Predictors of High-Risk Adenoma Occurrence at Surveillance Colonoscopy in Patients Who Undergo Colorectal Adenoma Removal.

OBJECTIVES: Surveillance colonoscopy is recommended after polypectomy because adenoma recurrence is common. The aim of this study was to evaluate the predictors of high-risk adenoma occurrence at surveillance colonoscopy in patients who undergo colorectal adenoma removal and to clarify the association between age and recurrent colorectal adenoma. METHODS: This retrospective study included 563 patients who had colorectal adenomas at baseline colonoscopy and who underwent surveillance colonoscopy. The risk factors for recurrent adenoma were evaluated and the 5-year cumulative incidence rates of overall and high-risk adenoma were compared according to age group. RESULTS: During a mean follow-up period of 3.1 years, 305 (54.2%) patients had overall adenoma recurrence, and 80 (14.2%) patients had high-risk adenoma at surveillance colonoscopy. In a multivariate analysis, old age (≥60 years) and presence of multiple adenomas (3 or more) were significantly associated with high-risk adenoma (p = 0.002 and p = 0.006 respectively). The 5-year cumulative incidence rates of high-risk adenoma were 7.4, 16.7, and 24.1% in the < 50, 50-59, and ≥60 years group respectively (p < 0.001). CONCLUSIONS: Old age (≥60 years) and presence of multiple adenomas (3 or more) were strongly associated with the occurrence of high-risk adenoma at surveillance colonoscopy. The 5-year cumulative incidence of high-grade adenoma was significantly high in the old age group.

[Ascending Colon Variceal Bleeding in Cirrhotic Patient with Emergent Endoscopic Variceal Obturation with N-butyl-2-cyanoacrylate].

Ectopic varices are rare among patients with portal hypertension, especially in the ascending colon. It is difficult to evaluate massive lower gastrointestinal bleeding in patients with liver cirrhosis by colonoscopy due to hemodynamic instability and poor bowel preparation. In Korea, there has only been one case report about ascending colon variceal bleeding, in which hemostasis was performed by venous coil embolization. We report another rare case of ascending colon variceal bleeding in a patient with alcoholic cirrhosis, who was successfully treated via two sessions of N-butyl-2-cyanoacrylate injection through colonoscopy. This case suggests that the careful endoscopic approach and hemostasis with glue injection might be an option for treating massive bleeding in the lower gastrointestinal varix.

A case of pemphigus vulgaris associated with ulcerative colitis.

Pemphigus vulgaris is an autoimmune bullous disorder characterized by the production of autoantibodies against the intercellular space of the epithelium. It has rarely been reported in association with inflammatory bowel disease. Ulcerative colitis is one of the forms of inflammatory bowel disease. A 62-year-old woman who had been treated for ulcerative colitis for 16 years developed pruritic bullae on the skin of her face and body. Histological findings and direct immunofluorescence examination of the skin showed pemphigus vulgaris. She was treated with systemic steroids, mesalazine, and azathioprine. Her cutaneous lesions have remained in remission and her ulcerative colitis has remained well-controlled. The relationship between pemphigus vulgaris and ulcerative colitis is unclear. An autoimmune response has been suspected in the pathogenesis of ulcerative colitis. Pemphigus vulgaris is also associated with an autoimmune mechanism. To our knowledge, this is the first case of ulcerative colitis associated with pemphigus vulgaris reported in Korea. The association may be causal.

Shorter waiting times from education to colonoscopy can improve the quality of bowel preparation: A randomized controlled trial.

BACKGROUND/AIMS: Adequate bowel preparation is essential for an effective and safe colonoscopy. This study aimed to evaluate the quality of bowel preparation according to waiting times from education to colonoscopy. MATERIALS AND METHODS: A prospective, investigator-blinded, randomized study was performed from December 2016 to March 2017. Patients were divided into two groups: within 2 weeks (group A, n=64) or more than 2 weeks (group B, n=66) from education about bowel preparation to colonoscopy. The primary outcome was the quality of bowel preparation as assessed by the Boston Bowel Preparation Scale (BBPS). The secondary outcome was the polyp and adenoma detection rate. RESULTS: A total of 130 patients were enrolled. The total BBPS score was significantly higher in group A (within 2 weeks from education to colonoscopy) than in group B (more than 2 weeks). Total BBPS scores were 8.25}0.97 in group A and 7.75}1.32 in group B (P=.017). The rate of good preparation (BBPS≥8) was higher in group A than in group B (78.1% vs. 59.1%, P=.020). The rates of polyp and adenoma detection were both slightly higher in group A (polyps, 42.2% vs. 38.5%, P=.667; adenoma, 31.2% vs. 22.7%, P=.275). A numerical trend was observed for the slightly superior polyp and adenoma detection rate in group A, but it was not statistically significant. CONCLUSION: This study demonstrated that shorter waiting times from education to colonoscopy can improve the quality of bowel preparation. Ensuring sufficient staff and equipment for endoscopy is one approach to reducing waiting times to colonoscopy. If waiting times can not be reduced, more contact through telephone, e-mail, and text messaging could be used to remind patients about information regarding bowel preparation.

Usefulness of plasma procalcitonin to predict severity in elderly patients with community-acquired pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is one of the leading causes of death among the elderly. Several studies have reported the clinical usefulness of serum procalcitonin, a biomarker of bacterial infection. However, the association between the levels of procalcitonin and the severity in the elderly with CAP has not yet been reported. The aim of this study was to evaluate usefulness of procalcitonin as a predictor of severity and mortality in the elderly with CAP. METHODS: This study covers 155 CAP cases admitted to Pusan National University Hospital between January 2010 and December 2010. Patients were divided into two groups (≥65 years, n=99; <65 years, n=56) and were measured for procalcitonin, C-reactive protein (CRP), white blood cell, confusion, uremia, respiratory rate, blood pressure, 65 years or older (CURB-65) and pneumonia severity of index (PSI). RESULTS: The levels of procalcitonin were significantly correlated with the CURB-65, PSI in totals. Especially stronger correlation was observed between the levels of procalcitonin and CURB-65 in the elderly (procalcitonin and CURB-65, ρ=0.408 with p<0.001; procalcitonin and PSI, ρ=0.293 with p=0.003; procalcitonin and mortality, ρ=0.229 with p=0.023). The correlation between the levels of CRP or WBC and CAP severity was low. The existing cut-off value of procalcitonin was correlated with mortality rate, however, it was not correlated with mortality within the elderly. CONCLUSION: The levels of procalcitonin are more useful than the levels of CRP or WBC to predict the severity of CAP. However, there was no association between the levels of procalcitonin and mortality in the elderly.

Testicular tuberculosis in multidrug-resistant pulmonary tuberculosis.

We report a rare case of multidrug-resistant pulmonary and testicular tuberculosis (TB) in a 25-year-old immunocompetent patient. The patient was suspected to have a testicular cancer. He underwent radical orchiectomy, and surgical pathology revealed a granuloma containing acid-fast bacilli in the testis. Bronchial washing fluid culture grew Mycobacterium tuberculosis resistant to isoniazid, rifampin, and ethambutol. To our knowledge, this patient represents the first case of testicular TB in multidrug-resistant pulmonary TB.

Extended pelvic lymph node dissection including internal iliac packet should be performed during robot-assisted laparoscopic radical prostatectomy for high-risk prostate cancer.

INTRODUCTION: The indication and anatomic limits of pelvic lymph node dissection (PLND) have not been clearly defined. Therefore, we assessed whether the extent of PLND at robot-assisted laparoscopic radical prostatectomy (RALP) had any benefit on lymph node yield, staging accuracy, and biochemical recurrence (BCR) in patients with high-risk prostate cancer. PATIENTS AND METHODS: Between July 2005 and July 2010, a retrospective analysis was performed on 200 patients with high-risk prostate cancer stratified by D'Amico classification. The study population was divided into different groups: patients in Group 1 had standard PLND, and Group 2 had extended PLND (ePLND). The clinicopathologic findings of patients and surgical outcomes of PLND with each procedure were measured. Kaplan-Meier and log rank tests were used to estimate BCR-free survival rates. Univariate and multivariate survival analyses were done with the Cox proportional hazard regression model. RESULTS: Medians of 15 (interquartile range, 11-19) and 24 (interquartile range, 18-28) lymph nodes were dissected in Groups 1 and 2, respectively (P<.001). The incidences of lymph node metastasis were 5.2% (8/155) in Group 1 and 22.2% (10/45) in Group 2. Regardless of the extent of PLND, the patients with positive lymph nodes had a significantly lower BCR-free survival than those with negative lymph nodes. Twenty-five percent (7/27) of positive lymph nodes were in the internal iliac packet and common iliac packet. In particular, of the positive internal iliac nodes, 75% (3/4) of nodes were found in that location, exclusively. CONCLUSIONS: An ePLND that identifies patients with lymph node metastasis including the internal iliac packet during RALP provides an accurate pathologic staging and may have survival benefits in high-risk prostate cancer.

Laparoendoscopic single site adrenal surgery.

Laparoscopic adrenal surgery is a standard procedure for the management of benign adrenal pathology and small malignant tumors. There has been an increasing interest over the last few years in the use of laparoendoscopic single-site surgery (LESS). From recent literatures, LESS adrenalectomy was demonstrated that this technique was safe and feasible despite the relatively difficult anatomical location of the adrenal gland. We reviewed the surgical techniques and outcomes of LESS adrenalectomy including robot-assisted approach and gave an overview of the current role of LESS in adrenalectomy.

The risk factor for urethral recurrence after radical cystectomy in patients with transitional cell carcinoma of the bladder.

PURPOSE: We evaluated the incidence and risk factors for urethral recurrence following radical cystectomy and urinary diversion in transitional cell carcinoma. PATIENTS AND METHODS: A retrospective review was performed of the 412 consecutive patients who underwent radical cystectomy and urinary diversion for transitional cell carcinoma of the bladder between 1986 and 2004. A total of 294 patients were enrolled in this study. We investigated the impact of various clinical and pathological features on urethral recurrence by univariate and multivariate analysis. RESULTS: Urethral recurrence developed in 13 patients (4.4%) and the 5-year urethral recurrence-free probability was 94.9%. On univariate analysis, positive urethral margin, prostatic stromal invasion, and prostatic urethral involvement had a significant influence on urethral recurrence (p < 0.05). The other clinical and pathological features were not significantly associated with urethral recurrence (p > 0.05). A multivariate Cox proportional hazard model revealed that a positive urethral margin (hazards ratio (HR) = 18.33, p < 0.001), prostatic urethral involvement (HR = 7.95, p < 0.001), and prostatic stromal invasion (HR = 5.80, p = 0.018) were independent risk factors for urethral recurrence. CONCLUSION: A positive urethral margin is considered an absolute indication for prophylactic urethrectomy. In addition, more careful patient selection is necessary for orthotopic urinary diversion in patients with prostatic urethral involvement and prostatic stromal invasion.

The prognostic significance of pathologic stage T0 on organ-confined bladder transitional cell carcinoma following radical cystectomy.

INTRODUCTION: We evaluated the prognostic significance of pT0 stage on organ-confined transitional cell carcinoma of the bladder following radical cystectomy. PATIENTS AND METHODS: We retrospectively reviewed the medical records of consecutive patients who underwent radical cystectomy for organ-confined transitional cell carcinoma of the bladder between 1986 and 2004. Patients who were treated with neoadjuvant or adjuvant therapy were excluded. A total of 197 patients were enrolled in this study. We investigated the impact of pathologic T stage on disease-specific survival. RESULTS: Overall disease-specific survival rate was 84.1% after 5 years. Five-year disease-specific survival rates according to pathologic stage were 88.7% in pT0, 92.2% in pTis-1 and 65.4% in pT2 disease. Overall disease-specific survival rate with pTis-1 or pT0 tumors was significantly higher than with pT2 tumors (p = 0.001, pT2 vs. pT0; p < 0.001, pT2 vs. pTis-1), but there was no difference in disease-specific survival between pTis-1 and pT0 tumors (p > 0.05). In the muscle-invasive tumor group, pT0 tumors had a more favorable prognosis than pT2 tumors (p = 0.042), but there was no difference in prognosis between pT0 and pTis-1 tumors. CONCLUSIONS: Pathologic stage T0 cystectomy can be considered a curative therapy in most cases, including pT0cT2 tumors, but there is a substantial risk of tumor recurrence.