Comparison of laparoscopic versus open surgery in a three-stage operation for obstructive left-sided colorectal cancer.

BACKGROUND: Treatment for obstructive left-sided colorectal cancer (OLCC) typically consists of a three-staged procedure. During the first stage, the obstruction is managed with diversion colostomy. Traditionally in the second stage, we perform open resection for the primary tumor. In this study, we evaluated the feasibility of laparoscopic resection of OLCC with diversion colostomy in terms of operative results and short-term outcomes. METHODS: A total of 20 patients underwent laparoscopic resection for OLCC (study group), 48 patients underwent open resection for OLCC (control group 1), and 53 patients underwent laparoscopic resection for non-OLCC (control group 2). Afterwards, results from the procedures were obtained and clinical data were analyzed. RESULTS: The operative time was significantly longer in the study group than in the control group 1 (153 minutes vs. 126 minutes, p = 0.041), and the length of hospitalization was shorter in the study group than in the control group 1 (5.3 days vs. 7.6 days, p = 0.032). Regarding the operative results and short-term outcomes, there were no significant differences between the study group and control group 2. Colostomy retraction was a specific morbidity which occurred in two patients of the study group. CONCLUSION: Laparoscopic resection of OLCC with diversion colostomy is feasible. Abdominal cavity adhesion is only limited. We strongly recommend that laparoscopic resection should be performed at least 2 weeks after diversion colostomy, and the plastic rod should be left in place during the pneumoperitoneum to reduce the risk of colostomy retraction.

Prevalence and risk factors of asymptomatic colorectal diverticulosis in Taiwan.

BACKGROUND: To investigate the prevalence and risk factors of asymptomatic colorectal diverticulosis in Taiwanese general population. METHODS: From January 2009 to December 2011, consecutive asymptomatic subjects undergoing a health check-up were evaluated by colonoscopy. The colorectal diverticulosis was assessed, and a medical history and demographic data were obtained from each subject. Logistic regression analysis was conducted to search the risk factors of colorectal diverticulosis. RESULTS: Of the 1899 asymptomatic subjects, the prevalence of colorectal diverticulosis was 13.5%. On univariate logistic regression analysis, age over 60 years old, male, adenomatous polyp, current smoking and heavy alcohol consumption were significantly associated with diverticulosis. Multivariate logistic regression analysis revealed that age over 60 years old (relative risk [RR], 2.57; 95% confidence interval [CI], 1.64-6.47), adenomatous polyps (RR, 2.18; 95% CI, 1.18-4.61) and heavy alcohol consumption (RR, 1.82; 95% CI, 1.04-3.08) were independent predictors for colorectal diverticulosis. CONCLUSIONS: The prevalence of asymptomatic colorectal diverticulosis was 13.5% in Taiwan. Age over 60 years old, adenomatous polyp and heavy alcohol consumption may affect the risk of development of the disease.

Measurement of peritoneal fluid urea nitrogen and creatinine levels is useful to detect iatrogenic urinary tract leakage in colorectal surgery.

BACKGROUND: Increased peritoneal drainage after colorectal surgery is a common problem. Measurement of peritoneal fluid urea nitrogen (UN) and creatinine (Cr) is a diagnostic tool to detect the urinary tract leakage (UTL). We evaluated its application in colorectal surgery. METHODS: We conducted a retrospective chart review study. We enrolled patients with iatrogenic UTL, and measured their UN and Cr levels in peritoneal fluid and compared them with those in blood and urine. Meanwhile, we assigned patients without UTL to a control group and compared clinical parameters of both groups. RESULTS: Twenty-three patients with iatrogenic UTL were recruited. The overall incidence was 0.5%. UN level in peritoneal fluid (322 ± 56 mg/dL) was significantly higher than that in blood (18.7 ± 4.0 mg/dL, p < 0.001); Cr level in peritoneal fluid (69.7 ± 14.3 mg/dL) was also significantly higher than that in blood (1.5 ± 0.5 mg/dL, p < 0.001). UN level in peritoneal fluid was significantly higher in the iatrogenic UTL group than in the control group (322 mL/dL vs. 9.3 mL/dL, p < 0.001); Cr level in peritoneal fluid was also significantly higher (69.7 mg/dL vs. 0.98 mg/dL, p < 0.001). CONCLUSION: When increased peritoneal drainage is found postoperatively in colorectal surgery, measurement of UN and Cr levels in peritoneal fluid can be a useful diagnostic tool to determine intraperitoneal iatrogenic UTL.

Prevalence and risk factors of asymptomatic colorectal polyps in taiwan.

Purpose. To investigate the prevalence and risk factors of hyperplastic and adenomatous colorectal polyps in a Taiwanese general population. Methods. From January 2009 to December 2011, consecutive asymptomatic subjects undergoing a routine health check-up were evaluated by colonoscopy. The colorectal polyps were assessed, and medical history and demographic data were obtained from each patient. Logistic regression analysis was conducted to search the independent risk factors for asymptomatic hyperplastic and adenomatous colorectal polyps. Results. Of the 1899 asymptomatic subjects, the prevalences of hyperplastic polyps and adenomatous polyps were 11.1% and 16.1%, respectively. Multivariate analysis revealed that high body mass index (BMI > 25: OR, 1.32, 95% CI, 1.05-1.71) and current smoking (OR, 1.87, 95% CI, 1.42-2.71) were independent predictors for hyperplastic colorectal polyps. Age over 60 years old (OR, 3.49, 95% CI, 1.86-6.51), high body mass index (BMI > 25: OR, 1.75, 95% CI, 1.21-2.71), heavy alcohol consumption (OR, 2.01, 95% CI, 1.02-3.99), and current smoking (OR, 1.31, 95% CI, 1.04-1.58) were independent predictors for adenomatous colorectal polyps. Conclusion. High BMI and smoking are common risk factors for both adenomatous and hyperplastic polyps. Old age and alcohol consumption are additional risk factors for the development of adenomatous polyps.

Drainage placement through the extraperitoneal tunnel can prevent its postoperative dislodgement effectively in laparoscopic rectal surgery.

BACKGROUND: Drainage placement is frequently used in laparoscopic rectal surgery, and dislodgement is common in conventional transperitoneal drainage placement. We proposed that extraperitoneal tunnel for drainage placement is useful to prevent the dislodgement. METHODS: We conducted an observational case-matched control study. In study group, a total of 40 patients undergoing laparoscopic rectal surgery with drainage through the extraperitoneal tunnel were enrolled. In control group, a total of 35 matched patients with drainage through the transperitoneal route were enrolled. Clinical data, tumor features, and intraoperative and postoperative characteristics were analyzed. RESULTS: Ten patients had drainage dislodgement in the transperitoneal group (28%) and 4 patients in the extraperitoneal group (10%). The P value was 0.039. Postoperative recovery was faster in the extraperitoneal group than in the transperitoneal group, as reflected by a shorter time to diet (P=0.049) and postoperative length of stay (P=0.032). In a multivariate analysis, drain dislodgement had a significant impact on the time to diet (P=0.023) and the postoperative length of stay (P=0.037). Drain placement influenced the time to diet (P=0.055) and the postoperative length of stay (P=0.079). CONCLUSIONS: In laparoscopic rectal surgery, drainage placement through the extraperitoneal tunnel can prevent its postoperative dislodgement effectively and is associated with better postoperative recovery.

Detection of resectable recurrences in colorectal cancer patients with 2-[18F]fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography.

PURPOSE: To evaluate the usefulness of 2-[(18)F]fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography (FDG-PET/CT) in the early detection of resectable recurrences of colorectal cancer (CRC) and the impacts on the clinical disease management. METHODS: FDG-PET/CT was performed on patients with elevated serum carcinoembryonic antigen (CEA) levels >5 ng/mL (Group 1) or suspicious recurrences without rise in serum CEA levels (Group 2). The results were analyzed on the basis of histological data, disease progression, and/or clinical follow-up. Recurrence was defined as evidence of recurrent lesions within 6 months of the FDG-PET/CT scan. Resectable recurrences and changes in management were calculated based on medical records. RESULTS: In our study, 128 consecutive FDG-PET/CT analyses (n=49 in Group 1 and n=79 in Group 2) were performed on 96 recruited patients. Recurrences were proven in 63. The overall sensitivity, specificity, and accuracy of FDG-PET/CT were 98.4%, 89.2%, and 93.8%, respectively, and were 100%, 88.9%, and 95.9% in Group 1 and 96.9% and 89.4% and 92.4% in Group 2, respectively. Surgical resections were performed in 38.7% (12/31) of Group 1 patients and 53.1% (17/32) of Group 2 patients. FDG-PET/CT induced changes in planned management in 48.4% (62/128) of all patients, which included 63.3% (31/49) of Group 1 patients and 39.2% (31/79) of Group 2 patients (p=0.008). After a follow-up, 3.4% (1/29) of patients who underwent surgical resection of recurrent lesions and 34.3% (11/34) patients who did not undergo resection died at the end of study (p=0.004). CONCLUSIONS: The surgical resection of limited recurrent disease, as determined by FDG-PET/CT, improves the survival of CRC patients. FDG-PET/CT should be performed not only in patients with elevated serum CEA levels, but also in those in whom recurrences are suspected to improve the early detection of resectable disease.

Comparison of the feasibility of laparoscopic resection of the primary tumor in patients with stage IV colon cancer with early and advanced disease: the short- and long-term outcomes at a single institution.

PURPOSE: The role of resection of the primary tumor in patients with stage IV colorectal cancer (CRC) remains controversial. Laparoscopic resection has become an accepted therapeutic option for treating early stage I-III CRC; however, it has not been evaluated for use in patients with advanced stage disease. METHODS: We conducted a retrospective observational study to evaluate the feasibility of laparoscopic resection of the primary tumor exclusively in patients with stage IV colon cancer compared to open resection in patients with stage IV colon cancer and laparoscopic resection in patients with stage I-III colon cancer in terms of operative results and short- and long-term outcomes. RESULTS: Laparoscopic resection was performed in 35 stage IV patients and open resection was performed in 40 stage IV patients. One hundred and eighteen stage I-III patients who underwent laparoscopic resection were evaluated. In the comparison between the laparoscopic group and the open group among patients with stage IV colon cancer, postoperative recovery appeared to be better in the laparoscopic group than in the open group, as reflected by shorter times to resumption of a regular diet (p = 0.049), shorter lengths of hospitalization (p = 0.083), increased feasibility of postoperative chemotherapy (p < 0.001), shorter time intervals from surgery to chemotherapy (p = 0.031) and longer median survival (p = 0.078) at the expense of longer operative times (p = 0.025). In the comparison between the laparoscopic resection in stage IV and stage I-III disease groups, no significant differences were observed in operative results and short- and long-term outcomes, except for the rate of ostomy creation (48.5 vs. 8.5%, p = 0.02). CONCLUSION: Laparoscopic resection of the primary tumor in patients with stage IV colon cancer achieves equivalent results to that performed in patients with stage I-III disease and that performed in patients with stage IV disease using open resection. The use of a minimally invasive approach in the laparoscopic procedure is beneficial because it results in shorter times to resumption of a normal diet, shorter lengths of hospitalization, increased feasibility of postoperative chemotherapy and shorter time intervals from surgery to chemotherapy at the expense of longer operative times. We believe that patients undergoing laparoscopic resection can receive targeted chemotherapy earlier and more aggressively, which might provide a survival benefit.

Oxaliplatin-induced severe anaphylactic reactions in metastatic colorectal cancer: case series analysis.

AIM: To investigate oxaliplatin-induced severe anaphylactic reactions (SAR) in metastatic colorectal cancer in a retrospective case series analysis and to conduct a systemic literature review. METHODS: During a 6-year period from 2006 to 2011 at Kaohsiung Veterans General Hospital, a total of 412 patients exposed to oxaliplatin-related chemotherapy were retrospectively reviewed. Relevant English-language studies regarding life-threatening SAR following oxaliplatin were also reviewed in MEDLINE® and PubMed® search. RESULTS: Eight patients (1.9%, 8 of 412 cases) were identified. Seven patients were successful resuscitated without any sequelae and one patient expired. We changed the chemotherapy regimen in five patients and rechallenged oxaliplatin use in patient 3. Twenty-three relevant English-language studies with 66 patients were reported. Patients received a median of 10 cycles of oxaliplatin (range, 2 to 29). Most common symptoms were respiratory distress (60%), fever (55%), and hypotension (54%). Three fatal events were reported (4.5%). Eleven patients (16%) of the 66 cases were rechallenged by oxaliplatin. CONCLUSION: SAR must be considered in patients receiving oxaliplatin-related chemotherapy, especially in heavily pretreated patients. Further studies on the mechanism, predictors, preventive methods and management of oxaliplatin-related SAR are recommended.

Health-seeking behaviors and sexuality in rectal cancer survivors in Taiwan: associations with spirituality and resourcefulness.

PURPOSE/OBJECTIVES: To examine the relationships between two health-seeking behaviors (HSBs), spirituality and resourcefulness, as well as demographics, cancer-related factors, and sexuality indicators, within the context of Schlotfeldt's health-seeking model in rectal cancer survivors. DESIGN: Secondary analysis, correlational, and cross-sectional. SETTING: A teaching hospital in southern Taiwan. SAMPLE: 120 adults with rectal cancer. METHODS: Data were collected during face-to-face interviews using the Body-Mind-Spirit Well-Being Inventory-Spirituality scale; Resourcefulness Scale; Sexual Self-Schema Scale (male and female versions); Evaluating and Nurturing Relationship Issues, Communication, Happiness (ENRICH) Couple Scale-Communication; ENRICH Sexual Relationship Scale; International Index of Erectile Function; and the Female Sexual Function Index. Correlational analysis, one-way analyses of variance, and independent sample t tests were used to analyze data. MAIN RESEARCH VARIABLES: Spirituality, resourcefulness, HSBs, and sexuality. FINDINGS: Spirituality and resourcefulness were associated with sexual self-concept and sexual satisfaction in men and women. Spirituality was correlated with resourcefulness. Greater resourcefulness was found in women, as well as in men and women who had higher education and fewer comorbid conditions. Spirituality was not associated with gender, education, or number of comorbid conditions. Neither spirituality nor resourcefulness was associated with age, religion, stage of disease, time since surgery, type of cancer treatment, or sexual function. CONCLUSIONS: Resourcefulness and spirituality were associated with the sexuality indicators of satisfaction and self-concept, which may have an impact on the physical and psychological health of adults with rectal cancer. IMPLICATIONS FOR NURSING: The findings suggest a need to focus on strengthening HSBs through teaching resourcefulness and encouraging spirituality to enhance sexual self-concept and improve sexual satisfaction in this patient group.

Factors that influence survival in colorectal cancer with synchronous distant metastasis.

BACKGROUND: Treatments for the purposes of curing or more effectively managing metastatic colorectal cancer (CRC) are evolving. Our study focused on patients with primary CRC with synchronous distant metastasis, and we analyzed the factors influencing patient survival. METHODS: Data review was conducted retrospectively. Clinicopathological parameters included age, sex, site of primary cancer, tumor cell differentiation, number of liver metastasis, presence of extrahepatic metastasis, treatment of liver metastasis, pre-treatment carcinoembryonic antigen (CEA) level, status of treatment response, salvage treatment and survival. RESULTS: A total of 420 patients were identified and considered for our study. Of those, 275 patients (65.4%) had liver-only metastasis, 100 patients (23.8%) had concomitant lung metastasis, and 40 patients (9.5%) had other metastases. Additionally, 145 patients (34.5%) had liver-directed treatment including surgical resection (28.5%), radiofrequency ablation (RFA) (10.6%) and transcatheter arterial chemoembolization (TAE) (1.2%). There were 80 patients (19%) with CEA levels < 10, 135 patients (32.1%) with CEA 10-100, and 165 patients (39.2%) with CEA > 100. There were 200 patients (47.6%) who had received chemotherapy, 130 patients (30.9%) with target therapy, and 40 patients (9.5%) who had not undergone any salvage treatment. Three significant factors were identified, including treatment of liver metastasis (p=0.027), pre-treatment CEA (p=0.04), and salvage treatment (p=0.005). CONCLUSION: We demonstrated three factors influencing patient survival including treatment of liver metastasis, pre-treatment CEA level, and salvage treatment. Aggressive treatment of liver metastasis including surgical resection or RFA combined with chemotherapeutic agents appear to provide an increased rate of survival to patients.

Demographics, cancer-related factors, and sexual function in rectal cancer patients in Taiwan: preliminary findings.

BACKGROUND: Sexual function has been ignored because survival issues associated with cancer treatment commonly take precedence over sexual issues. Sexual dysfunction remains a recognized complication after cancer treatment despite improvement in survival rates for patients with rectal cancer. OBJECTIVE: This study investigated the relationships among demographics (ie, age, gender, education, religion) and cancer-related factors (ie, stage of disease, type of treatment, time since operation, comorbid conditions) and sexual function in patients with rectal cancer. METHODS: A cross-sectional study with a convenience sample of 120 rectal cancer patients from a medical center in southern Taiwan completed the International Index of Erectile Function, Female Sexual Function Index, a demographic questionnaire, and medical data during face-to-face interviews. RESULTS: In both men and women, better sexual function was significantly associated with younger age but not with religion, time since operation, or number of chronic conditions. In men only, better sexual function was associated with earlier stage of cancer, fewer cancer treatments, and higher education. CONCLUSION: Sexual function may receive greater attention in Taiwan when rectal cancer patients receive appropriate care. A larger diverse sample is needed for further examination of sexual function over time. IMPLICATIONS FOR PRACTICE: Health promotion programs for long-term survivors should include a consistent assessment of sexual function before and after an operation, and patients should receive clinical sexual counseling.

Factors that influence survival in unresectable metastatic or locally advanced colorectal cancer.

PURPOSE: Half of patients with colorectal cancer (CRC) have metastasis during the whole course of the disease. Fewer than 10% of those are still alive at 5 years. Locally advanced CRC accounts for 7% to 33% of CRC relapses. Of these, only a small number of patients are resectable with a curative intent. Management of unresectable metastatic or locally advanced CRC is a significant challenge. In this study, we focus on patients with unresectable locally advanced or metastatic CRC and analyze survival rate and prognostic factors influencing the survival. METHODS: There were 277 patients identified. Several clinicopathologic parameters were evaluated. To determine the prognostic impact of the factors in survival, all parameters were tested from their relationship in Cox-regression model and Cox proportional hazards model. Survival curves were generated according to Kaplan-Meier method and the differences in survival were determined by employing the log-rank test. RESULTS: Three factors that influence the survival were identified: one or more than two organs involved (p = 0.041), higher carcinoembryonic antigen (CEA) level (p = 0.001), and different salvage treatment (p < 0.001). In Kaplan-Meier survival analysis, there were significant differences between patients with one and more than two organs involved (p = 0.027), different ranges of CEA level (p = 0.004), and different salvage treatment (p < 0.001). CONCLUSIONS: We clearly demonstrated three factors that influence the survival, including more than two organs involved, higher CEA level, and different salvage treatment. The higher the CEA level and the more organs (≥2) involved, the worse the survival. Even in patients with unresectable metastatic or locally advanced, aggressive treatment with target therapy seems to have survival benefit.

Acute rectocolitis following endoscopy in health check-up patients--glutaraldehyde colitis or ischemic colitis?

PURPOSE: Acute rectocolitis is a rare complication that follows endoscopy. It could be caused by glutaraldehyde or ischemic injury. The clinical, endoscopic, radiological, and pathological features of glutaraldehyde-induced colitis may mimic those of ischemic colitis. We reported our experiences regarding this problem. METHODS: The medical records of patients with acute rectocolitis following endoscopy treated at Kaohsiung Veterans General Hospital since 2001 were reviewed. The indication of endoscopy was health check-up for all patients. Published English-language studies regarding acute rectocolitis following endoscopy were also reviewed. RESULTS: An outbreak of six patients occurred in April 2002 and one cirrhotic patient was admitted in July 2008. All patients developed a self-limited syndrome of abdominal pain and bloody diarrhea within 48 h of uncomplicated endoscopy. One severely ill patient required hospitalization to receive intravenous fluid and antibiotics. After the investigation in April 2002, glutaraldehyde-induced colitis was diagnosed due to a defect in the endoscope-cleansing procedure. There were no any deficiencies in the cleansing procedure in July 2008. Considering the patient's concomitant disease, we postulated that ischemic colitis with cirrhosis-related intestinal inflammation and endotoxemia was the possible diagnosis in this sporadic case. CONCLUSIONS: Endoscopists should be aware of this iatrogenic complication in patients presenting with acute rectocolitis, especially in those who have undergone recent endoscopic examination. An outbreak of acute rectocolitis following endoscopy should be considered glutaraldehyde-induced and should lead to an investigation of cleansing and equipment-disinfection procedures. In the absence of strong evidence of an outbreak, an infectious disease, or contamination of glutaraldehyde, a sporadic case should be considered ischemic colitis especially in patients with relevant concomitant diseases or predisposing factors.

Shifting to first-line regimen after previous failure of irinotecan and oxaliplatin containing chemotherapies in unresectable metastatic colorectal cancer: a retrospective study of case analysis.

PURPOSE: Conventional use of FOLFIRI-FOLFOX or the reverse sequence is the optional regimen in metastatic unresectable colorectal cancer (CRC). We present our experience in chemotherapy (C/T) shifting to first-line regimen after previous failure of irinotecan and oxaliplatin containing regimens. MATERIALS AND METHODS: A total of 48 patients with metastatic unresectable CRC were examined retrospectively. All the patients had both failure of a first-line C/T and a second-line C/T. Of these patients, 13 patients received C/T shifting to first-line regimen. Data were collected retrospectively. RESULTS: Rate of disease control of 38.4% was achieved (five in 13 patients). In the positive disease control group, metastatic sites were all extra-hepatic (five patients). In the negative disease control group, hepatic metastatic rate was 62.5% (five in eight patients, P=0.044). CONCLUSIONS: Even after previous failure of irinotecan and oxaliplatin containing C/T, we observe positive disease control response and survival benefit in selected patients with C/T shifting to the first-line regimen especially in extra-hepatic metastasis. The preliminary results are proposed to gain insight into the need for further investigations and large-scale studies.

Factors that influence 12 or more harvested lymph nodes in early-stage colorectal cancer.

BACKGROUND: The number of lymph nodes required for accurate staging is a critical component in early-stage (stage A and B) colorectal cancer (CRC). Current guidelines demand at least 12 lymph nodes to be retrieved. Results of previous studies were contradictory in factors, which influenced the number of harvested lymph nodes. This study was designed to determine the factors that influence the number of harvested lymph nodes (> or =12) in early-stage CRC in a single institution. METHODS: Between 2003 and 2007, data on patients who underwent surgery for early-stage CRC were analyzed retrospectively. Data for a total of 470 patients were collected and all the tumor-bearing specimens were fixed with node identification performed. Several possible factors that influence 12 or more harvested lymph nodes were investigated and classified into four aspects: (1) operating surgeon, (2) examining pathologist, (3) patient (age, sex, and body mass index), and (4) disease (maximal length of tumor, length of specimen, tumor localization, tumor cell differentiation, Dukes stage, type of resection, and type of tumor). RESULTS: A total of 289 patients (61.5%) with 12 or more harvested lymph nodes and 181 patients (38.5%) with < 12 lymph nodes were analyzed. The results demonstrate that within a single institution the maximal length of tumor, tumor localization, and depth of tumor invasion according to Dukes stage were independent influencing factors of 12 or more harvested lymph nodes. Maximal length of tumor was associated with more harvested lymph nodes (P < 0.001). Neither the operating surgeon nor the examining pathologist had significant influence on the number of harvested lymph nodes. CONCLUSIONS: The number of harvested lymph nodes was highly variable in patients who underwent resection of early-stage CRC. Neither the operating surgeon nor the examining pathologist had significant influence on the number of harvested lymph nodes. Therefore, from the viewpoint of the surgeons, disease itself is the most important factor influencing the number of harvested lymph nodes.