Objectives: Although the aetiology of pouchitis after restorative proctocolectomy in ulcerative colitis (UC) remains unknown, infliximab (IFX) is often effective for this condition. However, indicators and predictors of treatment efficacy remain unclear. In this study, the association between serum tumor necrosis factor-alpha (TNF-α) levels and refractory pouchitis was evaluated. Methods: We conducted a prospective study between January 2014 and April 2016. Patients with antibiotic-refractory pouchitis were treated with IFX. Serum TNF-α levels were measured before IFX induction. Diagnoses were confirmed using the modified Pouchitis Disease Activity Index (m-PDAI). Responders were defined as patients with an m-PDAI score lower than 5. Recurrence was defined as an m-PDAI score exceeding 5 during maintenance treatment or a need for additional treatments. Associations between serum TNF-α level and efficacy of IFX during 52 weeks of maintenance therapy were evaluated. Results: Thirteen patients were eligible for this study. The short-term efficacy was 8/13 (61.5%). Four patients could not be maintained with IFX alone. The cumulative maintenance ratio was 30.8%/52 weeks, and the cut-off value for serum TNF-α was 1.93 pg/mL for short-term response. Although there was no significant association between serum TNF-α and treatment response, IFX treatment was unsuccessful for all five patients with TNF-α levels below 1.93 pg/mL, including four short-term non-responders and one long-term non-responder. Conclusion: Serum TNF-α level was not an independent predictor of IFX efficacy for refractory pouchitis. However, IFX may be effective for patients with elevated serum TNF-α. Future studies should assess this possibility.
Objectives: Rectoanal intussusception (RAI) is a common finding on defecography in patients with defecation disorders. This study aimed to compare the proctographic findings and symptoms between patients with anterior RAI and those with circular RAI. Methods: We included 208 patients who were diagnosed as having RAI on defecography. Anorectal function was evaluated using Constipation Scoring System (CSS) and Fecal Incontinence Severity Index (FISI). Results: Twenty-four patients had anterior RAI and 184 had circular RAI. While the anterior intussusception descent or pelvic floor descent was significantly smaller in patients with anterior RAI than those with circular RAI [14.3 vs. 18.5 mm, p=0.004; 12.4 vs. 21.6 mm, p=0.005], there were no significant differences in incidences of obstructed defecation (OD) and fecal incontinence (FI) between the groups. Sixteen patients with anterior RAI and 137 patients with circular RAI had OD. There was no significant difference in the CSS scores between the groups. Twelve patients with anterior RAI and 108 patients with circular RAI had FI. No significant difference in the FISI scores between the groups. Conclusions: Approximately one tenth of the whole RAI was anterior in location, and symptoms in patients with anterior RAI were similar to those with circular RAI.
Objectives: Palliative surgeries such as stoma creation and bypass are effective for relieving symptoms related to incurable abdominal malignancies; however, these methods are controversial in patients with severe metastatic disease or poor pre-surgical health. The aim of this study was to examine the clinical significance of the prognostic nutritional index (PNI) in evaluations for palliative surgery. Methods: We retrospectively analyzed data from 37 patients who underwent palliative surgery for histologically-proven colorectal adenocarcinoma from 2009 to 2015. We investigated both risk factors for postoperative complications and prognostic factors. We used a PNI cutoff value of 40, as defined by previous studies. Results: The reason for surgery was stenosis in 18 patients, obstruction in 12, fistula in 5, and bleeding in 2. Bypass was performed in 10 cases, ileostomy in 5, and colostomy in 22. Postoperative morbidity and mortality occurred in 9 and 2 patients, respectively. Median overall survival time was 8.9 months. Only low PNI correlated with postoperative complications at trend-level (p=0.07), and the 2 patients with mortality were classified as PNI-low. The presence of ascites (p=0.003) and PNI (p=0.02) were identified as independent prognostic factors. Conclusions: PNI could be used as an objective marker for deciding whether to proceed with palliative surgery, independent of the extent of metastatic disease.
Objective: This retrospective multicenter study compared short- and long-term results between Japanese patients with asymptomatic stage IV colorectal cancer who underwent palliative laparoscopic surgery (LS) versus those who underwent conventional open surgery (OS). Methods: Among 968 patients treated for stage IV colorectal cancer from January 2006 to December 2007 in 41 surgical units that were participating in the Japan Society of Laparoscopic Colorectal Surgery group, we studied 398 patients who received palliative resection of their asymptomatic primary colorectal tumor. Results: We analyzed data from patients undergoing LS (LS group, n=106) and OS (OS group, n=292). Fourteen (13.2%) LS group patients were converted to OS. Although the differences between groups for postoperative complications were not significant, the mean time to solid food intake and postoperative length of hospital stay for the LS group were significantly shorter than those for the OS group (2 vs. 3 days, p<0.0001; 13 vs. 16 days, p<0.0001, respectively). The LS group patients experienced a longer median survival time than that of the OS group (24.5 vs. 23.9 months, p=0.0357). Conclusions: Laparoscopic palliative resection (LS) offers advantages for short-term outcomes and no disadvantages for long-term outcomes. The use of laparoscopic procedures to treat asymptomatic, incurable stage IV colorectal cancer appears to be acceptable.
Objective: The aim of this study was to identify risk factors for bleeding complications in patients who receive Venous thromboembolism (VTE) prophylaxis with fondaparinux (FPX) after colorectal cancer surgery. Methods: Records of 546 patients who underwent VTE prophylaxis with intermittent pneumatic compression and FPX after colorectal cancer surgery between January 2009 and May 2014 were reviewed. Patient characteristics, surgical procedures, and patient laboratory data were examined to identify risk factors for bleeding complications using univariate and multivariate logistic regression. Results: We reviewed the records of 324 males and 222 females. Median age and BMI were 68.5 years and 22.7 kg/m2, respectively. The number of laparoscopic surgeries was 366. Median operative time and blood loss were 188.5 min and 20 ml, respectively. The incidence (%) of bleeding events was 5.3%. In univariate analysis, age ≥80 years, BMI ≥25.0 kg/m2, hypertension, and antithrombotic therapy were associated with a significantly higher incidence of bleeding events. Multivariate analysis identified age ≥80 years (odds ratio 5.814; 95% confidence interval 2.502-13.278) as an independent risk factor. Conclusion: Age ≥80 is a risk factor for bleeding in patients who receive FPX for VTE prophylaxis after colorectal cancer surgery.
Objectives: Temporary ileostomy is used to decrease morbidity from anastomotic leakages (ALs). However, ileostomies are associated with complications (i.e., stoma-related complications; SRCs), ileus due to stenosis, dehydration, and the need for a second operation. Here we retrospectively evaluated the impact of SRCs on the treatment of rectal cancer. Methods: We identified 180 consecutive patients who underwent curative resection for rectal cancer at Juntendo University Hospital between January 2006 and December 2014. We divided the patients into groups with and without defunctioning stoma (DS), and we compared the patient age and gender, tumor location, approach (laparotomy/laparoscopy), surgical procedure, distance of the tumor from the margin of the anus, T factor, stage, duration of postoperative hospital stay, and postoperative complications between these groups. Univariate and multivariate analyses were performed to determine the risk factors for postoperative hospital stay. Results: The symptomatic leakage rate in the DS group (n = 92) was not significantly different from that of the non-DS group (n = 88; p = 0.29). However, Grade ≥ 4 AL occurred significantly less frequently in the DS group (0%) than in the non-DS group (5.7%; p = 0.02). SRCs occurred in 14 DS-group patients (15.2%). The multivariate analysis demonstrated that both AL (odds ratio [OR] 9.24; confidence interval [CI] 4.91-19.4) and SRC (OR 1.84; CI 1.03-3.54) were independently predictive of short-term outcomes. Conclusions: The benefit of a DS is balanced against the risk of leakage and SRCs at rectal resection. Surgeons should focus on not only the consequences of AL, but also SRC risk.
Objectives: Pelvic organ prolapse (POP) POP is defined as the protrusion of pelvic organs from the vaginal canal. POP often coexists with internal rectal prolapse or external rectal prolapse (ERP). A series of patients with coexisting POP and ERP who underwent laparoscopic ventral rectopexy (LVR) combined with laparoscopic sacrocolpopexy (LSC) are reported here. Methods: Seven patients underwent LVR and LSC together. Fecal incontinence was assessed by the Fecal Incontinence Severity Index (FISI), constipation was assessed by the Constipation Scoring System (CSS), and urinary incontinence was assessed by the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). Anatomical disorders were assessed by Pelvic Organ Prolapse Quantification (POP-Q) and defecography. Results: The patients' median age was 81 (60-88) years. The median operative time was 380 (282-430) minutes. The median postoperative hospital stay was 3 (1-5) days. There were no postoperative complications. The FISI, CSS, POP-Q, and defecography findings improved postoperatively; however, the ICIQ-SF deteriorated in 2 of 5 patients. Conclusions: LVR combined with LSC for coexisting POP and ERP is feasible.