Eun Kyung Choe

Surgical outcomes and prognostic factors of emergency surgery for colonic perforation: would fecal contamination increase morbidity and mortality?

PurposeComplications resulting from colonic perforation are related to secondary peritonitis due to bacterial or fecal contamination. We investigated outcomes of emergency surgery for colonic perforation associated with fecal contamination with regard to early and late postoperative complication rates and mortality rates, and investigated prognostic factors influencing those outcomes.MethodsA retrospective analysis of prospectively collected data on factors influencing complications and mortality rates was conducted on data from 152 patients who had undergone emergent operations for colonic perforation between January 2005 and December 2011. Patients were categorized into two groups: those with and without gross fecal contamination at the time of operation.ResultsForty-one (26.9xa0%) patients had gross fecal contamination. Patients who had fetal contamination had a higher Mannheim peritonitis index (31.3u2009±u20095.1 vs. 21.9u2009±u20097.2, pu2009<u20090.001), higher organ failure rate (53.7 vs. 24.3xa0%, pu2009=u20090.001), and longer operating time (168.8u2009±u200949.9 vs. 144.8u2009±u200966.1xa0min, pu2009=u20090.036) than patients without fecal contamination. Early complications (<30xa0days) occurred more frequently in the fecal contamination group (82.9 vs. 49.5xa0%, pu2009=u20090.001), although late complications (46.2 vs. 39.3xa0%, pu2009=u20090.942) and mortality (17.1 vs. 8.1xa0%, pu2009=u20090.110) did not differ. In multivariate analysis, fecal contamination significantly predicted early complications (odds ratio, 2.78; pu2009=u20090.037) but not late complications or mortality.ConclusionsThe frequency of early complications can increase if fecal contamination exists. However, when early complications are well managed, fecal contamination does not significantly influence occurrences late complications or mortality.

Early postoperative small bowel obstruction is an independent risk factor for subsequent adhesive small bowel obstruction in patients undergoing open colectomy.

AbstractBackgroundThis prospective study was performed to investigate whether postoperative ileus (POI) or early postoperative small bowel obstruction (EPSBO) affects the development of adhesive small bowel obstruction (SBO) in patients undergoing colectomy.MethodsWe prospectively enrolled 1,002 patients who underwent open colectomy by a single surgeon. POI was defined as the absence of bowel function for more than 5xa0days or as a delay in oral intake beyond 7xa0days postoperatively. EPSBO was defined as the clinical and radiologic identification of SBO after resuming oral intake between postoperative days 7 and 30. Adhesive SBO was defined as SBO developing after 30xa0days because of intraperitoneal adhesion. The associations between POI, EPSBO, patient- and surgery-related variables, and the development of adhesive SBO were analyzed.ResultsA total of 85 (8.5 %) patients developed POI, and 42 patients (4.2 %) developed EPSBO, with seven patients experiencing both POI and EPSBO. During the follow-up period (median 51xa0months), 70 patients (7.0 %) developed adhesive SBO, six (8.6 %) of whom needed laparotomy. The occurrence of adhesive SBO was significantly higher in patients with EPSBO than in those without EPSBO (26.5 vs. 7.5 % at 5xa0years, Pxa0<xa00.001), but not in patients with POI (13.4 vs. 7.8 % at 5xa0years, Pxa0=xa00.158). Multivariable analysis showed colostomy (hazard ratio [HR] 2.530, Pxa0=xa00.006) and EPSBO (HR 4.063, Pxa0<xa00.001) as independent risk factors for adhesive SBO.nConclusionsThe development of adhesive SBO after colectomy is more frequent in patients with EPSBO and colostomy; however, POI does not increase the risk of adhesive SBO.

Electromechanical characteristics of the human colon in vitro: is there any difference between the right and left colon?

PurposeWe examined the electrical and mechanical characteristics of the smooth muscles in the human colon at the muscle cell, the muscle strip, and at the whole tissue levelsMethodsConventional microelectrode recordings and tension recordings were performed.ResultsThere was no difference in resting membrane potential, frequency, and amplitude of slow waves between the right and left colon; but there were significant differences in frequency and amplitude of the slow waves between inner circular muscle (CM) and longitudinal muscle (LM), and between inner CM and outer CM, but not between outer CM and LM. On tension recording of CM and LM strip and colonic segment, amplitude, frequency, and area under the curve showed no difference between the right and left colon. In whole colonic segment, high amplitude dominant waves (DW) were found both in CM and LM. Low amplitude non-DWs were detected only in CM, more commonly in right colon and propagated aborally. DWs in the CM were associated with DWs in the LM. In the CM of the left colon, all DWs in the CM propagetd aborally ending-up with DW in the LM layer. However, in the right colon, mixed pattern of propagation was detected in adjacent recording sites in 60% of tissues examined.ConclusionElectrophysiologic and mechanical characteristics were similar between the right and left human colon. However, the retrograde propagation of both DWs and non-DWs in the CM was more frequent in the right colon, accounting for mixing function in this region of the human colon.

Long-term Outcomes and Risk Factors for Reoperation After Surgical Treatment for Gastrointestinal Crohn Disease According to Anti-tumor Necrosis Factor-α Antibody Use: 35 Years of Experience at a Single Institute in Korea

Purpose Crohn disease is characterized by high rates of recurrence and reoperations. However, few studies have investigated long-term surgical outcomes in Asian populations. We investigated risk factors for reoperation, particularly those associated with anti-tumor necrosis factor-α (anti-TNF-α) antibody use, and long-term follow-up results. Methods We reviewed the records of 148 patients (100 males and 48 females) who underwent surgery for gastrointestinal Crohn disease and retrospectively analyzed long-term outcomes and risk factors. Results The mean age at diagnosis was 28.8 years. Thirty-eight patients (25.7%) received monoclonal antibody treatment before reoperation. A small bowel and colon resection was most commonly performed (83 patients, 56.1%). The median follow-up was 149 months, during which 47 patients underwent reoperation. The median interval between the primary and the secondary surgeries was 65 months, with accumulated reoperation rates of 16.5%, 31.8%, and 57.2% after 5, 10, and 15 years, respectively. Obstruction was the most common indication for reoperation (37 patients, 25.0%). In a multivariable analysis, age <17 years at diagnosis (A1) (odds ratio [OR], 2.20; P = 0.023), penetrating behavior (B3) (OR, 4.39; P < 0.001), and no azathioprine use (OR, 2.87; P = 0.003) were associated with reoperation. Anti-TNF-α antibody use did not affect the reoperation rate (P = 0.767). Conclusion We showed a high reoperation rate regardless of treatment with anti-TNF-α antibody, which indicates that recurrent surgery is still needed to cure patients with gastrointestinal Crohn diseases. Younger age at primary operation, penetrating behavior, and no azathioprine use were significant factors associated with reoperation for gastrointestinal Crohn disease.

Surgical Treatment of a Parastomal Hernia

Purpose Parastomal hernia is a major complication of an intestinal stoma. This study was performed to compare the results of various operative methods to treat parastomal hernias. Methods Results of surgical treatment for parastomal hernias (postoperative recurrence, complications and postoperative hospital stays) were surveyed in 39 patients over an 11-year period. The patients enrolled in this study underwent surgery by a single surgeon to exclude surgeon bias. Results Seventeen patients were male, and twenty-two patients were female. The mean age was 65.9 years (range, 36 to 86 years). The stomas were 35 sigmoid-end-colostomies (90%), 2 loop-colostomies (5%), and 2 double-barrel-colostomies. Over half of the hernias developed within two years after initial formation. Stoma relocation was performed in 8 patients, suture repair in 14 patients and mesh repair in 17 patients. Seven patients had recurrence of the hernia, and ten patients suffered from complications. Postoperative complications and recurrence were more frequent in stoma relocation than in suture repair and mesh repair. Emergency operations were performed in four patients (10.3%) with higher incidence of complications but not with increased risk of recurrence. Excluding emergency operations, complications of relocations were not higher than those of mesh repairs. Postoperative hospital stays were shortest in mesh repair patients. Conclusion In this study, mesh repair showed low recurrence and a low complication rate with shorter hospital stay than relocation methods, though these differences were not statistically significant. Further studies, including randomized trials, are necessary if more reliable data on the surgical treatment of parastomal hernias are to be obtained.

Small molecule-based lineage switch of human adipose-derived stem cells into neural stem cells and functional GABAergic neurons

Cellular reprogramming using small molecules (SMs) without genetic modification provides a promising strategy for generating target cells for cell-based therapy. Human adipose-derived stem cells (hADSCs) are a desirable cell source for clinical application due to their self-renewal capacity, easy obtainability and the lack of safety concerns, such as tumor formation. However, methods to convert hADSCs into neural cells, such as neural stem cells (NSCs), are inefficient, and few if any studies have achieved efficient reprogramming of hADSCs into functional neurons. Here, we developed highly efficient induction protocols to generate NSC-like cells (iNSCs), neuron-like cells (iNs) and GABAergic neuron-like cells (iGNs) from hADSCs via SM-mediated inhibition of SMAD signaling without genetic manipulation. All induced cells adopted morphological, molecular and functional features of their bona fide counterparts. Electrophysiological data demonstrated that iNs and iGNs exhibited electrophysiological properties of neurons and formed neural networks in vitro. Microarray analysis further confirmed that iNSCs and iGNs underwent lineage switch toward a neural fate. Together, these studies provide rapid, reproducible and robust protocols for efficient generation of functional iNSCs, iNs and iGNs from hADSCs, which have utility for modeling disease pathophysiology and providing cell-therapy sources of neurological disorders.

Incidence of Clinically Relevant Incisional Hernia After Colon Cancer Surgery and Its Risk Factors: A Nationwide Claims Study

AbstractBackgroundAs there is scant literature focusing on incisional hernia for which hospital care is sought, the aim of this study was to elucidate the incidence and risk factors of overt incisional hernia (OIH) after colon cancer surgery using nationwide claims data.nMethodsClaims data of colon cancer patients who underwent regional colectomy were obtained from the Health Insurance Review and Assessment Service database of South Korea. Data from 2010 to 2012 were collected to ensure adequate follow-up. OIH was considered to be present when either the diagnosis code for IH or the claim code for IH repair was entered after index colectomy for colon cancer.nResultsA total of 24,645 patients underwent regional colectomy for colon cancer during the study period. Of these, 376 (1.5%) patients had an OIH within 3xa0years after surgery, and 50.3% of OIHs developed within the first year after the index colectomy (883.7 cases/10,000 patient-years). The Cox proportional hazard model showed that age >65xa0years, female gender, open colectomy, and institution volume <100 colectomies per year were statistically significant risk factors for OIH. The 3-year cumulative OIH incidence rates according to age >65xa0years, female gender, open colectomy, and institution volume <100 colectomies per year were 2.1, 2.1, 2.0, and 2.1%, respectively.ConclusionsSeveral risk factors for OIH and its incidence after regional colectomy for colon cancer were identified. These findings are helpful for classifying patients undergoing segmental colectomy who have increased the likelihood of developing IH and are informative for patients and medical providers performing the surgery.

Genetic Polymorphisms of PNPLA3 and SAMM50 Are Associated with Nonalcoholic Fatty Liver Disease in a Korean Population

Background/Aims The development of nonalcoholic fatty liver disease (NAFLD) is associated with multiple genetic and environmental factors. Methods We performed a genome-wide association study to identify the genetic factors related to NAFLD in a Korean population-based sample of 1,593 subjects with NAFLD and 2,816 controls. We replicated the data in another sample that included 744 NAFLD patients and 1,137 controls. We investigated single-nucleotide polymorphisms (SNPs) that were related to NAFLD. Results After adjusting for age, sex and body mass index, rs738409, rs12483959 and rs2281135, located in the PNPLA3 gene, were validated in our population (p<8.56×10−8) in the same linkage disequilibrium block. Additionally, rs2143571, rs3761472, and rs2073080 in the SAMM50 gene showed significant associations with NAFLD (p<8.56×10−8). Furthermore, these six SNPs showed significant associations with the severity of fatty liver (all p<2.0×10−10 in the discovery set and p<2.0×10−6 in the validation set) and NAFLD, with elevated levels of alanine aminotransferase (all p<2.0×10−10 in the discovery set and p<2.0×10−6 in the validation set). Conclusions We demonstrated that the PNPLA3 and SAMM50 genes are significantly associated with the presence and severity of NAFLD in a Korean population. These findings confirm the important roles of genetic factors in the pathogenesis of NAFLD.

Health and Prevention Enhancement (H-PEACE): a retrospective, population-based cohort study conducted at the Seoul National University Hospital Gangnam Center, Korea

Purpose The Health and Prevention Enhancement (H-PEACE) study was designed to investigate the association of diagnostic imaging results, biomarkers and the predisease stage of non-communicable diseases (NCDs), such as malignancies and metabolic diseases, in an average-risk population in Korea. Participants This study enrolled a large-scale retrospective cohort at the Healthcare System Gangnam Center, Seoul National University Hospital, from October 2003 to December 2014. Findings to date The baseline and follow-up information collected in the predisease stage of NCDs allows for evaluation of an individual’s potential NCD risk, which is necessary for establishing personalised prevention strategies. A total of 91u2009336 health examinees were included in the cohort, and we repeatedly measured and collected information for 50.9% (n=46u2009484) of the cohort members. All participants completed structured questionnaires (lifestyle, medical history, mini-dietary assessment index, sex-specific variables and psychiatric assessment), doctors’ physical examinations, laboratory blood and urine tests and digital chest X-ray imaging. For participants with available data, we also obtained information on specific diagnostic variables using advanced diagnostic tests, including coronary CT for coronary calcium scores, colonoscopy and brain MRI. Furthermore, 17u2009455 of the participants who provided informed consent and donated blood samples were enrolled into the Gene-environmental interaction and phenotype study, a subcohort of the H-PEACE, from October 2013, and we analysed genome-wide single-nucleotide polymorphism array data for 6579 of these blood samples. Future plans The data obtained from this cohort will be used to facilitate advanced and accurate diagnostic techniques related to NCDs while considering various phenotypes. Potential collaborators can access the dataset after receiving approval from our institutional review board. Applications can be submitted on the study homepage (http://en-healthcare.snuh.org/HPEACEstudy).

Comparison between a new electronic bidet and conventional sitz baths: a manometric evaluation of the anal resting pressure in normal healthy volunteers.

BackgroundA bidet has been proposed as a replacement for the sitz bath. Like a sitz bath, it brings water into contact with the perineum. However, the high force of water from commercially used electronic bidets may harm the anus. We developed a new electronic bidet and evaluated its effects on anal resting pressure compared with a warm sitz bath.MethodsForty volunteers used the electronic bidet and sitz bath on separate days. The electronic bidet was newly designed with warm (38xa0°C) water and very low force (10 mN) with a fountain type of flow. Anal resting pressure at the high-pressure zone was measured before (control) and after the electronic bidet and sitz bath. Pressure changes after bidet or sitz bath were expressed as percentages compared with control. Water temperatures and rectal temperatures were also recorded.ResultsThe anal resting pressures before the electronic bidet and sitz bath were 90.2xa0±xa024.6 and 88.1xa0±xa016.8xa0mmHg, respectively. At 3xa0min after the electronic bidet and sitz bath, the anal resting pressures were 71.3xa0±xa023.4 and 69.6xa0±xa019.8xa0mmHg, respectively. The pressure changes compared with the control were 78.2xa0±xa012.9 and 78.1xa0±xa012.5xa0%, respectively, which were not significantly different. The maximal increase and minimal decrease were not significantly different. The rectal temperature was not elevated, and the water temperature decreased significantly with the sitz bath (pxa0<xa00.001).ConclusionsOur new electronic bidet may reduce the anal resting pressure much like a warm sitz bath does.