Clinical Characteristics and Incidence of Perianal Diseases in Patients With Ulcerative Colitis.

PURPOSE: While perianal disease (PAD) is a characteristic of patients with Crohn disease, it has been overlooked in patients with ulcerative colitis (UC). Thus, our study aimed to analyze the incidence and the clinical features of PAD in patients with UC. METHODS: We reviewed the data on 944 patients with an initial diagnosis of UC from October 2003 to October 2015. PAD was categorized as hemorrhoids, anal fissures, abscesses, and fistulae after anoscopic examination by experienced proctologists. Data on patients' demographics, incidence and types of PAD, medications, surgical therapies, and clinical course were analyzed. RESULTS: The median follow-up period was 58 months (range, 12-142 months). Of the 944 UC patients, the cumulative incidence rates of PAD were 8.1% and 16.0% at 5 and 10 years, respectively. The incidence rates of bleeding hemorrhoids, anal fissures, abscesses, and fistulae at 10 years were 6.7%, 5.3%, 2.6%, and 3.4%, respectively. The cumulative incidence rates of perianal sepsis (abscess or fistula) were 2.2% and 4.5% at 5 and 10 years, respectively. In the multivariate analyses, male sex (risk ratio [RR], 4.6; 95% confidence interval [CI], 1.7-12.5) and extensive disease (RR, 4.2; 95% CI, 1.6-10.9) were significantly associated with the development of perianal sepsis. CONCLUSION: Although the clinical course of PAD in patients with UC is not serious, in clinical practice, PAD is not rare in such patients. Therefore, careful examination and appropriate management for PAD is needed if the quality of life for patients with UC is to be improved.

Comparison of partially-absorbable lightweight mesh with heavyweight mesh for inguinal hernia repair: multicenter randomized study.

PURPOSE: Prosthetic mesh is widely used for inguinal hernia repair; however, pain and stiffness can develop. This study was a prospective, multicenter, single-blind, randomized trial to assess postoperative pain and quality of life according to mesh type after inguinal hernia repair. METHODS: Forty-seven patients who underwent Lichtenstein repair for unilateral inguinal hernia with prosthetic mesh were enrolled and randomly allocated to the partially-absorbable lightweight mesh (LW group, n = 24) or heavyweight mesh group (HW group, n = 23). Data were collected using a visual analogue scale (VAS), Carolinas Comfort Scale (CCS), and Activities Assessment Scale (AAS) at screening and postoperative day 1, 7, 90, and 120; foreign body sensation, sense of stiffness, and sense of pull during activity were also evaluated. RESULTS: There were no significant differences in patients' demographics and clinical characteristics between groups. The VAS at day 90 was significantly lower in the LW group (0.46 ± 0.78 vs. 0.96 ± 0.82, P = 0.027). The CCS and AAS were significantly lower in the LW group at day 1 (51.33 ± 20.29 vs. 64.65 ± 22.64, P = 0.047 and 39.83 ± 9.88 vs. 46.43 ± 7.82, P = 0.015, respectively). Foreign body sensation was significantly lower in the LW group at day 120 (4.2% vs. 30.4 %, P = 0.023), as was sense of stiffness (P = 0.023). The sense of pull during activity was lower in the LW group at day 90 and 120 (P = 0.012 and P = 0.022, respectively). There was no recurrence or serious complication during follow-up. CONCLUSION: Partially-absorbable lightweight prosthetic mesh can be used for inguinal hernia repair safely and improve functional outcomes and quality of life after surgery.

Comparative Evaluation of the Efficacy of Polyethylene Glycol With Ascorbic Acid and an Oral Sulfate Solution in a Split Method for Bowel Preparation: A Randomized, Multicenter Phase III Clinical Trial.

BACKGROUND: An adequate level of bowel preparation before colonoscopy is important. The ideal agent for bowel preparation should be effective and tolerable. OBJECTIVE: The purpose of this study was to compare the clinical efficacy and tolerability of polyethylene glycol with ascorbic acid and oral sulfate solution in a split method for bowel preparation. DESIGN: This was a prospective, multicenter, randomized controlled clinical trial. SETTINGS: Outpatients at the specialized clinics were included. PATIENTS: A total of 186 subjects were randomly assigned. After exclusions, 84 subjects in the polyethylene glycol with ascorbic acid group and 83 subjects in the oral sulfate solution group completed the study and were analyzed. INTERVENTIONS: Polyethylene glycol with ascorbic acid or oral sulfate solution in a split method was the included intervention. MAIN OUTCOME MEASURES: The primary end point was the rate of successful bowel preparation, which was defined as being excellent or good on the Aronchick scale. Tolerability and adverse events were also measured. RESULTS: Success of bowel preparation was not different between 2 groups (91.7% vs 96.4%; p = 0.20), and the rate of adverse GI events (abdominal distension, pain, nausea, vomiting, or abdominal discomfort) was not significantly different between the 2 groups. In contrast, the mean intensity of vomiting was higher in the oral sulfate solution group than in the polyethylene glycol with ascorbic acid group (1.6 ± 0.9 vs 1.9 ± 1.1; p = 0.02). LIMITATIONS: All of the colonoscopies were performed in the morning, and the subjects were offered enhanced instructions for bowel preparation. In addition, the results of tolerability and adverse effect may have a type II error, because the number of cases was calculated for confirming the efficacy of bowel preparation. CONCLUSIONS: Oral sulfate solution is effective at colonoscopy cleansing and has acceptable tolerability when it is compared with polyethylene glycol with ascorbic acid. The taste and flavor of oral sulfate solution still need to be improved to enhance tolerability.

Persistent Bleeding Following a Stapled Hemorrhoidopexy.

A stapled hemorrhoidopexy (SH) is widely used for treatment of patients with grades III and IV hemorrhoids. The SH is easy to perform, is associated with less pain and allows early return to normal activities. However, complications, whether severe or not, have been reported. Here, we present the case of a female patient with persistent bleeding after a SH. The bleeding was caused by the formation of granulation tissue at the stapler line, diagnosed with sigmoidoscopy, and successfully treated via transanal excision (TAE) under spinal anesthesia. The biopsy showed inflammatory granulation tissue. After the TAE, her symptom was completely gone.

Early Outcomes of Endoscopic Submucosal Dissection for Colorectal Neoplasms According to Clinical Indications.

BACKGROUND: Although endoscopic submucosal dissection has been shown to be safe and effective for colorectal tumors, its clinical outcomes vary. OBJECTIVE: The aim of this study is to assess the outcomes of endoscopic submucosal dissection according to clinical indications. DESIGN: This is a prospective, multicenter, single-arm study. SETTING: The study was conducted at special hospitals for colorectal diseases and cancers. PATIENTS: The study population included consecutive patients aged 20 to 80 years who underwent colorectal endoscopic submucosal dissection for 1) early colorectal cancer, 2) laterally spreading tumors ≥2 cm in diameter, and 3) submucosal tumors. INTERVENTIONS: Procedures were performed by experienced colonoscopists. MAIN OUTCOME MEASURES: The primary end points were en bloc and curative resection rates. En bloc resection was defined as endoscopic one-piece resection without tumor fragmentation. Curative resection was defined as en bloc resection and no pathologic requirement for additional surgery. Secondary end points included procedure time, complications, and hospital stay. RESULTS: Of 321 patients, 317 (98.8%) underwent en bloc resection and 231 (72.0%) underwent curative resection. The mean procedure time was 46.2 minutes. Mean hospital stay after the procedure was 3.1 days. Perforation occurred in 2 patients (0.6%), and bleeding occurred in 10 (3.1%) patients. All patients with complications were treated by endoscopic clipping or nonoperative management. Fifteen patients (4.7%) underwent additional radical surgery owing to the risks of lymph node metastasis. Although tumor size was smaller and procedure time shorter in the submucosal tumor group than in the laterally spreading tumor or early colorectal cancer group, there were no differences in clinical outcomes including en bloc and curative resection rates. Submucosal fibrosis was the only factor affecting endoscopic submucosal dissection procedure-related complications. LIMITATIONS: Early outcomes in a limited population and the potential for selection bias were limitations of this study. CONCLUSIONS: Outcomes of colorectal endoscopic submucosal dissection were acceptable in selected patients, with no difference in outcomes according to clinical indications. Because submucosal fibrosis can increase complications, it should be minimized before endoscopic submucosal dissection.

Clinical impact of atypical endoscopic features in rectal neuroendocrine tumors.

AIM: To validate the association between atypical endoscopic features and lymph node metastasis (LNM). METHODS: A total of 247 patients with rectal neuroendocrine tumors (NETs) were analyzed. Endoscopic images were reviewed independently by two endoscopists, each of whom classified tumors by sized and endoscopic features, such as shape, color, and surface change (kappa coefficient 0.76 for inter-observer agreement). All of patients underwent computed tomography scans of abdomen and pelvis for evaluation of LNM. Univariate and multivariate analyses were performed to identify the factors associated with LNM. Additionally, the association between endoscopic atypical features and immunohistochemical staining of tumors was analyzed. RESULTS: Of 247 patients, 156 (63.2%) were male and 15 (6.1%) were showed positive for LNM. On univariate analysis, tumor size (P < 0.001), shape (P < 0.001), color (P < 0.001) and surface changes (P < 0.001) were significantly associated with LNM. On multivariate analysis, tumor size (OR = 11.53, 95%CI: 2.51-52.93, P = 0.002) and atypical surface (OR = 27.44, 95%CI: 5.96-126.34, P < 0.001) changes were independent risk factors for LNM. The likelihood of atypical endoscopic features increased as tumor size increased. Atypical endoscopic features were associated with LNM in rectal NETs < 10 mm (P = 0.005) and 10-19 mm (P = 0.041) in diameter. Immunohistochemical staining showed that the rate of atypical endoscopic features was higher in non L-cell tumors. CONCLUSION: Atypical endoscopic features as well as tumor size are predictive factors of LNM in patients with rectal NETs.

Clinical Features of Tuberculous Versus Crohn's Anal Fistulas, in Korea.

BACKGROUND AND AIMS: In Western countries, tuberculous anal fistula may not be an issue because tuberculosis [TB] is not common, and this is a very rare form of extrapulmonary manifestation of TB. However in TB-endemic countries, careful diagnostic differentiation is required because the clinical features of TB anal fistula and Crohn's disease [CD] anal fistula are similar, with distinguishing features remaining unclear. We aimed to analyse the clinical features of TB versus CD anal fistulas. METHOD: Among 13872 patients who underwent anal fistula surgery from 2003 to 2014, 87 patients with TB fistulas and 116 patients with CD fistulas were included. Data on the annual incidence of TB and CD, as well as the clinical, pathological, ultrasonographic, colonoscopic and surgical data were analysed. RESULTS: Compared with CD, the TB group was older [median: 37 vs 22 years] and underlying chronic illness was more common [20.3% vs 2.6%]. In the TB group, 46 patients [59.7%] showed active or inactive pulmonary TB, and acid-fast bacilli and caseating granuloma were found in 56.3% and 62.1%, respectively. During colonoscopy, mucosal lesions were observed more frequently in CD [96.9% vs 16.9%]. CONCLUSIONS: TB anal fistula is clinically very similar to CD anal fistula. In Korea, the incidence of CD anal fistula has recently increased in prevalence, whereas the prevalence of TB anal fistula is decreasing but is still persistent. We recommend that clinicians should prepare for a possibility of TB as well as CD anal fistula in TB-endemic countries including Korea.

Influence of family history on survival in patients with colon and rectal cancer.

OBJECTIVE: We aimed to investigate the association between a family history (FH) of colorectal cancer (CRC) and cancer recurrence and survival in patients with stage III CRC. METHODS: From April 2001 to December 2007, 1102 patients with stage III CRC were enrolled and their data including FH, clinicopathological characteristics of the tumor were retrospectively analyzed. RESULTS: Of 971 patients that were finally enrolled, 63 (6.5%) reported CRC in at least one first-degree relative. Death occurred in 12.7% of the CRC patients with an FH and 21.8% in those without an FH. A multivariate analysis showed that patients with an FH of CRC, compared with those without FH, had an adjusted hazard ratios (HR) of 0.674 (P = 0.281) for overall survival (OS) and 0.672 (P = 0.220) for disease-free survival (DFS). However, the location of tumor, preoperative carcinoembryonic antigen (CEA) level, tumor invasion (T) stage and lymph node (N) metastasis significantly affected OS and DFS. Furthermore, whereas the FH of CRC patients was associated with a favorable prognosis in stage III colon cancer (HR 0.224, P = 0.040) but not in rectal cancer (HR 1.225, P = 0.640). CONCLUSIONS: In patients with stage III CRC, tumor location (especially in the rectum), a high preoperative CEA level and advanced T and N stages indicate a poor prognosis. However, in stage III colon cancer FH is associated with improved survival.

Influence of anemia on tumor response to preoperative chemoradiotherapy for locally advanced rectal cancer.

PURPOSE: In rectal cancer patients treated with preoperative chemoradiotherapy (CRT) and curative resection, we evaluated the influence of anemia on tumor response to preoperative CRT. METHODS: Between August 2001 and July 2007, 490 patients underwent preoperative CRT, followed by curative-intent surgery. Tumor responses were evaluated based on tumor regression grade (TRG), T- and N-level downstaging, and volume reduction rates. RESULTS: The level of pretreatment hemoglobin (Hb) was 12.9 +/- 1.7 g/dl (range, 7.2-17.6 g/dl). Tumor response rates were significantly different below and above the Hb level of 9.0 g/dl. Specifically, patients with Hb levels >or=9.0 g/dl achieved better tumor responses than those with Hb levels < 9.0 g/dl (rates of TRG 3 or 4-29.0% vs. 0%, p < 0.001). In addition, there is no differences in tumor response between the nontransfusion and transfusion groups of patients with Hb levels >or=9.0 g/dl (rates of TRG 3 or 4-29.1% vs. 23.1%, p = 0.445). CONCLUSIONS: The serum Hb level could be a one of prognostic factors that influences the pathologic tumor response, and pretreatment anemia (below 9.0 g/dl of Hb) is associated with poor response to preoperative CRT.

D3 lymphadenectomy using a medial to lateral approach for curable right-sided colon cancer.

BACKGROUND AND AIMS: The extended D3 lymphadenectomy using a medial to lateral (MtL) approach for the treatment of curable right-sided colon cancer is performed with a view to improving oncologic surgery outcomes. However, the feasibility and safety of this procedure has not been fully examined. The present study investigated the feasibility and safety of D3 lymphadenectomy using the MtL approach for curable right-sided colon cancers. METHODS: Between January 2005 and May 2007, 42 patients underwent a curative-intent right (25) or extended right (17) hemicolectomy including D3 lymphadenectomy using the MtL approach performed by the same single surgeon. The extent of the D3 lymphadenectomy followed the recommendations of the Japanese Society for Cancer of the Colon and Rectum. RESULTS: There were 27 male and 15 female patients, with a mean age of 59.2 years (range, 30-83). The mean operation time was 172.5 min (range, 55-274) and the mean blood loss was 128.3 ml (range, 50-500). All procedures were successful and no conversions to open surgery were required in laparoscopic cases (32 patients, 76.2%). The mean number of harvested lymph nodes was 45 (range, 18-92). There was no surgical mortality or morbidity, except one case of postoperative ileus which was conservatively managed. The mean postoperative hospital stay was 8.6 days (range, 6-15). CONCLUSION: The findings indicate that a D3 lymphadenectomy using the MtL approach is a feasible and safe procedure for the treatment of curable right-sided colon cancer.