthy adults. This may be related to the impaired proprioception, reduced strength, pain, or slower gait speed seen in this population.

Taiwan Society of Colon and Rectal Surgeons Consensus on mCRC Treatment.

Therapeutic options for metastatic CRC (mCRC) have changed significantly in recent years, greatly increasing the complexity of therapeutic decision-making. Although oncology guidelines have helped improve the care process, guidelines may also limit the flexibility to individualize in-clinic decision-making. This consensus paper addresses specific gaps in the current international guidelines to assist Taiwanese colon and rectal experts make specific therapeutic choices. Over 3 years and three meetings with selected experts on "real-world" Taiwanese practice patterns for mCRC, consensus was achieved. The experts also discussed specific questions during in-depth one-on-one consultation. Outcomes of the discussion were then correlated with published evidence by an independent medical writer. The final consensus includes clinically implementable recommendations to provide guidance in treating Taiwanese mCRC patients. The consensus includes criteria for defining fit and unfit intensive treatment patients, treatment goals, treatment considerations of molecular profiles, treatment consideration, and optimal treatment choices between different patient archetypes, including optimal treatment options based on RAS, BRAF, and microsatellite instability (MSI) status. This consensus paper is the second in the Taiwan Society of Colon and Rectal Surgeons (TSCRS) Consensus series to address unmet gaps in guideline recommendations in lieu of Taiwanese mCRC management. Meticulous discussions with experts, the multidisciplinary nature of the working group, and the final drafting of the consensus by independent medical professionals have contributed to the strong scientific value of this consensus.

Predictive values of stool-based tests for mucosal healing among Taiwanese patients with ulcerative colitis: a retrospective cohort analysis.

BACKGROUND/PURPOSE: Over the past two decades, ulcerative colitis (UC) has emerged in the Asia Pacific area, and its treatment goal has shifted from symptom relief to endoscopic remission. Endoscopy is the gold standard for the assessment of mucosal healing; however, it is an invasive method. Fecal calprotectin (FC) is a non-invasive stool-based inflammatory marker which has been used to monitor mucosal healing status, but it is expensive. By contrast, the immune fecal occult blood test (iFOBT) is a widely utilized stool-based screening tool for colorectal cancer. In this study, we compared the predictive values of iFOBT and FC for mucosal healing in Taiwanese patients with UC. METHODS: A total of 50 patients with UC identified via the electronic clinical database of Changhua Christian Hospital, Taiwan, were retrospectively enrolled from January 2018 to July 2019. Results of iFOBT, FC level, and blood tests as well as Mayo scores were reviewed and analyzed. Colonic mucosa was evaluated using the endoscopic Mayo subscore. RESULTS: The average age of the patients was 46 years, and 62% of the patients were men. Disease distribution was as follows: E1 (26%), E2 (40%), and E3 (34%). Complete mucosal healing (Mayo score = 0) was observed in 30% of patients. Endoscopic mucosal healing with a Mayo score of 0 or 1 was observed in 62% of the patients. Results of FC and iFOBT were compared among patients with and without mucosal healing. Predictive cutoff values were analyzed using receiver operating characteristics curves. iFOBT and FC had similar area under the curve for both complete mucosal healing (0.813 vs. 0.769, respectively, p = 0.5581) and endoscopic mucosal healing (0.906 vs. 0.812, respectively, p = 0.1207). CONCLUSION: In daily clinical practice, FC and iFOBT do not differ in terms of predictive values for mucosal healing among Taiwanese patients with UC.

Screen position effects on task performance in a delayed match to sample task.

Studies of working memory have used immediate and delayed recall of lists of items. Serial position effects are the phenomena where items at the beginning and end of a studied list are recalled differentially from items in the middle of the list. In matching versions of the task, study items may be presented serially or simultaneously in a grid. After a delay a single probe item is presented for which the participant determines whether or not it was in the study set. The effects of the position of an item when studied on a screen are currently not well understood and are the focus of the current work. Findings from a delayed match to sample task in 49 healthy young adults with 1 to 9 items presented in a 3 by 3 grid, demonstrate that the column of the studied items affect response time and accuracy. The effects of position on accuracy also significantly interact with task demands. The importance of screen position effects is demonstrated with simulations using the mean accuracies split by task demands and screen locations. Simulations demonstrate the possible range of accuracies based on screen effects when the number of trials presented to an individual is less than 20 for each task demand. This has important implications when a small number of trials are administered using randomly generated stimuli which is often the case in neuroimaging studies where tasks are delivered under constrained time limits.

Mutation spectra of RAS gene family in colorectal cancer.

BACKGROUND: The clinicopathologic features and frequency of KRAS mutations in colorectal cancer (CRC) patients have been reported; however, the characteristics and impact of NRAS and HRAS mutations on the survival of CRC patients have seldom been addressed. METHODS: Under institutional review board approval, 1,519 CRC patients who underwent surgery were enrolled. Mutation status of RAS was determined by polymerase chain reaction and mass spectrophotometry. RESULTS: The frequency of KRAS, NRAS, and HRAS mutations was 39.6%, 4.3%, and 1.7%, respectively. The KRAS mutation was associated with fewer left-sided tumors, fewer poor differentiated tumors, more mucin component, and less lymphovascular invasion. The NRAS or HRAS mutations were not associated with any of the clinicopathologic features examined. After univariate analysis, only NRAS mutation was associated with patients' overall and disease-free survival. However, the association of NRAS with patients' overall and disease-free survival disappeared after stepwise elimination. CONCLUSIONS: This study demonstrates the clinicopathologic characteristics of CRC patients with RAS mutations. Patients with NRAS mutation tended to have worse outcomes.

The role of adjuvant chemotherapy in stage II colorectal cancer patients.

PURPOSE: Adjuvant chemotherapy use in stage II colorectal cancer (CRC) is debated. We evaluated the prognostic significance of clinicopathological features recommended by most guidelines for identifying high-risk stage II CRC and adjuvant chemotherapeutic response. METHODS: We enrolled 1,039 stage II CRC patients who underwent curative surgery at Taipei Veterans General Hospital from January 2005 to December 2010. Seventy-seven patients who received radiotherapy were excluded. The endpoint was disease-free survival. RESULTS: Of 962 patients, 37 had stage T4 tumors; 50, lymphovascular invasion; 39, poor differentiation; 249, preoperative carcinoembryonic antigen (CEA) levels >5 ng/mL; and 53 underwent emergent operations. One hundred ninety-four patients received 5-fluorouracil-based adjuvant chemotherapy. During a median follow-up period of 60.2 months, recurrence developed in 110 patients (11.4 %). The 5-year disease-free survival (DFS) was 87.6 %. In multivariate analysis, preoperative CEA >5 ng/ml (p = 0.001), emergent operation for obstruction/perforation (p = 0.008), lymphovascular invasion (p = 0.014), and T4 disease (p = 0.030) were significantly associated with poor DFS. High-risk stage II patients (n = 484) benefited from adjuvant chemotherapy (5-year DFS with and without adjuvant chemotherapy, 87.3 vs. 78.9 %; p = 0.028). CONCLUSIONS: Adjuvant chemotherapy improved DFS in high-risk stage II CRC patients, but not in low-risk patients.

Impact of KRAS mutation on outcome of patients with metastatic colorectal cancer.

BACKGROUND/AIMS: KRAS mutation is present in 30%-50% of colorectal cancers and is associated with the inefficacy of anti-epidermal growth factor receptor therapy, while the impact of KRAS on survival is seldom discussed. The aim of this study was to elucidate the impact of KRAS status on the survival of patients with metastatic colorectal cancer. METHODOLOGY: Two hundred and one patients with metastatic colorectal cancer were enrolled. Amplification and sequencing of the KRAS gene were performed, with the overall survival according to KRAS status analyzed. RESULTS: KRAS mutations were present in 72 (35.8%) of patients, including 55 (27.3%) codon 12 mutations and 17 (8.5%) codon 13 mutations. Lymphovascular invasion (hazard ratio 1.841, 95% confidence interval 1.043-3.247, p = 0.035) and KRAS mutation (hazard ratio 1.919, 95% confidence interval 1.104-3.333, p = 0.021) were independent prognostic factors for overall survival. The median overall survival for patients with KRAS mutation at codon 12 was 27.3 months, and was similar to those with KRAS mutation at codon 13 (20.4 months, p = 0.628). CONCLUSIONS: KRAS mutation is a poor prognostic factor in patients with metastatic colorectal cancer. In KRAS mutation metastatic colorectal cancer, mutation at codon 12 or at codon 13 had no relationship with prognosis.

Neoadjuvant chemotherapy can improve outcome of colorectal cancer patients with unresectable metastasis.

BACKGROUND: The prognosis for colorectal cancer (CRC) patients with unresectable metastases is dismal. This study compared outcomes of different metastatic treatments. PATIENTS AND METHODS: We collected 653 CRC cases with unresectable metastases including 490 cases receiving primary tumor resection then chemotherapy (surgery group) and 163 patients receiving neoadjuvant chemotherapy then did or did not receive operations (chemotherapy (C/T) group) from 2004 to 2010. The statistical endpoint was overall survival from the date of diagnosis. RESULTS: In the C/T group, 124 (76%) patients received an operation after 9.0 ± 6.2 months of chemotherapy, including 57 (34.9%) patients with curative surgery. The C/T group had a higher proportion of T4 lesions (37.4%) than the surgery group (26.9%). Survival of the C/T group was longer than that of the surgery group (28.8 ± 8.8 vs. 24.3 ± 7.5 months; p = 0.043). Survival of 57 patients receiving curative surgery was 36.0 ± 6.3 months, which was significantly better than that of the 67 patients receiving palliative resection (25.2 ± 5.6, p < 0.001). In the surgery group, 42 (8.6%) patients received curative metastasectomy after 8.5 ± 7.1 months of postoperative chemotherapy; survival was 30.8 ± 7.8 months, which was significantly better than that of patients who did not receive metastasectomy (22.4 ± 6.3 months). In multivariate analysis, poor differentiation, lymphovascular invasion, isolated cancer nodules, clinical risk score, and curative surgery were independent prognostic factors of overall patient survival. CONCLUSIONS: Neoadjuvant chemotherapy can improve outcome of CRC patients with unresectable metastases.

Atrial myxoma presenting as total occlusion of the abdominal aorta and its major four branches.

The presentations of cardiac myxoma are diverse, from asymptomatic to a variety of symptoms due to embolization. Occlusion of abdominal aortic bifurcation by straddled myxoma is not common; however, obstructive level above renal artery is very rare. We present a patient with cardiac myxoma who presented with acute onset of paraplegia. The aorta was occluded from the level of the liver dome to the renal arteries, and catastrophic outcome (ischemia/reperfusion) following its removal.