Chao-Wen Hsu

Prevalence and risk factors of asymptomatic colorectal polyps in taiwan.

Purpose. To investigate the prevalence and risk factors of hyperplastic and adenomatous colorectal polyps in a Taiwanese general population. Methods. From January 2009 to December 2011, consecutive asymptomatic subjects undergoing a routine health check-up were evaluated by colonoscopy. The colorectal polyps were assessed, and medical history and demographic data were obtained from each patient. Logistic regression analysis was conducted to search the independent risk factors for asymptomatic hyperplastic and adenomatous colorectal polyps. Results. Of the 1899 asymptomatic subjects, the prevalences of hyperplastic polyps and adenomatous polyps were 11.1% and 16.1%, respectively. Multivariate analysis revealed that high body mass index (BMI > 25: OR, 1.32, 95% CI, 1.05–1.71) and current smoking (OR, 1.87, 95% CI, 1.42–2.71) were independent predictors for hyperplastic colorectal polyps. Age over 60 years old (OR, 3.49, 95% CI, 1.86–6.51), high body mass index (BMI > 25: OR, 1.75, 95% CI, 1.21–2.71), heavy alcohol consumption (OR, 2.01, 95% CI, 1.02–3.99), and current smoking (OR, 1.31, 95% CI, 1.04–1.58) were independent predictors for adenomatous colorectal polyps. Conclusion. High BMI and smoking are common risk factors for both adenomatous and hyperplastic polyps. Old age and alcohol consumption are additional risk factors for the development of adenomatous polyps.

Oxaliplatin-induced severe anaphylactic reactions in metastatic colorectal cancer: Case series analysis

AIM To investigate oxaliplatin-induced severe anaphylactic reactions (SAR) in metastatic colorectal cancer in a retrospective case series analysis and to conduct a systemic literature review. METHODS During a 6-year period from 2006 to 2011 at Kaohsiung Veterans General Hospital, a total of 412 patients exposed to oxaliplatin-related chemotherapy were retrospectively reviewed. Relevant English-language studies regarding life-threatening SAR following oxaliplatin were also reviewed in MEDLINE® and PubMed® search. RESULTS Eight patients (1.9%, 8 of 412 cases) were identified. Seven patients were successful resuscitated without any sequelae and one patient expired. We changed the chemotherapy regimen in five patients and rechallenged oxaliplatin use in patient 3. Twenty-three relevant English-language studies with 66 patients were reported. Patients received a median of 10 cycles of oxaliplatin (range, 2 to 29). Most common symptoms were respiratory distress (60%), fever (55%), and hypotension (54%). Three fatal events were reported (4.5%). Eleven patients (16%) of the 66 cases were rechallenged by oxaliplatin. CONCLUSION SAR must be considered in patients receiving oxaliplatin-related chemotherapy, especially in heavily pretreated patients. Further studies on the mechanism, predictors, preventive methods and management of oxaliplatin-related SAR are recommended.

Factors that influence survival in colorectal cancer with synchronous distant metastasis

Background: Treatments for the purposes of curing or more effectively managing metastatic colorectal cancer (CRC) are evolving. Our study focused on patients with primary CRC with synchronous distant metastasis, and we analyzed the factors influencing patient survival. Methods: Data review was conducted retrospectively. Clinicopathological parameters included age, sex, site of primary cancer, tumor cell differentiation, number of liver metastasis, presence of extrahepatic metastasis, treatment of liver metastasis, pre‐treatment carcinoembryonic antigen (CEA) level, status of treatment response, salvage treatment and survival. Results: A total of 420 patients were identified and considered for our study. Of those, 275 patients (65.4%) had liver‐only metastasis, 100 patients (23.8%) had concomitant lung metastasis, and 40 patients (9.5%) had other metastases. Additionally, 145 patients (34.5%) had liver‐directed treatment including surgical resection (28.5%), radiofrequency ablation (RFA) (10.6%) and transcatheter arterial chemoembolization (TAE) (1.2%). There were 80 patients (19%) with CEA levels < 10, 135 patients (32.1%) with CEA 10–100, and 165 patients (39.2%) with CEA > 100. There were 200 patients (47.6%) who had received chemotherapy, 130 patients (30.9%) with target therapy, and 40 patients (9.5%) who had not undergone any salvage treatment. Three significant factors were identified, including treatment of liver metastasis (p = 0.027), pre‐treatment CEA (p = 0.04), and salvage treatment (p = 0.005). Conclusion: We demonstrated three factors influencing patient survival including treatment of liver metastasis, pre‐treatment CEA level, and salvage treatment. Aggressive treatment of liver metastasis including surgical resection or RFA combined with chemotherapeutic agents appear to provide an increased rate of survival to patients.

Colorectal Perforation: Spectrum of the Disease and Its Mortality

Purpose. colorectal perforation is a major life-threatening clinical condition that requires emergency surgical intervention. In general peritonitis caused by colorectal perforation still remains a high risk for mortality and morbidity. The aim of this study is to identify clinical characteristics, outcomes and risk factors for patients with colorectal perforation. Methods. From January 1996 to December 2005, 141 patients with colorectal perforation were selected consecutively for this study. Several clinical variables were analyzed, such as sex, age, preoperative symptoms & signs, causes of perforation, concomitant diseases, ASA scores, preoperative albumin levels, WBC count, band form WBC, persistence of symptoms and signs, intervals between diagnosis to operation, operation times, perioperative blood loss and mortality rates. The statistical methods used in this study included Chi-square analysis, student T-test, univariate logistic regression, and multivariate logistic regression. Statistical significance was determined as a value of less than 0.05. Results. 141 patients were identified, with a median age of 66.77±14.48 years (range: 26-95 years); 99 patients were male and 44 were female. Causes of colorectal perforation were diverticulitis (54 patients, 37.8%), ischemic colitis (38 patients, 27.0%), iatrogenic injury (14 patients, 9.9%), malignancy (13 patients, 9.2%), idiopathic ulcer or deep ulcer (5 patients, 3.5%), and trauma (3 patients, 2.1%). Overall mortality rate was 36.9% (52 patients). The highest rate of disease-specific mortality was due to malignancy (61.5%), followed by ischemic colitis (60.5%), trauma (33.3%), iatrogenic injury (21.4%) and the last is diverticulitis (18.5%). Among several prognostic factors, a p-value of less than 0.05, including age (＞60 y/o), preoperative sepsis or septic shock, perioperative blood loss (＞450 mL), emergency operation, and more than 3 concomitant diseases. Conclusions. The most common causes of colorectal perforation are diverticulitis and ischemic colitis, with malignancy and ischemic colitis causing the highest mortality rate. In this study, we clearly demonstrated that patients with colorectal perforation are associated with a higher mortality rate when their age is greater than 60 y/o, combined with preoperative sepsis or septic shock, perioperative blood loss (＞450 mL), emergency operation, and more than 3 concomitant diseases.

Measurement of peritoneal fluid urea nitrogen and creatinine levels is useful to detect iatrogenic urinary tract leakage in colorectal surgery

Background Increased peritoneal drainage after colorectal surgery is a common problem. Measurement of peritoneal fluid urea nitrogen (UN) and creatinine (Cr) is a diagnostic tool to detect the urinary tract leakage (UTL). We evaluated its application in colorectal surgery. Methods We conducted a retrospective chart review study. We enrolled patients with iatrogenic UTL, and measured their UN and Cr levels in peritoneal fluid and compared them with those in blood and urine. Meanwhile, we assigned patients without UTL to a control group and compared clinical parameters of both groups. Results Twenty‐three patients with iatrogenic UTL were recruited. The overall incidence was 0.5%. UN level in peritoneal fluid (322 ± 56 mg/dL) was significantly higher than that in blood (18.7 ± 4.0 mg/dL, p < 0.001); Cr level in peritoneal fluid (69.7 ± 14.3 mg/dL) was also significantly higher than that in blood (1.5 ± 0.5 mg/dL, p < 0.001). UN level in peritoneal fluid was significantly higher in the iatrogenic UTL group than in the control group (322 mL/dL vs. 9.3 mL/dL, p < 0.001); Cr level in peritoneal fluid was also significantly higher (69.7 mg/dL vs. 0.98 mg/dL, p < 0.001). Conclusion When increased peritoneal drainage is found postoperatively in colorectal surgery, measurement of UN and Cr levels in peritoneal fluid can be a useful diagnostic tool to determine intraperitoneal iatrogenic UTL.

Comparison of laparoscopic versus open surgery in a three-stage operation for obstructive left-sided colorectal cancer.

Background Treatment for obstructive left‐sided colorectal cancer (OLCC) typically consists of a three‐staged procedure. During the first stage, the obstruction is managed with diversion colostomy. Traditionally in the second stage, we perform open resection for the primary tumor. In this study, we evaluated the feasibility of laparoscopic resection of OLCC with diversion colostomy in terms of operative results and short‐term outcomes. Methods A total of 20 patients underwent laparoscopic resection for OLCC (study group), 48 patients underwent open resection for OLCC (control group 1), and 53 patients underwent laparoscopic resection for non‐OLCC (control group 2). Afterwards, results from the procedures were obtained and clinical data were analyzed. Results The operative time was significantly longer in the study group than in the control group 1 (153 minutes vs. 126 minutes, p = 0.041), and the length of hospitalization was shorter in the study group than in the control group 1 (5.3 days vs. 7.6 days, p = 0.032). Regarding the operative results and short‐term outcomes, there were no significant differences between the study group and control group 2. Colostomy retraction was a specific morbidity which occurred in two patients of the study group. Conclusion Laparoscopic resection of OLCC with diversion colostomy is feasible. Abdominal cavity adhesion is only limited. We strongly recommend that laparoscopic resection should be performed at least 2 weeks after diversion colostomy, and the plastic rod should be left in place during the pneumoperitoneum to reduce the risk of colostomy retraction.

Life-threatening severe anaphylactic reactions in patients receiving oxaliplatin chemotherapy

Dear Editor: Oxaliplatin is a third-generation platinum compound frequently used in the treatment of stage III colorectal cancer (CRC) adjuvant chemotherapy and stage IV advanced CRC. Among the common reasons for its withdrawal are frequent peripheral neuropathy, a delayed hypersensitivity reaction, and, most troublesome, anaphylaxis when patients receive accumulated doses of oxaliplatin. Life-threatening severe anaphylactic reactions (SAR) had been reported but without a systemic review. We performed a retrospective analysis of our patients who had oxaliplatin exposure and selected those who developed SAR. During a 6-year period from 2006 to 2011 at Kaohsiung Veterans General Hospital, a total of 412 patients exposed to oxaliplatin-related chemotherapy (FOLFOX) were retrospectively reviewed. Life-threatening SAR was defined as side effects including symptomatic bronchospasm, allergyrelated edema/angioedema, hypotension or anaphylaxis (grade III/IV anaphylactic reactions reference by NIH common Toxicity Criteria v3.0) requiring hospitalization and medical interventions. Relevant English language studies regarding life-threatening SAR following oxaliplatin were also reviewed in MEDLINE® and PubMed® search. Seven patients (1.7 %, 7 of 412 cases) were identified who developed life-threatening SAR in this duration, which occurred after infusion of oxaliplatin-related chemotherapy. Six patients were successfully resuscitated with oxygen support and medical interventions and fully recovered without any sequelae. However, one patient suffered from SAR and went into shock status 20 min after infusion of oxaliplatin. Despite cardiopulmonary resuscitation and inotropic agent use, this patient expired 50 min later. We changed the chemotherapy regimen in five patients and rechallenged oxaliplatin use in patient 3. Because the patient 3’s disease manifestations responded well to FOLFOX chemotherapy regimen, continuation was felt to be desirable. We have thus decided to attempt rechallenge of oxaliplatin by prolongating the infusion rate and using premedications with additional 100 mg hydrocortisone plus diphenhydramine before the next treatment course. Fortunately, no anaphylactic reactions developed thereafter. Twenty-three relevant English language studies, published from 1997 to 2011, were reviewed. We found 59 reported cases that fitted the definition of life-threatening SAR. Together with this seven cases we presented, the median cycles of oxaliplatin given before was 10 (ranged from 2 to 29). The most common symptoms were respiratory distress (60 %), fever (55 %), and hypotension (54 %). Three fatal events were reported (4.5 %). Eleven patients of the 66 cases were rechallenged by oxaliplatin. The estimated incidence of oxaliplatin-induced SAR in most other series was less than 2 %. Multiple mechanisms of actions have been proposed but still unknown. In literature reviews, SAR developed after several cycles of oxaliplatin chemotherapy (median cycles before SAR is 10), suggesting a sensitization process of type I hypersensitivity due to the rapid appearance of symptoms. C.-W. Hsu : T.-M. King :M.-C. Chang : J.-H. Wang (*) Division of Colorectal Surgery, Department of Surgery, Kaohsiung Veteran General Hospital, 386 Ta-Chung 1st RD, Kaohsiung, Taiwan 81346, Republic of China e-mail: ss851124@yahoo.com.tw

Acute pancolitis after colonoscopy in liver cirrhosis patient

Dear Editor: Acute pancolitis is a rare complication following colonoscopy. It could be caused by circulatory disturbance due to temporal pressure and stretch of the colon in the colonoscopy procedure or caused by glutaraldehyde, a disinfectant commonly used in flexible endoscopes. Glutaraldehyde-induced colitis seems similar to ischemic colitis in biopsy specimens and cannot be diagnosed by histological analysis alone. Acute colitis occurring within 48 h of a colonoscopy should be considered iatrogenic and should lead to an investigation of procedures in use for cleaning and disinfecting endoscopic equipment. We repot a cirrhotic patient of acute pancolitis following colonoscopy. This 50-year-old man presented with a 10-year history of liver cirrhosis, hepatitis B virus, and alcohol-related (Child– Pugh Classification A). He had one episode of esophageal variceal bleeding and underwent endoscopic ligation 10 years ago. Then, he was regularly followed up in outpatient clinics without any medication use. He underwent regular physical checkup for painless colonoscopy under conscious sedation on 16th July, 2008. The colonoscopy revealed no visible abnormalities. Neither biopsy nor therapeutic intervention was performed. Two hours after the procedure, the patient developed diarrhea with bloody stool followed by chills. He had an elevated white blood cell (WBC) count (14,730 per microliter) and left shifting of differential count (neutrophil–lymphocyte 90/5), compared with the values before colonoscopy (3,910 per microliter and 51/42, respectively). He was subsequently admitted and underwent repeat colonoscopy, which disclosed markedly inflamed mucosa with erythematous change. Multiple ulcers from sigmoid colon up to descending colon were noted with slough of mucosa over the descending colon. Abdominal computed tomography (CT) showed pancolitis change with diffusely edematous wall thickening. No evidence of stenosis of thrombosis of superior mesenteric artery and inferior mesenteric artery was noted. Histologic examination showed colonic mucosal tissue characterized by the following: mild chronic inflammatory cell infiltration, moderate neutrophil infiltration with crypt abscess formation, and fibrinous exudates. All the microbiological studies in this patient were negative. Since there was no evidence of occlusion of the colonsupplying vessels and no pathogen was isolated, we speculate that glutaraldehyde-induced pancolitis contributed to the disease manifestation. The clinical manifestation that occurred in our patients was most likely the result of direct contact with the glutaraldehyde. The proposed mechanism of injury was inadequate rinsing of all the endoscopic channels and surfaces with water or contamination of the rinsing water with the agent. The patient made an uneventful recovery with conservative treatment and his WBC count and differential count returned to normal levels in 1 week. He was discharged 7 days after the first colonoscopy. Glutaraldehyde (2% solution) is the most common chemical germicide used for high-level disinfection of flexible gastrointestinal endoscopes. This agent is well Int J Colorectal Dis (2009) 24:467–468 DOI 10.1007/s00384-008-0564-3

Early Enteral Feeding after Colorectal Surgery: Preliminary Hospital Experience

Purpose. The aim of this study was to determinate whether early postoperative enteral feeding is suitable for patients undergoing colorectal surgery in our hospital. Methods. A retrospective review was performed of a prospectively collated database of patients undergoing colorectal surgery in our hospital between March 2014 and March 2015. Patients were divided into two groups, early enteral feeding and traditional ＂nil by mouth＂. The early feeding group was treated by a modified fast track protocol and the traditional group was treated as per usual practice. Primary end point was time to first defecation; secondary end point was anastomosis leakage. Results. Of the 200 enrolled patients, 190 patients were analyzed (95/ group). Mean time to flatus was 2.76 (1 to 10) days in the modified fast track group and 4.07 (3 to 7) days in the traditional group; mean time to first defecation was 4.04 (2 to 13) days and 6.05 (3 to 19) days, respectively. These results were statistically significant (p ＜ 0.05). Time to solid diet in the modified fast track group was 4.44 (3 to 17) days compared with 6.72 (4 to 21) days in the traditional group (p ＜ 0.05). There was one case of anastomic leakage in the traditional group (p=0.316). Conclusion. Early enteral feeding plays an important role in the recovery of patients after colorectal surgery and can improve gastrointestinal function without increasing postoperative complications. More aggressive patient treatment protocols with strict application should be considered in the future.

Horizontal Tumor Size is Inversely Related to Prognosis in Nodal-Positive Stage III Colorectal Cancer

Purpose. Vertical tumor growth, reflected by the T classification, is the most important prognostic variable in colorectal cancer. However, the data regarding the prognostic impact of horizontal tumor size are limited and contradictory. In the present study, we aimed to investigate the effect of maximal horizontal tumor size on patient outcome in patients with nodal-positive stage III colorectal cancer. Methods. We retrospectively reviewed the medical records from 1996 to 2009. We included individuals diagnosed with nodal-positive stage III colorectal cancer who underwent surgical resection, and for whom complete medical records were available. In our analysis, the cut-off values for tumor size were set at 1.0 cm and 0.5 cm. A Kaplan-Meier survival analysis and the Cox proportional hazard model were applied to the data for further analysis. Results. In total, 939 nodal-positive stage III colorectal cancer specimens were reviewed retrospectively. We classified the patients into two groups: those with a maximum horizontal tumor size of ＜ 1.0 cm (57 patients; 6%) and those with a maximum horizontal tumor size of ＞ 1.0 cm (887 patients; 94%).With regard to the TNM classification, the group of patients with tumors ＜ 1.0 cm in size had a greater number of T1-2 stage tumors compared to the group with tumors ＞ 1.0 cm in size (42.1% vs. 27%, p = 0.02).With regard to the primary tumor site, the group of patients with tumors ＜ 1.0 cm in size had a greater number of rectal tumors compared to the group with tumors ＞ 1.0 cm in size (61.7% vs. 45%, p = 0.01). The median disease-free-survival was shorter in patients with tumors ＜ 1.0 cm in size than in patients with tumors ＞ 1.0 cm in size (6.96 months vs. 17.64 months, p = 0.003). Survival was significantly different between these two groups of patients as well (p = 0.008). Using a Cox proportional hazard model, the hazard ratio was found to be 2.29 for patients with tumors ＜ 0.5 cm in size and 1.224 for those whose tumor measured 0.5-1.0 cm in size. Further multivariate analysis also demonstrated that small tumor size is a significant risk factor for a negative prognosis (p = 0.01). Conclusion. In nodal-positive stage III colorectal cancer, tumor size is inversely related to prognosis. We postulated that smaller nodal-positive tumors would display significantly more aggressive tumor behavior as compared to larger tumors. However, these interesting findings require further investigation to corroborate the results.