A case of bowel perforation due to traumatic hernia at a pelvic fracture site: a case report and review of the literature.

BACKGROUND: Common complications of pelvic fractures include visceral injury, large-volume hemorrhage, genitourinary injury, rectal injury, and pulmonary embolism. On the other hand, traumatic hernia is a rare complication, especially in association with pelvic fractures. We report a case of bowel perforation due to traumatic hernia at a pelvic fracture site. CASE PRESENTATION: A 65-year-old female was presented at our hospital for further examination and treatment of ileus. She was diagnosed with bowel perforation due to traumatic hernia at a pelvic fracture site, and an emergency operation was thus immediately performed. We performed segmental jejunum resection and constructed jejunostomy, and the iliac bone fracture was fixed with four pins. In the postoperative course, she received antibiotics and vasopressors for septic shock. However, there was no need for either a ventilator, dialysis or admission to the ICU. At seven days after the operation, a residual abscess was detected in the pouch of Douglas. We performed percutaneous drainage (Clavien-Dindo IIIa) and jejunostomy closedown 35 days after the first operation. The postoperative course was without complication, but she received rehabilitation until she was able to walk unaided. She was discharged 64 days after the first operation. CONCLUSION: The occurrence of traumatic hernia is rare, especially in association with pelvic fractures. Although its rarity, traumatic hernia follows a severe course. Thus, proper diagnosis and effective treatment are necessary. Surgeons treating patients with pelvic injuries should consider the possibility of any complications and perform a work-up examination in order to achieve an accurate diagnosis at an earlier time point.

Impact of the Preoperative Controlling Nutritional Status (CONUT) Score on the Survival after Curative Surgery for Colorectal Cancer.

BACKGROUND: Recently, the preoperative immune-nutritional status has been reported to correlate with the survival rate in patients with colorectal cancer (CRC). However, there have been no reports on the relationship between the controlling nutritional status (CONUT) score and the clinical outcome after curative surgery for CRC. We herein evaluated the prognostic significance of the CONUT score in patients with CRC, and then compared the accuracy of the CONUT score and the prognostic nutritional index (PNI) as a predictor of survival. METHODS: We retrospectively reviewed a database of 204 patients who underwent curative surgery for Stage II/III CRC. Patients were divided into two groups according to the CONUT score and the PNI. RESULTS: The five-year cancer-specific survival (CSS) rate was significantly higher at 92.7% in the low CONUT group, compared to a rate of 81.0% in the high CONUT group (p=0.0016). The five-year CSS was 71.2% in the low PNI group and 92.3% in the high PNI group, which showed a significant difference (p=0.0155). A multivariate analysis showed that lymph node metastasis and the CONUT score were independent risk factors for CSS. CONCLUSION: This study suggested that the CONUT score is a strong independent predictor of the survival among CRC patients.

The prognostic significance of the postoperative prognostic nutritional index in patients with colorectal cancer.

BACKGROUND: The preoperative prognostic nutritional index (PNI) has been reported to correlate with the prognosis in patents with various carcinomas. However, the prognostic significance of the postoperative PNI is unknown. The aim of this study was to evaluate the prognostic significance of the postoperative PNI in patients with colorectal cancer (CRC). METHODS: Two hundred and eighteen patients who underwent potentially curative surgery for stage II/III CRC were enrolled in this study. The PNI was calculated as 10 × serum albumin concentration (g/dl) + 0.005 × lymphocyte count (/mm(3)). The preoperative PNI was measured within two weeks before the operation and the postoperative PNI were measured at the first visit after leaving the hospital. We then examined the correlations between the preoperative/postoperative PNI and the prognosis for survival. RESULTS: In the validation study, the median preoperative PNI was 47.90 (range: 32.45-61.36) and the median postoperative PNI was 48.69 (range: 32.62-66.96). According to the receiver operating characteristic (ROC) curve, we set 43.0 as the cut-off value in the validation study. For both the preoperative and postoperative PNI, the overall survival rates were significantly worse in the low PNI group in the validation study (preoperative PNI, p = 0.0374; postoperative PNI, p = 0.0005). In the multivariate analysis of the validation study, the combination of pre- and postoperative PNI was an independent predictor of poor overall survival (p = 0.006). CONCLUSIONS: The postoperative PNI is, in addition to the preoperative PNI, a useful prognostic marker. The combination of pre- and postoperative PNI was an independent prognostic factor in patients with CRC who underwent potentially curative surgery and is important for considering the long-term outcome in patients with CRC.

The prognostic significance of a postoperative systemic inflammatory response in patients with colorectal cancer.

BACKGROUND: Recently, a preoperative systemic inflammatory response has been reported to be a prognostic factor in patients with colorectal cancer (CRC). However, the prognostic significance of a systemic inflammatory response in the early stage after surgery in patients with CRC is unknown. The aim of this retrospective study was to evaluate the prognostic significance of a postoperative systemic inflammatory response in patients with CRC. METHODS: Two hundred and fifty-four patients who underwent potentially curative surgery for stage II/III CRC were enrolled in this study. Univariate and multivariate analyses were performed to evaluate the relationship between the prognosis and clinicopathological factors, including the neutrophil-to-lymphocyte ratio (NLR) and Glasgow Prognostic Score (GPS), which were measured within two weeks before operation and at the first visit after leaving the hospital. RESULTS: The overall survival rates were significantly worse in the high preoperative NLR/preoperative GPS/postoperative NLR group. A multivariate analysis indicated that only preoperative GPS, postoperative NLR, and the number of lymph node metastases were independent prognostic factors for a poor survival. CONCLUSIONS: The postoperative NLR is an independent prognostic factor in patients with CRC who underwent potentially curative surgery.

The pretreatment albumin to globulin ratio predicts chemotherapeutic outcomes in patients with unresectable metastatic colorectal cancer.

BACKGROUND: The pretreatment albumin to globulin ratio (AGR) has been reported to correlate with the long-term survival in patients with various cancers. However, there are no reports regarding the correlation between the pretreatment AGR and chemotherapeutic outcomes in patients with unresectable metastatic colorectal cancer. The aim of this study was to evaluate the prognostic significance of the pretreatment AGR in patients with unresectable metastatic colorectal cancer. METHODS: A total of 66 patients with unresectable metastatic colorectal cancer who underwent palliative chemotherapy for metastatic tumors were enrolled. The AGR was calculated as follows: Albumin/(Total protein - Albumin). RESULTS: The median pretreatment AGR was 1.254 (range: 0.849-1.840). We set 1.25 as the cut-off value based on the receiver operating characteristic curve. Based on the cut-off value of 1.25, 34 patients were classified into the high-AGR group and 32 patients were classified into the low-AGR group. The high-AGR group had a significantly higher chemotherapeutic disease control rate (p = 0.040) and better progression-free survival (p = 0.0171) and overall survival (p = 0.0360) rates than the low-AGR group. According to a multivariate analysis of survival, the AGR was identified to be an independent prognostic factor for progression-free survival (Hazard Ratio: 2.662, 95% Confidence Interval: 1.085-6.631, p = 0.033) and overall survival (Hazard Ratio: 2.247, 95% Confidence Interval: 1.069-4.722, p = 0.033). CONCLUSIONS: The pretreatment AGR is a useful prognostic marker in patients with unresectable metastatic colorectal cancer who receive palliative chemotherapy.

Expression of xCT as a predictor of disease recurrence in patients with colorectal cancer.

BACKGROUND: The function of a cysteine-glutamate exchanger (xCT) transporter is to increase the intracellular concentration of glutathione in order to protect cells from oxidative stress. In several types of cancer, xCT is thought to play a role in the onset of resistance to chemotherapy and radiotherapy. xCT is stabilized on the tumor cell surface after combining with cluster of differentiation 44 variant (CD44v). MATERIALS AND METHODS: We examined the xCT and CD44v6 expression in 304 primary tumor samples obtained from patients with colorectal cancer using immunohistochemical analysis. RESULTS: Immunoreactivity for xCT was observed in 208 (68.4%) tumors. Among 218 patients with stage I-III disease who underwent curative surgery, the postoperative recurrence rate was 32.9% in those with xCT-positive tumors, which was significantly (p=0.003) higher than in those with xCT-negative tumors (10.7%). Immunoreactivity for CD44v6 was observed in 101 cases (33.2%), although the rate of postoperative recurrence in patients with CD44v6-positive tumors did not exhibit any significant correlation. Multivariate analyses revealed increased xCT expression to be an independent significant predictor of disease recurrence, in addition to depth of tumor invasion, lymph node metastasis and venous invasion.

Efficacy of intracorporeal reinforcing sutures for anastomotic leakage after laparoscopic surgery for rectal cancer.

BACKGROUND: The aim of the present study was to investigate the efficacy of intracorporeal reinforcing sutures for preventing anastomotic leakage (AL) after laparoscopic surgery for rectal cancer. METHODS: This was a retrospective single-institution study consisting of 201 consecutive patients who underwent laparoscopic proctectomy with double-stapling anastomosis for primary rectal cancer between August 2007 and December 2013. The data for patients who received intracorporeal reinforcing sutures were compared with those of patients who did not receive reinforcing sutures. Patient-, tumor- and surgery-related variables were collected and examined using univariate and multivariate analyses. RESULTS: The overall incidence of AL was 9.0% (18/201). No significant correlations were observed between the various clinicopathological factors and the use of reinforcing sutures. The multivariate analyses revealed the distance of the tumor from the anal verge, tumor size and presence of reinforcing sutures to be independent risk factors for AL. We classified the patients into two risk groups using a combination of the tumor site and tumor size: a low-risk group (patients without any risk factors, n = 134) and a high-risk group (patients with one or two risk factors, n = 67). The frequency of AL was significantly lower (p < 0.02) in the patients treated with reinforcing sutures than in those treated without reinforcing sutures in the high-risk group. However, no significant differences were observed in the low-risk group. CONCLUSIONS: The use of intracorporeal reinforcing sutures may reduce the incidence of AL. A prospective randomized trial is required to evaluate the effects of reinforcing sutures in preventing AL.

Maintenance of the nutritional prognostic index predicts survival in patients with unresectable metastatic colorectal cancer.

PURPOSE: Nutrition and immunity significantly affect the progression of cancer in cancer patients. Therefore, the evaluation of the nutritional and immune status would be useful as a prognostic factor and to determine the optimal treatment strategy for patients with unresectable metastatic colorectal cancer who are receiving chemotherapy. The aim of this retrospective study was to evaluate the prognostic significance of the nutritional and immune status in patients with unresectable metastatic colorectal cancer treated with chemotherapy. METHODS: We retrospectively reviewed 80 patients with colorectal cancer. A total of 22 patients had metachronous unresectable cancer, and 58 patients had synchronous unresectable cancer. All patients underwent combination chemotherapy with oxaliplatin or irinotecan plus 5-fluorouracil/leucovorin as first-line chemotherapy. We then examined the correlations between the Onodera's prognostic nutritional index (OPNI) and the patients' clinicopathological features. The OPNI was calculated as follows: 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm(3)). According to the receiver operating characteristic (ROC) curve analysis, the cutoff value for OPNI was 44.5. RESULTS: Patients with a pretreatment OPNI of ≧44.5 demonstrated a longer OS than those with a pretreatment OPNI of <44.5. Moreover, we categorized these patients into four groups according to the combination of the pre- and post-treatment OPNI. The patients in the group with both OPNIs ≥44.5 exhibited a better prognosis compared to the other group (p = 0.001). CONCLUSION: The OPNI is considered to be a useful marker for predicting the long-term outcome in patients who receive chemotherapy for unresectable metastatic colorectal cancer.

Elevated preoperative serum C-reactive protein levels are associated with poor survival in patients with colorectal cancer.

BACKGROUND/AIMS: Previous studies have reported that elevated preoperative serum C-reactive protein (CRP) levels are associated with a poor prognosis in patients with various types of cancer. The aim of this study was to evaluate the prognostic significance of the preoperative serum CRP levels in patients with colorectal cancer and determine an appropriate cutoff value of the serum CRP level. METHODOLOGY: We enrolled 855 patients who underwent surgery for stage I-IV colorectal cancer. The median serum CRP level was 0.13 (range: 0.01-22.8). We set 0.6 as the cutoff value of the serum CRP level based on the receiver operating characteristic curve. The patients were classified into two groups according to the serum CRP level. The prognostic significance of an elevated serum CRP level was evaluated using a multivariate analysis. RESULTS: The cancer-specific survival was significantly worse in the patients with a high serum CRP level. In particular, more significant differences were observed in the patients with stage IV disease. The multivariate analysis indicated that a high serum CRP level was an independent risk factor for poor survival. CONCLUSIONS: The preoperative serum CRP level is a convenient biomarker and predictor of a poor prognosis after surgery for colorectal cancer.

Low nutritional prognostic index correlates with poor survival in patients with stage IV colorectal cancer following palliative resection of the primary tumor.

BACKGROUND: We retrospectively investigated the prognostic significance of various clinicopathological factors and preoperative nutritional status to select patients with stage IV colorectal cancer (CRC) who will have a poor prognosis after palliative resection of the primary tumor. METHODS: A total of 100 stage IV CRC patients who underwent palliative resection were enrolled. Various clinicopathological factors and Onodera's prognostic nutritional index (OPNI) were evaluated to identify any possible relationship with the prognosis. RESULTS: At the time of the analysis, 83 patients had died, and the median survival time was 21 months. Of the 100 patients, 24 had primary tumor-related symptoms such as obstruction or bleeding. No significant correlation was noted between the OPNI and various clinicopathological factors. The multivariate analysis of patients without primary tumor-related symptoms revealed that the OPNI was an independent prognostic factor. The overall survival of the low-OPNI group was significantly worse than that of the high-OPNI group. CONCLUSIONS: This retrospective study suggested that patients with a low OPNI may not be candidates for palliative resection, because it provides no survival benefit to these patients.

Prognostic value of preoperative inflammation-based prognostic scores in patients with stage IV colorectal cancer who undergo palliative resection of asymptomatic primary tumors.

BACKGROUND: The need for palliative resection of asymptomatic primary tumor in patients with unresectable metastatic colorectal cancer (CRC) is still controversial. In order to identify predictors of survival after palliative resection, we investigated the correlations between clinicopathological factors, preoperative Glasgow prognostic score (GPS) and neutrophil-to-lymphocyte ratio (NLR), and survival. PATIENTS AND METHODS: A total of 94 patients were enrolled in the present study. The prognostic value of the clinicopathological factors, GPS and NLR were analyzed retrospectively. RESULTS: A multivariate analysis revealed that both the GPS and NLR were independent predictors of survival along with the preoperative Eastern Cooperative Oncology Group performance status (PS) and extent of distant metastasis. We classified the patients using a combination of these factors, and categorized them into three risk groups. The median survival time was five months in the high-risk group, compared to 21.5 months in the intermediate-risk group and 37 months in the low-risk group. CONCLUSION: Sub-classification based on the GPS, NLR, PS and extent of distant metastasis can classify patients into three independent groups. There may be no survival benefits associated with palliative resection in the high-risk group.

[Significance of preoperative neutrophil-to-lymphocyte ratio as a predictor of prognosis in patients with stage IV colorectal cancer].

This study aimed to investigate the clinical significance of preoperative neutrophil-to-lymphocyte ratio(NLR)as a predictor of prognosis in patients with Stage IV colorectal cancer. A total of 130 patients who underwent operation for Stage IV colorectal cancer were enrolled in the study. Of the patients, 69 had an NLR of ≥ 3.0 and were defined as the high-NLR group. Patients who received preoperative therapy and underwent emergency operation for perforation were excluded from the analysis. The 2-year survival rate was 58.1% in the high-NLR group and 43.5% in the low-NLR group. The median survival time was 38.0 months in the high-NLR group and 22.3 months in the low-NLR group. The patient prognosis in the high-NLR group was significantly worse than that in the low-NLR group. A univariate analysis indicated that high NLR, peritoneal dissemination, curability C, histological type( non-differentiated), and number of organs involved in metastasis (more than 1 organ) were the risk factors of poor survival. All of these factors, except peritoneal dissemination, were independent risk factors for poor survival on multivariate analysis. A high preoperative NLR may be considered as a convenient biomarker to identify patients with a poor prognosis after operation for stage IV colorectal cancer.

A role for elastography in the diagnosis of breast lesions by measuring the maximum fat lesion ratio (max-FLR) by tissue Doppler imaging.

BACKGROUND: The role of elastography for breast tumors is still ambiguous. The purpose of this study was to inquire how effectively elastography can be used in the diagnosis of breast tumors. METHODS: The fat lesion ratio (FLR) of 244 lesions (99 malignant and 145 benign lesions) was calculated using tissue Doppler imaging with elastography. The pathological confirmations were performed by core needle or excisional biopsy. Conventional ultrasonography (US) findings were classified according to the Breast Imaging Reporting and Data System. We tried to set the region of interest (ROI) at the hardest area of the target and measured the maximum FLR (max-FLR) of the target with elastography, whereas the control ROI was placed in the subcutaneous adipose tissue. The diagnostic potential of the max-FLR combined with the US category was evaluated. RESULTS: The mean max-FLR of malignant lesions was significantly greater than that of benign lesions, at 11.0 and 4.4, respectively (p < 0.01). The max-FLR showed a wide overlap range between benign and malignant lesions, but there were no malignant lesions showing a less than 2.0 max-FLR. Ninety-six percent of the lesions interpreted as category 3 were benign, and the negative predictive value measuring the max-FLR was kept at 98% as long as the max-FLR was less than 4.0. Measuring the max-FLR may reduce unnecessary biopsies by 57.5% in the category 3 group. CONCLUSIONS: Combining conventional US categories and measuring max-FLR with elastography may be helpful in reducing the number of unnecessary biopsies in category 3 lesions.