Clinical characteristics and prognostic impact of direct distant organ metastasis in colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) is the third most common type of cancer worldwide, and distant metastasis is frequently noted at diagnosis or follow-up. Notably, some patients with CRC can present with distant organ metastasis without any nodal involvement, which was defined as direct distant organ metastasis (DDOM). In this study, we evaluated the prognostic significance of DDOM for patients with CRC. METHODS: This study included 325 patients who had undergone primary colorectal cancer resection between August 2008 and December 2021. The patients with and without DDOM were compared (Kaplan-Meier analysis) in terms of overall survival (OS) and time to recurrence. Furthermore, the patients' clinicopathological risk factors and protective factors were analyzed (multivariate Cox proportional hazards model). RESULTS: Of the 325 patients, 65 (20%) had DDOM (Direct+ group) and 260 (80%) did not (Direct- group). The Kaplan-Meier analysis revealed that OS was significantly better in the Direct+ group than in the Direct- group (p < 0.01). A subgroup analysis by CRC stage was performed; for the patients with non-stage-IV CRC, the rate of OS was significantly higher in the Direct+ group than in the Direct- group (p = 0.02). However, DDOM did not affect the OS of the patients with stage IV CRC. The multivariate analysis indicated DDOM, left colon tumor location, and postoperative adjuvant chemotherapy were significant protective factors for disease-related mortality in the patients with non-stage-IV CRC; by contrast, body mass index, curative resection, and postoperative adjuvant chemotherapy were identified to be significant protective factors in the patients with stage IV CRC. CONCLUSIONS: DDOM appears to be significantly associated with improved OS in patients with non-stage-IV CRC but not in those with stage IV CRC. Furthermore, the time to cancer recurrence may not vary significantly between patients with DDOM and those without it.

Collagen patch cover facilitates recovery of bowel function after laparoscopic colectomy.

BACKGROUND: Numerous factors can influence bowel movement recovery and anastomotic healing in colorectal surgery, and poor healing can lead to severe complications and increased medical expenses. Collagen patch cover (CPC) is a promising biomaterial that has been demonstrated to be safe in animal models and has been successfully applied in various surgical procedures in humans. This study. METHODS: A retrospective review of medical records from July 2020 to June 2022 was conducted to identify consecutive patients who underwent laparoscopic colectomy. Patients who received CPC at the anastomotic site were assigned to the collagen group, whereas those who did not receive CPC were assigned to the control group. RESULTS: Data from 241 patients (collagen group, 109; control group, 132) were analyzed. Relative to the control group, the collagen group exhibited a faster recovery of bowel function, including an earlier onset of first flatus (2.93 days vs. 3.43 days, p < 0.01), first defecation (3.73 days vs. 4.18 days, p = 0.01), and oral intake (4.30 days vs. 4.68 days, p = 0.04). CPC use was also associated with lower use of postoperative intravenous analgesics. The complication rates in the two groups did not differ significantly. CONCLUSIONS: CPCs can be safely and easily applied to the anastomotic site during laparoscopic colectomy, and can accelerate bowel movement recovery. Further studies on the effectiveness of CPCs in colorectal surgery involving larger sample sizes are required. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT05831956 (26/04/2023).

PROX1 interaction with α-SMA-rich cancer-associated fibroblasts facilitates colorectal cancer progression and correlates with poor clinical outcomes and therapeutic resistance.

BACKGROUND: The tumor microenvironment (TME) plays a vital role in tumor progression through intricate molecular interactions. Cancer-associated fibroblasts (CAFs), notably those expressing alpha-smooth muscle actin (α-SMA) or myofibroblasts, are instrumental in this context and correlate with unfavorable outcomes in colorectal cancer (CRC). While several transcription factors influence TME, the exact regulator causing CAF dysregulation in CRC remains elusive. Prospero Homeobox 1 (PROX1) stands out, as its inhibition reduces α-SMA-rich CAF activity. However, the therapeutic role of PROX1 is debated due to inconsistent study findings. METHODS: Using the ULCAN portal, we noted an elevated PROX1 level in advanced colon adenocarcinoma, linking to a poor prognosis. Assays determined the impact of PROX1 overexpression on CRC cell properties, while co-culture experiments spotlighted the PROX1-CAF relationship. Molecular expressions were validated by qRT-PCR and Western blots, with in vivo studies further solidifying the observations. RESULTS: Our study emphasized the connection between PROX1 and α-SMA in CAFs. Elevated PROX1 in CRC samples correlated with increased α-SMA in tumors. PROX1 modulation influenced the behavior of specific CRC cells, with its overexpression fostering invasiveness. Kaplan-Meier evaluations demonstrated a link between PROX1 or α-SMA and survival outcomes. Consequently, PROX1, alone or with α-SMA, emerges as a CRC prognostic marker. Co-culture and animal experiments further highlighted this relationship. CONCLUSION: PROX1 appears crucial in modulating CRC behavior and therapeutic resistance within the TME by influencing CAFs, signifying the combined PROX1/α-SMA gene as a potential CRC prognostic marker. The concept of developing inhibitors targeting this gene set emerges as a prospective therapeutic strategy. However, this study is bound by limitations, including potential challenges in clinical translation, a focused exploration on PROX1/α-SMA potentially overlooking other significant molecular contributors, and the preliminary nature of the inhibitor development proposition.

Efficacy and safety of purified starch for adhesion prevention in colorectal surgery.

Background: Adhesions within the abdominal cavity develop in as many as 90 % of individuals following abdominal surgery. However, the true adhesive condition of patients can only be ascertained during the second surgery. Methods: We conducted a prospective, non-randomized study to assess the anti-adhesion properties of purified starch in patients who had undergone colorectal surgery in the past and then needed a subsequent surgical intervention. Adhesion scores have been prospectively recorded in operation notes since January 2020 when patients underwent a second surgery. Patients who had received purified starch during their initial surgery constituted the purified starch group, while those who had not received anti-adhesion medical materials were the control group. The main objectives of the study were to evaluate the extent and severity of adhesions as primary outcomes, while secondary outcomes included measuring blood loss, operation time, and postoperative complications. Results: We analyzed the data of 101 patients, with 61 in the purified starch group and 40 in the control group. In multivariate analysis, adhesion severity (Odds ratio, 0.20, 95 % confidence interval 0.08-0.54, P < 0.01) and adhesion area scores (Odds ratio, 0.13, 95 % confidence interval 0.04-0.45, P < 0.01) were significantly lower in the purified starch group than in the control group. There was no significant difference in operation times, blood loss, and postoperative complications between the two groups. Conclusion: Purified starch is a safe and effective anti-adhesion material that can significantly reduce the severity and extent of adhesion after colorectal surgery.

Comparison the effect of gelatin sponge and epinephrine-soaked gauze for hemostasis and pain control after hemorrhoidal surgery.

Post-operative pain and bleeding are the main complications following hemorrhoidal surgery. This study aimed to investigate whether an absorbable gelatin sponge is a superior hemostatic and analgesic agent compared to gauze soaked in epinephrine for post-hemorrhoidal surgery care. A retrospective study was conducted using data from a single institute. Data were collected from the electronic medical record database and outpatient patient questionnaire archive. The study encompassed 143 patients who received gauze soaked in epinephrine as the hemostatic agent after hemorrhoidal surgery and 148 patients who received an absorbable gelatin sponge. Most patients underwent stapled hemorrhoidopexy, with 119 (83.2%) in epinephrine group and 118 (79.7%) in gelatin sponge group. The primary outcome measurements were postoperative pain score, oral analgesic dosage and complications. Patients in the absorbable gelatin sponge group reported significantly lower pain scores from 8 h after their hemorrhoidal surgery (postoperative day 0) through postoperative day 2. The average pain scores in the absorbable gelatin sponge group and gauze soaked in epinephrine group were 5.3 ± 3.2 and 6.2 ± 3.2 (p = 0.03) on postoperative 8 h; 4.7 ± 3.0 and 5.8 ± 2.9 (p ≤ 0.01) on postoperative day one; and 4.4 ± 2.8 and 5.3 ± 2.9 (p = 0.01) on postoperative day two, respectively. There were no significant differences in postoperative recovery or complication rates between the two groups. Our study revealed that absorbable gelatin sponges provide more effective pain relief to patients during the initial postoperative days after hemorrhoidal surgery, without any adverse impact on patient outcomes. Consequently, absorbable gelatin sponges are recommended as a replacement for gauze soaked in epinephrine following hemorrhoidal surgery.

Outcomes of right-sided and left-sided colon cancer after curative resection.

The right and left side of the colon derived from the midgut and hindgut, respectively. Previous studies have reported different characteristics of right-sided colon cancer (RCC) and left-sided colon cancer (LCC), but oncological outcomes remain unclear. This study compared the outcomes of RCC and LCC. This retrospective study included 1017 patients who received curative colectomy for stage I-III colon cancer at a single institute between August 2008 and December 2019. Overall survival (OS) and time to recurrence (TTR) were analyzed as outcome measurements. No significant difference in the OS or TTR of patients with RCC and LCC were observed. In subgroup analysis, RCC was associated with shorter TTR than LCC in stage II colon cancer (HR 2.36, 95% confidence interval 1.24-4.48, p < 0.01). Multivariate analysis demonstrated that right sidedness, R1 resection, low body mass index (BMI) and adjuvant chemotherapy were independent factors for poor prognosis for stage II colon cancer. Low BMI, perineural invasion, higher T stage and N2 stage were independent factors for poor prognosis for stage III colon cancer. The results were confirmed by multivariate analysis after propensity score matching. Our study revealed that RCC was an independent risk factor for recurrence in stage II colon cancer.

The necessity of preoperative enema preparation for hemorrhoidal surgery: a single-center comparative study.

BACKGROUND: Hemorrhoidal surgery is a common treatment for high-grade hemorrhoids. The necessity of preoperative enema preparation (PEP) in hemorrhoidal surgery is inconclusive. This study aims to evaluate the benefit and safety of PEP in hemorrhoidal surgery. METHODS: This comparative study analyzed data from electronic medical record database and outpatient questionnaire archive. Data of patients who underwent hemorrhoidal surgery from March 2020 to February 2021 were obtained. Patients were allocated to either the PEP or non-PEP group. Primary outcome measurements were postoperative pain and oral analgesic use. Secondary outcomes were the number of days until first defecation, length of hospital stay, time to return to work, incidence of urinary retention, delayed bleeding, and local infection. RESULTS: Data of 270 consecutive patients, with 130 and 140 in the PEP and non-PEP groups, respectively, who underwent hemorrhoidal surgery were analyzed. Most patients underwent stapled hemorrhoidopexy, with 106 (81.54%) in PEP group and 113 (80.71%) in non-PEP group. The mean pain score was significantly higher in PEP than in non-PEP group at day 0 (6.21 ± 3.23 vs 5.31 ± 3.14), day 1 (5.79 ± 2.89 vs 4.68 ± 3.02), and day 2 (5.35 ± 2.86 vs 4.42 ± 2.76). No significant differences in postoperative recovery or complications rate were noted between groups. CONCLUSION: Our findings revealed that performing PEP before hemorrhoidal surgery produced no benefit when compared with not performing PEP. Typically, the procedure of PEP is inconvenient and discomforting for patients. Therefore, we suggest that it can be omitted in hemorrhoidal surgery.

Incidence and risk factor for infection of totally implantable venous access port.

BACKGROUND: Totally implantable venous access ports (TIVAP) have been widely used in cancer patients for many years. The early infection (within 30 days after TIVAP implantation) rate of TIVAP accounts for about one-third of all TIVAP infections, and early infection often causes port removal and affects subsequent cancer treatment. This study investigated the incidence and risk factors for early and late infection after TIVAP implantation. METHODS: From January 2013 to December 2018, all adult cancer patients who received TIVAP implantation in Taipei Medical University Shuang-Ho Hospital were reviewed. We evaluated the incidence of TIVAP-related infection, patient characteristics, and bacteriologic data. Univariable analysis and multiple logistic regression analysis were used to evaluate the risk factors of TIVAP-related infection. RESULTS: A total of 3001 TIVAPs were implanted in 2897 patients, and the median follow-up time was 424 days (range: 1-2492 days), achieving a combined total of 1,648,731 catheter days. Thirty-one patients (1.0%) had early infection and 167 (5.6%) patients had late infection. In multivariate analysis, TIVAP combined with other surgeries (p = 0.03) and inpatient setting (p < 0.001) was the risk factor of early infection, and TIVAP combined with other surgeries (p = 0.007), hematological cancer (p = 0.03), and inpatient setting (p < 0.001) was the risk factor of late infection. CONCLUSION: Inpatient TIVAP implantation and TIVAP implantation combined with other surgeries are associated with high rates of TIVAP-related early and late infections.

Comparison of the short-term outcomes of using DST and PPH staplers in the treatment of grade III and IV hemorrhoids.

Stapled hemorrhoidopexy has a few advantages such as less postoperative pain and faster recovery compared with conventional hemorrhoidectomy. There are two major devices used for stapled hemorrhoidopexy, PPH stapler (Ethicon EndoSurgery) and DST stapler (Covidien). This study was conducted to investigate the postoperative outcomes among patients with grade III and IV hemorrhoids who underwent hemorrhoidopexy with either of these two devices. A total of 242 consecutive patients underwent stapled hemorrhoidopexy with either PPH stapler (110 patients) or DST stapler (132 patients) at a single center in 2017. We performed a retrospective case-control study to compare the short-term postoperative outcomes and the complications between these two groups. After matching the cases in terms of age, gender, and the grade of hemorrhoids, there were 100 patients in each group (PPH versus DST). There were no significant differences in the postoperative visual analog scale (VAS) score and analgesic usage. Among complications, the incidence of anorectal stricture was significantly higher in the DST group (p = 0.02). Evaluation of the mucosal specimen showed that the total surface area, the muscle/mucosa ratio and the surface area of the muscle were also significantly higher in the DST group (p = 0.03). Further analysis of the DST group demonstrated that patients with anorectal stricture after surgery are younger than patients without anorectal stricture, and higher muscle/mucosa ratio (p = 0.03) and a higher surface area of the muscle (p = 0.03) also measured in the surgical specimen. The two devices provide similar outcomes of postoperative recovery. Patients who underwent DST stapled hemorrhoidopexy had a higher incidence rate of stricture, larger area of muscle excision, and higher muscle/mucosa ratio in the surgical specimen. Further investigation is warranted for a better understanding of the correlation between muscle excision and anorectal stricture.

Single-Incision Robotic Colectomy: Comparison of Short-Term Outcomes with Multiport Robotic Colectomy.

Background: Single-incision laparoscopic colectomy (SILC), although it achieves better cosmetic outcomes, less pain, and faster recovery compared with multiport laparoscopic colectomy, has several limitations and technical difficulties. Herein, we report our initial experience with single-incision robotic colectomy (SIRC) compared with multiport robotic colectomy (MPRC). Materials and Methods: From January 2017 to July 2019, we identified consecutive patients who underwent robotic colectomy. According to the surgical technique, we divided the patients into two groups: SIRC and MPRC. Results: A total of 40 patients underwent robotic colectomy; 20 patients underwent each of SIRC and MPRC. There were no significant differences in baseline characteristics between the two groups. The SIRC group had less blood loss and a shorter average incision length than the MPRC group (P < .05); SIRC also used fewer robotic instruments than MPRC (P ≤ .05). Conclusions: SIRC is a safe and feasible procedure in both right- and left-sided colectomy. SIRC can reduce the total incision length and surgical cost relative to MPRC, reduce surgical instrument collision, and improve the nonergonomic surgical operating environment faced by surgeons performing SILC during surgery.

Comparison of the short-term outcomes in lower rectal cancer using three different surgical techniques: Transanal total mesorectal excision (TME), laparoscopic TME, and open TME.

BACKGROUND: Total mesorectal excision (TME) is the standard surgical principle in the treatment of rectal cancer. However, in recent years, there has been an increasing debate about how to obtain better results in circumferential margin (CRM) and distal margins of the surgical specimen. The CRM and distal margin involvement rates have been linked to local recurrence and disease-free survival rates. In this study, we compared three surgical techniques for the treatment of lower rectal cancer. METHODS: From July 2008 to April 2018, we identified consecutive patients with lower rectal cancer who underwent TME. According to the surgical technique, we divided the patients into three groups: transanal TME (TaTME), laparoscopic TME (LaTME), and open TME (OpTME). RESULTS: A total of 126 patients underwent TME; 39, 64 and 23 patients underwent TaTME, LaTME, and OpTME respectively. Tumor location was lower in the TaTME group than the other groups (p < 0.01). TaTME resulted in longer operation time than the other two groups (p < 0.01). In pathological outcomes, no patients with a CRM <1 mm were observed in the TaTME group compared with five (7.8%) and three patients (13.0%) with CRM <1 mm in the LaTME and OpTME group respectively (p = 0.035). Patients in the TaTME and LaTME groups also had a better disease-free survival than OpTME group (p < 0.01). CONCLUSION: TaTME provides surgeons with a novel and effective method to treat lower rectal cancer. In the short-term outcomes, TaTME achieved better pathological results and disease free survival than OpTME but not significantly superior to LaTME. Further studies are necessary to evaluate the long-term oncological results.

Transanal Total Mesorectal Excision in Lower Rectal Cancer: Comparison of Short-Term Outcomes with Conventional Laparoscopic Total Mesorectal Excision.

BACKGROUND: Transanal total mesorectal excision (TaTME) is a novel technique to treat rectal cancer and also to obtain good-quality specimens. This study investigated the clinical results and perioperative and pathological outcomes of TaTME in lower rectal cancer treatment in comparison with laparoscopic total mesorectal excision (LaTME). METHODS: During January 2014 to May 2017, all consecutive patients with lower rectal cancer who underwent TaTME were identified. This cohort study was matched for age, gender, American Society of Anesthesiology (ASA) score, and clinical staging with a cohort of patients who underwent conventional LaTME. RESULTS: A total of 46 patients were analyzed in both groups. There were no significant differences in baseline characteristics between the groups. The estimated blood loss, duration of operation, and postoperative complications were also not different between both groups. Regarding pathological outcomes, no patients with circumferential margin (CRM) <1 mm were observed in the TaTME group compared to 4 patients with CRM <1 mm in the LaTME group (P = .037). CONCLUSION: TaTME is a safe and feasible procedure in this matched case-control study. TaTME had better pathological outcomes with CRM uninvolvement compared with laparoscopic surgery.

Outcome Analysis of Patients with Gallstone Disease Receiving Cholecystectomy: A Population-Based Cohort Study.

BACKGROUND/AIMS: Cholecystectomy is generally performed to treat patients with gallstone disease (GSD) in clinical practice. The present study aimed to investigate whether type 2 diabetes mellitus (T2DM) may influence the overall survival of GSD patients. METHODS: The National Health Insurance Research Database, a population-based registry data in Taiwan, was used to identify GSD patients from 2001 to 2008. The risk of cancers and effects of T2DM on the overall survival of GSD patients receiving cholecystectomy were estimated by hazards ratios (HRs) and 95% CIs using the Cox proportional hazard model. RESULTS: Among 392,028 eligible GSD patients, 81,971 underwent cholecystectomy, whereas 310,057 did not. After cholecystectomy, the HR for developing cancer was 1.14. The HR for the overall survival was 0.74-fold lower for patients who underwent cholecystectomy than that for patients who did not. GSD patients without T2DM who underwent cholecystectomy (0.78-fold lower risk) had a longer survival, whereas those with T2DM had shorter survival (1.64-fold higher risk without cholecystectomy and 1.13-fold higher risk with cholecystectomy) compared with those without T2DM who did not undergo cholecystectomy. CONCLUSIONS: Our major findings suggest that T2DM may worsen the prognosis of GSD patients after cholecystectomy, which provides useful insight into the treatment of T2DM among GSD patients in clinical settings.

Increased risk of atrial fibrillation in end-stage renal disease patients on dialysis: A nationwide, population-based study in Taiwan.

End-stage renal disease (ESRD) patients commonly have a higher risk of developing cardiovascular diseases than general population. Chronic kidney disease is an independent risk factor for atrial fibrillation (AF); however, little is known about the AF risk among ESRD patients with various modalities of renal replacement therapy. We used the Taiwan National Health Insurance Research Database to determine the incident AF among peritoneal dialysis (PD) and hemodialysis (HD) patients in Taiwan.Our ESRD cohort include Taiwan National Health Insurance Research Database, we identified 15,947 patients, who started renal replacement therapy between January 1, 2002 and December 31, 2003. From the same data source, 47,841 controls without ESRD (3 subjects for each patient) were identified randomly and frequency matched by gender, age (±1 year), and the year of the study patient's index date for ESRD between January 1, 2002 and December 31, 2003.During the follow-up period (mean duration: 8-10 years), 3428 individuals developed the new-onset AF. The incidence rate ratios for AF were 2.07 (95% confidence interval [CI] = 1.93-2.23) and 1.78 (95% CI = 1.30-2.44) in HD and PD groups, respectively. After we adjusted for age, gender, and comorbidities, the hazard ratios for the AF risk were 1.46 (95% CI = 1.32-1.61) and 1.32 (95% CI = 1.00-1.83) in HD and PD groups, respectively. ESRD patients with a history of certain comorbidities including hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, heart failure, valvular heart disease, and chronic obstructive pulmonary disease (COPD) have significantly increased risks of AF.This nationwide, population-based study suggests that incidence of AF is increased among dialysis ESRD patients. Furthermore, we have to pay more attention in clinical practice and long-term care for those ESRD patients with a history of certain comorbidities.

Effect of Glyceryl Trinitrate Ointment on Pain Control After Hemorrhoidectomy: A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Hemorrhoidectomy is associated with postoperative pain and prolonged wound healing. Glyceryl trinitrate has been shown to decrease muscle spasm and increase anodermal blood flow. A meta-analysis of randomized controlled trials was conducted to evaluate the efficacy of topical glyceryl trinitrate application in pain relief after hemorrhoidectomy. METHODS: PubMed, EMBASE, Cochrane Library, Scopus, and ClinicalTrials.gov registries were searched for studies published before August 2015. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate a pooled effect size using random effects models. Pain was assessed using a visual analog scale on days 1, 3, 7, and 14 after operation. Secondary outcomes included time taken to resume routine activities, wound healing at 3 weeks after operation, complication, and headache incidence. RESULTS: A total of 12 trials with 1095 patients were reviewed. Significant pain reduction was observed on days 1, 3, 7, and 14 after hemorrhoidectomy in the glyceryl trinitrate groups. Glyceryl trinitrate-treated patients appeared to resume routine activities earlier than those in the control group (weight mean difference -7.52; 95% confidence interval: 16.13-1.08). The wound healing rates 3 weeks after operation were significant higher in the glyceryl trinitrate-treated groups than in the control group (risk ratio 1.79; 95% confidence interval: 1.38-2.33). However, the incidence of headache significantly increased in the glyceryl trinitrate group (risk ratio 3.68; 95% confidence interval: 1.62-8.34). CONCLUSION: Topical application of glyceryl trinitrate effectively relieves pain and promotes wound healing after hemorrhoidectomy; however, the substantial headache incidence may limit extensive application.

The learning curve for laparoscopic colectomy in colorectal cancer at a new regional hospital.

BACKGROUND: Laparoscopic colorectal surgery has been extensively used, although mostly performed in medical centers or university hospitals. We analyzed the learning curve of laparoscopic colectomy in a new regional hospital and determined the experience necessary to achieve proficiency. METHODS: From July 2008 to December 2013, the retrospective clinical study enrolled 240 patients who underwent laparoscopic colectomy. They were sequentially divided into Group A (Patients 1-80), Group B (Patients 81-160), and Group C (Patients 161-240). Patient demographics and perioperative parameters were analyzed. Operation time, as a measure of learning time, was analyzed using the moving-average method. RESULTS: All patients were comparable for age, gender, body mass index, tumor location, cancer stage, length of hospital stay, intraoperative complication, morbidity, and mortality. Group A experienced more blood loss (p < 0.01) and longer operation time (p < 0.001). All laparoscopic operation time stabilized after 85 cases. Subgroup analysis showed that operation time stabilized after 15 cases for right hemicolectomy, 15 cases for sigmoidectomy, and 22 cases for low anterior resection with total mesorectal excision. CONCLUSION: Laparoscopic colectomy for colorectal cancer in a new regional hospital is feasible and safe. It does not need additional time for learning. Laparoscopic sigmoidectomy can be considered as the initial surgery for a trainee.