Purpose This randomized clinical trial was conducted to compare a fistulectomy and a fistulotomy with marsupialization in the management of a simple anal fistula. Methods Forty patients with simple anal fistula were randomized into two groups. Fistulous tracts were managed by using a fistulectomy (group A) while a fistulotomy with marsupialization was performed in group B. The primary outcome measure was wound healing time while secondary outcome measures were operating time, postoperative wound size, postoperative pain, wound infection, anal incontinence, recurrence and patient satisfaction. Results Postoperative wounds in group B healed earlier in comparison to group A wounds (4.85 ± 1.39 weeks vs. 6.75 ± 1.83 weeks, P = 0.035). No significant differences existed between the operating times (28.00 ± 6.35 minutes vs. 28.20 ± 6.57 minutes, P = 0.925) and visual analogue scale scores for postoperative pain on the first postoperative day (4.05 ± 1.47 vs. 4.50 ± 1.32, P = 0.221) for the two groups. Postoperative wounds were larger in group A than in group B (2.07 ± 0.1.90 cm2 vs. 1.23 ± 0.87 cm2), however this difference did not reach statistical significance (P = 0.192). Wound discharge was observed for a significantly longer duration in group A than in group B (4.10 ± 1.91 weeks vs. 2.75 ± 1.71 weeks, P = 0.035). There were no differences in social and sexual activities after surgery between the patients of the two groups. No patient developed anal incontinence or recurrence during the follow-up period of twelve weeks. Conclusion In comparison to a fistulectomy, a fistulotomy with marsupialization results in faster healing and a shorter duration of wound discharge without increasing the operating time.
Crohn's disease (CD) is a chronic inflammatory bowel disease of unknown etiology. Most patients with CD will eventually develop a stricturing or penetrating complication. Colonoscopic findings may predict the clinical course in patients with CD. Moreover, since CD patients are at increased risk for developing dysplasia and colorectal cancer, surveillance colonoscopy is necessary for the detection of malignancies. We describe here a CD patient with a high-grade anorectal stricture who successfully underwent a total colon examination with an ultra-slim upper endoscope after an insertion failure with a standard colonoscope and gastroscope.
PURPOSE:In recent years, the incidence of early-stage colorectal cancer (CRC) has markedly increased in the population within the Republic of Korea. The aim of this study was to evaluate the clinicopathologic features of adenomatous polyps in TNM stage I CRC patients and in the general population.METHODS:Between March 2003 and September 2009, 168 patients with stage I CRC were enrolled in this study. In addition, the records of 4,315 members of the general population without CRC, as determined by colonoscopy during a health check-up, were reviewed.RESULTS:Of the 168 patients with stage I CRC, 68 (40.5%) had coexisting colorectal adenomatous polyps and of the 4,315 members of the general population, 1,112 (26.0%) had coexisting adenomatous polyps (P = 0.006). The prevalences of adenomatous polyp multiplicity in early CRC and in the general population were 32% and 15%, respectively (P = 0.023). Patients with coexisting adenomatous polyps had a higher frequency of tubulovillous or villous adenomas than members of the general population with polyps (7.5% vs. 2.0%, P = 0.037). Furthermore, a subgroup analysis showed that the occurrence (44% vs. 34%, P = 0.006) and the multiplicity (32% vs. 15%, P = 0.023) of adenomatous polyps were greater for T2 than T1 cancer.CONCLUSION:The prevalence and the multiplicity of adenomatous polyps in TNM stage I CRC is higher than it is in the general population. The findings of this study suggest that depth of invasion of early stage CRC affects the prevalence and the number of adenomatous polyps in the remaining colon and rectum.
See Article on Page 241-246 A parastomal hernia at the site of a permanent end colostomy is a common and troublesome complication, and its incidence is estimated to be up to 48.1% [1]. The aim of this study was to analyze the incidence of and the risk factors for a parastomal hernia. In this study, the plausible risk factors for a parastomal hernia were as follows: female gender, age over 60 years, body mass index more than 25 kg/m2, and hypertension. Other risk factors from other studies were obesity and waist circumference greater than 100 cm. Although the prophylactic use of mesh may be an option for those patients requiring a permanent stoma [2], the efficacy of using prophylactic mesh for patients with a permanent stoma is a subject of debate due to mesh-associated complications [3, 4]. In this study, the parastomal hernias were assessed by using computed tomography scans. No objective grading-system was used, and no subject symptoms were noted. Also, no descriptions of the stoma-creation techniques used by the authors were given. The key factor to prevent a parastomal hernia is the surgical accuracy of stoma creation. As general rules, stomas should be placed through the rectus sheath for additional muscular support, fascial openings should be fit to the size of the exteriorized bowel circumference, prophylactic application of mesh may only be considered for those patients requiring a permanent stoma, and an extraperitoneal tunneling of the bowel may be considered [4]. The procedure of an end colostomy is usually performed as a final surgical procedure; the surgeon should do his or her best to create an appropriate stoma because the incidence of a "too loose stoma" might be double the incidence of a "too tight stoma." Further detailed studies regarding the degree of herniation and standardization of the stoma-creation method may be helpful for focusing on the risk factors. This study appears to support the prophylactic use of mesh in high-risk patients.
PURPOSE:The aim of this study was to compare survival in patients that underwent palliative resection treatment versus non-resection for incurable colorectal cancer (ICRC).METHODS:The case records of 201 patients with ICRC between January 2000 and December 2009 were reviewed. Demographics, American Society of Anesthesiologists (ASA) score, carcinoembryonic antigen (CEA) level, the location of the colon cancer, histology, metastasis, treatment options and median survival were analyzed retrospectively. We divided the patients into four groups according to the treatment modalities: resection alone, resection with post-operative chemotherapy, non-resection treatment by chemotherapy alone, and stent or bypass. Median survival times were compared according to each treatment option, and the survival rates were analyzed.RESULTS:105 patients underwent palliative resection whereas 96 were treated with non-resection modalities. A palliative resection was performed in 44 cases for resection alone and in 61 cases for resection with post-operative chemotherapy. In patients treated with non-resection of the primary tumor, chemotherapy alone was done in 65 cases and stent or bypass in 31 cases. Multivariate analysis showed a median survival of 14 months in patients with palliative resections with post-operative chemotherapy, which was significantly higher than those for chemotherapy alone (8 months), primary tumor resection alone (5 months), and stent or bypass (5 months). Gender, age, ASA score, CEA level, the location of colon cancer, histology and the presence of multiple metastases were not independent factors in association with the median survival rate.CONCLUSION:In the treatment of ICRC, palliative resection followed by post-operative chemotherapy shows the most favorable median survival compared to other treatment options.
PURPOSE:The objective of the current study was to identify the clinicopathological risk factors affecting recurrence after a curative resection for stage I colorectal cancer.METHODS:We retrospectively studied 434 patients who underwent a curative resection for stage I colorectal cancer between January 1999 and December 2004. Postoperative oral chemotherapy was performed in 189 patients (45.3%). The following prognostic factors were correlated with recurrence: age, gender, preoperative carcinoembryonic antigen level, location of tumor, T stage, size of tumor, histologic differentiation, growth pattern, and lymphovascular invasion. The median follow-up duration was 65 months.RESULTS:The overall recurrence rate was 4.6% (20/434). The median time to recurrence was 33 months. Two-thirds of the recurrence occurred more than two years after surgery. Risk factors associated with recurrence were rectal cancer (P = 0.009), T2 stage (P = 0.010), and infiltrative growth pattern (P = 0.020). A Cox proportional hazards regression analysis demonstrated that the infiltrative growth pattern was an independent predictor for recurrence. Tumor cell budding was observed in all pathologic reviews with recurrence.CONCLUSION:Long-term follow-up is necessary for stage I colorectal patients with high risk factors like rectal cancer, T2 stage, and infiltrative growth pattern.
PURPOSE:The purpose of the study is to evaluate the oncologic outcomes of a laparoscopic-assisted right hemicolectomy for the treatment of colon cancer and compare the results with those of previous randomized trials.METHODS:From June 2006, to December 2008, 156 consecutive patients who underwent a laparoscopic right hemicolectomy with a curative intent for colon cancer were evaluated. The clinicopatholgic outcomes and the oncologic outcomes were evaluated retrospectively by using electronic medical records.RESULTS:There were 84 male patients and 72 female patients. The mean possible length of stay was 7.0 ± 1.5 days (range, 4 to 12 days). The conversion rate was 3.2%. The total number of complications was 30 (19.2%). Anastomotic leakage was not noted. There was no mortality within 30 days. The 3-year overall survival rate of all stages was 93.3%. The 3-year overall survival rates according to stages were 100% in stage I, 97.3% in stage II, and 84.8% in stage III. The 3-year disease-free survival rate of all stages was 86.1%. The 3-year disease-free survival rates according to stage were 96.2% in stage I, 90.3% in stage II, and 75.6% in stage III. The mean follow-up period was 36.3 (3 to 60) months.CONCLUSION:A laparoscopic right hemicolectomy for the treatment of colon cancer is technically feasible and safe to perform in terms of oncologic outcomes. The present data support previously reported randomized trials.
See Article on Page 19-26 Since a robotic system was first applied to colorectal cancer surgery at Severance Hospital in 2006, robotic surgery cases have increased rapidly, while 33 da Vinci robotic systems being installed at 27 hospitals and a total of 14,067 cases by the end of 2010 in Korea. Among the total cases, 6,365 cases (45%) were in the field of general surgery, such as thyroid, stomach and colorectal surgery. Compared with laparoscopic surgery, Surgery with robotic systems is known to have several advantages, including a more ergonomic position, a stable camera platform, a stereoscopic view, elimination of tremors, and improved dexterity. The author, an experienced laparoscopic colorectal surgeon, analyzed his personal initial experiences with robotic and laparoscopic colorectal surgery. He found more positive results in robotic surgery than in laparoscopic surgery even though the parameters did not show any statistically significance differences. For example, a lower conversion rate, less blood loss, more harvested lymph nodes and better short-term clinical outcomes were noted in robotic series However, no cost-benefit-analysis data were presented in this article. These data are really in the same form as those in studies conducted during the initial period of laparoscopic surgery. The process of validating the feasibility and safety of robotic colorectal surgery seems to be following the same road map as that for laparoscopic surgery. Many papers have presented comparative studies between robotic colorectal surgery and open colorectal surgery. Large clinical prospective randomized clinical trials have also been conducted. Most studies, including this study, have reported that robotic colorectal surgery is safe and feasible based on short-term outcomes [1-4]. Baek et al. [5], based on a three-year follow-up, reported that robotic rectal surgery could be carried out safely in terms of recurrence and survival rates. However, all such studies are limited by small sample size and by the fact that they were conducted at a single institution. The short-term and the long-term outcomes of robotic colorectal surgery will be verified based on these clinical studies and on any advantages of the new robotic system compared with the conventional laparoscopic system (fewer conversions, fewer complications, etc.), but the high cost for robotic systems and instruments still remains a problem for wide application. Thus, some additional studies that are quite different from laparoscopic clinical studies and that will study the merits of robotic surgery are needed. We still hunger for strong evidence regarding the advantages to patients and surgeons that will outweigh the high cost of robotic systems and equipment. Recently, in a prospective comparative study of a laparoscopic and a robotic TME, the urogential function was recovered earlier in the robotic TME than in the laparoscopic one [6]. Recently, the robotic versus laparoscopic resection for rectal cancer trial, a prospective randomized clinical trial comparing robotic-assisted and laparoscopic surgery for rectal cancer, was begun. In Korea, the COLRAR trial, a prospective, randomized, controlled trial of assess robotic-assisted surgery and laparoscopy assisted surgery in patients with mild- or low rectal cancer, was also recently begun. Even though a good landmark has not yet been found, we must be on the path to find such a landmark.
PURPOSE:Recently, an increase in well-differentiated rectal neuroendocrine tumors (WRNETs) has been noted. We aimed to evaluate transanal endoscopic microsurgery (TEM) for the treatment of WRNETs.METHODS:Between December 1995 and August 2009, 109 patients with WRNETs underwent TEM. TEM was performed for patients with tumors sizes of up to 20 mm and without a lymphadenopathy. These patients had been referred from other clinics after having been diagnosed with WRNETs by using a colonoscopic biopsy; they had undergone a failed endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) and exhibited an involved resection margin and remaining tumor after ESD or EMR, regardless of the distance from the anal verge. This study included 38 patients that had more than three years of follow-up.RESULTS:The mean age of the patients was 51.3 ± 11.9 years, the mean tumor size was 8.0 ± 3.9 mm, and no morbidity occurred. Thirty-five patients were asymptomatic. TEM was performed after a colonoscopic resection in 13 cases because of a positive resection margin, a residual tumor or a non-lifting lesion. Complete resections were performed in 37 patients; one patient with a positive margin was considered surgically complete. In one patient, liver metastasis and a recurrent mesorectal node occurred after five and 10 years, respectively.CONCLUSION:TEM might provide an accessible and effective treatment either as an initial or as an adjunct after a colonoscopic resection for a WRNET.
Purpose Placenta growth factor (PlGF) is a member of the vascular endothelial growth factor (VEGF) family. PlGF is implicated in several pathologic processes, including the growth and spread of cancer and tumor angiogenesis. The aim of this study was to evaluate the expression and the clinical implications of PlGF in colorectal cancer. Methods In order to ascertain the clinical significance of PlGF expression in colorectal cancer, the researcher analyzed the expression pattern of PlGF by using an immunohistochemical method and attempted to establish if a relationship existed between PlGF expression and microvessel density (MVD), and subsequently between PlGF expression and the predicted prognosis. A total of 83 patients with colorectal cancer were included for immunohistochemical staining. Clinicopathological characteristics were defined according to the tumor-node-metastasis (TNM) criteria of the Union for International Cancer Control. Clinicopathologic factors, such as age, sex, histological types of tumors, tumor cell grade, TNM stage, lymphovascular invasion, and lymph-node metastasis, were reviewed. Results In this study, the PlGF protein expression level was significantly correlated with MVD, patient survival, and clinicopathological factors such as lymph-node metastasis, TNM staging, lymphatic invasion and vascular invasion. Conclusion PlGF may be an important angiogenic factor in human colorectal cancer, and in this study, PlGF expression level was significantly correlated with positive lymph-node metastases, tumor stage, and patient survival. These findings suggest that PlGF expression correlates with disease progression and may be used as a prognostic marker for colorectal cancer.
Although the incidence of local recurrence after curative resection of rectal cancer has decreased due to the understanding of the anatomy of pelvic structures and the adoption of total mesorectal excision, local recurrence in the pelvis still remains a significant and troublesome complication. While surgery for recurrent rectal cancer may offer a chance for a cure, conservative management, including radiation and chemotherapy, remain widely accepted courses of treatment. Recent improvement in imaging modalities, perioperative care, and surgical techniques, including bone resection and wound coverage, have allowed for reductions in operative mortality, though postoperative morbidity still remains high. In this review, the techniques, including surgical approaches, employed for management of locally recurrent rectal cancer are highlighted.
PURPOSE:For the treatment of acute appendicitis, a conventional laparoscopic appendectomy (LA) has been widely performed. Recently, the use of single incision laparoscopic surgery (SILS) is increasing because it is believed to have advantages over conventional laparoscopic surgery. In this study, we compared SILS and a conventional LA.METHODS:We analyzed the 217 patients who received laparoscopy-assisted appendectomies between August 2010 and April 2012 at Inje University Sanggye Paik Hospital. One hundred-twelve patients underwent SILS, and 105 patients underwent LA. For the two groups, we compared the operation times, postoperative laboratory results, postoperative pain, hospital stay, and postoperative complications.RESULTS:The patients' demographics, including body mass index, were not significantly different between the two groups. There were 6 perforated appendicitis cases in the SILS group and 5 cases in the LA group. The mean operative time in the SILS group was 65.88 ± 22.74 minutes whereas that in the LA group was 61.70 ± 22.27 minutes (P = 0.276). There were no significant differences in the mean hospital stays, use of nonsteroidal antiinflammatory drugs, and wound infections between the two groups.CONCLUSION:Postoperative pain, complications and hospital stay showed no statistically significant differences between the SILS and the LA groups. However, our SILS method uses a single trocar and two latex tubes, so cost savings and reduced interference during surgery are expected.
See Article on Page 304-308 The open appendectomy, which was described first by McBurney [1] in 1894, has been accepted as the gold standard of an appendectomy for around 100 years. Furthermore, since its introduction by Semm [2] in 1983, the laparoscopic appendectomy has been conducted more frequently than the open appendectomy due to its advantages of being minimally invasive and having a shorter length of stay, a faster return of bowel function, decreased use of narcotics and lower rates of wound complications. In addition, much attention has been paid to recent remarkable innovative developments and improvements in laparoscopic equipment, instruments and techniques. As emphasis has focused more on minimizing the surgical technique utilized to access the pathology and on the exponential development of therapeutic endoscopy, surgical procedures that enter the peritoneum through hollow visceras that can be accessed via natural body openings, precluding skin incision, have been developed. The new approaches, named natural orifice transluminal endoscopic surgery (NOTES), aim to further limit treatment morbidity, but studies addressing these approaches have yet to be initiated because the clinical techniques for these approaches are still being developed. One of the most critical issues in NOTES when it is applied to humans is whether to securely close the extraction site of an organ such as the stomach, vagina, or rectum. If the closure fails, serious morbidities such as intraperitoneal infection or fistula may arise. NOTES can be performed as a pure procedure involving one portal of entry or as a combined procedure involving use of multiple body openings. However, based predominantly on experimental results, pure NOTES should be actively pursued as a research topic until its safety has been proven. NOTES can also be performed as a hybrid procedure in conjunction with conventional transabdominal ports. Closely related to NOTES is the development of procedures performed through a solitary small transabdominal incision. These procedures have been referred to as single-port access surgery, single-port laparoscopy surgery, single-incision laparoscopy surgery (SILS), or laparoendoscopic single-site surgery; consensus on the most appropriate name for the approach has not been achieved. Since the first report of single-incision laparoscopic surgery for acute appendicitis by Rispoli et al. [3] in 2002, it has been proposed as the next evolution in minimally invasive surgery. However, evidence supporting the safety and efficacy of this innovative approach is limited. Nevertheless, the increased interest in single-incision laparoscopic appendectomy (SILA) has seemed to be primarily focused on better cosmesis (scarless abdominal surgery performed through an umbilical incision), less incisional pain, and conversion to standard multiport laparoscopic surgery if needed. SILA also has several disadvantages and limitations, such as the restricted degrees of freedom of movement, the number of ports that that can be used, and the proximity of the instruments to each other during the operation-all of which increase the complexity and the technical challenges of the operation. Many of these difficulties can be related to the technique of port placement and the utilization of instruments during single-incision laparoscopic surgery. In 2011, St Peter et al. [5] reported the results of their prospective randomized trial which compared a single-incision to a standard 3-port laparoscopic appendectomy. In that trial, the authors found that operative time, doses of narcotics, surgical difficultly and hospital charges were greater with the single-site approach. Also, the mean operative time was 5 minutes longer for the single-site group. This year, Gill et al. [6] reviewed nine studies that compared the SILA and the conventional laparoscopic appendectomy and found no significant differences in operative time, length of stay, pain scores, conversion rates, and complication rates between the SILA and the conventional laparoscopic appendectomy for acute appendicitis in adults. Currently in Korea, the single-incision laparoscopic appendectomy has been growing in popularity, and several case series have been reported. In this issue, Comparative Study of a Single-Incision Laparoscopic and a Conventional Laparoscopic Appendectomy for the Treatment of Acute Appendicitis is being published. Kang et al. [4] analyzed 112 SILS and 105 conventional laparoscopic appendectomies. In the study, the mean operative time in the SILS group was 65.88 ± 22.74 minutes whereas that in the LA group was 61.70 ± 22.27 minutes (P = 0.276). Although the difference was not statistically significant, the longer (about 4 minutes) operation time in the SILS group was comparable to that found in a recently reported randomized controlled trial in which the mean operation time was 5 minutes longer [5]. Also, the present study demonstrated no significant differences in mean hospital stay, use of nonsteroidal anti-inflammatory drugs, and wound infection between the two groups' the results being comparable to those of a systematic review of previously reported comparative studies [6]. The authors used a single trocar and two latex tubes, and they expected a cost savings and reduced interference by using their own system. They also advocated that the SILS appendectomy might have better cosmetic results. However, the authors could not provide any objective evidence to support their suggestions. These limitations came from the nature of retrospective nonrandomized comparative studies. Well-designed prospective trials are needed to develop more solid evidence and objective measuring tools for assessing cosmetic outcomes and patient satisfaction. Single-port surgery is gaining momentum and may represent the next frontier in minimally invasive surgery for various gastrointestinal diseases. Although many unanswered questions persist, surgeons should maintain their pioneering spirit and evaluate these new approaches carefully and scientifically.
Morbid obesity is another important risk factor for the development of an incisional hernia and a parastomal hernia [9,10].Schreinemacher et al. [9] reported that hernias were more prevalent in patients with morbid obesity (body mass index of 30 and higher) and in patients with a temporary stoma wound (25.8% vs. 59.1%).De Raet et al. [10] reported that a waist circumference in excess of 100 cm increased the risk of developing a parastomal hernia (odds ratio, 1.009; 95% confidence interval, 1.002 to 1.016).Other factors, such as anemia, hypoproteinemia, malnutrition, diabetes, immunosuppression, male gender, and old age, are related to surgical wound dehiscence and incisional hernias [11].Conditions that increase abdominal pressure, such as coughing, vomiting, distention, and ascites, also increase the incidence of incisional hernias.Surgeons have to be aware of poor wound healing conditions to prevent incisional hernias.Perioperative efforts to reduce risk factors and to select proper technical methods of wound closure are essential if the incidence of incisional hernias is to be reduced.
Purpose The purpose of this study was to evaluate the overall rate and risk factors for the development of an incisional hernia and a parastomal hernia after colorectal surgery. Methods The study cohort consisted of 795 consecutive patients who underwent open colorectal surgery between 2005 and 2007 by a single surgeon. A retrospective analysis of prospectively collected data was performed. Results The overall incidence of incisional hernias was 2% (14/690). This study revealed that the cumulative incidences of incisional hernia were 1% at 12 months and 3% after 36 months. Eighty-six percent of all incisional hernias developed within 3 years after a colectomy. The overall rate of parastomal hernias in patients with a stoma was 6.7% (7/105). The incidence of parastomal hernias was significantly higher in the colostomy group than in the ileostomy group (11.9% vs. 0%; P = 0.007). Obesity, abdominal aortic aneurysm, American Society of Anesthesiologists score, serum albumin level, emergency surgery and postoperative ileus did not influence the incidence of incisional or parastomal hernias. However, the multivariate analysis revealed that female gender and wound infection were significant risk factors for the development of incisional hernias female: P = 0.009, wound infection: P = 0.041). There were no significant factors related to the development of parastomal hernias. Conclusion Our results indicate that most incisional hernias develop within 3 years after a colectomy. Female gender and wound infection were risk factors for the development of an incisional hernia after colorectal surgery. In contrast, no significant factors were found to be associated with the development of a parastomal hernia.
See Article on Page 315-320 For detecting new biomarkers in colorectal cancer, whether they are prognostic or predictive, we should understand the mechanism of the metastatic process at the gene expression level. This article presents a new prognostic biomarker, 'placental growth factor (PlGF)' to the clinical field. PlGF, which is a member of the vascular endothelial growth factor (VEGF) family in conjunction with VEGF-A and VEGF-B, is a ligand for VEGF receptor-1, which is expressed on endothelial cells, monocytes/macrophages, and some tumor cells. PlGF was isolated in 1991 from the placenta and was found only in very low levels under physiological conditions, but it was up-regulated in pathological circumstances such as wound healing, ischemia and tumor growth [1]. PlGF up-regulation has been found in human meningiomas, hemangioblastomas, melanomas, and cervical squamous cell carcinomas and is associated with angiogenesis in renal cell carcinomas. On the contrary, PlGF is down-regulated in thyroid carcinomas, germ cell tumors and cervical adenocarcinomas. Chen et al. [2] reported that PlGF was significantly up-regulated in gastric cancer tissue and was significantly correlated with microvessel density-evaluated angiogenesis and tumor stage. In this research, the authors found that the PlGF protein expression level in colorectal cancer tissue was significantly correlated with microvessel density, overall patient survival, and clinicopathological factors such as lymph-node metastasis, tumor stage, and lymphovascular invasion. According to the authors, PlGF seems to be an independent surrogate prognostic factor for colorectal cancer progression. However, for these results to be adopted in the clinical filed, it is very important that a large-sample-size study be brought conducted in a validation setting. The findings of this research finding suggest that PlGF may constitute a novel approach to colorectal cancer treatment. Several agents against PlGF have already developed or are currently under development. Among these agents, two novel agents against PlGF will be briefly discussed. Firstly, aflibercept (ZALTRAP) is a recombinant fusion protein that acts as a soluble receptor that binds to VEGF-A, VEGF-B and PIGF. In April 2011, Van Cutsem et al. [3] reported that aflibercept improved the primary endpoint of overall survival in the Velour phase III clinical trial for second-line treatment for metastatic colorectal cancer. Secondly, the humanized anti-PlGF mAb (TB-403) is directed against PlGF. A trial with TB-403 has only completed its first phase. Antitumor activity has been demonstrated with TB-403 in human tumor xenograft models of renal cell carcinomas and hepatocellular carcinomas. The mechanism of action for TB-403 is currently under investigation; preclinical studies suggest its effects may include blocking tumor angiogenesis and primary tumor growth, as well as inhibition of metastasis. In addition, PIGF inhibition may complement and potentiate the antitumor effects of VEGF inhibition, in part by inhibiting macrophage recruitment [4].
PURPOSE:An anal condyloma is a proliferative disease of the genital epithelium caused by the human papillomavirus. This condition is most commonly seen in male homosexuals and is frequently recurrent. Some reports have suggested that immunosuppression is a risk factor for recurrence of a condyloma. Thus, we investigated the risk factors for a recurrent anal condyloma in human immunodeficiency virus (HIV)-positive patients.METHODS:We retrospectively analyzed 85 consecutive patients who were diagnosed with and underwent surgery for an anal condyloma from January 2007 to December 2011. Outcomes were analyzed based clinical and immunologic data.RESULTS:Recurrent anal condylomata were found in 25 patients (29.4%). Ten cases (40.0%) were within postoperative 3 months. At postoperative 6 months, the CD4 lymphocyte count in the recurrent group was lower than it was in the nonrecurrent group (P = 0.023).CONCLUSION:CD4-mediated immunosuppression is a risk factor for recurrent anal condylomata in HIV-positive patients.
Colouterine fistula is an extremely rare condition because the uterus is a thick, muscular organ. Here, we present a case of a colouterine fistula secondary to colonic diverticulitis. An 81-year-old woman was referred to the emergency department with abdominal pain and vaginal discharge. Computed tomography showed a myometrial abscess cavity in the uterus adherent to the thick sigmoid wall. Upon contrast injection via the cervical os for fistulography, we observed spillage of the contrast into the sigmoid colon via the uterine fundus. Inflammatory adhesion of the distal sigmoid colon to the posterior wall of the uterus was found during surgery. The colon was dissected off the uterus. Resection of the sigmoid colon, primary anastomosis, and repair of the fistula tract of the uterus were performed. The postoperative course was uneventful. This case represents an unusual type of diverticulitis complication and illustrates diagnostic procedures and surgical management for a colouterine fistula.
PURPOSE:The aim of this retrospective study was to evaluate the rate of recurrence and incontinence after the treatment of fistulae or fistulous abscesses by using the staged drainage seton method.METHODS:According to the condition, a drainage seton alone or a drainage seton combined with internal opening (IO) closure and relocation of the seton was used. After a period of time, the seton was changed with 3-0 nylon; then, after another period of time, the authors terminated the treatment by removing the 3-0 nylon. Telephone interviews were used for follow-up. The following were evaluated: the relationship between the type of fistula and recurrence; the relationship between the type of fistula and the period of treatment; the relationship between the recurrence and presence of abscess; the relationship between IO closure and recurrence; the relationship between the period of seton change and recurrence; reported continence for flatus, liquid stool, and solid stool.RESULTS:The recurrence rate of fistulae or suppuration was 6.5%, but for cases of horseshoe extension, the recurrence rate was 57.1%. The rate of recurrence was related to the type of fistula (P = 0.001). Incontinence developed in 3.8% of the cases. No statistically significant relationship was found between the rate of recurrence and the presence of an abscess or between the closure of the IO and the period of seton change or removal.CONCLUSION:In the treatment of anal fistulae or fistulous abscesses, the use of a staged drainage seton can reduce the rate of recurrence and incontinence.
Necrotizing fasciitis usually occurs after dermal injury or through hematogenous spread. To date, few cases have been reported as necrotizing fasciitis of the thigh secondary to rectal perforation in rectal cancer patients. A 66-year-old male complained of pelvic and thigh pain and subsequently developed necrotizing fasciitis in his right thigh. Four years earlier, he had undergone a low anterior resection and radiotherapy due to of rectal cancer. An ulcerative lesion had been observed around the anastomosis site during the colonoscopy that had been performed two months earlier. Pelvic computed tomography and sigmoidoscopy showed rectal perforation and presacral abscess extending to buttock and the right posterior thigh fascia. Thus, the necrotizing fasciitis was believed to have occurred because of ulcer perforation, one of the complications of chronic radiation colitis, at the anastomosis site. When a rectal-cancer patient complains of pelvic and thigh pain, the possibility of a rectal perforation should be considered.
