Comparison of clinical outcomes of stoma reversal during versus after chemotherapy for rectal cancer patients.

PURPOSE: The optimal timing of stoma closure during or after adjuvant chemotherapy for rectal cancer patients undergoing sphincter-preserving surgery remains unknown. This study aimed to investigate the influence of clinical and oncological outcomes depending on the timing of stoma closure. METHODS: Between January 2006 and December 2015, we enrolled 244 consecutive rectal cancer patients who underwent curative-intent sphincter-preserving surgery with diverting transverse colostomy and adjuvant chemotherapy. Patients with stoma closure during (During group) adjuvant chemotherapy were compared to those who had stoma closure after adjuvant chemotherapy (After group). RESULTS: Parastomal hernia occurred more frequently in the after group than in the during group. (10% vs. 2.9%, p = 0.028). Overall, no significant difference was observed in overall survival (OS) or disease-free survival (DFS) between the two groups (p = 0.911 for OS, p = 0.505 for DFS). However, an inferior OS occurred if reopen surgery was performed within 30 days of stoma closure in the during group, as compared with the after group (p = 0.004). In addition, a marginally poor DFS was observed in the group of patients who received further operations due to 30-day stoma closure complications compared to the other patients (p = 0.07). CONCLUSIONS: For rectal cancer patients who underwent sphincter-preserving surgery, attention should be given to avoid 30-day major complications after stoma reversal because patients who require reoperation during adjuvant chemotherapy may have poor long-term survival.

Improvement of ulcerative colitis control by searching and restricting of inflammatory trigger factors in daily clinical practice.

BACKGROUND/AIMS: Exacerbating factors of ulcerative colitis (UC) are multiple and complex with individual influence. We aimed to evaluate the efficacy of disease control by searching and restricting inflammation trigger factors of UC relapse individually in daily clinical practice. METHODS: Both patients with UC history or new diagnosis were asked to avoid dairy products at first doctor visit. Individual-reported potential trigger factors were restricted when UC flared up (Mayo endoscopy score ≥1) from remission status. The remission rate, duration to remission and medication were analyzed between the groups of factor restriction complete, incomplete and unknown. RESULTS: The total remission rate was 91.7% of 108 patients with complete restriction of dairy product. The duration to remission of UC history group was significantly longer than that of new diagnosis group (88.5 days vs. 43.4 days, P=0.006) in patients with initial endoscopic score 2-3, but no difference in patients with score 1. After first remission, the inflammation trigger factors in 161 relapse episodes of 72 patients were multiple and personal. Milk/dairy products, herb medicine/Chinese tonic food and dietary supplement were the common factors, followed by psychological issues, non-dietary factors (smoking cessation, cosmetic products) and discontinuation of medication by patients themselves. Factor unknown accounted for 14.1% of patients. The benefits of factor complete restriction included shorter duration to remission (P<0.001), less steroid and biological agent use (P=0.022) when compared to incomplete restriction or factor unknown group. CONCLUSIONS: Restriction of dairy diet first then searching and restricting trigger factors personally if UC relapse can improve the disease control and downgrade the medication usage of UC patients in daily clinical practice.

Preoperative risk stratification of permanent stoma in patients with non-metastatic mid and low rectal cancer undergoing curative resection and a temporary stoma.

BACKGROUND: Although a temporary stoma can mitigate the severity of anastomotic leakage, some rectal cancer patients retain a permanent stoma after sphincter-preserving surgery. Therefore, this study aimed to identify independent preoperative risk factors for permanent stoma and establish a prediction model for mid-and low-rectal cancer patients who underwent sphincter-preserving surgery and temporary stoma. METHODS: We retrospectively reviewed consecutive patients with non-metastatic rectal cancer between 2000 and 2015. The risk factors for permanent stomas were collected and analyzed. RESULTS: A total of 1020 rectal cancer patients with temporary stoma were included. The overall rate of permanent stoma was 17.5% (n = 179). Cancer progression and anastomotic complications are major causes of permanent stomas. Multivariate analysis showed that preoperative risk factors such as advanced age, male sex, preoperative CEA ≥ 10 ng/ml, T4 stage, N stage, low rectal tumor, and ASA ≥ III were independent preoperative risk factors after adjustment. The ROC curve of the risk factors and permanent stoma showed an AUC of 0.689, a cut-off value of 2.5, a sensitivity of 0.689, and a specificity of 0.622. The permanent stoma rates were significantly higher between risk scores ≤ 2 and > 2 (29.9% vs. 11.3%, p < 0.001). CONCLUSION: Preoperative CEA ≥ 10 ng/ml, T4 stage, N stage, low rectal tumor, advanced age, ASA ≥ III, and male sex were independent preoperative prognostic factors for a permanent stoma. The risk was higher with a score greater than two. Therefore, the risk of subsequent permanent stoma should be evaluated and informed to the patient prior to the primary surgery.

Smoking cessation for less than 10 years remains a risk factor of anastomotic leakage in mid-to-low rectal cancer patients undergoing sphincter-preserving surgery.

PURPOSE: Although cigarette smoking is a well-known risk factor for anastomotic leakage during rectal surgery, the proper duration of smoking cessation that can decrease anastomotic leakage in patients undergoing sphincter-preserving surgery is unclear. This study aimed to investigate the optimal duration of smoking cessation that can reduce this complication. METHODS: Between January 1, 2000, and December 31, 2012, we enrolled 1246 consecutive patients who underwent curative-intent sphincter-preserving surgery without preventive stoma at the Division of Colorectal Surgery of a tertiary referral center in Taiwan. Questionnaires were used to record their pre-surgical smoking status. The receiver operating characteristic (ROC) curve was used to determine the optimal cut-off duration of smoking cessation. Multivariate analysis was used to verify the effect of cigarette cessation on anastomotic leakage. RESULTS: The ROC curve showed a cut-off value of 10.5 years of cessation duration. Therefore, the former-smoker group was further divided using a cessation duration of 10 years. The overall anastomotic leakage rate was 5.29%. However, the anastomotic leakage rate in current smokers (9.3%) and in those who quit for < 10 years (12.9%) was significantly higher than that in non-smokers (3.3%) and those who quit for ≥ 10 years (4.5%). On multivariate analysis, current smokers (p = 0.022), former smokers with < 10 years of smoking cessation (OR 2.725; p = 0.029), male sex (p = 0.015), and low rectal cancer (p < 0.001) were all independently related to the development of anastomotic leakage. CONCLUSION: Smoking cessation for < 10 years remains a risk factor for anastomotic leakage in patients with mid-to-low rectal cancer undergoing sphincter-preserving surgery.

Free tissue transfers for reconstruction of weight-bearing heel defects: Flap selection, ulceration management, and contour revisions.

BACKGROUND: Soft tissue defects in the weight-bearing heel represent a reconstructive challenge because of tissue complexity and lack of local/regional coverage. This study presents our reconstruction outcomes of different defect aetiologies, reconstruction timing, and flap selection. METHODS: Patients with weight-bearing heel defects who underwent free tissue transfer from 2003 to 2014 and with at least 6 months of follow-up were retrospectively reviewed. Flap types (fasciocutaneous vs muscle/musculocutaneous), timing of reconstruction (early vs subacute vs delayed), and defect aetiology were compared in terms of flap failure, vascular complications, and ulceration. RESULTS: Seventy-four flaps were used to reconstruct weight-bearing heel defects in 70 patients. Defect aetiology included trauma in 53 patients (75%), chronic wound in 12 patients (17%), and tumour resection in 6 patients (8%). Flap survival was 97% (72/74). There was no significant difference in flap failures between muscle and fasciocutaneous flaps. The timing of reconstruction showed no difference in flap survival. There was a significant difference in ulceration rate between the trauma and non-trauma groups (p = 0.001). Twenty-eight ulcers (39%) developed, 12 (43%) of which presented 3 years postoperatively, while only 6 cases (21%) presented within one year postoperatively. CONCLUSION: Our experience represents one of the highest survival rates reported regarding free flap weight-bearing heel reconstruction. The anterolateral thigh flap was our first choice for extensive heel defects. Ulceration incidence was directly related to trauma and tends to develop 3 years after reconstruction. Delayed reconstruction was at least as safe as early or subacute reconstruction though with less need for debulking.

Lessons from the MOHW compensation pilot program on birth incidents: First step and looking forward.

OBJECTIVE: In Taiwan, the number of medical disputes and litigation has increased dramatically over the past 20 years. The seriousness of medical disputes continuing grows in clinical practice, especially in obstetricians. This study provided a possible solution to the medical dispute litigation issue. MATERIALS AND METHODS: The Ministry of Health and Welfare (MOHW) compensation program for birth incidents has been implemented since 2012 and it provided pecuniary compensation for mothers, newborns, and fetuses who got injured or died in birth-related medical incidents. We analyzed the amount and distribution of compensation, and assessed the effect of compensation on the number of medical dispute litigation. RESULTS: From 2012 to 2015, a total of 348 applications was received, 322 of which were examined by the committee. Among the examined cases, 278 were approved for compensation. The total amount of compensation had reached 266.16 million NTD (8.32 million USD). For the medical dispute litigation, a dramatic decrease in number was observed after the implementation of this compensation pilot program. CONCLUSION: Prompt compensation provided instant economic and spiritual support for patients and families. Pecuniary compensation could be an alternative choice of justice, which might encourage the injured to receive economic compensation, instead of filing a lawsuit against the physician or hospital institution. As a result, the number of dispute litigation has decreased. This indicates that the compensation program is an efficient way to improve medical dispute litigation difficulties.

Residents' perception of duty hour limits through teaching hospital accreditation status-experience in Taiwan.

Residents' work overload is a rising issue in Taiwan. Duty hours of the residents in the United States have been limited by the Accreditation Council for Graduate Medical Education Common Program Requirements since 2003; similar standards were not implemented in Taiwan until 2013. Taiwanese duty hour standards are the work hour limits adopted as part of the required teaching hospital accreditation status. In January 2015, the Ministry of Health and Welfare conducted a national survey for all house officers in Taiwan. We collected data including those on demographics and perceptions of residents regarding duty hour limits. Most respondents reported positive perceptions of the duty hour standards. They felt that these limits will improve resident education, quality of life, and patient safety. The strong incentive to follow the regulations (through teaching hospital accreditation) could help protect residents (and patients) from unsafe working conditions. However, further studies on the influence of shortened duty hour on professional development are necessary for future improvement.