What is related to postoperative outcome of frail status in elective colorectal cancer surgery?

Background: The population affected by colorectal cancer is growing, and there is an increasing need for prevention of functional decline following treatment. We proposed that the Kihon Checklist published by the Japanese Ministry of Health, Labor, and Welfare would be an appropriate means of frailty assessment for prediction of postoperative complications in older patients with colorectal cancer. This prospective cohort study aims to identify the factors influencing postoperative frailty. Methods: We prospectively enrolled consecutive patients with colorectal cancer and aged ≥ 65 year (N = 500) between May 2017 and December 2018. Eligible patients were assessed with the Kihon Checklist prior to surgery and 30 days after surgery. The main measures were variables related to postoperative change in view of frail status. Results: According to the Kihon Checklist questionnaire, 164 patients were frail preoperatively and 172 patients were frail postoperatively, whereas 38 patients changed from "nonfrail" before surgery to postoperative "frail." Overall complications were counted in 97 patients (19.4%), and 5 patients died. Performance status ≥ 2, history of laparotomy, open surgery, complication, ostomy creation, and delirium were significantly associated with changing postoperative "frail" (P = .014, P = .023, P = .006, P < .001, P = .023, and P = .024, respectively). In multivariate analysis, independent related factors of changing postoperative "frail" were complication (odds ratio 2.69, 95% confidence interval 1.19-6.09, P = .018) and ostomy creation (odds ratio 2.32, 95% confidence interval 1.01-5.33, P = .047). Conclusion: The Kihon Checklist questionnaire could identify the factors related to postoperative change of frailty status in older patients with colorectal cancer. This cohort concluded that whether postoperative complication occurred or not was closely associated with perioperative change of frailty status.

Vaginal stump metastasis from sigmoid colon cancer.

BACKGROUND: Vaginal metastasis from organs other than the uterus is rare. Generally, patients with vaginal metastasis from colorectal cancer have a dismal prognosis. Although biopsy is the best method to make the diagnosis, massive bleeding may occur. On the other hand, liquid-based cytology (LBC) has the utility to perform immunocytochemistry on additional unstained slides: we can make a diagnosis with several immunocytochemical findings. CASE: A 67-year-old postmenopausal female presented to our hospital with vaginal bleeding. The patient had undergone colectomy because of her stage III sigmoid colon cancer 3 years earlier. The patient had also undergone hysterectomy for cervical cancer 30 years earlier. LBC from the vaginal stump revealed adenocarcinoma. Immunocytochemically, cancer cells were negative for cytokeratin 7 and positive for cytokeratin 20, which suggested metastasis from the sigmoid colon cancer; the diagnosis was made without a biopsy. CONCLUSION: When the patient has a metastatic lesion from colon adenocarcinoma, LBC with immunocytochemistry is useful in making a diagnosis.

A wound protector shields incision sites from bacterial invasion.

BACKGROUND: Superficial surgical site infection (SSI) can be caused by bacterial invasion during surgery. We investigated whether bacteria are found at the wound margin during surgery and whether a wound protector (WP; Alexis® Wound Retractor; Applied Medical, Rancho Santa Margarita, CA) contributes to preventing invasion of the incision margin. METHODS: We studied 272 patients who underwent gastrointestinal surgery (115 gastric, 157 colorectal, including emergency operations) between October 2005 and July 2007. The WP was used in all operations. After the intra-abdominal procedures were complete, bacterial swabs were taken from the abdominal cavity side of the WP and from the incision margin and used to prepare smears and cultures. After the swabbing, peritoneal lavage was performed using 3,000-5,000 mL of physiologic saline, and, after suture of the fascia, 500-1,000 mL of physiologic saline was used to irrigate the subcutaneous tissue. RESULTS: Nine gastric surgery patients and 15 colorectal surgery patients had positive cultures from the abdominal cavity. No patients had positive cultures from the incision margin. Of the 24 patients with positive cultures, three suffered SSIs, all of whom had undergone colorectal surgery. Of the patients who had negative cultures, SSI occurred in only one patient, who had undergone colorectal surgery. CONCLUSIONS: These results suggest that the WP protects an incision site from bacterial invasion.

A case of pathological complete response of advanced rectal cancer to preoperative chemoradiotherapy using S-1.

In patients with advanced rectal cancer, preoperative chemoradiotherapy is superior to postoperative chemoradiotherapy because of causing less toxicity and achieving higher rates of sphincter preservation and curative resection. We treated a patient who had advanced rectal cancer with preoperative chemotherapy using S-1 and concurrent radiotherapy. S-1 was orally administered at a dose of 100 mg/day during the first cycle (two-week on and one week off). During the third cycle, radiotherapy was initiated concurrently and a total dose of 45 Gy was given. The most severe adverse event was grade 3 leukopenia during the third cycle. On day 42 after completing radiotherapy, low anterior resection with diverting colostomy was performed. Histological examination found no viable cancer cells in the resected specimens, including the primary tumor site and lymph nodes. Thus, a pathological complete response was achieved. Postoperatively, anastomotic leakage occurred, but it was resolved with transanal drainage. Preoperative chemoradiotherapy using S-1 contributed to sphincter preservation and curative resection in this patient. This regimen was both effective and well-tolerated, suggesting that it could be useful for advanced rectal cancer.

[Palliative care team in National Hospital Organization Osaka Minami Medical Center].

Preparation of a system of palliative care support is called for by The Basic Act on Anti-Cancer Measures and The Basic Plans for National Cancer Strategy. The Organization of Hospitals for Cancer Treatment should play a very important role in the regional palliative care network. The palliative care team in the Organization of Hospitals for Cancer Treatment should promote palliative care support throughout regional hospitals. In 2007, we established a palliative care team at the National Hospital Organization Osaka Minami Medical Center. We have drawn up a detailed report on the activities of palliative care team in our medical center.

Omental torsion secondary to right inguinal hernia: case report and cumulative review of the English literature.

A case of omental torsion secondary to right inguinal hernia in a 51-year-old man was operated on in Naga Hospital. Preoperative computed tomography (CT) showed a characteristic whirling fatty mass and entering into a right inguinal hernia. Omental torsion is a relatively rare disease, and the preoperative diagnosis is difficult because of nonspecific clinical signs and symptoms. In this report, we gathered 36 patients with omental torsion from the English language literature since 1986, with the addition of the patient herein reported, and clarified the symptoms, imaging findings, and management of omental torsion.

Development of an early diagnostic system using fuzzy theory for postoperative infections in patients with gastric cancer.

BACKGROUND: Early prediction of infection following surgery for gastric cancer may permit earlier intervention. AIM: The aim was to develop an early diagnostic system for postoperative infection. METHODS: Clinical and laboratory data were analyzed in 180 patients who had surgery for gastric cancer at the Wakayama Medical University Hospital (January 1992 to December 1994). Of these, 60 patients developed a postoperative infection. A predictive system was then devised using fuzzy theory and evaluated in a second set of 137 patients who underwent surgery for gastric cancer at Wakayama Medical University and 10 other associated hospitals (August 1995 to January 1997). RESULTS: The system identified seven parameters grouped into six rules and entered into a fuzzy logic system to predict either infection or non-infection. (1) Blood loss, and extent of resection; (2) the febrile pattern during days 2 to 4; (3) differential leukocyte count on day 4; (4) C-reactive protein level on day 4; (5) time sequential vectors during days 1-4 for the band cell neutrophil count, and (6) leukocyte count. The sensitivity was 86% (24/28), the specificity was 90% (98/109), the negative predictive value was 96% (98/102), the positive predictive value was 69% (24/35) and the overall accuracy was 80% (122/137). CONCLUSION: Fuzzy theory can provide early prediction of postoperative infection using standard clinical and biochemical parameters. The clinical utility of this system needs to be determined in future studies.