European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula.

AIM: The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology. METHODS: Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG. RESULTS: In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations. CONCLUSION: This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Short-Course Radiotherapy Followed by Consolidation Chemotherapy Is Safe and Effective in Locally Advanced Rectal Cancer: Comparative Short-term Results of Multicenter Propensity Score Case-Matched Study.

BACKGROUND: Consolidation chemotherapy strategies have demonstrated improved pathological complete response and tumor downstaging rates for patients diagnosed with rectal cancer. OBJECTIVE: This study aimed to compare perioperative outcomes and pathological complete response rates among different neoadjuvant treatment strategies in patients undergoing total mesorectal excision for locally advanced rectal cancer. DESIGN: Propensity score case-matched study. SETTING: High-volume tertiary care centers. PATIENTS: Consecutive patients undergoing curative total mesorectal excision between January 2014 and June 2021 were queried. INTERVENTIONS: Patients were divided into 3 groups: long-course chemoradiation therapy with (N = 128) or without (N = 164) consolidation chemotherapy or short-course radiotherapy (N = 53) followed by consolidation chemotherapy. MAIN OUTCOME MEASURES: Demographics, preoperative tumor characteristics, histopathologic outcomes, and postoperative complication rates were reviewed and compared. Propensity score match analysis was conducted. RESULTS: A total of 345 patients (mean age: 58 ± 12 years; female: 36%) met the study inclusion criteria. Time interval from neoadjuvant treatment until surgery was longer for patients receiving consolidation chemotherapy ( p < 0.001). Pathological complete response rates were comparable among patients receiving long-course chemoradiation therapy (20.3%) and short-course radiotherapy with consolidation chemotherapy (20.8%) compared to long-course chemoradiation therapy alone (14.6%) ( p = 0.36). After the propensity score case-matched analysis, 48 patients in the long-course chemoradiation therapy with consolidation chemotherapy group were matched to 48 patients in the short-course radiotherapy with consolidation chemotherapy group. Groups were comparable with respect to age, sex, clinical stage, tumor location, type of surgical approach, and technique. Pathological complete response rate was comparable between the groups (20.8% and 18.8%, p = 0.99). LIMITATIONS: Study was limited by its retrospective nature. CONCLUSIONS: Among recent neoadjuvant treatment modalities, pathological complete response rates, and short-term clinical outcomes were comparable. Short-course radiotherapy with consolidation chemotherapy is safe and effective as long-course chemoradiation therapy as in a short-term period. See Video Abstract at http://links.lww.com/DCR/C174 . LA RADIOTERAPIA DE CORTA DURACIN SEGUIDA DE QUIMIOTERAPIA DE CONSOLIDACIN ES SEGURA Y EFICAZ EN EL CNCER DE RECTO LOCALMENTE AVANZADO RESULTADOS COMPARATIVOS A CORTO PLAZO DEL ESTUDIO MULTICNTRICO DE CASOS EMPAREJADOS POR PUNTAJE DE PROPENSION: ANTECEDENTES: Las estrategias de quimioterapia de consolidación han demostrado una mejor respuesta patológica completa y tasas de reducción del estadio del tumor para pacientes diagnosticados con cáncer de recto.OBJETIVO: Comparar los resultados perioperatorios y las tasas de respuesta patológica completa entre diferentes estrategias de tratamiento neoadyuvante en pacientes sometidos a escisión mesorrectal total por cáncer de recto localmente avanzado.DISEÑO: Estudio de casos emparejados por puntaje de propensión.ENTORNO CLINICO: Centros de atención terciaria de alto volumen.PACIENTES: Pacientes consecutivos sometidos a escisión mesorrectal total curativa por cáncer de recto localmente avanzado entre enero de 2014 y junio de 2021.INTERVENCIONES: Los pacientes se dividieron en tres grupos según la modalidad de tratamiento neoadyuvante: quimiorradioterapia de ciclo largo con (N = 128) o sin (N = 164) quimioterapia de consolidación o radioterapia de ciclo corto (N = 53) seguida de quimioterapia de consolidación.PRINCIPALES MEDIDAS DE RESULTADO: El punto final primario fue la respuesta patológica completa. Se revisaron y compararon los datos demográficos, las características preoperatorias del tumor, los resultados histopatológicos y las tasas de complicaciones posoperatorias entre los grupos de estudio. Se realizó un análisis de casos emparejados por puntaje de propensión.RESULTADOS: Un total de 345 pacientes (edad media de 58 ± 12 años y mujeres: 36%) cumplieron los criterios de inclusión del estudio. El intervalo de tiempo desde el tratamiento neoadyuvante hasta la cirugía fue mayor para los pacientes que recibieron quimioterapia de consolidación ( p < 0,001). Las tasas de respuesta patológica completa fueron comparables entre los pacientes que recibieron quimiorradioterapia de larga duración con quimioterapia de consolidación (20,3 %) y radioterapia de corta duración con quimioterapia de consolidación (20,8%) en comparación con la quimiorradiación de larga duración sola (14,6%) ( p = 0,36). Después del análisis de casos emparejados por puntaje de propensión, 48 pacientes en el grupo de quimiorradioterapia de ciclo largo con quimioterapia de consolidación se emparejaron con 48 pacientes en el grupo de radioterapia de ciclo corto con quimioterapia de consolidación. Los grupos fueron comparables con respecto a la edad, sexo, estadio clínico, ubicación del tumor, tipo de abordaje quirúrgico y la técnica. La tasa de respuesta patológica completa fue comparable entre los grupos (20,8% y 18,8%, p = 0,99). La morbilidad postoperatoria a los 30 días y las tasas de fuga anastomótica fueron similares.LIMITACIONES: El estudio estuvo limitado por su naturaleza retrospectiva.CONCLUSIONES: Entre las modalidades de tratamiento neoadyuvante recientes, las tasas de respuesta patológica completa y los resultados clínicos a corto plazo fueron comparables. La radioterapia de corta duración con quimioterapia de consolidación es segura y eficaz como terapia de quimiorradioterapia de larga duración en un período corto. Consulte Video Resumen en http://links.lww.com/DCR/C174 . (Traducción-Dr. Fidel Ruiz Healy ).

Factors affecting operative morbidity and long-term outcomes in patients undergoing surgery for presacral tumours: a multicentric cohort study from the Turkish Collaborative Group for Quality Improvement in Colorectal and Pelvic Surgery.

AIM: Data regarding the operative management of presacral tumours present various dilemmas due to their rarity and heterogeneous nature. The aim of this study was to evaluate the management strategy, factors associated with operative morbidity and long-term postoperative outcomes in a large group of patients undergoing surgery for presacral tumours. METHOD: This study was designed as a multicentre retrospective cohort study. Records of patients who underwent surgery for presacral tumours at 10 tertiary colorectal centres between 1996 and 2017 were evaluated. RESULTS: One hundred and twenty seven patients (44 men) with a mean age of 46 years and body mass index of 27 kg/m2 were included. Fifty eight per cent of the patients had low sacral lesions (below S3). The operative approaches were transabdominal (17%), transsacral (65%) and abdominosacral (17%). The postoperative morbidity was 19%. Thirty per cent of the patients had a malignant tumour. Longer duration of symptoms (p = 0.001), higher American Society of Anesthesiologists score (p = 0.01), abdominosacral operations (p = 0.0001) and presacral tumours located above S3 (p = 0.004) were associated with an increased risk of postoperative morbidity. Overall long-term postoperative recurrence and mortality were 6% and 5%, respectively, within a 3-year mean follow-up period in patients with presacral malignant tumours. CONCLUSION: Reduced physical condition, omission of symptoms prior to surgery, combined resections and high sacral tumours are the risk factors associated with postoperative complications in patients undergoing surgery for presacral tumours. Meticulous planning of the operation and intensified perioperative care may improve the outcomes in high-risk patients.

Management and Morbidity of Major Pelvic Hemorrhage in Complex Abdominopelvic Surgery.

INTRODUCTION: Hemorrhage is a challenging complication of pelvic surgery. This study aimed to analyze the causes, management, and factors associated with morbidity in patients experiencing major pelvic hemorrhage during complex abdominopelvic surgery. METHODS: Patients who had major intraoperative pelvic hemorrhage during complex abdominopelvic surgery at 11 tertiary referral centers between 1997 and 2017 were included. Patient characteristics, management strategies to control bleeding, short- and long-term postoperative outcomes were evaluated retrospectively. RESULTS: There were 120 patients with a mean age of 56.6 ± 2.4 years and a mean BMI of 28.3 ± 1 kg/m2. While 104 (95%) of the patients were operated for malignancy, 16 (5%) of the patients had surgery for a benign disease. The most common bleeding site was the presacral venous plexus 90 (75%). Major pelvic hemorrhage was managed simultaneously in 114 (95%) patients. Electrocauterization 27 (23%), pelvic packing 26 (22%), suturing 7 (6%), thumbtacks application 7 (6%), muscle welding 4 (4%), use of energy devices 2 (2%), and topical hemostatic agents 2 (2%) were the management tools. Combined techniques were used in 43 (36%) patients. Short-term morbidity and mortality rates were 48 (40%) and 2 (2%), respectively. High preoperative CRP levels (p = 0.04), history of preoperative radiotherapy (p = 0.04), longer bleeding time (p = 0.006), and increased blood transfusion (p = 0.005) were the factors associated with postoperative morbidity. CONCLUSION: Postoperative morbidity related to major pelvic hemorrhage can be reduced by optimizing the risk factors. Prehabilitation prior to surgery to moderate inflammatory status and prompt action with proper technique to control major pelvic hemorrhage can prevent excessive blood loss in complex abdominopelvic surgery.

Botulinum toxin injection is an effective alternative for the treatment of chronic anal fissure.

OBJECTIVES: There are few published data on the optimized use of botulinum toxin A (BTA) for the treatment of chronic anal fissure (CAF). The aim of this study was to investigate the effect of injection of 100 IU BTA into the internal anal sphincter (IAS) at the side opposite of the fissure, using an anal retractor, sedation, and perianal transcutaneous pudendal nerve block. METHODS: The prospectively maintained data of 132 patients who underwent BTA injection for CAF were retrospectively analyzed. Demographic data, symptom duration, fissure location, post-procedure pain, complications, continence status, response to treatment, and follow-up period were investigated. Postoperative analgesic requirements of patients who did and did not receive pudendal nerve block were compared. RESULTS: Eighty-two patients were male and the median age was 40 (18-74) years. Sixty-six patients required no, 46 required oral, and 20 required parenteral analgesics. No complications were observed. Complete response was observed in 105 patients (79.5%). Symptomatic improvement was observed in 67.4% of patients within 3-7 d. Median follow-up was 24 (18-42) months. The median Wexner's incontinence score was 0 (0-8) at 1 month. In all, 104 patients had no, 22 patients had minor, and 6 patients had non-minor incontinence. All patients with incontinence recovered fully within 4 (2-13) weeks. CONCLUSIONS: BTA injection using an anal retractor under sedation and perianal transcutaneous pudendal nerve block is an effective and safe alternative to partial lateral internal sphincterotomy (LIS) for the treatment of CAF.

Early-stage colon cancer with high MALAT1 expression is associated with the 5-Fluorouracil resistance and future metastasis.

BACKGROUND: This study aimed to investigate the role of long noncoding RNA (LncRNA) expression profiles to predict relapse and 5-FU response in patients with stage I/II colon cancer (CC). METHODS AND RESULTS: The expression level of 15 LncRNA was analyzed in stage I/II colon tumors of 126 CC patients. To confirm the findings in-vitro, 5FU-resistant HT29 cells were generated by subjecting HT-29 cells to the increasing concentrations of 5FU for 6 months. The 5FU resistance was observed in WST-1 and Annexin V analyses. The colony formation and wound healing assays were assessed to determine the metastatic properties of the cells. Expression levels of LncRNAs and mRNA of EMT-related genes were determined by RT-PCR. The role of LncRNA on metastasis and 5FU sensitivity were confirmed in pcDNA3.0-PTENP1 and si-MALAT1 expressed 5FU-resistant HT29 cell lineages. RESULTS: High MALAT1 (p = 0.0002) and low PTENP1 (p = 0.0044) expressions were significantly associated with 5-FU resistance and tumor relapse in stage I/II CC. The invasiveness and colony-forming characteristics of 5-FU-resistant cell lineages were higher as compared to the parent HT-29. Moreover, the expression of MALAT1 (p = 0.0009) was increased while the expression of PTENP1 (p = 0.0158) decreased in 5FU-resistant-HT-29 cells. Si-MALAT1 treatment increased cell sensitivity to 5FU, whereas it decreased invasive behaviors of 5 FU-resistant-HT-29 cells. CONCLUSION: MALAT1 may be a biomarker in predicting recurrence in early-stage CC. Our findings suggest that a cell-based therapy to target MALAT1 could be established for these patients to prevent metastasis and 5-FU resistance.

Endoscopic pilonidal sinus treatment vs. laser-assisted endoscopic pilonidal sinus treatment: short-term results from a retrospective case-matched study.

BACKGROUND: The aim of this study was to investigate whether the addition of laser to the endoscopic pilonidal sinus treatment (EPSIT), laser-assisted EPSIT (LEPSIT) has an effect on the method and clinical results in the treatment of pilonidal sinus disease (PSD). METHODS: Between September 2019 and September 2020, patients who underwent LEPSIT and EPSIT procedures for PSD at Bursa Medicana Hospital, Turkey, were matched for age, pit location and number, body mass index (BMI), and sex. The primary endpoint was complete wound healing and the secondary endpoints were quality of life, cosmetic results, and cost. RESULTS: Twenty-four LEPSIT patients were matched to 72 EPSIT patients. Eighty-one (84.4%) of the included patients were male, and the median age was 26 years (range 16-52 years). The median follow-up time was 9 months (range 3-15 months).Wound healing rates (LEPSIT; 95.8% vs. EPSIT; 93%; p = 0.99) were similar in both groups. In patients who underwent LEPSIT, the operative time (p = 0.00086) was significantly shorter, time taken to return to work (p = 0.03572) and wound closure (p < 0.00001) were significantly less. However, the time taken to return to daily activities and the percentage of wound complications were similar in both groups. The pain scores on postoperative -days 1 7, and 14 were significantly higher after EPSIT (p = 0.0083, p = 0.00054, and p = 0.0479, respectively). The postoperative analgesic requirement was significantly higher after EPSIT (p = 0.01492). The total hospital cost was significantly less in patients who underwent EPSIT (p < 0.00001). Significantly better cosmetic improvement was observed in LEPSIT procedure (p = 0.00694). First month quality of life (evaluated with the Short Form 36 Health Survey Questionnaire) was similar except for bodily pain (better after LEPSIT). CONCLUSIONS: The success rates of LEPSIT and EPSIT are similar. LEPSIT results in better wound healing and patient comfort, and a shorter time to return to work.

Long-term Outcomes of Laser Ablation of Fistula Tract for Fistula-in-Ano: A Considerable Option in Sphincter Preservation.

BACKGROUND: Ablation of anal fistula tract using a radial laser-emitting probe is a sphincter-preserving technique. OBJECTIVE: The purpose of this study was to assess long-term outcomes of laser ablation of fistula tract. DESIGN: This was a retrospective analysis of the long-term outcomes of 100 patients who underwent laser ablation of fistula tract. SETTINGS: This was a single-center study from a tertiary center in Turkey. PATIENTS: All of the patients with fistula-in-ano were included. Exclusion criteria were the presence of perianal abscess, underlying Crohn's disease, fistula tract <2 cm, fistulas suitable for simple fistulotomy, and intersphincteric fistulas originated from posterior located chronic anal fissure. INTERVENTIONS: A probe housing a 15-watt laser emitting at a wavelength of 1470 nm and an energy level of 100 to 120 joule/cm was used. MAIN OUTCOME MEASURES: No discharge, no symptoms, and fibrotic scar on skin where previously an external opening was present were defined as overall complete healing. All results other than overall complete healing were accepted as failure. RESULTS: A total of 100 patients underwent laser ablation of fistula tract with a median age of 42 years (range, 21-83 y). The majority of them were men. The overall success rate was 62% (95% CI, 52%-71%) in a median follow-up time of 48 months (range, 6-56 mo). None of the patients experienced permanent major or minor anal incontinence. LIMITATIONS: The retrospective nature of this study is its main limitation. Other limitations consist of phone interview for follow-up of the majority of the patients, single-institution data, and the relatively small number of patients. CONCLUSIONS: Laser ablation of the fistula tract is a sphincter-preserving procedure with an acceptable long-term success rate. See Video Abstract at http://links.lww.com/DCR/B186. RESULTADOS A LARGO PLAZO DE LA ABLACIóN CON LáSER DEL TRACTO EN LA FíSTULA ANAL: UNA CONSIDERABLE OPCIóN EN LA PRESERVACIóN DEL ESFíNTER: La ablación con una sonda radial emisora de láser del tracto de fístula anal, es una técnica de preservación del esfínter.Evaluar los resultados a largo plazo de la ablación con láser del tracto fistuloso.Análisis retrospectivo de los resultados a largo plazo de 100 pacientes que se sometieron a la ablación con láser del tracto de fístula.Este es un estudio de centro único de un centro terciario en Turquía.Fueron incluidos todos pacientes con fístula anal. Los criterios de exclusión fueron la presencia de absceso perianal, enfermedad de Crohn subyacente, tracto de fístula menor de 2 cm, fístulas adecuadas para fistulotomía simple y fístulas interesfintéricas originadas en una fisura anal crónica posterior.Se utilizó una sonda que alberga un láser de 15 vatios que emite a una longitud de onda de 1,470 nm y un nivel de energía de 100-120 julios / cm.Sin secreción, sin síntomas y la cicatriz fibrótica en la piel, donde anteriormente estaba presente la apertura externa, se definió como "curación completa general." Todos los resultados que no sean "curación completa en general" se aceptaron como fracaso.Cien pacientes fueron sometidos a ablación con láser del tracto de fístula anal, con una edad media de 42 (21-83) años. La mayoría de ellos fueron varones. La tasa de éxito general fue del 62% (intervalo de confianza del 95%, 52%-71%) en una mediana de tiempo de seguimiento de 48 (6-56) meses. Ninguno de los pacientes experimentó incontinencia anal mayor o menor permanente.La naturaleza retrospectiva de este estudio es su principal limitación. Otras limitaciones consisten en una entrevista telefónica para el seguimiento de la mayoría de los pacientes, datos de una sola institución y un número relativamente pequeño de pacientes.La ablación con láser del tracto de la fístula anal, es un procedimiento de preservación del esfínter y con una aceptable tasa de éxito a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B186. (Traducción-Dr Fidel Ruiz Healy).

Can heat shock protein 32 be used for the early diagnosis of acute mesenteric ischemia?

OBJECTIVE: Acute mesenteric ischemia is a challenging and fatal disease. The aim of this study was to detect the heat shock protein 32 (HSP32) response in intestinal tissue and systemic blood to intestinal ischemia and ischemia/reperfusion to define a tool for the early diagnosis of acute mesenteric ischemia. MATERIAL AND METHODS: Thirty female Wistar albino rats were equally divided into 3 groups. Group 1 rats underwent simple laparotomy and closure (control). In Group 2 rats, 1-hour intestinal ischemia followed by 5-hour reperfusion was performed, and Group 3 rats were subjected to 6-hour intestinal ischemia. The experiment was repeated with a 24-hour waiting period. At the end of the waiting period, blood was withdrawn from the tail veins of the rats and the rats were sacrificed via cardiac puncture. Re-laparotomy was subsequently performed and intestinal tissue and luminal samples were obtained for biochemical and pathological investigations. The HSP32 levels of intestinal tissues, luminal contents and blood levels were compared among the groups. RESULTS: At the end of the 24-hour waiting period, the median tissue HSP32 levels were 0.43 (0-6.6) ng/mL for Group 1, 9.51 (2.5-49.9) ng/mL for Group 2 and 43.13 (6.3-121.3) ng/mL for Group 3 (p=0.001). The median blood HSP32 levels were 0.11 (0.1-1.4) ng/mL for Group 1, 0.42 (0.1-0.7) ng/mL for Group 2, and 0.25 (0.1-1.2) ng/mL for Group 3 (p=0.047). The HSP levels in the luminal contents were undetectable. CONCLUSION: Both ischemia and ischemia/reperfusion significantly raised intestinal tissue HSP32 levels in comparison with the control group. However, this change was not reflected in the circulating blood or luminal contents.

Laser ablation of fistula tract: a sphincter-preserving method for treating fistula-in-ano.

BACKGROUND: Lasers are used to treat various types of diseases, including fistula-in-ano. Until recently, the lasers used for this procedure radiated linear energy. OBJECTIVE: To assess the short-term outcomes of patients undergoing ablation of fistula in-ano tract using a new laser that radiates circumferential energy. DESIGN & SETTING: This study was approved by the local ethics committee at our institution. A 15-watt laser probe emitting at a wavelength of 1470 nm and producing 100-120 joules/cm of energy, was applied to 50 patients with fistula-in-ano under general anesthesia. Short-term outcomes, including success rate, complications, pain scores and time to return to normal daily activities, were evaluated. Success was defined as cessation of either the discharge or the patient's complaints. RESULTS: Thirty-seven male and 13 female patients with a median age of 41 years (range: 23-83 years) were treated on an outpatient basis. Among these patients, 10 had inter-sphincteric fistulas, 34 had low transsphinteric fistulas and 6 had high transsphinteric fistulas. None of the patients required parenteral analgesics. The return to daily activities required a median of 7 days (range: 5-17 days). The median follow-up period was 12 months (range: 2-18 months). The success rate was 82%. Patients for whom the laser treatment was unsuccessful were later treated using traditional surgical methods. LIMITATIONS: The retrospective review of the data and the fact that substantial follow-up was done by phone and not through physical examination are the main limiting factors in this study. CONCLUSION: Laser ablation of fistula tract is a safe, effective, sphincter-preserving therapy that can be successfully performed by surgeons.

MicroRNA expression patterns of tumors in early-onset colorectal cancer patients.

BACKGROUND: The expression of microRNAs (miRNAs) may differ in tumors from patients with different ethnic origins and ages. The aims of the present study were to clarify the appropriate alterations of miRNA expression associated with the early stages of carcinogenesis in early-onset Turkish colorectal cancer (CRC) patients and to define specific biomarkers that could be used as new diagnostic and prognostic markers for this population. MATERIALS AND METHODS: The expression profiles of 38 different miRNAs associated with CRC were evaluated using miRNA polymerase chain reaction arrays in tumors and surgical margin tissue samples from 40 sporadic early-onset Turkish CRC patients. The relationships between the miRNA expression profiles and the characteristics of the tumors and patients were evaluated. RESULTS: The expression of miR-106a was found to be upregulated, and miR-143 and miR-125b levels were found to be downregulated in tumor tissues compared with the normal tissues. The high expression level of miR-106a (2.93-fold; P = 0.031) and low expression level of miR-125b (2.42-fold; P = 0.063) were observed in tumors with lymph node metastases compared with the normal colorectal mucosa samples. However, the deregulation of these miRNAs was not significantly associated with survival (log-rank P > 0.05). CONCLUSIONS: The present results implied that miR-106a and the miR-125b were associated with the formation and invasion of colorectal tumors. Thus, these miRNAs might be used as significant prognostic factors and indicators of early-stage CRC. Further studies and validations are required; these miRNAs may provide novel molecular targets for CRC treatment.

The protective effect of ClinOleic against post-surgical adhesions.

BACKGROUND: Although the English-language literature is full of studies about post-surgical adhesions, no definitive method has yet been identified to prevent them. The goal of this study was to investigate the effect of ClinOleic on reducing post-surgical adhesion formation. METHODS: Surgery was performed on 40 adult female Sprague-Dawley rats that were randomly assigned to receive either intraperitoneal ClinOleic, which was used to mimic chyle (ClinOleic group), soybean oil (soybean oil group), olive oil (olive oil group), or 0.9% NaCl suspension (control group). All rats underwent laparotomy, side-wall and cecal abrasion, and primary closure. On the 30th day following surgery, rats were sacrificed and examined using the Majuzi adhesion classification and histopathological grading scales. RESULTS: The adhesion and histopathological scores of the ClinOleic group were significantly lower compared to the control group (0.9% NaCl) (p<0.05). A statistically significant decrease in fibrosis was observed in the soybean and olive oil groups when compared to the control group (p<0.05). However, the adhesion grades of the ClinOleic, soybean and olive oil groups were comparable. We did not observe any post-surgical adhesions in the ClinOleic group. CONCLUSION: The parenteral nutrition solution ClinOleic may be an effective and readily available agent for the prevention of post-surgical adhesions.

Minimally Invasive Pilonidal Sinus Treatment: EPSIT Versus PEBAI Method.

PURPOSE: We aimed to compare endoscopic pilonidal sinus treatment (EPSIT) and pit/sinus punch needle excision, brushing, ablation and irrigation (PEBAI) method that was performed with principles similar to EPSIT but without fistuloscope and vision in the treatment of pilonidal sinus disease (PSD). METHODS: Patients who underwent EPSIT and PEBAI methods for PSD in a single center between January 2020 and October 2021 were retrospectively analyzed. The primary endpoint was healing, the secondary endpoints were operative time, pain, wound closure, quality of life, cosmetic results, and cost. RESULTS: One hundred 4 patients who underwent EPSIT and 184 patients who underwent PEBAI were included in the study. Age ( P =0.871), sex ( P =0.669), BMI ( P =0.176), number of pits ( P =0.99) were similar in both groups. The operative time for PEBAI [20 min (18 to 32)] was shorter than EPSIT [32 min (24 to 44)] ( P <0.0000, u value=3096, z-score=-9.459). Postoperative first ( P =0.147) and 14th day( P =0.382) pain scores, postoperative analgesic requirements ( P =0.609), time to return to daily activities ( P =0.747), time to return to work ( P =0.345), and wound complications ( P =0.816) were similar, whereas the wound closure time was earlier after EPSIT [32 d (24 to 41)] than after PEBAI [37 d (26 to 58)] ( P <0.00001, u value=5344, z-score=6.22141). The median follow-up was 24 (12 to 34) months. Complete wound healing ( P =0.382), recurrence rate ( P =0.533), quality of life at first month and (Wound evaluation scale score at first year ( P =0.252) were similar in both groups. However, the cost of PEBAI [54.8 € (50.13 to 64.96)] was significantly lower than cost of EPSIT [147.36 € (132.53 to 169.60)] ( P <0.00001, u value=0, z-score=7.210). CONCLUSIONS: PEBAI method is a cheaper alternative to EPSIT with similar surgical principles and clinical outcomes.

Microsatellite instability status affects gene expression profiles in early onset colorectal cancer patients.

BACKGROUND: The association between microsatellite instability (MSI) status and gene expression profiles in the early onset sporadic colorectal cancer (CRC) has not been clearly established. The aim of this study was to identify the altered gene expression patterns depending on the MSI status of early onset CRC and determine specific biomarkers that could provide novel therapeutic molecular targets in the Turkish population. MATERIALS AND METHODS: MSI markers (BAT25, BAT26, D2S123, D5S346, and D17S250) were investigated in tumors from 36 early onset sporadic CRC patients in whom gene expression profiles were analyzed previously. The relationship between the gene expression profiles depending on MSI status was evaluated. RESULTS: A total of 15 tumors (16.66%) were identified as having MSI and 21 tumors (58.33%) were identified as having microsatellite stability (MSS). CK20 and MAP3K8 upregulation, observed in MSS tumors, was significantly associated with lymph node metastasis, recurrence, and/or distant metastasis and a short median survival (P < 0.05). REG1A upregulation is also correlated with recurrence and/or distant metastasis and a short median survival in patients with MSI tumors (P < 0.05). CONCLUSIONS: High expression levels of CK20 and MAP3K8 in MSS tumors and REG1A in MSI tumors correlated with a poor prognosis in CRC patients. Further studies and validations are required; these genes may provide novel therapeutic molecular targets for the development of anticancer drugs related to MSI status for early onset CRC treatment.

An asymptomatic patient with a pellet within the myocardium.

Penetrating injuries to the myocardium are rare but potentially lethal. We present a 22-year-old asymptomatic male patient with a pellet lodged in the myocardium as a result of a gunshot that took place three years before. His medical history was otherwise unremarkable. The chest X-ray showed multiple pellets within the thorax. Computed tomography of the chest demonstrated many pellets in the anterior chest wall, while a few lodging within the lung tissue and one within the myocardium. Transthoracic echocardiography showed a pellet within the left ventricular myocardium presenting as an acoustic shadowing. Thickening of the adjacent pericardium was also noted. There were no signs of constrictive pericarditis or regional wall motion abnormality. Holter monitoring and treadmill exercise test did not show any abnormal finding. The patient was included in a periodic follow-up program.

An international multi-institutional analysis of operative morbidity in patients undergoing elective diverticulitis surgery.

OBJECTIVE: We investigated surgical complications of elective surgery for diverticulitis in international multi-institution to identify a prediction model for potential opportunities of quality improvement. METHODS: We identified 1225 patients who underwent elective surgery for diverticulitis between January 2010 and January 2018. The data were obtained from the National Surgical Quality Improvement Program and the Turkish Diverticulitis Study Group Collaborative, retrospectively. RESULTS: We observed that the presence of chronic obstructive pulmonary disease (OR: 3.2, 95%CI 1.8-5.9, p<0.001) or abscess at the time of surgery (OR: 1.4, 95%CI 1.2-1.7, p£0.001) is associated with a higher rate of minor complications, while comorbidities such as dyspnea (OR: 2.8, 95%CI 1.6-4.9, p£0.001) and preoperative sepsis (OR: 4.1, 95%CI 2.3-7.3, p£0.001) are associated with major complications. The centers had similar findings in minor and major complications (OR: 0.8, 95%CI 0.5-1.4, p=0.395). The major independent predictors for complications were malnutrition (low albumin) (OR: 0.5, 95%CI 0.4-0.6, p<0.001) and the American Society of Anesthesiology score (OR: 1.7, 95%CI 1.2-2.4, p=0.002). CONCLUSION: Regarding the major and minor complications of diverticulitis of elective surgery, the malnutrition and higher American Society of Anesthesiology score showed higher impact among the quality improvement initiatives.

Coronary pseudoaneurysm and superior vena cava occlusion in a young patient with multicentric Castleman's disease and antiphospholipid antibody positivity.

Castleman disease is a non-malignant proliferative disease of the lymphoid system. It can be unicentric or multicentric. In this report, we present a case of multicentric Castleman disease to which coronary artery pseudoaneurysm, vena cava superior occlusion, and antiphospholipid antibody positivity was accompanying.