Incidence of low anterior resection syndrome and its association with the quality of life in patients with lower rectal tumors.

PURPOSE: Low anterior resection syndrome (LARS) causes devastating symptoms and impairs the quality of life (QOL). This study investigated the incidence and risk factors of LARS and their association with the QOL in patients with lower rectal tumors. METHODS: Patients who underwent anus-preserving surgery for lower rectal tumors between 2014 and 2019 and who had anal defecation between 2020 and 2021 were surveyed. The LARS score measured severity, and the QOL was evaluated using the Japanese version of the Fecal Incontinence Quality-of-Life Scale (JFIQL). The primary endpoint was the incidence of Major LARS, and the secondary endpoints were risk factors and association with the JFIQL. RESULTS: Of 107 eligible patients, 82 (76.6%) completed the LARS survey. The incidence of Major LARS was 48%. Independent risk factors included neoadjuvant chemoradiotherapy (CRT) and a short interval (< 24 months after surgery; odds ratio, 4.6; 95% confidence interval: 1.1-19, both). The LARS score was moderately correlated with the JFIQL generic score (correlation coefficient: - 0.54). The JFIQL scores were significantly worse in the Minor and Major LARS groups than in the No LARS group. CONCLUSIONS: Major LARS was found in 48% of lower rectal tumors, and independent risk factors include neoadjuvant CRT and a short interval. The QOL was significantly impaired in patients with both Minor and Major LARS.

Low anterior resection syndrome: Incidence and association with quality of life.

Aim: Low anterior resection syndrome (LARS) causes devastating symptoms and impairs quality of life (QOL). Although its incidence and risk factors have been reported, these data are scarce in Japan. This study aimed to elucidate the incidence and risk factors of LARS as well as to evaluate its association with QOL in Japanese patients. Method: Patients with anal defecation at the time of the survey between November 2020 and April 2021 were included, among those who underwent anus-preserving surgery for rectal tumors between 2014 and 2019 in tertiary referral university hospital. The severity of LARS and QOL were evaluated with the LARS score and the Japanese version of the fecal incontinence quality of life scale (JFIQL), respectively. Primary endpoint was the incidence of major LARS. Secondary endpoints were risk factors and association with JFIQL. Results: Of 332 eligible patients, 238 (71.7%) answered the LARS survey completely. The incidence of major LARS was 22% overall, and 48% when limited to lower tumors. Independent risk factors included lower tumors (OR: 7.0, 95% CI: 2.1-23.1, p = 0.001) and surgical procedures with lower anastomoses (OR: 4.6, 95% CI: 1.2-18.5, p = 0.03). The JFIQL generic score correlated moderately with the LARS score (correlation coefficient of -0.65). The JFIQL generic score was also significantly lower in lower tumors. Conclusions: The incidence of major LARS is 22% in Japanese patients, and independent risk factors include lower tumors and surgical procedures with lower anastomoses. More severe LARS is associated with worse QOL which is significantly more impaired in patients with lower tumors.

The effect of staple height and rectal-wall thickness on anastomotic leakage after laparoscopic low anterior resection.

BACKGROUND: The aim of this study was to evaluate the effect of staple height and rectal wall thickness on the development of an anastomotic leak after laparoscopic low anterior resection performed with the double stapling technique. METHODS: One hundred ninety-nine patients treated from 2013 to 2021 were enrolled. Patients were divided into two groups: those who developed an anastomotic leak (AL (+)) and those who did not (AL (-)). Clinicopathological factors were compared between the groups. RESULTS: Anastomotic leaks were observed in 8/199 patients (4%). A 1.5 mm linear stapler was used for 35/199 patients (17%), 1.8 mm for 89 (45%), and 2 mm for 75 (38%). In the AL (+) group (n = 8), lower staple height (1.5 mm or 1.8 mm) was used more frequently than in the AL (-) group (n = 191). Rectal wall thickness and the rectal wall thickness to staple height ratio was significantly (p < .05) greater in the AL (+) group. However, rectal wall thickness was significantly (p < .05) greater in patients who received neoadjuvant treatment and those with advanced T stage (T3,4) lesions. CONCLUSION: Linear stapler staple height and rectal wall thickness are significantly associated with the development of an anastomotic leak after laparoscopic low anterior resection. Larger staples should be selected in patients with a thicker rectal wall due to neoadjuvant treatment or adjacent advanced rectal tumors.

SAFETY AND EFFECTIVENESS OF A STATIC WEARABLE CHAIR FOR PATIENTS REQUIRING REHABILITATION: A PRELIMINARY REPORT.

OBJECTIVE: To evaluate the acceptability of using a static wearable chair for patients requiring rehabilitation. METHODS: The acceptability of use of a static wearable chair during rehabilitation was assessed via static balance and subjective evaluation of 7 healthy subjects and 3 patients during standing training. Participants performed 1 standing task in free mode (in which the knee could bend freely) and 1 in support mode (in which the user could sit on the wearable chair with the knee slightly bent) for 3 min. For balance evaluation, the skeletal coordinates were measured. For subjective evaluation, a visual analogue scale questionnaire was administered before and after each task. RESULTS: Balance assessment revealed that patients had less head sway during support, whereas subjective evaluation showed that the device support created a positive psychological state in terms of stability, comfort, satisfaction, interest in usage, and motivation for rehabilitation. However, patients reported feeling strangeness, fear, or restraint during support. CONCLUSION: The static wearable chair improved the static balance of 3 patients and created a more positive psychological state. Use of the device is considered acceptable for use with rehabilitation patients. However, patients might feel strangeness, fear, and restraint during support. Familiarization with the static wearable chair may make it more acceptable among rehabilitation patients.

Japanese Practice Guidelines for Fecal Incontinence Part 1-Definition, Epidemiology, Etiology, Pathophysiology and Causes, Risk Factors, Clinical Evaluations, and Symptomatic Scores and QoL Questionnaire for Clinical Evaluations-English Version.

Fecal incontinence (FI) is defined as involuntary or uncontrollable loss of feces. Gas incontinence is defined as involuntary or uncontrollable loss of flatus, while anal incontinence is defined as the involuntary loss of feces or flatus. The prevalence of FI in people over 65 in Japan is 8.7% in the male population and 6.6% among females. The etiology of FI is usually not limited to one specific cause, with risk factors for FI including physiological factors, such as age and gender; comorbidities, such as diabetes and irritable bowel syndrome; and obstetric factors, such as multiple deliveries, home delivery, first vaginal delivery, and forceps delivery. In the initial clinical evaluation of FI, the factors responsible for individual symptoms are gathered from the history and examination of the anorectal region. The evaluation is the basis of all medical treatments for FI, including initial treatment, and also serves as a baseline for deciding the need for a specialized defecation function test and selecting treatment in stages. Following the general physical examination, together with history taking, inspection (including anoscope), and palpation (including digital anorectal and vaginal examination) of the anorectal area, clinicians can focus on the causes of FI. For the clinical evaluation of FI, it is useful to use Patient-Reported Outcome Measures (PROMs), such as scores and questionnaires, to evaluate the symptomatic severity of FI and its influence over quality of life (QoL).

Japanese Practice Guidelines for Fecal Incontinence Part 2-Examination and Conservative Treatment for Fecal Incontinence- English Version.

Examination for fecal incontinence is performed in order to evaluate the condition of each patient. As there is no single method that perfectly assesses this condition, there are several tests that need to be conducted. These are as follows: anal manometry, recto anal sensitivity test, pudendal nerve terminal motor latency, electromyogram, anal endosonography, pelvic magnetic resonance imaging (MRI) scan, and defecography. In addition, the mental and physical stress most patients experience during all these examinations needs to be taken into consideration. Although some of these examinations mostly apply for patients with constipation, we hereby describe these tests as tools for the assessment of fecal incontinence. Conservative therapies for fecal incontinence include diet, lifestyle, and bowel habit modification, pharmacotherapy, pelvic floor muscle training, biofeedback therapy, anal insert device, trans anal irrigation, and so on. These interventions have been identified to improve the symptoms of fecal incontinence by determining the mechanisms resulting in firmer stool consistency; strengthening the pelvic floor muscles, including the external anal sphincter; normalizing the rectal sensation; or periodic emptying of the colon and rectum. Among these interventions, diet, lifestyle, and bowel habit modifications and pharmacotherapy can be performed with some degree of knowledge and experience. These two therapies, therefore, can be conducted by all physicians, including general practitioners and other physicians not specializing in fecal incontinence. However, patients with fecal incontinence who did not improve following these initial therapies should be referred to specialized institutions. Contrary to the initial therapies, specialized therapies, including pelvic floor muscle training, biofeedback therapy, anal insert device, and trans anal irrigation, should be conducted in specialized institutions as these require patient education and instructions based on expert knowledge and experience. In general, conservative therapies should be performed for fecal incontinence before surgery because its pathophysiologies are mostly attributed to benign conditions. All Japanese healthcare professionals who take care of patients with fecal incontinence are expected to understand the characteristics of each conservative therapy, so that appropriate therapies will be selected and performed. Therefore, in this chapter, the characteristics of each conservative therapy for fecal incontinence are described.

Japanese Practice Guidelines for Fecal Incontinence Part 3 -Surgical Treatment for Fecal Incontinence, Fecal Incontinence in a Special Conditions- English Version.

In Japan, the surgical treatment for fecal incontinence (FI) can be performed using minimally invasive surgery, such as anal sphincteroplasty and sacral neuromodulation (SNM), as well as antegrade continence enema (ACE), graciloplasty, and stoma construction. In addition, currently, several other procedures, including biomaterial injection therapy, artificial bowel sphincter (ABS), and magnetic anal sphincter (MAS), are unavailable in Japan but are performed in Western countries. The evidence level of surgical treatment for FI is generally low, except for novel procedures, such as SNM, which was covered by health insurance in Japan since 2014. Although the surgical treatment algorithm for FI has been chronologically modified, it should be sequentially selected, starting from the most minimally invasive procedure, as FI is a benign condition. Injuries to the neural system or spinal cord often cause disorders of the sensory and motor nerves that innervate the anus, rectum, and pelvic floor, leading to the difficulty in controlling bowel movement or FI and/or constipation. FI and constipation are closely associated; when one improves, the other tends to deteriorate. Patients with severe cognitive impairment may present with active soiling, referred to as "incontinence" episodes that occur as a consequence of abnormal behavior, and may also experience passive soiling.

Colonoscopic Treatment of a Fecaloma at the Anastomotic Site after Colectomy.

Fecalomas most commonly occur in constipated patients and are rarely reported after colectomy. A 55-year-old Japanese female presented with a fecaloma after colectomy, which was impacted at a functional end-to-end anastomosis (FEEA) site. Four and a half years ago, she underwent sigmoidectomy for colon cancer. A follow-up computed tomography (CT) scan revealed an 11 cm incidental fecaloma. The patient was advised to undergo surgery, but she desired nonoperative management because of minimal symptoms, and was referred to our institution. On the day of admission (day 1), mechanical fragmentation of the fecaloma was attempted during the first colonoscopy. Although a large block of stool was evacuated after a second colonoscopic fragmentation on day 8, the third colonoscopy on day 21 and CT scan on day 22 showed no significant change in the fecaloma. Frequent colonoscopic fragmentation was performed, with a fourth, fifth, and sixth colonoscopy on days 24, 29, and 31, respectively. After the size reduction was confirmed at the sixth colonoscopy, the patient was discharged home on day 34. The fecaloma completely resolved after the seventh colonoscopic fragmentation on day 44. Sixteen months after treatment, there is no evidence of recurrent fecaloma. According to the literature, risk factors for fecaloma after colectomy include female gender, left-side colonic anastomosis, and FEEA. FEEA might not be recommended for anastomoses in the left colon, particularly in female patients, to avoid this complication. Colonoscopic fragmentation is recommended for fecalomas at an anastomotic site after colectomy in patients without an absolute indication for surgery.

Dipeptidyl Peptidase (DPP)-4 Inhibitor Impairs the Outcomes of Patients with Type 2 Diabetes Mellitus After Curative Resection for Colorectal Cancer.

Dipeptidyl peptidase IV inhibitor (DPP-4i) has been shown to act either as a promoter or as a suppressor for cancer. Although epidemiologic studies suggest that DPP-4i does not correlate with the development of malignancies, its effects on cancer metastases are controversial. We evaluated the impact of DPP-4i on postoperative outcomes of the diabetic patients with colorectal cancer and microscopic features of the resected tumors. In 260 consecutive patients with type 2 diabetes mellitus (T2DM) who underwent curative resection of colorectal cancer, the correlation between DPP-4i use and prognosis was retrospectively examined. Expression of Zeb1 on tumor cells and density of infiltrating immune cells were quantitatively evaluated with multicolor IHC in 40 tumors from DPP-4i users, 40 tumors from propensity score-matched users, and 40 tumors from nonusers. Postoperative disease-free survival (DFS) was significantly lower in 135 patients treated with DPP-4i compared with 125 nontreated patients [5-year DFS, 73.7% vs. 87.4%; HR, 1.98; 95% confidence interval (CI), 1.05-3.71; P = 0.035]. IHC revealed that the number of Zeb1+ tumor cells increased in tumors from DPP-4i-treated patients than tumors from nonusers (P < 0.01). The densities of CD3+ and CD8+ T cells were significantly lower in tumors from DPP-4i users (P < 0.01) with decreased density of tertiary lymphoid structures (P < 0.001). However, the density of M2-type tumor-associated macrophages with CD68+ CD163+ phenotypes was significantly higher (P < 0.01) in tumors from DPP-4i users. Exposure of colorectal cancer to DPP-4i may accelerate epithelial-to-mesenchymal transition (EMT) creating a tumor-permissive immune microenvironment, which might impair the outcomes of the patients with colorectal cancer and T2DM. Significance: DPP-4i has been shown to enhance the antitumor effects of immunotherapy. However, we found that DPP-4i significantly impairs the outcomes of patients with colorectal cancer who underwent curative resection, possibly through acceleration of EMT and creation of a tumor-permissive immune microenvironment. This suggests that DPP-4i must be used with caution until its safety is fully confirmed by further studies of the mechanistic effects on existing cancers in humans.

Metformin changes the immune microenvironment of colorectal cancer in patients with type 2 diabetes mellitus.

Accumulating evidence suggests that metformin reduces the incidence and mortality of colorectal cancer (CRC). However, underlying mechanisms have not been fully clarified. The aim of this study was to examine the pathological characteristics of resected CRC from patients treated with metformin for type 2 diabetes mellitus (DM). In total, 267 patients with DM underwent curative colectomy for Stage I-III CRC and 53 (19.9%) patients had been treated medically including metformin. Pathological N-stage was significantly lower in metformin-treated patients (P < .05) with prolonged disease-free survival (DFS) (P < .05). Immunohistochemistry showed that the densities of CD3(+) and CD8(+) tumor-infiltrating lymphocytes (TILs) in the invasive front area were significantly higher in 40 patients treated with metformin compared with propensity score matched cases without metformin (P < .05). The density of tertiary lymphoid structures (TLS) in tumor stroma was markedly increased in metformin-treated patients (P < .001). In those tumors, there were more CD68(+) tumor-associated macrophages (TAM) infiltrated (P < .05), while the ratio of CD163(+) M2-phenotype was markedly reduced (P < .001). Stromal fibrosis tended to be suppressed by metformin intake (P = .051). These findings suggested that metformin drastically changes the characteristics of infiltrating immune cells in CRC and reprograms the tumor microenvironment from immunosuppressive to immunocompetent status, which may lead to suppression of microscopic tumor spread and improve the outcomes of patients with CRC and type 2 DM.

Goblet cell carcinoid of the rectum: a case report.

BACKGROUND: Goblet cell carcinoid (GCC) is a neuroendocrine tumor usually found in the appendix. GCCs exhibit characteristic findings with mixed endocrine-exocrine features such as staining positive for neuroendocrine markers and producing mucin. The primary GCC of the rectum is exceedingly rare. CASE PRESENTATION: A 77-year-old Japanese male presented with hematochezia. Anal tenderness and a hard mass in the anal canal were found on the digital rectal examination, and colonoscopy was performed. Colonoscopy showed an irregularly shaped mass in the anal canal. Biopsy showed mixed features including adenocarcinoma in situ, well-differentiated adenocarcinoma, and mucinous carcinoma with invasive proliferation. No metastatic lesions were found on the computed tomography scan. Pelvic magnetic resonance imaging scan showed extramural growth of a tumor on the ventral side of the rectum without invasion to the prostate. Laparoscopic abdominoperineal resection was performed. The final diagnosis was well-differentiated adenocarcinoma in the mucosa and goblet cell carcinoid from the submucosa to the adventitia of the rectum. The patient was discharged from the hospital on postoperative day 16. Six months after resection, a computed tomography scan revealed multiple metastatic lesions in the liver. Several chemotherapy regimens were given, and the patient has stable disease 27 months after surgery. CONCLUSION: We present a patient with rectal GCC with metachronous liver metastases. Since GCC grows intramurally and is biologically aggressive compared to typical carcinoid lesions, the disease is usually diagnosed at an advanced stage. The development of optimal adjuvant chemotherapy is needed for those patients.

Cost-Effectiveness Analysis of Transanal Irrigation for Managing Neurogenic Bowel Dysfunction in Japan.

BACKGROUND: Neurogenic bowel dysfunction (NBD) is a common sequela in Spinal Cord Injury (SCI) patients. Bowel dysfunction symptoms have a significant negative impact on quality of life (QOL) and are often socially disabling. Transanal irrigation (TAI) is a bowel management procedure that significantly mitigates NBD symptoms in patients refractory to standard bowel care (SBC) by reducing the incidence of fecal incontinence, ameliorating constipation, and improving QOL. TAI devices are used across many countries such as the United Kingdom, Germany, and France, and introduction of the devices is being considered in Japan. In this context, a cost-effectiveness analysis specific to Japanese settings is relevant. OBJECTIVES: To analyze the cost-effectiveness of TAI for bowel management of SCI patients with NBD in a Japanese clinical setting. METHODS: A modified version of a previously developed and published Markov model was used to evaluate the cost-effectiveness of TAI. In the model, SCI patients using TAI due to NBD were compared with SCI patients not responding to TAI and continuing with SBC. Quality-adjusted Life Years (QALYs) were used as the primary effectiveness measure, and the analysis was conducted from the payer's perspective. RESULTS: The model predicts a lifetime incremental cost of TAI to be 3 198 687 yen compared with SBC. TAI provided an additional 0.8 QALY, which leads to an incremental cost-effectiveness ratio (ICER) of TAI vs SBC of 4 016 287 yen/QALY. CONCLUSIONS: An ICER of 4 million yen falls within the range of reported willingness to pay (WTP) per QALY gain (5-6.7 million yen) in Japan, and TAI is therefore found to be a cost-effective treatment strategy compared to SBC. The result should be further corroborated in future Japanese trials of TAI.

Validity and reliability of the Japanese version of the Patient Assessment of Constipation Quality of Life questionnaire.

BACKGROUND: This study aimed to provide a psychometric evaluation of the Japanese version of the Patient Assessment of Constipation Quality of Life questionnaire (JPAC-QOL). METHODS: Data for scoring were collected prospectively from patients with constipation who visited our center from 2008 to 2010, and analyzed retrospectively. Reliability of the JPAC-QOL was evaluated using Cronbach's alpha to calculate internal consistency, and a test-retest study was performed to evaluate reproducibility. For concurrent validity assessment, the JPAC-QOL scores were compared with Constipation Scoring System (CSS) scores. In assessing responsiveness, the JPAC-QOL scores before and after treatments were compared in patients whose modified CSS (mCSS) scores decreased by >50 %. RESULTS: Internal consistency was assessed in 295 patients (165 women; mean age 67.0 years). Cronbach's alpha was >0.7 for the overall score and all four subscales, showing a strong internal consistency. The intraclass correlations for the 145 patients available for the test-retest study were >0.7 for the overall score and for all subscales except satisfaction. The JPAC-QOL scores were significantly associated with the CSS scores in 284 patients, demonstrating concurrent validity in all four subscales and the overall score. The mean JPAC-QOL score improved significantly after treatment in the 72 patients whose mCSS scores decreased by >50 %, indicating good responsiveness in all four subscales and in the overall score. CONCLUSIONS: Our study data confirmed the validity and reliability of the JPAC-QOL and demonstrated it ready for use in evaluating the symptom-specific QOL in Japanese patients with constipation.

Efficacy of laparoscopic gastric mobilization for esophagectomy: comparison with open thoraco-abdominal approach.

BACKGROUND: Less invasive esophagectomy using laparoscopic or thoracoscopic surgery has been reported to have the advantages in short-term recovery over the conventional open thoraco-abdominal approach. However, few reports directly compare laparoscopic gastric mobilization (LGM) and thoracotomy with laparotomy and thoracotomy. The aim of this study was to prove the clinical efficacy of LGM compared with open thoraco-abdominal esophagectomy (OE) in treating thoracic esophageal cancer. PATIENTS AND METHODS: We retrospectively reviewed 92 consecutive patients who underwent esophagectomy by OE (n=47) or LGM (n=45) between 1999 and 2009 at Kochi Medical School (Kochi, Japan) to analyze the surgical outcomes. RESULTS: Patients who underwent LGM had significantly lower operative blood loss (430 versus 1060 mL; P<.001), lower rate of postoperative infections (POIs) (33.3 versus 55.3%; P=.034), shorter length of intensive care unit stay (1 versus 3 days; P<.001), and hospital stay (35 versus 46 days; P=.003). CONCLUSIONS: LGM has clinical benefits compared with OE in reduced POIs and faster recovery for patients with esophageal cancer.

Oral supplementation of branched-chain amino acids reduces early recurrence after hepatic resection in patients with hepatocellular carcinoma: a prospective study.

PURPOSES: The long-term outcomes of branched-chain amino acids (BCAA) administration after hepatic resection in patients with hepatocellular carcinoma (HCC) remain unclear. This study assessed the effect of oral supplementation with BCAA on the development of liver tumorigenesis after hepatic resection in HCC patients. METHODS: Fifty-six patients were randomly assigned to receive either BCAA supplementation (Livact group, n = 26) or a conventional diet (Control group, n = 30). Twenty-six patients in the BCAA group were treated orally for 2 weeks before and 6 months after hepatic resection. Postoperative tumor recurrence was continuously evaluated in all patients by measuring various clinical parameters. RESULTS: There was no significant difference in the overall survival rate between the two patient groups; however, the recurrence rate at 30 months after surgery was significantly better in the Livact group in comparison to the Control group. Interestingly, the tumor markers, such as AFP and PIVKA-II, significantly decreased at 36 months after liver resection in the Livact group in comparison to the Control group. CONCLUSIONS: Oral supplementation of BCAA reduces early recurrence after hepatic resection in patients with HCC. This treatment regimen offers potential benefits for clinical use in such patients, even in cases with a well-preserved preoperative liver function.

Branched-chain amino acid-enriched nutrients stimulate antioxidant DNA repair in a rat model of liver injury induced by carbon tetrachloride.

Oxidative stress (OS) plays an important role in the progression of chronic liver disease including organ injury and hypoalbuminemia. Long-term oral supplementation with branched-chain amino acids (BCAAs) can inhibit liver dysfunction but their role in the prevention of liver fibrosis and injury to the liver is unclear. The aim of this study was to assess how BCAAs preserve liver function from OS. To investigate how BCAAs specifically prevent OS, we evaluated the effect of oral supplementation with BCAAs on OS using a rat liver cirrhosis model. Liver cirrhosis was induced in ten male Sprague-Dawley rats by administering carbon tetrachloride for 12 weeks. Five of the ten carbon tetrachloride-treated rats were assigned to a control group and five to a BCAA group. BCAA-supplementation significantly preserved plasma albumin concentrations and significantly inhibited the occurrence of organ injury as determined by blood chemistry analysis. Hepatic expression of OGG1 mRNA was increased in the BCAA group compared to the control group. In the BCAA group, increased hepatic levels of OGG1 protein were found by western blot. On the other hand, the number of 8-OHdG-positive cells was significantly higher in liver sections taken 1 month after carbon tetrachloride treatment. Furthermore, OGG1-positive cells were significantly increased in the hepatocytes around the central vein. BCAA was found to reduce OS, which could possibly lead to a decrease in the occurrence of hypoalbuminemia and organ injury. Our results indicate that BCAA-enriched nutrients stimulate antioxidant DNA repair in a rat model of liver injury induced by carbon tetrachloride.

Clinical characteristics of the idiopathic perforation of the colon.

BACKGROUND AND GOALS: Idiopathic perforation of the colon (IPC) is an extremely rare disease, the pathogenesis of which remains poorly understood. We investigate the clinical characteristics of IPC to help improve the diagnosis and treatment of this rare condition. STUDY: We performed a retrospective evaluation of 16 IPC cases diagnosed from 1999 to 2009 which included clinical findings, laboratory data, treatment procedure, and outcome. RESULTS: The most common site of colon perforation was the sigmoid colon (56.3%) followed by the transverse colon (25%). The median age of the IPC patient group was 72.5 years (range: 50 to 86 y) and the mortality rate for the IPC patient group was 18.8%. Eleven patients (68.8%) had a history of chronic constipation. Creatine phosphokinase (CPK) levels were significantly higher in the survivor group than the deceased group (182 U/L vs. 50 U/L; P=0.024), and CPK levels were higher in patients with constipation than in those without constipation (187 U/L vs. 46 U/L; P=0.024). Computed tomography images showed either free air or a dirty mass that indicated extraluminal feces in all cases. The median size of a perforation was 2.0 cm (range: 0.5 to 8.0 cm). Fourteen patients had resection of the perforation segment and colostomy and 2 of these patients had resection without diverting colostomy. CONCLUSIONS: IPC most commonly occurs in the sigmoid colon of elderly people who have chronic constipation. Although chronic constipation is correlated with high CPK levels, other factors, such as poor nutrition status or a delay in treatment, may be associated with an increased mortality rate in IPC patients.