Real-world survival after colorectal surgery for malignancy in Korean patients with chronic kidney disease: an analysis of Korean healthcare big data, 2002–2019

Purpose@#Globally, chronic kidney disease (CKD) is common and has been associated with an increased risk of colorectal cancer (CRC). There is a dearth of literature on the real-world morbidity and mortality associated with CKD comorbid with CRC. This study was performed to evaluate real-world survival outcomes of colorectal malignancy in Korean CKD patients. @*Methods@#The National Health Insurance Service of Korea provided data on patients who underwent surgical resection among patients diagnosed with CRC from 2002 to 2019. @*Results@#A total of 219,550 patients were included: 6,181 patients with underlying CKD and 213,369 patients without it.Each morbidity was significantly higher in the CKD-CRC group, and the postoperative mortality rates for the 30-day (3.11% vs. 1.78%, P < 0.001), 60-day (5.95% vs. 3.83%, P < 0.001), and 90-day mortality rate (8.12% vs. 5.32%, P < 0.001) were significantly higher in the CKD group. The median survival time (MST, year) was significantly lower in the CKD-CRC group (5.63; interquartile range [IQR], 5.26–5.91) than in the non-CKD-CRC group (8.71; IQR, 8.37–8.93). MST was significantly lower among CKD patients who received chemotherapy after adjustment by multivariate analysis (adjusted hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.37–1.49; P < 0.001]). Subgroup analysis showed that in the CKD-CRC group, MST was lower in patients who received dialysis than in those who did not, even after multivariate analysis (adjusted HR, 2.38;95% CI, 2.20–2.58; P < 0.001). @*Conclusion@#Prevention of CKD-to-end-stage renal disease progression should be adopted as a strategy to increase postoperative survival, along with active surveillance and cancer treatment.

Coring-out fistulectomy for perianal cryptoglandular fistula: a retrospective cohort study on 20 years of experience at a single center

Purpose@#Cryptoglandular fistula is one of the common anal diseases requiring surgical treatment. Various surgical techniques have been introduced; however, there is no known standard technique. Coring-out fistulectomy is a surgical technique that accurately resects only the fistula tract. However, only a few cases of this procedure have been reported.We aimed to analyze the surgical outcomes of coring-out fistulectomy for cryptoglandular anal fistulas. @*Methods@#We retrospectively reviewed the medical records of patients who underwent coring-out fistulectomy for a cryptoglandular fistula between 1999 and 2019. Primary outcomes were the treatment success rate (recurrence and healing rates) and incidence of fecal incontinence. @*Results@#A total of 184 patients were included in our study. The average age of the patients was 44 years (range, 16–75 years), and 88.0% were male. Twenty-four (13.0%), 13 (7.1%), and 68 patients (37.0%) underwent operation for recurrent fistula, multiple tracts, and complex type fistula, respectively. The healing rate was 92.4%, and recurrence occurred in 15 of 170 healed patients (8.8%). Thus, the treatment success rate was 84.2%. There was no fecal incontinence except in 1 patient who had preoperative fecal incontinence because of cauda equine syndrome. In multivariable analysis of the factors affecting the treatment success rate, the complex fistula (odds ratio [OR], 14.2; 95% confidence interval [CI], 4.7– 43.0; P < 0.001) and undetected internal opening during the operation (OR, 4.0; 95% CI, 1.4–11.6; P = 0.012) were significant factors. @*Conclusion@#Coring-out fistulectomy is a simple and feasible technique for sphincter-preserving anal fistula surgery.

The prognoses and postoperative outcomes of patients with both colorectal cancer and liver cirrhosis based on a nationwide cohort in Korea

Purpose@#The management of patients with colorectal cancer (CRC) who have liver cirrhosis (LC) requires a thorough understanding of both diseases; however, the prognoses and postoperative outcomes of such patients remain understudied. We investigated the effect of LC on surgical and oncologic outcomes in patients with CRC, and identified prognostic factors. @*Methods@#We analyzed 453 patients with CRC and LC (CRC-LC group), 906 with CRC only (CRC group), 906 with LC only (LC group), and 1,812 healthy subjects using health insurance claim data (2008–2013). @*Results@#The CRC-LC group had a higher frequency of intensive care unit admission than the CRC group; there were no differences between the 2 groups in terms of early and late postoperative small bowel obstruction and incisional hernia. However, the 30-day, 60-day, and 90-day mortality rates were all significantly higher in the CRC-LC group. The higher Charlson comorbidity index (hazard ratio [HR], 1.127) and the lower socioeconomic status (HR, 0.985) were significant worse predictors of 5-year survival. Patients with underlying LC had a significantly higher HR in both the advanced CRC (HR, 1.858) and nonadvanced CRC (HR, 1.799) subgroups. However, the nonadvanced CRC subgroup showed a lower HR than the LC group (HR, 0.730). @*Conclusion@#Patients with CRC who had underlying LC had a lower survival rate than did those without LC, although the incidence rates of postoperative complications were not significantly different. The presence of LC was associated with a significantly lower survival rate regardless of CRC presence.

The prognoses and postoperative outcomes of patients with both colorectal cancer and liver cirrhosis based on a nationwide cohort in Korea

Purpose@#The management of patients with colorectal cancer (CRC) who have liver cirrhosis (LC) requires a thorough understanding of both diseases; however, the prognoses and postoperative outcomes of such patients remain understudied. We investigated the effect of LC on surgical and oncologic outcomes in patients with CRC, and identified prognostic factors. @*Methods@#We analyzed 453 patients with CRC and LC (CRC-LC group), 906 with CRC only (CRC group), 906 with LC only (LC group), and 1,812 healthy subjects using health insurance claim data (2008–2013). @*Results@#The CRC-LC group had a higher frequency of intensive care unit admission than the CRC group; there were no differences between the 2 groups in terms of early and late postoperative small bowel obstruction and incisional hernia. However, the 30-day, 60-day, and 90-day mortality rates were all significantly higher in the CRC-LC group. The higher Charlson comorbidity index (hazard ratio [HR], 1.127) and the lower socioeconomic status (HR, 0.985) were significant worse predictors of 5-year survival. Patients with underlying LC had a significantly higher HR in both the advanced CRC (HR, 1.858) and nonadvanced CRC (HR, 1.799) subgroups. However, the nonadvanced CRC subgroup showed a lower HR than the LC group (HR, 0.730). @*Conclusion@#Patients with CRC who had underlying LC had a lower survival rate than did those without LC, although the incidence rates of postoperative complications were not significantly different. The presence of LC was associated with a significantly lower survival rate regardless of CRC presence.

Outcomes of surgical treatments for rectovaginal fistula and prognostic factors for successful closure: a single-center tertiary hospital experiences

PURPOSE: Rectovaginal fistula can result from various causes and diverse surgical procedures have developed as a result. We investigated the outcomes of surgical treatments for rectovaginal fistula according to causes and procedures. METHODS: Between 1998 and 2016, 92 patients underwent 128 operations for rectovaginal fistula. Prospectively collected data were recorded, and a retrospective review was conducted. RESULTS: The median age was 49 years, and low fistula occurred in 58 patients (63.0%). The most common cause was radiation therapy, followed by pelvic operation, birth injury, perineal operation, cancer invasion, and trauma. The most common procedure during the first operation was diverting ostomy alone, followed by transanal rectal advancement flap, sphincteroplasty with perineoplasty, bowel resection, fistulectomy with seton placement, and Martius flap. Thirty-one patients (33.7%) experienced successful closure after the first operation. Repeated operations were performed in 16 patients (17.4%), including gracilis muscle transpositions, stem cell injections, and Martius flaps. The overall success rate was 42.4% (n = 39). Radiation therapy and pelvic operation as cause of fistula were significantly poor prognostic factors (P = 0.010, P = 0.045) and Crohn disease had a tendency for poor prognostic factors (P = 0.058). CONCLUSION: Radiation therapy and pelvic operation for cancer were more common causes than birth injury, and these causes of rectovaginal fistula were the most important prognostic factors. An individualized approach and repeated surgeries with complex or newly developed procedures, even among high-risk causes of fistula, may be necessary to achieve successful closure.

Significance of lymph node metastasis in the survival of stage IV colorectal cancer by hematogenous metastasis

PURPOSE: Although lymph node (LN) metastasis is an important prognostic marker of colorectal cancer (CRC), the effect of LN metastasis on the survival of stage IV CRC is debated yet. METHODS: LN status and survivals as well as clinicopathological features of synchronous stage IV CRC patients, operated for 8 years, were analyzed. Patients with hematogenous metastases were included only but those with peritoneal seeding or preoperative adjuvant therapy were not included. RESULTS: Total 850 patients were enrolled and 77 (9.1%) were without LN metastases (N0M1). N0M1 patients were older and have favorable pathological features including lower CEA than patients with LN metastasis (N + M1). The pathologically poor features accumulated with N stage progression within N + M1. N0M1 had better 5-year overall survival (OS) and disease free survival than N + M1. And 5-year OS's within N + M1 group were stratified and different according to N stage progression, although the effect of N stage progression is different according to curative resection or not. When compared with stage III, 5-year OS of N0M1 with curative resection was comparable to that of anyTN2aM0 and was better than anyTN2bM1. CONCLUSION: LN metastasis is a significant prognostic factor in stage IV by hematogenous metastasis, too. N stage progression accumulates pathologically poor prognostic factors. However, the effect on survival of each N stage progression differs depending on curative resection or not of the hematogenous metastases.

Long-term Oncologic Outcomes of Obesity after Laparoscopic Surgery for Colorectal Cancer in Asian Patients

PURPOSE: The adverse effects of obesity on short-term surgical outcomes after laparoscopic colorectal surgery have been reported. However, the influence of obesity on long-term oncological outcomes after laparoscopic surgery in Asian patients has not been well understood. The aim of this study was to evaluate the effect of obesity on long-term oncologic outcomes in patients who underwent laparoscopic surgery for colorectal cancer. METHODS: Overall, 424 consecutive patients who underwent laparoscopic resection for colorectal cancer between January 2005 and July 2012 were included in this retrospective study. Patients were classified as non-obese (body mass index [BMI] <25.0 kg/m²) and obese (BMI ≥25.0 kg/m²) according to the categories proposed by the International Obesity Task Force. A survival analysis was performed using clinicopathologic characteristics, including obesity. RESULTS: Of the 424 patients, 325 (76.7%) were classified as non-obese and 99 (23.3%) as obese. The clinicopathologic characteristics of the obese and non-obese groups were similar, except that there were more underlying comorbidities, a lower frequency of smoking, and fewer tumors in rectum in the obese group. Results of the multivariate analysis showed that older age, elevated serum carcinoembryonic antigen, high-grade histology, advanced tumor stage, and perineural invasion were associated with poorer disease-free survival and overall survival. Obesity was not significantly associated with disease-free survival (hazard ratio [HR], 1.196; 95% confidence interval [CI], 0.686~2.086; p=0.528) or overall survival (HR, 1.156; 95% CI, 0.584~2.289; p=0.677). CONCLUSION: Laparoscopic surgery for colorectal cancer seems to be safe and feasible for obese patients in terms of long-term oncologic outcomes.

Prognostic Impact of Changes in Adipose Tissue Areas after Colectomy in Colorectal Cancer Patients

There have been few studies assessing the changes in the body components of patients after colectomy in colorectal cancer (CRC). The purpose of this study was to verify the trends in the adipose tissue areas of CRC patients before and after surgery and to determine their clinical relevance. Computed tomography (CT)-assessed subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) areas were recorded before and after curative resection in stage I to III CRC patients. Changes in the adipose tissue were assessed by calculating the difference in the adipose tissue area between preoperative CT and the most recent postoperative CT, which is disease-free state. Regarding obesity before surgery, there were no prognostic effect of body mass index (BMI), VAT and SAT, and 47.3% of patients had increases in VAT after colectomy. By multivariate analysis, adjusting sex, age, stage, differentiation, VAT change was the only obesity related factor to predict the prognosis, that patients who had increase in VAT after colectomy had better overall survival (HR, 0.557; 95% CI, 0.317-0.880) and disease-free survival (HR, 0.602; 95% CI, 0.391-0.927). BMI and SAT change had no significant association. In subgroup analysis of stage III CRC patients, VAT change had significance for prognosis only in patients who had adjuvant chemotherapy but not in those who did not receive postoperative chemotherapy. Increase in visceral adipose tissue after surgery is a favorable predictor of prognosis for CRC patients.

Long-term Outcomes and Risk Factors for Reoperation After Surgical Treatment for Gastrointestinal Crohn Disease According to Anti-tumor Necrosis Factor-alpha Antibody Use: 35 Years of Experience at a Single Institute in Korea

PURPOSE: Crohn disease is characterized by high rates of recurrence and reoperations. However, few studies have investigated long-term surgical outcomes in Asian populations. We investigated risk factors for reoperation, particularly those associated with anti-tumor necrosis factor-alpha (anti-TNF-alpha) antibody use, and long-term follow-up results. METHODS: We reviewed the records of 148 patients (100 males and 48 females) who underwent surgery for gastrointestinal Crohn disease and retrospectively analyzed long-term outcomes and risk factors. RESULTS: The mean age at diagnosis was 28.8 years. Thirty-eight patients (25.7%) received monoclonal antibody treatment before reoperation. A small bowel and colon resection was most commonly performed (83 patients, 56.1%). The median follow-up was 149 months, during which 47 patients underwent reoperation. The median interval between the primary and the secondary surgeries was 65 months, with accumulated reoperation rates of 16.5%, 31.8%, and 57.2% after 5, 10, and 15 years, respectively. Obstruction was the most common indication for reoperation (37 patients, 25.0%). In a multivariable analysis, age <17 years at diagnosis (A1) (odds ratio [OR], 2.20; P = 0.023), penetrating behavior (B3) (OR, 4.39; P < 0.001), and no azathioprine use (OR, 2.87; P = 0.003) were associated with reoperation. Anti-TNF-alpha antibody use did not affect the reoperation rate (P = 0.767). CONCLUSION: We showed a high reoperation rate regardless of treatment with anti-TNF-alpha antibody, which indicates that recurrent surgery is still needed to cure patients with gastrointestinal Crohn diseases. Younger age at primary operation, penetrating behavior, and no azathioprine use were significant factors associated with reoperation for gastrointestinal Crohn disease.

Rectourethral Fistula: Systemic Review of and Experiences With Various Surgical Treatment Methods

PURPOSE: A rectourethral fistula (RUF) is an uncommon complication resulting from surgery, radiation or trauma. Although various surgical procedures for the treatment of an RUF have been described, none has gained acceptance as the procedure of choice. The aim of this study was to review our experience with surgical management of RUF. METHODS: The outcomes of 6 male patients (mean age, 51 years) with an RUF who were operated on by a single surgeon between May 2005 and July 2012 were assessed. RESULTS: The causes of the RUF were iatrogenic in four cases (two after radiation therapy for rectal cancer, one after brachytherapy for prostate cancer, and one after surgery for a bladder stone) and traumatic in two cases. Fecal diversion was the initial treatment in five patients. In one patient, fecal diversion was performed simultaneously with definitive repair. Four patients underwent staged repair after a mean of 12 months. Rectal advancement flaps were done for simple, small fistula (n = 2), and flap interpositions (gracilis muscle flap, n = 2; omental flap, n = 1) were done for complex or recurrent fistulae. Urinary strictures and incontinence were observed in patients after gracilis muscle flap interposition, but they were resolved with simple treatments. The mean follow-up period was 28 months, and closure of the fistula was achieved in all five patients (100%) who underwent definitive repairs. The fistula persisted in one patient who refused further definitive surgery after receiving only a fecal diversion. CONCLUSION: Depending on the severity and the recurrence status of RUF, a relatively simple rectal advancement flap repair or a more complex gracilis muscle or omental flap interposition can be used to achieve closure of the fistula.

Gastrointestinal hemangioma in childhood: a rare cause of gastrointestinal bleeding / 소아과

Gastrointestinal (GI) hemangiomas are relatively rare benign vascular tumors. The choice of an appropriate diagnostic method depends on patient age, anatomic location, and presenting symptoms. However, GI hemangiomas are not a common suspected cause of GI bleeding in children because of their rarity. Based on medical history, laboratory results, and imaging study findings, the patient could be treated with either medication or surgery. Herein, we report 3 cases of GI hemangioma found in the small bowel, rectum, and GI tract (multiple hemangiomas). Better knowledge and understanding of GI hemangioma could help reduce the delayed diagnosis rate and prevent inappropriate management. Although rare, GI hemangiomas should be considered in the differential diagnosis of GI bleeding.

Feasibility of Superficial Femoral Artery Intervention Using Mobile C-arms Compared to Fixed C-arms / 대한혈관외과학회지

PURPOSE: Endovascular therapy (ET) for peripheral arterial occlusive disease has increased dramatically in the past decade. ET is currently being performed by different specialists with available resources, with some of these resources being far superior to others, yet there have been no studies comparing the interventional outcomes according to the varying resources. The aim of this study was to analyze the outcomes of ET for superficial femoral artery (SFA) atherosclerosis using a mobile C-arm, in comparison to a historical control group. METHODS: Between March 2009 and December 2010, ET for SFA atherosclerosis was performed in 54 limbs from 47 patients using a mobile C-arm in the operation theater (mobile group). In contrast, a historical group for comparison consisted of 60 patients, for whom ET for SFA atherosclerosis was performed in 76 limbs using a fixed C-arm in the angiographic suite, between July 2003 and May 2008 (fixed group). The outcomes of ET for both groups were retrospectively analyzed by a medical chart review. RESULTS: There was no statistically significant difference in gender, age, risk factors, Trans-Atlantic Inter-Society Consensus (TASC) classification, intervention type, and postoperative blood creatinine levels between the two groups. However, procedural time was statistically higher in the mobile group. Patency rates at 1 year were 68.3% and 68.1% in the fixed and mobile group, respectively, which was not statistically significant. Subgroup analysis of 1 year patency rates for TASC A, B lesions and TASC C, D lesions were also similar. CONCLUSION: ET using the mobile C-arm in the operating theater is as effective as using the fixed C-arm, in the treatment of SFA atherosclerosis in terms of the technical success, patency, and early postoperative outcomes.

Serongative Acute Hepatic Failure-associated Aplastic Anemia in Pediatric Liver Transplantation / 대한이식학회지

Aplastic anemia (AA) is a rare complication of liver transplantation. The causes of AA have not yet been identified, and optimal treatment for AA after liver transplantation has not been firmly established. We experienced two cases of AA accompanied with fulminant hepatitis among 157 pediatric recipients (1.3%) and among 17 recipients of Korean Network of Organ Sharing (KONOS) status 1 (11.8%). The patients were a 16-year-old girl and a 3-year-old boy who had jaundice and lethargy due to non-A, non-B, non-C fulminant hepatitis. The girl underwent split liver transplantation involving the liver of a 24-year-old man, and the boy underwent an emergency living donor liver transplantation with a liver obtained from his 16-year-old cousin. Each transplantation procedure was uneventful. However, both patients were diagnosed with AA caused by thrombocytopenia and neutropenia at 140 and 26 days, respectively, after liver transplantation. The girl recovered completely after undergoing bone marrow transplantation and was followed up for 70 months. However, the boy was conservatively treated because of the development of hyperbilirubinemia and pyrexia. He died of multi-organ failure 74 days after liver transplantation. AA is not a rare complication of pediatric liver transplantation for fulminant hepatic failure. Therefore, AA must be suspected in pediatric cases of cytopenia even after liver transplantation. Our findings indicate bone marrow transplantation is the treatment of choice for AA even in cases where AA develops after liver transplantation.

Serongative Acute Hepatic Failure-associated Aplastic Anemia in Pediatric Liver Transplantation / 대한이식학회지

Aplastic anemia (AA) is a rare complication of liver transplantation. The causes of AA have not yet been identified, and optimal treatment for AA after liver transplantation has not been firmly established. We experienced two cases of AA accompanied with fulminant hepatitis among 157 pediatric recipients (1.3%) and among 17 recipients of Korean Network of Organ Sharing (KONOS) status 1 (11.8%). The patients were a 16-year-old girl and a 3-year-old boy who had jaundice and lethargy due to non-A, non-B, non-C fulminant hepatitis. The girl underwent split liver transplantation involving the liver of a 24-year-old man, and the boy underwent an emergency living donor liver transplantation with a liver obtained from his 16-year-old cousin. Each transplantation procedure was uneventful. However, both patients were diagnosed with AA caused by thrombocytopenia and neutropenia at 140 and 26 days, respectively, after liver transplantation. The girl recovered completely after undergoing bone marrow transplantation and was followed up for 70 months. However, the boy was conservatively treated because of the development of hyperbilirubinemia and pyrexia. He died of multi-organ failure 74 days after liver transplantation. AA is not a rare complication of pediatric liver transplantation for fulminant hepatic failure. Therefore, AA must be suspected in pediatric cases of cytopenia even after liver transplantation. Our findings indicate bone marrow transplantation is the treatment of choice for AA even in cases where AA develops after liver transplantation.